Testing Robustness of Child STEPs Effects with Children and Adolescents: A Randomized Controlled Effectiveness Trial.

A critical task in psychotherapy research is identifying the conditions within which treatment benefits can be replicated and outside of which those benefits are reduced. We tested the robustness of beneficial effects found in two previous trials of the modular Child STEPs treatment program for youth anxiety, depression, trauma, and conduct problems. We conducted a randomized trial, with two significant methodological changes from previous trials: (a) shifting from cluster- to person-level randomization, and (b) shifting from individual to more clinically feasible group-based consultation with STEPs therapists. Fifty community clinicians from multiple outpatient clinics were randomly assigned to receive training and consultation in STEPs (n= 25) or to provide usual care (UC; n= 25). There were 156 referred youths-ages 6-16 (M= 10.52, SD = 2.53); 48.1% male; 79.5% Caucasian, 12.8% multiracial, 4.5% Black, 1.9% Latino, 1.3% Other-who were randomized to STEPs (n= 77) or UC (n= 79). Following previous STEPs trials, outcome measures included parent- and youth-reported internalizing, externalizing, total, and idiographic top problems, with repeated measures collected weekly during treatment and longer term over 2 years. Participants in both groups showed statistically significant improvement on all measures, leading to clinically meaningful problem reductions. However, in contrast to previous trials, STEPs was not superior to UC on any measure. As with virtually all treatments, the benefits of STEPs may depend on the conditions-for example, of study design and implementation support-in which it is tested. Identifying those conditions may help guide appropriate use of STEPs, and other treatments, in the future.

Counselor-Level Predictors of Sustained Use of an Indicated Preventive Intervention for Aggressive Children.

Despite widespread concern about the frequent failure of trained prevention staff to continue to use evidence-based programs following periods of intensive training, little research has addressed the characteristics and experiences of counselors that might predict their sustained use of a program. The current study follows a sample of school counselors who were trained to use an indicated preventive intervention, the Coping Power program, in an earlier dissemination study, and determines their levels of continued use of the program's child and parent components in the 2 years following the counselors' intensive training in the program. Counselor characteristics and experiences were also examined as predictors of their sustained use of the program components. The Coping Power program addresses children's emotional regulation, social cognitive processes, and increases in positive interpersonal behaviors with at-risk children who have been screened to have moderate to high levels of aggressive behavior. The results indicated that counselors' perceptions of interpersonal support from teachers within their schools, their perceptions of the effectiveness of the program, and their expectations for using the program were all predictive of program use over the following 2 years. In addition, certain counselor personality characteristics (i.e., conscientiousness) and the level of actual teacher-rated behavior change experienced by the children they worked with during training were predictors of counselors' use of the program during the second year after training. These results indicate the central importance of teacher support and of child progress during training in the prediction of counselors' sustained use of a prevention program.

A school-based post-Katrina therapeutic intervention.

The current study presents the implementation of a set of school based interventions in a greater New Orleans school district one year following Hurricane Katrina. The interventions included adaptation and implementation of evidence based treatments in a crisis situation with at-risk youth which involved training and clinical challenges. 386 students found to have significant depressive and/or disruptive disorder symptoms received treatment from the School Therapeutic Enhancement Program (STEP). Further, a district-wide mental health needs assessment of middle and high school students (N = 11,861) screened for behavioral and emotional difficulties at the beginning and end of the school year provided a benchmark for community youth's emotional and behavioral distress. High-need intervention students demonstrated clinically significant lower levels of emotional and behavioral problems, depression and inattention in comparison to pre-treatment levels as indicated by multiple informants (i.e., self, parent, teacher). Self-reported distress levels were also lower than screening group students at post-test. These findings support the efficacy of a school-based intervention for youth struggling with the aftereffects of a highly disruptive natural disaster. Implications for utilizing a flexible adaptation of an evidence-based training model involving coaching and consultation are discussed.

Three year follow-up of coping power intervention effects: evidence of neighborhood moderation?

