Effective treatment for mental disorders in children and adolescents

Prior Trauma Exposure for Youth in Treatment Foster Care

Very little research has focused on rates of trauma exposure for youth in treatment foster care (TFC). Available research has utilized record review for assessing exposure, which presents limitations for the range of trauma types examined, as records are predominantly focused on abuse and neglect. The current study examines exposure rates and association with emotional and behavioral outcomes for 229 youth in 46 TFC agencies. The youth in this study had exceptionally high rates of trauma exposure by foster parent report, similar to youth in traditional foster care, with nearly half of the sample exposed to four or more types of traumatic events. A composite child abuse and neglect exposure variable was associated with child and adolescent emotional and behavioral outcomes. Implications for services provided as part of TFC are discussed.

Characteristics and Behavioral Outcomes for Youth in Group Care and Family-Based Care: A Propensity Score Matching Approach Using National Data

This study aimed to answer two questions: (a) Given expected differences in children who are placed in group care compared to those in family-based settings, is it possible to match children on baseline characteristics? (b) Are there differences in behavioral outcomes for youth with episodes in group care versus those in family-based care? Using data from the National Survey of Child and Adolescent Well-Being, the study sample included 1,191 children with episodes in out-of-home care (n = 254 youth with group care episodes; n = 937 youth with episodes in family-based care and no group care). Conditioning variables were identified, which distinguished between the two groups of youth. Using propensity score matching, all youth placed into group care were matched on the propensity score with family-based care youth. Behavioral outcomes at 36 months, as measured by the Child Behavior Checklist, were compared for the matched sample. Of the total 254 youth with group care episodes, 157 could be matched to youth with episodes in family-based care. No significant differences remained between the two groups in the matched sample, and findings revealed no significant differences in longitudinal behavioral outcomes.

Collaborating With Clients and Improving Outcomes: The Relational Re-enactment Systems Approach to Treatment Model

The Relational Re-enactment Systems Approach to Treatment model is a coherent and comprehensive approach to residential treatment that increases family involvement through system-wide clinical consultation. The therapeutic alliance with youth and their families is emphasized as the key to creating client-centered goals for discharge to a less restrictive environment. The current study examined outcomes from four years of the model's implementation. Results indicated a significant increase in the proportion of youth discharged to a family home. Additionally, the proportion of discharges that were the result of youth running away from treatment was reduced by half.

The family empowerment program: an interdisciplinary approach to working with multi-stressed urban families

The family empowerment program (FEP) is a multi-systemic family therapy program that partners multi-stressed families with an interdisciplinary resource team while remaining attached to a "traditional" mental health clinic. The rationale for this model is that far too often, families presenting at community mental health centers struggle with multiple psychosocial forces, for example problems with housing, domestic violence, child care, entitlements, racism, substance abuse, and foster care, as well as chronic medical and psychiatric illnesses, that exacerbate symptoms and impact traditional service delivery and access to effective treatment. Thus, families often experience fragmented care and are involved with multiple systems with contradictory and competing agendas. As a result, services frequently fail to harness the family's inherent strengths. The FEP partners the family with a unified team that includes representatives from Entitlements Services, Family Support and Parent Advocacy, and Clinical Staff from the agency's Outpatient Mental Health Clinic practicing from a strength-based family therapy perspective. The goal of the FEP is to support the family in achieving their goals. This is accomplished through co-construction of a service plan that addresses the family's needs in an efficient and coherent manner-emphasizing family strengths and competencies and supporting family self-sufficiency.

Sustaining and expanding systems of care to provide mental health services for children, youth and families across America

The Substance Abuse and Mental Health Services Administration has been instrumental in supporting the development and implementation of systems of care to provide services to children and youth with serious mental health conditions and their families. Since 1993, 173 grants have been awarded to communities in all 50 states, Puerto Rico, Guam, the District of Columbia, and 21 American Indian/Alaska Native communities. The system of care principles of creating comprehensive, individualized services, family-driven and youth-guided care and cultural and linguistic competence, supported by a well-trained and competent workforce, have been successful in transforming the field of children's mental health and facilitating the integration of child-serving systems. This approach has achieved positive outcomes at the child and family, practice and system levels, and numerous articles have been published using data collected from system of care communities, demonstrating the effectiveness of this framework. This article will describe lessons learned from implementing the system of care approach, and will discuss the importance of expanding and sustaining systems of care across the country.

Supporting Young People at School With High Mental Health Needs

For young people still at school, the school setting is vital to their mental health and wellbeing. Not only does the school environment have a direct and indirect impact on mental health, it provides an opportunistic setting in which to identify and respond to emerging mental health problems. To do this effectively, schools and school staff must work in collaboration with the young people themselves, their families, and other support services within the community, particularly primary health care services, including general practice. The importance of developing effective partnerships and care pathways between schools and the primary health care sector is being increasingly acknowledged, and initiatives such as MindMatters Plus GP have advanced our understanding in this area.

