Manuscript: Defining Quality Standards for Intensive Home Based Treatment Programs for Youth with Serious Emotional Disorders.

Intensive Home Based Treatment (IHBT) is a critical component of the continuum of community-based behavioral healthcare for youth with serious emotional disorder (SED) and their families. Yet despite being used nationwide at costs of over $100 million annually in some states, a well-vetted, research-based set of quality standards for IHBT has yet to be developed. The current project aimed to define program and practice standards for IHBT, drawing upon literature review, expert interviews, and a systematic Delphi process engaging over 80 participants, including IHBT developers, experts in evidence-based youth mental health, youth and family advocates, IHBT providers, and state policymakers. After two rounds of quantitative and qualitative input, adequate consensus was achieved on 32 IHBT Program Standards and 43 IHBT Practice Standards. These standards hold potential for informing efforts such as development of state regulations, provider contracts, memoranda of agreement, and training and workforce development initiatives. Translation of the quality standards into measurement strategies holds potential for providing a method of continuous quality improvement across multiple levels as well as use in research on IBHT.

Factor Structure of the Parent-Report Mood and Feelings Questionnaire (MFQ) in an Outpatient Mental Health Sample.

The current investigation examined the internal structure and discriminant validity of the parent-report Mood and Feelings Questionnaire (MFQ-P), a commonly used measure of depressive symptoms in youth. A total of 1493 families with youth ages 5 to 18 (61.02 % male) presenting for treatment at an outpatient mental health clinic were randomly allocated to an Exploratory Sample 1 or to a Replication Sample 2. Internal structure of the MFQ-P was examined using exploratory factor analysis in Sample 1 (N = 769) and then replicated using confirmatory factor analysis in Sample 2 (N = 724). Results of the exploratory factor analysis yielded a 5-factor structure comprised of core mood, vegetative, suicidality, cognitive, and agitated distress symptom subscales. The 5-factor solution was replicated in Sample 2 with adequate fit, (CFI = 0.908, TLI = 0.974, RMSEA =0.067). Results lend statistical support for 5 candidate subscales of the MFQ-P. These potential subscales may aid in efficient identification of critical symptoms of depression.

Changes in mental health outcomes with the intensive in-home child and adolescent psychiatric service: a multi-informant, latent consensus approach.

This study investigates the Intensive In-home Child and Adolescent Psychiatric Service (IICAPS), a large-scale home-based intervention that collaboratively engages the family, school, and various other service providers (e.g. health practitioners or judicial systems) to prevent the hospitalization, institutionalization or out-of-home placement of children and adolescents with serious emotional disturbance. Multi-informant data (youth, parents and clinician) on the level of youth problem severity and functioning was gathered from 7169 youth and their families served by the IICAPS network, pre- and post-intervention. A newly developed "Multi-informant Latent Consensus" (MILC) approach was employed to measure mental health "baseline levels" and change, within a Structural Equation Modeling framework. The MILC approach demonstrated promise integrating information from multiple informants involved in the therapeutic process to yield a more accurate and systemic view of a child's level of functioning and problem severity than each report taken individually. Results indicated that the IICAPS family and community based intervention model led to a reduction of problem severity and improved functioning in children and adolescents with severe emotional disturbance.

Parent and youth report of youth anxiety: evidence for measurement invariance.

BACKGROUND: We characterized parent-youth disagreement in their report on the Screen for Child Anxiety Related Emotional Disorders (SCARED) and examined the equivalence of this measure across parent and youth report. METHODS: A clinically referred sample of 408 parent-youth dyads (M age youth = 14.33, SD = 1.89; 53.7% male; 50.0% Non-Hispanic White (NHW), 14.0% Hispanic, 29.7% African-American) completed the SCARED. We examined (a) differences between parents and youth in the total number of symptoms reported (difference scores) and in their ratings of specific symptoms (q correlations), (b) demographic factors associated with these indices, and (c) equivalence of the pattern and magnitude of factor loadings (i.e., configural and metric invariance), as well as item thresholds and residual variances, across informants. RESULTS: The mean difference score was -2.13 (SD = 14.44), with youth reporting higher levels of symptoms, and the mean q correlation was .32 (SD = .24). Difference scores were greater for African-American dyads than NHW pairs. We found complete configural, metric, and residual invariance, and partial threshold invariance. Differences in thresholds did not appear to reflect systematic differences between parent and youth report. Findings were comparable when analyses were conducted separately for NHW and ethnic minority families. CONCLUSION: Findings provide further evidence for the importance of considering youth report when evaluating anxiety in African-American families. The SCARED was invariant across informant reports, suggesting that it is appropriate to compare mean scores for these raters and that variability in parent and youth report is not attributable to their rating different constructs or using different thresholds to determine when symptoms are present.

