Empirically tested psychotherapies for youth internalizing and externalizing problems and disorders

Parental Involvement in Adolescent Psychological Interventions: A Meta-analysis

Psychological interventions for adolescents have shown mixed efficacy, and including parents in interventions may be an important avenue to improve treatment outcomes. Evidence from meta-analyses examining the role of parents in interventions for youth is inconsistent and has typically combined findings for both children and adolescents together. No prior meta-analysis has examined the specific role of parents in adolescent interventions as compared with interventions focused solely on adolescents across several disorders. To address this gap, systematic literature reviews were conducted utilizing a combination of searches among keywords including (parent * OR family) AND (intervention OR therap * OR treatment OR prevent*) AND (adolescen*). Inclusion criteria were (1) a randomized controlled trial of an individual psychological intervention compared to the same intervention with a parental component, and (2) adolescents must have at least current symptoms or risk to be included. Literature searches identified 20 trials (N = 1251). Summary statistics suggested that interventions involving parents in treatment have a significantly greater impact on adolescent psychopathology when compared to interventions that targeted adolescents alone (g = - 0.18, p < .01, 95% CI [- 0.30, - 0.07]). Examination with symptom type (internalizing or externalizing) as a moderator found that the significant difference remained for externalizing (g = - 0.20, p = .01, 95% CI [- 0.35, - 0.05]) but not internalizing psychopathology (p = .11). Findings provide evidence of the importance of including parents in adolescent therapy, particularly for externalizing problems.

A systematic review of attention-deficit/hyperactivity disorder in people living with cystic fibrosis

There is a lack of research that has focused on attention-deficit hyperactivity disorder (ADHD) in people with cystic fibrosis (pwCF). Given ADHD is associated with executive functioning impairments, exploring ADHD in the context of living with cystic fibrosis (CF) is of great importance. The purpose of the current systematic review was to examine ADHD in pwCF across the lifespan in terms of its prevalence, its impact on various health outcomes, and treatments for managing ADHD. This systematic review followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Articles reporting studies of any design that focused on ADHD in pwCF were included. Studies were excluded if they did not meet this criterion and if they were written in languages other than English. PsycINFO, MEDLINE, EMBASE, and CINAHL databases were searched. Search items were based on three concepts: (1) terms related to CF, (2) terms related to ADHD, and (3) terms related to age. Ten studies were included in this systematic review. Reported prevalence rates of ADHD in pwCF ranged from 5.26% to 21.9%. The reported relationships between ADHD and CF and other health outcomes is inconsistent. In terms of treatment considerations, pharmacological interventions and behavioural strategies for managing ADHD in the context of living with CF have been reported as being successful. Additional research is needed to further explore ADHD in the CF population and health variables that may be associated with CF prognosis.

The Operations Triad Model and Youth Mental Health Assessments: Catalyzing a Paradigm Shift in Measurement Validation

Researchers strategically assess youth mental health by soliciting reports from multiple informants. Typically, these informants (e.g., parents, teachers, youth themselves) vary in the social contexts where they observe youth. Decades of research reveal that the most common data conditions produced with this approach consist of discrepancies across informants' reports (i.e., informant discrepancies). Researchers should arguably treat these informant discrepancies as domain-relevant information: data relevant to understanding youth mental health domains (e.g., anxiety, depression, aggression). Yet, historically, in youth mental health research as in many other research areas, one set of paradigms has guided interpretations of informant discrepancies: Converging Operations and the Multi-Trait Multi-Method Matrix (MTMM). These paradigms (a) emphasize shared or common variance observed in multivariate data, and (b) inspire research practices that treat unique variance (i.e., informant discrepancies) as measurement confounds, namely random error and/or rater biases. Several yearsw ago, the Operations Triad Model emerged to address a conceptual problem that Converging Operations does not address: Some informant discrepancies might reflect measurement confounds, whereas others reflect domain-relevant information. However, addressing this problem requires more than a conceptual paradigm shift beyond Converging Operations. This problem necessitates a paradigm shift in measurement validation. We advance a paradigm (Classifying Observations Necessitates Theory, Epistemology, and Testing [CONTEXT]) that addresses problems with using the MTMM in youth mental health research. CONTEXT optimizes measurement validity by guiding researchers to leverage (a) informants that produce domain-relevant informant discrepancies, (b) analytic procedures that retain domain-relevant informant discrepancies, and (c) study designs that facilitate detecting domain-relevant informant discrepancies.

A Second and Third Look at FIRST: Testing Adaptations of A Principle-Guided Youth Psychotherapy

Objective: We examined the acceptability, integrity, and symptom trajectories associated with FIRST, a principle-guided treatment for youth internalizing and externalizing problems designed to support efficient uptake and implementation.Method: We conducted two open trials of an adapted FIRST, focusing on uptake and implementation by novice trainees in a university-affiliated clinic, limiting treatment duration to six sessions, and benchmarking findings against a 2017 FIRST trial with community therapists. In Study 1, trainees received a two-day training and weekly two-hour supervision (N = 22 youths, ages 7-17, 50% female, 54.54% Caucasian, 4.55% Latinx). In Study 2, trainees received a one-day training and weekly one-hour supervision, delivering the six-session FIRST in a predetermined sequence (N = 26 youths, ages 11-17, 42.31% female, 65.38% Caucasian, 7.69% Latinx). In Study 3, the original study therapists - now practitioners - evaluated FIRST's effectiveness and implementation difficulty, and reported their own post-study FIRST use.Results: Acceptability (treatment completion, session attendance, caregiver participation) and integrity (adherence, competence) were comparable across Study 1, Study 2 and the 2017 trial. Improvement effect sizes across ten outcome measures were in the large range in all three trials: M ES = 1.10 in the 2017 trial, 0.83 in Study 1, and 0.81 in Study 2. Study 3 showed high effectiveness ratings, low difficulty ratings, and continued use of FIRST by a majority of clinicians.Conclusions: Across two open trials and a follow-up survey, FIRST showed evidence of acceptability and integrity, with youth symptom reduction comparable to that in prior research.

