Assessing the effectiveness of care for youth with severe emotional disturbances: is there agreement between popular outcome measures?

Health equity in pediatrics: Current concepts for the care of children in the 21st century (Dis Mon)

This is an analysis of important aspects of health equity in caring for children and adolescents written by a multidisciplinary team from different medical centers. In this discussion for clinicians, we look at definitions of pediatric health equity and the enormous impact of social determinants of health in this area. Factors involved with pediatric healthcare disparities that are considered include race, ethnicity, gender, age, poverty, socioeconomic status, LGBT status, living in rural communities, housing instability, food insecurity, access to transportation, availability of healthcare professionals, the status of education, and employment as well as immigration. Additional issues involved with health equity in pediatrics that are reviewed will include the impact of the COVID-19 pandemic, behavioral health concepts, and the negative health effects of climate change. Recommendations that are presented include reflection of one's own attitudes on as well as an understanding of these topics, consideration of the role of various healthcare providers (i.e., community health workers, peer health navigators, others), the impact of behavioral health integration, and the need for well-conceived curricula as well as multi-faceted training programs in pediatric health equity at the undergraduate and postgraduate medical education levels. Furthermore, ongoing research in pediatric health equity is needed to scrutinize current concepts and stimulate the development of ideas with an ever-greater positive influence on the health of our beloved children. Clinicians caring for children can serve as champions for the optimal health of children and their families; in addition, these healthcare professionals are uniquely positioned in their daily work to understand the drivers of health inequities and to be advocates for optimal health equity in the 21st century for all children and adolescents.

Selection of a Child Clinical Outcome Measure for Statewide Use in Publicly Funded Outpatient Mental Health Programs

OBJECTIVE

This study describes the process of choosing a clinical outcome measure for a statewide performance outcome system for children receiving publicly funded mental health services in California.

METHODS

The recommendation is based on a five-phase approach, including an environmental scan of measures used by state mental health agencies; a statewide provider survey; a scientific literature review; a modified Delphi panel; and final rating of candidate measures by using nine minimum criteria informed by stakeholder priorities, scientific evidence, and state statute.

RESULTS

Only 10 states reported use of at least one standardized measure for outcome measurement. In California, the most frequently reported measures were the Child and Adolescent Needs and Strengths (CANS) (N=33), the Child Behavior Checklist (N=14), and the Eyberg Child Behavior Inventory (N=12). Based on modified Delphi panel ratings, only the Achenbach System of Empirically Based Assessment, the Strengths and Difficulties Questionnaire, and the Pediatric Symptom Checklist (PSC) were rated on average in the high-equivocal to high range on effective care, scientific acceptability, usability, feasibility, and overall utility. The PSC met all nine minimum criteria for recommendation for statewide use. In its final decision, the California Department of Health Care Services mandated use of the PSC and CANS.

CONCLUSIONS

There is a lack of capacity to compare child clinical outcomes across states and California counties. Frequently used outcome measures were often not supported by scientific evidence or Delphi panel ratings. Policy action is needed to promote the selection of a common clinical outcome measure and measurement methodology for children receiving publicly funded mental health care.

Rorschach Evaluation of Personality and Emotional Characteristics in Adolescents With Migraine Versus Epilepsy and Controls

The literature examining primary headache, including migraine, in adolescents, has pointed out the key role played by a wide range of psychiatric disorders in reducing the patients’ quality of life. Moreover, pioneering studies showed that preexisting personality characteristics, specific emotion regulation styles and psychological-psychiatric difficulties are likely to increase the risk of the onset, maintenance, and outcome of headache. Still personality issues in migraine have been poorly studied, in particular in children and adolescents. This study aims, therefore, to investigate the specific characteristics of personality, and in particular emotion regulation and coping strategies, in adolescent with migraine, comparing them with age-matched patients with idiopathic epilepsy and healthy adolescents. 52 adolescents (age: 11–17) were assessed using a multi-method test battery, which included a self-report questionnaire (the youth self-report), a proxy-report (child behavior checklist) along with a projective personality test, the Rorschach Test, administered and scored according to the Exner comprehensive system. The results showed specific personality characteristics in adolescents with migraine, revealing a marked difficulty in modulating and regulating affections through thoughts and reflections, resorting instead to impulsive acts and maladaptive coping strategies, thus revealing a vague and immature perception of reality. Differently from adolescents belonging to the general population, but similarly to patients with epilepsy, adolescents with migraine perceive a high situational stress, probably related to the condition of suffering from chronic disease. They have, therefore, a lower self-consideration and self-esteem along with a poorer insight regarding themselves as well as the relations with others. In line with previous findings, these preliminary results suggest the need for further research on ample samples, using also standardized projective test in order to better understand the pathogenesis of psychological difficulties in patients with migraine. As a clinical implication, the results seem to indicate that providing a psychological integrated approach can play a pivotal role in the assessment and treatment of adolescent with migraine, in order to improve the outcome and the quality of life of the young patients.

