Effective treatment for mental disorders in children and adolescents

Online remote behavioural intervention for tics in 9- to 17-year-olds: the ORBIT RCT with embedded process and economic evaluation

Background

Behavioural therapy for tics is difficult to access, and little is known about its effectiveness when delivered online.

Objective

To investigate the clinical and cost-effectiveness of an online-delivered, therapist- and parent-supported therapy for young people with tic disorders.

Design

Single-blind, parallel-group, randomised controlled trial, with 3-month (primary end point) and 6-month post-randomisation follow-up. Participants were individually randomised (1 : 1), using on online system, with block randomisations, stratified by site. Naturalistic follow-up was conducted at 12 and 18 months post-randomisation when participants were free to access non-trial interventions. A subset of participants participated in a process evaluation.

Setting

Two hospitals (London and Nottingham) in England also accepting referrals from patient identification centres and online self-referrals.

Participants

Children aged 9-17 years (1) with Tourette syndrome or chronic tic disorder, (2) with a Yale Global Tic Severity Scale-total tic severity score of 15 or more (or > 10 with only motor or vocal tics) and (3) having not received behavioural therapy for tics in the past 12 months or started/stopped medication for tics within the past 2 months.

Interventions

Either 10 weeks of online, remotely delivered, therapist-supported exposure and response prevention therapy (intervention group) or online psychoeducation (control).

Outcome

Primary outcome: Yale Global Tic Severity Scale-total tic severity score 3 months post-randomisation; analysis done in all randomised patients for whom data were available. Secondary outcomes included low mood, anxiety, treatment satisfaction and health resource use. Quality-adjusted life-years are derived from parent-completed quality-of-life measures. All trial staff, statisticians and the chief investigator were masked to group allocation.

Results

Two hundred and twenty-four participants were randomised to the intervention (n = 112) or control (n = 112) group. Participants were mostly male (n = 177; 79%), with a mean age of 12 years. At 3 months the estimated mean difference in Yale Global Tic Severity Scale-total tic severity score between the groups adjusted for baseline and site was -2.29 points (95% confidence interval -3.86 to -0.71) in favour of therapy (effect size -0.31, 95% confidence interval -0.52 to -0.10). This effect was sustained throughout to the final follow-up at 18 months (-2.01 points, 95% confidence interval -3.86 to -0.15; effect size -0.27, 95% confidence interval -0.52 to -0.02). At 18 months the mean incremental cost per participant of the intervention compared to the control was £662 (95% confidence interval -£59 to £1384), with a mean incremental quality-adjusted life-year of 0.040 (95% confidence interval -0.004 to 0.083) per participant. The mean incremental cost per quality-adjusted life-year gained was £16,708. The intervention was acceptable and delivered with high fidelity. Parental engagement predicted child engagement and more positive clinical outcomes.

Harms

Two serious, unrelated adverse events occurred in the control group.

Limitations

We cannot separate the effects of digital online delivery and the therapy itself. The sample was predominately white and British, limiting generalisability. The design did not compare to face-to-face services.

Conclusion

Online, therapist-supported behavioural therapy for young people with tic disorders is clinically and cost-effective in reducing tics, with durable benefits extending up to 18 months.

Future work

Future work should compare online to face-to-face therapy and explore how to embed the intervention in clinical practice.

Trial registration

This trial is registered as ISRCTN70758207; ClinicalTrials.gov (NCT03483493). The trial is now complete.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Technology Assessment programme (project number 16/19/02) and will be published in full in Health and Technology Assessment; Vol. 27, No. 18. See the NIHR Journals Library website for further project information.

Effectiveness of Group Parent-Child Interaction Therapy on Problem Behaviors in Chinese Kindergartners

Problem behaviors in early childhood may put young children at risk for negative behavioral and psychosocial problems. This study examined the effectiveness of group PCIT on Chinese young children's externalizing and internalizing problems. The participants were 58 mothers with their children aged 2-3 years (M = 2.95 years, SD = 0.22), assigned to an immediate treatment (n = 26) group or to a waitlist (n = 32) control group. The program involved comprehensive group intervention and featured weekly 60-90-min sessions, totaling ten sessions over three months. Results indicate that group PCIT not only significantly improved teacher-reported problem behaviors in children, but also improved observed maternal parenting behavior. These findings support the use of group PCIT in Chinese children and provide mothers with an evidence-based tool to address problem behaviors in a non-clinical population.

Burden of mental disorders in children in the general population and in health facilities: discrepancies in years lived with disability based on national prevalence estimates between populations receiving care or not

Little is known about the discrepancies in the burden of child mental disorders based on differences in prevalence between populations with and without care. Identifying such discrepancies may help to elucidate the unmet needs related to child mental disorders. We compared the years lived with disability (YLD) between children with and without care for mental disorders using a representative national survey, Taiwan's National Epidemiological Study of Child Mental Disorders (TNESCMD), and a national health facility database, the Taiwan National Health Insurance Research Database (TNHIRD). The comorbidity-adjusted YLD rate ratio (RR) was reported to quantify the YLD discrepancy. The overall YLD rate for all mental disorders in the TNESCMD was 9.05 times higher than that in the TNHIRD with the lowest and highest YLD RRs for autism spectrum disorder (RR 3.51) and anxiety disorders (RR 360.00). Unlike the YLD proportion explained by attention-deficit/hyperactivity disorder and autism spectrum disorder, the proportions explained by anxiety disorders and conduct disorder/oppositional defiant disorder relative to the total YLD were relatively lower in the TNHIRD than in TNESCMD and the Global Burden of Disease 2016. The discrepancies in YLD between populations with and without care in child mental disorders ranged from ± 55% to 99% and had an overall value of ± 80.1%. High YLD discrepancies in child mental disorders between estimates based on the general population and those in health facilities suggest significant unmet needs for care in child mental disorders and that estimates of disease burden that rely heavily on a single source may result in unreliable results.

