Early Childhood Referrals by HealthySteps and Community Health Workers.

This study explored how a community health worker (CHW) within a primary care team with a HealthySteps (HS) Specialist impacted referrals to social determinant of health resources for families with children aged birth to 5 years. Medical charts with documentation of HS comprehensive services between January and June 2018 were reviewed at 3 primary care clinics: 2 with an HS Specialist (HSS Only) and 1 with an HS Specialist and CHW (HSS + CHW). Eighty-six referrals were identified, 78 of which had documented outcomes. Outcomes were categorized as successful, unsuccessful, and not documented. The HSS + CHW group had a higher rate of successful referrals (96%) than the HSS Only group (74%). Statistical analysis (χ2 = 8.37, P = .004) revealed a significant association between the referral outcome and having a CHW on a primary care team with an HS Specialist. Therefore, primary care practices should consider adapting their HS model to include CHWs.

Self-harm and self-regulation in urban ethnic minority youth: a pilot application of dialectical behavior therapy for adolescents.

BACKGROUND: Difficulties in coping with stress and regulating emotions are transdiagnostic risk factors for self-harming behavior. Due to sociocultural stressors, ethnic minority adolescents may be at greater risk for self-regulation difficulties and self-harm. Dialectical behavior therapy for adolescents (DBT-A) frames adaptive skill acquisition as a mechanism of change, but few studies have investigated its impact on ethnic minority adolescents' self-regulation (i.e. coping, emotion regulation). Therefore, this pilot study examined relations between self-regulation and self-harm among ethnic minority adolescents and investigated changes in their self-regulation upon completing DBT-A. METHODS: A clinically referred sample of 101 ethnic minority adolescents (Mage  = 14.77; female = 69.3%) completed questionnaires about a history of self-harm, coping (DBT Ways of Coping Checklist), and emotion regulation (Difficulties in Emotion Regulation Scale). Of the initial sample, 51 adolescents (Mage  = 14.73; female = 80.4%) entered a 20-week DBT-A program due to self-harm and/or Borderline Personality features. RESULTS: In a pretreatment sample, the frequency of dysfunctional coping, but not of adaptive coping, differentiated self-injurers from non-self-injurers. Full information maximum likelihood estimation was used to address high attrition (60.8%) from DBT-A. Those who completed DBT-A (n = 20) reported significantly improved emotion regulation. Adaptive coping at pretreatment predicted increased DBT skills use at post-treatment. CONCLUSIONS: This non-randomized pilot study highlights dysfunctional coping and emotion dysregulation as risk factors for self-harm and suggests that 20-week DBT-A may help improve emotion regulation. Future research should employ a randomized design to further examine the effect of DBT-A on these transdiagnostic processes of psychopathology. KEY PRACTITIONER MESSAGE: Due to cultural and environmental stressors, ethnic minority adolescents may be at greater risk for developing self-regulatory difficulties - transdiagnostic mechanisms known to underly self-harming behaviors; however, we know little about whether empirically supported treatments for self-harm will improve youth's coping and emotion regulation. In a clinically referred, pretreatment sample of ethnic minority youth, levels of BPD symptomatology, emotion dysregulation, and dysfunctional coping, but not of adaptive coping, differentiated teens who self-harmed from those who did not. Self-harming ethnic minority youth who participated in an uncontrolled, pilot trial of dialectical behavior therapy for adolescents (DBT-A) at an urban mental health clinic reported improved emotion regulation at post-treatment. Baseline emotion regulation skills were not predictive of treatment-related changes, suggesting that other factors, such as DBT-A, may have played a decisive role in improving teens' emotion regulation. In contrast, adaptive coping skills at pretreatment were linked to increased DBT skills use at post-treatment, indicating that patients' baseline coping skills may play a predictive role in psychotherapy outcomes. Future research should employ a randomized control trial to examine the effect of DBT-A on vulnerable ethnic minority youth's development of self-regulation. It should also investigate the hypothesized mediating role of self-regulation in effecting lasting clinical gains.

Effect of Mental Health Screening and Integrated Mental Health on Adolescent Depression-Coded Visits.

