Stephen S. Leff

Variations in Anxiety and Depression as a Function of ADHD Subtypes Defined by DSM-IV: Do Subtype Differences Exist or Not?.

Concerns have been raised about the ability of diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) to distinguish subtypes that are clearly distinct from each other with regard to clinical correlates. One area of concern is that research regarding differences in anxiety and depression as a function of ADHD subtype has produced discrepant findings. This study was designed to systematically evaluate whether the ADHD subtypes differ with regard to level of internalizing symptoms. From a large pool of children referred to an ADHD center based in a pediatric hospital, children were differentiated into three groups: ADHD, Combined Type (ADHD/COM); ADHD, Inattentive Type (ADHD/I); and a non-ADHD, comparison group (COMP). Parent- and child-report measures using both dimensional and categorical methods were used to assess internalizing symptoms. The results indicated that children with ADHD/COM and ADHD/I had similar levels of anxiety and depression. Subtype differences related to parent-reported depression were accounted for by group differences in level of externalizing problems. The results were discussed with regard to their implications for refining the criteria used to differentiate children with ADHD into subtypes.

Assessing ADHD Across Settings: Contributions of Behavioral Assessment to Categorical Decision Making

Adapted methods of behavioral assessment to assess home and school functioning in a way that maps directly to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., [DSM-IV]; American Psychiatric Association, 1994). The study was conducted in a school-based sample with 5- to 12-year-old children referred to a school intervention team. A multigate set of procedures was used to assign children to one of 3 groups: attention deficit hyperactivity disorder (ADHD), inattentive group; ADHD, combined group; and a non-ADHD control group. The ADHD Rating Scale-IV was used to assess parent and teacher ratings of ADHD symptoms as delineated in DSM-IV. The findings suggest that the use of a fixed cutoff point (i.e., 6 or more symptoms), which is employed in the DSM-IV, is often not the best strategy for making diagnostic decisions. The optimal approach depends on whether diagnostic information is being provided by the parent or teacher and whether the purpose of assessment is to conduct a screening or a diagnostic evaluation. Also, the results indicate that a strategy that aggregates symptoms in the order in which they are accurate in predicting a diagnosis of ADHD is a more effective strategy than the approach used in DSM-IV, which aggregates any combination of a specific number of items. Implications for using methods of behavioral assessment to make diagnostic decisions using DSM-IV criteria are discussed.

Decaying Behavioral Effects in a Randomized, Multi-year Fruit and Vegetable Intake Intervention

OBJECTIVE To examine the effects of a multi-component, theory-based, 2.5-year intervention on childrens fruit and vegetable consumption, preferences, knowledge and body mass index. METHODS Four inner city elementary schools in the Northeastern United States were randomized to an intervention (n=149) or control group (n=148) in 2005. Fruit and vegetable consumption during school lunch (measured by plate waste), preferences, and knowledge, as well as body mass index, were assessed five times across 3.5 years (pre-intervention, spring 2006, 2007, 2008 and 2009). Hierarchical linear modeling was used to analyze program outcomes. RESULTS At the first post-test assessment, children in the experimental group ate 0.28 more servings/lunch of fruit and vegetable relative to children in the control group and changes in fruit and vegetable consumption were found in each year throughout the program. However, this effect declined steadily across time so that by the delayed one-year follow-up period there was no difference between the groups in fruit and vegetable consumption. There were persistent intervention effects on childrens knowledge. There were no effects on fruit and vegetable preferences and body mass index throughout the study. CONCLUSION Although there was initial fruit and vegetable behavior change, annual measurements indicated a gradual decay of behavioral effects. These data have implications for the design of school-based fruit and vegetable interventions.

Implementing a Trauma-Informed Approach in Pediatric Health Care Networks

Pediatric health care networks serve millions of children each year. Pediatric illness and injury are among the most common potentially emotionally traumatic experiences for children and their families. In addition, millions of children who present for medical care (including well visits) have been exposed to prior traumatic events, such as violence or natural disasters. Given the daily challenges of working in pediatric health care networks, medical professionals and support staff can experience trauma symptoms related to their work. The application of a trauma-informed approach to medical care has the potential to mitigate these negative consequences. Trauma-informed care minimizes the potential for medical care to become traumatic or trigger trauma reactions, addresses distress, provides emotional support for the entire family, encourages positive coping, and provides anticipatory guidance regarding the recovery process. When used in conjunction with family-centered practices, trauma-informed approaches enhance the quality of care for patients and their families and the well-being of medical professionals and support staff. Barriers to routine integration of trauma-informed approaches into pediatric medicine include a lack of available training and unclear best-practice guidelines. This article highlights the importance of implementing a trauma-informed approach and offers a framework for training pediatric health care networks in trauma-informed care practices.

The Role of Empowerment in a School-Based Community Service Program with Inner-City, Minority Youth.

