Reliability of the services assessment for children and adolescents.

OBJECTIVE: This study examined the test-retest reliability of a new instrument, the Services Assessment for Children and Adolescents (SACA), for children's use of mental health services. METHODS: A cross-sectional survey was undertaken at two sites. The St. Louis site used a volunteer sample recruited from mental health clinics and local schools. The Ventura County, California, site used a double-blind, community-based sample seeded with cases of service-using children. Participating families completed the SACA and were retested within four to 14 days. The reliability of service use items was calculated with use of the kappa statistic. RESULTS: The SACA- Parent Version had excellent test-retest reliability for both lifetime service use and previous 12-month use. The SACA also had good to excellent reliability when administered to children aged 11 and older for lifetime and 12-month use. Reliability figures for children aged nine and ten years were considerably lower for lifetime and 12-month use. The younger children's responses suggested that they were confused about some questions. CONCLUSIONS: This study demonstrates that parents and older children can reliably report use of mental health services by using the SACA. The SACA can be used to collect currently unavailable information about use of mental health services.

Specificity of relations between children's control-related beliefs and internalizing and externalizing psychopathology.

The authors examined the specificity of the relation between 3 types of control-related beliefs and internalizing and externalizing psychopathology in a sample of 290 clinic-referred children aged 7 to 17 years. Self-reported beliefs about control (the capacity to cause an intended outcome), contingency (the degree to which a desired outcome can be controlled by a relevant behavior), and competence (an individual's ability to produce the relevant behavior) across 3 domains (academic, behavioral, and social) showed more specific relations with psychopathology than have been previously reported. Among children with externalizing psychopathology, internalizing psychopathology may be specifically associated with increased self-critical awareness about their conduct; externalizing psychopathology may attenuate the specific negative relation between internalizing psychopathology and control-related beliefs in the social domain.

Control-related beliefs and depressive symptoms in clinic-referred children and adolescents: developmental differences and model specificity.

The contingency-competence-control (CCC) model links contingency and competence beliefs to perceived control and, in turn, to depression. However, a developmental perspective suggests that noncontingency may be too abstract a concept to be directly tied to depression before adolescence. We tested the CCC model and this developmental notion, using structural equation modeling, with 360 clinic-referred 8- to 17-year-olds. The CCC model fit the data well for the full sample accounting for 46% of the variance in depression. Separate analyses by age group placed perceived contingency in the best-fit model for adolescents (ages 12-17 years) but not for children (8-11 years). This suggests that abstract cause-effect concepts may have more direct affective impact after the cognitive changes of adolescence (e.g., formal operations) than before. Finally, the CCC model accounted for much more variance in depression than conduct problems, suggesting diagnostic specificity.

Why are we here at the clinic? Parent-child (dis)agreement on referral problems at outpatient treatment entry.

Do clinic-referred children and their parents agree on the problems for which treatment is undertaken? The authors asked 381 outpatient-clinic-referred children and their parents to list, independently, the child's target problems. Of the parent-child pairs, 63% failed to agree on even a single problem. When problems were grouped into broad categories (e.g., delinquent, withdrawn), more than a third of the pairs still failed to agree on a single broad problem area. Parent-child agreement was higher for externalizing than for internalizing problem categories (though poor for both). Low parent-child agreement may help explain the poor outcomes often reported for clinic-based child therapy.

Child and adolescent psychotherapy in research and practice contexts: review of the evidence and suggestions for improving the field.

The body of evidence on child and adolescent psychotherapy outcomes has now grown to more than 500 studies. Here we summarize key findings, focusing on effectiveness and efficacy research. Research is sparse on the effectiveness of treatment in everyday practice, but available evidence suggests little benefit. By contrast, extensive research on efficacy of structured treatments administered under controlled conditions shows very substantial evidence of benefit. We note several specific treatments for which evidence is encouraging, and we offer suggestions for future research. Particularly important will be research on treatment models most often used in practice settings, tests of outcome mediators and moderators, tests employing a broadened range of treatment delivery models, and research bridging the gap between lab-tested treatments and the conditions of real-world practice.

