Caroline L. Boxmeyer

Cognitive-Behavioral Therapy for Externalizing Disorders in Children and Adolescents

This article focuses on the use of cognitive-behavioral therapy (CBT) strategies for children and adolescents with externalizing disorders. Following a description of risk factors for youth antisocial behavior, several components common to CBT interventions for youth with externalizing behaviors will be described. Using the Coping Power Program as a model, child treatment components including Emotion Awareness, Perspective Taking, Anger Management, Social Problem Solving, and Goal Setting will be reviewed. CBT strategies for parents of youth with disruptive behaviors will also be described. Finally, the article summarizes the evidence for the effectiveness of CBT strategies for externalizing disorders and presents specific outcome research on several programs that include CBT techniques.

Evidence-based preventive intervention for preadolescent aggressive children: One-year outcomes following randomization to group versus individual delivery.

OBJECTIVE Some research suggests that group interventions with antisocial youth may, on occasion, have iatrogenic effects. This is the first study to test the effects of group versus individual delivery of evidence-based intervention for aggressive children. METHOD Three hundred sixty fourth-grade children were randomly assigned by school to group coping power (GCP) or individual coping power (ICP). Longitudinal assessments of teacher and parent reports of behavior (Behavior Assessment System for Children [BASC]; Peer Affiliation and Social Acceptance [PASA]) were collected from baseline through a 1-year follow-up. RESULTS Growth curve analyses revealed that children in both conditions reduced teacher- and parent-reported externalizing behavior problems and internalizing behavior problems by the end of the 1-year follow-up. However, the degree of improvement in teacher-reported outcomes was significantly greater for children receiving an individual version of the program. In addition, childrens baseline level of inhibitory control moderated intervention effects, showing children with low initial levels of inhibitory control to respond poorly in teacher-rated outcomes to group interventions compared to those delivered individually. CONCLUSIONS This study suggests overall benefits to children for either group or individual delivery of the Coping Power program under high-fidelity conditions; however, for children with low levels of initial self-regulation, individualized interventions will likely yield the most significant reduction in externalizing behavior in the school setting in preadolescence.

The prevention of conduct problems.

This article summarizes the current knowledge base in the prevention of childhood conduct problems. First, childhood conduct problems and comorbid conditions are described, followed by a review of risk factors that have been found to contribute to the development of conduct problems. Risk factors include both internal child characteristics such as temperament and genetic/neurobiological influences, and external factors such as family, peer, and neighborhood influences. Finally, descriptions are provided for several intervention programs that have demonstrated empirical support in the prevention of youth conduct problems.

Coping Power Dissemination Study: Intervention and Special Education Effects on Academic Outcomes.

This study examines whether a school-based preventive intervention for children with aggressive behavior affects childrens academic outcomes when it is implemented by school counselors in a dissemination field trial. The Coping Power program targets empirical risk factors for aggressive behavior and focuses primarily on teaching social and emotional skills rather than directly intervening around academic performance. This study examined the long-term effects (2 years postintervention) of Coping Power on language arts and mathematics grades in 531 children from 57 schools. Prior analyses found that students of counselors who received intensive training in how to implement Coping Power (CP-IT) had broad improvements in teacher-rated social and academic skills and in teacher-, parent-, and self-reported externalizing behavior problems in comparison to children in a control group and to children whose counselor received more basic training in Coping Power (Lochman et al., 2009). In the present study, students with CP-IT counselors had smaller declines in language arts grades through a 2-year follow-up than children in the control group. Significant effects of CP-IT on mathematics grades were not observed. Special education status did not moderate intervention effects, indicating that special education students’ academic outcomes were affected in similar ways by the intervention in comparison with students not in special education. Intervention effects were not evident for children who had basic-trained counselors. These findings have implications for educational policy and underscore the potential for school-based social-emotional interventions such as Coping Power to have a long-term impact on childrens academic outcomes.

Integrating the Family Check-Up and the parent Coping Power program

Engaging families in school-based preventive interventions for aggressive youth can be especially challenging. The current article describes an integration of a parent engagement model, called the Family Check-Up, with an evidence-based intervention for youth with aggressive behaviours called Coping Power. The overall goal of the integration was to increase parental involvement and exposure to the core elements of the Coping Power programme to optimize impact on families and their children. We describe both models, summarize evidence of their efficacy when implemented alone, and provide a rationale for their integration. We also provide case examples to illustrate the implementation of the integrated programme in schools as well as feasibility data to support its continued study and implementation.

Adaptations to the coping power program's structure, delivery settings, and clinician training.

