Between- and within-child level associations between externalizing and internalizing behavior problems in a nationally representative sample of US elementary school children.

BACKGROUND: Both transactional and common etiological models have been proposed as explanations of why externalizing behavior problems (EBP) and internalizing behavior problems (IBP) co-occur in children. Yet little research has empirically evaluated these competing theoretical explanations. We examined whether EBP and IBP are transactionally related at the within-child level while also identifying antecedents commonly associated with between-child differences in underlying stability of both EBP and IBP across elementary school. METHODS: We analyzed a nationally representative and longitudinal sample of US schoolchildren (N = 7,326; 51% male) using random-intercept cross-lagged panel modeling (RI-CLPM). We used teacher ratings of EBP and IBP as annually assessed from the spring of kindergarten (Mage = 6.12 years) through the spring of 5th grade (Mage = 11.09 years). Early childhood antecedents included child internal (i.e. inhibitory control, cognitive flexibility, working memory, and language/literacy) and external factors (i.e. parental warmth, harsh parenting, parenting stress, and maternal depressive symptoms). RESULTS: We found little evidence for within-child, transactional relations between EBP and IBP. Both types of behavior problems instead were substantially associated at the between-child level. Inhibitory control was the strongest common antecedent that explained this longitudinal overlap. Cognitive flexibility, working memory, language/literacy skills, and maternal depression contributed specifically to the stability of IBP. Measures of parenting were specific to the stability of EBP. CONCLUSIONS: Common etiological factors rather than transactional relations better explain the co-occurrence of EBP and IBP during elementary school. Inhibitory control is a promising target of early intervention efforts for schoolchildren at risk of displaying both EBP and IBP.

Sociodemographic disparities in ADHD diagnosis and treatment among U.S. elementary schoolchildren.

We examined whether some groups of U.S. elementary schoolchildren are less likely to be diagnosed and treated for ADHD in analyses of a population-based cohort (N = 10,920). We predicted ADHD diagnosis using measures of race and ethnicity, age, socioeconomic status, birthweight, individually assessed academic, behavioral, and executive functioning, family language use, mental health, health insurance coverage, marital status, school composition, and geographic region. We predicted prescription medication use among those diagnosed with ADHD. We stratified additional analyses by biological sex. Black children (aOR, 0.60), girls (aOR, 0.55), and emergent bilinguals (aOR, 0.29) were less likely to have an ADHD diagnosis than observationally similar White children, boys, or those from English-speaking households. Black children's under-diagnosis occurred among boys. Emergent bilingual children's under-diagnosis occurred among both boys and girls. Girls (aOR, 0.52) and emergent bilinguals (aOR, 0.24) with ADHD were less likely to use prescription medication. Sociodemographic disparities in ADHD diagnosis and treatment occur among U.S. elementary schoolchildren. Measured confounds including independently assessed ADHD symptomatology and impairment do not explain the disparities. The findings empirically support cultural, linguistic, and biological sensitivity in the ADHD diagnostic and treatment procedures in use for the U.S. pediatric population.

Factors Predictive of Being Bullies or Victims of Bullies in US Elementary Schools.

We analyzed a population-representative cohort (N=13,611; Mage at kindergarten, first, and second grade = 67.5, 79.5, and 91.5 months, respectively) to identify kindergarten to second grade factors predictive of being bullies or victims during third to fifth grade. We did so by estimating a block recursive structural equation model (SEM) with three sets of predictors. These were: (a) individual and school socio-demographics; (b) family distress and harsh parenting; and (c) individual behavior and achievement. Relations between each of the included variables and the bullying outcomes were simultaneously estimated within the SEM. Thus, each variable served as a control for estimating the effects of the other variables. We used robust standard errors to account for student clustering within schools. Results indicated that externalizing problem behavior strongly predicted being a bully ([ES] = .56, p<.001) and a victim (ES=.29, p<.001). We observed a negative relation between being Hispanic and being a victim (ES = -.10, p<.001) and a positive relation between being Black and being a bully (ES = .11, p<.001). We also observed statistically significant relations between a family's socioeconomic status and being a bully (ES = -.08, p<.001) as well as school poverty and being a victim (ES = .07, p<.001). The results advance the field's limited understanding of risk and protective factors for bullying perpetration or victimization during elementary school and provide additional empirical support for assisting young children already exhibiting externalizing problem behaviors.

