Early-onset Disruptive Behavior Research Articles

Online-Delivered Over Staff-Delivered Parenting Intervention for Young Children With Disruptive Behavior Problems: Cost-Minimization Analysis.

BackgroundHigh-prevalence childhood mental health problems like early-onset disruptive behavior problems (DBPs) pose a significant public health challenge and necessitate interventions with adequate population reach. The treatment approach of choice for childhood DBPs, namely evidence-based parenting intervention, has not been sufficiently disseminated when relying solely on staff-delivered services. Online-delivered parenting intervention is a promising strategy, but the cost minimization of this delivery model for reducing child DBPs is unknown compared with the more traditional staff-delivered modality.ObjectiveThis study aimed to examine the cost-minimization of an online parenting intervention for childhood disruptive behavior problems compared with the staff-delivered version of the same content. This objective, pursued in the context of a randomized trial, made use of cost data collected from parents and service providers.MethodsA cost-minimization analysis (CMA) was conducted comparing the online and staff-delivered parenting interventions. Families (N=334) with children 3-7 years old, who exhibited clinically elevated disruptive behavior problems, were randomly assigned to the two parenting interventions. Participants, delivery staff, and administrators provided data for the CMA concerning family participation time and expenses, program delivery time (direct and nondirect), and nonpersonnel resources (eg, space, materials, and access fee). The CMA was conducted using both intent-to-treat and per-protocol analytic approaches.ResultsFor the intent-to-treat analyses, the online parenting intervention reflected significantly lower program costs (t168=23.2; P<.001), family costs (t185=9.2; P<.001), and total costs (t171=19.1; P<.001) compared to the staff-delivered intervention. The mean incremental cost difference between the interventions was $1164 total costs per case. The same pattern of significant differences was confirmed in the per-protocol analysis based on the families who completed their respective intervention, with a mean incremental cost difference of $1483 per case. All costs were valued or adjusted in 2017 US dollars.ConclusionsThe online-delivered parenting intervention in this randomized study produced substantial cost minimization compared with the staff-delivered intervention providing the same content. Cost minimization was driven primarily by personnel time and, to a lesser extent, by facilities costs and family travel time. The CMA was accomplished with three critical conditions in place: (1) the two intervention delivery modalities (ie, online and staff) held intervention content constant; (2) families were randomized to the two parenting interventions; and (3) the online-delivered intervention was previously confirmed to be non-inferior to the staff-delivered intervention in significantly reducing the primary outcome, child disruptive behavior problems. Given those conditions, cost minimization for the online parenting intervention was unequivocal.Trial RegistrationClinicalTrials.gov NCT02121431; https://clinicaltrials.gov/ct2/show/NCT02121431

Direct-to-Consumer Marketing for Parent-Child Interaction Therapy: Impact of Language and Messenger.

Parent-Child Interaction Therapy (PCIT) is an effective therapy to treat early onset disruptive behavior problems and child physical maltreatment. In order to support the successful implementation and sustainment of PCIT, strategies are needed to recruit parents into care, especially for racial and ethnic minority families, who often have lower rates of access and utilization of mental health services. This study investigated the impact of direct-to-consumer advertisements on parents' attitudes towards PCIT. Advertisements were delivered in Spanish and English, with either a parent testimony or therapist explaining the treatment. Participants were parents of children between the ages of 2 and 7, who were recruited through Amazon Mechanical Turk. Participants (N = 204) were 38.2% female and 49.5% Spanish speaking. There were no main effects for language or messenger related to PCIT Help-Seeking Intentions, Attitudes, or Stigmatization. However, there was an interaction effect for language and messenger for PCIT Help-Seeking Intentions. Specifically, Spanish-speaking participants had higher intentions when the messenger was a therapist rather than a parent, and had lower intentions than English-speaking parents when the messenger was a parent. These findings are promising for direct-to-consumer advertising strategies that may help recruit more Spanish-speaking families into PCIT, which could help address disparities in access to mental health services.

Children With Early-Onset Disruptive Behavior: Parental Mental Disorders Predict Poor Psychosocial Functioning in Adolescence.

