Current Treatment Options in Pediatrics

, Volume 4, Issue 1, pp 37–48 | Cite as

Approaches to the Management of Young Children’s Externalizing Behavior Problems in the Primary Care Setting

  • Catherine S. Wolcott
  • Karen A. Frankel
  • Ross E. Goodwin
  • Joyce N. Harrison
Mental Health (WF Njoroge and TD Benton, Section Editors)
  • 28 Downloads
Part of the following topical collections:
  1. Topical Collection on Mental Health

Abstract

Purpose of review

The current review summarizes the management of early-childhood externalizing behavior problems (ages 2–5) within the primary care setting. The review highlights factors pediatricians should consider when addressing externalizing behavior problems and summarizes general principles, opportunities for prevention and health promotion, parent-training interventions, integrated models, and therapies to consider when referring families to a specialty mental health provider.

Recent findings

Pediatricians have an important role in addressing early-childhood externalizing behavior problems in the primary care setting, and practices can take a range of meaningful steps to address these issues both universally and for children with higher levels of impairment. In particular, integrated approaches offer the opportunity to increase access to behavioral health services while also providing the chance to build medical providers’ skills in managing early-childhood externalizing behavior problems in the primary care setting.

Summary

Pediatricians have a range of options to consider and can use the literature regarding evidence-based programs to guide their decisions on the best interventions to implement in their settings. Further dissemination work is needed to better understand which programs are most effective when implemented in community settings.

Keywords

Externalizing behavior problems Pediatric primary care Integrated behavioral health Early childhood mental health 

Introduction

Early-childhood externalizing behaviors include non-compliance, aggression, disruptive behaviors, and emotion regulation challenges [1]. Clinically significant externalizing behavior problems during the toddler and preschool years (ages 2–5) are estimated to occur in 10–20% of young children and are frequent presenting issues in pediatric offices and mental health clinics [2, 3]. Externalizing behavior problems in young children are common, have lasting negative impacts over time, and can be reliably assessed after infancy and beginning in the toddler years [2]. When left unaddressed, these behaviors are associated with family distress, parent-child relationship problems, and impaired social functioning [3••, 4]. In the long term, early externalizing behaviors are associated with academic impairment, psychopathology, and significant economic costs [2]. Primary care physicians (PCPs) are often the first professionals to address early externalizing behavioral concerns. As such, training regarding comorbidities and contributing factors in addition to knowledge of management options are critical [5].

The importance of context

When addressing early childhood externalizing behavior problems, PCPs must consider developmental domains, understand the environment surrounding the child, and carefully evaluate the quality of the important relationships that surround young children in the context of the family’s culture. Young children experience tremendous brain development and rapid physical, cognitive, and social emotional growth during the toddler and preschool years, eventually leading to greater ability to control and regulate behavior [6]. For this reason, PCPs should take into consideration developmentally appropriate expectations based on a child’s age and should refer children to appropriate assessment/intervention when developmental domains are delayed (e.g., communication, motor, and adaptive skills). Young children’s sensitivity to their environment highlights that stressful experiences, including abuse and neglect, parental substance use, maternal depression, and unsafe communities contribute to externalizing behavior problems [7]. Finally, for young children, the cornerstone of healthy development is nurturing and healthy relationships. These relationships are transactional, meaning that the temperament and behaviors of the child interact with parental characteristics to affect the quality of the caregiving relationship [8•]. Importantly, negative parenting practices, defined by low warmth and high negativity, are the single largest modifiable risk factor in young children’s externalizing behavior problems [9]. Conversely, positive parenting and caregiving relationships are a buffer in the face of adverse experiences and the stress associated with difficult life circumstances and economic disadvantage [10••]. PCPs must also consider that relationships exist in a cultural context, meaning that families have unique ways of relating to their children, interpreting and responding to behavioral difficulties, and determining what treatments and interventions may be acceptable depending on the culture in which families live [11].

