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African Americans and Hispanics in the U.S. have much higher rates of HIV than non-minorities. There is now strong evidence that a range of behavioral interventions are efficacious in reducing sexual risk behavior in these populations. While a handful of these programs are just beginning to be disseminated widely, we still have not implemented effective programs to a level that would reduce the population incidence of HIV for minorities. We propose that innovative approaches involving computational technologies be explored for their use in both developing new interventions as well as in supporting wide-scale implementation of effective behavioral interventions. Mobile technologies have a place in both of these activities. First, mobile technologies can be used in sensing contexts and interacting to the unique preferences and needs of individuals at times where intervention to reduce risk would be most impactful. Secondly, mobile technologies can be used to improve the delivery of interventions by facilitators and their agencies. Systems science methods, including social network analysis, agent based models, computational linguistics, intelligent data analysis, and systems and software engineering all have strategic roles that can bring about advances in HIV prevention in minority communities. Using an existing mobile technology for depression and three effective HIV prevention programs, we illustrate how eight areas in the intervention/implementation process can use innovative computational approaches to advance intervention adoption, fidelity, and sustainability.

The Good Behavior Game (GBG), a method of teacher classroom behavior management, was tested in first- and second-grade classrooms in 19 Baltimore City Public Schools beginning in the 1985-1986 school year. The intervention was directed at the classroom as a whole to socialize children to the student role and reduce aggressive, disruptive behaviors, confirmed antecedents of a profile of externalizing problem outcomes. This article reports on the GBG impact on the courses and interrelationships among aggressive, disruptive behavior through middle school, risky sexual behaviors, and drug abuse and dependence disorders through ages 19-21. In five poor to lower-middle class, mainly African American urban areas, classrooms within matched schools were assigned randomly to either the GBG intervention or the control condition. Balanced assignment of children to classrooms was made, and teachers were randomly assigned to intervention or control. Analyses involved multilevel growth mixture modeling. By young adulthood, significant GBG impact was found in terms of reduced high-risk sexual behaviors and drug abuse and dependence disorders among males who in first grade and through middle school were more aggressive, disruptive. A replication with the next cohort of first-grade children with the same teachers occurred during the following school year, but with minimal teacher mentoring and monitoring. Findings were not significant but generally in the predicted direction. A universal classroom-based prevention intervention in first- and second-grade classrooms can reduce drug abuse and dependence disorders and risky sexual behaviors.

Moving evidence-based practices into real-world settings is a high priority for education and public health. This paper describes the development of a partnership among the Houston Independent School District, the American Institutes of Research, and the Houston Federation of Teachers to support research on and program sustainability for the Good Behavior Game, a team-based classroom behavior management strategy that has shown positive impact in randomized field trials. The conceptual framework guiding partnership development is presented, followed by an application of the framework in Houston. Lessons learned and implications for the next stage of research and practice are then discussed.

School-based prevention programs can positively impact a range of social, emotional, and behavioral outcomes. Yet the current climate of accountability pressures schools to restrict activities that are not perceived as part of the core curriculum. Building on models from public health and prevention science, we describe an integrated approach to school-based prevention. These models leverage the most effective structural and content components of social-emotional and behavioral health prevention interventions. Integrated interventions are expected to have additive and synergistic effects that result in greater impacts on multiple student outcomes. Integrated programs are also expected to be more efficient to deliver, easier to implement with high quality and integrity, and more sustainable. We provide a detailed example of the process through which the PAX-Good Behavior Game and the Promoting Alternative Thinking Strategies (PATHS) curriculum were integrated into the PATHS to PAX model. Implications for future research are proposed.

