[Show abstract][Hide abstract] ABSTRACT: Background: Evidence-based treatments (EBTs) are available for treating childhood behavioral health challenges. Despite EBTs' potential to help children and families, they have primarily remained in university settings. Little empirical evidence exists regarding how specific, commonly used training and quality control models are effective in changing practice, achieving full implementation, and supporting positive client outcomes. Methods/design: This study (NIMH RO1 MH095750; ClinicalTrials.gov Identifier: NCT02543359), which is currently in progress, will evaluate the effectiveness of three training models (Learning Collaborative (LC), Cascading Model (CM), and Distance Education (DE)) to implement a well-established EBT , Parent-Child Interaction Therapy, in real-world, community settings. The three models differ in their costs, skill training, quality control methods, and capacity to address broader implementation challenges. The project is guided by three specific aims: (1) to build knowledge about training outcomes, (2) to build knowledge about implementation outcomes, and (3) to test the differential impact of training clinicians using LC, CM, and DE models on key client outcomes. Fifty (50) licensed psychiatric clinics across Pennsylvania were randomized to one of the three training conditions: (1) LC, (2) CM, or (3) DE. The impact of training on practice skills (clinician level) and implementation/sustainment outcomes (clinic level) are being evaluated at four timepoints coinciding with the training schedule: baseline, 6 (mid), 12 (post), and 24 months (1 year follow-up). Immediately after training begins, parent-child dyads (client level) are recruited from the caseloads of participating clinicians. Client outcomes are being assessed at four timepoints (pre-treatment, 1, 6, and 12 months after the pre-treatment). Discussion: This proposal builds on an ongoing initiative to implement an EBT statewide. A team of diverse stakeholders including state policy makers, payers, consumers, service providers, and academics from different, but complementary areas (e.g., public health, social work, psychiatry), has been assembled to guide the research plan by incorporating input from multidimensional perspective. Trial registration: ClinicalTrials.gov: NCT02543359
[Show abstract][Hide abstract] ABSTRACT: Childhood maltreatment can disturb brain development and subsequently lead to adverse socioemotional and mental health problems across the life span. The long-term association between childhood maltreatment and resting–wake brain activity during adulthood is unknown and was examined in the current study. Forty-one medically stable and medication-free military veterans (
= 29.31 ± 6.01 years, 78% male) completed a battery of clinical assessments and had [
F]-fluorodeoxyglucose positron emission tomography neuroimaging scans during quiet wakefulness. After statistically adjusting for later-life trauma and mental health problems, childhood maltreatment was negatively associated with brain activity within a priori defined regions that included the left orbital frontal cortex and left hippocampus. Childhood maltreatment was significantly associated with increased and decreased brain activity within six additional whole-brain clusters that included the frontal, parietal–temporal, cerebellar, limbic, and midbrain regions. Childhood maltreatment is associated with altered neural activity in adulthood within regions that are involved in executive functioning and cognitive control, socioemotional processes, autonomic functions, and sleep/wake regulation. This study provides support for taking a life span developmental approach to understanding the effects of early-life maltreatment on later-life neurobiology, socioemotional functioning, and mental health.
Development and Psychopathology 07/2015; DOI:10.1017/S0954579415000589 · 4.89 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to examine the satisfaction of families who participated in the Treatment of Severe Childhood Aggression (TOSCA) study.
TOSCA was a randomized clinical trial of psychostimulant plus parent training plus placebo (basic treatment) versus psychostimulant plus parent training plus risperidone (augmented treatment) for children with severe physical aggression, disruptive behavior disorder, and attention-deficit/hyperactivity disorder. Parents completed a standardized Parent Satisfaction Questionnaire (PSQ).
Of the 168 families randomized, 150 (89.3%) provided consumer satisfaction data. When they were asked if they would join the study again if they had the option to repeat, 136 (91%) said "yes," 11 (7%) said "maybe," and one (<1%) said "no." When asked if they would recommend the study to other parents with children having similar problems, 147 (98%) said "yes" and 3 (2%) said "maybe." Between 71% (rating one aspect of the Parent Training) and 96% (regarding the diagnostic interview) endorsed study procedures using the most positive response option. Asked if there were certain aspects of the study that they especially liked, 64 (43%) spontaneously reported parent training. Treatment assignment (basic vs. augmented) and responder status were not associated with reported satisfaction. However, responder status was strongly associated with parent confidence in managing present (p<0.001) and future (p<0.005) problem behaviors.
