Youth Substance Use in a Context of Family Homelessness.

OBJECTIVE: This study examines the relationship between family processes and youth substance use debuts among a sample of youth residing in urban family homeless shelters. METHOD: Data regarding shelter experiences, youth and family characteristics, and the use of three substances (i.e., cigarettes, alcohol, and marijuana) were gathered from a sample of youth (11-14 years) and their respective parents residing in an urban family homeless shelter system. Multinomial logistic regression analysis was used to examine the influences on youth substance use. RESULTS: Of the 198 youth included in the statistical analysis, 72% (n=143) reported no substance use debuts, while 18% (n=35) indicated one and 10% (n=20) indicated two to three substance use debuts. Within the final model, greater substance use debut was associated with being older (13-14 vs. 11-12; OR=7.5; 95% CI =1.8-30.9) and stressors exposure (OR=4.8; 95% CI =1.5-14.7). Furthermore, youth of adult caretakers that reported low levels of the three family processes considered were almost four and a half more likely (OR=4.4; 95% CI =1.2-16.5) to have made two to three substance use debuts. CONCLUSIONS: Family processes may be a particularly important intervention target toward reducing the rate of substance use among youth residing in urban family homeless shelters.

Methodological reporting in qualitative, quantitative, and mixed methods health services research articles.

OBJECTIVES: Methodologically sound mixed methods research can improve our understanding of health services by providing a more comprehensive picture of health services than either method can alone. This study describes the frequency of mixed methods in published health services research and compares the presence of methodological components indicative of rigorous approaches across mixed methods, qualitative, and quantitative articles. DATA SOURCES: All empirical articles (n = 1,651) published between 2003 and 2007 from four top-ranked health services journals. STUDY DESIGN: All mixed methods articles (n = 47) and random samples of qualitative and quantitative articles were evaluated to identify reporting of key components indicating rigor for each method, based on accepted standards for evaluating the quality of research reports (e.g., use of p-values in quantitative reports, description of context in qualitative reports, and integration in mixed method reports). We used chi-square tests to evaluate differences between article types for each component. PRINCIPAL FINDINGS: Mixed methods articles comprised 2.85 percent (n = 47) of empirical articles, quantitative articles 90.98 percent (n = 1,502), and qualitative articles 6.18 percent (n = 102). There was a statistically significant difference (χ(2) (1) = 12.20, p = .0005, Cramer's V = 0.09, odds ratio = 1.49 [95% confidence interval = 1,27, 1.74]) in the proportion of quantitative methodological components present in mixed methods compared to quantitative papers (21.94 versus 47.07 percent, respectively) but no statistically significant difference (χ(2) (1) = 0.02, p = .89, Cramer's V = 0.01) in the proportion of qualitative methodological components in mixed methods compared to qualitative papers (21.34 versus 25.47 percent, respectively). CONCLUSION: Few published health services research articles use mixed methods. The frequency of key methodological components is variable. Suggestions are provided to increase the transparency of mixed methods studies and the presence of key methodological components in published reports.

Family support in prevention programs for children at risk for emotional/behavioral problems.

We conducted a review of empirically based prevention programs to identify prevalence and types of family support services within these programs. A total of 238 articles published between 1990 and 2011 that included a family support component were identified; 37 met criteria for inclusion. Following the Institute of Medicine's typology, prevention programs were categorized as universal, selective, or indicated; programs containing more than one prevention level were characterized as multi-level. Family support types included those led by a mental health professional, led by a peer, or team-led. Among the 37 prevention programs reviewed, 27% (n=10) were universal, 41% (n=15) were selective, 16% (n=6) were indicated, and 16% (n=6) were multi-level. The predominant model of family support was professionally led (95%, n=35). Two (n=5%) provided team-led services. None were purely peer-led. In terms of content of family support services, all (100%, n=37) provided instruction/skill build. Information and education was provided by 70% (n=26), followed by emotional support (n=11, 30%) and instrumental or concrete assistance (n=11, 30%). Only 14% (n=5) provided assistance with advocacy. The distribution of models and content of services in prevention studies differ from family support within treatment studies. As family support is likely to be an enduring component of the child and family mental health service continuum, comparative effectiveness studies are needed to inform future development.

Retention and ongoing participation in residential substance abuse treatment: perspectives from adolescents, parents and staff on the treatment process.

Many adolescents entering substance abuse treatment do not stay for the full course of prescribed treatment. There have been few explorations into what facilitates the ongoing participation of adolescents while in treatment. This paper describes adolescent, parent, and treatment staff perceptions of the barriers and facilitators to retention and participation. Interviews were conducted with 87 adolescents, parents, and staff from three residential substance abuse treatment agencies in two states. Data were coded thematically and organized into themes by respondent type. Respondents reported barriers related to treatment population, program design, and communication and relationships, and reported facilitators related only to communication and relationships. Staff reported far more barriers than facilitators in comparison to either adolescents or parents. Findings suggest that parents and staff underestimate their contributions to the treatment process and practitioners might benefit from rethinking how to communicate the value of these stakeholders.