Parental mental disorders (MD) and child early-onset disruptive behavior (DB) are well-established risk factors for poor outcomes in adolescence. However, it is not clear whether parental MD increases risk of future maladjustment among children who already display DB. Parents of 9-year-old children reported on child DB, whereas a patient registry was used to determine parental MD. At follow-ups at ages 15 (n= 6,319) and 18 (n= 3,068) years, information about various problems were collected via registries, parent-, and self-reports. In the total sample, child DB was related to all outcomes (mean odds ratio [OR]= 1.18; range= 1.07-1.51; p values< .01), paternal MD to criminality, aggression, truancy, poor school performance, and a cumulative risk index of poor functioning, and maternal MD to peer problems, rule breaking, and truancy (mean OR= 1.67; range= 1.19-2.71; p values< .05). In the subsample of children with DB, paternal MD predicted criminality, consequences of antisocial behavior, truancy, poor school performance, and cumulative risk, whereas maternal MD predicted peer problems (mean OR= 1.94; range= 1.30-2.40; p values< .05). This study provides novel evidence that parental MD places 9-year-olds with DB at risk for negative outcomes in adolescence. In addition, paternal MD is a better predictor than maternal MD, regardless of child DB at age 9, suggesting that fathers should be given increased attention in future research. Treatment-as-usual of children with DB could be augmented with additional screening and, if necessary, treatment of mental health problems in their parents.

A randomized controlled trial evaluating a low-intensity interactive online parenting intervention, Triple P Online Brief, with parents of children with early onset conduct problems

ObjectiveThis randomized controlled trial examined the efficacy of Triple P Online Brief, a low-intensity online positive parenting program for parents of children with early onset disruptive behavior problems. MethodTwo hundred parents with 2–9-year-old children displaying early onset disruptive behavior difficulties were randomly assigned to either the intervention condition (n = 100) or a Waitlist Control group (n = 100). ResultsAt 8-week post-assessment, parents in the intervention group displayed significantly less use of ineffective parenting strategies and significantly more confidence in dealing with a range of behavior concerns. These effects were maintained at 9-month follow-up assessment. A delayed effect was found for child behavior problems, with parents in the intervention group reporting significantly fewer and less frequent child behavior problems at follow-up, but not at post-assessment. All effect sizes were in the small to medium range. There were no significant improvements in observed negative parent and child behavior. No change was seen for parents' adjustment, anger, or conflict over parenting. Consumer satisfaction ratings for the program were high. ConclusionsA brief, low-intensity parenting program delivered via the Internet can bring about significant improvements in parenting and child behavior.

Comparing Self-Regulation-Associated Event Related Potentials in Preschool Children with and without High Levels of Disruptive Behavior.

Deficient self-regulation plays a key role in the etiology of early onset disruptive behavior disorders and signals risk for chronic psychopathology. However, to date, there has been no research comparing preschool children with and without high levels of disruptive behavior using Event Related Potentials (ERPs) associated with specific self-regulation sub-processes. We examined 15 preschool children with high levels of disruptive behavior (35% female) and 20 peers with low disruptive behavior (50% female) who completed a Go/No-go task that provided emotionally valenced feedback. We tested whether 4 ERP components: the Error Related Negativity, the Error Positivity, the Feedback Related Negativity, and the No-go N2, differed in preschool children with and without high levels of disruptive behavior. Preschoolers with high levels of disruptive behavior showed less differentiation between the Error Positivity and corresponding waveforms following correct responses at posterior sites. Preschoolers with high and low disruptive behavior also showed differences in Go/No-go N2 waveform amplitudes across electrodes. These findings suggest that preschool children with high levels of disruptive behavior may show abnormal brain activity during certain self-regulation sub-processes, informing potential advances in conceptualizing and treating early disruptive behavior.

Identifying Unbiased Items for Screening Preschoolers for Disruptive Behavior Problems.