Problems with access to adolescent mental health care can lead to dealings with the criminal justice system

Mental disorders collectively constitute the largest burden of disease in young people. They have substantial negative short- and long-term outcomes across many domains, yet early identification and effective intervention can improve outcomes and can often lead to recovery. Unfortunately, many young people do not receive the mental health care they require and may consequently enter the justice system. Studies of incarcerated youths show that up to 70% of them have mental disorders. Many of these youth receive primarily custodial care. A variety of social, legal and medical interventions can and should be implemented to ensure that young people suffering from mental disorders do not inappropriately enter the justice system due to lack of access to health care and other services.

Parent advocates in children's mental health: program implementation processes and considerations

Children's mental health service systems are increasingly utilizing peer support services to support families experiencing serious child mental illness. The literature provides few detailed accounts of such peer-based approaches. This study qualitatively examined the approaches and processes of "parent advocate" programs implemented in two Ohio counties for children served through publicly funded mental health services. Descriptions of each county's program, the background and roles of parent advocates, reasons families decline advocate services, and challenges to advocates' work with families are provided. Implications for the field in developing clear and effective administrative and practice structures for peer support services are discussed.

What Works in Group Care? - A Structured Review of Treatment Models for Group Homes and Residential Care

This paper presents findings from a structured review of treatment models that are relevant to group care and residential treatment settings for children involved with the child welfare system. Initiated and guided by The California Evidence-Based Clearinghouse for Child Welfare, five treatment models - Positive Peer Culture, Teaching Family Model, Sanctuary Model, Stop-Gap Model, and Re-ED - were reviewed for effectiveness. In this paper, each model s treatment features are described and relevant outcome studies reviewed in terms of their effectiveness as well as relevance for child welfare practice. Findings indicate that four of the models are either supported or promising in terms of evidence for effectiveness. Implications for group care practice and research are discussed.

Toward a technology of derived stimulus relations: an analysis of articles published in the journal of applied behavior analysis, 1992-2009

Every article on stimulus equivalence or derived stimulus relations published in the Journal of Applied Behavior Analysis was evaluated in terms of characteristics that are relevant to the development of applied technologies: the type of participants, settings, procedure (automated vs. tabletop), stimuli, and stimulus sensory modality; types of relations targeted and emergent skills demonstrated by participants; and presence versus absence of evaluation of generalization and maintenance. In most respects, published reports suggested the possibility of applied technologies but left the difficult work of technology development to future investigations, suggestions for which are provided.

Post-discharge services and psychiatric rehospitalization among children and youth

This study examined risk and determinants of rehospitalization of children and adolescents (n = 186) following a first psychiatric hospitalization. It specifically examined the role of post-discharge services. Data were collected for a 30-month follow-up period through structured telephone interviews with caregivers and case record abstractions. 43% of youth experienced readmissions during the follow-up period. Risk of rehospitalization was highest during the first 30 days following discharge and remained elevated for 3 months. 72% of youth received 284 post-discharge services during the follow-up period, which significantly reduced the risk of rehospitalization. Longer first hospitalizations and a higher risk score at admission increased risk.

Youth Perspectives on Restrictive Mental Health Placement: Unearthing a Counter Narrative

Though research has focused on clinical characteristics and behavioral problems of youth in out-of-home mental health placement settings, few studies have examined how adolescents and emerging adults (Arnett, 2000) experience and make sense of treatment. In this study, semistructured interviews regarding the experience of mental health placement were conducted with 12 adolescent and emerging adult participants with emotional and behavioral challenges, between the ages of 16 and 23. The participants were previously placed in residential mental health treatment centers, facilities, and inpatient hospitals. At the time of the interviews, all participants were involved in youth-run forums across New York State, through which they engage in peer-support initiatives and advocacy efforts aimed at reforming the children’s mental health system. Miles and Huberman’s suggestions for qualitative data coding (1994) were used to analyze the narratives. The participants identified salient conflicts when describing their experiences in restrictive mental health settings and also described the negative psychosocial ramifications of these experiences, including stigma and alienation. The findings suggest that by eliciting critical youth perspectives on mental health placement, a “counternarrative” emerges (Bamberg, 2004; Solis, 2004), which challenges and complicates clinically oriented discourses on youth with emotional and behavioral challenges. Implications for mental health reform and directions for future research are discussed.