The Coping Power program is an indicated prevention program for at-risk aggressive preadolescent children, and has had demonstrated short-term effects on antisocial outcomes. This study provided a longer-term 3-year follow-up for a sample of 245 fourth grade children who had been randomly assigned to Coping Power or to a care-as-usual Comparison condition. Intervention took place during the fifth and sixth grade years, at the time of transition to middle school. Growth curve analyses indicate that Coping Power had linear effects through the 3 years after the end of intervention on reductions in children's aggressive behavior and academic behavior problems, children's expectations that aggression would lead to positive outcomes, and parents' lack of supportiveness with their children. Participants' homes were geocoded into census tracts, and neighborhood qualities which may have moderated outcomes involved neighborhood disadvantage based on census tract information, and parent-reported social organization of neighborhoods. There was limited support for the hypothesis that intervention effects would be greater in less problematic neighborhoods. Intervention produced the greatest improvement in parental supportiveness for families living in communities with less neighborhood disadvantage, but there were no similar effects for the behavioral and social cognitive outcomes, or in analyses using neighborhood social organization as a moderator. Counter the hypothesis, intervention produced the greatest reduction in children's aggression in neighborhoods characterized by poor social organization.

Adaptive Treatment for Youth With Substance Use and Depression: Early Depression Response and Short-term Outcomes.

OBJECTIVE: To investigate prevalence and predictors of early depression response (EDR) in adolescents with substance use and depression receiving cognitive-behavioral therapy (CBT) for substance use and to test the efficacy of supplemental CBT targeting depression (CBT-D) for non-EDR adolescents in an adaptive treatment approach. METHOD: At 2 sites, 95 youths (ages 14-21, mean [SD] = 17.4 [1.8]) with alcohol or cannabis use and depressive symptoms received up to 12 sessions of CBT for substance use over 14 weeks. Assessments were at baseline and weeks 4, 9, and 14. The Children's Depression Rating Scale-Revised was the primary depression measure, with a reduction of 50% or more on this scale at week 4 defining EDR. The primary substance use outcomes of alcohol use, heavy alcohol use, and cannabis use frequency were assessed via interview report on the Alcohol Consumption Questionnaire and the Drug Checklist. Urinalysis provided a secondary measure of cannabis use. Non-EDR adolescents were randomly assigned to supplemental CBT-D or enhanced treatment as usual (ETAU). RESULTS: Thirty-five adolescents (37%; 95% CI, 27%-47%) demonstrated EDR. Fewer days of cannabis use (odds ratio 0.977; 95% CI, 0.961-0.992) and absence of conduct disorder (odds ratio 0.149; 95% CI, 0.031-0.716) predicted EDR. Frequency of drinking (F1,82 = 11.09, η2 = 0.119, p = .001), heavy drinking (F1,82 = 19.91, η2 = 0.195, p < .0001), and cannabis use (F1,220 = 35.01, η2 = 0.137, p < .001) decreased over time for EDR, CBT-D, and ETAU adolescents, with EDR adolescents evidencing earlier lower cannabis use (F2,220 = 4.16, η2 = 0.036, p = .0169). Negative (clean) urine screens increased over time (F1,219 = 5.10, η2 = 0.023, p = .0249). Comparison of CBT-D and ETAU indicated that depression significantly decreased over time in both groups (F1,48 = 64.20, η2 = 0.572, p < .001), with no advantage for CBT-D. CONCLUSION: Approximately one-third of adolescents with substance use and depression attain EDR during substance use treatment. Less frequent cannabis use facilitates depression response. The relatively small sample may have precluded identification of additional EDR predictors. CLINICAL TRIAL REGISTRATION INFORMATION: Treatment for Teens With Alcohol Abuse and Depression; https://clinicaltrials.gov/; NCT02227589.

Feasibility of an Integrated Treatment Approach for Youth with Depression, Suicide Attempts, and Substance Use Problems.

