Outcomes of mental health care for children and adolescents: I. A comprehensive conceptual model

An Integrated Care Pathway for depression in adolescents: protocol for a Type 1 Hybrid Effectiveness-implementation, Non-randomized, Cluster Controlled Trial

INTRODUCTION

Our group developed an Integrated Care Pathway to facilitate the delivery of evidence-based care for adolescents experiencing depression called CARIBOU-2 (Care for Adolescents who Receive Information 'Bout OUtcomes, 2nd iteration). The core pathway components are assessment, psychoeducation, psychotherapy options, medication options, caregiver support, measurement-based care team reviews and graduation. We aim to test the clinical and implementation effectiveness of the CARIBOU-2 pathway relative to treatment-as-usual (TAU) in community mental health settings.

METHODS AND ANALYSIS

We will use a Type 1 Hybrid Effectiveness-Implementation, Non-randomized Cluster Controlled Trial Design. Primary participants will be adolescents (planned n = 300, aged 13-18 years) with depressive symptoms, presenting to one of six community mental health agencies. All sites will begin in the TAU condition and transition to the CARIBOU-2 intervention after enrolling 25 adolescents. The primary clinical outcome is the rate of change of depressive symptoms from baseline to the 24-week endpoint using the Childhood Depression Rating Scale-Revised (CDRS-R). Generalized mixed effects modelling will be conducted to compare this outcome between intervention types. Our primary hypothesis is that there will be a greater rate of reduction in depressive symptoms in the group receiving the CARIBOU-2 intervention relative to TAU over 24 weeks as per the CDRS-R. Implementation outcomes will also be examined, including clinician fidelity to the pathway and its components, and cost-effectiveness.

ETHICS AND DISSEMINATION

Research ethics board approvals have been obtained. Should our results support our hypotheses, systematic implementation of the CARIBOU-2 intervention in other community mental health agencies would be indicated.

Study protocol of a randomized trial of STRIPES: a schoolyear, peer-delivered high school intervention for students with ADHD

BACKGROUND

Youth with ADHD are at risk of academic impairments, dropping out of high school, and dysfunction in young adulthood. Interventions delivered early in high school could prevent these harmful outcomes, yet few high school students with ADHD receive treatment due to limited access to intervention providers. This study will test a peer-delivered intervention (STRIPES) for general education 9th grade students with impairing ADHD symptoms.

METHODS

A type 1 hybrid effectiveness-implementation design will be used to evaluate the effectiveness of STRIPES and explore the intervention's implementability. Analyses will test the impact of STRIPES vs. enhanced school services control on target mechanisms and determine whether differences in basic cognitive profiles moderate intervention response. The acceptability and feasibility of STRIPES and treatment moderators will also be examined.

DISCUSSION

This study will generate knowledge about the effectiveness and implementability of STRIPES, which will inform dissemination efforts in the future. A peer-delivered high school intervention for organization, time management, and planning skills can provide accessible and feasible treatment targeting declines in academic motivation, grades, and attendance during the ninth-grade year.

TRIAL REGISTRATION

This study is registered on OSF Registries (10.17605/OSF.IO/Q8V6S).

Assessing Functional Impairment in Youth: Development of the Adolescent Life Interference Scale for Internalizing Symptoms (ALIS-I)

This study described the psychometric properties of a self-report measure of functional impairment related to anxiety and depression in adolescents, the Adolescent Life Interference Scale for Internalizing symptoms (ALIS-I). A clinical sample of 266 adolescents and a community sample of 63 adolescents, aged 11 to 18 years (Mean = 14.7, SD = 1.71) completed the ALIS-I and additional measures assessing internalizing problems. Exploratory factor analyses indicated four distinct but correlated factors of life interference related to personal withdrawal/avoidance, peer problems, problems with study/work, and somatic symptoms. Reliability and retest reliability (8-12 weeks) of the total score were high and psychometric properties of the subscales were acceptable. The ALIS-I effectively discriminated between clinical and community control groups, and expected correlations were shown between ALIS-I subscales and other related symptom measures. The ALIS-I is a promising instrument for the assessment of functional impairment related to internalizing disorders in youth.

Future Directions in Youth and Family Treatment Engagement: Finishing the Bridge Between Science and Service

The field has spent more than 50 years investing in the quality of youth mental healthcare, with intervention science yielding roughly 1,300 efficacious treatments. In the latter half of this period, concurrent efforts in implementation science have developed effective methods for supporting front-line service organizations and therapists to begin to bridge the science to service gap. However, many youths and families still do not benefit fully from these strategic investments due to low treatment engagement: nearly half of youths in need of services pursue them, and among those who do, roughly another half terminate prematurely. The negative impact of low engagement is substantial, and is disproportionally and inequitably so for many. We contend that to build a robust and "finished" bridge connecting science and service, the field must go beyond its two historical foci of designing interventions and preparing therapists to deliver them, to include an intentional focus on the youths and families who participate in these interventions and who work with those therapists. In this paper, we highlight the significance of treatment engagement in youth mental healthcare and discuss the current state of the literature related to four priorities: conceptualization, theory, measurement, and interventions. Next, we offer an example from our own program of research as one illustration for advancing these priorities. Finally, we propose recommendations to act on these priorities.

