Jason W. Small

Subthreshold conditions as precursors for full syndrome disorders: a 15-year longitudinal study of multiple diagnostic classes.

BACKGROUND There has been increasing interest in the distinction between subthreshold and full syndrome disorders and specifically whether subthreshold conditions escalate or predict the onset of full syndrome disorders over time. Most of these studies, however, examined whether a single subthreshold condition escalates into the full syndrome form of that disorder. Equally important, though, is whether subthreshold conditions are likely to develop other full syndrome disorders and whether these associations are maintained after adjusting for comorbidity. METHODS A 15-year longitudinal study of subthreshold psychiatric conditions was conducted with 1,505 community-drawn young adults. We examined whether 1) subthreshold major depression, bipolar, anxiety disorders, alcohol use, substance use, conduct disorder and/or ADHD were precursors for the corresponding (homotypic) full syndrome disorder; 2) subthreshold conditions were precursors for other (heterotypic) full syndrome disorders; and 3) these homotypic and heterotypic precursors persisted after adjusting for comorbidity. RESULTS Subthreshold major depression, anxiety, alcohol use, substance use, and conduct all escalated into their corresponding full syndrome and nearly all homotypic developments were maintained after adjusting for comorbid subthreshold and full syndrome conditions. Many heterotypic associations were also observed and most remained after controlling for comorbidity, particularly among externalizing disorders (e.g., alcohol, substance, conduct/antisocial personality disorder). CONCLUSIONS Many subthreshold conditions have predictive validity as they may represent precursors for full syndrome disorders. Alternatively, dimensional conceptualizations of psychopathology which include these more minor conditions may yield greater validity. Subthreshold conditions may represent good targets for preventive interventions.

Separation Anxiety Disorder in Childhood as a Risk Factor for Future Mental Illness

OBJECTIVE To ascertain the extent to which childhood separation anxiety disorder (SAD) confers risk for the development of psychopathology during young adulthood (ages 19-30). METHOD A subset of the participants of the Oregon Adolescent Depression Project (n = 816) was used. Subjects provided retrospective reports of lifetime mental illness (including SAD) and concurrent reports of current mental illness at age 16 and were then followed prospectively until age 30. Diagnostic assessments were conducted twice during adolescence and again at ages 24 and 30. Based on diagnosis during childhood/adolescence, the subjects were partitioned into four orthogonal groups: SAD (n = 42), other anxiety disorders (n = 88), a heterogeneous psychiatric disorders control group (n = 389), and a not mentally ill control group (n = 297). Adjusting for demographic variables that were significantly associated with group status and for comorbid disorders prior to age 19, the results were analyzed with hierarchical multiple logistic regression. RESULTS SAD was a strong (78.6%) risk factor for the development of mental disorders during young adulthood. The major vulnerabilities were for panic disorder and depression. CONCLUSIONS Because SAD creates a major vulnerability for mental disorders during young adulthood, clinicians should be sensitive to the presence of SAD, and children and adolescents with SAD should be treated. Future research should evaluate whether successful treatment of SAD and/or the provision of a preventive intervention during childhood/adolescence reduce the risk for future psychopathology.

A Randomized Controlled Trial of the First Step to Success Early Intervention: Demonstration of Program Efficacy Outcomes in a Diverse, Urban School District.

This article reports on a randomized controlled trial of the First Step to Success early intervention that was conducted over a 4-year period in Albuquerque Public Schools. First Step is a selected intervention for students in Grades 1 through 3 with externalizing behavior problems, and it addresses secondary prevention goals and objectives. It consists of three modular components (screening, school intervention, parent training); lasts approximately 3 months; and is initially set up, delivered, and coordinated by a behavioral coach (e.g., school counselor, behavior specialist, social worker). Project Year 1 of this efficacy trial was devoted to gearing-up activities (e.g., hiring, training, planning, logistical arrangements); Years 2 and 3 each involved implementing First Step with approximately 100 behaviorally at-risk students. Students, teachers, and classrooms were randomly assigned to either intervention or usual care comparison conditions. Year 4 activities focused on conducting long-term, follow-up assessments and implementing sustainability procedures to preserve achieved gains. Pre-post teacher and parent ratings of student behavior and social skills showed moderately robust effect sizes, ranging from .54 to .87, that favored the intervention group. Direct measures of academic performance (oral reading fluency, letter—word identification) were not sensitive to the intervention. The implications and limitations of the study are discussed.

Psychosocial functioning of adults who experienced substance use disorders as adolescents

The authors examined whether substance use disorder (SUD) before age 19 was associated with functioning at age 30. Participants (N = 773) were assessed twice during adolescence and at ages 24 and 30. Eight of 14 adult measures were associated with adolescent SUD: education, unemployment, income, risky sexual behavior, suicide attempt, coping, stressful life events, and global adjustment. After adolescent comorbidity and functioning and adult SUD were controlled for, education and unemployment remained associated, and three variables emerged as significant: being a parent (significant only for participants without adult SUD), being currently married, and having decreased life satisfaction (significant only for participants with adult SUD). Adolescent SUD is associated with numerous functioning difficulties at age 30, some of which appear to be related to recurrent SUD, comorbid adolescent disorders, or functioning problems already evident in adolescence.

