Correlates of Menarcheal Age in a Psychiatric Sample of Adolescents

ABSTRACT

Early pubertal timing is associated with more adverse childhood experiences (ACEs) and increased risk for psychopathology during adolescence. However, most work to date has used community or epidemiological samples, and it remains unclear whether these associations persist in acute clinical samples. The present study examined associations between age at menarche and ACEs, psychiatric symptoms, and emotion regulation difficulties in a sample of N = 140 adolescents on a psychiatric inpatient unit. Youth with early menarche reported higher levels of depressive symptoms, more severe suicidal ideation, and greater difficulty with emotion regulation than youth with normative age at menarche. There was a marginal effect of youth with early menarche reporting more ACEs and more anxiety symptoms. These results suggest menarcheal age, and ACEs may be useful risk factors to assess in inpatient settings to predict risk for more severe outcomes, and future research on pubertal timing in high acuity settings is warranted.

Non-suicidal Self-Injury, Suicidal Behaviors, and Mental Health Symptoms among Sexual Minority Youth with Juvenile Justice System Involvement

Sexual minority youth have long remained an understudied population within the juvenile justice system, despite emerging evidence suggesting that sexual minority youth are overrepresented. Recent literature indicates that system-involved sexual minority youth may have more behavioral health concerns than their heterosexual counterparts. Even so, more work is needed to elucidate the unique needs of sexual minority youth who become involved in the system, especially as it pertains to suicidal behaviors and non-suicidal self-injury (NSSI). The present study provided a descriptive evaluation of the prevalence of sexual minority youth making early system contact and their mental health concerns. Of the 218 justice-involved youth from a Northeastern family court in the sample, over a quarter identified as a sexual minority (n = 58). Our findings indicated that these youth evidenced significantly higher scores on a mental health screener compared to their heterosexual counterparts, evidencing greater symptomology on scales indicative of depression/anxiety, thought disturbance, etc. Further, sexual minority youth reported higher rates of lifetime, past year, and past month NSSI as well as lifetime and past year suicide attempts. These findings highlight the need to support the well-being of sexual minority youth in the juvenile justice system by screening for and addressing their mental health needs in this unique setting.

Sleep disturbance and suicidality in psychiatrically hospitalized adolescents: The role of specific emotion regulation domains

BACKGROUND

Sleep disturbance is associated with broadband measurements of emotion regulation (ER). The linkage between ER, a multidimensional process, and suicidal ideation and suicide attempt is also documented in theoretical and empirical work. Recent research indicates that distinct profiles of ER are associated with psychiatric outcomes, including adolescent suicidal ideation and attempt. The present study examined whether specific domains of ER would explain the association between sleep disturbance, and ideation and attempt among psychiatrically hospitalized adolescents.

METHOD

The sample included 284 adolescents who completed self-report measures on sleep disturbance, ER, suicidal ideation, suicide attempt, and psychiatric symptoms upon inpatient hospitalization.

RESULTS

Findings indicated that sleep disturbance was associated with suicidal ideation. Further, a single ER domain (perceived limited access to ER strategies) fully accounted for the significant association between sleep disturbance and suicidal ideation. A reported suicide attempt in the past week was correlated with the nonacceptance of emotional responses, perceived limited access to ER strategies, and emotional clarity, but was not associated with sleep disturbance.

DISCUSSION

The current findings highlight the importance of examining narrowband ER and indicate the presence of differential associations between sleep disturbance, ER, and suicide-related outcomes. Findings further elucidate the possible role of impaired cognitive responses to emotional experiences in the co-occurrence of sleep disturbance and youth psychiatric outcomes.

Skills to Enhance Positivity in adolescents at risk for suicide: Protocol for a randomized controlled trial

BACKGROUND

Suicide and suicidal behavior during adolescence have been steadily increasing over the past two decades. The preponderance of interventions focuses on crisis intervention, underlying psychiatric disorders, regulating negative affect, and reducing cognitive distortions. However, low positive affectivity may be a mechanism that contributes to adolescent suicidal ideation and behaviors independent of other risk factors. Skills to Enhance Positivity (STEP) is an acceptance-based intervention, designed to increase attention to, and awareness of, positive affect and positive experiences. Results from a pilot RCT demonstrated engagement of the target (positive affect) and a decrease in clinical outcomes (suicidal events; i.e., either a suicide attempt or an emergency intervention for an acute suicidal crisis), providing support to test the clinical effectiveness of STEP in a larger clinical trial with clinical staff implementing the intervention.

