Parent Traumatic Events and Adolescent Internalizing Symptoms: The Mediating Role of Parental Depression Among Youth with Persistent Post-concussive Symptoms.

OBJECTIVE: Research has demonstrated associations between parental depression (PD) and negative psychological outcomes among their children. However, little is known about the pathways through which lifetime parent traumatic events (PTEs) influence their adolescents' internalizing symptoms. Our study examined whether PD mediates the association between PTE and adolescent depressive and anxious symptoms among youth with persistent postconcussive symptoms (PPCS). METHODS: We used baseline data from a randomized effectiveness trial of collaborative care for treatment of persistent postconcussive symptoms among sports-injured adolescents aged 11-18 years. Parent-adolescent dyads were recruited from pediatric clinics throughout western Washington. Eligible adolescents had three or more PPCS that lasted for at least 1 month but <9 months and spoke English. Of 1,870 potentially eligible adolescents, 1,480 (79%) were excluded for not meeting the inclusion criteria. Of the eligible 390 adolescents, 189 (49%) declined to participate/consent. Participants included 200 parent-adolescent dyads (adolescent Mage = 14.7 years, SD = 1.7). Parent respondents were mostly female (83%) and mothers (81%). Adolescents reported on their depressive (Patient Health Questionnaire-9; PHQ-9) and anxious symptoms (Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]) and parents reported on their depressive symptoms (M = 3.7, SD = 3.7; PHQ-9). RESULTS: Mediation analyses revealed two (out of four) significant indirect effects of PTE on both adolescent and parent report of depressive symptoms, but not anxiety. CONCLUSIONS: This study elucidates one pathway (PD) through which PTE history influences adolescent depressive symptoms, supporting a two-generation approach to pediatric patient care for youth experiencing PPCS.

Child- compared with parent-report ratings on psychosocial measures following a mild traumatic brain injury among youth with persistent post-concussion symptoms.

Primary Objective: To compare child- and parent-report ratings on the Health Behavior Inventory, Revised Child Anxiety and Depression Scale-Short Version (anxiety subscale), Patient Health Questionnaire-9, and Pediatric Quality of Life InventoryTM among children with persistent post-concussive symptoms following a sports- or recreation-related concussion, overall and by child age and gender.Research Design: Cross-sectional study examining baseline data from a randomized, comparative effectiveness trial.Methods and Procedures: Inter-rater reliability was assessed using two-way random effects model (absolute agreement) intraclass correlations, correlations were examined using Spearman's rho, mean differences were determined using paired t-tests, and agreement was examined using Bland-Altman plots.Main Outcomes and Results: The final analytic sample was 200 parent-child dyads [child Mage = 14.7 (95% CI: 14.5, 15.0)]. Reliability and correlations were modest overall. When considering child age and gender, reliability ranged from poor to excellent (-1.01-0.95) and correlations ranged from weak to strong (-0.64-0.94). Overall, children reported more symptoms but better functioning than parents, and mean differences in scores were greater among females (versus males) and ages 16-18 (versus younger groups).Conclusions: Findings should inform the use and interpretation of psychosocial measures when developing appropriate youth concussion treatment plans.

Prevalence and risk factors for depression, anxiety and suicidal ideation in youth with persistent post-concussive symptoms (PPCS).

Objectives: To assess the prevalence and risk factors for emotional distress in youth with persistent post-concussive symptoms (PPCS) greater than one month.Methods: We used baseline data from an intervention study for youth with PPCS, utilizing Poisson regression to examine factors associated with exceeding clinical cut-points on measures of depression, anxiety, self-harm and suicidal ideation. Predictors included: age, sex, socioeconomic status, mental health history, duration of concussion symptoms, history of prior concussion, trauma history and sleep quality.Results: The sample included 200 youth with PPCS, (mean 14.7 SD 1.7 years, 82% white, 62% female). Forty percent reported clinically significant depressive symptoms, 25% anxiety, 14% thoughts of self-harm and 8% thoughts of suicide. History of depression was associated with 3-fold higher risk for thoughts of self-harm (95% CI:1.82-6.99) and 6-fold higher risk for suicidal ideation (95% CI:1.74-24.46). Better sleep quality was associated with lower risk for all outcomes. History of prior concussion and duration of PPCS were not significantly associated with any outcomes.Conclusions: Suicidal thoughts are common post-concussion, and history of depression is a strong risk factor. Tailored interventions may be needed to address mental health in this population.