Efficient identification and referral to behavioral services are crucial in addressing early-onset disruptive behavior problems. Existing screening instruments for preschoolers are not ideal for pediatric primary care settings serving diverse populations. Eighteen candidate items for a new brief screening instrument were examined to identify those exhibiting measurement bias (i.e., differential item functioning, DIF) by child characteristics. Parents/guardians of preschool-aged children ( N = 900) from four primary care settings completed two full-length behavioral rating scales. Items measuring disruptive behavior problems were tested for DIF by child race, sex, and socioeconomic status using two approaches: item response theory-based likelihood ratio tests and ordinal logistic regression. Of 18 items, eight were identified with statistically significant DIF by at least one method. The bias observed in 8 of 18 items made them undesirable for screening diverse populations of children. These items were excluded from the new brief screening tool.

Treatment Outcome of Adolescent Inpatients With Early-Onset and Adolescent-Onset Disruptive Behavior.

Unlike adolescents with adolescent-onset (AO) disruptive behavior, adolescents with early-onset (EO) disruptive behavior may not benefit from treatment. Using Symptom Checklist (SCL-90-R) ratings at admission and discharge of adolescent inpatients with EO (n = 85) and AO (n = 60) disruptive behavior treatment outcome was determined by (a) a change in mean scores and (b) the Reliable Change Index. For a subgroup, ratings on the Satisfaction Questionnaire Residential Youth Care for Parents (n = 83) were used to verify the treatment outcome. Inpatients with EO disruptive behavior had a higher risk of dropout (44.4%) from treatment than the AO group (24.7%). Among the treatment completers, both onset groups reported improvements on the SCL-90-R, with 26.9% recovering and 31.7% improving. Inpatients who reported improvement were mostly rated as improved by their parents (r = .33). As EO inpatients are more likely to drop out, interventions should aim at motivating youngsters to continue treatment, particularly given the poor outcome in this group. Treatment may benefit both groups because those EO youths who stayed in treatment improved to the same extent as AO inpatients.

Distilling Common History and Practice Elements to Inform Dissemination: Hanf-Model BPT Programs as an Example.

There is a shift in evidence-based practice toward an understanding of the treatment elements that characterize empirically supported interventions in general and the core components of specific approaches in particular. The evidence base for behavioral parent training (BPT) and the standard of care for early-onset disruptive behavior disorders (oppositional defiant disorder and conduct disorder), which frequently co-occur with attention deficit hyperactivity disorder, are well established, yet an ahistorical, program-specific lens tells little regarding how leaders, University of Oregon Medical School, shaped the common practice elements of contemporary evidence-based BPT. Accordingly, this review summarizes the formative work of Hanf, as well as the core elements, evolution, and extensions of her work, represented in Community Parent Education (COPE; (Cunningham et al. in J Child Psychol Psychiatry 36:1141-1159, 1995; Cunningham et al. in COPE, the community parent education program: large group community-based workshops for parents of 3- to 18-year-olds, COPE Works, Hamilton, 2009), Defiant Children (DC; (Barkley in Defiant children: a clinician's manual for assessment and parent training, Guilford Press, New York, 1987; Barkley in Defiant children: a clinician's manual for assessment and parent training, Guilford Press, New York, 2013), Helping the Noncompliant Child (HNC; Forehand and McMahon in Helping the noncompliant child: a clinician's guide to parent training, Guilford Press, New York, 1981; McMahon and Forehand in Helping the noncompliant child: family-based treatment for oppositional behavior, 2nd ed., Guilford Press, New York, 2003), Parent-child interaction therapy (PCIT; Eyberg and Robinson in J Clin Child Adolesc Psychol 11:130-137, 1982. doi:10.1080/15374418209533076; Eyberg in Child Fam Behav Ther 10:33-46, 1988; Eyberg and Funderburk in Parent-child interaction therapy protocol, PCIT International, Gainesville, 2011), and the Incredible Years (IY; (Webster-Stratton in Behav Ther 12:634-642, 1981. doi:10.1016/S0005-7894(81)80135-9; Webster-Stratton in J Pediatr Psychol 7:279-294, 1982. doi:10.1093/jpepsy/7.3.279; Webster-Stratton in The incredible years: parents and children series. Leader's guide: preschool version of BASIC (ages 3-6years, The Incredible Years, Seattle, 2008). Our goal is not to provide an exhaustive review of the evidence base for the Hanf-Model programs, rather our intention is to provide a template of sorts from which agencies and clinicians can make informed choices about how and why they are using one program versus another, as well as how to make inform flexible use one program or combination of practice elements across programs, to best meet the needs of child clients and their families. Clinical implications and directions for future work are discussed.

