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Anirr J Orihopsvchiai 6-l(+'). Ocioher 1994

RISK AND PROTECTIVE FACTORS FOR DISRUPTIVE BEHAVIOR DISORDERS IN CHILDREN

Natalie Grizenko, M.D., F.R.C.P.(C), and Nicole Pawliuk, M.A.

Biological, psychological, and social risk and protective factors in the development of disruptive behavior disorders were assessed in 50 disordered and 50 control pre-

adolescents.

Significant risk factors included learning diflculties, hyperactivity,

perinatal complications, and violence in the home. Signijkant protective factors

included ability to expressfeelings and a good relationship with grandparents.

isruptive behavior disorders such as

D attention-deficit hyperactivity disorder,

oppositional defiant disorder, and conduct disorder are among the most common dis- orders in preadolescent children, with re- ported prevalence rates ranging from 10.1% in boys aged 4-11 years (Oflord, Boyle, Fleming, Blum, & Rae-Grant, 1989) to 19%

in children aged 6-19 (Keller et al

1992).

Disruptive behavior disorders have also been identified as the most frequent reason for referral to child psychiatric clinics (Ander- son, Williams, McGee. & Silva, 1987) and, in approximately 25% of cases, are associ- ated with antisocial and substance abuse disorders in adulthood (Gittelman, Man- nuzza, Shenker, & Bonagura, 1985; Hecht- man & Weiss, 1986; Robins, 1978; Wood, Wender, & Reimherr, 1983). It is impor- tant, therefore, to identify children who are at risk for developing disruptive disorders. It is also important to identify factors that may protect children from developing such disorders so that preventive programs can be designed for high-risk children.

Risk factors have been defined as vari- ables that increase the likelihood of psy- chopathology (Masten & Garme?, 1985). Investigations of the risk factors associated with behavioral disorders have been con- ducted using two research designs. The first of these selects children with particular be- havioral or emotional problems and com- pares their levels of risk factors to those in a matched control group of children with- out problems. The second design investigates the prevalence of psychopathology and as- sociated risk factors in a large population (a community survey), evaluated either cross- sectionally or longitudinally. An example of a matched design is the study by Jensen, Bloedau, Degroot, Ussery, and Davis (1990) that compared risk fac- tors in a sample of 134 children aged 6-12 years who had been referred to a psychi- atric clinic on a military base to risk factors in a control group of children of military personnel. The clinical group was found to have higher stress levels, greater parental psychopathology, and higher rates of pa-

Based on a paper presented at the 1993 annual meeting of the American Psychiatric Association in Sun Francisco Authors are at the Lyall Preadolescent Day Treatment Program, Douglas Hospital, Verdun, Quebec

534

0 1994 American Orthopsychiatric Association, Inc.

GRIZENKO AND PAWLIUK

rental divorce. Since the clinical group consisted only of children seen in a mili- tary psychiatric clinic, the results of the study may not be generalizable to the gen- eral population. A community survey method was used by Williams, Anderson, McGee, and Silva (1990) to assess 792 children, 13% of whom were found to have a psychiatric disorder. Behavioral and emotional disorders were associated with such risk factors as being male, having a mother with a current or previous depressive disorder, having a sin- gle mother, and having reading difficulties. The relation between risk factors and be- havioral disorders can also be assessed in the general population by means of a longi- tudinal design that measures risk factors at one point and psychiatric diagnoses years later. Such a design may give a clearer in- dication of the causal relationship between risk factors and psychopathology than do cross-sectional designs. Velez, Johnson, and Cohen (1989) conducted a longitudinal study of risk factors in a community sample of 9-1 8-year-olds and investigated subsequent diagnoses of externalizing or internalizing disorders. Risk factors tended to be related more to externalizing than to internalizing diagnoses. Low socioeconomic status (SES), single-parent families, parental sociopathy, numerous stressful life events, and school failure were identified as significant risk factors for the development of externaliz- ing disorders two years after the initial as- sessment. Notwithstanding design differences be- tween matched and community surveys, both methods have associated similar risk variables with psychopathology. These var- iables include biological risks such as parental psychopathology and sociopathy; psychological risks such as parental di- vorce, family dysfunction, and interpersonal difficulties; and social risks such as low SES and living with a single parent. However, since not all children exposed to these risk factors develop psychiatric disorders, there must also be mechanisms