OBJECTIVE

To test the effectiveness of STEP, compared to Enhanced Treatment as Usual (ETAU), in reducing suicidal events and ideation in adolescents admitted to inpatient psychiatric care due to suicide risk. We hypothesize that those randomized to STEP, compared to ETAU, will have lower rates of suicide events, active suicidal ideation (SI), and depressed mood over the 6-month follow-up period. We hypothesize that those randomized to STEP, compared to ETAU, will demonstrate greater improvement in the hypothesized mechanisms of attention to positive affect stimuli and gratitude and satisfaction with life.

METHODS

Participants will be randomized to either STEP or ETAU. STEP consists of four in-person sessions focused on psychoeducation regarding positive and negative affect, mindfulness meditation, gratitude, and savoring. Mood monitoring prompts and skill reminders will be sent via text messaging daily for the first month post-discharge and every other day for the following two months. The ETAU condition will receive text-delivered reminders to use a safety plan provided at discharge from the hospital and healthy habits messages, matched in frequency to the STEP group. This trial was registered on 6 August 2021 (ClinicalTrials.gov NCT04994873).

RESULTS

The STEP protocol was approved by the National Institute of Mental Health (NIMH) Data and Safety Monitoring Board on March 4, 2022. The RCT is currently in progress.

DISCUSSION

The STEP protocol is an innovative, adjunctive treatment that has the potential to have positive effects on adolescent suicidal ideation and attempts beyond that found for standard treatment alone.

Associations of Restraint and Seclusion With Race and Ethnicity on an Adolescent Inpatient Psychiatry Service

There is limited work examining the association of race and ethnicity with restraint and seclusion (R/S) in pediatric inpatient psychiatric units. The present study assessed risk of R/S by race and ethnicity based on a retrospective review of electronic medical records (EMRs) from an adolescent inpatient psychiatric service. Demographic, diagnostic, and R/S data were analyzed for all 1,865 admissions of 1,327 patients from an adolescent unit at a child and adolescent psychiatric hospital from June 2018 to June 2021. R/S occurred in 459 of the admissions. For the purpose of patient privacy and statistical analysis, race was grouped into the following: Black or African American, other (American Indian or Alaskan Native, Asian, multiracial, other), and White. Patients identified as unknown were not included in the analysis. A binary logistic regression with a repeated subject effect regressed R/S onto race and adjusted for age, gender, and length of stay (LOS). There was an overall significant association of R/S and race (χ22 = 16.81, p < .001), but not ethnicity. In a regression model adjusted for age, gender, and LOS, patients identified as Black or African American were at significantly higher risk of R/S compared with patients identified as White (odds ratio = 1.66, p = .036). There was no significant difference in risk of R/S between patients identified as White vs other. Younger age and longer LOS were also significantly associated with R/S. These findings highlight a critical health care disparity related to race on an inpatient adolescent psychiatry service. There is likely a combination of individual and systemic factors leading to discriminatory practices in the use of R/S. Future work will assess potential associations with diagnosis and child welfare involvement and will examine additional characteristics of R/S. Focus groups held with hospital and community stakeholders will guide next steps to address these findings.

Experiences of Child and Adolescent Psychiatric Patients Boarding in the Emergency Department from Staff Perspectives: Patient Journey Mapping

