How Do Treatment Protocols Affect the Use of Engagement Practices in Youth Mental Health Services?

PURPOSE: Treatment engagement poses challenges for youth mental health providers. With the expansion of evidence-based treatments (EBTs), providers face complex decisions regarding how to engage youth and families using available information sources. This study investigated how EBT protocols are associated with the selection and delivery of engagement practices. METHOD: Twenty engagement practices were coded in a sample of digital recordings of early treatment sessions (N = 193) from the Child STEPs in California study, a randomized trial testing modular treatment and community-implemented treatment for youth mental health problems. Data were collected on which protocols mental health providers reportedly used to guide their sessions and the protocols in which they had received training. We examined which information sources (i.e., the guiding protocol, other protocols in training history, unspecified source) were associated with observed engagement practices. RESULTS: In sessions guided by a protocol, most observed engagement practices were accounted for by the guiding protocol (p < .001), rather than protocols in training history or unspecified sources (p < .001). In sessions not guided by a protocol, most observed practices were accounted for by training history (p < .001). Practice frequency and extensiveness was generally greater when a protocol guided the session. CONCLUSIONS: Inclusion in protocols is associated with the selection and delivery of engagement practices, but this strategy might be insufficient for supporting the use of the full range of engagement practices supported by evidence. Supports are needed that leverage the engagement evidence base to ensure that selected practices empirically fit the engagement needs of youth and families.

Emergent Life Events: An In-Depth Investigation of Characteristics and Provider Responses during Youth Evidence-Based Treatment.

Emergent life events (ELEs), or acute client stressors disclosed within psychotherapy sessions, are not addressed by many evidence-based psychosocial treatments (EBTs). Preliminary provider-report studies suggest that ELEs may interfere with effective EBT implementation. The present study offers a detailed, observational examination of ELEs and their impact on EBT within therapy sessions. Data were observationally coded from 274 sessions with 55 primarily low-income, Latino youth clients (58% male, ages 5-15) in the modular EBT condition (Modular Approach to Therapy for Children [MATCH]) of the Child STEPs California trial. The ELE Coding System-Revised was used to measure ELEs, their characteristics, and provider responses to ELEs, including provider adherence to MATCH. Interrater reliability was generally high. At least one ELE was identified in 13% of randomly selected sessions. ELEs ranged widely in content, and their characteristics did not cluster together. Providers responded more frequently to ELEs with non-EBT content (e.g., information gathering, empathy) than EBT content; use of the ELE as a "teaching moment" for EBT content was the least common response (40% of ELEs). Multilevel regression analyses revealed that compared to sessions without an ELE, ELE sessions were significantly associated with reduced provider adherence to MATCH. Within ELE sessions, higher client distress when discussing the ELE was associated with reduced provider adherence to MATCH, but only when ELE severity was high. Beyond provider report, observational measures indicate that ELEs are prevalent and unpredictable in community settings and disrupt EBT delivery. Findings can inform the development of structured ELE management procedures to enhance existing EBTs.

Managing In-Session "Surprises:" Provider Responses to Emergent Life Events during Evidence-Based Treatment Implementation.

This study aimed to: (1) pilot a psychotherapy coding system for provider responses to emergent life events (ELEs; unexpected events that have a significant negative impact on the client), (2) examine the impact of ELEs on evidence-based treatment (EBT) delivery in community settings. Raters coded 30 randomly-sampled EBT session recordings with and without reported ELEs. Inter-rater reliability and validity for the system were generally high. When an ELE occurred, providers were significantly less likely to deliver the EBT, and when they did, they rarely linked the EBT to the event. Findings highlight the potential for ELEs to disrupt EBT implementation.

Cognitive-behavioral treatment of persistent functional somatic complaints and pediatric anxiety: an initial controlled trial.

BACKGROUND: Children and adolescents who seek medical treatment for persistent physical distress often suffer from co-occurring anxiety disorders. Treatment options for this impaired population are limited. This study tests the feasibility and potential efficacy of a cognitive-behavioral intervention targeting pain and anxiety for youth with impairing functional physical symptoms and anxiety disorders presenting to pediatricians for medical care. METHODS: Children and adolescents (aged 8-16) experiencing somatic complaints, without an explanatory medical disorder (i.e., functional), were recruited from primary care and specialty (gastroenterologists and cardiologists) pediatricians. Forty children, primarily with gastrointestinal symptoms, who met criteria for a co-occurring anxiety disorder, were randomly assigned to a cognitive-behavioral treatment addressing pain and anxiety, Treatment of Anxiety and Physical Symptoms (TAPS), or to a waiting list control. RESULTS: TAPS was found to be an acceptable treatment for this population and was superior to the waiting list condition. Eighty percent of children in TAPS were rated as treatment responders by independent evaluators compared with none of the controls. Overall, self- and parent ratings indicated reductions in children's somatic discomfort and anxiety following intervention. TAPS participants maintained clinical gains 3 months following treatment. CONCLUSIONS: The study supports the feasibility and preliminary efficacy of a cognitive-behavioral intervention targeting co-occurring physical distress and anxiety in youth presenting for medical treatment. Such an approach has the potential to exert broad impact on children's dysfunction and to minimize exposure to invasive, ineffective, and costly medical procedures and treatments.

Connecting Students to Mental Health Care: Pilot Findings from an Engagement Program for School Nurses.

Schools function as the major provider of mental health services (MHS) for youth, but can struggle with engaging them in services. School nurses are well-positioned to facilitate referrals for MHS. This pilot study examined the feasibility, acceptability, and preliminary efficacy of an engagement protocol (EP) designed to enhance school nurses' utilization of evidence-based engagement practices when referring youth to MHS. Participants were six school nurses and twenty-five adolescents in a large, urban school district. School nurses reported positive attitudes towards the EP, suggesting that they found it feasible and acceptable. Though there were small increases in school nurses' use of engagement practices and in adolescents' readiness for services following training, due to limited sample size, differences were not statistically significant. Still, pilot results suggest preliminary efficacy of training school nurses to strategically implement evidence-based engagement practices to increase adolescents' engagement in MHS.