Initial examination of the mental health disorders: screening instrument for athletes.

Introduction: There is a need to psychometrically develop assessment instruments capable of screening mental health disorders in athlete populations. The current study was conducted to determine reliability, validity and clinical utility of the Mental Health Disorders Screening Instrument for Athletes (MHDSIA). Methods and results: 259 collegiate athletes completed the MHDSIA. Factor analysis determined a single factor with good internal consistency, and this factor was positively correlated with an established measure of psychiatric symptomology (Symptom Checklist 90-R), demonstrating its concurrent validity. An optimum clinical cutoff score (i.e., 32) was determined using Receiver Operating Characteristic (ROC) analyses to assist appropriate mental health referrals. Discussion: Results suggest the MHSIA is a reliable, valid, and relatively quick and easy to interpret screen for the broad spectrum of mental health disorders in collegiate athletes. As expected, NCAA athletes reported lower MHDSIA scores than club and intramural athletes, while males reported similar severity scores as females.

Changes in ImPACT Cognitive Subtest Networks Following Sport-Related Concussion.

OBJECTIVE: High school athletes are administered ImPACT at the start of the academic year or sport season and again after suspected concussion. Concussion management involves the comparison of baseline and post-injury cognitive scores with declines in scores providing evidence for concussive injury. A network framework may provide additional information about post-concussive cognitive changes and expand characterization of sport-related concussion (SRC) recovery. DESIGN: Retrospective cohort study. SETTING: High school. PARTICIPANTS: High school athletes (n = 1553) were administered ImPACT at baseline (T1), post-SRC (T2 = 72 h of injury), and prior to return to play (T3 = within two weeks post-injury). INDEPENDENT VARIABLES: ImPACT cognitive subtest scores. MAIN OUTCOME MEASURES: Cognitive networks were calculated and compared over three time points. Centrality indices were calculated to determine the relative importance of cognitive variables within networks. RESULTS: Network connectivity increased from T1 to T2 and remained hyperconnected at T3. There was evidence of network reorganization between T1 and T3. Processing speed was central within each network, and visual memory and impulsivity became more central over time. CONCLUSIONS: The results suggest potential evidence of cognitive network change over time. Centrality findings suggest research specific to visual memory and impulse control difficulties during the post-concussion recovery period is warranted. Network analysis may provide additional information about cognitive recovery following SRC and could potentially serve as an effective means of monitoring persisting cognitive symptoms after concussion.

Sport and mental health performance optimization in an adolescent gymnast: A case evaluation.

The Optimum Performance Program in Sports (TOPPS) is a multi-component, sport-specific Family Behavior Therapy that has demonstrated improved sport performance, relationships, and mental health outcomes in adult and adolescent athletes with, and without, diagnosed mental health disorders in clinical trials. The current case trial demonstrates successful implementation of a novel component of TOPPS (i.e., talk aloud optimal sport performance imagery leading to dream mapping) in a biracial Latina and White adolescent gymnast without a mental health diagnosis. The participant demonstrated significant improvements from baseline to both post-treatment and 3-month follow-up in severity of mental health functioning, factors interfering with sports performance, and her relationships with teammates, coaches, and family. Results suggest it may be possible to optimize mental health through sport performance optimization.

Characterizing the Network Structure of Post-Concussion Symptoms.

OBJECTIVE: Assessment of post-concussion symptoms is implemented at secondary, post-secondary, and professional levels of athletics. Network theory suggests that disorders can be viewed as a set of interacting symptoms that amplify, reinforce, and maintain one another. Examining the network structure of post-concussion symptoms may provide new insights into symptom comorbidity and may inform targeted treatment. We used network analysis to examine the topology of post-concussion symptoms using the Post-Concussion Symptom Scale (PCSS) in high school athletes with recent suspected sport-related concussion. METHOD: Using a cross-sectional design, the network was estimated from Post Concussion Symptom Scale scores from 3,292 high school athletes, where nodes represented symptoms and edges represented the association between symptoms. Node centrality was calculated to determine the relative importance of each symptom in the network. RESULTS: The network consisted of edges within and across symptom domains. "Difficulty concentrating" and "dizziness" were the most central symptoms in the network. Although not highly central in the network, headaches were the highest rated symptom. CONCLUSIONS: The interconnectedness among symptoms supports the notion that post-concussion symptoms are interrelated and mutually reinforcing. Given their central role in the network, "difficulty concentrating" and "dizziness" are expected to affect the activation and persistence of other post-concussion symptoms. Interventions targeting difficulties with concentration and dizziness may help alleviate other symptoms. Our findings could inform the development of targeted treatment with the aim of reducing overall symptom burden. Future research should examine the trajectory of post-concussion symptom networks to advance the clinical understanding of post-concussive recovery.

