School Mental Health Professionals' Knowledge of Stereotypes and Implicit Bias Toward Black and Latinx Youths.

Clinician bias is a contributor to health care inequities, but research on racial-ethnic bias among mental health professionals, especially toward minoritized youths, is limited. This column describes two studies involving mental health clinicians in schools, where most youths access mental health services. Study 1 used a mixed-methods approach to identify stereotypes about Black and Latinx youths salient to clinicians (e.g., academic failure; anger and aggression). In study 2, the authors developed four Implicit Association Tests to assess clinicians' implicit prejudice and stereotyping of Black and Latinx youths and found pro-White and anti-Black/Latinx bias at levels similar to those of other health care providers and the general population.

How low can you go? Examining the effects of brief online training and post-training consultation dose on implementation mechanisms and outcomes for measurement-based care.

BACKGROUND: Initial training and ongoing post-training consultation (i.e., ongoing support following training, provided by an expert) are among the most common implementation strategies used to change clinician practice. However, extant research has not experimentally investigated the optimal dosages of consultation necessary to produce desired outcomes. Moreover, the degree to which training and consultation engage theoretical implementation mechanisms-such as provider knowledge, skills, and attitudes-is not well understood. This study examined the effects of a brief online training and varying dosages of post-training consultation (BOLT+PTC) on implementation mechanisms and outcomes for measurement-based care (MBC) practices delivered in the context of education sector mental health services. METHODS: A national sample of 75 clinicians who provide mental health interventions to children and adolescents in schools were randomly assigned to BOLT+PTC or control (services as usual). Those in BOLT+PTC were further randomized to 2-, 4-, or 8-week consultation conditions. Self-reported MBC knowledge, skills, attitudes, and use (including standardized assessment, individualized assessment, and assessment-informed treatment modification) were collected for 32 weeks. Multilevel models were used to examine main effects of BOLT+PTC versus control on MBC use at the end of consultation and over time, as well as comparisons among PTC dosage conditions and theorized mechanisms (skills, attitudes, knowledge). RESULTS: There was a significant linear effect of BOLT+PTC over time on standardized assessment use (b = .02, p < .01), and a significant quadratic effect of BOLT+PTC over time on individualized assessment use (b = .04, p < .001), but no significant effect on treatment modification. BOLT + any level of PTC resulted in higher MBC knowledge and larger growth in MBC skill over the intervention period as compared to control. PTC dosage levels were inconsistently predictive of outcomes, providing no clear evidence for added benefit of higher PTC dosage. CONCLUSIONS: Online training and consultation in MBC had effects on standardized and individualized assessment use among clinicians as compared to services as usual with no consistent benefit detected for increased consultation dosage. Continued research investigating optimal dosages and mechanisms of these established implementation strategies is needed to ensure training and consultation resources are deployed efficiently to impact clinician practices. TRIAL REGISTRATION: ClinicalTrials.gov NCT05041517 . Retrospectively registered on 10 September 2021.

A Brief Online Implicit Bias Intervention for School Mental Health Clinicians.

Clinician bias has been identified as a potential contributor to persistent healthcare disparities across many medical specialties and service settings. Few studies have examined strategies to reduce clinician bias, especially in mental healthcare, despite decades of research evidencing service and outcome disparities in adult and pediatric populations. This manuscript describes an intervention development study and a pilot feasibility trial of the Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT) for mental health clinicians in schools-where most youth in the U.S. access mental healthcare. Clinicians (N = 12) in the feasibility study-a non-randomized open trial-rated VIBRANT as highly usable, appropriate, acceptable, and feasible for their school-based practice. Preliminarily, clinicians appeared to demonstrate improvements in implicit bias knowledge, use of bias-management strategies, and implicit biases (as measured by the Implicit Association Test [IAT]) post-training. Moreover, putative mediators (e.g., clinicians' VIBRANT strategies use, IAT D scores) and outcome variables (e.g., clinician-rated quality of rapport) generally demonstrated correlations in the expected directions. These pilot results suggest that brief and highly scalable online interventions such as VIBRANT are feasible and promising for addressing implicit bias among healthcare providers (e.g., mental health clinicians) and can have potential downstream impacts on minoritized youth's care experience.

