Evidence-based practice in child and adolescent mental health最新文献

Background: The Summer Treatment Program (STP) includes an emphasis on teaching children sports skills and it embeds effective contingency management within recreational sports activities. It also includes a weekly parent training group. Due to clinical observations of infrequent male caregiver attendance in STP parent training group meetings, the clinical team developed the Coaching Our Acting-Out Children: Heightening Essential Skills (COACHES) program.

Objective: Describe the evolution of the COACHES program and how STP methods informed the approach.

Method: Using a narrative and systematic review approach, the adaptation of the STP procedures to be embedded within a parenting program aimed at supporting male caregivers is described. Treatment outcome studies evaluating the impact of the COACHES program will be identified and described to demonstrate the promise of this approach as a clinical intervention.

Results: Initial program development included pilot testing in the STP, focus group feedback elicited from potential participants, and a series of studies that evaluated the efficacy of the COACHES program. As a stand-alone extension of the STP, the COACHES program demonstrates improvements in caregiver parenting behaviors and child-focused outcomes. Five treatment outcome papers are reviewed.

Conclusions: There is evidence in support of the COACHES program as an effective approach for teaching male caregivers parenting strategies to support children with ADHD. Future directions include continued evaluation of the COACHES program, including extensions to other developmental levels and embedded activities.

Background: Evidence-based treatments for childhood attention-deficit/hyperactivity disorder (ADHD) include behavioral treatment and psychostimulants, preferably in combination. Research on the treatment of ADHD underscores a gap in the literature regarding the optimal sequencing of treatments (Pelham, Jr. & Altszuler, 2020). Emerging evidence supports starting with behavioral treatment before psychostimulants, though the mechanisms of this sequencing effect are not entirely understood.

Objective: This study explores one plausible mechanism-that psychostimulants reduce behaviors targeted by behavioral treatment, thereby reducing opportunities for children to learn and practice self-regulation skills. The article reports post hoc findings from a triple-masked, AB/BA crossover study, conducted in the Summer Treatment Program (STP).

Method: Two-hundred forty-eight children diagnosed with ADHD; 77% male; 85% Hispanic) were randomized to receive either (a) intensive behavior therapy plus medication ("COMB") or (b) intensive behavior therapy plus placebo ("BT") for 3 weeks, then crossed over to the other condition for 3 weeks. Behavior in recreational settings was systematically recorded and analyzed as a function of medication status and order of treatments.

Results: We found evidence that initial medication reduced the efficacy of subsequent behavior therapy. That is, children exhibited significantly more misbehaviors when unmedicated if they started with combined treatment, then had medication withdrawn, than if they started with behavior therapy alone.

Conclusion: These findings suggest that starting with a combined treatment approach had an unintended adverse impact on children's behavioral functioning when medication was withdrawn. The results support current clinical recommendations, which are to start treatment of ADHD with behavior therapy alone and to add medication as necessary.

Background: A Community-Based Learning Collaborative (CBLC) is a training/implementation package for evidence-based treatments (EBTs) involving multidisciplinary professionals to improve a community's response to trauma and the sustained adoption of EBTs. While CBLCs improve community-, organization-, and clinician-level factors for implementation and result in positive treatment outcomes, they require more investment than the standard Learning Collaborative (LC) model.

Objective: Research is needed to examine CBLC and LC treatment outcomes to inform decision-making on the selection of effective and cost-efficient training/ implementation packages. This study aims to address this gap by examining the impact of training type (CBLC vs LC) on TF-CBT outcomes.

Method: This study involved 441 community therapists participating in a TF-CBT LC (n=188) or CBLC (n=253). Analyses compared TF-CBT outcomes for 660 youth, ages 8-18.

Results: Mixed effect linear regressions with youth nested within therapists demonstrated no sample differences across models for child age or PTS at pre-treatment. Youth in the CBLC were more likely to be White, exhibit depressive symptoms at pre-treatment, and complete post-treatment assessments. Across both models, youth demonstrated significant decreases in PTS and depressive symptoms. The interaction of outcomes by training was not significant for depression, suggesting equivalent outcomes for the CBLC and LC. However, the significant interaction for PTS suggests the LC-trained therapists had better outcomes for youth than the CBLC.

Conclusions: The LC and CBLC for TF-CBT have similar effects on child depression, with the LC demonstrating more efficient results for the treatment of PTS. The multidisciplinary training within the CBLC may support accurate identification of depressive symptoms after a traumatic event as well as treatment retention.

Youth involved in the legal system (YLS) report suicidal ideation and attempts at rates nearly three times higher than the general population. However, most suicidality research within YLS populations has focused on detained or incarcerated youth, and validated suicidality screeners are inconsistently used outside detention centers. We examined youth referred to probation in one Midwest county from January 2020-August 2023. We report 1) suicidality prevalence assessed via the Columbia-Suicide Severity Rating Scale (C-SSRS), 2) cross-tabulation between probation officers' clinical decision making and C-SSRS risk categorization, and 3) prediction of C-SSRS receipt and severity among youth who underwent probation intake. Of 284 screens administered, with respect to the past month, 24.7% indicated desire to be dead, 21.5% suicidal ideation, 7.8% method, 10.2% suicidal intent, and 3.2% suicidal intent with a plan. Additionally, 2.1% indicated a suicide attempt within the past three months. Probation officers most commonly decided to only monitor youth after screening as high risk. Among 1,269 probation-referred cases, alleged felony charges and having more cases prior to the current case were associated with reduced odds of screening receipt. Female gender and not filing a court petition were associated with increased odds of screening higher risk. The results highlight the high suicidality prevalence, yet minimal service connection, among YLS. Research needs to investigate decision-making tools to aid post-screening intervention.

