A multi-tiered systems of support blueprint for re-opening schools following COVID-19 shutdown.

The COVID-19 pandemic will create enormous disruptions for youth and families with respect to economic and health status, social relationships, and education for years to come. The process of closing and intermittently reopening schools adds to this disruption and creates confusion for parents and school officials who must balance student educational progress with health and safety concerns. One framework that may serve as a roadmap in this regard is a multi-tiered systems of support (MTSS) model. This article briefly addresses four main domains of functioning (adjustment, traumatic stress, academic status, health and safety) across three tiers of support (universal, targeted, intensive). Each section draws on existing literature bases to provide specific recommendations for school officials who must address various and changing logistical, academic, and health-based challenges. The recommendations are designed to be flexible given fluctuations in the current crisis as well as focused on maximum-value targets. An MTSS approach adapted for contemporary circumstances can also be used to help address longstanding disparities that have been laid bare by the pandemic.

Student Veterans' Coping with Posttraumatic Stress Symptoms: A Glaserian Grounded Theory Study.

The present study investigated the ways in which student military veterans cope with their posttraumatic stress symptoms. The participants were a total of 21 military veterans attending a U.S. university. The results of the grounded theory data analysis reveal the core category of modulating intrusions, a process indicating how student veterans cope with recurrent and unwanted posttraumatic stress experiences. Our findings also demonstrate that veterans cope by either avoiding or allowing themselves to experience the pain associated from their traumatic experiences. The proposed framework can be meaningfully used to facilitate the development of adaptive coping among veterans with posttraumatic stress.

Latent Class Symptom Profiles of Selective Mutism: Identification and Linkage to Temperamental and Social Constructs.

Selective mutism (SM) is a stable, debilitating psychiatric disorder in which a child fails to speak in most public situations. Considerable debate exists as to the typology of this population, with empirically-based studies pointing to possible dimensions of anxiety, oppositionality, and communication problems, among other aspects. Little work has juxtaposed identified symptom profiles with key temperamental and social constructs often implicated in SM. The present study examined a large, diverse, non-clinical, international sample of children aged 6-10 years with SM to empirically identify symptom profiles and to link these profiles to key aspects of temperament (i.e., emotionality, shyness, sociability, activity) and social functioning (i.e., social problems, social competence). Exploratory and confirmatory factor analysis revealed anxiety/distress, oppositionality, and inattention domains. In addition, latent class analysis revealed nuanced profiles labeled as (1) moderately anxious, oppositional, and inattentive, (2) highly anxious, and moderately oppositional and inattentive, and (3) mildly to moderately anxious, and mildly oppositional and inattentive. Class 2 was the most impaired group and was associated with greater emotionality, shyness, and social problems. Class 3 was the least impaired group and was associated with better sociability and social competence and activity. Class 1 was largely between the other classes, demonstrating less shyness and social problems than Class 2. The results help confirm previous findings of anxiety and oppositional profiles among children with SM but that nuanced classes may indicate subtle variations in impairment. The results have implications not only for subtyping this population but also for refining assessment and case conceptualization strategies and pursuing personalized and perhaps less lengthy treatment.

Interventions for Posttraumatic Stress with Resilience as Outcome: An Integrative Review.

This integrative review explores the current state of knowledge on trauma-focused interventions with resilience as the outcome. The review synthesized the results of 17 intervention studies. Findings of the review demonstrate the importance of including resilience as an outcome measure for the effectiveness of trauma-focused interventions. Findings also provide preliminary evidence that effective trauma-focused interventions both reduce posttraumatic stress disorder (PTSD) symptoms and improve resilience. Further research should include a focus on developing interventions based on established theoretical frameworks, and using resilience outcome measurement tools appropriate to the interventions and the characteristics of the target population.

Mediators of Initial Acute and Later Posttraumatic Stress in Youth in a PICU.

