Initial development of tools to identify child abuse and neglect in pediatric primary care.

BACKGROUND: Child abuse and neglect (CAN) is prevalent, associated with long-term adversities, and often undetected. Primary care settings offer a unique opportunity to identify CAN and facilitate referrals, when warranted. Electronic health records (EHR) contain extensive information to support healthcare decisions, yet time constraints preclude most providers from thorough EHR reviews that could indicate CAN. Strategies that summarize EHR data to identify CAN and convey this to providers has potential to mitigate CAN-related sequelae. This study used expert review/consensus and Natural Language Processing (NLP) to develop and test a lexicon to characterize children who have experienced or are at risk for CAN and compared machine learning methods to the lexicon + NLP approach to determine the algorithm's performance for identifying CAN. METHODS: Study investigators identified 90 CAN terms and invited an interdisciplinary group of child abuse experts for review and validation. We then used NLP to develop pipelines to finalize the CAN lexicon. Data for pipeline development and refinement were drawn from a randomly selected sample of EHR from patients seen at pediatric primary care clinics within a U.S. academic health center. To explore a machine learning approach for CAN identification, we used Support Vector Machine algorithms. RESULTS: The investigator-generated list of 90 CAN terms were reviewed and validated by 25 invited experts, resulting in a final pool of 133 terms. NLP utilized a randomly selected sample of 14,393 clinical notes from 153 patients to test the lexicon, and .03% of notes were identified as CAN positive. CAN identification varied by clinical note type, with few differences found by provider type (physicians versus nurses, social workers, etc.). An evaluation of the final NLP pipelines indicated 93.8% positive CAN rate for the training set and 71.4% for the test set, with decreased precision attributed primarily to false positives. For the machine learning approach, SVM pipeline performance was 92% for CAN + and 100% for non-CAN, indicating higher sensitivity than specificity. CONCLUSIONS: The NLP algorithm's development and refinement suggest that innovative tools can identify youth at risk for CAN. The next key step is to refine the NLP algorithm to eventually funnel this information to care providers to guide clinical decision making.

Our Commitment to Promoting Diversity, Equity, Inclusion, and Justice in Child Maltreatment.

In this commentary, the editorial team of Child Maltreatment extends and expands on APSAC's position on diversity, equity, inclusion, and justice, affirms our commitment and plans for addressing these issues in this publication, and highlights articles in this issue that continue the discussion about race and racism in the child welfare and child protection systems.

Therapists' Perceived Competence in Delivering Trauma-Focused Cognitive Behavioral Therapy During Statewide Learning Collaboratives.

The learning collaborative (LC), a multi-component training and implementation model, is one promising approach to address the need for increased availability of trauma-focused evidence-based practices. The current study used data from four cohorts of a statewide LC on Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to 1) evaluate pre- to post-LC changes in therapists' perceived competence in delivering TF-CBT and 2) explore therapist and contextual factors related to therapists' perceived TF-CBT competence. Therapists (N = 237) completed pre- and post-LC measures of practice information, interprofessional collaboration, organizational climate, and TF-CBT knowledge, perceived competence, and use. Findings indicated therapists' perceived TF-CBT competence significantly increased, pre- to post-LC (d = 1.31), with greater use of trauma-focused practices at pre-training and more TF-CBT training cases completed predicting greater pre- to post-LC gains in perceived TF-CBT competence. These findings highlight the need to assist therapists in identifying and completing training cases to promote competence and implementation.

A Comparison of the Readiness of Youth Service Agencies to Implement a Technology-Based Toolkit to Support Treatment Delivery.

Implementation initiatives and technology-based resources aim to address barriers to Evidence-Based Practice (EBP) use by creating generalizable techniques that can be used for a variety of youth-serving agencies. However, research has not carefully examined unique differences between agency types or individual programs in readiness to use such technologies and implementation strategies. The current study explored differences between community mental health clinics and child advocacy centers on organizational cultural factors (e.g., ability to change and commitment for change) to implement a novel technology-based toolkit to support delivery of Trauma Focused Cognitive Behavioral Therapy (TF-CBT). Results indicated that TF-CBT providers from child advocacy centers reported greater commitment to change and more support to use the technology-based system than those from community mental health centers. Findings suggest that implementation initiatives should address the needs of individual agencies and service settings and adaptations should be explored to best meet the needs of these settings.

Therapists' Perceived Competence in Trauma-Focused Cognitive Behavioral Therapy and Client Outcomes: Findings From a Community-Based Learning Collaborative.

