Associations between Sex, Rumination, and Depressive Symptoms in Late Adolescence: A Four-Year Longitudinal Investigation.

OBJECTIVE: The literature on the association between sex, rumination, and depression indicates significant variability from childhood to adulthood. Although this variability indicates the need for a developmental lens, a surprising lack of research has been conducted on the association between these variables from middle to late adolescence. METHOD: The present study seeks to bridge this gap using structured equation modeling (SEM) to evaluate the reciprocal associations between sex, brooding rumination, reflective rumination, and depressive symptoms in a sample of students measured at 8th grade, 9th grade, and 12th grade time points. RESULTS: In line with findings across the lifespan, female participants indicated significantly higher average levels of both subtypes of rumination and depressive symptoms versus males. Novel results of this study include the findings that for male participants in this age range, brooding rumination predicted later depressive symptoms, while for female participants, early depressive symptoms predicted later brooding. For female participants, early reflective rumination predicted later depressive symptoms. CONCLUSIONS: This is the first investigation of its kind to demonstrate deleterious longitudinal effects of self-reflective rumination. Findings are interpreted through an ecological framework and mark the transition to high school as a potential risk for interrupted problem-solving of circumstances related to adolescents' distress.

Latent classes of oppositional defiant disorder in adolescence and prediction to later psychopathology.

Current conceptualizations of oppositional defiant disorder (ODD) place the symptoms of this disorder within three separate but related dimensions (i.e., angry/irritable mood, argumentative/defiant behavior, vindictiveness). Variable-centered models of these dimensions have yielded discrepant findings, limiting their clinical utility. The current study utilized person-centered latent class analysis based on self and parent report of ODD symptomatology from a community-based cohort study of 521 adolescents. We tested for sex, race, and age differences in the identified classes and investigated their ability to predict later symptoms of depression and conduct disorder (CD). Diagnostic information regarding ODD, depression, and CD were collected annually from adolescents (grades 6-9; 51.9% male; 48.7% White, 28.2% Black, 18.5% Asian) and a parent. Results provided evidence for three classes of ODD (high, medium, and low endorsement of symptoms), which demonstrated important developmental differences across time. Based on self-report, Black adolescents were more likely to be in the high and medium classes, while according to parent report, White adolescents were more likely to be in the high and medium classes. Membership in the high and medium classes predicted later increases in symptoms of depression and CD, with the high class showing the greatest risk for later psychopathology.

Mother's and Father's Serious Mental Illness and Risk of Child Injury in a Taiwanese Birth Cohort.

Objective: Parental serious mental illness (SMI) is associated with childhood injury. This study investigated whether child injury risk differs according to which parent is affected, SMI diagnosis, or timing of SMI onset.Methods: This cohort study included 1,999,322 singletons born in 2004-2014 identified from the national Taiwanese registries. General estimating equation Poisson models were used to estimate incidence rate ratios (IRRs) of injury events and hospitalizations before the age of 5 years among children according to which parent was affected, SMI diagnosis (schizophrenia [ICD-9-CM codes: 295, 297, 298.3, 298.4, 298.9], bipolar disorder [296.00-296.16, 296.40-296.81, 296.89-296.99, 298.1, 648.4], or major depressive disorder [MDD; 296.20-296.36, 296.82, 298.0]), and timing of diagnosis (before or after childbirth, as a proxy of timing of onset). Data analysis was performed on data obtained from April 20, 2017, to May 6, 2020.Results: Relative to unexposed children, the IRRs of injury hospitalizations for children with two SMI-affected parents, maternal SMI only, and paternal SMI only were 1.85 (95% CI, 1.38-2.48), 1.58 (95% CI, 1.48-1.68), and 1.34 (95% CI, 1.23-1.46), respectively. The IRRs of injury hospitalizations for maternal schizophrenia, bipolar disorder, and MDD were 2.09 (95% CI, 1.82-2.40), 1.77 (95% CI, 1.56-2.00), and 1.38 (95% CI, 1.26-1.50), respectively. The IRRs for paternal schizophrenia, bipolar disorder, and MDD were 1.39 (95% CI, 1.20-1.60), 1.61 (95% CI, 1.39-1.87), and 1.19 (95% CI, 1.05-1.36), respectively. The magnitude of excess risk was similar for children whose parent(s) experienced SMI diagnosed before and after childbirth.Conclusions: We found children with two SMI-affected parents or at least one parent with schizophrenia or bipolar disorder to be at greatest risk of severe injury requiring hospitalization. These parents may benefit from extra parenting support and injury prevention coaching.