Fixed Effect Estimates of Student-Teacher Racial or Ethnic Matching in U.S. Elementary Schools.

We used student fixed effects and statistical controls to investigate whether U.S. elementary students (N = 18,170) displayed greater academic achievement, social-emotional behavior, or executive functioning and were more likely to receive gifted or special education services when taught by teachers of the same race or ethnicity. We observed mostly null effects for student-teacher racial or ethnic matching across the study's 12 dependent measures in analyses adjusting for Type 1 error. For the full sample, matching resulted in lower science achievement (effect size [ES] = -.03 SD). For Black students, matching resulted in fewer internalizing problem behaviors (ES = 0.18 SD). We observed null effects for Hispanic students. Robustness checks including those stratified by race or ethnicity and biological sex or by prior levels of low or high level of achievement, behavior, or executive functioning largely supported the study's null findings. Exceptions were that matching resulted in fewer externalizing problem behaviors (ES = 0.22 SD) for Black girls and lower academic achievement (ES range = -0.04 to -0.14 SD) and fewer externalizing and internalizing problem behaviors (ES range = 0.24 to 0.33 SD) for students who had previously displayed low levels of academic, behavioral, or executive functioning. Collectively, the analyses provide limited support for student-teacher racial or ethnic matching as a school-based policy to address educational disparities in U.S. elementary schools.

Sociodemographic Disparities in Attention-Deficit/Hyperactivity Disorder Overdiagnosis and Overtreatment During Elementary School.

Attention-deficit/hyperactivity disorder (ADHD) overdiagnosis and overtreatment unnecessarily exposes children to potential harm and contributes to provider and community skepticism toward those with moderate or severe symptoms and significant impairments, resulting in less supportive care. Yet, which sociodemographic groups of children are overdiagnosed and overtreated for ADHD is poorly understood. We conducted descriptive and logistic regression analyses of a population-based subsample of 1,070 U.S. elementary schoolchildren who had displayed above-average levels of independently assessed behavioral, academic, or executive functioning the year prior to their initial ADHD diagnoses and who did not have prior diagnostic histories. Among these children, (a) 27% of White children versus 19% of non-White children were later diagnosed with ADHD and (b) 20% of White children versus 14% of non-White children were later using medication. In adjusted analyses, White children are more likely to later be diagnosed (odds ratio [OR] range = 1.70-2.62) and using medication (OR range = 1.70-2.37) among those whose prior behavioral, academic, and executive functioning suggested that they were unlikely to have ADHD.

Longitudinal Trajectories of Reading and Mathematics Achievement for Students With Learning Disabilities.

We examined to what extent subgroups of students identified with learning disabilities (LDs; N = 630) in the Early Childhood Longitudinal Study, Kindergarten Class of 1998 to 1999 (ECLS-K): 1998 national longitudinal study displayed heterogeneity in longitudinal profiles of reading and mathematics achievement from first to eighth grades. Multivariate growth mixture modeling yielded four classes of combined reading and mathematics trajectories for students with LD. The largest class of students with LD (Class 2, 54.3%) showed mean T-scores for both achievement domains that averaged about 1 SD below the mean, with modest decline over time. Almost a quarter of the sample (Class 1, 22.3%) displayed mean T-scores in both achievement areas near the peer-normed average; these students were mostly White, from higher socioeconomic status (SES) backgrounds, and had experienced earlier identification as having an LD as well as shorter duration of LD service. Classifying heterogeneity in longitudinal trajectories of both achievement areas shows promise to better understand the educational needs of students identified with an LD.

