Needs of Youth Enrolled in a Statewide System of Care: A Latent Class Analysis

Objective

Access to wraparound care coordination within systems of care (SOC) is increasing nationwide for youth with emotional and behavioral disorders and their families. Though wraparound care coordination serves a broad population of youth who experience a variety of complex needs, less is known about the impact of wraparound services based on these specified needs. Using latent class analysis, the current study aimed to first identify classes of youth based on their presenting needs and then examine the impact of class membership on treatment experiences and outcomes at baseline and six-month follow-up.

Method

Caregiver-reported data from 1,243 youth enrolled in wraparound care coordination services within a statewide SOC were used. Latent class analysis was used to determine classes of youth needs and regression results examined whether baseline characteristics, child and family team meeting characteristics, mental health outcomes, and perceptions of care differed based on identified classes.

Results

Results revealed five distinct classes of youth needs: Behavioral Needs, ADHD-related Behavior Needs, Educational Needs, Mental Health Needs, and Multi-Needs. Overall participants saw improvement in all follow-up outcomes. Significant between-class differences were also found in all outcome categories measured.

Conclusion

The current results further solidify the benefits of comprehensive wraparound care within a SOC. Additionally, understanding youth's needs and their impact on treatment services allows for more targeted care for youth and their families.

Needs of Caregivers of Youth Enrolled in a Statewide System of Care: A Latent Class Analysis

Objective

Systems of care (SOC) provide a coordinated array of services to youth with serious emotional and behavioral problems and their families. Little is known about what caregiver-specific needs at presentation to care may contribute to use of and engagement with care coordination and subsequent youth and family outcomes. This study aimed to determine latent classes of youth enrolled in wraparound care coordination within a statewide SOC based on caregiver needs impacting youth functioning and identify the relationship between class membership and characteristics of participation in Child and Family Team meetings (CFTs) and mental health outcomes at six-month follow-up.

Method

Participants were 703 youth (Mage = 11.21, SD = 3.67) and their caregivers that had information about caregiver needs and received a six-month follow-up assessment. Latent class analysis determined latent classes of families based on caregiver service needs at presentation to care, and differences in participation in care coordination and youth outcomes at 6-month follow up based on class membership was examined.

Results

Results indicated four classes of caregivers: Physical Health Needs, No Needs, Basic Needs, and Mental Health/Trauma Needs. Class membership was associated with size of the CFT, number of CFTs attended by the youth, percentage of CFTs with a natural support present, and percentage of CFTs that occurred in the family's home. Class membership was associated with caregiver ratings of objective strain at 6-month follow-up.

Conclusion

Assessing caregiver needs at presentation to care can provide direction for care coordinators to more directly target areas of family need through wraparound and individualize services.

Trauma Symptoms and Relationship With Child and Family Team Meeting Characteristics and Outcomes in a Statewide System of Care

Systems of care (SOCs) are comprehensive, community-based services for youth with emotional and behavioral disorders. For these youth, little is known about how trauma symptoms influence participation in SOC care coordination through the Child and Family Team (CFT) meeting. The current study assessed the extent to which exposure to potentially traumatic events (PTEs) and trauma symptoms were associated with participation in CFTs and youth and family outcomes. Participants were 464 youth (M _age = 11.02, SD = 3.72) and their caregivers. Families completed measures of youth and caregiver functioning, PTEs, and trauma symptoms at enrollment and 6-month follow-up. Care coordinators completed surveys assessing CFT characteristics following each meeting and assessments of youth functioning. Moderated multiple regression analyses tested the conditional effects of youth trauma symptoms on the relationships between CFT characteristics and youth and caregiver outcomes. Trauma symptoms moderated the relationship between the number of days to the first CFT meeting and youth impairment and the relationship between CFT meeting duration and youth impairment. Results suggest the presence of trauma and other contextual factors contributed to difficulty in initiating services and to changes in youth impairment. Implications for the provision of trauma-informed SOC services are discussed.

