Technology-Assisted Teachers' Training to Promote Socioemotional Well-Being of Children in Public Schools in Rural Pakistan.

BACKGROUND: The World Health Organization's (WHO) Eastern Mediterranean Regional Office (EMRO) developed a school mental health program (SMHP) to help reduce the burden of youth mental health problems. Designed in collaboration with international consultants, the SMHP draws on evidence-based interventions to train personnel to identify students in need, respond therapeutically, and engage families in seeking care. METHODS: Teams from Pakistan, Egypt, Iran, and Jordan collaborated with the WHO EMRO and British and U.S. universities to form the School Health Implementation Network: Eastern Mediterranean Region (SHINE), a National Institute of Mental Health-funded global mental health hub. SHINE partners used a "theory of change" process to adapt the SMHP to be more readily adopted by school personnel and replicated with fidelity. The adapted SMHP more directly addresses teachers' priorities and uses technology to facilitate training. RESULTS: A cluster-randomized implementation effectiveness trial enrolling 960 children ages 8-13 in 80 Pakistani schools will test the adapted SMHP against the original. Children who screen positive on first the teacher and subsequently the parent Strengths and Difficulties Questionnaires (SDQs) will be enrolled and tracked for 9 months. The primary trial outcome is reduction in parent-rated SDQ total difficulties scores. Secondary outcomes include children's well-being, academic performance, absenteeism, and perceived stigma; parent-teacher interaction; teachers' self-efficacy and subjective well-being; and school environment. Implementation outcomes include change in teachers' behavior and sense of program acceptability, cultural appropriateness, feasibility, penetration, and sustainability. NEXT STEPS: The trial began in October 2019, and the expected completion date is March 2021. Outcomes will inform dissemination of the SMHP in Pakistan and elsewhere.

Global Child Mental Health Research: Time for the Children.

Although 9 of 10 of the world's children live in low- and middle-income countries (LMICs), and children constitute nearly half of the populations of these countries, far too little research has focused on child mental health in LMICs.1 The expansion of research in global health and global mental health over the past several decades has not yet been matched by new research in child and adolescent mental health in LMICs.2 It is time for that to change. New research should include a focus on social drivers and the mechanisms by which they contribute to mental illnesses.

RISING SUN: Prioritized Outcomes for Suicide Prevention in the Arctic.

The Arctic Council, a collaborative forum among governments and Arctic communities, has highlighted the problem of suicide and potential solutions. The mental health initiative during the United States chairmanship, Reducing the Incidence of Suicide in Indigenous Groups: Strengths United Through Networks (RISING SUN), used a Delphi methodology complemented by face-to-face stakeholder discussions to identify outcomes to evaluate suicide prevention interventions. RISING SUN underscored that multilevel suicide prevention initiatives require mobilizing resources and enacting policies that promote the capacity for wellness, for example, by reducing adverse childhood experiences, increasing social equity, and mitigating the effects of colonization and poverty.

Strengthening mental health and research training in Sub-Saharan Africa (SMART Africa): Uganda study protocol.

BACKGROUND: Children in Sub-Saharan Africa (SSA) comprise half of the total regional population, yet existing mental health services are severely under-equipped to meet their needs. Although effective interventions for the treatment of disruptive behavioral disorders (DBDs) in youth have been tested in high-poverty and high-stress communities in developed countries, and are relevant for widespread dissemination in low- and middle-income countries (LMICs), most of these evidence-based practices (EBPs) have not been utilized in SSA, a region heavily impacted by poverty, diseases including HIV/AIDS, and violence. Thus, this paper presents a protocol for a scale-up longitudinal experimental study that uses a mixed-methods, hybrid type II, effectiveness implementation design to test the effectiveness of an EBP, called Multiple Family Group (MFG) aimed at improving child behavioral challenges in Uganda while concurrently examining the multi-level factors that influence uptake, implementation, sustainment, and youth outcomes. METHODS: The MFG intervention will be implemented and tested via a longitudinal experimental study conducted across 30 public primary schools located in both semi-urban and rural communities. The schools will be randomly assigned to three study conditions (n = 10 per study condition): (1) MFG delivered by trained family peers; (2) MFG delivered by community health workers; or; (3) comparison: usual care comprising mental health care support materials, bolstered with school support materials. A total of 3000 children (ages 8 to 13 years; grades 2 to 7) and their caregivers (N = 3000 dyads); 60 parent peers, and 60 community health workers will be recruited. Each study condition will comprise of 1000 child-caregiver dyads. Data will be collected at baseline, 8 and 16 weeks, and 6-month follow-up. DISCUSSION: This project is the first to test the effectiveness of the MFG intervention while concurrently examining multi-level factors that influence overall implementation of a family-based intervention provided in schools and aimed at reaching the large child population with mental health service needs in Uganda. Moreover, the study draws upon an EBP that has already been tested for delivery by parent peers and community facilitators, and hence will take advantage of the advancing science behind task-shifting. If successful, the project has great potential to address global child mental health needs. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03081195 . Registered on 16 March 2017.

