Enhancing Quality of Care Through Evidence-Based Practice: Training and Supervision Experiences.

OBJECTIVE: Evidence-based practice (EBP) is the preferred approach to treatment in mental health settings because it involves the integration of the best available research, clinical expertise, and patient values to optimize patient outcomes. Training on empirically supported treatments (ESTs) in mental health settings is an important component of EBP, and supervision of therapists' implementation of ESTs is critical for therapists to develop and maintain a strong EBP skill set. This study aimed to evaluate training and supervision histories of therapists in outpatient and inpatient psychiatric care settings as an essential first step in improving patient outcomes. METHODS: Electronic surveys were completed by 69 therapists, most of whom had a master's degree, within a psychiatry and behavioral sciences department at an academic institution. Participating therapists were recruited from several outpatient and inpatient mental health settings serving children, adolescents, and adults. RESULTS: Although most therapists reported completing some form of EST-related coursework, a majority did not receive any supervision related to implementation of ESTs (51% for cognitive-behavioral therapy cases, 76% for dialectical behavior therapy cases, and 52% for other EST cases) during graduate and postgraduate training. CONCLUSIONS: Although research from the past decade has supported the need for improvements in training on ESTs, and especially in supervision, problems related to limited exposure to training and supervision among therapists still exist. These findings have implications for how mental health centers can evaluate staff members' EST training and supervision experiences, training needs, and associated training targets to improve the quality of routine care.

Acute psychiatric care for pediatric patients.

Higher level or acute psychiatric care for youth is intended to be active but short-term treatment focussing on crisis stabilisation, assessment, safety monitoring, and longer-term treatment planning. The focus of this article is on describing common challenges and the effort to address these challenges through new approaches to acute psychiatric care for children and adolescents. The review finds that (1) inpatient paediatric psychiatry beds are in high demand and often difficult to access, (2) there are a number of common challenges these units face including managing length of stays, readmissions, and adverse events, and (3) there are encouraging therapeutic approaches adapted for this setting. There is still much work to be done to advance the evidence-base for acute psychiatric care for youth particularly in defining and assessing an effective admission. Paediatric psychiatry patients are a vulnerable population and call for our best tools to be put to use to improve the quality and safety of care.

Risk Factors for Seclusion in Children and Adolescents Inpatient Psychiatry: The Role of Demographic Characteristics, Clinical Severity, Life Experiences and Diagnoses.

OBJECTIVE: To understand the risk factors for seclusion in a sample of children and adolescents admitted to an inpatient psychiatry unit looking at demographic, clinical severity, life experience, and diagnostic characteristics. METHODS: An unmatched case-control retrospective analysis of psychiatric records in a pediatric inpatient unit from December 2011 to December 2015 (N = 1986) RESULTS: Individual characteristics, including demographics, clinical severity, and clinical presentation as per the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) jointly predicted seclusion in adolescents, with younger age, male sex, black race, having a prior admission, and having a disruptive behavior or bipolar and related disorder diagnoses being predictive of seclusion. While demographic and clinical severity factors were predictive of seclusion in multivariate models, clinical diagnoses only added modestly to the variance explained. CONCLUSIONS: High-risk demographic and clinical characteristics for seclusion events in children and adolescents can provide valuable information to guide interventions to prevent seclusion events during their hospitalization.

Evaluation of the Environmental Supports Scale with a Community Sample of Adolescents.

Environmental sources of psychosocial support have been found to modulate or protect against the development of psychopathology and risk behavior among adolescents. Capturing sources of environmental support across multiple developmental contexts requires the availability of well-validated, concise assessments-of which there are few in the existing literature. In order to address this need, the current study explored the factor structure, concurrent and convergent validity of the Environmental Supports Scale (ESS; Genetic, Social, and General Psychology Monographs, 117; 395-417, 1991) with a community sample of adolescents. An unconstrained exploratory factor analysis revealed a separate factor for home, school, and neighborhood settings. Internal consistency and test-retest reliability were evaluated for each factor. Concurrent and predictive validity analyses revealed that the ESS was associated in the expected directions across a range of constructs relevant to adolescent development including internalizing symptoms, well-being, external influences, and engagement in risk behavior. Convergent validity for the neighborhood context was established with an assessment of neighborhood environmental adversity. A brief assessment of perceived environmental support across key developmental contexts provides an important tool for research on resilience processes during adolescence and may help illuminate key protective factors and inform intervention and prevention efforts.