Shifting the treatment model: impact on engagement in outpatient therapy.

Attrition in youth outpatient mental health clinics ranges from 30 to 70 % and often occurs early in treatment. We implemented specific treatment planning strategies designed to reduce early attrition. Following implementation, 14.3 % of clients dropped out during the first five sessions compared to 26.1 % in the historical control (p < 0.001). During treatment, 33.6 % of clients dropped out in the intervention compared to 55.5 % in the historical control (p < 0.001). Engagement is central to the therapeutic process and may be particularly relevant early in treatment. Implementing evidence-based strategies to promote a collaborative relationship between the family and the clinician may increase engagement and decrease attrition.

Family accommodation in pediatric anxiety disorders.

BACKGROUND: Family accommodation has been studied in obsessive compulsive disorder using the Family Accommodation Scale (FAS) and predicts greater symptom severity, more impairment, and poorer treatment outcomes. However, family accommodation has yet to be systematically studied among families of children with other anxiety disorders. We developed the Family Accommodation Scale-Anxiety (FASA) that includes modified questions from the FAS to study accommodation across childhood anxiety disorders. The objectives of this study were to report on the first study of family accommodation across childhood anxiety disorders and to test the utility of the FASA for assessing the phenomenon. METHODS: Participants were parents (n = 75) of anxious children from two anxiety disorder specialty clinics (n = 50) and a general outpatient clinic (n = 25). Measures included FASA, structured diagnostic interviews, and measures of anxiety and depression. RESULTS: Accommodation was highly prevalent across all anxiety disorders and particularly associated with separation anxiety. Most parents reported participation in symptoms and modification of family routines as well as distress resulting from accommodation and undesirable consequences of not accommodating. The FASA displayed good internal consistency and convergent and divergent validity. Accommodation correlated significantly with anxious but not depressive symptoms, when controlling for the association between anxiety and depression. Factor analysis of the FASA pointed to a two-factor solution; one relating to modifications, the other to participation in symptoms. CONCLUSIONS: Accommodation is common across childhood anxiety disorders and associated with severity of anxiety symptoms. The FASA shows promise as a means of assessing family accommodation in childhood anxiety disorders.

Cross-ethnic measurement equivalence of the SCARED in an outpatient sample of African American and non-Hispanic White youths and parents.

The present study evaluated the measurement equivalence of the Screen for Child Anxiety Related Emotional Disorders (SCARED) in a clinical sample of non-Hispanic White (NHW) and African American (AA) youths and parents. In addition, we explored the concurrent criterion validity of parent report on the SCARED to a parent diagnostic interview. Cross-ethnic measurement equivalence was examined in both youth self-report (ages 11-18; N = 374) and parent report (youth ages 5-18; N = 808) using multiple group analysis. Sensitivity, specificity, positive predictive value, and negative predictive value of the SCARED parent report were also examined. The original five-factor structure of the SCARED was replicated using confirmatory factor analysis for both groups using parent and youth report, although factor loadings were not equivalent across groups. Sensitivity and specificity of the SCARED-P clinical cutoff score (Total ≥25) to anxiety diagnoses were acceptable in both ethnic groups. Although evidence for the cross-ethnic equivalence of SCARED was limited, results suggest a similar structure of anxiety symptoms across NHW and AA youths while demonstrating sensitivity in symptom-level differences in anxiety expression. Overall, results provide preliminary evidence for the SCARED as an acceptable screening tool for anxiety symptoms in NHW and AA youths.

Defining dropout from youth psychotherapy: how definitions shape the prevalence and predictors of attrition.