Two and five-factor models of negative symptoms in schizophrenia are differentially associated with trait affect, defeatist performance beliefs, and psychosocial functioning.

Recent factor analytic evidence supports both two-factor (motivation and pleasure, MAP; diminished expression, EXP) and five-factor (anhedonia, asociality, avolition, blunted affect, alogia) conceptualizations of negative symptoms. However, it is unclear whether these two conceptualizations of the latent structure of negative symptoms have differential associations with external correlates. The current study evaluated external correlates of the two- and five-factor structures by examining associations with variables known to have critical relations with negative symptoms: trait affect, defeatist performance beliefs, neurocognition, and community-based psychosocial functioning. Participants included a total of 245 outpatients diagnosed with schizophrenia who were rated on the Brief Negative Symptom Scale and completed a battery of additional measures during periods of clinical stability. These additional measures included the Positive and Negative Affect Schedule, Defeatist Performance Beliefs scale, MATRICS Consensus Cognitive Battery, and Level of Function Scale. Pearson correlations indicated differential patterns of associations between the BNSS scores and the external correlates. Support for the two-factor model was indicated by a stronger association of MAP with positive affect and psychosocial functioning, compared to EXP with neurocognition. Significance tests examining a differential magnitude of associations showed that the two-dimension negative symptom structure masked unique correlational relationships among the five negative symptom domains with neurocognition and social/vocational community functioning and captured unique patterns of correlation with trait affect. Support for the five-factor model was shown by a stronger association between Blunted Affect with Attention/Vigilance, and stronger associations between Avolition, Anhedonia, and Asociality with psychosocial functioning. Results offer support for both the two-dimension and five-domain model of negative symptoms as well as a hierarchical two-dimensions-five-domains model of negative symptoms. Findings may have implications for diagnostic criteria and descriptions of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), as well as possible treatment targets of negative symptoms.

A systematic review and meta-analysis of factors influencing ImPACT concussion testing in high school and collegiate athletes with self-reported ADHD and/or LD.

OBJECTIVE: Sport concussion is a common injury, and athletes with attention-deficit/hyperactivity disorder (ADHD) and/or learning disorder (LD) are at increased risk and require specialized attention in clinical settings. Although systematic reviews of the relationship between ADHD/LD and concussion are reported in the literature, these reviews do not include quantitative syntheses. Additionally, no reviews have focused on the most commonly utilized concussion assessment, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). The current review provides an update of sport concussion assessment in athletes with ADHD and/or LD from 2000 to 2021 on these topics: baseline and postconcussion performance on ImPACT, baseline and postconcussion symptom reporting using the Postconcussion Symptom Scale, invalid baseline classification on ImPACT, and self-reported history of concussion. METHOD: Meta-analyses were conducted on baseline ImPACT performance, symptom reporting, invalid baseline classification, and concussion rates. Thirty-four studies were included in systematic review and 19 were included in meta-analyses. RESULTS: Decreased baseline performance was found for athletes with ADHD (trivial to small effects), LD (small-to-medium effects), and ADHD/LD (small-to-medium effects). Increased baseline symptom reporting was found for athletes with ADHD (small effect). Increased odds of invalid baseline performance (trivial effect) and self-reported concussion history (small effect) were found in ADHD. CONCLUSIONS: These results provide the first quantitative synthesis of the literature in this area. It is recommended that future research further examines these topics in athletes with LD and co-occurring ADHD/LD (given the focus on ADHD), as well as the effects that all of these conditions may have on concussion recovery and return-to-play decision-making. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Latent structure of cognitive tests is invariant in men and women with schizophrenia.

