Bridging Gaps in Care Following Hospitalization for Suicidal Adolescents: As Safe As Possible (ASAP) and BRITE App.

OBJECTIVE: We present results from a 2-site, randomized clinical trial to assess the efficacy of a brief intervention (As Safe As Possible [ASAP]), a safety plan phone application (BRITE), and their combination on suicide attempts, suicidal ideation, non-suicidal self-injury, re-hospitalizations. and suicidal events among adolescents. METHOD: Adolescents (n= 240; 12-17 years of age) who were hospitalized for suicidal ideation with plan and/or intent, and/or suicide attempt, were assigned to 1 of 4 treatment conditions in a 2 by 2 design: ASAP+BRITE app+treatment as usual (TAU); (2) BRITE+TAU; (3) ASAP+TAU; and (4) TAU alone. Independent evaluators assessed suicidal ideation and behavior at 4, 12, and 24 weeks using the Columbia-Suicide Severity Rating Scale (C-SSRS) and re-hospitalization using the Child and Adolescent Services Assessment (CASA). RESULTS: No group differences were found on primary outcomes, except that ASAP participants were less likely to be re-hospitalized over 6 months (15.6%, vs 26.5%, p = .046). Participants hospitalized for an attempt and assigned to BRITE had a lower rate of subsequent attempts (odds ratio [OR] = 0.16, p = .01) and a greater time to attempt (hazard ratio [HR] = 0.20, p = .02). ASAP+BRITE, albeit not statistically significant, was most consistently associated with a reduction (60% reduction) in suicide attempts. CONCLUSION: ASAP, BRITE, and their combination are equally effective at decreasing risk for suicidal events 6 months post hospital discharge among suicidal adolescents; the ASAP intervention (with or without BRITE) was associated with lower rates of re-hospitalization. The BRITE app in youth hospitalized for suicide attempt had promising outcomes in regard to future attempts. DIVERSITY & INCLUSION STATEMENT: We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. The research was performed with permission from the University of Pittsburgh Institutional Review Board and the University of Texas Institutional Review Board. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. One or more of the authors of this paper received support from a program designed to increase minority representation in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. CLINICAL TRIALS REGISTRATION INFORMATION: Establishing Efficacy of an Inpatient Intervention and Phone App to Reduce Suicidal Risk (ASAP+BRITE); https://clinicaltrials.gov/study/; NCT03825588.

Key Challenges and Potential Strategies for Engaging Youth with Lived Experience in Clinical Science.

Centering the perspectives of youth with lived experience (YWLE) in psychopathology is critical to engaging in impactful clinical research to improve youth mental health outcomes. Over the past decade there has been a greater push in clinical science to include community members, and especially community members with lived experience, in all aspects of the research process. The goal of this editorial is to highlight the need for and importance of integrating YWLE into every stage of clinical science research, from idea generation to interpretation and dissemination of research findings. We identify five key problems associated with pursuing research on adolescent mental health without involvement of YWLE and propose strategies to overcome barriers to youth engagement in clinical science research. We conclude with a call to action, providing guidance to clinical scientists, institutions, and funding agencies in conducting research on youth psychopathology with YWLE.

Leveraging the developmental science of psychosocial risk to strengthen youth psychotherapy.

More than 50 years of randomized clinical trials for youth psychotherapies have resulted in moderate effect sizes for treatments targeting the most common mental health problems in children and adolescents (i.e., anxiety, depression, conduct problems, and attention disorders). Despite having psychotherapies that are effective for many children, there has been a dearth of progress in identifying the contextual factors that likely influence who will respond to a given psychotherapy, and under what conditions. The developmental psychopathology evidence base consistently demonstrates that psychosocial risk exposures (e.g., childhood adversities, interpersonal stressors, family dysfunction) significantly influence the onset and course of youth psychopathology. However, the developmental psychopathology framework remains to be well integrated into treatment development and psychotherapy research. We argue that advances in basic developmental psychopathology research carry promising implications for the design and content of youth psychotherapies. Research probing the effects of psychosocial risks on youth development can enrich efforts to identify contextual factors in psychotherapy effectiveness and to personalize treatment. In this article we review empirically supported and hypothesized influences of individual- and family-level risk factors on youth psychotherapy outcomes, and we propose a framework for leveraging developmental psychopathology to strengthen psychotherapies.