BACKGROUND AND AIMS: Attrition is a long-standing problem in mental health centres serving youth. However, attempts to understand attrition have not consistently identified the same risk factors. The way in which attrition was defined across studies may have had a significant impact on findings. This study examines three definitions of attrition across a large sample of children and adolescents receiving outpatient mental health services, and considers the different relationships observed between the identified predictors and each definition. METHOD: This study examined data collected concurrently from 1098 families who received services at an urban outpatient mental health clinic (OMHC). Logistic regression was used to examine the association between identified predictor variables and attrition, using three distinct definitions of attrition based on clinician judgment, missed last appointment, and specified dose. The results of each regression analysis were qualitatively compared to assess the impact on findings observed when applying different definitions of attrition. RESULTS: As anticipated, observed predictors of attrition varied by definition. Ethnicity predicted attrition across all definitions. Residing in a single-caregiver household predicted attrition across two of the three definitions, while living with a non-biological family, receiving state-funded, low-income insurance support, having low parent-reported youth functioning, routine intakes (as compared to urgent intakes), and longer wait predicted attrition within only one definition. CONCLUSIONS: Rates and factors associated with attrition may vary substantially depending on how treatment attrition is defined. In the evaluation of attrition in youth mental health settings, the definition used should be clearly stated and should reflect the research question posed.

Predictors of treatment attrition among an outpatient clinic sample of youths with clinically significant anxiety.

Predictors of treatment attrition were examined in a sample of 197 youths (ages 5-18) with clinically-significant symptoms of anxiety seeking psychotherapy services at a community-based outpatient mental health clinic (OMHC). Two related definitions of attrition were considered: (a) clinician-rated dropout (CR), and (b) CR dropout qualified by phase of treatment (pre, early, or late phases) (PT). Across both definitions, rates of attrition in the OMHC sample were higher than those for anxious youths treated in randomized controlled trials, and comorbid depression symptoms predicted dropout, with a higher rate of depressed youths dropping out later in treatment (after 6 sessions). Using the PT definition, minority status also predicted attrition, with more African-American youths lost pre-treatment. Other demographic (age, gender, single parent status) and clinical (externalizing symptoms, anxiety severity) characteristics were not significantly associated with attrition using either definition. Implications for services for anxious youths in public service settings are discussed. Results highlight the important role of comorbid depression in the treatment of anxious youth and the potential value of targeted retention efforts for ethnic minority families early in the treatment process.

Selecting measures for use in child mental health services: a scorecard approach.

The implementation of evidence-based treatments in mental health services requires reliable and valid measurements to guide treatment. This study evaluated the efficiency of three caretaker-report measures of child psychiatric disorders. Data from 211 caregivers were used to assess the CBCL, the OHIO, and the SDQ. A scorecard methodology was implemented to determine the efficiency of each scale as compared to the DISC-IV. Across measures, the OHIO was optimal for assessing services need while the CBCL and SDQ provided better disorder-specific assessment. Results may improve clinical practice by providing an empirical approach to the selection of assessment tools.

Psychological aspects of diabetes mellitus.

Diabetes mellitus (DM) presents itself in two forms: insulin-dependent (type 1 DM) and non-insulin-dependent (type 2 DM). Although type 2 DM usually has an adult onset, in recent years there has been a significant rise in the number of children diagnosed with type 2 DM in the United States. Reasons for this increased frequency are believed to be a larger percentage of children who are overweight, a family history of diabetes, and a considerable increase in the use of psychotropic medication in children. The diagnosis of DM is a significant stressor not only for patients but also for their environment. Children with DM are sometimes stigmatized by their peers and relatives who do not understand the illness or are frightened by it. Some children also may need to alter several of their customary routines and are often scared to participate in activities in which they were previously engaged. The family's response to the diagnosis of DM may have a negative effect on glycemic control. Differences have been found in the way patients with type 1 DM and type 2 DM cope with and adapt to their diagnosis.

Differences in younger, middle, and older children admitted to child psychiatric inpatient services.

Sociodemographic, family-environmental, clinical, and service use differences among younger (3-6 years), middle (7-10 years), and older (11-16 years) children admitted to a child psychiatric inpatient service were examined. Data was collected retrospectively on 327 children using a 152-item chart abstraction form from the children's medical charts in years 1993, 1995, 1996, and 1997. The results suggest that younger children compared to their older counterparts come from poorer functioning families and that family-environmental, rather than clinical, diagnostic variables differentiate these groups. Implications of the findings for future research and practice are discussed.

The administration of hospital-based services.

Hospital-based child psychiatric services have evolved rapidly in the past 15 years from stand-alone programs to integrated systems linked internally and externally. This evolution has occurred under the pressure of changing treatment technologies, organizational philosophies, and financing strategies. This article provides a brief overview of administrative concepts and functions, followed by descriptions of administrative issues related to specific programs and their integration into a coherent service. The specific services include specialized child inpatient and partial hospital programs, crisis intervention service, and consultation/liaison service.