Over the past decade, healthcare providers nationwide have contended with a growing boarding crisis as pediatric patients await psychiatric treatment in emergency departments (EDs). COVID-19 has exacerbated this urgent youth mental health crisis, driving EDs to act as crisis units. Journey mapping is a robust methodology with which to examine strengths and challenges in patient care workflows such as boarding and emergency psychiatric care. Psychiatric, emergency medicine, and hospitalist providers serving patients boarding at a northeastern children's hospital participated in semi-structured qualitative interviews. Investigators conducted directed content analysis with an inductive approach to identify facilitators, barriers, and persistent needs of boarding patients, which were summarized in a patient journey map. Findings were presented to participants for feedback and further refinement. Quantitative data showed a three-fold increase in the number of patients who boarded over the past three years and a 60% increase in the average time spent boarding in the ED. Emergent qualitative data indicated three stages in the boarding process: Initial Evaluation, Admitted to Board, and Discharge. Data highlighted positive and negative factors affecting patient safety, availability of beds in pediatric hospital and psychiatric inpatient settings, high patient-provider ratios that limited staffing support, and roadblocks in care coordination and disposition planning. Patient journey mapping provided insight into providers' experiences serving patients boarding for psychiatric reasons. Findings described bright points and pain points at each stage of the boarding process with implications for psychiatric care and systemic changes to reduce boarding volume and length of stay.

Assessing feasibility and acceptability of yoga and group CBT for adolescents with depression: A pilot randomized clinical trial

PURPOSE

Given increasing rates of depression in adolescents, there is a clear need for innovative treatments. In this pilot randomized clinical trial, we assessed acceptability and feasibility of two group-based interventions: yoga and cognitive-behavioral therapy (CBT). The goal of this work is to prepare for a future fully powered randomized trial to test the hypothesis that yoga is not inferior to an established adolescent depression treatment, namely, group CBT.

METHODS

We enrolled 42 adolescents with elevated depression symptoms. Participants were randomly assigned to a 12-week group-based intervention, yoga or CBT. We had a priori feasibility and acceptability targets, including for recruitment rate, retention rate, expectancy, credibility, program satisfaction, class attendance, engagement in home practice, and instructor/leader manual adherence. We assessed adverse events, and within-subject changes in outcomes (depression, anxiety, impairment, sleep disturbance) and possible mediators (mindfulness, self-compassion).

RESULTS

Both interventions met most acceptability and feasibility targets. The only target not met related to low engagement in home practice. Participants within each study arm showed decreased depression symptoms over time and increased self-compassion.

CONCLUSIONS

A yoga intervention appears to be acceptable and feasible to adolescents with depression. However, it may be challenging for this group to engage in unstructured home practice.

An examination of theory-based suicidal ideation risk factors in college students with multiple marginalized identities

Social marginalization increases the risk of suicidal ideation (SI) among individuals with diverse identities, yet research examining the effects of marginalization has focused on one identity. Emerging adulthood is a critical period of identity development and the age group with the highest rates of SI. Considering the challenges of living in potentially heterosexist, cissexist, racist, and sizeist environments, we tested whether possessing multiple marginalized identities was associated with severity of SI through factors proposed in the interpersonal-psychological theory (IPT) and the three-step theory (3ST) of suicide and if mediation paths were moderated by sex. A sample of 265 college students completed a cross-sectional online survey assessing SI and constructs related to IPT and 3ST. The number of marginalized identities was generated by adding minoritized sexual orientation, race/ethnicity other than non-Hispanic White, body mass index >25 kg/m2, sexual attraction to same sex but identified as heterosexual, and gender-fluid identity. In IPT multiple mediation analyses, possessing more marginalized identities was associated with SI severity through burdensomeness and hopelessness, but not belonging. Indirect paths through burdensomeness and belonging were moderated by sex. For 3ST, possessing more marginalized identities was associated with SI severity through hopelessness and psychological pain, but not social connection or meaning in life. Future research should consider intersecting social identities and test mechanisms by which multiply marginalized college students develop resilience to SI risk factors, such as support within their marginalized groups, to inform suicide assessment and intervention efforts on college campuses. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Digital media-related precursors to psychiatric hospitalization among youth

Digital media, including smartphones and social media, are central in youths' lives. This study aimed to examine the role of digital media in psychiatric hospital admissions among adolescents. 343 psychiatrically-hospitalized youth (Mage = 15.2; 70.3% White, 13.7% Black, 33.9% Hispanic; 48.7% female) completed self-report measures of potential digital media-related reasons for hospitalization, patterns of digital media use, and clinical symptoms (internalizing, externalizing, suicidal ideation and attempts). Digital media-related reasons for hospitalization were common, with over 40% of the sample endorsing at least one such reason; 24.8% endorsed having their phone taken away as a reason for admission. Younger adolescents and youth with addictive patterns of phone use were more likely to endorse digital media-related reasons for hospitalization, including phone restriction and negative social media experiences. In addition, youth endorsing suicide-related social media engagement (e.g., posting or messaging about suicide) as a precursor to admission reported more severe suicidal ideation and greater likelihood of a recent suicide attempt. Limitations of the study include a reliance on self-report measures and cross-sectional design. Findings highlight the need to identify youth who may be especially vulnerable to digital media experiences that contribute to risk for psychiatric hospitalization.