Locus of Control, Self-Control, and Gender as Predictors of Internalizing and Externalizing Problems in Children and Adolescents in Northern Chile

BACKGROUND

Both the control that people attribute to themselves over a situation (locus of control) and the control they attribute to themselves (self-control) have been proposed as aspects that can have an effect on internalizing problems in young people. There is little evidence of this relationship in the infantile-juvenile population in Latin America.

OBJECTIVE

To establish whether there is a significant predictive relationship of locus of control and self-control over internalizing and externalizing problems in the infantile-juvenile population, both at a general level and dimension-specific. These include depression, anxiety, social anxiety, somatic complaints, and post-traumatic stress.

METHODS

A cross-sectional-correlational study was carried out to establish if there was a possible predictive relationship in 3,664 schoolchildren of both primary (4th-6th grade) and secondary (7th-12th grade) in northern Chile, using the short version of the Nowicki-Strickland scale to measure locus of control, the Tangney scale to measure self-control, and the Child and Adolescent Evaluation System (SENA) to measure the dimensions of internalized problems.

HYPOTHESES

(1) Greater self-control is associated with lower levels of internalizing and externalizing problems. (2) Higher external locus of control is associated with higher levels of internalizing and externalizing problems. (3) Self-control, locus of control, and gender can together significantly predict each of the internalizing and externalizing problems.

RESULTS

Evidence is found to support the first two hypotheses fully and partially support the third, since gender did not function as a predictor in all models.

CONCLUSION

The results confirm previous international research in that both locus of control and self-control appear to have a significant influence on internalizing and externalizing problems. Implications for mental health promotion in this population are discussed.

Development of 'learn to dare!': An online assessment and intervention platform for anxious children

BACKGROUND

Many children and adolescents suffer from problematic levels of anxiety, but the multitude of these children do not receive an intervention. It is of importance to increase the accessibility and availability of child anxiety interventions, as to identify and treat anxious children early and successfully. Online platforms that include information, assessments and intervention can contribute to this goal. Interventions for child anxiety are frequently based on Cognitive Behavioral Therapy, because of its strong theoretical and empirical basis. However, the working mechanisms of Cognitive Behavioral Therapy in children are poorly studied. To our knowledge, mediation studies on child anxiety are non-existent regarding online Cognitive Behavioral Therapy.

METHODS

We will aim at children aged 8-13 years with problematic anxiety. We recruit these children via the community setting, and refer them to our online platform 'Learn to Dare!' (in Dutch: 'Leer te Durven!'), https://leertedurven.ou.nl, where information about child anxiety and our research is freely accessible. After an active informed consent procedure, the participants can access the screening procedure, which will select the children with problematic anxiety levels. Thereafter, these children will be randomized to an online intervention based on Cognitive Behavioral Therapy (n = 120) or to a waitlist control (WL, n = 120). The intervention consists of 8 sessions with minimal therapist support and contains psycho-education, exposure (based on inhibitory learning), cognitive restructuring and relapse prevention. Child anxiety symptoms and diagnoses, cognitions, avoidance behavior and level of abstract reasoning are measured. Assessments are the same for both groups and are performed before and after the proposed working mechanisms are offered during the intervention. A follow-up assessment takes place 3 months after the final session, after which children in the waitlist control group are offered to take part in the intervention.

DISCUSSION

This protocol paper describes the development of the online platform 'Learn to Dare!', which includes information about child anxiety, the screening procedure, anxiety assessments, and the online intervention. We describe the development of the online intervention. Offering easy accessible interventions and providing insight into the working mechanisms of Cognitive Behavioral Therapy contributes to optimizing Cognitive Behavioral Therapy for anxious youth.

Agency Leaders' Assessments of Feasibility and Desirability of Implementation of Evidence-Based Practices in Youth-Serving Organizations Using the Stages of Implementation Completion

Background: This study examined influences on the decisions of administrators of youth-serving organizations to initiate and proceed with implementation of an evidence-based practice (EBP).

Methods: Semi-structured interviews, developed using the Stages of Implementation Completion (SIC) as a framework, were conducted with 19 agency chief executive officers and program directors of 15 organizations serving children and adolescents.

Results: Agency leaders' self-assessments of implementation feasibility and desirability prior to implementation (Pre-implementation) were influenced by intervention affordability, feasibility, requirements, validity, reliability, relevance, cost savings, positive outcomes, and adequacy of information; availability of funding, support from sources external to the agency, and adequacy of technical assistance; and staff availability and attitudes toward innovation in general and EBPs in particular, organizational capacity, fit between the EBP and agency mission and capacity, prior experience with implementation, experience with seeking evidence, and developing consensus. Assessments during the Implementation phase included intervention flexibility and requirements; availability of funding, adequacy of training and technical assistance, and getting sufficient and appropriate referrals; and staffing and implementing with fidelity. Assessments during the Sustainment phase included intervention costs and benefits; availability of funding, support from sources outside of the agency, and need for the EBP; and the fit between the EBP and the agency mission.