Treatment Outcome of Adolescent Inpatients With Early-Onset and Adolescent-Onset Disruptive Behavior

OBJECTIVE

Unlike adolescents with adolescent-onset (AO) disruptive behavior, adolescents with early-onset (EO) disruptive behavior may not benefit from treatment.

METHOD

Using Symptom Checklist (SCL-90-R) ratings at admission and discharge of adolescent inpatients with EO (n = 85) and AO (n = 60) disruptive behavior treatment outcome was determined by (a) a change in mean scores and (b) the Reliable Change Index. For a subgroup, ratings on the Satisfaction Questionnaire Residential Youth Care for Parents (n = 83) were used to verify the treatment outcome.

RESULTS

Inpatients with EO disruptive behavior had a higher risk of dropout (44.4%) from treatment than the AO group (24.7%). Among the treatment completers, both onset groups reported improvements on the SCL-90-R, with 26.9% recovering and 31.7% improving. Inpatients who reported improvement were mostly rated as improved by their parents (r = .33).

CONCLUSION

As EO inpatients are more likely to drop out, interventions should aim at motivating youngsters to continue treatment, particularly given the poor outcome in this group. Treatment may benefit both groups because those EO youths who stayed in treatment improved to the same extent as AO inpatients.

Validation study of HSCL-10, HSCL-6, WHO-5 and 3-key questions in 14-16 year ethnic minority adolescents

BACKGROUND

There is a lack of validated instruments for detection of depression in ethnic minority adolescent patients in primary care. This study aimed to compare a subgroup of the bilingual, ethnic minority adolescents with the rest of the population using Hscl-10, Hscl-6, WHO-5 and 3-Key Questions for detection of depression in primary care.

METHOD

This is a cross-sectional, multicenter study conducted in General Practice in Norway and Denmark. A minor bilingual non-aggregated heterogenic ethnic minority group from non-European countries was compared with a major ethnic group of Norwegian/Danish adolescents. Participants completed questionnaires which were either mailed to them or found on our website. The Composite International Diagnostic Interview was used as gold standard. Depression classified by the International Classification of Diseases - 10. The Internal and external validity of the four questionnaires were examined. Optimal cut-off point for major depressive disorder was calculated using the Youden Index.

RESULTS

294 (77%) were interviewed; mean age was 15 years. The ethnic group comprised 44 (64% girls and 36% boys). Chronbach's alpha was above 0. 70 and area under curve was 0.80 or above for all instruments in the ethnic minority group. Cut-off points for major depressive disorder had sensitivities of 81% (Hscl-10), 82% (Hscl-6), 91% (Who-5) and 81% (3-key questions) in the ethnic minority group. Corresponding specificities were 80% (Hscl-10), 77% (Hscl-6), 80% (Who-5) and 67% (3-key questions). Cut-off points were the same Hscl-10, Who-5, the 3-key questions but differed for Hscl-6.

CONCLUSION

Hscl-10, Hscl-6, WHO-5 and 3-key questions seem to be valid instruments for detection of depression in bilingual, ethnic minority adolescents in primary care.

Predicting outcomes among adolescents with disruptive disorders being treated in a system of care program

BACKGROUND

"Systems of care" are strengths-based approaches to treating adolescents and others with disruptive disorders. However, little is known about why some adolescents improve and others do not.

OBJECTIVE

To examine changes in personal strengths and family functioning as predictors of behavioral and social functioning among adolescents with disruptive disorders who participated in a system of care program.

DESIGN

Secondary analyses of data from 114 adolescents (12-17 years of age) with disruptive disorders and their caregivers who participated in the Dawn Project Evaluation Study. Caregivers completed in-depth interviews conducted by trained data collectors using standardized questionnaires. Baseline and 12- month data are reported here.

RESULTS

Improvement in personal strengths was a significant predictor of improvement in adolescent behavioral and social functioning, controlling for demographics (p < .001).

CONCLUSION

In adolescents with disruptive disorders, psychiatric nurses should focus on enhancing adolescents' personal strengths to improve behavioral and social functioning.

Means, Intent, Lethality, Behaviors, and Psychiatric Diagnosis in Latina Adolescent Suicide Attempters

This article describes the means, intent, lethality, behavioral profile, and psychiatric diagnosis of adolescent Latina suicide attempters. From a large mixed-methods project studying the sociocultural processes of Latina suicide attempts, we selected 76 subjects for this report. In addition to quantitative research data, medical records were available for all 76 subjects and qualitative data from in-depth interviews for 34 of them. Using the qualitative and quantitative research data, we explored the intent and behavioral profile of the suicidal adolescents. Medical records provided additional information about the means the adolescents used in their attempts and about their psychiatric diagnosis. The lethality of suicide attempts was coded using the LSARS and the LSARS-II. Findings showed that Latina adolescent suicide attempts are of low lethality. Consistent with the literature, most adolescents reported that they attempted by using means available in their homes (cutting and overdosing with medications were the predominant methods). Interesting discrepancies emerged when comparing adolescents' self-reported behavioral profiles with clinicians' psychiatric diagnoses. This report has implications for diagnosis and treatment approaches for both inpatient and outpatient service providers.

