An update on the cause and treatment of sleep disturbance in children and adolescents with autism spectrum disorder

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by abnormalities in social communication/interaction and restrictive, repetitive patterns of behavior. ASD is a relatively common psychiatric disorder, with a prevalence of approximately 1.7% in children. Although many children and adolescents with ASD visit the hospital for medical help for emotional and behavioral problems such as mood instability and self-harming behavior, there are also many visits for sleep disturbances such as insomnia and sleep resistance. Sleep disturbances are likely to increase fatigue and daytime sleepiness, impaired concentration, negatively impact on daytime functioning, and pose challenges in controlling anger and aggressive behavior. Sleep disturbance in children and adolescents with ASD negatively affects the quality of life, nothing to say the quality of life of their families and school members. In this review, sleep disturbances that are common in children and adolescents with ASD and adolescents are presented. The developmental and behavioral impacts of sleep disturbances in ASD were also considered. Finally, non-pharmacological and pharmacological treatments for sleep disturbances in children and adolescents with ASD and adolescents are reviewed.

The Impact of Perceived Personal Discrimination on Problem Behavior of Left-Behind Children: A Moderated Mediating Effect Model

This study aimed to determine how pathological Internet use and emotional intelligence affect the relationship between perceived personal discrimination and problem behavior of left behind children. Data were collected from 406 left-behind students from 6 rural primary and secondary schools in Mainland China. Results indicated that perceived personal discrimination could be a predictor of left-behind children's pathological Internet use, and further cause their problem behavior. Pathological Internet use had a partial mediating effect on the relation between perceived personal discrimination and problem behavior. In addition, emotional intelligence played a moderating role in the relationship between perceived personal discrimination and problem behavior, as well as between pathological Internet use and problem behavior. Emotional intelligence could alleviate the negative impact of perceived personal discrimination on problem behavior, as well as the negative impact of pathological Internet use on problem behavior.

Young drivers vs. non-drivers: are there differences in behaviour?

BACKGROUND

Traditionally, a first step toward independence for a North American youth has been to obtain a driver's licence. Licensure can be associated with freedom and independence to provide teens opportunities to participate in conventional and health-enhancing behaviours, such as school, work, sporting events and other social activities, and/or provide opportunities to engage in unconventional, risk taking and health compromising behaviours. Yet, recent trends show that youth are delaying getting their licence.

OBJECTIVE

The purpose of this study was to use the constructs of conventional and unconventional behaviours identified in Problem Behaviour Theory (PBT) under the behaviour system to examine whether driver licensure status in youth was associated with conventional, health-enhancing behaviours or unconventional, health compromising, risky behaviours.

METHOD

Data were derived from the 2015 and 2017 cycles of the Ontario Student Drug Use Survey (OSDUHS). Analyses are based on a subsample of students who were at least 16 years of age. Included measures: driver's licence (at least a G1 - the first stage of a 3-stage graduated licensing system), conventional behaviours (academic performance, school connectedness, employment, physical activity, and sleep), unconventional behaviours (tobacco use, cannabis use, alcohol use, binge drinking, hazardous drinking, problematic drug use, screen time, and number of antisocial behaviours), and control factors (age, sex, region, family Socio-Economic Status (SES)).

RESULTS

67.97 % of youth 16-19 years of age obtained a driver's licence. Of the sample, 71.80 % of males, 75.05 % not living in the Greater Toronto Area (GTA), and 70.86 % of youth with an average family SES received their driver's licence. In regression analyses, older youth, males, and youth not living in the GTA had significantly higher odds of obtaining a driver's licence than younger youth, females, and youth living in the GTA. Conventional behaviours that were significantly positively associated with licensure status included youth who had high academic achievement, good social connectedness, and who were employed. Unconventional behaviours that were significantly positively associated with licensure status included alcohol use and binge drinking.

DISCUSSION

In agreement with Problem Behaviour Theory, the results show that youth who obtain their licence show limited problematic lifestyle or 'proneness' (Gohari, 2019). Alcohol use and binge drinking were significantly associated with youth obtaining a driver's licence but hazardous drinking was not. This study suggests that a driver's licence for youth could both control but also instigate unconventional behaviours as identified by PBT. A driver's licence could also provide opportunities for conventional behaviours associated with education and school connectedness. However, the independence provided by a driver's licence could offer youth unsupervised social opportunities to drink and binge drink that may be health-compromising. Thus, based on PBT, licensure status is associated with both conventional behaviours, as well as problem behaviours associated with alcohol use.

