Adaptive Interventions in Child and Adolescent Mental Health

Trajectories and predictive factors of weight recovery in patients with anorexia nervosa completing treatment. A latent class mixed model approach

BACKGROUND

Treatment of anorexia nervosa (AN) sometimes requires hospitalisation, which is often lengthy, with little ability to predict individual trajectory. Depicting specific profiles of treatment response and their clinical predictors could be beneficial to tailor inpatient management. The aim of this research was to identify clusters of weight recovery during inpatient treatment, and their clinical predictors.

METHODS

A sample of 181 inpatients who completed a treatment programme for AN was included in a retrospective study. A latent class mixed model approach was used to identify distinct weight-gain trajectories. Clinical variables were introduced in a multinomial logistic regression model as predictors of the different classes.

RESULTS

A four-class quadratic model was retained, able to correctly classify 63.7% of the cohort. It encompassed a late-rising, flattening, moderate trajectory of body mass index (BMI) increase (class 1), a late-rising, steady, high trajectory (class 2), an early-rising, flattening, high trajectory (class 3) and an early-rising, steady, high trajectory (class 4). Significant predictors of belonging to a class were baseline BMI (all classes), illness duration (class 2), and benzodiazepine prescription (class 3).

CONCLUSION

Predicting different kinetics of weight recovery based on routinely collected clinical indicators could improve clinician awareness and patient engagement by enabling shared expectations of treatment response.

Intervention Optimization: A Paradigm Shift and Its Potential Implications for Clinical Psychology

To build a coherent knowledge base about what psychological intervention strategies work, develop interventions that have positive societal impact, and maintain and increase this impact over time, it is necessary to replace the classical treatment package research paradigm. The multiphase optimization strategy (MOST) is an alternative paradigm that integrates ideas from behavioral science, engineering, implementation science, economics, and decision science. MOST enables optimization of interventions to strategically balance effectiveness, affordability, scalability, and efficiency. In this review we provide an overview of MOST, discuss several experimental designs that can be used in intervention optimization, consider how the investigator can use experimental results to select components for inclusion in the optimized intervention, discuss the application of MOST in implementation science, and list future issues in this rapidly evolving field. We highlight the feasibility of adopting this new research paradigm as well as its potential to hasten the progress of psychological intervention science.

Secondary Analysis to Inform the Development of Adaptive Preventive Interventions

For the past 30 years, scholars across the fields of epidemiology, education, psychology, and numerous other fields have worked to develop interventions designed to reduce risk and enhance protection to prevent mental, emotional, and behavioral problems across the lifespan. This article presents a series of next steps that leverage this foundational science to inform the development of adaptive preventive interventions. Adaptive preventive interventions (APIs) tailor the intervention to fit the diverse, sometimes changing, needs of participants with the goal of better prevention outcomes for more individuals. Secondary analyses of data from preventive intervention trials to identify moderators, mediators, and antecedents of attrition and intervention failure can be useful for designing effective APIs. Moderators that identify intervention effect heterogeneity can be used within an API to tailor the intervention to meet the unique needs of important participant subgroups. Mediators and predictors of disengagement and attrition can be helpful tailoring variables in an API to trigger change to the intervention. Preventive intervention trials that incorporate frequent assessment of potential mediators, moderators, and antecedents of attrition during the intervention period are needed. Secondary analyses of data from preventive intervention trials provide an important foundation for next-generation APIs.

Building a Life Course Intervention Research Framework

OBJECTIVES

To report on first steps toward building a Life Course Intervention Research Framework (LCIRF) to guide researchers studying interventions to improve lifelong health.

METHODS

The Life Course Intervention Research Network, a collaborative national network of >75 researchers, service providers, community representatives and thought leaders, participated in an iterative review process. Building on the revised Medical Research Council Guidance for Developing and Evaluating Complex Interventions, they identified 12 additional key models with features for inclusion in the LCIRF, then incorporated the 12 characteristics identified by the Life Course Intervention Research Network as actionable features of Life Course Interventions to produce the new LCIRF.

RESULTS

The LCIRF sets out a detailed step-wise approach to intervention development: (1) conceptualization and planning, (2) design, (3) implementation, (4) evaluation, and (5) spreading and scaling of interventions. Each step is infused with life course intervention characteristics including a focus on (1) collaborative codesign (2) health optimization, (3) supporting emerging health development capabilities (4) strategic timing, (5) multilevel approaches, and (6) health equity. Key features include a detailed transdisciplinary knowledge synthesis to inform intervention development; formation of strong partnerships with family, community, and youth representatives in intervention codesign; a means of testing the impact of each intervention on biobehavioral processes underlying emerging health trajectories; and close attention to intervention context.

CONCLUSIONS

This first iteration of the LCIRF has been largely expert driven. Next steps will involve widespread partner engagement in framework refinement and further development. Implementation will require changes to the way intervention studies are organized and funded.

Parent and Child Risk Profiles as Predictors of Response to a Conduct Problem Preventive Intervention

Current evidence-based prevention programming targeting child externalizing problems demonstrates modest overall effect sizes and is largely ineffective for a sizable proportion of youth who participate. However, our understanding of the youth and family characteristics associated with response to specific programming is quite limited. The current study used child and family risk profiles as predictors of response trajectories to the Early Risers conduct problem preventive intervention. A sample of 240 kindergarten-aged youth displaying elevated school-based aggression were randomized by school to either the Early Risers intervention or a control condition. Using a number of child and family risk variables, a latent profile analysis produced a solution consisting of five unique risk profiles. Three low and mixed risk profiles were associated with a limited response to the intervention. One high-risk profile characterized by maladaptive parenting and elevated child externalizing demonstrated notably improved trajectories of externalizing behavior over a 3-year period relative to the control condition. Another high-risk profile characterized by inconsistent discipline, high parental distress, and elevated child internalizing and externalizing symptoms seemed to have positive developmental trends disrupted by the intervention relative to the control condition, potentially consistent with an iatrogenic effect relative to the control condition. The study results support continued efforts to use broader risk profiles to examine heterogeneity in response to preventive interventions and, with replication, will have implications for intervention tailoring.

Cost-effectiveness analysis of paediatric mental health interventions: a systematic review of model-based economic evaluations

Mental health disorders among children and youth are causing significant burden on health care systems. Hence, identifying cost-effective interventions is important for effective mental health care allocation. Although model-based economic evaluations are an essential component of assessing cost-effectiveness, evidence are limited in the context of child and youth mental health care. The objective was to systematically review the model-based economic evaluations of mental health interventions for children and youth.

