Children who remain at home with their permanent caregivers following a child welfare (CW) involv... more Children who remain at home with their permanent caregivers following a child welfare (CW) involvement (e.g., investigation, out-of-home placement) manifest high rates of behavioral difficulties, which is a risk factor for further maltreatment and out-of-home placement if not treated effectively. A recently tested Multiple Family Group (MFG) service delivery model to treat youth Disruptive Behavior Disorders (DBDs) has demonstrated effectiveness in improving child behavior difficulties among hard-to-engage, socioeconomically disadvantaged families by addressing parenting skills, parent-child relationships, family communication and organization, social support, and stress. This exploratory study examines whether child behavioral outcomes for MFG differ for families with self-reported lifetime involvement in CW services compared to other families, as families with CW involvement struggle with additional stressors that can diminish treatment success. Youth (aged 7-11) and their families were assigned to MFG or services as usual (SAU) using a block comparison design. Caregivers reported on child behavior, social skills, and functional impairment. Mixed effects regression modeled multilevel outcomes across 4 assessment points (i.e., baseline, mid-test, post-test, 6-month follow-up). Among CW-involved families, MFG participants reported significantly reduced child oppositional defiant disorder symptoms at 6-month follow-up compared with SAU participants. No other differences were found in the effect of MFG treatment between CW and non-CW involved families. Findings suggest that MFG may be as effective in reducing child behavior difficulties for both CW and non-CW involved families. As a short-term, engaging, and efficient intervention, MFG may be a particularly salient service offering for families involved in the CW system.
Attention-deficit/hyperactivity disorder (ADHD) is a prevalent and chronic mental health conditio... more Attention-deficit/hyperactivity disorder (ADHD) is a prevalent and chronic mental health condition that often results in substantial impairments throughout life. Although evidence-based pharmacological and psychosocial treatments exist for ADHD, effects of these treatments are acute, do not typically generalize into non-treated settings, rarely sustain over time, and insufficiently affect key areas of functional impairment (i.e., family, social, and academic functioning) and executive functioning. The limitations of current evidence-based treatments may be due to the inability of these treatments to address underlying neurocognitive deficits that are related to the symptoms of ADHD and associated areas of functional impairment. Although efforts have been made to directly target the underlying neurocognitive deficits of ADHD, extant neurocognitive interventions have shown limited efficacy, possibly due to misspecification of training targets and inadequate potency. We argue herein th...
This paper presents preliminary outcomes associated with an experimental, longitudinal study of a... more This paper presents preliminary outcomes associated with an experimental, longitudinal study of a Multiple Family Group (MFG) service delivery approach set within thirteen urban outpatient clinics serving children and their families living in inner-city, primarily African American and Latino communities. Specifically, this paper focuses on parent reports of child oppositional behavior and parenting stress over time. MFG is a flexible, protocol-driven approach designed to address the most common reason for referral to outpatient child mental health clinics, childhood behavioral difficulties. The MFG also aims to enhance family-level engagement and retention in ongoing care. Further, the service delivery model was collaboratively developed with intensive input from parents rearing children with conduct difficulties, parent advocates, community-based child mental health providers and services research staff in order to ultimately expand the number of effective service models that can be situated within "real world," urban child mental health settings.
Professional Psychology: Research and Practice, 2012
What exactly is the psychologist to do to increase the probability that intervention can alter th... more What exactly is the psychologist to do to increase the probability that intervention can alter the multiple impairments and often poor long-term outcomes associated with preschool-onset attention-deficit/ hyperactivity disorder (ADHD)? Intervening to support a preschool child with ADHD is complex given the child's developmental stage and the need to coordinate services across multiple people and settings. Identifying what interventions have been empirically evaluated and the extent to which these interventions affect ADHD-related behaviors and impairments is a critical first-step to providing quality care for these children. Recent guidelines set forth by the American Academy of Pediatrics (2011, ADHD: Clinical practice guidelines for the diagnosis, evaluation and treatment of attention/deficit-hyperactivity disorder in children and adolescents. Pediatrics, 128, 1007Pediatrics, 128, -1022Pediatrics, 128, . doi:10.1542Pediatrics, 128, /peds.2011Pediatrics, 128, -2654 recommend that medication only be used when behavioral interventions are not available or when significant room for improvement exists following effective implementation of behavioral interventions. As such, we review herein nonpharmacological interventions for preschool ADHD, identifying approaches in the published literature focused on training parents, teachers, and children, as well as dietary restrictions, nutritional supplements, and acupuncture interventions. This review suggests that behaviorally based approaches focused on parent and teacher training are the most well-studied and effective interventions. Child-training approaches, dietary interventions, nutritional supplements, and acupuncture require substantially more evaluation before clinical implications can be fully appreciated. We conclude by discussing key principles gleaned from this literature for psychological practice for the treatment of preschool children with ADHD.
