Person-Centered Cultural Assessment Can Improve Child Mental Health Service Engagement and Outcomes

Understanding Signs and Sources of Anxiety in Urban Elementary Schools Serving Predominately Ethnically/Racially Minoritized Children

OBJECTIVE

This mixed-methods study examined teachers' perceptions of student anxiety in urban elementary schools serving predominantly low-income and ethnically/racially minoritized youth.

METHOD

Most participating teachers were female (87.7%) and from minoritized backgrounds themselves (89.2%), teaching in schools serving predominantly Black/African American (40%) or Hispanic (60%) students, and in which > 70% of students are eligible for free meals. Teachers were asked in surveys (N = 82) and interviews (n = 12) about the nature of student anxiety, and cultural/contextual considerations that influence anxiety.

RESULTS

Overall, teachers reported prevalence and signs of student anxiety that were consistent with the literature, but they reported higher levels of impairment than in previous community samples. Regressions revealed that greater levels of student exposure to community violence and higher proportions of Black students were associated with higher teacher-perceived prevalence and concern about student anxiety, respectively. Moreover, greater emotional exhaustion in teachers was associated with higher reports of anxiety-related impairment in students. Thematic coding of interviews emphasized how teachers perceived 1) most student anxieties to be proportional responses to realistic threats and stress in students' lives (e.g. resource insecurity), 2) systems-level problems (e.g. pressure to perform on standardized tests) contribute to student anxiety, and 3) school-based anxiety sources often interact with traumas and stressors students experience outside of school (e.g. immigration experiences).

CONCLUSIONS

Relative to the predominant literature that has focused on biological, cognitive, and other intraindividual factors as sources of anxiety, the present work underscores the importance of considering how broader economic and systems-level influences exacerbate anxiety in marginalized youth.

Improving the efficacy and effectiveness of evidence-based psychosocial interventions for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and impairing mental health disorder of childhood. Decades of empirical research has established a strong evidence-based intervention armamentarium for ADHD; however, limitations exist in regards to efficacy and effectiveness of these interventions. We provide an overview of select evidence-based interventions for children and adolescents, highlighting potential approaches to further improving the efficacy and effectiveness of these interventions. We conclude with broader recommendations for interventions, including considerations to moderators and under-explored intervention target areas as well as avenues to improve access and availability of evidence-based interventions through leveraging underutilized workforces and leveraging technology.

A Mixed-methods Examination of Culturally Responsive Adaptation to an Evidence-based Parent-mediated Intervention Implemented for Autistic Children

Parent-mediated interventions (PMIs) are considered an evidence-based practice for fostering social communication skills in young autistic children and for promoting parent responsivity and empowerment, yet barriers to caregiver engagement are evident when PMIs are implemented within historically underserved community settings. Issues of caregiver engagement can reflect a lack of fit between PMIs and the needs of diverse families. We used a mixed methods approach to examine barriers to participating in an evidence-based PMI, Project ImPACT (Ingersoll & Dvortcsak, 2019), within an outpatient setting, as well as strategies that clinicians reported using to deliver and adapt Project ImPACT for minoritized families. Participants included 134 caregivers of a child 13 to 48 months with autism or other social communication differences and six clinicians delivering Project ImPACT. Findings suggest that caregivers experience barriers to participating in Project ImPACT and that these barriers are associated with caregivers' ability to complete the program. Although quantitative findings indicate that adaptation to Project ImPACT did not differ by caregiver and child background, qualitative findings highlighted that clinicians attempt to deliver Project ImPACT to respond to the needs of families from minoritized backgrounds by actively considering the family's culture, psychosocial experiences, goals, and specific barriers. Further, both qualitative and quantitative findings suggest that culturally responsive care and adaptations may support caregiver engagement, including rapport, trust, buy-in, and attendance. Approaches to center cultural alongside contextual/psychosocial considerations within family-centered care in the implementation of PMIs are also highlighted.

Ethnic Identity and Mechanisms of Mental Health Service Engagement Among Young Adults with Serious Mental Illnesses

PURPOSE

Young adults from minoritized racial and ethnic groups have lower rates of engagement in treatment for serious mental illnesses (SMI). Previous research suggests a relationship between ethnic identity development and engagement in mental health services, but it remains unclear how a sense of belonging and attachment to one's racial and ethnic group influences participation in treatment among young adults with SMI.