Identifying Youth at Risk for Commercial Sexual Exploitation Within Child Advocacy Centers: A Statewide Pilot Study

Commercial sexual exploitation of children (CSEC) is a social problem in the United States that has recently received growing attention from policy makers, advocates, and researchers. Despite increasing awareness of this issue, information on the prevalence, demographic profile, and psychosocial needs of victims of CSEC is scarce. To better understand the scope of CSEC and to examine the feasibility of screening for CSEC in Child Advocacy Centers (CACs), a pilot study was initiated through Arkansas Building Effective Services for Trauma (ARBEST) to identify youth who may be at risk for commercial sexual exploitation. Data for this pilot study were collected from all of the state's CACs (n = 14) over a 6-month period. Family advocates completed a screening questionnaire adapted from Greenbaum, Dodd, and McCracken with 918 youth aged 12 to 18 years old treated at CACs. Almost 20% of youth were identified as being at high risk for experiencing CSEC. Furthermore, youth classified as high-risk for commercial sexual exploitation reported significantly more avoidance symptoms on the UCLA (University of California at Los Angeles) PTSD (Posttraumatic Stress Disorder) Reaction Index than youth classified as low-risk. The results suggest that a significant portion of youth treated at CACs in Arkansas are at high risk for experiencing commercial sexual exploitation, which may be associated with a particular pattern of trauma symptoms. These findings also lend support for the feasibility and utilization of a screening questionnaire as part of routine care in CACs to potentially identify youth at risk for CSEC.

Comparing Early-Childhood and School-Aged Systems of Care for Children with Emotional and Behavioral Difficulties: Risk, Symptom Presentation, and Outcomes

OBJECTIVES

Most large-scale evaluations of systems of care (SOCs) have focused on school-aged populations, with limited research examining early childhood SOCs. As a result, little is known about how risk profiles, symptom presentation, and outcomes may vary between early childhood and school-aged SOC participants. This descriptive study uses data from two SOCs-an early childhood SOC (EC-SOC) and a school-aged SOC (SA-SOC)-to examine the differences across age groups in how children and families present to SOCs and the extent to which risk factors and symptoms change over six months of enrollment.

METHOD

Participants were 184 children in the EC-SOC (m _age = 3.91) and 142 children in the SA-SOC (m _age = 9.36). Families completed measures assessing risk factors and functioning at enrollment and at six-month follow up. Descriptive analyses measured the presence of risk factors and symptoms at enrollment and follow-up. Correlations were computed to determine the associations between symptom measures.

RESULTS

Results identified areas of similarity and difference between families presenting for SOCs at different developmental stages. Younger children experienced greater behavioral problems (Hedge's g = 0.52, p < 0.001) with more associated caregiver stress (Hedge's g range = 0.34-0.62, p < 0.01) and strain (Hedge's g = 0.34, p = 0.005). Trauma was more strongly associated with child and caregiver symptoms among younger children. Greater change in symptom measures was observed for the EC-SOC.

CONCLUSIONS

Findings highlight the importance of providing services in early childhood and provide guidance for SOC service provision at different ages.

Child and Family Team Meeting Characteristics and Outcomes in a Statewide System of Care

Systems of care (SOC) have relied on the wraparound care process to individualize community-based services for children and youth with serious emotional and behavioral difficulties. A core element of wraparound care is Child and Family Team meetings (CFTs), which are designed to give youth and families a leadership role in developing and guiding their plan of care. The National Wraparound Initiative (NWI) has identified Practice Standards regarding CFT implementation. This study examined CFT characteristics and the association between those characteristics and youth and family outcomes in a statewide SOC. Participants were 363 youth (M_age  = 10.89, SD = 3.72) and their caregivers. Families completed measures of youth and caregiver functioning and symptoms at enrollment and 6-month follow-up. Care coordinators completed a survey assessing CFT implementation and characteristics following each meeting. Multiple regression analyses were used to examine the relationship between CFT characteristics and youth and caregiver outcomes. Results indicated that a higher number of CFTs was associated with poorer outcomes, while a higher percentage of natural supports at meetings was associated with better youth outcomes. Number of days to the first CFT was associated with greater caregiver strain. Implications for CFT implementation within wraparound are discussed.