Screening and assessment

Given that early childhood is a unique time of rapid development with a window of opportunity for impactful intervention and prevention, screening for early-childhood behavioral problems in primary care is crucial. Although developmental and behavioral health disorders are now among the top five chronic pediatric conditions causing functional impairment [12] and have rapidly increased to up to 30% of visits, most of the medical office-based mental health treatment for children is being provided by non-psychiatrists [13]. Behavioral disorders in early childhood are common and frequently mask or co-occur with other disorders such as autism or post-traumatic stress disorder [10••]. For this reason, pediatric providers have been encouraged to use standardized screening tools to identify children with behavioral and developmental problems [10••]. However, there are many obstacles to screening, and the validity of screeners is variable. Some common screens for young children include the Child Behavior Checklist 1.5–5 years [14] the Ages and Stages Questionnaire SE [15] for children 3 to 66 months, and the Strengths and Difficulties Questionnaire [16] for ages 2 to 21. The Early Childhood Screening Assessment (ECSA) is a parent-report questionnaire that identifies parental distress and depression in addition to child symptoms. A shorter version was recently validated for use in primary care [17]. The reader is referred to the article in this issue on screening for a more detailed review of screening processes and tools.

Key management principles

When behavioral problems come to the PCP’s attention, a framework for effective interventions to support the caregiver in addressing behavioral challenges is helpful. There are certain overarching key principles across the various evidence-based treatment approaches for externalizing behaviors in young children. Recurring themes include general wellness promotion, inclusion of family as partners, care coordination including shared records, and skill groups for parents [18]. These interventions are typically delivered by emphasizing praise and tangible reinforcement, often use modeling and role-playing to help caregivers learn supportive listening techniques, teach methods for ignoring the child’s problematic behavior, and coach caregivers to enforce rules and offer choices to the child [19]. Overall, objectives are to alter maladaptive caregiver-child interactions by elucidating problematic patterns between the dyad and helping the caregiver to develop confidence in the ability to apply positive reinforcement strategies in a consistent way while avoiding coercion of the child [20].

Universal approaches

Well-child visits present the opportunity to promote positive caregiving relationships and proactively address externalizing behavior problems. However, PCPs have multiple demands and limited time during appointments to address a range of concerns. Fortunately, several preventative programs have been shown to impact factors associated with the emergence of early-childhood behavior problems by using additional professionals or technologies in the primary care setting to provide anticipatory guidance and promote optimal development. Most preventative approaches reduce harsh parenting behaviors and increase warmth during the toddler and preschool years to support effective parental responses to challenging behavior [8•, 21]. Descriptions of the programs are listed below.

HealthySteps

The HealthySteps program has been evaluated across multiple sites with over 5000 children and is designed to provide enhanced developmental and behavioral guidance within the primary care setting at well-child visits [22, 23]. The model trains a developmental specialist—typically a nurse, social worker, or early childhood educator—to meet with families during or following their well-visits with PCPs from birth through 3 years in the primary care setting. The HealthySteps specialist offers six home visits in the first 3 years, a phone line for developmental questions, written materials, and parent group sessions. Evaluations of the program showed increased use of positive parenting strategies during the toddler years and reduced parent report of severe discipline strategies when measured both during the intervention and at follow-up at age 5 [22, 23].

EZParent program

Technology has also been used in the primary care setting to promote parents’ access to principles of effective discipline. The EZParent program is an adaptation of the evidence-based Chicago Parent Program and is a tablet-based model that parents can access independently [4]. The tablet-based program addresses key positive parenting practices through six modules that must be completed sequentially. The program was tested with 79 families recruited from a pediatric primary care setting and increased the use of warmth but had no effect on reports of corporal punishment, parenting stress, or overall level of behavior problems. Importantly, completion of the modules was greater than in the face-to-face version of the program, and effect sizes were similar to the in-person group format of the Chicago Parent Program, suggesting that the online modules increased access to evidence-based principles and impacted parenting warmth for families of young children.

Play nicely

Another technological approach is the Play Nicely Program [24]. The program is available on the internet and can be accessed by professionals and parents in Spanish and English (www.playnicely.com). Play Nicely is shown to parents while they wait in the exam room with their child. Parents watch a video of a scenario of a child hitting another child and then click on four options of how they might respond. Parents then listen to a 1-min video about whether the choice they selected was a great option, a good option after others had been tried, or an option that is not recommended. Following an intervention trial of the program with over 200 families, parents in the Play Nicely program reported a lower likelihood of using spanking and a higher likelihood of using positive strategies, suggesting that brief, technological interventions can affect parents’ attitudes toward harsh discipline.

