A PRELIMINARY EVALUATION OF THE MANAGING YOUTH TRAUMA EFFECTIVELY PROGRAM FOR SUBSTANCE-ABUSING WOMEN AND THEIR CHILDREN.

This article provides a description of the development, implementation, and preliminary evaluation of feasibility and acceptability of the Managing Youth Trauma Effectively (MYTE) program and highlights perceptions of changes in mothers' trauma-informed parenting practices. The program consists of a training and consultation program for staff of the U.S. State of Arkansas' Specialized Women's Programs (SWS), and an 8-week, group psychoeducational program designed to help mothers with substance-abuse problems learn how traumatic experiences may affect their children and how they may help support their children by creating a safe and nurturing environment. A posttraining evaluation with leadership and staff at SWS centers, feedback provided on consultation calls with MYTE facilitators, and a retrospective pre/post survey were used to examine feasibility, acceptability, and perceptions of changes in mothers' trauma-informed parenting practices. Preliminary results suggest that the MYTE program is feasible to implement and is acceptable to training participants, facilitators, and mothers participating in the program. Mothers reported significant growth in their perceptions of use of trauma-informed parenting practices. Future research is necessary to confirm these results and examine the effectiveness of the program using a randomized clinical trial.

Factors Associated with Clinician Participation in TF-CBT Post-workshop Training Components.

For proficiency in an evidence-based treatment (EBT), mental health professionals (MHPs) need training activities extending beyond a one-time workshop. Using data from 178 MHPs participating in a statewide TF-CBT dissemination project, we used five variables assessed at the workshop, via multiple and logistic regression, to predict participation in three post-workshop training components. Perceived in-workshop learning and client-treatment mismatch were predictive of consultation call participation and case presentation respectively. Attitudes toward EBTs were predictive of trauma assessment utilization, although only with non-call participants removed from analysis. Productivity requirements and confidence in TF-CBT skills were not associated with participation in post-workshop activities.

Effect of Symptom Over-Reporting on Heart Rate Variability in Veterans With Posttraumatic Stress Disorder.

Physiological assessment of posttraumatic stress disorder (PTSD) presents an additional avenue for evaluating the severity of PTSD symptoms. We investigated whether the presence of a high number of uncommon symptoms attenuated the relation between self-reported PTSD symptoms and heart rate variability (HRV). Participants were 115 veterans from Operation Iraqi Freedom and Operation Enduring Freedom with or without PTSD. Symptom over-report was assessed using the Miller Forensic Assessment of Symptoms Test (M-FAST). Participants completed the Clinician-Administered PTSD Scale and M-FAST and underwent physiological assessment to determine HRV. These data were then entered into a hierarchical linear regression equation to test the moderating effect of over-reporting on the relation between PTSD symptom severity and HRV. The result of this analysis failed to demonstrate a significant moderating effect of over-reporting on the PTSD and HRV relation. HRV was a significant predictor of PTSD symptom severity, and this relation did not differ across levels of over-reporting. These findings did not support the hypothesis that over-reporting would attenuate the relation between PTSD and HRV. Clinical and research implications and directions for future investigation are discussed.

Physical victimization of rural methamphetamine and cocaine users.

Substance use and physical violence often coincide, but little has been published on the correlates associated with receipt of partner versus nonpartner physical violence for rural users of methamphetamine and/or cocaine. In this study, participants' substance use, depression and past-year physical victimization were assessed. In separate logistic regression models, received partner violence in females was associated with age; alcohol, cocaine, and methamphetamine abuse/dependence; and number of drugs used in the past 6 months. In males, received nonpartner violence was associated with age, cocaine abuse/dependence, and being Caucasian. Findings suggest a relationship between stimulant use and received violence among rural substance users and a need for victimization screenings in settings where such individuals seek health care.

Young African American perceptions of substance use in rural eastern Arkansas communities.

This study examined barriers to substance abuse treatment through focus group interviews of African American youth in three rural, eastern Arkansas counties in the Mississippi Delta region. Participants in the study included adolescents with a current or prior history of substance use, non-substance using adolescents acquainted with other substance users, and adolescents who initiated substance use during adolescence (N = 41). Grand tour and subsequent probe questions elicited multiple themes regarding rural adolescent substance use, treatment decisions, and preferences. Adolescents' perceptions of substance use indicate that treatment or prevention programs will need to address multiple dimensions, ranging from individual to community-wide factors.

Stimulant use by young adult African Americans in a rural community: a pipeline to prison?