Background The Good Behavior Game (GBG), a method of classroom behavior management used by teachers, was tested in first- and second-grade classrooms in 19 Baltimore City Public Schools beginning in the 1985–1986 school year. The intervention was directed at the classroom as a whole to socialize children to the student role and reduce aggressive, disruptive behaviors, confirmed antecedents of later substance abuse and dependence disorders, smoking, and antisocial personality disorder. This article reports on impact to ages 19–21. Methods In five poor to lower-middle class, mainly African American urban areas, three or four schools were matched and within each set randomly assigned to one of three conditions: (1) GBG, (2) a curriculum-and-instruction program directed at reading achievement, or (3) the standard program. Balanced assignment of children to classrooms was made, and then, within intervention schools, classrooms and teachers were randomly assigned to intervention or control. Results By young adulthood significant impact was found among males, particularly those in first grade who were more aggressive, disruptive, in reduced drug and alcohol abuse/dependence disorders, regular smoking, and antisocial personality disorder. These results underline the value of a first-grade universal prevention intervention. Replication A replication was implemented with the next cohort of first-grade children with the same teachers during the following school year, but with diminished mentoring and monitoring of teachers. The results showed significant GBG impact for males on drug abuse/dependence disorders with some variation. For other outcomes the effects were generally smaller but in the predicted direction.

Background The Good Behavior Game (GBG) is a classroom behavior management strategy focused on socializing children to the role of student and aimed at reducing early aggressive, disruptive behavior, a confirmed antecedent to service use. The GBG was tested in a randomized field trial in 19 elementary schools with two cohorts of children as they attended first and second grades. This article reports on the impact of the GBG on service use through young adulthood. Methods Three or four schools in each of five urban areas were matched and randomly assigned to one of three conditions: (1) GBG, (2) an intervention aimed at academic achievement, or (3) the standard program of the school system. Children were assigned to classrooms to ensure balance, and teachers and classrooms were randomly assigned to intervention conditions. Results This study provides evidence of a positive impact of a universal preventive intervention on later service use by males, although not by females, for problems with emotions, behavior, or drugs or alcohol. For both cohorts, males in GBG classrooms who had been rated as highly aggressive, disruptive by their teachers in the fall of first grade had a lower rate of school-based service use than their counterparts in control classrooms. Replication The design employed two cohorts of students. Although both first- and second-grade teachers received less training and support with the second cohorts of students than with the first cohort, the impact of GBG was similar across both cohorts.

BACKGROUND: Antisocial personality disorder (ASPD), violent and criminal behavior, and drug abuse disorders share the common antecedent of early aggressive, disruptive behavior. In the 1985-1986 school year teachers implemented the Good Behavior Game (GBG), a classroom behavior management strategy targeting aggressive, disruptive behavior and socializing children to the student role. From first through seventh grade the developmental trajectories of 2311 students from 19 Baltimore City Public Schools were examined. We report the GBG impact on these trajectories and ASPD and violent and criminal behavior by age 19-21. METHODS: In five urban, poor to lower middle class predominately African-American areas, three to four schools were matched and within each set randomly assigned to one of three conditions: (1) GBG, (2) a reading achievement program, or (3) the standard program. Classrooms and teachers were randomly assigned to intervention or control. Measures at 19-21 included self reports and juvenile court and adult incarceration records. GBG impact was assessed via General Growth Mixture Modeling based on repeated measures of aggressive, disruptive behavior. RESULTS: Three trajectories of aggressive, disruptive behavior were identified. By young adulthood, GBG significantly reduced the rates of ASPD and violent and criminal behavior among males in the persistent high aggressive, disruptive trajectory. REPLICATION: A replication was implemented with the following cohort of first-grade children using the same teachers, but with diminished mentoring and monitoring. Beneficial impact was found among persistent high males through seventh grade. By young adulthood GBG effects on ASPD and violent and criminal behavior were non-significant, but generally in the hypothesized direction. Language: en

Increased availability of research-supported, school-based prevention programs, coupled with the growing national policy emphasis on use of evidence-based practices, has contributed to a shift in research priorities from efficacy to implementation and dissemination. A critical issue in moving research to practice is ensuring high-quality implementation of both the intervention model and the support system for sustaining it. The paper describes a three-level framework for considering the implementation quality of school-based interventions. Future directions for research on implementation are discussed.

This study examines how early entries into adult roles are associated with aggressive and violent behavior occurring from early adolescence to young adulthood among 499 males and 578 females living in low-income, central-city neighborhoods. Among males, engagement in adult roles accounted for the relationship between higher levels of aggressive behavior during early adolescence and violence in young adulthood. Males who lived independently and males who were behind in school or not in school at age 19 and 20 years (regardless of labor force participation) were at increased risk of engaging in violence in young adulthood. Among females, the positive association between early adolescent aggressive behavior and violence in young adulthood persisted even after accounting for involvement in adult roles. For females, parenthood and independent living were associated with involvement in violence during young adulthood in varying ways depending on labor force participation.

