This article was downloaded by: [University of Alabama at Tuscaloosa] On: 12 February 2013, At: 08:39 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Journal of Clinical Child & Adolescent Psychology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hcap20 Internalizing Problems as a Predictor of Change in Externalizing Problems in At-Risk Youth Matthew Jarrett a , Salma Siddiqui a , John Lochman a & Lixin Qu a a Department of Psychology, University of Alabama Version of record first published: 12 Feb 2013. To cite this article: Matthew Jarrett , Salma Siddiqui , John Lochman & Lixin Qu (2013): Internalizing Problems as a Predictor of Change in Externalizing Problems in At-Risk Youth, Journal of Clinical Child & Adolescent Psychology, DOI:10.1080/15374416.2013.764823 To link to this article: http://dx.doi.org/10.1080/15374416.2013.764823 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
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This article was downloaded by: [University of Alabama at Tuscaloosa]On: 12 February 2013, At: 08:39Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK
Journal of Clinical Child & Adolescent PsychologyPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/hcap20
Internalizing Problems as a Predictor of Change inExternalizing Problems in At-Risk YouthMatthew Jarrett a , Salma Siddiqui a , John Lochman a & Lixin Qu aa Department of Psychology, University of AlabamaVersion of record first published: 12 Feb 2013.
To cite this article: Matthew Jarrett , Salma Siddiqui , John Lochman & Lixin Qu (2013): Internalizing Problems asa Predictor of Change in Externalizing Problems in At-Risk Youth, Journal of Clinical Child & Adolescent Psychology,DOI:10.1080/15374416.2013.764823
To link to this article: http://dx.doi.org/10.1080/15374416.2013.764823
PLEASE SCROLL DOWN FOR ARTICLE
Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions
This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form toanyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation that the contentswill be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses shouldbe independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims,proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly inconnection with or arising out of the use of this material.
Internalizing Problems as a Predictor of Change inExternalizing Problems in At-Risk Youth
Matthew Jarrett, Salma Siddiqui, John Lochman, and Lixin Qu
Department of Psychology, University of Alabama
Intervention and prevention programs for children with externalizing problemsfrequently involve children with co-occurring internalizing problems. Little is knownabout how these co-occurring internalizing problems predict outcomes, particularlyfor programs involving cognitive-behavioral strategies. The current study examinedhow a set of child-related risk factors (including anxiety and depressive symptoms) pre-dicted change in parent- and teacher-reported externalizing problems following aschool-based preventative intervention for children at risk for externalizing problems.Participants included 112 preadolescent children (ages 9–12) who participated in a studydesigned to evaluate the efficacy of the Coping Power Program (Lochman & Wells,2004). Participants included 81 boys (68%) who were primarily African American(69%) or Caucasian (30%). Regression analyses were conducted to examine predictorsof change in parent- and teacher-reported externalizing problems on the BehaviorAssessment System for Children (Reynolds & Kamphaus, 1992). Results indicated thatgreater child depression symptoms (as reported by parent or teacher) were associatedwith a larger reduction in externalizing behavior problems based on parent or teacherreport. This effect was found in both the parent and teacher models and held after con-trolling for a number of child-oriented baseline variables including baseline aggression.Future research studies should examine whether co-occurring symptoms of depressionrelate to enhanced changes in externalizing problems following intervention for externa-lizing problems, particularly when cognitive-behavioral interventions are utilized. Inaddition, it will be important for studies to examine such effects relative to a controlgroup and=or alternative treatment conditions and to further explore possiblemechanisms of change.
INTRODUCTION
Externalizing behavior problems include a range ofproblematic behaviors such as aggression, defiance, dis-ruptive behavior, and conduct problems (Achenbach,1991; Campbell, 1995). Once established, these behaviorproblems are often stable over time and predictive ofviolence, delinquency, substance use, and other negativeoutcomes during adolescence and adulthood (Miller-Johnson, Coie, Maumary-Gremaud, Lochman, &Terry, 1999; Windle, 1990). Given the poor prognosisfor children with externalizing behavior problems, there
has been significant interest in the development ofevidence-based prevention and intervention programsfor children with externalizing behavior problems.Many of these programs have been parent-focused pro-grams that attempt to improve parent–child relation-ships or teach behavior management strategies (Eyberget al., 2001; Patterson, Dishion, & Chamberlain, 1993;Webster-Stratton, 1984, 1994). In contrast, somechild-focused programs have also shown evidence forefficacy. Generally, these child-focused programsemphasize skill building in a number of domains suchas anger control, coping, and problem-solving skills(Kazdin, Siegel, & Bass, 1992; Lochman & Wells,1996; Webster-Stratton, Reid, & Hammond, 2004).Finally, some programs have combined both parent-and child-focused elements, and there is evidence to
Correspondence should be addressed to Matthew Jarrett,
Department of Psychology, University of Alabama, Box 870348,
suggest that there may be larger intervention effectswhen both parent- and child-focused elements areutilized (Webster-Stratton et al., 2004).
