Effects of multidimensional treatment foster care on psychotic symptoms in girls

Exploring causal mechanisms of psychosis risk

Robust epidemiological evidence of risk and protective factors for psychosis is essential to inform preventive interventions. Previous evidence syntheses have classified these risk and protective factors according to their strength of association with psychosis. In this critical review we appraise the distinct and overlapping mechanisms of 25 key environmental risk factors for psychosis, and link these to mechanistic pathways that may contribute to neurochemical alterations hypothesised to underlie psychotic symptoms. We then discuss the implications of our findings for future research, specifically considering interactions between factors, exploring universal and subgroup-specific factors, improving understanding of temporality and risk dynamics, standardising operationalisation and measurement of risk and protective factors, and developing preventive interventions targeting risk and protective factors.

Psychosis Symptom Trajectories Across Childhood and Adolescence in Three Longitudinal Studies: An Integrative Data Analysis with Mixture Modeling

Psychotic-like experiences (PLEs) are common throughout childhood, and the presence of these experiences is a significant risk factor for poor mental health later in development. Given the association of PLEs with a broad number of mental health diagnoses, these experiences serve as an important malleable target for early preventive interventions. However, little is known about these experiences across childhood. While these experiences may be common, longitudinal measurement in non-clinical settings is not. Therefore, in order to explore longitudinal trajectories of PLEs in childhood, we harmonized three school-based randomized control trials with longitudinal follow-up to identify heterogeneity in trajectories of these experiences. In an integrative data analysis (IDA) using growth mixture modeling, we identified three latent trajectory classes. One trajectory class was characterized by persistent PLEs, one was characterized by high initial probabilities but improving across the analytic period, and one was characterized by no reports of PLEs. Compared to the class without PLEs, those in the improving class were more likely to be male and have higher levels of aggressive and disruptive behavior at baseline. In addition to the substantive impact this work has on PLE research, we also discuss the methodological innovation as it relates to IDA. This IDA demonstrates the complexity of pooling data across multiple studies to estimate longitudinal mixture models.

From Womb to Neighborhood: A Racial Analysis of Social Determinants of Psychosis in the United States

The authors examine U.S.-based evidence that connects characteristics of the social environment with outcomes across the psychosis continuum, from psychotic experiences to schizophrenia. The notion that inequitable social and economic systems of society significantly influence psychosis risk through proxies, such as racial minority and immigrant statuses, has been studied more extensively in European countries. While there are existing international reviews of social determinants of psychosis, none to the authors' knowledge focus on factors in the U.S. context specifically-an omission that leaves domestic treatment development and prevention efforts incomplete and underinformed. In this review, the authors first describe how a legacy of structural racism in the United States has shaped the social gradient, highlighting consequential racial inequities in environmental conditions. The authors offer a hypothesized model linking structural racism with psychosis risk through interwoven intermediary factors based on existing theoretical models and a review of the literature. Neighborhood factors, cumulative trauma and stress, and prenatal and perinatal complications were three key areas selected for review because they reflect social and environmental conditions that may affect psychosis risk through a common pathway shaped by structural racism. The authors describe evidence showing that Black and Latino people in the United States suffer disproportionately from risk factors within these three key areas, in large part as a result of racial discrimination and social disadvantage. This broad focus on individual and community factors is intended to provide a consolidated space to review this growing body of research and to guide continued inquiries into social determinants of psychosis in U.S. contexts.

