Two-year prediction of children's firesetting in clinically referred and nonreferred samples.

This study provides the first prospective evaluation of the course and predictors of children's involvement with fire over a 2-year period in 268 nonpatient and patient children (ages 6-13 yrs). Selected predictor variables obtained at initial (intake) assessment, which included fire-specific and general psychosocial measures, were examined in each sample using hierarchical logistic regression. Both samples reported heightened involvement in matchplay and firesetting at follow-up, though the frequency of each behavior was nearly four times higher in patients than in nonpatients. Fifty per cent and 59% of the initial firesetters in the nonpatient and patient samples, respectively, became recidivists. In the nonpatient sample, the child's initial involvement in firesetting and level of covert antisocial behavior were the only psychosocial predictors of follow-up firesetting that added incremental variance beyond demographics. In the patient sample, the child's initial involvement in fire-related acts and level of covert antisocial behavior were the only predictors of follow-up firesetting beyond any initial involvement in matchplay. The findings highlight somewhat different risk factors for subsequent firesetting in nonpatient and patient children, especially prior firesetting and matchplay, respectively, and bear implications for the prevention of firesetting recidivism.

Efficacy of cognitive-behavioral treatment and fire safety education for children who set fires: initial and follow-up outcomes.

The efficacy of cognitive-behavioral treatment (CBT) and fire safety education (FSE) for children who had set a recent fire was evaluated. Assessments were conducted with 38 children who were randomly assigned to CBT or FSE and with another 16 children who received a brief intervention (home visit from a firefighter or HVF) that paralleled routine services. Measures in four domains related to the child's fire history were obtained from children and their parents at pre-treatment, post-assessment, and 1-year follow-up. There were several improvements at post-treatment for all conditions on measures of fire involvement, interest, and risk. However, CBT and FSE were more efficacious than HVF on certain measures, including the frequency of firesetting and proportion of children playing with matches, severity of individualized problems with fire, and involvement in fire-related acts and other deviant fire activities. These and other group differences, along with certain time effects, were evident at 1-year follow-up. The findings from this initial comparison study are discussed in the context of needed clinical and research directions for work with firesetters and their families.

Anger and parent-to-child aggression in mood and anxiety disorders.

The relationship between anger and parent-to-child aggression (PTCA) was examined in mothers presenting for treatment of mood and anxiety disorders, because parental anger may have adverse effects on children and anger may decrease with treatment. Anger's role as mediator and moderator of the effects of the following predictors on PTCA was assessed: depression, anxiety, and ecologic variables that can induce or buffer against stress (partner verbal aggression, satisfaction with and perceived availability of social support, socioeconomic status, and number of children). Anger was found to mediate the effects of depression, partner verbal aggression, satisfaction with social support, and number of children on PTCA. Anger also had significant effects on PTCA after controlling for these variables. The other predictors did not have effects on PTCA, and anger did not moderate their effects. If replicated, these findings suggest the importance of examining whether treatment to reduce parental anger will reduce PTCA.

Compliance with recommendations to remove firearms in families participating in a clinical trial for adolescent depression.

OBJECTIVE: To assess the rate and correlates of compliance with clinicians' recommendations to remove firearms from the homes of depressed adolescents participating in a clinical trial. METHOD: The parents of 106 adolescents with major depression who participated in a randomized psychotherapy clinical trial were asked systematically about firearms in the home. Those who answered affirmatively were given information about the suicide risk conveyed by guns in the home and urged to remove them. The rates of gun removal and acquisition were assessed at the end of the treatment and over the subsequent 2-year naturalistic follow-up. RESULTS: Of those who had guns at intake, 26.9% reported removing them by the end of the acute trial. Retention was associated with urban origin, marital dissatisfaction, and paternal psychopathology. Of those who did not have guns at intake, 17.1% reported acquiring them over 2-year follow-up. Living in a 2-parent household and marital dissatisfaction were associated with gun acquisition. CONCLUSIONS: Families of depressed adolescents may frequently be noncompliant with recommendations to remove guns from the home despite compliance with other aspects of treatment. More efficacious interventions to reduce access to guns in the homes of at-risk youths are needed.