Studies comparing the cognitive functioning of men and women with schizophrenia have produced conflicting results which could arise from sex-based differences in the latent structure of cognitive abilities. The current study used multigroup confirmatory factor analysis to examine invariance in latent structure of cognitive abilities to between men and women with schizophrenia. Confirmatory factor analysis of an initial neurocognitive assessment (men n = 612, women n = 201) and cross-validation using second assessment (men n = 549, women n = 198) demonstrated that a bifactor seven-factor model fit the data best for both men and women. Invariance analyses further indicated this model was invariant across men and women at both assessments. Group comparisons indicated women had significantly higher scores for Semantic Memory, Verbal Memory, and General Cognitive factors, whereas men exhibited better performance on the Vigilance factor. Results indicate that cognition in SZ is characterized by both a general cognitive factor and specific domains for both men and women. Invariance analysis provides evidence that cognitive differences between men and women do not result from sex-based differences in the latent structure of cognitive abilities. Current results also indicate small but statistically significant neurocognitive differences between men and women with schizophrenia.

Cluster analysis of negative symptoms identifies distinct negative symptom subgroups.

The heterogeneity of schizophrenia has been acknowledged for decades because of the diverse presentation of symptoms, illness course, and treatment response noted between individuals diagnosed with the disorder. Cluster analysis has been used as a statistical method to determine whether schizophrenia subgroups might be identified based on symptom heterogeneity. However, there is very limited research examining whether heterogeneity in negative symptoms might be useful in establishing schizophrenia subtypes, particularly research examining newer models of negative symptoms based on five latent constructs including anhedonia, asociality, avolition, blunted affect, and alogia. The Brief Negative Symptom Scale was used to assess the five negative symptoms domains in a sample of 220 outpatients diagnosed with schizophrenia or schizoaffective disorder. Cluster analysis supported a four-cluster solution, comprising clusters of subjects with low negative symptoms (LNS), severe negative symptoms (SNS), and two clusters with moderate negative symptoms, one with predominantly elevated blunted affect (BA) and one with elevated avolition (AV). The LNS, SNS, BA, and AV clusters significantly differed on external validators including clinical characteristics, neurocognition, and functional outcome. Findings suggest that schizophrenia heterogeneity can be parsed according to negative symptom subtypes that have distinct clinical and neuropsychological profiles. Implications for diagnosis and treatment are discussed.

Validation of accelerometry as a digital phenotyping measure of negative symptoms in schizophrenia.

Negative symptoms are commonly assessed via clinical rating scales; however, these measures have several inherent limitations that impact validity and utility for their use in clinical trials. Objective digital phenotyping measures that overcome some of these limitations are now available. The current study evaluated the validity of accelerometry (ACL), a passive digital phenotyping method that involves collecting data on the presence, vigor, and variability of movement. Outpatients with schizophrenia (SZ: n = 50) and demographically matched healthy controls (CN: n = 70) had ACL continuously recorded from a smartphone and smartband for 6 days. Active digital phenotyping assessments, including surveys related to activity context, were also collected via 8 daily surveys throughout the 6 day period. SZ participants had lower scores on phone ACL variables reflecting vigor and variability of movement compared to CN. ACL variables demonstrated convergent validity as indicated by significant correlations with active digital phenotyping self-reports of time spent in goal-directed activities and clinical ratings of negative symptoms. The discriminant validity of ACL was demonstrated by low correlations with clinical rating scale measures of positive, disorganized, and total symptoms. Collectively, findings suggest that ACL is a valid objective measure of negative symptoms that may complement traditional approaches to assessing the construct using clinical rating scales.

Improving accuracy of ADHD subtype diagnoses with the ADHD symptom rating scale.

Neuropsychologists evaluate children and adults with ADHD to establish a diagnosis, quantify cognitive deficits associated with ADHD and other common comorbid conditions, and provide recommendations for education and vocational planning. Standardized instruments that align with DSM ADHD symptom criteria are recommended for increasing ADHD diagnostic accuracy. This study examined whether a brief DSM-based symptom rating scale would assist in differentiating subtypes of ADHD. Participants were 253 children diagnosed with ADHD-Inattentive (n = 163) or ADHD-Combined (n = 90). Parents completed the Behavior Assessment System for Children, Second Edition (BASC-2) and DSM-IV ADHD Symptom Rating Scale (SRS) as part of a comprehensive evaluation to establish ADHD diagnoses. The SRS displayed expected convergent and discriminant validity with BASC-2 subscales. The diagnostic accuracy of the SRS subscales to differentiate ADHD was also examined and compared with the BASC-2. Results indicated that SRS Impulsivity, SRS Hyperactivity, and BASC-2 Hyperactivity had significantly better classification accuracy than BASC-2 Attention Problems and SRS Inattention, although they did not differ from each other. The SRS produced symptom profiles consistent with ADHD-Inattentive and Combined subtypes with good classification accuracy when differentiating subtypes. Overall, the SRS is an economical measure that can assist in ADHD presentation differentiation when used as a component of ADHD evaluations.