Sexual attraction and experiences in the primary care setting: Examining disparities in satisfaction with provider and health self-efficacy.

INTRODUCTION: To test whether sexual minority males and females report lower satisfaction with primary care providers and lower health self-efficacy relative to heterosexual males and females. METHODS: Data from 535 adolescents who participated in one of two randomized clinical trials conducted in a primary care setting were analyzed. Multiple linear regressions controlling for demographic characteristics and treatment condition were used to examine sexual attraction differences in indicators of satisfaction with provider and health self-efficacy. RESULTS: Sexual minority and heterosexual youth both endorsed high satisfaction with providers. Relative to heterosexual males, sexual minority males reported lower self-efficacy in reaching their health goals. Relative to heterosexual females, sexual minority females reported lower confidence in positively impacting their own health, and lower self-efficacy in setting goals and working actively to improve their health. CONCLUSIONS: Sexual minority youth may benefit from additional support from health care providers to enhance their health self-efficacy and reach their health goals.

Changes in peer norms as a mediator of reduction in adolescent alcohol use.

Background: Evidence from college samples suggests that changes in peer norms (perception about peer use) mediate changes in alcohol use. There is relatively little intervention-based research in adolescents. Objectives: To investigate whether changes in peer norms mediate the relationship between a brief intervention to reduce alcohol use, and level of use; additionally, to determine whether any mediation effects differ by adolescent age. Methods: Eighty-four adolescents aged 14-18 (Mean = 16.49, SD = 1.00), presenting to school-based health centers with moderate to high risk alcohol use were randomized to receive an electronic screening and feedback tool (Check Yourself) in addition to their visit, or their visit alone. Check Yourself includes provision of normative feedback regarding adolescent alcohol use. Measures of self-reported alcohol use, and peer norms were collected at baseline and 2-month follow-up. Results: Changes in perceptions of the proportion of peers using alcohol significantly mediated the relationship between the intervention and all three alcohol outcomes (frequency, typical quantity, and maximum quantity) such that reductions in perceived peer use were associated with reduced use. Moderated mediation suggested that these effects were stronger for younger adolescents compared with older adolescents. Perceptions of the frequency and quantity of peer use were not significant mediators of alcohol use. Conclusions/Importance: Results suggest that integrating normative feedback regarding peer alcohol use is a promising approach in adolescent focused school interventions. They extend previous findings by suggesting that perceptions of the proportion of peers using may be particularly meaningful, and that effects may be more pronounced in younger adolescents.

Screening and brief intervention with adolescents with risky alcohol use in school-based health centers: A randomized clinical trial of the Check Yourself tool.

Background: This study aimed to compare care delivery and alcohol and marijuana use for adolescents with risky alcohol use who received a school-based health center (SBHC) visit with and without the Check Yourself tool, an electronic tool that gives motivational feedback on substance use and summarizes results for providers. Methods: We conducted a randomized controlled trial with 148 adolescents aged 13-18 who met criteria for moderate- to high- risk alcohol use, recruited from urban SBHCs. Participants were randomized to receive their SBHC visit with (n = 73) or without (n = 75) the Check Yourself screening and feedback tool. All SBHC providers received a brief training on motivational interviewing. Results: Adolescents who received the Check Yourself tool + SBHC visit reported higher levels of alcohol (67%) and marijuana (73%) counseling from the provider during their visit, compared with those who received a SBHC visit without the tool (40% and 45%, respectively, Ps < .005), and had higher motivation to decrease marijuana use relative to those who did not (P = .02). Relative to baseline, adolescents in both groups reduced their typical number of drinks of alcohol, maximum number of drinks of alcohol, and hours high on marijuana over time (Ps < .02) at 2-month follow-up. Conclusion: When adolescent patients are given an electronic screening and feedback tool, it can prompt providers to increase counseling of adolescents with substance use risk. Overall, participants who had a visit with a trained provider reported high satisfaction with care and decreased the amount of alcohol use over 2 months, suggesting that SBHCs are an excellent venue for delivery of brief substance use interventions.

Longitudinal trajectories of post-concussive and depressive symptoms in adolescents with prolonged recovery from concussion.