The Cognitive Walkthrough for Implementation Strategies (CWIS): a pragmatic method for assessing implementation strategy usability.

BACKGROUND: Implementation strategies have flourished in an effort to increase integration of research evidence into clinical practice. Most strategies are complex, socially mediated processes. Many are complicated, expensive, and ultimately impractical to deliver in real-world settings. The field lacks methods to assess the extent to which strategies are usable and aligned with the needs and constraints of the individuals and contexts who will deliver or receive them. Drawn from the field of human-centered design, cognitive walkthroughs are an efficient assessment method with potential to identify aspects of strategies that may inhibit their usability and, ultimately, effectiveness. This article presents a novel walkthrough methodology for evaluating strategy usability as well as an example application to a post-training consultation strategy to support school mental health clinicians to adopt measurement-based care. METHOD: The Cognitive Walkthrough for Implementation Strategies (CWIS) is a pragmatic, mixed-methods approach for evaluating complex, socially mediated implementation strategies. CWIS includes six steps: (1) determine preconditions; (2) hierarchical task analysis; (3) task prioritization; (4) convert tasks to scenarios; (5) pragmatic group testing; and (6) usability issue identification, classification, and prioritization. A facilitator conducted two group testing sessions with clinician users (N = 10), guiding participants through 6 scenarios and 11 associated subtasks. Clinicians reported their anticipated likelihood of completing each subtask and provided qualitative justifications during group discussion. Following the walkthrough sessions, users completed an adapted quantitative assessment of strategy usability. RESULTS: Average anticipated success ratings indicated substantial variability across participants and subtasks. Usability ratings (scale 0-100) of the consultation protocol averaged 71.3 (SD = 10.6). Twenty-one usability problems were identified via qualitative content analysis with consensus coding, and classified by severity and problem type. High-severity problems included potential misalignment between consultation and clinical service timelines as well as digressions during consultation processes. CONCLUSIONS: CWIS quantitative usability ratings indicated that the consultation protocol was at the low end of the "acceptable" range (based on norms from the unadapted scale). Collectively, the 21 resulting usability issues explained the quantitative usability data and provided specific direction for usability enhancements. The current study provides preliminary evidence for the utility of CWIS to assess strategy usability and generate a blueprint for redesign.

Implementation strategies for depression and anxiety screening in a pediatric cystic fibrosis center: A quality improvement project.

BACKGROUND: Guidelines to integrate mental health screening (MHS) into Cystic fibrosis (CF) care has increased adoption across the United States and European CF Centers, however, there has been limited discussion on specific strategies for implementation. OBJECTIVE: Share key strategies that led to successful MHS implementation in one pediatric CF center and report implementation and screening outcomes. METHODS: Parent partners, mental health experts from the Department of Psychiatry, and the CF clinic team codesigned interventions to support three major stakeholders: (a) patients and families (b) clinic team, and (c) hospital system. The mental health coordinator approached patients (12 and older) to introduce MHS and administered screening and reviewed results using an electronic tablet and digital measurement-feedback system. We used strategies that promoted visibility of screening progress and sharing of data with hospital administration. Descriptive statistics were used to assess prevalence of clinically significant symptoms of anxiety and depression and symptom severity within our sample. RESULTS: Over the first 2 years of the project, we exceeded our goal of screening 80% of eligible patients per year (80%-95% screened) and are on a similar trajectory within the first 7 months of year 3. We identified high prevalence of clinically significant symptoms of depression (16%) and anxiety (14%) similar to those found in other chronic illness populations. These data helped us advocate hospital leadership to support the development of new mental health services to address identified needs at our center. CONCLUSION: Leveraging coproduction to address stakeholder needs led to successful implementation of a sustainable MHS process.

Leveraging Health Information Technology to Meet The Joint Commission's Standard for Measurement-Based Care: A Case Study.