Psychological Distress and Revictimization Risk in Youth Victims of Sexual Abuse

Psychological distress, including depression and anxiety, has been associated with increased risk for sexual revictimization in youth who have experienced child sexual abuse. The present study utilized assessment information from treatment seeking youth with histories of sexual abuse to explore specific risk indicators for revictimization-risk taking, social problems, maladaptive cognitions, and posttraumatic stress-that may be indicated by self-reported distress. The relationship between initial levels of distress and change in symptoms over a 12-week course of treatment was also explored. Participants were 101 youth referred to a child-focused therapeutic group for victims of sexual abuse, 65 youth referred to an adolescent-focused group, and their non-offending caregivers. Results revealed that when combined into a distress score, depression and anxiety were associated with delinquent behaviors, interpersonal difficulties, maladaptive cognitions, and posttraumatic stress symptoms for child and adolescent group participants at presentation to treatment. Children exhibited improvement on measures of interpersonal difficulties, maladaptive cognitions, and self-reported posttraumatic stress disorder (PTSD) symptoms. Adolescents exhibited less change over time, with significant improvement on self-reported social problems and PTSD only. Higher psychological distress was associated with less improvement in regard to negative expectations of abuse impact for child group participants. The findings suggest that distress indicates the presence of specific revictimization risk indicators, helping to identify targetable symptoms for intervention. Therefore, screening for psychological distress after discovery of sexual abuse may help detect youth at higher risk for revictimization and guide treatment.

Examining the service-related experiences and outcomes of caregivers involved in a system of care who experienced everyday discrimination

Individuals who report everyday experiences of discrimination are at heightened risk for adverse health outcomes and tend to report underutilization of health services. Systems of care (SOCs) have the potential to engage members of minority groups and to reduce health disparities. We examined the service-related experiences of predominantly Latinx caregivers enrolled in a SOC for their children with severe psychological health needs. We used independent samples t-tests and regression analyses to compare relations among service access, perceived service characteristics, and caregiver stress according to whether caregivers reported frequent or infrequent discrimination. The frequent discrimination group scored significantly higher on dimensions of stress and had greater dosage than the infrequent group. There were no differences in relations between service characteristics and outcomes by group. Findings indicated important differences in the service-related experiences and outcomes of caregivers who reported frequent and infrequent discrimination. We discuss limitations and implications.

Predictors of Service Dosage, Recommendation, and Usage in an Early Childhood System of Care

OBJECTIVES

Children and families enrolled in early childhood systems of care (SOC) present with various psychological and behavioral risk factors that may inhibit healthy development. Within a SOC, wraparound services are designed to increase families' access to numerous child-serving sectors in order to target those risk factors. This study examined whether child and family risk factors at enrollment in an early childhood SOC predicted dosage, service recommendation, and usage of recommended services.

METHODS

Participants were 144 children ranging in age from 1.38 to 5.89 years and their caregivers. Families completed measures of child and caregiver functioning prior to participation in the SOC. Service recommendation and usage were measured at intake and three months, respectively. We used multiple regression analysis to examine the relationship between risk factors and dosage of services received. Logistic regression analyses identified the relationships between risk factors and service recommendation and usage according to specific service types within the SOC.

RESULTS

Children with greater behavior problems received more services overall (R² = .103, β = .243, p = .033). Child risk factors predicted recommendation for child welfare (trauma exposure: O R ^ = 1.352 , p = .052) and mental health services (behavior problems: O R ^ = 1.061 , p = .034; trauma exposure: O R ^ = 1.316 , p = .046), whereas families with substance use issues were less likely to be recommended for mental health services ( O R ^ = .229 , p = .017).