Methods

Four databases (MEDLINE, EMBASE, PsycINFO and Web of Science) were searched using appropriate search terms to retrieve model-based economic evaluations of mental health interventions for children and youth. The reporting quality of the included studies were appraised using the Consolidated health economic evaluation reporting standards (CHEERS) checklist.

Results

The database search yielded 1921 records. Of the 12 selected for review, 66% were published after year 2015. Most of the studies were related to anxiety and post-traumatic stress disorder. There were eight cost-utility studies, three cost-effectiveness studies, and one study using both forms of analysis. Six studies used Markov models, three used decision trees, and three studies used both types of models. However, the model structure, health states, time horizon, and economic perspective showed wide variation. The reporting quality of the included studies varied from 91 to 96%.

Conclusion

Model based mental health economic evaluations among children and youth are increasingly being reported in recent research. The included studies used Markov models and decision trees, either alone or in combination, and the majority of the articles were of good reporting quality.

Obesity prevention practices in early care and education settings: an adaptive implementation trial

Background

Despite the potential for Early Care and Education (ECE) settings to promote healthy habits, a gap exists between current practices and evidence-based practices (EBPs) for obesity prevention in childhood.

Methods

We will use an enhanced non-responder trial design to determine the effectiveness and incremental cost-effectiveness of an adaptive implementation strategy for Together, We Inspire Smart Eating (WISE), while examining moderators and mediators of the strategy effect. WISE is a curriculum that aims to increase children’s intake of carotenoid-rich fruits and vegetables through four evidence-based practices in the early care and education setting. In this trial, we will randomize sites that do not respond to low-intensity strategies to either (a) continue receiving low-intensity strategies or (b) receive high-intensity strategies. This design will determine the effect of an adaptive implementation strategy that adds high-intensity versus one that continues with low-intensity among non-responder sites. We will also apply explanatory, sequential mixed methods to provide a nuanced understanding of implementation mechanisms, contextual factors, and characteristics of sites that respond to differing intensities of implementation strategies. Finally, we will conduct a cost effectiveness analysis to estimate the incremental effect of augmenting implementation with high-intensity strategies compared to continuing low-intensity strategies on costs, fidelity, and child health outcomes.

Discussion

We expect our study to contribute to an evidence base for structuring implementation support in real-world ECE contexts, ultimately providing a guide for applying the adaptive implementation strategy in ECE for WISE scale-up. Our work will also provide data to guide implementation decisions of other interventions in ECE. Finally, we will provide the first estimate of relative value for different implementation strategies in this setting.

Trial registration

NCT05050539; 9/20/21.

Towards adaptive technology in routine mental health care

This paper summarizes the information technology-related research findings after 5 years with the INTROducing Mental health through Adaptive Technology project. The aim was to improve mental healthcare by introducing new technologies for adaptive interventions in mental healthcare through interdisciplinary research and development. We focus on the challenges related to internet-delivered psychological treatments, emphasising artificial intelligence, human-computer interaction, and software engineering. We present the main research findings, the developed artefacts, and lessons learned from the project before outlining directions for future research. The main findings from this project are encapsulated in a reference architecture that is used for establishing an infrastructure for adaptive internet-delivered psychological treatment systems in clinical contexts. The infrastructure is developed by introducing an interdisciplinary design and development process inspired by domain-driven design, user-centred design, and the person based approach for intervention design. The process aligns the software development with the intervention design and illustrates their mutual dependencies. Finally, we present software artefacts produced within the project and discuss how they are related to the proposed reference architecture. Our results indicate that the proposed development process, the reference architecture and the produced software can be practical means of designing adaptive mental health care treatments in correspondence with the patients’ needs and preferences. In summary, we have created the initial version of an information technology infrastructure to support the development and deployment of Internet-delivered mental health interventions with inherent support for data sharing, data analysis, reusability of treatment content, and adaptation of intervention based on user needs and preferences.

Multitiered Systems of Support, Adaptive Interventions, and SMART Designs

This article introduces the special section on adaptive interventions and sequential multiple-assignment randomized trial (SMART) research designs. In addition to describing the two accompanying articles, we discuss features of adaptive interventions (AIs) and describe the use of SMART design to optimize AIs in the context of multitiered systems of support (MTSS) and integrated MTSS. AI is a treatment delivery model that explicitly specifies how information about individuals should be used to decide which treatment to provide in practice. Principles that apply to the design of AIs may help to more clearly operationalize MTSS-based programs, improve their implementation in school settings, and increase their efficacy when used according to evidence-based decision rules. A SMART is a research design for developing and optimizing MTSS-based programs. We provide a running example of a SMART design to optimize an MTSS-aligned AI that integrates academic and behavioral interventions.

Associations between socioprovincial factors and self-reported mental disorders among students from grade 4 to 8 in rural China

Background

The focus on child mental health in developing countries was increasing. However, little was known in China. This study aimed to explore the associations between socioprovincial factors and self-reported mental disorders in rural China.

Methods

Data were from a publicly available survey with 54,498 students from Grade 4 to 8 in rural China. Chi-square test was used for descriptive analysis. Self-reported mental disorders included overall mental disorder, study anxiety, personal anxiety, loneliness, guilt, sensitivity, symptomatic psychosis, phobia, and impulsivity. Multiple logistic regressions and errors-in-variables regression models were employed to explore the associations between socioprovincial factors and mental disorders. Poisson regressions and errors-in-variables regression models were adopted to reveal the associations between socioprovincial factors and number of self-reported mental disorders.

Results

Descriptive statistics showed that mental health was poor in rural adolescents in China. Logistic regression showed that the odds of overall mental disorder and study anxiety were 189% (AOR = 2.89, 95%CI: 2.76, 3.02) and 92% (OR = 1.92, 95%CI: 1.84, 2.00) in Gansu more than those in Anhui, while the odds of personal anxiety, guilt, sensitivity, symptomatic psychosis, and phobia were 92% (AOR = 0.08, 95%CI: 0.08, 0.09), 71% (AOR = 0.29, 95%CI: 0.27, 0.30), 88% (AOR = 0.12, 95%CI: 0.11, 0.13), 69% (AOR = 0.31, 95%CI: 0.29, 0.32), and 78% (AOR = 0.22, 95%CI: 0.21, 0.23) in Gansu less than those in Anhui. Moreover, Gansu (Poisson regression: IRR =1.45, 95%CI: 1.42–1.47; errors-in-variables regression: Coefficient = 0.26, 95%CI: 0.16, 0.36), Ningxia (Poisson regression: IRR =1.63, 95%CI: 1.60–1.67; errors-in-variables regression: Coefficient = 0.43, 95%CI: 0.32, 0.53), Qinghai (Poisson regression: IRR =1.65, 95%CI: 1.60–1.69; errors-in-variables regression: Coefficient = 0.44, 95%CI: 0.34, 0.55), and Shaanxi (Poisson regression: IRR =1.28, 95%CI: 1.25–1.30; errors-in-variables regression: Coefficient = 0.11, 95%CI: 0.00, 0.21) were significantly associated with the number of self-reported mental disorders.

