Maternal and adolescent depressive symptoms and family conflict: An autoregressive cross-lagged examination of competing models in multi-stressed mothers and adolescents.

Maternal and adolescent depression are challenges that often co-occur. Many studies have drawn bivariate associations between maternal depressive symptoms, adolescent depressive symptoms, and family conflict, but few have examined reciprocal effects. Even among extant studies, there is a lack of clarity related to directionality of influence. Three competing theoretical models may explain the relationship between maternal depressive symptoms, adolescent depressive symptoms, and family conflict, and these processes may differ by adolescents' sex. Using three time points of data from 187 diverse mother-adolescent dyads, we fit a taxonomy of autoregressive cross-lagged structural equation models to simultaneously evaluate the competing theoretical models and also examine differences by sex using multiple-group analyses. Results indicate a symptom-driven model whereby adolescent depressive symptoms predicted increases in family conflict. Sex differences were also found. For males, but not females, greater adolescent depressive symptoms predicted subsequent increases in maternal depressive symptoms, which then predicted lower family conflict-possibly indicating maternal disengagement/withdrawal. Our findings suggest addressing adolescent depressive symptoms in order to prevent family conflict and that distinctive targets for the prevention/intervention of family conflict should account for differences by adolescents' sex.

Acquisition of Information About Innovative Practices in Outpatient Mental Health Clinics.

This study uses qualitative interviews with leaders of 34 mental health clinics in the context of a statewide rollout of clinical and business innovations to explore how clinics first learn about innovations and which external sources of information they access. Clinic leaders reported accessing information about innovations mainly from government agencies, professional associations, peer organizations, and research literature. Leaders mentioned an average of two external sources of information. There was evidence of variation in how leaders accessed information and how information about innovations was communicated within clinics. Findings have implications for improving dissemination of information about innovations in mental health systems.

Maternal Depressive Symptoms, Adolescent Daughters' Substance Use, and Father Residence in Minority Families.

Background: Maternal depression has been linked to substance use in adolescents, but the mechanisms of the relationship between maternal depression and adolescent substance use are less clear. Specifically, previous literature has overlooked the role of fathers as a potential protective or exacerbating factor in buffering this relationship. Objectives: The goal of this study was to investigate the association between maternal depressive symptoms and adolescent substance use, exploring father's residential status as a moderator for adolescents living with a mother with depressive symptoms. Method: Paper-and-pencil surveys were administered to a sample of 176 mothers and their adolescent daughters aged 14-18, predominantly identifying as African American/Black. Participants included a subset of mothers with HIV. Results: The results revealed that maternal depressive symptoms were not directly associated with adolescent substance use. However, father's residential status was found to be a significant moderator in the relationship between maternal depressive symptoms and adolescent substance use. Specifically, when fathers were involved in the daughter's life (residential or non-resident), substance use was higher in adolescents of mothers with high depressive symptoms than in those of mothers with low depressive symptoms. Conclusion: The results suggest that varied family dynamics are critical to understanding engagement in substance use among adolescent girls, including the influence of both mothers and fathers.

Research-Supported Intervention and Discretion Among Frontline Workers Implementing Home Visitation Services.

OBJECTIVE: We examine how frontline workers and supervisors delivering a research supported intervention (RSI) to reduce child neglect negotiated system-related challenges, the pragmatics of RSI implementation, and their professional identities and relationships with clients. METHODS: We conducted semi-structured interviews, small group discussions, and focus groups with frontline workers and supervisors in one large county over two time periods. We used iterative coding to analyze qualitative data. RESULTS: Frontline workers navigated several aspects of RSI implementation and sustainment: (1) contract requirements and information dissemination, (2) fidelity, (3) competing demands and crises, (4) structure versus creativity, and (5) relationships with clients. CONCLUSIONS: Workers dynamically negotiated multiple system- and provider-level (or outer- and inner-contextual) demands influencing RSI provision for clients with complex service needs. Results affirm the need to attend to the unintended consequences of implementing new contract, reimbursement, and other system organizational processes and to address the "committed work" supporting RSI delivery.

Sexual intercourse among adolescent daughters of mothers with depressive symptoms from minority families.