Baseline situational analysis in Bangladesh, Jordan, Paraguay, the Philippines, Ukraine, and Zimbabwe for the WHO Special Initiative for Mental Health: Universal Health Coverage for Mental Health.

INTRODUCTION: Mental, neurological and substance use conditions lead to tremendous suffering, yet globally access to effective care is limited. In line with the 13th General Programme of Work (GPW 13), in 2019 the World Health Organization (WHO) launched the WHO Special Initiative for Mental Health: Universal Health Coverage for Mental Health to advance mental health policies, advocacy, and human rights and to scale up access to quality and affordable care for people living with mental health conditions. Six countries were selected as 'early-adopter' countries for the WHO Special Initiative for Mental Health in the initial phase. Our objective was to rapidly and comprehensively assess the strength of mental health systems in each country with the goal of informing national priority-setting at the outset of the Initiative. METHODS: We used a modified version of the Program for Improving Mental Health Care (PRIME) situational analysis tool. We used a participatory process to document national demographic and population health characteristics; environmental, sociopolitical, and health-related threats; the status of mental health policies and plans; the prevalence of mental disorders and treatment coverage; and the availability of resources for mental health. RESULTS: Each country had distinct needs, though several common themes emerged. Most were dealing with crises with serious implications for population mental health. None had sufficient mental health services to meet their needs. All aimed to decentralize and deinstitutionalize mental health services, to integrate mental health care into primary health care, and to devote more financial and human resources to mental health systems. All cited insufficient and inequitably distributed specialist human resources for mental health as a major impediment. CONCLUSIONS: This rapid assessment facilitated priority-setting for mental health system strengthening by national stakeholders. Next steps include convening design workshops in each country and initiating monitoring and evaluation procedures.

MENTAL HEALTH IN KENYAN SCHOOLS: TEACHERS' PERSPECTIVES.

INTRODUCTION: This qualitative study, conducted in public primary and secondary schools, sought teachers' perceptions of mental health concerns that are relevant in school settings. Based on the phenomenological theory, the study aimed to understand the teachers experiences of mental health problems in the schools and how they handled them. METHOD: The schools sampled represented rural, suburban and urban sections of Kiambu County in Kenya. Data were collected through Focus Group Discussions (FGDs). The researcher made summary notes from both audio taped interviews and notes made by the research assistants and summarized the major themes. RESULTS: Teachers reported that they were aware that students suffered from mental health problems. They recognized learning difficulties, externalizing problems, internalizing problems, bizarre behavior, and problem substance use among students. Teachers reported that lack of skills and time were challenges in dealing with student mental health problems. CONCLUSION: Teachers perceive presence of mental health problems among the students. There is need for in- service training for identification and referral and that school psychologists be employed to deal with student mental health problems.

Implementation of Home-Based Telemental Health in a Large Child Psychiatry Department During the COVID-19 Crisis.