535

such as those that Rutter (1985) called “pro- tective processes,” which modify, ameliorate, or alter an individual’s response to envi- ronmental hazards that would otherwise lead to maladaptive outcomes. Unlike risk factors, which have a direct effect on the development of disorders, protective pro- cesses operate indirectly, their effects ap- parent only through interactions with risk factors (Rutter, 1990). Previous investiga- tions have assessed such interactions by fo- cusing on protective factors in resilient high-risk groups, or by matching high-risk subjects to low-risk subjects and compar- ing protective factors. In a case study of children from homes in which both parents had a major affective disorder and the mar- ital relationship was poor (Radke-Yarrow & Sherman, 1990),the “survivors” showed positive self-esteem, had warm relation- ships with at least one parent, and were

competent at school-variables

identified as protection against their chaotic home life. Werner (1989) conducted a 32-year lon- gitudinal follow-up study of high-risk in- fants in Kauai who had experienced perina- tal stress, low SES, or life in a discordant or divorced family environment with parental alcoholism or mental illness. One-third were considered “resilient” because, as adults, they had more positive life experiences than the remainder of the high-risk sample. These resilient adults were characterized in elementary school as getting along well with classmates, having good reasoning and reading skills, and having many interests and hobbies. They were also from smaller families, had few separations from their primary caretaker, and had emotional sup- port outside their families-variables seen as protecting the high-risk group from neg- ative life outcomes. Jenkins and Smith (1990) investigated protective factors in 9-1 2-year-olds from 57 disharmonious homes and matched them to children fiom 62 harmonious homes. They found that close sibling and adult relation- ships and positive recognition for activities

that were

outside the home served as protective fac- tors only for children from disharmonious homes. Alternatively, quality of parent-child relationships and friendships was related to reduced levels of emotional disturbance in children from both harmonious and dishar- monious homes. Thus, some factors worked in a protective manner only for high-risk children, while others had a more general protective influence. Rae-Grant, Thomas, Offord, and Boyle (1989) examined the predictive power of both risk and protective factors in the de- velopment of behavioral and emotional disorders in a community sample of chil- dren. They identified family and parental problems as risk factors significantly re- lated to conduct, hyperactivity, neurosis, and somatization disorders. Protective fac- tors that significantly reduced the risk of disorder included getting along with oth- ers, being a good student, and participating in two or more activities. Overall, research has indicated that psy- chological and social protective factors, whether measured in high-risk populations or through community surveys, include the competence of the child, positive personal- ity characteristics, positive relationships with family and friends, and participation in outside activities. Although these studies have identified various processes that pro- tect against the development of behavior disorders, they are limited by their assess- ment of relatively few risk and protective factors. For example, Velez et al. (1989) failed to assess such risk factors as child temperament or medical problems during pregnancy. Thus, it would be useful to have a method of assessment that can readily assess multi- ple risk and protective factors. The factors that discriminate most strongly between children with disruptive behavior disorders and a nondisordered control group could then be used to develop protective mea- sures to reduce the incidence of future be- havior disorders in at-risk children. The present study used a biopsychoso-

RISK AND PROTECTIVE FACTORS

cia1 model to assess and identify multiple factors that may put preadolescents at risk or protect them from developing disruptive behavior disorders. The factors to be evalu- ated were chosen from a review of the liter- ature by Grizenko and Fisher (1992).