Longitudinal course of depressive symptom severity among youths with bipolar disorders: Moderating influences of sustained attention and history of child maltreatment.

BACKGROUND: Pediatric bipolar disorders are often characterized by disruptions in cognitive functioning, and exposure to child maltreatment (e.g., physical and sexual abuse) is associated with a significantly poorer course of illness. Although clinical and developmental research has shown maltreatment to be robustly associated with poorer cognitive functioning, it is unclear whether maltreatment and cognitive function jointly influence the clinical course of bipolar symptoms. METHODS: This secondary analysis examined moderating effects of lifetime childhood physical and sexual abuse, and cognitive disruptions (sustained attention, affective information processing), on longitudinal ratings of depression symptom severity in youths from the Course and Outcome of Bipolar Youth (COBY) study, examined from intake (M = 12.24 years) through age 22 (N = 198; 43.9% female; Mean age of bipolar onset = 8.85 years). RESULTS: A significant moderating effect was detected for sustained attention and maltreatment history. In the context of lower sustained attention, maltreatment exposure was associated with higher depression symptom severity during childhood, but not late adolescence. There was no association between maltreatment and symptom severity in the context of higher sustained attention, and no association between attention and depression symptom severity for non-maltreated youths. LIMITATIONS: Depression symptom ratings at each assessment were subject to retrospective recall bias despite the longitudinal design. Cognitive assessments were administered at different ages across youths. CONCLUSIONS: Depressive symptoms in pediatric bipolar may be jointly moderated by impairments in attention and exposure to maltreatment. Assessment of these risks, particularly in childhood, may be beneficial for considering risk of recurrence or chronicity of depressive symptoms.

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.

Time course of pupillary response to threat words before and after attention bias modification for transdiagnostic anxiety disorders: A randomized controlled trial.

INTRODUCTION: Altered attention to threatening stimuli at initial and sustained stages of processing may be dissociable dimensions that influence the development and maintenance of transdiagnostic symptoms of anxiety, such as vigilance, and possibly require distinct intervention. Attention bias modification (ABM) interventions were created to implicitly train attention away from threatening stimuli and have shown efficacy in treating anxiety. ABM alters neurocognitive functioning during initial stages of threat processing, but less is known regarding effects of ABM on neural indices of threat processing at sustained (i.e., intermediate and late) stages, or if ABM-related neural changes relate to symptom response. The current study utilized pupillary response as a temporally sensitive and cost-effective peripheral marker of neurocognitive response to ABM. MATERIALS AND METHODS: In a randomized controlled trial, 79 patients with transdiagnostic anxiety provided baseline data, 70 were randomized to receive eight sessions of twice-weekly ABM (n = 49) or sham training (n = 21), and 65 completed their assigned treatment condition and returned for post-training assessment. RESULTS: Among ABM, but not sham, patients, pupillary response to threat words during initial and intermediate stages decreased from pre- to post-training. Pre- to post-training reductions in intermediate and late pupillary response to threat were positively correlated with reductions in patient-reported vigilance among ABM, but not sham, patients. CONCLUSIONS: All measured stages of threat processing had relevance in understanding the neural mechanisms of ABM, with overlapping yet dissociable roles exhibited within a single neurophysiological marker across an initial-intermediate-late time continuum. Pupillometry may be well suited to measure both target engagement and treatment outcome following ABM.

A Computer Adaptive Test (CAT) for knowledge of parent management skills: Prototype development and preliminary psychometrics.

