Initial development of tools to identify child abuse and neglect in pediatric primary care.

BACKGROUND: Child abuse and neglect (CAN) is prevalent, associated with long-term adversities, and often undetected. Primary care settings offer a unique opportunity to identify CAN and facilitate referrals, when warranted. Electronic health records (EHR) contain extensive information to support healthcare decisions, yet time constraints preclude most providers from thorough EHR reviews that could indicate CAN. Strategies that summarize EHR data to identify CAN and convey this to providers has potential to mitigate CAN-related sequelae. This study used expert review/consensus and Natural Language Processing (NLP) to develop and test a lexicon to characterize children who have experienced or are at risk for CAN and compared machine learning methods to the lexicon + NLP approach to determine the algorithm's performance for identifying CAN. METHODS: Study investigators identified 90 CAN terms and invited an interdisciplinary group of child abuse experts for review and validation. We then used NLP to develop pipelines to finalize the CAN lexicon. Data for pipeline development and refinement were drawn from a randomly selected sample of EHR from patients seen at pediatric primary care clinics within a U.S. academic health center. To explore a machine learning approach for CAN identification, we used Support Vector Machine algorithms. RESULTS: The investigator-generated list of 90 CAN terms were reviewed and validated by 25 invited experts, resulting in a final pool of 133 terms. NLP utilized a randomly selected sample of 14,393 clinical notes from 153 patients to test the lexicon, and .03% of notes were identified as CAN positive. CAN identification varied by clinical note type, with few differences found by provider type (physicians versus nurses, social workers, etc.). An evaluation of the final NLP pipelines indicated 93.8% positive CAN rate for the training set and 71.4% for the test set, with decreased precision attributed primarily to false positives. For the machine learning approach, SVM pipeline performance was 92% for CAN + and 100% for non-CAN, indicating higher sensitivity than specificity. CONCLUSIONS: The NLP algorithm's development and refinement suggest that innovative tools can identify youth at risk for CAN. The next key step is to refine the NLP algorithm to eventually funnel this information to care providers to guide clinical decision making.

A Comparison of the Readiness of Youth Service Agencies to Implement a Technology-Based Toolkit to Support Treatment Delivery.

Implementation initiatives and technology-based resources aim to address barriers to Evidence-Based Practice (EBP) use by creating generalizable techniques that can be used for a variety of youth-serving agencies. However, research has not carefully examined unique differences between agency types or individual programs in readiness to use such technologies and implementation strategies. The current study explored differences between community mental health clinics and child advocacy centers on organizational cultural factors (e.g., ability to change and commitment for change) to implement a novel technology-based toolkit to support delivery of Trauma Focused Cognitive Behavioral Therapy (TF-CBT). Results indicated that TF-CBT providers from child advocacy centers reported greater commitment to change and more support to use the technology-based system than those from community mental health centers. Findings suggest that implementation initiatives should address the needs of individual agencies and service settings and adaptations should be explored to best meet the needs of these settings.

Sustainment of Trauma-Focused and Evidence-Based Practices Following Learning Collaborative Implementation.

Given the need to develop and validate effective implementation models that lead to sustainable improvements, we prospectively examined changes in attitudes, behaviors, and perceived organizational support during and after statewide Community-Based Learning Collaboratives (CBLCs) promoting trauma-focused evidence-based practices (EBPs). Participants (N = 857; i.e., 492 clinicians, 218 brokers, and 139 senior leaders) from 10 CBLCs completed surveys pre- and post-CBLC; a subsample (n = 146) completed a follow-up survey approximately two years post-CBLC. Results indicated (a) medium, sustained increases in clinician-reported use of trauma-focused EBPs, (b) medium to large, sustained increases in perceived organizational support for trauma-focused EBPs, and (c) trivial to small, sustained increases in perceived organizational support for EBPs broadly. In contrast, clinician-reported overall attitudes towards EBPs decreased to a trivial degree pre- to post-CBLC, but then increased to a small, statistically significant degree from post-CBLC to follow-up. Notably, the degree of perceived improvements in organizational support for general and trauma-focused EBPs varied by professional role. Findings suggest the CBLC implementation strategies may both increase and sustain provider practices and organizational support towards EBPs, particularly those EBPs a CBLC explicitly targets.

Systems Measures of a Trauma-Informed Approach: A Systematic Review.

