Reaching "The Other Half": Teacher Referral Increases Inclusivity in Intervention Research for Neurodivergent School-Age Children.

OBJECTIVE: Researchers employed two recruitment strategies in a school-based comparative effectiveness trial for students with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) or autism. This study assessed the: 1) effectiveness of school-based referrals for identifying students meeting diagnostic criteria and 2) impact of eliminating requirements for existing diagnoses on recruitment, sample characteristics, and intervention response. METHOD: Autistic students and students with ADHD in schools serving underresourced communities were recruited for an executive functioning (EF) intervention trial over 2 years. In Year 1, school staff nominated students with previous diagnoses. In Year 2, school staff nominated students demonstrating EF challenges associated with ADHD or autism; previous diagnosis was not required. Study staff then confirmed diagnoses. RESULTS: More students were included in Year 2 (N = 106) than Year 1 (N = 37). In Year 2, 96% of students referred by school staff met diagnostic criteria for ADHD or autism, 53% of whom were not previously diagnosed. Newly identified students were less likely than previously diagnosed students to be receiving services and, for those with ADHD, were more likely to speak primarily Spanish at home. Previously diagnosed and newly identified students did not differ on other demographic variables or intervention response. Caregivers of previously diagnosed students reported more symptoms than caregivers of newly identified students for both diagnostic groups. Previously diagnosed students with ADHD had more researcher-rated symptoms than newly identified students. CONCLUSIONS: Recruitment for an intervention study using behavior-based referrals from school staff enhanced enrollment without compromising the sample's diagnostic integrity and engaged children who otherwise would have been excluded.

Parents matter: Parent acceptance of school-based executive functions interventions relates to improved child outcomes.

OBJECTIVES: School-based interventions with parent-training components might improve access among lower-income families to effective help for children with neurodevelopmental disorders. This potential might be realized, however, only if parents perceive the interventions as acceptable and therefore engage with treatment. METHODS: Parents (N = 124) of 3rd-5th grade students diagnosed with Autism Spectrum Disorder or Attention-Deficit/Hyperactivity Disorder rated the acceptability of their child's treatment (one of two culturally responsive behavioral interventions). Parent engagement was measured through attendance at parent training sessions and the extent to which they read a corresponding workbook. RESULTS: Education and income correlated inversely with parent perceptions of treatment acceptability. Acceptability correlated positively with engagement, more strongly among lower-income families. Acceptability had an indirect effect on treatment outcome, mediated by parent engagement. CONCLUSIONS: Treatment providers should focus on strategies to increase parent acceptability, with particular attention to improving access for lower-income families.

Mental health first aid USA implementation: Trainee reported quality and impact of training.

This study investigated the association of training implementation factors (Quality, Impact, Usefulness) with Mental Health First Aid (MHFA)-targeted outcomes (e.g., increased knowledge, confidence helping someone). Trainees who completed MHFA USA training in 2016 (N = 1003) were surveyed post training about its influence on their thoughts and behaviors, and about implementation factors. Some trainees completed 3- and 6-month follow-ups (N = 430, N = 276, respectively). Training Quality, Impact and Usefulness were rated highly. Differences in Quality and Impact across demographic groups were found; trainees from racially and ethnically marginalized backgrounds, and trainees with lower education levels, reported greater effect. Quality and Impact predicted positive changes in MHFA-targeted constructs such as self-efficacy, stigma and trainee perceived positive effect of MHFA strategies for those in crisis. Impact predicted positive change in mental health knowledge; this association strengthened over time. Results provide information about acceptability and perceived Impact of MHFA USA training and lead to recommendations for future evaluation and implementation.

Identifying adverse childhood experiences in pediatrics to prevent chronic health conditions.