E-Mental-Health aftercare for children and adolescents after partial or full inpatient psychiatric hospitalization: study protocol of the randomized controlled DigiPuR trial

Background

During reintegration to daily school life following psychiatric hospitalization, children and adolescents are confronted with various challenges and are at risk for rehospitalization. Tailored post-discharge services could support a successful readjustment and accompany the high-risk transition period after discharge. The study DigiPuR (“Digital gestützte Psychotherapie und Reintegration,” digitally supported psychotherapy and reintegration) aims to establish and to evaluate an innovative digital aftercare program to alleviate challenges during reintegration and improve cross-sectoral care.

Methods

DigiPuR is a randomized controlled trial comparing a digital aftercare service with regular aftercare (TAU) (planned N = 150, 25 children/adolescents, 25 parents, and 25 teachers in each group). In the intervention group, direct communication via secure and regular video calls until 8 weeks after discharge and a secure messenger system between the hospital, family, and school, as well as, if needed, external support systems, are established. A longitudinal pre-post-follow-up assessment at admission, discharge, and 8, 24, and 36 weeks after discharge takes place supplemented by a daily smartphone-based ambulatory assessment from a triadic perspective of patients, parents, and teachers. Primary outcomes include whether participants in the intervention group have fewer readmissions and higher treatment satisfaction and health-related quality of life as well as lower symptom severity than participants in the control group.

Discussion

The present study is essential to address the cross-sectoral challenges associated with reintegration into daily (school) life following child and adolescent psychiatric hospitalization and to determine possible needed adaptations in partial or full inpatient settings. If applicability and efficacy of the aftercare service can be demonstrated, integration into regular care will be sought.

Trial registration

ClinicalTrials.govNCT04986228. Registered on August 2, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06508-1.

Assessing the impact of mental health difficulties on young people's daily lives: protocol for a scoping umbrella review of measurement instruments

INTRODUCTION

An important consideration for determining the severity of mental health symptoms is their impact on youth's daily lives. Those wishing to assess 'life impact' face several challenges: First, various measurement instruments are available, including of global functioning, health-related quality of life and well-being. Existing reviews have tended to focus on one of these domains; consequently, a comprehensive overview is lacking. Second, the extent to which such instruments truly capture distinct concepts is unclear. Third, many available scales conflate symptoms and their impact, thus undermining much needed analyses of associations between the two.

METHODS AND ANALYSIS

A scoping umbrella review will examine existing reviews of life impact measures for use with children and youth aged 6-24 years in the context of mental health and well-being research. We will systematically search six bibliographic databases (MEDLINE, Embase, APA PsycINFO, CINAHL, Web of Science, and the COSMIN database of systematic reviews of outcome measurement instruments), and conduct systematic record screening, data extraction and charting based on methodological guidance by the Joanna Briggs Institute. Data synthesis will involve the tabulation of scale characteristics, feasibility and measurement properties, and the use of summary statistics to synthesise how these instruments operationalise life impact. The protocol was registered prospectively with the Open Science Framework (osf.io/ers48).

ETHICS AND DISSEMINATION

This study will provide a comprehensive road map for researchers and clinicians seeking to assess life impact in youth mental health, providing guidance in navigating available measurement options. We will seek to publish the findings in a leading peer-reviewed journal in the field. Formal research ethics approval will not be required.

Mental Health Surveillance Among Children - United States, 2013-2019

Mental health encompasses a range of mental, emotional, social, and behavioral functioning and occurs along a continuum from good to poor. Previous research has documented that mental health among children and adolescents is associated with immediate and long-term physical health and chronic disease, health risk behaviors, social relationships, education, and employment. Public health surveillance of children's mental health can be used to monitor trends in prevalence across populations, increase knowledge about demographic and geographic differences, and support decision-making about prevention and intervention. Numerous federal data systems collect data on various indicators of children's mental health, particularly mental disorders. The 2013-2019 data from these data systems show that mental disorders begin in early childhood and affect children with a range of sociodemographic characteristics. During this period, the most prevalent disorders diagnosed among U.S. children and adolescents aged 3-17 years were attention-deficit/hyperactivity disorder and anxiety, each affecting approximately one in 11 (9.4%-9.8%) children. Among children and adolescents aged 12-17 years, one fifth (20.9%) had ever experienced a major depressive episode. Among high school students in 2019, 36.7% reported persistently feeling sad or hopeless in the past year, and 18.8% had seriously considered attempting suicide. Approximately seven in 100,000 persons aged 10-19 years died by suicide in 2018 and 2019. Among children and adolescents aged 3-17 years, 9.6%-10.1% had received mental health services, and 7.8% of all children and adolescents aged 3-17 years had taken medication for mental health problems during the past year, based on parent report. Approximately one in four children and adolescents aged 12-17 years reported having received mental health services during the past year. In federal data systems, data on positive indicators of mental health (e.g., resilience) are limited. Although no comprehensive surveillance system for children's mental health exists and no single indicator can be used to define the mental health of children or to identify the overall number of children with mental disorders, these data confirm that mental disorders among children continue to be a substantial public health concern. These findings can be used by public health professionals, health care providers, state health officials, policymakers, and educators to understand the prevalence of specific mental disorders and other indicators of mental health and the challenges related to mental health surveillance.