Reward Processing, Functional Connectivity, Psychopathy, and Research Domain Criteria

Psychopathy is a disorder characterized by pronounced emotional deficits (including reduced guilt and empathy) and an increased risk for displaying antisocial behavior. The disorder was initially described by Cleckley and subsequently was characterized more formally via a behavioral checklist and interview developed by Hare ( 1 Hare R.D. A research scale for the assessment of psychopathy in criminal populations. Pers Individ Dif. 1980; 1: 111-119 Crossref Scopus (656) Google Scholar ). Hare’s characterization was important because it provided a description of a behavioral presentation associated with specific causal factors. In contrast, a wide variety of causal factors are associated with the more general antisocial behavior descriptions provided by DSM or ICD. Functional Connectivity Bias in the Prefrontal Cortex of PsychopathsBiological PsychiatryVol. 78Issue 9PreviewPsychopathy is characterized by a distinctive interpersonal style that combines callous-unemotional traits with inflexible and antisocial behavior. Traditional emotion-based perspectives link emotional impairment mostly to alterations in amygdala-ventromedial frontal circuits. However, these models alone cannot explain why individuals with psychopathy can regularly benefit from emotional information when placed on their focus of attention and why they are more resistant to interference from nonaffective contextual cues. Full-Text PDF Incentive Processing in Persistent Disruptive Behavior and Psychopathic Traits: A Functional Magnetic Resonance Imaging Study in AdolescentsBiological PsychiatryVol. 78Issue 9PreviewChildren with early-onset disruptive behavior disorder (DBD), especially those with callous-unemotional traits, are at risk of developing persistent and severe adult antisocial behavior. One possible underlying mechanism for persistence is deficient reward and loss sensitivity, i.e., deficient incentive processing. However, little is known about the relation between deficient incentive processing and persistence of antisocial behavior into adulthood or its relation with callous-unemotional and other psychopathic traits. Full-Text PDF

Caregiver Use of the Core Components of Technology-Enhanced Helping the Noncompliant Child: A Case Series Analysis of Low-Income Families

Children from low-income families are more likely to develop early-onset disruptive behavior disorders (DBDs) compared to their higher income counterparts. Low-income families of children with early-onset DBDs, however, are less likely to engage in the standard-of-care treatment, behavioral parent training (BPT), than families from other sociodemographic groups. Preliminary between-group findings suggested technology-enhanced BPT was associated with increased engagement and boosted treatment outcomes for low-income families relative to standard BPT. The current study used a case series design to take this research a step further by examining whether there was variability in use of, and reactions to, the smartphone enhancements within technology-enhanced BPT and the extent to which this variability paralleled treatment outcome. Findings provide a window into the uptake and use of technology-enhanced service delivery methods among low-income families, with implications for the broader field of children’s mental health.

Incentive Processing in Persistent Disruptive Behavior and Psychopathic Traits: A Functional Magnetic Resonance Imaging Study in Adolescents

BackgroundChildren with early-onset disruptive behavior disorder (DBD), especially those with callous-unemotional traits, are at risk of developing persistent and severe adult antisocial behavior. One possible underlying mechanism for persistence is deficient reward and loss sensitivity, i.e., deficient incentive processing. However, little is known about the relation between deficient incentive processing and persistence of antisocial behavior into adulthood or its relation with callous-unemotional and other psychopathic traits. In this study, we investigate the relationship between the neural correlates of incentive processing and both DBD persistence and psychopathic traits. MethodsIn a sample of 128 adolescents (mean age 17.7) with a history of criminal offending before age 12, functional magnetic resonance imaging was performed during a monetary incentive delay task designed to assess neural responses during incentive processing. Neural activation during incentive processing was then associated with DBD persistence and psychopathic traits, measured with the Youth Psychopathic Traits Inventory. ResultsCompared with both healthy control subjects and youths who had desisted from DBD, persistent DBD subjects showed lower neural responses in the ventral striatum during reward outcomes and higher neural responses in the amygdala during loss outcomes. Callous-unemotional traits were related to lower neural responses in the amygdala during reward outcomes, while other psychopathic traits were not related to incentive processing. ConclusionsIn the current study, aberrant incentive processing is related to persistence of childhood antisocial behavior into late adolescence and to callous-unemotional traits. This mechanism may underlie treatment resistance in a subgroup of antisocial youth and provide a target for intervention.

