The therapeutic alliance in adolescent substance abuse treatment: a one-with-many analysis.

Studies of the therapeutic alliance typically use a one-with-many (OWM) design in which each therapist (the one) treats multiple clients (the many). This study used Kenny, Kashy, and Cook's (2006) OWM method to examine the composition of the therapeutic alliance and to analyze the association between alliance and outcome in a sample of 398 adolescents treated for substance abuse by 14 therapists. Both the client and therapist alliance ratings yielded large relationship variances, with limited consensus among clients treated by the same therapist about the quality of the alliance. If a client reported an especially strong alliance with his or her therapist, the therapist was likely to also report an especially strong alliance with that client (dyadic reciprocity). The association between the components of the alliance and treatment outcome was complicated, with different levels of measurement and different components of the alliance (perceiver, partner, or relationship) derived from different informants (therapist or client) relating to different outcomes.

Patients' and caregivers' beliefs about depression screening and referral in the emergency department.

OBJECTIVES: To explore patients' and parents'/caregivers' beliefs about the acceptability of universal depression screening in the emergency department (ED) and their perceptions of the barriers and facilitators to a mental health referral following a positive screen. METHODS: We conducted semistructured interviews with 60 patients seeking care and 59 caregivers in the ED of an urban children's hospital. Interviews were audiotaped, transcribed, coded, and entered into N6 (version 6.0; QSR, Thousand Oaks, Calif) for coding and content analysis. RESULTS: Patients and caregivers supported the idea of depression screening in the ED, generally viewing screening as a reflection of care and concern. Respondents reported apprehension about stigma, privacy, and provider sensitivity. Introducing the screening concept early in the visit and as part of routine care was believed to reduce stigma. Respondents generally indicated that although they would likely follow through with a referral if given, stigma and denial were viewed as significant barriers. Caregivers also reported that logistical problems such as transportation, insurance, and agency hours created barriers to help seeking, but this could be offset by social supports and information about the agency and the provider. CONCLUSIONS: Patients and caregivers generally support depression screening in the pediatric ED but identified several barriers to screening and referral for treatment. Recommendations include introduction of universal screening early in the ED visit, provision of specific information about the meaning of screening results, and support from family and health care providers to help reduce stigma and increase referral acceptability.

Attitudes, practices, and barriers to adolescent suicide and mental health screening: a survey of pennsylvania primary care providers.

OBJECTIVE: To determine primary care providers' rates of screening for suicide and mental health problems in adolescents and the factors that promote or discourage this practice. PATIENTS AND METHODS: Overall, 671 medical professionals (ie, pediatricians, family physicians, nurse practitioners, physician assistants) completed an electronic survey. The 53 items focused on (1) attitudes, knowledge, and comfort with general psychosocial and suicide screening and (2) current practices and barriers regarding screening and referrals to behavioral health services. RESULTS: Forty percent had a patient attempt suicide in the past year, and 7.7% had 6 or more patients attempt suicide. At a well visit, 67% screened for mental health, and 35.2% screened for suicide risk. Most (61.1%) primary care providers rarely screened for suicide or only when it was indicated. Only 14.2% of primary care providers often used a standardized suicide screening tool. Factors associated with screening were being knowledgeable about suicide risk, being female, working in an urban setting, and having had a suicidal patient. Only 3.0% reported adequate compensation for these practices, and 44% agreed that primary care providers frequently use physical health billing codes for behavioral health services. Nearly 90% said parent involvement was needed if adolescents were to follow through with referrals to mental health services. Only 21% frequently heard back from the behavioral health providers after a referral was made. CONCLUSION: Policy that promotes mental health education for primary care providers, provides reimbursement for mental health screening, and encourages better service integration could increase suicide screening and save healthcare costs and patients' lives.

Suicidal ideation and self-harm behavior in a community sample of preadolescent youth: a case-control study.