Evidence Based Practice in Systems of Care for Children with Complex Mental Health Needs

Purpose: Community-based social work with families and youth with complex behavioral health needs highlights challenges to incorporating empirical evidence into routine practice. This article presents a framework for integrating evidence in community-based Systems of Care for these children and their families.Method: This article reviews research on various approaches to integrating evidence into children's behavioral health and community-based care and contextualizes it within dominant paradigms of Systems of Care (SoC) and Wraparound principles.Results: Based on this review, this article proposes the Evidence-Based Practice in Systems of Care (EBP in SoC) model. The model describes how to incorporate evidence into every aspect of community-based SoCs for children with mental health concerns.Discussion and Conclusion: Discussion of the model will focus on implications of using the framework for practitioners, mental health organizations, communities, and state and federal administration and policymaking.

Effectiveness of Stimulant Medications on Disruptive Behavior and Mood Problems in Young Children

Objective

There are very few studies on the effectiveness of stimulant medications for the treatment of disruptive mood and behavior problems in young children (less than 7 years) with Disruptive Behavior Disorders (DBD). The current study aims to determine whether young children (ages 4−7) in a long-term, intensive outpatient behavioral treatment program who are receiving stimulant medications show greater improvement in mood and behavior problems compared to peers who did not.

Methods

A retrospective chart review was conducted for 97 participants diagnosed with DBD, aged 4−7 years old who were enrolled in an intensive outpatient behavioral intervention program. Pre- and post-intervention Child Behavior Checklist (CBCL) scores for disruptive behavior and mood problems were compared between the children who received stimulant medications and those who did not.

Results

Paired t tests showed a statistically significant improvement in CBCL outcomes between pre- and post-intervention scores of disruptive behavior and mood problems. ANCOVA analysis, however, showed no clear further improvement in those same CBCL scores in the participants who received stimulant medications compared to the participants who did not. CBCL scores for Conduct Disorder were marginally significant for less improvement for the participants who received stimulant medications.

Conclusion

This retrospective review suggests a possibility that stimulant medications may not provide additional benefit for the long-term treatment of disruptive behavior and mood problems in young children under age 7. Future study is warranted to evaluate the efficacy/effectiveness of stimulant medications in the treatment of disruptive behavior and mood problems in this population.

Medically Treated Self-Injury Among Children and Adolescents: Repeated Attempts and Service Use Over 1 Year

OBJECTIVE

Clinical, demographic, and service use patterns of youths ages 6-18 years who had a medically treated self-injury were examined to understand factors associated with recurrence of such an injury in the subsequent year.

METHODS

This retrospective cohort analysis used data from 31,147 youths who were medically treated for self-injury. Data were from IBM/Watson MarketScan commercial claims and encounters databases (2007-2016). The index self-injury was defined as the first event with an ICD code related to self-injury or suicidal ideation combined with a wound code. Cox proportional hazards regression was used to determine the hazard ratios and 95% confidence intervals (CIs) describing associations with subsequent medically treated self-injury for youths who were hospitalized in psychiatric facilities in the seven days before or after the index self-injury versus those who were not.

RESULTS

Approximately 2% of the 31,147 youths had another medically treated self-injury in the year following the index self-injury. The hospitalized group had higher service use in the years prior to and following their self-injury, but the mean number of outpatient psychiatric visits before the index self-injury did not differ significantly between groups. Hazard ratios for clinical, demographic, and service use variables indicated that those who were hospitalized in psychiatric facilities for the index event were twice as likely (95% CI=1.7-2.7) as those who were not to have another medically treated self-injury in the year after the index event.

CONCLUSIONS

In this retrospective, observational study, psychiatric hospitalization after self-injury was strongly associated with recurrence of self-injury in the subsequent year.

Lessons Learned About Barriers to Implementing School-Based Interventions for Adolescents: Ideas for Enhancing Future Research and Clinical Projects

The majority of youth with mental health problems do not receive treatment, highlighting the critical need to transport evidence-based interventions into community settings, such as schools. Despite being able to reach a large number of adolescents and minority youth, the process of implementing evidence-based interventions to schools is challenging. This paper discusses some expected and unexpected challenges experienced during the implementation of an open trial and a pilot randomized controlled trial examining the acceptability and effectiveness of a school-based preventive intervention for adolescents at risk for internalizing disorders. First, we highlight key programs and findings on preventive interventions for adolescents at risk for depression and anxiety. Next, we provide a brief overview of the preventive intervention we implemented in schools. This provides a context for the section that describes implementation issues and highlights specific challenges and potential solutions for intervention implementation. Finally, the paper offers recommendations for researchers and clinicians interested in implementing school-based mental health services for adolescents.

Exploring pathways to mental healthcare for urban Aboriginal young people: a qualitative interview study

OBJECTIVES

To explore the perceptions of Aboriginal Community Controlled Health Service (ACCHS) staff involved in providing mental healthcare to Aboriginal young people of the current and ideal pathways to mental healthcare for urban Aboriginal young people attending ACCHSs, and to identify what additional supports staff may need to provide optimal mental healthcare to Aboriginal young people.

DESIGN

Qualitative interview study conducted during May 2016-2017.

SETTING

Primary care, at two ACCHSs participating in the Study of Environment on Aboriginal Resilience and Child Health in New South Wales.

PARTICIPANTS

Purposive sampling of staff involved in mental healthcare pathways of Aboriginal young people, including general practitioners (GPs), nurses and Aboriginal Health Workers (AHWs).