Assessing the Quality of Patient Responses to a Psychosocial Intervention Implemented on an Adolescent Psychiatric Inpatient Unit: Devising the Safety Plan Quality Metric

The Safety Planning Intervention (SPI) helps patients use coping strategies when in a suicidal crisis. This project aimed to characterize SPI quality and determine if it is associated with reduced risk of readmission to psychiatric hospitals. The sample included 145 participants hospitalized on an adolescent psychiatric unit from May to December 2018 who met suicidal criteria per items 18 and 91 on the Youth Self Report. The Safety Plan Quality Metric was created to rate SPI quality. A significant association between higher-quality SPI and fewer instances of readmission was identified (X2 (1, N = 94) = 4.32, p = .038). A logistic regression conducted to determine the impact of other patient factors on readmission did not yield a statistically significant model, (X2 (5, N = 94) = 8.43, p = 0.13). The results suggest that patients with higher quality SPIs were less likely to be rehospitalized.

Parent SMART (Substance Misuse in Adolescents in Residential Treatment): Protocol of a Randomized Effectiveness Trial of a Technology-Assisted Parenting Intervention

BACKGROUND

Adolescents in residential substance use treatment are at extremely high risk for relapse following discharge to the community. Parenting practices, including parental monitoring and parent-adolescent communication, have been established as key predictors of adolescent substance use outcomes and relapse. However, traditional office-based therapy may not be feasible for parents who face structural and systemic barriers. There is a clear need for effective, accessible, and scalable interventions for parents of adolescents receiving residential substance use treatment. In a prior pilot randomized controlled trial, we tested Parent SMART (Substance Misuse among Adolescents in Residential Treatment)-a technology-assisted parenting intervention informed by extensive formative research-as an adjunct to residential treatment as usual (TAU). Parent SMART demonstrated high feasibility and acceptability, as well as evidence of effectiveness in improving parental monitoring and communication.

OBJECTIVE

This protocol paper describes a fully-powered randomized controlled pragmatic effectiveness trial of Parent SMART as an adjunct to residential TAU. We hypothesize that families who receive Parent SMART will demonstrate greater improvements in parenting skills, reductions in adolescent substance use, and reductions in adolescent problem behaviors relative to families that receive residential TAU. We will test the exploratory hypothesis that reductions in adolescent substance use will be partially mediated by improvements in parenting skills.

METHODS

Adolescent-parent dyads (n = 220 dyads; 440 total) will be randomized to either residential TAU only or Parent SMART+TAU. Parents randomized to Parent SMART will receive access to a networking forum, an off-the-shelf computer program called Parenting Wisely, and up to four telehealth coaching calls. Multimethod follow-up assessments consisting of self-reported parent and adolescent measures, a parent-adolescent in vivo interaction task, and 8-panel urine screens will be conducted 6, 12, and 24 weeks postdischarge from residential care. Measures will assess parenting skills, adolescent substance use, and adolescent problem behaviors. Analyses will be conducted using latent change score structural equation modeling.

RESULTS

The trial was funded in August 2021; ethics approval was obtained in August 2020, prior to funding. Due to concerns with the administrative interface in the pilot trial, the Parent SMART networking forum is currently being rebuilt by a different vendor. The programming is scheduled to be completed by December 2021, with recruitment beginning in February 2022.

CONCLUSIONS

The proposed research has the potential to advance the field by serving a high-need, underserved population during a vital treatment juncture; targeting parenting practices (putative mediators) that have been shown to predict adolescent substance use outcomes; addressing barriers to accessing continuing care; and testing a highly scalable intervention model.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05169385; https://clinicaltrials.gov/ct2/show/NCT05169385.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/35934.

