Current maternal depression associated with worsened children's social outcomes during middle childhood: Exploring the role of positive affect socialization.

BACKGROUND: Maternal depression negatively predicts aspects of the mother-child relationship and social functioning in offspring. This study evaluated interrelations between mothers' depression history and current severity with dynamic indices of positive affect socialization and indices of offspring' social outcomes. METHODS: N = 66 mother-child dyads in which approximately 50 % of mothers had a history of maternal depression were recruited. Children were 6-8 years old and 47.7 % male. Dyads completed a positive interaction task, which was coded for mother and child positive affect. Mothers and children reported on peer functioning and social problems and children reported on the quality of their best friendships at 1-year follow-up. RESULTS: Current level of maternal depression, but not depression history, was related to more social problems and lower best friend relationship quality. Indices of positive affect socialization were not related to history or current levels of maternal depression, or social outcomes, with the exception of maternal depression history predicting greater likelihood of mothers joining their children in expressing positive affect. Exploratory, supplementary analysis revealed that this may be due to treatment history among these mothers. LIMITATIONS: Conclusions should be tempered by the small sample size, which limited the types of analyses that were conducted. CONCLUSION: Results suggest that the effect of maternal depression on aspects of child social outcomes could be specific to current levels. Our data also did not support previously found associations between maternal depression and positive affect socialization. Results suggest positive implications for the effect of treatment for maternal depression for mother-child dynamics.

Maternal invalidation and child RSA reactivity to frustration interact to predict teacher-reported aggression among at-risk preschoolers.

BACKGROUND: Aggression is a transdiagnostic indicator of risk and represents one of the most common reasons children are referred for mental health treatment. Theory and research highlight the impact of maternal invalidation on child aggression and suggest that its influence may vary based on differences in child physiological reactivity. Moreover, the interaction between these risk factors may be particularly pronounced among children of mothers with emotion regulation (ER) difficulties. The current study examined the independent and interactive effects of maternal invalidation and child physiological reactivity to frustration on teacher-reported aggression in an at-risk sample of preschool children. METHOD: Participants included 77 mothers (Mage = 33.17 years, s.d. = 4.83; 35% racial/ethnic minority) and their children (Mage = 42.48 months; s.d. = 3.78; 56% female; 47% racial/ethnic minority). Groups of mothers with and without clinician-rated ER difficulties reported on maternal invalidation, and child respiratory sinus arrhythmia (RSA) was assessed continuously during a frustration task as an indicator of physiological reactivity. Teachers or daycare providers reported on child aggression. RESULTS: Results demonstrated positive associations between maternal ER difficulties and both maternal invalidation and child RSA reactivity to frustration. As expected, the interaction between maternal invalidation and child RSA reactivity was significant, such that higher maternal invalidation and greater child RSA reactivity to frustration predicted more aggression in a daycare or preschool setting. Importantly, this effect was demonstrated while controlling for demographic covariates and baseline RSA. CONCLUSIONS: Findings are in line with diathesis-stress and biosocial models of risk and point to multiple targets for prevention and early intervention.

Operationalizing intimacy and identity aspects of personality functioning in relation to personality disorder in adolescents.

According to dimensional models of personality pathology, deficits in interpersonal (intimacy and empathy) and self (identity and self-direction) function (Criterion A) are core to all personality disorders. These aspects of personality functioning (Criterion A) have seldom been evaluated for how they might relate to one another in the context of personality pathology in adolescents. Moreover, the use of performance-based measures to evaluate aspects of Criterion A function remains an untapped resource. Therefore, the present study aimed to evaluate relations between two features of Criterion A, maladaptive intimacy and maladaptive (or diffused) identity, in adolescence. For intimacy, we leverage a performance-based approach to studying intimacy, operationalized in a developmentally relevant way (perceived parental closeness). For identity, we rely on a validated self-report measure of identity diffusion. We examined the relationship between these features with each other and their relations with borderline features. Additionally, we explored whether identity diffusion mediated the expected relationship between perceived parental closeness and borderline features. We hypothesized that greater distance in perceived parental closeness would be associated with higher levels of borderline features, as well as higher levels of identity diffusion, and that identity diffusion would account for the relationship between intimacy and personality pathology. The sample included 131 inpatient adolescents (M age = 15.35, 70.2% female). Results indicated that intimacy, operationalized as perceived parental closeness, with both mothers and fathers was significantly associated with levels of identity diffusion and borderline features. In addition, greater feelings of closeness with parents were associated with lower severity of borderline features via healthier identity function. Implications of the results, limitations, and future directions are discussed.