RESULTS

All individuals approached for interview (n=21) participated in the study. Four overarching themes and seven sub-themes were identified: availability and use of tools in practice (valuing training and desire for tools and established pathways), targeting the ideal care pathway (initiating care and guiding young people through care), influencing the care pathway (adversities affecting access to care and adapting the care pathway) and assessing future need (appraising service availability).

CONCLUSIONS

Participants desired screening tools, flexible guidelines and training for healthcare providers to support pathways to mental healthcare for Aboriginal young people. Both GPs and AHWs were considered key in identifying children at risk and putting young people onto a pathway to receive appropriate mental healthcare. AHWs were deemed important in keeping young people on the care pathway, and participants felt care pathways could be improved with the addition of dedicated child and adolescent AHWs. The ACCHSs were highlighted as essential to providing culturally appropriate care for Aboriginal young people experiencing mental health problems, and funding for mental health specialists to be based at the ACCHSs was considered a priority.

Review of services to inform clinical frameworks for adolescents and young adults with severe, persistent and complex mental illness

OBJECTIVE

Severe, persistent and complex mental illness (SPCMI) affects a small proportion of young people but is associated with severe disability and a large burden on families and health services. This article identifies and describes service models for adolescents and young adults with SPCMI.

METHODS

A systematic search was conducted for services for young people aged 12-25 years with SPCMI. The review sought service models providing extended care and/or multidisciplinary services to meet the complex and long-term needs of this population.

RESULTS

A total of 43 sources were identified. Evidence of effectiveness was found for both community- and bed-based services. Specific components suggested as important in service delivery included care provided by multidisciplinary teams, consumer and family involvement in care planning, intensive case management and service integration through the continuum of care.

CONCLUSION

Clinical frameworks for this population must incorporate effective community care integrated with inpatient treatment of short duration. Frameworks require consumer and family-centred care with flexibility to support progression through developmental stages and tasks while addressing issues related to risk management, fluctuation in illness severity and stages of recovery. A continuum of care is necessary to meet the needs that arise from SPCMI in adolescents and young adults.

Predictors of functional improvement in children and adolescents at a publicly funded specialist outpatient treatment clinic in a Canadian Prairie City

Children's mental health problems substantially impact their functioning. For clinically treated children and adolescents, we explored the impact of mental health treatment on functioning and identified predictors of functional improvement. Outpatient clinical data from a regional publicly funded specialist outpatient treatment clinic were analyzed. The Child and Adolescent Functional Assessment Scale (CAFAS) was used to assess outcomes. Non-parametric tests were used to compare baseline and exit scores. Logistic regression analysis was used separately for children and adolescents to examine predictors of improvement. Total CAFAS scores at exit showed a significant decrease from initial scores for both age groups, indicating improvements in clients' functioning. Children and adolescents had shared predictors for initial level of dysfunction, length of treatment and the presence of pervasive behavioral impairment (PBI). Primary presenting problem, caregiver support and area of residence were only associated with outcome among children. Clients with higher initial levels of dysfunction and PBI require longer treatment cycles to reach an acceptable outcome. Shortening the length of treatment cycles may improve the efficiency of resource use but can be detrimental to some clients. Personalized treatment should be tailored to the clients with specific characteristics and needs.

Evidence-Based Treatment Strategies in Youth Mental Health Services: Results from a National Survey of Providers

Previous surveys indicate infrequent use of evidence-based treatment (EBT) manuals in usual care youth mental health, but the extent to which providers use core and common EBT strategies and what contextual factors impact EBT strategy implementation need further study. In a national, multidisciplinary survey of 1092 youth-serving providers, providers reported regular use of many EBT strategies. Provider learning theory orientation, more recent degree, more standardized and ongoing assessment use, more positive attitudes toward innovation and evidence, fewer low-income clients, and perceptions that their agency valued quality care and provided fewer training resources predicted more frequent EBT strategy use.

Vocational coaches for justice-involved emerging adults

OBJECTIVE

The purpose of this study was to determine whether vocational supports for emerging adults with serious mental health conditions who are at high risk for rearrest are more effectively served within Multisystemic Therapy for Emerging Adults (MST-EA) through vocationally enhanced MST-EA Coaches or through referral to state vocational rehabilitation services.

METHOD

A pilot randomized controlled trial examined two MST-EA Coaching approaches. In the Standard Coach + VR condition (n = 16), MST-EA Coaches delivered standard skills curricula to participants and referred them to state vocational rehabilitation (VR) services for vocational supports. In the Vocational Coach (VC) condition (n = 16), MST-EA Coaches delivered the standard skills curricula enhanced with extensive education/employment components. Analyses included pre- to posttreatment comparisons of vocational outcomes, and between groups comparisons of fidelity, satisfaction, and services utilization.

RESULTS

Those in the VC condition had a 12-fold increase in the odds of posttreatment vocational activity compared with those in the Standard Coach + VR condition (92.9 vs. 57.1% employed or in school, respectively). Subgroup analyses of those who engaged in Coaching showed that there was specifically an increase in the odds of posttreatment educational engagement among those in the VC condition compared with those in Standard Coach + VR.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Based on the strength of the findings in this small pilot study the VC should be included in future clinical trials of MST-EA to maximize treatment impact for supporting emerging adult vocational functioning and thus reducing antisocial behavior. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Community Study of Outcome Monitoring for Emotional Disorders in Teens (COMET): A comparative effectiveness trial of a transdiagnostic treatment and a measurement feedback system

Emotional disorders, encompassing a range of anxiety and depressive disorders, are the most prevalent and comorbid psychiatric disorders in adolescence. Unfortunately, evidence-based psychosocial therapies typically focus on single disorders, are rarely adopted by community mental health center clinicians, and effect sizes are modest. This article describes the protocol for a comparative effectiveness study of two novel interventions designed to address these challenges. The first intervention is a transdiagnostic treatment (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents, UP-A), a promising new approach that uses a small number of common strategies to treat a broad range of emotional disorders, and their underlying shared emotional vulnerabilities. The second intervention is a standardized measurement feedback system, the Youth Outcomes Questionnaire (YOQ), designed to improve clinical decision making using weekly symptom and relational data. The three study arms are treatment as usual (TAU), TAU plus the YOQ (TAU+), and UP-A (used in combination with the YOQ). The primary aims of the study are to [1] compare the effects of the UP-A and TAU+ to TAU in community mental health clinics, [2] to isolate the effects of measurement and feedback by comparing the UP-A and TAU+ condition, and [3] to examine the mechanisms of action of both interventions. Design considerations and study methods are provided to inform future effectiveness research.