Expanding the cross-cultural psychological assessment tool box with IQ test short forms.

OBJECTIVE: Short forms of standard intelligence tests are useful in clinical and research settings where administration of a full intelligence test is impractical or unnecessary. In cross cultural contexts where few tests are available, including brief intelligence tests, short forms may be particularly useful to meet clinical and research needs. However, there is little cross-cultural research on the validity of short forms. This study evaluated feasibility of short form development for the Spanish version of the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) and examined comparability of short-form IQ estimates in Spanish- and English-speaking children with Attention-Deficit/Hyperactivity Disorder (ADHD). METHOD: Participants included children with ADHD who were administered the WISC-IV Spanish (n = 165) or WISC-IV (n = 299). Full Scale IQs (FSIQs) were calculated for two-, three-, four-, and five-subtest short forms. Misclassification rates, mean absolute differences, and intraclass correlation coefficients (ICCs) were used to determine short form accuracy in estimating FSIQ. RESULTS: The WISC-IV short forms examined had generally strong psychometric properties (e.g., ICCs ranged from .78 to .94) and level of accuracy in estimating FSIQ did not differ across primary language of Spanish or English. CONCLUSIONS: Findings support feasibility of IQ short form development to help address mental health disparities in research and clinical screening for Spanish- and English-speaking pediatric populations with ADHD.

Adapting an evidence-supported optimization program for mental health and sport performance in collegiate athletes to fit youth from ethnic/racial minority and low-income neighborhoods: A National Institutes of Health stage model feasibility study.

The current study addresses the need to empirically develop effective mental health interventions for youth from ethnic/racial minority and low-income neighborhoods. Using Stage Model evaluation methods supported by the National Institutes of Health in the US to address underutilization of mental healthcare among racial/ethnic minority youth, this feasibility study demonstrates empirical adaptation of an innovative sport-specific psychological intervention for use in youth from ethnic/racial minority and low-income neighborhoods. An international group of professionals familiar with sport performance and mental health intervention serving the target population experientially examined the adapted intervention protocols in workshops and provided feedback. Survey results indicated the professionals found the intervention components were easy to administer and likely to be safe, enjoyable, engaging and efficacious for youth mental health and sport performance. The protocols were revised based on feedback from these professionals and the intervention was examined in a case trial involving an Asian American youth who evidenced Social Anxiety Disorder. Case study results indicated the intervention could be implemented with integrity, and severity of psychiatric symptoms and factors interfering with sport performance decreased after intervention implementation. The participant's relationships with family, coaches and teammates were also improved.

Cognitive profiles following sport-related concussion in high school athletes.

OBJECTIVE: Heterogeneity is common following traumatic brain injury (TBI) with important implications for clinical outcome. Research in moderate to severe TBI identifies differentiated cognitive profiles. There is little research investigating potential clusters following sport concussion. METHODS: Cluster analysis was used to determine patterns of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) performance at three time points (72 hr, 4-7 days, and 8-30 days postconcussion). Participants included 1,817 high-school athletes (Mage = 15.5; 37.9% female) who completed ImPACT following concussion. RESULTS: Separate cluster analyses of cognitive scores were conducted at each postconcussion timepoint. Results indicated three clusters of cognitive performance within 1 week postinjury, while a two-cluster solution was identified at longer intervals (8-30 days). Clusters differed primarily by level of performance and also exhibited stratified differences in symptom severity and magnitude of change in cognitive function and symptom-reporting from pre- to postconcussion. The lowest performing cluster in each PC group was Mildly-to-Moderately Impaired and exhibited the highest rates of complicated recovery, suggesting an association between the current clusters and protracted recovery. CONCLUSIONS: Results provide preliminary evidence that ImPACT can identify clusters of athletes based on cognitive performance postconcussion that differ in clinically meaningful ways, including symptoms, magnitude of change from baseline, and concussion recovery outcomes. Discriminant functions can classify athletes into clusters based on postconcussion scores and a supplemental excel calculator is provided for such purposes. Absence of full demographic data regarding race/ethnicity and socioeconomic status may limit generalizability. Future work should investigate whether these clusters may assist in return-to-play decision-making by identifying at-risk athletes who may benefit from targeted intervention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Confirmatory factor analysis of imPACT cognitive tests in high school athletes.