Engaging Asian American youth and their families in quality mental health services

Asian American youth have a higher level of unmet mental health needs and lower level of mental health service engagement than White youth. We presented reasons for lack of engagement in mental health services among Asian American youth and families. Practical strategies to enhance their engagement in mental health services were provided.

Fatores de risco para problemas de saúde mental na infância/adolescência

Estudo de corte transversal conduzido em comunidade urbana de baixa renda do município de Embu-SP com objetivo de identificar fatores associados a problemas de saúde mental em crianças/adolescentes (PSMCA) em amostra probabilística (N=67, faixa etária 4-17 anos). Foram aplicados instrumentos estruturados às mães: Child Behavior Checklist (PSMCA); WorldSAFE Core Questionnaire (dados sociodemográficos; violência doméstica; embriaguez do pai/padrasto); Self-Report Questionnaire (problemas de saúde mental maternos, ideação suicida materna). Os resultados do estudo apontaram fatores estatisticamente associados aos PSMCA: criança/adolescente ser do sexo masculino e sofrer punição física grave; ideação suicida da mãe e violência conjugal física grave contra a mãe; embriaguez do pai/padrasto. Concluindo, grupos vulneráveis com características individuais/familiares identificadas neste estudo devem ser considerados prioritários em propostas de prevenção/tratamento.

Mental health care for children with disruptive behavior problems: a view inside therapists' offices

OBJECTIVES

In the United States, more money is spent on treatment for children's mental health problems than for any other childhood medical condition, yet little is known about usual care treatment for children. Objectives of this study were to characterize usual care outpatient psychotherapy for children with disruptive behavior problems and to identify consistencies and inconsistencies between usual care and common elements of evidence-based practices in order to inform efforts to implement evidence-based practices in usual care.

METHODS

Participants included 96 psychotherapists and 191 children aged four to 13 who were presenting for treatment for disruptive behavior to one of six usual care clinics. An adapted version of the Therapy Process Observational Coding System for Child Psychotherapy-Strategies scale (TPOCS-S) was used to assess psychotherapy processes in 1,215 randomly selected (out of 3,241 collected) videotaped treatment sessions; treatment sessions were recorded for up to 16 months.

RESULTS

Most children received a large amount of treatment (mean number of sessions=22, plus children received other auxiliary services), and there was great variability in the amount and type of care received. Therapists employed a wide array of treatment strategies directed toward children and parents within and across sessions, but on average all strategies were delivered at a low intensity. Several strategies that were conceptually consistent with evidence-based practices were observed frequently (for example, affect education and using positive reinforcement); however, others were observed rarely (for example, assigning or reviewing homework and role-playing).

CONCLUSIONS

Usual care treatment for these youths reflected great breadth but not depth. The results highlight specific discrepancies between evidence-based care and usual care, thus identifying potentially potent targets for improving the effectiveness of usual care.

Change what? Identifying quality improvement targets by investigating usual mental health care

Efforts to improve community-based children’s mental health care should be based on valid information about effective practices and current routine practices. Emerging research on routine care practices and outcomes has identified discrepancies between evidence-based practices and “usual care.” These discrepancies highlight potentially potent quality improvement interventions. This article reviews existing research on routine or “usual care” practice, identifies strengths and weaknesses in routine psychotherapeutic care, as well as gaps in knowledge, and proposes quality improvement recommendations based on existing data to improve the effectiveness of children’s mental health care. The two broad recommendations for bridging the research-practice gap are to implement valid, feasible measurement feedback systems and clinician training in common elements of evidence-based practice.

Psychosocial child adjustment and family functioning in families reached with an assertive outreach intervention

Families who experience a chronic complex of socio-economic and psychosocial problems are hard to reach with mainstream care. Evidence exists that the core of this problem is a problematic interaction between this type of family and current systems of care and services. To improve access to problem families, an assertive outreach intervention was implemented into the field of preventive child health care, The Netherlands. The study aimed to provide a more detailed insight into characteristics of the target group. Although there is consensus about some general features of hard to reach problem families, little is known about their specific characteristics because empirical studies among this group are rarely conducted. Especially, the problems of the children is shed insufficient light on. The studied population consisted of families included in the assertive outreach intervention delivered during one year (N=116). To assess psychosocial adjustment of the children, the Strengths and Difficulties Questionnaire was filled in by the parents. Furthermore, a Dutch questionnaire on family functioning was completed by professional carers. Descriptive data were calculated. The findings show that by using the assertive outreach intervention, programme staff came into contact with families characterised by a considerably higher than average proportion of single parents and unemployed households receiving social benefits. The families faced a high level of risk and a wide range of severe and multiple difficulties, including a lack of basic child care, an inadequate social network and poor parenting. Children in these families were also facing a number of risks. The proportion of psychosocial problems was well above the (inter)national average. The findings reveal the problem areas of unreached families and a need to improve the access to care for these families.