Cognitive and family therapies for adolescent depression: treatment specificity, mediation, and moderation.

The specificity of cognitive and family therapies, and potential treatment mediators and moderators, was examined in a randomized clinical trial for adolescent depression. After acute treatment, cognitive-behavioral therapy (CBT) exerted specific effects on cognitive distortions relative to either systemic-behavioral family therapy (SBFT) or nondirective supportive therapy (NST). At 2-year follow-up, SBFT was found to impact family conflict and parent-child relationship problems more than CBT; NST and CBT tended to show a greater reduction in anxiety symptoms than SBFT. Nonspecific therapist variables qualified few outcome analyses. No measures of cognitive distortion or family dysfunction mediated or moderated treatment outcome. As in adult studies, relatively few areas of treatment specificity or mediation were identified. The implications of these findings for clinical treatment and research in adolescent depression are discussed.

Anger attacks: correlates and significance of an underrecognized symptom.

BACKGROUND: Anger attacks over provocations described as trivial by the individual are an underrecognized symptom associated with aggressive acts. They are usually followed by guilt and regret. Anger attacks among mothers are an important problem because they are often directed at the woman's spouse and/or children. This study examines the prevalence and correlates of anger attacks in a psychiatric clinic for women who are either pregnant or up to 18 months postpartum. METHOD: Fifty consecutive consenting patients were assessed at initial presentation with the Structured Clinical Interview for DSM-IV Axis I Disorders, a modified Anger Attacks Questionnaire, self-reports of psychiatric symptoms and psychosocial variables, and clinician ratings. RESULTS: Thirty (60%) of 50 patients reported anger attacks. Of those with anger attacks, 76.7% worried about them, and 73.3% had tried to prevent them. Compared with women without anger attacks, those with anger attacks were significantly more likely to report higher state and trait anger (p < .001), have a diagnosis of unipolar depression (p < .01), report more aggression directed at immediate family, and avoid their children. Both groups displayed little angry affect in the interview, thus appearing similar at assessment. CONCLUSION: Anger attacks in response to children and spouse were common in this group of women and were associated with subjective distress. Because those with and without anger attacks appear similar at interview, inquiring about the presence of anger attacks is important to ensure that they become a focus of treatment.

Child victims' attributions about being physically abused: an examination of factors associated with symptom severity.

The goal of the present study was to examine a conceptual attributional model for the development of psychopathology after child physical abuse. Physically abused or maltreated children referred for treatment completed a series of measures to assess parent-to-child violence, abuse-specific attributions and general attributional style, other potential predictors, and children's psychopathology. Results revealed that the severity of current parent-to-child violence was associated with children's internalizing and externalizing symptoms. Attributions predicted the level of children's psychopathology beyond the variance accounted for by the severity of parent-to-child violence. The severity of parent-to-child violence, attributions about the abuse, general attributional style, and level of family functioning accounted for 28%-63% of the variance in children's abuse-specific, internalizing, and externalizing symptoms. Implications of the findings and research recommendations are discussed.

Methylphenidate and behavior modification in children with ADHD and comorbid ODD or CD: main and incremental effects across settings.

OBJECTIVE: Although the combination of methylphenidate (MPH) and behavior modification (BMOD) has been advocated to enhance clinical outcome for children with attention-deficit hyperactivity disorder (ADHD) and comorbid disruptive disorders, few group studies have been conducted. This study evaluates the separate and incremental effects of these modalities on rating scale and observational measures in multiple settings. METHOD: Sixteen of 22 children with ADHD and comorbid disruptive disorder completed a randomized, placebo-controlled study examining the separate and incremental effects of 2 doses of MPH and BMOD during a partial hospitalization program. Of the 6 who did not complete the study, 2 children developed significant side effects. For the 16 who did complete the study, effects were examined on measures of symptom ratings, behavioral frequencies, and stimulant side effects across program activities. RESULTS: Based on alpha-adjusted analyses of variance, there were several main effects of MPH and BMOD on ADHD symptoms, oppositional behavior, and positive social behavior, with certain effects unique to each intervention and setting. One incremental effect each was found for MPH (positive mood/behavior) and BMOD (negative behavior). MPH and BMOD were associated with few side effects. Effect sizes for each intervention showed considerable variability in clinical response. CONCLUSIONS: That MPH and BMOD had certain unique main and incremental effects extends findings supporting their combination and suggests that integrated studies evaluate multiple dimensions of functioning and in novel settings (e.g., home, school). The incorporation of other intervention components in combined treatments may be warranted to enhance clinical efficacy.