State and Trait Anxiety of Adolescents with Autism Spectrum Disorders

OBJECTIVE

This study examined how state and trait anxiety of adolescents with autism spectrum disorders (ASD) are associated with their demographic characteristics, repetitive and restricted behaviors (RRBs), and internalizing and externalizing problem behaviors.

METHODS

A total of 96 participants with ASD (mean age=14.30 years; 91 males) completed a battery of tests including the State/Trait Anxiety Inventory (STAI), the Autism Diagnostic Interview-Revised, the Social Responsiveness Scale (SRS), and a cognitive test measuring intelligence quotient (IQ). Participants' parents completed the Child Behavior Checklist (CBCL). Pearson's correlations among age, IQ, two subscales of the STAI (i.e., STAIS and STAIT, measuring self-reported state and trait anxiety, respectively), and the Anxiety subscale of CBCL (i.e., CBCL-Anxiety, measuring parent-reported trait anxiety) were computed. Subsequently, Pearson's correlations were computed among the three anxiety measures, RRBs, and problem behaviors, while controlling for participants' age and IQ.

RESULTS

The STAIS and CBCL-Anxiety were both significantly correlated with higher age, sensory sensitivity, depressive symptoms, somatic complaints, and aggressive behaviors. All three anxiety variables were significantly and positively correlated with total SRS RRB scores. Additionally, the STAIS and STAIT were significantly associated with more severe Compulsion/Adherence behaviors, and the CBCL-Anxiety was also significantly associated with more severe Rule-breaking Behaviors.

CONCLUSION

Self-reported state anxiety showed association patterns similar to those of parent-reported trait anxiety. Future studies investigating the precise operationalization of different anxiety instruments are needed to accurately measure the anxiety of adolescents with ASD.

A Randomized Controlled Trial of Functional Communication Training via Telehealth for Young Children with Autism Spectrum Disorder

Many children with autism spectrum disorder (ASD) have problem behaviors that interfere with learning and social interaction. This randomized controlled trial compared treatment with functional communication training (FCT) to "treatment as usual" for young children with ASD (n = 38, ages 21-84 months). FCT was conducted by parents with training and real-time coaching provided by behavioral consultants using telehealth. FCT treatment via telehealth achieved a mean reduction in problem behavior of 98% compared to limited behavioral improvement in children receiving "treatment as usual" during a 12-week period. Social communication and task completion also improved. For children with ASD and moderate to severe behavior problems, parent-implemented FCT using telehealth significantly reduced problem behavior while ongoing interventions typically did not.

Early childhood psychosocial family risks and cumulative dopaminergic sensitizing score: Links to behavior problems in U.S. 9-year-olds

BACKGROUND

We examined, (a) whether in early childhood exposure to risky family environment in different domains (socioeconomic, mental, parenting practices, health behavior, and child-related risks) and accumulatively across various domains (cumulative risk) is associated with child's problem behavior at age 9, and (b) whether the association is more pronounced in children carrying cumulative dopaminergic sensitizing genotype or living in low-income families.

METHODS

Participants were 2,860 9-year old children (48% females; 48% Black) and their mothers from the 'Fragile Families and Child Wellbeing Study', a probability birth cohort from large U.S. cities. Mothers responded to questions on child's problem behavior (CBCL). Children responded to questions about their vandalism and substance use.

RESULTS

Cumulative family risk was associated with higher internalizing and externalizing behavior and higher vandalism and substance use. All domain-specific risk clusters were associated with higher internalizing behavior and, with the exception of child-related risk, with higher externalizing behavior. Mental health risks, risky parenting practices, and risky health behavior were associated with higher vandalism. Risky parenting practices were associated with higher substance use. The associations were robust to adjustment for cumulative dopaminergic sensitizing genotype. No G x E interactions with dopaminergic genotype and family SES were observed.

LIMITATIONS

Sample size was relatively small for genetic analysis and polygenic risk scores were not available.

CONCLUSIONS

Exposure to cumulative psychosocial family risks from early childhood is associated with early indicators of problem behavior in adolescence.