Objective: Telemental health (TMH) is not well described for mental health service delivery during crises. Most child and adolescent psychiatry training programs have not integrated TMH into their curricula and are ill equipped to respond during crises to their patients' needs. In this study, we present the implementation of a home-based TMH (HB-TMH) service during the COVID-19 pandemic. Methods: We describe the technological, administrative, training, and clinical implementation components involved in transitioning a comprehensive outpatient child and adolescent psychiatry program to a HB-TMH virtual clinic. Results: The transition was accomplished in 6 weeks. Most in-clinic services were rapidly moved off campus to the home. Owing to challenges encountered with each implementation component, phone sessions bridged the transition from in-clinic to reliable virtual appointments. Within 3 weeks (March 20, 2020) of planning for HB-TMH, 67% of all appointments were conducted at home, and within 4 weeks (March 27, 2020), 90% were conducted at home. By week 6 (April 3, 2020), reliable HB-TMH appointments were implemented. Conclusions: The COVID-19 pandemic crisis created the opportunity to innovate a solution to disrupted care for our established patients and to create a resource for youth who developed problems during the crisis. Our department was experienced in providing TMH services that facilitated the transition to HB-TMH, yet still had to overcome known and unanticipated challenges. Our experience provides a roadmap for establishing a HB-TMH service with focus on rapid implementation. It also demonstrates a role for TMH during (rather than after) future crises when usual community resources are not available.

Association of Parental Mental Illness With Child Injury Occurrence, Hospitalization, and Death During Early Childhood.

Importance: Injury is a leading cause of childhood morbidity and mortality worldwide. Serious mental illness (SMI) is a major contributor to the global burden of disease. Objective: To compare injury event rates in children from birth to 5 years of age among Taiwanese children with and without parents with SMI, including schizophrenia, bipolar disorder, and major depressive disorder. Design, Setting, and Participants: This population-based, retrospective cohort study of an 11-year Taiwanese birth cohort used data from the Taiwan National Health Insurance Research Database (covering 99% of Taiwanese citizens), the Maternal and Child Health Database, and birth and death certificate databases. The study included 1 999 322 singletons with Taiwanese citizenship born from January 1, 2004, to December 31, 2014, and followed up from birth to their fifth birthday, December 31, 2014, or the date of death, yielding a total of 7 741 026 person-years. Data analysis was performed from April 20, 2017, to September 24, 2019. Exposures: Physician-diagnosed parental SMI defined using outpatient and inpatient records from 6 years before the child's birth to 5 years after delivery. Main Outcome and Measures: Rates of medically attended injury events, injury hospitalization, and injury death retrieved from outpatient records, inpatient records, and death certificates. Generalized estimating equation for log-linear models estimated injury incidence rate ratios (IRRs) comparing parental SMI-exposed children and unexposed children. Results: The study cohort included 1 999 322 singletons (52.1% males without parental SMI and 52.2% males with parental SMI). Incidence rates of child injury-related outcomes were higher among children exposed to parental SMI (294.8 injury events per 1000 person-years) compared with children who were unexposed (256.1 injury events per 1000 person-years). After adjustment for sociodemographic factors, children with parental SMI had higher rates of injury events (IRR, 1.14; 95% CI, 1.13-1.15), injury hospitalization (IRR, 1.49; 95% CI, 1.42-1.57), and injury death (IRR, 1.82; 95% CI, 1.38-2.39) compared with unexposed children. The results were confirmed in sensitivity analyses. Appendicitis, a negative control outcome, was not associated with parental SMI (IRR, 1.10; 95% CI, 0.94-1.28). In addition, children with and without parental SMI had similar patterns of preventive health care. The mean (SD) number of prenatal visits was 8.09 (2.50) for children with parental SMI and 8.17 (2.47) among unaffected children. The mean (SD) number of well-child visits was 5.70 (2.24) for children with parental SMI and 5.80 (2.21) among unaffected children. Conclusions and Relevance: In this study, children with parental SMI had increased risk of injury, particularly serious injury. Excess risk may be reduced by providing effective mental health treatment, parenting support, and home safety education to parents with SMI who are raising young children.

Trauma among Kenyan School Children in Urban and Rural Settings: PTSD Prevalence and Correlates.

