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What do relationally disturbed girls look like? : introducing girls with a high risk on a cluster of risk factors indicating a disturbance in relationships.

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What do relationally disturbed girls look like?

Introducing girls with a high risk on a cluster of risk factors indicating a disturbance in relationships.

N. Annema Master thesis Orthopedagogiek, Pedagogische en Onderwijskundige Wetenschappen, University of Amsterdam Mw. A.R. van Beek M.Sc.

Mw. dr. C.E. van der Put Amsterdam, July 2012

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ABSTRACT

The aim of this study was to examine differences on risk items of the Early Assessment Risk List for Girls (EARL-21G) and scale scores of the Child Behavior Checklist (CBCL) between girls (n=84; age 6 – 12) with a high (RD) and low risk (non-RD) on the Relational

Disturbance cluster. Research showed that this newly found cluster of risk factors

significantly predicted future criminal offending in girls (Augimeri et al., 2010). Therefore it is important for clinicians to understand more about the specific characteristics of RD girls necessary for effective risk management. This may lead to different treatment components for RD girls, which can minimize the chance for these girls to proceed on a negative trajectory. The girls participating in this study were part of a quasi-experimental evaluation study of the evidence-based SNAP® GC program at the Child Development Institute (CDI) in Toronto, Canada (Yuile, 2007). The results showed a significantly higher score for RD girls on both individual risk items (i.g., onset of behavioral difficulties, peer socialization, academic performance, neighborhood, antisocial attitudes and behavior) and familial risk items (i.g., household circumstances, supports, stressors and caregiver-daughter interaction).

Key words: risk items, EARL-21G, CBCL, girls, relational disturbance, risk management, SNAP® GC program.

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INTRODUCTION

The age-crime curve is well known within criminology and shows that criminal offending peaks around the age of 15 with a decline in following years (Farrington, 1986; Weijers & Eliaerts, 2008). As a result, research on criminal behavior and related risk factors has focused on the adolescent age-group (Loeber, Slot, van der Laan, Hoeve, & Graas, 2010). However, there are some adolescents who start in early childhood, the so-called early-onset offenders (Moffitt, 1993; Moffitt & Caspi, 2001).

These offenders are best described in the Dual Taxonomy Theory (DTT) by Moffitt (1993), who describes two types of youth delinquents: Adolescence Limited (AL) and Life-Course Persistent (LCP). The AL-type starts delinquency in adolescence and desists at the end of adolescence or early adulthood. The LCP-type starts in early childhood, by showing

disruptive and antisocial behavior, and slowly develops into a chronic offender. The LCP-type is two to three times more likely to become a violent, serious and chronic offender throughout adulthood than the AL-type (Loeber, Farrington, & Petechuk, 2003). Moreover, the financial costs of the LCP-type for society is five to eight times higher than the AL-type (Welsh et al., 2008). Only a small proportion of children committing offences can be viewed as the LCP-type and these children experience an accumulation of risk factors within multiple domains of their lives (e.g., individual, family, community) (Loeber & Farrington, 2000; Moffitt, 1993; Moffitt, Caspi, Rutter, & Silva, 2001).

Risk factors increase the probability of criminal behavior and can also reinforce other key risk factors. For example, risk factors can influence age of onset, persistence and duration of delinquent behavior, but age of onset itself is a risk factor for future delinquent behavior (Kazdin, Kraemer, Kessler, Kupfer, & Offord, 1997; Loeber, Farrington, Stouthamer-Loeber, & White, 2008; Loeber & Stouthamer-Loeber, 1998; Stouthamer-Loeber, Loeber, Wei, Farrington, & Wikstrom, 2002). An accumulation of risk factors, as described above, results in a spiral of negativity in the child’s behavior and/or environment (Moffitt et al., 2001). For example, parents who experience distress from unemployment may react harshly to their aggressive child, which in turn can lead to more aggressive behavior of the child. This is where the negative spiral starts. The spiral continues with negative behavior of the parents and the situation worsens. The circumstances in this situation become difficult to change. In the literature this is described as ‘narrowing options for change’ (Moffitt, 1993; Moffitt et al., 2001) or the ‘coercive cycle’ (van Aken, 2002; Patterson, Dishion, & Bank, 1984). While the

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term LCP implies a life-persistent criminal career, this in fact differs for each individual and therefore speaks to the importance of identifying risk factors as soon as possible (Donker & Slotboom, 2008).

To identify the key risk factors related to early onset delinquency, it is necessary to be aware of sex differences. Most of criminological research has focused on risk factors for boys. Until recently girl delinquents were not part of this research. If a girl did commit offences, it was viewed as temporary and not serious (Weijers & Krabbendam, 2008). Nevertheless, research slowly shifted towards girl delinquents and in the ‘90s research of female

delinquents started in the Netherlands. It became apparent that there is in fact a problem with girls showing disruptive behavior. Girls account for 17% of the total youth delinquency, while in the ´80s this was around 10%. Although these percentages differ between countries, there is an equal global trend (Weijers & Krabbendam, 2008).

