Behavioral Health in Primary Care: Brief Screening and Intervention Strategies for Pediatric Clinicians.

Despite the high prevalence of behavioral health concerns presenting in pediatric primary care and the growing support for integrating behavioral health services into this setting, a majority of primary care providers do not have access to on-site behavioral health specialists. Fortunately, primary care providers can implement some services typically provided by behavioral health clinicians. This article outlines screening, brief intervention, and referral guidelines for prominent behavioral health problems seen in primary care. The evidence-based approaches have the potential to supplement typical management of behavioral health problems in primary care and provide a foundation for future integrated behavioral health practice.

Temporal precedence in the identification of mediators of change: A brief comment on "Mediators of change in the child/adolescent multimodal treatment study" (Kendall et al., 2016).

OBJECTIVE: Comment on the issue of temporal precedence and the implications for interpreting the results of the mediation analyses in the Child/Adolescent Multimodal Treatment Study. METHOD: Review of Kendall et al. (2016). RESULTS: Kendall et al. reported that residualized (baseline to posttreatment) change in coping efficacy, but not anxious self-talk, mediated residualized (baseline to follow-up) change in anxiety symptoms in cognitive-behavior therapy (CBT), sertraline (SRT), and CBT + SRT compared to placebo. Because the measure of anxiety symptoms included data from follow-up, it was concluded that "the gains being referred to can be viewed as 'change following treatment'" (p. 8) and, therefore, the analyses captured "true temporal precedence" (p. 3). However, the anxiety scores represented an amalgam of change occurring within and after treatment, and available data suggest much of the anxiety change occurred during the treatment, the time when the change in coping occurred. CONCLUSIONS: Given the measurement timeline, a clear and unambiguous claim of demonstrating temporal precedence is not justified. Nonetheless, these results remain important for other reasons when interpreted in the context of the broad cognitive-behavioral conceptual model of anxiety that led to the selection of these mediators for examination. (PsycINFO Database Record

Identifying mechanisms of change: utilizing single-participant methodology to better understand behavior therapy for child depression.

This study examined therapeutic mechanisms of action at the single-participant level in a behavior therapy (BT) for youth depression. By controlling for non-specific early responses, identifying potential mechanisms of action a priori, taking frequent measures of hypothesized mechanisms and dependent variables, rigorously evaluating internal validity, and using a variety of analytic methods, a unique model for analysis of potential mediators was created. Eleven children (M age = 9.84) meeting criteria on the Children's Depression Rating Scale-Revised (M = 55.36) and Children's Depression Inventory (M = 23.45) received non-directive therapy (NDT), followed by BT for those still displaying significant symptoms. Four participants (36%) had a clinically significant response to NDT. For the remaining seven, statistically significant changes in depressive symptoms and family interactions during the BT interval were found at the group level. At the single-participant level, evidence suggesting that outcome was at least partially mediated by changes in treatment targets was obtained for four of seven (57%). As the field further embraces efforts to learn not only whether treatments work but also how they work, the single-participant approach to evaluating mediators provides a useful framework for evaluating theories of therapeutic change.

Combined Individual Cognitive Behavior Therapy and Parent Training for Childhood Depression: 2-3-Year Follow-Up.

Fourteen children with significant depressive symptoms from an open clinical trial of Primary and Secondary Control Enhancement Training augmented with Caregiver-Child Relationship Enhancement Training, participated in a 2-3-year follow-up assessment. The results suggested that the significant decreases in depressive symptoms observed at post-treatment were maintained at 2-3-year follow-up. Mothers' reports of significant improvement of child psychosocial functioning were also maintained, providing social validation of the effects. Pre-treatment child-rated mother-child relations predicted depressive symptoms at 2-3-year follow-up. These long-term data support the use of the combined intervention and suggest the need for further research on caregiver involvement in treatment.

Combining individual cognitive behaviour therapy and caregiver-child sessions for childhood depression: an open trial.

The objective was to obtain preliminary evidence on the feasibility and efficacy of combining individual cognitive behavior therapy (CBT) with complimentary caregiver-child sessions for depressed youths. Fifteen children participated in an open clinical trial. Treatment included 16 CBT sessions combined with seven caregiver/caregiver-child sessions over 12 weeks. Data were collected at pre-, mid-, and post-treatment and at one- and six-month follow-ups. Significant decreases in depressive symptoms were apparent, with the majority showing clinically meaningful improvement. Benchmarked against the literature, the combination equaled or outperformed CBT in other studies and was superior to control conditions. Mother and teacher reports of child functioning significantly improved, providing social validation of the effects. Mothers reported improved caregiver-child relationships and less parenting stress. Children did not report acute improvements in relations with their caregivers. However, when a father participated, improved father-child relations were reported in the follow-up period. Younger age and lower pretreatment severity predicted greater symptom change. The positive treatment effects provide support for the combined intervention and suggest a further research focus on the effects of caregiver involvement in the treatment of depressed youths.

Single-participant assessment of treatment mediators: strategy description and examples from a behavioral activation intervention for depressed adolescents.

Determining the means by which effective psychotherapy works is critical. A generally recommended strategy for identifying the potential causal variables is to conduct group-level statistical tests of treatment mediators. Herein the case is made for also assessing mediators of treatment outcome at the level of the individual participant. Single-participant assessment of mediators requires documenting, for each participant, that treatment was received, that change occurred on the mediator and relevant clinical outcome measures, and that the change on the mediator happened at an expected time in the treatment protocol and prior to substantive change on the dependent variable. Data from four depressed adolescents who demonstrated remission following a behavioral activation intervention illustrate the use of the approach in assessing whether changes in activation level or negative thinking mediated the changes in depression. For two participants, increased activation appeared to be a mediator, whereas decreased dysfunctional thinking never emerged as a plausible mediator. It is concluded that single-participant assessment of mediators of treatment outcome offers a useful additional tool for determining possible mechanisms of action in effective psychotherapy.