This study examined therapists' perceived competence in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and its association with youth treatment outcomes (posttraumatic stress and depression). Participants included 99 community therapists enrolled in a TF-CBT-focused Learning Collaborative (LC), along with one of their randomly selected TF-CBT training cases. Analyzed data included: 1) caregiver/youth-reported posttraumatic stress and depressive symptoms, pre- and post-treatment, and 2) therapist-perceived competence with TF-CBT components across treatment delivery. Youth- and caregiver-reports indicated large, significant pre- to post-treatment decreases in youth posttraumatic stress (ds = 1.10-1.30, ps < .001) and depressive symptoms (d = 1.01, p < .001). Higher therapist-perceived competence with TF-CBT predicted positive treatment responses for posttraumatic stress (ds = 0.38-0.39, ps = .03) and depression (d = 0.25), though only the former association was significant (ps = .03 vs. p = .15). Findings highlight the need to monitor and improve therapists' competencies to enhance clinical outcomes for trauma-exposed youth and suggest that LCs may be an effective training/implementation model to help achieve those critical goals.

Longitudinal Relations among Adolescent Risk Behavior, Family Cohesion, Violence Exposure, and Mental Health in a National Sample.

Violence is a public health concern linked with mental health problems among adolescents, and risk behavior increases the likelihood of violence exposure. Family cohesion may attenuate the negative effects of risk behavior. The purpose of this study was to examine family cohesion as a moderator in the relation between risk behavior (substance use and delinquency) and violence exposure, and to explore longitudinal associations among cohesion, violence exposure, and subsequent mental health outcomes (PTSD and depression). Data were drawn from the National Survey of Adolescents-Replication, a nationally representative sample of 3604 adolescents, with data collected via structured phone interviews at three waves spanning a two-year period. Hypotheses were tested using longitudinal structural equation modeling. Findings revealed that high family cohesion attenuated the relation between risk behavior and subsequent violence exposure. Wave 2 violence exposure was associated with more Wave 3 mental health problems, but high family cohesion was related to fewer subsequent symptoms. Follow-up analyses revealed that family cohesion moderated the relation between risk behavior and experiencing, but not witnessing, violence. Several demographic associations were observed. Although risk behavior increases exposure to violence, and in turn, mental health problems, family cohesion may serve as a protective factor, attenuating the link between risk behavior and subsequent negative consequences. This effect emerged even when accounting for demographic and socioeconomic covariates. Interventions with adolescents should target family relationships as a protective factor to reduce risk of violence exposure and mental health problems, particularly for adolescents who are engaging in high-risk behaviors.

Sustainment of Trauma-Focused and Evidence-Based Practices Following Learning Collaborative Implementation.

Given the need to develop and validate effective implementation models that lead to sustainable improvements, we prospectively examined changes in attitudes, behaviors, and perceived organizational support during and after statewide Community-Based Learning Collaboratives (CBLCs) promoting trauma-focused evidence-based practices (EBPs). Participants (N = 857; i.e., 492 clinicians, 218 brokers, and 139 senior leaders) from 10 CBLCs completed surveys pre- and post-CBLC; a subsample (n = 146) completed a follow-up survey approximately two years post-CBLC. Results indicated (a) medium, sustained increases in clinician-reported use of trauma-focused EBPs, (b) medium to large, sustained increases in perceived organizational support for trauma-focused EBPs, and (c) trivial to small, sustained increases in perceived organizational support for EBPs broadly. In contrast, clinician-reported overall attitudes towards EBPs decreased to a trivial degree pre- to post-CBLC, but then increased to a small, statistically significant degree from post-CBLC to follow-up. Notably, the degree of perceived improvements in organizational support for general and trauma-focused EBPs varied by professional role. Findings suggest the CBLC implementation strategies may both increase and sustain provider practices and organizational support towards EBPs, particularly those EBPs a CBLC explicitly targets.

Systems Measures of a Trauma-Informed Approach: A Systematic Review.

Interest in trauma-informed approaches has grown substantially. These approaches are characterized by integrating understanding of trauma throughout a program, organization, or system to enhance the quality, effectiveness, and delivery of services provided to individuals and groups. However, variation in definitions of trauma-informed approaches, coupled with underdeveloped research on measurement, poses challenges for evaluating the effectiveness of models designed to support a trauma-informed approach. This systematic review of peer-reviewed and gray literature identified 49 systems-based measures that were created to assess the extent to which relational, organizational, and community/system practices were trauma-informed. Measures were included if they assessed at least one component of a trauma-informed approach, were not screening or diagnostic instruments, were standardized, were relevant to practices addressing the psychological impacts of trauma, were printed in English, and were published between 1988 and 2018. Most (77.6%) measures assessed organizational-level staff and climate characteristics. There remain several challenges to this emerging field, including inconsistently reported psychometric data, redundancy across measures, insufficient evidence of a link to stakeholder outcomes, and limited information about measurement development processes. We discuss these opportunities and challenges and their implications for future research and practice.