This study estimated the prevalence and correlates of PTSD in Kenyan school children during a period of widespread post-election violence. The UCLA PTSD Reaction Index was administered to 2482 primary and secondary school students ages 11-17 from rural and urban communities. A high proportion of school children had witnessed people being shot at, beat up or killed (46.9%) or had heard about the violent death or serious injury of a loved one (42.0%). Over one quarter (26.8%, 95% CI = 25.1% - 28.7%) met criteria for PTSD. Correlates of PTSD included living in a rural (vs urban) area (AOR = 1.72, 95% CI = 1.41-2.11), attending primary (vs secondary) school (AOR = 2.25, 95% CI = 1.67-3.04) and being a girl (with girl as referent AOR = .70, 95% CI = .57-.86). We recommend training Kenyan teachers to recognize signs of emotional distress in school children and psychosocial counselors to adapt empirically-supported mental health interventions for delivery in primary and secondary school settings.

Primary Care Management of Children with Attention-Deficit/Hyperactivity Disorder Appears More Assertive Following Brief Psychiatric Intervention Compared with Single Session Consultation.

Objectives: We examined primary care providers' (PCPs') management of attention-deficit/hyperactivity disorder (ADHD) during and following families' participation in two arms of the Children's ADHD Telemental Health Treatment Study. We hypothesized that more intensive treatment during the trial would show an "after-effect" with more assertive PCPs' management during short term follow-up. Methods: We conducted a pragmatic follow-up of PCPs' management of children with ADHD who had been randomized to two service delivery models. In the Direct Service Model, psychiatrists provided six sessions over 22 weeks of pharmacotherapy followed by behavior training. In the Consultation Model, psychiatrists provided a single-session consultation and made treatment recommendations to PCPs who implemented these recommendations at their discretion for 22 weeks. At the end of the trial, referring PCPs for both service delivery models resumed ADHD treatment for 10 weeks. We performed intent-to-treat analysis using all 223 original participants. We applied linear regression models on continuous outcomes, Poisson regression models on count outcomes, and logistic regression models to binary outcomes. Missing data were addressed through imputations. Results: Participants in the Direct Service Model had more ADHD visits than those in the Consultation Model across the full 32 weeks (mean = 7.05 visits vs. 3.36 visits; adjusted rate ratio = 2.1 [1.85-2.38]; p < 0.0001). During follow-up, participants in the DSM were more likely to be taking ADHD-related medications (82% vs. 61%; adjusted odds ratio = 2.44 [1.24-4.81], p = 0.01). At 32 weeks, participants in the Direct Service Model had higher stimulant dosages (adjusted difference = 5.64 [0.12-11.15] mg; p = 0.046). Conclusion: These results from a pragmatic follow-up of a randomized trial suggest an "after-effect" for brief intensive treatment in the Direct Service Model on the short term follow-up management of ADHD in primary care.

The impact of exposure to parental intimate partner violence on adolescent precocious transitions to adulthood.

INTRODUCTION: Precocious transitions can create stress by placing excessive demands on adolescents and are associated with adverse outcomes that extend into adulthood. The current study assessed whether exposure to parental intimate partner violence (IPV) is associated with adolescent precocious transitions to adulthood. METHODS: Data come from 33,360 individuals aged 18+ years in the United States who participated in the National Epidemiologic Surveys of Alcohol and Related Conditions. Six precocious transitions (leaving home early, early sex, early marriage, early parenthood, early full-time employment, and dropping out of high school) were examined. Robust Poisson regression was used to calculate relative risks for the association between IPV exposure and each precocious transition, adjusting for confounders. We assessed effect modification by gender and by exposure to childhood abuse or neglect. RESULTS: Participants exposed to IPV in childhood were at higher risk of engaging in early sex; dropping out of high school; entering into early full-time employment; entering into early marriage; and entering into early parenthood relative to participants not exposed to IPV. Significant interactions between gender and exposure to IPV were detected for early sex and early full-time work outcomes, such that the associations were stronger for females compared to males. Participants exposed to more frequent or more severe IPV in childhood were at even higher risk for experiencing precocious transitions. CONCLUSIONS: Individuals exposed to IPV in childhood are more likely to experience precocious transitions to adulthood. Findings highlight the need for interventions to mitigate adverse outcomes in adolescence for children exposed to IPV.