Efficacy of cognitive behavioural therapy for children and adolescents with traumatic brain injury

PURPOSE

Behavioural and psychological disorders after traumatic brain injury (TBI) are very common. The purposes of this study were to estimate the frequency of these problems in our sample, to evaluate the effectiveness of cognitive behavioural therapy (CBT) and to assess the predictive value of important clinical variables for the treatment outcome.

METHOD

Forty patients aged 4-18 years were included in this study. Twenty-eight patients received CBT at our Institute (clinical group), while 12 patients did not receive any treatment at all (control group). The CBCL/4-18 and the VABS were administered to parents at the beginning of the study and after 12 months.

RESULTS

A high frequency of psychological and behavioural problems was found in both groups of patients. After CBT, the clinical group showed a significant advantage on several CBCL scales and a greater increase in adaptive behaviour on the VABS Socialisation domain. The Glasgow Coma Scale score, days of unconsciousness and age at injury were not predictors of the severity of psychological problems at the follow-up for the patients of the clinical group.

CONCLUSIONS

Our results suggest that CBT is an effective intervention for young patients with psychological problems after TBI.

Mental health care for children with disruptive behavior problems: a view inside therapists' offices

OBJECTIVES

In the United States, more money is spent on treatment for children's mental health problems than for any other childhood medical condition, yet little is known about usual care treatment for children. Objectives of this study were to characterize usual care outpatient psychotherapy for children with disruptive behavior problems and to identify consistencies and inconsistencies between usual care and common elements of evidence-based practices in order to inform efforts to implement evidence-based practices in usual care.

METHODS

Participants included 96 psychotherapists and 191 children aged four to 13 who were presenting for treatment for disruptive behavior to one of six usual care clinics. An adapted version of the Therapy Process Observational Coding System for Child Psychotherapy-Strategies scale (TPOCS-S) was used to assess psychotherapy processes in 1,215 randomly selected (out of 3,241 collected) videotaped treatment sessions; treatment sessions were recorded for up to 16 months.

RESULTS

Most children received a large amount of treatment (mean number of sessions=22, plus children received other auxiliary services), and there was great variability in the amount and type of care received. Therapists employed a wide array of treatment strategies directed toward children and parents within and across sessions, but on average all strategies were delivered at a low intensity. Several strategies that were conceptually consistent with evidence-based practices were observed frequently (for example, affect education and using positive reinforcement); however, others were observed rarely (for example, assigning or reviewing homework and role-playing).

CONCLUSIONS

Usual care treatment for these youths reflected great breadth but not depth. The results highlight specific discrepancies between evidence-based care and usual care, thus identifying potentially potent targets for improving the effectiveness of usual care.

Organizational and clinical implications of integrating an alcohol screening and brief intervention within non-substance abuse serving agencies

Although there have been efforts to advance evidenced-based practices into community-based organizations the limited successes of dissemination and poor implementation of efficacious treatments within these organizations are beginning to be documented. This article builds on the knowledge gained from organizational research and those internal structures (e.g., culture and climate), which possibly impede or enhance evidenced-based practice implementation within community-based organizations. While there are many evidenced-based practices available to human services organizations, there seems to be a gap between research and the implementation of these clinical practices. Recommendations are provided to better enable community-based organizations to integrate evidenced-based practice into its existing service structures.

Patterns of movement for youth within an integrated continuum of residential services

This study examined patterns of movement for youth receiving services within a continuum of intensive and restrictive residentially-based programs. Data were collected for 701 completed episodes of care within a three-program residential continuum of care over a 5 year period, and examined time within program, movement between programs, in-program disruptive behavior, and discharge status. Results showed that most youth either remained in a stable placement in the least restrictive of the programs, or followed a pattern of placements that systematically moved them from more restrictive to less restrictive settings. Of note, transitions from more restrictive to less restrictive programs correspond to deescalating levels of problem behavior; and over 80% of the youth were stepped down to either family-based or independent living situations at the time of departure. Findings support the notion that a continuum of intensive residential services can serve the needs of youth with significant emotional and behavioral needs.

Factors associated with use of evidence-based practice strategies in usual care youth psychotherapy

The purpose of this study was to gain an understanding of how therapists providing usual care (UC) psychotherapy are using elements of treatment common to evidence-based practices (EBPs) for children with disruptive behavior disorders (DBPs) and to identify client and therapist characteristics that may be associated with EBP strategies directed toward children and those directed to their caregivers. Results indicate that certain child, family, and therapist characteristics are associated with use of EBP strategies; however, much of the variability in practice was not explained by the variables examined. These findings highlight the complexity of UC psychotherapy and provide directions for future research on implementation of EBPs in UC.