One should notice, however, that this trend does not necessarily show an actual increase of girl delinquency. It is possible, for example, that there is a decrease in ‘dark number’, i.e. the problem behavior of girls is reported more often to and noticed by the

official authorities (Weijers & Krabbendam, 2008). This may be due to the gain in knowledge about the character of girls’ aggressive behavior and related risk factors. Research on this topic shows that girlhood aggression expresses itself most often in the context of the home and is more verbal and relation focused (Pepler, Craig, Jiang, & Connolly, 2011). Examples of these types of aggression are gossip, social exclusion and bullying (Bjorkqvist, Lagerspetz, & Kaukiainen, 1992; Crick & Grotpeter, 1995).

Aggressive behavior in girls can be seen as a result of interactional problems within the family. The family is the primary social context of a girl’s life. Therefore, the girl is constantly shaped by those around her (Patterson, 1982; Loeber & Stouthamer-Loeber, 1986). Especially for girls, the family factors are important, because they tend to be more tied to their families and spend more time with them than boys (Maccoby, 1998). A positive interaction within the family can act as a social control against antisocial behavior (Sampson & Laub, 1993). Examples of risk factors related to family relationships are: parent-child conflict, poor problem-solving, weak attachment, and rejection by caregivers (Brook, Whiteman & Finch, 1993; Pakaslahti, Spoof, Asplun-Peltola, & Keitikangas-Javinen, 1998; Pepler & Sedighdeilami, 1998; Sprott & Doob, 1998).

Pepler et al. (2011) note that, most of the time, girls with problem behavior lack the critical social skills (e.g.; emotional and behavioral regulation) needed for a positive

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interaction. The problems they face with positive interaction influence their relationship with parents and peers. This in turn leads to distress in girls due to the social goal for women to have close relationships (Maccoby, 1998; Underwood, 2003). A paradox occurs, girls’ central social goal is having close relationships, but their aggressive behavior shows itself in this relationship context (Ehrensaft, 2005). The main concern with these girls, who are unable to keep healthy relationships, is that this development will transfer to marital, parenting and workplace relationships in adulthood (Pepler et al., 2011).

Research shows girls are exposed to similar risk factors as boys. However, differences exist between boys and girls on the impact of these risk factors related to the negative

trajectories (Weijers & Krabbendam, 2008). Compared to boys, girls tend to show more problem behavior during adolescence than childhood, which relates to the AL-type (Loeber & Farrington, 2001; Loeber et al., 2008). During childhood only a small group of girls show disruptive behavior in comparison to boys (Loeber, Pardini, Stouthamer-Loeber, & Raine, 2007). This two-trajectory model, however, is not necessary applicable to girls. Silverthorn, Frick and Reynolds (2001) show girls have a later age of onset, but have the same personality traits (e.g., low impulse control, callous and unemotional interpersonal style) as childhood-onset boys.

Regardless of the age of onset, there is a need to identify high risk girls as early as possible (Augimeri, Walsh, Liddon, & Dassinger, 2011; Moffitt, 1993). Therefore, a reliable and valid risk assessment tool is needed (Loeber & Farrington, 2001). The available risk assessment tools are primarily adolescent male orientated. Examples of these tools are the Structured Assessment of Violence Risk in Youth (SAVRY; Borum, Bartel, & Forth, 2002), the Youth Level of Service/Case Management Inventory (YLS/CMI; Hoge & Andrews, 1994), and the Washington State Juvenile Court Assessment (WSJCA; Barnoski, 1998). There are only two risk assessment tools available for children under the age of 12: the ESTER (0-18 years; Andershed & Andershed, 2010) and the Early Assessment Risk List for boys and girls (EARL-20B/21G; Augimeri, Koegl, Webster, & Levene, 2001; Levene et al., 2001).

The EARL-21G is the only gender-specific risk assessment tool for girls under the age of 12 and was developed by the Child Development Institute (CDI) in Toronto, Canada. Clinicians evaluate individuals on the established risk factors of the EARL-21G and assess the appropriate degree of risk, making this tool a structured professional judgment tool (Hrynkiw-Augimeri, 2005). The 21 items of the EARL-21G are related to an increase in the

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probability of future antisocial behavior and/or violence in the child (Augimeri et al., 2010; Douglas & Kropp, 2002; Hilton, Harris, & Rice, 2006; Loeber, Slot, & Stouthamer-Loeber, 2010). The risk items of the EARL-21G are both dynamic (e.g., Academic Performance) and static (e.g., Abuse/Neglect/Trauma) risk factors. The static items are difficult to alter, due to the historical nature of these factors. Dynamic items can be altered through intervention (Hanson, 2005).