Rationale and Considerations for the Internet-Based Delivery of Parent–Child Interaction Therapy

Given the enormous individual, familial, and societal costs associated with early disruptive behavior disorders, transformative efforts are needed to develop innovative options for overcoming traditional barriers to effective care and for broadening the availability of supported interventions. This paper presents the rationale and key considerations for a promising innovation in the treatment of early-onset disruptive behavior disorders—that is, the development of an Internet-based format for the delivery of Parent–Child Interaction Therapy (PCIT) directly to families in their own homes. Specifically, we consider traditional barriers to effective care, and discuss how technological innovations can overcome problems of treatment availability, accessibility, and acceptability. We then detail our current Internet-delivered PCIT treatment program (I-PCIT), which is currently being evaluated across multiple randomized clinical trials relative to waitlist comparison, and to traditional in-office PCIT. Embedded video clips of children treated with I-PCIT are used to illustrate novel aspects of the treatment.

A Comparison of Online Versus Workbook Delivery of a Self-Help Positive Parenting Program

A noninferiority randomized trial design compared the efficacy of two self-help variants of the Triple P-Positive Parenting Program: an online version and a self-help workbook. We randomly assigned families of 193 children displaying early onset disruptive behavior difficulties to the online (N=97) or workbook (N=96) interventions. Parents completed questionnaire measures of child behavior, parenting, child maltreatment risk, personal adjustment and relationship quality at pre- and post-intervention and again at 6-month follow up. The short-term intervention effects of the Triple P Online program were not inferior to the workbook on the primary outcomes of disruptive child behavior and dysfunctional parenting as reported by both mothers and fathers. Both interventions were associated with significant and clinically meaningful declines from pre- to post-intervention in levels of disruptive child behavior, dysfunctional parenting styles, risk of child maltreatment, and inter-parental conflict on both mother and father report measures. Intervention effects were largely maintained at 6-month follow up, thus supporting the use of self-help parenting programs within a comprehensive population-based system of parenting support to reduce child maltreatment and behavioral problems in children.

Observed parenting behaviors interact with a polymorphism of the brain-derived neurotrophic factor gene to predict the emergence of oppositional defiant and callous–unemotional behaviors at age 3 years

Using the Durham Child Health and Development Study, this study (N = 171) tested whether observed parenting behaviors in infancy (6 and 12 months) and toddlerhood/preschool (24 and 36 months) interacted with a child polymorphism of the brain-derived neurotrophic factor gene to predict oppositional defiant disorder (ODD) and callous-unemotional (CU) behaviors at age 3 years. Child genotype interacted with observed harsh and intrusive (but not sensitive) parenting to predict ODD and CU behaviors. Harsh-intrusive parenting was more strongly associated with ODD and CU for children with a methionine allele of the brain-derived neurotrophic factor gene. CU behaviors were uniquely predicted by harsh-intrusive parenting in infancy, whereas ODD behaviors were predicted by harsh-intrusive parenting in both infancy and toddlerhood/preschool. The results are discussed from the perspective of the contributions of caregiving behaviors as contributing to distinct aspects of early onset disruptive behavior.

