Correlates of clinic referral for early conduct problems: variable- and person-oriented approaches.

The current study utilized both variable- and person-oriented analyses to examine correlates of early disruptive behavior problems. Participants included 80 preschool boys referred to a child psychiatry clinic and diagnosed with oppositional defiant disorder (with or without attention-deficit hyperactivity disorder) and 80 case-matched normal comparison boys. The study examined four domains of correlates: vulnerable child characteristics, poor parenting practices, insecure attachment, and adverse family ecology. Results indicated that the combination of these factors provided relatively high sensitivity (81%) and specificity (85%), clearly differentiating referred from comparison boys. A dramatic increase in clinic status occurred when three or more factors were present, and specific combinations of factors were differentially predictive of conduct problems. However, no correlates were found to be either necessary or sufficient for clinic status. By maintaining the integrity of individual cases, person-oriented analyses were able to answer different questions than more traditional variable-oriented analyses. Discussion focuses on the value of person-oriented analyses for understanding heterogeneous clinical groups.

Social-cognitive processes in preschool boys with and without oppositional defiant disorder.

The social-cognitive characteristics of 88 preschool boys with Oppositional Defiant Disorder (ODD) and 80 nondisruptive boys were assessed 3 times over a 2-year period. Three questions were addressed: (1) Do social-cognitive processes (encoding, attribution, problem solving, and response evaluation) distinguish clinic-referred preschool boys from peers without behavior problems? (2) What is the relation between preschoolers' social-cognitive processes and observed problem behavior? (3) Are the social-cognitive processes of clinic boys with ODD influenced by comorbidity with Attention Deficit Hyperactivity Disorder (ADHD)? Boys were presented hypothetical, peer-oriented social dilemmas to resolve. At all 3 assessments, clinic boys were twice as likely as were comparison group boys to generate aggressive solutions. Relative to comparison boys, clinic boys' encoding of social information was less accurate. The groups did not differ in their attributions or response evaluations. Verbal IQ and language skills were modestly correlated with problem solving and encoding. Within the clinic group, social-cognitive processes were not affected by ADHD comorbidity and they showed little relation to later diagnostic status or severity of behavior problems.

Are infants with orofacial clefts at risk for insecure mother-child attachments?

OBJECTIVE: Several risk factors in the early lives of children with clefts are believed to interfere with their development of secure attachments to parents; however, this possibility has rarely been studied empirically. This study compared 12- and 24-month attachment classifications of infants with cleft palate (CP), infants with cleft lip and palate (CLP), and a comparison group of unimpaired infants (COMP). METHOD: Twenty-two CP infants, 24 CLP infants, and 61 matched COMP infants were assessed at 12 and 24 months of age in an urban children's hospital. At both visits, mothers and infants participated in the Strange Situation, which was videotaped and subsequently coded for patterns of attachment behavior. RESULTS: CP infants displayed a lower rate of 12-month attachment security than infants in the CLP or COMP groups. By 24 months, no diagnostic group differences in attachment classification were found. Stable 12- to 24-month attachment classifications were less likely in the CP group (36.3%) than in the COMP (62.3%) group. CP infants who were insecure at 12 months were more likely to become secure by 24 months than were CLP or COMP group infants. CONCLUSIONS: In contrast to previous theory and clinical speculation, the facial appearance of infants with CLP does not appear to affect the early mother-infant relationship adversely. The infancy period is marked by attachment instability for infants with CP, who demonstrated lower-than-expected rates of security at 12 months. However, these problems resolved in nearly all cases by 24 months of age. Most infants with clefts emerged from the first 2 years of life with secure maternal attachments.

Preschool boys with oppositional defiant disorder: clinical presentation and diagnostic change.

