The process of adapting a sexual health intervention for Black early adolescents: a stakeholder engagement approach.

Young Black women are disproportionately affected by sexually transmitted infections (STIs) and HIV. Notably, few sexual health interventions for Black girls have documented the process of utilizing stakeholder input from the Black community to culturally tailor content. We conducted formative work in Chicago to adapt a mother-daughter HIV/STI prevention intervention originally designed for Black adolescent girls aged 14-18 years to meet the needs of early adolescent girls aged 11-13 years. Our iterative process involved three phases: (i) soliciting feedback from an expert panel and community advisory board; (ii) conducting focus groups with experienced research participants; and (iii) theater testing a new curriculum in the target population. Key findings of this process indicate the importance of sophisticated community engagement strategies to shape research design and program implementation. Findings may be used to inform processes for future adaptation work, especially in sexual health programs for young Black girls and their mothers.

Pathways from witnessing community violence to mental health problems among South African adolescents.

BACKGROUND: The intersection of violence exposure and mental health problems is a public health crisis for South African (SA) adolescents. Understanding the impact of community violence on adolescent mental health can inform future interventions. OBJECTIVES: To assess pathways between community violence exposure and internalising and externalising problems in SA adolescents receiving mental healthcare, and the roles of parent and peer relationships in these associations. METHODS: Participants (N=120 parent-adolescent pairs) were recruited from four mental health clinics in Western Cape Province to participate in a pilot test of a family-based HIV prevention study. Adolescents reported on their exposure to community violence, parental attachment, peer support of risk behaviour, and mental health. Parents reported on adolescents' internalising and externalising mental health problems. Participants received transport money (ZAR30 = USD3) and a shopping voucher or cash (ZAR50 = USD5) for their time. RESULTS: Adolescents were 12 - 18 years old (mean (standard deviation) 14.39 (1.82) years), 53% were male, and 67% and 33% reported black African and mixed-race ethnicity, respectively. Parents were 94% female and reported an average monthly income of ZAR3 973 (USD397). Boys reported significantly higher rates of witnessing community violence than girls. Among boys, significant paths emerged from community violence and low parent attachment to externalising symptoms and from community violence to peer support of risky behaviour. For girls, the only significant path was from low parent attachment to peer support of risky behaviour. CONCLUSIONS: This cross-sectional study sheds new light on the possible pathways from witnessing community violence to mental health problems among SA adolescents. Identifying factors that drive and mitigate psychological distress in the context of persistent community violence is critical to SA's future and can inform the selection and delivery of appropriate and targeted evidence-based interventions.

An Exploration of Family and Juvenile Justice Systems to Reduce Youth HIV/STI Risk.

Using in-depth interviews with 20 probation youth (60% female; 35% white; 30% Hispanic; mean age 15years, range=13-17), their caregivers (100% female; mean age 44years, range=34-71) and 12 female probation officers (100% white; mean age 46years, range=34-57), we explored how family and probation systems exacerbate or mitigate sexual risk. We conducted thematic analyses of interviews, comparing narratives of families of sexually risky (n=9) versus non-sexually risky (n=11) youth. Family functioning differed by youth sexual risk behavior around quality of relationships, communication, and limit-setting and monitoring. The involvement of families of sexually risky youth in probation positively influenced family functioning. Data suggest these families are amenable to intervention and may benefit from family-based HIV/STI interventions delivered in tandem with probation.

Understanding AIDS-risk behavior among adolescents in psychiatric care: links to psychopathology and peer relationships.

OBJECTIVE: Severely mentally ill youths are at elevated risk for human immunodeficiency virus infection, but little is known about acquired immunodeficiency syndrome (AIDS) risk behavior in adolescents who seek outpatient mental health services or about the links between psychiatric problems and particular high-risk behaviors. This pilot study used structural equation modeling to conduct a path analysis to explore the direct and indirect effects of adolescent psychopathology on risky sex, drug/alcohol use, and needle use. METHOD: Ethnically diverse youths (N = 86) and their caregivers who sought outpatient psychiatric services in Chicago completed questionnaires of adolescent psychopathology. Youths reported their relationship attitudes, peer influence, sexual behavior, and drug/alcohol use. RESULTS: Different AIDS-risk behaviors were associated with distinct forms of adolescent psychopathology (e.g., delinquency was linked to drug/alcohol use, whereas aggression was related to risky sexual behavior), and peer influence mediated these linkages. Some patterns were similar for caregiver- and adolescent-reported problems (e.g., peer influence mediated the relation between delinquency and drug/alcohol use), but others were different (e.g., caregiver-reported delinquency was associated with risky sex, whereas adolescent-reported delinquency was not). CONCLUSIONS: Findings underscore the complexity of factors (types of informants and dimensions of psychopathology) that underlie AIDS risk in troubled youths, and they offer specific directions for designing and implementing uniquely tailored AIDS prevention programs, for example, by targeting delinquent behavior and including high-risk peers and important family members in interventions.

Clinical trials versus mental health services research: contributions and connections.

The growing emphasis on using empirical data to guide mental health policy decision making has contributed, in part, to a developing dichotomy along the continuum of research on mental health interventions. At one end of the continuum is research on the efficacy of mental health interventions, traditionally referred to as clinical trials research. The goal of clinical trials research is to determine whether or not a specific intervention can be shown to be efficacious for a specific problem. At the other end of the continuum is research on the implementation and evaluation of mental health interventions, traditionally referred to as mental health services research. The goals of mental health services research are to understand the access to, organization and financing of, and outcomes of mental health interventions. The conceptual, methodological, and measurement features of both types of research are presented and suggestions are offered to bridge the gap between the two paradigms. The purpose of this article is to highlight each discipline's unique contributions to mental health research and, in so doing, facilitate a discussion that fosters scientific integration and collaboration between clinical trials and mental health services investigators.