Reducing preschoolers' disruptive behavior in public with a brief parent discussion group

This study examined the efficacy of a brief 2-h discussion group for parents of preschool children that show disruptive behavior on shopping trips. Forty-six parents with children aged 2-6 years were randomly assigned to either the intervention condition or a waitlist control group. Significant intervention effects were found for measures of problem child behavior, dysfunctional parenting styles and parents' confidence in the parenting role. No group differences were found for parental adjustment or conflict over parenting. Intervention gains were maintained at 6-month follow-up. Results are discussed within a primary care and public health framework.

Evidence-based practice implementation and staff emotional exhaustion in children's services

Understanding the implementation of evidence-based practice (EBP) in community service settings is critical for the successful translation of research to practice. However, we have limited research evidence about the impact of EBP implementation on the mental health and social service workforce. In a previous study we demonstrated reduced staff turnover where an EBP was implemented with fidelity monitoring in the form of supportive ongoing supervision and consultation. Other research has shown that staff burnout and emotional exhaustion in particular is associated with poor quality of care and increased staff turnover intentions and turnover. Current research, however, has focused less on the effects that EBP implementation may have on staff emotional exhaustion. The present study investigates the association of EBP implementation and fidelity monitoring with staff emotional exhaustion in a statewide EBP implementation study. The 21 case-management teams in this study were randomized in a 2 (EBP vs. services as usual [SAU]) by 2 (monitoring vs. no monitoring) design. The EBP in this study was SafeCare, a home-based intervention that aims to reduce child neglect in at-risk families. SafeCare was developed from a behavior analysis approach and is based in cognitive behavioral principles. In keeping with our previous research, we hypothesized that providers implementing SafeCare with monitoring would have the lowest levels of emotional exhaustion and those receiving additional monitoring not in the context of EBP implementation would have higher emotional exhaustion relative to the other groups. Results supported our hypotheses in that we found lower emotional exhaustion for staff implementing the EBP but higher emotional exhaustion for staff receiving only fidelity monitoring and providing SAU. Together, these results suggest a potential staff and organizational benefit to EBP implementation and we discuss implications of the findings relative to EBPs and to fidelity monitoring.

Examining externalizing behavior trajectories of youth in group homes: is there evidence for peer contagion?

Although concerns about peer contagion are often cited in critiques of group treatments for troubled youths, few studies have examined the effects of exposure to deviant peers in residential group care settings. This study used administrative data of youth served at Boys Town, a nationally-known group care provider. Using latent class growth analysis, this study identified the externalizing behavior trajectories of youth in group care as well as the behavior trajectory of the peers with whom they lived, assessed the relationship between youth trajectory classes and individual and peer group characteristics as well as the relationship between an individual youth's behavior pattern and the behavior pattern of proximal peers. Several results suggested the presence of peer contagion in group care: a trajectory class of gradually increasing externalizing behavior problems, the strength of deviant peer density in predicting an individual youth's externalizing behavior trajectories and significant associations between behavior patterns of youth and proximal peers. While there is some evidence that suggests an increase in problem behavior during care, results from this study indicated that over 90% of the youth did not have an increase in problem behaviors and that positive peer influences may also be protective and inhibit problem behaviors.

Persistence and change in pediatric symptom checklist scores over 10 to 18 months

OBJECTIVE

There are many studies of the Pediatric Symptom Checklist (PSC), but none has followed a naturalistic sample longitudinally. We aimed to examine persistence and change in PSC scores over time in children seen in an ambulatory pediatric setting.

METHODS

The sample of 1033 patients was PSC screened at 2 consecutive preventive care visits (10 to 18 months apart) in 2 pediatric clinics. Longitudinal analyses were conducted to assess predictors of change in PSC category and score.

RESULTS

Approximately 30% of the initially screened population did not return for preventive pediatric care. Those who did not return were significantly more likely to have positive PSC scores than those who returned (8% compared with 4.3%, P < .01). PSC scores were highly stable at visit 2 for those who initially scored negative, but they fluctuated more for those who initially scored positive. After controlling for sociodemographic variables and counseling at either visit, referral at visit 1 (P < .0001) predicted changes in mean PSC scores at visit 2. On average, PSC score decreased 3.2 points among those referred at visit 1 but increased 1.6 points in nonreferred children.

CONCLUSIONS

This is the first study to document the stability and change in PSC scores in a sample of ambulatory pediatric patients. The statistically significant association between pediatrician referral and improved PSC scores provides evidence for the value of referral in primary care, although the study did not examine the relationship between PSC screening and referral. The high rate of positive scores in children who did not return for follow-up suggests the need for alternative strategies for this population.

