An ecological approach to child and family clinical and counseling psychology

The ecological model of child and family clinical and counseling psychology considers mental health service delivery within a health maintenance framework, approaching the complexity of children's behavior in a systematic and organized fashion using science-based intervention practices. The service delivery framework integrates assessment, intervention, and motivation at all phases of an intervention. Assessments enhance the participants' and professionals' appraisal, which in turn impact motivation to change. Interventions are sensitive to assessment-based targets and participant motivation. A menu of interventions range from assessment, feedback, and brief interventions to more extensive mental health services, potentially integrated with other community agencies and school settings. The ecological model suggests revisions in the conceptualization of child and adolescent psychopathology, training for mental health professionals, and strategies for the design and testing of interventions. In general, a reformulation of mental heath services for children and families within an ecological framework enhances the potential for integrating science and practice.     

Predictors and Outcomes of Psychiatric Hospitalization in Youth Presenting to the Emergency Department with Suicidality

Youth suicide attempters presenting to the emergency department (ED) are frequently admitted to psychiatric inpatient hospitals, yet little is known about how clinicians decide which youths to admit versus discharge to outpatient care. We examine predictors of inpatient hospitalization and describe service use outcomes associated with hospitalization in 181 youths drawn from consecutive ED admissions for suicidality. Predictors of hospitalization include ED site, suicide plan, and parent report of problems. Hospitalization was associated with improved linkage to outpatient treatment and more intensive service use. Future research is needed to understand the best service delivery and treatments for these high‐risk youth.     

Decrease in suicide rates after a change of policy reducing access to firearms in adolescents: a naturalistic epidemiological study

The use of firearms is a common means of suicide. We examined the effect of a policy change in the Israeli Defense Forces reducing adolescents' access to firearms on rates of suicide. Following the policy change, suicide rates decreased significantly by 40%. Most of this decrease was due to decrease in suicide using firearms over the weekend. There were no significant changes in rates of suicide during weekdays. Decreasing access to firearms significantly decreases rates of suicide among adolescents. The results of this study illustrate the ability of a relatively simple change in policy to have a major impact on suicide rates.     

Parent and child MMPI responses: Characteristics among families with adolescents in inpatient and outpatient settings

The relationship of parent personality to child psychopathology has been investigated in numerous MMPI studies over the past three decades. Very few of these studies, however, have directly analyzed MMPI response patterns of both parents and offspring. The current study included the MMPI responses of 199 families with adolescents entering inpatient and outpatient psychiatric setting (N = 542). Inpatient parents and adolescents had significantly higher mean scores across a variety of MMPI scales than did their outpatient counterparts. The linear combination of adolescent and maternal MMPI scale data, in a stepwise discriminative function analysis, resulted in accurate classification of 75% of all children in inpatient treatment and 74% of all children assigned to outpatient treatment. Findings were discussed in terms of salient MMPI differences between inpatient and outpatient families and shared psychopathological characteristics among family members with offspring in psychiatric treatment settings.     

Treatment adherence among Latina female adolescent suicide attempters

Clinicians must identify factors among suicide-attempting adolescents and their families that increase treatment adherence. Researchers assessed a consecutive series of 140 disenfranchised Latina adolescents (ages 12-18 years) and their mothers presenting at a large urban emergency room after a suicide attempt by the adolescent. Adherence was examined as it related to service delivery, individual background characteristics, and psychosocial factors (current symptomatology, treatment attitudes). Each factor was found to predict adolescent treatment adherence. Adolescents receiving a specialized emergency room program, those with a diagnosis of disruptive behavior disorder, and those from single-parent households attended significantly more therapy sessions compared to their suicide-attempting peers receiving standard emergency room care. Adolescents with a diagnosis of anxiety disorders and those whose mothers reported more psychopathology and perceived more cohesive family relationships tended to attend significantly fewer treatment sessions. The implications for the delivery of emergency room interventions are discussed.     

Risk Factors for Adolescent Suicide and Suicidal Behavior: Mental and Substance Abuse Disorders,Family Environmental Factors,and Life Stress

This review focuses on psychopathologic risk factors for adolescent suicide and suicidal behavior, namely, affective, disruptive, substance abuse, psychotic, and personality disorders. The interaction of psychopathology with age and gender is discussed. The role of family environmental risk factors and stress events in suicide and suicidal behavior, both alone, and in interaction with psychopathology are reviewed. Research reviewed will include psychological; autopsy studies, longitudinal studies examining predictors of suicide, and epidemiologic studies of suicide attempts.     

Establishing family inclusive acute inpatient mental health services: a staff training programme in Somerset

In spite of policies advocating the involvement of families in the care of mental health service users in the UK there are few examples of training initiatives to bring this about. This article describes the delivery of a whole-team training initiative to promote family inclusive working in all acute inpatient units in Somerset. The three-day staff-training programme is described and training outcomes are reported. Staff reported a significant increase in confidence in their skills for working with families, and a pre- and post-training case note audit showed an increased consideration of the needs of families. This was accompanied by a modest increase in the average number of family meetings. Obstacles to family inclusive ways of working on inpatient units are described, and strategies to overcome these are discussed.     