Impact of Empowerment Training on the Professional Work of Family Peer Advocates.

A pilot study using a prospective design examined the impact of a collaboratively developed training model, called the Parent Empowerment Program (PEP), for professionally-employed family peer advocates who work with caregivers of children with mental health needs. This training used a combination of didactic, practice exercises, and group discussion. It targeted specific mental health knowledge content and collaborative skills to facilitate the work of family peer advocates in empowering caregivers. Co-delivered by a family peer advocate and clinician, the training consisted of a 40-hour face-to-face training, followed by six monthly face-to-face booster sessions. A total of 15 advocates participated in assessments conducted at baseline and post-training. This group of experienced family peer advocates showed no significant increase in knowledge about mental health content, but post-training assessments indicated increased collaborative skills and mental health services self-efficacy. This initial evaluation has implications for expanding training and support for the emergent workforce of professionally-employed family peer advocates in children's mental health.

Barriers to HIV care: an exploration of the complexities that influence engagement in and utilization of treatment.

This study is an exploration of engagement in outpatient medical care, medication utilization, and barriers to treatment utilization among 24 predominantly low-income, ethnic minority adults who were admitted to an urban hospital for HIV-related illnesses. A semi-structured interview was administered during the sample's hospital stay to explore patterns of service use and identify barriers to care. The majority of the sample was connected to an outpatient provider and satisfied with the care they received; however, most missed treatment appointments and skipped medication dosages. Health and treatment-related barriers, competing demands, and co-occurring mental health symptoms and illicit substance use were identified as barriers to care. Multiple obstacles indigenous to the individual, their treatment, and the environment prevented consistent treatment use among an economically disadvantaged ethnic minority sample: Implications and future directions in engaging vulnerable populations into health care for HIV are discussed.

Developing the Support, Teambuilding, and Referral (STAR) Intervention: A Research/Community Partnership.

This paper describes the process by which child mental health researchers partnered with paraprofessionals called peer family advisors to create a stress-reducing intervention for caregivers of children and adolescents with mental health challenges. The issues that arose as the team strove to develop an intervention that was both relevant to the issues that these caregivers grapple with, as well as palatable and feasible for peers to deliver, are discussed.

Correlates of Externalizing Behavior Symptoms Among Youth Within Two Impoverished, Urban Communities.

The current study examines whether risk factors associated with child externalizing behavior symptoms differ between two similar low-income urban communities, using baseline parent data of 154 African American youth (ages 9-15) participating in the Collaborative HIV-Prevention and Adolescent Mental Health Project (CHAMP) family program. Separate multiple regression analyses of each city sample indicated that greater child externalizing symptoms were associated with increasing parenting hassles for New York families (n = 46), but greater parent mental health symptoms for participants in Chicago (n = 108). Understanding such distinctions between communities is an important first step towards tailoring services to unique community needs.

Family support in children's mental health: a review and synthesis.

A comprehensive review of structured family support programs in children's mental health was conducted in collaboration with leadership from key national family organizations. The goals were to identify typologies of family support services for which evaluation data existed and identify research gaps. Over 200 programs were examined; 50 met criteria for inclusion. Programs were categorized by whether they were delivered by peer family members, clinicians, or teams. Five salient components of family support were identified: (a) informational, (b) instructional, (c) emotional, (d) instrumental, and (e) advocacy. Clinician-led programs were heavily represented (n = 33, 66%), followed by family-led (n = 11, 22%), and team-delivered (n = 6, 12%) programs. Key differences between programs delivered by clinicians or by peer family members were found in the degree of emphasis, research methodology, and outcomes. However, the content of the components was similar across all three program types. There are both important differences in emphasis across typologies of family support provided by clinicians, family members, or teams as well as important similarities in content. Family-delivered support may be an important adjunct to existing services for parents, although the research base remains thin. A research agenda to promote more rigorous evaluations of these services especially those delivered by peer family members is critical.

Cultural Pride Reinforcement as a Dimension of Racial Socialization Protective of Urban African American Child Anxiety.

The study objective was to examine how parental endorsement of cultural pride reinforcement messages may explain African American child anxiety. Data were gathered from 72 African American parents and their elementary school-aged children. Results indicated stronger parental endorsement of cultural pride reinforcement messages predicted less child anxiety. Additionally parental endorsement of these messages moderated the relationship between child mental health risk factor exposure and child anxiety. Specifically in the presence of high exposure, children of parents who endorsed high levels of cultural pride reinforcement messages had significantly lower anxiety scores relative to children of parents who endorsed low levels of these messages. Findings indicated parental endorsement of these messages may be an important factor in explaining African American child anxiety.