A comprehensive mapping of outcomes following psychotherapy for adolescent depression: The perspectives of young people, their parents and therapists

As mental health systems move towards person-centred care, outcome measurement in clinical research and practice should track changes that matter to young people and their families. This study mapped the types of change described by three key stakeholder groups following psychotherapy for depression, and compared the salience of these outcomes with the frequency of their measurement in recent quantitative treatment effectiveness studies for adolescent depression.Using qualitative content analysis, this study identified and categorized outcomes across 102 semi-structured interviews that were conducted with depressed adolescents, their parents, and therapists, as part of a randomized superiority trial. Adolescents had been allocated to Cognitive-Behavioral Therapy, Short-Term Psychoanalytic Psychotherapy, or a Brief Psychosocial Intervention.The study mapped seven high-level outcome domains and 29 outcome categories. On average, participants discussed change in four domains and six outcome categories. The most frequently discussed outcome was an improvement in mood and affect (i.e., core depressive symptoms), but close to half of the participants also described changes in family functioning, coping and resilience, academic functioning, or social functioning. Coping had specific importance for adolescents, while parents and therapists showed particular interest in academic functioning. There was some variation in the outcomes discussed beyond these core themes, across stakeholder groups and treatment arms.Of the outcomes that were frequently discussed in stakeholder narratives, only symptomatic change has been commonly reported in recent treatment studies for adolescent depression. A shift towards considering multiple outcome domains and perspectives is needed to reflect stakeholder priorities and enable more nuanced insights into change processes.

International consensus on a standard set of outcome measures for child and youth anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder

A major barrier to improving care effectiveness for mental health is a lack of consensus on outcomes measurement. The International Consortium for Health Outcomes Measurement (ICHOM) has already developed a consensus-based standard set of outcomes for anxiety and depression in adults (including the Patient Health Questionnaire-9, the Generalised Anxiety Disorder 7-item Scale, and the WHO Disability Schedule). This Position Paper reports on recommendations specifically for anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder in children and young people aged between 6 and 24 years. An international ICHOM working group of 27 clinical, research, and lived experience experts formed a consensus through teleconferences, an exercise using an adapted Delphi technique (a method for reaching group consensus), and iterative anonymous voting, supported by sequential research inputs. A systematic scoping review identified 70 possible outcomes and 107 relevant measurement instruments. Measures were appraised for their feasibility in routine practice (ie, brevity, free availability, validation in children and young people, and language translation) and psychometric performance (ie, validity, reliability, and sensitivity to change). The final standard set recommends tracking symptoms, suicidal thoughts and behaviour, and functioning as a minimum through seven primarily patient-reported outcome measures: the Revised Children's Anxiety and Depression Scale, the Obsessive Compulsive Inventory for Children, the Children's Revised Impact of Events Scale, the Columbia Suicide Severity Rating Scale, the KIDSCREEN-10, the Children's Global Assessment Scale, and the Child Anxiety Life Interference Scale. The set's recommendations were validated through a feedback survey involving 487 participants across 45 countries. The set should be used alongside the anxiety and depression standard set for adults with clinicians selecting age-appropriate measures.

Systematic Review of Self-Report Measures of General Mental Health and Wellbeing in Adolescent Mental Health

The assessment of general mental health and wellbeing is important within child and adolescent mental health services (CAMHS) for both clinicians and policy makers. Measurement tools are routinely relied upon to aid assessment and to monitor and evaluate treatment and service effectiveness. We conducted a systematic review using the COSMIN checklist to identify measures of general mental health and wellbeing for an adolescent mental health population. A systematic database search was performed using PsychINFO, MEDLINE, EMBASE, and CINAHL in accordance with PRISMA guidelines. Database searching produced 9587 records, with 27 papers meeting eligibility criteria and 16 measures identified and critically appraised. The Y-QOL-R and the Y-QOL.30.1 had the most robust psychometric properties. When considering the clinical utility of measures alongside psychometric properties of measures, the GHQ-12, ORS and YP CORE had the greatest clinical utility. The psychometric quality of measures reviewed overall, however, were generally poor in quality. Measuring outcomes in CAMHS and ensuring appropriate treatment pathways for young people is important. This review highlights the need for more robust testing of the psychometric properties of adolescent measures. When selecting measurement tools, clinicians should not only consider the purpose of the measure, (i.e., discriminative, predictive, and evaluative) and characteristics of the instrument (e.g., intended population, measure length), but should also the quality of the psychometric properties of the instrument.

Implementing Parent-Teen Motivational Interviewing + Behavior Therapy for ADHD in Community Mental Health

Despite the promise of psychosocial interventions for adolescent Attention Deficit Hyperactivity Disorder (ADHD), there are no studies that examine their implementation in community mental health contexts. In this study, we evaluate the implementation of community-based Supporting Teens' Autonomy Daily (STAND), a parent-teen Motivational Interviewing + Behavior Therapy intervention for adolescents with ADHD. Adolescents with ADHD (N = 225), who were clients at four community mental health agencies, received treatment from 82 therapists. There was double randomization of adolescents and therapists to STAND or Usual Care (UC). Nearly all therapists randomized to STAND completed the training and regularly attended supervision, rating STAND as acceptable and lower burden than UC practices. In the STAND group, MI competence and implementation were lower than in university trials (benchmark range, 19.5% for reflection to question ratio to 83.1% for technical globals). MI integrity in the STAND group was significantly higher than UC across most MITI indices. Content fidelity was adequate in STAND's engagement and skills phases (76.4-85.0%), but not its planning phase (24.4%). Therapists commonly neglected weekly review of goals and home practice and deviated from manualized pace and sequencing of therapy tasks. Learning MI was more challenging for bilingual therapists and therapists with more years of experience. STAND was delivered with higher integrity in earlier sessions and office-based sessions. Discussion identifies future directions for exporting adolescent ADHD interventions to community settings. Patient outcome data for this trial is presented elsewhere. Trial Registration: NCT02694939 www.clinicaltrials.gov .