The treatment histories and service involvement of physically and sexually abusive families: description, correspondence, and clinical correlates.

OBJECTIVE: This study examines the treatment histories, and the service needs, concerns, and involvement of cases referred to Child Protective Services (CPS) following an allegation of child physical or sexual abuse in an effort to document their services experiences. METHOD: Standardized clinical assessments were conducted with child victims and their caregivers at intake and at a second assessment following an initial service about 4 to 8 months later (M = 6 mos.). Group differences due to informant type and abuse allegation were examined at each assessment and across time. RESULTS: Thirty percent of the caregivers and children had a past history of psychiatric hospitalization. Reports from both informants at intake identified a range of perceived service needs, treatment goals, and obstacles to service participation. At the post-service assessment, children and their caregivers reported high rates of family (54%, 51%) and parent counseling (50%, 51%), and lower rates for child treatment (13%, 18%). Some significant differences between the two abuse subgroups were found in their patterns of service involvement and in their ratings of service goals and obstacles. Four variables predicted overall family service use at intake: child is Caucasian, low child anxiety, high parental distress, and parental abuse history as a child. CONCLUSIONS: These findings extend initial descriptions of the service involvement of CPS families and bear implications for both practice and research on the delivery of services in CPS.

A clinical trial for adolescent depression: predictors of additional treatment in the acute and follow-up phases of the trial.

OBJECTIVE: To examine the predictors of additional service use among participants in a clinical trial for depression. METHOD: 107 adolescents with DSM-III-R depression were randomly assigned to receive either cognitive-behavioral therapy, systemic behavioral family therapy, or nondirective supportive therapy for 12 to 16 weeks of acute treatment and followed up periodically for 24 months after the termination of acute treatment. RESULTS: More than half (53.3%) of the 107 randomized adolescents received additional treatment beyond that provided in the clinical trial, with a median time to additional treatment from intake of 7.2 months. The rates and times to additional treatment were similar in the 3 treatment groups, despite the superior efficacy of cognitive-behavioral therapy in the acute phase. The severity of the index depressive episode and comorbid dysthymia were a predictor of additional treatment in the acute phase, whereas in the follow-up period the severity of depressive symptomatology, the presence of disruptive disorders, and family problems predicted additional treatment. CONCLUSIONS: Subsequent clinical trials for early-onset depression must focus on the entire depressive episode, rather than just the acute phase, to prevent depressive relapse. In addition, attendant family difficulties and comorbid behavioral problems must be addressed.

Child abuse potential in parents with histories of substance use disorder.

OBJECTIVE: To examine the relationship between parental history of substances use disorders (SUDs) and abuse potential. METHOD: Milner's (1986) Child Abuse Potential Inventory (CAPI) was administered to fathers and mothers (with and without histories of SUDs) of 10- to 12-year-old boys. RESULTS: Fathers and mothers with lifetime histories of SUDs had higher Abuse Scale scores and were more likely to score in the Elevated range (as determined by clinically significant cutoff scores) than parents without such histories. No differences were found between parents with current diagnoses of SUD and those with past (but not current) histories of SUD. Fathers and mothers with a partner who had a history of SUD were more likely to score in the Elevated range, regardless of their own SUD histories. Separate regression models revealed that, for both fathers and mothers, emotional dysregulation (positive and negative affectivity) predicted Abuse Scale scores. Additional contributors to Abuse Scale scores were SUD status in fathers, and lack of involvement with the child in mothers. CONCLUSIONS: History of SUDs in both fathers and mothers increases abuse potential. Contributors to abuse potential differed in fathers and mothers, underscoring the importance of examining parents separately in child maltreatment research.

Rapid response to psychosocial treatment for adolescent depression: a two-year follow-up.