Discussion: The results point to opportunities for using agency leader models to develop strategies to facilitate implementation of evidence-based and innovative practices for children and adolescents. The SIC provides a standardized framework for guiding agency leader self-assessments of implementation.

The Effectiveness of Psychosocial Interventions Delivered by Teachers in Schools: A Systematic Review and Meta-Analysis

The growing mental health needs of students within schools have resulted in teachers increasing their involvement in the delivery of school-based, psychosocial interventions. Current research reports mixed findings concerning the effectiveness of psychosocial interventions delivered by teachers for mental health outcomes. This article presents a systematic review and meta-analysis that examined the effectiveness of school-based psychosocial interventions delivered by teachers on internalizing and externalizing outcomes and the moderating factors that influence treatment effects on these outcomes. Nine electronic databases, major journals, and gray literature (e.g., websites, conference abstract) were searched and field experts were contacted to locate additional studies. Twenty-four studies that met the study inclusion criteria were coded into internalizing or externalizing outcomes and further analyzed using robust variance estimation in meta-regression. Both publication and risk of bias of studies were further assessed. The results showed statistically significant reductions in students' internalizing outcomes (d = .133, 95% CI [.002, .263]) and no statistical significant effect for externalizing outcomes (d = .15, 95% CI [-.037, .066]). Moderator analysis with meta-regression revealed that gender (%male, b = -.017, p < .05), race (% Caucasian, b = .002, p < .05), and the tier of intervention (b = .299, p = .06) affected intervention effectiveness. This study builds on existing literature that shows that teacher-delivered Tier 1 interventions are effective interventions but also adds to this literature by showing that interventions are more effective with internalizing outcomes than on the externalizing outcomes. Moderator analysis also revealed treatments were more effective with female students for internalizing outcomes and more effective with Caucasian students for externalizing outcomes.

Knowledge, Attitudes, Social Desirability, and Organizational Characteristics in Youth Mental Health Services

This project investigated the extent to which knowledge of evidence-based practices (EBPs) and organizational characteristics predicted attitudes toward EBPs, while controlling for social desirability and organization membership. Participants were 167 public sector youth practitioners. Hierarchical multiple regression analyses were conducted to determine which factors significantly predicted EBP attitudes. Findings suggested that social desirability, organization membership, and various organizational characteristics predicted EBP attitudes. Results are discussed as they relate to the importance of including social desirability in future research and identifying different factors that influence EBP attitudes across various organizations.

Socio-contextual Determinants of Research Evidence Use in Public-Youth Systems of Care

Recent efforts have been devoted to understanding the conditions by which research evidence use (REU) is facilitated from the perspective of system leaders in the context of implementing evidence-based child mental health interventions. However, we have limited understanding of the extent to which outer contextual factors influence REU. Outer contextual factors for 37 counties in California were gathered from public records in 2008; and child welfare, juvenile justice, and mental health system leaders' perceptions of their REU were measured via a web-based survey from 2010 to 2012. Results showed that leaders with higher educational attainment and in counties with lower expenditures on inpatient mental health services were significantly associated with higher REU. Positive relationships between gathering research evidence and racial minority concentration and poverty at the county level were also detected. Results underscore the need to identify the organizational and socio-political factors by which mental health services and resources meet client demands that influence REU, and to recruit and retain providers with a graduate degree to negotiate work demands and interpret research evidence.

An update on interventions for conduct disorder

Childhood conduct disorder casts a long shadow over adulthood, often leading to antisocial personality, drug misuse, increased rates of psychosis and earlier death. This article reviews a range of effective treatments, and shows what is ineffective. The common theme underlying interventions that work is that they change the environment around the young person, with parent training emerging as the most effective. Medication is largely ineffective. The task now is to enable more of these interventions to be available at a reasonably early age.

Therapist Training on Cognitive Behavior Therapy for Anxiety Disorders Using Internet-Based Technologies

This study investigated a technology-enhanced training protocol to facilitate dissemination of therapist training on cognitive behavior therapy (CBT) for anxiety disorders. Seventy community clinicians received an online tutorial followed by live remote observation of clinical skills via videoconference. Impact of training on patient outcomes was also assessed. Training resulted in a significant increase in both trainee knowledge of CBT concepts and techniques and therapist competence in applying these skills. Patients treated by trainees following training had significant reductions in anxiety and depression. Ratings of user satisfaction were high. Results provide support for the use of these technologies for therapist training in CBT.

Adoption of innovative and evidence-based practices for children and adolescents in state-supported mental health clinics: a qualitative study

Background

This study examined how mental health clinic administrators decided whether or not to adopt evidence-based and other innovative practices by exploring their views of implementation barriers and facilitators and operation of these views in assessment of implementation costs and benefits.

Methods

Semi-structured interviews were conducted with 75 agency chief executive officers and program directors of 34 New York State-licensed mental health clinics serving children and adolescents.

