Validating a Pragmatic Measure of Evidence-Based Practice (EBP) Delivery: Therapist Reports of EBP Strategy Delivery and Associations with Child Outcome Trajectories.

Pragmatic measures of evidence-based practice (EBP) implementation can support and evaluate implementation efforts. We examined the predictive validity of therapist reports of EBP strategy delivery for children's mental health outcomes. Data were obtained from 1,380 sessions with 248 children delivered by 76 therapists in two county systems. Children (Mage=11.8 years, SD = 3.7) presented with internalizing (52%), externalizing (27%), trauma (16%), and other (5%) concerns. Therapists reported their delivery of EBP strategies on a revised version of the EBP Concordant Care Assessment (ECCA; Brookman-Frazee, et al., Administration and Policy in Mental Health and Mental Health Services Research, 48, 155-170, 2021) that included 25 content (e.g., parenting, cognitive behavioral) and 12 technique strategies (e.g., modeling, practice/role-play). On average, 5.6 ECCA session reports (SD = 2.3) were obtained for each client, and caregivers reported symptoms on the Brief Problem Checklist (Chorpita, et al., Journal of Consulting and Clinical Psychology, 78(4), 526-536, 2010) at baseline, weekly over two months, and again at four months. Multilevel models examined whether the mean extensiveness of each EBP strategy predicted trajectories of child outcomes. More individual technique (6 of 12) than content strategies (1 of 25) were associated with outcome trajectories. For techniques, more extensive use of Performance Feedback and Live Coaching and less extensive use of Addressing Barriers were associated with greater declines in total symptoms, and more extensive use of Establishing/Reviewing Goals, Tracking/Reviewing Progress, and Assigning/Reviewing Homework was associated with declines in externalizing symptoms. For content, more extensive use of Cognitive Restructuring was associated with declines in total symptoms. In addition, higher average extensiveness ratings of the top content strategy across sessions was associated with greater declines in total and externalizing symptoms. Therapist-reported delivery of some EBP strategies showed evidence of predictive validity and may hold utility in indexing quality of care.

Shared Decision-Making with Latinx Caregivers During Community Implemented Evidence-Based Practices: Determinants and Associations with Alliance.

OBJECTIVE: The current observational study examined shared decision-making (SDM) with caregivers of Latinx youth within the delivery of multiple evidence-based practices (EBPs) in community mental health services. The aims of the study were to (1) Identify therapist and client factors associated with increased SDM within EBP sessions and (2) Examine the association between SDM and therapeutic alliance between community therapists and Latinx caregivers. METHOD: The Observing Patient Involvement in Decision-Making (OPTION) instrument measured SDM in 210 audio-recorded therapy sessions with 62 community therapists (91.94% female; 69.35% Latinx) and 109 Latinx caregivers (91.43% female) of youth who were an average age of 8.26 years (SD = 3.59). We used the Therapy Process Observational Coding System for Child Psychotherapy-Alliance scale to measure the caregiver-therapist alliance observationally. Multilevel linear regressions were conducted to examine research questions. RESULTS: Greater SDM was observed within sessions where therapists targeted conduct problems versus trauma (B = -8.79, 95% CI[-14.09, -3.49], p = .001). There was a trend that SDM was higher in English-language sessions compared to Spanish. We found that the global measurement of SDM (B = .04, 95% CI[.01, .08], p = .03) and the OPTION item Integrate Preferences (B = .69, 95% CI[.07, 1.32], p = .03) were positively associated with alliance. CONCLUSIONS: SDM may help foster Latinx caregiver engagement within EBP delivery. Provider training in SDM may be warranted with consideration of the specific clinical contexts (e.g., by presenting problem) that are appropriate for collaborative treatment planning. More research is needed to further establish the benefits of SDM in youth psychotherapy.

Immigration stress and internalizing symptoms among Latinx and Asian American students: The roles of school climate and community violence.

Immigration-related problems and stressors are prevalent and pressing concerns among Latinx and Asian American school-age youth. Youth fears related to family deportation have been associated with adverse mental health outcomes. This study used an ecological framework to examine the impact of immigration stress and school- and community-level resources and protective factors on Latinx and Asian American youth internalizing symptoms. The sample included 1309 Asian American and 701 Latinx students (N = 2010) who participated in a routine school-based mental health needs assessment survey. Multilevel regressions analyses revealed that first-generation youth, Latinx youth, and female youth were more vulnerable to experiencing immigration-related problems and worry. Student perceptions of negative school climate and community violence were associated with greater internalizing symptoms regardless of immigration worry. Moderation analyses revealed that immigration-related problems and worry were positively associated with internalizing symptoms and that this relationship did not differ by race/ethnicity. However, immigration worry was a particular risk factor for students who perceived their neighborhood community as safe. Findings highlight that a sociopolitical climate that sows immigration-related challenges fuels youth distress and that students' experiences of their community environment can play an essential role as a psychological resource.

