A National Institutes of Health Approach for Advancing Research to Improve Youth Mental Health and Reduce Disparities.

Even before the COVID-19 pandemic, mental health challenges were the leading cause of disability and poor health outcomes in youth. Challenges are even greater for youth from racially and ethnically minoritized groups in the United States. Racially and ethnically minoritized youth are more vulnerable to mental health problems than White adolescents, yet are less likely to use mental health services. In late 2021, the National Institutes of Health (NIH) sponsored a virtual conference to examine the state of the science around youth mental health disparities (YMHD), focusing on youth from racially and ethnically minoritized populations and the intersection of race and ethnicity with other drivers of mental health disparities. Key findings and feedback gleaned from the conference have informed strategic planning processes related to YMHD, which has included the development of a strategic framework and funding opportunities, designed to reduce YMHD. This commentary briefly describes the collaborative approach used to develop this framework and other strategies implemented across the NIH to address YMHD and serves as an urgent call to action.

Strategic Directions in Preventive Intervention Research to Advance Health Equity.

As commissioned by the Society for Prevention Research, this paper describes and illustrates strategic approaches for reducing health inequities and advancing health equity when adopting an equity-focused approach for applying prevention science evidence-based theory, methodologies, and practices. We introduce an ecosystemic framework as a guide for analyzing, designing, and planning innovative equity-focused evidence-based preventive interventions designed to attain intended health equity outcomes. To advance this process, we introduce a health equity statement for conducting integrative analyses of ecosystemic framework pathways, by describing the role of social determinants, mechanisms, and interventions as factors directly linked to specific health equity outcomes. As background, we present health equity constructs, theories, and research evidence which can inform the design and development of equity-focused intervention approaches. We also describe multi-level interventions that when coordinated can produce synergistic intervention effects across macro, meso, and micro ecological levels. Under this approach, we encourage prevention and implementation scientists to apply and extend these strategic directions in future research to increase our evidence-based knowledge and theory building. A general goal is to apply prevention science knowledge to design, widely disseminate, and implement culturally grounded interventions that incrementally attain specific HE outcomes and an intended HE goal. We conclude with recommendations for conducting equity-focused prevention science research, interventions, and training.

Perspectives From the National Institutes of Health on Multidimensional Mental Health Disparities Research: A Framework for Advancing the Field.

Racial, ethnic, and other mental health disparities have been documented for several decades. However, progress in reducing or eliminating these disparities has been slow. In this review, the authors argue that understanding and addressing mental health disparities requires using a multidimensional lens that encompasses a wide array of social determinants of health at individual, interpersonal, organizational, community, and societal levels. However, much of the current research on mental health disparities, including research funded by the National Institutes of Health, is characterized by a narrower focus on a small number of determinants. The authors offer a research framework, adapted from the National Institute on Minority Health and Health Disparities Research Framework, that provides examples of determinants that may cause or sustain mental health disparities and that can serve as intervention targets to reduce those disparities. They also discuss different types of mental health disparities research to highlight the need for more research testing and implementing interventions that directly modify social determinants of health and promote mental health equity.

Innovative Directions to Advance Mental Health Disparities Research.

Disparities in mental health have persisted or worsened despite our awareness of their existence, increased understanding of their causes, and efforts at reduction and mitigation. Although much is known, there is still much to be done in mental health research to meaningfully impact disparities. In November 2020, the National Institute of Mental Health (NIMH) and the National Institute of Minority Health and Health Disparities (NIMHD) co-sponsored a virtual workshop to explore the complexities of mental health disparities, which revealed several gaps and opportunities for the field to pursue to advance mental health disparities research. This article, the introduction to a Special Issue on Mental Health Disparities, provides a frame for four articles that stem from and are inspired by the virtual NIMH/NIMHD workshop, all of which illustrate innovative research on understanding the complex mechanisms of disparities and how this knowledge can be translated into effective intervention development that advances mental health equity.

A call to action to address rural mental health disparities.

Rural residents in the USA experience significant disparities in mental health outcomes even though the prevalence of mental illness in rural and metropolitan areas is similar. This is a persistent problem that requires innovative approaches to resolve. Adopting and appropriately modifying the National Institute on Minority Health and Health Disparities research framework are the potential approaches to understanding how these disparities might be addressed through research. Using this research framework can facilitate interrogation of multiple levels of influence, encompassing complex domains of influence and consideration of the entire life course trajectory, which is consistent with several National Institute of Mental Health priorities.

Literature Review of the National CLAS Standards: Policy and Practical Implications in Reducing Health Disparities.

The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care are a practical tool for health and health care organizations to improve their provision of culturally and linguistically appropriate services (CLAS). Published by the Office of Minority Health at the U.S. Department of Health and Human Services, the National CLAS Standards provide health and health care organizations with a set of action steps for better meeting the needs of individuals from culturally and linguistically diverse backgrounds. Few studies have examined the concept of CLAS or the National CLAS Standards, and they have rarely been extensively studied or reviewed. The authors conducted three literature searches between February 2014 and May 2015, examining the organizational challenges, applicability, and policy implications related to the National CLAS Standards or CLAS, and selected 55 articles for inclusion in the review. The literature highlights a number of challenges in implementing the National CLAS Standards and/or providing CLAS, including issues related to the communication within health care organizations and the inconsistency of accountability measures. This literature review contributes to the growing knowledge base of the National CLAS Standards and CLAS in health and health care.