This article describes the conceptual framework for the Coping Power program that has focused on proximal risk factors that can actively alter preadolescent childrens aggressive behavior. The results of initial controlled efficacy trials are summarized. However, consistent with the theme of this special section, some clinicians and workshop participants have indicated barriers to the implementation of the Coping Power program in their service settings. In response to these types of concerns, three key areas of programmatic adaptation of the program that serve to address these concerns are then described in the article. First, existing and in-process studies of variations in how the program can be delivered are presented. Existing findings indicate how the child component fares when delivered by itself without the parent component, how simple monthly boosters affect intervention effects, and whether the program can be reduced by a third of its length and still be effective. Research planned or in progress on program variations examines whether group versus individual delivery of the program affects outcomes, whether the program can be adapted for early adolescents, whether the program can be delivered in an adaptive manner with the use of the Family Check Up, and whether a brief, efficient version of the program in conjunction with Internet programming can be developed and be effective. Second, the program has been and is being developed for use in different settings, other than the school-based delivery in the efficacy trials. Research has examined its use with aggressive deaf youth in a residential setting, with Oppositional Defiant Disorder and Conduct Disorder children in outpatient clinics, and in after-school programs. Third, the article reports how variations in training clinicians affect their ability to effectively use the program.

Influence of Risk Factors for Child Disruptive Behavior on Parent Attendance at a Preventive Intervention

Although preventive interventions that include both parent and child components produce stronger effects on disruptive behavior than child-only interventions, engaging parents in behavioral parent training is a significant challenge. This study examined the effects of specific risk factors for child disruptive behavior on parent attendance in behavioral parent training. Structural equation modeling was used to test the impact of parenting characteristics, childrens social goals, and contextual characteristics on parent attendance in the parent component of the Coping Power preventive intervention, as well as interrelations among these latent variables. The sample included 121 aggressive at-risk fifth-grade children and their parents who were randomly assigned to the intervention condition in a controlled trial. Parenting characteristics were the strongest predictor of parent intervention attendance and were found to mediate the relationship between contextual factors and parent attendance and childrens social goals. These analyses support and expand previous findings that parent attendance in behavioral parent training is systematically associated with risk factors for child disruptive behavior and highlight the role of parenting characteristics. Innovative strategies are needed for teaching positive parenting skills to the parents of children at greatest risk.

Predictors of Engagement in a School-Based Family Preventive Intervention for Youth Experiencing Behavioral Difficulties

The researchers longitudinally assessed parent and child levels of engagement in an evidence-based preventive intervention for children. The sample included 114 fifth graders with aggressive, disruptive behaviors and their parents who participated in the Coping Power Program. Findings indicate that levels of engagement differentially fluctuated for children and parents throughout the course of the intervention. Results also suggest that child levels of engagement early in the course of the program influenced parent mid-intervention levels of engagement. Further, these relationships persisted when the influence of family environment variables were included in analyses.

Variation in Response to Evidence-Based Group Preventive Intervention for Disruptive Behavior Problems: A View from 938 Coping Power Sessions

Prior research suggests that under some conditions, interventions that aggregate high-risk youth may be less effective, or at worse, iatrogenic. However, group formats have considerable practical utility for delivery of preventive interventions, and thus it is crucial to understand child and therapist factors that predict which aggressive children can profit from group intervention and which do not. To address these questions we video-recorded group Coping Power intervention sessions (938 sessions), coded both leader and participant behavior, and analyzed both leader and children’s behaviors in the sessions that predicted changes in teacher and parent, reports of problem behavior at 1-year follow up. The sample included 180 high-risk children (69% male) who received intervention in 30 separate Coping Power intervention groups (six children assigned per group). The evidence-based Coping Power prevention program consists of 32 sessions delivered during the 4th and 5th grade years; only the child component was used in this study. The behavioral coding system used in the analyses included two clusters of behaviors for children (positive; negative) and two for the primary group leaders (group management; clinical skills). Growth spline models suggest that high levels of children’s negative behaviors predicted increases in teacher and parent rated aggressive and conduct problem behaviors during the follow-up period in the three of the four models. Therapist use of clinical skills (e.g., warmth, nonreactive) predicted less increase in children’s teacher-rated conduct problems. These findings suggest the importance of clinical training in the effective delivery of evidence-based practices, particularly when working with high-risk youth in groups.

Oxytocin Receptor Gene Variant Interacts with Intervention Delivery Format in Predicting Intervention Outcomes for Youth with Conduct Problems

Coping Power is an evidence-based preventive intervention program for youth with aggressive behavior problems that has traditionally been delivered in small group formats. Because of concerns about iatrogenic effects secondary to aggregation of high risk youth, the current study examined whether genetic risk may moderate intervention outcome when youth were randomly assigned to group versus individual formats of an intervention. The oxytocin receptor gene (OXTR) has been associated with social behavior and may influence susceptibility to social reinforcement in general and deviant peer influence in particular. One variant of OXTR (rs2268493) was examined in 197 fourth-grade African-American children (64% male) who were randomly assigned to Group Coping Power or Individual Coping Power (Lochman et al. 2015). Longitudinal assessments of teacher- and parent-reported behavior were collected through a 1-year follow-up. Growth curve analyses revealed a genotype by delivery format interaction. Youth with the A/A genotype demonstrated reductions in externalizing problems over the course of the intervention regardless of intervention format. In contrast, carriers of the G allele receiving the group-based intervention showed little improvement during the intervention and a worsening of symptoms during the follow-up year, while those receiving the individual format demonstrated reductions in externalizing problems. Given the associations between this OXTR variant and social bonding, carriers of the G allele may be more sensitive to social rewards from deviant peers in the group setting. This study suggests that genetic factors may be useful in predicting which type of intervention will be most effective for a particular individual.