Availability of Youth Services in U.S. Mental Health Treatment Facilities

Despite concern about access to mental health (MH) services for youth, little is known about the specialty treatment infrastructure serving this population. We used national data to examine which types of MH treatment facilities (hospital- and community-based) were most likely to offer youth services and which types of communities were most likely to have this infrastructure. Larger (p < 0.001) and privately owned (p < 0.001) facilities were more likely to offer youth services. Rural counties, counties in which a majority of residents were nonwhite, and/or counties with a higher percentage of uninsured residents were less likely to have a community-based MH treatment facility that served youth (p < 0.001).

Distilling Common History and Practice Elements to Inform Dissemination: Hanf-Model BPT Programs as an Example

There is a shift in evidence-based practice toward an understanding of the treatment elements that characterize empirically supported interventions in general and the core components of specific approaches in particular. The evidence base for behavioral parent training (BPT) and the standard of care for early-onset disruptive behavior disorders (oppositional defiant disorder and conduct disorder), which frequently co-occur with attention deficit hyperactivity disorder, are well established, yet an ahistorical, program-specific lens tells little regarding how leaders, University of Oregon Medical School, shaped the common practice elements of contemporary evidence-based BPT. Accordingly, this review summarizes the formative work of Hanf, as well as the core elements, evolution, and extensions of her work, represented in Community Parent Education (COPE; (Cunningham et al. in J Child Psychol Psychiatry 36:1141-1159, 1995; Cunningham et al. in COPE, the community parent education program: large group community-based workshops for parents of 3- to 18-year-olds, COPE Works, Hamilton, 2009), Defiant Children (DC; (Barkley in Defiant children: a clinician's manual for assessment and parent training, Guilford Press, New York, 1987; Barkley in Defiant children: a clinician's manual for assessment and parent training, Guilford Press, New York, 2013), Helping the Noncompliant Child (HNC; Forehand and McMahon in Helping the noncompliant child: a clinician's guide to parent training, Guilford Press, New York, 1981; McMahon and Forehand in Helping the noncompliant child: family-based treatment for oppositional behavior, 2nd ed., Guilford Press, New York, 2003), Parent-child interaction therapy (PCIT; Eyberg and Robinson in J Clin Child Adolesc Psychol 11:130-137, 1982. doi:10.1080/15374418209533076; Eyberg in Child Fam Behav Ther 10:33-46, 1988; Eyberg and Funderburk in Parent-child interaction therapy protocol, PCIT International, Gainesville, 2011), and the Incredible Years (IY; (Webster-Stratton in Behav Ther 12:634-642, 1981. doi:10.1016/S0005-7894(81)80135-9; Webster-Stratton in J Pediatr Psychol 7:279-294, 1982. doi:10.1093/jpepsy/7.3.279; Webster-Stratton in The incredible years: parents and children series. Leader's guide: preschool version of BASIC (ages 3-6 years, The Incredible Years, Seattle, 2008). Our goal is not to provide an exhaustive review of the evidence base for the Hanf-Model programs, rather our intention is to provide a template of sorts from which agencies and clinicians can make informed choices about how and why they are using one program versus another, as well as how to make inform flexible use one program or combination of practice elements across programs, to best meet the needs of child clients and their families. Clinical implications and directions for future work are discussed.

Implementing Evidence-Based Practice in Residential Care - How Far Have We Come?

Residential care agencies have been making efforts to provide better quality care through the implementation of evidence-based program models and evidence-based treatments. This paper retraces the developments that led to such efforts. It further aims to answer two questions based on the available conceptual and empirical literature: (1) What is the current status on milieu-based program models that were developed for residential care settings with a therapeutic focus? (2) What is known about the implementation of client- or disorder-specific evidence-based treatments into residential care settings? Findings from this review will be integrated to provide recommendations to residential care providers about the integration of evidence-based treatments into their agencies and to point to the challenges that remain for the field.

Changes in J-SOAP-II and SAVRY Scores Over the Course of Residential, Cognitive-Behavioral Treatment for Adolescent Sexual Offending

Although the Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II) and the Structured Assessment of Violence Risk in Youth (SAVRY) include an emphasis on dynamic, or modifiable factors, there has been little research on dynamic changes on these tools. To help address this gap, we compared admission and discharge scores of 163 adolescents who attended a residential, cognitive-behavioral treatment program for sexual offending. Based on reliable change indices, one half of youth showed a reliable decrease on the J-SOAP-II Dynamic Risk Total Score and one third of youth showed a reliable decrease on the SAVRY Dynamic Risk Total Score. Contrary to expectations, decreases in risk factors and increases in protective factors did not predict reduced sexual, violent nonsexual, or any reoffending. In addition, no associations were found between scores on the Psychopathy Checklist:Youth Version and levels of change. Overall, the J-SOAP-II and the SAVRY hold promise in measuring change, but further research is needed.

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.