METHOD

Population The disruptive behavior-disorder group consisted of 26 boys and 24 girls, mean age nine years (SD=2.l), with severe behavior problems as determined by total scores of at least 70 on the Revised Child Behavior Profile (RCBP) (Achenbach & Edelbrock, 1983). The mean T-score on the RCBP was 79.7 (SD=5.3). Forty children were re- ferred to a day treatment program and ten to outpatient services at the Douglas Hos- pital Centre in Quebec. All referrals were for severe disruptive behavior at home or school. Diagnoses were made independently by a psychiatrist (NG) and a psychologist in the hospital’s children’s services, utiliz- ing information from the psychiatric as- sessment, previous interviews with parents, and reports from teachers. Diagnoses were as follows: 30 children had oppositional defiant disorder (ODD), 13 had attention- deficit hyperactivity disorder (ADHD), six had both ODD and ADHD, and one child was diagnosed with conduct disorder (CD). Both outpatient and day treatment lasted between four and six months. The matched control group was recruited from five summer day camps in the Mon- treal area. It included children aged 6-12 whose parents consented to their participa- tion, and who had a total RCBP score be- low 70 (not in the problem range). The mean T-score on the RCBP was 50.7 (SD=8.2). The group consisted of 24 boys and 26 girls with a mean age of 8.3 years (SD=2.0). Preliminary analyses revealed no signifi- cant difference in age between the control and behavior problem groups (t[98]=-1.61, p>.05), and a significant difference in RCBP scores between control and behavior prob- lem groups (tp)8]=20.98,p<.OOl).

GRIZENKO AND PAWLIUK

Measures Behavior was assessed by parents’ re- sponses to the RCBP; this is a 113-item questionnaire that measures internalizing and externalizing behavior, for which test- retest reliability of mothers’ ratings over a one-week period is .89 and construct valid- ity ranges from .71 to .92 (Achenbach & Edelbrock, 1983). Risk and protective factors over the life- time of the child were assessed using a questionnaire based on the factors identi- fied by Grizenko and Fisher (1992). The yesho-format questionnaire consists of 70 questions concerning biological, psycho- logical, and social risk and protective fac- tors. Factors were categorized by a group of 16 child psychiatrists and psychologists, and those not achieving 75% agreement on category placement (seven factors) were discarded from analysis. Biological factors included those indicating genetic links to behavior (e.g., parental psychiatric disor- der, alcoholism) and those presenting a bi- ological basis for behavior (e.g., perinatal complications, learning disabilities). Psy- chological factors were characterized by descriptors of personality traits (e.g., “is shy,” “has a sense of humor”), and possible abuse that could affect psychological func- tioning (e.g., frequent punishment, emotional neglect). Social factors included those de- scribing the child’s social relationships (e.g., has many friends), living conditions (has many siblings, lives with both parents), so- cial instability (moving many times, being placed), and general economic indicators (family’s being on welfare). Parents were interviewed by research assistants either in person or over the telephone. (A copy of the questionnaire is available from the authors upon request.) The number of recent negative life events was assessed using a checklist based on the psychosocial stressors scale (Axis IV) of DSM-Ill-R (American Psychiatric Associa- tion, 1987). Severe life events included separation, divorce, or death of a parent, sexual or physical abuse, and serious ill-

537

ness. Fifty-three children (19 in the control group and 34 in the behavior-problem group) had experienced at least one “severe” life event in the last six months.

Design All variables were categorized as biolog- ical, psychological, or social risk factors or biological, psychological, or social protec- tive factors, thus yielding six subgroups. Variables in each subgroup were analyzed separately by forward stepwise logistic re- gression, which can be used with dichoto- mous independent variables to predict a di- chotomous outcome (Norusis, 1990). The forward stepwise procedure evaluates each predictor variable in turn for strength of re- lationship to outcome by calculating an im- provement x . The predictor with the strongest relationship is entered first, then the predictor with the next-strongest rela- tionship, until a specified entry criterion (set at p=.lO) is met. Two dichotomous outcome variables were investigated:total RCBP score (70 and over vs under 70) for the entire sam- ple and for boys and girls separately; and di- agnosis (none vs ODD and none vs ADHD). Risk factors were defined as those that significantly predicted disruptive behavior disorders. Protective factors were defined as those that significantly reduced the pre- diction of behavior disorder under condi- tions of high stress (Rutter, 1985). Severe life stress was viewed as a hazard possibly leading to poor outcome, as has been re- ported in previous investigations (Costello, 1989; Forehand et al., 1991; Stanger, Mc- Conaughy, & Achenbach, 1992). Thus, only the data for subjects scoring one or more recent severe life events were used to analyze protective factors. Stressors were distinguished from risk factors by their in- clusion of severe life stress within the last six months, whereas risk factors were in- vestigated over the child’s lifetime.