Adolescent depression causes morbidity and is underdiagnosed. It is unclear how mental health screening and integrated mental health practitioners change adolescent depression identification. We conducted a retrospective primary care network natural cohort study where 10 out of 19 practices implemented mental health screening, followed by the remaining 9 practices implementing mental health screening with less coaching and support. Afterward, a different subset of 8 practices implemented integrated mental health practitioners. Percentages of depression-coded adolescent visits were compared between practices (1) with and without mental health screening and (2) with and without integrated mental health practitioners, using difference-in-differences analyses. The incidence of depression-coded visits increased more in practices that performed mental health screening (ratio of odds ratios = 1.22; 95% confidence interval =1.00-1.49) and more in practices with integrated mental health practitioners (ratio of odds ratios = 1.58; 95% confidence interval = 1.30-1.93). Adolescent mental health screening and integrated mental health practitioners increase depression-coded visits in primary care.

Treating postpartum mood and anxiety disorders in primary care pediatrics.

Postpartum psychiatric disorders represent a significant public health problem that has not been readily addressed, particularly in the primary care setting. As maternal mood and anxiety difficulties are associated with a number of adverse outcomes for the mother, her offspring and the family system, addressing these concerns during the perinatal period is of critical importance. Although researchers and clinicians have become increasingly aware of the problem, postpartum mood and anxiety disorders (PMADs) remain widely unrecognized and poorly understood by both patients and providers. As pediatric primary care providers encounter mothers repeatedly throughout the postpartum period, the pediatric clinician has the unique opportunity to intervene with mothers suffering from mental illness. Given the potentially devastating impact of PMADs across multiple domains, the purpose of this article is to provide guidelines for pediatric clinicians to better manage maternal mental illness within the primary care pediatric setting. As such, we review the categories and prevalence of PMADs and provide strategies for responding to a positive PMADs screen or concerns raised during surveillance of the mother-infant-dyad. In addition, we offer a summary of the literature on evidence-based treatments for PMADs to allow pediatricians to guide the parents of their patients towards the most effective interventions. Finally, we provide an overview of alternative treatment models that can facilitate the screening and treatment of behavioral health concerns within the primary care setting.

Comparing Two Models of Integrated Behavioral Health Programs in Pediatric Primary Care.

This study examined how to design, staff, and evaluate the feasibility of 2 different models of integrated behavioral health programs in pediatric primary care across primary care sites in the Bronx, NY. Results suggest that the Behavioral Health Integration Program model of pediatric integrated care is feasible and that hiring behavioral health staff with specific training in pediatric, evidence-informed behavioral health treatments may be a critical variable in increasing outcomes such as referral rates, self-reported competency, and satisfaction.

Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity.

OBJECTIVE: Although identifying adverse childhood experiences (ACEs) among children with behavioral disorders is an important step in providing targeted therapy and support, little is known about the burden of ACEs among children with attention deficit-hyperactivity disorder (ADHD). We described the prevalence of ACEs in children with and without ADHD, and examined associations between ACE type, ACE score, and ADHD diagnosis and severity. METHODS: Using the 2011 to 2012 National Survey of Children's Health, we identified children aged 4 to 17 years whose parents indicated presence and severity of ADHD, and their child's exposure to 9 ACEs. Multivariate logistic regression was used to estimate associations between ACEs, ACE score, and parent-reported ADHD and ADHD severity, adjusted for sociodemographic characteristics. RESULTS: In our sample (N = 76,227, representing 58,029,495 children), children with ADHD had a higher prevalence of each ACE compared with children without ADHD. Children who experienced socioeconomic hardship (adjusted odds ratio [aOR], 1.39; 95% confidence interval [CI], 1.21-1.59), divorce (aOR, 1.34; 95% CI, 1.16-1.55), familial mental illness (aOR, 1.55; 95% CI, 1.26-1.90), neighborhood violence (aOR, 1.47; 95% CI, 1.23-1.75), and incarceration (aOR, 1.39; 95% CI, 1.12-1.72) were more likely to have ADHD. A graded relationship was observed between ACE score and ADHD. Children with ACE scores of 2, 3, and ≥4 were significantly more likely to have moderate to severe ADHD. CONCLUSIONS: Children with ADHD have higher ACE exposure compared with children without ADHD. There was a significant association between ACE score, ADHD, and moderate to severe ADHD. Efforts to improve ADHD assessment and management should consider routinely evaluating for ACEs.

The Role of Sleep Disturbance in Suicidal and Nonsuicidal Self-Injurious Behavior among Adolescents.

The relationship between different sleep disturbances and self-harm thoughts and behaviors was examined among 223 adolescents presenting to a community clinic for mood disorders and suicidal and nonsuicidal self-injurious behaviors. Two-thirds of the adolescents reported nightly, severe sleep complaints. Relative to adolescents without significant sleep complaints, patients with severe sleep complaints at the time of clinic entry endorsed significantly more engagement in nonsuicidal self-injury. Middle insomnia and circadian reversal were both significant predictors of suicide attempts. Terminal insomnia was significantly associated with suicidal ideation. Results support the importance of assessing sleep difficulties among adolescents at risk for suicide.