Nonsuicidal Self-Injury of Adolescents

Nonsuicidal self-injury (NSSI) is more common in adolescent and young adult populations than in the past. NSSI is typically used to deal with distressing negative affective states, especially anger and depression, and mixed emotional states. Pediatricians; primary care, family medicine, and emergency room physicians; and mental health professionals are faced with the charge of responding to NSSI behaviors among patients. Physicians in family medicine, pediatrics, and primary care settings play an essential role in initiating the beginning step in the treatment process for those who self-injure. All providers can strengthen the care provided to those who engage in NSSI via assessing the risk accurately, understanding the functions of the behavior, and assisting the patient in connecting with treatment. This article provides medical and mental health professionals with an overview of intervention strategies that may be useful when counseling adolescents and their families. In addition, areas for continued research are discussed.

Distilling Common History and Practice Elements to Inform Dissemination: Hanf-Model BPT Programs as an Example

There is a shift in evidence-based practice toward an understanding of the treatment elements that characterize empirically supported interventions in general and the core components of specific approaches in particular. The evidence base for behavioral parent training (BPT) and the standard of care for early-onset disruptive behavior disorders (oppositional defiant disorder and conduct disorder), which frequently co-occur with attention deficit hyperactivity disorder, are well established, yet an ahistorical, program-specific lens tells little regarding how leaders, University of Oregon Medical School, shaped the common practice elements of contemporary evidence-based BPT. Accordingly, this review summarizes the formative work of Hanf, as well as the core elements, evolution, and extensions of her work, represented in Community Parent Education (COPE; (Cunningham et al. in J Child Psychol Psychiatry 36:1141-1159, 1995; Cunningham et al. in COPE, the community parent education program: large group community-based workshops for parents of 3- to 18-year-olds, COPE Works, Hamilton, 2009), Defiant Children (DC; (Barkley in Defiant children: a clinician's manual for assessment and parent training, Guilford Press, New York, 1987; Barkley in Defiant children: a clinician's manual for assessment and parent training, Guilford Press, New York, 2013), Helping the Noncompliant Child (HNC; Forehand and McMahon in Helping the noncompliant child: a clinician's guide to parent training, Guilford Press, New York, 1981; McMahon and Forehand in Helping the noncompliant child: family-based treatment for oppositional behavior, 2nd ed., Guilford Press, New York, 2003), Parent-child interaction therapy (PCIT; Eyberg and Robinson in J Clin Child Adolesc Psychol 11:130-137, 1982. doi:10.1080/15374418209533076; Eyberg in Child Fam Behav Ther 10:33-46, 1988; Eyberg and Funderburk in Parent-child interaction therapy protocol, PCIT International, Gainesville, 2011), and the Incredible Years (IY; (Webster-Stratton in Behav Ther 12:634-642, 1981. doi:10.1016/S0005-7894(81)80135-9; Webster-Stratton in J Pediatr Psychol 7:279-294, 1982. doi:10.1093/jpepsy/7.3.279; Webster-Stratton in The incredible years: parents and children series. Leader's guide: preschool version of BASIC (ages 3-6 years, The Incredible Years, Seattle, 2008). Our goal is not to provide an exhaustive review of the evidence base for the Hanf-Model programs, rather our intention is to provide a template of sorts from which agencies and clinicians can make informed choices about how and why they are using one program versus another, as well as how to make inform flexible use one program or combination of practice elements across programs, to best meet the needs of child clients and their families. Clinical implications and directions for future work are discussed.

Who Goes Where? Exploring Factors Related to Placement Among Group Homes

Despite their widespread use as a placement option for youth with mental health problems, there is relatively little research on group homes for youth. Available data highlight concerns with practices and treatment within group homes and mixed results on youth-level outcomes. However, existing research appears to collapse a wide range of group residential settings into a single amorphous category. This article explores potential variations among group homes to examine whether different programs are systematically serving different types of youth. It examines, in particular, placement in homes using the teaching family model (TFM) versus homes that do not. Findings suggest that demographics are not significantly associated with TFM placement. However, custody status, types of mental health problems, and use of psychotropic medications are. Homes appear to be serving distinct niches within a geographic area. Implications for future research and policy/practice are discussed.

Health managers' views on the status of national and decentralized health systems for child and adolescent mental health in Uganda: a qualitative study

BACKGROUND

Robust health systems are required for the promotion of child and adolescent mental health (CAMH). In low and middle income countries such as Uganda neuropsychiatric illness in childhood and adolescence represent 15-30 % of all loss in disability-adjusted life years. In spite of this burden, service systems in these countries are weak. The objective of our assessment was to explore strengths and weaknesses of CAMH systems at national and district level in Uganda from a management perspective.

METHODS

Seven key informant interviews were conducted during July to October 2014 in Kampala and Mbale district, Eastern Uganda representing the national and district level, respectively. The key informants selected were all public officials responsible for supervision of CAMH services at the two levels. The interview guide included the following CAMH domains based on the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS): policy and legislation, financing, service delivery, health workforce, medicines and health information management. Inductive thematic analysis was applied in which the text in data transcripts was reduced to thematic codes. Patterns were then identified in the relations among the codes.

RESULTS

Eleven themes emerged from the six domains of enquiry in the WHO-AIMS. A CAMH policy has been drafted to complement the national mental health policy, however district managers did not know about it. All managers at the district level cited inadequate national mental health policies. The existing laws were considered sufficient for the promotion of CAMH, however CAMH financing and services were noted by all as inadequate. CAMH services were noted to be absent at lower health centers and lacked integration with other health sector services. Insufficient CAMH workforce was widely reported, and was noted to affect medicines availability. Lastly, unlike national level managers, lower level managers considered the health management information system as being insufficient for service planning.

CONCLUSION

Managers at national and district level agree that most components of the CAMH system in Uganda are weak; but perceptions about CAMH policy and health information systems were divergent.