Is There an Ace Up Our Sleeve? A Review of Interventions and Strategies for Addressing Behavioral and Neurobiological Effects of Adverse Childhood Experiences in Youth

Exposure to early life adversity (ELA) is a major public health crisis posing as a significant risk of immediate and sustained mental and physical health consequences. While a remarkable body of knowledge has been amassed showing psychological, cognitive, social, developmental, and neurobiological consequences of ELA exposure, little has been done to improve the long-term mental and physical health outcomes for youth exposed to ELA. Furthermore, neurobiological processes underlying poor outcomes in this population have been largely left out of prevention and intervention target efforts. In this review, we first describe ELA-related alterations across psychological and neurobiological systems in children and adolescents. Next, we describe existing evidence-based interventions targeting ELA-related outcomes. We then turn to experimental studies examining individual differences in mechanistic functioning consequent to ELA exposure, and strategies that target these mechanisms and modulate disrupted functioning. Finally, we highlight areas of future research that may be promising in engaging behavioral and neurobiological targets through novel preventive interventions or augmentation of existing interventions, thereby reducing negative mental and physical health outcomes later in life.

Severe conduct problems in adolescence and risk of schizophrenia in early adulthood

AIM

Reform school (RS) is a foster care institution for adolescents with severe conduct problems. Both instability of early rearing environment and severe conduct problems in adolescence may associate with later psychotic disorders. We studied whether the risk of schizophrenia in adulthood is elevated in RS adolescents, and whether it is related to the age at first foster care placement or placement instability.

METHODS

Adult age schizophrenia spectrum disorder data from RS subjects (N = 1099) were compared to a comparison group matched by age, sex, and place of birth (N = 5437) in a register based follow-up study, with up to 23 years follow-up time. Schizophrenia was also predicted with chosen placement factors. Cox proportional regression model was used in the analysis.

RESULTS

RS subjects had an 8-fold (HR = 7.82, 95% CI 5.63-10.87) risk of schizophrenia compared to the comparison group. RS subjects also had an earlier age of schizophrenia onset. RS cohort, gender, placement instability, or age during the first out-of-home placement did not predict later schizophrenia.

CONCLUSIONS

Adolescents with severe conduct problems are a specific high-risk group for later schizophrenia. The risk manifests early, which compromises the pathway to the adult well-being. Specialized screening procedures for psychosis risk should be implemented in the standard clinical procedures when working with adolescents with severe behaviour problems, and early intervention programs should be available.

Utilising Genetically-Informed Research Designs to Better Understand Family Processes and Child Development: Implications for Adoption and Foster Care Focused Interventions

Understanding the interplay between genetic factors and family environmental processes (e.g., inter-parental relationship quality, positive versus negative parenting practices) and children's mental health (e.g., anxiety, depression, conduct problems, ADHD) in the contexts of adoption and foster-care research and practice is critical for effective prevention and intervention programme development. Whilst evidence highlights the importance of family environmental processes for the mental health and well-being of children in adoption and foster care, there is relatively limited evidence of effective interventions specifically for these families. Additionally, family-based interventions not specific to the context of adoption and foster-care typically show small to medium effects, and even where interventions are efficacious, not all children benefit. One explanation for why interventions may not work well for some is that responses to intervention may be influenced by an individual's genetic make-up. This paper summarises how genetically-informed research designs can help disentangle genetic from environmental processes underlying psychopathology outcomes for children, and how this evidence can provide improved insights into the development of more effective preventative intervention targets for adoption and foster-care families. We discuss current difficulties in translating behavioural genetics research to prevention science, and provide recommendations to bridge the gap between behavioural genetics research and prevention science, with lessons for adoption and foster-care research and practice.

Does the Fast Track Intervention Prevent Later Psychosis Symptoms?

The Fast Track (FT) intervention was a multimodal preventive intervention addressing antisocial development across 10 years of childhood and early adolescence. The intervention included parent management training, child social-cognitive skills training, peer coaching and mentoring, academic skills tutoring, and a classroom social-emotional learning program. While not specifically designed to target psychosis symptoms (e.g., social withdrawal, thought abnormalities), the present study aimed to examine whether the FT intervention prevented psychosis symptoms through childhood and adolescence and into adulthood. Participants included the FT intervention and high-risk control samples (N = 891; 69% male; M age = 6.58 years, SD = .48). Psychosis symptoms were assessed using the "thought problems" subscale of the parent-report Child Behavior Checklist during grades 1, 2, 4, 5, and 7, and the self-report Adult Behavior Checklist at age 25 years, in line with prior research using this measure. Growth models included the FT condition and covariates (i.e., initial risk screen score, cohort, socioeconomic status, rural/urban status, race, and sex) as predictors; and child, adolescent, and adult psychosis symptoms as outcomes. Intervention status was not significantly associated with the slope of psychosis symptoms; however, after controlling for concurrent cannabis use, intervention participants reported lower levels of psychosis symptoms over time. Findings suggest that interventions targeting antisocial behavior may prevent psychosis symptoms in the long term.