OBJECTIVE: Research has focused on understanding risk factors associated with suicidal ideation and self-harm behaviors in older youth, but less is known regarding these behaviors in preadolescents. We examined characteristics associated with suicidal ideation and self-harm behavior in youth aged 10-13 years. DESIGN/METHODS: A community sample of 387 youth was enrolled in a prospective study assessing precursors of risk behaviors. Twenty-three subjects endorsing items regarding suicidal ideation or self-harm behaviors (Achenbach's Youth Self-Report) (endorsers) were matched with 23 non-endorsers. Groups were compared on problem behaviors, impulsivity, neurocognitive function, risk behaviors, and other variables. RESULTS: Endorsers had higher levels of impulsivity, were more likely in borderline/clinical range on 5 of 8 Youth Self-Report Syndrome scales, and reported more risk taking. Endorsers and non-endorsers were similar in neurocognitive function. More non-endorsers were on stimulants, but groups were similar in parental monitoring and parental report of behavioral/emotional issues, socioeconomic status, and marital status. CONCLUSION: In this study, preadolescent endorsers report significantly more problem behaviors than non-endorsers. However, parental monitoring and parent report of problems were similar between groups. Given these findings, we suggest that at-risk youth may be underrecognized at young ages.

Standardized screening for suicidal adolescents in primary care.

OBJECTIVE: To determine if brief standardized screening for suicide risk in pediatric primary care practices will increase detection rates of suicidal youth, maintain increased detection and referral rates, and be replicated in other practices. PATIENTS AND METHODS: Physicians in 3 primary care practices received brief training in suicide risk, and 2 standardized questions were inserted into their existing electronic medical chart psychosocial interview. The questions automatically populated for all adolescents aged 12.0 to 17.9 years. Deidentified data were extracted during both intervention trials and for the same dates of the previous year. Referral rates were extracted from social work records. RESULTS: The rates of inquiry about suicide risk increased 219% (clinic A odds ratio [OR]: 2.04 [95% confidence interval (CI): 1.56-2.51]; clinic B OR: 3.20 [95% CI: 2.69-3.71]; clinic C OR: 1.85 [95% CI: 1.38-2.31]). The rate of case detection increased in clinic A (OR: 4.99 [95% CI: 4.20-5.79]), was maintained over 6 months after the intervention began (OR: 4.38 [95% CI: 3.74-5.02]), and was replicated in both clinic B (OR: 5.46 [95% [CI: 3.36-7.56]) and clinic C (OR: 3.42 [95% CI: 2.33-4.52]). The increase in case detection was 392% across all 3 clinics. Referral rates of suicidal youth to outpatient behavioral health care centers increased at a rate equal to that of the detection rates. CONCLUSIONS: Standardized screening for suicide risk in primary care can detect youth with suicidal ideation and prompt a referral to a behavioral health care center before a fatal or serious suicide attempt is made.

Attachment-based family therapy for adolescents with suicidal ideation: a randomized controlled trial.