Which Students With Disabilities are Placed Primarily Outside of U.S. Elementary School General Education Classrooms?

Students with disabilities (SWD) who are Black or Hispanic have been reported to be more likely to be placed primarily outside of general education classrooms while attending U.S. schools. Federal law and regulation require monitoring of special education placement based on race or ethnicity. Yet, whether and to what extent racial or ethnic disparities in placement are explained by bias or by other explanatory factors is currently unclear. We evaluated for racial and ethnic bias in special education placement by analyzing longitudinal data from two independent samples of SWD (N values range 590-1,130) attending U.S. elementary schools. We statistically controlled for plausibly exogenous sociodemographic, academic, and behavioral risk factors measured in kindergarten in analyses of the students as they attended first, third, and fifth grades between the 1999-2000 and 2015-2016 school years. Of the resulting 12 Black or Hispanic grade-year-specific tests, 11 (i.e., 92%) indicated that controls for kindergarten explanatory factors-particularly significant academic difficulties-fully explained the risk initially attributable to race or ethnicity. We observed little evidence that bias explains racial or ethnic disparities in special education placement in U.S. elementary schools.

Disparities in Family-Centered Care Among US Children and Youth with Special Healthcare Needs.

Cross-sectional analyses of 4 nationally representative samples indicate disparities in family-centered care occur among US children and youth with special healthcare needs by race and ethnicity, family income and composition, insurance coverage, and healthcare setting. Measured confounds including children's health and impairment severity do not explain the disparities.

Taking a School-Based Child Sexual Abuse Prevention Program to Scale: a Cost Analysis.

Cost analyses are used to determine overall costs of implementing evidence-based programming and may help decision makers determine how best to allocate finite resources. Child sexual abuse (CSA), regularly viewed as a human rights violation, is also a public health concern estimated to impact 27% of females and 5% of males by age 18. Universal, school-based CSA programs are one prevailing prevention strategy. However, there are no known cost analyses of school-based CSA prevention programming, thereby limiting potential scalability. Using the ingredients method, this cost analysis presents the findings of implementing Safe Touches, an evidence-based universal prevention program, across four sites (i.e., counties) in one mid-Atlantic state. Reaching a total of 14,235 s grade students, results indicate an average cost of $43 per student, an average classroom cost of $859, an average district cost of $10,637, and an average site cost of $154,243. There was a noted decrease in costs when more students were reached, suggesting a need to focus efforts on bolstering the reach of implementation efforts. Sensitivity analyses explored variations in implementation constraints such as personnel and facilities suggesting a range of per-student costs (lower-bound per-student cost = $34; upper-bound per-student cost = $64). Findings presented herein may be used to inform future universal CSA prevention efforts by providing detailed information about the costs of large-scale implementation of an evidence-based program among elementary-aged children.

Which Children are Frequently Victimized in U.S. Elementary Schools? Population-based Estimates.

We analyzed a population-based cohort of 11,780 U.S. kindergarten children to identify risk and protective factors predictive of frequent verbal, social, reputational, and/or physical bullying victimization during the upper elementary grades. We also stratified the analyses by biological sex. Both girls and boys displaying kindergarten externalizing problem behaviors were at consistently higher risk of frequent victimization during 3rd-5th grade (for the combined sample of boys and girls, verbal odds ratio [OR] = 1.82, social OR = 1.60, reputational OR = 1.85, physical OR = 1.67, total OR = 1.93). Hispanic children relative to non-Hispanic White children and those from higher income families were the most strongly and consistently protected from victimization. Boys were more likely to be physically bullied but less likely to be verbally, socially or reputationally bullied than girls. Other variables including disability, cognitively stimulating parenting, academic achievement, and internalizing behavior problems had statistically significant but less consistent and generally weaker relations with frequent victimization.

Risk and Protective Factors for Frequent Electronic Device Use of Online Technologies.