Differences Between Self-Reported Psychotic Experiences, Clinically Relevant Psychotic Experiences, and Attenuated Psychotic Symptoms in the General Population

Purpose: Psychotic experiences in childhood (such as hearing voices or being suspicious) represent an important phenotype for early intervention. However, these experiences can be defined in several ways: self-reported psychotic experiences (SRPE) rely exclusively on the child's report, clinically validated psychotic experiences (CRPE) are based on clinical assessment, and attenuated psychotic symptoms (APS) represents a categorization to do with clinical relevance in relation to severity. Very few studies have investigated how these distinctions impact clinical and other domains. The present study aims to compare SRPE, CRPE, and APS among children and adolescents. Methods: This study is part of the Brazilian High-Risk Cohort Study for Psychiatric Disorders, in which 2,241 individuals aged 6-14 years provided self-ratings of 20 psychotic experiences using the Community Assessment of Psychic Experiences (CAPE). A trained psychologist conducted an interview to validate or reject reported experiences and to rate the presence of APS and affective flattening. In parallel, parents provided information about child mental health to an independent interviewer. We tested the association of mutually exclusive categories of non-validated SRPE (nSRPE), clinically validated PE below the threshold for APS (nCRPE), and APS (nSRPE = 33%, nCRPE = 11%, APS = 6%), with parents' information about the child's positive attributes and levels of psychopathology and psychologist assessment of blunted affect. Results: Most associations were qualitatively similar, and there was a dose-response in the strength of associations across categories, such that APS > nCRPE > nSRPE. Experiences in all three categories were associated with female sex. nSRPE were associated with overall levels of psychopathology, but to a lesser degree than nCRPE and APS. APS and nCRPE were associated with less positive attributes, with APS more so than nCRPE. Only APS was associated with affective flattening. Conclusions: In children and adolescents, SRPE, CRPE, and APS all index liability for psychopathology, but as clinician rated relevance increases, associations get stronger and become evident across more domains.

The Coping with Unusual Experiences for Children Study (CUES): A pilot randomized controlled evaluation of the acceptability and potential clinical utility of a cognitive behavioural intervention package for young people aged 8-14 years with unusual experiences and emotional symptoms

OBJECTIVES

Health care guidelines recommend psychological interventions for childhood unusual experiences that are associated with distress or adverse functional impact (UEDs), based on adult, rather than child-specific, evidence. We report the first randomized controlled evaluation of the acceptability and potential clinical utility of cognitive behavioural therapy for childhood UEDs (CBT-UED).

DESIGN

Pilot randomized controlled trial.

METHODS

Participants aged 8-14 years were recruited from referrals to community services for children with emotional/behavioural problems and screened for self-reported UEDs.