CONCLUSIONS

Findings highlight opportunities for improved service provision and service-level decision making in early childhood SOCs.

Child advocacy center based group treatment for child sexual abuse

The present study examines initial symptom presentation among participants, outcomes, and social validity for a group treatment for child sexual abuse delivered at a child advocacy center. Participants were 97 children and their nonoffending caregivers who were referred to Project SAFE (Sexual Abuse Family Education), a standardized, 12-week cognitive-behavioral group treatment for families who have experienced child sexual abuse. Sixty-four percent of children presented with clinically significant symptoms on at least one measure with established clinical cutoffs. Caregivers of children who presented with clinically significant symptoms reported more distress about their competence as caregivers. Children who presented as subclinical were more likely to have experienced intrafamilial sexual abuse. Posttreatment results indicated significant improvements in functioning for all children who participated in treatment, with greater improvements reported for children who initially presented with clinically significant symptoms. Overall, the program was rated favorably on the posttreatment evaluation of social validity.

Predictors of crying, feeding and sleeping problems: a prospective study

BACKGROUND

Infant regulatory problems, that is, excessive crying, feeding and/or sleeping difficulties, are precursors of adverse development. However, the aetiology of regulatory problems is still unclear. The aim of this study was to investigate pre-, peri- and post-natal neurophysiological and psychosocial predictors of single and multiple regulatory problems at 5 months of age.

METHODS

This prospective longitudinal study included all children born at neonatal risk in a geographically defined area in southern Germany. The data of n = 5093 singleton infants (83.6%) were analysed using crude and multivariate logistic regression analyses. As outcome measures we used single and multiple regulatory problems, that is, crying, feeding and/or sleeping difficulties at 5 months of age, which were assessed via a standardized interview with the parents by study paediatricians as part of a neurodevelopmental examination.

RESULTS

In total, 30.7% of the sample suffered from single or multiple regulatory problems at 5 months. Breastfeeding increased the odds of single sleeping problems 5.12-fold, but decreased the odds of single feeding problems [odds ratio (OR) 0.51; 95% confidence interval (CI) 0.35-0.74]. Very preterm birth was predictive of single feeding (OR 1.79; 95% CI 1.25-2.55) and multiple regulatory problems (OR 2.03; 95% CI 1.19-3.46), and foetal abnormalities increased the odds of single feeding and multiple regulatory problems from 1.53- to 1.64-fold. Family adversity and psychosocial stress factors were associated with single crying and multiple regulatory problems.

CONCLUSIONS

Pre-, peri- and post-natal neurophysiological and psychosocial factors are predictive of single and multiple regulatory problems. The results may be useful in terms of early recognition of at risk groups for regulatory problems.

A prospective study on the persistence of infant crying, sleeping and feeding problems and preschool behaviour

AIM

To determine the persistence of regulatory problems (RP), i.e. excessive crying (>3 months of age), feeding and sleeping difficulties from infancy to preschool age, and to evaluate whether RP at 5 months are predictive of preschool adaptive behaviour and social skills.

METHOD

A prospective population study of newborns admitted to neonatal care. RP at 5, 20 and 56 months of age were obtained via parent interviews and neurological examination and preschool adaptive behaviour and social skills by parent ratings. Logistic and linear regression analyses were conducted and controlled for psychosocial and neurological factors.

RESULTS

More than half of the sample had RP at least at one measurement point. In about 8% of infants, RP persisted across the preschool years. Multiple RP and feeding problems increased the odds of eating problems at 20 and 56 months. Persistent RP and feeding problems were predictive of deficits in preschool adaptive behaviour and social skills. In addition, sex differences were found.

CONCLUSIONS

Multiple RP and feeding problems had the highest stability. Persistent RP were predictive of adverse social and adaptive behaviour. Understanding of the aetiology may help to prevent persistent RP.

American medical students in Israel: stress and coping--a follow-up study

BACKGROUND

Medical students studying abroad face the double stress of adjusting to a new cultural environment while at the same time, coping with the usual stresses of medical school. In a previous article, we examined the perceived stress and coping of American medical students studying in Israel.