Preliminary evidence supporting the practice of psychosis-risk screening within an inpatient psychiatric setting serving adolescents

Evidence supports the use of brief psychosis-spectrum screening measures to identify individuals at elevated risk for psychosis, however, there is limited research on psychosis-spectrum screening among adolescents hospitalized for acute mental health concerns. Given the psychiatric vulnerability of this population, screening efforts within inpatient settings may help identify adolescents at greatest risk for ongoing mental health concerns including psychosis. This study investigates the use of two brief screening tools to identify psychosis-spectrum symptoms in psychiatrically hospitalized adolescents. Upon intake, adolescents completed two screening measures, the PRIME Screen-Revised and the Youth Self-Report Thought Problems scale, followed by a brief interview to evaluate psychosis-spectrum diagnoses. Associations between screening scores and diagnostic status were explored to evaluate the use of these tools to identify psychosis-spectrum conditions in this population. The sample included 57 adolescents, 28 of whom met psychosis-spectrum criteria. Psychosis-spectrum status was strongly correlated with PRIME scores (r = 0.59) and Thought Problems T scores (r = 0.55). Logistic regression analyses indicated that both screening measures demonstrate promising accuracy (74-81%) for identifying adolescents meeting psychosis-spectrum criteria. The PRIME and Thought Problems scale may be appropriate screening tools for use in adolescent inpatient settings to identify those experiencing clinically significant psychosis-spectrum symptoms.

Single-arm Pilot Trial of Hatha Yoga for Adolescents with Depression

The prevalence of adolescent depression is increasing, particularly among girls. Existing evidence-based treatments have limitations and/or may not be acceptable to all adolescents and parents. There is evidence that hatha yoga may be useful as an adjunctive treatment for depression in adults. The purpose of the current study was to assess acceptability and feasibility of hatha yoga for depression in teens. We conducted a single-arm pilot trial of 12 weeks of manualized yoga classes specifically targeted toward teens with elevated depression symptoms. We assessed acceptability and feasibility by several metrics and compared our results against a priori benchmarks. We also collected qualitative feedback on the classes. We enrolled 11 teens. We met a priori benchmarks for recruitment and retention rates, credibility of the yoga classes, satisfaction with classes, and (lack of) adverse events causally related to classes. Class attendance and amount of home practice fell below planned benchmarks. Qualitative feedback was positive from the majority, although not all, participants. Results from this study may be used to further refine yoga classes for depressed teens.

13 Reasons Why: Perceptions and Correlates of Media Influence in Psychiatrically Hospitalized Adolescents

OBJECTIVE

The Netflix series 13 Reasons Why (13RW) has sparked controversy due to graphic depictions of youth suicide, bullying, and sexual assault. However, further research is needed examining experiences of the show among youth with psychiatric illness. This exploratory, mixed-methods study examines adolescents' perceptions of 13RW and associations among viewership, suicide-related media influence processes, and self-injurious thoughts and behaviors (SITBs).

METHOD

Participants were 242 adolescents hospitalized in a psychiatric inpatient facility; 60.7% female, 30.2% male, 9.1% other genders; ages 11 to 18; and 74.3% White, 7.5% Black, and 21.8% Hispanic. Participants completed measures of series viewership, media message processing, and SITBs. Participants who watched completed open-ended questions regarding beliefs and opinions about the series.

RESULTS

In all, 50.4% of participants watched 13RW, with girls (63.3%) more likely to have watched than boys (26.0%). More than half (55.9%) of youth expressed negative reactions to the show, while approximately one-third (33.8%) expressed positive reactions. Having watched the series was associated with greater likelihood of past-year non-suicidal self-injury (NSSI), but not with suicidal ideation or past-year suicide attempts. Youth's interpretation of media messages in 13RW, including greater identification with and perceived likeability of the main character, were associated with suicidal ideation and past-year NSSI.

CONCLUSIONS

Findings suggest high rates of 13RW viewership among psychiatrically hospitalized youth, particularly girls, and provide insight into factors that may affect youths' vulnerability to suicide-related media effects.

