Health Service Utilization Among Children and Adolescents with Posttraumatic Stress Disorder: A Case-Control Study.

OBJECTIVE: Trauma exposure is widely prevalent, with more than 60% of adolescents having experienced at least 1 traumatic event and a third of those at high risk to develop posttraumatic stress disorder (PTSD). Data are scarce and out of date on the services children and adolescents with PTSD receive, impeding efforts to improve care and outcomes. This study examines health service use for a large and diverse sample of children and adolescents with and without a diagnosis of PTSD. METHOD: Using a matched case-control study, we gathered information from 4 large health care systems participating in the Mental Health Research Network. Data from each site's electronic medical records on diagnoses, health care encounters, and demographics were analyzed. Nine hundred fifty-five 4- to 18-year-olds with a diagnosis of PTSD were identified and matched on a 1:5 ratio to 4770 controls. We compared cases with controls on frequency of service use in outpatient primary care, medical specialty care, acute care, and mental health care. We also assessed psychotropic medication use. RESULTS: Children and adolescents diagnosed with PTSD used nearly all physical and mental health service categories at a higher rate than controls. However, one-third of children and adolescents did not receive even 1 outpatient mental health visit (36.86%) during the year-long sampling window. CONCLUSION: Our findings suggest that children and adolescents diagnosed with PTSD may have unmet mental health needs. They are high utilizers of health services overall, but lower utilizers of the sectors that may be most helpful in resolving their symptoms.

Personalizing Behavioral Parent Training Interventions to Improve Treatment Engagement and Outcomes for Culturally Diverse Families.

Behavioral Parent Training (BPT) interventions are efficacious for young children with externalizing behavior problems. However, not all families benefit, and ethnic minority families in particular are less likely to enroll, engage, and improve in BPT. Versions of BPT interventions tailored for specific ethnic groups have been successful at improving engagement and outcomes for ethnic minorities; however, the specificity of these models presents challenges for broad dissemination. This article presents a personalization approach (PersIn) that utilizes cultural assessment results to tailor treatment protocols to the characteristics of individual families. We believe this approach has the potential to maximize cultural sensitivity while preserving generalizability to both minority and non-minority ethnic groups. We further propose that personalization on Parent Explanatory Model (PEM) parameters that have been found to vary across ethnic groups and to impact treatment engagement and/or outcomes is a promising approach to decreasing disparities in BPTs. We describe examples of evidence-supported PEMs that present good targets for personalization and provide examples from MY PCIT to illustrate how PersIn can be applied to Parent-Child Interaction Therapy (PCIT).

Household composition and maltreatment allegations in the US: Deconstructing the at-risk single mother family.

BACKGROUND: Previous research has demonstrated the association between child maltreatment and household composition, with increased maltreatment risk generally present in single mother households. However, existing research does not fully examine the complexity and configuration of single mother households. In particular, less is known about important variants of single parent family structures, such as grandparents residing in the home, and the extent to which household compositions change across time. OBJECTIVE: The present study examines rates of maltreatment allegations across various household compositions in a sample of single biological mother households. PARTICIPANTS AND SETTING: Youth participants (N = 417) were part of the larger multi-site Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) study. METHODS: Participants completed longitudinal assessments of household composition and maltreatment allegations from ages 4 to 10. RESULTS: The present study illustrates substantial variability in the rate of maltreatment allegations across different types of single mother household compositions. In particular, the presence of non-relatives, especially unrelated males, demonstrated an increased risk for maltreatment allegations in the home. Conversely, single mother homes with two or more adult relatives, especially grandmothers, were at reduced risk for child maltreatment allegations. CONCLUSIONS: This study highlights variability in maltreatment allegations among single mother homes, including how maltreatment allegations vary across different household configurations, across child age periods and across different risk levels.

Parent Educational Involvement in Middle School: Longitudinal Influences on Student Outcomes.

The present study examined influences of 6th grade student-reported parent educational involvement on early adolescent peer group affiliations at 7th and 8th grade. In addition, student gender and ethnicity were explored as possible moderators. Drawn from a large effectiveness trial, participants in this study were 5,802 early adolescents across twenty middle schools in the Northwest region of the United States. Findings suggested that specifically parent's educational involvement in 6th grade predicted increases in positive peer affiliation, when controlling for a general score of parent monitoring practices. The relation between parent educational involvement and peer affiliation varied by student ethnicity but not by gender. Findings suggest the social benefits of parent's engagement with the school context on early adolescent development.