These findings indicate high levels of satisfaction with TOSCA study involvement and, taken together with previous pediatric psychopharmacology social validity studies, suggest high levels of support for the research experience. These findings may inform research bioethics and may have implications for deliberations of institutional review boards.
Treatment of Severe Childhood Aggression (The TOSCA Study), NCT00796302, clinicaltrials.gov .
Journal of child and adolescent psychopharmacology 04/2015; 25(3):225-233. DOI:10.1089/cap.2014.0097 · 2.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Suicide attempts are strong predictors of suicide, a leading cause of adolescent mortality. Suicide attempts are highly familial, although the mechanisms of familial transmission are not understood. Better delineation of these mechanisms could help frame potential targets for prevention.
To examine the mechanisms and pathways by which suicidal behavior is transmitted from parent to child.
In this prospective study conducted from July 15, 1997, through June 21, 2012, a total of 701 offspring aged 10 to 50 years (mean age, 17.7 years) of 334 clinically referred probands with mood disorders, 191 (57.2%) of whom had also made a suicide attempt, were followed up for a mean of 5.6 years.
The primary outcome was a suicide attempt. Variables were examined at baseline, intermediate time points, and the time point proximal to the attempt. Participants were assessed by structured psychiatric assessments and self-report and by interview measures of domains hypothesized to be related to familial transmission (eg, mood disorder and impulsive aggression).
Among the 701 offspring, 44 (6.3%) had made a suicide attempt before participating in the study, and 29 (4.1%) made an attempt during study follow-up. Multivariate logistic regression revealed that proband suicide attempt was a predictor of offspring suicide attempt (odds ratio [OR], 4.79; 95% CI, 1.75-13.07), even controlling for other salient offspring variables: baseline history of mood disorder (OR, 4.20; 95% CI, 1.37-12.86), baseline history of suicide attempt (OR, 5.69; 95% CI, 1.94-16.74), and mood disorder at the time point before the attempt (OR, 11.32; 95% CI, 2.29-56.00). Path analyses were consistent with these findings, revealing a direct effect of proband attempt on offspring suicide attempt, a strong effect of offspring mood disorder at each time point, and impulsive aggression as a precursor of mood disorder.
Parental history of a suicide attempt conveys a nearly 5-fold increased odds of suicide attempt in offspring at risk for mood disorder, even after adjusting for the familial transmission of mood disorder. Interventions that target mood disorder and impulsive aggression in high-risk offspring may attenuate the familial transmission of suicidal behavior.
[Show abstract][Hide abstract] ABSTRACT: Interpersonal violence (IPV) is common in children with a disruptive behavior disorder (DBD) and increases the risk for greater DBD symptom severity, callous–unemotional (CU) traits, and neuroendocrine disruption. Thus, IPV may make it difficult to change symptom trajectories for families receiving DBD interventions given these relationships. The current study examined whether IPV prior to receiving treatment for a DBD predicted trajectories of a variety of associated outcomes, specifically DBD symptoms, CU traits, and cortisol concentrations. Boys with a DBD diagnosis (N = 66; age range = 6–11 years; 54.5% of whom experienced IPV prior to treatment) of either oppositional defiant disorder or conduct disorder participated in a randomized clinical trial and were assessed 3 years following treatment. Multilevel modeling demonstrated that prior IPV predicted smaller rates of change in DBD symptoms, CU traits, and cortisol trajectories, indicating less benefit from intervention. The effect size magnitudes of IPV were large for each outcome (d = 0.88–1.07). These results suggest that IPV is a predictor of the long-term treatment response for boys with a DBD. Including trauma-focused components into existing DBD interventions may be worth testing to improve treatment effectiveness for boys with a prior history of IPV.