Global services and support for children with developmental delays and disabilities: Bridging research and policy gaps.

Pamela Collins and colleagues explain the research and policy approaches needed globally to ensure children with developmental delays and disabilities are fully included in health and education services.

Cultural neuroscience and global mental health: addressing grand challenges.

Mental, neurological and substance-use (MNS) disorders comprise approximately 13% of the global burden of disease. The Grand Challenges in Global Mental Health Initiative has recently identified research priorities for the next decade to address prevention and treatment of MNS disorders. One main research priority is to identify the root causes, risks and protective factors associated with global mental health. Recent advances in cultural neuroscience have identified theoretical, methodological, and empirical methods of identifying biomarkers associated with mental health disorders across nations. Here we review empirical research in cultural neuroscience that address meeting the grand challenges in global mental health.

Age of Parental Concern, Diagnosis, and Service Initiation Among Children With Autism Spectrum Disorder.

Children with autism spectrum disorder (ASD) require substantial support to address the core symptoms of ASD and co-occurring behavioral/developmental conditions. This study explores the early diagnostic experiences of school-aged children with ASD using survey data from a large probability-based national sample. Multivariate linear regressions were used to examine age when parent reported developmental concern to doctor, received ASD diagnosis, and first obtained services. Children whose parents had concerns about their child's verbal communication reported earlier ages for all outcomes when compared to children of parents who did not have verbal communication concerns. Children whose parents had concerns about their child's nonverbal communication or unusual gestures/movements received an earlier diagnosis than children whose parents did not have these specific concerns.

Reported Wandering Behavior among Children with Autism Spectrum Disorder and/or Intellectual Disability.

OBJECTIVE: To characterize wandering, or elopement, among children with autism spectrum disorder (ASD) and intellectual disability. STUDY DESIGN: Questions on wandering in the previous year were asked of parents of children with ASD with and without intellectual disability and children with intellectual disability without ASD as part of the 2011 Survey of Pathways to Diagnosis and Services. The Pathways study sample was drawn from the much larger National Survey of Children with Special Health Care Needs conducted in 2009-2010. RESULTS: For children with special healthcare needs diagnosed with either ASD, intellectual disability, or both, wandering or becoming lost during the previous year was reported for more than 1 in 4 children. Wandering was highest among children with ASD with intellectual disability (37.7%) followed by children with ASD without intellectual disability (32.7%), and then children with intellectual disability without ASD (23.7%), though the differences between these groups were not statistically significant. CONCLUSIONS: This study affirms that wandering among children with ASD, regardless of intellectual disability status, is relatively common. However, wandering or becoming lost in the past year was also reported for many children with intellectual disability, indicating the need to broaden our understanding of this safety issue to other developmental disabilities.

Diagnosis lost: Differences between children who had and who currently have an autism spectrum disorder diagnosis.

Autism spectrum disorder diagnoses sometimes change due to misdiagnosis, maturation, or treatment. This study uses a probability-based national survey-the Survey of Pathways to Diagnosis and Services-to compare currently diagnosed (n = 1420) and previously diagnosed (n = 187) children aged 6-17 years based on retrospective parental reports of early concerns about their children's development, responses to those concerns by doctors and other healthcare providers, the type of provider who made the first autism spectrum disorder diagnosis, and the autism spectrum disorder subtype diagnoses received (if any). Propensity score matching was used to control for differences between the groups on children's current level of functioning and other current characteristics that may have been related to diagnosis loss. Approximately 13% of the children ever diagnosed with autism spectrum disorder were estimated to have lost the diagnosis, and parents of 74% of them believed it was changed due to new information. Previously diagnosed children were less likely to have parents with early concerns about verbal skills, nonverbal communication, learning, and unusual gestures or movements. They were also less likely to have been referred to and diagnosed by a specialist. Previously diagnosed children were less likely to have ever received a diagnosis of Asperger's disorder or autistic disorder.