Conclusion

Class and provincial disparities in self-reported mental disorders were reported among the students from Grade 4 to 8 in rural China. Mental health care supported by governments and schools could be an effective way to reduce the disparities in mental disorders among the adolescents.

Moderators of Outcome for Youth Anxiety Treatments: Current Findings and Future Directions

Objective: To improve outcomes and create more personalized interventions, the field has sought to identify moderators of treatment response (variables that specify which treatments work for whom and under what conditions).Method: The current review examines moderators of youth anxiety treatments.Results: The majority of studies to date have examined variables of convenience, including demographics (age, sex, race, ethnicity, socioeconomic status), pretreatment youth clinical characteristics (anxiety severity, principal diagnosis, comorbidity) and pretreatment parent variables (parent psychopathology, parenting). Findings indicate few consistent moderators.Conclusions: Future directions are discussed, including (a) group to individual generalizability, (b) power considerations, and (c) updates to study design and measure selection.

The Fears of Evaluation About Performance (FEAP) Task: Inducing Anxiety-Related Responses to Direct Exposure to Negative and Positive Evaluations

Fears of negative and positive evaluation (i.e., evaluative fears) manifest within performance-based situations (e.g., public speaking, group presentations), particularly among those experiencing social anxiety. Within these performance-based situations, individuals experiencing such evaluative fears frequently display a variety of impairments (e.g., avoidance, nervousness) that might manifest within and across various settings (e.g., employment, school). How do those who experience these fears react to in-the-moment feedback about their performance? We constructed the Fear of Evaluation About Performance (FEAP) task to examine ecologically valid experiences with anxiety when reacting to positive and negative feedback. During the task, participants gave a speech, and subsequent to this and in counterbalanced order, received positive and negative feedback about their speech, with continued assessment of anxiety-related arousal throughout the task. We tested the FEAP task among 127 adults, who provided self-reports of fears of positive and negative evaluation before completing the task. Fears of positive evaluation uniquely predicted arousal following receipt of positive feedback, whereas fears of negative evaluation uniquely predicted arousal following receipt of negative feedback. Relative to participants receiving positive feedback first, those receiving negative feedback first experienced elevated post-feedback arousal, followed by a steep decline in arousal post-positive feedback. Conversely, participants receiving positive feedback first experienced a buffer effect whereby arousal post-negative feedback remained low, relative to the arousal experienced post-negative feedback among those who received negative feedback first. We expect the FEAP task to inform basic science on fears of negative and positive evaluation, as well as treatment planning in applied clinical settings.

Peer engagement in toddlers with autism: Community implementation of dyadic and individual Joint Attention, Symbolic Play, Engagement, and Regulation intervention

LAY ABSTRACT

Although young children may participate in education and intervention programs that take place in classrooms or groups, there is little information about how toddlers with special needs, and specifically toddlers with autism, are engaging with their peers. This study takes place in a public center-based early intervention program for toddlers with autism. Classrooms of toddlers were randomly assigned to an individual social communication intervention or the same intervention adapted to include a peer. Children in both groups made gains in social communication and play skills. Children who had the peer intervention were more engaged with peers when an adult was present, but not when the children were unsupported. This article adds information about early skills that may be important for children to master so that they have more success when trying to interact with their peers. These skills include understanding language (referred to as "receptive language" at 12 months or more) and play skills including building and stacking (referred to as "combination play"-for example, building with blocks or completing a puzzle) and extending familiar actions to themselves, others, and figures (referred to as "presymbolic play"-for example, putting a bottle to the doll or to themselves). Understanding which skills to target can help practitioners focus their instruction to build children's skills toward connecting with peers through play.

Identifying optimal level-of-care placement decisions for adolescent substance use treatment

BACKGROUND

Adolescents respond differentially to substance use treatment based on their individual needs and goals. Providers may benefit from guidance (via decision rules) for personalizing aspects of treatment, such as level-of-care (LOC) placements, like choosing between outpatient or inpatient care. The field lacks an empirically-supported foundation to inform the development of an adaptive LOC-placement protocol. This work begins to build the evidence base for adaptive protocols by estimating them from a large observational dataset.

METHODS

We estimated two-stage LOC-placement protocols adapted to individual adolescent characteristics collected from the Global Appraisal of Individual Needs assessment tool (n = 10,131 adolescents). We used a modified version of Q-learning, a regression-based method for estimating personalized treatment rules over time, to estimate four protocols, each targeting a potentially distinct treatment goal: one primary outcome (a composite of ten positive treatment outcomes) and three secondary (substance frequency, substance problems, and emotional problems). We compared the adaptive protocols to non-adaptive protocols using an independent dataset.

RESULTS

Intensive outpatient was recommended for all adolescents at intake for the primary outcome, while low-risk adolescents were recommended for no further treatment at followup while higher-risk patients were recommended to inpatient. Our adaptive protocols outperformed static protocols by an average of 0.4 standard deviations (95 % confidence interval 0.2-0.6) of the primary outcome.

CONCLUSIONS

Adaptive protocols provide a simple one-to-one guide between adolescents' needs and recommended treatment which can be used as decision support for clinicians making LOC-placement decisions.

Trial Registration and Outcome Reporting in Child and Pediatric Psychology: A Systematic Review

OBJECTIVE

To examine rate of registration for randomized controlled trials (RCTs) published in the Journal of Pediatric Psychology (JPP) and Journal of Clinical Child & Adolescent Psychology (JCCAP). Secondary aims were to investigate associations between trial characteristics and registration status and compare registered and published primary outcomes.

METHODS

RCTs published in JPP or JCCAP between January 1, 2007 and December 31, 2017 were included. Secondary analyses of previously published RCTs, meta-analytic, systematic, and narrative reviews, and articles reporting primary aims related to intervention acceptability, feasibility, and/or cost-effectiveness were excluded. Trial registration status, primary registered and published outcomes, dates of registration, participant enrollment and publication, sample size, and country where the trial was conducted were extracted from articles and trial registries.