[Show abstract][Hide abstract] ABSTRACT: This study adapts the Posterior Probability of Diagnosis (PPOD) Index for use with screening data. The original PPOD Index, designed for use in the context of comprehensive diagnostic assessments, is overconfident when applied to screening data. To correct for this overconfidence, we describe a simple method for adjusting the PPOD Index to improve its calibration when used for screening. Specifically, we compare the adjusted PPOD Index to the original index and naïve Bayes probability estimates on two dimensions of accuracy, discrimination and calibration, using a clinical sample of children and adolescents (N = 321) whose caregivers completed the Vanderbilt Assessment Scale to screen for attention-deficit/hyperactivity disorder and who subsequently completed a comprehensive diagnostic assessment. Results indicated that the adjusted PPOD Index, original PPOD Index, and naïve Bayes probability estimates are comparable using traditional measures of accuracy (sensitivity, specificity, and area under the curve), but the adjusted PPOD Index showed superior calibration. We discuss the importance of calibration for screening and diagnostic support tools when applied to individual patients.
[Show abstract][Hide abstract] ABSTRACT: This study solicited the perspectives of community-based behavioral health practitioners and supervisors about their perceived clinical training needs and preferences using a mixed-methods approach. Forty one participants completed quantitative questionnaires before engaging in qualitative focus groups or interviews. Of those, 34 practitioners participated in a focus group discussion and 7 supervisors participated in semistructured interviews. Quantitative analyses (one-way analysis of variance [ANOVA]; t test) indicated differences in attitude toward the adoption of evidence-based practices across service line, but not role (staff vs. supervisor), with wraparound staff being more open and willing to implement evidence-based practices. Qualitative data were coded by 2 independent coders. Four themes emerged: include training support from trainers, agencies, supervisors, and peers within and across departments; use interactive training methods rather than lecture-based formats; schedule and structure training sessions with an appreciation of the time constraints upon practitioners; and offer training in content areas that are both efficacious and of interest. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
Professional Psychology Research and Practice 06/2014; 45(3):188. DOI:10.1037/a0036488 · 1.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Child disruptive behavior disorders (DBD), characterized by oppositionality, disruptiveness, aggression, and rule-breaking behavior, are the most common reason for child mental health referrals. The efficacy of interventions for child DBD has been demonstrated in both clinic and community settings. However, a significant minority of cases show limited initial response or an initial response that is not maintained. Therefore, it is important to explore predictors and moderators of effectiveness to better understand for whom treatments are more or less effective. It is also important to identify elements of the treatment process (treatment parameters) that influence response. This study examines predictors, moderators, and treatment parameters in a clinical trial comparing effects of treatment applied by study clinicians in the community (COMM) or a clinic (CLINIC) for children with Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD). This study differs from other moderator/predictor studies in comparing setting type (COMM versus CLINIC) rather than treatment versus control.
Participants included 144 children (ages 6 – 11; 53% African American) with ODD (n = 115) or CD (n = 29) randomly assigned to treatment in the community (COMM; n = 72) or clinic (CLINIC; n = 72). Variables across child, parent, and family domains were examined in relation to changes in child externalizing behaviors or number of ODD and CD symptoms endorsed at pretreatment, posttreatment, and 36-month follow-up. Associations between treatment parameters (e.g., hours of child, parent, and parent-child treatment received, treatment completion, referral for additional services) and child outcomes were also explored. Four significant moderators were found. Higher baseline child impairment among those in COMM was associated with higher posttreatment symptoms whereas in CLINIC, baseline impairment was not differentially related to outcomes. In addition, those with no ADHD diagnosis in COMM had lower DBD symptoms at posttreatment whereas those with no ADHD diagnosis in CLINIC had higher symptoms. At 36-month follow-up, those with lower baseline family conflict in COMM had higher externalizing behavior whereas those with lower baseline family conflict in CLINIC had lower externalizing behavior. Several predictors were also found: children who had no history of interpersonal violence and whose parents had lower depressive symptoms, higher incomes, and were employed had lower posttreatment symptoms. Response was also related to a few treatment parameters (e.g., hours of child and parent treatment, treatment completion, referral for services). We discuss implications of these findings for maximizing the benefits of modular treatment by personalizing approaches for children with DBD.