Although these programs are clearly efficacious, fewstudies have examined predictors of outcomes followingthese interventions. In particular, only a handful ofstudies have examined the role of co-occurringsymptomatology or comorbid disorders (Beauchaine,Webster-Stratton, & Reid, 2005; Brestan & Eyberg,1998; Ollendick, Jarrett, Grills-Taquechel, Hovey, &Wolff, 2008). Currently, even the most effective inter-ventions for externalizing problems show efficacy foronly about two thirds of the children (Webster-Stratton& Hammond, 1997). Thus, there is substantial interestin factors that may be associated with enhanced out-comes following intervention. Although studies to datehave explored factors such as comorbidity, few studieshave considered conceptual reasons for why comorbidor co-occurring disorders might predict outcomes fol-lowing intervention or specific symptom domains thatmight be more relevant to outcomes. In addition, themajority of research examining comorbidity and=orco-occurring symptomatology as it relates to externaliz-ing behavior outcomes has been for studies examiningparent-focused interventions (e.g., parent training).Research on the role of comorbidity or co-occurringsymptomatology for child-focused interventions isclearly needed.
Predictors and Moderators of Intervention forExternalizing Problems
Surprisingly, only a handful of studies have examinedcomorbidity or co-occurring symptomatology as a pre-dictor of outcomes following intervention for externaliz-ing behavior problems. Studies to date have typicallyinvolved the examination of comorbidity on a broadlevel (e.g., whether the presence of one or moreadditional disorders affects outcomes) or in terms of aclass of disorder (e.g., the effect of an ‘‘internalizing’’disorder on outcomes). In relation to comorbiditybroadly, Weiss, Harris, Catron, and Han (2003) exam-ined the efficacy of the Reaching Educators, Children,and Parents prevention program for children experienc-ing concurrent internalizing and externalizing problems.Overall, the authors did not find comorbidity to bea significant predictor of outcomes. Children who werehigh in externalizing problems relative to internalizingproblems responded the same to intervention as childrenwho were high on internalizing problems relative toexternalizing problems. Subsequently, Kazdin andWhitley (2006) studied comorbidity in two samples ofclinically referred children receiving intervention (i.e.,parent management training) for oppositional defiantdisorder or conduct disorder and found that children
with the greatest degree of comorbidity showed thegreatest amount of improvement from preinterventionto postintervention in comparison to children withouta comorbid disorder.
Very few studies have focused on specificco-occurring symptom domains or comorbid disorders(e.g., anxiety and depression). In one of the few studiesthat examined the effect of internalizing problems,Beauchaine et al. (2005) examined how parent-reportedanxiety=depressive symptoms predicted and moderatedoutcomes. Overall, parent-reported child anxiety=depression was a predictor of outcomes for all interven-tions. Elevated child anxiety=depression symptoms wereassociated with enhanced outcomes for externalizingproblems across all intervention modalities. In addition,parent-reported child anxiety=depression was also amoderator. For example, the authors reviewed studiesthat involved parent training, child training, and teachertraining for externalizing behavior problems. Childrenreceived various combinations of these interventiontypes. For analytic purposes, groups were created to iso-late the specific training element (i.e., groups with parenttraining vs. groups without parent training, groups withchild training vs. groups without child training, groupswith teacher training vs. groups without teacher train-ing). The authors found that interventions involvingparent training resulted in better 1-year follow-up out-comes than interventions without parent training forchildren scoring below the sample mean (T¼ 56) onthe Child Behavior Checklist Anxious=Depressed sub-scale. Overall, the results of the study broadly suggestedenhanced outcomes when anxiety=depression is elevatedbut better long-term response to parent training whenanxiety=depression symptoms are below average. Theseresults suggest that the effects of co-occurring anxiety=depression on outcomes may partially depend on theintervention type.