The association between stimulant use and legal outcomes was examined in rural adults aged 18-21 years (n = 98) in the Mississippi River Delta of Arkansas from 2003 through 2008. Participants were interviewed at baseline and every 6 months for 2 years, using the Substance Abuse Outcomes Module, Addiction Severity Index, Short-Form 8 Health Survey, Brief Symptom Inventory, Patient Health Questionnaire depression screen, and an abbreviated antisocial personality disorder measure. More than three quarters were arrested before baseline; 47 were arrested over the next 2 years. Early arrest but not substance use was related to subsequent arrest. Limitations and implications for interventions are discussed.

Identifying Youth at Risk for Commercial Sexual Exploitation Within Child Advocacy Centers: A Statewide Pilot Study.

Commercial sexual exploitation of children (CSEC) is a social problem in the United States that has recently received growing attention from policy makers, advocates, and researchers. Despite increasing awareness of this issue, information on the prevalence, demographic profile, and psychosocial needs of victims of CSEC is scarce. To better understand the scope of CSEC and to examine the feasibility of screening for CSEC in Child Advocacy Centers (CACs), a pilot study was initiated through Arkansas Building Effective Services for Trauma (ARBEST) to identify youth who may be at risk for commercial sexual exploitation. Data for this pilot study were collected from all of the state's CACs (n = 14) over a 6-month period. Family advocates completed a screening questionnaire adapted from Greenbaum, Dodd, and McCracken with 918 youth aged 12 to 18 years old treated at CACs. Almost 20% of youth were identified as being at high risk for experiencing CSEC. Furthermore, youth classified as high-risk for commercial sexual exploitation reported significantly more avoidance symptoms on the UCLA (University of California at Los Angeles) PTSD (Posttraumatic Stress Disorder) Reaction Index than youth classified as low-risk. The results suggest that a significant portion of youth treated at CACs in Arkansas are at high risk for experiencing commercial sexual exploitation, which may be associated with a particular pattern of trauma symptoms. These findings also lend support for the feasibility and utilization of a screening questionnaire as part of routine care in CACs to potentially identify youth at risk for CSEC.

Two-year trajectory of stimulant use in 18- to 21-year-old rural African Americans.

Little is known about stimulant use trajectories of rural African American youth. The purpose of the present study is to explore substance use over 24 months in 98 African Americans, ages 18 to 21, who used cocaine or methamphetamine 30 days prior to baseline. The majority was male, unemployed, and had not graduated from high school. At baseline, almost half of the participants met criteria for abuse/dependence of cocaine--the primary stimulant used--which decreased to 25% by the final follow-up. Similar decreases were noted in rates of alcohol and marijuana abuse/dependence, although monthly use remained high. Participants reported minimal utilization of mental health or substance abuse services, but demonstrated significant improvements on physical and mental health measures. In summary, cocaine use declined, but other substances were used at high rates, suggesting a significant need for intervention services that address multisubstance use in rural areas.

Young adult, rural, African American stimulant users: antecedents and vulnerabilities.

Early initiation of substance use appears to be an alarming trend among rural minorities. This study focuses on 18- to 21-year-old African American stimulant users in the Arkansas Mississippi Delta. Most participants had no high school diploma and were unemployed; 74.5% had already been arrested. Substance use was initiated early and nearly all of the men and three-quarters of the women already met criteria for lifetime abuse or dependence. Only 18% reported that they had ever received substance abuse treatment. The results suggest that substance use interventions in rural communities will require multi-faceted strategies addressing economic, educational and healthcare disparities.

Empirically-guided assessment of complex trauma for children in foster care: A focus on appropriate diagnosis of attachment concerns.

Complex trauma is defined as repeated or prolonged exposure to traumatic events perpetrated within the caregiving relationship during early childhood. Diagnostic decision making is challenging for this vulnerable population, given the widespread impact of these experiences across domains of developmental, social, emotional, and behavioral functioning. One domain, attachment, receives considerable attention for youth within the child welfare system, leading to frequent diagnosis of attachment disorders (i.e., reactive attachment disorder and disinhibited social engagement disorder). This is concerning, given the rarity, level of misunderstanding, associated stigma, and lack of psychometrically sound measures to assess attachment disorders. This article provides an overview of complex trauma and its effects, with a focus on attachment concerns. It subsequently describes one statewide assessment program for youth in the child welfare system with a history of experiencing complex trauma, elaborating on strengths and areas of future growth. A case study demonstrates the program's adherence to established guidelines and the resulting diagnoses and recommendations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Heart Rate Variability and Cognitive Bias Feedback Interventions to Prevent Post-deployment PTSD: Results from a Randomized Controlled Trial.