The prevalence of behavioral problems among school-aged children in home quarantine during the COVID-19 pandemic in china

BACKGROUND

To prevent spreading of the COVID-19 infection, many countries have implemented a nationwide school closure. We aimed to assess the prevalence of behavioral problems in school-aged children during home confinement.

METHODS

We conducted an internet-based survey involving 1264 children (grades 2-6) and their parents from two primary schools between February 25 and March 8, 2020, in Hubei province, China. Behavioral problems were evaluated using the Strengths and Difficulties Questionnaire (SDQ).

RESULTS

The prevalence of prosocial behaviors among children was 10.3%, followed by total difficulty (8.2%), conduct problems (7.0%), peer problems (6.6%), hyperactivity-inattention (6.3%) and emotional problems (4.7%). Compared with children who did not exercise, children with psychical activity had a lower hyperactivity-inattention risk (Odds Ratio (OR): 0.44 for 1-2 days/week; OR: 0.56 for more than 2 days/week) and less prosocial behaviors problems (OR: 0.65 for 1-2 days/week; OR: 0.55 for more than 2 days/week). Children of parents with anxious symptoms were associated with increased risks of emotional symptoms and total difficulty (OR: 5.64 and 3.78, respectively).

LIMITATIONS

We adopted self-report questionnaires and did not collect baseline information before COVID-19 outbreak. The potential self-selection bias inherent in the study should be noted.

CONCLUSION

The prevalence of behavioral problems among school-aged children varied from 4.7% to 10.3% in home quarantine during the COVID-19 outbreak. Taking physical exercise may be an efficient measure to reduce behavioral problems for school-aged children in home confinement.

Emotional/Behavioural Problems and Functional Impairment in Children with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

This study aimed to compare the emotional/behavioural problems and functional impairment between early school-age children with attention-deficit/hyperactivity disorder (ADHD) and non-ADHD controls. Factors associated with behavioural problem scores were also evaluated.

METHODS

Children aged 6 to 10 years who were diagnosed with ADHD based on the Swanson, Nolan and Pelham version IV Scale (SNAP-IV) and the DSM-5 criteria for ADHD were compared with age-and sex-matched controls with negative SNAP-IV results in terms of emotional/behavioural problems (as assessed by the Child Behavioural Checklist) and functional impairment (as assessed by the Strength and Difficulties Questionnaire).

RESULTS

40 children with ADHD and 40 non-ADHD controls with a mean age of 8.40 ± 1.44 years were included. The ADHD group scored significantly higher than controls in terms of all eight subscales of emotional/behavioural problems (p<0.001 to p<0.01). Regarding functional impairment, the ADHD group reported significantly higher scores than controls in terms of total difficulties, conduct problems, and hyperactivity (all p<0.01); and significantly lower prosocial scores (p<0.03). In the multiple linear regression analysis, among the ADHD group, comorbid medical disorders were associated with higher total problem score, internalising behaviour problems score, and externalising behaviour problems score; whereas combined subtype ADHD was associated with higher total difficulties score.

CONCLUSIONS

Early school-age children with ADHD have more emotional/behavioural problems and functional impairment than non-ADHD controls, and they need further evaluation and intervention for psychosocial functioning, particularly those with comorbid medical disorder or combined subtype ADHD.

Long-Term Effects of Homophobic Stigmatization During Adolescence on Problem Behavior in Emerging Adult Offspring of Lesbian Parents

The long-term impact of homophobic stigmatization on adolescents with lesbian parents has not been explored. This longitudinal study investigated the effects of homophobia experienced during adolescence on problem behavior among emerging adult offspring of lesbian parents. The 72 offspring (37 females and 35 males; all cisgender and 25 years old) were predominantly White, heterosexual, and highly educated. As 17-year-old adolescents, 40.3% (n = 29) reported that they had been treated unfairly because of having lesbian parents. Experienced homophobia during adolescence was indirectly associated with internalizing problems during emerging adulthood through psychological problems during adolescence and meaning in life in emerging adulthood. Adolescent experiences of homophobia were also indirectly related to externalizing problems during emerging adulthood through adolescent psychological problems, but not through meaning in life in emerging adulthood. These findings indicate that long-term effects of homophobic stigmatization during adolescence persist into adulthood. School and community interventions should include all types of families in their diversity appreciation programs.