Outside the Clinic Door: How Neighborhood Sociodemographic Disadvantage is Associated with Community Therapist Secondary Traumatic Stress and Emotional Exhaustion.

Therapists serving families with high rates of trauma exposure in community mental health clinics face the potential risk of experiencing secondary traumatic stress and emotional exhaustion, both of which pose barriers for the implementation and sustainment of evidence-based practices. Previous research documents negative effects of living in socioeconomic disadvantaged neighborhoods on child development but has not examined the effects of working in these neighborhoods on therapist well-being. The current study merges publicly available data, administrative claims data on mental health services, and therapy survey data to 1) identify associations between neighborhood sociodemographic disadvantage and two community therapist well-being constructs, specifically secondary traumatic stress and emotional exhaustion; and 2) examine potential clinic- and therapist-level explanatory factors in the associations between neighborhood sociodemographic disadvantage and therapist well-being. A cumulative risk index approach was applied to calculate neighborhood sociodemographic disadvantage. Greater neighborhood sociodemographic disadvantage was significantly associated with higher levels of therapist secondary traumatic stress (B=.09, p<.05) but not emotional exhaustion. Because therapists in higher risk neighborhoods face higher secondary traumatic stress levels, additional research is needed to better understand how these therapists can be best supported; thus, supporting families receiving treatment and implementation of evidence-based practices.

Temporal Orientation and the Association Between Adverse Life Events and Internalizing Symptoms in Vietnamese American and European American Adolescents.

Adverse life events are associated with greater internalizing symptoms. However, prior research has identified cross-cultural variation in whether and to what extent factors amplify or buffer the impact of these stressors. Broadly defined as the tendency to focus on past, present, or future events, temporal orientation is a dispositional factor that is culturally influenced and may explain variance in internalizing symptoms following adverse events. Cultural congruence, or the degree to which a factor is considered normative in an individual's culture, may be an important explanation of variation in levels of risk. The current study examines how culturally congruent temporal orientation differentially impacts the relation between adverse life events and internalizing symptoms in a longitudinal sample of 10th and 11th grade Vietnamese American (n = 372) and European American adolescents (n = 304). Results indicated that Vietnamese American adolescents endorsed significantly higher levels of past and present, but not future, temporal orientation compared to European American adolescents. Among both Vietnamese and European American adolescents, past temporal orientation was positively associated with internalizing symptoms and adverse life events. Findings also demonstrated that the influence of present temporal orientation on the relation between adverse life events and internalizing symptoms was further moderated by ethnicity, such that present temporal orientation buffered risk for negative outcomes among European Americans but not Vietnamese Americans. These data highlight the importance of measuring and testing specific dimensions of culturally relevant processes when considering responses to adverse life events.

Advances in the adaptation and implementation of evidence-based interventions for historically marginalized groups.

This collection of six articles showcases innovative approaches to adapting and deploying evidence-based interventions with individuals from historically marginalized groups to advance mental health equity. The field of cultural adaptation has matured beyond initial questions about whether specific culturally adapted interventions work, and must now adopt designs that can yield generalizable knowledge concerning how and under what circumstances such adaptations can promote improved engagement and effectiveness with underserved groups. Crucial to this goal is identifying the target mechanisms presumed to underlie poorer clinical and engagement outcomes among minoritized groups that must be addressed by the adaptation. Furthermore, contributors have gone beyond adaptations to EBI therapeutic content and processes, to the mobilization of implementation strategies that increase the reach and impact of EBIs outside conventional service settings. Our featured investigators have also illuminated critical modifications to the entire research enterprise to center community needs in the conduct of intervention research with historically marginalized groups. We are grateful for the opportunity to highlight these contributions spanning intervention science, adaptation science, and implementation science in Behaviour Research and Therapy.

Leader and Provider Perspectives on Implementing Safe Alternatives for Teens and Youth - Acute (SAFETY-A) in Public School Districts Serving Racial/ethnic Minoritized Youth.

