How Do Treatment Protocols Affect the Use of Engagement Practices in Youth Mental Health Services?

PURPOSE: Treatment engagement poses challenges for youth mental health providers. With the expansion of evidence-based treatments (EBTs), providers face complex decisions regarding how to engage youth and families using available information sources. This study investigated how EBT protocols are associated with the selection and delivery of engagement practices. METHOD: Twenty engagement practices were coded in a sample of digital recordings of early treatment sessions (N = 193) from the Child STEPs in California study, a randomized trial testing modular treatment and community-implemented treatment for youth mental health problems. Data were collected on which protocols mental health providers reportedly used to guide their sessions and the protocols in which they had received training. We examined which information sources (i.e., the guiding protocol, other protocols in training history, unspecified source) were associated with observed engagement practices. RESULTS: In sessions guided by a protocol, most observed engagement practices were accounted for by the guiding protocol (p < .001), rather than protocols in training history or unspecified sources (p < .001). In sessions not guided by a protocol, most observed practices were accounted for by training history (p < .001). Practice frequency and extensiveness was generally greater when a protocol guided the session. CONCLUSIONS: Inclusion in protocols is associated with the selection and delivery of engagement practices, but this strategy might be insufficient for supporting the use of the full range of engagement practices supported by evidence. Supports are needed that leverage the engagement evidence base to ensure that selected practices empirically fit the engagement needs of youth and families.

Implementation-as-Usual in Community-Based Organizations Providing Specialized Services to Individuals with Autism Spectrum Disorder: A Mixed Methods Study.

Autism spectrum disorder (ASD) is a highly prevalent neurodevelopmental disorder. ASD community-based organizations (ASD-CBOs) underutilize or inconsistently utilize evidence-based practices (ASD-EBPs) despite numerous available EBPs to treat ASD. Nonetheless, ASD-CBOs implement changes to practices regularly. Understanding ASD-CBO's implementation-as-usual (IAU) processes may assist to develop strategies to facilitate ASD-EBP adoption, implementation and sustainment. A convergent mixed methods (quan + QUAL) design was utilized. Twenty ASD-CBO agency leaders (ALs) and 26 direct providers (DPs), from 21 ASD-CBOs, completed the Autism Model of Implementation Survey Battery, including demographic and agency IAU process questions. Surveys were analyzed through descriptive and content analyses. A subset of 10 ALs provided qualitative interview data that were analyzed using coding, consensus and comparison methods to allow for a more comprehensive understanding of the IAU process within their ASD-CBOs. Quantitative analyses and qualitative coding were merged utilizing a joint display and compared. Results suggest that the IAU process follows some phases identified in the Exploration, Preparation, Implementation, Sustainment (EPIS) framework but were conducted in an informal manner-lacking specificity, structure and consistency across and within ASD-CBOs. Moreover, data suggest adding a specific adoption decision phase to the framework. Nonetheless, most ALs felt previous implementation efforts were successful. IAU processes were explored to determine whether the implementation process may be an area for intervention to increase ASD-EBP utilization in ASD-CBOs. Developing a systematized implementation process may facilitate broader utilization of high quality ASD-EBPs within usual care settings, and ultimately improve the quality of life for individuals with ASD and their families.

The influence of parents and schools on developmental trajectories of antisocial behaviors in Caucasian and African American youths.

African American youths are overrepresented in the American juvenile justice system relative to Caucasians. Yet, research on antisocial behaviors (ASB) has focused on predominantly Caucasian populations. Furthermore, relatively little is known about how environmental factors, such as supportive parenting (e.g., how close adolescents feel to their parent) and school connectedness (e.g., how supported adolescents feel at school), affect trajectories of ASB in Caucasians versus African Americans. This study mapped developmental trajectories of ASB in Caucasians (n = 10,764) and African Americans (n = 4,091) separately, using four waves of data from the National Longitudinal Study of Adolescent to Adult Health. We then examined supportive parenting and school connectedness on the trajectories of ASB. Four trajectories of ASB were identified for both Caucasians and African Americans: negligible, adolescence-peaked, low-persistence, and high-persistence ASB, although prevalence rates differed by racial-ethnic status. Supportive parenting reduced the risk of membership into the adolescence-peaked trajectory for both Caucasians and African Americans. However, school connectedness was less protective for African Americans than for Caucasians because it only predicted a lower risk of adolescence-peaked membership for African Americans. Findings may reflect the complex social dynamics between race and schools in the development of ASB.

Observational Assessment of Engagement Strategies to Promote Parent Homework Planning in Community-Based Child Mental Health Treatment: A Pilot Study.