RESULTS

Of 61 RCTs included, 48% were registered. Among registered trials, only 14% were registered before participant enrollment began. Most were registered late (i.e., retrospectively; 86%) in ClinicalTrials.gov (90%). Registration status did not differ based on journal, study sample size, or geographic region where the study was conducted. A greater proportion of trials published in 2013-2017 were registered (61%) relative to those published in 2007-2012 (32%), p = .03. Among registered trials, 57% had discrepancies between registered and published primary outcomes.

CONCLUSIONS

Findings reveal low rates of prospective registration and considerable risk for incomplete or selective outcome reporting among RCTs published in JPP and JCCAP. Coordinated efforts from all stakeholders involved in the conduct and reporting of clinical child and pediatric psychology research are needed to improve transparent reporting of clinical trials.

The Balanced Opioid Initiative: protocol for a clustered, sequential, multiple-assignment randomized trial to construct an adaptive implementation strategy to improve guideline-concordant opioid prescribing in primary care

BACKGROUND

Rates of opioid prescribing tripled in the USA between 1999 and 2015 and were associated with significant increases in opioid misuse and overdose death. Roughly half of all opioids are prescribed in primary care. Although clinical guidelines describe recommended opioid prescribing practices, implementing these guidelines in a way that balances safety and effectiveness vs. risk remains a challenge. The literature offers little help about which implementation strategies work best in different clinical settings or how strategies could be tailored to optimize their effectiveness in different contexts. Systems consultation consists of (1) educational/engagement meetings with audit and feedback reports, (2) practice facilitation, and (3) prescriber peer consulting. The study is designed to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics.

METHODS/DESIGN

The study is a hybrid type 3 clustered, sequential, multiple-assignment randomized trial (SMART) that randomizes clinics from two health systems at two points, months 3 and 9, of a 21-month intervention. Clinics are provided one of four sequences of implementation strategies: a condition consisting of educational/engagement meetings and audit and feedback alone (EM/AF), EM/AF plus practice facilitation (PF), EM/AF + prescriber peer consulting (PPC), and EM/AF + PF + PPC. The study's primary outcome is morphine-milligram equivalent (MME) dose by prescribing clinicians within clinics. The study's primary aim is the comparison of EM/AF + PF + PPC versus EM/AF alone on change in MME from month 3 to month 21. The secondary aim is to derive cost estimates for each of the four sequences and compare them. The exploratory aim is to examine four tailoring variables that can be used to construct an adaptive implementation strategy to meet the needs of different primary care clinics.

DISCUSSION

Systems consultation is a practical blend of implementation strategies used in this case to improve opioid prescribing practices in primary care. The blend offers a range of strategies in sequences from minimally to substantially intensive. The results of this study promise to help us understand how to cost effectively improve the implementation of evidence-based practices.

TRIAL REGISTRATION

NCT04044521 (ClinicalTrials.gov). Registered 05 August 2019.

Moving Toward a Precision-Based, Personalized Framework for Prevention Science: Introduction to the Special Issue

The goal of this Special Issue is to introduce prevention scientists to an emerging form of healthcare, called precision medicine. This approach integrates investigation of the mechanisms of disease and health-compromising behaviors with prevention, treatment, and cure resolved at the level of the individual. Precision Medicine and its derivative personalized prevention represents a promising paradigm for prevention science as it accounts for response heterogeneity and guides development of targeted interventions that may enhance program effect sizes. If successfully integrated into prevention science research, personalized prevention is an approach that can inform the development of decision support tools (screening measures, prescriptive algorithms) and enhance the utility of mobile health technologies that will enable practitioners to use personalized consumer data to inform decisions about the best type and/or intensity of a prevention strategy for particular individuals or subgroups of individuals. In this special issue, we present conceptual articles that provide a heuristic framework for precision-based, personalization prevention research and empirical studies that address research questions exemplary of a new generation of precision-based personalized preventive interventions focused on children's mental health, behavioral health, and education.

Pragmatic trial evaluating the effectiveness of a patient navigator to decrease emergency room utilisation in transition age youth with chronic conditions: the Transition Navigator Trial protocol

INTRODUCTION

Transition to adult care is a challenging and complex process for youth with special healthcare needs. We aim to compare effectiveness of a patient navigator service in reducing emergency room (ER) use among adolescents with chronic health conditions transitioning to adult care.

METHODS AND ANALYSIS

Pragmatic randomised controlled trial parallel group design comparing ER visit rates between patients with access to a personalised navigator intervention compared with usual care. Unit of randomisation is the patient. Treatment assignment will not be blinded. Embedded qualitative study to understand navigator's role and cost analysis attributable to the intervention will be performed. Patients aged 16-21 years, followed within a chronic disease clinic, expected to be transferred to adult care within 12 months and residing in Alberta during study period will be recruited from three tertiary care paediatric hospitals. Sample size will be 300 in each arm. Navigator intervention over 24 months is designed to assist participants in four domains: transition preparation, health system brokering, socioeconomic determinants of health and self-management. Primary outcome is ER visit rate during observation period. Secondary outcomes are ambulatory and inpatient care utilisation measures, as well as Transition Readiness Assessment Questionnaire score, and Short-Form Health Survey 12 (SF-12) score at 6 and 18 months post-randomisation. Poisson regression will compare rates of ER/urgent care visits between navigator and control participants, using intention to treat principle. Cost analysis of the intervention will be conducted. Thematic analysis will be used to identify perceptions of stakeholders regarding the role of navigators.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the University of Calgary Conjoint Health Research Ethics Board (REB #162561) and the University of Alberta Health Research Ethics Board (Pro00077325). Our team is composed of diverse stakeholders who are committed to improving transition of care who will assist with dissemination of results.

TRIAL REGISTRATION NUMBER

NCT03342495.

A Data Analysis Method for Using Longitudinal Binary Outcome Data from a SMART to Compare Adaptive Interventions

Sequential multiple assignment randomized trials (SMARTs) are a useful and increasingly popular approach for gathering information to inform the construction of adaptive interventions to treat psychological and behavioral health conditions. Until recently, analysis methods for data from SMART designs considered only a single measurement of the outcome of interest when comparing the efficacy of adaptive interventions. Lu et al. proposed a method for considering repeated outcome measurements to incorporate information about the longitudinal trajectory of change. While their proposed method can be applied to many kinds of outcome variables, they focused mainly on linear models for normally distributed outcomes. Practical guidelines and extensions are required to implement this methodology with other types of repeated outcome measures common in behavioral research. In this article, we discuss implementation of this method with repeated binary outcomes. We explain how to compare adaptive interventions in terms of various summaries of repeated binary outcome measures, including average outcome (area under the curve) and delayed effects. The method is illustrated using an empirical example from a SMART study to develop an adaptive intervention for engaging alcohol- and cocaine-dependent patients in treatment. Monte Carlo simulations are provided to demonstrate the good performance of the proposed technique.