Embedding evidence-informed practices for children with mental health needs into "real-world" com... more Embedding evidence-informed practices for children with mental health needs into "real-world" community settings has proven challenging. In this article, we discuss how the Practical, Robust, Implementation, and Sustainability Model (PRISM) guided statewide (New York) implementation of an evidence-informed intervention targeting families and youth with oppositional defiant and conduct disorders, collectively referred to as disruptive behavior disorders. Additionally, we present qualitative findings based on provider reports of integrating a novel, evidence-informed intervention within their respective community mental health settings. Finally, we discuss a process of modifying the intervention to address agency-level factors, as well as inform more widespread implementation efforts.
The Strategies to Enhance Positive Parenting (STEPP) program, an enhanced behavioral parent train... more The Strategies to Enhance Positive Parenting (STEPP) program, an enhanced behavioral parent training (BPT) intervention, was developed to improve engagement in and outcomes following treatment for single-mother families of school-age youth with attention-deficit/hyperactivity disorder (ADHD). A previous randomized clinical trial of the STEPP program demonstrated that the intervention resulted in statistically significant improvements at the group-level in child oppositional behavior, various areas of child impairment, parental stress, and parenting behavior, relative to a wait-list control condition and a traditional BPT group. Despite benefits at the group-level, little is known about outcomes at the individual-level of enhanced BPT relative to traditional BPT for various child-and parent-level outcomes. The current study compares the extent to which traditional BPT and the STEPP program result in reliable change and recovery across various child-and parent-level outcomes in a sample of 80, 5-12 year old youth with ADHD (70 % male).
Behavioral parent training (BPT) is an evidencebased intervention for the treatment of attention-... more Behavioral parent training (BPT) is an evidencebased intervention for the treatment of attention-deficit/hyperactivity disorder (ADHD) and related disruptive behavioral disorders of childhood. Despite convincing data on effectiveness, engagement to BPT, particularly for high-risk families, has been a long standing, yet understudied, issue. Data from a clinical trial of a comprehensive BPT approach to enhance engagement and outcomes (the Strategies to Enhance Positive Parenting [STEPP] program) are presented herein. The STEPP program was compared to a traditional group-based BPT program on propensity to attend treatment, propensity to complete homework over the course of treatment, and dropout from BPT. Additionally, factors empirically related to engagement to treatment and targeted by the STEPP program were analyzed to determine whether these factors were enhanced by participation in the STEPP program. In a randomized cohort of 80 single-mothers of school-age children with ADHD, analyses demonstrated that the STEPP program lead to greater propensity to attend treatment over time and a greater propensity to complete homework over the course of treatment. Furthermore, participation in the STEPP Program was associated with a lower rate of dropout. Finally, data suggested that parents assigned to the STEPP program reported significant improvements in factors empirically related to engagement that were targeted within the STEPP program (i.e., amount and quality of social support from their group members, expectations for treatment, and perceived barriers to treatment participation). Results of the study have implications for targeting engagement throughout the process of BPT, particularly for high-risk families.
Background-This paper describes efforts to apply the principles and strategies of an empirically-... more Background-This paper describes efforts to apply the principles and strategies of an empirically-supported treatment for children with disruptive behaviour problems to a park afterschool program serving children in urban poverty.