Introduction: There is a long history of pre-deployment PTSD prevention efforts in the military and effective pre-deployment strategies to prevent post-deployment PTSD are still needed. Materials and Methods: This randomized controlled trial included three arms: heart rate variability biofeedback (HRVB), cognitive bias modification for interpretation (CBM-I), and control. The hypothesis was that pre-deployment resilience training would result in lower post-deployment PTSD symptoms compared with control. Army National Guard soldiers (n = 342) were enrolled in the Warriors Achieving Resilience (WAR) study and analyzed. The outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at pre-deployment, 3- and 12-month post-deployment. Due to the repeated measures for each participant and cluster randomization at the company level, generalized linear mixed models were used for the analysis. This study was approved by the Army Human Research Protection Office, Central Arkansas Veterans Healthcare System Institutional Review Board (IRB), and Southeast Louisiana Veterans Health Care System IRB. Results: Overall, there was no significant intervention effect. However, there were significant intervention effects for subgroups of soldiers. For example, at 3-months post-deployment, the HRVB arm had significantly lower PCL scores than the control arm for soldiers with no previous combat zone exposure who were age 30 and older and for soldiers with previous combat zone exposure who were 45 and older (unadjusted effect size -0.97 and -1.03, respectively). A significant difference between the CBM-I and control arms was found for soldiers without previous combat zone exposure between ages 23 and 42 (unadjusted effect size -0.41). Similarly, at 12-months post-deployment, the HRVB arm had significantly lower PCL scores in older soldiers. Conclusion: Pre-deployment resilience training was acceptable and feasible and resulted in lower post-deployment PTSD symptom scores in subgroups of older soldiers compared with controls. Strengths of the study included cluster randomization at the company level, use of iPod device to deliver the resilience intervention throughout the deployment cycle, and minimal disruption of pre-deployment training by using self-paced resilience training. Weaknesses included self-report app use, study personnel not able to contact soldiers during deployment, and in general a low level of PTSD symptom severity throughout the study. In future studies, it would important for the study team and/or military personnel implementing the resilience training to be in frequent contact with participants to ensure proper use of the resilience training apps.

Developing Telemental Health Partnerships Between State Medical Schools and Federally Qualified Health Centers: Navigating the Regulatory Landscape and Policy Recommendations.

BACKGROUND: Federally Qualified Health Centers (FQHCs) deliver care to 26 million Americans living in underserved areas, but few offer telemental health (TMH) services. The social missions of FQHCs and publicly funded state medical schools create a compelling argument for the development of TMH partnerships. In this paper, we share our experience and recommendations from launching TMH partnerships between 12 rural FQHCs and 3 state medical schools. EXPERIENCE: There was consensus that medical school TMH providers should practice as part of the FQHC team to promote integration, enhance quality and safety, and ensure financial sustainability. For TMH providers to practice and bill as FQHC providers, the following issues must be addressed: (1) credentialing and privileging the TMH providers at the FQHC, (2) expanding FQHC Scope of Project to include telepsychiatry, (3) remote access to medical records, (4) insurance credentialing/paneling, billing, and supplemental payments, (5) contracting with the medical school, and (6) indemnity coverage for TMH. RECOMMENDATIONS: We make recommendations to both state medical schools and FQHCs about how to overcome existing barriers to TMH partnerships. We also make recommendations about changes to policy that would mitigate the impact of these barriers. Specifically, we make recommendations to the Centers for Medicare and Medicaid about insurance credentialing, facility fees, eligibility of TMH encounters for supplemental payments, and Medicare eligibility rules for TMH billing by FQHCs. We also make recommendations to the Health Resources and Services Administration about restrictions on adding telepsychiatry to the FQHCs' Scope of Project and the eligibility of TMH providers for indemnity coverage under the Federal Tort Claims Act.

Quality of mental health care for depressed adolescents.