Despite evidence that over 40% of youth in the United States have one or more adverse childhood experiences (ACEs), and that ACEs have cumulative, pernicious effects on lifelong health, few primary care clinicians routinely ask about ACEs. Lack of standardized and accurate clinical assessments for ACEs, combined with no point-of-care biomarkers of the "toxic stress" caused by ACEs, hampers prevention of the health consequences of ACEs. Thus, there is no consensus regarding how to identify, screen, and track ACEs, and whether early identification of toxic stress can prevent disease. In this review, we aim to clarify why, for whom, when, and how to identify ACEs in pediatric clinical care. To do so, we examine the evidence for such identification; describe the efficacy and accuracy of potential screening instruments; discuss current trends in, and potential barriers to, the identification of ACEs and the prevention of downstream effects; and recommend next steps for research, practice, and policy.

Children and Adolescents With Suicidal Ideation and the Emergency Department.

This Viewpoint discusses the need for formal training in suicide prevention for frontline emergency clinicians and staff, including standardized screening practices, assessment and targeted interventions, and increased connection to outpatient mental health services after discharge from the emergency department.

Brief Interventions for Suicidal Youths in Medical Settings: A Meta-Analysis.

CONTEXT: Most youths who die by suicide have interfaced with a medical system in the year preceding their death, placing outpatient medical settings on the front lines for identification, assessment, and intervention. OBJECTIVE: Review and consolidate the available literature on suicide risk screening and brief intervention with youths in outpatient medical settings and examine common outcomes. DATA SOURCES: The literature search looked at PubMed, OVID, CINAHL, ERIC, and PsychInfo databases. STUDY SELECTION: Interventions delivered in outpatient medical settings assessing and mitigating suicide risk for youths (ages 10-24). Designs included randomized controlled trials, prospective and retrospective cohort studies, and case studies. DATA EXTRACTION: Authors extracted data on rates of referral to behavioral health services, initiation/adjustment of medication, follow-up in setting of assessment, suicidal ideation at follow-up, and suicide attempts and/or crisis services visited within 1 year of initial assessment. RESULTS: There was no significant difference in subsequent suicide attempts between intervention and control groups. Analysis on subsequent crisis service could not be performed due to lack of qualifying data. Key secondary findings were decreased immediate psychiatric hospitalizations and increased mental health service use, along with mild improvement in subsequent depressive symptoms. LIMITATIONS: The review was limited by the small number of studies meeting inclusion criteria, as well as a heterogeneity of study designs and risk of bias across studies. CONCLUSIONS: Brief suicide interventions for youth in outpatient medical settings can increase identification of risk, increase access to behavioral health services, and for crisis interventions, can limit psychiatric hospitalizations.

Parenting in a Pandemic: Preliminary Support for Delivering Brief Behavioral Parent Training Through Telehealth.

Behavioral problems, such as noncompliance and aggression, are a common referral reason to mental health services for young children. Behavioral parent training (BPT) is the leading intervention for addressing behavioral problems and leads to benefits in a variety of parental factors (e.g., parenting efficacy and parenting stress). While the COVID-19 pandemic dramatically shifted service delivery toward telehealth services, limited work has evaluated the effectiveness of BPT when delivered in a brief, group format through telehealth. The current retrospective chart review study evaluated the engagement to and preliminary effectiveness of a brief version of BPT delivered through telehealth to 64 families of 3- to 7-year-olds referred for behavioral problems. Families attended an average of 4.55 of 6 sessions and most families had two caregivers who engaged in the intervention. Significant reductions in caregivers' report of children's behavioral problems and improvements in parenting self-efficacy resulted. Future research and clinical implications are discussed.

Assessment of Sesame Street online autism resources: Impacts on parental implicit and explicit attitudes toward children with autism.