Multiple group analysis and general growth mixture modeling was used to determine whether aggressive- disruptive behavior trajectories during elementary school, and their association with young adulthood antisocial outcomes, vary by gender. Participants were assessed longitudinally beginning at age 6 as part of an evaluation of 2 school-based preventive programs. Two analogous trajectories were found for girls and boys: chronic high aggression- disruption (CHAD) and stable low aggression- disruption (LAD). A 3rd class of low moderate aggression- disruption (LMAD) for girls and increasing aggression- disruption (IAD) for boys also was found. Girls and boys in analogous CHAD classes did not differ in trajectory level and course, but girls in the CHAD and LAD classes had lower rates of antisocial outcomes than boys. Girls with the LMAD trajectory differed from boys with the IAD trajectory.

This study attempted to assess whether family demographic characteristics and child aggressive behavior are equal to or better than child self-reported depressive symptoms in predicting suicidal behavior. Participants were a community population of African Americans first recruited at age 6 and followed periodically through age 19-20. Measures included child self-reports of depressed mood, hopelessness, and suicidal ideation, teacher reported child aggression in grades 4-6, 6 th grade caregiver report of family demographic characteristics, and the participants' report at age 19-20 of suicide attempts. Depressed mood proved the most consistent predictor of adolescent/young adult attempts in our logistic regression analyses of the data from the population as a whole and among females. The relationship between depressed mood and suicide attempts in males was in the expected direction, but was not statistically significant. Teacher-reported youth aggressive behavior did prove to be a significant predictor of attempts in 4 th and 5 th grade for the population as a whole, but not in our analyses by gender. The relationships between family demographic characteristics and attempts failed to reach statistical significance, but were, generally, in the expected direction. The study revealed that African American children's self-reports of depressed mood as early as grade 4 may prove useful in predicting adolescent/young adult suicide attempts, particularly among females. Neither family demographics nor teacher-reported child aggressive behavior proved equal to child self-reported depressive symptoms in predicting later suicide attempts.

Background: The U.S. Surgeon General recently highlighted the relative dearth of research on the mental health of minority populations in the U.S. The present report describes the prevalence of major depressive disorder (MDD) in an epidemiologically-defined population of 1197, predominately poor, African-American 19–22-year-olds, living in the greater Baltimore, MD metropolitan area. Method: The prevalence and correlates of MDD, its comorbidity with other mental and substance disorders, and unmet mental health service need were assessed via a structured clinical interview administered by lay interviewers. Results: Using DSM-IV criteria, the overall prevalence of lifetime MDD for the study population was 9.4%, whereas the last year and last month prevalences were 6.2 and 2.7%, respectively. Females were approximately 1.6 times more likely to report a lifetime episode of MDD than males. MDD was highly comorbid with substance disorders. Just under 10% of those who had experienced an episode of MDD within the last year reported receiving mental health specialty services within the last year. Limitations: A major limitation was the reliance on a single interview conducted by a lay interviewer as opposed to a comprehensive psychiatric assessment carried out by a highly trained clinician, integrating information on symptoms and functioning from multiple sources. Conclusions: The lifetime prevalence of MDD found in the present study suggests that it is a significant mental health problem in the African-American young adults studied, particularly amongst women. Moreover, most episodes of MDD went untreated. D 2003 Elsevier B.V. All rights reserved.

Research on school removal, either through suspension or expulsion, typically focuses on boys who have higher rates of removal than do girls. The present study compares girls to boys on proximal and distal characteristics and outcomes related to this event. Results supported known individual risk factors for school removal such as gender, race, SES, repeating a grade, and early aggressive behaviors which varied across gender by a contextual variable, that of school/community poverty. Regarding more distal risks, school removal differentially impacted later juvenile delinquency as well as early pregnancy and parenting depending on gender and the contextual factor of school/community poverty.