Innovative delivery models

It is also important to mention additional innovative delivery models during early childhood pediatric well-visits, including group care, non-face-to-face formats for anticipatory guidance, and non-medical providers offering information [25••]. Although these models have not been shown to reduce behavior problems per se, these approaches offer the possibility of providing additional time to address the factors associated with early-childhood externalizing behavior problems, thereby holding promise for prevention.

Parent-training programs

A variety of evidence-based parent-training programs have been tested in the primary care setting for caregivers who have expressed concern or who have children with elevated externalizing behaviors (see Table 1). The delivery of the programs in the primary care setting is intended to increase participation and reduce stigma. Parent-training programs focus on teaching caregivers skills to manage difficult behaviors rather than working primarily with the child. All models begin with an assessment of the behavior to understand triggers and responses and offer psychoeducation about developmental expectations and early-childhood behavior problems. Each program starts with a component of relationship building and positive strategies to enhance caregiver-child interactions, typically through individualized play with the child and praise for good behavior. Programs are conducted with therapist support and coaching so that caregivers receive feedback on the issues they encounter during the program.
Table 1

Targeted parent-training programs implemented in the pediatric office

Intervention name and study authors

Professionals required for program

Subjects and ages

Dosage and key components

Relevant outcomes

Triple P parenting program [26, 27]

 

Triple-P practitioners and psychologists

- 10 families, children ages 3–7

- Family concern for behavior problems (USA)

- 4 sessions total: (a) assessing behavior, (b) creating parenting plan, (c) using evidence-based parenting strategies, and (d) reviewing implementation

- Reduced observed and parent-reported child behavior problems with results maintained at follow up

 

Nurses

- 30 low-income families

- Children ages 2–6 (Australia)

- 3–4, 30-min family consultations: creating parenting plan, using evidence-based parenting strategies, and reviewing implementation

- Lower levels of parent-reported behavior problems, parental stress, dysfunctional parenting, and parenting anxiety

- Largely maintained at 6-month follow-up

Pri-Care [28]

Licensed mental health professionals co-located in primary care

- 120 largely low-income, English-speaking children with behavior concerns (USA)

- Group-based model for 6–8 parents

- 6 sessions for 1.5 h each

- Sessions focus on positive play, impact of stress, strategic ignoring, and commands

- 43% attended three or more sessions

- Decreases in parent-reported child behavior problems

- Improved parenting attitudes (empathy, corporal punishment, power and independence)

Incredible Years [29, 30]

Nurse practitioner and doctoral student in psychology

- 23 families of 2–3-year-olds with elevated Oppositional Defiant Disorder/ADHD symptoms (USA)

- 10 weeks for 2 h in parenting groups at pediatric practice

- Modules cover play, praise, and rewards; effective limit setting; and handling misbehavior

- Parents and providers satisfied with program

- Reduced parenting stress and child behavior problems

- Improved parent-reported parenting skills

Distanced-based treatment [31]

Graduate students in psychology provided phone coaching

- 178 parents of 2–5 year olds who expressed concerns to their doctor about behavior (Canada)

- 6-week treatment period with self-help booklet for parents and telephone coach at 2 and 5 weeks providing 20 min of support

- Developmentally appropriate expectations, rituals, and routines; modeling; praise/rewards; reducing negative behaviors

- Decreased parent-reported child behavior problems over time following the intervention when measured at 3, 6, and 12 months

Internet-Assisted Parent Training [32]

Licensed healthcare professionals conducted telephone calls

- 464 parents of 4-year-old children with elevated behavior problems (Finland)

-11 sessions, 45-min weekly phone calls

- Strengthen relationships and reinforce behavior, reduce conflict, manage transition, plan for difficult situations, and encourage prosocial

