Improving the Transportability of CBT for Internalizing Disorders in Children

Research provides strong support for the efficacy and effectiveness of cognitive behavioral therapy (CBT) for the treatment of childhood internalizing disorders. Given evidence for limited dissemination and implementation of CBT outside of academic settings, efforts are underway to improve its transportability so that more children with mental health needs may benefit from treatment. Creative modifications to existing treatments aim to deliver CBT for anxiety disorders and depression in a more transportable format. Notable progress has been made within the areas of computerized CBT, camp-based CBT, school-based CBT, and CBT delivered through primary care settings. These approaches are discussed within the context of key elements of transportability that are particularly germane to the dissemination and implementation of child treatments.     

Pilot Evaluation of a Tablet-Based Application to Improve Quality of Care in Child Mental Health Treatment

Mental health systems need scalable solutions that can reduce the efficacy–effectiveness gap and improve mental health outcomes in community mental health service settings. Two major challenges to delivery of high-quality care are providers’ fidelity to evidence-based treatment models and children’s and caregivers’ engagement in the treatment process. We developed a novel, tablet-based application designed to enhance via technology the quality of delivery of trauma-focused cognitive-behavioral therapy (TF-CBT). We piloted its use in four community mental health service organizations using a blocked randomized controlled trial to examine the feasibility of implementing tablet-facilitated TF-CBT versus standard TF-CBT with 13 providers and 27 families. Provider fidelity and child engagement in treatment were observationally measured via session audio recording. Parent and child perceptions of the tablet application were assessed using structured interviews and mixed-method analyses. Providers actively and appropriately used tablet TF-CBT to facilitate treatment activities. Providers and families expressed high satisfaction with its use, demonstrating acceptability of this approach. Youth and caregivers in both conditions reported high alliance with their providers. Overall, we found that tablet-facilitated treatment is accepted by providers and families and may be integrated into mental health treatment with minimal training. Further study is needed to examine the extent to which technology-based applications may enhance the reach, quality, and clinical outcomes of mental health treatment delivered to children and families.     

Evidence-based assessment of depression in adults

From diverse perspectives, there is little doubt that depressive symptoms cohere to form a valid and distinct syndrome. Research indicates that an evidence-based assessment of depression would include (a) measures with adequate psychometric properties; (b) adequate coverage of symptoms; (c) adequate coverage of depressed mood, anhedonia, and suicidality; (d) an approach to suicidality that distinguishes between resolved plans and preparations and desire and ideation; (e) assessment of the atypical, seasonal, and melancholic subtypes; (f) parameters of course and chronicity; and (g) comorbidity and bipolarity. These complexities need to be accounted for when certain assessment approaches are preferred, and when ambiguity exists regarding the categorical versus dimensional nature of depression, and whether and when clinician ratings outperform self-report. The authors conclude that no one extant procedure is ideal and suggest that the combination of certain interviews and self-report scales represents the state of the art for evidence-based assessment of depression.     

Cognitive-behavioral treatment of childhood obsessive-compulsive disorder in community-based clinical practice: clinical significance and benchmarking against efficacy

Objective

To evaluate the feasibility and outcomes of evidence-based (EB) manualized, cognitive-behavioral treatment (CBT) for childhood obsessive-compulsive disorder (OCD), when delivered in an outpatient community-based specialist clinic.

Method

This study, conducted in an outpatient private clinic in South-East Queensland Australia, involved thirty-three children and adolescents with OCD. Children were assessed at pre- and post-treatment, by means of diagnostic interviews, symptom severity interviews, and self-report. Treatment involved 12 sessions CBT delivered either individually or in small groups and included parental involvement.

Results

Manualized CBT could be transported to the community setting effectively, with 63% of the current sample responding positively, based on post-treatment diagnosis. Significant change was evident across a wide-range of outcomes; including, diagnostic severity, symptom severity, child reported depression and anxiety, and both child and parent reported OCD functional impairment.

Conclusions

This study provides evidence for the transportability of manualized CBT in clinical community practice for pediatric OCD. The next important step is larger community based dissemination and effectiveness studies to advance both research and clinical practice outcomes.     

