Research Review: The internalizing paradox - youth anxiety and depression symptoms, psychotherapy outcomes, and implications for research and practice.

BACKGROUND: Youth anxiety and depression have long been combined within the empirically derived internalizing syndrome. The two conditions show substantial comorbidity, symptom co-occurrence, and overlap in treatment procedures, but paradoxically diverge in psychotherapy outcomes: strong, positive effects for anxiety and weak effects for depression. METHODS: Drawing on recent research, we examine candidate explanations for this paradox to help identify strategies for addressing it by improving outcomes for youth depression. RESULTS: Candidate explanations include that youth depression, compared with youth anxiety, has more varied comorbidities and more heterogeneous symptom combinations, has greater uncertainty regarding mediators and mechanisms of change, is treated with more complex and potentially confusing protocols, and has characteristics that may impede client engagement. Candidate strategies for shrinking the psychotherapy effectiveness gap include personalizing through transdiagnostic modular treatment, simplifying therapy by focusing on empirically supported principles of change, developing effective strategies for engaging family members as intervention allies, using shared decision-making to inform clinical decisions and boost client engagement, capitalizing on youth-friendly technological advances, and shortening and digitizing treatments to enhance their accessibility and appeal. CONCLUSIONS: Recent advances suggest explanations for the internalizing paradox, which in turn suggest strategies for shrinking the youth anxiety-depression psychotherapy outcome gap; these form an agenda for a promising new era of research.

What Four Decades of Meta-Analysis Have Taught Us About Youth Psychotherapy and the Science of Research Synthesis.

Intervention scientists have published more than 600 randomized controlled trials (RCTs) of youth psychotherapies. Four decades of meta-analyses have been used to synthesize the RCT findings and identify scientifically and clinically significant patterns. These meta-analyses have limitations, noted herein, but they have advanced our understanding of youth psychotherapy, revealing (a) mental health problems for which our interventions are more and less successful (e.g., anxiety and depression, respectively); (b) the beneficial effects of single-session interventions, interventions delivered remotely, and interventions tested in low- and middle-income countries; (c) the association of societal sexism and racism with reduced treatment benefit in majority-girl and majority-Black groups; and, importantly, (d) the finding that average youth treatment benefit has not increased across five decades of research, suggesting that new strategies may be needed. Opportunities for the future include boosting relevance to policy and practice and using meta-analysis to identify mechanisms of change and guide personalizing of treatment.

Shared Decision-Making as a Tool for Navigating Multi-Stakeholder Discrepancies in Youth Psychotherapy.

OBJECTIVE: Discrepancies among the key stakeholders in youth psychotherapy (e.g., caregivers, youths) commonly present an obstacle to treatment planning, forcing clinicians to align with one perspective over another and increasing the likelihood of a treatment plan that is not fully responsive to divergent opinions. At the same time, multi-stakeholder discrepancies can also offer opportunities to build an inclusive, effective treatment plan, guided by the integration of numerous sources of domain-specific knowledge related to the concerns for which families seek clinical care. METHOD: We aim to: 1) investigate the degree to which multi-stakeholder discrepancies are observed when youths and caregivers are invited to report their treatment priorities, rather than the presence and severity of youth symptoms, 2) describe the rationale for, as well as the promise and challenges of, shared decision-making (SDM)-an approach designed to facilitate multi-stakeholder collaboration during treatment planning, 3) provide a case example illustrating how a clinician, youth, and caregiver could use SDM to navigate discrepancies and identify therapy targets, and 4) propose future directions for exploring the potential value of SDM in youth psychotherapy. RESULTS: Different levels of multi-stakeholder agreement were observed when caregivers and youths were asked to identify their treatment priorities, compared to youth symptom presence and severity, revealing nuances in multi-stakeholder agreement in youth psychotherapy. CONCLUSIONS: Multi-stakeholder discrepancies can inform treatment planning processes, and SDM may be an effective approach for navigating them and building a treatment plan that integrates the perspective of all stakeholders in youth psychotherapy.

Shifting the discourse on disability: Moving to an inclusive, intersectional focus.