METHODS

Bivariate analyses and structural equation modeling (SEM) were used to examine whether ethnic identity was associated with treatment engagement (attendance and investment in treatment) and how ethnic identity might influence engagement through theoretical proximal mediators. Eighty-three young adults with SMI (95% from minoritized racial and ethnic groups) were recruited from four outpatient psychiatric rehabilitation programs and assessed at least 3 months after initiating services.

RESULTS

Stronger ethnic identity was associated with greater investment in treatment but not with treatment attendance. The SEM analysis indicated that stronger ethnic identity may improve investment in treatment by enhancing hope (0.53, p < .05) and beliefs that mental health providers are credible (0.32, p < .05), and by increasing self-efficacy (-0.09, p < .05). Proximal mediators of engagement were associated with investment in treatment (hope and credibility, p < .05, and self-efficacy p = 0.055).

CONCLUSIONS

Findings provide preliminary evidence of an empirical and theoretical relationship between ethnic identity development and engagement in treatment among young adults with SMI. Assessment and strengthening of a young person's ethnic identity may be a promising approach for improving their engagement in services and reducing inequities in their care.

An 18-week model of Parent-Child Interaction Therapy: clinical approaches, treatment formats, and predictors of success for predominantly minoritized families

Introduction

Disruptive behavior disorders are among the most prevalent pediatric mental health referrals for young children. However, families from historically minoritized social identities have experienced disparities in treatment access, retention, and outcomes. Evidence-based interventions such as Parent-Child Interaction Therapy (PCIT) have been found to be effective in reducing children's disruptive behaviors in minoritized families. However, variable treatment length as a result of skill-based graduation criteria (e.g., observed caregiver verbalizations) may slow and/or hinder treatment progress, particularly for families where expected treatment verbalizations are less linguistically relative (e.g., no exact English to Spanish translations) and/or culturally familiar. Time-limited PCIT has been proposed as a strategy for promoting equity in treatment completion and outcomes amongst minoritized families, because treatment progression and/ or completion is not contingent upon caregiver linguistic skill demonstration.

Methods

The current study evaluated the overall effectiveness of an 18-week model of PCIT and examined predictors of retention and treatment outcomes. Participants (N = 488 dyads) included predominantly racially, ethnically, linguistically, and socioeconomically diverse children aged two to eight years, and their caregivers.

Results

Overall findings indicate that the 18-week PCIT model is an effective intervention for reducing children's externalizing and internalizing behaviors and improving caregiver parenting skills for most treatment completers. Despite advances in treatment completion, some caregiver social identities and PCIT treatment characteristics were predictive of lower completion rates and/or less optimal treatment outcomes.

Discussion

Overall, this study provides strong support for widely disseminating use of the 18-week model of PCIT for most families served. Clinical implications and considerations for continued treatment inequity are discussed.

A Natural Helper Intervention to Address Disparities in Parent Child-Interaction Therapy: A Randomized Pilot Study

OBJECTIVE

Parent-child interaction therapy (PCIT) is an effective intervention to address child externalizing behaviors. However, disparities in access and retention are pervasive, which relate to the availability of PCIT in low-income communities, inadequate workforces to provide culturally appropriate care, and distrust in services due to systemic discrimination. This study incorporated natural helpers who had been trained as community health workers into PCIT delivery to improve disparities in engagement and outcomes.

METHOD

Families from three low-income, predominately Latino/a/x and Black neighborhoods in Miami qualified for services if they had a child aged 2-8 with clinically elevated externalizing behaviors. Families were randomly assigned into either Standard-PCIT group (N = 30 families; 80% boys, 57% Latino/a/x, 27% Black) or a PCIT plus Natural helper (PCIT+NH) group (N = 51 families; 66% boys, 76% Latino/a/x, 18% Black). Families in the PCIT+NH group received home visits and support addressing barriers to care from a natural helper. Path analyses within an intention-to-treat framework examined group-differences in treatment engagement, child behavior, and parenting skills and stress.

RESULTS

Families in both groups demonstrated large improvements in child externalizing behavior, caregiver stress, and parenting skills from pre-to-post-treatment. Externalizing behavior improved significantly more in the PCIT+NH group compared to the Standard-PCIT group. There were no significant group differences in parenting skills or caregiver stress. Though differences in engagement were not significant, the PCIT+NH group had a small effect on treatment retention.