Considering equifinality in treatment planning for social impairment: Divergent paths in neurodevelopmental disorders

Youth with autism spectrum disorder (ASD) present with deficits in both social cognition and executive functioning (EF), which contribute to social impairment. Autistic youth are also frequently diagnosed with comorbid attention-deficit/hyperactivity disorder (ADHD), a disorder that, like ASD, includes impaired EF and social functioning. The comorbidity of ASD and ADHD may result in compounded social impairment, but prior research has not sufficiently evaluated the extent to which this comorbidity profile responds to evidence-based intervention targeting social deficits. It is conceivable that dually targeting EF and social cognition impairment will be more impactful than direct social skills training alone. The authors present an integrative model for intervention programming that examines pathways to social impairment in order to more effectively improve social skills and thereby impact both proximal (e.g., emotion expression, current peer relationships) and more distal outcomes (e.g., depression, self-esteem) in youth with ASD and other neurodevelopmental disorders.

Hybrid Cognitive-Behavioral Therapy Intervention for Adolescents With Co-Occurring Migraine and Insomnia: A Single-Arm Pilot Trial

OBJECTIVE

This study aimed to evaluate feasibility and acceptability of a hybrid cognitive-behavioral therapy intervention for adolescents with co-occurring migraine and insomnia.

BACKGROUND

Many youth with chronic migraine have co-occurring insomnia. Little research has been conducted to evaluate behavioral treatments for insomnia in youth with migraine.

DESIGN AND METHODS

We conducted a single-arm pilot trial to evaluate the feasibility and acceptability of delivering cognitive-behavioral therapy for insomnia to 21 youth (mean age 15.5, standard deviation 1.6) with co-occurring chronic migraine and insomnia. Adolescents completed up to 6 individual treatment sessions over 6 to 12 weeks, and 1 booster session 1 month later. Assessments included a prospective 7-day headache and sleep diary, and self-report measures of insomnia, sleep quality, sleep habits, and activity limitations at pre-treatment, immediate post-treatment, and 3-month follow-up.

RESULTS

Adolescents demonstrated good treatment adherence and families rated the intervention as highly acceptable. Preliminary analyses indicated improvements from pre-treatment to post-treatment in primary outcomes of headache days (M = 4.7, SD = 2.1 vs M = 2.8, SD = 2.7) and insomnia symptoms (M = 16.9, SD = 5.2 vs M = 9.5, SD = 6.2), which were maintained at 3-month follow-up (M = 2.7, SD = 2.8; M = 9.3, SD = 5.0, respectively). We also found improvements in secondary outcomes of pain-related activity limitations as well as sleep quality, sleep hygiene, and sleep patterns.

CONCLUSIONS

These preliminary data indicate that hybrid cognitive-behavioral therapy is feasible and acceptable for youth with co-occurring chronic migraine and insomnia. Future randomized controlled trials are needed to test treatment efficacy on migraine, sleep, and functional outcomes. ClinicalTrials.gov Identifier: NCT03137147.

Piloting a Sequential, Multiple Assignment, Randomized Trial for Mothers with Attention-Deficit/Hyperactivity Disorder and Their At-Risk Young Children

Objective: Parental attention-deficit/hyperactivity disorder (ADHD) is associated with suboptimal parenting and reduces the effectiveness of child ADHD treatments. We conducted a Pilot Sequential, Multiple Assignment, Randomized Trial (SMART Pilot) to evaluate the feasibility and acceptability of sequencing medication and behavioral treatments for mothers with ADHD to target outcomes, including maternal ADHD, parenting, and child ADHD symptoms/impairment in multiplex ADHD families. Methods: Thirty-five mothers with ADHD and their 5- to 8-year-old child with ADHD symptoms were enrolled. Mothers were randomized to 8 weeks of individually titrated stimulant medication (MSM) or behavioral parent training (BPT), followed by rerandomization to 8 weeks of continued first-line treatment (with as-needed modifications) or combined treatment, leading to four treatment sequences (MSM-MSM, MSM-BPT, BPT-MSM, and BPT-BPT). Results: Recruitment of multiplex ADHD families came primarily from child providers. Mothers were adherent to medication and had high therapy session attendance. Mothers and clinicians found both treatments to be acceptable and preferred combination treatment, especially receiving medication before BPT. Monotherapy treatment visits were viewed as more burdensome (MSM-MSM, BPT-BPT). Conclusions: Maternal stimulant medication and BPT are acceptable and feasible interventions for families in which both the mother and child have ADHD symptoms. Mothers with concerns about their children's ADHD symptoms are receptive to receiving treatment themselves as an initial strategy for improving their children's health and functioning. Fully powered SMART designs show promise in evaluating the sequencing of interventions and helping clinicians develop algorithms for treating multiplex families in real-world practice settings.

Special considerations in conducting clinical trials of chronic pain management interventions in children and adolescents and their families

INTRODUCTION

Disabling chronic pain is a common experience for children and adolescents. However, the evidence base for chronic pain interventions for youth is extremely limited, which has hindered the development of evidence-based practice guidelines for most pediatric chronic pain conditions.

OBJECTIVES

To review and provide recommendations on clinical trial design and evaluation in children and adolescents with chronic pain.

METHODS

In this article, we summarize key issues and provide recommendations for addressing them in clinical trials of chronic pain interventions in children and adolescents and their families.

RESULTS

To stimulate high-quality trials of pediatric chronic pain management interventions, attention to key issues including sample characterization, trial design and treatment administration, outcome measurement, and the ethics of intervening with children and adolescents, as opposed to adults with chronic pain, is needed.

CONCLUSION

Future research to develop interventions to reduce or prevent childhood chronic pain is an important priority area, and requires special considerations in implementation and evaluation in clinical trials.