CDI researchers started looking at the relationship between EARL item scores, total risk scores and responsiveness to treatment (Walsh, Yuile, Jiang, Augimeri, & Pepler, 2007; Yuile, Walsh, Jiang, Pepler, & Levene, 2007). In these studies a high total and Family risk score predicted lower levels of change during treatment. Furthermore, ten EARL items predicted problem behavior at admission (i.e., Supports, Parenting Style, Caregiver-Daughter Interaction, Antisocial Values and Conduct, Abuse/Neglect/Trauma,

Hyperactivity/Impulsivity/Attention deficits, Peer Socialization, Academic Performance, Sexual Development and Coping Ability). A different study (Loeber, Farrington, Stouthamer-Loeber, & White, 2008a) showed that a high score on the gender-specific item Sexual

Development of girls influenced a higher total risk score and a lower responsivity to treatment.

Augimeri et al. (2010) presented a new 3-Factor model of the EARL-21G: Family, Child and Relational Disturbance (RD) (see Appendix A). The Family and RD cluster significantly predicted future criminal offending. The total risk score in the EARL-21G and future offending showed a relationship, although not significant. This is an indication of the predictive validity of the RD and Family cluster, which might be higher than the predictive validity of the total risk score. The RD cluster, which is explored in this thesis, consists of the items Caregiver Continuity, Antisocial Values and Conduct, Abuse/Neglect/Trauma and Sexual Development. The first two items belong to the Family domain and the last two items belong to the Child domain of the EARL-21G.

The item Caregiver Continuity looks at multiple caregivers the girl had (Levene et al., 2001). This also includes separation from a caregiver due to an out-of-home placement, hospitalization or residency in a foreign country (Artz, 1998; Cernkovich & Giordano, 1987; Fergusson & Woodward, 2000; Morris, 1964; Ward & McFall, 1986; Werner & Smith, 1992). Research shows that the development of a secure attachment is affected by continuity of care and a discontinuity of care affects delinquent behavior in girls. The majority of delinquent girls come from broken homes and research shows that 10% of these girls are abandoned by

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both parents (Rosenbaum, 1989). Furthermore, there is positive relationship between delinquent girls and out-of-home placement (Chamberlain & Reid, 1994; Lenssen,

Doreleijers, van Dijk, & Hartman, 2000; Corrado, Odgers, & Cohen, 2000). A Canadian study shows that girl offenders experienced an out-of-home placement eleven times on average before the age of 12 (Corrado et al., 2000).

The item Antisocial Values and Conduct looks at family members openly involved in illegal activities (Levene et al., 2001). It also includes families with strongly distorted, antisocial thinking that effects everyday functioning. These factors are all seen as predictors of delinquency in girls (Herrenkohl et al., 2000; Huesmann, Eron, Lefkowitz, & Walder, 1984; Lipsey & Derzon, 1998; Pillow, Barrera, & Chassin, 1998). Also, antisocial behavior of siblings is of influence on problem behavior in girls (Hill, Howell, Hawkins, &

Battin-Pearson, 1999; Pepler & Sedighdeilami, 1998). A majority of delinquent girls (68.8%) reported that a member of their immediate or extended family had a criminal record (Corrado et al., 2000). Important to note is that even the absence of a parental figure (e.g.;

incarceration) is of influence on the problem behavior of a child (Levene et al., 2001). Drug and alcohol problems of family members are also of influence on girl delinquency (Pihl et al., 1998).

The item Abuse/Neglect/Trauma includes documented or well-substantiated evidence of physical, sexual or emotional abuse; severe neglect; a traumatic event; or witness of violence experienced by the girl (Levene et al., 2001). Research shows that criminal involvement for girls is influenced by exposure to physical, sexual and emotional violation (Acoca, 1998). In fact, over half of girl delinquents has a history of victimization (Chesney-Lind, 1987; Corrado et al., 2000; Funk, 1999), either physically (67%) or sexually (52%) (Corrado et al., 2000). Moreover, experiencing abuse leads to all sorts of problems, like drug use, gang membership (Acoca, 1998) and relationships with violent men (Simons, Johnson, Beaman, & Conger, 1993). This last finding is important, because a pro-social partner can be viewed as a promotive factor (Loeber et al., 2010). Physical and sexual abuse between parents is also of influence on externalizing behavior of the girl. The impact of this item is stronger on girls than on boys (O’Keefe, 1994; Sternberg et al., 1993). Trauma (e.g., death girl’s sibling, absence parent) also plays a substantial role in the development of delinquent behavior in girls (Werner & Smith, 1992).