Results

Three interconnected themes relating to barriers and facilitators were identified, namely costs and benefits associated with adoption, capacity for adoption, and acceptability of new practices. The highest percentage of participants (86.7%) mentioned costs as a barrier, followed by limited capacity (55.9%) and lack of acceptability (52.9%). The highest percentage (82.3%) of participants identified available capacity as a facilitator, followed by acceptability (41.2%) and benefits or limited costs (24.0%). Assessment of costs and benefits exhibited several principles of behavioural economics, including loss aversion, temporal discounting use of heuristics, sensitivity to monetary incentives, decision fatigue, framing, and environmental influences.

Conclusions

The results point to opportunities for using agency leader models to develop strategies to facilitate implementation of evidence-based and innovative practices for children and adolescents.

Cascading effects of BPT for child internalizing problems and caregiver depression

Behavioral Parent Training (BPT) is the standard of care for early onset (3 to 8years old) disruptive behavior disorders (DBDs). Preliminary evidence suggests that BPT may also produce cascading treatment effects for comorbid and interrelated symptomatology in children, primarily internalizing problems, as well as symptomatology in multiple systems of the family, including caregiver depressive symptomatology. What is less well understood, however, is why and how BPT functions to impact these multiple symptom clusters within and between family members. Accordingly, this manuscript aims to serve as a conceptual and theoretical consideration of the mechanisms through which BPT may produce generalized treatment effects among children with early onset DBDs and internalizing problems, as well as the psychosocial difficulties among their caregivers. It is our intention that the hypothesized mechanisms highlighted in this review may guide advances in clinical research, as well as assessment and practice.

Measuring Use of Research Evidence: The Structured Interview for Evidence Use

OBJECTIVES

This article describes the Standard Interview for Evidence Use (SIEU), a measure to assess the level of engagement in acquiring, evaluating, and applying research evidence in health and social service settings.

METHOD

Three scales measuring input, process, and output of research evidence and eight subscales were identified using principal axis factor analysis and parallel analysis of data collected from 202 state and county child welfare, mental health, and juvenile justice systems leaders.

RESULTS

The SIEU scales and subscales demonstrate strong internal consistency as well as convergent and discriminant validity.

CONCLUSIONS

The SIEU is easy to use and can be administered as a complete scale or as three smaller scales to separately examine evidence in acquisition, evaluation, or application. The measure demonstrates potential in understanding the role of research evidence in service settings and in monitoring the process of evidence-based practice and application of scientific principles in social work practice.

Behavioral, Social, and Emotional Symptom Comorbidities and Profiles in Adolescent Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study

PURPOSE

In the general population, psychological symptoms frequently co-occur; however, profiles of symptom comorbidities have not been examined among adolescent survivors of childhood cancer.

PATIENTS AND METHODS

Parents of 3,893 5-year survivors of childhood cancer who were treated between 1970 and 1999 and who were assessed in adolescence (age 12 to 17 years) completed the Behavior Problems Index. Age- and sex-standardized z scores were calculated for symptom domains by using the Childhood Cancer Survivor Study sibling cohort. Latent profile analysis identified profiles of comorbid symptoms, and multivariable multinomial logistic regression modeling examined associations between cancer treatment exposures and physical late effects and identified symptom profiles. Odds ratios (ORs) and 95% CIs for latent class membership were estimated and analyses were stratified by cranial radiation therapy (CRT; CRT or no CRT).

RESULTS

Four symptoms profiles were identified: no significant symptoms (CRT, 63%; no CRT, 70%); elevated anxiety and/or depression, social withdrawal, and attention problems (internalizing; CRT, 31%; no CRT, 16%); elevated headstrong behavior and attention problems (externalizing; CRT, no observed; no CRT, 9%); and elevated internalizing and externalizing symptoms (global symptoms; CRT, 6%; no CRT, 5%). Treatment with ≥ 30 Gy CRT conferred greater risk of internalizing (OR, 1.7; 95% CI, 1.0 to 2.8) and global symptoms (OR, 3.2; 95% CI, 1.2 to 8.4). Among the no CRT group, corticosteroid treatment was associated with externalizing symptoms (OR, 1.9; 95% CI, 1.2 to 2.8) and ≥ 4.3 g/m(2) intravenous methotrexate exposure was associated with global symptoms (OR, 1.5; 95% CI, 0.9 to 2.4). Treatment late effects, including obesity, cancer-related pain, and sensory impairments, were significantly associated with increased risk of comorbid symptoms.

CONCLUSION

Behavioral, emotional, and social symptoms frequently co-occur in adolescent survivors of childhood cancer and are associated with treatment exposures and physical late effects. Assessment and consideration of symptom profiles are essential for directing appropriate mental health treatment for adolescent survivors.

The Relationship Between the Level of Program Integrity and Pre- and Post-Test Changes of Responsive-Aggression Regulation Therapy (Re-ART) Outpatient: A Pilot Study

Responsive-Aggression Regulation Therapy (Re-ART) Outpatient is a cognitive behavioral-based intervention for adolescents and young adults (16-24 years) with severe aggressive behavioral problems. This pilot study (N = 26) examined the level of program integrity (PI; that is, the delivery of the intervention as it is originally intended) of Re-ART. We also investigated the pre- and post-test changes in several outcome variables, and the relation between the level of PI and these changes. Participants were recruited from three different outpatient forensic settings. Results showed that the PI of half of the treatments was not sufficient (e.g., the intensity of the program was too low and some standard modules were not offered). In addition, this pilot study demonstrated that sufficient PI was related to positive changes in aggression, cognitive distortions, social support, coping (reported by therapist), and distrust (responsiveness to treatment).