The Knowledge of Effective Parenting Test (KEPT) is a measure of parent management skills that was developed as an outcome measure for clinical trials of psychosocial treatments for disruptive behavior disorders. In the current study, we developed a computer adaptive test (CAT; KEPT-CAT) prototype and compared it to the full item bank (21 items; KEPT-Full) and to a brief static version (10 items; KEPT-Brief) using simulations from a large (N = 1,570) nationally representative dataset. Results showed that the KEPT-CAT prototype (median = 8 items) was slightly more efficient than the KEPT-Brief and had a significantly higher (p < .001) correlation with scores from the full item bank (r = .97) than the KEPT-Brief (r = .94). The KEPT-CAT prototype has additional advantages over the static KEPT-Brief, including the potential selection of different items from one administration to the next. This flexibility can reduce practice effects that might result from repeated administration of the same fixed items. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Development and Validation of the Parents' Gendered Emotion Beliefs Scale.

OBJECTIVES: The aim of the current research was to develop and validate a parent, self-report questionnaire to measure parents' gendered beliefs about emotion. METHODS: Scale items were first developed based on a previous qualitative study examining emotions, parenting, and gender in a sample of parents. The Parents' Gendered Emotion Beliefs scale (PGEB) was validated in a sample of 704 parents of middle childhood youth. RESULTS: Item-response theory analyses indicated a three-factor solution with factors measuring beliefs consistent with: gendered emotion expression, gender-neutral emotion expression, and gendered emotion socialization. All factors showed good internal consistency with alphas ranging from 0.79 to 0.90. Analyses then examined convergent validity by correlating PGEB factors to established measures of broad emotion beliefs, emotion socialization, family expressiveness, and child emotion regulation and psychopathology. CONCLUSIONS: Overall, findings support the PGEB, its factor structure and psychometric properties, and its potential to contribute to our understanding of the role of gender in emotion socialization and children's emotional development.

Dimensions of adversity in association with adolescents' depression symptoms: Distinct moderating roles of cognitive and autonomic function.

Exposure to adverse events is prevalent among youths and robustly associated with risk for depression, particularly during adolescence. The Dimensional Model of Adversity and Psychopathology (DMAP) distinguishes between adverse events that expose youths to deprivation versus threat, positing unique mechanisms of risk (cognitive functioning deficits for deprivation, and altered fear and emotion learning for threat) that may require different approaches to intervention. We examined whether deprivation and threat were distinctly associated with behavioral measures of cognitive processes and autonomic nervous system function in relation to depression symptom severity in a community sample of early adolescents (n = 117; mean age 12.73 years; 54.7% male). Consistent with DMAP, associations between threat and depression symptoms, and between economic deprivation and depression symptoms, were distinctly moderated by physiological and cognitive functions, respectively, at baseline but not follow-up. Under conditions of greater cognitive inhibition, less exposure to deprivation was associated with lower symptom severity. Under conditions of blunted resting-state autonomic response (electrodermal activity and respiratory sinus arrhythmia), greater exposure to threat was associated with higher symptom severity. Our findings support the view that understanding risk for youth depression requires parsing adversity: examining distinct roles played by deprivation and threat, and the associated cognitive and biological processes.

Development and Validation of the Praise, Indulgence, and Status Parenting Scale.

The overarching aim of this study was to develop and validate a new scale (i.e., the Praise, Indulgence, and Status Parenting Scale [PISPS]) to measure modern parenting practices and behaviors consistent with instilling ideals of specialness (i.e., the notion that one is special), self-esteem, and status in children. In 2 studies on emerging adults (Study 1: N = 582, M age = 19.46; Study 2: N = 464, M age = 19.58), the PISPS was developed and validated using classical test theory (Study 1) and further refined using item-response theory (Study 2). Results from both studies indicated a 3-factor structure with factors differentially linked with correlates of interest including parenting strategies, self-esteem, narcissism, entitlement, and internalizing symptoms. Study 3 further validated the PISPS in a sample of parents (N = 638, M age = 35.79) reporting on their parenting and their child's emotion regulation and symptoms of psychopathology. Overall, findings support the PISPS, its psychometric properties, and its unique contribution to child symptoms.