A sample of 10,460 U.S. elementary schoolchildren was analyzed to identify early predictors of frequent use of online technologies (i.e., messaging, online gaming, and social networking). Children (Mage  = 67.44 months) at greater risk displayed more externalizing problem behaviors in kindergarten (messaging OR = 1.11; online gaming OR = 1.21; social networking OR = 1.12) or were Black (messaging OR = 1.65; online gaming OR = 1.64; social networking OR = 1.68). Children from higher-income families were at lower risk (online gaming OR = 0.89; social networking OR = 0.89). Boys were more frequent users of online gaming (OR = 3.35) but less frequent users of messaging (OR = 0.62) and social networking (OR = 0.80). Protective factors included specific parenting behaviors.

The opioid epidemic, neonatal abstinence syndrome, and estimated costs for special education services.

Children whose mothers used or misused opioids during their pregnancies are at an increased risk of exhibiting cognitive or behavioral impairments in the future, which may result in identifiable disabilities that require special education services in school. The costs associated with these additional educational services, however, have remained unknown. Using data from available empirical work, we calculated a preliminary set of cost estimates of special education and related services for children diagnosed with neonatal abstinence syndrome (NAS). We estimated these costs for a single cohort of children from the Commonwealth of Pennsylvania with a diagnosis of NAS. The resulting cost estimates were $16,506,916 (2017 US$) in total educational services provisions, with $8,253,458 (2017 US$) of these costs attributable to the additional provision of special education services. This estimate includes both opioid use during pregnancy that was linked to NAS in general and NAS that resulted specifically from prescription opioid use. We estimate the total annual education costs for children born in Pennsylvania with NAS associated with maternal use of prescription opioids to be $1,012,506 (2017 US$). Of these costs, we estimate that $506,253 (2017 US$) are attributable to the additional provision of special education services. We detail the calculation of these cost estimates and provide an expanded set of estimates for additional years of special education services (3-year, 5-year, and 13-year, or the K-12 educational time frame). We conclude with a discussion of limitations and suggestions for future work.

Are students with disabilities suspended more frequently than otherwise similar students without disabilities?

Students with disabilities (SWD) have been reported to be disproportionately suspended from U.S. schools and so more likely to experience the "school-to-prison pipeline" through suspension's associations with lower academic achievement, dropout, juvenile delinquency, and adult criminality. Yet few studies have estimated SWD's risk of more frequent suspension while simultaneously controlling for potential confounds. Negative binomial regression modeling of suspension count data from a nationally representative and longitudinal sample (N = 6,740) indicated that males, those from lower resourced families, and students attending more economically segregated schools were more frequently suspended. On average, students who are Black received about 1.6 times as many suspensions by the end of 8th grade as otherwise similar White students. In contrast, having a disability by 1st grade was not a risk factor for more frequent suspension by the end of 8th grade while simultaneously accounting for other risk factors (e.g., gender, race/ethnicity, family SES, prior history of externalizing problem behaviors, being from a English-speaking household, school-level economic composition). Students with specific disability conditions (e.g., emotional disturbances, speech or language impairments) were not at increased risk for more frequent suspension. Students with disabilities who are Black, Hispanic, or of other race/ethnicity were not more frequently suspended than SWD who are White.

Kindergarten Children's Executive Functions Predict Their Second-Grade Academic Achievement and Behavior.

Whether and to what extent kindergarten children's executive functions (EF) constitute promising targets of early intervention is currently unclear. This study examined whether kindergarten children's EF predicted their second-grade academic achievement and behavior. This was done using (a) a longitudinal and nationally representative sample (N = 8,920, Mage  = 97.6 months), (b) multiple measures of EF, academic achievement, and behavior, and (c) extensive statistical control including for domain-specific and domain-general lagged dependent variables. All three measures of EF-working memory, cognitive flexibility, and inhibitory control-positively and significantly predicted reading, mathematics, and science achievement. In addition, inhibitory control negatively predicted both externalizing and internalizing problem behaviors. Children's EF constitute promising targets of experimentally evaluated interventions for increasing academic and behavioral functioning.