Participants were 68 children referred for treatment for ADHD evaluated in two cohorts during sub... more Participants were 68 children referred for treatment for ADHD evaluated in two cohorts during subsequent years. Data was collected as part of the intake evaluation to determine eligibility for a Summer Treatment Program (STP) study evaluating effects of different doses of medication versus behavior modification on 5-12 year-old children with ADHD. The ethnic background of the sample was as follows: 79% Caucasian, 12% African-American, and 9% other. 84% of the children were boys. The mean age of the sample was 9.13 years. Eligibility for the study involved conducting a multi-method comprehensive assessment of children's presenting problems and functioning. ADHD diagnosis was established by consensus of a clinical team using data available from parent reports, parent interviews, and teacher reports. Children were excluded from the study if they did not meet criteria for ADHD or if they had an IQ below 80. (DISC IV; Shaffer et al., 1993). The computer-administered version of the DISC was used for the present study. The modules employed were those for ADHD, ODD, and CD. Primary caregivers were administered the DISC to establish diagnostic status. Disruptive Behavior Disorders Interview (DBD Interview; Pelham et al., 1992). The DBD Interview is a clinician-administered semi-structured interview addressing DSM-IV symptoms of ADHD, ODD, and CD across different situations: at home, at school, and in other settings. Parents are asked to indicate whether problem behaviors occur in each situation and, if so, to rate the severity from mild (1) to severe (3). Clinicians then give each symptom an overall rating based on primary caregivers' reports of severity within each setting. Symptoms are counted as present if children receive an overall rating of 2 or 3. Disruptive Behavior Disorders Rating Scale (DBD-Rating Scale; Pelham et al., 1992). The DBD Rating Scale is comprised of 45 items representing symptoms of ADHD, ODD, and CD.
INTRODUCTION Behavioral and pharmacological treatments both have an evidence base for the treatme... more INTRODUCTION Behavioral and pharmacological treatments both have an evidence base for the treatment of children with ADHD. Reviews of the treatment literature show general superiority of combined treatment to unimodal treatments (eg, Pelham & Waschbusch, 1999). ...
This paper reports on the 6-month follow-up outcomes of an effectiveness study testing a multiple... more This paper reports on the 6-month follow-up outcomes of an effectiveness study testing a multiple family group (MFG) intervention for clinic-referred youth (aged 7-11) with disruptive behavior disorders (DBDs) and their families in socioeconomically disadvantaged families compared to services-as-usual (SAU) using a block comparison design. The settings were urban community-based outpatient mental health agencies. Clinic-based providers and family partner advocates facilitated the MFG intervention. Parent-report measures targeting child behavior, social skills, and impairment across functional domains (i.e., relationships with peers, parents, siblings, and academic progress) were assessed across four timepoints (baseline, mid-test, post-test, and 6-month follow-up) using mixed effects regression modeling. Compared to SAU participants, MFG participants reported significant improvement at 6-month follow-up in child behavior, impact of behavior on relationship with peers, and overall impairment/need for services. Findings indicate that MFG may provide longer-term benefits for youth with DBDs and their families in community-based settings. Implications within the context of a transforming healthcare system are discussed.
To investigate the prevalence of asthma and mental health problems among representative samples o... more To investigate the prevalence of asthma and mental health problems among representative samples of youth in high-risk service settings and the community, and to examine the relationship between asthma and mental health in these groups. Data were drawn from the Alternative Service Use Patterns of Youth with Serious Emotional Disturbance Study (SED) (n = 1181), a combined representative, cross-sectional sample of youth in various clinical settings and the community. Multiple logistic regression analyses were used to examine the association between asthma and mental disorders. Demographic characteristics were investigated as potential confounders. Asthma was common among 15.2% of youth in service settings and 18.8% of youth in the community. The prevalence of mental disorders was extremely high among youth with and without asthma in all service settings, and asthma was associated with increased prevalence of mental disorders among youth in the community, but not among youth in service settings. The relationship between asthma and internalizing disorders among youth in the community does not appear entirely attributable to confounding by demographics. Findings are consistent with and extend previous data by showing that both asthma and mental disorders are disproportionately common among youth in high-risk service settings. Almost half of youth with asthma in service settings meet diagnostic criteria for a mental disorder. Clinicians and policy makers who are responsible for the health care of youth in these high-risk groups should be aware that asthma is common, and that the prevalence of internalizing disorders are especially common among those with asthma.
