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«by Amy Lynn Byrd, Ph.D. B.S. in Psychology, College of Charleston, 2006 M.S. in Clinical Psychology, University of Pittsburgh, 2010 Submitted to the ...»

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Scan Day Assessment On the day of the scan session, CP and HC youth and their caregiver completed questionnaires (described below) prior to the fMRI scan. Once questionnaires were complete, youth underwent task training and performed a brief practice version of the reward/punishment processing task on a laptop computer to ensure task comprehension. In addition, youth were given the opportunity to complete a scan simulation in order to familiarize them with the scanning procedure. Youth then completed a one hour scan that consisted of a T2 localizer, a reward/punishment card guessing task, an implicit emotion processing task and a structural scan.

For the purpose of the current dissertation, only the reward/punishment card guessing task was utilized (task and imaging details described below). Following the scan, youth completed a questionnaire about their experience in the scanner as well as their perception of the task. Of the

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often due to claustrophobia. This resulted in 52 CP youth with completed scans. Of the 57 eligible HC, 5 refused to initiate the scan and 12 were unable to complete the scan, again most often due to claustrophobia. This resulted in 40 HC with completed scans.

Treatment and Follow-up Assessment Following the fMRI scan session, CP youth received one of two treatment conditions for approximately 3 months: 1) a comprehensive CBT/PMT intervention (i.e., SNAP) or 2) treatment as usual (TAU) in the community as a part of the larger treatment study (Burke & Loeber, 2014). Both conditions are described in more detail below. CP youth were also reassessed following treatment at 3-, 9- and 15-months from baseline, at which time measures of CP and CU were administered again. The 3-month follow-up assessment occurred directly following treatment and, due to attrition, consisted of 34 CP youth. This assessment was the focus of the current dissertation.

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Random assignment Upon signing consent and meeting eligibility requirements, CP youth were randomly assigned to study condition. Randomization was performed by the study investigators independently of the treatment providers using a random number generating computer program.

Those enrolled in the fMRI substudy included 21 randomly assigned to SNAP and 16 to TAU;

however, those assessed at follow-up included 19 youth assigned to SNAP and 15 youth assigned to TAU.

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Participants assigned to SNAP services were referred to the participating agency closest to their home. Following assignment and referral, no further efforts to influence parent or child participation in services were made by research staff to ensure the effectiveness of the trail. As described in the previous chapter, SNAP is an empirically supported, manualized program that incorporates child-focused CBT and skills training as well as PMT (Augimeri, et al., 2007). The child-focused component teaches children cognitive-behavioral self-control skills and problemsolving techniques within a group setting. The second component is focused on teaching parents effective child management strategies. Specifically, parents are taught behavioral strategies that focus on consistent reward and punishment implementation designed to improve the quality and consistency of their response to negative (e.g., defiance) and positive (e.g., compliance) child behavior. Treatment is administered in a group setting and both of these core components are offered simultaneously during weekly 90-minute group sessions for 12 consecutive weeks. The fidelity of SNAP service delivery was monitored independently by SNAP staff in Toronto through review of video recordings, and by local study team members through periodic observation of SNAP group sessions from behind one way glass. These fidelity measurements revealed an adherence to specific SNAP treatment protocols of at least 92% or greater at all measurement occasions.

Treatment as Usual (TAU) Participants who were assigned to the TAU condition received assistance from project staff in their efforts to engage in treatment services, with a particular focus on securing evaluations to determine eligibility for wraparound services available in the local community.

Wraparound services were considered to reflect the highest intensity of service in the community

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hours per week. Research staff assisted participants by facilitating contact between participants and a wraparound provider agency close to them. TAU participants were provided with a letter summarizing the primary indicators of the level of severity of behavioral and affective problems from their initial study measures, so that parents might give this information to potential providers. Despite the high level of behavioral problems shown by participants, clinical evaluations conducted by providers in the community did not always result in recommendations for wraparound services. In some instances, recommendations were made for less intensive service options. For those receiving recommendations, parents reported a number of barriers that impeded their ability to obtain services, including availability of appointments, issues with travel and the commitment of time, and parental motivation.

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Child-Behavior Checklist (CBCL; Achenbach, 1991). The CBCL is 113-item parent-report questionnaire that assesses emotional and behavioral problems in children. This measure includes scales for problem behaviors as well as Diagnostic and Statistical Manual of Mental Disorders (DSM)-oriented clinical scales. Caregivers rated their children's behavior using a 3point scale (0=‘not true’ to 2=‘very often true’), with higher scores representing more severe CP.





Scores on the DSM-oriented conduct problem subscale (17 items) served as the focus of the current dissertation; however, scores on the aggressive behavior subscale (18-item), rule breaking subscale (17-item) and externalizing behavior composite (35-item) are also noted given

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assessment and caregivers of CP youth completed the CBCL again during the 3-month follow-up assessment. The reliability alpha for the CP subscale at baseline (⍺=.93) and follow-up (⍺=.83) ranged from excellent to good. The reliability alpha for the aggressive behavior subscale (⍺=.96), rule breaking subscale (⍺=.87) and externalizing behavior composite (⍺=.96) at baseline also ranged between excellent and good.