OBJECTIVE: To examine the differential course and treatment outcome of patients who participated in a randomized clinical trial, comparing cognitive, family, and supportive psychotherapies for adolescent major depressive disorder. METHOD: In a sample of 100 depressed adolescents, remission, clinical recovery, recurrence, and functional improvement were examined at the end of acute treatment and at 1- and 2-year follow-up, according to their type of response to treatment. Rapid response was defined as a decline of > or = 50% in the Beck Depression Inventory (BDI) score from pretreatment until the beginning of the second session of psychotherapy, intermediate as a decline of < 50% but > 0%, and initial nonresponse as a BDI score that stayed the same or increased. RESULTS: Rapid responders showed a better outcome at acute treatment, 1-year, and in some measures, 2-year follow-up. For those who had recurrences over time, rapid responders showed a longer period before recurrence. Subjects were most likely to respond rapidly, or not at all, in the supportive cell. CONCLUSIONS: These findings suggest that milder forms of depression may benefit from initial supportive therapy or short trials of more specialized types of psychotherapy. The use of a placebo run-in period might help to "wash out" nonspecific responders.

Effects of methylphenidate on aggressive urban children with attention deficit hyperactivity disorder.

Determined the efficacy of methylphenidate (MPH) in a clinical population of aggressive, urban children diagnosed with attention deficit hyperactivity disorder (ADHD). In previous studies of prepubertal children with ADHD, MPH has been shown to be effective when compared with placebo. Eighteen inner-city children (ages 6 to 12 years), diagnosed with ADHD and attending a summer treatment program for youth with disruptive behavior disorders, participated in a double-blind placebo trial with assessment data obtained from staff in the program and parents at home. Based on staff ratings of the children's behavior in the program and an academic classroom, the children displayed significant improvements in ADHD symptoms and aggressive behavior with low- and high-dose MPH conditions. At home, parents and guardians reported few significant differences between placebo and MPH on behavior ratings. In both settings, MPH was well tolerated with few side effects found during active drug conditions.

Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression.

OBJECTIVE: To assess the predictors of treatment outcome across treatments, as well as those associated with differential treatment response. METHOD: One hundred seven adolescent outpatients, aged 13 to 18 years, with DSM-III-R major depression were randomly assigned to one of three manual-based, brief (12 to 16 sessions) psychosocial treatments: cognitive-behavioral therapy (CBT), systemic-behavioral family therapy, or nondirective supportive therapy. Those with good and poor outcomes were compared. RESULTS: Continued depression was predicted by clinical referral (versus via advertisement) and was in part mediated by hopelessness. Other predictors of depression were comorbid anxiety disorder and higher levels of cognitive distortion and hopelessness at intake. Achievement of clinical remission was predicted by a higher level of self-reported depression. Poorer functional status was predicted by a higher level of initial interviewer-rated depression. Comorbid anxiety and maternal depressive symptoms predicted differential treatment efficacy. CBT's performance continued to be robust with respect to nondirective supportive therapy, even in the presence of the above-noted adverse predictors. CONCLUSION: Predictors of poor outcome may give clues as to how to boost treatment response. Subjects who come to treatment for clinical trials via advertisement (versus clinical referral) may show more favorable treatment responses. CBT is likely to be a robust intervention even in more complex and difficult-to-treat patients.

Psychotherapy: definitions, mechanisms of action, and relationship to etiological models.

In this paper, we define psychotherapy as a modality of treatment in which the therapist and patient(s) work together to ameliorate psychopathologic conditions and functional impairment through focus on the therapeutic relationship; the patient's attitudes, thoughts, affect, and behavior; and social context and development. The possible mechanisms of action and active ingredients of psychotherapy in children and adolescents are discussed, with an emphasis on the above-noted domains. The adult psychotherapy literature strongly supports the central roles of the therapeutic relationship and therapeutic empathy; this has been much less intensively explored in the child and adolescent psychotherapy literature. Similarly, there have been few studies examining the mediation of treatment effects by impact on specific domains. Ideally, treatment studies should gather data that can be informative about the impact of putative mediating and moderating psychosocial and biological variables on outcome and course. The results of such studies can aid further refinements in both theories of etiology and improvement in treatments for children and adolescents.