Global research challenges and opportunities for mental health and substance-use disorders.

The research agenda for global mental health and substance-use disorders has been largely driven by the exigencies of high health burdens and associated unmet needs in low- and middle-income countries. Implementation research focused on context-driven adaptation and innovation in service delivery has begun to yield promising results that are improving the quality of, and access to, care in low-resource settings. Importantly, these efforts have also resulted in the development and augmentation of local, in-country research capacities. Given the complex interplay between mental health and substance-use disorders, medical conditions, and biological and social vulnerabilities, a revitalized research agenda must encompass both local variation and global commonalities in the impact of adversities, multi-morbidities and their consequences across the life course. We recommend priorities for research - as well as guiding principles for context-driven, intersectoral, integrative approaches - that will advance knowledge and answer the most pressing local and global mental health questions and needs, while also promoting a health equity agenda and extending the quality, reach and impact of scientific enquiry.

Estimating the prevalence of any impairing childhood mental disorder in the national health interview survey.

This study investigates whether the six-item Strengths and Difficulties Questionnaire SDQ (five symptoms and one impact item) included in the National Health Interview Survey (NHIS) can be used to construct models that accurately estimate the prevalence of any impairing mental disorder among children 4-17 years old as measured by a shortened Child/Adolescent or Preschool Age Psychiatric Assessment (CAPA or PAPA). A subsample of 217 NHIS respondents completed a follow-up CAPA or PAPA interview. Logistic regression models were developed to model presence of any child mental disorder with impairment (MDI) or with severe impairment (MDSI). Models containing only the SDQ impact item exhibited highly biased prevalence estimates. The best-performing model included information from both the five symptom SDQ items and the impact item, where absolute bias was reduced and sensitivity and concordance were increased. This study illustrates the importance of using all available information from the six-item SDQ to accurately estimate the prevalence of any impairing childhood mental disorder from the NHIS. Copyright © 2015 John Wiley & Sons, Ltd.

Service and treatment use among children diagnosed with autism spectrum disorders.

OBJECTIVE: Children diagnosed with autism spectrum disorder (ASD) require substantial support to address not only core ASD symptoms but also a range of co-occurring conditions. This study explores treatment and service use among children with ASD with and without intellectual disability (ID) and parents' perception of unmet needs from these treatments. METHODS: Data were retrieved from a probability-based national sample of 2077 children diagnosed with ASD, ID, or both (ASD and ID). Weighted multivariate logistic regressions examined differences between diagnostic groups for current medication and service utilization with a subanalysis exploring differences among those with co-occurring psychiatric conditions. Additional modeling examined parents' perception of unmet needs. RESULTS: Children diagnosed with ASD and ID were significantly more likely to be receiving current medication and services when compared with children with ID only or ASD only. Children with a co-occurring psychiatric diagnosis, from all 3 diagnostic groups, were more likely to be receiving a current medication, but not more likely to be receiving a current service when compared with children without a co-occurring psychiatric diagnosis. Children with ASD and a co-occurring psychiatric diagnosis were significantly more likely to have parents who reported unmet needs when compared with parents of children with ASD without a co-occurring psychiatric diagnosis. CONCLUSIONS: Children diagnosed with ASD and ID, especially those with a comorbid psychiatric condition, represent a vulnerable population with substantial rates of current service (98%) and medication (67%) usage, but despite these high rates, approximately 30% of parents report that their child's developmental needs are still not being met by their current treatment and services.

Data for building a national suicide prevention strategy: what we have and what we need.