INTRODUCTION: Three decades of research have shown that routinely collecting patient-reported outcomes throughout treatment to inform clinical decision making or measurement-based care (MBC) can improve clinical outcomes, yet widespread adoption continues to be elusive. APPROACH: This article describes how a community behavioral health center addressed Element of Performance (EP) 1 of The Joint Commission's revised MBC standard using health information technology (HIT)-facilitated MBC and a comprehensive implementation plan grounded in the Consolidated Framework for Implementation Research. RESULTS: Across the initial 15-month implementation period, 96.8% of patients who had an intake evaluation also completed baseline measurements via an HIT known as a measurement feedback system (MFS), and 91.5% (78.6%-100%) completed at least one repeated measure. CONCLUSION: MFS reduces many of the logistical barriers of MBC, but implementation of MFS-facilitated MBC requires a comprehensive implementation plan that includes strategies to address barriers across all relevant domains for successful uptake.

Dr. Liu et al. Reply.

While there is growing acceptance within the field that measurement-based care (MBC) is a valuable and effective care quality improvement strategy, broad and sustained implementation continues to be elusive for most organizations.1 This is partly attributable to the lack of proven implementation strategies for MBC. Although implementation science has made significant progress in recent years,1 more work is needed to identify the most effective and efficient strategies for MBC implementation across a range of service delivery contexts.

Is Treatment Working? Detecting Real Change in the Treatment of Child and Adolescent Depression.

OBJECTIVE: Despite advances in evidence-based treatments for youth depression in recent decades, overall treatment effects are modest at best, with 30% to 50% of youth being nonresponders. Practice parameters consistently recommend systematic assessment and routine monitoring of depressive symptoms, or measurement-based care (MBC), to enhance youth depression treatment. However, the literature offers few guidelines on how to use assessment results to inform care decisions or to detect real and clinically meaningful change. Thus the current study produced reliable change indices (RCIs) per Jacobson and Truax for two commonly used standardized assessments of youth depression (ie, Patient Health Questionnaire-9 items, Modified for Adolescents [PHQ-9A], the Short Moods and Feelings Questionnaire [SMFQ]). METHOD: The study sample (N = 1,738) consisted of youths 6 to 18 years old seen in a child and adolescent psychiatry clinic of a regional pediatric medical center who completed at least one of the target depression measures. We examined the factor structure and internal reliability for the PHQ-9A, and calculated RCIs for patients with a depression-related diagnosis for both measures. RESULTS: Analyses confirmed a one-factor solution and adequate internal consistency (α = .86) for the PHQ-9A. All measures yielded acceptable test-retest reliabilities (r > 0.75) and RCIs that equate to clinical practice recommendations of using reliable changes scores of 7, 6, and 8 for the PHQ-9A, the SMFQ-Child Report, and the SMFQ-Parent Report, respectively. CONCLUSION: Psychometric validation of the PHQ-9A and these RCIs are timely and significant contributions to the treatment of youth depression, by facilitating effective use of MBC-a critical evidence-based strategy for improving treatment outcomes.

Mind the Gap: Considering Disparities in Implementing Measurement-Based Care.

Synergistic advancements in evidence-based practice, implementation science, health care policy, and health information technology (HIT) have led to increasing efforts to broadly implement measurement-based care (MBC)-the systematic use of repeated outcome measures to monitor treatment progress and support clinical decision making1-in psychiatric services. Much of this work has been done with adult populations, and more efforts are needed for MBC to gain traction in child and adolescent psychiatry. In this Letter to the Editor, we describe a quality improvement (QI) project that leveraged HIT to implement MBC in the child and adolescent psychiatry department of a regional pediatric tertiary-care center and report long-term (5-year) implementation outcomes (ie, adoption and penetration). Although a myriad of implementation strategies was used, here we focus on the most complex strategy-integrating a digital measurement-feedback system (MFS) into standard workflow. Then, we discuss pitfalls and lessons learned with special attention to potential unintended effects of QI efforts on existing health disparities.

Health Information Technologies-Academic and Commercial Evaluation (HIT-ACE) methodology: description and application to clinical feedback systems.