Efficient Monitoring of Treatment Response during Youth Psychotherapy: The Behavior and Feelings Survey.

An emerging trend in youth psychotherapy is measurement-based care (MBC): treatment guided by frequent measurement of client response, with ongoing feedback to the treating clinician. MBC is especially needed for treatment that addresses internalizing and externalizing problems, which are common among treatment-seeking youths. A very brief measure is needed, for frequent administration, generating both youth- and caregiver-reports, meeting psychometric standards, and available at no cost. We developed such a measure to monitor youth response during psychotherapy for internalizing and externalizing problems. Across 4 studies, we used ethnically diverse, clinically relevant samples of caregivers and youths ages 7-15 to develop and test the Behavior and Feelings Survey (BFS). In Study 1, candidate items identified by outpatient youths and their caregivers were examined via an MTurk survey, with item response theory methods used to eliminate misfitting items. Studies 2-4 used separate clinical samples of youths and their caregivers to finalize the 12-item BFS (6 internalizing and 6 externalizing items), examine its psychometric properties, and assess its performance in monitoring progress during psychotherapy. The BFS showed robust factor structure, internal consistency, test-retest reliability, convergent and discriminant validity in relation to three well-established symptom measures, and slopes of change indicating efficacy in monitoring treatment progress during therapy. The BFS is a brief, free youth- and caregiver-report measure of internalizing and externalizing problems, with psychometric evidence supporting its use for MBC in clinical and research contexts.

Meta-Analysis: 13-Year Follow-up of Psychotherapy Effects on Youth Depression.

OBJECTIVE: Youth depression is a debilitating condition that constitutes a major public health concern. A 2006 meta-analysis found modest benefits for psychotherapy versus control. Has 13 more years of research improved that picture? We sought to find out. METHOD: We searched PubMed, PsychINFO, and Dissertation Abstracts International for 1960 to 2017, identifying 655 randomized, English-language psychotherapy trials for individuals aged 4 to 18 years. Of these, 55 assessed psychotherapy versus control for youth depression with outcome measures administered to both treatment and control conditions at post (κ = 53) and/or follow-up (κ = 32). Twelve study and outcome characteristics were extracted, and effect sizes were calculated for all psychotherapy versus control comparisons. Using a three-level random-effects model, we obtained an overall estimate of the psychotherapy versus control difference while accounting for the dependency among effect sizes. We then fitted a three-level mixed-effects model to identify moderators that might explain variation in effect size within and between studies. RESULTS: The overall effect size (g) was 0.36 at posttreatment and 0.21 at follow-up (averaging 42 weeks after posttreatment). Three moderator effects were identified: effects were significantly larger for interpersonal therapy than for cognitive behavioral therapy, for youth self-reported outcomes than parent-reports, and for comparisons with inactive control conditions (eg, waitlist) than active controls (eg, usual care). Effects showed specificity, with significantly smaller effects for anxiety and externalizing behavior outcomes than for depression measures. CONCLUSION: Youth depression psychotherapy effects are modest, with no significant change over the past 13 years. The findings highlight the need for treatment development and research to improve both immediate and longer-term benefits.

Development and validation of the Knowledge of Effective Parenting Test (KEPT) in a nationally representative sample.

We report on the development and psychometric properties of an instrument for the assessment of knowledge of effective parenting skills specific to conduct problems using an item response theory (IRT) framework. The initial item pool (36 items) for the Knowledge of Effective Parenting Test (KEPT) was administered online to a national sample (N = 1,570) selected to match the U.S. population on key demographic variables. Items with strong psychometric properties and without significant differential item functioning (DIF) by race/ethnicity were retained, resulting in a 21-item version of the KEPT with excellent reliability and validity. We also created a brief 10-item version of the KEPT to reduce respondent burden and to enhance its utility for repeated measurement in longitudinal and intervention research. We report norms and percentiles for both the 21-item version (KEPT-Full) and the 10-item version (KEPT-Brief). (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Are Psychotherapies for Young People Growing Stronger? Tracking Trends Over Time for Youth Anxiety, Depression, Attention-Deficit/Hyperactivity Disorder, and Conduct Problems.