PRIMARY OBJECTIVE: To investigate the symptom trajectories of depressive and post-concussive symptoms (PCS) in slow-to-recover adolescents to understand how the two sets of symptoms are related. RESEARCH DESIGN: We used data from a randomized clinical trial of a collaborative care intervention for post-concussive symptoms to better understand how these two sets of symptoms change in parallel over 6 months. METHODS AND PROCEDURE: PCS and depressive symptom scores for 49 adolescents (ages 11-17) were measured at enrolment and after 1, 3, and 6 months. Latent growth curve modelling for parallel processes was used to simultaneously examine change in PCS and depressive symptoms over time and to evaluate the influence of one change process on the other. MAIN OUTCOMES AND RESULTS: On average, patients enrolled 66 days following injury (Interquartile range (IQR) 43.5, 88.5). PCS and depressive symptoms were significantly associated at enrolment and over time, and both decreased over the course of 6 months. Higher PCS at enrolment predicted a greater decrease in depressive symptoms over time. CONCLUSIONS: Our results suggest that clinicians should screen for and treat depressive symptoms in patients with high post-concussive symptoms one month following injury.

Adolescents' Perspectives on Personalized E-Feedback in the Context of Health Risk Behavior Screening for Primary Care: Qualitative Study.

BACKGROUND: Electronic health screening tools for primary care present an opportunity to go beyond data collection to provide education and feedback to adolescents in order to motivate behavior change. However, there is limited research to guide feedback message development. OBJECTIVE: The aim of this study was to explore youth perceptions of and preferences for receiving personalized feedback for multiple health risk behaviors and reinforcement for health promoting behaviors from an electronic health screening tool for primary care settings, using qualitative methodology. METHODS: In total, 31 adolescents aged 13-18 years completed the screening tool, received the electronic feedback, and subsequently participated in individual, semistructured, qualitative interviews lasting approximately 60 min. Participants were queried about their overall impressions of the tool, perceptions regarding various types of feedback messages, and additional features that would help motivate health behavior change. Using thematic analysis, interview transcripts were coded to identify common themes expressed across participants. RESULTS: Overall, the tool was well-received by participants who perceived it as a way to enhance-but not replace-their interactions with providers. They appreciated receiving nonjudgmental feedback from the tool and responded positively to information regarding the consequences of behaviors, comparisons with peer norms and health guidelines, tips for behavior change, and reinforcement of healthy choices. A small but noteworthy minority of participants dismissed the peer norms as not real or relevant and national guidelines as not valid or reasonable. When prompted for possible adaptations to the tool, adolescents expressed interest in receiving follow-up information, setting health-related goals, tracking their behaviors over time, and communicating with providers electronically between appointments. CONCLUSIONS: Adolescents in this qualitative study desired feedback that validates their healthy behavior choices and supports them as independent decision makers by neutrally presenting health information, facilitating goal setting, and offering ongoing technological supports.

Twelve-Month Outcomes of a Randomized Trial of the Positive Thoughts and Action Program for Depression Among Early Adolescents.

This study was conducted to examine the 12-month effects on depression and depressive symptoms of a group-based cognitive-behavioral preventive intervention for middle school students (Positive Thoughts and Actions, or PTA), relative to a brief, individually administered supportive intervention (Individual Support Program, or ISP). A randomized clinical trial was conducted with 120 early adolescents (73 girls and 47 boys; age 12-14 years) drawn from a school-based population who had elevated depressive symptoms. Youths completed measures of depressive symptoms at baseline, post-intervention, and 6 and 12 months into the follow-up phase. Measures of internalizing problems, externalizing problems, school adjustment, interpersonal relationships, and health behavior were obtained from parents and/or youth. Multilevel models indicated that the effect of PTA on youth-reported depressive symptoms persisted until 12-month follow-up; d = 0.36 at post-intervention, d = 0.24 at 6-month follow-up, and d = 0.21 at 12-month follow-up. PTA youths also reported lower internalizing symptoms at post-intervention, d = 0.44, and at 12-month follow-up, d = 0.39. Time-limited effects were found for parent-reported internalizing symptoms and health behavior. Onset of new depressive episodes did not differ based on intervention group (21 % ISP; 17 % PTA). Results demonstrate support for the long-term efficacy of PTA, a cognitive-behavioral preventive intervention in which youths engage in personal goal-setting and practice social-emotional skills.

Teletherapy delivery of caregiver behavior training for children with attention-deficit hyperactivity disorder.