Risk Factors for Seclusion and Restraint in a Pediatric Psychiatry Day Hospital.

The use of seclusion and restraints (SR) in acute hospital settings remains a controversial practice. Despite the focus on SR in the psychiatric services literature, data on SR use in pediatric day hospital settings is lacking. A case-control retrospective analysis for children admitted into a pediatric psychiatry day hospital in a 2-year span examined predictors of SR use. Demographic and clinical descriptors were examined in relation to SR events using univariate and multivariate regression models. Significant univariate risk factors for SR use were psychiatric morbidity, history of physical abuse, post-traumatic stress disorder, having any anxiety disorder, and younger age. Knowledge of risk factors for SR use in pediatric psychiatric day hospitals can avert use of SR and lead to improved safety in a trauma-informed care model.

Effects of naltrexone on adolescent alcohol cue reactivity and sensitivity: an initial randomized trial.

Adolescent alcohol use is associated with myriad adverse consequences and contributes to the leading causes of mortality among youth. Despite the magnitude of this public health problem, evidenced-based treatment initiatives for alcohol use disorders in youth remain inadequate. Identifying promising pharmacological approaches may improve treatment options. Naltrexone is an opiate receptor antagonist that is efficacious for reducing drinking in adults by attenuating craving and the rewarding effects of alcohol. Implications of these findings for adolescents are unclear; however, given that randomized trials of naltrexone with youth are non-existent. We conducted a randomized, double-blinded, placebo-controlled cross-over study, comparing naltrexone (50 mg/daily) and placebo in 22 adolescent problem drinkers aged 15-19 years (M = 18.36, standard deviation = 0.95; 12 women). The primary outcome measures were alcohol use, subjective responses to alcohol consumption, and alcohol-cue-elicited craving assessed in the natural environment using ecological momentary assessment methods, and craving and physiological reactivity assessed using standard alcohol cue reactivity procedures. Results showed that naltrexone reduced the likelihood of drinking and heavy drinking (P's ≤ 0.03), blunted craving in the laboratory and in the natural environment (P's ≤ 0.04), and altered subjective responses to alcohol consumption (P's ≤ 0.01). Naltrexone was generally well tolerated by participants. This study provides the first experimentally controlled evidence that naltrexone reduces drinking and craving, and alters subjective responses to alcohol in a sample of adolescent problem drinkers, and suggests larger clinical trials with long-term follow-ups are warranted.

Analogue study of peer influence on risk-taking behavior in older adolescents.

This experimental study aimed to examine whether adolescents act in a riskier manner in the presence of peers and whether peer presence alone influences risk behavior or if a direct influence process is necessary. Utilizing a behavioral task assessing risk-taking, 183 older adolescents (18­20 year olds) came to the laboratory alone once and then were randomized to one of three conditions as follows: alone, peers present, and peers encouraging. An interaction was found such that at baseline, there were no significant differences between the three conditions, but at the experimental session, there was a significant increase in risk task scores particularly for the encouraging condition. These findings challenge proposed models of the interaction between peer influence and risk taking by providing evidence that adolescents take more risks when being encouraged by peers, but that the presence of peers on its own does not lead to more risks than when completing the task alone.

Subtypes of Depressed Youth Admitted for Inpatient Psychiatric Care: A Latent Profile Analysis.

Depressed youth frequently present with comorbid symptoms. Comorbidity is related to a poorer prognosis, including treatment resistance, academic problems, risk of suicide, and overall impairment. Studies examining the latent structure of depression support the notion of multiple presentations of depressed youth; however, it is unclear how these presentations are represented among acutely impaired youth. Participants (n = 457) in this naturalistic study were admitted to a psychiatric inpatient unit (Mean age = 14.33 years, SD = 1.94;76% female;46.6% Black/African-American). Selected subscales from the parent-report Behavior Assessment System for Children, Second Edition, were utilized as indicators in a latent profile analysis. Subgroups were validated based on their relationships with meaningful clinical correlates (e.g., family factors, discharge diagnosis) and further described by their associations with demographic variables. A five-class model provided the best balance of fit and parsimony. Subtypes of depressed youth included Predominantly Depressed (39.1%), Oppositional (28.2%), Severely Disruptive (12.3%), Anxious-Oppositional (11.6%), and Anxious-Withdrawn (8.8%). Comorbid symptoms were present in four of the five classes (60.9% of sample). High levels of externalizing symptoms were a prominent clinical feature associated with three classes (52.1% of the sample). Construct validity of the respective classes was demonstrated by differential association with clinical correlates, family characteristics, and demographics. Findings suggest that depressed youth presenting for acute inpatient psychiatric care displayed varied clinical presentations. The identified latent groups aligned with existing research reflecting comorbidity with anxiety, inattention, and externalizing disorders. Findings underscore the need for an increased clinical appreciation of comorbidity and encourage more targeted and effective prevention and treatment strategies.