The role of youths' cardiac autonomic balance and parental responses to youth emotion in vulnerability to borderline personality disorder development.

Developmental models of borderline personality disorder (BPD) emphasize the effects of youths' biological vulnerabilities and their experiences of parental responses to emotion, as well as the interaction between these two elements. The current study evaluated the independent and interactive effects of two indices of autonomic nervous system response and parental responses to youth negative emotions on severity and exacerbation of youths' BPD features during the transition to adolescence. The sample consisted of 162 psychiatric youth (10-14 years; 47.2% female) and their parents. At baseline, youth and their parents completed a lab-based conflict discussion during which parasympathetic and sympathetic nervous system response were measured and indices of sympathetic-parasympathetic balance and coactivation/coinhibition were calculated. Youth also reported on supportive and non-supportive parental responses. At baseline and after 9 months, youth self-reported on their BPD features. Results demonstrated that shifting toward sympathetic dominance independently predicted exacerbation of BPD across 9 months. Additionally, fewer experiences of supportive parental responses and more non-supportive parental responses were associated with greater severity of BPD features in youth. This study highlights the role of autonomic response to parent-child conflict as well as the significance of parental responses to youth emotion for the development of BPD during this developmental window.

Sampling methods in personality pathology research: Some data and recommendations.

The field of personality disorder research has grown since the publication of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, in 1980; with a notable evolution in the way that personality disorders are defined and operationalized. In evaluating this research, it is necessary to consider the range of sampling practices used. The goal of this study was to describe current sampling methods in personality disorder research and provide recommendations to guide sample design in future personality disorder research. To do this, we coded sampling practices described in recent empirical articles published in four journals that showcase research on personality disorders. We summarized aspects of sampling design including the combination of study question and sample characteristics (e.g., sample size, sample source, and use of screening), study design, and demographic representation of samples. Findings reveal a need for studies to better consider whether their samples are fit for purpose and to make explicit their target population and sampling frame, as well as the specific procedures (i.e., recruitment) used to carry out sampling. We also discuss issues that arise when attempting to capture low-base rate pathology, which is often associated with high comorbidity. We emphasize a process-oriented approach to developing a sampling strategy for personality disorders research. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Bullying Perpetration and Victimization as Social Mechanisms in the Development of Borderline Personality Traits during Adolescence: A Longitudinal Study.

INTRODUCTION: Borderline personality features are often associated with toxic social relationships and problematic peer functioning. Less is known, however, about the extent to which bullying experiences may shape the development and maintenance of borderline-related traits during crucial periods of rapid normative developments in impulse and emotion regulation skills. Given the core interpersonal character of borderline personality pathology (BPP), such research focus may be relevant to better understand possible causal social mechanisms in the development of personality difficulties within the borderline trait spectrum. METHOD: The current longitudinal study examined whether experiences of both bullying perpetration and victimization in pre-adolescence mediated the developmental course of BPP traits between childhood and adolescence. To examine these associations, a sample of children (N = 242; 57% girls; Mage = 10.87 years) was recruited and followed up 1 and 4 years later. RESULTS: Mediation analysis indicated that the prospective link between child and adolescent BPP trait vulnerability was shaped by pre-adolescent experiences of bullying victimization, but not by bullying perpetration. DISCUSSION: These results indicate that the continuity between child and adolescent borderline trait features are partly explained by exposure to bullying victimization, indicating that the impact of environmental invalidation on BPP development also extends to the peer context.

Are We Thinking about the Same Disorder? A Trifactor Model Approach to Understand Parents' and Their Adolescents' Reports of Borderline Personality Pathology.