Understanding the quality of routine care for adolescent depression constitutes the initial step in designing and implementing improvement strategies. This study assessed depression detection and type and duration of services for adolescents in mental health care settings. Medical record diagnosis and standardized research interview results were compared for youth seeking mental health treatment. The majority of depressed adolescents received care consistent with guidelines and evidence. However, only 51% received appropriate medication; fewer than half received at least 8 sessions of outpatient care or follow-up after hospitalization. Males received significantly fewer components of quality care compared with females. Depression diagnoses in routine care may be facilitated by using structured interviews or questionnaires. Quality monitoring and improvement initiatives may also increase rates of care components that are consistent with guidelines and evidence. Methods tested in this study may facilitate the evaluation of quality improvement initiatives for adolescent depression or other mental health disorders.

Equity in veterans' mental health care: Veterans Affairs medical center clinics versus community-based outpatient clinics.

This study examined differences in structures and processes of mental health care at Veterans Administration (VA) primary care clinics, comparing VA medical center (VAMC) clinics to community-based outpatient clinics (CBOCs). A survey was conducted of nurse managers at 46 of 49 primary care clinics (23 VAMC clinics and 23 CBOCs) within a VA health care network in the south central United States. Integration of care and services overall was comparable between VAMC clinics and CBOCs. The service mix differed. Integrated CBOCs more often offered group therapy, medication management, and smoking cessation. Integrated VAMC clinics more frequently used written suicide protocols and depression screening. Distance to offsite specialty care and wait times for referrals were shorter for patients at VAMCs than at CBOCs. The provision of mental health care at CBOCs is comparable to that at VAMC clinics, although differences in patient access to offsite care indicate that full equity was not achieved at the time of the survey. Since 2000, the VA has initiated several programs to address this need.

Blending education, research, and service missions: the Arkansas model.

Creating school and community partnerships with academic health centers (AHC) offers one strategy for initiating and sustaining broad-based change in health systems. This article describes the development, initial evaluation, and current iteration of the Arkansas Partners in Behavioral Health Sciences Model, a collaboration between personnel from an AHC and K-12 schools to address behavioral health issues in children. The model's focus on education, research, and service provides an opportunity for AHC faculty and school personnel to collaborate to promote mental health in school-aged youth. Quantitative and qualitative methods have been used to inform development and confirm effectiveness of the program. From 2001 through 2005, more than 2,700 school personnel from 72 of the 75 counties in Arkansas participated in more than 30,000 hours of continuing education. The programs have also targeted students using interactive televideo presentations, supplemental classroom curricula, and an exhibit in a state science museum, resulting in an outreach to more than 2,500 youths. Results of longitudinal and randomized studies also show changes in knowledge, attitudes, and behaviors. In an era of extraordinary need and finite resources for school systems, AHCs are poised to provide the critical link to improve the scientific knowledge and understanding of behavioral health conditions. The current program targets behavioral health, but AHCs also can incorporate other health conditions, scientific topics, and medical interventions to provide a important service for the public and to accomplish an important mission toward health leadership in the community.

Assessing Culture and Climate of Federally Qualified Health Centers: A Plan for Implementing Behavioral Health Interventions.

OBJECTIVE: This study examines organizational factors relating to climate and culture that might facilitate or impede the implementation of evidence-based practices (EBP) targeting behavioral health in federally qualified health centers (FQHCs). METHODS: Employees at six FQHCs participating in an evidence-based quality improvement (EBQI) initiative for mood disorders and alcohol abuse were interviewed (N=32) or surveyed using the Organizational Context Survey (OCS) assessing culture and climate (N=64). RESULTS: The FQHCs scored relatively well on proficiency, a previously established predictor of successful EBP implementation, but also logged high scores on scales assessing rigidity and resistance, which may hinder implementation. Qualitative data contextualized scores on FQHC culture and climate dimensions. CONCLUSIONS: Results suggest that the unique culture of FQHCs may influence implementation of evidence-based behavioral health interventions.

Modes of Large-Scale Brain Network Organization during Threat Processing and Posttraumatic Stress Disorder Symptom Reduction during TF-CBT among Adolescent Girls.