An experimental test of the Bridges to High School intervention on harsh parenting and early age intercourse among Mexican American adolescents.

OBJECTIVE: Can an intervention that contained no content on sex or contraception reduce rates of early-age intercourse among Mexican American adolescents? The current study examined whether the Bridges to High School intervention designed, in part, to decrease harsh parenting, had a longitudinal effect on decreasing rates of early-age intercourse in the treatment versus control groups, as well as the moderating role of gender and linguistic acculturation. METHOD: The sample consisted of 516 Mexican American adolescents (Mage = 12.31 years; 50.8% female) and their mothers who participated in a randomized, intervention trial. A series of longitudinal, meditational path models were used to examine the effects of the intervention on harsh parenting practices and early-age intercourse. RESULTS: Our findings revealed that participation in the treatment versus control group was indirectly linked to a lower likelihood of early-age intercourse through decreased maternal harsh parenting. Tests of mediation were significant. These findings did not vary across gender and linguistic acculturation. CONCLUSION: Results suggest that the Bridges to High School intervention successfully decreased early-age intercourse among Mexican American adolescents through reduced harsh parenting among mothers. This finding is consistent with positive youth development programs that have been found to have broad, and sometimes nontargeted, effects on adolescent sexual behaviors. (PsycINFO Database Record

Dialectical Behavior Therapy for Suicidal Latina Adolescents: Supplemental Dialectical Corollaries and Treatment Targets.

The primary aim of this paper is to describe extreme behavioral patterns that the authors have observed in treating Latina adolescents who are suicidal and their parents within the framework of dialectical behavior therapy (DBT). These extreme patterns, called dialectical corollaries, serve to supplement the adolescent/family dialectical dilemmas described by Rathus and Miller (2002) as part of dialectical behavior therapy for suicidal adolescents with borderline personality features. The dialectical corollaries proposed are "old school versus new school" and "overprotecting" versus "underprotecting," and they are described in-depth. We also identify specific treatment targets for each corollary and discuss therapeutic techniques aimed at achieving a synthesis between the polarities that characterize each corollary. Lastly, we suggest clinical strategies to use when therapists reach a therapeutic impasse with the parent-adolescent dyad (i.e., dialectical failures).

Maternal Warmth Moderates the Link between Harsh Discipline and Later Externalizing Behaviors for Mexican American Adolescents.

OBJECTIVE: This study examined maternal warmth as a moderator of the relation between harsh discipline practices and adolescent externalizing problems 1year later in low-income, Mexican American families. DESIGN: Participants were 189 adolescents and their mothers who comprised the control group of a longitudinal intervention program. RESULTS: Maternal warmth protected adolescents from the negative effects of harsh discipline such that, at higher levels of maternal warmth, there was no relation between harsh discipline and externalizing problems after controlling for baseline levels of externalizing problems and other covariates. At lower levels of maternal warmth, there was a positive relation between harsh discipline practices and later externalizing problems. CONCLUSIONS: To understand the role of harsh discipline in the development of Mexican American youth outcomes, researchers must consider contextual variables that may affect youths' perceptions of their parents' behavior such as maternal warmth.

Randomized trial of a broad preventive intervention for Mexican American adolescents.

OBJECTIVE: This randomized trial of a family-focused preventive intervention for Mexican American (MA) adolescents evaluated intervention effects on adolescent substance use, internalizing and externalizing symptoms, and school discipline and grade records in 8th grade, 1 year after completion of the intervention. The study also examined hypothesized mediators and moderators of intervention effects. METHOD: Stratified by language of program delivery (English vs. Spanish), the trial included a sample of 516 MA adolescents (50.8% female; M = 12.3 years, SD = 0.54) and at least one caregiver that were randomized to receive a low-dosage control group workshop or the 9-week group intervention that included parenting, adolescent coping, and conjoint family sessions. RESULTS: Positive program effects were found on all 5 outcomes at 1-year posttest but varied depending on whether adolescents, parents, or teachers reported on the outcome. Intervention effects were mediated by posttest changes in effective parenting, adolescent coping efficacy, adolescent school engagement, and family cohesion. The majority of intervention effects were moderated by language, with a larger number of significant effects for families who participated in Spanish. Intervention effects also were moderated by baseline levels of mediators and outcomes, with the majority showing stronger effects for families with poorer functioning at baseline. CONCLUSION: Findings not only support the efficacy of the intervention to decrease multiple problem outcomes for MA adolescents but also demonstrate differential effects for parents and adolescents receiving the intervention in Spanish vs. English, and depending on their baseline levels of functioning.

