Meta-analysis of associations between childhood adversity and diurnal cortisol regulation.

Childhood adversity has been associated with hypothalamic-pituitary-adrenal axis dysregulation, which is associated with mental and physical health consequences. However, associations between childhood adversity and cortisol regulation in the current literature vary in magnitude and direction. This multilevel meta-analysis examines the association between childhood adversity and diurnal cortisol measures, as well as potential moderators of these effects (adversity timing and type, study or sample characteristics). A search was conducted in online databases PsycINFO and PubMed for papers written in English. After screening for exclusion criteria (papers examining animals, pregnant women, people receiving hormonal treatment, people with endocrine disorders, cortisol before age 2 months, or cortisol after an intervention), 303 papers were identified for inclusion. In total, 441 effect sizes were extracted from 156 manuscripts representing 104 studies. A significant overall effect was found between childhood adversity and bedtime cortisol, r = 0.047, 95% CI [0.005, 0.089], t = 2.231, p = 0.028. All other overall and moderation effects were not significant. The lack of overall effects may reflect the importance of the timing and nature of childhood adversity to adversity's impact on cortisol regulation. Thus, we offer concrete recommendations for testing theoretical models linking early adversity and stress physiology.

National Norms for the Vanderbilt ADHD Diagnostic Parent Rating Scale in Children.

OBJECTIVE: To provide national norms and percentiles for both research and clinical scoring modalities of the Vanderbilt Attention Deficit/Hyperactivity Disorder (ADHD) Diagnostic Parent Rating Scale (VADPRS) for a representative sample of children ages 5-12 in the United States. METHOD: The five clinical subscales of the VADPRS were completed by 1,570 caregivers of children ages 5-12 in the United States, with children representative of the national population on key demographic variables including race, sex, ethnicity, family income, and family educational level. Descriptive statistics and measures of internal consistency of both dimensional and symptom count scoring were provided for each of the five clinical subscales of the inventory, as well as percentiles and group comparisons for select dimensional scoring subscales based on age and child sex. RESULTS: Measures of internal consistency for each subscale using both scoring modalities of the VADPRS ranged from high to acceptable. There were statistically significant differences among the different subscales for both age (ADHD hyperactivity, anxiety/depression) and sex [both presentations of ADHD, oppositional defiant disorder (ODD)] for the total sample. These differences, however, were modest in magnitude and unlikely to be clinically meaningful. CONCLUSIONS: This study enhances the research and clinical utility of the VADPRS by providing national norms and percentiles for each of its subscales. Differences between age and sex across the sample were statistically significant for two of the subscales (Hyperactivity and Anxiety/Depression) with additional subscales significant for sex alone (Inattentive and ODD), but these differences were not substantial enough to indicate a need for separate cut-offs for screening purposes.

Regulating digital therapeutics for mental health: Opportunities, challenges, and the essential role of psychologists.

With so many promising digital therapeutics for anxiety and obsessive-compulsive (OC) spectrum problems, there is an urgent need to consider how evolving regulatory oversight of digital therapeutics is poised to shift how these tools are developed, evaluated, reimbursed, and delivered. In this commentary, we discuss both opportunities and potential pitfalls associated with emerging government regulations of digital therapeutics for mental health, and we consider how applying the traditional 'prescription-based' medical approval paradigm to digital therapeutics for mental health could ultimately undermine and limit the broad accessibility of these software-based innovations that have been explicitly designed to expand the accessibility of care. For example, the vast majority of behavioural and mental health providers do not have 'prescription privileges' (a term originally rooted in pharmacologic practices), and as a result, under current regulations in the U.S. would not be authorized to make FDA-cleared digital therapeutics available to their patients. This is particularly concerning given that most digital therapeutics for mental health are directly rooted in psychological and behavioural science, yet psychologists would not be authorized to incorporate these innovations into their practice. We consider how synchronizing regulatory standards across countries may prove useful, and we conclude by arguing that multidisciplinary teams making regulatory decisions concerning digital therapeutics for mental health must include representation from the discipline and practice of psychology. PRACTITIONER POINTS: Emerging government regulations of digital therapeutics for mental health present both opportunities and potential pitfalls Applying the traditional 'prescription-based' medical approval paradigm to digital therapeutics for mental health could ultimately undermine the broad accessibility of these software-based innovations. Synchronizing regulatory standards across countries may prove useful. Multidisciplinary teams making regulatory decisions concerning digital therapeutics for mental health must include representation from the field of psychology.