Multiple informant assessment is the norm when evaluating borderline personality pathology (BPP) in adolescence, especially by including reports from both parents and adolescents. However, these reports tend to be discrepant, and it is unclear how to integrate. The current study used a trifactor model to isolate sources of variance in parents' and adolescents' reports of BPP due to their shared and unique perspectives in a sample of 652 inpatient adolescents (63% female; Mage = 15.31, SD = 1.45) and their parents (81% mothers). Consensus/agreement was characterized by the externalizing features of BPP whereas idiosyncratic views of adolescent BPP covered the full latent BPP construct, suggesting that simple aggregation of parent and adolescent reports is inappropriate. Measurement invariance suggested that unique perspectives were characterized by slightly different operationalizations of BPP and response biases for specific features of BPP. Attachment security and parents' interpersonal problems predicted shared and unique perspectives differently for female and male adolescents. Lastly, we found that shared and unique perspectives differentially predicted interview based BPP, length of stay, and adolescent mentalizing. In sum, findings replicate previous evidence of parent-child informant discrepancy in youth psychopathology, broadly, and provide insights specific to BPP. Discussion includes practical recommendations for assessment and interpretation of BPP assessment.

The Assessment of Identity Development in Adolescence (AIDA) Questionnaire: First Psychometric Evaluation in Two North American Samples of Young People.

The Assessment of Identity Development in Adolescence (AIDA) is a recently developed measure of identity diffusion in young people. Originally validated in Switzerland, the English version has not yet been validated. Our aim was to evaluate the AIDA's internal factor structure, internal consistency, incremental validity, and relations to other variables in adolescents and young adults and derive clinical cutoffs for use in clinical settings. Study 1, involving 2,119 undergraduate students between the ages of 18-25 years, confirmed the expected bi-factor structure for the AIDA. Study 2 involved the recruitment of 122 adolescent inpatients (ages 12-17), of whom 36 met full DSM-based criteria for Borderline Personality Disorder, in addition to 164 adolescents of the same age, recruited from public schools (total 286 adolescents). Results of both studies demonstrated strong internal consistency and correlations of the expected magnitude and direction with other self-report measures of personality pathology. In addition, Study 2 demonstrated that the AIDA could successfully discriminate between adolescent inpatients with and without BPD, as well as healthy controls, and established preliminary clinical cutoffs that should be replicated in future studies. In all, these studies provide support for further validation and use of the AIDA in young people.

Levels of Personality Functioning Questionnaire 12-18 (LoPF-Q 12-18): Factor Structure, Validity, and Clinical Cut-Offs.

The Levels of Personality Functioning Questionnaire 12-18 (LoPF-Q 12-18) is the only self-report measure informed by the Level of Personality Functioning (Diagnostic and Statistical Manual of Mental Disorders [5th ed.; DSM-5; American Psychiatric Association, 2013]) Alternative Model of Personality Disorders developed for adolescents. The present investigation includes two studies evaluating the English LoPF-Q 12-18. In Study 1, single-factor and bifactor structures (unidimensional severity criterion and four specific factors: identity, self-direction, empathy, intimacy) were evaluated in an ethnically diverse community sample (N = 453; age 10-18; 57% female). Study 2 used a community control (n = 298; age 10-18; 54.4% female) and clinical sample (n = 94; age 11-18; 58.5% female) to examine reliability, validity, and clinical utility. Study 1 results supported the bifactor model, with a robust general factor and little multidimensionality caused by the group factors, suggesting an essentially unidimensional structure. Study 2 revealed good internal consistency and construct validity and provided clinical cut-offs, supporting the use of the LoPF-Q 12-18 total score in research and clinical applications.

Internalizing and Externalizing Problems Among At-Risk Preschoolers: The Mediating Role of Maternal Invalidation.

Children of parents with emotion regulation (ER) difficulties may be at heightened risk for internalizing and externalizing problems, and maternal invalidation may explain this association. The current study used a cross-informant design to test the indirect effect of clinician-rated maternal ER difficulties on teacher-reported internalizing and externalizing problems through maternal invalidation. This risk pathway was tested in two groups of preschoolers: children of mothers with ER difficulties and children of mothers without ER difficulties (healthy controls; HC). Participants were 85 mothers (Mage =33.30 years; 36% racial/ethnic minoritized status) and their children (Mage =4234 months; 47% racial/ethnic minoritized status). Maternal ER difficulties had a significant indirect effect on child internalizing problems and externalizing problems, specifically aggressive behavior, through maternal invalidation. Specifically, mothers with ER difficulties reported more maternal invalidation, and their children exhibited more internalizing problems and aggressive behavior in a preschool/daycare setting, pointing to multiple avenues for prevention and intervention.