CONCLUSIONS

Natural helpers may help to address structural barriers that systematically impact communities of color, apply treatment in naturalistic environments, and promote improved treatment outcomes.

Introduction to the Special Issue: Advancing Racial Justice in Clinical Child and Adolescent Psychology

Relative to White youth, racially and ethnically marginalized youth in the U.S. are less likely to initiate treatment, stay in treatment, and receive adequate care. This special issue attends to racial injustice in clinical child and adolescent psychology. While numerous factors drive these racial disparities, this special issue focuses specifically on opportunities and responsibilities we have as mental health providers, teachers, mentors, researchers, and gatekeepers to make our field more racially just. In this introduction to the special issue, we review barriers and solutions across multiple contexts including structural, institutional, and practice-based. We also discuss challenges and opportunities to diversify our field and increase the representation of racially and ethnically marginalized practitioners and scholars in clinical child and adolescent psychology. We then briefly review the special issue articles and make final recommendations for how to move the field forward.

Psychometric Evaluation of the Abbreviated Multidimensional Acculturation Scale (AMAS) in a Treatment-Seeking Sample of First-Generation Immigrant Caregivers

The unique needs of first-generation immigrants and their families have not been prioritized in mental healthcare. Cultural tailoring of child services requires valid, reliable, and efficient assessments of family cultural identity. The Abbreviated Multidimension Acculturation Scale (AMAS) is a self-report of acculturation and enculturation that has been evaluated in community, but not clinical, samples. We offer the first AMAS psychometric evaluation in a treatment-seeking sample of first-generation immigrant caregivers presenting for children's mental healthcare (N = 219). Analyses examined the internal consistency, concurrent validity, and factor structures of the long-form AMAS (42 items, six subscales), AMAS-10 (10 items, four subscales), and AMAS-14 (14 items, six subscales). Findings provide support for the AMAS-10 and AMAS-14, but not the full-length AMAS, in the present sample. Given urgent needs for culturally responsive care for first-generation populations, the AMAS-10 and AMAS-14 can be used in clinical settings to support cultural assessment, case conceptualization, and treatment planning.

Future Directions in Youth and Family Treatment Engagement: Finishing the Bridge Between Science and Service

The field has spent more than 50 years investing in the quality of youth mental healthcare, with intervention science yielding roughly 1,300 efficacious treatments. In the latter half of this period, concurrent efforts in implementation science have developed effective methods for supporting front-line service organizations and therapists to begin to bridge the science to service gap. However, many youths and families still do not benefit fully from these strategic investments due to low treatment engagement: nearly half of youths in need of services pursue them, and among those who do, roughly another half terminate prematurely. The negative impact of low engagement is substantial, and is disproportionally and inequitably so for many. We contend that to build a robust and "finished" bridge connecting science and service, the field must go beyond its two historical foci of designing interventions and preparing therapists to deliver them, to include an intentional focus on the youths and families who participate in these interventions and who work with those therapists. In this paper, we highlight the significance of treatment engagement in youth mental healthcare and discuss the current state of the literature related to four priorities: conceptualization, theory, measurement, and interventions. Next, we offer an example from our own program of research as one illustration for advancing these priorities. Finally, we propose recommendations to act on these priorities.

Telehealth Treatment of Behavior Problems in Young Children With Developmental Delay: A Randomized Clinical Trial

Importance

Early behavior problems in children with developmental delay (DD) are prevalent and impairing, but service barriers persist. Controlled studies examining telehealth approaches are limited, particularly for children with DD.

Objective

To evaluate the efficacy of a telehealth parenting intervention for behavior problems in young children with DD.

Design, Setting, and Participants

A randomized clinical trial was conducted from March 17, 2016, to December 15, 2020, in which children with DD and externalizing behavior problems were recruited from early intervention and randomly assigned to a telehealth parenting intervention or control group and evaluated through a 12-month follow-up. Most children were from ethnic or racial minoritized backgrounds. Over one-half of children were in extreme poverty or low income-need ratio categories.