BACKGROUND: Preliminary studies suggest that videoteleconferencing (VTC) may be an effective means to deliver behavioral interventions to families. Subjects consisted of a subsample of children (n=37) and caregivers who participated in the Children's Attention-Deficit Hyperactivity Disorder (ADHD) Telemental Health Treatment Study (CATTS) (n=223), a randomized trial testing the effectiveness of delivering treatments for ADHD to families residing in their home communities using distant technologies. Families randomized to the CATTS intervention arm received pharmacotherapy and caregiver behavior training. MATERIALS AND METHODS: Thirty-seven families from the CATTS intervention arm participated. All families received pharmacotherapy through VTC. Twelve families received the caregiver behavior training through VTC, or teletherapy, and 25 received the intervention in-person. We assessed children's outcomes at 25 weeks with the Vanderbilt ADHD Parent Rating Scale and the Columbia Impairment Scale. We assessed caregivers' outcomes using measures of distress in caring for a child with ADHD, including depression, stress, strain, and empowerment. We used analysis of covariance to assess outcomes from baseline to 25 weeks. RESULTS: Families in the two conditions showed comparable attendance at sessions and satisfaction with their care. Caregivers in both conditions reported comparable outcomes for their children's ADHD-related behaviors and functioning, but caregivers in the teletherapy group did not report improvement in their own distress. CONCLUSIONS: Findings support the feasibility, acceptability, and effectiveness of treating children with ADHD through teletherapy. Future work should investigate how teletherapy may improve caregivers' distress. Teletherapy is a promising modality for delivering behavioral interventions for children with ADHD.

Mediators of the Associations Between Externalizing Behaviors and Internalizing Symptoms in Late Childhood and Early Adolescence.

This study tests the predictive associations between externalizing behaviors and internalizing symptoms and examines the mediating roles of social competence, parent-child conflicts, and academic achievement. Using youth-, parent-, and teacher-reported longitudinal data on a sample of 523 boys and 460 girls from late childhood to early adolescence, we found evidence for pathways between externalizing behaviors and internalizing symptoms in both directions. Parent-child conflict, but not social competence and academic achievement, was found to be a significant mediator such that externalizing behaviors predicted parent-child conflicts, which in turn, predicted internalizing symptoms. Internalizing symptoms showed more continuity during early adolescence for girls than boys. For boys, academic achievement was unexpectedly, positively predictive of internalizing symptoms. The results highlight the importance of facilitating positive parental and caregiver involvement during adolescence in alleviating the risk of co-occurring psychopathology.

Triadic Collaboration Between Adolescents, Caregivers, and Health-Care Providers to Promote Healthy Behavior.

PURPOSE: To further elucidate the various aspects of the triadic relationship between health-care providers (HCP), adolescents, and caregivers during adolescent health-care visits, with the goal of helping HCPs better understand how they can best support adolescents to choose healthy behaviors. METHODS: Adolescents (ages 13-18 years) and caregivers of adolescents were recruited to participate in qualitative interviews regarding preferences for provider interactions around health behavior change. Data analysis was conducted using inductive thematic analysis to identify and describe patterns of themes across the dataset. RESULTS: Thirty one adolescents and 30 caregivers participated. Fourteen themes emerged in the analysis regarding adolescent and caregiver preferences for direct and indirect relationships between adolescents, caregivers, and HCPs in promoting healthy behavior. These themes were organized into a triadic collaboration framework to promote healthy behavior using an adolescent-centered and caregiver-involved approach. DISCUSSION: This study supports findings of previous research on triadic interactions between HCPs, adolescents, and caregivers while deepening our understanding of the HCP's role in helping adolescents to choose healthy behaviors. These themes are representative of the continuing shift toward an adolescent-centered and caregiver-involved approach to adolescent health care and provide further guidance to HCPs on how to work collaboratively with both adolescents and caregivers to promote healthy behaviors and improve health outcomes.

A randomized trial of the Positive Thoughts and Action program for depression among early adolescents.

This study was conducted to compare the outcomes of a group-based cognitive-behavioral preventive intervention (Positive Thoughts and Actions [PTA]) tailored to youth in middle school with a brief, individually administered supportive intervention (Individual Support Program [ISP]). A randomized, controlled trial was conducted with 120 early adolescents (72 girls, 48 boys; age = 11-15 years) who had elevated depressive symptoms and were selected from a school-based population. Measures of internalizing problems, externalizing problems, personal adjustment, school problems, and interpersonal relations were obtained from parents, youth, and/or teachers at preintervention (Time 1) and postintervention (Time 2, 5-7 months after preintervention). General linear model repeated measures analyses yielded a significant Group × Time interaction on youth-reported, but not parent-reported, depressive symptoms and internalizing symptoms. Youth in the PTA group showed greater decreases following intervention compared to youth who received ISP, yielding effect sizes (Cohen's d) of 0.36 for depressive symptoms, 95% CI [-.02, .73], and 0.44, 95% CI [.05, .82], for internalizing symptoms. PTA youth also showed improvements in their personal adjustment (sense of inadequacy, self-esteem), and parent-reported social skills, but no differences emerged between groups for externalizing symptoms, school problems, or interpersonal relationships. Cognitive-behavioral preventive interventions in which youth engage in personal goal-setting and practice social-emotional skills, such as PTA, may be beneficial for the reduction of depressive symptoms over and above general support and empathy.