Depression, suicidal behaviors and substance use problems frequently co-occur, and treatment for youth with these co-occurring problems is often fragmented and challenging. An integrated cognitive-behavioral treatment approach that builds upon a relapse prevention framework and applies common core skills, language, and approach for treating these related problems may be clinically beneficial. Following a description of the integrated approach, we present results of a pilot trial (n = 13) to examine the acceptability and feasibility of the Cognitive-Behavioral Therapy - Relapse Prevention (CBT-RP) intervention plus enhanced treatment as usual (TAU) compared to enhanced TAU alone. The feasibility of the CBT-RP + TAU intervention was reflected by high rates of retention (86%). The acceptability was reflected in positive evaluations regarding the helpfulness of the intervention by adolescents and families. The majority of youth in both CBT-RP + TAU and TAU alone groups evidenced reductions in depression and suicide ideation from study entry to Week 20. Patterns of reduction were more consistent, however, for youth receiving CBT-RP + TAU, and reductions were slower to emerge for some youth receiving TAU alone. Reductions in alcohol and marijuana problems were similar, but half of the youth in TAU alone (and none in the CBT-RP + TAU group) had emergency department visits related to psychiatric crises or substance related problems. These findings, although based on a small sample, underscore the feasibility and acceptability of an integrated cognitive-behavioral relapse prevention approach for youth with depression, suicide attempt histories, and substance use problems.

Parent-reported homework problems in the MTA study: evidence for sustained improvement with behavioral treatment.

Parent-report of child homework problems was examined as a treatment outcome variable in the MTA-Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (ADHD). Five hundred seventy-nine children ages 7.0 to 9.9 were randomly assigned to either medication management, behavioral treatment, combination treatment, or routine community care. Results showed that only participants who received behavioral treatment (behavioral and combined treatment) demonstrated sustained improvements in homework problems in comparison to routine community care. The magnitude of the sustained effect at the 10-month follow-up assessment was small to moderate for combined and behavioral treatment over routine community care (d = .37, .40, respectively). Parent ratings of initial ADHD symptom severity was the only variable found to moderate these effects.

An exploratory analysis of the impact of family functioning on treatment for depression in adolescents.

This article explores aspects of family environment and parent-child conflict that may predict or moderate response to acute treatments among depressed adolescents (N = 439) randomly assigned to fluoxetine, cognitive behavioral therapy, their combination, or placebo. Outcomes were Week 12 scores on measures of depression and global impairment. Of 20 candidate variables, one predictor emerged: Across treatments, adolescents with mothers who reported less parent-child conflict were more likely to benefit than their counterparts. When family functioning moderated outcome, adolescents who endorsed more negative environments were more likely to benefit from fluoxetine. Similarly, when moderating effects were seen on cognitive behavioral therapy conditions, they were in the direction of being less effective among teens reporting poorer family environments.

The relation between childhood proactive and reactive aggression and substance use initiation.

The current study examined whether proactive and reactive aggression were associated with the risk for initiation of substance use from fourth to ninth grade in a sample of 126 aggressive children (66% male). In addition, the study examined whether these functions of aggression increased risk for initiation via peer delinquency and peer rejection. Proactive aggression was marginally significantly directly associated with risk for initiation of alcohol use and indirectly associated with risk for initiation of marijuana and tobacco use through peer delinquency. Reactive aggression was associated with increased risk for initiation of tobacco and marijuana use through a complex chain that included both peer rejection and peer delinquency. However, high levels of reactive aggression that did not lead to peer rejection were negatively associated with risk for initiation of tobacco and marijuana use. Implications for intervention are discussed.

Developmental trajectories of proactive and reactive aggression from fifth to ninth grade.

This study examined the developmental trajectories of proactive and reactive aggression from 5th to 9th grade in a sample of 126 children (66% male) screened to be in the top 31% on a measure of aggression. Prospective relations between proactive and reactive aggression and delinquency were also examined. Findings suggested that levels of both proactive and reactive aggression peaked in the 6th grade and declined thereafter. Delinquency was stable from 5th to 9th grade. Neither change in proactive nor reactive aggression were associated with overall levels of delinquency from 5th to 9th grade. However, 1-year cross-lagged paths indicated that proactive aggression predicted increases in delinquency, not vice versa.