This study investigated the association between maternal depressive symptoms and adolescent engagement in sexual intercourse in a non-clinical sample of mothers and their adolescent daughters from minority families. The current study explores ways in which maternal depression, family factors, and adolescent sex interact. Data were from a cross-sectional study of 176 mother-daughter dyads, including a subset of mothers with HIV. Logistic regression analyses revealed that among mothers who were not current marijuana users, more maternal depressive symptoms was associated with daughters' engagement in sexual intercourse. Neither parent-child conflict nor parental involvement significantly mediated the relationship between maternal depressive symptoms and adolescent sex. This study provides the first empirical evidence that non-clinical depressive symptoms in mothers are associated with adolescent engagement in sexual intercourse.

Leadership, Organizational Climate, and Perceived Burden of Evidence-Based Practice in Mental Health Services.

The use of evidence-based practices (EBPs) is associated with favorable client outcomes, yet perceived burden of using EBPs may affect the adoption and implementation of such practices. Multilevel path analysis was used to examine the associations of transformational leadership with organizational climate, and their associations with perceived burden of using EBPs. Results indicated significant relationships between transformational leadership and empowering and demoralizing climates, and between demoralizing climate and perceived burden of EBPs. We found significant indirect associations of leadership and perceived burden through organizational climate. Findings suggest that further research is needed to examine the extent to which improving leadership and organizational climate may reduce perceived burden and use of EBPs with the ultimate goal of enhancing quality of care.

Collaboration, negotiation, and coalescence for interagency-collaborative teams to scale-up evidence-based practice.

Implementation and scale-up of evidence-based practices (EBPs) is often portrayed as involving multiple stakeholders collaborating harmoniously in the service of a shared vision. In practice, however, collaboration is a more complex process that may involve shared and competing interests and agendas, and negotiation. The present study examined the scale-up of an EBP across an entire service system using the Interagency Collaborative Team approach. Participants were key stakeholders in a large-scale county-wide implementation of an EBP to reduce child neglect, SafeCare. Semistructured interviews and/or focus groups were conducted with 54 individuals representing diverse constituents in the service system, followed by an iterative approach to coding and analysis of transcripts. The study was conceptualized using the Exploration, Preparation, Implementation, and Sustainment framework. Although community stakeholders eventually coalesced around implementation of SafeCare, several challenges affected the implementation process. These challenges included differing organizational cultures, strategies, and approaches to collaboration; competing priorities across levels of leadership; power struggles; and role ambiguity. Each of the factors identified influenced how stakeholders approached the EBP implementation process. System-wide scale-up of EBPs involves multiple stakeholders operating in a nexus of differing agendas, priorities, leadership styles, and negotiation strategies. The term collaboration may oversimplify the multifaceted nature of the scale-up process. Implementation efforts should openly acknowledge and consider this nexus when individual stakeholders and organizations enter into EBP implementation through collaborative processes.

Parentification, substance use, and sex among adolescent daughters from ethnic minority families: the moderating role of monitoring.

Guided by structural family systems theory, this study explored the relationship between parentification and adolescent daughters' sexual risk engagement and substance use. We also explored how adolescent reports of parental monitoring moderated the relationship between parentification and adolescent risk. Data were from a cross-sectional, cross-generational study of 176 mother-daughter dyads from low-income, inner-city, ethnic minority families. In this sample, which included a subset of mothers with HIV, parental physical symptoms were associated with slightly higher levels of parentification. Parentification was associated with adolescent daughters' intention to have sex (but not substance use) in a direction opposite to prediction. Higher parentification was associated with lower intention to have sex. Parental monitoring did not moderate relationships between parentification and adolescent risk. These findings highlight that despite the negative influence hypothesized in structural family systems theory, parentification was not associated with risk engagement of high-risk adolescent daughters in ethnic minority families with low income.

Exploration and Adoption of Evidence-based Practice by US Child Welfare Agencies.

OBJECTIVE: To examine the extent to which child welfare agencies adopt new practices and to determine the barriers to and facilitators of adoption of new practices. METHODS: Data came from telephone interviews with the directors of the 92 public child welfare agencies that constituted the probability sample for the first National Survey of Child and Adolescent Well-being (NSCAWI). In a semi-structured 40 minute interview administered by a trained Research Associate, agency directors were asked about agency demographics, knowledge of evidence-based practices, use of technical assistance and actual use of evidence-based practices.. Of the 92 agencies, 83 or 90% agreed to be interviewed. RESULTS: Agencies reported that the majority of staff had a BA degree (53.45%) and that they either paid for (52.6%) or provided (80.7%) continuing education. Although agencies routinely collect standardized child outcomes (90%) they much less frequently collect measures of child functioning (30.9%). Almost all agencies (94%) had started a new program or practice but only 24.8% were evidence-based and strategies used to explore new programs or practices usually involved local or state contracts. Factors that were associated with program success included internal support for the innovation (27.3%), and an existing evidence base (23.5%). CONCLUSIONS: Directors of child welfare agencies frequently institute new programs or practices but they are not often evidence-based. Because virtually all agencies provide some continuing education adding discussions of evidence-based programs/practices may spur adaption. Reliance on local and state colleagues to explore new programs and practices suggests that developing well informed social networks may be a way to increase the spread of evidence0based practices.