Evaluating the Efficacy and Social Validity of a Culturally Adapted Training Program for Parents and Service Providers in India

In regions such as India, where one-to-one behavior-analytic intervention is not easily accessible, parents and service providers may advocate for children with disabilities better if they have foundational training in behavioral approaches to problem behavior. The purpose of this study was to evaluate a culturally adapted training delivered in an underresourced region of India. Ten parents and professionals from Chennai completed the training, and the researchers evaluated its effects using a multiple-baseline design. Participants showed improvements in correct responses on a structured form designed to capture skills involved in function-based assessment and intervention, as well as the fidelity of implementation of extinction and functional communication training. Moreover, participants rated the acceptability of training highly on measures of social validity. Guidelines for the education of parents and service providers in underresourced areas outside of the United States are discussed.

Telehealth-enabled behavioral treatment for problem behaviors in boys with fragile X syndrome: a randomized controlled trial

Background

Children with fragile X syndrome (FXS) are at increased risk for exhibiting problem behaviors such as aggression and self-injury. However, many children with FXS have limited access to behavioral treatments that have known efficacy due to the low availability of treatment providers and the wide geographical dispersion of families with FXS across the country. Telehealth may offer a cost-effective and practical solution to overcome these significant barriers. We examined the effect of administering an established behavior analytic intervention called functional communication training (FCT) via telehealth on levels of problem behaviors exhibited by boys with FXS. We also examined treatment acceptability, as well as the effect of the treatment on levels of parenting stress.

Methods

Boys with FXS, aged 3 to 10 years, who displayed problem behaviors daily, were randomized to receive FCT via telehealth (n = 30) or treatment as usual (n = 27) over 12 weeks. Outcome measures included in-session observations of problem behavior, the Aberrant Behavior Checklist—Community (ABC-C), the Treatment Acceptability Rating Form—Revised (TARF-R), and the Parenting Stress Index, 4th edition (PSI-4).

Results

Intention-to-treat analyses indicated that scores on the irritability subscale of the ABC-C, our primary outcome measure, decreased significantly for boys who received FCT via telehealth compared to boys who received treatment as usual (p < .001, Cohen’s d = 0.65). In-session observations conducted for those who received treatment showed that levels of problem behavior decreased by 91% from baseline. Levels of parenting stress related to child behavioral problems were also lower following FCT treatment, and caregivers reported that the intervention was acceptable.

Conclusions

These findings support telehealth-enabled FCT as a framework for expanding access to behavioral treatments for problem behaviors in children with FXS. Expanded delivery of behavior analytic treatment via telehealth also has the potential to lower healthcare costs, improve child and family quality of life, and lead to advances in the treatment of problem behavior in the broader population of individuals with neurodevelopmental disorders.

Trial registration

ClinicalTrials.gov, NCT03510156. Registered 27 April 2018

Animal Behavior and Learning: Support from Applied Behavior Analysis

Applied behavior analysis (ABA) is a relevant field for veterinarians helping clients whose animals engage in problem behaviors. In ABA, learning is defined as behavior change due to changes in the environment. Changing behavior then requires changes in conditions. Understanding the importance of control and the difference between emotional behavior and emotional feelings also is informed by ABA. Every behavior intervention should start with a systematic, analytical process called a functional assessment. Behavior change strategies are described, including an ethical procedural hierarchy based on the least intrusive, effective behavior change solution.

Collateral Effects of Behavioral Treatment for Problem Behavior on Caregiver Stress

When individuals with autism and intellectual and developmental disabilities exhibit severe problem behavior, assessment and treatment are often warranted. Parents of such individuals are at high risk for developing parenting stress. In this study, 194 parents completed the Parenting Stress Index-Short Form at their child's time of admission to and discharge from inpatient or outpatient treatment for severe problem behavior. Parent stress was examined in relation to rate and function of child problem behavior as determined via functional analysis. Repeated measures analyses of variance were conducted, and differential effects were observed when child participants exhibited an attention, automatic, or mands function for problem behavior. These findings highlight the importance of considering function of problem behavior in relation to parenting stress.

Disadvantaged neighborhoods, birth weight, and problem behavior in five- and six-year-old pre-school children: Evidence from a cohort born in Amsterdam

RATIONALE

Low birth weight has been found to increase the problem behavior of children. Yet, little attention has been given to adequately account for the impact of the child's neighborhood on this relation. The residential neighborhood is a choice, based on factors that are usually not observed that may also influence birth weight and problem behavior.