Objective: There were three aims: (1) assess the prevalence of reported exposure to negative caregiver strategies in a community-based African-American population, (2) examine the sources of variation in caregiver parenting strategies, including demographic variables and child characteristics, (3) investigate whether mental disorders in young adulthood may differ based on reported degree of exposure to negative strategies. Method: The participants were 1197 African-Americans involved in a 1999–2001 young adult follow-up (age M =19.6, SD =.6) of an evaluation of school-based interventions in the Baltimore, MD metropolitan area. Measures included teacher-report of child aggression in first grade, parent-report of demographic variables in first and sixth grade, and young adult self-report of symptomatology, suicidal behaviors, and childhood caregiver discipline strategies. Results: Fifty-four percent of the sample reported some use of physical discipline by caregivers. Lower family income and younger caregiver age, as well as teacher reports of child aggression, were related to reports of caregiver’s high use of negative strategies. In addition, young adults who reported a high rate of negative caregiver strategies had a significantly increased risk for psychopathology and were over twice as likely to have experienced a history of suicidal ideation than those reporting low exposure. Conclusions: The results demonstrate the importance of examining variation in this population, with the poorest and the youngest using negative parenting strategies more frequently. In addition, the present study replicated previous findings of the link between negative caregiver discipline strategies and psychopathology. This association appears robust across diverse populations. The implications for preventive interventions are discussed.

Moving evidence-based practices for classroom behavior management into real-world settings is a high priority for education and public health. This article describes the development and use of a model of training and support for the Good Behavior Game (GBG), one of the few preventive interventions shown to have positive outcomes for elementary schoolchildren lasting through to young adulthood, ages 19–21, including reductions in the use of drugs and alcohol, school-based mental health services, and suicide ideation and attempts. We first describe the conceptual framework guiding the development of the model of training and support. Data on implementation of the model, from an ongoing trial of GBG being conducted in partnership with the Houston Independent School District, are then presented. We end with a discussion of the lessons learned and the implications for the next stage of research and practice.

In this article, we examine the impact of two universal, first-grade preventive interventions on the prevalence of conduct problems and disorder and mental health service need and use in early adolescence. The classroom-centered (CC) intervention was designed to reduce the risk for later conduct problems and disorder by enhancing teachers' behavior management in first grade, whereas the Family-School Partnership (FSP) intervention targeted improvement in parent-teacher communication and parents' child behavior management strategies. At Grade 6, or age 12, CC and FSP intervention children received significantly lower ratings from their teachers for conduct problems than control children. CC and FSP children were also significantly less likely than control children to meet diagnostic criteria for Conduct Disorder and to have been suspended from school in the last year. In addition, the CC intervention was associated with significantly lower rates of child mental health service need and utilization. Overall, the CC intervention appeared to be the more effective of the two in reducing the prevalence of conduct problems and disorder at age 12 and in reducing mental health service need and utilization. Nevertheless, future studies may show that the combination of CC and FSP interventions produces additive or even synergistic effects.

Objectives (1) To estimate the proportion of first graders perceived by their parents as needing mental health or educational services, (2) to examine the validity of these perceptions, and (3) to examine whether factors found to be associated with children's referral to or use of services are associated with parental perceptions. Method Subjects are an epidemiological sample of 467 first graders. Children's social adaptational status and psychological well-being were assessed by multiple methods. Logistic regression was used to investigate the associations between indicators of need and parental perceptions of their children's need for services. Results More than 39% of the children were perceived by their parents as needing services. Predictors of parents perceiving their children as needing services were parent and teacher ratings of children's behavior and symptoms, children's standardized achievement test scores, and gender. Conclusions Given that a large proportion of parents reported their children as needing mental health and educational services and that parents play a central role in children's receiving services, longitudinal studies that investigate the entire process by which children enter into and are maintained in the service delivery system are needed.

The Good Behavior Game (GBG), a universal classroom behavior management method, was tested in first- and second-grade classrooms in Baltimore beginning in the 1985–1986 school year. Followup at ages 19–21 found significantly lower rates of drug and alcohol use disorders, regular smoking, antisocial personality disorder, delinquency and incarceration for violent crimes, suicide ideation, and use of school-based services among students who had played the GBG. Several replications with shorter followup periods have provided similar early results. We discuss the role of the GBG and possibly other universal prevention programs in the design of more effective systems for promoting children’s development and problem prevention and treatment services.

