Avoidance as an obstacle to preventing depression among urban women at high risk for violent trauma.

The impact of depression interventions is often attenuated in women who have experienced trauma. We explored whether psychological avoidance could explain this phenomenon. We synthesized two pilot randomized trials of problem-solving education (PSE) among a total of 93 urban mothers. Outcomes included depressive symptoms and perceived stress. Mothers with avoidant coping styles experienced an average 1.25 episodes of moderately severe depressive symptoms over 3 months of follow-up, compared to 0.40 episodes among those with non-avoidant coping (adjusted incident rate ratio [aIRR] 2.18; 95 % CI 1.06, 4.48). PSE tended to perform better among mothers with non-avoidant coping. Among mothers with non-avoidant coping, PSE mothers experienced an average 0.24 episodes, compared to 0.58 episodes among non-avoidant controls (aIRR 0.27; 95 % CI 0.05, 1.34). Among mothers with avoidant coping, PSE mothers experienced an average 1.26 episodes, compared to 1.20 episodes among avoidant controls (aIRR 0.76; 95 % CI 0.44, 1.33). This trend toward differential impact persisted when avoidance was measured as a problem-solving style and among traumatized mothers with and without avoidant PTSD symptoms. Further research is warranted to explore the hypothesis that psychological avoidance could explain why certain depression treatment and prevention strategies break down in the presence of trauma.

Characterizing patients reporting unchanged or worsened mental health symptoms after completing a partial hospital program: A mixed-methods study.

Research is needed to better understand and characterize individuals who do not benefit from evidence-based psychiatric services or whose symptoms worsen following treatment. This study aimed to compare clinical severity at admission, treatment outcomes, treatment beliefs, and satisfaction with care among patients (N = 5,129) with perceived improved, unchanged, or worsened mental health at discharge from a partial hospital program. Chi-square tests, one-way analyses of variances (ANOVAs), analyses of covariances (ANCOVAs), and qualitative analyses were used to probe study aims. Patients perceiving overall unchanged or worsened mental health at discharge did not appear more clinically severe at admission compared to patients perceiving overall improved mental health at discharge; however, they did report more negative beliefs about treatment, poorer outcomes across specific clinical severity indices, and poorer patient satisfaction at discharge. Patients most frequently attributed their unchanged or worsened mental health to engaging with difficult emotions for the first time, being a poor fit for an otherwise helpful program, and/or needing more time to apply new skills. Findings suggest that patients who do not perceive benefit from evidence-based acute psychiatric care may not be more clinically severe at admission, yet they may enter care with more negative treatment perceptions and report poorer outcomes on specific psychiatric indices at discharge compared to those perceiving treatment benefit. Efforts are needed to improve treatment for patients who do not benefit from psychiatric services; yet, for some, unchanged or worsened mental health in the short term may represent a step along the trajectory to long-term recovery. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Potential impact of trauma on the ability to prevent depression among low-income mothers.

BACKGROUND: Violent trauma is common in urban communities. We explored the hypothesis that past trauma could moderate the effect of a cognitive behavioral intervention designed to prevent depression among urban, low-income mothers. METHODS: Synthesis of two pilot randomized trials of problem solving education (PSE) among 93 mothers of children hospitalized in the neonatal intensive care unit or enrolled in community-based Early Intervention programs. Outcomes included depressive symptoms, perceived stress, and social functioning. Results were adjusted for baseline depressive symptoms, then stratified according to subjects' trauma history. RESULTS: Fifteen of the 44 PSE subjects (34%) experienced a moderately severe depressive symptom episode during the 3-month follow-up period, as opposed to 21 of 45 control subjects (47%), for a nearly significant adjusted odds ratio (aOR) of 0.36 (95% CI: 0.13, 1.02). Among mothers without trauma histories, far fewer PSE mothers (5 of 24; 21%) experienced an episode of moderately severe depressive symptoms than control mothers (12 of 26; 46%) for a significant aOR of 0.15 (95% CI: 0.03, 0.79). Conversely, among mothers with trauma histories, a similar proportion of PSE mothers (10 of 19; 53%) experienced an episode of moderately severe depressive symptoms as control mothers (9 of 19; 47%). Similar trends held for perceived stress and social functioning. CONCLUSIONS: PSE may be more effective at preventing depression among mothers without trauma histories. Our results are consistent with the depression treatment literature, but are novel because they support the principle of intervention moderation in risk prevention, as opposed to treatment, paradigm.