Interventions

Internet-delivered parent-child interaction therapy (iPCIT), which leverages videoconferencing to provide live coaching of home-based caregiver-child interactions. Families received 20 weeks of iPCIT (provided in English or in Spanish) or referrals as usual (RAU).

Main Outcomes and Measures

Observational and caregiver-report measures of child and caregiver behaviors and caregiving stress were examined at preintervention, midtreatment, and postintervention and at 6- and 12-month follow-ups.

Results

The sample included a total of 150 children (mean [SD] age, 36.2 [1.0] months; 111 male children [74%]) and their caregivers with 75 each randomly assigned to iPCIT or RAU groups. Children receiving iPCIT relative to RAU displayed significantly lower levels of externalizing problems (postintervention Cohen d = 0.48; 6-month Cohen d = 0.49; 12-month Cohen d = 0.50) and significantly higher levels of compliance to caregiver direction after treatment. Of those children with data at postintervention, greater clinically significant change was observed at postintervention for children in the iPCIT group (50 [74%]) than for those in the RAU group (30 [42%]), which was maintained at the 6-month but not the 12-month follow-up. iPCIT did not outperform RAU in reducing caregiving stress, but caregivers receiving iPCIT, relative to RAU, showed steeper increases in proportion of observed positive parenting skills (postintervention odds ratio [OR], 1.10; 95% CI, 0.53-2.21; 6-month OR, 1.31; 95% CI, 0.61-2.55; 12-month OR, 1.64; 95% CI, 0.70-3.07) and sharper decreases in proportion of observed controlling/critical behaviors (postintervention OR, 1.40; 95% CI, 0.61-1.52; 6-month OR, 1.72; 95% CI, 0.58-1.46; 12-month OR, 2.23; 95% CI, 0.53-1.37). After treatment, iPCIT caregivers also self-reported steeper decreases in harsh and inconsistent discipline than did than RAU caregivers (postintervention Cohen d = 0.24; 6-month Cohen d = 0.26; 12-month Cohen d = 0.27).

Conclusions and Relevance

Results of this randomized clinical trial provide evidence that a telehealth-delivered parenting intervention with real-time therapist coaching led to significant and maintained improvements for young children with DD and their caregivers. Findings underscore the promise of telehealth formats for expanding scope and reach of care for underserved families.

Trial Registration

ClinicalTrials.gov Identifier: NCT03260816.

"If there is a tension about something, I can solve it": A qualitative investigation of change processes in a trial of brief problem-solving interventions for common adolescent mental health problems in India

OBJECTIVES

There is limited understanding of change processes and long-term effects of low-intensity psychosocial interventions. We investigated these aspects in two brief problem-solving intervention formats for adolescents with elevated mental health symptoms and associated distress/impairment.

METHODS

This qualitative study was nested within a school-based randomized controlled trial in New Delhi, India, which compared two problem-solving intervention formats: a lay counsellor-led format supported by printed materials (intervention arm) and printed problem-solving materials alone ("bibliotherapy" control arm). A total of 32 participants, ranging in age from 14 to 20 years (mean = 16.4 years, SD = 1.9) and comprising 21 males and 11 females, were interviewed across both trial arms at 12-month follow-up.

RESULTS

Five themes were derived using thematic framework analysis. The "impacts on symptoms and functioning" theme described symptomatic improvements and functional gains. "Processes underlying problem solving" reflected changes in positive beliefs, attitudes and emotions when confronted with problems, and the use of a more effective problem-solving coping style. "Experiences of problem-solving materials" covered benefits (e.g. access to relatable stories and readymade solutions) and limitations (e.g. diminishing use over time) of printed problem-solving handouts. "Role of supporting figures" accounted for the facilitating roles played by counsellors and trusted others. There were also accounts of researchers functioning as de facto counsellors in the bibliotherapy arm. "Recommended modifications for intervention delivery" included more flexible and private ways to access the interventions, greater personalization of the counselling process, more engaging and relevant supporting materials, and suggestions for widening access to the interventions in schools and community settings.

CONCLUSIONS

We infer from our qualitative analysis that changes in problem-solving style and problem orientation underpinned long-term symptomatic and functional improvements. Participants in the counsellor-led intervention appeared better able to sustain the use of problem-solving skills and generalize this approach beyond the original presenting problems. We attribute the differences between arms to the influence of direct advice and supportive interactions with counsellors. Practice implications are discussed.