Pathways to service receipt: modeling parent help-seeking for childhood mental health problems

Understanding parent appraisals of child behavior problems and parental help-seeking can reduce unmet mental health needs. Research has examined individual contributors to help-seeking and service receipt, but use of structural equation modeling (SEM) is rare. SEM was used to examine parents' appraisal of child behavior, thoughts about seeking help, and receipt of professional services in a diverse, urban sample (N = 189) recruited from women infant and children offices. Parents of children 11-60 months completed questionnaires about child behavior and development, parent well-being, help-seeking experiences, and service receipt. Child internalizing, externalizing, and dysregulation problems, language delay, and parent worry about child behavior loaded onto parent appraisal of child behavior. Parent stress and depression were positively associated with parent appraisal (and help-seeking). Parent appraisal and help-seeking were similar across child sex and age. In a final model, parent appraisals were significantly associated with parent thoughts about seeking help, which was significantly associated with service receipt.

Modular Approach to Therapy for Anxiety, Depression, Trauma, or Conduct Problems in outpatient child and adolescent mental health services in New Zealand: study protocol for a randomized controlled trial

BACKGROUND

Mental health disorders are common and disabling for young people because of the potential to disrupt key developmental tasks. Implementation of evidence-based psychosocial therapies in New Zealand is limited, owing to the inaccessibility, length, and cost of training in these therapies. Furthermore, most therapies address one problem area at a time, although comorbidity and changing clinical needs commonly occur in practice. A more flexible approach is needed. The Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH-ADTC) is designed to overcome these challenges; it provides a range of treatment modules addressing different problems, within a single training program. A clinical trial of MATCH-ADTC in the USA showed that MATCH-ADTC outperformed usual care and standard evidence-based treatment on several clinical measures. We aim to replicate these findings and evaluate the impact of providing training and supervision in MATCH-ADTC to: (1) improve clinical outcomes for youth attending mental health services; (2) increase the amount of evidence-based therapy content; (3) increase the efficiency of service delivery.

METHODS

This is an assessor-blinded multi-site effectiveness randomized controlled trial. Randomization occurs at two levels: (1) clinicians (≥60) are randomized to intervention or usual care; (2) youth participants (7-14 years old) accepted for treatment in child and adolescent mental health services (with a primary disorder that includes anxiety, depression, trauma-related symptoms, or disruptive behavior) are randomly allocated to receive MATCH-ADTC or usual care. Youth participants are recruited from 'mainstream', Māori-specific, and Pacific-specific child and adolescent mental health services. We originally planned to recruit 400 youth participants, but this has been revised to 200 participants. Centralized computer randomization ensures allocation concealment. The primary outcome measures are: (i) the difference in trajectory of change of clinical severity between groups (using the parent-rated Brief Problem Monitor); (ii) clinicians' use of evidence-based treatment procedures during therapy sessions; (iii) total time spent by clinicians delivering therapy.

DISCUSSION

If MATCH-ADTC demonstrates effectiveness it could offer a practical efficient method to increase access to evidence-based therapies, and improve outcomes for youth attending secondary care services.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12614000297628 .

Review: Comprehensive treatments for youth comorbidity - evidence-guided approaches to a complicated problem

BACKGROUND

Evidence-based treatments (EBTs) with a single-disorder focus have improved the potential for youth mental health care, yet may be an imperfect fit to clinical care settings where diagnostic comorbidity and co-occurring problems are commonplace. Most EBTs were developed to treat one diagnosis or problem (or a small homogenous cluster), but most clinically referred youths present with multiple disorders and problems.

FINDINGS

Three emerging approaches may help address the comorbidity that is so common in treated youths. Conceptually unified treatments target presumed causal and maintaining factors that are shared among more than one disorder or problem area; preliminary open trials and case studies show promising results. Modular protocols combine the 'practice elements' that commonly appear in separate single-disorder EBTs and repackage them into coordinated delivery systems; one modular protocol, MATCH, has produced positive findings in a randomized effectiveness trial. Monitoring and Feedback Systems (MFSs) provide real-time data on client progress to inform clinical decision-making, encompassing comorbid and co-occurring problems; one study shows beneficial effects in everyday practice with diverse youth problems.

CONCLUSIONS

All three approaches - conceptually unified, modular, and MFS - can be strengthened by increased research attention to treatment integrity, clinician user-appeal, design simplicity, and the infrastructure necessary for successful implementation.

Meeting the complex needs of urban youth and their families through the 4Rs 2Ss Family Strengthening Program: The "real world" meets evidence-informed care

Youth living in poverty face compounding familial and environmental challenges in utilizing effective community mental health services. They have ongoing stressors that increase their dropout rate in mental health service use. Difficulties also exist in staying engaged in services when they are involved with the child welfare system. This study examines the 4Rs 2Ss Family Strengthening Program, developed across four broad conceptual categories related to parenting skills and family processes that form a multiple family group service delivery approach. A total of 321 families were enrolled in this randomized intervention study, assigned to either the 4Rs 2Ss Family Strengthening Program or standard care services. Caregivers and their children randomly assigned to the experimental condition received a 16 week multiple family group intervention through their respective outpatient community mental health clinic. Data was collected at baseline, midtest (8 weeks), posttest (16 weeks), and 6 month follow-up. Major findings include high engagement in the 4Rs 2Ss Family Strengthening Program, compared to standard services. Although child welfare status is not related to attendance, family stress and parental depression are also related to participant engagement in this multiple family group intervention. Involvement in the 4Rs 2Ss Family Strengthening Program resulted in improved effects for child behaviors. Lastly, no evidence of moderation effects on family stress, child welfare involvement, or parental needs were found. The 4Rs 2Ss Family Strengthening Program appeared able to engage families with more complex "real world" needs.

