Effectiveness of a multidisciplinary treatment with youth-initiated mentoring for youths with mental health needs from multi-problem families: a quasi-experimental study.

BACKGROUND: Children from multi-problem families have an increased risk for experiencing mental health problems. These families face problems in several domains that are often found to be chronic and intergenerational. Yet, the effects of mental health care for youths from multi-problem families are small at best, urging research on new treatment programs. The InConnection approach is an integrated care program to improve resilience of youths with mental health needs from multi-problem families by connecting professional expertise from multiple disciplines with the informal social network of the youth. Youths are asked to nominate a youth-initiated mentor (YIM) from the supportive adults in their network. METHODS: This quasi-experimental study compared the effectiveness of the InConnection approach to treatment as usual in a sample of 107 families (n = 66 intervention group, n = 41 control group) with n = 115 youths receiving treatment (cases). Youths (n = 102 reports, Mage = 15.59 years), parents (n = 85 reports) and case managers (n = 107 reports) responded to questionnaires four times over 15 months. Using these data, we measured youth resilience as the primary outcome, seven secondary outcomes, and three intermediate outcomes. RESULTS: Latent growth models showed only one significant change in outcomes over time across conditions, namely a decrease in case manager-reported child unsafety, and only two condition effects, which were both parent-reported. Parents in the InConnection group reported improvements over time in youth's emotional and behavioral problems and their own positive parenting, whereas control parents reported no changes (ps ≤ 0.013). DISCUSSION: The treatment conditions were not effective in improving most of the youth and parental outcomes over time, except for child safety reported by the case manager. The InConnection approach only outperformed care as usual on two parent-reported outcomes. Future research should examine for whom and under what circumstances the InConnection approach works more convincingly. TRIAL REGISTRATION: Netherlands Trial Register NL7565. Retrospectively registered on 05/03/2019.

Group Climate in Residential Youth Care: Development and Validation of the Group Climate Instrument-Revised.

Group climate in residential youth care is considered to be essential for treatment of youth and young adults. Various instruments exist to measure quality of living group climate, but some are lengthy, use complicated wording, which make them difficult to fill out by youth and individuals with a mild intellectual disability. The present study describes the development and rationale for the Group Climate Instrument-Revised (GCI-R). Construct validity and reliability of the GCI-R were examined by means of Confirmatory Factor Analysis (CFA) in a two-step validation process using a construction sample (n = 190 youth, representing 41 groups) and a validation sample (n = 207 youth, representing 42 groups). Results indicated a good fit of a five-factor model (Support, Growth, Physical Environment, Peer interactions, and Repression). Reliability of the scales was good. These findings indicate that the GCI-R can be used as a parsimonious, valid, and reliable instrument to assess perceptions of group climate in youth. Recommendations for future research and practice are suggested.

Victims of Child Abuse Dropping Out of Trauma-Focused Treatment: A Meta-Analysis of Risk Factors.

A substantial number of children who experienced child maltreatment drop out of evidence-based trauma-focused treatments (TF-CBT). Identifying child, family, and treatment-related factors associated with treatment dropout is important to be able to prevent this from happening and to effectively treat children's trauma-related symptoms. Methods: A quantitative review was performed based on a systematic synthesis of the literature on potential risk factors for dropout of trauma-focused treatment in maltreated children. Results: Eight studies were included, that examined TF-CBT, reporting on 139 effects of potential risk factors for dropout. Each factor was classified into one of ten domains. Small but significant effects were found for the "Demographic and Family" risk domain (r = .121), with factors including being male, child protective services involvement or placement, and minority status, and for the "Youth Alliance" risk domain (r = .207), with factors including low therapist-child support and low youth perception of parental approval. Moderator analyses suggested that family income and parental education may better predict the risk for TF-CBT dropout than other variables in the "Demographic and Family" domain. Conclusions: Our results provide a first overview of risk factors for dropout of trauma-focused treatments (TF-CBT) after child maltreatment, and highlight the role of the therapeutic relationship in this. Supplementary Information: The online version contains supplementary material available at 10.1007/s40653-022-00500-2.