Racial/ethnic minoritized (REM) youth represent a high-risk group for suicide, yet there are striking disparities in their use of mental health services (MHS) even after risk is identified in schools. Prior research suggests that school-based risk assessments and hospitalization encounters can be negatively experienced by REM youth and families, thus deterring likelihood of seeking follow-up care. The Safe Alternatives for Teens and Youth-Acute (SAFETY-A) is a brief, strengths-based, cognitive-behavioral family intervention demonstrated to increase linkage to MHS when implemented in emergency departments. With its focus on strengths and family engagement, SAFETY-A may cultivate a positive therapeutic encounter suited to addressing disparities in MHS by enhancing trust and family collaboration, if appropriately adapted for schools. Thirty-seven school district leaders and frontline school MHS providers from districts serving primarily socioeconomically disadvantaged REM communities participated in key informant interviews and focus groups. First, interviews were conducted to understand usual care processes for responding to students with suicidal thoughts and behaviors, and perspectives on the strengths and disadvantages of current practices. An as-is process analysis was used to describe current practices spanning risk assessment, crisis intervention, and follow-up. Second, focus groups were conducted to solicit perceptions of the fit of SAFETY-A for these school contexts. Thematic analysis of the interviews and focus groups was used to identify multilevel facilitators and barriers to SAFETY-A implementation, and potential tailoring variables for implementation strategies across school districts.

Supporting Emotionally Exhausted Community Mental Health Therapists in Appropriately Adapting EBPs for Children and Adolescents.

Evidence-based practices (EBPs) are often adapted during community implementation to improve EBP fit for clients and the service context. Augmenting EBPs with additional dosing and content may improve fit. However, reducing EBP content can reduce EBP effectiveness. Using multilevel regression models, this study examined whether supportive program climate and program-furnished EBP-specific implementation strategies (e.g., materials, ongoing training, in-house experts) are associated with augmenting and reducing adaptations, and whether therapist emotional exhaustion moderated these associations. Data were collected from surveys completed by 439 therapists from 102 programs 9 years after a system-driven EBP implementation initiative. Supportive program climate was associated with more augmenting adaptations. Emotional exhaustion was a significant moderator. When organizations used more EBP-specific implementation strategies, more emotionally exhausted therapists reduced EBPs less and less emotionally exhausted therapists augmented EBPs more. Findings provide guidance on how organizations can support appropriate EBP adaptations in spite of therapist emotional exhaustion.

Inpatient Care Utilization Following Mobile Crisis Response Encounters Among Racial/Ethnic Minoritized Youth.

OBJECTIVE: There has been an increase in youth psychiatric emergencies and psychiatric inpatient hospitalizations in recent years. Mobile crisis response (MCR) services offer an opportunity to meet acute youth mental health needs in the community and to provide linkage to care. However, an understanding of MCR encounters as a care pathway is needed, including how patterns of subsequent care may vary by youth race/ethnicity. The current study examines racial/ethnic differences in the rates of inpatient care use following MCR among youth. METHOD: Data included Los Angeles County Department of Mental Health (LACDMH) administrative claims for MCR in 2017 and psychiatric inpatient hospitalizations and outpatient services from 2017-2020 for youth aged 0 to 18 years. RESULTS: In this sample of 6,908 youth (70.4% racial/ethnic minoritized youth) who received an MCR, 3.2% received inpatient care within 30 days of their MCR, 18.6% received inpatient care beyond 30 days of their MCR, and 14.7% received repeated inpatient care episodes during the study period. Multivariate models revealed that Asian American/Pacific Islander (AAPI) youth were less likely to receive inpatient care, whereas American Indian/Alaska Native (AI/AN) youth were more likely to receive inpatient care following MCR. Youth age, primary language, primary diagnosis, and insurance status also predicted future inpatient episodes. CONCLUSION: Findings highlight differential rates of inpatient use following MCR among AAPI and AI/AN youth relative to youth from other groups. Alternative interpretations for the findings are offered related to differential levels of need and disparate penetration of community-based outpatient and prevention-focused services.

Shared decision making between community therapists and Latinx caregivers during evidence-based practice delivery in publicly-funded children's mental health services.