Personality lives in the intersubjective space between people: Comment on Miskewicz et al. (2022).

Comments on the original article by Miskewicz et al. (see record 2021-98114-001) regarding personality traits and personality processes. The authors want to be clear that they are not advocating for the retention of a categorical diagnosis of borderline personality disorder (BPD). Rather, they are advocating for the possibility that the BPD construct, all along, has captured an essential and core "process" associated with personality pathology that has to do with how an individual manages the self in relation to others. Here, they urge Miskewicz et al. (2022) along with others (Fleeson et al., 2019; Hopwood, 2018) to go beyond redescription of traits-that is, defining the core process of personality pathology through a simple stimulus-response (trigger-symptom) lens. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychometric Properties of the Parent and Youth Versions of the Inadequate Boundaries Questionnaire in Community and Clinical Samples of Adolescents.

The Inadequate Boundaries Questionnaire (IBQ) was created as a multi-dimensional measure of boundary violations in parent-child relationships. Use of the IBQ has been increasing; however, its psychometric properties, including its proposed five-factor structure, have yet to be comprehensively evaluated. The current study examined the factor structure, reliability, mother-adolescent agreement, and convergent and discriminant validity of the IBQ-Parent and -Youth English versions among community and clinical adolescents and their mothers. Confirmatory factor analysis most strongly supported four factors: Guilt Induction-Psychological Control, Parentification, No Boundaries (Enmeshment), and Triangulation. The scales showed acceptable to excellent reliability. Mother-adolescent agreement was moderate in the healthy community sample and weaker in the clinical sample. Convergent and discriminant associations supported the validity of the Guilt Induction-Psychological Control scale, with a more complex picture emerging for other scales. Implications of these findings and directions for future research with the IBQ are discussed.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, alternative model conceptualization of borderline personality disorder: A review of the evidence.

In the 10 years following the publishing of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), studies have accumulated testing the validity and utility of the alternative model for personality disorders (AMPD) in the context of borderline personality disorder (BPD). In this article, we review the studies that have tested how well the AMPD conceptualization of BPD captures the traditional (DSM-5, Section II) conceptualization of BPD. Although we note that studies that measure the full conceptualization of the AMPD-BPD are limited compared with studies focusing on a single aspect of the AMPD, studies reviewed suggest that the AMPD conceptualization of BPD largely overlaps with Section II, is associated with a similar range of external constructs, and can be measured with similar levels of interrater reliability. This evidence is promising in terms of the goal of the AMPD developers to not lose relevant and clinically meaningful information associated with traditional conceptualizations of BPD. However, further applied research is needed to understand how the AMPD may improve upon our existing categorical conceptualization of BPD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Adolescent Sleep Disturbance, Emotion Regulation and Borderline Features in an Inpatient Setting.

Objective: The current study aimed to examine the relation between sleep disturbance, emotion dysregulation and borderline personality features in adolescent inpatients.Method: N = 217 adolescents (67.1% female; ages 12-17) with the following racial/ethnic breakdown: 67.4% White, 3.7% Hispanic, 2.8% Asian, 1.8% African American, and 6.4% multiracial) completed self-report measures of sleep disturbance, emotion dysregulation and borderline personality symptoms at admission to, discharge from, and at 6-months-post discharge from an inpatient psychiatric hospital. Group comparison and path analyses were conducted to examine differences in sleep disturbance between those with and without borderline personality disorder and the mediating role of emotion dysregulation in the relation between sleep disturbance and borderline personality features.Results: Borderline personality features and emotion dysregulation were significantly related to indices of sleep disturbance. Path models revealed that some sleep disturbance indices at admission directly predicted levels of borderline features at discharge and at 6-months-post-discharge. However, none of the indirect pathways between sleep disturbance at admission, emotion dysregulation at discharge, and borderline features at discharge or 6-months post-discharge were significant.Conclusions: Findings are consistent with prior literature which suggest that a unique relation exists between sleep disturbance and BPD, beyond comorbid depression symptoms. However, contrary to our hypotheses, the current study did not provide empirical support for the mediating role of emotion regulation in this relation. These findings have implications for existing personality disorder and sleep interventions and suggest further research into the mechanisms underlying the relation between sleep disturbance and borderline personality pathology is necessary.