Case Management as a Significant Component of Usual Care Psychotherapy for Youth with Disruptive Behavior Problems

Youth with disruptive behavior problems (DBPs) represent the majority of youth served in usual care (UC) psychotherapy, and are at high risk for maladaptive outcomes. Little is known about UC psychotherapeutic strategies utilized with this population. Researchers and clinicians suggest that case management (CM) is a major activity occurring in usual care. CM includes coordinating care with service providers and individuals, including schools, psychiatrists, and community-based services. This study assesses the prevalence and predictors of clinician use of CM in usual care. Results from this study suggest that CM is frequently used in UC psychotherapy with youth with DBPs. The extent of use of CM in UC may have implications for implementation of evidence-based practices in usual care psychotherapy.

Predictors of residential placement following a psychiatric crisis episode among children and youth in state custody

This study examined the extent and correlates of entry into residential care among 603 children and youth in state custody who were referred to psychiatric crisis services. Overall, 27% of the sample was placed in residential care within 12 months after their 1st psychiatric crisis screening. Among the children and youth placed in residential care, 51% were so placed within 3 months of their 1st crisis screening, with an additional 22% placed between 3 and 6 months after screening. Risk behavior and functioning, psychiatric hospitalization following screening, older age, placement type, and caregiver's capacity for supervision were associated with increased residential placement. The findings highlight the importance of early identification and treatment of behavior and functioning problems following a crisis episode among children and youth in state custody to reduce the need for subsequent residential placement. Having an inpatient psychiatric episode following a crisis episode places children at greater risk for residential placement, suggesting that the hospital is an important point for diversion programs. Children and youth in psychiatric crisis may also benefit from efforts to include their families in the treatment process.

Beliefs about mental health problems and help-seeking behavior in Dutch young adults

BACKGROUND

Mental health problems in young adults are frequent and impairing, but are often left untreated. This study among young adults with self-perceived mental health problems examines beliefs about mental health problems (i.e. their cause, consequences, timeline, and controllability) and help-seeking behaviour.

METHOD

A cross-sectional population survey (n = 2,258) in the south-west Netherlands. Participants were included who reported having mental health problems during the past year (n = 830). Beliefs about cause, consequences, timeline, and controllability of self-perceived mental health problems were assessed with the Illness Perception Questionnaire. Internalizing and externalizing psychopathology was assessed with the Adult Self-Report.

RESULTS

A multivariate logistic regression analysis indicates that independent of sex, age, and severity of psychopathology, higher levels on the intra-psychic causes scale (OR = 1.95, 95%CI = 1.48-2.58), the consequences scale (OR = 1.81, 95%CI = 1.40-2.33), and the treatment control scale (OR = 1.97, 95%CI = 1.60-2.41) are associated with an increased likelihood of mental health service use, while higher levels of personal control (OR = 0.76, 95%CI = 0.62-0.93) are associated with a decreased likelihood.

CONCLUSIONS

Beliefs that may encourage young adults with mental health problems to seek professional help include the beliefs that mental health problems have adverse consequences and that treatment can help. Since these beliefs are related to young adults' knowledge of mental health problems, help-seeking behavior may be encouraged by educating young adults about mental health problems and the effective mental health treatments which are available.

Attitudes Toward Adoption of Evidence-Based Practices: A comparison of Autism Early Intervention Providers and Children's Mental Health Providers

Across the country, states are reporting increases in the number of children with autistic spectrum disorders (ASD) served each year in the early intervention system. Research examining factors impacting the successful dissemination and implementation of evidence-based practice (EBPs) into service systems for these children is limited. Preliminary information indicates that adoption of EBPs is variable. Provider attitudes toward the adoption of EBPs may be one factor that limits or facilitates implementation of efficacious treatments and these attitudes vary by organizational context and provider individual differences. The current study examines cross-context differences in provider attitudes toward EBPs by comparing the attitudes of 71 education-based early intervention providers working with children with ASD to the attitudes of 238 mental health providers in the public mental health system. This provides the first examination of ASD early intervention provider attitudes toward EBP. Results indicated that early intervention providers reported significantly more favorable attitudes toward adopting EBPs than did mental health providers. Early intervention providers with extended experience in the field perceived less divergence between their current practice and EBPs. Implications are discussed.

Young adults face major barriers to seeking help from mental health services

OBJECTIVE

Mental health problems often emerge in young adulthood. Although effective treatments are available, young adults are unlikely to seek professional help. This study examined barriers-to-care in young adults with serious internalizing or externalizing problems.