How Substance Users With ADHD Perceive the Relationship Between Substance Use and Emotional Functioning.

OBJECTIVE: Although substance use (SU) is elevated in ADHD and both are associated with disrupted emotional functioning, little is known about how emotions and SU interact in ADHD. We used a mixed qualitative-quantitative approach to explore this relationship. METHOD: Narrative comments were coded for 67 persistent (50 ADHD, 17 local normative comparison group [LNCG]) and 25 desistent (20 ADHD, 5 LNCG) substance users from the Multimodal Treatment Study of Children with ADHD (MTA) adult follow-up (21.7-26.7 years-old). RESULTS: SU persisters perceived SU positively affects emotional states and positive emotional effects outweigh negative effects. No ADHD group effects emerged. Qualitative analysis identified perceptions that cannabis enhanced positive mood for ADHD and LNCG SU persisters, and improved negative mood and ADHD for ADHD SU persisters. CONCLUSION: Perceptions about SU broadly and mood do not differentiate ADHD and non-ADHD SU persisters. However, perceptions that cannabis is therapeutic may inform ADHD-related risk for cannabis use.

3-year follow-up of the NIMH MTA study.

OBJECTIVE: In the intent-to-treat analysis of the Multimodal Treatment Study of Children With ADHD (MTA), the effects of medication management (MedMgt), behavior therapy (Beh), their combination (Comb), and usual community care (CC) differed at 14 and 24 months due to superiority of treatments that used the MTA medication algorithm (Comb+MedMgt) over those that did not (Beh+CC). This report examines 36-month outcomes, 2 years after treatment by the study ended. METHOD: For primary outcome measures (attention-deficit/hyperactivity disorder [ADHD] and oppositional defiant disorder [ODD] symptoms, social skills, reading scores, impairment, and diagnostic status), mixed-effects regression models and orthogonal contrasts examined 36-month outcomes. RESULTS: At 3 years, 485 of the original 579 subjects (83.8%) participated in the follow-up, now at ages 10 to 13 years, (mean 11.9 years). In contrast to the significant advantage of MedMgt+Comb over Beh+CC for ADHD symptoms at 14 and 24 months, treatment groups did not differ significantly on any measure at 36 months. The percentage of children taking medication >50% of the time changed between 14 and 36 months across the initial treatment groups: Beh significantly increased (14% to 45%), MedMed+Comb significantly decreased (91% to 71%), and CC remained constant (60%-62%). Regardless of their treatment use changes, all of the groups showed symptom improvement over baseline. Notably, initial symptom severity, sex (male), comorbidity, public assistance, and parental psychopathology (ADHD) did not moderate children's 36-month treatment responses, but these factors predicted worse outcomes over 36 months, regardless of original treatment assignment. CONCLUSIONS: By 36 months, the earlier advantage of having had 14 months of the medication algorithm was no longer apparent, possibly due to age-related decline in ADHD symptoms, changes in medication management intensity, starting or stopping medications altogether, or other factors not yet evaluated.

Secondary evaluations of MTA 36-month outcomes: propensity score and growth mixture model analyses.

OBJECTIVE: To evaluate two hypotheses: that self-selection bias contributed to lack of medication advantage at the 36-month assessment of the Multimodal Treatment Study of Children With ADHD (MTA) and that overall improvement over time obscured treatment effects in subgroups with different outcome trajectories. METHOD: Propensity score analyses, using baseline characteristics and severity of attention-deficit/hyperactivity disorder symptoms at follow-up, established five subgroups (quintiles) based on tendency to take medication at the 36-month assessment. Growth mixture model (GMM) analyses were performed to identify subgroups (classes) with different patterns of outcome over time. RESULTS: All five propensity subgroups showed initial advantage of medication that disappeared by the 36-month assessment. GMM analyses identified heterogeneity of trajectories over time and three classes: class 1 (34% of the MTA sample) with initial small improvement followed by gradual improvement that produced significant medication effects; class 2 (52%) with initial large improvement maintained for 3 years and overrepresentation of cases treated with the MTA Medication Algorithm; and class 3 (14%) with initial large improvement followed by deterioration. CONCLUSIONS: We failed to confirm the self-selection hypothesis. We found suggestive evidence of residual but not current benefits of assigned medication in class 2 and small current benefits of actual treatment with medication in class 1.