Development and Validation of the Parenting Skill Use Diary (PSUD) in a Nationally Representative Sample.

Objective: We describe the development and psychometric properties of an instrument designed to assess the use of effective parenting skills reported with a daily diary. The Parenting Skill Use Diary (PSUD) was developed iteratively relying on a "common elements" approach to quantify the use of evidence-based parenting techniques for responding to child misbehaviors and positive behaviors.Method: The PSUD was administered online daily for seven days to parents/guardians of children aged 5-12. The nationally representative sample (N = 1,570) was selected to match the US population of such parents/guardians on key demographic variables.Results: The instrument demonstrated the ability to capture significant between person variability in the appropriate use of parent management skills. A weekly summary score discriminated between parents/guardians whose children screened positive versus negative for Conduct Disorder (AUC = .72) and Oppositional Defiant Disorder (AUC = .70).Conclusions: The results supported the reliability of validity of the diary as a research tool for examining mean differences.

Psychometric Properties of the SCARED in a Nationally Representative U.S. Sample of 5-12-Year-Olds.

OBJECTIVE: To examine the factor structure of the Screen for Child Anxiety Related Emotional Disorders - Parent Report (SCARED-P) in young children and elucidate normative levels of parent-reported anxiety using a nationally representative sample of parents of children ages 5-12 years living in the United States. METHOD: The 41-item SCARED-P was administered to parents of 1,570 youth who were selected to match the U.S. population on key demographic variables. SCARED-P model fit and mean score differences by age, race/ethnicity, and sex were assessed. RESULTS: SCARED-P model fit and subscale reliability appeared almost identical in younger children (ages 5-8) and older children (ages 9-12), although model fit for a five-factor model was poor in both groups. Symptoms of generalized anxiety increased from age 5 to 12, while symptoms of separation anxiety disorder decreased. Parents reported significantly more symptoms of social anxiety in females than males. No significant differences by race/ethnicity were found for mean levels of anxiety or model fit. CONCLUSIONS: The SCARED-P shows some utility as an anxiety screening instrument in a representative sample of U.S. youth as young as 5-years-old, but caution should be used when interpreting subscale scores.

Association between maternal depression and maternal sensitivity from birth to 12 months: a meta-analysis.

Maternal sensitivity plays a central role in shaping children's development across a number of domains, and may be disrupted by depression. The current meta-analysis quantified the magnitude of the association between depression and maternal sensitivity, defined broadly as timely, contingent, and appropriate responding to infants' cues, from birth to 12 months. Across k = 48 studies and n = 4,934 mother-infant dyads, the aggregate effect size between depression and maternal sensitivity was r = -.16, p < .0001, indicating that mothers with higher depression levels were less sensitive than mothers with lower depression levels. Studies that compared a depressed group with a nondepressed/control group had larger effect sizes (r = -.35, p < .0001) than studies that examined depression within a single sample of either unselected cases or clinical-only cases (r = -.11, p < .001), suggesting that clinical levels of depression may pose a particular threat to sensitive parenting. Clinical implications (e.g. screening, prevention) are discussed.

Development and Preliminary Feasibility Testing of a Decision Support Tool for Childhood Anxiety Treatment.