Review: What Outcomes Count? A Review of Outcomes Measured for Adolescent Depression Between 2007 and 2017

OBJECTIVE

Measurement of treatment outcomes in childhood depression has traditionally focused on assessing symptoms from the clinician's perspective, without exploring other outcome domains or considering young people's perspectives. This systematic review explored the extent to which multidimensional and multi-informant outcome measurements have been used in clinical research for adolescent depression in the past decade and how patterns have evolved over time.

METHOD

Embase, Medline, and PsycINFO were searched, and studies that were published from 2007 through 2017 and assessed the effectiveness of treatments or service provision for adolescent depression were included. Of 7,483 studies screened, 95 met the inclusion criteria and were included for data extraction and analysis.

RESULTS

Ten outcomes domains were identified, 2 of which were assessed on average using 4 outcome measures. Most studies (94%) measured symptoms, followed by functioning (52%). Other domains such as personal growth, relationships, quality of life, and service satisfaction were each considered by less than 1 in 10 studies. Youth self-report was considered by 54% but tended to focus on secondary outcomes. Multidimensional and multi-informant measurements were more frequent in studies published since 2015.

CONCLUSION

Recent clinical research continues to prioritize symptoms measurement based on clinician report and has not yet fully embraced multidimensional and multi-informant approaches. In the context of significant policy shifts toward patient-centered and evidence-based care, measuring what matters most to patients has become a priority, but this is not yet widely reflected in clinical research.

Latino Family Participation in Youth Mental Health Services: Treatment Retention, Engagement, and Response

Although researchers have identified a multitude of factors that contribute to family participation in mental health services, few studies have examined them specifically for Latino youth and their families in the U.S., a population that continues to experience significant disparities related to the availability, accessibility, and quality of mental health services. Latino youth and their families are at greater risk of dropping out of treatment prematurely and demonstrating poor treatment engagement, both of which have subsequent negative effects on treatment response outcomes. In order to help to guide efforts to improve the accessibility and quality of mental health services for Latino youth and their families, the current paper integrates modern conceptualization of family participation in youth mental health services and provides a summary of contextual factors within an ecological framework (Bronfenbrenner in The ecology of human development: experiments by nature and design, Harvard University Press, Cambridge, 1979). The current review aims to integrate empirical research on the impact of various contextual factors across multiple levels (i.e., culture, community, mental health system, family, parent/caregiver, and child/adolescent) on Latino family participation in youth mental health services, including treatment retention, engagement, and response. Clinical implications will be discussed, and an integrated, conceptual model will be presented. Not only does this model help to demonstrate the way in which existing literature is conceptually linked, but it also helps to highlight factors and underlying processes that health care providers, administrators, and policy makers must consider in working to improve mental health services for Latino youth and their families living in the U.S.

Capitalizing on Scientific Advances to Improve Access to and Quality of Children's Mental Health Care

The majority of mental health problems begin in childhood or adolescence. The potential benefits of early identification and treatment of such problems are well established, and models of effective mental health interventions for children have proliferated in recent decades. However, barriers in access to care and challenges in assuring delivery of high-quality care significantly limit the public health impact of services for children and families. Specifically, the majority of children who need mental health care do not receive it, and when children are in care, many do not receive interventions that are most likely to have the greatest positive impact. A commitment to social justice requires significant improvement in access to care and quality of care to maximize human potential. The purpose of this manuscript is to highlight promising scientific advances in the development of effective mental health services for children and families, as well as the vexing challenges of actually delivering these services to those most in need. Key challenges to be discussed include disparities in access to care and quality of care, including race/ethnic disparities and complexities of navigating the multi-sector mental health service system for children, and difficulties in implementing effective intervention models more consistently in community care. The authors will propose practice and policy reform recommendations to address these challenges. Copyright © 2017 John Wiley & Sons, Ltd.

Can the Health of the Nation Outcome Scales for Children and Adolescents predict the necessity of inpatient stay during assertive community treatment?

Understanding the trajectories of youths within Child and Adolescents Mental Health Service (CAMHS) is of primary importance. Our objective is to assess the usefulness of the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) to predict inpatient (IP) stay for youths followed by assertive community treatment (ACT) teams. 82 youths followed exclusively by ACT and 42 who needed IP were assessed with the HoNOSCA at admission to the program. The HoNOSCA allowed the computing of three scores: a total score, an externalizing symptoms (Ext) score and an emotional problems (Emo) score. Logistic regressions revealed that the three HoNOSCA scores at admission of ACT predicted later need for hospitalization. Using ROC curve analyses, we set up cut off scores with appropriate sensitivity and specificity for the HoNOSCA Total and Ext to optimally predict the need for hospitalization. This study revealed that the HoNOSCA may be a useful tool to predict the need for later IP during ACT. Such knowledge is important to set up the best therapeutic strategies.

A Program Evaluation Strategy in a Community-Based Behavioral Health and Education Services Agency for Children and Families

Evaluation research and outcomes measurement in the arena of behavioral health services for children must be adapted for the community agency setting. Through evaluation research, it is possible to address service goals as well as more traditional academic research goals. This article examines a variety of activities that have been implemented to evaluate children’s behavioral and educational services in a Northern California non-profit community agency. It is noted that there are multiple formats for collecting information from and providing comments to children’s parents, their clinicians, and program administration staff, all of which can be used to effectively address service-focused evaluation research goals. Challenges to doing scientifically rigorous research in a community setting require additional considerations regarding organizational culture and structure. Based on the experiences of the authors and the experiences of others, the article describes general principles that can guide evaluation research and outcomes measurement with children and their families in the community health agency setting.