The current study sought to characterize implicit bias toward children with autism and examine whether viewing educational materials about autism would change attitudes toward children with autism. A website developed by Sesame Street containing information about autism and resources for families was distributed to parents of children with autism (n = 473) and parents of children without autism (n = 707). Pre- and post-test measures of implicit bias toward children with autism; explicit attitudes and knowledge about autism; and parenting confidence, strain, and stigma were completed before and after the website was presented. Results indicated that parents of children with autism showed less implicit bias compared with those of non-autistic children during the pre-test, but the groups did not differ at the post-test. Parents without autistic children and those with more negative explicit attitudes showed a greater reduction in implicit bias from the pre- to the post-test. In addition, for parents of children with autism, a more positive change in explicit attitudes and increased knowledge from the pre- to the post-test was associated with more empowerment at the post-test. Together, our findings suggest that the online educational resources can reduce implicit bias against children with autism and help mitigate some of the psychological issues associated with parenting children with autism.

Disparities in autism spectrum disorder diagnoses among 8-year-old children in Colorado: Who are we missing?

LAY ABSTRACT: Although autism can be reliably diagnosed as early as 2 years of age, many children are not diagnosed with autism until much later. We analyzed data to determine why many of the 8-year-old children who resided in Colorado and were identified as having autism through a review of their health and/or educational records did not have a documented clinical diagnosis of autism and were not eligible for special education services under an autism eligibility. We found that children who did not have a documented clinical diagnosis of autism and were not eligible for special education services under an autism eligibility were more likely to be female, aggressive, and argumentative. They had a poorer quality of information in their records and were less likely to have had a developmental regression, sleep problems, or an autism screener or diagnostic measure in their records. These results suggest that the symptoms characteristic of autism among this group of children may have been attributed to another disorder and that clinicians may be able to recognize autism more readily in children with more functional impairment and those who experience a developmental regression. We also discovered that differences in symptom presentations among children who had a documented clinical diagnosis of autism and/or were eligible for special education services under an autism eligibility were associated with different ages at autism diagnosis.

Sleep architecture and behavioral abnormalities in children and adolescents.

OBJECTIVE: To investigate the association between sleep disordered breathing (SDB) and parent report of attention and behavioral problems in children, as well as the association between sleep stage duration and measures of child functioning in a clinically referred sample. METHODS: A chart review was conducted of 95 children with clinical history of SDB who completed an overnight polysomnography study in a pediatric sleep laboratory. Child functioning was assessed at the time of the sleep study by parent report on the Child Behavior Checklist (CBCL). The apnea hypopnea index was used as a measure of SDB severity. RESULTS: The apnea hypopnea index was associated with externalizing behavior, but not attention problems on the CBCL. In children 2-3 years old, stage 4 sleep duration was associated with externalizing behavior. In children 4-16 years old, REM sleep duration was associated with externalizing behavior. CONCLUSIONS: Children with increased SDB severity may be at greater risk for behavioral problems. Differences between the association of sleep stages and externalizing behavior in toddlers compared with older children suggests possible developmental differences in the association between sleep and behavior.

Increasing autism acceptance: The impact of the Sesame Street "See Amazing in All Children" initiative.

To promote knowledge and acceptance of autism, Sesame Workshop created an online initiative: See Amazing in All Children. This nationwide evaluation of See Amazing assessed whether it increased knowledge and acceptance, promoted community inclusion, reduced parenting strain, and enhanced parenting competence. Survey responses were collected online from parents of children (age ⩽ 6) with and without autism before (N = 1010), 1 week after (N = 510), and, for parents of autistic children, 1 month after (N = 182) they viewed the See Amazing materials. Following exposure, parents of non-autistic children showed small but significant increases in knowledge of autism and, like parents of autistic children, greater acceptance of autistic children. Parents of autistic children reported less strain, increased parenting competence, and more hope about involving their child in their community. That the See Amazing materials invoked positive changes in the general parent community and in parents of autistic children suggests that See Amazing materials have the potential to be an effective resource to increase acceptance and community inclusion, although limitations of self-selection, dropout rate, and lack of control group constrain interpretation. Implications include support for targeting acceptance as a step beyond awareness campaigns, though actual behavior change is a subject for future research.

Multimodal treatments versus pharmacotherapy alone in children with psychiatric disorders: implications of access, effectiveness, and contextual treatment.