OBJECTIVE

Using a model that accounts for such endogeneity of both neighborhood choice and birth weight, we have analyzed behavioral problems in 4210 pre-school children between the ages of 5 and 6, birth weight, and neighborhood status, simultaneously.

METHOD

The data used are from the Amsterdam Born Children and their Development (ABCD) cohort for whom a complete prospective record of birth outcomes, pregnancy, socio-demographic characteristics, and indicators of problem behavior are available. Neighborhood data obtained from Statistics Netherlands are merged with the ABCD data file.

RESULTS

Our results suggest that ignoring endogeneity attenuates the effect of disadvantaged neighborhoods on both birth weight and problem behavior in pre-school children. Living in a disadvantaged neighborhood decreases the birth weight and increases the probability of problem behavior. Accounting for the endogeneity of neighborhood choice increases the estimated impacts (marginal effects: from -10% to -44% for birth weight and from 3% to 11% for problem behavior). Lower birth weight increases the probability of problem behavior, but it is only significant after adjusting for endogeneity. The coefficients of other factors have the expected associations with problem behavior.

CONCLUSIONS

These significant effects of disadvantaged neighborhood on birth weight and problem behavior could inform policies and practices that improve neighborhood development for children born in Amsterdam.

Using Extinction to Increase Behavior: Capitalizing on Extinction-Induced Response Variability to Establish Mands With Autoclitic Frames

Members (behaviors) of a response class are equivalent in that they produce the same functional reinforcer. Oftentimes, some members of a response class occur at higher rates than others. This can be problematic when the members that occur at high rates are socially inappropriate (e.g., self-injury, aggression, or disruption). The participant in this study was a 16-year-old female diagnosed with autism spectrum disorder who demonstrated aggression, one-word mands, and mands with autoclitic frames. In a series of contingency reversals, we placed 2 behaviors on extinction (e.g., aggression and one-word mands), which resulted in extinction-induced variability. Capitalizing on extinction-induced variability, we reinforced a different behavior (e.g., mands with autoclitic frames). The results confirmed that (a) the rate of responding for each topography was a function of extinction-induced response variability and differential reinforcement and (b) all response topographies belonged to the same response class. These results provide empirical support for the use of extinction-induced variability to differentially increase the rate of socially appropriate behaviors while decreasing socially inappropriate behaviors that belong to the same response class.

Enhancing the Lives of Foster Youth with Behavioral Interventions

As members of state-funded team to monitor psychotropic medication use and examine cost-effective methods for behavioral treatment in foster care, the authors review behavioral studies on interventions for foster youth who engage in challenging behavior. Four behavioral technologies-preference assessments, teaching procedures, functional behavioral assessment and intervention, and parent training-are discussed. Four case studies and behavioral data for foster youth treated using these technologies are provided. Finally, pediatric providers are encouraged to recommend a practitioner with specialized training in behavior analysis to foster parents if a child displays disruptive behavior.

Examining the impact of a social skills training program on preschoolers' social behaviors: a cluster-randomized controlled trial in child care centers

Background

Preschoolers regularly display disruptive behaviors in child care settings because they have not yet developed the social skills necessary to interact prosocially with others. Disruptive behaviors interfere with daily routines and can lead to conflict with peers and educators. We investigated the impact of a social skills training program led by childcare educators on children’s social behaviors and tested whether the impact varied according to the child’s sex and family socio-economic status.

Methods

Nineteen public Child Care Centers (CCC, n = 361 children) located in low socio-economic neighborhoods of Montreal, Canada, were randomized into one of two conditions: 1) intervention (n = 10 CCC; 185 children) or 2) wait list control (n = 9 CCC; 176 children). Educators rated children’s behaviors (i.e., disruptive and prosocial behaviors) before and after the intervention. Hierarchical linear mixed models were used to account for the nested structure of the data.

Results

At pre-intervention, no differences in disruptive and prosocial behaviors were observed between the experimental conditions. At post-intervention, we found a significant sex by intervention interaction (β intervention by sex = − 1.19, p = 0.04) indicating that girls in the intervention condition exhibited lower levels of disruptive behaviors compared to girls in the control condition (f2 effect size = − 0.15). There was no effect of the intervention for boys.