Internet-assisted delivery of cognitive behavioural therapy (CBT) for childhood anxiety: systematic review and meta-analysis

AIM

To conduct a systematic review and meta-analysis of the literature to assess efficacy of internet-delivered cognitive behavioural therapy (CBT) for child anxiety disorder.

METHOD

A systematic search of 7 electronic databases was conducted to assess CBT intervention for children with anxiety problems with remote delivery either entirely or partly via technology. Six articles reporting 7 studies were included.

RESULTS

The findings together suggested that CBT programmes involving computerised elements were well received by children and their families, and its efficacy was almost as favourable as clinic-based CBT. The mixture of children and adolescents included the studies, diverse range of programmes, and lack of consistency between study designs made it difficult to identify key elements of these programmes or draw conclusions on the treatment efficacy.

CONCLUSIONS

Analysis supports online delivery for wider access of this evidence-based therapy. Areas in need of improvement for this new method are indicated.

A pilot study of a school-based prevention and early intervention program to reduce oppositional defiant disorder/conduct disorder

Oppositional defiant disorder (ODD) or conduct disorder (CD) occurs when children's disruptive and antisocial behaviours start to interfere with their academic, emotional and/or social development. Recently, there has been a considerable investment to implement national school-based early intervention programs to help prevent the onset of ODD/CD.

AIM

This paper describes the delivery of the Royal Children's Hospital, Child and Adolescent Mental Health Service and Schools Early Action Program: a whole school, multi-level, multidisciplinary approach to address emerging ODD/CD and pre- versus post-delivery assessment in 40 schools over a 4-year period (2007-2010).

METHODS

All children from preparatory to grade 3 (ages 4-10 years) were screened for conduct problems (n = 8546) using the Strengths and Difficulties Questionnaire. Universal, targeted and indicated interventions were delivered in school settings. In total, 304 children participated in the targeted group program where the Child Behaviour Checklist was used as a pre- and post-intervention measure. Cohen's d effect sizes and a reliability change index were calculated to determine clinical significance.

RESULTS

Significant reductions in both parent- and teacher-reported internalizing and externalizing symptoms were noted. Parent, teacher and child feedback were very positive.

CONCLUSIONS

A future randomized controlled trial of the program would address potential placebo and selection bias effects.

Do evidence-based interventions work when tested in the "real world?" A systematic review and meta-analysis of parent management training for the treatment of child disruptive behavior

Evidence-based interventions are often unavailable in everyday clinical settings. This may partly reflect practitioners' assumptions that research evidence does not reflect "real-world" conditions. To examine this further, we systematically assessed the clinical effectiveness of parent management training (PMT) for the treatment of child disruptive behavior across different real-world practice contexts. We identified 28 relevant randomized controlled trials from a systematic search of electronic bibliographic databases and conducted a meta-analysis of child outcomes across trials. Planned subgroup analyses involved comparisons between studies grouped according to individual real-world practice criteria and total real-world practice criteria scores, reflecting the extent to which PMT was delivered by non-specialist therapists, to a clinic-referred population, in a routine setting, and as part of a routine service. Meta-analysis revealed a significant overall advantage for PMT compared with waitlist control conditions. Subgroup analyses did not demonstrate significant differences in effect size estimates according to the total number of real-world practice criteria met by studies. Moreover, no consistent relationships were found between specific practice criteria and effect size estimates. In conclusion, PMT appears to be an effective treatment for children with disruptive behavior problems. There was no clear evidence that conducting PMT in real-world practice contexts is a deterrent to achieving effective child behavior outcomes, although relative advantage to "usual care" was not directly examined and the power of the analysis was limited as a result of significant heterogeneity. More research is needed to investigate whether this finding is generalizable to other psychological interventions. Suggestions are also made for developing more differentiated criteria to assist with evaluating the specific applicability of research evidence to different care providers.

Statewide implementation of the 4 Rs and 2 Ss for strengthening families

Embedding evidence-informed practices for children with mental health needs into "real-world" community settings has proven challenging. In this article, we discuss how the Practical, Robust, Implementation, and Sustainability Model (PRISM) guided statewide (New York) implementation of an evidence-informed intervention targeting families and youth with oppositional defiant and conduct disorders, collectively referred to as disruptive behavior disorders. Additionally, we present qualitative findings based on provider reports of integrating a novel, evidence-informed intervention within their respective community mental health settings. Finally, we discuss a process of modifying the intervention to address agency-level factors, as well as inform more widespread implementation efforts.

Future directions in the design, development, and investigation of technology as a service delivery vehicle

Treatment outcome research with children and adolescents has progressed to such an extent that numerous handbooks have been devoted to reviewing and summarizing the evidence base. Ensuring that consumers of these advancements in state-of-the-field interventions have the opportunity to access, engage in, and benefit from this evidence base, however, has been wrought with challenge. As such, much discussion exists about innovative strategies for overcoming the gap between research and practice; yet no other potential solution that has received more attention in both the popular and academic press than technology. The promise of technology is not surprising given the fast-paced evolution in development and, in turn, a seemingly endless range of possibilities for novel service delivery platforms. Yet this is precisely the most formidable challenge threatening to upset the very promise of this potential solution: The rate of emerging technologies is far outpacing the field's capacity to demonstrate the conceptual or empirical benefits of such an approach. Accordingly, this article aims to provide a series of recommendations that better situate empirical enquiry at the core of a collaborative development, testing, and deployment process that must define this line of work if the promise of mental health technologies is going to be a reality for front-line clinicians and the clients they serve.