Effects of stimulant medication on growth rates across 3 years in the MTA follow-up.

OBJECTIVE: To evaluate the hypothesis of stimulant medication effect on physical growth in the follow-up phase of the Multimodal Treatment Study of Children With ADHD. METHOD: Naturalistic subgroups were established based on patterns of treatment with stimulant medication at baseline, 14-, 24-, and 36-month assessments: not medicated (n = 65), newly medicated (n = 88), consistently medicated (n = 70), and inconsistently medicated (n = 147). Analysis of variance was used to evaluate effects of subgroup and assessment time on measures of relative size (z scores) obtained from growth norms. RESULTS: The subgroup x assessment time interaction was significant for z height (p <.005) and z weight (p <.0001), due primarily to divergence of the newly medicated and the not medicated subgroups. These initially stimulant-naïve subgroups had z scores significantly >0 at baseline. The newly medicated subgroup showed decreases in relative size that reached asymptotes by the 36-month assessment, when this group showed average growth of 2.0 cm and 2.7 kg less than the not medicated subgroup, which showed slight increases in relative size. CONCLUSIONS: Stimulant-naïve school-age children with Combined type attention-deficit/hyperactivity disorder were, as a group, larger than expected from norms before treatment but show stimulant-related decreases in growth rates after initiation of treatment, which appeared to reach asymptotes within 3 years without evidence of growth rebound.

Delinquent behavior and emerging substance use in the MTA at 36 months: prevalence, course, and treatment effects.

OBJECTIVE: To compare delinquent behavior and early substance use between the children in the Multimodal Treatment Study of Children With ADHD (MTA; N = 487) and those in a local normative comparison group (n = 272) at 24 and 36 months postrandomization and to test whether these outcomes were predicted by the randomly assigned treatments and subsequent self-selected prescribed medications. METHOD: Most MTA children were 11 to 13 years old by 36 months. Delinquency seriousness was coded ordinally from multiple measures/reporters; child-reported substance use was binary. RESULTS: Relative to local normative comparison group, MTA children had significantly higher rates of delinquency (e.g., 27.1% vs. 7.4% at 36 months; p = .000) and substance use (e.g., 17.4% vs. 7.8% at 36 months; p = .001). Children randomized to intensive behavior therapy reported less 24-month substance use than other MTA children (p = .02). Random effects ordinal growth models revealed no other effects of initial treatment assignment on delinquency seriousness or substance use. By 24 and 36 months, more days of prescribed medication were associated with more serious delinquency but not substance use. CONCLUSIONS: Cause-and-effect relationships between medication treatment and delinquency are unclear; the absence of associations between medication treatment and substance use needs to be re-evaluated at older ages. Findings underscore the need for continuous monitoring of these outcomes as children with attention-deficit/hyperactivity disorder enter adolescence.

Pathways from proactive and reactive aggression to substance use.

Childhood aggression is a known risk factor for adolescent substance use; however, aggression is a complex construct, and developmental researchers have identified a variety of subdimensions that may be germane to substance use. Very little research has examined risk pathways from subdimensions of aggression. The current study examined a developmental model and tested whether childhood proactive aggression, reactive aggression, or both were related to the development of substance use in adolescence in a sample of 126 children (mean age at initial assessment = 10.4 years, SD = 0.51). Peer rejection and peer delinquency were examined as potential mediators of these relations. The findings suggest that proactive aggression was indirectly associated with substance use through peer delinquency. Reactive aggression was also indirectly associated with substance use through a complex mediational chain, such that high levels of reactive aggression were associated with high levels of peer rejection, which in turn were associated with peer delinquency (p = .06), which subsequently predicted substance use.

Child and parent predictors of perceptions of parent--child relationship quality.