Cognitive control training for urgency: A pilot randomized controlled trial in an acute clinical sample.

Urgency - rash action in the context of strong emotion - is a facet of impulsivity closely related to many psychological disorders. Deficits in working memory and response inhibition are potential mechanisms underlying urgency, and a previous study showed that cognitive training targeting these domains is efficacious in reducing urgency. However, the feasibility and efficacy of this intervention has not yet been tested in a clinical sample or naturalistic treatment setting. To fill this gap, we conducted a pilot study of cognitive training for individuals reporting high levels of urgency in a partial hospitalization program. We evaluated this intervention in an open trial (n = 20), followed by a randomized controlled trial (n = 46) comparing cognitive training plus treatment as usual to treatment as usual. Results supported the feasibility and acceptability of cognitive training. Participants in the training group showed significant improvement on cognitive tasks, but groups did not differ in urgency. In pooled analyses combining the open trial and RCT, there was a significant reduction in distress intolerance in the training group only. Results indicate the potential benefit of cognitive training for distress intolerance, but do not support the use of cognitive training for urgency in acute clinical settings. The study conducted in the RCT phase of this manuscript is registered on ClinicalTrials.gov (NCT: NCT03527550). The full trial protocol is available on ClinicalTrials.gov.

Using Clinical Data to Predict Accurate ADHD Diagnoses Among Urban Children.

Diagnosing attention deficit hyperactivity disorder (ADHD) requires reports of child behavior from 2 settings-most commonly home and school. Obtaining this information from teachers, however, is often challenging. We sought to determine if clinical data, supplementary to parent symptom scales, could be useful in predicting DSM-compliant diagnoses. Parents and teachers reported ADHD symptoms for 156 children using Vanderbilt scales; care managers collected clinical data; a team of specialists determined whether children met diagnostic criteria for ADHD. The ability of a parent Vanderbilt alone to predict an ADHD diagnosis was 56% (95% confidence interval = 45%, 67%). By adding child age and grade retention history to the multivariable model, the probability rose to 78% (95% confidence interval = 59%, 93%). In the maximally predictive model-which included 5 covariates-the predictive validity rose to 84% (95% confidence interval = 52%, 99%). Supplementing parent symptom reports with clinical data may be a viable alternative in certain cases when teacher reports are unavailable.

Reducing Disparities in Timely Autism Diagnosis Through Family Navigation: Results From a Randomized Pilot Trial.

OBJECTIVE: Emerging evidence suggests that autism spectrum disorder (ASD) can be diagnosed by age 18 months and that early intensive behavioral intervention positively affects ASD core deficits. This pilot randomized controlled trial examined the feasibility of using an adapted form of patient navigation, Family Navigation (FN), to improve timely diagnosis of ASD in low-income families from racial-ethnic minority groups. METHODS: Forty children referred for an ASD diagnostic assessment were randomly allocated to receive FN or usual care. The primary outcome, time to diagnostic resolution, was assessed with survival analysis. RESULTS: Nineteen of 20 FN children completed the diagnostic assessment, compared with 11 of 19 children receiving usual care (hazard ratio=3.21, 95% confidence interval=1.47-6.98, p<.01). In regard to engagement of participants, 17 of 20 families (85%) met with the navigator for the targeted three in-person visits (median=4, range 1-9). CONCLUSIONS: FN may be a promising intervention to address barriers that impede timely ASD diagnosis.

Collaborative care for children with ADHD symptoms: a randomized comparative effectiveness trial.