Engineering youth service system infrastructure: Hawaii's continued efforts at large-scale implementation through knowledge management strategies

Hawaii's Child and Adolescent Mental Health Division provides a unique illustration of a youth public mental health system with a long and successful history of large-scale quality improvement initiatives. Many advances are linked to flexibly organizing and applying knowledge gained from the scientific literature and move beyond installing a limited number of brand-named treatment approaches that might be directly relevant only to a small handful of system youth. This article takes a knowledge-to-action perspective and outlines five knowledge management strategies currently under way in Hawaii. Each strategy represents one component of a larger coordinated effort at engineering a service system focused on delivering both brand-named treatment approaches and complimentary strategies informed by the evidence base. The five knowledge management examples are (a) a set of modular-based professional training activities for currently practicing therapists, (b) an outreach initiative for supporting youth evidence-based practices training at Hawaii's mental health-related professional programs, (c) an effort to increase consumer knowledge of and demand for youth evidence-based practices, (d) a practice and progress agency performance feedback system, and (e) a sampling of system-level research studies focused on understanding treatment as usual. We end by outlining a small set of lessons learned and a longer term vision for embedding these efforts into the system's infrastructure.

Prevention and early intervention for borderline personality disorder: current status and recent evidence

Borderline personality disorder (BPD) is a leading candidate for developing empirically based prevention and early intervention programmes because it is common in clinical practice, it is among the most functionally disabling of all mental disorders, it is often associated with help-seeking, and it has been shown to respond to intervention, even in those with established disorder. Moreover, it can be reliably diagnosed in its early stages and it demarcates a group with high levels of current and future morbidity and mortality. Data also suggest considerable flexibility and malleability of BPD traits in youth, making this a key developmental period during which to intervene. Novel indicated prevention and early intervention programmes have shown that BPD in young people responds to intervention. Further work is required to develop appropriate universal and selective preventive interventions.

Predictors and moderators of outcome in child and adolescent anxiety and depression: a systematic review of psychological treatment studies

The aim of this literature review was to examine pre-treatment child and adolescent characteristics as predictors and moderators of outcome in psychotherapy treatment trials of anxiety and depressive disorders. A literature search was conducted using several databases and resulted in 45 published studies (32 anxiety studies and 13 depression studies) meeting predefined methodological criteria. Ten client demographic (age, gender, ethnicity, IQ) and clinical factors (duration, type of diagnosis, pre-treatment severity, comorbidity) were examined across studies. The majority of findings showed non-significant associations between demographic factors (gender and age) with treatment outcome for both the anxiety and the depression treatment trials. Some important differences between the results of the anxiety and depression treatment trials were found. The majority of findings for the anxiety studies suggest that there are no demographic or clinical factors that predict or moderate treatment outcome. For the depression studies, however, the findings suggest that baseline symptom severity and comorbid anxiety may impact on treatment response. Overall, existing studies of pre-treatment patient variables as predictors and moderators of anxiety and depression treatment outcome provide little consistent knowledge concerning for what type of patients and under what conditions treatments work. Suggestions for future research are discussed.

Peer problems mediate the relationship between developmental coordination disorder and behavioral problems in school-aged children

The aim of this study was to gain insights into the relationship between developmental coordination disorder, peer problems, and behavioral problems in school-aged children where both internalizing and externalizing behavioral problems were considered. We assumed that the relationship between developmental coordination disorder and internalizing/externalizing problems in school-aged children is mediated by peer problems and tested the hypothesis that a greater degree of motor impairment causes a greater degree of peer problems and thus a greater degree of internalizing or externalizing problems. Seventy boys and girls aged between 5 and 11 years were examined using the Movement Assessment Battery for Children 2 and the Intelligence and Developmental Scales. The results of path analysis showed that the relationship between developmental coordination disorder and internalizing/externalizing problems in school-aged children is mediated at least in part by peer problems. However, the cross-sectional design of the study does not provide conclusive evidence for a cause-effect relationship and only allows for the conservative prognosis that a greater degree of motor impairment may cause a greater degree of peer problems and thus a greater degree of internalizing/externalizing problems. Nevertheless, the results of this study emphasize the importance of being well-integrated in their peer group especially for children with developmental coordination disorder.

