Which family factors predict children's externalizing behaviors following discharge from psychiatric inpatient treatment?

The presenting problem that most often occasions the admission of preadolescents to inpatient psychiatric care is conduct disturbance, usually involving aggressive dyscontrol (Gutterman, 1998; Nicholson, Young, Simon, Fisher, & Bateman, 1998). These difficulties, often called externalizing behavior, manifest chiefly in the context of chronic disruptive behavior disorders and they typically develop alongside deficient impulse control and affective instability (Angold, Costello, & Erkanli, 1999; Burke, Loeber, Lahey, & Rathouz, 2005; Eisenberg, Fabes, Guthrie, & Reiser, 2000; Lynam, 1998). Family factors occupy a prominent position in efforts to understand externalizing behaviors and their ramifications. Most obviously, interpersonal difficulties inhere in the symptom criteria for disruptive disorders, which emphasize behaviors toward others that are harmful, antagonistic, and in poor conformity with authority. Family members are most often on the receiving end of these behaviors (Loeber & Dishion, 1984; MacLeod, McNamee, Boyle, Offord, & Friedrich, 1999), and familial stress and discord are common repercussions (Angold et al., 1998; Burt, McGue, Krueger, & Iacono, 2005). Parents’ management of child behavior may influence the genesis or maintenance of conduct problems. Inconsistent, abrasive, or permissive discipline is prevalent, as is poor parent–child relationship quality (Burt et al., 2005; Thompson, Hollis,D Barry, Dunlap, Cotten, Lochman,W Stoolmiller, 2001). Studies evaluating treatments that focus on improving parent–child relations and behavioral management demonstrate improvements in children’s behavior (Beauchaine, Webster-Stratton, & Reid, 2005; Brestan & Eyberg, 1998; Scott, Spender, Doolan, Jacobs, & Aspland, 2001). When a child’s behavioral disturbance eventuates in psychiatric hospitalization, such interweaving of conduct problems with family factors suggests that strong relationships may exist between postdischarge outcomes and family variables. However, the nature and extent of such associations have been the subject of little study in this patient group. The few previous studies combined children with adolescents, did not assess change over time in family-relevant predictors, and did not consider multiple predictors in the same outcome-prediction models (Green et al., 2001). The high cost (Ringel & Sturm, 2001), high patient risk (Lundy, Pfohl, & Kuperman, 1993; Sourander & Piha, 1998), and high rates of rehospitalization among preadolescents (Blader, 2004; Pottick, McAlpine, & Andelman, 2000) underscore the practical value of data that clarify their prognoses and focus treatment on areas likely to leverage favorable outcomes. Longitudinal measurements of family variables and clinical course can play a useful role in furnishing such data. This study followed a cohort of 5–13-year-old children admitted to an acute psychiatric inpatient service. Assessments at admission, and three, six, and 12 months after discharge included measures of behavioral status, parenting practices, parenting stress, family environment, and parents’ self-report of their own psychological symptoms. The primary goal was to develop a model of behavioral outcome vis-a-vis these family variables and their changes over time.