The Development of Criterion A Personality Pathology: The Relevance of Childhood Social Functioning for Young Adult Daily Self-Functioning.

The DSM-5 alternative model for the diagnosis of personality disorders (AMPD) states that self- and interpersonal (Criterion A) dysfunction is necessary to diagnose a personality disorder, qualified by maladaptive personality trait profiles (Criterion B). This study tested whether childhood maladaptive personality traits predict interpersonal dysfunction during adolescence, which further predicts lower self-functioning in young adulthood. A mixed clinical-community sample of 157 10-year-olds participated for ten years. Social problems and personality traits were rated by parents at age 10 and 12. At age 20, young adults completed 14 daily ratings of self-functioning. Traits of emotional instability and disagreeableness predicted social problems and self-problems. Social problems predicted worse self-functioning in adulthood. An indirect effect of childhood narcissistic traits on higher levels of self-functioning via lower levels of social problems was found. Results are discussed in terms of their contribution to our understanding of the AMPD from a developmental perspective.

Momentary borderline personality disorder symptoms in youth as a function of parental invalidation and youth-perceived support.

BACKGROUND: Parental invalidation is central to etiological models of borderline personality disorder (BPD). Previous studies relied on retrospective accounts or laboratory observations to examine these associations. There is a dearth of research assessing these constructs in daily life, and limited studies have tested the effect of parental invalidation on BPD symptoms during early adolescence, when BPD onsets. The current study took a dynamic approach to assess parents' validating and invalidating behavior and its effect on youths' BPD symptom expression in daily life, while accounting for parent-perceived helpfulness of these behaviors and youth-perceived support. METHODS: A psychiatric sample of 162 early adolescents (age range = 10-14 years; 47% female) and their parent completed a four-day ecological momentary assessment study. Parents reported on the use of validating and invalidating (e.g. punishing and ignoring) behaviors during parent-child conflict, as well as perceived helpfulness of these behaviors. Youth reported on their BPD symptoms and perceived parental support. Multilevel models were used to test the between- and within-person effects of parents' validating and invalidating behaviors, parent-perceived helpfulness and youth-perceived support, and their interaction on youth's momentary expression of BPD symptoms. RESULTS: At the between-person level, invalidating behaviors, specifically punishing behaviors, were related to greater BPD symptoms in daily life, while ignoring behaviors were associated with fewer BPD symptoms. Youth-perceived support predicted fewer BPD symptoms. CONCLUSIONS: Results underscore the importance of parental invalidation for the expression of BPD symptoms in daily life and also highlight the importance of youth's subjective experience of parental support. Findings are discussed in terms of etiological and intervention models that emphasize a dyadic framework.

Mediational Intervention for Sensitizing Caregivers to Improve Mental Health Outcomes in Orphaned and Vulnerable Children.

OBJECTIVE: There is an urgent need to equip community-based careworkers with the skills to address the mental health needs of orphans and vulnerable children (OVC) as an essential response to shortages in human resources for mental health in Sub-Saharan Africa. We conducted a quasi-experimental feasibility trial in South Africa to adapt and evaluate an established year-long semi-structured, manualized video-feedback caregiver intervention (the Mediational Intervention for Sensitizing Caregivers; MISC) for community-based organizations (CBOs). METHODS: Following a year-long iterative cross-cultural adaptation of MISC, we recruited 88 OVC (ages 7-11; 45.5% girls) and their CBO careworkers (N = 18; 94.4% female). Two CBOs (45 children; 9 CBO careworkers) received 12 months of MISC, and two CBOs (43 children; 9 CBO careworkers) received treatment as usual. Child mental health and quality of caregiving were assessed at 6 months into the intervention and at completion through multi-informant questionnaires and video-recordings of careworker-child interactions. Qualitative interviews were conducted to evaluate feasibility and acceptability. RESULTS: MISC-CBO was acceptable and feasible in terms of attendance and post-intervention interviews. MISC improved child mental health, as well as the quality of careworker caregiving in terms of interactive effects for affective and cognitive (Expanding) components of MISC, and main effects for the cognitive components of Rewarding and Provision of meaning. MISC components did not mediate the effects of the intervention. CONCLUSIONS: The current study shows that laypersons with no tertiary education and virtually no prior training who undergo MISC training can improve caregiving quality and the mental health of OVCs.