The relationships of child and parent factors with children's anxiety symptoms: parental anxious rearing as a mediator

A considerable body of research has identified various child and parent factors that contribute to and maintain anxiety symptoms in children. Yet relatively few studies have examined child factors (including threat-based cognitive bias, neuroticism, gender, puberty and age) as well as parent factors (including maternal anxiety and child-rearing style) in association with child anxiety symptoms, and the extent to which these factors serve as unique predictors of child anxiety. Moreover, research is lacking on whether parent factors such as child-rearing style, which is often targeted in early intervention and treatment programs, might mediate the association between child factors such as neuroticism, and child anxiety symptoms. In a sample of 85 children between 7 and 12 years of age with varying levels of anxiety, including those with diagnosed anxiety disorders, results showed that children were more anxious when they were reported to be more advanced in pubertal status by their parents, when they had a tendency to interpret more threat in ambiguous situations, and when they self-reported more neuroticism. Regarding parent factors, maternal self-reported trait anxiety and children's perceptions of their mother as having an anxious child-rearing style were associated with higher levels of child anxiety. Moreover, when these correlates of child anxiety were examined in a multivariate model to identify those that had direct as well as indirect associations via maternal anxious child-rearing style, child neuroticism remained as a significant and unique predictor of child anxiety that was also mediated by maternal anxious-rearing. Child neuroticism also mediated the relationship between child pubertal stage and anxiety symptoms. Results are discussed in terms of relevant theory and empirical evidence regarding the roles of both child and parent factors in the development of child anxiety.

Practice Parameter for psychodynamic psychotherapy with children

This Practice Parameter describes the principles of psychodynamic psychotherapy with children and is based on clinical consensus and available research evidence. It presents guidelines for the practice of child psychodynamic psychotherapy, including indications and contraindications, the setting, verbal and interactive (play) techniques, work with the parents, and criteria for termination.

Effects of workshop trainings on evidence-based practice knowledge and attitudes among youth community mental health providers

Enhancing the public health impact of evidence-based practices (EBPs) in usual care settings is a key priority of the National Institute of Mental Health. Longitudinal data from community mental health providers (N = 268) participating in a series of state-sponsored workshops in modular approaches to EBPs for youth are presented. EBP workshop attendance for youth anxiety resulted in increased knowledge for EBPs for anxiety (and not other conditions) and EBP workshop attendance for youth disruptive behaviors resulted in increased knowledge for EBPs for disruptive behaviors (and not other conditions). Providers' tendencies toward incorrectly classifying non-EBP therapies as evidence-based increased over time, suggesting that providers over-generalize the EBP label as a result of attending these types of workshops. Regarding EBP attitudes, most measures of attitudes improved when providers attended a workshop. Additionally, an overly inclusive view of what constitutes an EBP at intake was related to significant decreases in openness to trying EBPs over time, whereas more positive attitudes at intake was related to achieving a more refined view of what constitutes an EBP over the course of attending trainings. Study limitations and implications for implementation of EBPs in usual care settings are discussed.

Improvement in symptoms versus functioning: how do our best treatments measure up?

We examined the effects of redefining standards of evidence for treatments targeting childhood mental health problems by expanding outcomes beyond symptom reduction to include functioning. Over 750 treatment protocols from 435 randomized controlled trials were rated based on empirical evidence. Nearly two-thirds (63.9%) demonstrated at least a minimum level of evidence for reducing symptoms; however, only 18.8% of treatments demonstrated evidence for reducing functional impairment. Of those treatments with empirical support for symptom reduction, the majority did not demonstrate empirical support for improvement in functioning because measures of functioning were not included in the studies in which these treatments were tested. However, even when measures of functioning were included, it was much more difficult for treatments to achieve improvement. Among treatments that achieved improvement in functioning, the most notable were Collaborative Problem Solving for disruptive behavior and Cognitive Behavioral Therapy plus Medication for traumatic stress because they demonstrated no support for symptom reduction but good support for improvement in functioning. Results are discussed within the context of evaluating the standards of evidence for treatments and the opportunity to move towards a multidimensional framework whose utility has the potential to exceed the sum of its parts.

Social networks and implementation of evidence-based practices in public youth-serving systems: a mixed-methods study

Background

The present study examines the structure and operation of social networks of information and advice and their role in making decisions as to whether to adopt new evidence-based practices (EBPs) among agency directors and other program professionals in 12 California counties participating in a large randomized controlled trial.

Methods

Interviews were conducted with 38 directors, assistant directors, and program managers of county probation, mental health, and child welfare departments. Grounded-theory analytic methods were used to identify themes related to EBP adoption and network influences. A web-based survey collected additional quantitative information on members of information and advice networks of study participants. A mixed-methods approach to data analysis was used to create a sociometric data set (n = 176) for examination of associations between advice seeking and network structure.

Results

Systems leaders develop and maintain networks of information and advice based on roles, responsibility, geography, and friendship ties. Networks expose leaders to information about EBPs and opportunities to adopt EBPs; they also influence decisions to adopt EBPs. Individuals in counties at the same stage of implementation accounted for 83% of all network ties. Networks in counties that decided not to implement a specific EBP had no extra-county ties. Implementation of EBPs at the two-year follow-up was associated with the size of county, urban versus rural counties, and in-degree centrality. Collaboration was viewed as critical to implementing EBPs, especially in small, rural counties where agencies have limited resources on their own.

Conclusions

Successful implementation of EBPs requires consideration and utilization of existing social networks of high-status systems leaders that often cut across service organizations and their geographic jurisdictions.

Trial Registration

NCT00880126

Patients' contexts and their effects on clinicians' impressions of conduct disorder symptoms

The purpose of this study was to examine whether contextual information about patients' clinical presentations affected clinicians' judgments of conduct disorder symptoms. Forty-five clinicians read vignettes describing hypothetical patients who displayed one conduct disorder symptom alongside information about the patients' home, school, and peer contexts. Clinicians judged the likelihood of patients meeting conduct disorder criteria. Contextual information highly affected judgments and these effects varied across the 15 conduct disorder symptoms. It is important to note that clinical judgments were not in agreement on the symptoms affected by context.