Changes in maternal depression are associated with MST outcomes for adolescents with co-occurring externalizing and internalizing problems

The efficacy of Multisystemic therapy (MST) in treating adolescent aggression has been established, however, not all youth and their families benefit from MST. One reason for this treatment variability could be the failure to distinguish between different aggressive subtypes with different risk factors, developmental prognoses and treatment needs. We investigated whether changes in maternal depression over MST would lead to different outcomes for two aggressive subtypes: pure externalizers (EXT) and mixed externalizers/internalizers (MIXED). Forty-two EXT and 27 MIXED youth and their families underwent MST for six months. Maternal depression, youth externalizing and internalizing behaviour were assessed before and after MST. Results showed a marginally greater change in externalizing for EXT youth. In addition, reductions in maternal depression were related to successful treatment outcomes for MIXED youth only. Our findings have implications for MST clinicians, namely the importance of reducing depressive symptoms in mothers of MIXED youth to improve their outcomes.

Clinically significant symptom change in children with attention-deficit/hyperactivity disorder: does it correspond with reliable improvement in functioning?

This study examined the relation between clinically significant (CS) change in symptoms of attention-deficit/hyperactivity disorder (ADHD) and of oppositional defiant disorder (ODD), and reliable change in multiple domains of functioning in children who participated in the Multimodal Treatment Study of Children with ADHD. Children with CS change in symptoms were significantly more likely than children without CS change to have reliable change across five domains of functioning. Interestingly, however, depending on the measure of functioning, 14 to 52% of children who did not achieve CS change in symptoms showed reliable improvement in functional domains. The results have implications for the definition and measurement of CS change in child treatment-outcome studies.

Messung der Prozess- und Ergebnisqualität in der Therapie von Kindern und Jugendlichen

Zusammenfassung. Psychotherapeuten sind verpflichtet, Maßnahmen zur Qualitätssicherung (QS) und zum Qualitätsmanagement (QM) durchzuführen. Welcher Art diese Maßnahmen sein sollten, ist gesetzlich jedoch nicht geregelt. Für den Teilbereich der Strukturqualität gibt es mittlerweile Vorgaben (z. B. DIN ISO 9001 ff.), deren Umsetzung zur Zertifizierung von Einrichtungen führen kann. Erheblich komplizierter stellen sich die Bereiche Prozess- und Ergebnisqualität dar. Wege der Umsetzung von Konzepten in diesen beiden Zweigen des Qualitätsmanagements wurden bisher nur in einigen wenigen Studien im Erwachsenenbereich aufgezeigt, aber noch nicht in der Kinder- und Jugendlichentherapie. Es besteht hier bisher jedoch noch keinerlei Konsens zwischen den Beteiligten oder zumindest den Experten, wie Prozess- und Ergebnisqualität erfasst werden kann/soll. Dabei spielen sicherlich immer noch die Schulenstreitigkeiten eine bedeutsame Rolle, da auch innerhalb der Therapieschulen im Kinder- und Jugendlichentherapiebereich keine Einigkeit über Therapieerfolg und wie er zu messen sei, erreicht worden ist. In diesem Beitrag wird die gegenwärtige Diskussion zur Verbesserung der Prozess- und Ergebnisqualität in der Kinder- und Jugendlichenpsychotherapie kurz skizziert, es werden Schlussfolgerungen für künftige Bemühungen abgeleitet.

Triagem em saúde mental infantil

Este estudo foi conduzido para comparar os resultados de um procedimento grupal aberto e um procedimento individual estruturado para avaliação do comportamento da criança conforme o relato materno. Participaram deste estudo 29 mães que buscavam atendimento para seus filhos em uma unidade de saúde mental infanto-juvenil. As primeiras 15 mães que procuraram o serviço foram entrevistadas individualmente conforme um roteiro estruturado desenvolvido a partir do CBCL e depois foram entrevistadas em grupo, em formato aberto. As outras 14 mães participaram da entrevista grupal aberta e em seguida participaram da entrevista individual estruturada. Os resultados das entrevistas foram comparados tomando como referência as 67 categorias comportamentais identificadas a partir do roteiro individual e quatro variáveis contextuais relatadas nos dois procedimentos. Os resultados mostram que um número substancialmente maior de comportamentos-problema foi identificado através de entrevista individual estruturada do que através de entrevista grupal aberta realizada com os mesmos informantes. É possível que o uso de um roteiro estruturado em entrevistas grupais possa oferecer mais informações com otimização do tempo de avaliação.