Antisocial Process Screening Device (APSD; Frick & Hare, 2001). The APSD is a 20 item scale that has been extensively used to assess psychopathic features in children. This scale has shown evidence of construct and predictive validity in numerous previous studies with children (e.g., Frick, et al., 2003) and factor analysis has consistently indicated that the APSD assesses 3 interrelated dimensions in both clinic and community samples, including a 6-item CU dimension (e.g., “you feel bad or guilt when you do something wrong”), a 7-item narcissism dimension (e.g., “you use or ‘con’ other people to get what you want”) and a 5-item impulsivity dimension (e.g., “you do risky or dangerous things”) (Frick, et al., 2000). Caregivers and youth were asked to rate items on a 3-point Likert scale (0=’not true’ to 2=’very true’) and positively worded items were reverse scored so that higher values represent increased levels of these features. For the purpose of the present study, items were combined across the two informants by taking the higher of the two ratings for each item and the CU subscale served as the primary focus (see below for more details). All caregivers and participants completed the APSD during the scan day assessment and CP youth and their caregivers completed the APSD again during the impulsivity) and total score at baseline ranged between acceptable and good (⍺=.69, ⍺=.76, 3-month follow-up assessment. The reliability alpha for each of the subscales (CU, narcissism, ⍺=.71 and ⍺=.89, respectively). Similarly, the reliability alpha for each of the subscales and total

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respectively).

Potential Confounds The variables outlined below were examined as potential confounds in light of research documenting their consistent association with conduct problems in previous studies (Campbell, Shaw, & Gilliom, 2000; Loeber & Keenan, 1994; Waschbusch, 2002).

Earlscourt Family Information Form (Earlscourt Child and Family Center, 2001). The Earlscourt Family Information Form is a parent-report questionnaire used to attain basic demographic information. All caregivers answered questions about their child’s age and race (dichotomized as Caucasian=0, African-American=1) as well as questions regarding their family’s socioeconomic status (SES). The current dissertation focused on caregivers’ report of annual income and receipt of public assistance (dichotomized as no=0; yes=1). Parents rated their annual income from all sources on a Likert scale from 0 (between $0-$4999) to 13 (over $150,000).

Kaufman Brief Intelligence Test-2 (KBIT-2; Kaufman & Kaufman, 2004). The KBIT is a

well-validated brief (i.e., 15-30 minutes) assessment instrument designed to index IQ (age range:

4-90 years). The KBIT is comprised of two subscales that provide indices of verbal and nonverbal intelligence. These subscales can be combined to provide a composite score indicative of overall IQ. This composite was used in the current dissertation and has been shown to correlate at.80 with the Wechsler Intelligence Scale for Children—Revised Full Scale score.

Child-Behavior Checklist (CBCL; Achenbach, 1991). Parent-report on the CBCL was used to assess co-occurring ADHD and internalizing symptoms. The ADHD subscale (7-item) and internalizing composite scale (32-item) of the CBCL exhibited high internal consistency

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risk versus non-significant ADHD symptoms and internalizing problems, operationalized as a Tscore of 65 on the CBCL on the respective scale, and this dichotomous variable was used in the current dissertation.

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CPCU To examine potential differences in reward/punishment processing within subgroups of children with CP, boys were first divided into groups based on the presence of CU as measured by the APSD. This group classification is referred to as ‘CP CU’. In line with the new ‘with limited prosocial emotions’ specifier for conduct disorder in the DSM-5 (American Psychiatric Association, 2013), 4 items from the CU subscale (i.e., lack of remorse or guilt, lack of empathy, unconcerned about performance, and shallow or deficient affect) were used to categorize CP youth with and without CU traits. To form the specifier, items scored as ‘very true’ were rated as present and youth with the presence of at least two of the four items met criteria for the specifier, consistent with the existing DSM-5 symptom threshold (American Psychiatric Association, 2013). This resulted in 24 youth with CP only (i.e., CPCU-) and 13 youth with CP and CU (i.e., CPCU+). Noteworthy, four HC were excluded from analysis due to high CU traits (i.e., met criteria for CU-subtype specifier), resulting in 27 HC.

CP PSY Secondary analyses examined an alternative classification criterion that more closely mirrors past research in this area (e.g., Finger et al., 2008; 2011). Specifically, these analyses

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includes features associated with CU, narcissism and impulsivity. This group classification is referred to as ‘CP PSY’. Consistent with previous studies (Budhani & Blair, 2005; Finger, et al., 2011; Finger, et al., 2008), a cutoff score of 20 or higher was used to delineate youth with high and low psychopathic features. This resulted in 11 youth with CP only (CP PSY-) and 26 youth with CP and psychopathic features (CP PSY+). One HC was excluded from these analyses due to increased psychopathic features (i.e., APSD total score=23) resulting in 26 HC. A summary of group membership and participant overlap between the two classifications is presented in Table 1.

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During each fMRI scan, participants completed an event-related task designed to assess neural response to the receipt of uncertain reward and punishment outcomes (Delgado, Nystrom,

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with the goal of accumulating as much money as possible, up to a maximum of $20, which would be paid to them after completing the task. They were informed that the card had an unknown value between 1 and 9 and were instructed that they could earn money by ‘guessing’ whether the number was higher or lower than 5. A schematic illustrating the events of each trial is presented in Figure 4. Trials began with the presentation of a card with a centrally located question mark (2.5 seconds). Using a response glove, participants indicated whether they thought the number on the card was higher (right index finger) or lower (right middle finger) than 5.

After their guess was made, the “actual” number was presented in the middle of the screen for 750ms, followed by feedback indicating whether their guess was correct or incorrect (750ms).

Feedback consisted of one of 4 possible outcomes (i.e., big reward, little reward, big punishment, little punishment), specified by an arrow and monetary value. A correct guess led to the display of either a large green arrow with a monetary reward of $2.00 (big reward) or a small green arrow and a reward of $0.20 (little reward). Conversely, an incorrect guess led to the display of either a large red arrow pointing downward with a loss of a $1.00 (big punishment), or a small red downward arrow with a loss of $0.10 (little punishment). For trials in which a response was not made in time, a pound sign (#) was shown as feedback, and the trial was considered to be

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