The item Sexual Development looks at early onset of menarche and girls who exhibit precocious sexualized behavior (Levene et al., 2001). There is some evidence that early

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menarcheal timing plays a role in the emotional health (Brooks-Gunn & Reiter, 1990; Ge, Conger, & Elder, 1996) and delinquency of girls (Caspi & Moffitt, 1991). However, there is still a lot to learn about the specific factors contributing to this (Herman-Giddens et al., 1997). The early onset of menarche can also lead to joining a deviant social network and hanging out with older boys (Caspi, Lynam, Moffitt, & Silva, 1993). These girls are exposed to a

psychosocial environment for which they are poorly prepared psychological. Moreover, early menarche is associated with negative body image (Cairns & Cairns, 1994), substance abuse (Dick, Rose, Viken, & Kaprio, 2000), and sexualized behavior (Pithers, Gray, Busconi, & Houchens, 1998).

Girls with a high risk on all four risk items may be at higher risk for future delinquent behavior (e.g. drug use, gang membership, relations with violent men, precocious sexualized behavior, problems in emotional health). These girls do not experience a stable home

environment with healthy values. Instead, these girls experience separation and/or absence of parents, antisocial behavior in the family and victimization. This RD cluster is probably a better indicator of future criminal offending than the total EARL-21G score, but little is known about girls scoring high on this cluster. Therefore it is important for clinicians to understand more about the specific characteristics of RD girls. This may lead to more

effective risk management for RD girls and minimizes the chance for these girls to proceed on a negative trajectory

Therefore this thesis will explore the characteristics of these girls. The following research question will be addressed: To what extent do girls between the age of six and eleven years with a high risk on the Relational Disturbance cluster of the EARL-21G, differ from girls without such risk across individual and family characteristics? It is expected that girls with a high score on the RD cluster show more problems (1) on individual and familial risk factors of the EARL-21G and (2) on the different scales of the CBCL than girls with a lower score on the RD cluster.

METHODS

Participants.

The participants in this study are girls that were part of a quasi-experimental evaluation of the evidence-based SNAP® Girls Connection program (SNAP® GC; previously known as the Earlscourt Girls Connection program) at the CDI (Yuile, 2007). This treatment stands for Stop Now And Plan and uses the cognitive-behavioral approach (CDI, 2012).

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The girls were admitted to the SNAP® GC program between 1997 and 2001 and the evaluation of the program began in 2002. Girls were referred to by schools, Children´s Aid Societies, other mental health agencies and the police. Of the 103 families admitted to the program, 85 families voluntarily agreed to participate in the research study (Yuile, 2007).

The database used in this study consists of 88 girls of whom 4 girls are excluded due to lack of information. The average age is 8.6 years (SD = 1.8; range 5 - 12). For testing difference in age between the two groups of girls the Mann-Whitney U test is used, which will be described more fully under Statistical analyses. Between the RD and non-RD girls no statistically significant age difference was found (U= 632.00, n₁= 31, n₂= 45, p= .48, two-tailed).

The admission criteria for participation in the SNAP® GC program were age (6-12 years) and an externalizing behavior score in the clinical range on the parent report of the Brief Child and Family Phone Interview (BCFPI; Cunningham, Boyle, Hong, Pettingill, & Bohaychuk, 2009). The BCFPI is a clinical intake instrument conducted over the phone which systematically identifies high risk problem behavior in children. The exclusion criteria for participation in the SNAP® GC program included having significant developmental delay and living outside the area of the City of Toronto.

The majority of the girls (90.6%) live with their birth parent(s), of which 48.8% RD girls and 41.5% RD girls. A small percentage of the girls (7.3% RD girls and 1.2% non-RD) live with their adoptive parent(s), foster parent(s), grandparent(s) or their aunt/uncle. For testing difference in primary caregivers between the two groups of girls the Mann-Whitney U test is used, which will be described more fully under Statistical analyses. This difference between non-RD and RD girls first primary caregiver is statistically significant (U= 726.00, n₁= 34, n₂= 43, p= 0.04, one-tailed). Furthermore, the girls have a diverse ethnic background (n= 28), with the majority of girls being White (42.9%), other (25.0%) and African American (21.4%). A small number of girls are Latin American (3.6%), Native American (3.6%) and Pacific Islander (3.6%).

Data sources.

The data used in this study was scored prospectively by using the following instruments: EARL-21G. This Early Assessment Risk List takes those risk factors into account which are important for girls’ aggressive pathways (see Table 1). The items can be divided into three different domains of risk factors: Family, Child and Responsivity (Levene et al.,

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2001). The items of the Family domain (Chronbach’s a = .751) assess the quality of nurture, support, supervision, and encouragement by the child’s parents or caregivers. The items of the Child domain (Chronbach’s a = .752) focus on individual risk factors related to the

development of the child. The items of the Responsivity domain (Chronbach’s a = .290) assess the ability and willingness of the child and family to engage in treatment (Levene et al., 2001). This last domain cannot be seen as reliable, due to the low Chronbach’s alpha.