Interest in trauma-informed approaches has grown substantially. These approaches are characterized by integrating understanding of trauma throughout a program, organization, or system to enhance the quality, effectiveness, and delivery of services provided to individuals and groups. However, variation in definitions of trauma-informed approaches, coupled with underdeveloped research on measurement, poses challenges for evaluating the effectiveness of models designed to support a trauma-informed approach. This systematic review of peer-reviewed and gray literature identified 49 systems-based measures that were created to assess the extent to which relational, organizational, and community/system practices were trauma-informed. Measures were included if they assessed at least one component of a trauma-informed approach, were not screening or diagnostic instruments, were standardized, were relevant to practices addressing the psychological impacts of trauma, were printed in English, and were published between 1988 and 2018. Most (77.6%) measures assessed organizational-level staff and climate characteristics. There remain several challenges to this emerging field, including inconsistently reported psychometric data, redundancy across measures, insufficient evidence of a link to stakeholder outcomes, and limited information about measurement development processes. We discuss these opportunities and challenges and their implications for future research and practice.

Enhancing the Delivery of an Empirically-Supported Trauma-Focused Treatment for Adolescents: Providers' Views of the Role of Technology and Web-Based Resources.

This mixed-methods study assessed providers' views of the use of technology in the delivery of an empirically supported mental health treatment for adolescents (Trauma-Focused Cognitive Behavioral Therapy; TF-CBT). Thematic qualitative interviews were conducted with nine experienced providers. Emerging themes served as the basis for the creation of a quantitative web-based survey, completed by 56 TF-CBT experts, to assess the perceived helpfulness of the recommendations. Technology was perceived as a useful, appealing, and familiar tool that could greatly enhance the delivery of this treatment modality with adolescents. Main recommendations included the creation of a mobile application targeting all of the treatment components and a website with developmentally appropriate resources for providers, caregivers, and teens. Technology may be a useful tool for enhancing service delivery and promoting engagement among youth receiving trauma-focused mental health treatment.

Community-Based Learning Collaboratives and Participant Reports of Interprofessional Collaboration, Barriers to, and Utilization of Child Trauma Services.

Given the high prevalence and severe consequences of child trauma, effective implementation strategies are needed to increase the availability and utilization of evidence-based child trauma services. One promising strategy, the Community-Based Learning Collaborative (CBLC), augments traditional Learning Collaborative activities with a novel set of community-focused strategies. This prospective, observational study examined pre-to post-changes in CBLC participant reports of interprofessional collaboration (IPC), barriers to, and utilization of evidence-based child trauma treatment in their communities. Participants of five CBLCs from a statewide dissemination initiative, comprising 572 child abuse professionals (296 clinicians, 168 brokers, and 108 senior leaders), were surveyed pre-and post-CBLC participation. Results suggested that CBLCs significantly decreased barriers to child trauma treatment and significantly increased IPC and perceived utilization of evidence-based child trauma treatment. Further, changes in barriers partially mediated this relationship. Finally, small to medium differences in participants' reports were detected, such that senior leaders perceived significantly greater IPC than clinicians and brokers did, while brokers perceived significantly greater barriers to child trauma treatment than clinicians and senior leaders did. Collectively, these preliminary findings suggest the CBLC implementation model-which augments traditional Learning Collaborative models with a focus on fostering IPC-can reduce barriers and increase the utilization of evidence-based mental health treatment services.

Relationship violence victimization and binge drinking trajectories among a nationally representative sample of adolescents.

The present study evaluated the impact of relationship violence (RV) victimization on the longitudinal trajectory of binge drinking (BD) among 3614 US adolescents (51.2% male) who participated in an initial telephone interview regarding physical and sexual RV victimization and binge drinking. Two follow-up phone interviews were completed over approximately three years. Multilevel modeling revealed small, but significant, increases in BD over time; older adolescents and those who had ever experienced RV victimization were more likely to report BD at Wave 1 compared to younger adolescents and non-victims. Although new RV victimization reported during the study predicted an increase in the likelihood of BD at that occasion, those who had ever experienced RV victimization were less likely to report BD over time compared to non-victims. Contrary to expectations, no sex differences emerged. Findings indicate that BD may precede RV. Interventions to reduce alcohol-related RV may be especially useful in this population.

Clinician Perspectives on Treating Adolescents with Co-occurring Post-Traumatic Stress Disorder, Substance Use, and Other Problems.

Clinicians (n=138) who treat adolescents with co-occurring posttraumatic stress and substance use disorders (PTSD+SUD) were surveyed about their attitudes and practice behaviors. Most providers were trained in PTSD treatment; fewer were trained in SUD or PTSD+SUD treatments. PTSD+SUD treatment was rated more difficult than treatment of other diagnoses. Providers typically addressed symptoms of PTSD and SUD separately and sequentially, rather than with integrated approaches. There was no consensus about which clinical strategies to use with adolescent PTSD+SUD. Continued treatment development, training, and dissemination efforts are needed to equip providers with resources to deliver effective treatments to adolescents with PTSD+SUD.

Can Learning Collaboratives Support Implementation by Rewiring Professional Networks?