A Three-level Meta-analysis on the Alliance-Outcome Association in Child and Adolescent Psychotherapy.

Previous meta-analyses have found small to moderate associations between child-therapist alliance and treatment outcomes. However, these meta-analyses have not taken into account changes in alliance (i.e., alliance shifts), alliance agreement (i.e., congruence or discrepancies between child-therapist ratings), and the role of alliance as a moderator in relation to treatment outcomes (i.e., an interaction effect of alliance and treatment condition on treatment outcomes). A series of multilevel meta-analyses of 99 studies was conducted to investigate several types of alliance-outcome associations in child and adolescent psychotherapy. Associations between child-therapist alliance and child outcomes (r = 0.17), changes in child-therapist alliance and child outcomes (r = 0.19), child-therapist alliance as a moderator of outcomes (r = 0.09), and parent-therapist alliance and child outcomes (r = 0.13) were small. Associations between child-therapist alliance agreement and outcomes (r = 0.21) and between parent-therapist alliance and parent outcomes (r = 0.24) were small to moderate. This meta-analysis provides the most updated and comprehensive overview of the alliance-outcome association in child and adolescent psychotherapy, showing that the alliance continues to show impact on treatment outcomes. Alliance research in youth psychotherapy has increasingly focused on several complex aspects of the alliance-outcome association, such as the role of changes in alliance, alliance discrepancies, client and therapist variability, and the reciprocal association between alliance and prior symptom change in relation to treatment outcomes. Implications for future research and clinical practice are discussed.

A Meta-Analysis on Differences and Associations between Alliance Ratings in Child and Adolescent Psychotherapy.

OBJECTIVE: The alliance in child and adolescent psychotherapy is widely recognized as an important factor in therapy. Studies on the alliance have increasingly focused on assessment of the alliance as a dyadic construct, measuring both client and therapist alliance ratings. However, cross-informant reports of the alliance in child psychotherapy have not yet been subjected to meta-analysis. Therefore, the present meta-analysis aims to increase knowledge on the degree of convergence and divergence between child, parent, therapist, and observer alliance ratings in child and adolescent psychotherapy. METHODS: A series of three-level meta-analyses of 78 studies was conducted to investigate differences and associations between child, parent, therapist, and observer alliance ratings in child and adolescent psychotherapy. RESULTS: Findings indicated that children and parents in general rated the alliance more positively than their therapists (d = 0.35, d = 0.72, respectively), and that child-therapist and parent-therapist alliance ratings were moderately correlated (r = .32, r = .23, respectively). Associations between child and therapist ratings and observer ratings were moderate to large (r = .43, r = .53, respectively). CONCLUSIONS: It can be concluded that children and parents generally report more positively on the alliance compared to their therapists, which is consistent with research on the alliance in adult populations. The small to moderate associations between alliance ratings indicate that individuals to some extent have a shared perspective on their alliance, and that the various perspectives on alliance should be acknowledged when dealing with children and parents in therapy. Implications for future research are discussed.

Resilience, well-being and informal and formal support in multi-problem families during the Covid-19 pandemic.

BACKGROUND: The Covid-19 pandemic may have had negative effects on youth and parental mental health, especially in high-risk populations such as multi-problem families (i.e., families that experience problems in multiple domains, such as mental health and social network problems). Using one to four assessments during all phases of the Covid-19 pandemic up until January 2022, we examined the associations between pandemic-related stress and mental health (resilience and well-being) of youth and parents from multi-problem families. We also investigated whether experienced informal (i.e., youth informal mentoring) and formal support (i.e., therapist support) served as protective factors in this association. METHODS: A total of 92 youth aged 10-19 years (46.7% girls; mean age 16.00 years) and 78 parents (79.5% female; mean age 47.17 years) filled in one to four questionnaires between March 2020 and January 2022. Multi-level analyses were conducted to account for the nested structure of the data. RESULTS: For youth, pandemic-related stress was associated with lower well-being, but not with resilience. Perceived support from both mentors and therapists was positively associated with youth mental health. Furthermore, high perceived therapist support protected youth from the negative effect of pandemic-related stress on resilience. For parents, pandemic-related stress was not related to mental health, irrespective of therapist support. Yet, therapist support was directly and positively associated with parental mental health. CONCLUSIONS: Youth from multi-problem families who experience pandemic-related stress are at risk of (elevated) mental health problems during the pandemic, specifically if they have no or weak therapist support. The mental health of parents, however, was minimally affected by pandemic-related stress, indicating strength and flexibility. Youth and parents who experienced support during the pandemic reported higher levels of resilience and well-being, demonstrating the importance of support for individuals' mental health during stressful times such as a pandemic.