Therefore the need to interpret the results on this domain carefully.

The child and family workers assessed the presence and severity of risk factors in girls’ lives using the EARL-21G. For each risk factor the manual of the EARL-21G provides a brief literature review which describes the contribution of this factor to girlhood aggression. This is followed by the coding criteria for the risk factor using a scoring scale of 0 (not

present), 1 (possibly present/low risk), or 2 (present/high risk) (Levene et al., 2001). To assess the presence and severity of each risk factor the clinicians are instructed to use multiple sources of information (e.g., school reports, psychological reports, standardized measures). The scores of the EARL-21G are recorded using an EARL-21G summary sheet (see

Appendix B). On this sheet a total score can be calculated by the sum of all scores across the 21 risk items. After calculating the total score clinicians are able to provide an ‘Overall Clinical Judgment’ rating of low, moderate or high. This can be viewed as a global assessment of the estimated impact of cumulative risk on the girls’ development.

A number of studies have been completed on the clinical utility, reliability and validity of the EARL-21G. The first study (Levene, Walsh, Augimeri, & Pepler, 2004) was conducted retrospectively and focused on the reliability and validity of the EARL-21G. This study found a moderate-to-high agreement between raters, with statistically significant positive Pearson correlations from .64 to .84. Also, an intra-class correlation coefficients of .67 (single measure) and .86 (average measure) was found. The second study was conducted

prospectively and repeated the inter-rater reliability coding exercise. In this study, a high rate of agreement was found with a Pearson correlation of .81 average and an intra-class

correlation coefficients of .80 (single measure) and .96 (average measure) (Koegl, Augimeri, Ferrante, Walsh, & Slater, 2010).

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Table 1

EARL-21G Items and Item Content per Domain (Koegl, 2011, p.12)

Family domain

Household Circumstances Poverty, low SES, crowded living conditions Caregiver Continuity * Absence of stable caregivers, out of home

placements

Supports Lack of productive familial supports

Stressors Parental mental illness, unemployment

Parenting Style Punitive or laissez-faire parenting style, lack of supervision

Caregiver-Daughter Interaction Lack of warmth between girl and her primary caregiver

Antisocial Values and Conduct (AVC) * Parental or sibling criminality

Child domain

Developmental Problems Learning disabilities; failure to reach developmental milestones

Onset of Behavioral Difficulties Documentation of behavioral problems at a young age

Abuse/Neglect/Trauma (ANT) * Severe neglect; physical, sexual or emotional abuse

Hyperactivity/Impulsivity/Attention Deficits (HIA)

Observation or diagnosis of ADHD, ADD and impulsivity problems

Likeability Poor social skills, unattractive physical appearance

Peer Socialization Deviant peer group, age-inappropriate friends, social exclusion

Academic Performance Child functioning is 1-2 years behind grade level in core subjects

Neighborhood Dangerous neighborhoods, lack of community

resources

Sexual Development * Early sexual development, precocious behavior Antisocial Attitudes Attitudes in favor of rule breaking, lack of guilt or

empathy

Antisocial Behavior Antisocial behavior that is severe, frequent, chronic, and occurs across settings

Coping Ability Emotional distress, anxiety, depression or withdrawal

Responsivity domain

Family Responsivity Parental denial of a problem, lack of treatment engagement

Child Responsivity Child lack of cooperation, unwillingness to engage in treatment

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Child Behavior Checklist (CBCL). This instrument was used to assess girls’ internalizing and externalizing behavior as reported by parents (Achenbach & Rescorla, 2001). The instrument consists of an external scale, which is derived from the subscales on aggression and rule-breaking, and an internalizing scale. This standardized measure has an acceptable reliability, with an Inter-rater reliability range from .93 to .96. The criterion validity was assessed and is acceptable in measuring multiple informants’ reports of children’s externalizing and internalizing problems (Achenbach & Rescorla, 2001). All

syndrome scales (a 0,66 – 0,90) and total scales (a 0,73 - 0,89) of the CBCL used in this study have an acceptable reliability.

Procedure.

The families participating in this study signed a written consent after they were informed of the research component at admission to the SNAP® GC program. Refusal to participate in the research in no way jeopardized their involvement in treatment and the limits of confidentiality were fully explained (i.e., concerns of abuse or harm). After admission, clinicians (child and family workers) used the EARL-21G to assess the girls’ risk and behavior problems and parents rated the behavior problems and social skills of their daughters using the CBCL. These measures were repeated on four follow-up points: post-group treatment, 6, 12 and 18 months following treatment (Yuile, 2007). For answering the research question in this study only the Pre-measures are used.