Callous-unemotional traits and conduct disorder symptoms as prospective risk factors for adolescent sexual activity.

Conduct disorder (CD) has been shown to increase risk for adolescent sexual activity and pregnancy. Despite increasing evidence underscoring callous-unemotional (CU) traits as a marker for youth with CD prone to especially poor outcomes, researchers have yet to explore whether CU traits confer additional risk of early sexual intercourse, unprotected sex, and pregnancy. The Developmental Pathways Project sample, including 471 ethnically diverse 6th-grade boys and girls followed into 12th grade, was used to examine whether CU traits and CD symptoms in 6th grade uniquely and/or synergistically predicted having sexual intercourse by age 13 as well as unprotected sex and pregnancy by 12th grade. Parent-rated CU traits and CD symptoms interacted to predict young adolescents having sexual intercourse, such that youth with elevated CU traits and CD symptoms in 6th grade were more likely to reporting having sex by age 13 than those with low CU traits and/or low CD symptoms. Elevated CD symptoms, but not CU traits, uniquely increased risk of pregnancy by 12th grade. Neither CU traits nor CD symptoms predicted engagement in unprotected sex in 12th grade. Our findings indicate that adolescents with conduct problems and CU traits are especially at risk for early sexual intercourse. Conversely, elevated CU traits do not appear to increase risk of unprotected sex or pregnancy among young adolescents with conduct problems. Research is needed to replicate these findings and to explore mechanisms underlying the association between CU traits, CD symptoms, and early adolescent sexual activity.

Associations Between Sleep Duration and Positive Mental Health Screens During Adolescent Preventive Visits in Primary Care.

OBJECTIVE: The purpose of this paper was to understand associations between low sleep duration (<8.ßhours) and positive mental health screens among adolescents (ages 13...18) seen for preventive visits in primary care. METHODS: Data were from two randomized controlled trials testing the efficacy of an electronic health risk behavior screening and feedback tool for adolescent preventive visits. Participants (n.ß=.ß601) completed screeners at baseline, 3 months, and 6 months which included sleep duration in hours and the Patient Health Questionnaire 9 and Generalized Anxiety Disorder 7 screeners for depression and anxiety, respectively. Main analyses included adjusted logistic regressions testing associations between low sleep duration and positive mental health screens. RESULTS: Adjusted models showed that low sleep duration was associated with significantly greater odds of a positive depression screen (OR.ß=.ß1.58, 95% CI: 1.06...2.37) but not with a positive anxiety screen or co-occurring positive depression and anxiety screens. However, follow-up analyses indicated an interaction between sleep duration and anxiety in the association with a positive depression screen, such that the association between low sleep and a positive depression screen was driven by those who did not screen positive for anxiety. CONCLUSIONS: As pediatric primary care guidelines for sleep continue to evolve, further research, training, and support for sleep screening are warranted to ensure effective early intervention for sleep and mental health problems during adolescence.

Psychometric Properties and Validation of the General Anxiety Disorder 7-Item Scale Among Adolescents With Persistent Post-Concussive Symptoms.

The General Anxiety Disorder 7-Item (GAD-7) scale is commonly used in primary care as a self-report measure of general anxiety symptoms with adult populations. There is little psychometric research on this measure with adolescent populations, particularly those with persistent post-concussive symptoms (PPCS). This study examined the psychometrics properties of the GAD-7 among youth with PPCS. We used baseline data from a randomized controlled trial of collaborative care for treatment of PPCS among 200 sports-injured adolescents 11-18 years of age (Mage = 14.7 years, standard deviation = 1.7). Eligible adolescents had three or more PPCS that lasted for ≥1 month and spoke English. Adolescents reported on their anxious (GAD-7 and Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]; RCADS) and depressive (Patient Health Questionnaire-9; PHQ-9) symptoms. Parents used the RCADS to report on their adolescents' anxious symptoms. The GAD-7 had good internal validity (Cronbach's alpha = 0.87), and significant (p < 0.001) correlations were detected between the GAD-7 and youth and parent report of anxiety on RCADS (r = 0.73 and r = 0.29) and PHQ-9 (r = 0.77) scores. Confirmatory factor analysis suggested a one-factor solution. These results suggest that the GAD-7 is a valid measure of anxiety with good psychometric properties for youth experiencing PPCS. ClinicalTrials.gov identifier: NCT03034720.