2

RESULTS

The results of the forward stepwise lo- gistic regressions for each of the subgroups

are shown in TABLES 1-5. TABLESla and Ib illustrate the odds ratio, improvement x2 and corresponding probability for each sig- nificant variable. TABLES2-5 present odds ratios for significant variables only. The odds ratios indicate the likelihood that each variable predicts behavioral problems or diagnosis. Values greater than 1.O repre- sent increased odds for predicting a behav- ior disorder and values smaller than 1.0 represent decreased odds for predicting a behavioral disorder (as would be predicted for protector variables). The percentages appended to each of the subgroup headings represent cases correctly classified using these subgroups. TABLESla and Ib show the significant risk and protective factors evaluated using the outcome measure of high vs low RCBP score. TABLES2 and 3 present the same cal- culations for boys and girls, respectively. TABLES4 and 5 present the significant risk and protective factors evaluated for control vs ADHD and control vs ODD diagnoses, respectively. The analyses of the subgroups (TABLES 2-5) were seen as a method of test- ing the stability of the factors from the ini- tial logistic regression.

RISK AND PROTECTIVE FACTORS

DISCUSSION

Risk and protective factors that signifi- cantly discriminate between behavior prob- lem and control children were examined. The biological factors placing children at risk for the development of disruptive be- havior disorders included hyperactivity as an infant, learning disabilities, school fail- ure, perinatal complications, and a history of maternal depression. There is adequate support in the literature for the association of these risk factors with behavior disor- ders. Early hyperactivity, for example, has been associated with later conduct disor- ders (Coon, Carey, Corky, & Fulker, 1992). School failure and learning disabilities have also been reported in children with disruptive behavior disorders (Costello, 1989; Reeves, Werv, Elkind, & Zametkin, 1987; Semrud- Clikemanet al., 1992). Perinatal complica- tions have been reported both in children with disruptive behavior disorders (Reeves et al., 1987) and in 20% of a high-risk fol- low-up sample in need of long-term mental health services (Werner & Smith, 1979). Previous investigations have also reported a link between maternal or familial depres- sion and disruptive behavior disorders (Bie-

Table la

RISK FACTORS EVALUATED FOR BEHAVIOR-PROBLEM(RCBP>70) VS CONTROL GROUPS (RCBPr70) (W100)

FACTORS

IMPROVEMENT (x2)

Biological

[97%]

P ODDS RATIOa

Failed at least one year of school

40

5

0

000

86

0

Hyperactiveas infant

32

8

0 000

1oo+

Learningdisabled

15

1

0

000

26

3

Perinatal complications

98

0

002

35

6

Mother history of depression

81

0

004

81

Psychological

[93%]

Frequently sad

45

6

0 000

1oo+

Jealous

187

0

000

loo+

Clings to parents

11 1

0001

1oo+

Needs to be center of attention

 

45

0

034

93

Frequently punished

44

0

036

50

1

Anxious

38

0

052

86

Emotionally neglected

 

33

0

07

1oo+

Social

184%)

Social work involvement

30 9

0

000

37

Moved three or more times

10

5

0001

47

Parents immigrants

10

0

0

002

142

Violence in home

81

0

004

14

7

Chanoed schools four+ times

43

0

039

1oo+

Note Figures in brackets indicate percentage of cases correctly classified using these factors 'Odds ratio=likelihood of each vanable predictino behavioral problems

GRIZENKO AND PAWLIUK

539

Table 1b

PROTECTIVE FACTORS EVALUATED FOR BEHAVIOR-PROBLEM (RCBP>70) VS CONTROL GROUPS (RCBP<70) (W53)

FACTORS

IMPROVEMENT ,y2

P

ODDS RATIOa

Biological

[70%]

Happy temperament as infant

11 2

 

0 001

0 12

Psychological

[89%]

Copes with stress

28

1

0 000

0 03

Adapts to change easily

13 7

28

0 000

0 18

Expresses feelings easily

0 093

0 03

Social

[75%]

Good relationship grandparents

13 0

 