Addressing disparities in mental health agencies: strategies to implement the National CLAS Standards in Mental Health.

Historically, the mental health system has not effectively addressed the needs of culturally and linguistically diverse individuals (President's New Freedom Commission on Mental Health, 2003), which has contributed to significant racial and ethnic disparities in mental health care (USDHHS, 2001). This paper focuses on exploring how a U.S. Department of Health and Human Services' Office of Minority Health policy initiative, the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (or the National CLAS Standards), may be used by mental health agencies to reduce mental health care disparities. The National CLAS Standards are a set of action steps that inform and facilitate the implementation of culturally and linguistically appropriate services. We first discuss the role of cultural and linguistic competency in mental health care disparities reduction efforts, and then describe specific strategies to facilitate the organizational implementation of the National CLAS Standards.

The baby or the bath water? Lessons learned from the National Action Alliance for Suicide Prevention Research Prioritization Task Force literature review.

CONTEXT: The Research Prioritization Task Force of the National Action Alliance for Suicide Prevention conducted a comprehensive literature review of suicide prevention/intervention trials to assess the quality of the scientific evidence. EVIDENCE ACQUISITION: A literature "review of reviews" was conducted by searching the most widely used databases for mental health and public health research. The quality of the reviews was evaluated using the Revised Assessment of Multiple Systematic Reviews system; the quality of the scientific evidence for the suicide preventions/interventions was assessed using U.S. Preventive Services Task Force criteria. The reviews were limited to peer-reviewed publications with human subjects published in English. EVIDENCE SYNTHESIS: Ninety-eight systematic reviews and 45 primary sources on suicide prevention/interventions published between January 2000 and September 2012 were evaluated. The results suggest that the quality of both the systematic reviews and the scientific evidence for suicide preventions/interventions were mixed. The majority of the systematic reviews and prevention/interventions were evaluated as fair to poor in quality. CONCLUSIONS: There are many promising suicide prevention/intervention trials, but research findings are often inconclusive because of methodologic problems. Methodologic problems across systematic reviews include not conducting hand searches, not surveying gray literature, and being unable to aggregate data across studies. Methodologic problems with the scientific quality of the prevention/intervention trials include paucity of information on sample demographic characteristics, poorly defined outcomes, and excluding actively suicidal participants. Suggestions for ways to improve the quality of the systematic reviews and suicide preventions/interventions are provided.

The effect of waiting time on youth engagement to evidence based treatments.

Prolonged waiting times to receive mental health services are common and may have negative consequences. This study examines the relationship between waiting time and treatment engagement among 2,054 youth referred to an evidence based treatment (EBT). Findings indicate that families are more likely to refuse services if they face longer waiting times. Families exposed to a prolonged waiting time were also more likely to drop out prematurely from Functional Family Therapy, but this relationship was not significant among youth receiving Multisystemic Therapy. Implications for EBT implementation and strategies for engaging families are discussed.

System-level change in cultural and linguistic competence (CLC): how changes in CLC are related to service experience outcomes in systems of care.

As US demographic trends shift toward more diversity, it becomes increasingly necessary to address differential needs of diverse groups of youth in mental health service systems. Cultural and linguistic competence (CLC) is essential to providing the most appropriate mental health services to youth and their families. The successful implementation of CLC often begins at the system level. Though various factors may affect change and system-level factors set the tone for broad acceptance of CLC within systems, there is limited empirical evidence linking culturally competent practices to outcomes. The purpose of the present study was to examine system-level CLC changes over time within systems of care and their associations with service experiences among youth and their families. Participants were 4,512 youth and their families enrolled in the national evaluation of the Children's Mental Health Initiative (CMHI). Results suggest that implementation of CLC at the system level improves over time in funded systems of care. Further, variation exists in specific system-level components of CLC. In addition, the changes in CLC at the system level are related to family/caregiver participation in treatment. Implications for supporting positive changes in CLC among systems of care communities, and specific strategies for community psychologists, are discussed.

Behavioral and Emotional Strengths among Youth in Systems-of-Care and the Effect of Race/Ethnicity.

Behavioral and emotional strengths are important to consider when understanding youth mental health and treatment. This study examined the association between youth strengths and functional impairment, and whether this association is modified by race/ethnicity. Multinomial logistic regression models were used to estimate the effects of strengths on impairment, and examine whether race and ethnicity modified this relationship in 8,129 Caucasian, African American, Hispanic, and American Indian/Alaska Native youth, between 5 and 18 years of age. Results suggest that youth with average and above average strengths were less likely to have impairment compared to youth with below average strengths. Race and ethnicity modified this relationship in both expected and unexpected ways. Among youth with average and above average strengths, racial and ethnic minority youth appear to have more impairment than Caucasian youth. However, among youth with below average strengths, racial and ethnic minority youth have less impairment than Caucasian youth. Findings highlight the importance of incorporating strengths-based approaches in youth mental health treatment and the need for further research to understand the specific nature of strengths as it effects impairment across racial/ethnic groups. Implications and recommendations are discussed.