Society for Prevention Research 22nd Annual Meeting 2013; 05/2014
[Show abstract][Hide abstract] ABSTRACT: Sleep problems and adaptive functioning were examined in children who were exposed to intimate partner violence (IPV). Participants included 100 mothers. Forty mothers experienced IPV and were residing in an IPV shelter with their 6- to 13-year-old child. These mothers reported on their experience of IPV in the presence of their child, their psychopathology symptoms, their child’s adaptive functioning, and their child’s sleep problems. Sixty community-based mothers with 6- to 11-year-old children provided reference values for maternal psychopathology and child sleep problems, which were lower than IPV-exposed mothers’ and children’s values, respectively. Two-thirds (63%) of children exposed to IPV (vs. reference value = 45%) had a sleep problem(s). Increased physical and verbal IPV were associated with increased maternal psychopathology, which was associated with increased child sleep problems. IPV-exposed children with sleep problems demonstrated worse adaptive functioning than children without sleep problems; however, differences may be accounted for by maternal psychopathology. (PsycINFO Database Record (c) 2014 APA, all rights reserved)
Psychological Trauma Theory Research Practice and Policy 05/2014; 6(3):290. DOI:10.1037/a0033108 · 2.31 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the efficacy of collaborative care for behavior problems, attention-deficit/hyperactivity disorder (ADHD), and anxiety in pediatric primary care (Doctor Office Collaborative Care; DOCC).
Children and their caregivers participated from 8 pediatric practices that were cluster randomized to DOCC (n = 161) or enhanced usual care (EUC; n = 160). In DOCC, a care manager delivered a personalized, evidence-based intervention. EUC patients received psychoeducation and a facilitated specialty care referral. Care processes measures were collected after the 6-month intervention period. Family outcome measures included the Vanderbilt ADHD Diagnostic Parent Rating Scale, Parenting Stress Index-Short Form, Individualized Goal Attainment Ratings, and Clinical Global Impression-Improvement Scale. Most measures were collected at baseline, and 6-, 12-, and 18-month assessments. Provider outcome measures examined perceived treatment change, efficacy, and obstacles, and practice climate.
DOCC (versus EUC) was associated with higher rates of treatment initiation (99.4% vs 54.2%; P < .001) and completion (76.6% vs 11.6%, P < .001), improvement in behavior problems, hyperactivity, and internalizing problems (P < .05 to .01), and parental stress (P < .05-.001), remission in behavior and internalizing problems (P < .01, .05), goal improvement (P < .05 to .001), treatment response (P < .05), and consumer satisfaction (P < .05). DOCC pediatricians reported greater perceived practice change, efficacy, and skill use to treat ADHD (P < .05 to .01).
Implementing a collaborative care intervention for behavior problems in community pediatric practices is feasible and broadly effective, supporting the utility of integrated behavioral health care services.
[Show abstract][Hide abstract] ABSTRACT: Because the integration of mental or behavioral health services in pediatric primary care is a national priority, a description and evaluation of the interventions applied in the healthcare setting is warranted. This article examines several intervention research studies based on alternative models for delivering behavioral health care in conjunction with comprehensive pediatric care. This review describes the diverse methods applied to different clinical problems, such as brief mental health skills, clinical guidelines, and evidence-based practices, and the empirical outcomes of this research literature. Next, several key treatment considerations are discussed to maximize the efficiency and effectiveness of these interventions. Some practical suggestions for overcoming key service barriers are provided to enhance the capacity of the practice to deliver behavioral health care. There is moderate empirical support for the feasibility, acceptability, and clinical utility of these interventions for treating internalizing and externalizing behavior problems. Practical strategies to extend this work and address methodological limitations are provided that draw upon recent frameworks designed to simplify the treatment enterprise (e.g., common elements). Pediatric primary care has become an important venue for providing mental health services to children and adolescents due, in part, to its many desirable features (e.g., no stigma, local setting, familiar providers). Further adaptation of existing delivery models may promote the delivery of effective integrated interventions with primary care providers as partners designed to address mental health problems in pediatric healthcare.