METHODS

Population-based study among 2258 19-32-year olds in the south-west region of the Netherlands. Barriers-to-care were examined in participants with serious internalizing or externalizing problems who did not seek professional help. A potential barrier was that participants denied that they had mental health problems. In those admitting problems, barriers were assessed with the Barriers-to-Care checklist and analyzed with Latent Class Analysis.

RESULTS

Of 362 participants with serious internalizing or externalizing problems 237 (65.5%) did not seek professional help. Of non-help-seeking young adults 36% denied having problems; additionally Latent Class Analysis revealed that 37% Perceived Problems as Self-Limiting (e.g., they believed that problems were not serious) and 24% Perceived Help-Seeking Negatively (e.g., they believed that treatment would not help).

CONCLUSIONS

Young adults' barriers-to-care reflect limitations in their knowledge of mental health problems and available treatments, but possibly also a failure of existing mental health services to engage young people. More knowledge is urgently needed about the effectiveness of mental health treatments for young adults specifically.

PRACTICE IMPLICATIONS

Treatment accessibility for young adults may be augmented by improving their mental health literacy.

Modifications à la psychothérapie focalisée sur le transfert (PFT) pour le traitement des adolescents avec une identité diffuse

Cet article présente une version modifiée de la psychothérapie focalisée sur le transfert (PFT) appliquée aux adolescents démontrant une identité diffuse. Cette méthode a déjà démontré son efficacité auprès d’adultes souffrant d’importants problèmes de diffusion de l’identité. Nous signalons l’importance de distinguer la crise identitaire normale à l’adolescence de la diffusion de l’identité, afin de bien repérer les adolescents qui pourraient bénéficier de ce traitement. Les principales modifications apportées à la PFT pour s’adapter aux adolescents impliquent divers changements : des changements quant à la fréquence et à la durée de certaines techniques particulières (par exemple une clarification accrue ; une plus grande attention aux relations extra-transférentielles avant d’aborder directement le transfert), des changements quant aux tactiques (par exemple l’inclusion de la famille à l’étape de l’évaluation et dans le contrat qui établit les phases de traitement, l’inclusion d’interventions de soutien dans le milieu tout en gardant la position analytique au cours des séances), des changements quant aux stratégies (par exemple tenter de lever les blocages qui nuisent au développement normal de l’intégration de l’identité, plutôt que de « forcer la maturation »). Le traitement vise à améliorer les relations de l’adolescent avec ses amis, ses parents et ses professeurs ; à clarifier ses objectifs dans la vie ; à acquérir une estime de lui-même et à être mieux préparé à s’investir dans les relations amoureuses.

Identifying common elements of evidence-based psychosocial treatments for children's disruptive behavior problems

OBJECTIVE

: Almost all of the efforts to study and implement evidence-based practice (EBP) have used individual treatments as the unit of analysis. A complementary approach using aggregated common elements of multiple individual evidence-based treatment programs has been introduced. The purpose of this article is to describe a new method for identifying common elements of EBP and to present common elements resulting from a systematic review of interventions for children with disruptive behavior problems and their parents.

METHOD

: We identified eight individual treatment programs with established efficacy for children ages 4 to 13 with disruptive behavior problems, reviewed all of the treatment materials thoroughly, identified core elements of each treatment, and determined which elements were common to at least half of the programs. The validity of these common core elements was confirmed through a survey of national experts using a modified Delphi technique.

RESULTS

: We identified 21 treatment elements that were common to multiple evidence-based treatment programs. These included therapeutic content (e.g., principles of positive reinforcement, problem-solving skills training), treatment techniques (e.g., role-playing, assigning homework), aspects of the working alliance, and other parameters such as treatment duration.

CONCLUSIONS

: Identification of common core elements of EBP has important implications for efforts to characterize practice, as well as therapist training and implementation of EBP in community-based service settings. Therapist training and ongoing supervision that builds on common elements of EBP could potentially improve the effectiveness of care overall. It could also build a strong foundation for targeted individual treatment implementation efforts by enhancing therapists' skills and attitudes about EBP.

Implementing cognitive behavioral therapy in the real world: a case study of two mental health centers

BACKGROUND

Behavioral health services for children and adolescents in the U.S. are lacking in accessibility, availability and quality. Evidence-based interventions for emotional and behavioral disorders can improve quality, yet few studies have systematically examined their implementation in routine care settings.

METHODS

Using quantitative and qualitative data, we evaluated a multi-faceted implementation strategy to implement cognitive-behavioral therapy (CBT) for depressed adolescents into two publicly-funded mental healthcare centers. Extent of implementation during the study's duration and variables influencing implementation were explored.