AIMS

The current study was designed to follow up changes in made in response to the original study.

PARTICIPANTS

First year students, NY/American Program, Sackler School of Medicine, Tel Aviv University, Israel.

METHODS

Ways of Coping Checklist (WCCL), Appraisal Dimension Scale (ADS) and two instruments specifically designed for the study.

RESULTS

Students' coping with their adjustment to Israel was highly correlated to their adjustment to medical school. There was significant improvement in student mental health and student satisfaction and a corresponding reduction in dysfunctional defence mechanism and a previous pattern of heavy drinking.

DISCUSSION

The results are discussed in terms of improvements in the student support system proposed at the time of the initial study as well as changes in the student body. Limitations and future directions for research are also discussed.

Expression of human herpesvirus 8-encoded cyclin D in Kaposi's sarcoma spindle cells

BACKGROUND

Human herpesvirus 8 (HHV-8) DNA sequences have been detected in Kaposi's sarcoma, in primary effusion lymphoma (an unusual high-grade non-Hodgkin's lymphoma seen primarily in patients with acquired immunodeficiency syndrome [AIDS]), and in Castleman's disease (a rare lymphoproliferative disorder); however, proof that HHV-8 is involved in the pathogenesis of these diseases remains to be established. HHV-8 contains a gene, i.e., v-cyclin D, that is a homologue of the cellular cyclin D2 gene, which encodes a protein that promotes passage through G1 phase of the cell cycle. Previous studies have identified v-cyclin D messenger RNA (mRNA) in biopsy specimens of Kaposi's sarcoma. In this study, we isolated a full-length v-cyclin D complementary DNA and characterized the pattern of v-cyclin D mRNA expression in Kaposi's sarcoma.

METHODS

Standard methods were used to construct and to screen HHV-8 genomic and complementary DNA libraries. Reverse transcription-polymerase chain reaction (RT-PCR) methods and in situ hybridization with RNA probes were used to examine v-cyclin D mRNA expression.

RESULTS

RT-PCR demonstrated the presence of v-cyclin D mRNA in biopsy specimens of AIDS-related Kaposi's sarcoma, in early-passage spindle cells from classical (i.e., not AIDS-related) Kaposi's sarcoma, and in spindle cells isolated from the peripheral blood of patients with AIDS-related Kaposi's sarcoma. In situ hybridization indicated that mRNAs for v-cyclin D and kaposin, an HHV-8 latency-associated gene, were present in approximately 1% of the spindle cells in early patch lesions and approximately 60% of the spindle cells in late nodular lesions of Kaposi's sarcoma.

CONCLUSIONS

Spindle cells of Kaposi's sarcoma, which have been regarded as the tumor cells of this cancer, contain v-cyclin D mRNA. Expression of v-cyclin D protein may be involved in the pathogenesis of Kaposi's sarcoma by promoting cell proliferation.

Expression of HHV-8 latency-associated T0.7 RNA in spindle cells and endothelial cells of AIDS-associated, classical and African Kaposi's sarcoma

Analysis by polymerase chain reaction (PCR) and serological studies have demonstrated a close association between the novel human herpes virus, Kaposi's sarcoma-associated herpes virus (KSHV) or human herpes virus-8 (HHV-8) and the development of Kaposi's sarcoma (KS). To clarify the role of HHV-8 in KS pathogenesis, we investigated at the cellular level by in situ hybridization the expression of a recently described 0.7-kb HHV-8-encoded mRNA (T0.7 mRNA) in KS tissues of different epidemiological origin (AIDS-KS, African endemic KS and classical KS). The T0.7 mRNA likely encodes a small membrane protein, supposedly expressed in latently HHV-8-infected cells. Indeed, we detected T0.7 mRNA in virtually all cells of the cell line BCBL-1 established from a body cavity-based lymphoma (BCBL) and latently infected with HHV-8. In all KS biopsies examined, independent of their epidemiological type, the late-stage (nodular) KS tissues showed a high level of T0.7 mRNA expression in typical KS spindle cells but also in endothelial cells lining blood vessels, indicating latent HHV-8 infection of these cells. The presence of T0.7-expressing cells was restricted to KS tumor tissue and therefore appears to indicate an important role of latent HHV-8 infection in KS pathogenesis.