ImPACT is the most commonly utilized computerized neurocognitive assessment for the clinical management of sport concussion. The cognitive composite scores that ImPACT currently reports include Verbal Memory, Visual Memory, Visual Motor Speed, Reaction Time, and Impulse Control. However, exploratory factor analytic studies report that two or more factors may better represent ImPACT's latent structure, suggesting that the current cognitive composites may not adequately represent the cognitive constructs ImPACT assesses. The latent structure of ImPACT cognitive baseline scores was examined using exploratory (EFA) and confirmatory factor analysis (CFA) of valid baseline ImPACT scores for 36,091 high school athletes. These athletes were randomly divided into two samples. The first sample was a calibration sample used for EFA and the second sample was a cross-validation sample used for CFA to estimate the best model identified in the calibration phase, along with other models that were reported in the literature or based on theoretical considerations, including hierarchical and bifactor models. EFA identified a first-order four-factor solution consisting of Visual Memory, Visual Reaction Time, Verbal Memory, and Working Memory constructs. CFA indicated that this four-factor model provided superior fit for the data, while the current five-composite structure of ImPACT provided a poor fit for the data. The latent constructs identified in this study using CFA do not map well onto the composite scores that are currently used to interpret ImPACT performance. Future research should investigate whether interpretation of ImPACT based on the constructs identified here will be more useful for clinical decision making than current approaches. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Bifactor model of cognition in schizophrenia: Evidence for general and specific abilities.

BACKGROUND: Despite extensive study of cognition in schizophrenia, it remains unclear as to whether cognitive deficits and their latent structure are best characterized as reflecting a generalized deficit, specific deficits, or some combination of general and specific constructs. METHOD: To clarify latent structure of cognitive abilities, confirmatory factor analysis was used to examine the latent structure of cognitive data collected for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) for Schizophrenia study. Baseline assessment data (n = 813) were randomly divided into calibration (n = 413) and cross-validation samples (n = 400). To examine whether generalized or specific deficit models provided better explanation of the data, we estimated first-order, hierarchical, and bifactor models. RESULTS: A bifactor model with seven specific factors and one general factor provided the best fit to the data for both the calibration and cross-validation samples. CONCLUSIONS: These findings lend support for a replicable bifactor model of cognition in schizophrenia, characterized by both a general cognitive factor and specific domains. This suggests that cognitive deficits in schizophrenia might be best understood by separate general and specific contributions.

Influence of Autism and Other Neurodevelopmental Disorders on Cognitive and Symptom Profiles: Considerations for Baseline Sport Concussion Assessment.

OBJECTIVE: The presence of neurodevelopmental disorders (ND) such as attention-deficit/hyperactivity disorder (ADHD) and learning disorders (LD) have demonstrated effects on Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) performance. No current research has directly examined whether autism spectrum disorder (ASD) has similar effects. The current study compared ImPACT cognitive and symptom profiles in athletes with self-reported ASD to other NDs and healthy controls using case-control matching. METHOD: The current study compared ImPACT baselines of high school athletes with ASD to athletes with other NDs (ADHD, LD, and co-occurring ADHD/LD) and healthy controls on cognitive composites and symptom reporting. Participants included 435 athletes (87 controls, 87 with ASD, 87 with ADHD, 87 with LD, and 87 with ADHD/LD) selected from a larger naturalistic sample. Athletes were matched to the ASD group based on age, sex, and sport using randomized case-matched selection from the larger database. RESULTS: Results revealed that athletes with ASD performed more poorly than healthy controls on the Visual Motor Speed composite. No differences were found for Post-concussion Symptom Scale (PCSS) domain scores. Differences in cognitive and symptom profiles among the athletes with other NDs were also found. CONCLUSIONS: Results elucidate patterns of baseline performance for athletes with ASD, demonstrating that there may not be significant differences between ASD and healthy controls on four of the five ImPACT composites, and no symptom reporting differences. Cognitive and symptom differences found for other NDs should be considered when interpreting baseline performance and for making return-to-play decisions in the absence of baseline assessment.