Does dose of early intervention matter for preschoolers with externalizing behavior problems? A pilot randomized trial comparing intensive summer programming to school consultation

The goals of this study were to (a) isolate the ideal length (i.e., 4 or 8 weeks) of the Summer Treatment Program for Kindergarteners (STP-PreK) for improving school readiness and kindergarten success outcomes of preschool children with externalizing behavior problems (EBPs) during the transition to kindergarten; and (b) compare the STP-PreK model to a more standard approach in school settings (i.e., behavioral school consultation). Forty-five preschool children (82% boys; Mage = 5.16 years; 93% Hispanic/Latino background) were randomized to one of three intervention conditions: 1) 8-week STP-PreK (8W); 2) 4-week STP-PreK (4W); or 3) school year behavioral consultation (SC). Both STP-PreK groups included an 8-week parent training component. Baseline, post-intervention, and 6-month follow-up data were collected on children's school readiness and kindergarten success outcomes including parent, teacher, and objective assessment measures. Analyses using linear mixed models indicated that children's behavioral, academic, social-emotional, and self-regulation functioning significantly improved across groups. Few significant differences were found between children receiving the 4W and 8W programs, suggesting that both programs have the potential to prepare preschool children with EBP for the transition to school. Both 4W and 8W groups experienced greater initial growth across time in most domains compared to children in the SC group. However, by the end of the kindergarten year, children in the SC group caught up to children in both 4W and 8W groups on most domains. Overall, these findings suggest that all three intervention doses are effective in improving kindergarten year functioning, with some important considerations for intervention timing in preparation for the transition to elementary school. Clinical implications for school personnel are discussed.

Future Directions in Affirmative Psychological Interventions with Transgender Children and Adolescents

Transgender children and adolescents experience a gender identity that is incongruent with their sex assigned at birth, often resulting in gender dysphoria. Emerging literature has explored the etiology of transgender identities, documented transgender youths' risk for psychopathology, and evaluated whether social and medical gender transition processes are appropriate and effective for transgender youth. However, there is a dearth of empirical data on gender-affirmative psychological interventions designed to reduce the forms of psychological distress experienced by many transgender youths. This is surprising given the elevated rates of psychological distress among transgender youth and the broad recommendation for psychotherapy for youth going through a gender transition. To identify future directions in psychological interventions for transgender youth, we first review key background information on transgender youths' identity development and the role of psychological support in affirmative care. Next, we present future directions in this literature, which emphasizes the need for theory-driven empirical research that incorporates the developmental context of transgender youth to understand the mechanisms underlying group-specific psychological distress. Finally, we lay out the application of these future directions by exploring 3 domains relevant to transgender youth's psychological distress: gender dysphoria, parent and peer interactions, and co-occurring psychopathology. Within each domain, we review extant empirical research, present the current state of affirmative psychological interventions, and discuss implications for future directions. Future research on affirmative psychological care for transgender youth is urgently needed and must focus on clearly articulating which youth could benefit from psychological interventions and why those interventions might be effective.

Adaptive Interventions Are Required for Efficient and Personalized Adolescent Depression Treatment

Psychological treatments for adolescent depression demonstrate small to moderate effect sizes, with a substantial portion of youth showing insufficient response to treatment.1,2 The management of an adolescent who has not responded to front-line treatments is a common clinical scenario in which clinicians, in the absence of compelling data to drive decision making, are left with having to take a trial-and-error approach in order to promote adequate treatment response.

Emergency department text messaging for adolescent violence and depression prevention: A pilot randomized controlled trial

This study's purpose was to evaluate feasibility and acceptability, obtain preliminary efficacy data, and evaluate predictors of improvement with iDOVE, a technology-augmented violence and depression prevention intervention for high-risk adolescents seen in the emergency department (ED). We conducted a pilot randomized controlled trial (RCT) with 116 English-speaking adolescents (ages 13-17 years), presenting to the ED for any reason, who reported past-year physical peer violence and current depressive symptoms. The cognitive-behavioral therapy- and motivational interviewing-based intervention consisted of a brief in-ED intervention session and 8 weeks of automated text-message daily mood queries and tailored responses. The control was a brief in-ED presentation and twice-weekly text messages on healthy behaviors. Follow-up was conducted at 8 and 16 weeks. Descriptive statistics, bivariate comparisons, mixed-effects longitudinal regression models, and latent class models (LCMs) were calculated. iDOVE had high acceptability and feasibility, with 86% of eligible youth consenting (n = 116), 95% completing 8-week follow-up, and 91% completing 16-week follow-up. High quantitative and qualitative satisfaction were reported by intervention and control participants. Comparing intervention to control, improved depressive symptoms (p = .07) and physical peer violence (p = .01) were observed among the more symptomatic youth in the intervention group (but no difference in symptoms between full intervention and control groups). LCMs showed that intervention responsiveness correlated with lower mood (measured through daily text messages) at Day 7 of the intervention. This RCT of a technology-augmented intervention shows high feasibility and acceptability and a promising signal of reduced violence among the highest-risk participants. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

AF-CBT for Families Experiencing Physical Aggression or Abuse Served by the Mental Health or Child Welfare System: An Effectiveness Trial

The Partnerships for Families project is a randomized clinical trial to evaluate the effectiveness of Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT), an evidence-based treatment (EBT) for families who are at risk of or have histories of child physical abuse. Across 10 agencies whose programs were supported by referrals from the mental health or child welfare system, individual providers were randomized to receive AF-CBT training ( n = 90) in a 6-month learning community or treatment as usual (TAU; n = 92) which provided trainings per agency routine. We recruited families served by providers in the AF-CBT ( n = 122) and TAU ( n = 73) conditions and collected multiple outcomes at up to four time points (0, 6, 12, and 18 months). Using univariate tests and growth curve models, the analyses revealed that AF-CBT (vs. TAU) showed improvements in both service systems (e.g., abuse risk, family dysfunction) or one service system (e.g., threats of force, child to parent minor assault), with some outcomes showing no improvement (e.g., parental anger). These findings are discussed in relation to AF-CBT, service system, provider, and family characteristics, and training/dissemination methods that affect the delivery of an EBT for this population in community settings.

American Psychological Association practice guidelines for psychopharmacology: Ethical practice considerations for psychologists involving psychotropic use with children and adolescents

OBJECTIVES

This study discusses the implications of the American Psychological Association's 2011 Practice Guidelines for Pharmacology as they apply to psychologists working with juvenile clients. Special considerations apply due to concerns about the developmental side effects that occur when psychotropic medications are prescribed to children and adolescents.

METHODS OR DESIGN

This study provides recommendations for implementing each of the Practice Guidelines. Constructive criticism of the Practice Guidelines is also discussed with the aim of improving service delivery.

RESULTS

This study provides specific recommendations for psychologists regarding obtaining adequate knowledge about psychopharmacology to inform clients or consult with physicians. Suggestions are made for continuing education requirements for psychologists who work with juveniles.

CONCLUSIONS

Recommendations are made for psychologists working with juveniles to increase their knowledge of psychotropic medications for a more ethical and informed voice regarding the prescribing of such medications.