Conclusions

Girls may benefit more than boys from social skills training offered in the child care context. Studies with larger sample sizes and greater intervention intensity are needed to confirm the results.

Trial registration

Current clinical trial number is ISRCTN84339956 (Retrospectively registered in March 2017). No amendment to initial protocol.

Rules and Statements of Reinforcer Loss in Differential Reinforcement of Other Behavior

Providing a rule regarding consequences for behavior can increase the efficacy of differential reinforcement of other behavior (DRO) procedures in the treatment of severe problem behavior (Watts, Wilder, Gregory, Leon, and Ditzian, Journal of Applied Behavior Analysis, 46, 680-684, 2013). The purpose of the current study was to replicate and extend the literature on DRO procedures by evaluating the efficacy of rules and statements of reinforcer loss (SRL) in the treatment of severe problem behavior. Conditions included baseline, no rule DRO, rule DRO, and rule DRO with SRL. For 2 of 3 participants, neither the no rule DRO nor the rule DRO condition reduced problem behavior. The rule DRO with SRL condition produced a substantial decrease in problem behavior for all participants, suggesting that a consequent rule enhances the efficacy of DRO. The current study extends the literature on DRO procedures by providing data on nontargeted ("other") behavior. An increase in other behavior was observed for 2 participants.

On the Standardization of the Functional Analysis

The functional analysis procedures described in the seminal Iwata et al. (1982/1994) study are prominent in the applied behavior analytic literature, having been replicated hundreds of times over the past 30 years (Beavers, Iwata, & Lerman, 2013; Hanley, McCord, Iwata, 2003). However, the extent to which particular components of this functional analysis model have become more or less prominent over time is not clear from these literature reviews. We therefore conducted a review of the functional analysis literature between the years of 1965 and 2016 to determine the trends in the usage of particular components over time and to determine if the published literature reflects a standardization of the manner in which functional analyses of problem behavior are conducted. Furthermore, we discuss whether or not this standardization of a functional analysis model is currently necessary.

Blue Light Covers Increase Stereotypy and Decrease On-Task Behavior for Students with Autism

Some recommended strategies for individuals with autism spectrum disorder (ASD) are not empirically based. The purpose of the study was to evaluate effects of blue light covers on levels of stereotypy and on-task behavior. Four male children with ASD who engaged in repetitive behavior participated. Placing light covers over the classroom's fluorescent lights relative to normal classroom lighting did not improve on-task behavior or stereotypy.

Supporting Strategic Investment in Social Programs: a Cost Analysis of the Family Check-Up

High-quality evidence about the costs of effective interventions for children can provide a foundation for fiscally responsible policy capable of achieving impact. This study estimated the costs to society of the Family Check-up, an evidence-based brief home-visiting intervention for high-risk families implemented in the Early Steps multisite efficacy trial. Intervention arm families in three sites were offered 4 consecutive years of intervention, when target children were ages 2 through 5. Data for estimating total, average, and marginal costs and family burden (means and standard deviations, 2015 USD, discounted at 3% per year) came from a detailed database that prospectively documented resource use at the family level and a supplemental interview with trial leaders. Secondary analyses evaluated differences in costs among higher and lower risk families using repeated measures analysis of variance. Results indicated annual average costs of $1066 per family (SD = $400), with time spent by families valued at an additional $84 (SD = $99) on average. Costs declined significantly from ages 2 through 5. Once training and oversight patterns were established, additional families could be served at half the cost, $501 (SD = $404). On the margin, higher risk families cost more, $583 (SD = $444) compared to $463 (SD = $380) for lower risk families, but prior analyses showed they also benefited more. Sensitivity analyses indicated potential for wage-related cost savings in real-world implementation compared to the university-based trial. This study illustrates the dynamics of Family Check-up resource use over time and across families differing in risk.

Effects of Household Income Change on Children's Problem Behavior: Findings From a Longitudinal Study

PURPOSE

This study aimed to examine the effect of changes in equivalized disposable household income (EHDI) on children's problem behavior.

METHODS

Data were collected from the Korean Welfare Panel Study (2006, 2009, 2012). A total of 1,005 school-aged children were included in the analysis. Children's problem behavior was measured using the Korean version of the Child Behavior Checklist. Using the generalized linear mixed model for repeated measures, we investigated the effect of actual household income changes on children's problem behavior, based on the family's EHDI.