Statistical Analyses.

This study compares two groups of girls. One group consists of girls who score low on the risk items of the RD cluster (non-RD girls) and one group who scores high on those risk items (RD girls). A median split is made in the data file on the sum of the four risk items belonging to the RD cluster to create the two groups of girls.

The two hypotheses in this study expect a higher score of RD on the three domains of the EARL-21G and the scales of the CBCL in comparison to non-RD girls. The Mann-Whitney U test is used most often to compare data by ranking the data. This test is the nonparametric equivalent of the independent t-test, which in turn compares the means from two independent groups of individuals (Brace et al., 2009). Most of the data in this study is not normally distributed data and violates other assumptions of the independent t-test, which makes it irresponsible to use parametric tests. A few scales of the CBCL are normally

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distributed and meet other assumptions of the independent t-test and therefore this test is also used for these scales. For processing and analyzing the data in this study the program

Statistical Package for the Social Sciences (IBM SPSS) version 19 is used.

RESULTS

Risk Items and Total Score of the EARL-21G.

It is expected that RD girls show more problems on individual and familial risk factors of the EARL-21G than non-RD girls. To test this hypothesis the Mann-Whitney U test was used, because the data did not meet the assumptions necessary for parametric testing. Table 2 presents an overview of the results per risk item and of the Total score of the EARL-21G. Even though the data is nonparametric, the mean is presented in the table to make

interpretation clearer.

The Family domain of the EARL-21G looks at the familial risk factors. The results show statistically significant differences between RD and non-RD girls on most of the risk items, of which RD girls score higher. The families of RD girls experienced more financial problems, less positive support and more stressors. Also, the interaction between RD girls and their caregiver was more problematic than for non-RD girls. Only the risk item Parenting Style in this domain does not show a significant difference between RD and non-RD girls.

The Child domain of the EARL-21G looks at the individual risk factors. Also within this domain most risk items show statistically significant differences between RD girls and non-RD girls. RD girls started showing problem behavior at a younger age than non-RD girls and experienced more problems within their social relationships, school and in their

neighborhood. Also, RD girls had more antisocial attitudes and showed more antisocial behavior. No significant difference was found on the cognitive development of the girls and problems with hyperactivity, impulsivity or attention deficits. Also, no significance was found on the risk item likeability. Both RD and non-RD girls had likeable qualities that were offset by their pleasant characteristics. Finally, no significant difference was found on the risk item Coping Ability.

Within the last domain, Responsivity, no significant difference was found between non-RD and RD girls. Both groups of girls and their families were responsive to the idea of change and easy to engage and committed to work on their problems. Finally, RD girls scored significantly higher on the Total score of the EARL-21G in comparison to non-RD girls.

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Based on the results described above the first hypothesis in this study is accepted. RD girls show more problems on multiple individual and familial EARL-21G risk items than non-RD girls. The majority of these differences between the two groups of girls are statistically significant. Also, the overall risk score was significant higher for RD girls.

Table 2

EARL-21G risk items

Risk item Mean non-RD

girls (n=36) Mean RD girls (n=48) U Family domain Household circumstances 0.56 1.15 532.50* Caregiver Continuity¹ - - - Supports 0.58 0.94 619.50* Stressors 0.92 1.44 544.50* Parenting Style 1.08 1.21 778.00 Caregiver-Daughter Interaction 0.72 1.15 575.50*

Antisocial Values and Conduct¹ - - -

Child domain

Developmental Problems 0.22 0.38 785.00

Onset of Behavioral Difficulties 1.36 1.58 693.50*

Abuse/Neglect/Trauma¹ - - - Hyperactivity/Impulsivity/Attention Deficits (HIA) 0.75 0.77 830.00 Likeability 0.61 0.67 827.00 Peer Socialization 1.03 1.33 645.00* Academic Performance 0.64 1.04 664.50* Neighborhood 0.22 0.54 636.00* Sexual Development¹ - - - Antisocial Attitudes 0.75 1.04 653.00* Antisocial Behavior 1.33 1.60 659.00* Coping Ability 0.97 1.21 728.50 Responsivity domain Family Responsivity 0.25 0.17 818.00 Child Responsivity 0.28 0.25 834.00 Total score 13.22 20.98 284.00*

¹ excluded from analysis/part of RD cluster * significance (p<0,05)

CBCL scales and Total score.