RESULTS

Of around 1,000 referrals over 36 months, 304 (30%) were identified to the research team, 174 (57%) were successfully contacted, 110 (63%) consented to screening, 96 (87%) attended a screening assessment, and 51 (53%) reported UEDs. Forty-nine (96%) consented to randomization to either CBT-UED (9-12 weekly sessions of 40-50 min, adjunctive to usual care, n = 24) or treatment-as-usual/waitlist control (TAU/WL, n = 25). Childhood internalizing emotional symptoms (e.g., feeling 'nervous'/'scared'/'tearful'/'worried'/'sick'; proposed primary outcome), UEDs, depression, anxiety, and childhood psychopathology (secondary outcomes) were measured at baseline, at 12 weeks, and, where therapy was ongoing but incomplete (<12 sessions) at 12 weeks, at end-of-treatment (EOT). Twenty-two CBT-UED participants (92%) attended ≥5 sessions. Forty-four participants (90%) completed 12-week assessments (CBT-UED, n = 21/24, 88%; TAU/WL, n = 23/25, 92%). Preliminary findings were encouraging for emotional symptoms and UEDs, but otherwise mixed.

CONCLUSIONS

Retention, screening, and consent rates were as anticipated; recruitment took longer than planned. Trial procedures were acceptable to young people, their families, and clinicians. Therapy exceeded 12 weeks, but was well-received, with no serious adverse events attributed to participation. Further evaluation is needed.

PRACTITIONER POINTS

Around half of 8- to 14-year-olds in Child and Adolescent Mental Health Services reported distressing unusual experiences. An age-adapted cognitive behavioural intervention appears feasible, and safe to deliver, with the potential to augment standard care. This is a pilot study, and further evaluation is needed. Longer term outcomes should be a focus of future evaluation.

The Oregon Model of Behavior Family Therapy: From Intervention Design to Promoting Large-Scale System Change

This paper reviews the evolution of the Oregon model of family behavior therapy over the past four decades. Inspired by basic research on family interaction and innovation in behavior change theory, a set of intervention strategies were developed that were effective for reducing multiple forms of problem behavior in children (e.g., Patterson, Chamberlain, & Reid, 1982). Over the ensuing decades, the behavior family therapy principles were applied and adapted to promote children's adjustment to address family formation and adaptation (Family Check-Up model), family disruption and maladaptation (Parent Management Training-Oregon model), and family attenuation and dissolution (Treatment Foster Care-Oregon model). We provide a brief overview of each intervention model and summarize randomized trials of intervention effectiveness. We review evidence on the viability of effective implementation, as well as barriers and solutions to adopting these evidence-based practices. We conclude by proposing an integrated family support system for the three models applied to the goal of reducing the prevalence of severe problem behavior, addiction, and mental problems for children and families, as well as reducing the need for costly and largely ineffective residential placements.

Trajectories of childhood internalizing and externalizing psychopathology and psychotic-like experiences in adolescence: A prospective population-based cohort study

Adolescent internalizing and externalizing psychopathology is strongly associated with adult psychiatric morbidity, including psychotic disorders. This study examined whether internalizing or externalizing trajectories (continuity/discontinuity of symptoms) from middle childhood were associated with adolescent psychotic-like experiences (PLEs). Prospective data were collected from a community sample of 553 children (mean age = 10.4 years; 50% male) and their primary caregivers. Participants completed questionnaire reports of internalizing and externalizing psychopathology and PLEs at baseline, and again approximately 2 years later. Logistic regression was used to examine the association of adolescent PLEs with four trajectories of internalizing and externalizing psychopathology (persistent, incident, remitting, and none), controlling for a range of potential confounders and sampling bias. Significant associations were identified between adolescent PLEs and the incident internalizing (adjusted odds ratio [adj. OR] = 2.96; 95% confidence interval [CI] = 1.60–5.49) and externalizing psychopathology (adj. OR = 2.14; 95% CI = 1.11–4.14) trajectories, as well as the persistent internalizing (adj. OR = 1.90; 95% CI = 1.13–3.18) and externalizing (adj. OR = 1.81, 95% CI = 1.02–3.19) trajectories. Children with remitting psychopathology trajectories were no more likely to present later PLEs than those who never experienced psychopathology. While for many individuals symptoms and illness remit during development without intervention, this study provides important insights regarding potential targets and timing for delivery of early intervention and prevention programs.