Evidence Base Update: 50 Years of Research on Treatment for Child and Adolescent Anxiety

Anxiety disorders are the most common mental health disorder among children and adolescents. We examined 111 treatment outcome studies testing 204 treatment conditions for child and adolescent anxiety published between 1967 and mid-2013. Studies were selected for inclusion in this review using the PracticeWise Evidence-Based Services database. Using guidelines identified by this journal (Southam-Gerow & Prinstein, 2014), studies were included if they were conducted with children and/or adolescents (ages 1-19) with anxiety and/or avoidance problems. In addition to reviewing the strength of the evidence, the review also examined indicators of effectiveness, common practices across treatment families, and mediators and moderators of treatment outcome. Six treatments reached well-established status for child and adolescent anxiety, 8 were identified as probably efficacious, 2 were identified as possibly efficacious, 6 treatments were deemed experimental, and 8 treatments of questionable efficacy emerged. Findings from this review suggest substantial support for cognitive-behavioral therapy (CBT) as an effective and appropriate first-line treatment for youth with anxiety disorders. Several other treatment approaches emerged as probably efficacious that are not primarily CBT based, suggesting that there are alternative evidence-based treatments that practitioners can turn to for children and adolescents who do not respond well to CBT. The review concludes with a discussion of treatments that improve functioning in addition to reducing symptoms, common practices derived from evidence-based treatments, mediators and moderators of treatment outcomes, recommendations for best practice, and suggestions for future research.

The unknown citizen: epidemiological challenges in child mental health

Growing concern about the global burden of child mental health disorders has generated an increased interest in population-level efforts to improve child mental health. This in turn has led to a shift in emphasis away from treatment of established disorders and towards prevention and promotion. Prevention efforts are able to draw on a substantial epidemiological literature describing the prevalence and determinants of child mental health disorders. However, there is a striking lack of clearly conceptualised and measurable positive outcomes for child mental health, which may result in missed opportunities to identify optimal policy and intervention strategies. In this paper, we propose an epidemiological approach to child mental health which is in keeping with public health principles and with the WHO definition of health, and which is grounded in current thinking about child development. Constructs such as competence offer the opportunity to develop rigorous outcome measures for epidemiological research, while broader ideas about 'the good life' and 'the good society' derived from philosophical thinking can enable us to shape policy initiatives based on normative ideas of optimal child mental health that extend beyond individuals and undoubtedly beyond the traditional boundaries of the health sector.

Consistency with evidence-based treatments and perceived effectiveness of children's community-based care

This study examined whether delivery of psychotherapeutic strategies consistent with common elements of evidence-based (EB) treatments for child disruptive behavior problems was associated with parents' report of treatment effectiveness. The intensity of delivery of practice elements consistent with EB treatments was coded from a random sample of 538 videotaped psychotherapy sessions with 157 children/families and 75 therapists from six community-based clinics. Multilevel regression analyses tested whether intensity of EB practice elements was associated with parents' report of treatment effectiveness after 4 months, controlling for intensity of other practice elements. Results indicate parents reported greater perceived treatment effectiveness when community-based treatment included more intensive delivery of practice elements consistent with EB treatments to children. These findings may reassure providers about the acceptability of EB practice elements and may motivate efforts to integrate EB practice elements more intensively into community-based care.

Depression and anxiety in adolescents with pediatric-onset spinal cord injury

BACKGROUND

Little is known about depression and anxiety in adolescents with spinal cord injury (SCI).

OBJECTIVE

To examine how depression, anxiety, suicidal ideation, and usage of treatment differ by age and sex among adolescents with SCI.

METHOD

Youth 12 to 18 years old who had acquired SCI at least 1 year prior were recruited from 3 specialty hospitals. They completed the Children's Depression Inventory (ages 12-17 years) or Beck Depression Inventory-II (18 years), and Revised Children's Manifest Anxiety Scale (12-18 years). Analyses assessed differences between younger and older adolescents and between males and females.

RESULTS

The 236 participants were an average age of 15.58 years (SD 1.98), 58% were male, and 60% Caucasian. Average age at injury was 10.57 years (SD 5.50), and 62% had paraplegia. For depression, 5.5% of adolescents ages 12 to 17 years exceeded the clinical cutoff and 12.7% of 18-year-old adolescents fell into a range of moderate or severe depression. For anxiety, 10.6% of adolescents ages 12 to 18 years exceeded the clinical cutoff. Univariate results revealed that older adolescents were more depressed than younger adolescents, and girls were more anxious than boys. An interaction between sex and age emerged, in that older adolescent girls were significantly more anxious than other youth. Older adolescents were also more likely to be taking medications for emotional, psychological, or behavioral reasons. Reports of suicidal ideation did not differ by adolescent age or sex.

CONCLUSION

For these adolescents, depression differed with age, and anxiety differed based on age and sex. Implications for intervention include early identification and treatment for struggling adolescents.

Adolescent psychotherapy outcomes in community mental health: how do symptoms align with target complaints and perceived change?