Also more problems on the different scales of the CBCL are expected for RD girls in comparison to non-RD girls. To test this hypotheses the Mann-Whitney U test was used for

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the majority of the scales, because the data did not meet the assumptions necessary for parametric testing. A few scales did meet the assumptions necessary for parametric testing, therefore the independent t-test was used for these scales. Table 3 shows an overview of the results of all scales of the CBCL. Even though most of the data is nonparametric, the mean is mentioned in the table to make interpretation clearer.

The Internal scale of the CBCL showed a statistical significant difference between non-RD and RD girls. The non-RD girls average score fell within the sub clinical range of the internal scale, while RD girls scored in the clinical range. This indicates that RD girls showed more internalizing problems (e.g., anxious, depressed, somatic complaints). Two of the three syndrome scale of the Internal scale show statistically significant differences between the groups of girls, namely anxious/depressed and somatic complaints. The average score of the anxious/depressed scale for non-RD girls fell within the normal range of the scale, while RD girls scored within the sub clinical range. This indicates that RD girls showed more feelings of anxiety and depression (e.g., crying, scared for animals). On average both non-RD girls and RD girls scored within the normal range of the somatic complaints scale, but RD girls more often showed somatic problems (e.g., headache, problems with bowel movement). No statistical significant difference was found on the syndrome scale withdrawn/depressed.

The External scale of the CBCL also showed a statistical significant difference between non-RD and RD girls. On average both non-RD girls and RD girls scored within the clinical range of the External scale. This indicates that both groups of girls showed symptoms of externalizing problems, but RD girls tended to show more of these problems than non-RD girls (e.g., rule-breaking behavior, aggression). Within this scale only the syndrome scale rule-breaking behavior showed a statistically significant difference. On average both non-RD girls and RD girls scored within the sub clinical range of the scale. Nevertheless, RD girls showed more rule-breaking behavior (e.g., showing no guilt after misbehaviour). For the syndrome scale aggressive behavior no significant difference was found and both non-RD girls and RD girls average score fell within the clinical level of the scale. Both groups of girls showed symptoms of aggressive behavior (e.g., bullying, fighting).

Finally, RD girls showed a significant higher score on the Total scale of the CBCL in comparison to non-RD girls. On average both non-RD girls and RD girls scored within the clinical range of total scale. This indicates that both groups of girls exhibited internal and external problems, but RD girls show more of the combination of problems than non-RD girls. Of the remaining syndrome scales only a statistically significant difference was found

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on the social problem scale. The non-RD girls average score fell within the normal range and RD girls scored within the sub clinical range of the scale. RD girls had more social problems than non-RD girls (e.g., feeling lonely). No statistically significant difference was found on the attention problem scale and both groups of girls average score fell within the sub clinical range of this scale. This indicates some attention difficulties (e.g., doesn’t finish tasks she starts) for both groups of girls.

Table 3

Syndrome Scales of the CBCL

Scale Mean Non-RD

girls (n=31) Mean RD girls (n=44) U t Anxious/depressed 62.80 (SE 2.11) 67.60 (SE 1.62) - -1.81* Withdrawn/depressed 61.58 64.43 549.00 - Somatic complaints 57.55 61.18 501.00* - Social problems 63.35 67.48 520.50* - Thought problems 62.10 64.41 572.00 - Attention problems 66.39 69.02 599.50 - Rule-breaking problems 64.61 69.43 342.50* - Aggressive behavior 69.90 (SE 1.79) 73.10 (SE 1.52) - -1.36 Internal Scale 61.20 (SE 2.01) 67.30 (SE 1.45) - -2.54* External Scale 68.45 71.73 435.50* - Total Scale 66.16 70.16 457.50* - * Significance (p<0,05)

Table 4 shows the results of the CBCL DSM-oriented scales. The DSM-oriented scales have an acceptable reliability (a 0,71 - 0,80). The scales somatic problems and conduct problems showed a statistically significant difference between non-RD girls and RD girls. RD girls showed more somatic problems (e.g., pain without medical grounds) and behavioral problems (e.g., cruel towards animals, bullying). On average both groups of girls scored within the normal range of the somatic problems and within the clinical range of the conduct problems. For the Attention deficit/hyperactivity problems both groups of girls on average scored within the subclinical range of the CBCL scale. This indicates some symptoms of attention deficit and hyperactivity in both groups of girls (e.g., short attention span). Even though no statistically significant difference was found for the oppositional defiant problems

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scale, non-RD girls scored within the sub clinical scale and RD girls scored in the clinical scale. The results of the DSM-oriented scales provided a similar picture as the results of the syndrome scales.

Based on the results described above the second hypothesis in this thesis is (partly) accepted. RD girls show more problems on the majority of the internalizing syndrome scales and the overall Internalizing scale. The results on the externalizing syndrome scales also show some differences between non-RD and RD girls, but not all expected syndrome scales were significantly different.