The Association Between Reflective Functioning and Parent–Child Relationship Quality

Research consistently links adult and infant attachment styles, yet the means by which attachment is transmitted is relatively elusive. Recently, attention has been directed to the psychological underpinnings of caregiver sensitivity—originally thought to be the mechanism of transmission—as indicated by caregivers’ ability to keep in mind children’s mental states when interpreting children’s behavior, or reflective functioning. Unfortunately for researchers, extant measures of reflective functioning are time-consuming and require extensive observation and coding. A self-report measure could help facilitate the study and assessment of reflective functioning in research and clinical settings. This study investigated the relationship between parental reflective functioning and multiple aspects of the parent–child relationship, by using a new, self-report measure of reflective functioning. Participants were 79 caregivers (M _age = 31.8 years) who completed self-report measures assessing reflective functioning, parent–child relationship characteristics, perceived rejection in early relationships, attachment anxiety and avoidance in current close relationships, depression, and substance use. The results indicated that reflective functioning is a strong predictor of parent–child relationship quality (i.e., parental involvement, communication, parent satisfaction, limit setting, and parental support), independent of other potential indicators. Findings support parental reflective functioning as a contributor to the quality of parent–child relationship and suggest that a parent’s capacity to reflect on the mental states of his or her child in parent–child interactions may provide a key target for interventions that aim to improve parent–child relationships.     

Angststörungen und Phobien im Kindes- und Jugendalter

Anxiety disorders belong to the most frequent mental disorders in childhood and adolescence. They cause severe impairment, show poor long-term outcome and they are often not recognized as a mental disorder. For a reliable and valid diagnosis and treatment outcome evaluation a multi-informant approach is essential including information from the child and the parents. Methods of choice are structured clinical interviews and questionnaires filled out by the child and the parents. Meta-analyses showed that only cognitive-behavioral treatment can be considered as a sufficiently evidence-based treatment. No differences in outcome were found between individual and group treatments or child and family focused treatments. Medication treatment with selective serotonin reuptake inhibitor (SSRI) showed short-term efficacy. Major evidence-based interventions are psycho-education, exposure techniques and cognitive restructuring strategies.     

Psychometric properties of the Dominic interactive assessment: a computerized self-report for children

The reliability and validity of the Dominic Interactive (DI) assessment were evaluated. The DI is a computerized self-report measure for children, which assesses symptom presence for seven DSM-IV diagnoses. The participants were 322 children (169 cocaine exposed, 153 non-cocaine exposed) who were recruited at birth for a prospective longitudinal study. At 6 years of age, measures of self-report, parent report, and observational data were collected. Moderate to excellent internal consistencies on the DI were found for the total sample as well as for subsamples based on cocaine status and gender. Concurrent validity correlations between DI scales and the Child Behavior Checklist, Affect in Play Scale, a modified Conners's Teachers Rating Scale, and the Parenting Stress Index were examined. Significant relationships among scales were more apt to be among comparisons that assessed externalizing behaviors. Overall, low correlations were obtained, which are comparable to other studies that evaluate agreement between child and parent report of behaviors.     

Community Implementation of MI-Enhanced Behavior Therapy for Adolescent ADHD: Linking Fidelity to Effectiveness

Evidence-based behavior therapy for adolescent ADHD faces implementation challenges in real-world settings. The purpose of this trial was to investigate the relationship between implementation fidelity and outcomes among adolescents receiving services in the active treatment arm (N = 114; Motivational Interviewing [MI]-enhanced parent-teen behavior therapy) of a community-based randomized trial of adolescent ADHD treatment. Participants received therapy from community clinicians (N = 44) at four agencies in a large, ethnically diverse metropolitan setting. Therapists provided self-report of session-by-session adherence to content fidelity checklists and audio recordings of sample sessions that were coded for MI integrity. Parents provided report of ADHD symptoms and family impairment at baseline, posttreatment, and follow-up, while academic records were obtained directly from the local school district. Results indicated that content fidelity significantly waned across the 10 manualized sessions (d = -1.23); these trends were steepest when therapy was delivered outside the office-setting and parent attendance was low. Community therapist self-report of content fidelity predicted significantly greater improvements in academic impairment from baseline to follow-up. MI delivery quality was not associated with improved outcomes; contrary to hypotheses, lower MI relational scores predicted significantly greater improvements in family impairment over time. Findings indicate that community-based outcomes for evidence-based ADHD treatment are enhanced when treatment is implemented with fidelity. Future work should revise community-based implementation strategies for adolescent ADHD treatment to prevent declines in fidelity over time, thereby improving outcomes.     