Individuals with disabilities comprise one of the largest marginalized groups in the United States and experience systemic barriers in health care. In Westernized communities, disability has historically been conceptualized via the medical model, which considers disability an individual-level deficit in need of correction. Although other models of disability (e.g., social model) have been developed to address the medical model's ableist shortcomings, these fail to consistently acknowledge intersectionality. Specifically, these models fail to consider that (a) a disabled individual may hold other marginalized or oppressed identities and (b) these intersecting oppressions may exacerbate health inequities. Intersectionality, which originates from Black feminist literature, describes the ways that systems of power and oppression (e.g., racism, sexism) interact to form an individual's unique experience. To date, the intersection of disability and other marginalized identities has been neglected in psychology and related fields, leaving little guidance for how scholars, clinicians, and other stakeholders can address disability via an intersectional lens. The present article discusses how a disability-affirmative, intersectional approach can serve as a strategy for challenging and reforming oppressive systems across the field of psychology. We assert that, ultimately, this approach has the potential to optimize and expand access to equitable, inclusive mental health care, and we propose actionable steps psychologists can take in research, practice, training, and policy in pursuit of this aim. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Operations Triad Model and Youth Mental Health Assessments: Catalyzing a Paradigm Shift in Measurement Validation.

Researchers strategically assess youth mental health by soliciting reports from multiple informants. Typically, these informants (e.g., parents, teachers, youth themselves) vary in the social contexts where they observe youth. Decades of research reveal that the most common data conditions produced with this approach consist of discrepancies across informants' reports (i.e., informant discrepancies). Researchers should arguably treat these informant discrepancies as domain-relevant information: data relevant to understanding youth mental health domains (e.g., anxiety, depression, aggression). Yet, historically, in youth mental health research as in many other research areas, one set of paradigms has guided interpretations of informant discrepancies: Converging Operations and the Multi-Trait Multi-Method Matrix (MTMM). These paradigms (a) emphasize shared or common variance observed in multivariate data, and (b) inspire research practices that treat unique variance (i.e., informant discrepancies) as measurement confounds, namely random error and/or rater biases. Several yearsw ago, the Operations Triad Model emerged to address a conceptual problem that Converging Operations does not address: Some informant discrepancies might reflect measurement confounds, whereas others reflect domain-relevant information. However, addressing this problem requires more than a conceptual paradigm shift beyond Converging Operations. This problem necessitates a paradigm shift in measurement validation. We advance a paradigm (Classifying Observations Necessitates Theory, Epistemology, and Testing [CONTEXT]) that addresses problems with using the MTMM in youth mental health research. CONTEXT optimizes measurement validity by guiding researchers to leverage (a) informants that produce domain-relevant informant discrepancies, (b) analytic procedures that retain domain-relevant informant discrepancies, and (c) study designs that facilitate detecting domain-relevant informant discrepancies.

The Biochemical Assessment of Mitochondrial Respiratory Chain Disorders.

Mitochondrial respiratory chain (MRC) disorders are a complex group of diseases whose diagnosis requires a multidisciplinary approach in which the biochemical investigations play an important role. Initial investigations include metabolite analysis in both blood and urine and the measurement of lactate, pyruvate and amino acid levels, as well as urine organic acids. Recently, hormone-like cytokines, such as fibroblast growth factor-21 (FGF-21), have also been used as a means of assessing evidence of MRC dysfunction, although work is still required to confirm their diagnostic utility and reliability. The assessment of evidence of oxidative stress may also be an important parameter to consider in the diagnosis of MRC function in view of its association with mitochondrial dysfunction. At present, due to the lack of reliable biomarkers available for assessing evidence of MRC dysfunction, the spectrophotometric determination of MRC enzyme activities in skeletal muscle or tissue from the disease-presenting organ is considered the 'Gold Standard' biochemical method to provide evidence of MRC dysfunction. The purpose of this review is to outline a number of biochemical methods that may provide diagnostic evidence of MRC dysfunction in patients.

The Needs-to-Goals Gap: How informant discrepancies in youth mental health assessments impact service delivery.