Shared Decision-Making in Youth Mental Health Care: Using the Evidence to Plan Treatments Collaboratively

The shared decision-making (SDM) model is one in which providers and consumers of health care come together as collaborators in determining the course of care. The model is especially relevant to youth mental health care, when planning a treatment frequently entails coordinating both youth and parent perspectives, preferences, and goals. The present article first provides the historical context of the SDM model and the rationale for increasing our field's use of SDM when planning psychosocial treatments for youth and families. Having established the potential utility of SDM, the article then discusses how to apply the SDM model to treatment planning for youth psychotherapy, proposing a set of steps consistent with the model and considerations when conducting SDM with youth and families.

Heterogeneous weight restoration trajectories during partial hospitalization treatment for anorexia nervosa

Early response to treatment has been shown to predict good outcome in family-based treatment, but little is known about who responds quickly.

OBJECTIVE

The purpose of the current study was to examine the short-term weight gain trajectories among youth receiving partial hospitalization program services for anorexia nervosa (AN), and to identify predictors of these trajectories.

METHOD

Adolescent and young adults (n = 102) with AN or subthreshold AN completed semi-structured interviews and self-report measures on admission to a family-based partial hospitalization program. Patients participated in programming 5 days a week.

RESULTS

Three weight gain trajectories were found to indicate slow, moderate, and rapid weight gain trajectories. All rapid responders gained at least four lbs. in the first 4 weeks of treatment, compared to 86.1% of moderate responders and 51.2% of slow responders. Patients were less likely to have a moderate or rapid response trajectory if they had a mood disorder diagnosis and higher parental expressed emotion. Additionally, the presence of compensatory behavior increased the likelihood of having a rapid response.

DISCUSSION

Despite the sometimes chronic nature of AN, most patients fell into one of the two favorable response trajectories. The identification of these trajectories underscores the importance of considering the core disordered eating behaviors (i.e., restricting, binge eating, and purging), comorbid psychopathology, and parental expressed emotion.

Future Directions for Research on Early Intervention for Young Children at Risk for Social Anxiety

Anxiety disorders are common among young children, with earlier onset typically associated with greater severity and persistence. A stable behaviorally inhibited (BI) temperament and subsequent shyness and social withdrawal (SW) place children at increased risk of developing anxiety disorders, particularly social anxiety. In this Future Directions article, we briefly review developmental and clinical research and theory that point to parenting and peer interactions as key moderators of both the stability of BI/SW and risk for later anxiety, and we describe existing interventions that address early BI/SW and/or anxiety disorders in young children. We recommend that future research on early intervention to disrupt the trajectory of anxiety in children at risk (a) be informed by both developmental science and clinical research, (b) incorporate multiple levels of analysis (including both individual and contextual factors), (c) examine mediators that move us closer to understanding how and why treatments work, (d) be developed with the end goal of dissemination, (e) examine moderators of outcome toward the goal of treatment efficiency, (f) consider transdiagnostic or modular approaches, (g) integrate technology, and (h) consider cultural norms regarding BI/SW/anxiety and parenting.

Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions

This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.

Developing Optimized Adaptive Interventions in Education

Hedges (2018) encourages us to consider asking new scientific questions concerning the optimization of adaptive interventions in education. In this commentary, we have expanded on this (albeit briefly) by providing concrete examples of scientific questions and associated experimental designs to optimize adaptive interventions, and commenting on some of the ways such designs might challenge us to think differently. A great deal of methodological work remains to be done. For example, we have only begun to consider experimental design and analysis methods for developing "cluster-level adaptive interventions" (NeCamp, Kilbourne, & Almirall, 2017), or to extend methods for comparing the marginal mean trajectories between the adaptive interventions embedded in a SMART (Lu et al., 2016) to accommodate random effects. These methodological advances, among others, will propel educational research concerning the construction of more complex, yet meaningful, interventions that are necessary for improving student and teacher outcomes.

Technology 2.0: A Commentary on Progress, Challenges, and Next Steps

This commentary highlights the importance and promise of the innovative strategies described in the Child Maltreatment special issue on "Technology 2.0: A Focus on the Newest Technological Advances in Child Maltreatment Research." The commentary first highlights the collective advancements reflected in the articles in the special issue, with a primary focus on how the authors' work addresses a general challenge in services research that is perhaps nowhere more problematic than in the field of maltreatment. Next, the commentary extends the discussion of these articles to raise remaining gaps in our knowledge, theory, and methodology, which must be the focus of ongoing research if the true potential of technology as a service delivery vehicle is to be realized. Finally, the commentary concludes with a call for subsequent research which will be inspired by the articles in this special issue.

Developmental and clinical predictors of comorbidity for youth with obsessive compulsive disorder

OBJECTIVE

To date, few studies of childhood obsessive compulsive disorder (OCD) have been adequately powered to examine patterns and predictors of comorbidity, despite the frequency with which it occurs. We address this gap, drawing on a large sample of youth with OCD who were systematically assessed through research and clinical programs in a university-based specialty program for children and adolescents with OCD. We examine patterns of comorbidity across different epochs of development and predict specific classes of OCD (comorbidity internalizing/externalizing/both) from key demographic and clinical variables that may be useful in guiding individualized treatment.

METHOD

A total of 322 youths (mean age = 12.28, 53% male) were assessed using the Anxiety Disorders Interview Schedule (ADIS; Silverman and Albano, 1996), the Children's Yale Brown Obsessive Compulsive Scale (CYBOCS; Scahill et al., 1997) and other standardized measures.

RESULTS

Consistent with prior research, 50% of youth met criteria for a co-occurring anxiety or depressive disorder. Rates of externalizing disorders were lower (16%). Developmental differences emerged such that older youth met criteria for a higher number of co-occurring disorders. As expected, adolescents in particular were more likely to have a co-occurring internalizing disorder compared to early or pre-adolescent peers. Surprisingly, they were also more likely to have a comorbid externalizing disorder. Developmental trends were particularly striking with respect to depression, with adolescents with OCD demonstrating a six-fold greater likelihood of co-occurring depressive disorder compared to younger counterparts.

DISCUSSION

Clinical implications are discussed with eye toward tailoring interventions, particularly during the transition to adolescence when youth are at heightened risk for depression.