Therapy homework includes tasks given to clients to complete outside of session to facilitate new knowledge/skills or to advance treatment goals. Homework completion, an important element of parent engagement in child mental health (MH) treatment, has been associated with improved child outcomes. The current pilot study assessed the design/assign phase of the therapy homework process to examine a) the extent to which therapists implemented engagement strategies with parents and b) whether therapist deployment of engagement strategies in early treatment predicted subsequent parent participation in homework planning. We included an ethnically-diverse sample of 10 therapists and 11 parent/child dyads receiving community-based MH services who participated in a pilot intervention study. Two observational coding systems were developed to code treatment session recordings for the extent to which a) therapists implemented engagement strategies with parents and b) parents contributed to therapy homework planning. Findings revealed low extensiveness of therapist implementation of engagement strategies with parents. As hypothesized, therapist use of engagement strategies (Collaboration, Empowerment, and Psychoeducation) in early treatment significantly predicted subsequent parent homework planning (sharing perspective on homework planning). However, therapist use of Alliance was unrelated to parent homework planning. These preliminary results suggest that therapist implementation of engagement strategies in early treatment may promote parent participation in homework planning, which is an important precursor to homework completion. This pilot study suggests potential future directions for both research on and training for community-based therapists in implementing successful strategies to promote parent homework planning in child MH treatment.

Randomized Trial of the Parent And Caregiver Active Participation Toolkit for Child Mental Health Treatment.

The purpose of this pilot study was to examine preliminary feasibility, acceptability, and effectiveness of a toolkit (Parent And Caregiver Active Participation Toolkit) to increase parent participation in community-based child mental health services. Study participants included 29 therapists (93% female; M age = 34.1 years; 38% Latino) and 20 parent/child dyads (children 80% female; M age = 8.6 years; parents 40% Latino) in 6 diverse community mental health clinics. Therapists were randomly assigned to standard care or the toolkit with standard care. Therapist and parent survey data and observational coding of treatment sessions were utilized. Mean comparisons and repeated measures analyses were used to test differences between study conditions over 4 months. Results supported preliminary feasibility and acceptability of the toolkit, with therapists assigned to the toolkit participating in ongoing training, adhering to toolkit use, and perceiving the toolkit as feasible and acceptable within their setting. Results preliminarily demonstrated improvement in therapists' job attitudes, as well as actual use of parent engagement strategies. Results also preliminarily demonstrated increases in parent participation in child therapy sessions and more regular attendance, as well as some indication of support for perceived treatment effectiveness. Overall, results suggest the feasibility, acceptability, and potential effectiveness of the toolkit to enhance therapist job attitudes; practices that support parent engagement, parent engagement itself, and consumer perspectives on treatment outcomes; and the potential promise of future research in the area of parent participation interventions in child mental health services.

Psychoeducation as a Mediator of Treatment Approach on Parent Engagement in Child Psychotherapy for Disruptive Behavior.

Parent engagement in treatment for child disruptive behavior has been associated with improved child outcomes in care. However, many families who enter care do not receive an adequate dose of treatment, and parents are often not involved. We examined therapists' use of psychoeducation, a therapeutic practice used to present factual information about target problems and treatments, and its association with parent engagement in child psychotherapy. Participants were drawn from the Child System and Treatment Enhancement Projects' multisite trial contrasting standard evidence-based treatments, modular treatment, or usual care. We included an ethnically diverse sample of 46 youth (ages 7-13) who received treatment for disruptive behavior in modular treatment or usual care. A reliable observational coding system was developed to assess therapists' in-session use of psychoeducation strategies (e.g., discussing causes of misbehavior, describing and providing rationale for treatment, etc.), as well as other engagement strategies (e.g., collaborative goal setting, managing expectations, etc.), in the early phase of treatment. Findings revealed that modular treatment therapists provided more psychoeducation and other engagement strategies compared with usual care therapists. Furthermore, psychoeducation strategies employed by therapists early on uniquely predicted subsequent parent involvement in treatment, over and above the use of other engagement strategies. Finally, therapists' use of the psychoeducation strategy of discussing causes of child's misbehavior mediated the effect of treatment condition on parent involvement in their child's therapy. These findings suggest that the implementation of psychoeducation strategies upon entry into care promotes parent involvement in child psychotherapy for disruptive behavior.

Using Observational Assessment to Help Identify Factors Associated with Parent Participation Engagement in Community-Based Child Mental Health Services.