Treatment and Prevention of Depression and Anxiety in Youth: Test of Cross-Over Effects.

Anxiety and depression are highly comorbid and share several common etiological processes. Therefore, it may be more efficient to develop interventions that treat or prevent these problems together rather than as separate entities. The present meta-analytic review examined whether interventions for children and adolescents that explicitly targeted either anxiety or depression showed treatment specificity or also impacted the other outcome (i.e. cross-over effects). We addressed this question both within the same type of study (i.e. treatment, prevention) and across study types. Only randomized controlled trials (RCTs) that assessed both constructs with dimensional measures were included in this review. For treatment studies, RCTs targeting anxiety (n = 18) showed significant effects on both anxious and depressive symptoms, although more strongly on anxiety than depression; similarly, RCTs treating depression (n = 9) yielded significant effects on both depressive and anxious symptoms, but stronger effects on depression than anxiety. Thus, there were cross-over effects in treatments purportedly targeting either anxiety or depression, and also treatment specificity, such that larger effects were seen for the target problem at which the treatment was aimed. Anxiety prevention studies (n = 14) significantly affected anxious, but not depressive symptoms, indicating no cross-over effect of anxiety prevention trials on depression. For depression prevention studies (n = 15), the effects were not significant for either depressive or anxiety symptoms, although the effect was significantly larger for depressive than for anxious symptoms. Post-hoc analyses revealed that the effect on depressive symptoms was significant in depression preventions trials of targeted but not universal samples. Implications for transdiagnostic interventions are discussed.

Family check-up effects across diverse ethnic groups: reducing early-adolescence antisocial behavior by reducing family conflict.

Multicultural responsiveness and adaptation have been a recent area of emphasis in prevention and intervention science. The changing demographics of the United States demand the development of intervention strategies that are acceptable and effective for diverse cultural and ethnic groups. The Family Check-Up (FCU) was developed to be an intervention framework that is flexible and adaptive to diverse cultural groups (Dishion & Stormshak, 2007 ). We empirically evaluated the extent to which the intervention is effective for improving youth adjustment and parent-child interactions for diverse cultural groups. A sample of 1,193 families was drawn from 2 large-scale randomized prevention trials conducted in diverse urban middle schools. We formulated 3 groups on the basis of youth self-identification of ethnicity (European American, African American, Hispanic) and examined group differences in the hypothesized mediating effect of family conflict (FC) on later antisocial behavior (ASB). Path analysis revealed that youths in the intervention condition reported significantly less ASB over a 2-year period (Grades 6-8). Moreover, youth-reported reductions in FC at 12 months were an intervening effect. Ethnicity did not moderate this relationship. Consistent with one of the primary tenets of coercion theory, participation in the FCU acts on ASB through FC across diverse ethnic groups, lending support to the multicultural competence of the model. Limitations of this study are discussed, along with areas for future research.

A personalized and control systems engineering conceptual approach to target childhood anxiety in the contexts of cultural diversity.

In the child and adolescent anxiety area, some progress has been made to develop evidence-based prevention protocols, but less is known about how to best target these problems in children and families of color. In general, data show differential program effects with some minority children benefiting significantly less. Our preliminary data, however, show promise and suggest cultural parameters to consider in the tailoring process beyond language and cultural symbols. It appears that a more focused approach to culture might help activate intervention components and its intended effects by focusing, for example, on the various facets of familismo when working with some Mexican parents. However, testing the effects and nuances of cultural adaption vis-à-vis a focused personalized approach is methodologically challenging. For this reason, we identify control systems engineering design methods and provide example scenarios relevant to our data and recent intervention work.

Predictors of Initial Engagement in Child Anxiety Mental Health Specialty Services.