Ethnic Variations of Trajectories in Suicide Ideation and Attempt: From Middle School to High School.

The purpose of this study was to compare patterns of suicide ideation and suicide attempt in three ethnic groups. We analyzed data from 463 students with ethnic backgrounds of African American (AA), Asian American (ASA), and European American (EA) for 6 years. The best fit model was a three-trajectory class model for all groups. The majority of adolescents belonged in the nonideators trajectory. The high level of ideation was found in the high ideators (4%), high-fluctuating ideators (8%), and high-decreasing ideators (4%) trajectory in AA, ASA, and EA, respectively. In the AA group, being a member of ideators was not a significant predictor of suicide attempt. In the ASA group, being a member of high-fluctuating ideators was a significant predictor. In the EA group, being a member of both ideators predicted suicide attempt. The timing of onset, patterns of change, and peak time in the ideators trajectories in the three ethnic groups were markedly different. The high level of attempts found in the ASA-AA group was not explained by having suicide ideation. Findings suggest the need for in-depth examination of suicide behaviors across ethnic groups and culturally adapted preventive efforts with distinct developmental timing for adolescents from different ethnic backgrounds.

Emergence of Depressive Symptoms from Kindergarten to Sixth Grade.

This study documents the emergence of symptoms of anxiety and depression in a community sample of school-age children and describes the temporal progression of symptoms leading to depressive episodes. Caregivers of 468 seventh graders reported retrospectively the manifestation of 14 symptoms of depression and anxiety in their children from kindergarten through sixth grade. The sample was balanced by sex and reflected the racial and economic diversity of the urban school district. Childhood period prevalence was calculated for each symptom, and discrete time survival analyses compared likelihoods of early symptom emergence in children who did and did not meet diagnostic criteria for major depressive disorder (MDD) by ninth grade. Symptom prevalence ranged between 20% (excessive guilt) and 50% (concentration problems) during the elementary school years. The 4-year period prevalence of MDD was 8.9%, 95% confidence interval [6.5%, 12.1%]. Low energy, excessive worry, excessive guilt, anhedonia, social withdrawal, and sadness or depressed mood were each associated with a significantly higher likelihood of onset of MDD. Compared to girls, boys were more likely to exhibit sad mood, fatigue, and trouble concentrating. Children who later met criteria for MDD demonstrated a significantly higher likelihood of showing core features of depressive and anxiety disorders during their elementary school years. The findings underscore the importance of recognizing early signs and developing interventions to help children manage early symptoms and prevent later psychiatric illness.

Research strategy for health sciences: Facebook friend request is non-differentially accepted in a diverse, young adult population.

Social media is being used for recruitment and the study of health-care choices and behavior, and could be particularly helpful to reach young adult populations outside of a 4 year college setting. The aim of this study was to report on overall success of recruiting young adults in diverse settings with respect to education and employment into a study using Facebook (FB). Young adults (n = 380, 50% male, 44% white) who had been involved in a longitudinal research project received a friend request from the research study group's profile. Acceptance rates of friend requests and sociodemographic and mental health factors associated with acceptance were evaluated. Approximately 67% of 318 participants who received a friend request accepted the request. Sociodemographic and mental health characteristics were similar between those who did and did not accept friend requests, suggesting non-differential recruitment through FB. Friending through FB is a feasible way to reach young adults involved in health and behavioral research, and could be a way to expand the populations that are studied in health science research to maximize generalizability of the conclusions drawn.

Correction to: Depression during pregnancy and preterm delivery: a prospective cohort study among women attending antenatal clinic at Pumwani Maternity Hospital.

[This corrects the article DOI: 10.1186/s12991-018-0202-6.].

Depression during pregnancy and preterm delivery: a prospective cohort study among women attending antenatal clinic at Pumwani Maternity Hospital.