[Show abstract][Hide abstract] ABSTRACT: Objective:
Changes in adolescent interpersonal behavior before and after an acute course of psychotherapy were investigated as outcomes and mediators of remission status in a previously described treatment study of depressed adolescents. Maternal depressive symptoms were examined as moderators of the association between psychotherapy condition and changes in adolescents' interpersonal behavior.
Adolescents (n = 63, mean age = 15.6 years, 77.8% female, 84.1% White) engaged in videotaped interactions with their mothers before randomization to cognitive behavior therapy (CBT), systemic behavior family therapy (SBFT), or nondirective supportive therapy (NST) and after 12-16 weeks of treatment. Adolescent involvement, problem solving, and dyadic conflict were examined.
Improvements in adolescent problem solving were significantly associated with CBT and SBFT. Maternal depressive symptoms moderated the effect of CBT, but not SBFT, on adolescents' problem solving; adolescents experienced increases in problem solving only when their mothers had low or moderate levels of depressive symptoms. Improvements in adolescents' problem solving were associated with higher rates of remission across treatment conditions, but there were no significant indirect effects of SBFT on remission status through problem solving. Exploratory analyses revealed a significant indirect effect of CBT on remission status through changes in adolescent problem solving, but only when maternal depressive symptoms at study entry were low.
Findings provide preliminary support for problem solving as an active treatment component of structured psychotherapies for depressed adolescents and suggest one pathway by which maternal depression may disrupt treatment efficacy for depressed adolescents treated with CBT.
Journal of Consulting and Clinical Psychology 02/2014; 82(2). DOI:10.1037/a0035718 · 4.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study examines predictors, moderators, and treatment parameters associated with two key child outcomes in a recent clinical trial comparing the effects of a modular treatment that was applied by study clinicians in the community (COMM) or a clinic (CLINIC) for children with oppositional defiant disorder (ODD) or conduct disorder (CD). Based on a literature review, moderator and predictor variables across child, parent, and family domains were examined in relation to changes in parental ratings of the severity of externalizing behavior problems or the number of ODD and CD symptoms endorsed on psychiatric interview at pretreatment, posttreatment, and 36-month posttreatment follow-up. In addition, associations between parameters of treatment (e.g., hours of child, parent, and parent–child treatment received, treatment completion, referral for additional services at discharge) and child outcomes were explored. Path models identified few moderators (e.g., level of child impairment, attention deficit hyperactivity disorder diagnosis, level of family conflict) and several predictors (child trauma history, family income, parental employment, parental depression) of treatment response. Treatment response was also related to a few treatment parameters (e.g., hours of child and parent treatment received, treatment completion, referral for additional services at discharge). We discuss the implications of these findings for maximizing the benefits of modular treatment by optimizing or personalizing intervention approaches for children with behavior disorders.
Journal of Child and Family Studies 12/2013; 24(3). DOI:10.1007/s10826-013-9884-1 · 1.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the parent intervention outcome literatures, discipline practices are generally quantified as absolute frequencies or, less commonly, as relative frequencies. These differences in methodology warrant direct comparison as they have critical implications for study results and conclusions among treatments targeted at reducing parental aggression and harsh discipline. In this study, we directly compared the absolute frequency method and the relative frequency method for quantifying physically aggressive, psychologically aggressive, and nonaggressive discipline practices. Longitudinal data over a 3-year period came from an existing data set of a clinical trial examining the effectiveness of a psychosocial treatment in reducing parental physical and psychological aggression and improving child behavior (N = 139). Discipline practices (aggressive and nonaggressive) were assessed using the Conflict Tactics Scale. The two methods yielded different patterns of results, particularly for nonaggressive discipline strategies. We suggest that each method makes its own unique contribution to a more complete understanding of the association between parental aggression and intervention effects.