Multiple needs and multiple treatments. What's a clinician to do? Update on the psychosocial treatment of disruptive behaviours in childhood

PURPOSE OF REVIEW

There are a wide range of psychosocial treatment options, delivered in different modalities, for children with disruptive behaviour. However, clinicians face many challenges in ensuring the empirically supported treatments (ESTs) they select will be effective for their patient. This has prompted studies to generate knowledge on how to improve treatment outcomes for children with disruptive behaviour. This review identifies the major challenges in treatment selection as well as emerging research seeking to improve outcomes.

RECENT FINDINGS

This review emphasizes the salience of the research-practice gap associated with establishing ESTs using narrow definitions of clinical problems. Recent research is reviewed considering the complex determinants of disruptive behaviours, including parent and family factors that influence outcomes. The review subsequently outlines recent advances in research and clinical practice guidelines aiming to surmount these challenges. Key advances discussed include examining the most impactful components of ESTs, personalizing interventions by targeting core dysfunction underlying behaviour, and addressing parent factors including mental health and cultural relevance to improve outcomes.

SUMMARY

Thorough assessment of patients' needs, combined with knowledge of treatment response predictors, are recommended to determine the most suitable treatment plan. Recent advances have focused on developing and designing interventions that meet needs in a way that is flexible and tailored.

Tools to Craft a Cultural Formulation

Clinicians should strive to understand every patient from their own perspective. The authors present tools to help patients narrate their own experiences and elaborate on the context of their symptoms, allowing clinicians to appreciate the cultural influences on a patient and how that affects their symptomatology. This knowledge can then be crafted into a nuanced cultural formulation of the patient, with the goals of not only better understanding the patient's specific, intersectional context but also guiding treatment planning. As a result, the patient is evaluated in a holistic manner, and their specific needs are central in their care.

How Flexible are Treatments for Youth Internalizing Disorders? Examining Modification Guidelines Included across Supported Treatments

OBJECTIVE

Treatment protocols for youth-internalizing disorders have been developed, however these protocols have yielded mixed findings in routine care settings. Despite increased recognition of the importance of flexibility when delivering evidence-based treatments (EBTs), little is known about the extent to which protocols offer guidance to providers in flexible EBT implementation. The current study examined the extent to which supported EBTs for youth internalizing disorders explicitly incorporate guidance for treatment modification.

METHODS

Supported treatment protocols for youth internalizing disorders were identified (N = 44), from which 4,021 modification guidelines were extracted and coded using a structured coding system to classify modification strategies (i.e., the forms that recommended modifications take), and associated tailoring factors (i.e., the rationale for which modifications are recommended).

RESULTS

Across all EBTs, modification guidelines were quite common, with the average protocol including almost 91 text passages providing guidance for modification. The majority of modification guidelines functionally increase session or treatment length by recommending the addition or repetition of material, whereas less than 5% of modification guidelines provided strategies for condensing or streamlining care. Strikingly, less than 2% of modification guidelines in EBT protocols address patient cultural factors, and rarely address provider or setting issues that can challenge standard implementation.

CONCLUSIONS

Findings highlight critical gaps in the available guidance to modify EBTs for youth internalizing disorders, and suggest EBT protocols may not be optimally poised to flexibly address the broad diversity of children and adolescents across varied settings in need of mental health care.

Future Directions on BIPOC Youth Mental Health: The Importance of Cultural Rituals in the COVID-19 Pandemic

Culture plays an important role in the development of mental health, especially during childhood and adolescence. However, less is known about how participation in cultural rituals is related to the wellbeing of youth who are Black, Indigenous, and People of Color (BIPOC), and part of the Global Majority. This is crucial amid the COVID-19 pandemic, a global event that has disproportionally affected BIPOC youth and disrupted participation in rituals. The goal of this paper is to promote advances in clinical child and adolescent psychology focused on rituals. We begin by defining culture and rituals and examining their role on development. We illustrate these issues with the Lunar New Year in China, Maya rituals in México, Ramadan in Turkey, and Black graduations and Latinx funerals in the United States. We discuss how the pandemic has affected participation in these rituals and their potential impact on BIPOC children and adolescents' mental health. We propose future directions and recommendations for research.