Hygiene and mental health among middle school students in India and 11 other countries

The Global School-based Student Health Survey (GSHS) collects data from early adolescents who are approximately 13-15 years old and enrolled in middle schools (also known as junior secondary schools). We used logistic regression models to examine the associations between self-reported hygiene practices and mental health status as assessed by the 2007 India GSHS. Then, we used meta-analysis to compare the results from India with those from 11 other GSHS-participating countries in Asia and Africa (Djibouti, Indonesia, Jordan, Kenya, Lebanon, Myanmar, the Philippines, Tanzania, Thailand, Uganda, and the United Arab Emirates). Among 7904 middle school students in India, 25.5% reported symptoms of depression, 8.6% reported loneliness, and 7.8% reported anxiety-related insomnia. Both males and females who reported symptoms of depression had an increased likelihood of poor hand and oral hygiene, including washing their hands rarely or never and brushing their teeth less than daily. The meta-analysis for this association yielded statistically significant pooled odds ratios for both boys and girls. In girls, loneliness was also associated with poor hand and oral hygiene. Reduced mental health status in adolescents may lead to worse hygiene behaviors and an increased risk of infections. Teachers, parents, healthcare workers, and other adults who observe suboptimal hygiene status in an adolescent should consider whether this indicates a mental health issue that requires clinical services.

Parent-child inpatient treatment for children with behavioural and emotional disorders: a multilevel analysis of within-subjects effects

BACKGROUND

The importance of parental involvement in child treatment is well-established. Several child psychiatric clinics have, therefore, set up inpatient family units where children and parents are both actively involved in the treatment. Unfortunately, evidence supporting the benefits of these units is sparse.

METHODS

We evaluated the effectiveness of inpatient treatment for families with severe parent-child interaction problems in a child psychiatric setting. Consecutive admissions to the parent-child ward (N = 66) were studied. A within-subjects design was used with four assessment points (baseline, admission, discharge, four-week follow-up). Outcome measures were 1) parent and teacher ratings of child behaviour, and 2) parent self-ratings of parenting practices, parental strains and parental mental health. Data were analyzed using multilevel modelling for longitudinal data (piecewise growth curve models).

RESULTS

All parent-rated measures improved significantly during the four-week treatment period (d = 0.4 - 1.3). These improvements were significantly greater than those observed during the four-week pre-admission period. In addition, benefits were maintained during the four-week follow-up period. Only parents' self-efficacy in managing their child's behaviour showed continued improvement during follow-up. Teacher ratings of children's disruptive behaviour at school were stable during the pre-admission period and showed significant improvements at follow-up (d = 0.3 - 0.4).

CONCLUSIONS

We conclude that parent-child inpatient treatment has positive effects on child and parent behaviour and mental health, and can therefore be recommended for children with behavioural and emotional disorders and severe parent-child interaction problems.

Youth in group home care: youth characteristics and predictors of later functioning

This paper presents the findings of an exploratory research study of foster care youth residing in group homes in a mid-Atlantic state in the USA. The aims of the present study were to (1) describe youth characteristics, (2) explore whether baseline functioning differed by gender or ethnicity, (3) explore predictors of cross-time differences in psychosocial functioning, and (4) explore predictors of later functioning, specifically age, gender, and length of stay. Psychosocial functioning at two time points (i.e., T1 = admission into group home; T2 = current or discharge) in 180 charts from 29 randomly selected group homes were reviewed. Youth were on average 14.86 years of age, predominantly male (71%; n = 128), and predominantly African American (79%). Findings suggest that group home placement may benefit some youth but not others, particularly girls and younger children with lower initial level of need. Findings underscore the potential complexity of intervention impact in the context of unique youth, family, and environment factors.

Does Insurance Matter? Implementing Dialectical Behavior Therapy with Two Groups of Youth Engaged in Deliberate Self-harm

This paper presents the outcomes of a Dialectical Behavior Treatment (DBT) program, implemented in intensive outpatient care with two groups of adolescents (n = 55 and n = 45), ages 12-18, who engaged in deliberate self-harm (DSH) but had different insurance/funding sources and risk backgrounds. This pre-post study examined variability in clinical functioning and treatment utilization between the two groups and investigated moderating risk factors. Findings support DBT's effectiveness in improving clinical functioning for youth with DSH regardless of insurance type. However, lower rates of treatment completion among youth without private insurance call for extra engagement efforts to retain high-risk youth in DBT.

Does the Hospital Predict Readmission? A Multi-level Survival Analysis Approach

Time to psychiatric rehospitalization was predicted for a sample of 1473 Medicaid-insured youth in Illinois in 2005 and 2006. A multi-level model statistical strategy was employed to account for the fact that youth days to rehospitalization were nested within hospital and to test the hypothesis that hospitals would vary significantly in return rates, controlling for individual-level (e.g., symptom, demographic) variables. Hospitals did not vary significantly in days to rehospitalization. At the individual-level, level of externalizing behavior and residential treatment placement predicted a faster return to the hospital. These results support the perspective that hospital outcomes are best operationalized using variables tied more directly to the inpatient episode (e.g., LOS, reductions in acuity).

Practitioner characteristics and organizational contexts as essential elements in the evidence-based practice versus cultural competence debate

The different pathways chosen to efficiently and effectively provide relief to those struggling with mental health challenges reflect different assumptions about the human condition and have led to disagreements over which intervention strategies are best suited to particular individuals or populations. Evidence-based practice and culturally competent services, as discussed within the United States, have been characterized as opposites. However, neither approach captures all of the elements that embody the full treatment experience. This article offers a framework that includes the personal identity of the practitioner and the organizational context as two elements that serve as active agents in the helping relationship, although they have rarely been included in the discourse about evidence-based practice or cultural competence. Suggestions for practice, education, and research are included based on this analysis.