OBJECTIVES: Youth in a PICU and their parents may experience initial symptoms of acute stress disorder and later symptoms of posttraumatic stress disorder. The objective of this study was to examine potential mediators of these conditions, including youth anxiety, depression, negative affect, and hospital fear, as well as parent anxiety and depression DESIGN: This study involved a short longitudinal design that encompassed initial assessments in a PICU setting and later assessments 4-7 weeks after discharge. SETTING: Youth and their parents completed dependent measures in the hospital and at follow-up at the youth's home or an outpatient clinic setting. PATIENTS: Fifty youth aged 9-17 yrs were admitted to a PICU for respiratory illness/asthma (30.0%), trauma (26.0%), surgery and after surgery recovery (20.0%), infections/viral illness (8.0%), neurologic disorder (6.0%), or other (10.0%). Parents (n = 50) were also assessed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Measures were utilized for youth anxiety, acute stress, depression, negative affect, posttraumatic stress, and hospital fear, as well as parent anxiety, acute stress, depression, and posttraumatic stress. Some youth (26%) and parents (24%) had substantial posttraumatic stress disorder symptoms develop. Youth acute stress disorder symptoms in the PICU predicted later youth posttraumatic stress disorder symptoms, parent acute stress disorder symptoms in the PICU predicted later parent posttraumatic stress disorder symptoms, and youth acute stress disorder symptoms in the PICU predicted later parent posttraumatic stress disorder symptoms. Youth anxiety, negative affect, and hospital fear mediated initial youth acute stress disorder symptoms and later youth posttraumatic stress disorder symptoms. CONCLUSIONS: Youth in a pediatric intensive care unit are at increased risk for posttraumatic stress disorder and should be screened for acute stress disorder.

Child and Adolescent Psychiatry and Underrepresented Youth With School Attendance Problems: Integration With Systems of Care, Advocacy, and Future Directions.

School attendance problems (SAPs) include full-day and partial absences (eg, missing classes, tardiness) as well as difficulties going to or remaining in school. SAPs also include nonparticipation in distance/hybrid learning formats or lack of access to necessary technology or equipment. SAPs are particularly prevalent among students of color, students in poverty, students with disabilities, English language learners, and migrant populations. SAPs are often part of a complicated clinical picture of mental health (eg, emotional, neurodevelopmental, conduct disorders) and somatic (eg, abdominal, cardiovascular, respiratory problems) challenges. These challenges are exacerbated by disparities in socioeconomic status, childhood adversities, family structure, and neighborhood-level factors that have an impact on mental health outcomes.1 SAPs have serious negative consequences in childhood (eg, lower academic achievement, greater risk of dropout) and in adulthood (eg, lower lifetime earning potential, greater occupational and mental health problems). Unfortunately, underrepresented youth with SAPs often have less access to proper care, especially psychiatric care.

Exploring the relationships between resilience, mindfulness, and experiential avoidance after the use of a mindfulness- and acceptance-based mobile app for posttraumatic stress disorder.

PURPOSE: This study used a mindfulness- and acceptance-based mobile app to examine the relationships between resilience, mindfulness, experiential avoidance, and posttraumatic stress disorder (PTSD) symptoms. DESIGN AND METHODS: A quasi-experimental pre-posttest, single-group study design was used. A total of 23 college student veterans used the app for 4 weeks. Outcomes of resilience, mindfulness, experiential avoidance, and PTSD were measured at three time-points (baseline, end of Week 2, and end of Week 4). FINDINGS: All outcomes significantly improved at postintervention. Improvements in resilience and PTSD significantly correlated with improvement in mindfulness. PRACTICE IMPLICATIONS: Mindfulness- and acceptance-based mobile apps can be safely used by individuals with PTSD as a complementary approach to enhance resilient coping with PTSD.

Posttraumatic stress and related symptoms among neglected and physically and sexually maltreated adolescents.

Posttraumatic stress disorder (PTSD) is common among maltreated youth, but few investigations compare neglect with other maltreatment types. This study examined 84 adolescents who experienced neglect only, physical and/or sexual maltreatment only, or neglect with physical and/or sexual maltreatment. Symptoms of PTSD, dissociation, and depression were measured. Adolescents who experienced physical and/or sexual maltreatment, whether neglected or not, reported significantly greater symptomatology than adolescents who experienced neglect only (η2 = .094). This difference applied to PTSD symptoms, dissociative amnesia, depersonalization and derealization, negative mood, and anhedonia. Adolescents exposed to neglect only displayed substantial psychopathology but less than that of other groups. The findings may reflect emerging cascade models of the etiology of symptoms of PTSD following extensive maltreatment history.