BACKGROUND: Preterm birth occurs among 9.6% of births worldwide and is the leading cause of long-term neurodevelopmental disabilities among children and also responsible for 28% of neonatal deaths. No single etiological factor is responsible for preterm birth, but various risk factors have been identified. Prior studies have reported that compromised maternal mental health occurring during pregnancy may lead to various adverse obstetric outcomes. OBJECTIVE: To determine whether antenatal depression is significantly associated with preterm delivery in a low resource hospital sample from suburbs of Nairobi. METHODS: 292 women attending the antenatal clinic at Pumwani Maternity Hospital in Nairobi meeting the study criteria were recruited. The Edinburgh Postnatal Depression Scale was administered to screen for depression. A clinical cutoff score of 10 and above was regarded as possible depression. Thereafter, a clinical interview together with the Patient Health Questionnaire-9 was administered to evaluate the participants on DSM-V criteria for major depressive disorder. Only 255 of the women were successfully followed-up to delivery with an attrition rate of 12.7%. Records of gestation at delivery and birth weight were collected at second contact. DATA ANALYSIS: Preterm birth was associated with various demographic, psychosocial and medical variables. Relative risks were estimated via log binomial regression analysis to determine whether depression was a risk factor for preterm birth. RESULTS: Of the 255 participants, 98(38.4%) found to have depressive symptoms and 27(10.7%) delivered preterm. The risk of delivering preterm was 3.8 times higher among those with depressive symptoms. CONCLUSION: There is a positive association between antenatal depression and preterm delivery. This highlights the importance of screening for mental health challenges in the antenatal period as a means to reduce adverse obstetric outcomes.

Comparing Mental Health of US Children of Immigrants and Non-Immigrants in 4 Racial/Ethnic Groups.

BACKGROUND: To compare the mental health status of children of immigrant (COI) and non-immigrant (NI) parents and to determine whether differences in mental health status between COI and NI vary across 4 racial/ethnic groups. METHODS: We conducted universal mental health screening of 2374 sixth graders in an urban public school district. To screen, we administered well-validated adolescent depression and disruptive behavior problem questionnaires. We evaluated associations between child mental health, parent immigration status, and race/ethnicity using binomial regression. RESULTS: Among Asian American/Pacific Islanders and Latinos, COI had significantly higher depression and disruptive behavior scores compared to NI. For Blacks/African Americans, children of NI parents had significantly higher disruptive behavior scores compared to COI. For European Americans, scores of COI and NI did not differ and were relatively low. CONCLUSION: Our study suggests that how the emotional health of COI is faring relative to children of NI depends on the child's race/ethnicity.

Prospective Effects of Parenting on Substance Use and Problems Across Asian/Pacific Islander and European American Youth: Tests of Moderated Mediation.

OBJECTIVE: Parental warmth and knowledge are protective factors against substance use, whereas parental psychological control is a risk factor. However, the interpretation of parenting and its effects on developmental outcomes may vary cross-culturally. This study examined direct and indirect effects of three parenting dimensions on substance use across Asian/Pacific Islander (API) and European Americans. METHOD: A community sample of 97 API and 255 European Americans were followed from Grades 6 to 12. Participants reported on parenting in Grade 7, academic achievement and externalizing behaviors in Grades 7 and 8, and substance use behaviors in Grades 7, 9, and 12. RESULTS: Direct effects of parenting were not moderated by race. Overall, mother psychological control was a risk factor for substance use problems in Grade 9, whereas father knowledge was protective against alcohol use in Grade 9, substance use problems in Grades 9 and 12, and alcohol dependence in Grade 12. Moderated mediation analyses indicated significant mediational links among European Americans only: Mother knowledge predicted fewer externalizing problems in Grade 8, which in turn predicted fewer substance use problems in Grades 9 and 12. Father warmth predicted better academic achievement in Grade 8, which in turn predicted fewer substance use problems in Grades 9 and 12, as well as alcohol and marijuana dependence in Grade 12. CONCLUSIONS: Better academic achievement and fewer externalizing behaviors explain how positive parenting reduces substance use risk among European Americans. Promoting father knowledge of adolescents' whereabouts can reduce substance use risk among both European and API Americans.

Examination of cumulative effects of early adolescent depression on cannabis and alcohol use disorder in late adolescence in a community-based cohort.