A Mixed-Methods Study of Clinician Adaptations to Parent-Child Interaction Therapy - What about Culture?

Parent-Child Interaction Therapy (PCIT) is an evidence-based practice (EBP) for young children with challenging behaviors. PCIT has been adapted to treat varying presentations and culturally diverse families. Although efforts have been made to disseminate PCIT into community settings, which often serve clinically complex, socio-culturally diverse, and marginalized communities, barriers to disseminating adapted models remain. An alternative strategy to understanding how to increase access to appropriately adapted PCIT is to learn from community clinicians' practice-based adaptations to meet their clients' diverse needs related to clinical presentation, culture, and language. This mixed-method study investigated community clinician adaptations of PCIT. Clinicians (N = 314) were recruited via PCIT listservs to complete a survey collecting background information, and adaptations to PCIT. Most clinicians had a master's degree (72.1%), were licensed (74.2%), and were PCIT-certified (70.7%). Qualitative interviews were conducted with a purposeful sample of 23 community clinicians, who were 39% Spanish-speaking, were 30% Latinx, and 30% reported serving a ≥50% Latinx clientele. Clinicians reported engaging in adaptations aimed at augmenting PCIT more extensively than adaptations involving removing core components. Themes from qualitative interviews converged with quantitative findings, with clinicians most frequently describing augmenting adaptations, and highlighted reasons for adapting PCIT. Clinicians primarily augmented treatment to address clients' clinical presentations. Clinicians rarely adapted treatment specifically for culture, but when mentioned, clinicians discussed tailoring idioms and phrases to match clients' culture for Spanish-speaking clients. Implications for training PCIT clinicians in intervention adaptations will be discussed.

Aiming High: Monitoring Population Level Indicators of Child Wellbeing as a Goal of Community-Academic Partnerships

INTRODUCTION

Community-academic partnerships (CAPs) aim to improve neighborhood population health. Though measuring the impact of partnership activities at a population level can be difficult, evaluating indicators of wellbeing may increase understanding of how communities benefit from CAPs. This study examined child health indicators over time in two low-income, predominantly Black/African American and Hispanic communities where partnerships between an academic child development center and community coalitions were formed with the intention of improving child well-being.

METHODS

Trends in three child wellbeing indicators (graduation rates, kindergarten readiness, and proportion of youth in school and/or employed) were compared between two CAP communities and several neighboring comparison communities. Data between 2011 and 2017 were analyzed to calculate percent change from baseline and mapped using ArcGIS to visualize trends by zip code. Proportions of youth meeting benchmarks were also determined.

RESULTS

Kindergarten readiness and high-school graduation rates improved in CAP communities but not in geographically proximal and socioeconomically similar comparison communities. No improvements were found in the proportion of youth in school or employed.

DISCUSSION

This study revealed population-level indicators improved over time in CAP communities. Because community-level child health and wellbeing are influenced by many factors, this correlation is not proof of a causal relationship. Assessing population level indicators can nonetheless provide insight into the benefit of CAPs, and the commitment to monitoring such outcomes can itself advance how academic and community partners plan activities and set long-term goals.

Harnessing Home-School Partnerships and School Consultation to Support Youth With Anxiety

Youth with anxiety often experience significant impairment in the school setting. Despite the relevance and promise of addressing anxiety in schools, traditional treatment approaches to school-based anxiety often do not adequately address generalization to the school setting, or they require removing the student from the classroom to deliver time- and staff-intensive programs. Such programs often leave teachers and caregivers feeling ill-equipped to support the student with anxiety throughout the natural course of the school day. Given the heavy demands placed on teachers and documented burnout among school professionals, providing effective school supports requires collaborative partnerships among outpatient therapists/specialists, school personnel, and caregivers. Drawing from literature on collaborative models for externalizing problems, we offer recommendations for outpatient therapists and specialists working to implement evidence-based supports in school settings and promote home-school partnerships to benefit youth with anxiety in the school setting. Our recommendations touch upon several components of such school consultation, including (a) identification of key parties involved, (b) conducting a needs assessment, (c) collaborative goal setting and development of a fear hierarchy, (d) plan development and implementation (e.g., facilitating a school-based exposure mindset, promoting home-school communication, enhancing school relationships), and (e) progress monitoring and ongoing support. We conclude with a case example to bring these recommendations to life.