Feasibility of Text Messages for Enhancing Therapeutic Engagement Among Youth and Caregivers Initiating Outpatient Mental Health Treatment: Mixed Methods Study.

BACKGROUND: Pathways to mental health services for youth are generally complex and often involve numerous contact points and lengthy delays. When starting treatment, there are a host of barriers that contribute to low rates of therapeutic engagement. Automated text messages offer a convenient, low-cost option for information sharing and skill building, and they can potentially activate positive behaviors in youth and caregivers prior to beginning formal therapy. To date, there is little evidence for the feasibility of initiating transdiagnostic text messages during the early stages of youth and caregiver contact with community outpatient mental health services. OBJECTIVE: To develop and test the feasibility of implementing 2 novel text messaging campaigns aimed at youth clients and their caregivers during the early stages of engaging with outpatient mental health services. METHODS: A multidisciplinary panel of experts developed two 12-message interventions with youth and caregivers prior to deployment. Each message included a link to an external interactive or multimedia resource to extend skill development. Enrollment of youth aged 13 to 18 years, their caregivers, or both occurred at 2 early treatment timepoints. At both time points, text messages were delivered automatically 2 times a week for 6 weeks. Analytics and survey data were collected in 2 phases, between January and March 2020 and between January and May 2021. Enrollment, willingness to persist in using the intervention, engagement, satisfaction, perceived value, and impact were measured. Descriptive statistics were used to summarize youth and caregiver outcomes. RESULTS: A total of 41 caregivers and 36 youth consented to participate. Follow-up survey response rates were 54% (22/41) and 44%, (16/36) respectively. Over 1500 text messages were sent throughout the study. More than three-quarters (14/16, 88%) of youth reported that they learned something new and noticed a change in themselves due to receiving the texts; the same proportion (14/16, 88%) of youth said they would recommend the text messages to others. Youth ranked the first text message, related to coping with difficult emotions, as the most helpful of the series. Caregivers reported acting differently due to receiving the texts. Over two-thirds of caregivers were satisfied with the texts (16/22, 73%) and would recommend them to others (16/22, 73%). Caregivers perceived diverse levels of value in the text topics, with 9 of the 12 caregiver texts rated by at least one caregiver as the most helpful. CONCLUSIONS: Results are preliminary but show that brief, core skill-focused text messages for youth clients and caregivers in community outpatient mental health services are feasible. Both youth and caregivers reported promising knowledge and behavior change with exposure to only 12 messages over 6 weeks. A larger study with statistical power to detect changes in both perceived helpfulness and engagement is required to confirm the effectiveness of this type of transdiagnostic intervention.

Text Message Interventions in Adolescent Mental Health and Addiction Services: Scoping Review.

BACKGROUND: The vast majority of adolescent mental health and substance use disorders go undiagnosed and undertreated. SMS text messaging is increasingly used as a method to deliver adolescent health services that promote psychological well-being and aim to protect adolescents from adverse experiences and risk factors critical for their current and future mental health. To date, there has been no comprehensive synthesis of the existing literature on the extent, range, and implementation contexts of these SMS text message interventions. OBJECTIVE: The objective of this scoping review was to map and categorize gaps in the current body of peer-reviewed research around the use of SMS text messaging-based interventions for mental health and addiction services among adolescents. METHODS: A scoping review was conducted according to Levac's adaptation of Arksey and O'Malley's methodological framework for scoping reviews in six iterative stages. A search strategy was cocreated and adapted for five unique databases. Studies were screened using Covidence software. The PICO (patient, intervention, comparator, outcome) framework and input from multiple stakeholder groups were used to structure and pilot a data extraction codebook. Data were extracted on study methodology and measures, intervention design, and implementation characteristics, as well as policy, practice, and research implications. RESULTS: We screened 1142 abstracts. Of these, 31 articles published between 2013 and 2020 were eligible for inclusion. Intervention engagement was the most common type of outcome measured (18/31), followed by changes in cognitions (16/31; eg, disease knowledge, self-awareness) and acceptability (16/31). Interventions were typically delivered in less than 12 weeks, and adolescents received 1-3 messages per week. Bidirectional messaging was involved in 65% (20/31) of the studies. Limited descriptions of implementation features (eg, cost, policy implications, technology performance) were reported. CONCLUSIONS: The use of SMS text messaging interventions is a rapidly expanding area of research. However, lack of large-scale controlled trials and theoretically driven intervention designs limits generalizability. Significant gaps in the literature were observed in relation to implementation considerations, cost, clinical workflow, bidirectionality of texting, and level of personalization and tailoring of the interventions. Given the growth of mobile phone-based interventions for this population, a rigorous program of large-scale, well-designed trials is urgently required.

Effectiveness of Day Treatment for Disruptive Behaviour Disorders: What is the Long-term Clinical Outcome for Children?

OBJECTIVE: The present study investigates the clinical long-term outcomes (2½ to 4 years post-discharge) of children aged 12 and under with a primary diagnosis of a Disruptive Behaviour Disorder (DBD) who attended a short-term day treatment program using best-practice treatment strategies. This study compared children's admission, discharge, and follow-up test scores on standardized measures of behaviour and functioning, as rated by parents. METHOD: Measures of clinical symptoms in the children and parent report of stress were used. To test for treatment effects across time, two repeated-measures ANOVAs were calculated. RESULTS: There was significant treatment change across time points on measures of social problems, externalizing symptoms, levels of aggression, intensity of problems, and symptoms of ADHD. CONCLUSIONS: Children with DBD who attended a short-term day treatment program using best-practice treatment strategies showed significant improvement in their behaviour at home. These improvements were relatively long lasting. The current study lends support to the effectiveness of day treatment and the idea that severe DBD can be treated using multi-modal, intensive, and evidence-based treatment techniques resulting in long-term change.