The Heterogeneity of Selective Mutism: A Primer for a More Refined Approach.

Selective mutism is a persistent and debilitating psychiatric disorder in which a child fails to speak in situations where speaking is expected. Although listed as an anxiety disorder, the multifaceted and heterogeneous nature of selective mutism indicates that a more accurate conceptualization may be as a neurodevelopmental disorder. This article serves as a primer of historical and clinical presentations, empirical clinical profiles, clinical distinctions, assessment, and treatment related to the complexity of selective mutism. The article includes a brief discussion of selective mutism within a developmental psychopathology perspective with an eye toward reformed efforts for prevention, assessment, and treatment regarding this population.

The School Climate and Academic Mindset Inventory (SCAMI): Confirmatory Factor Analysis and Invariance Across Demographic Groups.

School climate is a multidimensional construct of the quality of a student's academic environment, often subsuming dimensions such as safety, instructional practices, social relationships, school facilities, and school connectedness. Positive school climate has beneficial effects on a wide range of adjustment variables in youth, including academic achievement, mental health, school attendance and graduation, and school-based behavior. Studies regarding school climate assessment have burgeoned in recent years but remain marked by limited sample sizes, narrow developmental levels, restricted items, unclear psychometric strength across multiple demographic groups, and lack of integration with key student education contextual factors such as academic mindset and social emotional learning. The present study evaluated a comprehensive measure of aspects of school climate, academic mindset, and social emotional learning in a sample of 105,379 diverse students (M age = 13.47 years; SD = 2.47). The 9-factor structure of the School Climate and Academic Mindset Inventory was supported via confirmatory factor analysis. A trimmed model displayed adequate goodness-of-fit for males and females, younger age groups, and European American, biracial/multiracial, Hispanic, Native American, and Native Hawaiian/Pacific Islander students. The trimmed model was slightly less strong for older age groups as well as for African American and Asian American students. The scale may be useful for assessing school climate interventions, longitudinal climate patterns, and school-based algorithms of future performance, though additional validation of the scale remains necessary.

A Multidimensional, Multi-tiered System of Supports Model to Promote School Attendance and Address School Absenteeism.

School attendance and school completion are important benchmarks of successful development. Unfortunately, school absenteeism and school dropout remain debilitating and prevalent conditions among youth. Stakeholders invested in promoting school attendance and reducing school absenteeism generally agree that multifaceted ecological frameworks are needed to account for these heterogeneous problems as well as differences across local education agencies and broader jurisdictions. A multi-tiered system of supports (MTSS) framework emphasizes many aspects that match well with school attendance and its problems, including prevention and a continuum of supports, screening, evidence-based assessment and intervention, problem-solving and data-based decision-making, implementation fidelity, and natural embedding into extant school improvement plans. This article outlines a multidimensional MTSS model for school attendance and absenteeism to account for recent developments regarding service delivery within schools. Such developments include integrated models of multi-tiered service delivery to concurrently address multiple domains of functioning, the development of more nuanced approaches for students with various challenges, and consideration of three-dimensional (pyramidal) perspectives to allow simultaneous and yet nuanced strategies for several domain clusters. Sample domain clusters common to the literature that could populate the multiple dimensions or sides of a MTSS pyramid model for school attendance and absenteeism are presented. These domain clusters include (1) school refusal/truancy/school withdrawal/school exclusion, (2) functional profiles and analysis, (3) preschool/elementary/middle/high school, (4) ecological levels of impact on school attendance and its problems, and (5) low/moderate/high absenteeism severity. Recommendations are made as well regarding broader MTSS integration and implementation science vis-à-vis school attendance and its problems.

Family Environment Variables as Predictors of School Absenteeism Severity at Multiple Levels: Ensemble and Classification and Regression Tree Analysis.