OBJECTIVE: Little is known about the clinical presentation and course of oppositional defiant disorder (ODD) when first diagnosed in the preschool years. Patterns of ODD symptomatology, comorbidity, persistence of disorder, and predictors of diagnostic outcome were examined in clinic-referred preschool boys. METHOD: Boys (aged 4-5.5 years) with a DSM-III-R diagnosis of ODD were prospectively followed over a 2-year period. Multiple assessment procedures were used, including a modified version of the Diagnostic Interview Schedule for Children and parent and teacher ratings. RESULTS: Ninety-two boys (mean age 56.9 months) with ODD were followed; 42 had comorbid attention-deficit hyperactivity disorder (ADHD). Among 79 boys assessed 2 years later, 76% had ODD, ADHD, or both. Of those, 25% had other diagnoses as well, primarily anxiety and/or mood disorders. Conduct disorder was rare. Subjects with comorbid ODD/ADHD at intake were significantly more likely to have a psychiatric disorder at follow-up, especially ADHD alone. CONCLUSIONS: The findings suggest that ODD in the preschool period is a clear indicator of high risk, especially when co-occurring with ADHD. Further investigation of individual patterns of ODD symptom expression is recommended.

Attachment in boys with early onset conduct problems.

Few studies have examined the association between attachment and psychopathology in samples of clinically diagnosed children or the relation between attachment variables and the continuity of clinical symptoms. Clinic-referred preschool boys (n = 80) with early onset conduct problems (as indicated by diagnoses of Oppositional Defiant Disorder) were compared with a case-matched group of 80 nonproblem boys to determine whether observed attachment behaviors could: (a) differentiate the groups, (b) explain concurrent variation in problem severity within the clinic group, and (c) predict the outcomes of clinic boys 1 and 2 years later. Over half of the clinic boys with early onset conduct problems (54%) exhibited an insecure attachment strategy during reunion, as opposed to 18% of comparison group boys. All insecure patterns were overrepresented in the clinic group. Clinic boys were more likely than comparison boys to engage in provocative behavior when separated from their mothers. Contrary to our hypothesis, attachment variables showed little ability to explain concurrent or future variation in the problem severity or diagnostic status of clinic boys. We conclude that observable attachment behaviors exhibited during the preschool years are related to the initial identification of early onset conduct problems but may have little value by themselves in predicting the subsequent course and severity of problems in the 2 years following clinic referral.

Fathers and preschool behavior problems.

Fathers have seldom been the focus of research investigating the causes and correlates of early behavior problems. Two studies examined fathers of preschool boys with and without clinic-referred behavior problems. Six domains of risk were examined: life stress, social support, psychological symptoms, parenting attitudes, positive involvement, and harsh discipline. Clinic fathers differed from fathers of matched comparison boys with respect to all of these except social support, but only harsh discipline contributed uniquely to clinic status. These domains correctly classified 81% of the boys. Within the clinic group, teacher-rated problem severity 1 year later was predicted by fathers' life stress, psychological symptoms, and positive involvement, indicating that different factors may account for initial clinic status versus stability of problems. Mothers' self-report data better predicted clinic group membership, whereas fathers' data better predicted Year 2 outcomes for clinic boys.

Early-Onset Oppositional Defiant Disorder: What Factors Predict Its Course?

Although the early onset of Oppositional Defiant Disorder (ODD) is associated with an elevated risk of later psychopathology (including but not limited to conduct disorder and antisocial personality disorder), little is known about the factors influencing the course of this disorder in early life. In this article we first review data and theory from four conceptually-distinct domains of risk factors for disruptive disorders (child characteristics reflecting biologic vulnerabilities, parent-child attachment, parenting practices, and family adversity). Then we describe an empirical study that examined the power of these four domains (representing 10 specific risk factors) to predict the prognosis of clinic-referred, preschool boys with ODD; risk factors were assessed when these youngsters were first evaluated in the clinic and outcomes were measured 2 years later. The primary goal was to determine the unique importance of risk factors in the context of others examined simultaneously, a strategy that few previous studies have used. We found that the four-factor risk model predicted significant variance in mother's reports of externalizing (disruptive) behavior problems at the 2-year follow-up; however, the model did not predict teacher externalizing scores or clinicians' assessments of Diagnostic and Statistical Manual (DSM) disorders, as hypothesized. Analyses of specific factors within domains suggested that three were most consistently related to the negative outcomes of ODD boys: greater use of physical discipline by parents, greater life stress for families, and a greater number of pre- and perinatal complications. Nearly a third of the variance in mothers' reports of internalizing (inhibited) problems was attributable to two of these risk factors (life events stress and birth history) and to a third factor, delayed child development.