The Mexican American Cultural Values scales for Adolescents and Adults.

This research evaluates the properties of a measure of culturally linked values of Mexican Americans in early adolescence and adulthood. The items measure were derived from qualitative data provided by focus groups in which Mexican Americans' (adolescents, mothers and fathers) perceptions of key values were discussed. The focus groups and a preliminary item refinement resulted in the fifty-item Mexican American Cultural Values Scales (identical for adolescents and adults) that includes nine value subscales. Analyses of data from two large previously published studies sampling Mexican American adolescents, mothers, and fathers provided evidence of the expected two correlated higher order factor structures, reliability, and construct validity of the subscales of the Mexican American Cultural Values Scales as indicators of values that are frequently associated with Mexican/Mexican American culture. The utility of this measure for use in longitudinal research, and in resolving some important theoretical questions regarding dual cultural adaptation, are discussed.

Engaging suicidal youth in outpatient treatment: theoretical and empirical underpinnings.

Suicidal and non-suicidal self-injurious behaviors are pernicious and highly prevalent among youth worldwide. Studies confirm that engaging suicidal youth in outpatient treatment is a challenge for most therapists and that a substantial number of suicidal youth never follow through with treatment referrals received in emergency departments and eventually re-attempt suicide. The treatment engagement literature for suicidal youth has largely focused on identifying empirical correlates of attendance and testing interventions to increase compliance. In an effort to promote the use of theory in this field, this article employs Staudt's (2007) conceptual model of the treatment engagement process to both organize the empirical literature and to explain specific treatment engagement and retention strategies used in dialectical behavior therapy for suicidal adolescents. Recommendations for future research are offered.

Familism Values as a Protective Factor for Mexican-origin Adolescents Exposed to Deviant Peers.

This study examined interactive relations between adolescent, maternal and paternal familism values and deviant peer affiliations in predicting adolescent externalizing problems within low-income, Mexican-origin families (N = 598). Adolescent, maternal and paternal familism values interacted protectively with deviant peer affiliations to predict lower levels of externalizing problems according to two independent teacher reports. These relations were not found with parent reports of adolescent externalizing problems although these models showed a direct, protective effect of maternal familism values. Consistent with the view that traditional cultural values are protective for Latino adolescents, these results suggest that supporting familism values among Mexican-origin groups is a useful avenue for improving adolescent conduct problems, particularly in a school context.

Mexican American adolescents' cultural orientation, externalizing behavior and academic engagement: the role of traditional cultural values.

This study of 598 7th grade students of Mexican origin examined the role of traditional cultural values as a mediator of the effects of immigrant status, Mexican cultural orientation and Anglo cultural orientation on adolescent externalizing behavior and academic engagement. Immigrant status of adolescents and their maternal caregivers uniquely predicted increased Mexican cultural orientation and decreased Anglo cultural orientation, and both Mexican and Anglo cultural orientation related positively to adolescents' endorsement of traditional cultural values. Endorsement of traditional cultural values related, in turn, to decreased externalizing behaviors and increased academic engagement and these findings were replicated across adolescent and teacher report of these two outcomes. Tests of mediation provided further evidence to support these pathways. Findings support the central importance of traditional cultural values as a protective resource that explains why immigrant youth exhibit fewer externalizing problems and increased academic engagement when compared to their second and third generation peers.

Engaging Mexican origin families in a school-based preventive intervention.

This study describes a culturally sensitive approach to engage Mexican origin families in a school-based, family-focused preventive intervention trial. The approach was evaluated via assessing study enrollment and intervention program participation, as well as examining predictors of engagement at each stage. Incorporating traditional cultural values into all aspects of engagement resulted in participation rates higher than reported rates of minority-focused trials not emphasizing cultural sensitivity. Family preferred language (English or Spanish) or acculturation status predicted engagement at all levels, with less acculturated families participating at higher rates. Spanish-language families with less acculturated adolescents participated at higher rates than Spanish-language families with more acculturated adolescents. Other findings included two-way interactions between family language and the target child's familism values, family single- vs. dual-parent status, and number of hours the primary parent worked in predicting intervention participation. EDITORS' STRATEGIC IMPLICATIONS: The authors present a promising approach-which requires replication-to engaging and retaining Mexican American families in a school-based prevention program. The research also highlights the importance of considering acculturation status when implementing and studying culturally tailored aspects of prevention models.