School attendance problems, including school absenteeism, are common to many students worldwide, and frameworks to better understand these heterogeneous students include multiple classes or tiers of intertwined risk factors as well as interventions. Recent studies have thus examined risk factors at varying levels of absenteeism severity to demarcate distinctions among these tiers. Prior studies in this regard have focused more on demographic and academic variables and less on family environment risk factors that are endemic to this population. The present study utilized ensemble and classification and regression tree analysis to identify potential family environment risk factors among youth (i.e., children and adolescents) at different levels of school absenteeism severity (i.e., 1 + %, 3 + %, 5 + %, 10 + %). Higher levels of absenteeism were also examined on an exploratory basis. Participants included 341 youth aged 5-17 years (M = 12.2; SD = 3.3) and their families from an outpatient therapy clinic (68.3%) and community (31.7%) setting, the latter from a family court and truancy diversion program cohort. Family environment risk factors tended to be more circumscribed and informative at higher levels of absenteeism, with greater diversity at lower levels. Higher levels of absenteeism appear more closely related to lower achievement orientation, active-recreational orientation, cohesion, and expressiveness, though several nuanced results were found as well. Absenteeism severity levels of 10-15% may be associated more with qualitative changes in family functioning. These data may support a Tier 2-Tier 3 distinction in this regard and may indicate the need for specific family-based intervention goals at higher levels of absenteeism severity.

Internalizing Symptoms as Predictors of School Absenteeism Severity at Multiple Levels: Ensemble and Classification and Regression Tree Analysis.

School attendance problems are highly prevalent worldwide, leading researchers to investigate many different risk factors for this population. Of considerable controversy is how internalizing behavior problems might help to distinguish different types of youth with school attendance problems. In addition, efforts are ongoing to identify the point at which children and adolescents move from appropriate school attendance to problematic school absenteeism. The present study utilized ensemble and classification and regression tree analysis to identify potential internalizing behavior risk factors among youth at different levels of school absenteeism severity (i.e., 1+%, 3+%, 5+%, 10+%). Higher levels of absenteeism were also examined on an exploratory basis. Participants included 160 youth aged 6-19 years (M = 13.7; SD = 2.9) and their families from an outpatient therapy clinic (39.4%) and community (60.6%) setting, the latter from a family court and truancy diversion program cohort. One particular item relating to lack of enjoyment was most predictive of absenteeism severity at different levels, though not among the highest levels. Other internalizing items were also predictive of various levels of absenteeism severity, but only in a negatively endorsed fashion. Internalizing symptoms of worry and fatigue tended to be endorsed higher across less severe and more severe absenteeism severity levels. A general expectation that predictors would tend to be more homogeneous at higher than lower levels of absenteeism severity was not generally supported. The results help confirm the difficulty of conceptualizing this population based on forms of behavior but may support the need for early warning sign screening for youth at risk for school attendance problems.

Reconciling Contemporary Approaches to School Attendance and School Absenteeism: Toward Promotion and Nimble Response, Global Policy Review and Implementation, and Future Adaptability (Part 1).

School attendance is an important foundational competency for children and adolescents, and school absenteeism has been linked to myriad short- and long-term negative consequences, even into adulthood. Many efforts have been made to conceptualize and address this population across various categories and dimensions of functioning and across multiple disciplines, resulting in both a rich literature base and a splintered view regarding this population. This article (Part 1 of 2) reviews and critiques key categorical and dimensional approaches to conceptualizing school attendance and school absenteeism, with an eye toward reconciling these approaches (Part 2 of 2) to develop a roadmap for preventative and intervention strategies, early warning systems and nimble response, global policy review, dissemination and implementation, and adaptations to future changes in education and technology. This article sets the stage for a discussion of a multidimensional, multi-tiered system of supports pyramid model as a heuristic framework for conceptualizing the manifold aspects of school attendance and school absenteeism.

Reconciling Contemporary Approaches to School Attendance and School Absenteeism: Toward Promotion and Nimble Response, Global Policy Review and Implementation, and Future Adaptability (Part 2).

As noted in Part 1 of this two-part review, school attendance is an important foundational competency for children and adolescents, and school absenteeism has been linked to myriad short- and long-term negative consequences, even into adulthood. Categorical and dimensional approaches for this population have been developed. This article (Part 2 of a two-part review) discusses compatibilities of categorical and dimensional approaches for school attendance and school absenteeism and how these approaches can inform one another. The article also poses a multidimensional multi-tiered system of supports pyramid model as a mechanism for reconciling these approaches, promoting school attendance (and/or prevention of school absenteeism), establishing early warning systems for nimble response to school attendance problems, assisting with global policy review and dissemination and implementation, and adapting to future changes in education and technology.