Children who remain at home with their permanent caregivers following a child welfare (CW) involv... more Children who remain at home with their permanent caregivers following a child welfare (CW) involvement (e.g., investigation, out-of-home placement) manifest high rates of behavioral difficulties, which is a risk factor for further maltreatment and out-of-home placement if not treated effectively. A recently tested Multiple Family Group (MFG) service delivery model to treat youth Disruptive Behavior Disorders (DBDs) has demonstrated effectiveness in improving child behavior difficulties among hard-to-engage, socioeconomically disadvantaged families by addressing parenting skills, parent-child relationships, family communication and organization, social support, and stress. This exploratory study examines whether child behavioral outcomes for MFG differ for families with self-reported lifetime involvement in CW services compared to other families, as families with CW involvement struggle with additional stressors that can diminish treatment success. Youth (aged 7-11) and their families were assigned to MFG or services as usual (SAU) using a block comparison design. Caregivers reported on child behavior, social skills, and functional impairment. Mixed effects regression modeled multilevel outcomes across 4 assessment points (i.e., baseline, mid-test, post-test, 6-month follow-up). Among CW-involved families, MFG participants reported significantly reduced child oppositional defiant disorder symptoms at 6-month follow-up compared with SAU participants. No other differences were found in the effect of MFG treatment between CW and non-CW involved families. Findings suggest that MFG may be as effective in reducing child behavior difficulties for both CW and non-CW involved families. As a short-term, engaging, and efficient intervention, MFG may be a particularly salient service offering for families involved in the CW system.
Attention-deficit/hyperactivity disorder (ADHD) is a prevalent and chronic mental health conditio... more Attention-deficit/hyperactivity disorder (ADHD) is a prevalent and chronic mental health condition that often results in substantial impairments throughout life. Although evidence-based pharmacological and psychosocial treatments exist for ADHD, effects of these treatments are acute, do not typically generalize into non-treated settings, rarely sustain over time, and insufficiently affect key areas of functional impairment (i.e., family, social, and academic functioning) and executive functioning. The limitations of current evidence-based treatments may be due to the inability of these treatments to address underlying neurocognitive deficits that are related to the symptoms of ADHD and associated areas of functional impairment. Although efforts have been made to directly target the underlying neurocognitive deficits of ADHD, extant neurocognitive interventions have shown limited efficacy, possibly due to misspecification of training targets and inadequate potency. We argue herein th...
This paper presents preliminary outcomes associated with an experimental, longitudinal study of a... more This paper presents preliminary outcomes associated with an experimental, longitudinal study of a Multiple Family Group (MFG) service delivery approach set within thirteen urban outpatient clinics serving children and their families living in inner-city, primarily African American and Latino communities. Specifically, this paper focuses on parent reports of child oppositional behavior and parenting stress over time. MFG is a flexible, protocol-driven approach designed to address the most common reason for referral to outpatient child mental health clinics, childhood behavioral difficulties. The MFG also aims to enhance family-level engagement and retention in ongoing care. Further, the service delivery model was collaboratively developed with intensive input from parents rearing children with conduct difficulties, parent advocates, community-based child mental health providers and services research staff in order to ultimately expand the number of effective service models that can be situated within "real world," urban child mental health settings.
Professional Psychology: Research and Practice, 2012
What exactly is the psychologist to do to increase the probability that intervention can alter th... more What exactly is the psychologist to do to increase the probability that intervention can alter the multiple impairments and often poor long-term outcomes associated with preschool-onset attention-deficit/ hyperactivity disorder (ADHD)? Intervening to support a preschool child with ADHD is complex given the child's developmental stage and the need to coordinate services across multiple people and settings. Identifying what interventions have been empirically evaluated and the extent to which these interventions affect ADHD-related behaviors and impairments is a critical first-step to providing quality care for these children. Recent guidelines set forth by the American Academy of Pediatrics (2011, ADHD: Clinical practice guidelines for the diagnosis, evaluation and treatment of attention/deficit-hyperactivity disorder in children and adolescents. Pediatrics, 128, 1007Pediatrics, 128, -1022Pediatrics, 128, . doi:10.1542Pediatrics, 128, /peds.2011Pediatrics, 128, -2654 recommend that medication only be used when behavioral interventions are not available or when significant room for improvement exists following effective implementation of behavioral interventions. As such, we review herein nonpharmacological interventions for preschool ADHD, identifying approaches in the published literature focused on training parents, teachers, and children, as well as dietary restrictions, nutritional supplements, and acupuncture interventions. This review suggests that behaviorally based approaches focused on parent and teacher training are the most well-studied and effective interventions. Child-training approaches, dietary interventions, nutritional supplements, and acupuncture require substantially more evaluation before clinical implications can be fully appreciated. We conclude by discussing key principles gleaned from this literature for psychological practice for the treatment of preschool children with ADHD.