Over 60 years of research reveal that informants who observe youth in clinically relevant contexts (e.g., home, school)-typically parents, teachers, and youth clients themselves-often hold discrepant views about that client's needs for mental health services (i.e., informant discrepancies). The last 10 years of research reveal that these discrepancies reflect the reality that (a) youth clients' needs may vary within and across contexts and (b) informants may vary in their expertise for observing youth clients within specific contexts. Accordingly, collecting and interpreting multi-informant data comprise "best practices" in research and clinical care. Yet, professionals across settings (e.g., health, mental health, school) vary in their use of multi-informant data. Specifically, professionals differ in how or to what degree they leverage multi-informant data to determine the goals of services designed to meet youth clients' needs. Further, even when professionals have access to multiple informants' reports, their clinical decisions often signal reliance on one informant's report, thereby omitting reports from other informants. Together, these issues highlight an understudied research-to-practice gap that limits the quality of services for youth. We advance a framework-the Needs-to-Goals Gap-to characterize the role of informant discrepancies in identifying youth clients' needs and the goals of services to meet those needs. This framework connects the utility of multi-informant data with the reality that services often target an array of needs within and across contexts, and that making decisions without accurately integrating multiple informants' reports may result in suboptimal care. We review evidence supporting the framework and outline directions for future research.

Effectiveness of youth psychotherapy delivered remotely: A meta-analysis.

Reports on remote psychotherapies for youth (e.g., technology-based treatment) suggest it is acceptable, feasible, and useful in overcoming logistical barriers to treatment. But how effective is remote care? To find out, PsycINFO and PubMed were searched from 1960 through 2020, supplemented by journal searches and reference trails, to identify randomized controlled trials of youth psychotherapy for anxiety (including obsessive-compulsive disorder and trauma), depression, attention-deficit/hyperactivity disorder (ADHD), or conduct problems, in which all therapeutic contact occurred remotely. Articles (N = 37) published from 1988 through 2020, reporting 43 treatment-control group comparisons, were identified. Robust variance estimation was used to account for effect size dependencies and to synthesize overall effects and test candidate moderators. Pooled effect size was .47 (95% confidence interval [CI: .26, .67], p < .001) at posttreatment, .44 (95% CI [.12, .76], p < .05) at follow-up-comparable to effects reported in meta-analyses of in-person youth psychotherapy. Effects were significantly (a) larger for remote psychotherapies supported by therapeutic provider contact (.64) than for those accessed by youths, with only logistical support (.22), (b) larger for treatments with phone contact (.65) than for those without (.25), (c) larger for treatment of anxiety (.62) and conduct problems (.78) than ADHD (-.03), and (d) smaller for therapies involving attention/working memory training (-.18) than for those without (.60). Among studies with therapeutic contact, effects were significantly larger when therapists facilitated skill-building (e.g., practicing exposures or problem solving [.68]) than when therapists did not (.18). These findings support the effectiveness of remote psychotherapies for youths, and they highlight moderators of treatment benefit that warrant attention in future research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Using Mixed Methods to Identify the Primary Mental Health Problems and Needs of Children, Adolescents, and Their Caregivers during the Coronavirus (COVID-19) Pandemic.

Our understanding of child, adolescent, and caregiver mental health (MH) problems during the coronavirus pandemic, and which interventions are needed, may be advanced by consumer input. 133 general population caregivers reported top MH problems and needs for themselves and their children (Mage = 8.21; SD = 4.94), using standardized and idiographic measures. We applied linear regression models to quantitative data and thematic analysis to qualitative data. Caregivers' COVID-era depression and anxiety symptom means fell within the clinical range, as did their children's MH symptoms. Caregiver-reported child and adolescent symptoms were positively associated with number of children in the home. Caregiver and caregiver-reported child and adolescent symptoms were more pronounced in regions with more lenient COVID-19 restrictions. Among the kinds of help most urgently needed, MH services were ranked #1 for caregivers and adolescents, #2 for 6-12 year-olds, and #3 for 1-5 year-olds. Top problems identified for each age group highlight pressing pandemic-related intervention targets.

Adolescent Suicide Attempt Prevention: Predictors of Response to a Cognitive-Behavioral Family and Youth Centered Intervention.