In this practical application, we describe the steps to build a decision-support tool using GeNIe 2.1 software. The method incorporates principles of decision analyses and allows for a systematic strategy to balance treatment efficacy data with patient preferences. We illustrate the utility for helping clinicians and patients choose between two or more efficacious treatment options (CBT, medication, or their combination). Preliminary pilot data from families (n = 5) seeking services at a specialty clinic for childhood anxiety disorders support the usability of the tool and high patient satisfaction. We use case examples and sample graphical output to illustrate how the decision-support system can be used to integrate data on, 1) baseline symptom severity 2) the relative effectiveness of two or more treatment options, and 3) patient preferences and values, to arrive at a personalized treatment recommendation. The decision-support tool enabled child and parent preferences to be explicitly stated and facilitated discussions about how best to incorporate their preferences into an evidenced-based treatment strategy.

Introduction to the Special Series: Current Directions for Measuring Parenting Constructs to Inform Prevention Science.

Parenting behaviors are multifaceted and dynamic and therefore challenging to quantify. Measurement methods have critical implications for study results, particularly for prevention trials designed to modify parenting behaviors. Although multiple approaches can complement one another and contribute to a more complete understanding of prevention trials, the assumptions and implications of each approach are not always clearly addressed. Greater attention to the measurement of complex constructs such as parenting is needed to advance the field of prevention science. This series examines the challenges of measuring changes in parenting behaviors in the context of prevention trials. All manuscripts in the special series address measurement issues and make practical recommendations for prevention researchers. Manuscripts in this special series include (1) empirical studies that demonstrate novel measurement approaches, (2) re-analyses of prevention trial outcome data directly comparing and contrasting two or more methods, and (3) a statistical primer and practical guide to analyzing proportion data.

Treatment Effects of a Primary Care Intervention on Parenting Behaviors: Sometimes It's Relative.

The goal of this brief report is to demonstrate the utility of quantifying parental discipline practices as relative frequencies in measuring changes in parenting behavior and relations to child behavior following intervention. We explored comparisons across methodological approaches of assessing parenting behavior via absolute and relative frequencies in measuring improvements in parent-reported disciplinary practices (increases in positive parenting practices in response to child behavior; decreases in inconsistent discipline and use of corporal punishment) and child behavior problems. The current study was conducted as part of a larger clinical trial to evaluate the efficacy of a collaborative care intervention for behavior problems, ADHD, and anxiety in pediatric primary care practices (Doctor Office Collaborative Care; DOCC). Participants were 321 parent-child dyads (M child age = 8.00, 65 % male children) from eight pediatric practices that were cluster randomized to DOCC or enhanced usual care (EUC). Parents reported on their own discipline behaviors and child behavior problems. While treatment-related decreases in negative parenting were found using both the absolute and relative frequencies of parenting behaviors, results were different for positive parenting behaviors, which showed decreases when measured as absolute frequencies but increases when measured as relative frequencies. In addition, positive parenting was negatively correlated with child behavior problems when using relative frequencies, but not absolute frequencies, and relative frequencies of positive parenting mediated relations between treatment condition and outcomes. Our findings indicate that the methods used to measure treatment-related change warrant careful consideration.

Analyzing Proportion Scores as Outcomes for Prevention Trials: a Statistical Primer.

In prevention trials, outcomes of interest frequently include data that are best quantified as proportion scores. In some cases, however, proportion scores may violate the statistical assumptions underlying common analytic methods. In this paper, we provide guidelines for analyzing frequency and proportion data as primary outcomes. We describe standard methods including generalized linear regression models to compare mean proportion scores and examine tools for testing normality and other assumptions for each model. Recommendations are made for instances when the assumptions are not met, including transformations for proportion scores that are non-normal. We also discuss more sophisticated analytical tools to model change in proportion scores over time. The guidelines provide ready-to-use analytical strategies for frequency and proportion data that are commonly encountered in prevention science.

Deficits in Parent Knowledge of Behavior Management Skills is Strongly Associated with CD Symptoms but Not ODD Symptoms.