This study examined the relationship between clinically significant symptom change (rated by youth and parents), severity of client-defined primary presenting problems (i.e., Target Complaints), and perceived change in therapy. Participants were 117 adolescents receiving outpatient therapy and their parents. Participants completed the following measures at intake and 3 months into treatment: Ohio Scales, Target Complaints, and Perceived Change. Results indicate significant correspondence between clinically significant symptom change and other outcomes, offering preliminary evidence that global symptom measures represent change that is meaningful to adolescent clients. However, the modest magnitude of the correspondence also suggests that such measures as perceived change and individualized Target Complaints may offer unique utility in capturing the multidimensional nature of outcomes in youth therapy and provide useful avenues for future research focused on enhancing client engagement and retention. Recommendations for outcome assessment in community mental health centers are provided.

Outcomes of child psychiatric treatment

OBJECTIVE

The aim of this study was to investigate outcomes of child psychiatric outpatient treatment as usual and to identify outcome predictors, with special regard to attention-deficit/hyperactivity disorder (ADHD), mood disorder, obsessive-compulsive disorder and conduct disorder.

METHOD

Routinely collected data from 12 613 outpatients between July 2006 and January 2010 in Stockholm, Sweden were analysed. The outcome measure was change in Children's Global Assessment Scale (CGAS) ratings between first visit and case closure (∆CGAS).

RESULTS

CGAS improved during the course of treatment across all diagnostic groups, ranging from a mean change of 4 (mental retardation) to 16 (suicide attempts). ∆CGAS was two times higher in the mood disorder group compared with the ADHD group. In the mood disorder group, several psychotherapies were associated with better outcome but not medication. In the ADHD group, psychotherapeutic interventions were also associated with better outcome, but those who received treatment with central stimulants received less non-medical interventions.

CONCLUSION

Whereas the functional impairment and the level of improvement in mood disorder corresponded to previous efficacy studies, the ADHD patients were more impaired and improved less after treatment. This should prompt a critical discussion as to whether ADHD patients receive the best available treatment in CAMHS in Stockholm and elsewhere.

A comparison of seminar and computer based training on the accuracy and reliability of raters using the Children's Global Assessment Scale (CGAS)

The aim of this study was to compare two methods to conduct CGAS rater training. A total of 648 raters were randomized to training (CD or seminar), and rated five cases before and 12 months after training. The ICC at baseline/end of study was 0.71/0.78 (seminar), 0.76/0.78 (CD), and 0.67/0.79 (comparison). There were no differences in training effect in terms of agreement with expert ratings, which speaks in favor of using the less resource-demanding CD. However, the effect was modest in both groups, and untrained comparison group improved of the same order of magnitude, which proposes more extensive training.

Children First

Although the importance of healthy mental development in children and youth is not disputed, the mental health needs of far too many Canadian children are being ignored. Within the context of recent federal and provincial calls for systemic reform of the mental health care systems for children and youth, we underscore the necessity for ongoing innovation, development, education, and evaluation. This article describes our aims to establish demonstration and research sites focused on promising frameworks that draw from systems of care, public health, and resiliency approaches.

Parent and family impact of autism spectrum disorders: a review and proposed model for intervention evaluation

Raising a child with an autism spectrum disorder (ASD) can be an overwhelming experience for parents and families. The pervasive and severe deficits often present in children with ASD are associated with a plethora of difficulties in caregivers, including decreased parenting efficacy, increased parenting stress, and an increase in mental and physical health problems compared with parents of both typically developing children and children with other developmental disorders. In addition to significant financial strain and time pressures, high rates of divorce and lower overall family well-being highlight the burden that having a child with an ASD can place on families. These parent and family effects reciprocally and negatively impact the diagnosed child and can even serve to diminish the positive effects of intervention. However, most interventions for ASD are evaluated only in terms of child outcomes, ignoring parent and family factors that may have an influence on both the immediate and long-term effects of therapy. It cannot be assumed that even significant improvements in the diagnosed child will ameliorate the parent and family distress already present, especially as the time and expense of intervention can add further family disruption. Thus, a new model of intervention evaluation is proposed, which incorporates these factors and better captures the transactional nature of these relationships.

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.

Multidimensional Treatment Foster Care: An Alternative to Residential Treatment for High Risk Children and Adolescents

This paper describes the Multidimensional Treatment Foster Care program (MTFC), an evidence based approach for providing psychotherapeutic treatment for very troubled children and adolescents that is an alternative to residential care. Versions of the MTFC program have been developed and validated for young children with a history of maltreatment as well as for older children and adolescents who are involved with the youth justice system. In the paper we describe the development of the MTFC program and its foundations in the social learning model that originated at the Oregon Social Learning Center in the 1960's and 70's. We present information about program elements. We then review the research that has been conducted on MTFC.

Children, adolescents and their carers' expectations of child and adolescent mental health services (CAMHS)

BACKGROUND

The use of service users' views as performance indicators highlights the trend to make services more responsive to patients' needs. However, recent research indicates that there is a lack of clear understanding about specialist CAMHS and the outcomes that children, adolescents and their parents hope to achieve from treatment differ.

AIMS

To explore children/young people's and parents/carers' expectations of CAMHS in Leicestershire, England.

METHODS

Sixty children/young people and their parents/carers were asked to identify goals they want to achieve following contact with CAMHS. Qualitative thematic analysis in relation to Hoagwood's SFCES model (Symptoms, Functional, Consumer perspectives, Environment and Systems) was used.