Borderline personality disorder in adolescence: The role of narrative identity in the intrapsychic reasoning system.

Borderline personality disorder (BPD) manifests in adolescents, serving as a forerunner for later dysfunctionality and life constraints. BPD is characterized by multiple difficulties in understanding the self and others, and it has been implied that intrapsychic processes of reasoning might be the primary driver of these disturbances. In this study, we examined the role of narrative identity, the dynamic and evolving story people construct about their personal pasts, presents, and futures, as a potentially important but largely overlooked aspect of temporal reasoning within the intrapsychic system of adolescents with BPD features. A total of 174 American inpatient adolescents (Mage = 15.12 years, SD = 1.52) completed self-report measures of BPD upon hospital admission. Adolescents' narrative identity (i.e., themes/future wishes of agency and communion), mentalizing, and emotion dysregulation were assessed. Results showed that narrative identity (i.e., thwarted themes of agency and communion) was associated with lower mentalizing and higher emotional dysregulation capacities, supporting narrative identity's relation to other relevant aspects of intrapsychic processes of reasoning in BPD. Regression analyses showed that both higher levels of emotion dysregulation and more thwarted narrative themes of agency (but not mentalizing) were significantly associated with BPD features. Intriguingly, narrative identity (i.e., thwarted themes of agency) showed incremental validity in accounting for features of BPD, over and above emotion dysregulation. It is concluded that disturbances related to narrative identity might be a prominent component of the intrapsychic reasoning system in BPD and should be included in future work on the topic. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

An Evaluation of Age-Group Latent Mean Differences in Maladaptive Identity in Adolescence.

Little is known about the differences between age groups in maladaptive personality function as denoted in Criterion A of the Alternative Model for Personality Disorder (AMPD) in the DSM-5, which is the entry criterion for diagnosing personality disorder in the upcoming ICD-11. The current study aimed to address this gap by evaluating latent mean age group differences in maladaptive identity, which is one aspect that has been identified as an important feature of maladaptive, general personality function as represented in the DSM-5 and ICD-11. We were also interested whether mean differences would track with mean differences in borderline personality disorder (BPD) features given prior data suggesting that general personality function overlap with the construct of BPD. A community sample of N = 2,381 adolescents, representing a mix of different socio-economic and educational backgrounds, ages 12-18 (M = 14.92, SD = 1.94; 46% male) completed a measure of maladaptive identity. A subset (n = 1,165) completed a measure of borderline personality features. Latent variable modeling was used to evaluate latent mean differences across seven age bands. Results suggested a normative increase in maladaptive identity after age 12, which remained consistent until age 17 when it dropped back to levels observed in 12-year-olds. Maladaptive identity was significantly associated with mean-level increases in borderline personality features, with these constructs becoming more closely associated with increasing age.

Positive and harmful effects of parental disciplinary tactics on dark trait development throughout childhood and adolescence.

Children with a constellation of dark traits may be particularly challenging to parents because these traits are associated with an increased chance for parents to lose a supportive attitude in dealing with the child's difficultness and to turn instead toward punishing strategies. The present study looks with more detail into the construct of parental punishment and examines differences and similarities in the effects of physical (harsh) versus nonphysical (corrective) discipline on the developmental course of childhood five-factor model-based dark traits across a 10-year time span. Data were drawn from an ongoing (masked for review) longitudinal study, including five assessment points across 10 years (Ntime 1 = 720, 54.4% girls, age range Time 1 = 8-14.78 years, M = 10.73, SD = 1.39). Latent growth modeling suggested significant differences between both kinds of parental discipline in terms of contrasting effects on subsequent growth in dark traits and also showed a number of age-and gender-specific effects of parental discipline on the developmental course of dark traits. These findings underscore the relevance of a more differentiated perspective on effects of parental punishment in understanding childhood maladaptive trait outcomes and may offer fruitful guidelines for the development of intervention programs targeting children that are difficult to manage. (PsycInfo Database Record (c) 2021 APA, all rights reserved).