Development and Implementation of a Transdiagnostic,Stepped-Care Approach to Treating Emotional Disorders in Children via Telehealth

Stepped-care interventions may increase the accessibility of evidence-based treatments but remain relatively underexplored in the child mental health literature. Further, while the feasibility and efficacy of stepped-care interventions have been examined for specific diagnoses or classes or disorders, transdiagnostic stepped-care interventions have not yet been developed. We discuss the development and initial implementation of a transdiagnostic approach to emotional disorders using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C; Ehrenreich-May et al., 2018). A case series is presented to illustrate the delivery of UP-C stepped care (UPC-SC) via telehealth, using a collaborative decision-making process to inform step-up/step-down decisions. Lessons learned are discussed to guide refinements of UPC-SC and inform a larger trial.     

Activating Veterans Toward Sources of Reward: A Pilot Report on Development,Feasibility, and Clinical Outcomes of a 12-Week Behavioral Activation Group Treatment

This pilot study evaluates a 12-week group Behavioral Activation protocol adapted to meet the needs of a Veteran population seeking treatment in an outpatient mental health clinic at a Veteran Affairs Medical Center. In a detailed Method we describe the treatment structure. Acceptability and feasibility are addressed by providing data on referral sources, treatment retention, attendance, and patient satisfaction. Initial clinical outcomes are presented, focusing on symptom reduction, improved quality of life, and changes in the hypothesized mechanism of treatment: improving motivated behavior to pursue rewards (decisional anhedonia). Finally, feedback from individual exit interviews is presented. We conclude with implementation tips and challenges in the service of continuing to improve our evidence-based interventions in Veteran Affairs facilities.     

Mental health assessment of infants,toddlers, and preschoolers in a service program and a treatment outcome research program

This article describes the mental health assessment in preparation for treatment conducted in two University-based clinical programs that offer dyadic child-parent psychotherapy as the treatment modality. The Infant-Parent Program is a mental health program serving children between birth and 3 years of age and their families when the parent-child relationship is jeopardized by risk factors in the parent, child, or family circumstances. The Child Trauma Research Project is an intervention outcome research program serving preschool- aged children and their mothers when the child witnessed domestic violence. The programs share a similar assessment approach emphasizing the importance of a working alliance, spontaneous parental reports, and observation of child-parent interaction in a variety of settings. However, their different functions in terms of clinical service and research dictate appropriate modifications in their respective assessment procedures. The two assessment protocols and their rationale will be described in the context of the clinical and research goals of the programs. © 1997 Michigan Association for Infant Mental Health     

Computer-administered interviews and rating scales

To evaluate the value of computer-administered interviews and rating scales, the following topics are reviewed in the present article: (a) strengths and weaknesses of structured and unstructured assessment instruments, (b) advantages and disadvantages of computer administration, and (c) the validity and utility of computer-administered interviews and rating scales. Computer-administered evaluations are more comprehensive and reliable and less biased than evaluations routinely conducted in clinical practice. Also, the use of continuous monitoring systems, which increasingly entail the use of computer administration, has been related to improved treatment outcome. However, the use of computer-administered interviews and rating scales will sometimes lead to false positive diagnoses, and for this reason, it is recommended that computer assessment be combined with clinical judgment.     