0 000

0 05

Has two or more hobbies

46

0 032

0 21

Note Figures in brackets indicate percentage of cases correctly classified using these factors aOdds ratio=likelihood of each variable predicting behavorial problems

derman et al., 1987; Brown, Borden, Clinger- man & Jenkins, 1988; Williams et al., 1990). Due to the cross-sectional nature of the present study, it was difficult to determine whether maternal depression occurred pri- or to or as a consequence of dealing with a child with behavior disorders. Psychological risk factors associated with disruptive behavior disorders included neg- ative personality traits (e.g.,jealousy, anxi- ety, clinging to parents, and needing to be the center of attention), and a history of fre- quent punishment and emotional neglect. Previous investigations have associated neg- ative personality traits with behavior disor- ders. For example, Coon et al. (1992) re- ported that conduct-disordered seven-year- old children were rated by parents as hav-

ing more difficult temperaments than their peers. Maziade et al. (1990) found that a greater proportion of seven-year-old chil- dren with extremely difficult temperaments were diagnosed with externalizing disor- ders at ages 12 and 16 than were those with easy temperaments. Difficult temperament may be linked to increased psychiatric risk through its relation to increased parental hostility, criticism, and irritability (Rutter, 1990), which can lead to frequent punish- ment and emotional neglect on the part of parents. Frequent sadness was also found to be a significant risk factor related to dis- ruptive behavior disorders, an association well established in the literature (Jensen, Burke, & Garfnkel, 1988; Politano, Edinger, & Nelson, 1989; Woolstonet al., 1989).

Table 2

ODDS RATIO FOR RISK AND PROTECTIVE FACTORS EVALUATED FOR BOYS IN THE BEHAVIOR-PROBLEM (RCBP270) VS CONTROL GROUPS (RCBP<70)

RISK FACTORS (N=50)

ODDS RATIOa

PROTECTIVE FACTORS (N=28)

ODDS RATIO

Biological

[go%]

Biological

[68%]

Failed at least one year school

1oo+

Above average at school

0 23

Hyperactive as infant

1oo+

Psychological

[92%]

Psychological [89%]

 

History of physical abuse

1oo+

Copes with stress

<o 0001

Holds a grudge

46 2

Adapts to change easily

<o 0001

Frequently punished 19 8

 

Child is a loner

15

7

Child is easily jealous

15

1

Social

[74%]

Social

[71%]

Changed schools four+ times

1oo+

Good relationship with grandparents

0 07

Social work involvement

51

Note Figures in brackets indicate percentage of cases correctly classified using these factors aOdds ratio=likelihood of each variable predicting behavioral problems

540

RISK AND PROTECTIVE FACTORS

Table 3

ODDS RATIOS FOR RISK AND PROTECTIVE FACTORS EVALUATED FOR GIRLS IN THE BEHAVIOR-PROBLEM (RCBP>70) VS CONTROL GROUPS (RCBP<70)

RISK FACTORS (N=50)

Biological

[El%]

Learning disabled

Psychological

Child is frequently sad

[82%]

Social

[82%]

Child is an immigrant Violence in the home Social work involvement

ODDS RATIOa

1oo+

PROTECTIVE FACTORS (N=25)

Biological

[72%]

Happy temperament as infant

ODDS RATIO

<0.001

1oo+

Psychological [96%]

 

Copes with stress

0.04

Positive self-image

0.04

1oo+

16 8

Social

[68%]

16 2

Has two or more hobbies

0 0001

Note Figures in brackets indicate percentage of cases correctly classified using these factors aOdds ratio=likelihood of each variable predicting behavioral problems

Changing schools and moving often, ex- amples of an unstable home environment that has been associated with poor adjust- ment (Wyman et al., 1992), were identified as social risk factors. Having parents who were immigrants was also a significant risk factor; previous investigations have estab- lished a link between changes in parental life due to immigration and behavior disor- ders in children (Barankin, Konstantareas, & de Bosset, 1989; Minde & Minde, 1976). Violence in the home and social-work in- volvement were further significant predic- tors of disruptive behavior disorder. Wolfe and Jaffe (1991) reported elevated levels of externalizing behavior in children living in shelters for battered women. Due to the cross-sectional nature of the study, it is dif- ficult to determine causality for social-

work involvement and behavior disorders. A child’s acting-out behavior may cause a family to request social-work intervention, or social services may become involved because of factors such as violence in the home, which may lead to behavior prob- lems. Significant protective factors were de- fined as those associated with a reduced risk of behavior disorder under conditions of recent high stress. The social protective factors that significantly discriminated be- tween behavior-problem and control chil- dren were: having two or more hobbies and a positive relationship with grandparents. Previous investigations have also reported such protective factors in children without disturbance or resilient high-risk subjects (Jenkins & Smith, 1990; Rae-Grant et al.,