Sexual abuse in the family. Suggestions for medical curricula

Awareness of the recent escalation of sexual abuse in the RSA has exposed inconsistencies in the intervention and treatment process and has implications for routine health care. Fifth-year medical students at the University of the Witwatersrand are involved with children in institutions as part of their community paediatric course. During 1985, 9 of the 50 students had to deal with children who had previously been sexually abused. The students recognized their limitations in dealing with the sexually abused child and became aware of their own feelings when confronted with this problem. This has implications for the teaching of the dynamics of sexual abuse to medical students. It is suggested that knowledge of sexual abuse and its ramifications be addressed at the medical school curriculum level and be taught in the various clinical departments and incorporated into ward teaching rounds and seminars.

The effectiveness of a preoperation preparation program in reducing anxiety in children

A study to assess the effectiveness of a preoperative preparation program on the child and family was undertaken. Three groups of mothers and children who were to undergo tonsillo-adenoidectomy were tested, pre- and postoperatively, using a questionnaire and IPAT Anxiety Scale. Differences were noted in the socioeconomic and educational backgrounds of the mothers who came of their own accord, those who were telephoned and those who did not attend the preoperative program. These differences affected the parents' expectations of the program and their explanations to the children. Children's, but not mothers', anxiety appeared to reduced by attendance at the program. The IPAT Anxiety Scale revealed that the anxiety of mothers of children who did not attend the preoperative preparation program was the highest of all three groups.

Teaching interpersonal communication skills in paediatrics with the help of mothers

Medical students were randomly assigned by two groups. The experimental or Family Health Project (FHP) group was given a short training course in conducting a first interview, which incorporated the content of the paediatric history as well as the process of the interview. Students in the FHP and control of Community Care (CC) groups conducted a videotaped interview with a mother of a child. The students viewed themselves on a replay and were given feedback information on their performance during the interview. An objective content checklist was used to assess the content of the interview. For the process of the interview all the videotapes were rated by the mothers, using the Flanders method of interaction analysis modified by Helfer. Significant differences were noted between the FHP and CC groups, which have implications for patient compliance and satisfaction. Medical students were enthusiastic about this form of learning.

An innovation in an undergraduate paediatric teaching programme

The reasons for removal of children into care and the effects of institutionalization are described. Medical students were attached to children's institutions and played various roles in befriending individual children, caring for groups of children, undertaking health education, and monitoring growth and development. The majority of students became committed to assisting the children and, simultaneously, the learning objectives were fulfilled. The programme has potential as a learning experience and a community service.

Interns' attitudes towards aspects of their medical education

During December 1977, the last month of the internship year, students who had obtained the M.B. B.Ch. degree at the University of the Witwatersrand at the end of 1976 completed questionnaires to reveal their attitudes towards aspects of their undergraduate education. Sixty-seven per cent of the class responded. The interns thought that their undergraduate education had prepared them ore adequately for manual tasks than for dealing with emotional aspects of patient care, especially a dying patient. More anxiety was aroused when managing a dying patient and his relatives than when performing diagnostic procedures. The health care function of allied professionals was not fully appreciated, and as a result their services were not fully used.

Attitudes of medical students to a family attachment scheme

A family attachment scheme is described, in which a few fourth-year students followed-up the babies they delivered during their obstetric training until the final year of study. Fifth-year students visited families of a normal newborn infant or a child who had presented with an illness or abnormality until the end of their final year. Some students felt that the project had been worth while, while others thought that it was pointless. Families visited by the students thought the scheme had been beneficial, mainly because the student was somebody they could talk to about their problems.