Reducing recidivism and symptoms in emerging adults with serious mental health conditions and justice system involvement

The peak years of offending in the general population and among those with serious mental health conditions (SMHC) are during emerging adulthood. There currently are no evidence-based interventions for reducing offending behavior among 18-21 year olds, with or without SMHC. This open trial examined outcomes from an adaptation of Multisystemic Therapy (MST), an effective juvenile recidivism reduction intervention, modified for use with emerging adults with SMHC and recent justice system involvement. MST for emerging adults (MST-EA) targets MH symptoms, recidivism, problem substance use, and young adult functional capacities. All study participants (n = 41) were aged 17-20 and had a MH diagnosis and recent arrest or incarceration. Implementation outcomes indicated that MST-EA was delivered with strong fidelity, client satisfaction was high, and the majority of participants successfully completed the intervention. Research retention rates also were high. Pre-post-analyses revealed significant reductions in participants' MH symptoms, justice system involvement, and associations with antisocial peers.

The effectiveness of Multisystemic Therapy (MST): a meta-analysis

Multisystemic Therapy (MST) is a well-established intervention for juvenile delinquents and/or adolescents showing social, emotional and behavioral problems. A multilevel meta-analysis of k=22 studies, containing 332 effect sizes, consisting of N=4066 juveniles, was conducted to examine the effectiveness of MST. Small but significant treatment effects were found on delinquency (primary outcome) and psychopathology, substance use, family factors, out-of-home placement and peer factors, whereas no significant treatment effect was found for skills and cognitions. Moderator analyses showed that study characteristics (country where the research was conducted, efficacy versus effectiveness, and study quality), treatment characteristics (single versus multiple control treatments and duration of MST treatment), sample characteristics (target population, age, gender and ethnicity) and outcome characteristics (non-specific versus violent/non-violent offending, correction for pretreatment differences, and informant type) moderated the effectiveness of MST. MST seems most effective with juveniles under the age of 15, with severe starting conditions. Furthermore, the effectiveness of MST may be improved when treatment for older juveniles is focused more on peer relationships and risks and protective factors in the school domain.

Use of Psychotropic Medications among Youth in Treatment Foster Care

We describe the use of psychotropic medications among youth in treatment foster care (TFC). Data from 240 youth were coded to examine rates of medication use, including polypharmacy and an indicator of "questionable polypharmacy." Fifty-nine percent of youth in TFC had taken a psychotropic medication within the past two months. Of the youth taking psychotropics, 61% took two or more and 22% met criteria for questionable polypharmacy. The majority of youth taking psychotropics also received psychosocial mental health services and were more likely to receive such services than youth not taking medication. Use of psychotropic medication use was not significantly related to demographic factors, maltreatment history, or custody. However, youth with more severe symptoms were more likely to be on medications and to be on multiple medications. Youth with "questionable polypharmacy" were less likely than other youth on multiple medications to have a recent visit to a psychiatrist.

Predictors and moderators of treatment response in childhood anxiety disorders: results from the CAMS trial

OBJECTIVE

We sought to examine predictors and moderators of treatment outcomes among 488 youths ages 7-17 years (50% female; 74% ≤ 12 years) meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) criteria for diagnoses of separation anxiety disorder, social phobia, or generalized anxiety disorder who were randomly assigned to receive either cognitive behavioral therapy (CBT), sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) in the Child/Adolescent Anxiety Multimodal Study (CAMS).

METHOD

Six classes of predictor and moderator variables (22 variables) were identified from the literature and examined using continuous (Pediatric Anxiety Ratings Scale; PARS) and categorical (Clinical Global Impression Scale-Improvement; CGI-I) outcome measures.

RESULTS

Three baseline variables predicted better outcomes (independent of treatment condition) on the PARS, including low anxiety severity (as measured by parents and independent evaluators) and caregiver strain. No baseline variables were found to predict Week 12 responder status (CGI-I). Participants' principal diagnosis moderated treatment outcomes but only on the PARS. No baseline variables were found to moderate treatment outcomes on Week 12 responder status (CGI-I).

DISCUSSION

Overall, anxious children responded favorably to CAMS treatments. However, having more severe and impairing anxiety, greater caregiver strain, and a principal diagnosis of social phobia were associated with less favorable outcomes. Clinical implications of these findings are discussed.

Residential treatment of serious behavioral disturbance in autism spectrum disorder and intellectual disability

For children diagnosed with an autism spectrum disorder and/or intellectual disability, the co-occurrence of serious behavioral disturbance can pose significant health and safety risks, impede normal learning and development, and put great stress on family systems. The complexity and seriousness of the clinical concerns often tax the existing service and funding systems. Although residential treatment has been criticized as an outdated and ineffective mode of treatment, newer models of residential treatment that combine specialized comprehensive services, evidence-based interventions, intensive family support and training, and treatment overlap with community providers can offer an effective and efficient treatment option.

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.

Family voice with informed choice: coordinating wraparound with research-based treatment for children and adolescents

The wraparound process is a type of individualized, team-based care coordination that has become central to many state and system efforts to reform children's mental health service delivery for youths with the most complex needs and their families. Although the emerging wraparound research base is generally positive regarding placements and costs, effect sizes are smaller for clinical and functional outcomes. This article presents a review of literature on care coordination and wraparound models, with a focus on theory and research that indicates the need to better connect wraparound-enrolled children and adolescents to evidence-based treatment (EBT). The article goes on to describe how recently developed applications of EBT that are based on quality improvement and flexible application of "common elements" of research-based care may provide a more individualized approach that better aligns with the philosophy and procedures of the wraparound process. Finally, this article presents preliminary studies that show the feasibility and potential effectiveness of coordinating wraparound with the Managing and Adapting Practice system, and discusses intervention development and research options that are currently under way.