Clinician Perspectives of Diagnosis and Perceived Client Change in “Real World” Psychotherapy for Youth Emotional and Behavioral Disorders

We investigated the extent to which clinician-assigned diagnoses of emotional and behavioral disorders and clinicians’ perceptions of client change are consistent with structured measures of youth clinical functioning and parent/family characteristics within the context of usual care or “real world” psychotherapy. A total of 54 therapists from two publicly-funded youth outpatient mental health clinics and 128 youths and parents from the therapists’ combined caseloads were included in the study. Clinician-assigned diagnosis and youth and family demographics were collected at the initial visit, clinician-reported perceived client change was collected at 6-month follow-up, and structured measures of youth clinical functioning and parent/family characteristics were collected at both time points. Results indicate some overlap between clinician-assigned diagnosis, clinician-reported perceived client change, and structured measures of youth clinical functioning and parent/family characteristics after controlling for demographic factors. Results are discussed in terms of implications for the implementation of evidence-based practices in real world community settings.     

“Like Drawing Into Sand”: Acceptability,Feasibility, and Appropriateness of a New e‐Mental Health Resource for Service Providers Working With Aboriginal and Torres Strait Islander People

Cross‐cultural considerations and difficulties recruiting and retaining skilled workers in rural and remote regions may contribute to poorer service use for Aboriginal and Torres Strait Islander people. However, electronic resources may provide the opportunity for remote workforces to deliver structured, evidence‐based, culturally appropriate treatments with limited training burden. The aim was to develop and determine the acceptability, feasibility, and appropriateness of a new e‐mental health resource (the Australian Integrated Mental Health Initiative [AIMhi] Stay Strong App) for service providers working with Aboriginal and Torres Strait Islander people in the Northern Territory. Eleven semi‐structured interviews were conducted with 15 service providers and managers from a range of rural and remote primary health care service settings in the Northern Territory. All participants were given the resource to trial for at least 1 month before being interviewed about perceived barriers and enablers, acceptability, and feasibility. Thematic analysis revealed support for the acceptability, feasibility, and appropriateness of the resource among service providers. Major themes identified included acceptability, building relationships, broad applicability, training recommendations, integration with existing systems, and constraints to implementation. This is one of the first studies to explore the acceptability of e‐mental health approaches for Aboriginal people among the remote health workforce. It is likely that e‐mental health interventions, such as the AIMhi Stay Strong App will assist services to deliver evidence‐based, structured interventions to improve well‐being for Aboriginal and Torres Strait Islander clients.     

Evidence-based assessment of personality disorders

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change.     

A Community Mental Health Implementation of Parent–Child Interaction Therapy (PCIT)

Parent–Child Interaction Therapy (PCIT) has been identified as an evidence-based practice in the treatment of externalizing behavior among preschool-aged youth. Although considerable research has established its efficacy, little is known about the effectiveness of PCIT when delivered in a community mental health setting with underserved youth. The current pilot study investigated an implementation of PCIT with primarily low-socioeconomic status, urban, ethnic minority youth and families. The families of 14 clinically referred children aged 2–7 years and demonstrating externalizing behavior completed PCIT initial assessment, and 12 began treatment. Using standard PCIT completion criteria, 4 families completed treatment; and these families demonstrated clinically significant change on observational and self-report measures of parent behavior, parenting stress, and child functioning. Although treatment dropouts demonstrated more attenuated changes, observational data and parent-reported problems across sessions indicated some improvements with lower doses of intervention. Attendance and adherence data, referral source, barriers to treatment participation, and treatment satisfaction across completers and dropouts are discussed to highlight differences between the current sample and prior PCIT research. The findings suggest that PCIT can be delivered successfully in an underserved community sample when families remain in treatment, but that premature dropout limits treatment effectiveness. The findings suggest potential directions for research to improve uptake of PCIT in a community service setting.     