We conducted secondary analyses of existing data to examine the association between parent scores on the Knowledge of Effective Parenting Test (KEPT) and child symptoms of Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD). Parent knowledge of behavior management skills and child behavior symptoms were assessed in a nationally representative sample of parents/guardians (N = 1,570) of children aged 5-12 from all 50 states. Results showed consistent and robust correlations between parent knowledge of behavior management skills and CD symptoms but not ODD symptoms. These findings suggest that parent knowledge of behavior management may be a greater risk factor for CD than ODD, with implications for taxonomy and understanding the etiology of these two disorders. We also discuss the implications of these findings for the prevention and treatment of these two disorders which are often grouped together in treatment trials.

An Exposure-Based Video Game (Dr. Zoo) to Reduce Needle Phobia in Children Aged 3 to 6 Years: Development and Mixed Methods Pilot Study.

BACKGROUND: Needle phobia, which affects 19% of children aged 4 to 6 years, prevents many children from receiving necessary or preventive medical treatments. Digital interventions have been made to target needle phobia but currently rely on distraction rather than evidence-based exposure. OBJECTIVE: We designed and evaluated a serious exposure-based mobile game called Dr. Zoo to reduce the fear of needles in children aged 3 to 6 years, where players administered shots to cartoon animals. METHODS: We conducted a mixed methods study with 30 parents (mean age 35.87, SD 4.39 years) and their 36 children (mean age 4.44, SD 1.11 years) who played the game for 5 days leading to a scheduled appointment that included an injection (eg, influenza vaccination). After the study, parents completed exit surveys and participated in semistructured interviews to evaluate ease of use, acceptability, and preliminary effectiveness of the game and to provide insights on their experience with the game to inform future developments. Interview transcripts were analyzed by 3 independent coders following an open coding process and subsequently coded and discussed to reach consensus. RESULTS: Parents rated their child's difficulty in completing the game as very low on average (scale 1-5; mean 1.76, SD 0.82) and were highly likely to recommend Dr. Zoo to other parents (scale 1-5; mean 4.41, SD 0.87), suggesting Dr. Zoo's strong ease of use and high acceptability. In the exit survey, parents rated their child's fear as significantly lower after participating in the study (scale 1-5; mean 3.09, SD 1.17) compared with that before participating (scale 1-5; mean 4.37, SD 0.81; z score=-4.638; P<.001). Furthermore, 74% (26/35) of the parents reported that the game had a positive impact on their child's fear or perception of needles (only 2 parents reported a negative impact). Qualitative analysis of the interview transcripts revealed potentially important features of the game in this positive impact, such as the game's interactive design, as observed in 69% (24/35) of our participants. CONCLUSIONS: The results suggest that an evidence-based serious mobile game can be an easy-to-use, acceptable, and potentially effective intervention for changing young children's fear and perceptions of needles. Leveraging digital interventions may be a potential solution to needle anxiety as a public health concern.

Quantifying Potential Bias Resulting From Child Age on Screening for Hyperactive/Impulsive Presentations of ADHD.

OBJECTIVE: This study aims to quantify the potential age bias in screening of hyperactive/impulsive presentations of ADHD in children ages 5 to 12 through comparison of age-based and overall percentiles in screening. METHOD: A referred clinical sample of 307 children ages 5 to 12 with behavioral concerns completed the Vanderbilt Attention Deficit-Hyperactivity Disorder Diagnostic Parent Rating Scale (VADPRS) and were formally evaluated for ADHD with a diagnostic interview. Analysis utilizing logistic regression and receiver operating characteristic (ROC) curves was performed to compare the screening performance of agebased and overall percentiles. RESULTS: The age-based percentiles demonstrated no improvement in the analyzed models compared to overall percentiles in hyperactive presentation ADHD screening. This finding was present in the overall sample and in the sub analysis of the 5 to 6 year old children. CONCLUSIONS: This study identifies no improvement in modeling of hyperactive/impulsive ADHD screening when considering a child's age using age-based percentiles.

National Norms and Percentiles for the Pediatric Emotional Distress Scale.