BACKGROUND: Health information technologies (HIT) have become nearly ubiquitous in the contemporary healthcare landscape, but information about HIT development, functionality, and implementation readiness is frequently siloed. Theory-driven methods of compiling, evaluating, and integrating information from the academic and commercial sectors are necessary to guide stakeholder decision-making surrounding HIT adoption and to develop pragmatic HIT research agendas. This article presents the Health Information Technologies-Academic and Commercial Evaluation (HIT-ACE) methodology, a structured, theory-driven method for compiling and evaluating information from multiple sectors. As an example demonstration of the methodology, we apply HIT-ACE to mental and behavioral health measurement feedback systems (MFS). MFS are a specific class of HIT that support the implementation of routine outcome monitoring, an evidence-based practice. RESULTS: HIT-ACE is guided by theories and frameworks related to user-centered design and implementation science. The methodology involves four phases: (1) coding academic and commercial materials, (2) developer/purveyor interviews, (3) linking putative implementation mechanisms to hit capabilities, and (4) experimental testing of capabilities and mechanisms. In the current demonstration, phase 1 included a systematic process to identify MFS in mental and behavioral health using academic literature and commercial websites. Using user-centered design, implementation science, and feedback frameworks, the HIT-ACE coding system was developed, piloted, and used to review each identified system for the presence of 38 capabilities and 18 additional characteristics via a consensus coding process. Bibliometic data were also collected to examine the representation of the systems in the scientific literature. As an example, results are presented for the application of HIT-ACE phase 1 to MFS wherein 49 separate MFS were identified, reflecting a diverse array of characteristics and capabilities. CONCLUSIONS: Preliminary findings demonstrate the utility of HIT-ACE to represent the scope and diversity of a given class of HIT beyond what can be identified in the academic literature. Phase 2 data collection is expected to confirm and expand the information presented and phases 3 and 4 will provide more nuanced information about the impact of specific HIT capabilities. In all, HIT-ACE is expected to support adoption decisions and additional HIT development and implementation research.

Family stress and coping for Mexican origin adolescents.

Family-related stressors pose special challenges for adolescents of Mexican origin, given traditional cultural norms that compel youths to get involved with family problems despite their limited ability to effect change. The current study examines the prospective effects of coping strategies (i.e., active, distraction, avoidance, support-seeking, and religious coping) on psychological symptoms in the context of family stress with a sample (N = 189) of Mexican Origin adolescents (11-14). Hypotheses on the limits of coping were partially supported. Stress-coping interaction effects were further moderated by gender. Stress-buffering effect of active coping for internalizing symptoms was only found for girls and only at low levels of family stress for boys. Support-seeking and distraction coping both increased internalizing symptoms for boys at high levels of family stress.

Sampling and recruitment in studies of cultural influences on adjustment: a case study with Mexican Americans.

Research examining how cultural factors affect adjustment of ethnic minority individuals would be strengthened if study samples better represented the diversity within these populations. To recruit a representative sample of Mexican American families, the authors implemented a multiple-step process that included sampling communities to represent diversity in cultural and economic conditions, recruiting participants through schools, using culturally attractive recruitment processes, conducting interviews in participants' homes, and providing a financial incentive. The result was a sample of 750 families that were diverse in cultural orientation, social class, and type of residential communities and were similar to the census description of this population. Thus, using culturally appropriate adaptations to common recruitment strategies makes it possible to recruit representative samples of Mexican Americans.

Self-construal, mental distress, and family relations: a mediated moderation analysis with Asian American adolescents.

The interactive effects between interdependent and independent self-construal on family cohesion and mental distress were examined. Survey responses from 153 Asian American high school students supported the hypothesized moderation of interdependence by independence on family cohesion, which was found to further mediate the relationship between self-construal and mental distress. Specifically, interdependence was positively associated with family cohesion when independence was high and negatively associated with family cohesion when independence was low. Accounting for the mediator effects of family cohesion, mental distress was positively associated with interdependence and more so for those low on independence than those high on independence. The benefits of biculturalism and research implications for the bidimensional conceptualization of self-construal for ethnic minority populations are discussed.