RESULTS

The question was answered by 46.7% of children and young people and 60% of carers. Overall, children, young people and parents/carers agreed that symptomatic modification and functional aspects were the most important goals. However, internalising items seemed more important for parents/carers than children and adolescents, who in contrast hoped for improvement in externalising factors. Goals outside the scope of CAMHS were also noted for both groups.

CONCLUSION

Attention to children/young people and their parents/carers' expectations of services is needed to improve therapeutic relationships and engagement. Improvement in mental health literacy and practitioners' guidance is required to allow service users to set realistic and achievable treatment goals.

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.

Examining Outcomes of Acute Psychiatric Hospitalization among Children

Within the past two decades, few studies have examined outcomes of acute psychiatric hospitalization among children, demonstrating change in emotional and behavioral functioning. A secondary analysis of pre-test/post-test data collected on 36 children was conducted, using the Target Symptom Rating (TSR). The TSR is a 13-item measure with two subscales - Emotional Problems and Behavioral Problems and was designed for evaluation of outcome among children and adolescents in acute inpatient psychiatric settings. Results of this study, its limitations, and the barriers encountered in the implementation of the TSR scale as part of routine clinical practice are discussed.

Toward the integration of education and mental health in schools

Education and mental health integration will be advanced when the goal of mental health includes effective schooling and the goal of effective schools includes the healthy functioning of students. To build a solid foundation for this reciprocal agenda, especially within the zeitgeist of recent educational reforms, a change in the fundamental framework within which school mental health is conceptualized is needed. This change involves acknowledging a new set of priorities, which include: the use of naturalistic resources within schools to implement and sustain effective supports for students' learning and emotional/behavioral health; inclusion of integrated models to enhance learning and promote health; attention to improving outcomes for all students, including those with serious emotional/behavioral needs; and strengthening the active involvement of parents. A strong research agenda to support these new priorities is essential.

A framework for measurement feedback to improve decision-making in mental health

The authors present a multi-level framework for conceptualizing and designing measurement systems to improve decision-making in the treatment and prevention of child and adolescent mental health problems as well as the promotion of well-being. Also included is a description of the recommended drivers of the development and refinement of these measurement systems and the importance of the architecture upon which these measurement systems are built. The authors conclude with a set of recommendations for the next steps for the field.

Development and evaluation of the Social Anxiety and Depression Life Interference-24 (SADLI-24) inventory

We describe the development of a new self-report instrument, the Social Anxiety and Depression Life Interference-24 (SADLI-24) inventory. We initially retained 30 content specific items for the instrument (Study 1). In Study 2 (N = 438), we established a 2-factor solution, Social Anxiety Life Interference-12 (SALI-12) and Depression Life Interference-12 (DLI-12). We also examined estimates of known-groups and concurrent validity. Confirmatory factor analysis in Study 3 (N = 430) provided support for the oblique two-factor structure. In Study 4 (N = 179), we provided additional support for estimates of known-groups validity. In Study 5 (N = 63), we evaluated estimates of test-retest reliability. Both SADLI-24 scale scores showed good estimates of internal consistency.

Does cognitive behavioral therapy for youth anxiety outperform usual care in community clinics? An initial effectiveness test

OBJECTIVE

Most tests of cognitive behavioral therapy (CBT) for youth anxiety disorders have shown beneficial effects, but these have been efficacy trials with recruited youths treated by researcher-employed therapists. One previous (nonrandomized) trial in community clinics found that CBT did not outperform usual care (UC). The present study used a more stringent effectiveness design to test CBT versus UC in youths referred to community clinics, with all treatment provided by therapists employed in the clinics.

METHOD

A randomized controlled trial methodology was used. Therapists were randomized to training and supervision in the Coping Cat CBT program or UC. Forty-eight youths (56% girls, 8 to 15 years of age, 38% Caucasian, 33% Latino, 15% African-American) diagnosed with DSM-IV anxiety disorders were randomized to CBT or UC.

RESULTS

At the end of treatment more than half the youths no longer met criteria for their primary anxiety disorder, but the groups did not differ significantly on symptom (e.g., parent report, eta-square = 0.0001; child report, eta-square = 0.09; both differences favoring UC) or diagnostic (CBT, 66.7% without primary diagnosis; UC, 73.7%; odds ratio 0.71) outcomes. No differences were found with regard to outcomes of comorbid conditions, treatment duration, or costs. However, youths receiving CBT used fewer additional services than UC youths (χ(2)(1) = 8.82, p = .006).

CONCLUSIONS

CBT did not produce better clinical outcomes than usual community clinic care. This initial test involved a relatively modest sample size; more research is needed to clarify whether there are conditions under which CBT can produce better clinical outcomes than usual clinical care. CLINICAL TRIAL REGISTRY INFORMATION: Community Clinic Test of Youth Anxiety and Depression Study, URL: http://clinicaltrials.gov, unique identifier: NCT01005836.

Changes in maltreated children's emotional-behavioral problems following typically provided mental health services

Child welfare agencies serve as gate keepers for children's mental health services (MHS). Yet, the impact of offered services on behavioral outcomes has not been well studied. Data from the National Survey of Child and Adolescent Well-Being (NSCAW) were examined to measure caregivers' reported change in children's emotional-behavioral problems. Over 600 children in three age groups were matched and problem levels compared across 3 years. Although behavioral problems for the total group improved across time, scores for children who received MHS slightly worsened. Children who received MHS scored 1.4-3.7 points worse than children who did not receive MHS. Additionally, young Black, Hispanic, and other racially identified children had more problems than young White children, regardless of service. Higher behavior problem scores were noted for school-age children and adolescents. Although child welfare appears to rely on a cluster of MHS, including school-based counseling and private practitioner services, future service delivery should expand from improving access to achieving outcomes.