Social network influences on service use among urban, African American youth with mental health problems.

PURPOSE: To examine the associations between the size and quality of African-American adolescents' social networks and their mental health service use, and to examine whether these social network characteristics moderate the association between need for services because of emotional or behavioral difficulties and use of services. METHOD: Participants were a community sample of African-American adolescents (N = 465; 46.2% female; mean age, 14.78) initially recruited in 1st grade for participation in an evaluation of two preventive intervention trials. Social network influences and adolescents' mental health service use in schools and community were accessed. RESULTS: A significant positive association between adolescents' perception that their social network was helpful and their use of school mental health services was identified. The significant associations between need for services for anxiety, depression, or behavior problems, and school and outpatient service use were moderated by size of the social network. Specifically, among youth in need of services for anxiety or depression, school-based service use was higher for those with larger social networks. CONCLUSIONS: Implications for enhancing access to formal mental health services include further examination of key social network influences that potentially serve as facilitators or barriers to formal help-seeking. The findings also suggest that it might be important to integrate social network members into interventions to address the mental health needs of adolescents.

Stigmatizing experiences of parents of children with a new diagnosis of ADHD.

OBJECTIVE: The experiences of parents of a child who received an initial diagnosis of attention-deficit hyperactivity disorder (ADHD) were examined to determine the ways in which they may have encountered stigmatizing situations. METHODS: Forty-eight parents of children aged six to 18 years were interviewed about their experiences leading up to their child's ADHD diagnosis, including their decisions to seek treatment. All interviews were recorded, transcribed, and analyzed using grounded theory methods. Codes were identified using a constant comparative approach, which led to theoretically defined thematic constructs of stigma. RESULTS: Stigmatizing experiences were noted by 77% of the sample. Nearly half (N=21, 44%) were concerned about how society would label their child, 40% (N=19) felt social isolation and rejection, and 21% (N=10) perceived health care professionals and school personnel as being dismissive of their concerns. Parents' own attitudes about ADHD treatment were shaped by their exposure to negative media (N=10, 21%), their mistrust of medical assessments (N=8, 17%), and the influence of general public views (N=3, 6%). These stigmatizing views were related to parental concerns about the impact that diagnosis and treatment would have on their child's self-esteem and opportunities for future success. CONCLUSIONS: The range of ways in which parents in the study experienced stigma highlights the need for multiple perspectives for community outreach and public health programs that are aimed at addressing and eliminating mental health stigma. Even though stigma is a well-established barrier to mental health service use, the anticipated benefits of treatment may outweigh parents' experiences with stigma.

Differences in mental health service sector utilization among African American and Caucasian youth entering systems of care programs.

Differences in unmet need and access to services between African American and Caucasian youth have been established; less is known about differences in specific mental health service sectors. This study examined differences in past year outpatient, school-based, day treatment and residential/inpatient service utilization among African American and Caucasian youth (n = 3,649) entering a federally funded system of care program. Random effect logistic regression models were implemented to examine the relationship between race and past year service utilization. Analyses revealed that African American youth were less likely than Caucasian youth to have utilized school-based and residential/inpatient mental health services in the past year. Findings suggest that racial disparities exist in service use for certain types of service sectors and highlight the importance of understanding and identifying individual, family, and community factors that contribute to disparities in service utilization.

Caregiver strain and youth suicide attempt: Are they related?

There are scant data documenting the relationship between caregiver strain and suicidal behavior among youth. This study includes data from the caregivers of 1,854 youth who received services through the Comprehensive Community Mental Health Services for Children and Their Families Program. Caregiver strain, family functioning, and youth functional impairment were assessed with the Caregiver Strain Questionnaire, Family Life Questionnaire, and Columbia Impairment Scale. Caregivers of suicidal and nonsuicidal youth differed in subjective internalizing strain (e.g., worry and guilt) and objective strain (e.g., constraints on activities). Differences in objective strain persisted even after controlling for family life and youth functional impairment.

Perceived norms and mental health help seeking among African American college students.

In general, African Americans do not seek mental health treatment from formal sources at the same rates as Caucasians. The present study examined whether culturally relevant factors (i.e., perceived negative peer and family norms about help seeking) influence help-seeking intentions in a late adolescent African-American sample (n = 219) and whether there is a gender difference in the predictive strength between peer and family norms. Participants were primarily female (n = 144). Multiple regressions were implemented to explore the relationship between perceived norms and help-seeking intentions. Analyses revealed that males had higher perceived peer norms, and family norms were a stronger predictor of intentions than peer norms for females. Individually, peer norms and family norms were related to help-seeking intentions. When perceived norms were analyzed together, only negative family norms were related to intentions. Findings suggest that incorporating family norms is critical when developing interventions to increase formal service utilization among African Americans.