Validation of a Process for Shared Decision-Making in Pediatrics.

OBJECTIVE: We sought to confirm, refute, or modify a 4-step process for implementing shared decision-making (SDM) in pediatrics that involves determining 1) if the decision includes >1 medically reasonable option; 2) if one option has a favorable medical benefit-burden ratio compared to other options; and 3) parents' preferences regarding the options; then 4) calibrating the SDM approach based on other relevant decision characteristics. METHODS: We videotaped a purposive sample of pediatric inpatient and outpatient encounters at a single US children's hospital. Clinicians from 7 clinical services (craniofacial, neonatology, oncology, pulmonary, pediatric intensive care, hospital medicine, and sports medicine) were eligible. English-speaking parents of children who participated in inpatient family care conferences or outpatient problem-oriented encounters with participating clinicians were eligible. We conducted individual postencounter interviews with clinician and parent participants utilizing video-stimulated recall to facilitate reflection of decision-making that occurred during the encounter. We utilized direct content analysis with open coding of interview transcripts to determine the salience of the 4-step SDM process and identify themes that confirmed, refuted, or modified this process. RESULTS: We videotaped 30 encounters and conducted 53 interviews. We found that clinicians' and parents' experiences of decision-making confirmed each SDM step. However, there was variation in the interpretation of each step and a need for flexibility in implementing the process depending on specific decisional contexts. CONCLUSIONS: The 4-step SDM process for pediatrics appears to be salient and may benefit from further guidance about the interpretation of each step and contextual factors that support a modified approach.

Can patterns of alcohol use disorder in young adulthood help explain gender differences in depression?

OBJECTIVE: To test whether gender differences in the prevalence of major depressive disorder differ by longitudinal patterns of alcohol use disorder symptoms. METHOD: Data are from a prospective longitudinal study examining a broad range of mental health and substance use problems. A gender-balanced sample of 808 participants was interviewed at ages 21, 24, 27, and 30. The sample was divided into subgroups corresponding to longitudinal patterns of alcohol use disorder derived from latent class growth analysis. RESULTS: Four patterns of alcohol use disorder symptoms were identified: A "low disorder symptom" group, a "decreaser" group, an "increaser" group, and a "chronic disorder symptom" group. Rates of depression were significantly higher for females only among those with a pattern of chronic or decreasing alcohol disorder symptoms. CONCLUSIONS: Elevated rates of depression among females in young adulthood may depend on patterns of co-occurring alcohol disorder symptoms. Practitioners should pay particular attention to signs of chronic alcohol use disorders and associated risks for depression among young adult women.

Barriers to Increasing Access to Brief Pediatric Mental Health Treatment From Primary Care.

A quality improvement process targeted mental health care uptake and system capacity in an underserved region. The pediatric program created pathways for rapid referral from primary care and schools to four sessions of evidence-based treatments for disruptive behavior and depression with community clinicians. Of 250 referrals, 46 families enrolled in treatments for disruptive behavior and 21 for depression. Many families did not respond or required more intensive treatment. Acceptability of the program was high for participating families, referrers, and clinicians. Brief treatment met most participating families' needs. The process demonstrated barriers to mental health care access and delivery and the need for integrated and multitiered care delivery.

Same, opposite and both-sex attracted adolescents' mental health, safe-sex practices and substance use.

This study examined mental health, substance use, and sexual health across sexual attraction groups. 428 adolescents recruited from school-based health centers completed self-report measures. 72% were only opposite-sex attracted, 19% both-sex attracted, 3% same-sex attracted, 4% not sure. Reported partners did not always align with reported attraction. Compared to opposite-sex attracted youth, 1) both-sex attracted youth had significantly higher rates of marijuana use (OR=1.75, p=.04), depressive symptoms (OR=2.62, p=.001) and inconsistent condom use (OR=1.71, p=.05); 2) the "not sure" group had higher anxiety symptoms (OR=4, p=.01). This study highlights the importance of considering sexual attraction in providing quality care to young people.