Caregiver-reported psychological and behavioural functioning of children with suicidal thoughts and behaviour: A case-control design.

OBJECTIVE: This exploratory project aims to provide an empirical understanding of the caregiver-reported emotional and behavioural functioning of children 12 and under who present to an inpatient psychiatric unit with suicidal ideation and/or attempts. METHOD: A retrospective chart review was conducted, including all patients (n = 573) aged 12 and under admitted to a psychiatric inpatient unit between September 2011-December 2015 for suicidal ideation without proximal attempt (n = 155) or a suicide attempt (n = 37). Inpatients without suicidal thoughts and behaviour in the same age range (n = 381) served as a control group. The three groups were compared on a range of variables, including patient history/demographics, caregiver-reported emotional/behavioural functioning, and discharge diagnoses. RESULTS: Children who were admitted to a psychiatric inpatient unit following suicide attempts and/or ideation demonstrated clinically significant levels of externalizing and internalizing symptoms. Children with suicidal thoughts and behaviour (STB) were more likely to be female and older than their peers without STB, more likely to report a history of sexual abuse and non-suicidal self-injury, and to be diagnosed with a depressive disorder. CONCLUSIONS: Children with STB differ demographically, symptomatically, and diagnostically from their peers without STB with comparable levels of psychiatric impairment (i.e., necessitating inpatient admission). Results provide provisional information on this concerning group of children, which can be used to aid identification of risk factors, inform treatment, and stimulate future work.

The Role of Social Adjustment in a Collegiate Behavioral Activation Program.

The transition to college is associated with significant changes in social support networks and concomitant increases in depressive symptoms. First-year students who are more socially engaged within their new academic settings may experience greater overall wellbeing. Behavioral activation (BA) is an evidence-based intervention which promotes individuals' engagement with valued activities and has been examined as a possible primary prevention for depressive symptoms among first-year students. Yet, the important role of social adjustment, and its impact on students' activity level, has not yet been considered. The current study is a secondary data analysis of research evaluating a BA-based intervention embedded into a first-year orientation course. The aim of the project was to evaluate the efficacy of BA on improving social adjustment and the effect of social adjustment on subsequent depressive symptoms. A diverse sample of college students (n = 71) attending a state university in the mid-Atlantic region reported on their levels of depression, behavioral activation, and social adjustment. Students then received either BA or standard programming. Results suggest that improved engagement in valued activities at mid-intervention was associated with increases in students' perceptions of their own social adjustment. This, in turn, predicted steeper decreases in rates of depressive symptoms post-intervention. Findings also indicate that greater social adjustment improved the efficacy of a BA-based intervention in reducing depressive symptoms, but had no impact on depressive symptoms for students receiving the standard orientation programming.

Factors associated with a change in disposition for mental health patients boarding in an urban Paediatric emergency department.

AIM: Paediatric emergency departments (ED) nationwide experience a shared burden of boarding mental health patients. Whilst boarding, some patients have a change in disposition from hospitalization to discharge home. This phenomenon raises concern because EDs often have scarce resources for mental health patients. We sought to understand which patient and clinical factors are associated with a change in disposition outcome. METHODS: A nested age-sex-race frequency-matched case-control study was conducted including paediatric patients who presented to an urban PED for mental healthcare over a 36-month period. Control patients included patients admitted to an inpatient psychiatric facility, whilst case patients were those discharged home. Descriptive statistics and multivariable logistic regression analyses were performed to compare groups. RESULTS: Case patients were more likely to receive intramuscular Haloperidol (OR 2.2 [CI 1.1-4.4]) for agitation and a psychiatric consult (OR 2.3 [1.4-3.9]) whilst boarding. Case patients were also more likely to present with behavioural concerns (OR 1.8 [CI 1.1-3.1]) and have additional complexities such as medical comorbidities (OR 1.8 [CI 1.1-2.9]) or suicidal ideation/attempt (OR 2.6 [CI 1.1-6.1]). Amongst the most common themes for disposition change was improved patient status (58.8%). CONCLUSION: These findings suggest that boarding mental health patients have different disposition outcomes and thus may benefit from patient-specific treatment interventions. Given that patients' statuses may change during the boarding period prompting discharge to home, more focus should be directed to developing brief evidence-based practises that may be implemented in the ED and effectively bridge the gap to outpatient mental health services.