Although these past findings have been valuable, nostudy was identified that examined symptoms of anxietyand depression separately, and the majority of studieshave focused exclusively on intervention programs thatinvolve parent training. Overall, there are limited dataon how the presence of child internalizing problemsrelates to outcomes for child externalizing problemsfollowing child-focused interventions (e.g., cognitive-behavioral interventions) for externalizing behaviorproblems. Finally, it is important to note the absenceof any study that has focused on similar variables inprevention programs that target children at risk forexternalizing or aggressive behavior problems.
Current Study
The current study sought to examine predictors of out-comes following a prevention program that primarily
uses child-focused intervention components for childrenat risk for externalizing behavior problems (i.e., theCoping Power Program; Lochman & Wells, 2004).Our central question in the current study was whetheranxiety and depression symptoms predicted reductionsin externalizing behavior following a targeted preven-tion program for preadolescent children. We chose toaddress this question for a variety of reasons. First,anxiety and depression commonly co-occur with exter-nalizing behavior problems (Angold & Costello, 1993;Capaldi, 1991; Marmorstein & Iacono, 2003). Second,since that the current intervention is cognitive-behavioralin nature, the role of co-occurring anxiety and depressionis particularly important, because cognitive-behavioraltherapy is often the intervention of choice for theseinternalizing disorders (David-Ferdon & Kaslow, 2008;Silverman, Pina, & Viswesvaran, 2008). The presence ofco-occurring anxiety and=or depression may predictenhanced externalizing problem outcomes if a child’sexternalizing problems are partially driven by a deficit thatcuts across both internalizing and externalizing problems(e.g., emotion regulation difficulties). Finally, it should benoted that the age range for our sample is particularly wellsuited for examining such effects given that children in thisage range (i.e., ages 9–12) have the cognitive skills to bene-fit from cognitive-behavioral interventions.
In selecting predictors for our current study, wesought to examine a variety of child-related variablessince we were interested in examining outcomes follow-ing a child-oriented intervention. First, we includeddemographic variables such as race, gender, and socio-economic status, as these variables are often related tochild externalizing problems and=or post-interventionchanges in externalizing problems (Brestan & Eyberg,1998; Capaldi & Stoolmiller, 1999; Lundahl, Risser, &Lovejoy, 2006). Age was not included in the currentanalyses, due to the limited age variability in oursample (i.e., ages 9–12). Although we did not have a puremeasure of cognitive functioning, we chose to includea variable reflecting whether a child had a repeateda grade as a school-related behavioral and cognitive riskfactor. In relation to symptomatology, we includeda measure of preintervention aggression (Dodge &Coie, 1987) to determine if the level of preinterventionaggression predicted outcomes following interventionfor externalizing behavior problems. Finally, weincluded our primary variables of interest for the currentstudy: preintervention parent- and teacher-reportedmeasures of anxiety and depression symptoms.
In line with past studies, we predicted that higherlevels of anxiety and depression would predict greaterreductions in parent- and teacher-reported externalizingproblems. We also predicted that repeating a gradewould be related to fewer changes in externalizingproblems. Given the mixed literature on demographic
variables such as gender and race (Brestan & Eyberg,1998; Conduct Problems Prevention Research Group,2002; Hawkins, von Cleve, & Catalano, 1991), we didnot have specific predictions for these variables.
METHOD
Participants
Participants were children recruited for an interventionstudy designed to evaluate the efficacy of the CopingPower intervention for at-risk youth (for additionalinformation, see Lochman, Boxmeyer, Powell, Roth, &Windle, 2006). Participants were selected based onteacher ratings of children who were in the top 30% foraggressive behavior among fourth grade students (Dodge& Coie, 1987). Children came from seven elementaryschools in urban and suburban areas of Alabama.Although the original study involved a treatment groupand a control group, the present study is based on thetreatment group only (n¼ 112). Of the study samplemembers, 67.5% were male. The majority of the parti-cipants identified themselves as African American(69%). Thirty percent were Caucasian, and 1% were ofanother race or ethnicity. Thirty percent of the samplehad repeated a grade at least once. Participants camefrom predominantly working-class or low middle-classfamilies (Hollingshead Index; M¼ 27.89, SD¼ 13.61).