A Cohort Study on the Effect of Parental Mind-Mindedness in Parent-Child Interaction Therapy.

Parent-child interaction therapy (PCIT) is a short-term, evidence-based intervention for caregivers with children aged between 2 and 7 who exhibit behavioral problems. PCIT is effective, but has a high attrition rate ranging from 27% to 69%. We hypothesize that a low level of parental mind-mindedness-the parent's propensity to treat the child as an intentional agent with its own thoughts and emotions-might contribute to premature attrition or cause families to profit less from treatment. To test these hypotheses, we performed a retrospective cohort study in a time-limited, home-based PCIT sample (n = 19) and in a clinic-based PCIT sample (n = 25), to investigate whether parents with a medium-high level of mind-mindedness differ from parents with a medium-low level of mind-mindedness in the outcome measures of PCIT (child's behavioral problems, parenting skills and stress and mothers' anxious and depressed symptoms). Furthermore, we examined if mind-mindedness was related to attrition and (for clinic-based PCIT only) number of sessions. Repeated measures ANOVA showed that mothers with a medium-high level of mind-mindedness displayed more improvement in two parenting skills benefiting a positive parent-child interaction. Furthermore, we found a group effect of mind-mindedness in the PCIT-home sample, with mothers with a medium-high level of mind-mindedness showing better results on most outcome measures. Our findings suggest that adding a mind-mindedness improving intervention prior to or during PCIT could benefit mothers with a medium to low level of mind-mindedness.

Prevalence of Adverse Childhood Experiences in Students with Emotional and Behavioral Disorders in Special Education Schools from a Multi-Informant Perspective.

Adverse childhood experiences (ACEs) are associated with an increased risk of developing severe emotional and behavioral problems; however, little research is published on ACEs for students with emotional and behavioral disorders (EBD) in special education (SE) schools. We therefore systematically explored the prevalence, type and timing of ACEs in these students from five urban SE schools in the Netherlands (Mage = 11.58 years; 85.1% boys) from a multi-informant perspective, using students' self-reports (n = 169), parent reports (n = 95) and school files (n = 172). Almost all students experienced at least one ACE (96.4% self-reports, 89.5% parent reports, 95.4% school files), and more than half experienced four or more ACEs (74.5% self-reports, 62.7% parent reports, 59.9% school files). A large majority of students experienced maltreatment, which often co-occurred with household challenges and community stressors. Additionally, 45.9% of the students experienced their first ACE before the age of 4. Students with EBD in SE who live in poverty or in single-parent households were more likely to report multiple ACEs. Knowledge of the prevalence of ACEs may help understand the severe problems and poor long-term outcomes of students with EBD in SE.

What makes Dutch youth comply with preventive COVID-19 measures? An explorative study.

The measures to contain the spread of COVID-19 are challenging for youth, especially the social isolation measures. These measures are antagonistic to healthy youth development, which requires sufficient social contact with peers and adults. This explorative study examined what factors are associated with adherence to COVID-19 measures in a sample of Dutch youth (N = 263; 79.8% female) with ages ranging between 16 and 24 years (M = 21.1 years; SD = 2.44 years), who completed an online questionnaire about their compliance to measures, resilience, coping strategies, mental health, and availability of a natural mentor. Results showed that youth with fewer depressive symptoms adhered better to measures of social distance. Youth who were less suspicious, more resilient, and those with an active coping strategy or a natural mentor more often complied with COVID-19 measures. These results can be used to help youth comply with the COVID-19 measures.

A Meta-Analysis of the Effectiveness of EMDR and TF-CBT in Reducing Trauma Symptoms and Externalizing Behavior Problems in Adolescents.