Eight-Year Latent Class Trajectories of Academic and Social Functioning in Children with Attention-Deficit/Hyperactivity Disorder.

We examined trajectories of academic and social functioning in children with attention-deficit/hyperactivity disorder (ADHD) to identify those who might be at risk for especially severe levels of academic and social impairment over time. We estimated a series of growth mixture models using data from two subsamples of children participating in the NIMH Collaborative Multisite Multimodal Treatment Study of Children with ADHD (MTA) including those with at least baseline and 96-month data for reading and mathematics achievement (n = 392; 77.3% male; M age = 7.7; SD = 0.8) or social skills ratings from teachers (n = 259; 74.9% male; M age = 7.6; SD = 0.8). We compared latent trajectories for children with ADHD to mean observed trajectories obtained from a local normative (i.e., non-ADHD) comparison group (n = 289; 80.6% male; M age = 9.9; SD = 1.1). Results indicated six latent trajectory classes for reading and mathematics and four classes for teacher social skills ratings. There was not only a relationship between trajectories of inattention symptoms and academic impairment, but also a similarly strong association between trajectory classes of hyperactive-impulsive symptoms and achievement. Trajectory class membership correlated with socio-demographic and diagnostic characteristics, inattention and hyperactive-impulsive symptom trajectories, externalizing behavior in school, and treatment receipt and dosage. Although children with ADHD display substantial heterogeneity in their reading, math, and social skills growth trajectories, those with behavioral and socio-demographic disadvantages are especially likely to display severe levels of academic and social impairment over time. Evidence-based early screening and intervention that directly address academic and social impairments in elementary school-aged children with ADHD are warranted. The ClinicalTrials.gov identifier is NCT00000388.

Opportunities and challenges in screening for childhood sexual abuse.

Retrospective studies suggest 1 in 4 girls and 1 in 6 boys will experience sexual abuse before 18 years of age, resulting in future morbidity. Successful interventions exist, however, victims are reluctant to disclose. Screening for childhood sexual abuse (CSA) may provide an opportunity to overcome this barrier, yet no current model for universal CSA screening exists. We sought to understand the perspective of key stakeholders on CSA screening through qualitative research. Eight focus groups of 7-10 participants each (n=62) were conducted from April-September 2016. Stakeholders included school nurses, school teachers, counselors and administrators, pediatric providers, and parents. The interview guide focused on reporting suspected CSA and impressions of a CSA screening tool. Sessions were audiotaped and transcribed. Researchers used qualitative content analysis to develop conceptual categories that related to CSA screening and reporting. Two research team members independently open-coded 20% of the data for interrater reliability (kappa=0.98) prior to completing the coding process. Three major categories emerged to inform CSA screening. First, early screening (e.g. kindergarten) was preferred. Confidentiality was a concern, specifically privacy in the school-setting. As CSA perpetrators are often known to the child, parental presence in the medical office was also a concern. Finally, refinement of the screening process was discussed starting with routine education on safe touch and defining "normal." Rather than direct questioning, consistent and repeated offering of opportunities to disclose CSA and identification of a trusted adult were suggested. Next steps should involve partnering with evidence-based CSA prevention programs to incorporate and evaluate the aforementioned elements.

Executive Functioning Deficits Increase Kindergarten Children's Risk for Reading and Mathematics Difficulties in First Grade.

Whether executive functioning deficits result in children experiencing learning difficulties is presently unclear. Yet evidence for these hypothesized causal relations has many implications for early intervention design and delivery. We used a multi-year panel design, multiple criterion and predictor variable measures, extensive statistical control for potential confounds including autoregressive prior histories of both reading and mathematics difficulties, and additional epidemiological methods to preliminarily examine these hypothesized relations. Results from multivariate logistic regression analyses of a nationally representative and longitudinal sample of 18,080 children (i.e., the Early Childhood Longitudinal Study-Kindergarten Cohort of 2011, or ECLS-K: 2011) indicated that working memory and, separately, cognitive flexibility deficits uniquely increased kindergarten children's risk of experiencing reading as well as mathematics difficulties in first grade. The risks associated with working memory deficits were particularly strong. Experimentally-evaluated, multi-component interventions designed to help young children with reading or mathematics difficulties may also need to remediate early deficits in executive function, particularly in working memory.