OBJECTIVES: This observational study examined shared decision-making (SDM) with caregivers of Latinx youth within the delivery of multiple evidence-based practices (EBPs) in community mental health services. Study aims were to (1) Characterize therapist use of SDM strategies and (2) Describe the types of treatment decisions that were the focus of therapist use of SDM. METHODS: The OPTION instrument was used to measure SDM in 210 audio-recorded therapy sessions with 62 community therapists and 109 Latinx caregivers; frequency and mean ratings of OPTION items were examined. Qualitative analysis on the descriptions of treatment decisions being deliberated was also conducted. RESULTS: Results revealed that therapists used at least one SDM step in most sessions (N = 192; 91.43%) with a mean composite score of 32.78 (SD=17.79; range: 6.25-81.25). Four superordinate categories of decisions were: (1) Treatment planning, (2) Evidence-based Parenting Strategies, (3) Addressing Youth Functioning, and (4) Addressing Family Psychosocial Needs. CONCLUSIONS: Findings suggest that community therapists serving Latinx families are naturalistically engaging in SDM steps about a variety of decisions during most EBP sessions, but only at modest levels.

Misalignment in Community Mental Health Leader and Therapist Ratings of Psychological Safety Climate Predicts Therapist Self-Efficacy with Evidence-Based Practices (EBPs).

Therapist self-efficacy in delivering evidence-based practices (EBPs) is associated with implementation outcomes, including adoption and sustainment in community mental health settings. Inner context organizational climate, including psychological safety, can proximally shape therapist learning experiences within EBP implementation. Psychologically safe environments are conducive to learning behaviors including taking risks, admitting mistakes, and seeking feedback. Organization leaders are instrumental in facilitating psychological safety, but may have differing perspectives of organizational climate than front-line therapists. Discrepant leader and therapist views of psychological safety may have independent associations with therapist EBP learning and implementation outcomes over and above average therapist perceptions of climate. This study examined survey data from 337 therapists and 123 leaders from 49 programs contracted to deliver multiple EBPs within a study examining determinants of sustainment within a large system-driven implementation. Both leaders and therapists completed measures of psychological safety climate and therapists reported on their self-efficacy in delivering multiple EBPs in children's mental health services. Polynomial regression and response surface analysis models were conducted to examine the associations of therapist and leader reports of psychological safety and therapist EBP self-efficacy. Greater discrepancies between leader and therapist reports of psychological safety, in either direction, were associated with lower therapist EBP self-efficacy. Alignment in leader and therapist views of psychological safety climate may impact EBP implementation outcomes. Strategies for improving alignment in perceptions and priorities among organizational members can be included in organizational implementation interventions and may represent unexamined implementation mechanisms of action.

After the Crisis: Racial/Ethnic Disparities and Predictors of Care Use Following Youth Psychiatric Emergencies.

OBJECTIVE: Youth psychiatric emergencies have increased at alarming rates, and disproportionately so for youth of color. Outpatient follow-up care is critical for positive youth outcomes, but rates of follow-up remain low, especially for racial/ethnic minoritized youth. Mobile crisis response can initiate care connection. The current study (1) describes the population who received mobile crisis response (MCR) within the nation's largest county public mental health system, (2) assesses rates of follow-up outpatient services after MCR, and (3) examines racial/ethnic disparities in outpatient services and correlates of receipt of therapy dose (≥8 sessions). METHOD: Administrative claims for MCR and outpatient services for youth ages 0 to 18 were abstracted from the Los Angeles County Department of Mental Health. RESULTS: From October 2016-2019, 20,782 youth received a MCR, 52.5% of youth were female, and youth mean age was 13.41 years. The majority of youth (91.8%) received some outpatient services after their first MCR. However, only 56.7% of youth received ≥1 therapy session. In a logistic regression, youth age, gender, race/ethnicity, primary language, primary diagnosis, insurance status, MCR call location, and MCR disposition significantly predicted receipt of ≥8 therapy sessions. CONCLUSIONS: Findings highlight disparities in therapy receipt for Asian American Pacific Islander, Black, and White youth (relative to Latinx youth), older youth, youth whose MCR was initiated from a police station call, and youth whose MCR did not result in hospitalization. We discuss priorities for quality improvement for MCR processes and strategies to promote linkage to care to achieve mental health equity.

Observed Engagement in Community Implemented Evidence-Based Practices for Children and Adolescents: Implications for Practice Delivery.