This multi-level meta-analysis tested if evidence-based trauma treatment was effective in reducing trauma symptoms and externalizing behavior problems in adolescents. Based on eight independent samples and 75 effect sizes, results indicated that Trauma Focused-Cognitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization Reprocessing (EMDR) had a large and significant overall effect (d = 0.909) on reducing trauma symptoms and externalizing behavior problems. Trauma treatment significantly decreased trauma symptoms (large effect) and externalizing behavior problems (medium effect). Age and type of control group moderated treatment effects. Treatment was more effective in older adolescents. Trauma treatment for adolescents with externalizing behavior problems had a larger effect compared to no treatment, but not compared to treatment as usual. It seems important to provide a broad treatment offer for adolescents with severe externalizing behavior problems, in which, besides trauma treatment, attention is paid to reducing relevant individual risk factors for behavior problems.

Cross-age peer mentoring for youth: A meta-analysis.

Although most mentoring programs for youth are structured around intergenerational relationships, a growing number of programs rely on cross-age peer mentoring. Such programs capitalize on the availability of youth mentors to promote positive outcomes in younger peers. This study used a multilevel meta-analytic approach to estimate the effect size of cross-age peer mentoring programs and evaluate potential moderators of peer mentoring program effectiveness. Analyses included six studies and revealed a medium-sized overall effect of cross-age peer mentoring programs (g = 0.45). Several characteristics moderated effect sizes, with larger effects for programs that were conducted outside of the school setting (i.e., weekend, summer, or in community settings), conducted in urban settings, and had moderate/high levels of adult oversight and supervision. Results highlight the potential benefits of cross-age peer mentoring for youth.

Effective Components of School-Based Prevention Programs for Child Abuse: A Meta-Analytic Review.

School-based programs seem promising for child abuse prevention. However, research mainly focused on sexual child abuse and knowledge is lacking on how individual program components contribute to the effectiveness of school-based prevention programs for any form of child abuse. This study aimed to examine the overall effect of these school-based programs on (a) children's child abuse-related knowledge and (b) self-protection skills by conducting two three-level meta-analyses. Furthermore, moderator analyses were performed to identify how program components and delivery techniques were associated with effectiveness. A literature search yielded 34 studies (158 effect sizes; N = 11,798) examining knowledge of child abuse and 22 studies (99 effect sizes; N = 7804) examining self-protection skills. A significant overall effect was found of school-based programs on both knowledge (d = 0.572, 95% CI [0.408, 0.737], p < 0.001) and self-protection skills (d = 0.528, 95% CI [0.262, 0.794], p < 0.001). The results of the first meta-analysis on children's child abuse knowledge suggest that program effects were larger in programs addressing social-emotional skills of children (d = 0.909 for programs with this component versus d = 0.489 for programs without this component) and self-blame (d = 0.776 versus d = 0.412), and when puppets (d = 1.096 versus d = 0.500) and games or quizzes (d = 0.966 versus d = 0.494) were used. The second meta-analysis on children's self-protections skills revealed that no individual components or techniques were associated with increased effectiveness. Several other study and program characteristics did moderate the overall effects and are discussed. In general, school-based prevention programs show positive effects on both knowledge and self-protection skills, and the results imply that program effectiveness can be improved by implementing specific components and techniques.

Validation and further development of a risk assessment instrument for child welfare.

BACKGROUND: Although many child maltreatment risk assessment instruments have been implemented in child welfare organizations, thorough studies on their predictive validity are scarce. OBJECTIVE: To examine (1) the predictive validity of a risk assessment instrument that has been widely implemented in the Netherlands, and to examine (2) whether the actuarial risk estimation could be improved and simplified to widen the instrument's applicability to different organizations serving different populations. PARTICIPANTS AND SETTING: The sample comprised risk assessments (N = 3,681) performed for families enrolled at one of five child welfare agencies in the Netherlands between January 2015 and December 2017. METHODS: In a follow-up period of at least one year, child maltreatment was operationalized as whether or not child protection orders, residential care, or hotline reports occurred. Area Under the Curve values were calculated to determine the predictive accuracy of the risk classifications. Chi-square Automatic Interaction Detection was used to develop a new risk classification based on a new cumulative risk variable. RESULTS: The original risk classification and the newly developed and simplified risk classification showed a similar discriminative accuracy for the different outcome measures: Area Under the Curve values were .68 and .69 for child protection orders, .62 and .63 for residential care, and .58 and .60 for hotline reports, respectively. CONCLUSIONS: The original and new risk classification of the instrument had a medium predictive validity with the latter being simpler, more widely applicable, and based on more valid risk factors.