Training Pediatric Primary Care Residents in Trauma-Informed Care: A Feasibility Trial.

This study examined the feasibility and outcomes of a training designed to enhance pediatric residents' trauma-informed practices in primary care. Paired samples t tests examined changes in 33 residents' attitudes, perceived competence, and perceived barriers toward trauma-informed care after a 2-hour training. Fisher's exact tests measured changes in residents' screening and referral behaviors. A subsample (n = 9) of residents were interviewed about the training. Residents reported increases in favorable attitudes (P = .065) and perceived competence (P < .001) and decreases in perceived barriers (P = .001 to .521) to implementing trauma-informed care practices. Chart reviews revealed a significant increase in completed trauma screens (0% to 8.0%, P < .001) but no difference in referrals for psychology/psychiatry services (1.9% to 4.2%, P = .200). Residents reported finding the training helpful. Although residents were willing and understood the utility of assessing for trauma, they faced substantial barriers.

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.

Statewide implementation of child trauma-focused practices using the community-based learning collaborative model.

A significant number of youth in the United States experience traumatic events that substantially increase the risk of physical and behavioral health problems across the life span. This public health concern warrants concerted efforts to promote trauma-informed, evidence-based practices that facilitate recovery. Although youth-focused trauma-specific treatments exist, determining effective ways to disseminate and implement these services-so that they are available, accessible, and sustainable-poses an ongoing challenge. This paper describes a comprehensive model for such implementation, the community-based learning collaborative (CBLC), developed as part of Project BEST, a four-phase statewide initiative to promote trauma-focused practices. The CBLC augments the learning collaborative model by including clinical and nonclinical (i.e., broker) professionals from multiple service organizations within a targeted community. CBLCs aim to build capacity for sustained implementation of trauma-focused practices by promoting interprofessional collaboration among those involved in the coordination and provision of these services. This paper describes the iterative development of the CBLC by examining participant completion data across the three completed phases of Project BEST (N = 13 CBLCs; 1,190 participants). Additionally, data from Project BEST's third phase (N = 6 CBLCs; 639 participants) were used to evaluate changes in the frequency of specific practices, pre- to post-CBLC, and post-CBLC perceived utility of CBLC components. High participant completion rates, significant increases in reported trauma-focused practices, and positive ratings of the CBLC's utility provisionally support the feasibility and efficacy of the model's final iteration. Implications for implementation and CBLC improvements are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Advice-seeking during implementation: a network study of clinicians participating in a learning collaborative.

BACKGROUND: Successful implementation depends on the transfer of knowledge and expertise among clinicians, which can occur when professionals seek advice from one another. This study examines advice-seeking patterns among mental health clinicians participating in learning collaboratives (a multi-component implementation and quality improvement strategy) to implement trauma-focused cognitive behavioral therapy (TF-CBT). We apply transactive memory system theory, which explains how professionals access and retrieve knowledge, to examine factors associated with the evolution of advice-seeking relationships during implementation. Our aim is to unpack learning collaboratives' mechanisms by investigating how and why advice-seeking networks change, which may help us understand how implementation strategies can best target networks. METHODS: Using social network analysis and a pretest-post-test design, we examined patterns in general and treatment-specific advice-seeking among 146 participants (including five clinical experts) from 27 agencies participating in a regional scale-up of TF-CBT. Surveys were administered in-person at the first and last of three in-person learning sessions (10 months apart) that comprise a core component of learning collaboratives. Participants nominated up to five individuals from whom they seek general and treatment-specific advice. Exponential random graph models (ERGMs) tested the likelihood of maintaining or forming advice-seeking relationships based on indicators of expertise quality, accessibility, need, and prior advice-seeking relationships. RESULTS: Participants formed or maintained advice-seeking relationships with those who possess perceived expertise (e.g., learning collaborative faculty experts, supervisors, and those with greater field experience than themselves). Participants also tended to seek advice from those within the same organization and with similar disciplinary training, highlighting the importance of expertise accessibility. Prior relationships and network structural features were associated with advice-seeking, indicating that participants built on existing social ties. Advice-seeking did not vary based on participants' role or experience. CONCLUSIONS: Given the importance of accessible clinical expertise and ongoing supervision for delivering treatment with fidelity, learning collaboratives may support implementation by promoting clinicians' awareness of and access to others' expertise, especially those with substantial expertise to share (e.g., faculty experts and supervisors). Future controlled studies are needed to verify the effectiveness of learning collaboratives for building networks that connect clinicians and experts and for improving implementation.