Background While a number of preventive interventions delivered within schools have shown both short-term and long-term impact in epidemiologically based randomized field trials, programs are not often sustained with high-quality implementation over time. This study was designed to support two purposes. The first purpose was to test the effectiveness of a universal classroom-based intervention, the Whole Day First Grade Program (WD), aimed at two early antecedents to drug abuse and other problem behaviors, namely, aggressive, disruptive behavior and poor academic achievement. The second purpose--the focus of this paper--was to examine the utility of a multilevel structure to support high levels of implementation during the effectiveness trial, to sustain WD practices across additional years, and to train additional teachers in WD practices. Methods The WD intervention integrated three components, each previously tested separately: classroom behavior management; instruction, specifically reading; and family-classroom partnerships around behavior and learning. Teachers and students in 12 schools were randomly assigned to receive either the WD intervention or the standard first-grade program of the school system (SC). Three consecutive cohorts of first graders were randomized within schools to WD or SC classrooms and followed through the end of third grade to test the effectiveness of the WD intervention. Teacher practices were assessed over three years to examine the utility of the multilevel structure to support sustainability and scaling-up. Discussion The design employed in this trial appears to have considerable utility to provide data on WD effectiveness and to inform the field with regard to structures required to move evidence-based programs into practice. Trial Registration Clinical Trials Registration Number: NCT00257088

This paper reports the impact of two first- and second-grade classroom based universal preventive interventions on the risk of Suicide Ideation (SI) and Suicide Attempts (SA) by young adulthood. The Good Behavior Game (GBG) was directed at socializing children for the student role and reducing aggressive, disruptive behavior. Mastery Learning (ML) was aimed at improving academic achievement. Both were implemented by the teacher.The design was epidemiologically based, with randomization at the school and classroom levels and balancing of children across classrooms. The trial involved a cohort of first-grade children in 19 schools and 41 classrooms with intervention at first and second grades. A replication was implemented with the next cohort of first grade children with the same teachers but with little mentoring or monitoring.In the first cohort, there was consistent and robust GBG-associated reduction of risk for suicide ideation by age 19-21 years compared to youths in standard setting (control) classrooms regardless of any type of covariate adjustment. A GBG-associated reduced risk for suicide attempt was found, though in some covariate-adjusted models the effect was not statistically robust. No statistically significant impact on these outcomes was found for ML. The impact of the GBG on suicide ideation and attempts was greatly reduced in the replication trial involving the second cohort.A universal preventive intervention directed at socializing children and classroom behavior management to reduce aggressive, disruptive behavior may delay or prevent onset of suicide ideation and attempts. The GBG must be implemented with precision and continuing support of teachers.

Theoretical models and empirical studies suggest that there are a number of distinct pathways of aggressive behavior development in childhood that place youth at risk for antisocial outcomes in adolescence and young adulthood. The prediction of later antisocial behavior based on these early pathways, although substantial, is not perfect. The goal of the present study was to identify factors that explain why some boys on a high-risk developmental trajectory in middle childhood do not experience an untoward outcome, and, conversely, why some boys progressing on a low-risk trajectory do become involved in later antisocial behavior. To that end, we explored a set of theoretically derived predictors measured at entrance to elementary and middle school and examined their utility in explaining discordant cases. First-grade reading achievement, race, and poverty status proved to be significant early predictors of discordance, whereas the significant middle-school predictors were parent monitoring, deviant peer affiliation, and neighborhood level of deviant behavior.

The present study used general growth mixture modeling to identify pathways of antisocial behavior development within an epidemiological sample of urban, primarily African American boys. Teacher-rated aggression, measured longitudinally from 1st to 7th grade, was used to define growth trajectories. Three high-risk trajectories (chronic high, moderate, and increasing aggression) and one low-risk trajectory (stable low aggression) were found. Boys with chronic high and increasing trajectories were at increased risk for conduct disorder, juvenile and adult arrest, and antisocial personality disorder. Concentration problems were highest among boys with a chronic high trajectory and also differentiated boys with increasing aggression from boys with stable low aggression. Peer rejection was highest among boys with chronic high aggression. Interventions with boys with distinct patterns of aggression are discussed.