Academic and Social Functioning Associated with Attention-Deficit/Hyperactivity Disorder: Latent Class Analyses of Trajectories from Kindergarten to Fifth Grade.

Children with attention-deficit/hyperactivity disorder (ADHD) are known to exhibit significantly lower academic and social functioning than other children. Yet the field currently lacks knowledge about specific impairment trajectories experienced by children with ADHD, which may constrain early screening and intervention effectiveness. Data were analyzed from a nationally representative U.S. cohort in the Early Childhood Longitudinal Study, Kindergarten Class of 1998-1999 (ECLS-K) for 590 children (72.7 % male) whose parents reported a formal diagnosis of ADHD. Children's math, reading, and interpersonal skills were assessed at 5 time points between kindergarten and fifth grade. Growth mixture model analyses indicated 4 latent trajectory classes for reading, 8 classes for math, and 4 classes for interpersonal skills. Membership in reading and math trajectory classes was strongly related; overlaps with interpersonal skills classes were weaker. Trajectory class membership was correlated with demographic characteristics and behavioral functioning. Children with ADHD display substantial heterogeneity in their reading, math, and interpersonal growth trajectories, with some groups of children especially likely to display relatively severe levels of academic and social impairment over time. Early screening and intervention to address impairment, particularly reading difficulties, among kindergarten students with ADHD is warranted.

Who Is At Risk for Persistent Mathematics Difficulties in the United States?

We analyzed two nationally representative, longitudinal data sets of U.S. children to identify risk factors for persistent mathematics difficulties (PMD). Results indicated that children from low socioeconomic households are at elevated risk of PMD at 48 and 60 months of age, as are children with cognitive delays, identified developmental delays or disabilities, and vocabulary difficulties. In contrast, children attending preschool either in Head Start or non-Head Start classrooms are at initially lower risk of PMD. Kindergarten-aged children experiencing either low socioeconomic status or mathematics difficulties are at greatest risk for PMD across third, fifth, and eighth grades. Also at risk for PMD between third and eighth grades are children displaying reading difficulties or inattention and other learning-related behaviors problems, children with identified disabilities, and those who are retained. Educationally relevant and potentially malleable factors for decreasing young children's risk for PMD may include increasing children's access to preschool, decreasing their risk of experiencing vocabulary or reading difficulties, and avoiding use of grade retention.

Which kindergarten children are at greatest risk for attention-deficit/hyperactivity and conduct disorder symptomatology as adolescents?

We sought to identify which kindergarten children are simultaneously at risk of moderate or severe symptomatology in both attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) as adolescents. These risk factor estimates have not been previously available. We conducted multinomial logistic regression analyses of multiinformant ratings by the end of middle school of a population-based, longitudinal sample of children followed from kindergarten to eighth grade (N = 7,456). Kindergarten children from low SES households, those raised by mothers with depressive symptoms or experiencing emotional problems or substance abuse, or those who were punished by spanking were significantly more likely to later display severe levels of ADHD-CD symptomatology in eighth grade. Kindergarten children frequently engaging in ADHD-CD-type behaviors were more likely to later experience both moderate (covariate adjusted OR = 2.37) and severe (covariate adjusted OR = 3.63) ADHD-CD symptomatology. Low academic achievement uniquely increased the risk of both moderate and severe symptomatology (adjusted OR range = 1.7 to 2.24). The results should guide early screening and school-based intervention efforts for ADHD-CD. Reducing children's risk for adolescent ADHD-CD symptomatology may require remediating low behavioral and academic functioning by the end of kindergarten. When these 2 modifiable factors occur together they increase kindergarten children's odds of experiencing severe ADHD-CD symptomatology in eighth grade by a multiplicative factor of 8.1.