Co-occurrence of Witnessed Parental Violence and Child Physical Abuse from a National Sample of Adolescents.

This study examined the relations between witnessed parental violence (PV) and child physical abuse (CPA) over a one-year period among a nationally representative sample of 2,514 adolescents, ages 12-18. History of witnessed PV (Wave 1) prospectively predicted new experiences (controlling for abuse history) and first experiences of CPA reported at Wave 2. Conversely, history of CPA predicted new experiences of PV, but not first experiences. For adolescents who reported witnessed PV and CPA, witnessed PV preceded CPA in 70% of cases. Most common configuration was single-perpetrator of violence. Additional perpetrator and sequencing configurations are reported. Study findings addressed several limitations in the literature by including use of adolescent report, longitudinal design, inclusion of perpetrator identity, and a nationally representative sample.

Enhancing the Delivery of an Empirically-Supported Trauma-Focused Treatment for Adolescents: Providers' Views of the Role of Technology and Web-Based Resources.

This mixed-methods study assessed providers' views of the use of technology in the delivery of an empirically supported mental health treatment for adolescents (Trauma-Focused Cognitive Behavioral Therapy; TF-CBT). Thematic qualitative interviews were conducted with nine experienced providers. Emerging themes served as the basis for the creation of a quantitative web-based survey, completed by 56 TF-CBT experts, to assess the perceived helpfulness of the recommendations. Technology was perceived as a useful, appealing, and familiar tool that could greatly enhance the delivery of this treatment modality with adolescents. Main recommendations included the creation of a mobile application targeting all of the treatment components and a website with developmentally appropriate resources for providers, caregivers, and teens. Technology may be a useful tool for enhancing service delivery and promoting engagement among youth receiving trauma-focused mental health treatment.

Community-Based Learning Collaboratives and Participant Reports of Interprofessional Collaboration, Barriers to, and Utilization of Child Trauma Services.

Given the high prevalence and severe consequences of child trauma, effective implementation strategies are needed to increase the availability and utilization of evidence-based child trauma services. One promising strategy, the Community-Based Learning Collaborative (CBLC), augments traditional Learning Collaborative activities with a novel set of community-focused strategies. This prospective, observational study examined pre-to post-changes in CBLC participant reports of interprofessional collaboration (IPC), barriers to, and utilization of evidence-based child trauma treatment in their communities. Participants of five CBLCs from a statewide dissemination initiative, comprising 572 child abuse professionals (296 clinicians, 168 brokers, and 108 senior leaders), were surveyed pre-and post-CBLC participation. Results suggested that CBLCs significantly decreased barriers to child trauma treatment and significantly increased IPC and perceived utilization of evidence-based child trauma treatment. Further, changes in barriers partially mediated this relationship. Finally, small to medium differences in participants' reports were detected, such that senior leaders perceived significantly greater IPC than clinicians and brokers did, while brokers perceived significantly greater barriers to child trauma treatment than clinicians and senior leaders did. Collectively, these preliminary findings suggest the CBLC implementation model-which augments traditional Learning Collaborative models with a focus on fostering IPC-can reduce barriers and increase the utilization of evidence-based mental health treatment services.

Relationship violence victimization and binge drinking trajectories among a nationally representative sample of adolescents.

The present study evaluated the impact of relationship violence (RV) victimization on the longitudinal trajectory of binge drinking (BD) among 3614 US adolescents (51.2% male) who participated in an initial telephone interview regarding physical and sexual RV victimization and binge drinking. Two follow-up phone interviews were completed over approximately three years. Multilevel modeling revealed small, but significant, increases in BD over time; older adolescents and those who had ever experienced RV victimization were more likely to report BD at Wave 1 compared to younger adolescents and non-victims. Although new RV victimization reported during the study predicted an increase in the likelihood of BD at that occasion, those who had ever experienced RV victimization were less likely to report BD over time compared to non-victims. Contrary to expectations, no sex differences emerged. Findings indicate that BD may precede RV. Interventions to reduce alcohol-related RV may be especially useful in this population.