Embedding evidence-informed practices for children with mental health needs into "real-world" com... more Embedding evidence-informed practices for children with mental health needs into "real-world" community settings has proven challenging. In this article, we discuss how the Practical, Robust, Implementation, and Sustainability Model (PRISM) guided statewide (New York) implementation of an evidence-informed intervention targeting families and youth with oppositional defiant and conduct disorders, collectively referred to as disruptive behavior disorders. Additionally, we present qualitative findings based on provider reports of integrating a novel, evidence-informed intervention within their respective community mental health settings. Finally, we discuss a process of modifying the intervention to address agency-level factors, as well as inform more widespread implementation efforts.
The Strategies to Enhance Positive Parenting (STEPP) program, an enhanced behavioral parent train... more The Strategies to Enhance Positive Parenting (STEPP) program, an enhanced behavioral parent training (BPT) intervention, was developed to improve engagement in and outcomes following treatment for single-mother families of school-age youth with attention-deficit/hyperactivity disorder (ADHD). A previous randomized clinical trial of the STEPP program demonstrated that the intervention resulted in statistically significant improvements at the group-level in child oppositional behavior, various areas of child impairment, parental stress, and parenting behavior, relative to a wait-list control condition and a traditional BPT group. Despite benefits at the group-level, little is known about outcomes at the individual-level of enhanced BPT relative to traditional BPT for various child-and parent-level outcomes. The current study compares the extent to which traditional BPT and the STEPP program result in reliable change and recovery across various child-and parent-level outcomes in a sample of 80, 5-12 year old youth with ADHD (70 % male).
Behavioral parent training (BPT) is an evidencebased intervention for the treatment of attention-... more Behavioral parent training (BPT) is an evidencebased intervention for the treatment of attention-deficit/hyperactivity disorder (ADHD) and related disruptive behavioral disorders of childhood. Despite convincing data on effectiveness, engagement to BPT, particularly for high-risk families, has been a long standing, yet understudied, issue. Data from a clinical trial of a comprehensive BPT approach to enhance engagement and outcomes (the Strategies to Enhance Positive Parenting [STEPP] program) are presented herein. The STEPP program was compared to a traditional group-based BPT program on propensity to attend treatment, propensity to complete homework over the course of treatment, and dropout from BPT. Additionally, factors empirically related to engagement to treatment and targeted by the STEPP program were analyzed to determine whether these factors were enhanced by participation in the STEPP program. In a randomized cohort of 80 single-mothers of school-age children with ADHD, analyses demonstrated that the STEPP program lead to greater propensity to attend treatment over time and a greater propensity to complete homework over the course of treatment. Furthermore, participation in the STEPP Program was associated with a lower rate of dropout. Finally, data suggested that parents assigned to the STEPP program reported significant improvements in factors empirically related to engagement that were targeted within the STEPP program (i.e., amount and quality of social support from their group members, expectations for treatment, and perceived barriers to treatment participation). Results of the study have implications for targeting engagement throughout the process of BPT, particularly for high-risk families.
Background-This paper describes efforts to apply the principles and strategies of an empirically-... more Background-This paper describes efforts to apply the principles and strategies of an empirically-supported treatment for children with disruptive behaviour problems to a park afterschool program serving children in urban poverty.