behavior

- Reduced parent-reported behavior problems at 6 and 12 months

- Improved parent-reported parenting behaviors at 6 and 12 months

Despite these commonalities, there are several differences in the interventions that have been offered in primary care settings. Several well-established programs from outpatient mental health or early care settings have been delivered in the pediatric practice to increase access and decrease stigma (e.g., Triple-P [26, 27] and The Incredible Years [29]). On the other hand, Pri-Care [28], Internet-Assisted Parent Training [32], and Distance-based treatment [31] were designed specifically for primary care and use general principles of effective behavior management as a foundation. In addition, the programs vary in their target population and in their dosage. For example, Triple-P, Pri-Care, and Distance-based treatment use parental concern about behavior problems as inclusion criteria, whereas Internet-Assisted Parent Training and The Incredible Years select children based on established measures of behavior problems. Most programs rely on the use of a mental health professional (Internet-Assisted Parent Training, Distance-based treatment, Incredible Years, Pri-Care, and Triple P), although Triple P and the Incredible Years also employ nurses or other healthcare professionals to deliver the treatment. Similarly, the duration of the programs differs and is related to how children are selected to participate in the interventions. Both the Incredible Years and Internet-Assisted Parent Training include children who have elevated behavior problems on standardized measures and have the longest duration of treatment (about 10 sessions), whereas the other programs vary in their intensity and last from four to six sessions. Finally, outcomes across studies generally show modest impacts on parents’ reports of child behavior problems, with results typically maintained at follow-up intervals. A trial of Triple-P [26] evidenced improvements in observed behavior problems, and Internet-Assisted Parent Training [32] impacted positive parenting behaviors.

Results from these trials provide a framework for parent training in the primary care setting. The sequencing of effective programs suggests that intervention should start by assessing the behavior and improving the quality of caregiver-child interactions to increase warmth and decrease negativity. These skills should be taught before discussing discipline strategies such as removal of privileges or time-out. The ongoing nature of coaching during the program suggests that follow-up from professionals and continued guidance and trouble-shooting are important in effecting/sustaining change. Novel approaches using technology and phone support suggest that non-face-to-face delivery hold promise for increasing engagement and enhancing the completion of parent-training programs [31, 32].

Integrated care

Another effective strategy to address behavioral problems in primary care is the integration of mental health practitioners into primary care settings. The increase in visits for behavioral problems to primary care, the functional impairment resulting from untreated early childhood behavioral problems, and the barriers to accessing specialized providers have led to an explosion of consultation models and innovative office-based interventions. Given the frequency of visits in infancy and early childhood, PCPs are uniquely poised for early identification and intervention. SAMHSA-HRSA’s Center for Integrated Health Solutions describes a framework to describe five levels of integrated behavioral health care in the primary care setting [33]. Levels 1 through 3 involve minimal to basic collaboration between two separate systems of mental health services and other health care. Levels 4 and 5 entail close collaboration in a partially or fully integrated system, with regular face-to-face interaction and shared location and treatment planning. The following section describes innovative integrated care models addressing early childhood behavioral problems.

Child psychiatry access programs

Collaborative care in the form of CPAPs launched in 2004 with the Massachusetts Child Psychiatry Access Project (MCPAP) [34]. MCPAP represents the second level of care, as the program has regional teams but maintains a separate system. These CPAPs now exist in 30 states and vary in their level of integration. The services provided by these programs range from “warm lines” for pediatric primary care providers staffed by child psychiatrists to off-site live consultation and brief intervention by mental health professionals.

Behavioral health integration in pediatric primary care

Maryland’s CPAP, behavioral health integration in pediatric primary care (BHIPP), which began in 2012, specifically addresses training and support for PCPs related to early childhood mental health issues. Based on data from qualitative interviews with providers across the state [35], a learning collaborative focused on early childhood mental health was created: The Children’s Health and Emotional Care Learning Community for Primary Care Providers (CHECKup). The collaborative consisted of a series of three dinner meetings with presentations on topics including early childhood assessment, psychopharmacology, screening, and the impact of trauma. The meetings also included PCP case discussions for providers across the state. Through CHECKup, the team provided training for 58 PCPs in 10 counties in developmental and mental health needs and recruited 98 early childhood education and mental health providers to attend training events with PCPs to encourage care coordination and communication [35]. Web-based resources, videos, and training materials were developed for use by the BHIPP team.