Practice guidelines for the treatment of youth with mental health problems tend to endorse integrating psychopharmacologic treatment with psychosocial interventions, such as psychotherapy and parent skills training. However, poor access to pediatric mental health specialists and inadequate training of primary care physicians in psychosocial interventions make it difficult for families to receive this standard of care. Large pediatric randomized, multicenter trials, including the Multimodal Treatment Study of ADHD (attention deficit hyperactivity disorder) [MTA] and the Treatment for Adolescents with Depression Study (TADS), have begun to identify specific advantages of multimodal treatment compared with psychopharmacology alone. Advantages of combined treatment include improvement of both symptoms and family functioning. More research is needed to determine effective and appropriate multimodal interventions for complex and severe pediatric mental illness. Advantages of multimodal treatment must be balanced with the treatment burden on the family system.

Tracking progress in peer-delivered family-to-family support.

Peer delivered, family-to-family (F2F) support-defined as the provision of outreach, engagement, knowledge, care coordination, and support to family members of children and youth with mental health challenges-is a rapidly growing and needed component of the service array. Progress is occurring toward greater specification of program models and core competencies for the parent support providers (PSPs) with lived experience providing these services; however, strategies to inform quality improvement and ensure accountability are lacking. The Family Journey Assessment (FJA), completed by PSPs and family members, fills this gap by tracking caregiver progress toward self-advocacy and self-efficacy. Analyses of 436 FJAs showed a reliable 3-component structure, reflecting progress in the recognition of needs, collaboration to access help from formal and natural supports, and activation of skills to cope with stress, enhance resilience, and develop and carry out plans of care. PSP feedback provided strong evidence for relevance and usability. Examination of FJAs at baseline and follow-up provides one of the first reports showing significant improvement in key indicators of benefit of F2F for participating families. The FJA holds promise as a measure of the impact of F2F services on key goals and as a way to identify benchmarks for focused and individualized peer-to-peer support depending on the family's level of need. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Evaluation of Mental Health First Aid USA Using the Mental Health Beliefs and Literacy Scale.

PURPOSE: This study assessed the impact of Mental Health First Aid (MHFA) in the United States with a theoretically based and psychometrically sound measure, the Mental Health Beliefs and Literacy Scale (MBLS). DESIGN: Online MBLS surveys were administered pre-MHFA training, 3-weeks post-training, and 6-months posttraining. SETTING: Mental Health First Aid trainings carried out across the United States. PARTICIPANTS: Six hundred sixty-two trainees were contacted, and 273 (41%) completed the presurvey. Of those, 63% filled out the postsurvey and 35% completed the 6-month survey. Seventy-six individuals completed all 3 surveys. INTERVENTION: Mental Health First Aid is an 8-hour education program to help the general public identify, understand, and respond to signs of mental illness and substance abuse; to date, almost 1 million people have been trained. MEASURE: The MLBS, based on the Unified Theory of Behavior Change framework, consists of attitudinal, social-, and skill-based constructs affecting the intention to perform and achievement of MHFA actions and reports of their actual completion. ANALYSIS: Change across time points was assessed using multivariate repeated measures analysis of variance. RESULTS: Significant short- and longer term changes were found in internally consistent constructs tapping positive beliefs about MHFA actions, the confidence and intention to perform them as well as mental health literacy. CONCLUSION: The MBLS documented strong positive effects of MHFA training that were greater in individuals without prior mental health training, the intended targets of MHFA efforts.

Cancer genetic health communication in families tested for hereditary breast/ovarian cancer risk: a qualitative investigation of impact on children's genetic health literacy and psychosocial adjustment.