Discrepancy between mother and child reports of parental knowledge and the relation to risk behavior engagement.

The study examined discrepancies in mother and child reports of parental knowledge (PK) of a child's whereabouts, activities, and companions, as well as the extent to which discrepancies in reports of PK are related to child risk-taking behavior concurrently and prospectively across two time points. The sample consisted of 219 mother and early adolescent youth (M age = 11.0, SD = .8) dyads. Mother and child reports of PK significantly differed and, at both waves, scores on the risk taking composite related negatively to both mother and child reports of PK and positively to the discrepancy between the two reports. A significant interaction between mother and child reports was found at Wave 2, such that the relation between child reported PK and risk behavior was stronger when mothers reported high levels of parental knowledge versus low levels of parental knowledge. Prospective analyses indicated a main effect of mother report.

Integration of the brief behavioral activation treatment for depression (BATD) into a college orientation program: depression and alcohol outcomes.

College freshmen face a variety of academic and social challenges as they adjust to college life that can place them at risk for a number of negative outcomes, including depression and alcohol-related problems. Orientation classes that focus on teaching incoming students how to better cope with college-oriented stress may provide an opportunity to prevent the development of these adjustment problems. This article outlines a program based on behavioral activation that can be integrated into college orientation programs to provide a more comprehensive orientation experience. Data are presented from an initial pilot study in which 71 first-semester freshman at the University of Maryland participated in a 15-week, 2 hr per week orientation class (n = 37 in the behavioral activation-enhanced orientation classes and n = 34 in the control orientation as usual classes). Students' depression and alcohol use were evaluated at the beginning, middle, and end of the course. Results indicated a Time × Group interaction such that problem drinking (but not consumption) was significantly reduced across assessments in the behavioral activation classes and largely unchanged in the standard classes. No difference was observed in depression scores; however, fairly low depression scores across the 3 time points may have limited the opportunity to observe any meaningful impact of the orientation classes on depression. The authors conclude with a discussion of the implications of their findings for preventing adjustment problems among incoming college students and future directions.

Changes in sensation seeking and risk-taking propensity predict increases in alcohol use among early adolescents.

BACKGROUND: Conceptual models implicating disinhibitory traits often are applied to understanding emergent alcohol use, but, little is known of how inter-individual changes in these constructs relate to increases in alcohol use in early adolescence. The current study utilized behavioral and self-report instruments to capture the disinhibitory-based constructs of sensation seeking and risk-taking propensity to examine if increases in these constructs over time related to increases in early adolescent alcohol use. METHODS: Participants included a community sample of 257 early adolescents (aged 9 to 12) who completed a self-report measure of sensation seeking, a behavioral task assessing risk-taking propensity, and a self-report of past year alcohol use, at 3 annual assessment waves. RESULTS: Both sensation seeking and risk-taking propensity demonstrated significant increases over time, with additional evidence that change in the behavioral measure of risk-taking propensity was not because of practice effects. Greater sensation seeking and greater risk-taking propensity demonstrated concurrent relationships with past year alcohol use at each assessment wave. Prospective analyses indicated that after accounting for initial levels of alcohol use, sensation seeking, and risk-taking propensity at the first assessment wave, larger increases in both constructs predicted greater odds of alcohol use at subsequent assessment waves. CONCLUSIONS: Results indicate the role of individual changes in disinhibitory traits in initial alcohol use in early adolescents. Specifically, findings suggest it is not simply initial levels of sensation seeking and risk-taking propensity that contribute to subsequent alcohol use but in particular increases in each of these constructs that predict greater odds of use. Future work should continue to assess the development of sensation seeking and risk-taking propensity in early adolescence and target these constructs in interventions as a potential means to reduce adolescent alcohol use.

Positive and negative reinforcement underlying risk behavior in early adolescents.