Multi-dimensional Treatment Foster Care in England: differential effects by level of initial antisocial behaviour

Multi-dimensional Treatment Foster Care (MTFC), recently renamed Treatment Foster Care Oregon for Adolescents (TFCO-A) is an internationally recognised intervention for troubled young people in public care. This paper seeks to explain conflicting results with MTFC by testing the hypotheses that it benefits antisocial young people more than others and does so through its effects on their behaviour. Hard-to-manage young people in English foster or residential homes were assessed at entry to a randomised and case-controlled trial of MTFC (n = 88) and usual care (TAU) (n = 83). Primary outcome was the Children's Global Assessment Scale (CGAS) at 12 months analysed according to high (n = 112) or low (n = 59) baseline level of antisocial behaviour on the Health of the Nation Outcome Scales for Children and Adolescents. After adjusting for covariates, there was no overall treatment effect on CGAS. However, the High Antisocial Group receiving MTFC gained more on the CGAS than the Low group (mean improvement 9.36 points vs. 5.33 points). This difference remained significant (p < 0.05) after adjusting for propensity and covariates and was statistically explained by the reduced antisocial behaviour ratings in MTFC. These analyses support the use of MTFC for youth in public care but only for those with higher levels of antisocial behaviour. Further work is needed on whether such benefits persist, and on possible negative effects of this treatment for those with low antisocial behaviour.Trial Registry Name: ISRCTNRegistry identification number: ISRCTN 68038570Registry URL: www.isrctn.com.

Risks, Outcomes, and Evidence-Based Interventions for Girls in the US Juvenile Justice System

The proportion of the juvenile justice population that comprises females is increasing, yet few evidence-based models have been evaluated and implemented with girls in the juvenile justice system. Although much is known about the risk and protective factors for girls who participate in serious delinquency, significant gaps in the research base hamper the development and implementation of theoretically based intervention approaches. In this review, we first summarize the extant empirical work about the predictors and sequelae of juvenile justice involvement for girls. Identified risk and protective factors that correspond to girls' involvement in the juvenile justice system have been shown to largely parallel those of boys, although exposure rates and magnitudes of association sometimes differ by sex. Second, we summarize findings from empirically validated, evidence-based interventions for juvenile justice-involved youths that have been tested with girls. The interventions include Functional Family Therapy, Multisystemic Therapy, Multidimensional Family Therapy, and Treatment Foster Care Oregon (formerly known as Multidimensional Treatment Foster Care). We conclude that existing evidence-based practices appear to be effective for girls. However, few studies have been sufficiently designed to permit conclusions about whether sex-specific interventions would yield any better outcomes for girls than would interventions that already exist for both sexes and that have a strong base of evidence to support them. Third, we propose recommendations for feasible, cost-efficient next steps to advance the research and intervention agendas for this under-researched and underserved population of highly vulnerable youths.

The Dunedin Multidisciplinary Health and Development Study: overview of the first 40 years, with an eye to the future

The Dunedin Multidisciplinary Health and Development Study began more than four decades ago. Unusual at the time, it was founded as a multidisciplinary research enterprise, and was strongly supported by the Dunedin community, both professional and lay, in its early years. Seven research themes have evolved over the past 40 years focusing on mental health and neuro-cognition, cardiovascular risk, respiratory health, oral health, sexual and reproductive health, and psychosocial functioning. A seventh, more applied theme, seeks to maximise the value of the Study findings for New Zealand's indigenous people-Māori (or tangata whenua transl people of the land). The study has published over 1200 papers and reports to date, with almost 2/3 of these being in peer-reviewed journals. Here we provide an overview of the study, its history, leadership structure, scientific approach, operational foci, and some recent examples of work that illustrate the following: (a) the value of multidisciplinary data; (b) how the study is well positioned to address contemporary issues; and (c) how research can simultaneously address multiple audiences-from researchers and theoreticians to policy makers and practitioners. Near-future research plans are described, and we end by reflecting upon the core aspects of the study that portend future useful contributions.