OBJECTIVES: Although many attention-deficit/hyperactivity disorder (ADHD) care models have been studied, few have demonstrated individual-level symptom improvement. We sought to test whether complementing basic collaborative care with interventions that address common reasons for symptom persistence improves outcomes for children with inattention and hyperactivity/impulsivity. METHODS: We conducted a randomized comparative effectiveness trial of 2 care management systems for 6- to 12-year-old children being evaluated for ADHD (n = 156). All participants received care management with decision support. Care managers in the enhanced care arm also were trained in motivational and parent management techniques to help parents engage in their child's treatment, address their own mental health needs, and manage challenging child behaviors. We used multivariable models to assess inattention, hyperactivity/impulsivity, oppositionality, and social skills over 1 year. RESULTS: Both treatment arms generated guideline concordant diagnostic processes in 94% of cases; 40% of children had presentations consistent with ADHD. For the entire sample, there were no differences in symptom trajectories between study arms; mean differences in change scores at 12 months were -0.14 (95% confidence interval -0.34 to 0.07) for inattention; -0.13 (-0.31 to 0.05) for hyperactivity/impulsivity; -0.09 (-0.28 to 0.11) for oppositionality; and 3.30 (-1.23 to 7.82) for social skills. Among children with ADHD-consistent presentations, enhanced arm participants experienced superior change scores for hyperactivity/impulsivity of -0.36 (-0.69 to -0.03), oppositionality -0.40 (-0.75 to -0.05), and social skills 9.57 (1.85 to 17.28). CONCLUSIONS: Among children with ADHD-consistent presentations, addressing barriers to engagement with care and challenging child behaviors has potential to improve the effectiveness of collaborative care.

Improving maternal mental health after a child's diagnosis of autism spectrum disorder: results from a randomized clinical trial.

IMPORTANCE: The prevalence of psychological distress among mothers of children with autism spectrum disorder (ASD) suggests a need for interventions that address parental mental health during the critical period after the child's autism diagnosis when parents are learning to navigate the complex system of autism services. OBJECTIVE: To investigate whether a brief cognitive behavioral intervention, problem-solving education (PSE), decreases parenting stress and maternal depressive symptoms during the period immediately following a child's diagnosis of ASD. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial compared 6 sessions of PSE with usual care. Settings included an autism clinic and 6 community-based early intervention programs that primarily serve low-income families. Participants were mothers of 122 young children (mean age, 34 months) who recently received a diagnosis of ASD. Among mothers assessed for eligibility, 17.0% declined participation. We report outcomes after 3 months of follow-up (immediate postdiagnosis period). INTERVENTIONS: Problem-solving education is a brief, cognitive intervention delivered in six 30-minute individualized sessions by existing staff (early intervention programs) or research staff without formal mental health training (autism clinic). MAIN OUTCOMES AND MEASURES: Primary outcomes were parental stress and maternal depressive symptoms. RESULTS: Fifty-nine mothers were randomized to receive PSE and 63 to receive usual care. The follow-up rate was 91.0%. Most intervention mothers (78.0%) received the full PSE course. At the 3-month follow-up assessment, PSE mothers were significantly less likely than those serving as controls to have clinically significant parental stress (3.8% vs 29.3%; adjusted relative risk [aRR], 0.17; 95% CI, 0.04 to 0.65). For depressive symptoms, the risk reduction in clinically significant symptoms did not reach statistical significance (5.7% vs 22.4%; aRR, 0.33; 95% CI, 0.10 to 1.08); however, the reduction in mean depressive symptoms was statistically significant (Quick Inventory of Depressive Symptomatology score, 4.6 with PSE vs 6.9 with usual care; adjusted mean difference, -1.67; 95% CI, -3.17 to -0.18). CONCLUSIONS AND RELEVANCE: The positive effects of PSE in reducing parenting stress and depressive symptoms during the critical postdiagnosis period, when parents are asked to navigate a complex service delivery system, suggest that it may have a place in clinical practice. Further work will monitor these families for a total of 9 months to determine the trajectory of outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01021384.