We estimated norms and percentiles for the Pediatric Emotional Distress Scale (PEDS) in order to enhance its utility as a screening tool for emotional and behavioral distress following a major. The PEDS was administered to a nationally representative sample of parents of children ages 5-12 from all 50 states (N = 1,570). Approximately 15% of the parents reported a trauma/stress in the past 12 months. Results showed good internal consistency (α = .92) and concurrent validity, with significantly higher scores for the trauma/stress subsample compared to the no trauma/stress subsample. PEDS scores were also significantly higher in younger children (age 5-6) compared to older children (7-12), pointing to the need for separate clinical cut-off scores for younger versus older children. Finally, we examined the factor structure of the PEDS with results supporting a four factor solution in the trauma/stress subsample. For screening purposes, we recommend cut-off scores of 39 (ages 5-6) and 35 (ages 7-12) which correspond to the 90th percentile.

Enhancing attachment organization among maltreated children: results of a randomized clinical trial.

Young children who have experienced early adversity are at risk for developing disorganized attachments. The efficacy of Attachment and Biobehavioral Catch-up (ABC), an intervention targeting nurturing care among parents identified as being at risk for neglecting their young children, was evaluated through a randomized clinical trial. Attachment quality was assessed in the Strange Situation for 120 children between 11.7 and 31.9 months of age (M = 19.1, SD = 5.5). Children in the ABC intervention showed significantly lower rates of disorganized attachment (32%) and higher rates of secure attachment (52%) relative to the control intervention (57% and 33%, respectively). These results support the efficacy of the ABC intervention in enhancing attachment quality among parents at high risk for maltreatment.

Objective Measurement of Hyperactivity Using Mobile Sensing and Machine Learning: Pilot Study.

BACKGROUND: Although hyperactivity is a core symptom of attention-deficit/hyperactivity disorder (ADHD), there are no objective measures that are widely used in clinical settings. OBJECTIVE: We describe the development of a smartwatch app to measure hyperactivity in school-age children. The LemurDx prototype is a software system for smartwatches that uses wearable sensor technology and machine learning to measure hyperactivity. The goal is to differentiate children with ADHD combined presentation (a combination of inattentive and hyperactive/impulsive presentations) or predominantly hyperactive/impulsive presentation from children with typical levels of activity. METHODS: In this pilot study, we recruited 30 children, aged 6 to 11 years, to wear a smartwatch with the LemurDx app for 2 days. Parents also provided activity labels for 30-minute intervals to help train the algorithm. Half of the participants had ADHD combined presentation or predominantly hyperactive/impulsive presentation (n=15), and half were in the healthy control group (n=15). RESULTS: The results indicated high usability scores and an overall diagnostic accuracy of 0.89 (sensitivity=0.93; specificity=0.86) when the motion sensor output was paired with the activity labels. CONCLUSIONS: State-of-the-art sensors and machine learning may provide a promising avenue for the objective measurement of hyperactivity.

Trajectories of symptom reduction during treatment for behavior problems in pediatric primary-care settings.

We examined trajectories of symptom reduction during the course of on-site treatment for behavior problems in pediatric primary-care settings for a subset of children from a larger clinical trial. Participants (N = 80) were children (ages 6-11) referred for treatment due to moderate elevations (≥75th percentile) on the externalizing subscale of the Pediatric Symptom Checklist (PSC-17). The sample was recruited from six pediatric practices in an urban setting. The treatment (Protocol for an Office-based Nurse-administered Intervention; PONI) was administered on-site by trained nurses over the course of 3-6 months. Overall, symptom reduction from the first session to last session was moderate (ES = 0.61) and gradual. Roughly two-thirds (72%) of symptom reduction took place over the first 8 weeks of treatment. The average trajectory of symptom reduction was characterized by a negative slope that flattened over time, consistent with a quadratic growth model. Initial symptom severity predicted final symptom severity (r = .36, P < .01), even though patients with greater initial symptom severity remained in treatment for a significantly greater number of sessions (r = .24, P < .05). The implications of these findings for enhancing the efficiency and effectiveness of treatment are discussed.

Perceived Facilitators of and Barriers to Implementation of a Decision Support Tool for Adolescent Depression and Suicidality Screening: Focus Group and Interview Study.