Table 4

ODDS RATIOS FOR RISK AND PROTECTIVE FACTORS EVALUATED BY ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) DIAGNOSIS

RISK FACTORS (N=69)

Biological

[93%]

ODDS RATIOa

PROTECTIVE FACTORS (N=30)

Biological

[EO%]

ODDS RATIO

Hyperactive as infant

1oo+

Happy temperament as infant

0.07

Child chronically ill

1oo+

Failed at least one year school

1oo+

Psychological

[94%]

History of physical abuse Frequently punished Child is easily jealous Child is anxious

Social

[83%]

Child is an immiarant

Violence in the tome

1oo+

1oo+

51.1

10.6

1oo+

14.7

Psychological [87%] Adapts to change easily

Social

[87%]

Has manv friends Good relationshio with orandoarents

<0.0001

<0.0001

~0.0001

Note. Figures in brackets indicate percentage of cases correctly classified using these factors aOdds ratio=likelihood of each variable Dredictina ADHD diaanosis.

GRIZENKO AND PAWLIUK

541

Table 5

ODDS RATIOS FOR RISK AND PROTECTIVE FACTORS EVALUATED BY OPPOSITIONAL DEFIANT DISORDER (ODD) DIAGNOSIS

RISK FACTORS (N=80)

ODDS RATIOa

PROTECTIVE FACTORS (N=41)

ODDS RATIO

Biological

[92%]

Biological

[71%]

Failed at

least one year

school

29 3

Happy temperament as infant

0

13

Learning disabled

 

84 5

CNS injury

 

1oo+

Psychological

[92%]

Psychological [85%]

 

Child

is

frequently sad

 

1oo+

Copes with stress

0 03

Child

is

easily jealous

1oo+

Adapts to change easily

0

04

Child clings to parents

1oo+

Emotional neglect

1oo+

Social

[84%]

Social

[73%]

Changed schools four+ times

1oo+

Good relationship with grandparents

0

08

Social work involvement

10 6

Has two or more hobbies

0

21

Violence in the home

63

Note Figures in brackets indicate percentage of cases correctly classified using these factors =Odds ratio=likelihood of each variable predicting ODD diagnosis

1989; Werner, 1989). Self-esteem may be increased by participation in activities, and grandparents can provide support in situa- tions of stress. The significant psychological protective factors under conditions of high stress were: the ability to cope with stress, adapt to change easily, and express feelings eas- ily, factors that may be viewed as psychol- goical components of the biological factor of happy infant temperament. “Easy tem- perament” in infancy appears to be associ- ated with reduced risk of psychiatric disor- der (Maziade et al., 1990). For example, Werner (1989) noted that resilient adults were described as having been good-na- tured and affectionate at age one and as seeking novel experiences at 20 months. Examination of TABLES 2 and 3 reveals that most risk and protective factors were similar for boys and girls. It appears, how- ever, that boys with a history of physical abuse and who were described as being “loners” were more at risk than girls with the same attributes, and that girls were pro- tected to a greater degree by a positive self- image than were boys. TABLES4 and 5 indicate that the protec- tive factors were similar for both ADHD and ODD diagnostic groups. Very few risk factors differentiated these groups. Not sur- prisingly, hyperactivity as an infant was a

-

significant risk factor for ADHD children only.

CONCLUSION

By means of an easily administered ques- tionnaire given to parents of children with and of children without disruptive behavior disorders, the present study identified a constellation of the most important risk and protective factors, which are consistent with those presented in the literature. The ques- tionnaire used identified risk and protective factors that represented biological, psycho- logical, and social processes related to the development of behavior disorders. Inves- tigations limited to just one of these areas may miss information useful in identifying high-risk groups and developing protective measures. Some of the protective factors identified can be cultivated in at-risk children as a means of preventing future behavioral dis- order. For example, after-school programs can be utilized to encourage outside activi- ties, build friendships, and develop hob- bies, all of which may serve as an escape from stressful home situations and provide the child with experiences of success or mastery. Individual and family therapy can increase a child’s ability to understand and express feelings before problems escalate (Grizenko, Papineau, & Sqegh, 1993; Han-