The Coping Power Program
Lochman, Wells, and Lenhart (2008) developeda multicomponent preventive intervention for aggressivechildren that includes 34 intervention sessions forchildren delivered over 15 months. In addition, 16 parentsessions are delivered over the same period. The programis based on the contextual social-cognitive model(Lochman & Wells, 2002a) with a focus on the cognitiveprocesses involved in a child’s response to interpersonalconflicts or frustrations with environmental obstacles(see Larson & Lochman, 2002). The Coping PowerProgram (CPP) has been found to be effective in reducingrates of substance use and proactive aggression andimproving social competence and teacher-reportedbehavior problems (Lochman & Wells, 2002b). Studiesinvestigating the efficacy and effectiveness of the inter-vention have indicated in two separate samples that theCPP produces lower rates of delinquent behavior andsubstance use at postintervention and 1-year follow-upin comparison to a randomly assigned control condition.
The current study is based upon an abbreviatedversion of the CPP that included 24 child group sessionsand 10 parent group sessions (Lochman, 2006). Thisversion of the program has shown evidence for efficacy
in the form of greater changes on child externalizingproblems (via the Behavior Assessment System for Chil-dren Externalizing Problems construct) in the treatmentcondition relative to a control group (Lochman et al.,2006). Parent group attendance was generally very low(i.e., 68% attended fewer than half of the parentsessions; 28% attended no sessions). The mean numberof Coping Power parent sessions attended was 3.76(SD¼ 3.58; range¼ 0–10). Thus, the current inter-vention is primarily a child-focused intervention withsome limited parenting components given the low rateof attendance. Each child and parent group was co-ledby two members of the research team; the child groupswere conducted at the participating elementary schoolswith five to six children in each group and focused onteaching coping and problem-solving skills as well asstrategies for enhancing social relationships and resist-ing peer pressure. The parent group included parentsand primary caregivers of the target children andfocused on teaching behavior management skills andimproving family problem solving, communication,and cohesion. Children had an attendance level of93%. The child-focused portion of the interventionstarted at the beginning of the school year and termi-nated at the end of the school year. In relation toattrition, all children completed the intervention proto-col, although some parent and teacher informants didnot complete postintervention measures (teacherattrition: n¼ 4, 3%; parent attrition: n¼ 11, 9%).
Measures
Aggression screener (Dodge & Coie, 1987). Thesix items on this measure evaluate total aggression aswell as reactive and proactive aggression. Parents useda 5-point Likert scale from 1 (never) to 5 (almostalways), indicating how frequently each item appliedto their child. Three items represent reactive aggression(‘‘overreacts angrily to accidents,’’ ‘‘when teased, strikesback,’’ and ‘‘blames others in fights’’), and three itemsrepresent proactive aggression (‘‘threatens or bulliesothers,’’ ‘‘gets others to gang up on a peer,’’ and ‘‘usesphysical force to dominate others’’). The reliability ofthis version of the scale has been supported in prior stu-dies (e.g., Dodge, Lochman, Harnish, Bates, & Pettit,1997; Vitaro, Brendgen, & Tremblay, 2002). Vitaroet al. (2002) reported high internal consistency for theseconstructs (a¼ .83 for reactive aggression, a¼ .82 forproactive aggression). Total aggression was used foraggression screening purposes for the current study(a¼ .84 at preintervention).
Behavior Assessment System for Children (Reynolds& Kamphaus, 1992). Parents completed the BASC
Parent Rating Scale (BASC–PRS), and teachers com-pleted the BASC Teacher Rating Scale (BASC–TRS)by rating how often they observe the child engaging invarious behaviors on a 4-point scale ranging from neverto always. The Externalizing Problems Composite scalewas used to assess changes in externalizing behaviors.This scale is a composite of three scales—AggressiveBehavior, Conduct Problems, and Hyperactivity. TheExternalizing Problems Composite had strong internalconsistency (a¼ .96 at both pre- and postintervention).Outcomes were assessed by subtracting the Time 2 scorefrom the Time 1 score for both parents and teachers.Thus, positive change scores reflect improvement in theExternalizing Problems Composite, whereas negativechange scores reflect an increase in the ExternalizingProblems Composite. Time 1 depression and anxietywere also assessed using the BASCDepression and Anxi-ety scales. Reliability was very high for parent ratings ofDepression (a¼ .84) and Anxiety (a¼ .79) as well as tea-cher ratings of Depression (a¼ .84) and Anxiety (a¼ .78)at preintervention.