BACKGROUND: Child and family mental health services remain largely underutilized despite the relatively high rate of youth suffering from mental, emotional, and behavioral (MEB) disorders. As such, it is important to address challenges and examine factors related to child mental health service use and engagement, especially when it comes to children in need of services for anxiety. OBJECTIVE: Informed by the Behavioral Model of Health Services Use (BMHS), the present study sought to examine predictors of service use and engagement for families seeking assistance for their anxious children. Initial levels of engagement in culturally tailored services were predicted from predisposing characteristics (e.g., child age, ethnicity), enabling resources (e.g., Spanish services, transportation), and need characteristics (e.g., child clinical severity). METHOD: Participants included Latino (n = 126) and Caucasian (n = 116) families who presented to a specialty clinic due to child emotional and behavior problems related to anxiety. Initial service utilization and engagement was assessed along the following levels toward services care: (1) initiated contact and completed a clinical intake, (2) completed a home screen, and (3) completed an on-site diagnostic assessment. All procedures were culturally tailored to the presenting needs of families. RESULTS: Predisposing characteristics, enabling resources and need characteristics emerged as significant predictors of child mental health service use, with some variations. Child age, ethnicity, referral source, and enabling resources predicted completion of a home screen. Proximity to services predicted completion of the on-site diagnostic assessment. CONCLUSION: Knowledge of factors that predict engagement in child mental health services can help identify avenues to promote service utilization, especially among ethnic minority children and families. Our culturally tailored approach to serving families appears to be promising in bridging the cross-ethnic services gap and therefore has implications for practice.

Indicated prevention and early intervention for childhood anxiety: a randomized trial with Caucasian and Hispanic/Latino youth.

OBJECTIVE: This trial of a randomized indicated anxiety prevention and early intervention explored initial program effects as well as the role of ethnicity and language on measured outcomes. METHOD: A total of 88 youth (M = 10.36 years; 45 girls, 52 Latino) received 1 of 2 protocols with varying degrees of parent involvement, and response was measured at posttest and 6-month follow-up. RESULTS: Findings showed that child anxiety symptoms improved significantly across protocols, although additional gains were found for children in the child plus parent condition. Program effects did not vary by Latino ethnicity or Spanish language use in the intervention. CONCLUSIONS: The cognitive and behavioral strategies established for Caucasian children may be promising for Hispanic/Latino children when applied in a culturally responsive manner.

Pre-sleep arousal and sleep problems of anxiety-disordered youth.

The current study examined sleep problems and pre-sleep arousal among 52 anxious children and adolescents, aged 7-14 years, in relation to age, sex, ethnicity, and primary anxiety disorder. Assessment included structured diagnostic interviews and parent and child completed measures of sleep problems and pre-sleep arousal. Overall, 85% of parents reported clinically-significant child sleep problems, whereas 54% of youth reported trouble sleeping. Young children, those with primary generalized anxiety disorder, and Latino youth experienced the greatest levels of sleep disturbance. Additionally, greater levels of pre-sleep cognitive rather than somatic arousal were found and pre-sleep thoughts were associated with decreased total sleep duration and greater sleep problems. Findings suggest that attention to sleep should be part of assessment procedures for anxious children in both research and clinical settings.

The Factor Structure of Effortful Control and Measurement Invariance Across Ethnicity and Sex in a High-Risk Sample.

Measurement invariance of a one-factor model of effortful control (EC) was tested for 853 low-income preschoolers (M age = 4.48 years). Using a teacher-report questionnaire and seven behavioral measures, configural invariance (same factor structure across groups), metric invariance (same pattern of factor loadings across groups), and partial scalar invariance (mostly the same intercepts across groups) were established across ethnicity (European Americans, African Americans and Hispanics) and across sex. These results suggest that the latent construct of EC behaved in a similar way across ethnic groups and sex, and that comparisons of mean levels of EC are valid across sex and probably valid across ethnicity, especially when larger numbers of tasks are used. The findings also support the use of diverse behavioral measures as indicators of a single latent EC construct.

Psychosocial Interventions for School Refusal Behavior in Children and Adolescents.

This article reviews empirical evidence for the efficacy of psychosocial interventions for school refusal behavior. Data corresponding to eight experimental single-case and seven group-design studies are presented. Across studies, behavioral and cognitive-behavioral treatments emerged as promising lines of intervention. These interventions produced improvements in school attendance and youths'symptom levels (e.g., anxiety, fear, depression, anger) based on this study's examination of effect sizes. The article concludes with suggestions for interventionists, researchers, and policymakers attempting to deal with the problem of school refusal.