OBJECTIVE/METHOD: Predictors of perceptions of parent-child relationship quality were examined for 175 children with ADHD, 119 comparison children, and parents of these children, drawn from the follow-up phase of the Multimodal Treatment Study of Children with ADHD. RESULTS/CONCLUSION: Children with ADHD perceived their mothers and fathers as more power assertive than comparison children. Children higher on depressive symptomatology also perceived their mothers and fathers as less warm and more power assertive. Mothers perceived themselves as more power assertive and fathers perceived themselves as less warm if they were higher on depressive symptomatology themselves or had children with ADHD or higher levels of depressive symptomatology. Several interactions indicated that the association between child factors and parental perceptions of warmth and power assertion often depended on parental depressive symptomatology. The findings resolve a previous contradiction in the literature regarding the relationship between child depressive symptoms and parental perceptions of parent-child relationship quality.

Treatment-related changes in objectively measured parenting behaviors in the multimodal treatment study of children with attention-deficit/hyperactivity disorder.

The present study examined treatment outcomes for objectively measured parenting behavior in the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (ADHD). Five hundred seventy-nine ethnically and socioeconomically diverse children with ADHD-combined type (ages 7.0-9.9 years) and their parent(s) were recruited at 6 sites in the United States and Canada and randomly assigned to 1 of 4 treatment groups for 14 months of active intervention: medication management (MedMgt), intensive behavior therapy, combination of the 2 (Comb), or a community-treated comparison (CC). Baseline and posttreatment laboratory observations of parent-child interactions were coded by observers blind to treatment condition. Comb produced significantly greater improvements in constructive parenting than did MedMgt or CC, with effect sizes approaching medium for these contrasts. Treatment effects on child behaviors were not significant. The authors discuss the importance of changes in parenting behavior for families of children with ADHD and the need for reliable and objective measures in evaluating treatment outcome.

Parental aggression as a predictor of boys' hostile attribution across the transition to middle school.

Aggression among youth is public health problem that is often studied in the context of how youth interpret social information. Social cognitive factors, especially hostile attribution biases, have been identified as risk factors for the development of youth aggression, particularly across the transition to middle school. Parental behaviors, including parental aggression to children in the form of corporal punishment and other aggressive behavior, have also been linked to aggressive behavior in children at these ages. Despite the important role played by these two risk factors, the connection between the two has not been fully studied in the literature. This study examined the link between parental aggression and children' hostile attributions longitudinally among a diverse sample of 123 boys as they entered middle school. Results support acceptance of a model in which parental aggression to children prior to entering middle school predicted children's hostile attributions after the transition to middle school above and beyond that which was predicted by previous levels of hostile attributions. As expected, hostile attributions also predicted change in parent- and teacher-rated child aggression. These findings provides important evidence of the role that parental behavior plays in youth social cognition at this critical age, which has implications for understanding the development of aggressive behavior.

The influence of maternal stress and distress on disruptive behavior problems in boys.

OBJECTIVE: The current study examined how self-reported maternal stress and distress are associated with child disruptive behaviors. METHOD: Mother and teacher ratings of child disruptive behavior problems (attention problems, aggression, and delinquency) were collected for 215 male participants, ranging in age from 9 to 12 years. Participating mothers also provided self-report data on socioeconomic status (SES), parenting stress, and distress (depression and anxiety/somatization). RESULTS: Low SES was significantly associated with both mother- and teacher-reported child disruptive behavior problems. Regression analyses indicated a relation between parenting stress and mother-reported child disruptive behavior problems, even when controlling for SES. Results also indicated a significant relation between maternal distress and mother-reported child disruptive behavior problems (particularly attention problems), even when controlling for SES and parenting stress. Maternal stress and distress were not significantly related to teacher-reported child disruptive behavior problems. CONCLUSIONS: Although the lack of an association between teacher-reported behavior problems and maternal stress and distress could be interpreted as a rater bias by these mothers, it may be that the mothers' symptoms are associated with a stressful home environment, thus exacerbating child disruptive behavior problems and eventually leading to a reciprocal relation between symptomatology in mothers and children.