The objectives of the present study were four-fold. First, to determine the lifetime, last year, and 6-month prevalence and demographic correlates of suicidal behavior in a defined population of urban, African American young adults. Second, to determine the degree of mental health service utilization among attempters. Third, to study the comorbidity between mental disorders and suicidal behavior, along with the variation in the numbers and types of psychiatric disorders associated with attempts versus ideation only. Fourth, to examine gender differences in the psychiatric diagnoses associated with attempts and ideation. Data relevant to each of these objectives were gathered through structured interviews of 1,157 economically disadvantaged, African American young adults. Lifetime, last year, and 6-month prevalence rates for attempts were 5.3%, 1.2%, and 0.4%, respectively, whereas the lifetime and 6-month prevalence of ideation were 14% and 1.9%, respectively. Approximately two thirds of those who reported lifetime ideation, and a similar proportion of those who reported lifetime attempts, had a history of at least one lifetime psychiatric disorder. There were no gender differences in terms of the degree of risk for suicidal behavior (ideation or attempts) associated with any of the comorbid psychiatric diagnoses assessed. Despite the severity of most attempts, few attempters received mental health services in their lifetime or at the time of their most recent attempt.

Objective To examine the characteristics associated with barriers to children's mental health services, focusing on the effect of children's psychosocial problems on parents. Method Data come from a first-grade, prevention-intervention project conducted in Baltimore, Maryland. Analyses were restricted to 116 families who participated in seventh-grade interviews and indicated the index child needed services. The Services Assessment for Children and Adolescents was used to measure barriers to children's mental health services. Results More than 35% of parents reported a barrier to mental health services. Types of barriers included those related to structural constraints, perceptions of mental health, and perceptions of services (20.7%, 23.3%, and 25.9%, respectively). Although parenting difficulties were associated with all barriers (structural: OR=10.63, 95% CI: 2.37, 47.64; mental health: OR=8.31, 95% CI: 1.99, 34.79; services: OR=5.22, 95% CI: 1.56, 17.51), additional responsibilities related to attendance at meetings was associated only with structural barriers (OR = 5.49, 95% CI: 1.22, 24.59). Conclusions Researchers and policymakers interested in increasing children's access to mental health services should consider strategies to reduce barriers related to perceptions about mental health problems and services, in addition to structural barriers. Particular attention should be given to programs that focus on the needs of families who are most affected by their child's psychosocial problems.

In this chapter we elaborate on the principles and theoretical perspectives that have formed the foundation for the Johns Hopkins University Prevention Intervention Research Center’s (JHU-PIRC) work over the last decade. During this time, we fielded two sets of classroom-based, universal preventive intervention trials in 28 Baltimore City schools with three cohorts of first graders. We also fielded a universal, or primary, preventive intervention trial, along with a nested mental health services intervention, in three Baltimore Head Start centers. In each trial, the focus was on the early risk behaviors of poor academic readiness and aggressive and shy behavior and their distal correlates of antisocial behavior, substance abuse, and anxious and depressive symptoms and disorders. We believe the principles and perspectives that have guided our preventive and services interventions work are equally applicable to researchers in the child clinical and pediatric psychology arenas. As will become apparent, we advocate an interdisciplinary approach to mental health research, which requires an integration of the life course developmental, public health, community epidemiological, and experimental trials perspectives. We provide the reader with examples from our own research as well as that of others that we hope will highlight the strengths of our developmental epidemiological framework and its applicability to the challenges faced by child clinical and pediatric psychology researchers. Among the topics addressed are: (1) the need for grounding our clinical and basic research in developmental theory (Coie et al., 1993; Kellam & Rebok, 1992; Reid, 1993; Sandler et al., 1992); (2) the use of intervention trials as tests of our etiologic models of development and psychopathology (Coie et al., 1993; Kellam & Rebok, 1992; Reid, 1993; Sandler et al, 1992); (3) the benefits of a public health perspective with respect to the dissemination and acceptance of interventions found to be efficacious in research settings (Kellam & Rebok, 1992); (4) the pitfalls associated with the use of clinic samples and samples of convenience in clinical research and research on development and psychopathology (Greenley & Mechanic, 1976; Greenley, Mechanic, & Clearly, 1987); and (5) economically and logistically feasible methods for defining and selecting research populations in accord with epidemiological principles (Gordis, 1996).