Caregiver reports of serious injuries in children who remain at home after a child protective services investigation.

The study objectives were to examine serious injuries requiring medical attention among children who remain at home after a child welfare/child protective services (CPS) maltreatment investigation in the US and to determine whether child/caregiver characteristics and ongoing CPS involvement are related to injuries requiring medical attention. Using the National Survey of Child and Adolescent Well-being, we analyzed data on the subsample of children who remained at home (N = 3,440). A multivariate logistic regression model included child characteristics, chronic illness and disability in the child, level of CPS involvement, subsequent foster care placement, caregiver characteristics, and caregiver/family psychological variables. Injuries requiring medical attention were identified in 10.6% of the in-home population over a 15-month period, with no differences in rates by age. Children with a chronic medical condition (OR = 2.07; 95% CI, 1.20-3.58) and children with depressed caregivers (OR = 2.28; 95% CI, 1.45-3.58) were more likely to have an injury that required medical care. Older caregivers (>54 years) were less likely (OR = 0.15; 95% CI, 0.03-0.69) to have a child with an injury requiring care. Injuries were not related to further involvement with CPS after the initial maltreatment investigation. Children with chronic medical conditions who remained in their biological homes or whose caregivers were depressed were likely to experience an injury requiring medical attention. Older caregivers were less likely to report a child injury. Extending existing health policies for foster children to children who remain at home following referral to CPS may encourage more comprehensive injury prevention for this population.

Evaluating child welfare policies with decision-analytic simulation models.

The objective was to demonstrate decision-analytic modeling in support of Child Welfare policymakers considering implementing evidence-based interventions. Outcomes included permanency (e.g., adoptions) and stability (e.g., foster placement changes). Analyses of a randomized trial of KEEP-a foster parenting intervention-and NSCAW-1 estimated placement change rates and KEEP's effects. A microsimulation model generalized these findings to other Child Welfare systems. The model projected that KEEP could increase permanency and stability, identifying strategies targeting higher-risk children and geographical regions that achieve benefits efficiently. Decision-analytic models enable planners to gauge the value of potential implementations.

Vulnerable, Resilient, or Both? A Qualitative Study of Adaptation Resources and Behaviors to Heat Waves and Health Outcomes of Low-Income Residents of Urban Heat Islands.

Little is known of how low-income residents of urban heat islands engage their knowledge, attitudes, behaviors, and resources to mitigate the health impacts of heat waves. In this qualitative study, we conducted semi-structured interviews with 40 adults in two such neighborhoods in Los Angeles California to explore their adaptation resources and behaviors, the impacts of heat waves on physical and mental health, and threat assessments of future heat waves. Eighty percent of participants received advanced warning of heat waves from television news and social media. The most common resource was air conditioning (AC) units or fans. However, one-third of participants lacked AC, and many of those with AC engaged in limited use due primarily to the high cost of electricity. Adaptation behaviors include staying hydrated, remaining indoors or going to cooler locations, reducing energy usage, and consuming certain foods and drinks. Most of the participants reported some physical or mental health problem or symptom during heat waves, suggesting vulnerability to heat waves. Almost all participants asserted that heat waves were likely to increase in frequency and intensity with adverse health effects for vulnerable populations. Despite limited resources, low-income residents of urban heat islands utilize a wide range of behaviors to minimize the severity of health impacts, suggesting they are both vulnerable and resilient to heat waves.

Racial and Ethnic Differences in Depressive Profiles of Child Welfare-Involved Families Receiving Home Visitation Services.