RESULTS

Of the 35 clinicians eligible to participate, 25 (71%) were randomized into intervention (n = 11) or usual care (n = 14). Nine intervention clinicians completed the CBT training. Sixteen adolescents were enrolled in CBT with six of the intervention clinicians; half of these received at least six CBT manually-based sessions. Multiple barriers to CBT adoption and sustained use were identified by clinicians in qualitative interviews.

CONCLUSION

Strategies to implement evidence-based interventions into routine clinical settings should include multi-method, pre-implementation assessments of the clinical environment and address multiple barriers to initial uptake as well as long-term sustainability.

Predicting Frequency of Treatment Visits in Community-Based Youth Psychotherapy

The current study examines factors associated with the number of treatment visits attended by a youth and/or family, including sociodemographic variables, youth clinical characteristics and parent/family characteristics at intake, therapist characteristics, and treatment entry characteristics. A total of 57 therapists in two publicly-funded youth mental health clinics and 169 youths and parents from the therapists' combined caseloads were included in the study. Negative binomial regression was used to examine whether factors within these domains predict the number of treatment visits in this community-based sample. Both therapist and treatment entry characteristics significantly predicted the frequency of treatment visits. Specifically, youth self report of higher symptom severity and stronger parent-youth treatment goal agreement were associated with a higher number of treatment visits. Implications for research and practice are discussed.

Assessing the organizational social context (OSC) of mental health services: implications for research and practice

The organizational social context in which mental health services are provided is believed to affect the adoption and implementation of evidence-based practices (EBPs) as well as the quality and outcomes of the services. A fully developed science of implementation effectiveness requires conceptual models that include organizational social context and tools for assessing social context that have been tested in a broad cross-section of mental health systems. This paper describes the role of organizational social context in services and implementation research and evaluates a comprehensive contextual measure, labeled Organizational Social Context (OSC), designed to assess the key latent constructs of culture, climate and work attitudes. The psychometric properties of the OSC measure were assessed in a nationwide study of 1,154 clinicians in 100 mental health clinics with a second-order confirmatory factor analysis of clinician responses, estimates of scale reliabilities, and indices of within-clinic agreement and between-clinic differences among clinicians. Finally, the paper illustrates the use of nationwide norms in describing the OSC profiles of individual mental health clinics and examines the cross-level association of organizational-level culture and climate with clinician-level work attitudes.

Comments on NICE Guidelines for 'Depression in Children and Young People'

The recent NICE depression guidelines recommend that cognitive-behavioural and interpersonal psychotherapies should be the treatments of choice for child or adolescent depression. This paper argues that in so doing, NICE goes beyond the evidence adduced and judges too much relevant data ineligible. This is likely to be due to a methodology developed for biomedicine, where NICE-eligible data are substantial. Consequently, NICE risks distorting practice in a small specialty where randomised controlled trials are comparatively rare and usually involve small samples.

Mental health of young people: a global public-health challenge

Mental disorders account for a large proportion of the disease burden in young people in all societies. Most mental disorders begin during youth (12-24 years of age), although they are often first detected later in life. Poor mental health is strongly related to other health and development concerns in young people, notably lower educational achievements, substance abuse, violence, and poor reproductive and sexual health. The effectiveness of some interventions for some mental disorders in this age-group have been established, although more research is urgently needed to improve the range of affordable and feasible interventions, since most mental-health needs in young people are unmet, even in high-income countries. Key challenges to addressing mental-health needs include the shortage of mental-health professionals, the fairly low capacity and motivation of non-specialist health workers to provide quality mental-health services to young people, and the stigma associated with mental disorder. We propose a population-based, youth focused model, explicitly integrating mental health with other youth health and welfare expertise. Addressing young people's mental-health needs is crucial if they are to fulfil their potential and contribute fully to the development of their communities.

Implementation of Evidence-based Practice in Child Welfare: Service Provider Perspectives

Implementation of evidence-based practices (EBP) in child welfare is a complex process that is often fraught with unanticipated events, conflicts, and resolutions. To some extent, the nature of the process, problems, and solutions may be dependent on the perspectives and experiences of a given stakeholder group. In order to better understand the implementation process in the child-welfare system, we interviewed comprehensive home-based services (CHBS) case managers who were actively engaged in implementing an EBP to reduce child neglect in a state youth services system. Six primary factors were identified as critical determinants of EBP implementation: (1) Acceptability of the EBP to the caseworker and to the family, (2) Suitability of the EBP to the needs of the family, (3) Caseworker motivations for using the EBP, (4) Experiences with being trained in the EBP, (5) Extent of organizational support for EBP implementation, and (6) Impact of EBP on process and outcome of services. These factors reflect two broader themes of attitudes toward or assessments of the EBP itself and experiences with learning and delivering the EBP. Eventual implementation is viewed as the consequence of perseverance, experience, and flexibility.