This study examined how a learning collaborative focusing on trauma-focused CBT (TF-CBT) impacted advice-seeking patterns between clinicians and three key learning sources: (1) training experts who share technical knowledge about TF-CBT, (2) peers from other participating organizations who share their implementation experiences, and (3) colleagues from their own agency who provide social and professional support. Based on surveys administered to 132 clinicians from 32 agencies, participants' professional networks changed slightly over time by forming new advice-seeking relationships with training experts. While small, these changes at the clinician-level yielded substantial changes in the structure of the regional advice network.

Posttraumatic Stress and Depression in the Nonoffending Caregivers of Sexually Abused Children: Associations With Parenting Practices.

Caregiver mental health is a known correlate of parenting practices, and recent research indicated that parental depression following childhood sexual abuse disclosure is associated with concurrent parenting difficulties. The present study extended this line of research by investigating posttraumatic stress symptoms and depression in a sample of caregivers (N = 96) of children who experienced sexual abuse recruited from a child advocacy center as well as parenting practices reported by both caregivers and their children (mean age = 10.79 years, SD = 3.29; 79% female). Twenty-four percent of caregivers met criteria for presumptive clinical depression, clinically significant posttraumatic stress, or both. Results indicated elevated caregiver-reported inconsistent parenting in the context of clinically significant distress across symptom groups; children reported particularly elevated inconsistent parenting for caregivers with posttraumatic stress only. Caregiver depression was associated with low self-reported positive parenting and caregiver involvement in addition to self-reported inconsistencies. Directions for future research are offered to further elucidate the relationships between caregiver mental health and parenting practices following childhood sexual abuse.

National trainers' perspectives on challenges to implementation of an empirically-supported mental health treatment.

This study examined perceived challenges to implementation of an empirically supported mental health treatment for youth (Trauma-Focused Cognitive Behavioral Therapy; TF-CBT) and explored the potential use of technology-based resources in treatment delivery. Thematic interviews were conducted with 19 approved national TF-CBT trainers to assess their perspectives about challenges to implementation of TF-CBT and to explore their perceptions about the potential value of innovative, technology-based solutions to enhance provider fidelity and improve quality of care. These data offer some important insights and implications for training in evidence-based treatments, provider fidelity and competence, and patient engagement, particularly for those interventions targeting trauma-related symptoms among youth.

Therapists' Perceived Competence in Delivering Trauma-Focused Cognitive Behavioral Therapy During Statewide Learning Collaboratives.

The learning collaborative (LC), a multi-component training and implementation model, is one promising approach to address the need for increased availability of trauma-focused evidence-based practices. The current study used data from four cohorts of a statewide LC on Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to 1) evaluate pre- to post-LC changes in therapists' perceived competence in delivering TF-CBT and 2) explore therapist and contextual factors related to therapists' perceived TF-CBT competence. Therapists (N = 237) completed pre- and post-LC measures of practice information, interprofessional collaboration, organizational climate, and TF-CBT knowledge, perceived competence, and use. Findings indicated therapists' perceived TF-CBT competence significantly increased, pre- to post-LC (d = 1.31), with greater use of trauma-focused practices at pre-training and more TF-CBT training cases completed predicting greater pre- to post-LC gains in perceived TF-CBT competence. These findings highlight the need to assist therapists in identifying and completing training cases to promote competence and implementation.

Our Commitment to Promoting Diversity, Equity, Inclusion, and Justice in Child Maltreatment.

In this commentary, the editorial team of Child Maltreatment extends and expands on APSAC's position on diversity, equity, inclusion, and justice, affirms our commitment and plans for addressing these issues in this publication, and highlights articles in this issue that continue the discussion about race and racism in the child welfare and child protection systems.

Therapists' Perceived Competence in Trauma-Focused Cognitive Behavioral Therapy and Client Outcomes: Findings From a Community-Based Learning Collaborative.

This study examined therapists' perceived competence in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and its association with youth treatment outcomes (posttraumatic stress and depression). Participants included 99 community therapists enrolled in a TF-CBT-focused Learning Collaborative (LC), along with one of their randomly selected TF-CBT training cases. Analyzed data included: 1) caregiver/youth-reported posttraumatic stress and depressive symptoms, pre- and post-treatment, and 2) therapist-perceived competence with TF-CBT components across treatment delivery. Youth- and caregiver-reports indicated large, significant pre- to post-treatment decreases in youth posttraumatic stress (ds = 1.10-1.30, ps < .001) and depressive symptoms (d = 1.01, p < .001). Higher therapist-perceived competence with TF-CBT predicted positive treatment responses for posttraumatic stress (ds = 0.38-0.39, ps = .03) and depression (d = 0.25), though only the former association was significant (ps = .03 vs. p = .15). Findings highlight the need to monitor and improve therapists' competencies to enhance clinical outcomes for trauma-exposed youth and suggest that LCs may be an effective training/implementation model to help achieve those critical goals.

Predictors of rape: findings from the National Survey of Adolescents.