Components associated with the effect of home visiting programs on child maltreatment: A meta-analytic review.

BACKGROUND: Home visiting programs are widely endorsed for preventing child maltreatment. Yet, knowledge is lacking on what and how individual program components are related to the effectiveness of these programs. OBJECTIVE: The aim of this meta-analysis was to increase this knowledge by summarizing findings on effects of home visiting programs on child maltreatment and by examining potential moderators of this effect, including a range of program components and delivery techniques. METHODS: A literature search yielded 77 studies (N=48,761) examining the effectiveness of home visiting programs, producing 174 effect sizes. In total, 35 different program components and delivery techniques were coded. RESULTS: A small but significant overall effect was found (d=0.135, 95 % CI (0.084, 0.187), p<0.001). Programs that focused on improving parental expectations of the child or parenthood in general (d = 0.308 for programs with this component versus d = 0.112 for programs without this component), programs targeting parental responsiveness or sensitivity to a child's needs (d = 0.238 versus d = 0.064), and programs using video-based feedback (d = 0.397 versus d = 0.124) yielded relatively larger effects. Providing practical and instrumental assistance was negatively associated with program effectiveness (d=0.044 versus d = 0.168). Further, program effects were larger when percentages of non-Caucasians/non-Whites in samples and follow-up durations increased. CONCLUSIONS: In general, home visiting programs can prevent child maltreatment only to a small extent. However, implementing specific components and techniques can improve program effectiveness.

A quasi-experimental pilot study to the effects of Responsive Aggression Regulation Therapy (Re-ART) Outpatient for young adults.

It is important to provide treatment for juvenile and young adult violent offenders, since no or (too) late treatment increases the risk of recidivism and persistent aggressive behavior in adulthood. In this study, we investigated the efficacy of the intervention Responsive Aggression Regulation Therapy (Re-ART) Outpatient, which has been developed for adolescents and young adults between 16 and 24 years old with severe aggression problems. This quasi-experimental (pilot) study compared the effects of Re-ART Outpatient (n = 47) with a control group (n = 29) receiving treatment as usual on measures regarding risk of violent recidivism, impulsivity, emotional/personal functioning, family functioning, motivation, handling anger, self-reported problem behavior, coping skills, and cognitive distortions. Re-ART showed significantly better results than the control group on risk of violent recidivism, impulsivity, emotional/personal functioning, motivation, handling anger, certain coping skills, and certain cognitive distortions. Family functioning and self-reported rule-breaking behavior did not differ significantly between the groups. The results implicate that Re-ART is a promising outpatient intervention for young adults with severe aggressive behavior. The results can be explained by the fact that Re-ART treats both systemically and individually and pays specific attention to stress reduction and the improvement of executive functions.

'Caring for children who have experienced trauma' - an evaluation of a training for foster parents.

BACKGROUND: Foster children, mostly maltreated in their birth families, may be fostered by parents who know little about the impact of traumatic experiences. OBJECTIVE: The present study investigated whether the training Caring for Children who Have Experienced Trauma for foster parents can break the negative circle of traumatic stress. The hypothesis was that improvement in parents' knowledge on trauma and mind-mindedness would be associated with a reduction of their parenting stress, children's post-traumatic stress symptoms, and behaviour problems. METHOD: Forty-eight foster parents (n female = 35) participated in a pre-test (T1), post-test (T2), and follow-up (T3) assessment. Questionnaires on knowledge on trauma, parenting stress, child post-traumatic stress symptoms, the child's behaviour, and the evaluation of the training were administered. Parents' mind-mindedness was assessed using the describe-your-child interview. RESULTS: Foster parents highly appreciated the training, their knowledge on child trauma increased at T2 and this growth persisted at T3. The parents who gained most knowledge experienced a small decrease in parenting stress at T2. Although the general mind-mindedness did not significantly change, foster parents' mind-mindedness with positive valence substantially increased at T2 and T3, while their mind-mindedness with neutral valence decreased. Foster parents' report on child PTSS declined at T3 compared to T2, but not compared to T1. No changes were found in children's behaviour as reported by the foster parents. The proportion of foster children receiving trauma-focused treatment increased at T2 and T3. CONCLUSION: This study provides evidence that training in trauma-informed parenting can be effective in improving foster parents' knowledge on the impact of traumatic experiences and in increasing a positive mental representation of their foster child as well as in reducing children's post-traumatic symptoms.