Technology-Enhanced Program for Child Disruptive Behavior Disorders: Development and Pilot Randomized Control Trial

Early onset disruptive behavior disorders are overrepresented in low-income families; yet these families are less likely to engage in behavioral parent training (BPT) than other groups. This project aimed to develop and pilot test a technology-enhanced version of one evidence-based BPT program, Helping the Noncompliant Child (HNC). The aim was to increase engagement of low-income families and, in turn, child behavior outcomes, with potential cost-savings associated with greater treatment efficiency. Low-income families of 3- to 8-year-old children with clinically significant disruptive behaviors were randomized to and completed standard HNC (n = 8) or Technology-Enhanced HNC (TE-HNC; n = 7). On average, caregivers were 37 years old; 87% were female, and 80% worked at least part-time. More than half (53%) of the youth were boys; the average age of the sample was 5.67 years. All families received the standard HNC program; however, TE-HNC also included the following smartphone enhancements: (a) skills video series, (b) brief daily surveys, (c) text message reminders, (d) video recording home practice, and (e) midweek video calls. TE-HNC yielded larger effect sizes than HNC for all engagement outcomes. Both groups yielded clinically significant improvements in disruptive behavior; however, findings suggest that the greater program engagement associated with TE-HNC boosted child treatment outcome. Further evidence for the boost afforded by the technology is revealed in family responses to postassessment interviews. Finally, cost analysis suggests that TE-HNC families also required fewer sessions than HNC families to complete the program, an efficiency that did not compromise family satisfaction. TE-HNC shows promise as an innovative approach to engaging low-income families in BPT with potential cost-savings and, therefore, merits further investigation on a larger scale.

Evaluation of a booster intervention three years after acute treatment for early-onset disruptive behavior disorders.

This study examines the impact of a brief booster treatment administered 3years after the delivery of an acute treatment in a group (n = 118) of clinically referred boys and girls (ages 6 to 11) originally diagnosed with Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD). At the conclusion of the acute treatment and three-year follow-up period (i.e., study month 42), the sample was re-randomized into Booster treatment or Enhanced Usual Care and then assessed at four later timepoints (i.e., post-booster, and 6-, 12- and 24-month booster follow-up). Booster treatment was directed towards addressing individualized problems and some unique developmental issues of adolescence based on the same original protocol content and treatment setting, whereas the Enhanced Usual Care condition involved providing clinical recommendations based on the assessment and an outside referral for services. HLM analyses identified no significant group differences and few time effects across child, parent, and teacher reports on a broad range of child functioning and impairment outcomes. Analyses examining the role of putative moderators or predictors (e.g., severity of externalizing behavior, dose of treatment) were likewise non-significant. We discuss the nature and implications of these novel findings regarding the role and timing of booster treatment to address the continuity of DBD over time.

A randomized controlled trial evaluating the efficacy of Triple P Online with parents of children with early-onset conduct problems

ObjectiveThis study examined the efficacy of Triple P Online (TPOL), an eight-module intensive online positive parenting program for parents of children with early-onset disruptive behavior problems. MethodOne hundred and sixteen parents with 2–9-year-old children displaying early-onset disruptive behavior difficulties were randomly assigned to either the intervention condition (N = 60) or an internet-use-as-usual control group (N = 56). ResultsAt post-intervention assessment, parents receiving the internet intervention TPOL had significantly better outcomes on measures of problem child behavior, dysfunctional parenting styles, parents’ confidence in their parenting role, and parental anger. At 6-month follow-up assessment intervention gains were generally maintained, and in some cases enhanced. Consumer satisfaction ratings for the program were high. ConclusionsInternet-delivered self-help parenting programs appear to make a valuable contribution to a comprehensive public health approach to parenting support.

Trajectories of Symptom Reduction and Engagement During Treatment for Childhood Behavior Disorders: Differences Across Settings

In this study, we examined trajectories of symptom reduction and family engagement during the modular treatment phase of a clinical trial for early-onset disruptive behavior disorders that was applied either in community settings or a clinic. Participants (N=139) were 6-11 year-old children with diagnoses of Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD). Symptoms of ODD/CD and level of engagement were assessed at every session during the course of treatment. Overall, symptom reduction was characterized by a gradual decline in symptoms over the first 11 sessions followed by a flatter slope beginning with session 12. Clinic participants evidenced a greater decline in symptoms after session 11 compared to participants in community settings. Overall, engagement remained stable during the course of treatment. However, clinic participants had higher levels of engagement throughout treatment compared to participants in the community settings. These setting differences in level of engagement did not account for the differences in trajectories of symptom reduction across the treatment settings.

Parent-child interaction therapy: An examination of cost-effectiveness.