OBJECTIVE: Suicide is a leading cause of adolescent death. Recent data support the efficacy of cognitive-behavioral treatments with strong family components for reducing suicide risk; however, not all youth benefit from current interventions. Identifying predictors of treatment response can inform treatment selection and optimize benefits. METHOD: This study examines predictors of response to a DBT-informed cognitive-behavioral family treatment (SAFETY), among 50 youth with recent suicide attempts/self-harm. Youth and parents were assessed at baseline and post-treatment. RESULTS: Results indicated medium-to-large effect sizes for SAFETY on youth suicidal behavior (SB; defined as suicide attempts, aborted attempts, and planning), depression, hopelessness, social adjustment, and parental depression. Classification tree analysis, with a correct classification rate of 93.3%, and follow-up logistic analyses indicated that 35% of youths reporting active SB at baseline reported active SB at post-treatment, whereas post-treatment SB was rare among youths whose active suicidality had resolved by the baseline assessment (5%). Among youths reporting baseline SB, those endorsing sleep problems were more likely to report post-treatment SB (53%) versus those without sleep problems (0%). CONCLUSIONS: These findings highlight the potential value of personalized treatment approaches based on pretreatment characteristics and the significance of baseline SB and sleep problems for predicting treatment response.

Who benefits the most from cognitive change in cognitive therapy of depression? A study of interpersonal factors.

OBJECTIVE: Research suggests that decreases in negative cognitions coincide with symptom improvements over the course of cognitive therapy (CT) of depression, but the role cognitive change (CC) plays in reducing symptoms remains controversial. METHOD: A total of 126 adults (mean age = 31.7, SD = 13.35; 60% female; 83% Caucasian) participated in CT for depression. Patients completed the Beck Depression Inventory-II and the Immediate Cognitive Change Scale at each session. At intake evaluation, maladaptive personality traits (Personality Inventory for DSM-5, Brief Form) and interpersonal problems (Inventory of Interpersonal Problems, Short Version) were assessed via self-report, and social skills were assessed through patients' evaluation of their performance following a series of behavioral role-plays (standardized interaction task). To rule out between-patient differences as potential confounds, our model disaggregated within- and between-patient components of CC and depression scores. RESULTS: Within-patient CC significantly predicted within-patient change in depressive symptoms. This relation was moderated by patients' evaluations of their social skills and patients' level of interpersonal problems, with CC predicting symptoms more robustly for patients with fewer perceived social skills and for those with greater interpersonal problems. Maladaptive personality traits did not emerge as a moderator. Additional analyses showed the relation of CC and symptom change was particularly strong among those with social anxiety disorder and among those observers rated as having lower social skills. CONCLUSIONS: CC in CT sessions appears to foster subsequent depressive symptom reduction, especially among patients with lower levels of self-evaluated social skills and greater interpersonal problems. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Reducing Health Risk Behaviors and Improving Depression in Adolescents: A Randomized Controlled Trial in Primary Care Clinics.

Objective: Primary care (PC) is a major service delivery setting that can provide preventive behavioral health care to youths. To explore the hypothesis that reducing health risk behaviors (HRBs) would lower depressive symptoms, and that health risk and depression can be efficiently targeted together in PC, this study (1) evaluates an intervention designed to reduce HRBs among adolescent PC patients with depressive symptoms and (2) examines prospective links between HRBs and depressive symptoms. Method: A Randomized controlled trial was conducted comparing a behavioral health intervention with enhanced Usual PC (UC+). Participants were 187 adolescents (ages 13-18 years) with past-year depression, assessed at baseline, 6 months, and 12 months. Primary outcome was the Health Risk Behavior Index (HRBI), a composite score indexing smoking, substance use, unsafe sex, and obesity risk. Secondary/exploratory outcomes were an index of the first three most correlated behaviors (HRBI-S), each HRB, depressive symptoms, and satisfaction with mental health care. Results: Outcomes were similar at 6 and 12 months, with no significant between-group differences. HRBI, HRBI-S, and depressive symptoms decreased, and satisfaction with mental health care increased across time in both groups. HRBI, HRBI-S, and smoking predicted later severe depression. Conversely, severe depression predicted later HRBI-S and substance use. Conclusions: UC+ and the behavioral health intervention yielded similar benefits in reducing HRBs and depressive symptoms. Findings underscore the bidirectional links between depression and HRBs, supporting the importance of monitoring for HRBs and depression in PC to allow for effective intervention in both areas.