Day treatment for disruptive behaviour disorders: can a short-term program be effective?

OBJECTIVE: The present study investigates the effectiveness of a short-term day treatment program for children with a primary diagnosis of a Disruptive Behaviour Disorder (DBD) using best-practice treatment strategies. This study, using a wait list control, compared children's admission and discharge test scores on standardized measures of behaviour and functioning, as rated by parents. METHOD: A repeated measures MANOVA was used to evaluate symptom change. RESULTS: The treatment group was found to have improved significantly more than the waitlist group on parent reports of externalizing behaviour, aggression, social problems, hyperactivity and parent stress. CONCLUSIONS: Children with DBD who attended a short-term day treatment program using best-practice treatment strategies showed significant improvement in their behaviour at home. The current study lends support to the idea that severe DBD can be treated using multi-modal, intensive and evidence-based treatment techniques.

Prevention and intervention strategies to alleviate preoperative anxiety in children: a critical review.

Preoperative anxiety (anxiety regarding impending surgical experience) in children is a common phenomenon that has been associated with a number of negative behaviors during the surgery experience (e.g., agitation, crying, spontaneous urination, and the need for physical restraint during anesthetic induction). Preoperative anxiety has also been associated with the display of a number of maladaptive behaviors postsurgery, including postoperative pain, sleeping disturbances, parent-child conflict, and separation anxiety. For these reasons, researchers have sought out interventions to treat or prevent childhood preoperative anxiety and possibly decrease the development of negative behaviors postsurgery. Such interventions include sedative premedication, parental presence during anesthetic induction, behavioral preparation programs, music therapy, and acupuncture. The present article reviews the existing research on the various modes of intervention for preoperative anxiety in children. Clinical implications and future directions are discussed.

Effects of midazolam on explicit vs implicit memory in a pediatric surgery setting.

RATIONALE: Placebo-controlled studies show that midazolam impairs explicit memory in children undergoing surgery (Buffett-Jerrott et al., Psychopharmacology 168:377-386, 2003; Kain et al., Anesthesiology 93:676-684, 2000). A recent within-subjects study showed that midazolam impaired explicit memory while leaving implicit memory intact in a sample of older children undergoing painful medical procedures (Pringle et al., Health Psychol 22:263-269, 2003). OBJECTIVES: We attempted to replicate and extend these findings in a randomized, placebo-controlled design with younger children undergoing surgery. MATERIALS AND METHODS: Children aged 3-6 years who were undergoing ear tube (myringotomy) surgery were randomly assigned to receive midazolam (n = 12) or placebo (n = 11). After surgery, they were tested on explicit (recognition) and implicit (priming) memory for pictures encoded before surgery. RESULTS: Relative to placebo, the midazolam-treated children showed poorer recognition memory on the explicit task but equivalent priming on the implicit task. CONCLUSIONS: Overall, it appears that midazolam induces a dissociation between explicit and implicit memory in young children in the pediatric surgery setting. Theoretical and clinical implications of the findings are discussed along with directions for future research.

High levels of impulsivity may contraindicate midazolam premedication in children.

PURPOSE: To investigate the effects of midazolam on emotional reactivity during induction of anesthesia in a pediatric day surgery setting. A secondary purpose was to determine if these effects were influenced by child temperament factors. METHODS: Forty children (age four to six years) scheduled for myringotomy were randomly assigned, in a double blind fashion, to receive either oral midazolam 0.5 mg.kg-1 mixed with acetaminophen suspension or acetaminophen alone. The Emotionality, Activity, Sociability, and Impulsivity (EASI) scale was used as a measure of child temperament. The modified Yale Preoperative Anxiety Scale (m-YPAS), an observer-rated measure of state anxiety, was employed to assess anxiety pre- and post-drug, and also at induction of anesthesia. RESULTS: Children who received midazolam reacted significantly less to induction of anesthesia than did children in the placebo control group, F (1, 38) = 7.46, P = 0.01. A significant positive association was observed between baseline levels of anxiety and observer-rated anxiety at anesthetic induction, but only in the placebo group, r = 0.58, P < 0.01. A significant positive association was observed between levels of impulsivity at baseline and observer-rated anxiety at anesthetic induction, but only in the midazolam group, r = 0.42, P < 0.05. CONCLUSIONS: Midazolam dampened adverse reactivity during anesthetic induction, particularly among children with high baseline levels of anxiety. Baseline level of impulsivity was positively associated with adverse reactions to anesthesia induction in the drug group, but not in the placebo group, suggesting that high levels of trait impulsivity may contraindicate the use of midazolam as a preoperative medication.

Effects of benzodiazepines on explicit memory in a paediatric surgery setting.

RATIONALE: Many laboratory-based studies indicate that benzodiazepines impair explicit memory performance, increase sedation, and impair attention. OBJECTIVES: The present study was designed to extend prior lab-based findings to an applied setting in which the amnestic effects of benzodiazepines may be beneficial for users. In addition, the study extended the previous adult-focused research by examining the cognitive effects of benzodiazepines in children. METHODS: The present study examined the use of a specific benzodiazepine (midazolam) as a premedicant among 40 children aged 4-6 years old having ear tube (myringotomy) surgery, who were randomly assigned to receive midazolam or placebo. RESULTS: Consistent with previous studies, the results indicated that midazolam causes significant amnesia on a cued recall task. In addition, free recall for post-drug events were also impaired by midazolam relative to placebo, indicating that benzodiazepine-induced amnesia occurs even for highly salient information. CONCLUSIONS: Overall, it appears that benzodiazepines do impair memory in a pediatric population. This amnesia was not secondary to the inattention and sedation also caused by midazolam administration. The theoretical and clinical implications of these findings are discussed, as are potential future studies.