Fathering and early onset conduct problems: positive and negative parenting, father-son attachment, and the marital context.

Research literature linking negative and positive aspects of the father-child relationship with early onset conduct problems is reviewed. Evidence from the Preschool Families Project, a longitudinal study of clinic-referred preschool boys at risk for conduct disorder, is presented, including previously unpublished data on father-child attachment. Both negative (e.g., harsh, angry, and physically punitive) and positive (involvement, warmth, and secure attachment) dimensions of fathering, as well as aspects of the marital relationship, appear to be associated with the emergence of early onset conduct problems.

Observed family interaction during clinical interviews: a comparison of families containing preschool boys with and without disruptive behavior.

The clinical intake interview is an opportunity to observe family interactions and formulate hypotheses about their influence on presenting problems. In this study family interactions were assessed during an unstructured segment of a clinical intake. Families with disruptive preschool boys were compared with those having nonproblem boys. Mother's and fathers' reports of marital satisfaction, parenting involvement, and child behavior problems were examined in relation to observed behavior during intake. Patterns of family interaction emerged which were consistent with previous research and with family systems theory. Clinic boys oriented more toward mothers than fathers and interacted more negatively with their fathers than did comparison boys. Implications for integrating the assessment of family interactions into clinical practice and research with behavior problem children are discussed.

Disruptive behavior disorder and intergenerational attachment patterns: a comparison of clinic-referred and normally functioning preschoolers and their mothers.

This study examined linkages between child disruptive behavior disorder (DBD), quality of mother-child interactions, and mothers' recollections of and attitudes toward their own parents. Twenty-five preschool boys referred to a psychiatric clinic were matched with normally functioning boys. Mothers and sons were videotaped during a separation-reunion sequence, the Adult Attachment Interview was administered to mothers, and mothers completed questionnaires assessing family environment. Mothers of boys with DBD described relationships with their own parents less coherently than comparison mothers did, indicating less secure representations of attachment. Maternal and child attachment classifications were concordant. Log-linear analyses suggested that the influence of maternal representation of attachment on disruptive behavior problems was secondary to the quality of mother-child interaction.

Clinic referral for oppositional defiant disorder: relative significance of attachment and behavioral variables.

Attachment classifications have been found to distinguish clinic-referred, oppositional preschool boys from controls, but there has been no previous effort to examine the relative contribution of attachment when behaviors from a social learning perspective are also considered. The present study examined the contribution of attachment and behavioral variables to the prediction of clinic referral for oppositional defiant disorder in a sample of preschool boys. We hypothesized that the attachment measures would offer better discrimination of clinic and control group boys at this age. This hypothesis was confirmed when the attachment measures were compared with the parent-child behaviors most strongly associated with social learning conceptualizations of disruptive problems (maternal commands and criticism, and child noncompliance), but rejected in a more stringent test in which the attachment measures were compared with the behavioral variables distinguishing the groups in this particular sample.

Relationship between behavioral marital therapy outcome and process variables.

This study was conducted to identify therapist and client behaviors associated with a positive response to social learning-based behavioral marital therapy. A sample of 32 couples receiving treatment was examined. Immediately after each therapy session, the therapist, husband, and wife independently completed process rating forms that measured therapist and client behaviors during the session. Composite scales, derived from these ratings, were entered into multiple regression equations to examine their relationship with posttherapy marital satisfaction. After controlling for pretherapy marital satisfaction and the other predictor variables, therapists', husbands', and wives' ratings of positive client behavior (i.e., collaboration, active participation, and homework compliance) were positively associated with therapy outcome. Implications for marital therapy and suggestions for future research are discussed.