The Service Assessment for Children and Adolescents (SACA): adult and child reports.

OBJECTIVE: To describe differences in parent-child responses to the Service Assessment for Children and Adolescents (SACA). METHOD: Studies were done at UCLA and Washington University based on service-using and community subjects drawn from community households or public school student lists, respectively. Results are presented for 145 adult-youth pairs in which the youth was 11 or older. RESULTS: The SACA adult-youth correspondence for lifetime use of any services, inpatient services, outpatient services, and school services ranged from fair to excellent (kappa = 0.43-0.86, with most at 0.61 or greater). Similarly, the SACA showed a good to excellent correspondence for services that had been used in the preceding year (kappa = 0.45-0.77, with most greater than 0.50). The parent-youth correspondence for use of specific service settings in the above generic categories ranged from poor to excellent (kappa = 0.25-0.83, with half at 0.50 or greater). CONCLUSIONS: The SACA has better adult-youth correspondence than any service use questionnaire with published data, indicating that both adult and youth reports are not needed for all research on mental health services. This is especially encouraging news for researchers working with high-risk youth populations, in which a parent figure is often not available.

Can we trust parent reports in research on cultural and ethnic differences in child psychopathology? Using the bicultural family design to test parental culture effects.

Research comparing cultural and ethnic groups on child psychopathology has relied heavily on parent reports. But don't parents' own cultural backgrounds bias their reports, undermining valid assessment of actual child behavior? The question is hard to address because parent and child culture tend to be confounded. To solve this problem, we assembled an unusual but heuristically valuable sample: 50 bicultural families, each with an ethnic Thai parent reared in Thailand and a Caucasian parent reared in the U.S. Parents in each pair independently completed standardized problem checklists on the same child in their family. Across all 10 empirically derived problem syndromes, no parental culture effect was either significant or larger than "small," by Cohen's (1988) standards; across all 140 specific problems, the mean percent of variance accounted for by parent culture was less than 1%. Results do not point to a biasing effect of parental culture.

Culture, coping, and context: primary and secondary control among Thai and American youth.

Do cultural values and traditions influence the development of coping styles ? To address this question, we compared self-reports of coping by 6-14-year-olds in Thailand and the U.S. One hundred and forty-one children were interviewed about six common stressors: separation from a friend, injection in a doctor's office, adult anger, peer animosity, school failure, and physical injury. Children's self-reported coping methods were coded as overt or covert. Coping goals were coded as reflecting primary control (attempts to influence objective conditions), secondary control (attempts to adjust oneself to objective conditions), or relinquished control. Although findings revealed numerous cross-national similarities, there were also multiple main and interaction effects involving culture, suggesting that sociocultural context may be critical to our understanding of child coping. Consistent with literature on Thai culture, Thai children reported more than twice as much covert coping as American children for stressors involving adult authority figures (i.e. adult anger, injection in doctor's office). Thai children also reported more secondary control goals than Americans when coping with separation, but American children were five times as likely as Thais to adopt secondary control goals for coping with injury. The findings support a model of coping development in which culture and stressor characteristics interact, with societal differences most likely to be found in situations where culture-specific norms become salient.

Homesickness in preadolescent and adolescent girls: risk factors, behavioral correlates, and sequelae.

Examined homesickness in 117 girls ages 8 to 16 during a 2-week stay at summer camp. (Homesickness is the distress or impairment caused by an actual or anticipated separation from home. It is characterized by acute longing and preoccupying thoughts of home and attachment objects.) Elevated preseparation levels of homesickness, high expectations of homesickness, negative separation attitudes, low decision control, and little previous separation experience predicted in-camp levels of homesickness. During the separation, homesickness was associated with insecure interpersonal attitudes, negative initial impressions of the novel environment, high perceived distance from home, and low perceived control. Female surrogate caregivers rated homesick girls as having lower social status and more somatic complaints, social problems, and externalizing behavior than less homesick girls. Although the prevalence, intensity, and longitudinal course of homesickness in girls did not differ from analogous samples of boys, girls' profile of risk factors, correlates, and sequelae is unique in its mixed behavioral presentation and small correlations with age and experience.