Family history and demographic form. Parentscompleted a family history and demographic form thatassessed general background information about the childand his or her family. This form included indicated childrace and gender, variables that were used in the currentstudy. The Hollingshead Index was calculated based onparental educational level and occupation as a measureof socioeconomic status (Hollingshead, 1975) and wasincluded in the current study. Finally, this form alsoasked whether a child had ever repeated a grade, andthis variable was also used in the current study asa school-related behavioral and cognitive risk factor.
Procedure
Following informed consent and assent, parent andchild measures were completed in the participants’homes or the researchers’ offices, depending on parentpreference. In most cases, the parent reporter was thechild’s biological parent (93.3%). The initial baselinedata collection for parent- and child-reported infor-mation took place during the summer prior to thestudents’ fifth-grade year. Teacher-reported baselinedata consisted of pencil-and-paper rating scales of thechildren’s behavior that were collected a few monthsafter students began their fifth-grade year. For teacher-reported data, Time 2 data collection took place at theend of the students’ fifth-grade year (i.e., at the end ofthe intervention). For parents and children, Time 2 datacollection took place during the summer followingstudents’ fifth-grade year (roughly 1 year after the initialassessment and shortly after the end of the intervention).
Table 1 includes means, standard deviations, andcorrelations among study variables. Regression analyseswere utilized to examine predictors of change in theparent- and teacher-reported Externalizing ProblemsComposite on the BASC.1 Table 2 displays the resultsof linear regression analyses for parent and teacheroutcomes. In our regression analyses, we also exploredmulticollinearity diagnostics such as tolerance and thevariation inflation factor (VIF). We used Allison’s(1999) definition for problematic multicollinearity (i.e.,VIF� 2.5 and tolerance< .40). All values of toleranceand VIF were in the acceptable range.
For change in parent-reported Externalizing Prob-lems on the BASC, the only significant predictor wasparent-reported child depression (b¼ .30, p¼ .01), sug-gesting that higher child depression was associated withgreater improvement on parent-reported ExternalizingProblems. For teacher-reported Externalizing Problems,the only significant predictor was teacher-reported childdepression (b¼ .56, p¼ .01), suggesting that higher childdepression was associated with greater improvement onteacher-reported Externalizing Problems.
DISCUSSION
The current study examined the role of internalizingproblems such as anxiety and depression symptoms inpredicting changes in externalizing problems followinga prevention program for children at risk for exter-nalizing behavior problems. A strength of the currentstudy was an examination of anxiety and depression asseparate predictors, an approach that has not been usedin past studies. In addition, the current study also utilizedadditional child-related predictors to understand theunique predictive effects of child anxiety and depression.Although most studies in this research area have involvedchildren in the clinical range for externalizing problems,the current study involved intervention with children atrisk for these problems. Finally, the current study wasunique in that it involved a child-focused interventionthat was cognitive-behavioral in nature. This approachis in contrast to most other studies in this researcharea, which have involved primarily parent managementtraining for externalizing behavior problems.
The primary finding from the current study wasthat parent- and teacher-reported child depression was
TABLE 1
Means, Standard Deviations, and Correlations Among Study Variables
child did not repeat grade¼ 0. SES¼ socioeconomic status; BASC¼Behavior Assessment System for Children.�p< .05.
1Although we originally planned to include Time 1 BASC Externa-
lizing Problems as a predictor, we encountered problems with multicol-
linearity. When regression models were ran with pretreatment BASC
Externalizing Problems and BASC Depression as predictors, BASC
Depression had elevated multicollinearity statistics that are considered
problematic based on expert recommendations (Allison, 1999; rec-
ommendation of requiring all predictors to have a VIF� 2.5 and
tolerance> .40). These statistics were elevated in both the parent and
teacher models. Given this multicollinearity issue, we chose to pursue
gain scores rather than repeated measures analysis of covariance,
because repeated measures analysis of covariance would require that
pretreatment BASC Externalizing Problems be included in the model.