The current report examines data for 872 female adolescents obtained during the initial and follow-up interviews of the National Survey of Adolescents, a nationally representative sample. Lifetime prevalence of violence exposure reported was 12% and 13% for sexual assault, 19% and 10% for physical assault/punishment, and 33% and 26% for witnessing violence at Waves I and II, respectively. Racial/ethnic status, posttraumatic stress disorder (PTSD), childhood sexual abuse (CSA), and family drug problems emerged as significant predictors of new rape. Each of the PTSD symptom clusters significantly predicted new rape and analyses supported the mediational role of PTSD between CSA and new rape. African American or other racial identity was associated with lower risk.

The role of traumatic event history in non-medical use of prescription drugs among a nationally representative sample of US adolescents.

BACKGROUND: Building on previous research with adolescents that examined demographic variables and other forms of substance abuse in relation to non-medical use of prescription drugs (NMUPD), the current study examined potentially traumatic events, depression, posttraumatic stress disorder (PTSD), other substance use, and delinquent behavior as potential correlates of past-year non-medical use of prescription drugs. METHOD: A nationally representative sample of 3,614 non-institutionalized, civilian, English-speaking adolescents (aged 12-17 years) residing in households with a telephone was selected. Demographic characteristics, traumatic event history, mental health, and substance abuse variables were assessed. NMUPD was assessed by asking if, in the past year, participants had used a prescription drug in a non-medical manner. Multivariable logistic regressions were conducted for each theoretically derived predictor set. Significant predictors from each set were then entered into a final multivariable logistic regression to determine significant predictors of past-year NMUPD. RESULTS: NMUPD was endorsed by 6.7% of the sample (n = 242). The final multivariable model showed that lifetime history of delinquent behavior, other forms of substance use/abuse, history of witnessed violence, and lifetime history of PTSD were significantly associated with increased likelihood of NMUPD. CONCLUSIONS: Risk reduction efforts targeting NMUPD among adolescents who have witnessed significant violence, endorsed abuse of other substances and delinquent behavior, and/or endorsed PTSD are warranted. Interventions for adolescents with history of violence exposure or PTSD, or those adjudicated for delinquent behavior, should include treatment or prevention modules that specifically address NMUPD.

Screening and assessment of crime victimization and its effects.

The authors provide a review of tools used to screen and assess history and mental health consequences of adult crime victimization. These measures can be utilized across a broad range of settings that may serve crime victims, including venues for first response (e.g., law enforcement offices or emergency departments), primary medical care, or mental health treatment facilities, regardless of whether or not the crime was reported. The authors conclude with a discussion on limitations in the field and directions for future research.

The impact of crime victimization on quality of life.

The authors review the extant literature examining the functional impact of crime victimization on indices of quality of life. They present findings within a conceptual framework comprised of role functioning, life satisfaction, and well-being, and social-material conditions, including crime-related medical, mental health, and employer costs, and health care utilization. The review indicates that crime victimization impacts multiple domains, including parenting skills, impaired occupational functioning, higher rates of unemployment, and problematic intimate relationships. However, data on relationships between crime victimization and overall life satisfaction were mixed, suggesting the need for further investigation. The authors conclude with a brief discussion of directions for future research.

Predicting child abuse potential: an empirical investigation of two theoretical frameworks.

This study investigated two theoretical risk models predicting child maltreatment potential: (a) Belsky's (1993) developmental-ecological model and (b) the cumulative risk model in a sample of 610 caregivers (49% African American, 46% European American; 53% single) with a child between 3 and 6 years old. Results extend the literature by using a widely accepted and valid risk instrument rather than occurrence rates (e.g., reports to child protective services, observations). Results indicated Belsky's developmental-ecological model, in which risk markers were organized into three separate conceptual domains, provided a poor fit to the data. In contrast, the cumulative risk model, which included the accumulation of risk markers, was significant in predicting child abuse potential.

Has adolescent suicidality decreased in the United States? Data from two national samples of adolescents interviewed in 1995 and 2005.

We compared the prevalence and correlates of adolescent suicidal ideation and attempts in two nationally representative probability samples of adolescents interviewed in 1995 (National Survey of Adolescents; N = 4,023) and 2005 (National Survey of Adolescents-Replication; N = 3,614). Participants in both samples completed a telephone survey that assessed major depressive episode (MDE), post-traumatic stress disorder, suicidal ideation and attempts, violence exposure, and substance use. Results demonstrated that the lifetime prevalence of suicidal ideation among adolescents was lower in 2005 than 1995, whereas the prevalence of suicide attempts remained stable. MDE was the strongest predictor of suicidality in both samples. In addition, several demographic, substance use, and violence exposure variables were significantly associated with increased risk of suicidal ideation and attempts in both samples, with female gender, nonexperimental drug use, and direct violence exposure being consistent risk factors in both samples.