Extension for community healthcare outcomes

The Extension for community healthcare outcomes (ECHO) model is a variation of Level 3 collaborative care via teleconferencing with de-identified case discussion and didactics. The model has been embraced by the American Academy of Pediatrics to increase the capability of PCPs to provide specialized care. ECHO uses videoconference to connect multiple PCPs in remote settings with academic specialists. The goal of the model is to create local experts and support specialized treatment in the medical home through case-based learning. The ECHO model’s success in enhancing primary care treatment of adult behavioral disorders has been documented [38]. There are currently 139 ECHO models across the world for a variety of disorders including HIV, substance abuse, autism, and Hepatitis C, but to date, only one ECHO exists for behavioral, emotional, and developmental concerns in very young children. Kennedy Krieger Institute’s Network for Early Childhood Telehealth (KKI-NECT) is an HRSA-funded case-based learning collaborative for behavioral, emotional, and developmental concerns in children ages birth to 5. KKI-NECT replicates the ECHO model of a “hub” (KKI/Johns Hopkins faculty team of developmental pediatricians, child psychiatrist, behavioral psychologist, neurologist, social workers) that hosts weekly teleconferences with a cohort of 10–12 pediatric primary care providers or school-based health center nurse practitioners in underserved areas across the state of Maryland. During weekly 1-h tele-clinics, providers present a de-identified case for discussion by participants, which concludes with a summary and recommendations by the hub specialists. A 15-min didactic is presented based on a needs assessment of the providers as well as cases discussed. Providers earn CME credit and continue to manage the patients in their practice, and there is opportunity for follow-up discussion for ongoing management. Preliminary data from the first cohort’s provider satisfaction surveys show significant increases in comfort levels for identifying and managing early childhood behavioral disorders in their practices (unpublished). All of the providers in the first year’s cohort requested to continue for the second year, with the exception of one school-based practitioner who changed employment.

DC mental health access in pediatrics

The DC mental health access in pediatrics (DC MAP) in Washington D.C. is another example of a CPAP designed to integrate mental health into primary care settings. As part of DC MAP, the DC collaborative working group surveyed PCPs and found that 79% reported that their comfort level and knowledge related to identifying and addressing mental health problems were lower for children under age 5 than for older children [36]. To address this gap, the collaborative implemented routine screening for perinatal depression and early childhood mental health concerns. The program integrated an early childhood mental health team into primary care settings with explicit focus on serving families with children aged 0–5 years, an example of level 5, close collaboration in a fully integrated system. These embedded clinicians address “relational health” using models like the PRIDE (Parent Resource for Information, Development, Education) training program [37], which includes topics such as child attachment issues, the effects of abuse and neglect, discipline, and behavior interventions. They work directly with families providing support and psychoeducation and regularly interface with PCPs to discuss concerns and treatment progress.

Consultation liaison in mental health and behavior (project CLIMB)

Project CLIMB at Children’s Hospital Colorado is an example of a Level 5 program that provides integrated behavioral health services in primary care with young children and families [39]. The program employs embedded clinicians (psychology/psychiatry trainees and supervisors), some of whom are dedicated to early childhood behavioral health activities. Clinicians meet with families during their children’s medical visits and engage in a range of activities, spanning from prevention/health promotion, consultation, assistance with screening processes, and referrals to behavioral health services in the community. Over 60% of patients seen by CLIMB clinicians are between 0 and 6, and because of the wide scope of activities that clinicians are engaged in within the clinic, young children’s behavior problems are addressed through multiple avenues. For example, behavior problems arise in the context of discussing screening, during visits dedicated to mental health concerns brought up by the family, when caregiver mental health concerns or family circumstances are discussed and during prevention opportunities at well-child checks. This flexible approach allows clinicians to access a large number of families and provide support and guidance to medical providers and medical trainees to help conceptualize and manage early-childhood externalizing behavior problems within the primary care setting.

Outpatient therapies

If in-office interventions and integrated care are unavailable, unsuccessful, or behaviors reach a threshold that require specialty care, pediatricians can refer to outpatient mental health professionals such as psychologists, counselors, or clinical social workers (see Table 2). Therapies emphasize parenting skills and offer psychoeducation around developmental theories and patterns of parent-child dyadic interactions [20, 30, 40, 41, 45, 46]. Importantly, behavior problems that are primarily a result of traumatic experiences usually require different treatment modalities, such as child-parent psychotherapy [45] or trauma-focused cognitive behavior therapy [46]. Treatment for behavior problems in outpatient mental health settings offers material for both the parent and child at various points in the course of therapy, and these therapies yield significant improvements in child conduct and the stability of the relationship between caregiver and child. Equipped with knowledge of the basic frameworks for these selected evidence-based therapies, a pediatrician stands better prepared to refer families to a child psychologist or social worker and to help choose what approach may be most appropriate for an individual patient and family.
Table 2