Clinical monitoring of treatment course in child physical abuse: psychometric characteristics and treatment comparisons.

Weekly reports of high-risk indicators designed to monitor the course of treatment were obtained from physically abused, school-aged children and their parents/guardians who were randomly assigned to Individual Child and Parent Cognitive-Behavioral Treatment (CBT) or Family Therapy (FT). Measures of parental anger and physical discipline/force, and family problems were obtained each session. The measures showed moderate stability and parent-child correspondence. Between 20% and 23% of the two informant's reports acknowledged high levels of physical discipline/force during the early and late phases of treatment, respectively, and an even higher percentage of cases reported heightened parental anger and family problems. Early treatment reports from both informants predicted late period reports, but only parent reports were related to validity measures. The overall levels of parental anger and physical discipline/force were lower in CBT than FT families, though each group showed a reduction on these items from the early to late treatment sessions. The importance of routine monitoring of clinical course during intervention, especially in the identification of cases at-risk of reabuse, is discussed.

Child physical abuse and aggression: preliminary findings on the role of internalizing problems.

OBJECTIVE: To test the prediction that the interaction of physical abuse and internalizing problems will heighten levels of aggressive behavior in a group of disruptive children. METHOD: Fifty-two clinic-referred disruptive children (aged 7 through 15 years) were assessed in terms of history of physical abuse, internalizing behavior problems (rated by parents), and aggressive behavior (rated by parents, teachers, and clinic staff). RESULTS: Physically abused children with co-occurring high levels of internalizing problems (based on a median split) exhibited significantly higher levels of aggression as rated by parents (p < .000) and teachers (p < .020) and a trend toward heightened aggression as rated by staff (p < .08). The patterns were similar across the three independent informants and remained regardless of age, gender, or race. CONCLUSIONS: Physical abuse was related to heightened levels of aggression only in those children who also had emotional difficulties. Results lend some support to a transactional model of the development of aggression, suggesting that problems arise out of interactions between child factors (such as internalizing problems) and adverse family experiences (such as physical abuse).

Salivary testosterone and cortisol in disruptive children: relationship to aggressive, hyperactive, and internalizing behaviors.

OBJECTIVE: To test predictions that basal salivary testosterone and cortisol are related to antisocial and internalizing behaviors, respectively, and that cortisol moderates the testosterone-aggression relationship. METHOD: Saliva samples were assayed to determine testosterone and cortisol levels in 40 clinic-referred disruptive children (aged 7 through 14 years) who were rated on aggression, inattention/overactivity, and internalizing behavior by parents, teachers, and clinic staff members. RESULTS: Results indicated significant positive relationships between testosterone and staff-rated aggression and between cortisol and parent-rated internalizing behavior. A significant negative relationship was found between cortisol and staff-rated inattention/overactivity. No interactions between testosterone and cortisol were found. These results were maintained regardless of age, racial background, height, weight, diagnosis, or medication status. CONCLUSIONS: Results suggest moderate relationships between testosterone and observed aggression, and between cortisol and emotional behaviors, in a group of disruptive children. Cortisol did not moderate the testosterone-aggression relationship in this population.

Children's descriptions of their firesetting incidents: characteristics and relationship to recidivism.

OBJECTIVE: The primary purpose of the study was to identify characteristics of children's firesetting incidents and examine the relationship of reported characteristics to psychopathology and firesetting history. METHOD: A sample of 95 firesetters were interviewed using the Fire Incident Analysis for Children (FIAC). Other child or parent measures were obtained reflecting behavioral correlates and risk factors for firesetting at initial assessment, and firesetting history measures at 2-year follow-up. RESULTS: Access to incendiaries, lack of child remorse and parental consequences, and motives of curiosity and fun were commonly reported characteristics. Certain firesetting characteristics were associated with follow-up recidivism. Repeat versus single-incident firesetters at initial assessment were similar in firesetting characteristics but differed in measures of psychopathology and follow-up recidivism. CONCLUSIONS: Children can report on personal and environmental details of their firesetting incidents, which may help to identify those children most at-risk for setting an additional fire. The findings bear implications for understanding firesetting risk-assessment measures, the role of specialized child interviews, and potential predictors of firesetting recidivism among children.