Mental health and well-being of black women: Toward strategies of empowerment

This review of the literature on Black women's mental health has three goals: 1) to describe the mental health issues, needs, and adaptive behaviors of Black women; 2) to discuss the research, intervention, and public policy efforts of mental health professionals and Black women's groups to address the multiple needs of this population; and 3) to identify effective strategies by which community psychologists can improve the mental health status of Black women through efforts to reduce their environmental stressors, to increase their resources and access to services, and to facilitate their empowerment in American society. The authors propose a number of recommendations to improve Black women's mental health, including changes in research paradigms, changes in education and training programs, and the development of culturally competent service delivery systems.     

Psychodynamics of Suicide in Lesbian,Gay, Bisexual,or Transgender Youth

Lesbian, gay, bisexual, and transgender (LGBT) youth are a vulnerable population at high risk of suicide and, as such, benefit from an informed psychotherapeutic approach to treatment. While it is clear that sexual orientation and gender identity are independent dimensions from psychopathology, LGBT youth are frequently marginalized and may face unique challenges with self-acceptance and identification with peers, family, and society, increasing risk of social isolation, which in turn increases vulnerability to anxiety, mood disorders, substance use, and suicide. We elaborate on the common phenomenon of ambivalent repression of the sexual self in adolescents associated with intertwined themes frequently expressed in suicidal lesbian, gay, transgender, bisexual, and queer patients on the inpatient adolescent unit: anger directed toward internal and external objects; desire for self-punishment, atonement, and possibly rebirth; and desperation and desire to escape psychic pain. We enhance our discussion with case examples and practical therapeutic considerations that emerge from these themes that can be harnessed across treatment settings.     

Adolescent mental health: the role of youth and college pastors

The present study investigates the gatekeeping role of youth and college pastors, specifically exploring their psychological training, perceptions, attitudes, and interactions concerning adolescent congregants' mental illness. Texas youth and college pastors were anonymously surveyed regarding referral patterns, mental health interventions and contact, adolescent mental health perceptions, and means of collaboration. While the sample reported actively working with numerous adolescent mental health issues, the majority did not feel qualified to work with significant psychopathology. Despite this, they reported using various intervention methods, with the most common being initial counselling followed by a referral. Although the sample frequently referred to other professionals, they described many perceived barriers in collaborating with others in the mental health field. Overall, a positive role exists for youth and college pastors in adolescent mental health; however, tensions and conflicts between pastors and mental health professionals hinder the usefulness of these unique gatekeepers. Implications and recommendations for mental health professionals are highlighted.     

Family support in the home. Programs, policy, and social change.

The need for a coordinated national policy on family support in the home is discussed. First, the history of home visiting programs is reviewed. Then, recommendations for practice, training, and research in family support programs are presented. A discussion of the impact of new federal initiatives on family support programs and research demonstration efforts follows.     

Guns,Impulsive Angry Behavior,and Mental Disorders: Results from the National Comorbidity Survey Replication (NCS-R)

Analyses from the National Comorbidity Study Replication provide the first nationally representative estimates of the co-occurrence of impulsive angry behavior and possessing or carrying a gun among adults with and without certain mental disorders and demographic characteristics. The study found that a large number of individuals in the United States self-report patterns of impulsive angry behavior and also possess firearms at home (8.9%) or carry guns outside the home (1.5%). These data document associations of numerous common mental disorders and combinations of angry behavior with gun access. Because only a small proportion of persons with this risky combination have ever been involuntarily hospitalized for a mental health problem, most will not be subject to existing mental health-related legal restrictions on firearms resulting from a history of involuntary commitment. Excluding a large proportion of the general population from gun possession is also not likely to be feasible. Behavioral risk-based approaches to firearms restriction, such as expanding the definition of gun-prohibited persons to include those with violent misdemeanor convictions and multiple DUI convictions, could be a more effective public health policy to prevent gun violence in the population. Copyright © 2015 John Wiley & Sons, Ltd.     

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.     

Training program in psychosocial intervention for high-risk infants and their families

A multidisciplinary training program for psychosocial intervention in the Neonatal Intensive Care Unit (NICU) was developed. The purpose of the program was to train mental health and health care professionals in a psychosocial preventive intervention model for high-risk infants and their families throughout the infants' hospital course in the NICU. The program was divided into modules that include assessment and intervention with the infant, parents, family, and larger caregiving environment. Over a 3-year period 40 trainees from 9 disciplines were trained. A randomized clinical trial was conducted which showed the positive effects of the intervention. A clinical service including inpatient and outpatient follow-up has been established in the NICU based on the psychosocial model developed from the training program.     