Efficacy and effectiveness of child and adolescent psychotherapy and pharmacotherapy.

Decades of intervention research have produced a rich body of evidence on the effects of psychotherapies and pharmacotherapies with children and adolescents. Here we summarize and critique that evidence. We review findings bearing on the efficacy of psychosocial treatments and medications under controlled experimental conditions. We also report evidence, where available, on the effectiveness of both classes of treatment with clinically referred youth treated in real-world clinical contexts. In general, the large body of evidence on efficacy contrasts sharply with the small base of evidence on effectiveness. Addressing this gap through an enriched research agenda could contribute importantly to linking scientific inquiry and clinical practice-to the benefit of both ventures. This is one element of a multifaceted agenda for future research and for synthesis of research, which will require the interplay of multiple disciplines related to child and adolescent mental health.

Finding, evaluating, refining, and applying empirically supported treatments for children and adolescents.

Structured child and adolescent treatments, tested through controlled clinical trials, have produced beneficial effects in hundreds of studies. By contrast, the limited pool or research on traditional clinical treatments raises doubts about their effectiveness. Thus, identification of empirically supported treatments may contribute something of real value to clinical practice and training. The Child Task Force report represents an important initial step in this direction. Here we offer both praise and critique, suggesting a number of ways the task force process and product may be improved. In addition, we suggest several ways to strengthen and enrich the clinical trials research available to the Task Force, emphasizing the need to test empirically supported treatments with referred youth in practice settings.

Identifying and developing empirically supported child and adolescent treatments.

Child and adolescent therapy outcome research findings attest to the efficacy of a variety of treatments. This article illustrates promising treatments for selected internalizing (anxiety and depression), externalizing (oppositional, and antisocial behavior), and other (obesity and autism) conditions, and for other aims (preparation for medical and dental procedures). Studies in these areas illustrate worthwhile characteristics that can help inform the search for empirically supported treatments. These characteristics include randomized controlled trials, well-described and replicable treatments, tests with clinical samples, tests of clinical significance, broad-based outcome assessment including measures of real-world functioning, and others. Continued research progress will depend on greater attention to magnitude and maintenance of therapeutic change, long-term follow-up, moderators and mediators of change, and development and testing of treatment in conditions relevant to clinical practice.

Ego control, Ego resiliency, and the Five-Factor Model as predictors of behavioral and emotional problems in clinic-referred children and adolescents.

The relations of Ego control (EC), Ego resiliency (ER), and the Five-Factor Model of Personality (FFM) with behavioral and emotional problems were explored among 116 clinic-referred children. Within the EC-ER model, Ego undercontrol was most important in predicting externalizing problems, and both Ego brittleness (the relative absence of ER) and Ego undercontrol made equal contributions to predicting internalizing problems. Within the FFM, Extraversion and Agreeableness were independent predictors of externalizing problems, whereas only Neuroticism predicted internalizing problems. When the EC-ER model was tested against the FFM, the latter model appeared to outperform the former in predicting externalizing but not internalizing problems; when clinical syndrome groups were examined, dimensions from both personality models were differentially salient for children with primary internalizing, externalizing, or comorbid problems.

Brief treatment of mild-to-moderate child depression using primary and secondary control enhancement training.

Elementary school children with mild-to-moderate depressive symptoms were randomly assigned to a control group or an 8-session Primary and Secondary Control Enhancement Training program. The program focused on (a) primary control (changing objective conditions to fit one's wishes; e.g., through activity selection and goal attainment) and (b) secondary control (changing oneself to buffer the impact of objective conditions; e.g., altering depressogenic thinking, practicing mood-enhancing cognitions). At immediate posttreatment and 9-month follow-up, the treatment group showed greater reductions than the control group in depressive symptomatology on the Children's Depression Inventory and the Revised Children's Depression Rating Scale, and treated children, more than controls, shifted from above to within the normal range on both measures. Future research is needed to test treatment effects with severely depressed youths.