Effectiveness and Implementation of Evidence-Based Practices in Residential Care Settings

PURPOSE

Prompted by calls to implement evidence-based practices (EBPs) into residential care settings (RCS), this review addresses three questions: (1) Which EBPs have been tested with children and youth within the context of RCS? (2) What is the evidence for their effectiveness within such settings? (3) What implementation issues arise when transporting EBPs into RCS?

METHODS

Evidence-based psychosocial interventions and respective outcome studies, published from 1990-2012, were identified through a multi-phase search process, involving the review of four major clearinghouse websites and relevant electronic databases. To be included, effectiveness had to have been previously established through a comparison group design regardless of the setting, and interventions tested subsequently with youth in RCS. All outcome studies were evaluated for quality and bias using a structured appraisal tool.

RESULTS

Ten interventions matching a priori criteria were identified: Adolescent Community Reinforcement Approach, Aggression Replacement Training, Dialectical Behavioral Therapy, Ecologically-Based Family Therapy, Eye Movement and Desensitization Therapy, Functional Family Therapy, Multimodal Substance Abuse Prevention, Residential Student Assistance Program, Solution-Focused Brief Therapy, and Trauma Intervention Program for Adjudicated and At-Risk Youth. Interventions were tested in 13 studies, which were conducted in different types of RCS, using a variety of study methods. Outcomes were generally positive, establishing the relative effectiveness of the interventions with youth in RCS across a range of psychosocial outcomes. However, concerns about methodological bias and confounding factors remain. Most studies addressed implementation issues, reporting on treatment adaptations, training and supervision, treatment fidelity and implementation barriers.

CONCLUSION

The review unearthed a small but important body of knowledge that demonstrates that EBPs can be implemented in RCS with encouraging results.

Harnessing innovative technologies to advance children's mental health: behavioral parent training as an example

Disruptive behaviors of childhood are among the most common reasons for referral of children to mental health professionals. Behavioral parent training (BPT) is the most efficacious intervention for these problem behaviors, yet BPT is substantially underutilized beyond university research and clinic settings. With the aim of addressing this research-to-practice gap, this article highlights the considerable, but largely unrealized, potential for technology to overcome the two most pressing challenges hindering the diffusion of BPT: (1). The dearth of BPT training and supervision opportunities for therapists who work with families of children with disruptive behaviors; and (2). The failure to engage and retain families in BPT services when services are available. To this end, this review presents a theoretical framework to guide technological innovations in BPT and highlights examples of how technology is currently being harnessed to overcome these challenges. This review also discusses recommendations for using technology as a delivery vehicle to further advance the field of BPT and the potential implications of technological innovations in BPT for other areas of children's mental health are discussed.

Partial hospitalization treatment for preschoolers with severe behavior problems: child age and maternal functioning as predictors of outcome

BACKGROUND

This study focused on the behavioral functioning and treatment outcomes of preschool-aged children who attended a specialized, family focused psychiatric partial hospitalization program.

METHOD

Study data were collected between 2002 and 2007. Maternal reports of child behavioral functioning were obtained at program admission and discharge. Maternal parenting stress and psychiatric impairment were assessed at admission.

RESULTS

Children's symptom severity decreased from admission to discharge, particularly with respect to externalizing symptoms. Both child age and maternal functioning emerged as predictors of treatment outcome.

CONCLUSIONS

Specialized partial hospitalization may be an effective approach to treatment for preschool children with severe psychopathology.

Outcome domains in child mental health research since 1996: have they changed and why does it matter?

OBJECTIVE

Child mental health treatment and services research yields more immediate public health benefit when they focus on outcomes of relevance to a broader group of stakeholders. We reviewed all experimental studies of child and adolescent treatment and service effectiveness published in the last 15 years (1996-2011) and compared the distribution and types of outcome domains to a prior review that focused on studies from the prior 15 years (1980-1995).

METHOD

Studies were included if they focused on children from birth to 18 years of age with specific or general psychiatric conditions, employed randomized designs, and examined intervention effects with a six-month or longer post-treatment assessment in treatment studies or a 6-month or longer post-baseline assessment for services studies. Two hundred (n=200) studies met criteria. Reported outcome measures were coded into conceptual categories drawn from the 1980-1995 review.

RESULTS

There was a five-fold increase in the total number of studies (38 versus 200) across the two 15-year time periods, with the largest increase in the number of studies that focused on consumer-oriented outcomes (from eight to 47 studies, an almost sixfold increase); two new domains, parent symptoms and health-related outcomes, were identified. The majority of studies (more than 95%) continued to focus on symptoms and diagnoses as an outcome. Impact ratings were higher among studies examining four or more outcomes versus one to two outcomes in all categories with the exception of Posttraumatic Stress Disorder.

CONCLUSIONS

Given major shifts in health care policy affecting mental health services, the emergence of health and parent-related outcomes as well as greater attention to consumer perspectives parallels emerging priorities in health care and can enhance the relevance of child outcome studies for implementation in the real world.

Identification and management of behavioral/mental health problems in primary care pediatrics: perceived strengths, challenges, and new delivery models

This study describes the experiences of and barriers for pediatricians in Kentucky in providing behavioral/mental health (B-MH) services in primary care settings. These data will serve as a foundation for improving service delivery. An online survey was completed by 70 pediatricians. Descriptive data are presented. More than 90% of the respondents said that they saw at least one patient a month with 1 of 10 specific B-MH diagnoses. Physicians' comfort with diagnosing and treating disorders varied widely by diagnosis, age-group, and drug classification. Major barriers to providing optimal care were inaccessibility of mental health professionals for consultation and referral, lack of communication, and lack of knowledge. Respondents were more likely to favor consultation and co-location models over an integration model of care delivery. Overall, the authors found that pediatricians are dealing with patients with B-MH problems for which they may not have been adequately trained. Communication and collaboration needs were identified.