Outpatient therapy referrals

Intervention name and study authors

Professionals required for program

Subjects and ages

Dosage and key components

Relevant outcomes

Parent-child interaction therapy [40, 41]

Child mental health practitioner

2–7 years

- 15 weekly sessions

- Child-directed interaction: improve quality of parent-child relationship and strengthen attention and reinforcement for positive behavior

- Parent-directed interaction: effective instructions and follow through with consistent consequences

- Intensive live skills coaching

- Significant improvements in conduct-disordered behavior of preschool children

- Changes in interactional style of parents in play with children

Chicago Parent Program [20, 42]

Group leaders’ education ranging from high school diploma to graduate degree

2–5 years

- 11 weekly sessions plus one booster 2 months later

- Community-based prevention intervention

- Helps clarify parents’ values and childrearing goals

- Meant to be relevant and effective for diverse families

- Reductions in behavior problems based on parent report, teacher report, and observation

- Evident in both African American and Latino parents

Parent management training—Oregon Model [43]

Child mental health practitioner

4–12 years

- Break coercive cycles of family interactions

- Improve parenting dimensions: skill encouragement, monitoring, problem solving, positive involvement, and effective discipline

- 26 h split between child and parent

- Improvements in effective discipline and family cohesion

- Reduction in aversive behavior

- Reduced problem behaviors and increased social competence by teacher report

Circle of Security [44]

Psychologist or social worker

1–7 years

- 20 weekly 90-min sessions

- Aims to promote secure parent-child attachment relationships

- Psychoeducation on attachment theory and psychological defenses

- Individualized psychotherapeutic/tape

review sessions

- Reduction in parent-reported internalizing and externalizing symptoms

- Teacher-reported improvement in externalizing symptoms

Conclusion

Externalizing behavior problems in young children are common and have lasting negative impacts over time. When left unaddressed, these behaviors are associated with family distress, parent-child relationship problems, and impaired social functioning. PCPs are often the first professionals to be consulted about behavioral concerns. Given the unique nature of early childhood as a time of rapid development with a window of opportunity to impact and prevent or treat problems, screening for early-childhood behavioral problems in primary care is crucial. Once screening is in place and other contributors such as developmental concerns or exposure to adversity and traumatic experiences have been evaluated, PCP’s must be aware of options for prevention, intervention, interdisciplinary consultation and collaboration, and referrals to outside mental health professionals in order to support families. There are multiple programs available for use in primary care to address externalizing, acting out, disruptive, and defiant behavior in young children. These programs range from universal prevention, to in-person and online parent guidance, to intensive dyadic and group psychotherapies provided by onsite mental health professionals. Support by mental health and developmental specialists consulting to and/or integrated into primary care settings can be invaluable in providing support for families and primary care providers when addressing challenging behaviors. Continued data collection related to the implementation and outcomes of programs designed to address early-childhood externalizing behavior problems in the primary care setting will help to inform best practice and bring effective programs to scale.

Notes

Acknowledgments

Dr. Harrison would like to acknowledge the support of Maryland’s BHIPP team and Maryland State Department of Education’s Race to the Top initiative team members Kay Connors MSW, Larry Wissow MD, Kelly Coble MSW, Mary Leppert MBBCH, Janna Steinberg, MA, Kate Wasserman, MSW, and Catharine Weiss, PhD.

Compliance with Ethical Standards

Conflict of Interest

Karen A. Frankel declares that she has no conflict of interest. Ross E. Goodwin declares that he has no conflict of interest. Joyce N. Harrison declares that she has no conflict of interest.

Catherine S. Wolcott reports completing postdoctoral training with project CLIMB (Consultation Liaison in Mental Health and Behavior) at the University of Colorado School of Medicine/Children’s Hospital Colorado.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Catherine S. Wolcott
    • 1
  • Karen A. Frankel
    • 2
  • Ross E. Goodwin
    • 3
  • Joyce N. Harrison
    • 4
  1. 1.Department of PsychiatryUniversity of Colorado School of MedicineAuroraUSA
  2. 2.Departments of Psychiatry and PediatricsUniversity of Colorado School of MedicineAuroraUSA
  3. 3.Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent PsychiatryThe Johns Hopkins HospitalBaltimoreUSA
  4. 4.Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Kennedy Krieger InstituteThe Johns Hopkins HospitalBaltimoreUSA

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