Antecedentes: Los niños acogidos, en su mayoría maltratados en sus familias de origen, pueden ser criados por padres que sepan poco acerca del impacto de las experiencias traumáticas.Objetivo: El presente estudio investigó si el entrenamiento 'Cuidando de Niños que han experimentado un Trauma' para padres de acogida puede romper el círculo negativo del estrés traumático. La hipótesis fue que el mejoramiento del conocimiento de los padres en el trauma y la mente mentalizante, disminuye el estrés de la paternidad, los síntomas post-traumáticos de los niños, y sus problemas conductuales.Método: Cuarenta y ocho padres sustitutos (n de mujeres=35) participaron en pre-test (T1), post-test (T2) y seguimiento (T3). Se administraron cuestionarios sobre conocimientos en trauma, estrés de la paternidad, síntomas postraumáticos de los niños, problemas conductuales, comportamiento prosocial y de evaluación del entrenamiento. Se evaluó la mente mentalizante de los padres mediante una entrevista describe-a-tu-hijo.Resultados: Los padres sustitutos apreciaron mucho el entrenamiento, su conocimiento en trauma infantil se incrementó en T2 y este crecimiento persistió en T3. Los padres que ganaron más conocimiento experimentaron una pequeña disminución en estrés de la paternidad en T2. Aunque la mente mentalizante en general no tuvo un cambio significativo, la mente mentalizante de los padres sustitutos con valencia positiva se incrementó sustancialmente en T2 y T3, mientras que su mente mentalizante con valencia neutral disminuyó. El reporte de los padres de acogida sobre los síntomas postraumáticos de los niños disminuyó en T3, comparado con T2 pero no respecto a T1. No se encontraron cambios en la conducta de los niños de acuerdo al reporte de los padres de acogida. La proporción de los niños que inició un tratamiento centrado en trauma se incrementó en T2 y T3.Conclusión: Este estudio provee evidencia de que el entrenamiento puede ser efectivo en mejorar el conocimiento de los padres de acogida en el impacto de las experiencias traumáticas y en aumentar una representación mental positiva de sus hijos de acogida así como también en reducir los síntomas postraumáticos de los niños.

Responsive Aggression Regulation Therapy (Re-ART) Improves Executive Functioning in Adolescents and Young Adults with Severe Aggression Problems: A Pilot Study.

This pilot study (N = 25) compared the effects of a short, four-month version of Responsive Aggression Regulation Therapy Outpatient (Re-ART Compact) and the entire, ten-month intervention (Re-ART Complete) on specific executive functioning (EF) and the risk of violent recidivism in adolescents and young adults (13-23 years). Re-ART is a cognitive behavioral-based intervention for adolescents and young adults with severe aggression problems. The Re-ART Compact and Re-ART Complete groups were comparable on the EF measures inhibition, flexibility, emotion regulation, self-evaluation, and self-control, but the Re-ART Complete group showed more improved risk of violent recidivism. We conclude that Re-ART Compact can be used as a compact, short intervention for EF, which is a valuable addition to the field of forensic mental health care where many problem behaviors relate to poor EF.

Exploring the interrelatedness of risk factors for child maltreatment: A network approach.