542

RISK AND PROTECTIVE FACTORS

specific problem (disruptive behavior dis- orders), thus avoiding inconsistencies due to the presentation of a different constella- tion of risk and protective factors for chil- dren of varying age groups and clinical Presentations. The use of the RCBP in identifying Problems was also important because it assesses both externalizing and

ported and encouraged. internalizing behavior. A child may be re-

Findings of the present study must be viewed and applied with caution. This in-

sen & Cohen, 1984). Teachers or guidance counselors should be encouraged to de- velop programs that help children in stress- ful situations to identify, understand, and appropriately express their feelings instead of acting them out through delinquent be- havior. Lastly, the protective role that grand- parents play with children should be sup-

ferred for treatment for acting out and at the same time be experiencing depression and anxiety, which also need treatment. The problem found to place children at risk for disruptive behavior disorders, and those that protected them from devel- oping disorders in situations of high stress remained consistent when assessed for different-sex subgroups or diagnostic groups. Further, the of risk and pro- tective processes identified are similar to those of previous investigations.

Future research should

to testing

applicationsof these findings via assess- ment ofpreventive programs in the areas of

social skills training, group work, and after- school programs for children identified as at risk but not yet diagnosed with disrup-

follow-

up of children at risk should be incorpo- rated into future research designs to allow for an of causalityand the long-term consequences of risk and protec-

tive factors.

tive behavior disorders, Long-te,,,,

REFERENCES Achenbach, T.M., & Edelbrock, C. (1983). Manual for the Child Behavior Checklist and Revised Child Behavior Pro)le. Burlington: University of Vermont, Department of Psychiatry. American Psychiatric Association. (1987). Diag- nositic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. Anderson, J.C., Williams, S., McGee, R., & Silva, P.A. (1987). DSM-111 disorders in preadolescent children: Prevalence in a large sample from the general population. Archives of General fsychia- 19, 44, 69-76. Barankin, T., Konstantareas, M.M., & de Bosset, I:. (1989). Adaptation of recent Soviet Jewish immi- grants and their children to Toronto. Canadian Journal of Psychiatry, 34, 5 12-5 18. Biederman, J., Munir, K., Knee, D., Armentano, M., Autor. S., Waternaux, C., & Tsuang, M. (1987). High rate of affective disorders in probands with

vestigation

was not intended to create a

checklist of risk and protective factors for each child, but rather to identify certain constellations of factors that may be pro- tective and others that may place a child at risk for developing disruptive behavior dis- orders. It is also important to recognize that

the

may differ from individual to individual

(Richters & Weintraub, 1990; Rutter. 1990).

Several methodological limitations should

group was Only

matched to the behavior-problem group with regard to age and sex; variables such as 'Q were not assessed in the control group because of time constraints. In addi- tion, due to the cross-sectional nature of the could not be determined. For example, it was unclear whether social- work involvement preceded Or followed the expression of disruptive behavior in children. Further, the dichotomous nature of the variables measured may have ob- scured important gradations in concepts

such as self-esteem or peer relations. The use of scales to assess these variables may improve the predictability of the measures. The study only used parental reports, which may not accurately reflect a child's functioning. Kashani, Orvaschel, Burk, and Reid (1985) reported poor agreement be- tween parental and child ratings of child behavior. The strengths of the present study include the use of a biopsychosocial model to de- termine a global assessment of risk and pro- tective factors. The study targeted a spe- cific age group (preadolescence) with a

be noted. First, the control

factors

of risk and protective

GRIZENKO AND PAWLIUK

attention deficit disorder and in their relatives: A controlled family study. American Journal of Psy- chiatry, 144, 330-333. Brown, R.T., Borden, K.A., Clingerman, S.R., & Jenkins, P. (1988). Depression in attention deficit- disordered and normal children and their parents.

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For repnnts Natalie Gnzenko,M D , F R C P (C),Lyall Pawlion, Douglas Hospital, 6875 LaSalleBlvd ,Verdun,Quebec,CanadaH4H IR3