OBJECTIVE: This observational study characterizes youth and caregiver behaviors that may pose challenges to engagement within a system-driven implementation of multiple evidence-based practices (EBPs). We examined links between Engagement Challenges and therapist EBP implementation outcomes. METHOD: Community therapists (N = 102) provided audio recordings of EBP sessions (N = 666) for youth (N = 267; 71.54%, Latinx; 51.69%, female; Mage = 9.85, Range: 1-18). Observers rated the extent to which youth and/or caregivers engaged in the following behaviors: Caregiver and/or Youth Expressed Concerns about interventions, and Youth Disruptive Behaviors. Multilevel modeling was used to identify predictors of observable Engagement Challenges, and examine associations between Engagement Challenges, and therapist-reported ability to deliver planned activities, and observer-rated extensiveness of EBP strategy delivery. RESULTS: At least one Engagement Challenge was observed in 43.99% of sessions. Youth Engagement Challenges were not associated with outcomes. Caregiver Expressed Concerns were negatively associated with therapist-reported ability to carry out planned session activities (B = -.21, 95% CI[-.39-(-.02)], p < .05). However, Caregiver Expressed Concerns were positively associated with extensiveness of EBP Content strategy delivery (B = .08, 95% CI[.01-.15], p < .05). CONCLUSIONS: Results suggest that Youth Engagement Challenges have little observed impact on EBP delivery. In contrast, although therapists perceive that Caregiver Expressed Concerns derail their planned activities, Caregiver Expressed Concerns are associated with more extensive delivery of content about therapeutic interventions. Community therapists' implementation of EBPs appear unaffected by common youth in-session behavioral challenges, but future research is needed to clarify whether caregivers' concerns about interventions prompt, or are prompted by, more intensive therapist EBP content instruction.

Scaling-up Child and Youth Mental Health Services: Assessing Coverage of a County-Wide Prevention and Early Intervention Initiative During One Fiscal Year.

PURPOSE: In the U.S., the percentage of youth in need of evidence-based mental health practices (EBPs) who receive them (i.e., coverage rate) is low. We know little about what influences coverage rates. In 2010, the Los Angeles County Department of Mental Health (LACDMH) launched a reimbursement-driven implementation of multiple EBPs in youth mental health care. This study examines two questions: (1) What was the coverage rate of EBPs delivered three years following initial implementation? (2) What factors are associated with the coverage rates? METHODS: To assess coverage rates of publicly insured youth, we used LACDMH administrative claims data from July 1, 2013 to June 30, 2014 and estimates of the size of the targeted eligible youth population from the 2014 American Community Survey (ACS). The unit of analysis was clinic service areas (n = 254). We used Geographic Information Systems and an OLS regression to assess community and clinic characteristics related to coverage. RESULTS: The county coverage rate was estimated at 17%, much higher than national estimates. The proportion of ethnic minorities, individuals who are foreign-born, adults with a college degree within a geographic area were negatively associated with clinic service area coverage rates. Having more therapists who speak a language other than English, providing care outside of clinics, and higher proportion of households without a car were associated with higher coverage rates. CONCLUSION: Heterogeneity in municipal mental health record type and availability makes it difficult to compare the LACDMH coverage rate with other efforts. However, the LACDMH initiative has higher coverage than published national rates. Having bilingual therapists and providing services outside the clinic was associated with higher coverage. Even with higher coverage, inequities persisted.

Improving Care Linkage for Racial-Ethnic Minority Youths Receiving Emergency Department Treatment for Suicidality: SAFETY-A.

OBJECTIVE: This study evaluated the effects of Safe Alternatives for Teens and Youths-Acute (SAFETY-A), a brief strengths-based, cognitive-behavioral family intervention, on racial-ethnic minority youths receiving emergency department (ED) treatment for suicidal episodes. METHODS: Participants were 105 racial-ethnic minority youths enrolled in a randomized controlled trial evaluating SAFETY-A versus enhanced usual care for youths receiving ED treatment for suicidal episodes. Analyses examined group effects on care linkage after discharge and adequate treatment dose. A sample of 55 White youths was included for comparison. RESULTS: Racial-ethnic minority youths who received SAFETY-A had higher treatment linkage rates than those receiving usual care. Adequate treatment dose rates did not differ by group. CONCLUSIONS: Racial-ethnic minority youths receiving SAFETY-A had higher treatment linkage rates after discharge than those receiving usual care. SAFETY-A is a promising approach to enhance care continuity and mental health equity for racial-ethnic minority youths at risk for suicide.

How discrimination experiences relate to racial/ethnic identity and mental health across first- and second-generation Vietnamese American adolescents.