OBJECTIVE: To evaluate whether Attachment-Based Family Therapy (ABFT) is more effective than Enhanced Usual Care (EUC) for reducing suicidal ideation and depressive symptoms in adolescents. METHOD: This was a randomized controlled trial of suicidal adolescents between the ages of 12 and 17, identified in primary care and emergency departments. Of 341 adolescents screened, 66 (70% African American) entered the study for 3 months of treatment. Assessment occurred at baseline, 6 weeks, 12 weeks, and 24 weeks. ABFT consisted of individual and family meetings, and EUC consisted of a facilitated referral to other providers. All participants received weekly monitoring and access to a 24-hour crisis phone. Trajectory of change and clinical recovery were measured for suicidal ideation and depressive symptoms. RESULTS: Using intent to treat, patients in ABFT demonstrated significantly greater rates of change on self-reported suicidal ideation at post-treatment evaluation, and benefits were maintained at follow-up, with a strong overall effect size (ES = 0.97). Between-group differences were similar on clinician ratings. Significantly more patients in ABFT met criteria for clinical recovery on suicidal ideation post-treatment (87%; 95% confidence interval [CI] = 74.6-99.6) than patients in EUC (51.7%; 95% CI = 32.4-54.32). Benefits were maintained at follow-up (ABFT, 70%; 95% CI = 52.6-87.4; EUC 34.6%; 95% CI = 15.6-54.2; odds ratio = 4.41). Patterns of depressive symptoms over time were similar, as were results for a subsample of adolescents with diagnosed depression. Retention in ABFT was higher than in EUC (mean = 9.7 versus 2.9). CONCLUSIONS: ABFT is more efficacious than EUC in reducing suicidal ideation and depressive symptoms in adolescents. Additional research is warranted to confirm treatment efficacy and to test the proposed mechanism of change (the Family Safety Net Study).Clinical Trial Registry Information: Preventing Youth Suicide in Primary Care: A Family Model, URL: http://www.clinicaltrials.gov, unique identifier: NCT00604097.

Development, validation, and utility of internet-based, behavioral health screen for adolescents.

OBJECTIVES: The goals were to develop and to validate the Internet-based, Behavioral Health Screen (BHS) for adolescents and young adults in primary care. METHODS: Items assessing risk behaviors and psychiatric symptoms were built into a Internet-based platform with broad functionality. Practicality and acceptability were examined with 24 patients. For psychometric validation, 415 adolescents completed the BHS and well-established rating scales. Participants recruited from primary care waiting rooms were 12 to 21 years of age (mean: 15.8 years); 66.5% were female and 77.5% black. RESULTS: The BHS screens in 13 domains by using 54 required items and 39 follow-up items. The administration time was 8 to 15 minutes (mean: 12.4 minutes). The scales are unidimensional, are internally consistent (Cronbach's alpha = 0.75-0.87), and discriminate among adolescents with a range of diagnostic syndromes. Sensitivity and specificity were high, with overall accuracy ranging from 78% to 85%. Patients with scores above scale cutoff values for depression, suicide risk, anxiety, and posttraumatic stress disorder symptoms were > or =4 times more likely to endorse other risk behaviors or stressors. CONCLUSIONS: The BHS addresses practical and clinical barriers to behavioral health screening in primary care. It is a brief but comprehensive, self-report, biopsychosocial assessment. The psychiatric scales are valid and predictive of risk behaviors, which facilitates exclusion of false-positive results, as well as assessment and triage.

Feasibility and effects of a Web-based adolescent psychiatric assessment administered by clinical staff in the pediatric emergency department.

OBJECTIVES: To determine the adoption rate of the Web-based Behavioral Health Screening-Emergency Department (BHS-ED) system during routine clinical practice in a pediatric ED, and to assess this system's effect on identification and assessment of psychiatric problems. DESIGN: Descriptive design to evaluate the feasibility of a clinical innovation. SETTING: The ED of an urban tertiary care children's hospital. PARTICIPANTS: Adolescents from 14 to 18 years of age, without acute or critical injuries or illness, presenting with nonpsychiatric symptoms. INTERVENTION: The ED clinical staff initiated the use of the BHS-ED system, which identifies and assesses adolescents for depression, suicidal ideation, posttraumatic stress, substance use, and exposure to violence. Treating clinicians reviewed results and followed routine care practices thereafter. MAIN OUTCOME MEASURES: Adoption rate of the BHS-ED system by nursing staff, identification rates of occult psychiatric problems, and social worker or psychiatrist assessment. Data were collected for 19 months before implementation of the BHS-ED system and for 9 months during implementation. RESULTS: Of 3979 eligible patients, 1327 (33.4%) were asked by clinical staff to get screened using the BHS-ED; of these 1327 patients, 857 (64.6%) completed the screening and 470 (35.4%) refused. During implementation, identification of adolescents with psychiatric problems increased significantly (4.2% vs 2.5%; odds ratio [OR], 1.70; 95% confidence interval [CI], 1.38-2.10), as did ED assessments by a social worker or psychiatrist (2.5% vs 1.7%; OR, 1.47; 95% CI, 1.13-1.90). Of the 857 patients who were screened with the BHS-ED, 90 (10.5%) were identified as having psychiatric problems (OR, 4.58; 95% CI, 3.53-5.94), and 71 (8.3%) were assessed (OR, 5.12; 95% CI, 3.80-6.88). CONCLUSIONS: In a busy pediatric ED, computerized, self-administered adolescent behavioral health screening can be incorporated into routine clinical practice. This can lead to small but significant increases in the identification of unrecognized psychiatric problems.