Posttraumatic stress disorder (PTSD) is often chronic and disabling across the lifespan. The gold standard treatment for adolescent PTSD is Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), though treatment response is variable and mediating neural mechanisms are not well understood. Here, we test whether PTSD symptom reduction during TF-CBT is associated with individual differences in large-scale brain network organization during emotion processing. Twenty adolescent girls, aged 11-16, with PTSD related to assaultive violence completed a 12-session protocol of TF-CBT. Participants completed an emotion processing task, in which neutral and fearful facial expressions were presented either overtly or covertly during 3T fMRI, before and after treatment. Analyses focused on characterizing network properties of modularity, assortativity, and global efficiency within an 824 region-of-interest brain parcellation separately during each of the task blocks using weighted functional connectivity matrices. We similarly analyzed an existing dataset of healthy adolescent girls undergoing an identical emotion processing task to characterize normative network organization. Pre-treatment individual differences in modularity, assortativity, and global efficiency during covert fear vs neutral blocks predicted PTSD symptom reduction. Patients who responded better to treatment had greater network modularity and assortativity but lesser efficiency, a pattern that closely resembled the control participants. At a group level, greater symptom reduction was associated with greater pre-to-post-treatment increases in network assortativity and modularity, but this was more pronounced among participants with less symptom improvement. The results support the hypothesis that modularized and resilient brain organization during emotion processing operate as mechanisms enabling symptom reduction during TF-CBT.

Heart rate variability: Pre-deployment predictor of post-deployment PTSD symptoms.

Heart rate variability is a physiological measure associated with autonomic nervous system activity. This study hypothesized that lower pre-deployment HRV would be associated with higher post-deployment post-traumatic stress disorder (PTSD) symptoms. Three-hundred-forty-three Army National Guard soldiers enrolled in the Warriors Achieving Resilience (WAR) study were analyzed. The primary outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at baseline, 3- and 12-month post-deployment. Heart rate variability predictor variables included: high frequency power (HF) and standard deviation of the normal cardiac inter-beat interval (SDNN). Generalized linear mixed models revealed that the pre-deployment PCL*ln(HF) interaction term was significant (p<0.0001). Pre-deployment SDNN was not a significant predictor of post-deployment PCL. Covariates included age, pre-deployment PCL, race/ethnicity, marital status, tobacco use, childhood abuse, pre-deployment traumatic brain injury, and previous combat zone deployment. Pre-deployment heart rate variability predicts post-deployment PTSD symptoms in the context of higher pre-deployment PCL scores.

Differentiating between appraisal process and product in cognitive theories of posttraumatic stress.

Biased appraisal is central to cognitive theories of posttraumatic stress, but little research has examined the potentially distinct meanings of the term. The ongoing process of appraising social information and the beliefs that emerge as products of that process can be distinguished conceptually. This study sought to examine whether these 2 meanings are empirically distinct as well, and if so, to begin exploring potential relations between these appraisal constructs and posttraumatic stress symptoms. Soldiers (N = 424) preparing for deployment to Iraq or Afghanistan were administered measures of each construct. Results of confirmatory factor analysis suggest that the appraisal process and the products of that process (i.e., beliefs) are indeed distinct. Structural equation models are consistent with cognitive bias and social information processing literatures, which posit that a biased appraisal process may contribute to the development of dysfunctional beliefs and posttraumatic stress symptoms following trauma. The potential utility of distinctly conceptualizing and measuring the appraisal process in both clinical and research settings is discussed.

Amygdala response predicts trajectory of symptom reduction during Trauma-Focused Cognitive-Behavioral Therapy among adolescent girls with PTSD.

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is the gold standard treatment for pediatric PTSD. Nonetheless, clinical outcomes in TF-CBT are highly variable, indicating a need to identify reliable predictors that allow forecasting treatment response. Here, we test the hypothesis that functional neuroimaging correlates of emotion processing predict PTSD symptom reduction during Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) among adolescent girls with PTSD. Thirty-four adolescent girls with PTSD related to physical or sexual assault were enrolled in TF-CBT, delivered in an approximately 12 session format, in an open trial. Prior to treatment, they were engaged in an implicit threat processing task during 3T fMRI, during which they viewed faces depicting fearful or neutral expressions. Among adolescent girls completing TF-CBT (n = 23), slopes of PTSD symptom trajectories during TF-CBT were significantly related to pre-treatment degree of bilateral amygdala activation while viewing fearful vs neutral images. Adolescents with less symptom reduction were characterized by greater amygdala activation to both threat and neutral images (i.e., less threat-safety discrimination), whereas adolescents with greater symptom reduction were characterized by amygdala activation only to threat images. These clinical outcome relationships with pre-treatment bilateral amygdala activation remained when controlling for possible confounding demographic or clinical variables (e.g., concurrent psychotropic medication, comorbid diagnoses). While limited by a lack of a control group, these preliminary results suggest that pre-treatment amygdala reactivity to fear stimuli, a component of neurocircuitry models of PTSD, positively predicts symptom reduction during TF-CBT among assaulted adolescent girls, providing support for an objective measure for forecasting treatment response in this vulnerable population.