The goal of the current study was to examine the combined influence of positive reinforcement processes using a behavioral task measuring risk taking propensity (RTP) and negative reinforcement processes using a behavioral task measuring deficits in distress tolerance (DT) on a range of risk taking behaviors among early adolescents. Participants included a community sample of 230 early adolescents (aged 9-13) who completed two behavioral tasks assessing reinforcement processes as well as reported on past year risk behavior involvement as assessed by items from the Youth Risk Behavior Surveillance System at a baseline and a 1-year follow-up assessment. Data indicated that at the Wave 2 assessment, RTP was positively related to number of risk-taking behaviors in the past year but only for those with low DT, with this finding persisting after controlling for the significant influence of male gender and higher sensation seeking. Results of the present study highlight the importance of considering both positive and negative reinforcement processes in combination when investigating vulnerability factors for early risk behavior engagement in youth.

Family and Maternal Characteristics of Children With Co-Occurring ADHD and Depression.

Objective: This study examined differences between children with ADHD and comorbid depression (n = 26), ADHD only (n = 111), and a community control group (n = 130) on measures of family and maternal characteristics. Method: The present study utilized a large, community sample. Diagnoses required positive endorsements from multiple sources. ANOVAs and chi-square tests were conducted to determine group differences. Results: Compared with children with ADHD alone and community controls, mothers of depressed ADHD children reported decreased family cohesion, limited participation in social/recreational activities, increased maternal depressive symptoms, difficulty coping with parenting roles, and higher rates of bipolar and anxiety disorders. Mothers of children with ADHD (with or without comorbid depression) reported increased conflict, decreased cohesion, and poor maternal coping compared with community controls. Conclusion: Findings are consistent with prior literature suggesting that families of children with ADHD and depression demonstrate both similar and unique characteristics. Clinical implications are discussed.

The effect of posttraumatic stress disorder on risk-taking propensity among crack/cocaine users in residential substance abuse treatment.

BACKGROUND: The co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) has been found to be associated with a range of negative clinical outcomes (e.g., relapse, suicide, legal problems, HIV infection). However, less is known about the particular factors that may be placing individuals with a co-occurring PTSD and SUD diagnosis at risk for these outcomes. The construct of risk-taking propensity may hold particular promise. METHODS: To investigate the relevance of risk-taking propensity to PTSD-SUD patients, differences in risk-taking propensity were examined among 90 crack/cocaine dependent patients in residential substance abuse treatment with (n=20) or without (n=70) a current PTSD diagnosis. Risk-taking propensity was assessed using an established behaviorally based measure, the Balloon Analogue Risk Task (BART). RESULTS: Crack/cocaine dependent patients with PTSD exhibited significantly greater levels of risk-taking propensity than patients without PTSD, and this difference remained significant even when controlling for the presence of comorbid psychiatric disorders and current psychotropic medication use. No evidence was found for a different pattern of change in risk-taking propensity from the beginning to the end of the task as a function of PTSD status. CONCLUSIONS: Although preliminary, results suggest the need to further investigate risk-taking propensity as a factor that may be associated with the negative clinical outcomes observed among crack/cocaine users with PTSD.

Extending extant models of the pathogenesis of borderline personality disorder to childhood borderline personality symptoms: the roles of affective dysfunction, disinhibition, and self- and emotion-regulation deficits.

Although research has been conducted on the course, consequences, and correlates of borderline personality disorder (BPD), little is known about its emergence in childhood, and no studies have examined the extent to which theoretical models of the pathogenesis of BPD in adults are applicable to the correlates of borderline personality symptoms in children. The goal of this study was to examine the interrelationships between two BPD-relevant personality traits (affective dysfunction and disinhibition), self- and emotion-regulation deficits, and childhood borderline personality symptoms among 263 children aged 9 to 13. We predicted that affective dysfunction, disinhibition, and their interaction would be associated with childhood borderline personality symptoms, and that self- and emotion-regulation deficits would mediate these relationships. Results provided support for the roles of both affective dysfunction and disinhibition (in the form of sensation seeking) in childhood borderline personality symptoms, as well as their hypothesized interaction. Further, both self- and emotion-regulation deficits partially mediated the relationship between affective dysfunction and childhood borderline personality symptoms. Finally, results provided evidence of different gender-based pathways to childhood borderline personality symptoms, suggesting that models of BPD among adults are more relevant to understanding the factors associated with borderline personality symptoms among girls than boys.