Screening for suicide risk in the pediatric emergency and acute care setting.

PURPOSE OF REVIEW: This paper reviews epidemiology, psychiatric comorbidities, risk factors, warning signs, screening measures, and issues related to screening for suicide risk in the pediatric emergency department and acute care settings. RECENT FINDINGS: For the first time in over a decade, rates of adolescent suicide are increasing. A recent review found physician gatekeeper training to be one of only two effective prevention strategies. Limited methods exist to assess for suicide risk in pediatric acute care settings that are able to meet the demands and challenges presented in time-limited medical settings. SUMMARY: Suicide is the third leading cause of death in adolescents. Although a prior suicide attempt is the single most important risk factor, affective, cognitive, family and peer factors also affect risk of completed suicide. Practitioners in the acute care and emergency department setting are well positioned to identify, assess, and appropriately refer these adolescents and their families. Screening instruments in this setting need to be accurate, brief, and relevant to patients, families, and providers. We propose a two-question algorithm that targets imminent risk for a suicide attempt. This type of screening also needs to be accompanied by hospital or community-based support systems for further assessment, intervention and follow-up.

Adolescent and therapist perception of barriers to outpatient substance abuse treatment.

Attrition is one of the most vexing problems for the effective delivery of behavioral health services. Most prior studies focus on patient demographics and psychopathology factors predicting dropout. We examined patient and therapist post-treatment reports of barriers to attending treatment. Six hundred adolescents and their therapists completed the Perceived Barriers to Treatment scale (PBT) at discharge from a brief substance abuse intervention. After adjusting for covariates, results suggest that perceived barriers, in particular, practical obstacles, lack of treatment readiness, relevance, and compatibility, are related to sessions attended. Shifting to a more patient-centered approach for understanding treatment retention is discussed.

Impact of victimization on substance abuse treatment outcomes for adolescents in outpatient and residential substance abuse treatment.

This paper considers whether victimization moderates adolescents' outcomes in substance abuse treatment. Adolescents (N=975) in outpatient and residential settings were assessed at intake, three, six, nine, and 12 months. Differential outcomes by gender and degree of victimization were analyzed. Dependent variables were marijuana use and substance-related problems. The residential sample reported higher baseline marijuana use and victimization. Both samples significantly reduced marijuana use and associated problems during treatment. Victimization was significantly related to more substance-related problems at intake and follow-up. More severe trauma histories in residential females were associated with significantly greater persistence in substance-related problems post-discharge.

Early therapeutic alliance as a predictor of treatment outcome for adolescent cannabis users in outpatient treatment.

The association of early alliance to treatment attendance and longitudinal outcomes were examined in 356 adolescents participating in a randomized clinical trial targeting cannabis use. Both patient and therapist views of alliance were examined, and outcomes were evaluated over 12 months after numerous other sources of variance were controlled. Patient-rated alliance predicted a reduction in cannabis use at three and six months and a reduction in substance-related problem behaviors at six months. Therapist-rated alliance did not predict outcomes. Neither patient nor therapist alliance ratings were associated with attendance. The findings support the important and often overlooked role that alliance can play in treating substance abusing, often delinquent, adolescents.