Executive Functioning in Adolescent Depressive Disorders

Previous research on executive functioning within adolescent depression has provided somewhat inconsistent results, although the majority of research has identified at least partial evidence of executive functioning deficits in adolescent depression. The present study attempted to explore adolescent depression, specifically depressive disorder diagnoses and self-reported depressive/anxious symptoms, as well as executive functioning through the retrospective chart review of an inpatient/outpatient adolescent sample. The total sample (N = 155) was divided into four groups. The psychiatric inpatient sample was subdivided into a Major Depression Group (n = 22), Minor Depression Group (n = 28), Inpatient Control Group (n = 73) based on the discharge diagnoses. The Outpatient Control Group (n = 33) consisted of a group of adolescents who received evaluations at a neuropsychological evaluation clinic. Analyses of variance between the four clinical groups and follow-up pairwise comparisons revealed lowered executive functioning performance in major and minor depression groups compared to the outpatient control. Lowered working memory/simple attention was identified in minor and major depression, while lowered cognitive flexibility/set shifting was only identified in major depression, suggesting a continuum of executive dysfunction and depression severity. More generally, the inpatient groups displayed lower executive functioning than the outpatient control, with no identified executive functioning differences between inpatient groups. Additionally, no negative correlations were observed between self-reported depressive/anxious symptoms and executive functioning. These results are consistent with the majority of related research, and highlight the importance of executive functions in adolescent depression, and more broadly in adolescent psychopathology.     

The Fort Bragg managed care experiment: Short term impact on psychopathology

Many concerns have been raised about mental health services for children and adolescents. These concerns have included not treating those in need and providing inappropriate services to those who are treated. The continuum of care philosophy purports to remedy these problems by offering a comprehensive and coordinated range of services emphasizing community-based treatment. Services in the continuum include alternatives to trditional restrictive forms of care such as hospitalization. The provision of more appropriate care is hypothesized to improve the clinical outcomes of children treated in a continuum of care. The Fort Bragg Evaluation compared quality, use, outcome, and cost of the continuum of care model to a more traditional, fragmented system of care. This paper presents the effects of a service delivery system on short term psychopathology outcomes.     

Prognosis after Adolescent Suicide Attempt: Mental Health,Psychiatric Treatment,and Suicide Attempts in a Nine‐Year Follow‐up Study

The prevalence of mental health and suicidal behavior was examined 8 to 10 years after an adolescent suicide attempt. Of 71 persons, 79% had at least one psychiatric disorder (mean 1.7) at follow‐up, most commonly depression (46%), personality disorder (46%), and anxiety disorder (42%). The stability of diagnoses was moderate. The suicide attempters had received a substantial amount of treatment. One third had received inpatient treatment, and 78% psychiatric treatment, despite low compliance shortly after the index suicide attempt. At follow‐up, repeated suicide attempts were found in 44% of the sample, and half of those had an affective or personality disorder.     

Impact of Firearm Availability and Gun Regulation on State Suicide Rates

Past studies on suicide have investigated the association of firearm ownership and suicide risk in the United States. The aim of the present study was to build on previous work by examining the impact of firearm storage practices and the strictness of firearm regulation on suicide rates at the state level. Data were compiled from primarily three sources. Suicide and firearm ownership information was obtained from the Centers for Disease Control and Prevention. Strictness of handgun regulation was derived from figures available at the Law Center to Prevent Violence, and controls were taken from the US Bureau of the Census. Mixed models were fitted to the data. Household firearm ownership was strongly associated with both suicide by all mechanisms, and firearm suicide. Storage practices had especially elevated consequences on suicide rates. Percent with loaded guns and gun readiness increased suicide rates, and strictness of gun regulation reduced suicide rates. Ready access to firearms can make a difference between life and death. Loaded and unlocked firearms within reach become risk factors for fatal outcomes from suicidal behavior. Future research might want to examine ways of obtaining more recent data on individual firearm ownership. This study proposes several policy recommendations for suicide prevention.     

Behavioral Risk Assessment of the Guarded Suicidal Patient

Psychiatrists and other mental health professionals are trained to assess patients by direct observation and examination. Short inpatient length of stay, brief outpatient visits, emergency room evaluations, and other time‐limited clinical settings require rapid assessment of suicide risk. Recognition of behavioral suicide risk factors can assist in the early identification of the guarded suicidal patient, thus avoiding total reliance on the patient's reporting.     

Aging family caregivers: policies and practices

This review examines later life family support for adults with developmental disabilities from a life course perspective that takes into account social trends and changes in service patterns and in attitudes of families. Key issues addressed include: (1) trends affecting family caregiving, (2) health and social outcomes of life-long caregiving, (3) support needs of families, (4) family support policies and practices, and (5) recommendations for a research and policy agenda. Research examining outcomes of life-long caregiving has shown that most families adapt well to having a family member with disabilities. However, some families are at risk for poorer physical and mental health outcomes. These include cultural minorities and families of adults with behavioral challenges. Caregiving does seem to have a negative impact on maternal employment and family income as mothers often give up or cut back on employment to care for a child with developmental disabilities, who is more likely to continue living in the family home throughout adulthood than other adult children. Federal and state initiatives are addressing issues of family support through both the developmental disabilities and aging service systems.