School absenteeism and school refusal behavior in youth: a contemporary review.

Absenteeism from school is a serious public health issue for mental health professionals, physicians, and educators. The prevalence of unexcused absences from school exceeds that of major childhood behavior disorders and is a key risk factor for violence, injury, substance use, psychiatric disorders, and economic deprivation. This article involves a contemporary research review on absenteeism prevalence, comorbid physical and psychiatric conditions, classification, contextual risk factors, cross-cultural variables, assessment, intervention, and outcome. Contextual risk factors include homelessness and poverty, teenage pregnancy, school violence and victimization, school climate and connectedness, parental involvement, and family variables, among others. A description of intervention includes medical, clinical, and systemic interventions. Medical professionals, community- and school-based mental health professionals, and educators are encouraged to fully understand the parameters of school absenteeism to develop better, consensual policies regarding definition, classification, assessment, and intervention of youths with problematic school absenteeism.

Functional profiles of school refusal behavior and their relationship with depression, anxiety, and stress.

Negative emotional states are common among youth with problematic school absenteeism, but little is known about their presence across different school refusal behavior profiles. The aim of this study was twofold: to identify different cluster solutions across functional profiles of school refusal behavior (I. Avoidance of Negative Affectivity, II. Escape from Social and/or Evaluative Situations, III. Pursuit of Attention, and IV. Pursuit of Tangible Reinforcement) and to determine whether these profiles differ from each other based on dimensions of depression, anxiety, and stress. The sample consisted of 1582 Ecuadorian adolescents aged 12-18 years (M = 14.83; SD = 1.86) who completed the School Refusal Assessment Scale-Revised (SRAS-R) and the Depression, Anxiety and Stress Scale-21 (DASS-21). Latent class analysis revealed three school refusal profiles: non-school refusal behavior, school refusal behavior by tangible reinforcements, and school refusal behavior by multiple reinforcements. The last group displayed the most maladaptive profile and revealed highest mean scores on the three dimensions of the DASS-21 compared to other groups. To promote mental health in this group it is a necessary goal due to their link with these negative emotional states. Prevention measures to strengthen emotional self-regulation should be considered in these cases.

Posttraumatic symptoms among maltreated youth using classification and regression tree analysis.

Individual psychological factors have been shown to exacerbate risk for posttraumatic stress disorder (PTSD) symptoms in youth following maltreatment, but the novel contribution of the present study includes a focus on interactive relationships between these factors on specific PTSD symptom clusters. This study identified maltreated youth at highest risk for re-experiencing, avoidance, and hyperarousal symptom clusters via cognitive, affective, and demographic variables. Participants (n=400) included ethnically diverse maltreated youth. Classification and regression tree (CART) analysis, a form of binary recursive partitioning (BRP), identified subgroups of maltreated youth at highest risk for three core PTSD symptom clusters. Posttraumatic cognitions, anhedonia, negative mood, processing speed, and ethnicity best predicted re-experiencing symptoms. Depersonalization/derealization, verbal comprehension, sexual maltreatment, and age best predicted avoidance symptoms. Negative cognitions about self, IQ, dissociation, working memory, and posttraumatic cognitions best predicted hyperarousal symptoms. Core PTSD symptom clusters may thus be associated with unique collections of risk factors for maltreated youth. Clinical protocols for this population could be recalibrated to be more sensitive to specific profiles that more accurately identify highest risk maltreated youth and better inform evidence-based treatment practices.

School absenteeism and school refusal behavior: a review and suggestions for school-based health professionals.

School absenteeism and school refusal behavior are particularly difficult problems that school health professionals often face. Unfortunately, few recommendations are available to such professionals about how to address this population. In this article, we (1) outline the major characteristics of school absenteeism and school refusal behavior, (2) review school-based health programs that have been designed in part to reduce absenteeism, and (3) provide suggestions for school health professionals regarding individual youths with school refusal behavior.