Therapist, Parent, and Youth Perspectives of Treatment Barriers to Family-Focused Community Outpatient Mental Health Services

This exploratory qualitative study describes treatment barriers to receiving family-focused child mental health services for youths with disruptive behavior problems from multiple perspectives. Data were collected during a series of focus groups and interviews, including: 4 therapist focus groups (n = 26), 3 parent focus groups (n = 14), and 10 youth (10–13 years) semi-structured interviews. Data analysis followed inductive, iterative processes typical of qualitative research using an editing style and thematic content analysis approach. Therapist, parent, and youth stakeholder participants discussed perceived barriers to effective treatment, the problems with current child outpatient therapy, and desired changes (i.e., policy, intervention, etc.) to improve mental health services. Results indicate similar themes around treatment barriers and dissatisfaction with services within and across multiple stakeholder groups, including inadequate service system support, lack of family involvement and feeling overwhelmed with the complexities of families’ needs; however, parents and therapists, in particular, identified different contributing factors to these barriers. Therapists highly endorse using family-focused therapy and desire parent participation; however, parents feel unsupported by their child’s therapist. Parents’ report feeling blamed and not heard by service providers which negatively impacts their attitude about service delivery, causing discomfort and resistance to participation in their youth’s treatment. Youth also discussed dissatisfaction with mental health services, specifically related to their direct experiences in therapy, and desired more active, directive family-focused approaches. Overall, stakeholders reported much frustration and dissatisfaction with current community-based outpatient child therapy services. Study findings can inform service provision, intervention development, and future research.     

Challenges in implementing evidence-based treatment practices for co-occurring disorders in the criminal justice system

The presence of adults with mental health and substance abuse disorders within the criminal justice system has become increasingly evident over the past decade. Interventions and treatment services have been designed and research conducted in an effort to establish evidence-based practices that effectively address the complex needs of this population. However, adopting and implementing these evidence-based interventions and practices within the real-world setting of criminal justice environments is challenging. This article reviews the research literature related to evidence-based treatment practices for offenders with co-occurring mental health and substance abuse disorders and explores the inherent challenges of fitting these interventions and services within criminal justice settings.     

A Systematic Review and Psychometric Evaluation of Adaptive Behavior Scales and Recommendations for Practice

Adaptive behavior scales are vital in assessing children and adolescents who experience a range of disabling conditions in school settings. This article presents the results of an evaluation of the design characteristics, norming, scale characteristics, reliability and validity evidence, and bias identification studies supporting 14 norm-referenced, informant-based interviews and rating scales designed to measure adaptive behaviors. To derive these results, the manuals for each of these scales were reviewed using a standardized coding procedure, and information about each scale was double-coded by reviewers. Findings reveal that several evidence-based adaptive behavior scales are available to school psychologists. Concluding recommendations address selection and use of adaptive behavior scales as part of a comprehensive assessment, using the optimal methods of administration of adaptive behavior scales, and interpreting resultant scores that have demonstrated the highest levels of reliability and the largest body of validity evidence.     

A Randomized Community-Based Trial of Behavior Therapy vs. Usual Care for Adolescent ADHD: Secondary Outcomes and Effects on Comorbidity

Though behavior therapy (BT) for ADHD in adolescence is evidence-based, almost no work examines its implementation and effectiveness in community settings. A recent randomized community-based trial of an evidence-based BT for adolescent ADHD (Supporting Teens’ Autonomy Daily; STAND; N = 278) reported high clinician, parent, and youth acceptability but variable implementation fidelity. Primary outcome analyses suggested no significant differences between STAND and usual care (UC) unless the clinician delivering STAND was licensed. The present study reports secondary outcomes for this trial on indices of comorbidity (anxiety, depression, oppositional defiant disorder, conduct disorder) and ADHD outcomes not targeted by the active treatment (social skills, sluggish cognitive tempo). We also examine whether therapist licensure moderated treatment effects (as in primary outcome analyses). Using intent-to-treat and per protocol linear mixed models, patients randomized to STAND were compared to those randomized to UC over approximately 10 months of follow-up. Group × Time effects revealed that, overall, STAND did not outperform usual care when implemented by community clinicians. However, a Group × Time × Licensure interaction revealed a significant effect on conduct problems when STAND was delivered by licensed clinicians (d = .19–.47). When delivered in community settings, behavior therapy for adolescent ADHD can outperform UC with respect to conduct problems reduction. Community mental health clinics should consider: (1) assigning adolescent ADHD cases to licensed professionals to maximize impact and (2) choosing psychosocial approaches when ADHD presents with comorbid conduct problems. There is also a need to reduce implementation barriers for unlicensed clinicians in community settings.