Optimizing Engagement in Behavioral Parent Training: Progress Toward a Technology-Enhanced Treatment Model

Low-income families are more likely to have a child with an early-onset Behavior Disorder (BD); yet, socioeconomic strain challenges engagement in Behavioral Parent Training (BPT). This study follows a promising pilot to further examine the potential to cost-effectively improve low-income families’ engagement in and the efficiency of BPT. Low-income families were randomized to (a) Helping the Noncompliant Child (HNC; McMahon & Forehand, 2003), a weekly, mastery-based BPT program that includes both the parent and child or (b) Technology-Enhanced HNC (TE-HNC), which includes all of the standard HNC components plus a parent mobile application and therapist web portal that provide between-session monitoring, modeling, and coaching of parent skill use with the goal of improved engagement in the context of financial strain. Relative to HNC, TE-HNC families had greater homework compliance and mid-week call participation. TE-HNC completers also required fewer weeks to achieve skill mastery and, in turn, to complete treatment than those in HNC without compromising parent satisfaction with treatment; yet, session attendance and completion were not different between groups. Future directions and clinical implications are discussed.     

Emotion knowledge as a predictor of social behavior and academic competence in children at risk

Following leads from differential emotions theory and empirical research, we evaluated an index of emotion knowledge as a long-term predictor of positive and negative social behavior and academic competence in a sample of children from economically disadvantaged families ( N = 72). The index of emotion knowledge represents the child's ability to recognize and label emotion expressions. We administered control and predictor measures when the children were 5 years old and obtained criterion data at age 9. After controlling for verbal ability and temperament, our index of emotion knowledge predicted aggregate indices of positive and negative social behavior and academic competence. Path analysis showed that emotion knowledge mediated the effect of verbal ability on academic competence. We argue that the ability to detect and label emotion cues facilitates positive social interactions and that a deficit in this ability contributes to behavioral and learning problems. Our findings have implications for primary prevention.     

Examining the Validity of Cyclothymic Disorder in a Youth Sample: Replication and Extension

DSM-IV-TR defines four subtypes of bipolar disorder (BP): bipolar I, bipolar II, cyclothymic disorder and bipolar not otherwise specified (NOS). However, cyclothymic disorder in children is rarely researched, or often subsumed in an “NOS” category. The present study tests the replicability of findings from an earlier study, and expands on the criterion validity of cyclothymic disorder in youth. Using the Robins and Guze (1970) framework we examined the validity of cyclothymic disorder as a subtype of BP. Using a youth (ages 5–17) outpatient clinical sample (N?=?894), participants with cyclothymic disorder (n?=?53) were compared to participants with other BP spectrum disorders (n?=?399) and to participants with non-bipolar disorders (n?=?442). Analyses tested differences in youth with cyclothymic disorder and bipolar disorder not otherwise specified who do, and those who do not, have a parent with BP. Compared to youth with non-bipolar disorders, youth with cyclothymic disorder had higher irritability (p?<?0.001), more comorbidity (p?<?0.001), greater sleep disturbance (p?<?0.005), and were more likely to have a family history of BP (p?<?0.001). Cyclothymic disorder was associated with a younger age of onset compared to depression (p?<?0.001) and bipolar II (p?=?0.05). Parental BP status was not significantly associated with any variables. Results support that cyclothymic disorder belongs on the bipolar spectrum. Epidemiological studies indicate that cyclothymic disorder is not uncommon and involves significant impairment. Failing to differentiate between cyclothymic disorder and bipolar NOS limits our knowledge about a significant proportion of cases of bipolarity.     

Structure and measurement of depression in youths: applying item response theory to clinical data

Our goals in this article were to use item response theory (IRT) to assess the relation of depressive symptoms to the underlying dimension of depression and to demonstrate how IRT-based measurement strategies can yield more reliable data about depression severity than conventional symptom counts. Participants were 3,403 children and adolescents from 12 contributing clinical and nonclinical samples; all participants had received the Kiddie Schedule of Affective Disorders and Schizophrenia for School-Aged Children. Results revealed that some symptoms reflected higher levels of depression and were more discriminating than others. Furthermore, use of IRT-based information about symptom severity and discriminability in the measurement of depression severity was shown to reduce measurement error and increase measurement fidelity.     