OBJECTIVES: Racial/ethnic discrimination has been linked to behavioral and emotional problems in youth from marginalized groups. However, the psychological experience associated with discrimination may differ between immigrant and nonimmigrant youth. Race-based discrimination may impact an adolescent's view of their own group (private regard) and/or their sense of how others view their group (public regard). Owing to differences in racialization, immigrant adolescents may be affected differently by experiences of discrimination than their U.S.-born peers. The present study examined whether nativity moderated the paths from racial/ethnic discrimination to private and public regard to mental health problems among Vietnamese American youth. METHOD: Surveys were completed by 718 Vietnamese American 10th and 11th graders (Mage = 15.54 years, 61.4% female, 38.6% male). In this sample, 21.2% were first-generation (i.e., born outside of the United States) and 78.8% were second-generation (i.e., born in the United States with at least one parent born outside of the United States). RESULTS: Multigroup path analysis tested the direct and indirect effects of racial/ethnic discrimination on behavioral and emotional problems via private and public regard and whether associations differed for first- versus second-generation youth. Racial/ethnic discrimination was associated with lower public regard, but not private regard, for both first- and second-generation Vietnamese American youth. Public regard was negatively associated with behavioral and emotional problems only among second-generation youth. No indirect effects were significant. CONCLUSIONS: Findings suggest differences in racialized experiences, as well as opportunities to support second-generation Vietnamese American and other marginalized youth from immigrant families from the mental health impacts of discrimination. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Latent profile analyses of disordered eating behaviors and nonsuicidal self-injury among Vietnamese adolescents.

OBJECTIVE: Comorbidity of disordered eating (DE) behaviors and nonsuicidal self-injury (NSSI) is linked to increased functional impairment. The present study identified subtypes of DE and NSSI comorbidity in a non-Western, low- and middle-income country where there has been particularly little research in this area. METHOD: Latent profile analyses (LPA) were conducted to identify patterns of subgroup comorbidity in self-reported DE behaviors and NSSI behaviors, in a sample of Vietnamese high-school students (N = 1451, 51% female). Parallel-process LPA was used to predict NSSI subgroup membership from DE subgroup membership. RESULTS: A seven-class LPA model was identified for DE: (1) Low frequencies of all DE behaviors; (2) Frequent levels of all DE behaviors; (3) Frequent fasting and purging behaviors; (4) Frequent binge eating only; (5) Moderate binge eating; (6) Moderate fasting and purging behaviors; (7) Exercise and fasting. A two-class (high versus low) model was identified for NSSI. Odds of membership in the high-NSSI class were significantly increased for all DE classes except the class characterized by moderate binge eating. Odds of belonging to the high-NSSI class were highest for those in DE classes involving purging behaviors. Males predominated in classes characterized by high behavior dysregulation. DISCUSSION: DE and NSSI represent important clinical concerns among Vietnamese youth in urban contexts, and males may show particular vulnerability for certain risk behaviors. The association of classes of DE behaviors to NSSI was particularly strong for classes that involved purging, highlighting the importance of this specific behavior for understanding comorbidity of DE and NSSI. PUBLIC SIGNIFICANCE: Disordered eating and nonsuicidal self-injury (NSSI; hurting oneself without intending to die) commonly co-occur. There has been less research on disordered eating and NSSI among individuals from non-Western or low/middle-income countries. We examined patterns of these behaviors in a school-based sample of Vietnamese adolescents. We found that patterns of disordered eating distinguished by purging showed particular links to NSSI, which could have implications for screening and treatment.

Resilience and Family Socialization Processes in Ethnic Minority Youth: Illuminating the Achievement-Health Paradox.

Youth in marginalized communities who "strive" to rise above adversity, including systemic racism and poverty, are considered "resilient." African-American, Latinx, and Asian-American youth often achieve admirable academic success despite limited social capital and high early life stress by adopting a "striving persistent behavioral style" (SPBS). SPBS may be supported by family socialization processes that facilitate reliance on self-regulation processes. Unfortunately, a young person's resilience in one domain (i.e., academic) can come at a cost in other domains, including physical and mental health morbidities that are under-identified and under-treated. Indeed, research suggests a link between SPBS in the face of adversity and later health morbidities among ethnic minority youth. Herein, we describe SPBS as an adaptation to minority stress that not only promotes social mobility but may also stoke physical and mental health disparities. We review how family processes related to academic, emotional, and ethnic-racial socialization can facilitate the striving persistent behavioral style. We emphasize the double bind that ethnic minority families are caught in and discuss directions for future research and clinical implications for individual and family-level interventions. While needed, we argue that individual and family-level interventions represent a near-term work around. Solutions and factors that shape the need for SPBS and its cost must be addressed structurally.