RESULTS

Children who experienced high EHDI decrement exhibited a significant increase in problem behavior compared with those who did not experience sizable EHDI change (high decrement: β = .21, standard error = .09, p = .016). Furthermore, problem behavior was higher in girls who experienced a decrement in EHDI compared with boys.

CONCLUSIONS

These findings suggest that changes in family's economic status might negatively affect the probability of children's problem behavior when there is a large decrease in EHDI.

Intraoperative Disruptive Behavior: The Medical Student's Perspective

OBJECTIVE

Intraoperative disruptive behavior can reduce psychological safety and hinder teamwork and communication. Medical students may provide unique insights into how to prevent these adverse impacts. We sought to characterize medical student perspectives on the causes and consequences of intraoperative disruptive behavior and ideal intraoperative working environments.

DESIGN

In this retrospective qualitative analysis, authors coded de-identified field notes from residency interviews to identify themes and key insights and to explore gender differences in perspectives.

SETTING

A tertiary academic medical training center in the Midwestern United States.

PARTICIPANTS

Forty-two medical students applying for urology residency placement.

RESULTS

Students were 57% male with an average age of 26 years (range 23-34). Most students witnessed intraoperative disruptive behavior (usually by surgeons) such as yelling, throwing instruments, or blaming others. Students described frustration with missing instruments and incompetent assistants as the most common instigators of disruptive behavior. They noted undesirable effects of disruptive behavior, including decreased communication/teamwork, lack of learning, increased technical mistakes, and recalled feeling afraid and stressed by these situations. They described ideal intraoperative working environments as calm, efficient and collaborative environments where questioning and learning is encouraged.

CONCLUSIONS

Students provide a valuable perspective on the causes and consequences of disruptive behavior during surgery and point to potential pathways to improvement. Their experiences suggest prevention or reduction of surgeon frustration might be a fruitful target for intervention efforts to prevent intraoperative disruption.

Comparison of Traditional and Embedded DTT on Problem Behavior and Responding to Instructional Targets

Embedded discrete trial training (DTT) involves the presentation of instructional targets in an activity-based situation, and serves as an alternative to traditional, table-top instruction (Geiger, Carr, LeBlanc, Hanney, Polick, et al. Behavior Analysis in Practice 5, 49-59, 2012). The current study compared the effects of Traditional and Embedded DTT on responding to instructional targets and problem behavior for one child with autism. Although the results showed similar levels of accuracy for instructional targets across both conditions, there were more target exposures and no problem behavior during Embedded DTT. The results are discussed along with future directions for research and clinical practice.

A Cross-National Comparison of the Development of Adolescent Problem Behavior: a 1-Year Longitudinal Study in India, the Netherlands, the USA, and Australia

The world youth population is the largest ever and the levels of problem behavior will influence future global health. Recognition of these issues raises questions as to whether adolescent development knowledge can be internationally applied. To date, most research examining adolescent problem behavior has been completed in the United States (USA) and there has been neglected analysis of health inequalities. The aim of the present study was to compare the structure and predictors of problem behavior in representative samples from the USA, Australia, India, and the Netherlands. Two timepoints of longitudinal data were analyzed from the International Youth Development Study that originally recruited state-representative student cohorts in 2002 in Washington State, USA (analytic sample N = 1942) and Victoria, Australia (N = 1957). Similar aged samples were recruited in Mumbai, India, in 2010 (N = 3.923) and the Netherlands in 2008 (N = 682). Surveys were matched and follow-up occurred over 1-year (average baseline ages 12 to 13). CFA identified a latent problem behavior construct comprised of substance use and antisocial behavior indicators. There were cross-national differences in the indicators for this construct. Factor loadings and items were similar between Australia and the USA; however, different items loaded on the construct for the Indian and Netherlands sample. SEM identified that problem behavior at time 2 was predicted by time 1 behavior, with cross-national differences evident. Low parent education was predictive in the USA and India. The number of risk factors present was predictive of problem behavior in all four nations. The findings suggest that evaluated preventative strategies to reduce adolescent problem behavior may have international applications. The analysis of cross-nationally matched longitudinal data appears feasible for identifying prevalence and predictor differences that may signify policy and cultural contexts, to be considered in adapting prevention programs.