Future Directions for the Examination of Mediators of Treatment Outcomes in Youth

How do psychological therapies work? How can we enhance treatment to improve outcomes? Questions of mediation lie at the heart of these inquiries. However, within the child and adolescent treatment literature, studies of mediation often rely on methodological and statistical approaches that limit the inferences that can be drawn from study findings. This future directions review delineates some of these issues and suggests improvements through two interrelated paths. We propose that mediation studies in the youth treatment literature will be enhanced (a) by adopting best practices in nomothetic (group-based) methodologies for assessing putative mediating variables and conducting appropriate statistical analyses and (b) by increasing the use of idiographic (individual-focused) approaches to youth outcome research through mediation studies that use innovative designs, data collection techniques, and analytic methods. We discuss the applicability of findings using these approaches to the treatment of youth in particular.

Cognitive Abilities, Social Adaptation, and Externalizing Behavior Problems in Childhood and Adolescence: Specific Cascade Effects Across Development

Children's and adolescents' cognitive abilities, social adaptation, and externalizing behaviors are broadly associated with each other at the bivariate level; however, the direction, ordering, and uniqueness of these associations have yet to be identified. Developmental cascade models are particularly well-suited to (1) discern unique pathways among psychological domains and (2) model stability in and covariation among constructs, allowing for conservative tests of longitudinal associations. The current study aimed to identify specific cascade effects among children's cognitive abilities, social adaptation, and externalizing behaviors, beginning in preschool and extending through adolescence. Children (46.2 % female) and mothers (N = 351 families) provided data when children were 4, 10, and 14 years old. Cascade effects highlighted significant stability in these domains. Unique longitudinal associations were identified between (1) age-10 cognitive abilities and age-14 social adaptation, (2) age-4 social adaptation and age-10 externalizing behavior, and (3) age-10 externalizing behavior and age-14 social adaptation. These findings suggest that children's social adaptation in preschool and externalizing behavior in middle childhood may be ideal intervention targets to enhance adolescent well-being.

ESCAschool study: trial protocol of an adaptive treatment approach for school-age children with ADHD including two randomised trials

BACKGROUND

The ESCAschool study addresses the treatment of school-age children with attention-deficit/hyperactivity disorder (ADHD) in a large multicentre trial. It aims to investigate three interrelated topics: (i) Clinical guidelines often recommend a stepped care approach, including different treatment strategies for children with mild to moderate and severe ADHD symptoms, respectively. However, this approach has not yet been empirically validated. (ii) Behavioural interventions and neurofeedback have been shown to be effective, but the superiority of combined treatment approaches such as medication plus behaviour therapy or medication plus neurofeedback compared to medication alone remains questionable. (iii) Growing evidence indicates that telephone-assisted self-help interventions are effective in the treatment of ADHD. However, larger randomised controlled trials (RCTs) are lacking. This report presents the ESCAschool trial protocol. In an adaptive treatment design, two RCTs and additional observational treatment arms are considered.

METHODS

The target sample size of ESCAschool is 521 children with ADHD. Based on their baseline ADHD symptom severity, the children will be assigned to one of two groups (mild to moderate symptom group and severe symptom group). The adaptive design includes two treatment phases (Step 1 and Step 2). According to clinical guidelines, different treatment protocols will be followed for the two severity groups. In the moderate group, the efficacy of telephone-assisted self-help for parents and teachers will be tested against waitlist control in Step 1 (RCT I). The severe group will receive pharmacotherapy combined with psychoeducation in Step 1. For both groups, treatment response will be determined after Step 1 treatment (no, partial or full response). In severe group children demonstrating partial response to medication, in Step 2, the efficacy of (1) counselling, (2) behaviour therapy and (3) neurofeedback will be tested (RCT II). All other treatment arms in Step 2 (severe group: no or full response; moderate group: no, partial or full response) are observational.

DISCUSSION

The ESCAschool trial will provide evidence-based answers to several important questions for clinical practice following a stepped care approach. The adaptive study design will also provide new insights into the effects of additional treatments in children with partial response.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) DRKS00008973 . Registered 18 December 2015.

Editorial Perspective: Longitudinal research in autism - introducing the concept of 'chronogeneity'

Autism Spectrum Disorder (ASD or autism) is a heterogeneous neurodevelopmental disorder. We are now at a critical juncture in autism research where we have the knowledge base and expertise to begin to think about studies that view heterogeneity, not as 'statistical noise' that can be 'accounted for' using data-reduction techniques (such as group trajectories), but rather as 'informative variance' that can help form a more precise and dynamic picture of autism. In this Editorial we coin a new term and introduce the concept of 'chronogeneity' for the study of autism heterogeneity in relation to the dimension of time (chrono). Using examples of ongoing research and analytical advances we build the case for the potential utility of the concept of 'chronogeneity' and argue that a refined approach to the longitudinal investigation of autism (and other neurodevelopmental disorders) may move us closer to more precise and adaptive models of care for the children and youth affected by these disorders.

Parent ADHD and Evidence-Based Treatment for Their Children: Review and Directions for Future Research

One fourth to one half of parents of children with attention-deficit/hyperactivity disorder (ADHD) have ADHD themselves, complicating delivery of evidence-based child behavioral and pharmacological treatments. In this article, we review the literature examining the relation between parent ADHD and outcomes following behavioral and pharmacological treatments for children with ADHD. We also review research that has incorporated treatment of parent ADHD (either alone or in combination with child treatment) with the goal of improving parenting and child outcomes. Finally, we offer recommendations for future research on the relation between parent ADHD and evidence-based treatment outcomes for their children, with the purpose of advancing the science and informing clinical care of these families.

Advancing Research on Structural Stigma and Sexual Orientation Disparities in Mental Health Among Youth

Psychological research on stigma has focused largely on the perceptions of stigmatized individuals and their interpersonal interactions with the nonstigmatized. This work has been critical in documenting many of the ways in which stigma operates to harm those who are targeted. However, this research has also tended to overlook broader structural forms of stigma, which refer to societal-level conditions, cultural norms, and institutional policies and practices that constrain the lives of the stigmatized. In this article I describe the emerging field of research on structural stigma and review evidence documenting the harmful consequences of structural stigma for the mental/behavioral health of lesbian, gay, and bisexual youth. This research demonstrates that structural stigma represents an important, but thus far largely underrecognized, mechanism underlying mental health disparities related to sexual orientation among youth. I offer several suggestions to advance research in this area, including (a) adopting a life-course approach to the study of structural stigma; (b) developing novel measures of structural stigma; (c) expanding both the range of methods used for studying structural stigma and the sequelae of structural stigma that are evaluated; (d) identifying potential mediators and moderators of the structural stigma-health relationship; (e) examining intersectionalities; and (f) testing generalizability of structural stigma across other groups, with a particular focus on transgender youth. The implications of this research for preventive interventions and for public policy are also discussed.