"You can try or you can just give up": the impact of perceived control and coping style on childhood homesickness.

Research on children's coping with homesickness during relatively uncontrollable separations has suggested that secondary control coping (i.e., adjusting oneself to fit objective conditions) is often preferred over primary control coping (i.e., modifying objective conditions to fit oneself). Related research suggests that negative affect is associated with (a) relinquishing control or using primary control to cope with uncontrollable stressors and (b) perceiving low control over stressors. The convergence of these factors was examined for the stressor of homesickness. Among 1,032 boys and girls spending 2 weeks at residential summer camps, the most frequent and effective way of coping with homesickness was to exert secondary control by engaging in a distracting physical activity. Contrary to speculation, the use of secondary control coping rose in adolescence. Congruent with empirical predictions, the most homesick children perceived low control over homesickness and separation, and coped by relinquishing control.

More of what? Issues raised by the Fort Bragg study.

The sobering findings of the Fort Bragg study illustrate why ambitious demonstration projects must be combined with objective outcome evaluations. The study does suggest that "more is not always better" (L Bickman, 1996), but more of what? Little is known about the specific interventions that were combined to form the Fort Bragg system of care, so the study does not really reveal what failed or what needs to be changed. Moreover, there is no evidence that the specific treatments used had any empirical support. Combining and systematizing various treatments may not produce improved outcomes if the treatments are not effective in the first place. Costly demonstration programs that combine untested treatments may be a poor investment. A better strategy may be to develop and test an array of well-documented treatments for an array of child and family problems, creating the building blocks needed for effective systems of care in the future.

Experimental task and speaker effects on parent-child interactions of aggressive and depressed/anxious children.

Parent-child interactions of aggressive and depressed/anxious clinic-referred children were observed during two different tasks: planning a vacation and discussing a conflict. Marked group differences were found as a function of the type of task, who was speaking (parent vs. child), and type of child psychopathology. Negative behaviors (e.g., Belittling and Blaming) were especially pronounced in the conflict task, whereas positive behaviors (e.g., Nurturing and Protecting) were more common in the planning task. Parents displayed other-directed behavior (e.g., Watching and Controlling), whereas children showed more self-directed behavior (e.g., Walling Off and Distancing), and patterns of child psychopathology interacted with task and speaker in theoretically important ways; for example, parents of aggressive children showed more Belittling and Blaming than their children in the conflict task, but not in the planning task. The findings highlight key factors that may need to be incorporated into models of parent-child interaction and child psychopathology.

Reciprocal influences among adrenocortical activation, psychosocial processes, and the behavioral adjustment of clinic-referred children.

The reciprocal effects among cognitive-behavioral, environmental, and biological influences on clinic-referred children's (N = 64; 34 boys; M age 12.71 years) short-term psychological and psychiatric adjustment were studied. At clinic intake and 6 months later, standardized measures of adjustment and control-related beliefs were assessed. Before and after conflict-oriented parent-child interaction tasks the children's saliva was sampled. Adrenocortical responses (i.e., increases in salivary cortisol) to the social conflict task predicted children's internalizing problem behaviors and anxiety disorders at follow-up. Consistently high adrenocortical reactivity at intake and follow-up was associated with deflated social competence over the 6-month period. Also, specific patterns of discontinuity in children's internalizing behavior problems predicted individual differences in their subsequent adrenocortical responsiveness. Specifically, rising behavior problem levels across time predicted higher and declining behavior problem levels predicted lower adrenocortical reactivity at follow-up. Findings are among the first to suggest links among internalizing behavior problems, adrenocortical responsiveness to social challenge, and clinic-referred children's short-term cognitive-behavioral and emotional adjustment.