Community-based implementation of trauma-focused interventions for youth: Economic impact of the learning collaborative model.

This study investigated the economics of the learning collaborative (LC) model in the implementation of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), an evidence-based intervention for traumatic stress in youth. We evaluated the cost-effectiveness of the LC model based on data from 13 LCs completed in the southeastern United States. Specifically, we calculated cost-effectiveness ratios (CERs) for 2 key service outcomes: (a) clinician TF-CBT competence, based on pre- and post-LC self-ratings (n = 574); and (b) trauma-related mental health symptoms (i.e., traumatic stress and depression), self- and caregiver-reported, for youth who received TF-CBT (n = 1,410). CERs represented the cost of achieving 1 standard unit of change on a measure (i.e., d = 1.0). The results indicated that (a) costs of $18,679 per clinician were associated with each unit increase in TF-CBT competency and (b) costs from $5,318 to $6,548 per youth were associated with each unit decrease in mental health symptoms. Thus, although the impact of LC participation on clinician competence did not produce a favorable CER, subsequent reductions in youth psychopathology demonstrated high cost-effectiveness. Clinicians and administrators in community provider agencies should consider these findings in their decisions about implementation of evidence-based interventions for youth with traumatic stress disorders. (PsycINFO Database Record

Clinician Perspectives on Treating Adolescents with Co-occurring Post-Traumatic Stress Disorder, Substance Use, and Other Problems.

Clinicians (n=138) who treat adolescents with co-occurring posttraumatic stress and substance use disorders (PTSD+SUD) were surveyed about their attitudes and practice behaviors. Most providers were trained in PTSD treatment; fewer were trained in SUD or PTSD+SUD treatments. PTSD+SUD treatment was rated more difficult than treatment of other diagnoses. Providers typically addressed symptoms of PTSD and SUD separately and sequentially, rather than with integrated approaches. There was no consensus about which clinical strategies to use with adolescent PTSD+SUD. Continued treatment development, training, and dissemination efforts are needed to equip providers with resources to deliver effective treatments to adolescents with PTSD+SUD.

Testing the Community-Based Learning Collaborative (CBLC) implementation model: a study protocol.

BACKGROUND: High rates of youth exposure to violence, either through direct victimization or witnessing, result in significant health/mental health consequences and high associated lifetime costs. Evidence-based treatments (EBTs), such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), can prevent and/or reduce these negative effects, yet these treatments are not standard practice for therapists working with children identified by child welfare or mental health systems as needing services. While research indicates that collaboration among child welfare and mental health services sectors improves availability and sustainment of EBTs for children, few implementation strategies designed specifically to promote and sustain inter-professional collaboration (IC) and inter-organizational relationships (IOR) have undergone empirical investigation. A potential candidate for evaluation is the Community-Based Learning Collaborative (CBLC) implementation model, an adaptation of the Learning Collaborative which includes strategies designed to develop and strengthen inter-professional relationships between brokers and providers of mental health services to promote IC and IOR and achieve sustained implementation of EBTs for children within a community. METHODS/DESIGN: This non-experimental, mixed methods study involves two phases: (1) analysis of existing prospective quantitative and qualitative quality improvement and project evaluation data collected pre and post, weekly, and monthly from 998 participants in one of seven CBLCs conducted as part of a statewide initiative; and (2) Phase 2 collection of new quantitative and qualitative (key informant interviews) data during the funded study period to evaluate changes in relations among IC, IOR, social networks and the penetration and sustainment of TF-CBT in targeted communities. Recruitment for Phase 2 is from the pool of 998 CBLC participants to achieve a targeted enrollment of n = 150. Study aims include: (1) Use existing quality improvement (weekly/monthly online surveys; pre-post surveys; interviews) and newly collected quantitative (monthly surveys) and qualitative (key informant interviews) data and social network analysis to test whether CBLC strategies are associated with penetration and sustainment of TF-CBT; and (2) Use existing quantitative quality improvement (weekly/monthly on-line surveys; pre/post surveys) and newly collected qualitative (key informant interviews) data and social network analysis to test whether CBLC strategies are associated with increased IOR and IC intensity. DISCUSSION: The proposed research leverages an on-going, statewide implementation initiative to generate evidence about implementation strategies needed to make trauma-focused EBTs more accessible to children. This study also provides feasibility data to inform an effectiveness trial that will utilize a time-series design to rigorously evaluate the CBLC model as a mechanism to improve access and sustained use of EBTs for children.