The Protective Effect of Adult Mental Health Upon the Utilization of Racial Socialization Parenting Practices.

The purpose of this paper is to examine the impact of parental mental health and types of racial socialization. The sample consisted of 169 African-American parents and their children (ages 9-11) who participated in a federally funded research project, "Knowledge about the African American Research Experience" (KAARE). Bivariate analyses revealed significant positive relationships between parent mental health status and two forms of racial socialization: spiritual/religious coping, and racial awareness teaching, while multivariate analyses supported the positive association between parental mental health and spiritual/religious coping. These results suggest that parental characteristics may influence the use of specific types of racial socialization to assist youth in coping with discriminatory societal messages.

An Introduction to Parenting and Mental Health Services Utilization Among African American Families: The Role of Racial Socialization.

The articles in this special issue are a significant contribution to the literature pertaining to racial socialization, which is defined as messages parents communicate about race and culture, how African Americans are perceived societally, and how to cope with discrimination due to their skin color. More specifically, these articles examine the relationship between racial socialization and parental mental health status, child socio-behavioral functioning, and the utilization of mental health and prevention services for both parent and child. Overall, the results of these articles indicate that various racial socialization practices do indeed influence key variables such as the child's behavioral functioning and decision-making, parental mental health status, and the receipt of prevention and mental health services. Implications of these findings suggest that racial socialization beliefs and practices may in fact influence the health and functioning of African American youth and families.

The Effect of Racial Socialization on Urban African American Use of Child Mental Health Services.

OBJECTIVE: To examine how parental endorsement of racial socialization parenting practices relates to child mental health service use among an urban sample of African American families. METHODS: A cross-sectional sample of urban African American parents (n = 96) provided ratings of their beliefs concerning various dimensions of racial socialization constructs, i.e., spiritual or religious coping (SRC), extended family caring (EFC), cultural pride reinforcement (CPR), and assessed regarding their use of child mental health services. RESULTS: At the multivariate level, the use of child mental health services was significantly positively associated with moderate levels of endorsement of SRC and EFC. Inversely, scores in the moderate range of CPR were associated with a reduced likelihood of child mental health service use. CONCLUSION: Parental endorsement of racial socialization parenting practices appear to play a salient role in child mental health service use among an urban African American families. Further research with larger and more representative samples should be pursued.

Symptoms of posttraumatic stress disorder in a community sample of low-income pregnant women.

OBJECTIVE: The purpose of this study was to examine symptoms of posttraumatic stress disorder (PTSD) in a community sample of low-income pregnant women who met the DSM-IV diagnostic criteria for the disorder. METHOD: Pregnant women (N=948) were screened for trauma, PTSD, depression, and co-occurring illicit substance use. PTSD symptoms were compared in traumatized pregnant women and a sample of nonpregnant traumatized women from the National Comorbidity Survey. RESULTS: Suicidal thoughts and a high degree of psychiatric comorbidity were common in pregnant women with PTSD. Pregnant women were selectively and significantly less likely to endorse reexperiencing symptoms of PTSD (29.5%, N=82), compared to nonpregnant women (79.4%, N=464). CONCLUSIONS: PTSD in pregnancy was associated with comorbidity, poor health behaviors, and lower recall of memory-related PTSD symptoms. Further prospective study is needed.

Screening for and detection of depression, panic disorder, and PTSD in public-sector obstetric clinics.

OBJECTIVE: This study assessed rates of detection and treatment of minor and major depressive disorder, panic disorder, and posttraumatic stress disorder among pregnant women receiving prenatal care at public-sector obstetric clinics. METHODS: Interviewers systematically screened 387 women attending prenatal visits. The screening process was initiated before each woman's examination. After the visit, patients were asked whether their clinician recognized a mood or anxiety disorder. Medical records were reviewed for documentation of psychiatric illness and treatment. RESULTS: Only 26 percent of patients who screened positive for a psychiatric illness were recognized as having a mood or anxiety disorder by their health care provider. Moreover, clinicians detected disorders among only 12 percent of patients who showed evidence of suicidal ideation. Women with panic disorder or a lifetime history of domestic violence were more likely to be identified as having a psychiatric illness by a health care provider at some point before or during pregnancy. All women who screened positive for panic disorder had received or were currently receiving mental health treatment outside the prenatal visit, whereas 26 percent of women who screened positive for major or minor depression had received or were currently receiving treatment outside the prenatal visit. CONCLUSIONS: Detection rates for depressive disorders in obstetric settings are lower than those for panic disorder and lower than those reported in other primary care settings. Consequently, a large proportion of pregnant women continue to suffer silently with depression throughout their pregnancy. Given that depressive disorders among perinatal women are highly prevalent and may have profound impact on infants and children, more work is needed to enhance detection and referral.