In regard to mental health impairment, disruptive behavior has been found to be the most frequent cause of child outpatient or inpatient referral (Wells & Forehand, 1985) and is estimated to affect up to 23% of children (O'Brien, 1996). In addition to an especially poor prognosis, the societal cost of children with disruptive behavior disorders (DBD) is great. Estimates indicate that a child with severe behavioral problems is about ten times more expensive than a child without such problems (Scott, Knapp, Henderson, & Maughan, 2001). Given the potential monetary benefits of early among this population, as well as the intangible gains associated with improved behavior and a safer community, it is advantageous to explore DBD treatments that are efficacious and financially prudent. The current paper sets out to evaluate the cost-effectiveness of Parent-Child Interaction Therapy (PCIT; Eyberg, Boggs, & Algina, 1995; Hembree-Kigin & McNeil, 1995), an empirically supported treatment for child DBD, and in doing so, assess the anticipated financial costs and behavior improvements associated with its implementation and practice. First, we will review the extant literature and examine the implications, financial and otherwise, of untreated DBD. Next, we introduce PCIT and demonstrate the empirical support for the use of PCIT for children with DBD. Following such an introduction, we commence with an analysis of the costs and anticipated behavior changes associated with the use of PCIT on a per-child basis. Additionally, we discuss the startup costs necessary for implementing PCIT. Lastly, we conclude with a discussion of the implications of the results and suggest future directions for research in this area. We hope that this paper will encourage the use of PCIT in new settings, including both community and university clinics. Particularly when considering the exuberant costs of DBD, PCIT may be an attractive option to clinicians and policymakers if it is demonstrated to be a cost-effective treatment. The class of externalizing behaviors referred to as DBD is generally typified by aggressive, defiant, and impulsive behaviors which are commonly diagnosed as either Conduct Disorder (CD) or Oppositional Defiant Disorder (ODD). CD is characterized by aggression, theft, destruction of property, and defiance of societal norms. ODD is defined as a persistent pattern of behavior which includes arguing, disobedience of adult requests, and anger. All, by definition, lead to clinically significant impairment in the academic, interpersonal, and/or occupational domains (American Psychiatric Association, 2000). Additionally, these disorders are typically present early in life and can be recognized in children as as two years of age (Muntz, Hutchings, Edwards, Hounsome, & O'Celleachair, 2004). Among the numerous biological and situational correlates for the development of DBD, some of the strongest data indicate that family factors greatly contribute to child behavior. Indeed, among others, parental depression (Querido, Eyberg, & Boggs, 2001), reports of parental stress (Eyberg, Boggs, & Rodriguez, 1992), and parent-child interactions (Olson, Bates, & Bayles, 1990) have all been demonstrated to be associated with the display of child disruptive behavior. Indeed, research on this population indicates that parent-child interactions are one of the strongest determinants of the development of childhood behavior problems (Campbell, 1997; Patterson, 1982). Given the severity of these behaviors, there is a strong need for effective and early interventions. McNeil, Capage, Bahl, and Blanc (1999) reported that young children with severe behavior problems do not immediately 'outgrow' their disruptive behaviors without intervention (p. 451). Such a statement is not hyperbole as early-onset disruptive behavior is indicative of an especially poor prognosis (McMahon & Wells, 1998). …

Defining the “Disruptive” in Preschool Behavior: What Diagnostic Observation Can Teach Us

This paper presents the clinical/developmental framework underlying a new diagnostic observational tool, the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS). The special importance of observation for clinical assessment during the preschool period is delineated. The developmental rationale for a multi-dimensional assessment of disruptive behavior in young children, including problems in modulation of negative affect and low competence is discussed. The ways in which the DB-DOS will elucidate distinctions between normative and atypical behavior during this developmental period via (a) the integration of qualitative and quantitative dimensions of behavior within a clinically-sensitive coding system, (b) the observation of child behavior both within, and outside of, the parent-child context and (c) the use of specially designed tasks to "press" for clinically salient behaviors are addressed. The promise of this new method for yielding a more precise, developmentally based description of the phenotype of early onset disruptive behavior problems and for providing a standardized clinical tool for observational assessment of disruptive behavior in young children is presented. Large-scale validation of the measure is currently underway.