Measuring homework compliance in cognitive-behavioral therapy for adolescent depression: review, preliminary findings, and implications for theory and practice.

Despite the importance placed on completion of extra-session homework in cognitive-behavioral therapy (CBT), a review of the available literature suggests there is much about the nature of homework compliance that remains to be empirically evaluated. This is especially true among youth receiving CBT. The present study begins to address how best to measure homework compliance and offers a fine-grained, single-case analysis of homework compliance during acute treatment with depressed adolescents. The results demonstrate that 56% of homework assignments were completed. Also observed was substantial within-subject temporal variability in homework compliance and a tendency for compliance to decrease during the course of treatment. These data call into question the adequacy of any static aggregate measure of homework compliance and have implications for both researchers and clinicians.

Acceptance and commitment therapy and behavioral activation for the treatment of depression: description and comparison.

The field of clinical behavior analysis is growing rapidly and has the potential to affect and transform mainstream cognitive behavior therapy. To have such an impact, the field must provide a formulation of and intervention strategies for clinical depression, the "common cold" of outpatient populations. Two treatments for depression have emerged: acceptance and commitment therapy (ACT) and behavioral activation (BA). At times ACT and BA may suggest largely redundant intervention strategies. However, at other times the two treatments differ dramatically and may present opposing conceptualizations. This paper will compare and contrast these two important treatment approaches. Then, the relevant data will be presented and discussed. We will end with some thoughts on how and when ACT or BA should be employed clinically in the treatment of depression.

The prevalence and impact of large sudden improvements during adolescent therapy for depression: a comparison across cognitive-behavioral, family, and supportive therapy.

This study assessed the treatment specificity and impact on outcome of large, abrupt symptomatic improvements occurring prior to and during cognitive-behavioral, family, and supportive therapy. Eighty-seven depressed adolescents receiving at least 8 therapy sessions were included. Abrupt large decreases in depressive symptoms were identified by changes in weekly Beck Depression Inventory scores. Overall, 28% experienced a pretreatment gain and 39% a sudden within-treatment gain. Both types of gains were associated with superior outcome on self-report and interviewer ratings of depression. Among those participants failing to experience a pretreatment or sudden within-treatment gain, cognitive-behavioral therapy produced the superior outcomes. These findings suggest pretreatment and sudden within-treatment gains are important therapeutic events worthy of further investigation.

Response rate viewed as engagement bouts: resistance to extinction.

Rats obtained food pellets by nose poking a lighted key, the illumination of which alternated every 50 s during a session between blinking and steady, signaling either a relatively rich (60 per hour) or relatively lean (15 per hour) rate of reinforcement. During one training condition, all the reinforcers in the presence of the rich-reinforcement signal were response dependent (i.e., a variable-interval schedule); during another condition only 25% were response dependent (i.e., a variable-time schedule operated concurrently with a variable-interval schedule). An extinction session followed each training block. For both kinds of training schedule, and consistent with prior results, response rate was more resistant to extinction in the presence of the rich-reinforcement signal than in the presence of the lean-reinforcement signal. Analysis of interresponse-time distributions from baseline showed that differential resistance to extinction was not related to baseline differences in the rate of initiating response bouts or in the length of bouts. Also, bout-initiation rate (like response rate) was most resistant to extinction in the presence of the rich-reinforcement signal. These results support the proposal of behavioral momentum theory (e.g., Nevin & Grace, 2000) that resistance to extinction in the presence of a discriminative stimulus is determined more by the stimulus-reinforcer (Pavlovian) than by the stimulus-response-reinforcer (operant) contingency.

The generality of selective observing.

Four rats obtained food pellets by poking a key and 5-s presentations of the discriminative stimuli by pressing a lever. Every 1 or 2 min, the prevailing schedule of reinforcement for key poking alternated between rich (either variable-interval [VI] 30 s or VI 60 s) and lean (either VI 240 s, VI 480 s, or extinction) components. While the key was dark (mixed-schedule stimulus), no exteroceptive stimulus indicated the prevailing schedule. A lever press (i.e., an observing response), however, illuminated the key for 5 s with either a steady light (S+), signaling the rich reinforcement schedule, or a blinking light (S-), signaling the lean reinforcement schedule. One goal was to determine whether rats would engage in selective observing (i.e., a pattern of responding that maintains contact with S+ and decreases contact with S-). Such a pattern was found, in that a 5-s presentation of S+ was followed relatively quickly by another observing response (which likely produced another 5-s period of S+), whereas exposure to S- resulted in extended breaks from observing. Additional conditions demonstrated that the rate of observing remained high when lever presses were effective only when the rich reinforcement schedule was in effect (S+ only condition), but decreased to a low level when lever presses were effective only during the lean reinforcement component (S- only condition) or when lever presses had no effect (in removing the mixed stimulus or presenting the multiple-schedule stimuli). These findings are consistent with relativistic conceptualizations of conditioned reinforcement and extend the generality of selective observing to procedures in which the experimenter controls the duration of stimulus presentations, the schedule components both offer intermittent food reinforcement, and rats serve as subjects.