Using gain scores allowed us to use a substitute measure for pretreat-
ment externalizing problems as a predictor of the average change in
BASC Externalizing Problems. It should be noted that the aggression
screener measure was significantly associated with BASC Externalizing
Problems (.44 for teachers, .28 for parents) but not significantly asso-
ciated or as strongly associated with parent or teacher depression (.09
for parents and .27 for teachers; this latter correlation is significant).
When models were ran using the gain score approach with the screener
measure for Time 1 aggression, multicollinearity diagnostic statistics
were not in a problematic range.
INTERNALIZING AND EXTERNALIZING PROBLEMS 5
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associated with greater reductions in externalizing beha-vior problems at the end of treatment within the inter-vention group. First, it should be noted that we areunable to draw any causal conclusions from this findingin relation to treatment, because the current analyses didnot involve a control group. At the same time, we wouldlike to discuss our findings further and speculate onpossible reasons for such findings if they are indeedrelated to treatment effects. Overall, the findings werewithin-source in that parent-reported child depressionpredicted change in parent-reported child externalizingproblems and teacher-reported child depression pre-dicted change in teacher-reported externalizing prob-lems. It is important to note that the findings were notspecific to just the parent informant, which helps toaddress concerns regarding perceptual biases regardingchild behavior that may relate to parental depression(Chronis et al., 2007; Cummings & Davies, 2006).Although cross-source predictions could have had inter-esting implications for cross-setting predictive effects,our findings suggest that it may be important for theassessment of depression to occur in the same settingwhere behavior change is observed. At the same time,it is unclear as to how depression would significantly dif-fer across settings. Alternatively, if such a finding isrelated to treatment, a more general perceptual biascould have affected our findings in that if a parent orteacher believes that a child is a depressed, the informantmay see the child as more motivated to change and=or
more likely to respond to treatment. The informantmay also want to see greater change if they see thechild as depressed. Of interest, anxiety was not a predic-tor in either of the regression models, and neitherparent-reported anxiety (r¼ .09) nor teacher-reportedanxiety (r¼ .19) was associated with change in externa-lizing behavior problems at the zero-order level (seeTable 1). If our findings are in fact related to treatmenteffects, one possibility is that moderate feelings ofdepression and sadness, especially about consequencesfor misbehavior, may be associated with greater motiv-ation to change. Another possibility for this finding isthat the intervention strategies of the Coping PowerProgram are more relevant to depression symptomsthan anxiety symptoms. The Coping Power Programincludes intervention components related to regulatingemotions, cognitions, and behaviors, but many ofthese components are focused on frustrating situationsor situations that evoke anger (Lochman, Powell,Boxmeyer, Siddiqui, et al., 2012). These interventioncomponents appear to overlap more with interventioncomponents for depression than anxiety disorders(e.g., regulating irritability). In contrast, cognitive-behavioral intervention for anxiety involves the criticalelement of exposure to anxiety-producing situations,a component that was not present in the Coping Powerprotocol. Once again, though, it should be noted thatthese ideas are speculative, as the current set of analysesdid not involve a control group.
TABLE 2
Predicting Change in BASC Externalizing Problems Composite
Dependent Variable df Error Predictor B SE b t p CI (b)
child did not repeat grade¼ 0. Positive change scores reflect improvement in the Externalizing Problems Composite, whereas negative change scores
reflect an increase in the Externalizing Problems Composite. BASC¼Behavior Assessment System for Children; SES¼ socioeconomic status.�Significant coefficients at p< .05.
It should be noted that preintervention aggressionwas not associated with changes in externalizing beha-vior problems, suggesting that changes were not affectedby aggression severity. In addition, whether a childrepeated a grade was not a significant predictor, a find-ing that differed from our initial hypothesis. Socioeco-nomic status also did not predict outcomes. Onepossibility for this lack of effect may be due to the factthat studies that have found socioeconomic status tobe a predictor have primarily been studies that involveparent training (Lundahl, Risser, & Lovejoy, 2006),which may relate to factors such as intervention adher-ence. In the current study, intervention adherence forchild-oriented intervention components was high (i.e.,93% of children completed all sessions), so socioeco-nomic status may be less of a predictor of outcomesfor child-oriented interventions that involve cognitive-behavioral therapy in a school-based setting. Finally,race and gender were also not significant predictors.Given the diverse nature of our sample in terms of eth-nicity and gender, our findings may be applicable forsimilar intervention protocols utilized with alternativepopulations or in alternative settings. Overall, children’sreductions in externalizing behavior by the end of theCoping Power Program were similar for boys and girls,for children with different racial and socioeconomicstatus, for children with different levels of baselineaggression, and for children who had been retainedversus children not retained.