Early-Onset Bipolar Spectrum Disorders: Diagnostic Issues

Since the mid 1990s, early-onset bipolar spectrum disorders (BPSDs) have received increased attention in both the popular press and scholarly press. Rates of diagnosis of BPSD in children and adolescents have increased in inpatient, outpatient, and primary care settings. BPSDs remain difficult to diagnose, particularly in youth. The current diagnostic system makes few modifications to accommodate children and adolescents. Researchers in this area have developed specific BPSD definitions that affect the generalizability of their findings to all youth with BPSD. Despite knowledge gains from the research, BPSDs are still difficult to diagnose because clinicians must: (1) consider the impact of the child’s developmental level on symptom presentation (e.g., normative behavior prevalence, environmental limitations on youth behavior, pubertal status, irritability, symptom duration); (2) weigh associated impairment and course of illness (e.g., neurocognitive functioning, failing to meet full DSM criteria, future impairment); and (3) make decisions about appropriate assessment (differentiating BPSD from medical illnesses, medications, drug use, or other psychiatric diagnoses that might better account for symptoms; comorbid disorders; informant characteristics and assessment measures to use). Research findings concerning these challenges and relevant recommendations are offered. Areas for further research to guide clinicians’ assessment of children with early-onset BPSD are highlighted. Principal Investigators and Coinvestigators of Longitudinal Assessment of Manic Symptoms (LAMS) Group are listed in Appendix.     

Adaptation and communicative design.

Two theoretical frameworks that examine the nature of adaptability and mutual influence in interaction, interpersonal deception theory and interaction adaptation theory, were used to derive hypotheses concerning patterns of interaction that occur across time in truthful and deceptive conversations. Two studies were conducted in which senders were either truthful or deceptive in their interactions with a partner who increased or decreased involvement during the latter half of the conversation. Results revealed that deceivers felt more anxious and were more concerned about self‐presentation than truthtellers prior to the interaction and displayed less initial involvement than truthtellers. Patterns of interaction were also moderated by deception. Deceivers increased involvement over time but also reciprocated increases or decreases in receiver involvement. However, deceivers were less responsive than truthtellers to changes in receiver behavior. Finally, partner involvement served as feedback to senders regarding their own performance.     

Who are the comorbid adolescents? Agreement between psychiatric diagnosis,youth, parent,and teacher report

The investigators examined the rates of psychiatric comorbidity for externalizing and internalizing behavior problems, using semistructured diagnostic interview and parent, teacher, and youth report on the Achenbach checklists. The study also evaluated the effects of conjunctive, compensatory, and disjunctive data combination strategies. Using the same data and identical diagnostic thresholds, between 5 and 74% of 189 youths presenting to an outpatient clinic were identified as having comorbid internalizing and externalizing problems. Parent report and semistructured interview indicated the highest comorbidity rates. Despite good cross-source agreement (rs .29–.58), there was very little agreement about which specific youths presented with comorbid internalizing and externalizing problems (kappas .14–.40). Results also indicate that single DSM-IV disorders, such as bipolar disorder, can manifest comorbid patterns of behavior problems on checklists.     

The relations between cluster indexes of risk and promotion and the problem behaviors of 6- and 7-year-old children from economically disadvantaged families

This study examined the relations between alternative representations of poverty cofactors and promotion processes and teacher reports of the problem behaviors of 6- and 7-year-old children from economically disadvantaged families (N = 159). The results showed that single-index representations of risk and promotion variables predicted child aggressive behaviors but not child anxious/depressed behaviors. An additive model of individual risk indicators performed similarly. Smaller indexes representing clusters of parent adjustment variables and family instability variables, however, differentially predicted aggressive and anxious/depressed behaviors, respectively. The results suggest the importance of promotion processes and of representing environmental adversity at varying levels of specificity for children from economically disadvantaged families.     

Transporting a Manualized Treatment for Children’s Disruptive Behavior to a Community Clinic

We compared a research-based, manualized intervention called Helping the Noncompliant Child (HNC; McMahon and Forehand 2003) to treatment as usual (TAU) for 194 children, 3–9?years old, with disruptive behavior disorders in a community clinic. The two interventions did not produce different outcomes or levels of parent satisfaction. However, almost three times as many parents in the HNC condition stated they ended therapy because their goals had been met, and almost three times as many parents in TAU stated they terminated because of practical obstacles. Number of sessions was related to outcome in the HNC condition but not in TAU.     

Evidence-Based Strategies Improve Assessment of Pediatric Bipolar Disorder by Community Practitioners

The misdiagnosis of pediatric bipolar disorder (PBD) has become a major public health concern. Would available evidence-based assessment (EBA) strategies help improve diagnostic accuracy, and are clinicians willing to consider these strategies in practice? The purpose of the present study was to document the extent to which using an EBA decision tool--a probability nomogram--improves the interpretation of family history and test data by clinicians and to examine the acceptability of the nomogram technique to clinicians. Over 600 clinicians across the US and Canada attending continuing education seminars were trained to use the nomogram. Participants estimated the probability that a youth in a clinical vignette had bipolar disorder, first using clinical judgment and then using the nomogram. Brief training of clinicians (less than 30 minutes) in using the nomogram for assessing PBD improved diagnostic accuracy, consistency, and agreement. The majority of clinicians endorsed using the nomogram in practice. EBA decision aids, such as the nomogram, may lead to a significant decrease in overdiagnosis and help clinicians detect true cases of PBD.