Despite considerable fiscal and structural support for youth service programs, research has not demonstrated consistent outcomes across participants or programs, suggesting the need to identify critical program processes. The present study addresses this need through preliminary examination of the role of program empowerment in promoting positive identity development in inner-city, African American youth participating in a pilot school-based service program. Results suggest that participants who experienced the program as empowering experienced increases in self-efficacy, sense of civic responsibility, and ethnic identity, over and above general engagement and enjoyment of the program. Preliminary exploration of differences based on participant gender suggests that some results may be stronger and more consistent for males than females. These findings provide preliminary support for the importance of theoretically grounded program processes in producing positive outcomes for youth service participants.

A family-school homework intervention program for children with attention-deficit/hyperactivity disorder

Children with attention-deficit/hyperactivity disorder (ADHD) typically have multiple problems with homework performance that may contribute to academic skills deficits and underachievement. Specialized interventions to address the homework problems of children with ADHD is greatly needed. A brief family-school training program to address the homework problems of children with ADHD is described. The Homework Success Program (HSP) involves group parent training in cognitive and behavioral principles and strategies that have empirical support in the literature. This program involves increasing parent understanding of their childs behavior and training in behavioral techniques to improve academic productivity and behavioral functioning. In addition, an emphasis is placed on improving goal-setting skills and increasing parent-teacher collaboration to address homework problems. Procedures for incorporating children into the intervention program are also included. Suggestions are made for assessing progress and outcomes in academic and behavioral functioning and parent-child interactions. Case illustrations are presented to demonstrate methods that may be useful in evaluating program effectiveness and to describe the types of outcomes that may occur when this program is implemented. Future research directions and suggestions for implementing this program in community and school settings are discussed.

Initial Validation of a Knowledge-Based Measure of Social Information Processing and Anger Management

Over the past fifteen years many schools have utilized aggression prevention programs. Despite these apparent advances, many programs are not examined systematically to determine the areas in which they are most effective. One reason for this is that many programs, especially those in urban under-resourced areas, do not utilize outcome measures that are sensitive to the needs of ethnic minority students. The current study illustrates how a new knowledge-based measure of social information processing and anger management techniques was designed through a partnership-based process to ensure that it would be sensitive to the needs of urban, predominately African American youngsters, while also having broad potential applicability for use as an outcome assessment tool for aggression prevention programs focusing upon social information processing. The new measure was found to have strong psychometric properties within a sample of urban predominately African American youth, as item analyses suggested that almost all items discriminate well between more and less knowledgeable individuals, that the test-retest reliability of the measure is strong, and that the measure appears to be sensitive to treatment changes over time. In addition, the overall score of this new measure is moderately associated with attributions of hostility on two measures (negative correlations) and demonstrates a low to moderate negative association with peer and teacher report measures of overt and relational aggression. More research is needed to determine the measure’s utility outside of the urban school context.

Effect of Aggression and Bullying on Children and Adolescents: Implications for Prevention and Intervention

Peer aggression and bullying is of considerable importance given the large number of youth involved with or witnesses to this behavior and the association with maladjustment and other negative outcomes. This article reviews current literature on aggression and bullying among school-age youth, including subtypes and differentiating between aggression and bullying. We then highlight important considerations for intervening and preventing these behaviors. Finally, implications for psychiatrists, other mental health professionals, and providers are discussed in an effort to provide specific strategies to help youth, families, and schools more successfully navigate the challenges that aggression and bullying often cause.

Developing measures of community-relevant outcomes for violence prevention programs: A community-based participatory research approach to measurement

Community-Based Participatory Research is a research paradigm that encourages community participation in designing and implementing evaluation research, though the actual outcome measures usually reflect the “external” academic researchers’ view of program effect and the policy-makers’ needs for decision-making. This paper describes a replicable process by which existing standardized psychometric scales commonly used in youth-related intervention programs were modified to measure indicators of program success defined by community partners. This study utilizes a secondary analysis of data gathered in the context of a community-based youth violence prevention program. Data were retooled into new measures developed using items from the Alabama Parenting Questionnaire, the Hare Area Specific Self-Esteem Scale, and the Youth Asset Survey. These measures evaluated two community-defined outcome indicators, “More Parental Involvement” and “Showing Kids Love.” Results showed that existing scale items can be re-organized to create measures of community-defined outcomes that are psychometrically reliable and valid. Results also show that the community definitions of parent or parenting caregivers exemplified by the two indicators are similar to how these constructs have been defined in previous research, but they are not synonymous. There are nuanced differences that are important and worthy of better understanding, in part through better measurement.

Better Understanding and Intervening to Prevent Relational Aggression

There has been increased attention paid to the reduction of aggressive behaviors among youth since the Columbine High School massacre in 1999, an incident which reportedly occurred in response to the perpetrators’ victimization by peers (Larkin, 2009). The shocking display of extreme physical violence at Columbine influenced American researchers to focus on daily incidents of peer bullying and the implications of being an ongoing victim of peer bullying or abuse (Safran, 2007). More recently, harassment and bullying through nonphysical means (e.g., cyberbullying, relational aggression) has received media attention given the rash of suicides by youth who were being victimized by these forms of aggression. Although the media focus on nonphysical forms of aggression has only recently sparked the interest of the general public and lawmakers, research on these forms of aggression, particularly relational forms of aggression, is not a new phenomenon.