Background: The increasing demand for acute inpatient psychiatric unit (IPU) treatment for children and adolescents in recent years has put significant pressure on hospital systems to provide efficient and effective care. However, there is a gap in the literature regarding the characteristics of IPU care for children and adolescents in the US, making it difficult for institutions to benchmark their performance against nationwide standards or understand generalizability of existing research.

Objective: To address this gap in the literature by beginning to collect descriptive data on significant variables for youth care from a geographically and institutionally diverse group of on Child and Adolescent IPUs.

Method: A multi-institutional research team conducted a nationwide (US) survey of child and adolescent IPU clinicians using snowball sampling. Recruitment emails were sent to IPU groups in the American Psychological Association and the American Academy Child and Adolescent Psychiatry.

Results: The study yielded data from 12 institutions with a total of 20 IPUs, representing over 23,000 admissions in the years 2019 and 2020. The results of the survey show wide variability in institutional definitions of key variables (such as readmissions and safety events) as well as large ranges in length of stay, restraints, seclusions, and safety events.

Conclusion: This study reveals the importance of IPU clinical researchers taking steps to build a robust evidence base for IPU care, including developing consensus definitions of key variables and conceptualizing why high degrees of variability exist in important variables of IPU care. The survey results provide valuable insights for hospital systems, policymakers, and clinicians in the field of child and adolescent psychiatry.

Background: Youth anxiety disorders are prevalent but undertreated. Poor diagnostic agreement between clinicians and researchers may contribute to misdiagnosis and mistreatment. However, few studies of diagnostic agreement focus specifically on anxiety disorders.

Objective: The current study evaluates diagnostic agreement between community clinicians and independent evaluators (IE) associated with a research study.

Method: IEs administered the Anxiety Disorders Interview Schedule for DSM-5, Child Version, Child and Parent Forms to youth participating in a randomized controlled trial. Diagnostic agreement was assessed using Cohen's kappas. Youth (N=103) were about 14.3 years old (SD=1.6), largely cis-gender female (66%, n=68), heterosexual (57.3%, n=59), Hispanic/Latinx (53.4%, n=55), and White (53.4%, n=55).

Results: IEs assigned significantly more diagnoses than community clinicians (t(99)=-12.738, d=1.66, p<.001). Individual diagnoses were collapsed into diagnostic clusters: anxiety, depression, trauma and stressor, obsessive-compulsive, and behavioral disorders. There was no agreement for anxiety, trauma and stressor, obsessive-compulsive clusters (ks<0.20). The depression cluster showed minimal agreement (k=0.28, p<.001), and behavioral disorders showed weak agreement (k=0.49, p<.001). There was no agreement for four individual anxiety disorder diagnoses (ks<0.20) except for panic disorder, which had minimal agreement (k=.32, p<.001). Four additional anxiety disorder diagnoses could not be analyzed due to no diagnoses in one or both settings.

Discussion: This study shows diagnostic agreement is poor between clinicians and researchers, especially for anxiety disorders. Findings suggest that semi-structured interviews can detect diagnoses that are being missed by clinicians. Future work should seek to identify and address barriers to implementation of evidenced-based assessments in community settings.

Background: Prior systematic reviews and research have suggested that certain organizational characteristics and training methods may support the sustainability of new practices, yet these factors have not been adequately studied in behavioral health.

Objective: The objective of this study was to test the indirect effects of training design (e.g., training condition and consultation call attendance) on clinician-reported sustainability through post-training organizational resources, training exposure and utilization, and organizational climate.

Method: Fifty licensed outpatient clinics, including 100 clinicians, 50 supervisors, and 50 administrators were randomized to one of three training conditions: 1) Learning Collaborative (LC), 2) Cascading Model (CM) or 3) Distance Education (DE). All were trained to provide Parent Child Interaction Therapy (PCIT). Data to assess training and implementation outcomes were collected at 4 time points coinciding with the training period: baseline, 6- (mid), 12- (post), and 24-months (1-year follow-up). Multi-level path analysis was utilized to examine the role of organizational barriers and training approaches on sustainability of PCIT (caseload, protocol use, number of families seen).

Results: Clinician-reported resources, training exposure and utilization, and organizational climate varied among study conditions, with the most favorable conditions reported in the CM condition and the least favorable conditions reported in the LC condition. The CM condition was associated with greater PCIT caseload, more families served by the PCIT program, and less use of the full PCIT protocol as compared to the DE condition, while the LC condition was associated with fewer families served and more use of the full PCIT protocol.

Conclusions: Organizational factors such as available resources, organizational climate, and training exposure and utilization indirectly influence the effect of training approach and consultation on PCIT sustainability two years after baseline and vary based on condition. A possible mechanism of the cascading training model on sustainability, through increased organizational resources, was also identified.

Background: Major depressive disorder is one of the most common psychological disorders affecting teens. However, most teens do not receive treatment for depression, and one reason may be because teens' attitudes towards available treatments. Therefore, it is important to understand how teens perceive commonly used treatments for depression including individual psychotherapy, group therapy, medication management, as well as other coping skills for depression.

Methods: Twenty-two teens participated in focus groups (n=14) and individual qualitative interviews (n=8) asking about their beliefs and perceptions of treatments for depression. Applied thematic analysis was used to analyze the qualitative data.

Results: Teens were generally familiar with individual therapy, group therapy, medication management, and coping skills for depression. Teens generally believed these were helpful and legitimate treatment modalities. Teens voiced concerns about the context of group therapy, and generally preferred to be in groups with non-previously known teens. Teens believed that decisions regarding treatment for depression should be made in collaboration with parents/guardians.

Conclusions: Overall, depressed teens are familiar with treatment options available for depression, and their willingness to try treatment is impacted by parental and peer beliefs about mental health and treatment.