Suicide is a leading cause of death in the U.S. As both the rate and number of suicides continue to climb, the country struggles with how to reverse this alarming trend. Using population-based data from publically available sources including the Web-based Injury Statistics Query and Reporting System, National Survey on Drug Use and Health, the authors identified patterns of suicide that can be used to steer a public health-based suicide prevention strategy. That most suicide deaths occur upon the first attempt, for example, suggests that a greater investment in primary prevention is needed. The fact that definable subgroups receiving care through identifiable service systems, such as individuals in specialty substance use treatment, exhibit greater concentrations of suicide risk than the general public suggests that integrating suicide prevention strategies into those service system platforms is an efficient way to deliver care to those with heightened need. The data sets that reveal these patterns have both strengths (e.g., population-level) and weaknesses (e.g., lack of longitudinal data linking changing health status, intervention encounters, suicidal behavior, and death records). Some of the data needed for crafting a comprehensive, public health-based approach for dramatically reducing suicide are currently available or may be available in the near term. Other resources will have to be built, perhaps by enhancing existing federal surveillance systems or constructing new ones. The article concludes with suggestions for immediate and longer-term actions that can strengthen public data resources in the service of reducing suicide in the U.S.

Reducing the burden of suicide in the U.S.: the aspirational research goals of the National Action Alliance for Suicide Prevention Research Prioritization Task Force.

BACKGROUND: The National Action Alliance for Suicide Prevention Research Prioritization Task Force (RPTF) has created a prioritized national research agenda with the potential to rapidly and substantially reduce the suicide burden in the U.S. if fully funded and implemented. PURPOSE: Viable, sustainable scientific research agendas addressing challenging public health issues such as suicide often need to incorporate perspectives from multiple stakeholder groups (e.g., researchers, policymakers, and other end-users of new knowledge) during an agenda-setting process. The Stakeholder Survey was a web-based survey conducted and analyzed in 2011-2012 to inform the goal-setting step in the RPTF agenda development process. The survey process, and the final list of "aspirational" research goals it produced, are presented here. METHODS: Using a modified Delphi process, diverse constituent groups generated and evaluated candidate research goals addressing pressing suicide prevention research needs. RESULTS: A total of 716 respondents representing 49 U.S. states and 18 foreign countries provided input that ultimately produced 12 overarching, research-informed aspirational goals aimed at reducing the U.S. suicide burden. Highest-rated goals addressed prevention of subsequent suicidal behavior after an initial attempt, strategies to retain patients in care, improved healthcare provider training, and generating care models that would ensure accessible treatment. CONCLUSIONS: The Stakeholder Survey yielded widely valued research targets. Findings were diverse in focus, type, and current phase of research development but tended to prioritize practical solutions over theoretical advancement. Other complex public health problems requiring input from a broad-based constituency might benefit from web-based tools that facilitate such community input.

A strategic approach for prioritizing research and action to prevent suicide.

It is time to strategically apply science and accountability to the public health problem of preventable suicide. U.S. suicide rates have remained stable for decades. More than 36,000 individuals now die by suicide each year. A public health-based approach to quickly and substantially reduce suicides requires strategic deployment of existing evidence-based interventions, rapid development of new interventions, and measures to increase accountability for results. The purpose of this Open Forum is to galvanize researchers to further develop and consolidate knowledge needed to guide these actions. As researchers overcome data limitations and methodological challenges, they enable better prioritization of high-risk subgroups for targeted suicide prevention efforts, identification of effective interventions ready for deployment, estimation of the implementation impact of effective interventions in real-world settings, and assessment of time horizons for taking implementation to scale. This new knowledge will permit decision makers to take strategic action to reduce suicide and stakeholders to hold them accountable for results.

Diagnostic history and treatment of school-aged children with autism spectrum disorder and special health care needs.

Data from the 2011 Survey of Pathways to Diagnosis and Services The median age when school-aged children with special health care needs (CSHCN) and autism spectrum disorder (ASD) were first identified as having ASD was 5 years. School-aged CSHCN identified as having ASD at a younger age (under age 5 years) were identified most often by generalists and psychologists, while those identified later (aged 5 years and over) were identified primarily by psychologists and psychiatrists. Nine out of 10 school-aged CSHCN with ASD use one or more services to meet their developmental needs. Social skills training and speech or language therapy are the most common, each used by almost three-fifths of these children. More than one-half of school-aged CSHCN with ASD use psychotropic medication.