Table 4

DSM-Oriented Scales of the CBCL

Scale Mean Non-RD

girls (n=31) Mean RD girls (n=44) U t Affective problems¹ - - - - Anxiety problems 61.74 63.23 602.00 - Somatic problems 55.97 60.45 468.00* - Attention deficit/hyperactivity problems 64.40 (SE 8.98) 66.70 (SE 8.31) - -1.17

Oppositional defiant problems 67.16 68.93 560.00 -

Conduct problems 69.26 72.93 440.50* -

¹ No data available * Significance (p<0,05)

DISCUSSION

Early identification of risk factors for problem behavior in girls is necessary to be able to manage this behavior. Therefore recent research has focused more on the key risk factors related to girlhood problem behavior. Due to this research more is known about the influence and impact of certain risk factors on this behavior. This study contributes to this research by looking at a specific combination of risk factors in girls. The following research question will be discussed in this section: To what extent do girls between the age of six and eleven years with a high risk on the cluster Relational Disturbance of the EARL-21G, differ from girls without such risk across individual and family characteristics?

On the individual risk items it was expected that RD girls scored higher than non-RD girls. This hypothesis is supported by the results in this study. The onset of behavioral problems for RD girls was observed before the age of six, while non-RD girls tend to show this behavior a few years later. RD girls showed more problem behavior across multiple settings in comparison to non-RD girls. Within the school setting RD girls more often

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experienced academic difficulties. This risk item has a strong link with aggressive and delinquent behavior (Levene et al., 2001). One could expect that RD girls also show developmental problems, like having a below average IQ, because they have learning problems. The item developmental problems, however, showed no statistical significant difference.

Within the social setting, RD girls showed more social problems by experiencing more problems in peer socialization than non-RD girls. RD girls more often have difficulty

connecting to age-appropriate positive peers and spend time with other children who get into trouble. Therefore, it would be expected RD girls are seen as less likeable. However, the item likeability did not show a significant difference between the two groups of girls. A possible explanation is that the item likeability was reviewed by the point of view of adults in the girls’ life, while the other items look at the interaction of the girl with her age-appropriate peers.

Furthermore, RD girls showed more problems on the risk items antisocial attitudes and behavior of the EARL-21G. Moreover, the syndrome scale rule breaking of the CBCL

showed a significant difference. It was expected RD girls showed more problem behavior than non-RD girls. The accumulation of risk factors in multiple domains can create a spiral of negativity (Moffitt et al., 2001) and in turn leads to more problem behavior. An interesting finding, however, is that the syndrome scale aggressive behavior did not show a significant difference. This implies that RD girls do show more antisocial behavior, but not necessarily more aggressive behavior in comparison to non-RD girls. Both groups of girls show a moderate to high risk score on aggressive behavior. It is interesting for further research to look at the specific antisocial behavior in which these groups of girls differ.

On the familial risk items it was expected that RD girls scored higher than non-RD girls, which is also supported by the results in this study. The families of RD girls more often experienced major financial problems, had more crowded housing, experienced less positive support and more stressors. Within the family, the interaction between daughter and caregiver was marked by high conflict, rejection and poor problem-solving interactions. These results imply a coercive cycle (Van Aken, 2002; Patterson et al., 1984). For example, financial problems can lead to more stress and in turn can influence the interaction between family members. No analyses were conducted on which factor causes the other, but it is possible there is a correlation between these items. Surprisingly, the item parenting style did not show significant difference between the two groups of girls. One would expect, in case of a possible coercive cycle, that parents react more harshly to their child. These findings have an

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important impact on RD girls, because positive interaction within the family can act as a social control against antisocial behavior (Sampson & Laub, 1993).

The results presented in this study should be interpreted in light of some limitations of this study. First, this study had a small sample size. Due to this small sample size some interesting questions could not be answered, like effect of treatment. It will be interesting to conduct the same study on a larger sample of girls. The suggestion is made here to continue conducting the same instruments on girls following treatment at this moment in time and thereby creating a larger database. Second, this study did not look at the relation between the different risk items. It is unknown how these risk items interact with each other and influence each other. It is possible, for example, girls are experiencing academic difficulties because they experience problems at home, or the other way around. This would be interesting for further research.

In conclusion, this study presents interesting findings about girlhood problem behavior and the importance of interaction in close relationships. The RD girls presented here are exposed to multiple risk factors within different settings that influence their current and future lives. These results underline the importance of effective risk management as early as

possible, because it is known that long exposure to risk factors narrows the window of behavioral change (Moffitt et al., 1993; Moffitt et al., 2001). Without such risk management the situation may worsen and causes girls to enter or stay on a life course persistent pathway. It is unknown what effect treatment has on these two groups of girls and it is recommended for further research to explore this effect.

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APPENDIX A

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APPENDIX B

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