[Show abstract][Hide abstract] ABSTRACT: Offspring of depressed parents are at increased risk for psychiatric disorders. Although bipolar disorder (BD) and major depressive disorder (MDD) are both found in the same families, it is not clear whether transmission to offspring of BD or MDD tends to occur from parents with the same mood disorder subtype. Our primary hypothesis was that the offspring of parents with BD would be at increased risk for BD and other comorbid disorders common to BD, such as anxiety and substance use, relative to the offspring of parents with MDD. The offspring of parents with BD versus those with MDD were also hypothesized to be at greater risk for externalizing disorders (i.e., conduct disorder, attention-deficit hyperactivity disorder, or antisocial personality disorder).
Parents (n = 320) with mood disorders and their offspring (n = 679) were studied. Adult offspring were administered the Structured Clinical Interview for DSM-IV Axis I Disorders to establish the presence of psychopathology. Offspring aged 10-18 years were assessed using the School Aged Schedule for Affective Disorders and Schizophrenia, Present and Lifetime version, and parents of children under the age of ten completed the Child Behavioral Checklist. Data were examined using Cox proportional hazard regression.
There was no difference in hazard of mood disorders in the offspring of parents with BD as compared to the offspring of parents with MDD. However, a number of other parent and offspring characteristics increased the risk of mood, anxiety, externalizing, and substance use disorders in the offspring, including self-reported childhood abuse in the parent or offspring, offspring impulsive aggression, and the age at onset of parental mood disorder.
Mood disorders are highly familial, a finding that appears independent of whether the parent's condition is unipolar or bipolar, suggesting considerable overlap in the heritability of MDD and BD. Although parental characteristics had a limited influence on the risk of offspring psychopathology, reported childhood adversity, be it in the parent or child, is a harbinger of negative outcomes. These risk factors extend previous findings, and are consistent with diathesis-stress conceptualizations.
[Show abstract][Hide abstract] ABSTRACT: Childhood sexual abuse has been consistently associated with suicidal behavior. We studied suicide attempt features in depressed individuals sexually abused as children. On average, sexual abuse started before age 9. It frequently coexisted with physical abuse. Suicide attempters more often had personality disorders and had endured abuse for longer, but did not differ in terms of other clinical characteristics from non-attempters. Earlier onset of sexual abuse and its duration were associated with more suicide attempts. However, when personality disorders were included in the regression model, only these disorders predicted number of attempts. The severity of sexual abuse and the coexistence of physical abuse were correlated with age at first suicide attempt. However, only severity of sexual abuse was marginally associated with age at first suicide attempt in the regression model. Finally, the earlier the age of onset of sexual abuse, the higher the intent, even after controlling for age, sex and personality disorders. This suggests that the characteristics of childhood sexual abuse, especially age of onset, should be considered when studying the risk for suicidal behavior in abused populations.
World psychiatry: official journal of the World Psychiatric Association (WPA) 06/2013; 12(2):149-54. DOI:10.1002/wps.20039 · 14.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We review 85 empirical articles published since 2000 that measured the acquisition and/or utilization of parent management skills and/or child cognitive-behavioral skills in the context of an evidence-based treatment (EBT) for childhood behavior problems. Results showed that: (1) there are no standardized measures of skill acquisition or skill utilization that are used across treatments, (2) little is known about predictors, correlates, or outcomes associated with skill acquisition and utilization, and (3) few studies systematically examined techniques to enhance the acquisition and utilization of specific skills. Meta-analytic results from a subset of 68 articles (59 studies) showed an overall treatment-control ES = .31, p < .01 for skill acquisition and ES = .20, p = ns for skill utilization. We recommend that future research focus on the following three areas: (1) development of standardized measures of skill acquisition and utilization from a "common elements" perspective that can used across EBTs; (2) assessment of the predictors, correlates, and outcomes associated with skill acquisition and utilization; and (3) development of innovative interventions to enhance the acquisition and utilization of cognitive-behavioral and parent management skills.
Clinical Child and Family Psychology Review 05/2013; 17(1). DOI:10.1007/s10567-013-0136-0 · 4.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study examines the impact of a brief booster treatment administered 3 years 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.