In summary, results suggest that co-occurringdepression may be an important variable to considerin future cognitive-behavioral intervention and preven-tion trials for children with externalizing behavior prob-lems. If our findings do reflect a treatment effect, onepossible mechanism for this finding is that children withdepressive symptoms and externalizing problems mayhave broad deficits in emotion regulation which maymanifest as both symptoms of depression (e.g., difficultyregulating sadness and irritability) and externalizingbehavior problems (e.g., difficulty regulating anger).Because Coping Power teaches social-emotional skillsand emotion regulation strategies, it may equip thechild with new skills by modifying their cognitive distor-tions, problem-solving capabilities, and ability to regu-late emotions (Lochman, Powell, Boxmeyer, Ford, &Minney, in press). For children with higher levels ofpreintervention depression symptoms, it may be thatbroad emotion regulation difficulties contribute to theirexternalizing problems in addition to or instead ofdysfunctional parent–child relationships. Of interest,Beauchaine et al. (2005) found that below-averageanxiety=depression symptoms were associated withenhanced response to parent training. Children withmore significant mood regulation problems may benefitmore from cognitive-behavioral interventions than
parent management training. Although speculative, thishypothesis could be explored in future prevention andintervention studies for externalizing behavior problemsthat could examine moderation (i.e., differentialresponse to a set of interventions) rather than predic-tion. It is important that these future studies includecontrol group analyses in order to make stronger con-clusions about causality. An alternative hypothesis thatshould be briefly noted is that our results could also beexplained by the possibility that youth who are engagingin externalizing behavior are more amenable to change ifthey feel bad, either about their behavior or about theconsequences of it (getting in trouble, etc.). Future stu-dies should seek to measure beliefs about externalizingbehavior problems in order to better address this latterhypothesis.
Implications for Research, Policy, and Practice
Results indicate that co-occurring depressive symptomsin children may be an important factor to consider whenselecting an intervention program for a child with exter-nalizing problems. For example, as previously noted, thepresence of such symptoms may suggest the need fora more child-focused cognitive-behavioral interventionprogram rather than a parent training approach (at leastfor children in the 9–12 age range). At the same time,parenting components are likely to be an important partof intervention for children with externalizing behaviorproblems given their role in the development and main-tenance of such problems (Capaldi, 1991; Pettit & Bates,1989) and potential influences on the development ofboth problem areas (Compton, Snyder, Schrepferman,Bank, & Shortt, 2003).
Limitations of the current study include reliance onparent and teacher report of child depressive symptoms.Child report of depressive symptoms would havestrengthened our findings. Another perceived limitationmay be that the Coping Power Program does not trans-late to interventions that most clinicians would providein individual therapy in a clinic setting. At the sametime, the strategies taught in Coping Power can alsobe adapted to individual sessions as well (Lochmanet al., 2008). Our analyses also did not include a com-parison condition. It is unclear whether our findingsare specific to the intervention or whether such a findingwould also be found in untreated children or in analternative intervention approach such as parenttraining. Future studies that involve control groupsand multiple treatment conditions are needed to answersuch a question. Another limitation of the study wasthat the high correlation between BASC Depressionand BASC Externalizing Problems caused problems inrelation to multicollinearity in our initial regressionmodels. In turn, we had to utilize an alternative measure
of Time 1 aggression in our regression models. It shouldbe noted, though, that this measure was significantlycorrelated with Time 1 BASC Externalizing Problems.
Finally, although we have speculated on the reasonsfor our findings, our current study was unable to exam-ine possible mechanisms of change. Future research isneeded to better understand why co-occurring symptomsmay relate to changes in problem behaviors followingintervention using designs that can examine mediationalprocesses of change (LaGreca, Silverman & Lochman,2009; Lochman & Wells, 2002a).
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