Children's literacy about the genetics of late-onset hereditary breast/ovarian cancer (HBOC) often develops through conversations with parents about BRCA gene testing and adults' cancer diagnoses. These conversations may promote early understanding of HBOC, but the long-term impact on children's psychosocial adjustment remains unclear. We investigated cancer genetic health communication in BRCA-tested families to consider benefits, risks, and moderating influences on children's understanding and well-being. Adolescent and young adult children (ages 12-24) of mothers who underwent BRCA testing 1+ years previously completed qualitative interviews that were transcribed, coded (intercoder K ≥ .70), and content-analyzed (N = 34). Children readily recalled conversations about BRCA testing and HBOC (100%) that they considered important (94%), but implications for children were ambiguous and obfuscated their concerns. Psychosocial impacts were muted, multifaceted, and displayed a range of favorable (82%), neutral (71%), and unfavorable (59%) response-frequently co-occurring within the same child over different aspects (e.g., medical, concern for self and others). Children verbalized active (50%) and avoidant (38%) coping strategies: about 1:5 endorsed transient thoughts about vulnerability to HBOC, 1:3 had not further considered it, and all reported specific actions they had or would undertake to remain healthy (e.g., diet/exercise). A majority (94%) of children had or would consider genetic testing for themselves, usually later in life (59%). Long-term outcomes highlighted benefits (awareness of HBOC, psychological hardiness, healthier lifestyle behaviors), as well as some psychosocial concerns that could be managed through interventions promoting genetic health literacy.

Precipitants of adolescent suicide: possible interaction between allergic inflammation and alcohol intake.

Suicide is a leading cause of mortality among adolescents. There is a pressing public health need to investigate triggers and novel vulnerabilities for suicide in order to improve risk assessment and develop innovative prevention strategies. Alcohol is a well established risk factor for adolescent suicide. In this paper, we outline a novel mechanism linking allergy, alcohol, and suicide, reviewing (a) the association between allergic inflammation, depression, and suicide; and (b) the role of alcohol in inducing phosphorylation and rearrangement of tight junction proteins of the blood-brain barrier (BBB) resulting in increased "leakiness", i.e. passage of cells and molecules. Seasonal peaks of suicide in spring have been consistently reported, but their causality is poorly understood. A preliminary epidemiologic study found increased nonviolent suicide rates in females in spring during intervals of high tree pollen, in comparison to similar intervals of low tree pollen. This initial report added to the emerging literature proposing a relationship between allergy and depression, and is being further pursued at clinical, epidemiological, animal and postmortem tissue levels. We propose that allergic inflammation influences depression-related brain function via molecular and cellular mediators, but those mediators have a very limited access to the brain when the BBB is intact. Alcohol intake disrupts BBB, allowing increased brain exposure to cellular mediators of allergy. Considering the greater prevalence of allergy in adolescence when alcohol use starts, studies investigating the connection between allergy, alcohol, and suicide should be expanded to also include a focus on youth.

Mental Health Screening Quality Improvement Learning Collaborative in Pediatric Primary Care.

BACKGROUND: In the United States, up to 20% of children experience a mental health (MH) disorder in a given year, many of whom remain untreated. Routine screening during annual well visits is 1 strategy providers can use to identify concerns early and facilitate appropriate intervention. However, many barriers exist to the effective implementation of such screening. METHODS: A 15-month quality improvement learning collaborative was designed and implemented to improve screening practices in primary care. Participating practices completed a survey at 3 time points to assess preparedness and ability to promote and support MH issues. Monthly chart reviews were performed to assess the rates of screening at well visits, documentation of screening results, and appropriate coding practices. RESULTS: Ten practices (including 107 providers) were active participants for the duration of the project. Screening rates increased from 1% at baseline to 74% by the end of the project. For the 1 practice for which more comprehensive data were available, these screening rates were sustained over time. Documentation of results and appropriate billing for reimbursement mirrored the improvement seen in screening rates. CONCLUSIONS: The learning collaborative model can improve MH screening practices in pediatric primary care, an important first step toward early identification of children with concerns. More information is needed about the burden placed on practices and providers to implement these changes. Future research will be needed to determine if improved identification leads to improved access to care and outcomes.