Cognitive-behavioral therapy versus usual clinical care for youth depression: an initial test of transportability to community clinics and clinicians

Community clinic therapists were randomized to (a) brief training and supervision in cognitive-behavioral therapy (CBT) for youth depression or (b) usual care (UC). The therapists treated 57 youths (56% girls), ages 8-15, of whom 33% were Caucasian, 26% were African American, and 26% were Latino/Latina. Most youths were from low-income families and all had Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) depressive disorders (plus multiple comorbidities). All youths were randomized to CBT or UC and treated until normal termination. Session coding showed more use of CBT by CBT therapists and more psychodynamic and family approaches by UC therapists. At posttreatment, depression symptom measures were at subclinical levels, and 75% of youths had no remaining depressive disorder, but CBT and UC groups did not differ on these outcomes. However, compared with UC, CBT was (a) briefer (24 vs. 39 weeks), (b) superior in parent-rated therapeutic alliance, (c) less likely to require additional services (including all psychotropics combined and depression medication in particular), and (d) less costly. The findings showed advantages for CBT in parent engagement, reduced use of medication and other services, overall cost, and possibly speed of improvement--a hypothesis that warrants testing in future research.

The Child and Adolescent Symptom Inventory-Progress Monitor: a brief Diagnostic and Statistical Manual of Mental Disorders, 4th edition-referenced parent-report scale for children and adolescents

The Child and Adolescent Symptom Inventory-Progress Monitor-Parent Form (CASI-PM-P) is a 29-item rating scale designed to evaluate symptom change for commonly referred child and adolescent disorders. Its intended applications include monitoring longer-term changes in clinical status and assessing intervention responsiveness. To enhance practicality, there is one version of the CASI-PM-P for all age groups with a common set of norms for both genders. Scoring procedures allow clinicians to assess whether observed symptom changes exceeded chance fluctuations. Using a clinical sample of 2,693 children ages 3-17 years, the 29 symptom-related items were identified that had the best item-to-total minus item correlations on the three age-appropriate scales of the Symptom Inventories. Item-to-total minus item correlations of similar magnitude were also obtained for those items with the standardization sample. In clinical samples, the CASI-PM-P scores had both high levels of internal consistency and test-retest reliability and were sensitive to change in a treated sample. Collectively, the findings support the reliability and validity of the CASI-PM-P as a measure of behavioral change in clinical settings, while continued research will be necessary to improve clinical utility and provide better documentation of the scale's strengths and weaknesses.

Developing a new system to measure outcomes in a service coordination program for youth with severe emotional disturbance

This paper presents information on re-developing an outcome evaluation for a state-funded program providing service coordination utilizing wraparound to youth with severe emotional disturbance (SED) and their families. Originally funded by the Robert Wood Johnson Foundation, the Kentucky IMPACT program has existed statewide since 1990. Changing data needs and limitations of the original evaluation required revamping the program's data collection system. The new evaluation uses the extant knowledge base to improve: (1) design, (2) measures, and (3) utility. A pre-post design with multiple follow-ups provides the framework for data collection. An ecological framework provides a conceptual structure for selecting measures focusing on both the service recipients and their environment. Data collection via a personal digital assistant (PDA) ensures utility of the data for both consumers and researchers. Issues ranging from conceptualization to implementation of the project as well as lessons learned are discussed.

The Brief Child and Family Phone Interview (BCFPI): 1. Rationale, development, and description of a computerized children's mental health intake and outcome assessment tool

BACKGROUND

This study describes the development of the Brief Child and Family Phone Interview (BCFPI) - a computer-assisted telephone interview which adapts the revised Ontario Child Health Study's (OCHS-R) parent, teacher, and youth self-report scales for administration as intake screening and treatment outcome measures in children's mental health services. It focuses on the factor structure of the BCFPI's hypothesized parent-reported child mental health scales describing attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), separation anxiety disorder (SAD), generalized anxiety disorder (GAD), and major depression (MDD).

METHODS

Data for the analysis come from an OCHS-R measurement study that included two groups of children and adolescents selected from the same urban area: a general population sample (n = 1,712) and a clinic-referred sample (n = 1,512); and a third sample that was enlisted in a province-wide implementation study of clinic-referred 6- to 18-year-olds (n = 56,825). We used confirmatory factor analysis to assess the factor structure of the BCFPI scales in different populations and to test measurement equivalence across selected groups.

RESULTS

Despite the strong constraints imposed on the measurement models, estimates of model fit across the three samples were comparable in magnitude and approached the cut-offs suggested for the GFI and CFI (>.9) and RMSEA (<.05). Measurement equivalence was demonstrated between the OCHS-R clinic and provincial implementation samples. Within the implementation sample, the factor structure of the BCFPI scales was equivalent for boys versus girls and for 6- to 12- versus 13- to 18-year-olds. A companion paper examines the test-retest reliability, sensitivity, specificity, and validity of these BCFPI scales when used for screening.

CONCLUSION

This project supports the feasibility and acceptability of a computer-assisted telephone interview for assessing emotional-behavioral problems of children and adolescents referred to children's mental health services.

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

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