BACKGROUND: Screening Wizard (SW) is a technology-based decision support tool aimed at guiding primary care providers (PCPs) to respond to depression and suicidality screens in adolescents. Separate screens assess adolescents' and parents' reports on mental health symptoms, treatment preferences, and potential treatment barriers. A detailed summary is provided to PCPs, also identifying adolescent-parent discrepancies. The goal of SW is to enhance decision-making to increase the utilization of evidence-based treatments. OBJECTIVE: This qualitative study aims to describe multi-stakeholder perspectives of adolescents, parents, and providers to understand the potential barriers to the implementation of SW. METHODS: We interviewed 11 parents and 11 adolescents and conducted two focus groups with 18 health care providers (PCPs, nurses, therapists, and staff) across 2 pediatric practices. Participants described previous experiences with screening for depression and were shown a mock-up of SW and asked for feedback. Interviews and focus groups were transcribed verbatim, and codebooks were inductively developed based on content. Transcripts were double coded, and disagreements were adjudicated to full agreement. Completed coding was used to produce thematic analyses of the interviews and focus groups. RESULTS: We identified five main themes across the interviews and focus groups: parents, adolescents, and pediatric PCPs agree that depression screening should occur in pediatric primary care; there is concern that accurate self-disclosure does not always occur during depression screening; SW is viewed as a tool that could facilitate depression screening and that might encourage more honesty in screening responses; parents, adolescents, and providers do not want SW to replace mental health discussions with providers; and providers want to maintain autonomy in treatment decisions. CONCLUSIONS: We identified that providers, parents, and adolescents are all concerned with current screening practices, mainly regarding inaccurate self-disclosure. They recognized value in SW as a computerized tool that may elicit more honest responses and identify adolescent-parent discrepancies. Surprisingly, providers did not want the SW report to include treatment recommendations, and all groups did not want the SW report to replace conversations with the PCP about depression. Although SW was originally developed as a treatment decision algorithm, this qualitative study has led us to remove this component, and instead, SW focuses on aspects identified as most useful by all groups. We hope that this initial qualitative work will improve the future implementation of SW.

National Norms and Correlates of the PHQ-8 and GAD-7 in Parents of School-age Children.

Anxiety and depressive disorders are global public health concerns, and research suggests that these disorders are common in parents and can adversely influence family functioning. However, little is known about normative levels of anxiety and depressive symptoms in parents of school-age children. The present study reports on generalized anxiety and depressive symptoms in 1570 parents and guardians of a nationally representative sample of children ages five to twelve years using two widely used and validated questionnaires: the eight-item variant of the Patient Health Questionnaire depression scale (PHQ-8) and the seven-item Generalized Anxiety Disorder scale (GAD-7). Moderate to severe levels of generalized anxiety symptoms were reported in 12.7% of the total sample and moderate to severe levels of depressive symptoms were reported in 14.1% of the sample; 17.7% of the sample reported moderate to severe levels of either generalized anxiety or depressive symptoms. This percentage was higher for females, younger parents and guardians, and parents and guardians reporting lower household incomes. These data, collected online in early 2018, may be useful for researchers and clinicians studying and treating anxiety and depression in parents. Further, these data provide a baseline for researchers currently studying the impact of changes related to the novel coronavirus (COVID-19) pandemic (e.g., school closures) on the mental health of parents of school-age children.

Workforce Turnover in Community Behavioral Health Agencies in the USA: A Systematic Review with Recommendations.

Rates of behavioral health workforce turnover are chronically high, with detrimental effects on the agency and remaining staff, as well as hypothesized negative impacts on client care and outcomes. Turnover also creates challenges for studies investigating the effectiveness and/or implementation of behavioral health interventions. Research examining factors that precede and predict behavioral health staff turnover has become increasingly important, as have studies that include recommendations for preventing and reducing turnover. The current paper systematically reviews the body of research on factors associated with behavioral health staff turnover, synthesizes recommendations made for combating turnover, and identifies gaps in this important area of research.