OBJECTIVE: Profiles of depressive symptoms were identified among Hispanic, Black, and White parents involved in the child welfare service system, including changes in symptoms over time. METHODS: Participants (N=2,109) were parents receiving SafeCare, a home visitation intervention provided in a large, diverse child welfare system. Depressive symptoms were assessed with the Centers for Epidemiological Studies Depression Scale at baseline and at approximately every sixth home visit, up to a total of four times. Univariate tests examined the relationship between baseline symptoms, race-ethnicity, and service participation. Latent class growth analyses identified trajectories of depressive symptoms during participation in child welfare services. RESULTS: Participation in services was affected by depressive symptoms. Forty percent of parents did not remain long enough in the program to complete a second CES-D assessment, and those who reported more symptoms at baseline were significantly less likely to do so. Among parents who engaged in services, distinct profiles of depressive symptoms emerged that differed by race-ethnicity. For non-Hispanic Black parents, no changes in depressive symptoms over time were noted, regardless of level of severity at baseline. Parents with the highest levels of symptoms did not improve over time. CONCLUSIONS: Despite receipt of supportive and recovery-oriented services specifically focused on empowering child welfare-involved parents, many experienced elevated depressive symptoms. Integration of child welfare and community mental health systems may improve both service engagement and mental health among child welfare-involved families.

Child and family therapy process: concordance of therapist and observational perspectives.

The objective of this study is to examine the characteristics of outpatient mental health services delivered in community-based outpatient clinics, comparing information obtained from two different sources, therapists serving children and families, and observational coders viewing tapes of the same treatment sessions. Videotaped therapy sessions were rated by therapists and independent coders regarding goals and strategies pursued during each session. Sixty-three sessions were taped of outpatient care provided to 18 children and their caregivers by 11 therapists. Children were 4-13 years old and families were receiving services at least in part due to reported child behavior problems, confirmed by ratings from the Child Behavior Checklist and Conners Parent Rating Scale-Revised. Analyses assessed the frequency, type, and intensity of goals and strategies pursued in therapy sessions from both therapist and observational coders' perspectives. Reliability of observer ratings and correspondence between therapist and observer reports were also examined. The reliability of observational coding of goals and strategies was moderate to good, with 76% of 39 codes having ICCs of .5 or greater. Therapists reported pursuing 2.5 times more goals and strategies per session, on average, than identified by observational coders. Correspondence between therapists and coders about the occurrence of specific goals and strategies in treatment sessions was low, with 20.5% of codes having a Kappa of .4 or higher. Substantial differences exist in what therapists and independent coders report as occurring in outpatient treatment sessions. Both perspectives suggest major differences between the content of services provided in community-based outpatient clinics and the structure of evidence-based programs, which emphasize intense pursuit of a small number of goals and strategies in each treatment session. Implications of the findings for quality improvement efforts in community-based mental health care settings are discussed.

Methodological challenges of characterizing usual care psychotherapeutic practice.

There is minimal existing research providing detailed, reliable data characterizing usual community-based psychotherapy practice, and, thus, limited established methods for such research. This article identifies methodological challenges of usual care descriptive research, including, (a) general design considerations, (b) measurement, (c) data analytic, and (d) ethical challenges. Case examples drawn from studies reported in this special issue are used to illustrate the implications, strengths, and weaknesses of different methodological decisions. Central themes include achieving an acceptable balance of scientific rigor, feasibility, and generalizable practice relevance, as well as working collaboratively with practice partners to select and implement study methods.

Incorporators, Early Investors, and Learners: a longitudinal study of organizational adaptation during EBP implementation and sustainment.

BACKGROUND: The majority of literature on evidence-based practice (EBP) adaptation focuses on changes to clinical practices without explicitly addressing how organizations must adapt to accommodate a new EBP. This study explores the process of organizational-rather than EBP-adaptation during implementation and sustainment. To the authors' knowledge, there are no previous implementation studies that focus on organizational adaptation in this way. METHODS: This analysis utilizes a case study approach to examine longitudinal qualitative data from 17 community-based organizations (CBOs) in one state and seven county-based child welfare systems. The CBOs had sustained a child-neglect intervention EBP (SafeCare®) for 2 to 10 years. The unit of analysis was the organization, and each CBO represented a case. Organizational-level profiles were created to describe the organizational adaptation process. RESULTS: Three organizational-level adaptation profiles were identified as follows: incorporators (n = 7), early investors (n = 6), and learners (n = 4). Incorporators adapted by integrating SafeCare into existing operations to meet contractual or EBP fidelity requirements. Early Investors made substantial organizational adaptations during the early implementation period, then operated relatively consistently as the EBP became embedded in the organization and service system. Learners were characterized by steady and continuous attention to new ways that the organization could adapt to support the EBP. CONCLUSION: The profiles demonstrated that there can be multiple effective paths to EBP sustainment. Organizational adaptation was calibrated to fit a CBO's operations (e.g., size of the program) and immediate environmental constraints (e.g., funding levels). Additionally, organizations fulfilled different functional roles in the network of entities involved in EBP implementation. Knowing organizational roles and adaptation profiles can guide implementation planning and help to structure contract designs that bridge the outer (system) and inner (organizational) contexts. Adaptation profiles can also inform the intensity of the implementation strategy tailoring process and the way that strategies are marketed to organizations.