Using Different Measures, Informants, and Clinical Cut-Off Points to Estimate Prevalence of Emotional or Behavioral Disorders in Preschoolers: Effects on Age, Gender, and Ethnicity

The early identification and remediation of emotional or behavior disorders are high priorities for early-childhood researchers and are based on the assumption that problems such as school failure can be averted with early screening, prevention, and intervention. Presently, prevalence, severity, and topography of mental health needs among low-income preschoolers and their families have not been well documented. Tools for screening and intervention for behavior problems in preschool children are few and many of those tools have not been studied within diverse Head Start systems. In this study, five instruments of symptoms and functional impairment, completed by teachers and two completed by parents, were obtained on a sample of 1,781 Head Start children from diverse racial and ethnic backgrounds from the Head Start Mental Health Research Consortium. Clinical cut-off scores were used to identify children who could be considered at relatively serious risk for emotional or behavioral disorders. At-risk classifications using clinical cut-offs at both 1.0 and 1.5 standard deviations for each measure were examined singly and in combination and then compared to the overall sample for age, gender, and ethnicity. Identification of children considered at risk ranged from a low of 1% to a high of 38%, with evidence of differential effects on age, gender, or ethnicity for some individual measures, but these tended to diminish when combinations of symptom and impairment measures were used. Implications for choosing instruments to establish eligibility for emotional or behavioral disorders in preschoolers are discussed.

Family study of subthreshold psychopathology in a community sample

BACKGROUND There has been increasing interest in the validity and familial transmission of subthreshold psychiatric conditions and the relationship between subthreshold conditions and full syndrome (FS) disorders. However, most of these studies examined a single subthreshold condition and thus fail to take into account the high co-morbidity among subthreshold conditions and between subthreshold conditions and FS disorders. METHOD A family study of subthreshold psychiatric conditions was conducted with 739 community-drawn young adults and their 1744 relatives. We examined (1) whether relatives of probands with subthreshold major depression, bipolar disorder, anxiety disorders, alcohol use, substance use, and/or conduct disorder exhibited an increased rate of the corresponding (homotypic) FS disorder; (2) whether subthreshold disorders were associated with increased familial rates of other (heterotypic) FS disorders; (3) whether subthreshold and FS conditions are associated with similar familial liabilities; and (4) whether these homotypic and heterotypic associations persisted after controlling for co-morbidity. RESULTS Significant homotypic associations were observed for subthreshold anxiety, alcohol, conduct, and a trend was observed for major depression. Only the homotypic association for alcohol and conduct remained after controlling for co-morbid subthreshold and FS conditions. Many heterotypic associations were observed and most remained after controlling for co-morbidity. CONCLUSIONS It is important to broaden the study of subthreshold psychopathology to multiple disorders. In particular cases, controlling for co-morbidity with other subthreshold and FS conditions altered the patterns of familial aggregation. Etiological processes that are common to particular disorders and subthreshold conditions are discussed.

Assessing the Effectiveness of First Step to Success Are Short-Term Results the First Step to Long-Term Behavioral Improvements?

This article reports on the effectiveness of First Step to Success, a secondary-level intervention appropriate for students in early elementary school who experience moderate to severe behavior problems and are at risk for academic failure. The authors demonstrate the intervention’s short-term effects on multiple behavioral and academic outcomes as delivered off-the-shelf in a variety of classrooms and schools across the country—effects that were mitigated by fidelity of implementation. Furthermore, the authors assess the body of evidence on First Step to Success against the standards for effectiveness and widespread dissemination promulgated by the Society for Prevention Research, thereby suggesting directions for further research.

The Efficacy of a Home-School Intervention for Preschoolers with Challenging Behaviors: A Randomized Controlled Trial of Preschool First Step to Success.

The field of early intervention is currently faced with the challenge of reducing the prevalence of antisocial behavior in children. Longitudinal outcomes research indicates that increased antisocial behavior and impairments in social competence skills during the preschool years often serve as harbingers of future adjustment problems in a number of domains including mental health, interpersonal relations, and academic achievement. This article reports the results of a cross-site randomized controlled trial, in which 128 preschool children with challenging behaviors were assigned to either a Preschool First Step to Success (PFS) intervention (i.e., experimental) or a usual-care (i.e., control) group. Regression analyses indicated that children assigned to the Preschool First Step intervention had significantly higher social skills, and significantly fewer behavior problems, across a variety of teacher- and parent-reported measures at postintervention. Effect sizes for teacher-reported effects ranged from medium to large across a variety of social competency indicators; effect sizes for parent-reported social skills and problem behaviors were small to medium, respectively. These results suggest that the preschool adaptation of the First Step intervention program provides early intervention participants, staff, and professionals with a viable intervention option to address emerging antisocial behavior and externalizing behavior disorders prior to school entry.

Transporting Motivational Interviewing to School Settings to Improve the Engagement and Fidelity of Tier 2 Interventions

The majority of Tier 2 interventions are facilitated by specialized instructional support personnel, such as a school psychologists, school social workers, school counselors, or behavior consultants. Many professionals struggle to involve parents and teachers in Tier 2 behavior interventions. However, attention to the motivational issues for influencing parents and teachers’ decisions to participate or implement the intervention as it was intended are often missing. In this article, the authors describe their efforts to infuse motivational interviewing into a well-established Tier 2 intervention, First Step to Success. Specifically, they summarize the iterative process that they followed in order to develop this integrated model and the methods and results found in training coaches to implement it. Implications for practice and research are also discussed.

Comparative use of the Ages and Stages Questionnaires in low- and middle-income countries

To map the breadth of use of the Ages and Stages Questionnaires (ASQ) in low‐ and middle‐income countries (LMICs) across world regions, and examine procedures for ASQ translation, adaptation, psychometric evaluation, and administration.