Reconsidering "between-group psychotherapy outcome research and basic science:" applications to child and adolescent psychotherapy outcome research.

Borkovec and Miranda (1996) proposed that the purpose of controlled outcome studies is to increase our understanding of the change mechanisms associated with psychotherapy, and they suggested several ways that between-group outcome research establishes cause-and-effect relationships. Child psychotherapy outcome research presents special challenges for the issues raised by Borkovec and Miranda and four of these are discussed herein: (a) the multitude of influences on children and adolescents that affect their functioning and therapy outcomes, (b) accurately defining the referral problem, (c) identifying appropriate outcome measures and reliable informants of change in child and adolescent treatment, and (d) considering developmental processes that influence therapeutic effectiveness. It is suggested that transporting clinical trials methods to natural settings is of limited value in identifying cause-and-effect relationships, and an alternative methodology is proposed for advancing child therapy outcome research. This approach advocates developing a profile of the underlying causes that predict psychopathology and therapy outcome for individual children in real clinical settings and then aggregating the data for youth with similar profiles and outcomes. These data can then be used to generate hypotheses about what interventions work for specific children, and investigators can employ prospective studies of therapy outcome for youth with similar profiles.

Experimental task and speaker effects on parent-child interactions of aggressive and depressed/anxious children.

Parent-child interactions of aggressive and depressed/anxious clinic-referred children were observed during two different tasks: planning a vacation and discussing a conflict. Marked group differences were found as a function of the type of task, who was speaking (parent vs. child), and type of child psychopathology. Negative behaviors (e.g., Belittling and Blaming) were especially pronounced in the conflict task, whereas positive behaviors (e.g., Nurturing and Protecting) were more common in the planning task. Parents displayed other-directed behavior (e.g., Watching and Controlling), whereas children showed more self-directed behavior (e.g., Walling Off and Distancing), and patterns of child psychopathology interacted with task and speaker in theoretically important ways; for example, parents of aggressive children showed more Belittling and Blaming than their children in the conflict task, but not in the planning task. The findings highlight key factors that may need to be incorporated into models of parent-child interaction and child psychopathology.

Bridging the gap between laboratory and clinic in child and adolescent psychotherapy.

Meta-analyses of laboratory outcome studies reveal beneficial effects of psychotherapy with children and adolescents. However, the research therapy in most of those lab studies differs from everyday clinic therapy in several ways, and the 9 studies of clinic therapy the authors have found show markedly poorer outcomes than research therapy studies. These findings suggest a need to bridge the long-standing gap between outcome researchers and clinicians. Three kinds of bridging research are proposed and illustrated: (a) enriching the research data base on treatment effects by practitioners in clinical settings--including private practice and health maintenance organizations, (b) identifying features of research therapy that account for positive outcomes and applying those features to clinical practice, and (c) exporting lab-tested treatments to clinics and assessing their effects with referred youths. If these bridging strategies were widely adopted, despite the numerous obstacles described herein, real progress might be made toward more effective treatment in clinical practice.

Child and adolescent psychotherapy outcomes in experiments versus clinics: why the disparity?

In a recent article, Weisz, Weiss, and Donenberg (1992) compared the effects of child and adolescent psychotherapy in experimental studies and in studies of clinic practice. Here we update that report with new information and we explore 10 possible reasons why, to date, therapy in experiments appears to have shown larger effect sizes than therapy in clinics. We find that beneficial therapy effects are associated with three factors which are more common in research therapy than in clinic therapy: (a) the use of behavioral (including cognitive-behavioral) methods, (b) reliance on specific, focused therapy methods rather than mixed and eclectic approaches, and (c) provision of structure (e.g., through treatment manuals) and monitoring (e.g., through review of therapy tapes) to foster adherence to treatment plans. These three factors all involve dimensions along which clinic procedures could be altered.

The impact of young children with externalizing behaviors on their families.

Compared the impact on families of young children with externalizing behaviors (e.g., hyperactive, aggressive; n = 22), autism (n = 20), or no significant problem behaviors (n = 22) on several measures of family functioning. Previous studies have found heightened stress and parental maladjustment in families with externalizing children. The present study expanded upon that literature by (1) including a clinical control group to determine the specific impact of externalizing problems, (2) focusing on preschool aged children, and (3) using a new measure to directly ascertain parents' perception of impact. Compared to parents with normally developing children, parents with externalizing children reported more negative impact on social life, more negative and less positive feelings about parenting, and higher child-related stress. Moreover, parents of externalizing children reported levels of impact and stress as high as those reported by parents of children with autism. On broader measures of parental and marital well-being, however, the three groups of families of preschoolers did not differ. The implications of these findings for intervention are discussed.

The lab versus the clinic. Effects of child and adolescent psychotherapy.

Four recent meta-analyses, involving more than 200 controlled outcome studies, have shown consistent evidence of beneficial therapy effects with children and adolescents. However, most of the studies involved experimental procedures, nonreferred subjects, specially trained therapists with small caseloads, and other features that may not represent conventional clinic therapy. Research focused on more representative treatment of referred clients in clinics has shown more modest effects; in fact, most clinic studies have not shown significant effects. Interpretation studies have not shown significant effects. Interpretation of these findings requires caution; such studies are few and most could profit from improved methodology. The clinic studies do raise questions as to whether the positive lab findings can be generalized to the clinics where most therapy occurs; however, the lab interventions that have worked so well may point the way to enhanced therapy effects in clinics.