Common elements of evidence-based systemic treatments for adolescents with disruptive behaviour problems.

A growing number of evidence-based systemic treatments for adolescents with disruptive behaviour problems exist. However, it is not clear to what extent these treatments have unique and common elements. Identification of common elements in the different treatments would be beneficial for the further understanding and development of family-based interventions, training of therapists, and research. Therefore, the aim of this Review was to identify common elements of evidence-based systemic treatments for adolescents with disruptive behaviour. Several common elements of systemic treatments were identified, showing a strong overlap between the interventions. Investigation of these common mechanisms and techniques could potentially build strong universal systemic treatment and training modules for a broad spectrum of adolescents with problem behaviours.

Child abuse and neglect re-report rates for young children with developmental delays.

The study objective was to examine the likelihood and magnitude of child abuse and neglect (CAN) re-reports for young children (0-71 months) with delays in cognitive, language, and adaptive development, compared to typically developing children. The National Survey of Child and Adolescent Well-Being (NSCAW II), a nationally representative and longitudinal survey, was used to examine CAN re-reports at two follow-up waves, 18- and 36-months post baseline assessments. Logistic regression models were employed to determine the correlation between number of developmental delays and a CAN re-report at waves 2 and 3. Results indicate that children with three or more domains of delays had odds 4.73 times higher than children without developmental delays of re-report to CPS at wave 2 but not at wave 3. In this study, children with multiple developmental delays have elevated rates of CAN re-reports when compared to typically developing children. Allocation of child welfare resources should include strategies for preventing maltreatment risk among children with developmental delays.

Child sociodemographic characteristics and common psychiatric diagnoses in medicaid encounter data: are they valid?

This study describes the rate that Medicaid encounter data on gender, race/ethnicity, and diagnosis matched information in the medical record, among a statewide sample of Medicaid children who received ongoing care for attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), and major depression (MD) in outpatient specialty mental health clinics in 1998-1999. The match rate for gender was 99%; and for race/ethnicity it was 71.8%, 90.5%, and 89.7% for Caucasian, African American, and Hispanic children, respectively. Misidentified Caucasian children were more likely to be recorded as African American or Hispanic than misidentified minority children to be recorded as Caucasian. Diagnosis match rates were high (ADHD: 98%, CD: 89%, MD: 89%). If the California Department of Mental Health relied solely on Medicaid encounter data, misclassification of African American or Hispanic children as Caucasian could produce an underestimate of their service use.

Effects of Parent Immigration Status on Mental Health Service Use Among Latino Children Referred to Child Welfare.

OBJECTIVE: Latino families may be at risk of experiencing stressors resulting from the immigration process, such as those related to documentation status and acculturation, that may increase their need for mental health services. However, little research exists on the mental health needs and service use of Latino children. This study examined how parental nativity and legal status influence mental health needs and service utilization among children in Latino families investigated by child welfare. METHODS: Data from the second National Survey of Child and Adolescent Well-Being, a nationally representative, prospective study of families investigated by child welfare agencies for maltreatment, were used to examine mental health need and service use in a subset of Latino children who remained in the home following a maltreatment investigation (N=390). RESULTS: Although children of immigrants did not differ from children of U.S.-born parents in levels of clinical need, they had lower rates of mental health service receipt. After the analyses accounted for other relevant variables, the odds of receiving services were significantly lower (odds ratio=.09) for children whose parents were undocumented compared with children whose parents were U.S. citizens. CONCLUSIONS: This study contributes to growing discourse on Latino family needs within the child welfare system. Analyses support earlier research regarding the effects of parent nativity on mental health service use and advance the literature by identifying parent legal status as a unique barrier to child service receipt.