With the development of empirically supported treatments over the decades, have youth psychotherapies grown stronger? To investigate, we examined changes over time in treatment effects for four frequently treated youth mental-health problems: anxiety, depression, attention-deficit hyperactivity disorder (ADHD), and conduct disorders. We used PubMed and PsycINFO to search for randomized controlled trials (RCTs) that were published between January 1960 and May 2017 involving youths between the ages of 4 and 18 years. We also searched reviews and meta-analyses of youth psychotherapy research, followed reference trails in the reports we identified, and obtained additional studies identified by therapy researchers whom we contacted. We identified 453 RCTs (31,933 participants) spanning 53 years (1963-2016). Effect sizes for the problem-relevant outcome measures were synthesized via multilevel meta-analysis. We tracked temporal trends for each problem domain and then examined multiple study characteristics that might moderate those trends. Mean effect size increased nonsignificantly for anxiety, decreased nonsignificantly for ADHD, and decreased significantly for depression and conduct problems. Moderator analyses involving multiple study subgroups showed only a few exceptions to these surprising patterns. The findings suggest that new approaches to treatment design and intervention science may be needed, especially for depression and conduct problems. We suggest intensifying the search for mechanisms of change, making treatments more transdiagnostic and personalizable, embedding treatments within youth ecosystems, adapting treatments to the social and technological changes that alter youth dysfunction and treatment needs, and resisting old habits that can make treatments unduly skeuomorphic.

Associations Between Trauma Type, Timing, and Accumulation on Current Coping Behaviors in Adolescents: Results from a Large, Population-based Sample.

The development of adolescents' coping in response to stress is critical for adaptive functioning; these coping strategies may be shaped by numerous environmental factors during childhood, including experiences such as exposure to trauma. Childhood trauma has been shown to undermine contemporaneous coping, but how does a history of exposure to trauma and the characteristics of that trauma (type, timing, and accumulation) relate to current coping among adolescents? We addressed this question using a nationally-representative sample of 9427 adolescents (ages 13-18; 48.9% female; 66% White). Adolescents reported on their lifetime exposure to 18 different traumas, including witnessing or experiencing interpersonal violence, accidents, disasters, and violent or accidental loss of loved ones, as well as their current use of coping behaviors when under stress (problem-focused, positive emotion-focused, and negative emotion-focused coping strategies). The study's results highlight that exposure to nearly all forms of trauma was unrelated to problem-focused and positive emotion-focused coping behaviors, but strongly associated with increased negative emotion-focused coping. Use of each coping style did not vary with age at first exposure to trauma, but increased with the number of lifetime traumatic events experienced. The findings suggest that the extent of prior exposure to trauma, including variations across type and timing, may be related to a particular form of coping that has been linked to increased risk for mental health problems. Study results highlight coping strategies as a potential target for prevention and treatment efforts, and indicate a need to better understand the malleability and trajectory of coping responses to stress for promoting healthy youth development.

What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice.

Across 5 decades, hundreds of randomized trials have tested psychological therapies for youth internalizing (anxiety, depression) and externalizing (misconduct, attention deficit and hyperactivity disorder) disorders and problems. Since the last broad-based youth meta-analysis in 1995, the number of trials has almost tripled and data-analytic methods have been refined. We applied these methods to the expanded study pool (447 studies; 30,431 youths), synthesizing 50 years of findings and identifying implications for research and practice. We assessed overall effect size (ES) and moderator effects using multilevel modeling to address ES dependency that is common, but typically not modeled, in meta-analyses. Mean posttreatment ES was 0.46; the probability that a youth in the treatment condition would fare better than a youth in the control condition was 63%. Effects varied according to multiple moderators, including the problem targeted in treatment: Mean ES at posttreatment was strongest for anxiety (0.61), weakest for depression (0.29), and nonsignificant for multiproblem treatment (0.15). ESs differed across control conditions, with "usual care" emerging as a potent comparison condition, and across informants, highlighting the need to obtain and integrate multiple perspectives on outcome. Effects of therapy type varied by informant; only youth-focused behavioral therapies (including cognitive-behavioral therapy) showed similar and robust effects across youth, parent, and teacher reports. Effects did not differ for Caucasian versus minority samples, but more diverse samples are needed. The findings underscore the benefits of psychological treatments as well as the need for improved therapies and more representative, informative, and rigorous intervention science. (PsycINFO Database Record