Participants were 68 children referred for treatment for ADHD evaluated in two cohorts during sub... more Participants were 68 children referred for treatment for ADHD evaluated in two cohorts during subsequent years. Data was collected as part of the intake evaluation to determine eligibility for a Summer Treatment Program (STP) study evaluating effects of different doses of medication versus behavior modification on 5-12 year-old children with ADHD. The ethnic background of the sample was as follows: 79% Caucasian, 12% African-American, and 9% other. 84% of the children were boys. The mean age of the sample was 9.13 years. Eligibility for the study involved conducting a multi-method comprehensive assessment of children's presenting problems and functioning. ADHD diagnosis was established by consensus of a clinical team using data available from parent reports, parent interviews, and teacher reports. Children were excluded from the study if they did not meet criteria for ADHD or if they had an IQ below 80. (DISC IV; Shaffer et al., 1993). The computer-administered version of the DISC was used for the present study. The modules employed were those for ADHD, ODD, and CD. Primary caregivers were administered the DISC to establish diagnostic status. Disruptive Behavior Disorders Interview (DBD Interview; Pelham et al., 1992). The DBD Interview is a clinician-administered semi-structured interview addressing DSM-IV symptoms of ADHD, ODD, and CD across different situations: at home, at school, and in other settings. Parents are asked to indicate whether problem behaviors occur in each situation and, if so, to rate the severity from mild (1) to severe (3). Clinicians then give each symptom an overall rating based on primary caregivers' reports of severity within each setting. Symptoms are counted as present if children receive an overall rating of 2 or 3. Disruptive Behavior Disorders Rating Scale (DBD-Rating Scale; Pelham et al., 1992). The DBD Rating Scale is comprised of 45 items representing symptoms of ADHD, ODD, and CD.
INTRODUCTION Behavioral and pharmacological treatments both have an evidence base for the treatme... more INTRODUCTION Behavioral and pharmacological treatments both have an evidence base for the treatment of children with ADHD. Reviews of the treatment literature show general superiority of combined treatment to unimodal treatments (eg, Pelham & Waschbusch, 1999). ...
This paper reports on the 6-month follow-up outcomes of an effectiveness study testing a multiple... more This paper reports on the 6-month follow-up outcomes of an effectiveness study testing a multiple family group (MFG) intervention for clinic-referred youth (aged 7-11) with disruptive behavior disorders (DBDs) and their families in socioeconomically disadvantaged families compared to services-as-usual (SAU) using a block comparison design. The settings were urban community-based outpatient mental health agencies. Clinic-based providers and family partner advocates facilitated the MFG intervention. Parent-report measures targeting child behavior, social skills, and impairment across functional domains (i.e., relationships with peers, parents, siblings, and academic progress) were assessed across four timepoints (baseline, mid-test, post-test, and 6-month follow-up) using mixed effects regression modeling. Compared to SAU participants, MFG participants reported significant improvement at 6-month follow-up in child behavior, impact of behavior on relationship with peers, and overall impairment/need for services. Findings indicate that MFG may provide longer-term benefits for youth with DBDs and their families in community-based settings. Implications within the context of a transforming healthcare system are discussed.
To investigate the prevalence of asthma and mental health problems among representative samples o... more To investigate the prevalence of asthma and mental health problems among representative samples of youth in high-risk service settings and the community, and to examine the relationship between asthma and mental health in these groups. Data were drawn from the Alternative Service Use Patterns of Youth with Serious Emotional Disturbance Study (SED) (n = 1181), a combined representative, cross-sectional sample of youth in various clinical settings and the community. Multiple logistic regression analyses were used to examine the association between asthma and mental disorders. Demographic characteristics were investigated as potential confounders. Asthma was common among 15.2% of youth in service settings and 18.8% of youth in the community. The prevalence of mental disorders was extremely high among youth with and without asthma in all service settings, and asthma was associated with increased prevalence of mental disorders among youth in the community, but not among youth in service settings. The relationship between asthma and internalizing disorders among youth in the community does not appear entirely attributable to confounding by demographics. Findings are consistent with and extend previous data by showing that both asthma and mental disorders are disproportionately common among youth in high-risk service settings. Almost half of youth with asthma in service settings meet diagnostic criteria for a mental disorder. Clinicians and policy makers who are responsible for the health care of youth in these high-risk groups should be aware that asthma is common, and that the prevalence of internalizing disorders are especially common among those with asthma.
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