BACKGROUND: Parent engagement in child mental health (MH) services has received growing attention due to its significance in intervention outcomes and evidence-based care. In particular, parent participation engagement (PPE) reflects active and responsive contributions in and between sessions. Yet, limited research has examined factors associated with PPE, particularly within community-based MH services where PPE is low and highly diverse families are often served. OBJECTIVE: This study examined child, parent, and therapist factors associated with PPE in a sample of racially/ethnically diverse parent-child dyads receiving publicly-funded, community-based MH services. METHODS: This prospective study included 18 parent-child dyads receiving community-based MH services from 17 therapists in five outpatient clinics for child disruptive behaviors. PPE was measured using in-session observational assessment of therapy recordings. Child factors that were examined included age, first time child MH service use, and intensity of child behavior problems. Parent factors included ethnicity, education, depression symptoms, and parent motivation to participate in therapy. Therapist factors included therapist training in parent-mediation interventions, attitudes towards organizational functioning, and attitudes towards parent participation strategies. RESULTS: Results from linear regression analyses indicated that first time child MH service use, intensity of child behavior problems, parent ethnicity and motivation to participate in therapy, as well as therapists' training and attitudes about their practice were each significantly associated with PPE. CONCLUSIONS: Results highlight specific child, parent, and therapist characteristics that may impact observed PPE in child MH therapy. These findings underscore the importance of considering the influence of family and provider factors on PPE in community-based child MH services.

Problem-specific racial/ethnic disparities in pathways from maltreatment exposure to specialty mental health service use for youth in child welfare.

The authors examined racial/ethnic differences in pathways from maltreatment exposure to specialty mental health service use for youth in contact with the Child Welfare system. Participants included 1,600 non-Hispanic White, African American, and Latino youth (age 4-14) who were the subjects of investigations for alleged maltreatment and participated in the National Survey of Child and Adolescent Well-Being. Maltreatment exposure, internalizing, and externalizing problems were assessed at baseline and subsequent specialty mental health service use was assessed 1 year later. Maltreatment exposure predicted both internalizing and externalizing problems across all racial/ethnic groups, but non-Hispanic White youth were the only group for whom maltreatment exposure was linked with subsequent service use via both internalizing and externalizing problem severity. Only externalizing problems predicted subsequent service use for African American youth and this association was significantly stronger relative to non-Hispanic White youth. Neither problem type predicted service use for Latinos. Future research is needed to understand how individual-, family-, and system-level factors contribute to racial/ethnic differences in pathways linking maltreatment exposure to services via internalizing/externalizing problems.

Mental health service use by youths in contact with child welfare: racial disparities by problem type.

OBJECTIVE: This study examined racial disparities in mental health service use by problem type (internalizing versus externalizing) for youths in contact with the child welfare system. METHODS: Participants included 1,693 non-Hispanic white, African-American, and Hispanic youths (ages four to 14) from the National Survey of Child and Adolescent Well-Being, a national probability study of youths who were the subject of investigations of maltreatment by child welfare agencies. Mental health need, assessed at baseline, was considered present if the youth had internalizing or externalizing scores in the clinical range on either the Child Behavior Checklist or the Youth Self-Report. Out patient mental health service use in the subsequent year was assessed prospectively. RESULTS: Children who were removed from the home and those investigated for abuse (versus neglect) were more likely to receive services in the year after the child welfare investigation. Overall, African-American youths were less likely than non-Hispanic white youths to receive mental health services. However, race-ethnicity moderated the association between externalizing need and service use such that African Americans were more likely to receive services when externalizing need was present (26% versus 4%) compared with non-Hispanic white youths (30% versus 14%). Race and ethnicity did not moderate the association between youth internalizing need and service use, but internalizing need was associated with increased probability of service use only for non-Hispanic white youths. CONCLUSIONS: Examinations of overall racial disparities in service use may obscure important problem specific disparities. Additional research is needed to identify factors that lead to disparities and to develop strategies for reducing them.

The youth self report: applicability and validity across younger and older youths.

The Youth Self Report (YSR) is a widely used measure of youth emotional and behavioral problems. Although the YSR was designed for youths ages 11 to 18, no studies have systematically evaluated whether youths younger than age 11 can make valid reports on this measure. This study thus examined the reliability and validity of the YSR scales scores for younger (ages 7-10; n = 184) and older (ages 11-14; n = 147) youths. Results demonstrated that younger youths were able to provide reliable reports on the YSR broad band (Internalizing, Externalizing) scales, though less so on the narrow band scales. Across all scales, the externalizing scales performed more favorably than the internalizing scales among both younger and older youth. Younger youths' DSM-oriented scales corresponded significantly with DSM diagnoses.

Do social networks push families toward or away from youth mental health services?: A national study of families in child welfare.

Social support networks may encourage or dissuade help-seeking for youth behavior problems in ways that contribute to racial/ethnic disparities in mental health services. We examined how parental social network characteristics were related to the use of mental health services in a diverse sample of families in contact with Child Welfare. Data from 1519 families of White (n=812), African American (n=418), and Latino (n=289) origin were drawn from the National Survey of Child and Adolescent Well-Being. Data were collected prospectively after the initiation of a Child Welfare investigation for alleged maltreatment. Results revealed that parental perceptions of support were negatively associated with service use across racial/ethnic groups, and this association was explained by better subsequent mental health status enjoyed by children of parents with stronger social support. Moderator analyses suggested that larger social networks were associated with a decreased use of services among Whites and more highly educated families.