The role of postdeployment social factors in linking deployment experiences and current posttraumatic stress disorder symptomatology among male and female veterans.

BACKGROUND AND OBJECTIVES: The postdeployment social context is likely highly salient in explaining mental health symptoms following deployment. The aim of this study was to examine the role of postdeployment social factors (social support and social reintegration difficulty) in linking deployment-related experiences (warfare exposure, sexual harassment, concerns about relationship disruptions, and deployment social support) and posttraumatic stress disorder (PTSD) symptomatology in male and female veterans. DESIGN: A survey was administered to 998 potential participants (after accounting for undeliverable mail) who had returned from deployment to Afghanistan or Iraq. Completed surveys were received from 469 veterans, yielding a response rate of 47%. METHODS: Hypotheses were examined using structural equation modeling. RESULTS: For male and female veterans, deployment factors predicted later PTSD symptoms through postdeployment social support and social reintegration, with lower support and higher social reintegration difficulty both associated with higher PTSD symptomatology. While the final models for women and men indicated similar risk mechanisms, some differences in pathways were observed. Sexual harassment presented more of a risk for women, whereas lower social support was a greater risk factor for men. CONCLUSIONS: Postdeployment social factors appear to represent potentially important targets for interventions aiming to reduce the potential impact of stressful deployment experiences.

Racial/ethnic differences in youth depression indicators: An item response theory analysis of symptoms reported by White, Black, Asian, and Latino youths.

Accurate assessment of dysfunction is central to clinical psychological science, essential for valid conclusions about prevalence, risk, and appropriate intervention. Measures applied without adjustment across diverse racial/ethnic groups may risk errors if measurement equivalence has not been established. We tested this possibility in the domain of youth depression, applying item response theory (IRT) and differential item functioning (DIF) analyses to reports by White, Black, Latino, and Asian youths (N = 2,335) on the most widely-used measure of symptoms, the Children's Depression Inventory (CDI). Analyses revealed that 77% of CDI items were non-equivalent indicators of symptom severity across groups. CDI sum scores exhibited marked over-estimations of group differences and inappropriate classification as "clinically-elevated" for 29% of Latino, 23% of Black, and 10% of Asian youths. Applying DIF adjustment corrected these errors. The study demonstrates a useful strategy for ethnically sensitive assessment, applicable to other symptom domains and ethnic groups.

Family stressors and postdeployment mental health in single versus partnered parents deployed in support of the wars in Afghanistan and Iraq.

Little is known about the family-related stress and postdeployment adjustment of single versus partnered parents deployed in support of the wars in Iraq and Afghanistan. This study examined exposure to family-related stressors during and after deployment, as well as postdeployment psychological symptoms in a national sample of 318 single (n = 74) and partnered (n = 244) parent veterans of Operation Enduring Freedom and Operation Iraqi Freedom. Results demonstrated that single parents experienced higher levels of concern about life and family disruptions during deployment, lower levels of social support during and after deployment, and poorer postdeployment family functioning than partnered parents. Single parents also reported higher posttraumatic stress symptom severity, but not depression or anxiety symptom severity, compared with partnered parents. Family-related stressors demonstrated different associations with mental health for single and partnered parents, suggesting that some stressor-symptom relations may be more salient for single parents, and others may be more salient for partnered parents. Findings suggest that the deployment and postdeployment experiences of parents differ based on their partnered status, which has implications for the design and provision of services to single and partnered parents.