BACKGROUND: Theories on the etiology of child maltreatment generally focus on the interaction between multiple risk and protective factors. Moreover, the quadratic model of cumulative risk describes a threshold at which the risk of child maltreatment increases exponentially, suggesting a synergistic effect between risk factors. OBJECTIVE: This study explored the interrelatedness of risk factors for child maltreatment. PARTICIPANTS AND SETTING: The sample consisted of risk assessments performed for both high-risk families (n = 2,399; child protection services) and lower risk families (n = 1,904; community outreach services). METHODS: Network analyses were performed on parental risk factors. Three networks were constructed: a cross-sample network, a high-risk network, and a lower risk network. The relations between risk factors were examined, as well as the centrality of each risk factor in these networks. Additionally, the networks of the two samples were compared. RESULTS: The networks revealed that risk factors for child maltreatment were highly interrelated, which is consistent with Belsky's multi-dimensional perspective on child maltreatment. As expected, risk factors were generally stronger related to each other in the high-risk sample than in the lower risk sample. Centrality analyses showed that the following risk factors play an important role in the development of child maltreatment: "Caregiver was maltreated as a child", "History of domestic violence", and "Caregiver is emotionally absent". CONCLUSIONS: We conclude that studying the interrelatedness of risk factors contributes to knowledge on the etiology of child maltreatment and the improvement of both risk assessment procedures and interventions for child maltreatment.

Effectiveness and working mechanisms of the InConnection approach in multi-problem families: study protocol of a mixed-methods study.

BACKGROUND: Multi-problem families face problems in several domains that are often found to be chronic and intergenerational. Effective mental health care for youth from these families is currently lacking, urging research on new methods. The InConnection approach is an integrated care program to improve resilience in multi-problem families by connecting the professional expertise from multiple disciplines with the informal social network of the youth. Specifically, youth are asked to nominate a youth initiated mentor (YIM) from among the supportive adults in their network. The aim of this protocol is to describe the design of a mixed-methods study to examine the effectiveness and working mechanisms of the InConnection approach. METHOD/DESIGN: The effectiveness of the InConnection approach is studied in a quasi-experimental questionnaire study using propensity score matching, with N = 300 families with youth aged 10-23 years receiving treatment in either the intervention group (InConnection approach) or the control group (care as usual). The main outcome variables include youth resilience (primary), youth mental health, parental functioning, and the number, duration and types of out-of-home placements. Mediators, moderators, and predictors of effectiveness are examined. Assessments take place at the start of the care program and after three, nine and 15 months. Additionally, semi-structured interviews are conducted with families who have and have not nominated a YIM to understand why some families successfully nominate a YIM, whereas others do not. DISCUSSION: Effective care for youth in multi-problem families is urgently needed. Given its flexibility and accessibility to suit all youth aged 10-23 years from multi-problem families, and its low costs compared to out-of-home placements, the InConnection approach seems an appealing approach to support these families. The current study will provide information on the effectiveness of the InConnection approach. Strengths of this study include its robust design, the ecological validity, and the inclusion of possible mediators, predictors, and moderators of treatment effects. TRIAL REGISTRATION: Netherlands Trial Register NL7565 . Retrospectively registered on March 5, 2019.

Can an Emoji a Day Keep the Doctor Away? An Explorative Mixed-Methods Feasibility Study to Develop a Self-Help App for Youth With Mental Health Problems.

Today's smartphones allow for a wide range of "big data" measurement, for example, ecological momentary assessment (EMA), whereby behaviours are repeatedly assessed within a person's natural environment. With this type of data, we can better understand - and predict - risk for behavioral and health issues and opportunities for (self-monitoring) interventions. In this mixed-methods feasibility study, through convenience sampling we collected data from 32 participants (aged 16-24) over a period of three months. To gain more insight into the app experiences of youth with mental health problems, we interviewed a subsample of 10 adolescents who received psycthological treatment. The results from this feasibility study indicate that emojis) can be used to identify positive and negative feelings, and individual pattern analyses of emojis may be useful for clinical purposes. While adolescents receiving mental health care are positive about future applications, these findings also highlight some caveats, such as possible drawback of inaccurate representation and incorrect predictions of emotional states. Therefore, at this stage, the app should always be combined with professional counseling. Results from this small pilot study warrant replication with studies of substantially larger sample size.