BACKGROUND AND AIMS: Although they often co-occur, the longitudinal relationship between depression and substance use disorders during adolescence remains unclear. This study estimated the effects of cumulative depression during early adolescence (ages 13-15 years) on the likelihood of cannabis use disorder (CUD) and alcohol use disorder (AUD) at age 18. DESIGN: Prospective cohort study of youth assessed at least annually between 6th and 9th grades (~ age 12-15) and again at age 18. Marginal structural models based on a counterfactual framework that accounted for both potential fixed and time-varying confounders were used to estimate cumulative effects of depressive symptoms over early adolescence. SETTING: The sample originated from four public middle schools in Seattle, Washington, USA. PARTICIPANTS: The sample consisted of 521 youth (48.4% female; 44.5% were non-Hispanic White). MEASUREMENTS: Structured in-person interviews with youth and their parents were conducted to assess diagnostic symptom counts of depression during early adolescence; diagnoses of CUD and AUD at age 18 was based the Voice-Diagnostic Interview Schedule for Children. Cumulative depression was defined as the sum of depression symptom counts from grades 7-9. FINDINGS: The past-year prevalence of cannabis and alcohol use disorder at the age 18 study wave was 20.9 and 19.8%, respectively. A 1 standard deviation increase in cumulative depression during early adolescence was associated with a 50% higher likelihood of CUD [prevalence ratio (PR) = 1.50; 95% confidence interval (CI) = 1.07, 2.10]. Although similar in direction, there was no statistically significant association between depression and AUD (PR = 1.41; 95% CI = 0.94, 2.11). Further, there were no differences in associations according to gender. CONCLUSIONS: Youth with more chronic or severe forms of depression during early adolescence may be at elevated risk for developing cannabis use disorder compared with otherwise similar youth who experience fewer depressive symptoms during early adolescence.

The Children's Attention-Deficit Hyperactivity Disorder Telemental Health Treatment Study: Caregiver Outcomes.

The Children's Attention-deficit Hyperactivity Disorder (ADHD) Telemental Health Treatment Study (CATTS) tested the hypotheses that children and caregivers who received guideline-based treatment delivered through a hybrid telehealth service delivery model would experience greater improvements in outcomes than children and caregivers receiving treatment via a comparison delivery model. Here, we present caregiver outcomes. 88 primary care providers (PCPs) in seven geographically underserved communities referred 223 children (ages 5.5 - 12.9 years) to the randomized controlled trial. Over 22 weeks, children randomized to the CATTS service delivery model received six sessions of telepsychiatry and six sessions of caregiver behavior management training provided in person by community therapists who were trained and supervised remotely. Children randomized to the comparison Augmented Primary Care (APC) service model received management in primary care augmented by a single telepsychiatry consultation. Caregiver outcomes included changes in distress, as measured by the Patient Health Questionnaire (PHQ-9), Parenting Stress Index (PSI), Caregiver Strain Questionnaire (CSQ) and Family Empowerment Scale (FES). Caregivers completed five assessments. Multilevel mixed effects regression modeling tested for differences between the two service delivery models in caregiver outcomes from baseline to 25 weeks. Compared to caregivers of children in the APC model, caregivers of children in the CATTS service model showed statistically significantly greater improvements on the PHQ-9 (ß = -1.41, 95 % CI = [-2.74, -0.08], p < .05), PSI (ß = -4.59, 95 % CI = [-7.87, - 1.31], p < .001), CSQ (ß = -5.41, 95 % CI = [- 8.58, -2.24], p < .001) and FES (ß = 6.69, 95 % CI = [2.32, 11.06], p < .01). Improvement in child ADHD symptoms mediated improved caregiver scores on the PSI and CSQ. Improvement in child ODD behaviors mediated caregiver CSQ scores. The CATTS trial supports the effectiveness of a hybrid telehealth service delivery model for reducing distress in caregivers of children with ADHD and suggests a mechanism through which the service model affected caregiver distress.