Social Cognition in Children With ADHD.

Objective: Despite evidence of social skill deficits in children with ADHD, there is no consensus regarding a social cognitive profile and whether these skills predict behavior. Therefore, a comprehensive battery was used to investigate the relationship between social cognition and behavioral functioning. Method: Children ages 7 to 13 with ADHD (n = 25) and controls (n = 25) completed tests assessing social cognitive domains (affect recognition and theory of mind [ToM]). Parents completed measures of social cognition (pragmatic language ability and empathy), behavioral symptoms, and adaptive functioning. Results: Children with ADHD performed significantly worse on measures of cognitive ToM and affect recognition and received lower ratings of pragmatic language and cognitive empathy than typically developing peers. These domains, particularly pragmatic language, predicted parent ratings of problematic and adaptive behaviors. Conclusion: Results establish a relationship between specific social cognitive abilities and daily functioning, which has implications for treatment.

Influence of Special Education, ADHD, Autism, and Learning Disorders on ImPACT Validity Scores in High School Athletes.

OBJECTIVE: The Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is commonly used to assist with post-concussion return-to-play decisions for athletes. Additional investigation is needed to determine whether embedded indicators used to determine the validity of scores are influenced by the presence of neurodevelopmental disorders (NDs). METHOD: This study examined standard and novel ImPACT validity indicators in a large sample of high school athletes (n = 33,772) with or without self-reported ND. RESULTS: Overall, 7.1% of athletes' baselines were judged invalid based on standard ImPACT validity criteria. When analyzed by group (healthy, ND), there were significantly more invalid ImPACT baselines for athletes with an ND diagnosis or special education history (between 9.7% and 54.3% for standard and novel embedded validity criteria) when compared to athletes without NDs. ND history was a significant predictor of invalid baseline performance above and beyond other demographic characteristics (i.e., age, sex, and sport), although it accounted for only a small percentage of variance. Multivariate base rates are presented stratified for age, sex, and ND. CONCLUSIONS: These data provide evidence of higher than normal rates of invalid baselines in athletes who report ND (based on both the standard and novel embedded validity indicators). Although ND accounted for a small percentage of variance in the prediction of invalid performance, negative consequences (e.g., extended time out of sports) of incorrect decision-making should be considered for those with neurodevelopmental conditions. Also, reasons for the overall increase noted here, such as decreased motivation, "sandbagging", or disability-related cognitive deficit, require additional investigation.

Examination of the Influence of Cognitive Behavior Therapy Components, Consumer Satisfaction and Engagement in Mothers Referred for Drug Abuse and Child Neglect on Treatment Outcomes.

Psychological interventions for child maltreatment have predominately been limited to family-supported, multi-component behavioral therapies. Although these comprehensive programs have resulted in positive outcomes, they are relatively costly and there is limited information available as to how the components of these programs influence treatment outcomes. In this study, the CBT components of an evidence-based treatment for child neglect and drug abuse (Family Behavior Therapy) were examined in regards to consumer preferences, consumer engagement and treatment outcomes. Thirty-five mothers identified for child neglect and drug abuse were administered various CBT components successively and cumulatively based on their preferences. Repeated measure ANOVAs indicated that participants chose to receive components that were specific to managing antecedents to drug abuse and child neglect most frequently, followed by parenting skills training, communication skills training, and job/financial skills training. No differences were found in treatment providers' ratings of the participants' engagement across intervention components throughout treatment. Participants rated the intervention components as similarly helpful. Partial correlations revealed that participants' ratings of helpfulness and provider ratings of participants' engagement were not associated with improved drug use outcomes at 6- and 10-months post baseline. Participants' ratings of helpfulness were associated with child maltreatment outcomes at 10-month post baseline, and provider ratings of participants' engagement were associated with child maltreatment outcomes at both 6- and 10-month post baseline. Participants identified for neglect not related to drug exposure in utero improved at a higher percentage than did participants identified for in utero drug exposure, and receiving behavioral intervention components more frequently led to greater percentages of participants improving in both drug use and child maltreatment outcomes.