Social media use, sleep, and psychopathology in psychiatrically hospitalized adolescents

Sleep disruption among adolescents represents a major public health concern, and social media use may play an important role in affecting sleep and subsequent mental health. While prior studies of youth sleep and mental health have often focused on social media use frequency and duration, adolescents' emotional experiences related to social media have been underexplored, particularly among clinically acute populations. This study offers a preliminary investigation of associations among negative emotional experiences using social media, sleep disturbance, and clinical symptom severity in a sample of psychiatrically hospitalized youth. A sample of 243 adolescents (Mage = 15.34) completed self-report measures at a single time point. Measures assessed social media use, including frequency and duration, subjective experiences of use, and emotional responses to use, as well as sleep disturbance and clinical symptom severity, including suicidal ideation, internalizing symptoms, and attention problems. Results revealed that more frequent negative emotional responses to social media use were linked to greater sleep disturbance and higher clinical symptom severity. Furthermore, sleep disturbance mediated the relation between negative emotional responses to social media and clinical symptom severity. While gender differences were revealed in characteristics of social media use, sleep disturbance, and clinical outcomes, the associations among these constructs did not vary across gender groups. Overall, these findings highlight sleep disturbance as a potential mechanism through which negative emotional experiences on social media may impact clinical symptoms in psychiatrically vulnerable youth.

Psychosis-spectrum experiences linked to specific psychotherapy readiness domains among psychiatrically hospitalized adolescents

AIM

Early psychosocial treatment for psychosis-spectrum symptoms has been linked to positive outcomes, whereas delayed treatment is associated with poorer prognosis. Thus, there is a critical need to bolster psychotherapy engagement efforts, particularly among high-risk groups and during high-risk periods, in order to maximize recovery. This study explores the relation between psychosis-spectrum symptoms and psychotherapy readiness among psychiatrically hospitalized adolescents, a foundational step for developing more effective psychotherapy engagement approaches for this population.

METHODS

Adolescents (n = 704; 12-18 years) who were admitted to a psychiatric inpatient unit completed the Readiness for Psychotherapy Index (RPI), a psychosis-spectrum questionnaire (PRIME Screen), and a brief diagnostic interview at intake. Correlational patterns and regression analyses were used to explore associations between variables.

RESULTS

The PRIME Screen was negatively associated with the RPI Openness subscale and positively associated with the Distress subscale, beyond the effects of demographics (ie, age, sex, race) and psychiatric diagnoses.

CONCLUSIONS

Results indicate that the RPI probes multiple facets of psychotherapy readiness that have unique associations with psychosis-spectrum experiences. Adolescents with higher PRIME scores endorsed greater mental health-related distress and lower levels of openness to psychotherapy. These psychotherapy readiness factors warrant further exploration, as they may be significant barriers or facilitators to engaging adolescents with psychosis-spectrum symptoms in much needed early treatment services.

COVID-19 Related Daily Stressors, Coping, and Suicidal Ideation in Psychiatrically Hospitalized Youth

Background

Given reports of the adverse effects of COVID-19 on adolescent mental health, it is critical to understand how it impacts psychiatrically hospitalized youth who may be particularly vulnerable to its effects.

Objective

This study aimed to advance our understanding of high-risk adolescents’ experiences of COVID-19, including COVID-19-related stress, changes in daily functioning, and coping as they relate to suicidal ideation (SI).

Method

Participants were 107 youth (ages 11–18; M = 15.06, SD = 1.79) admitted to an adolescent psychiatric inpatient unit during the time when the initial COVID-19 safety measures (i.e., school closure, stay-at-home- order) and reopening initiatives (Phase I, II, and III) were implemented in Rhode Island between March 13th and July 19th 2020. Adolescents completed measures of COVID-19-related stress, coping, functioning, and SI at the time of admission.

Results

Nearly half of the sample (43%) reported a negative impact of COVID-19 on daily functioning. Youth who endorsed COVID-19-related decline in functioning evidenced higher levels of SI compared to youth with no change or improvement in functioning due to COVID-19. Overall levels of stress were not associated with SI. Greater coping repertoire, but not the use of specific coping strategies was associated with higher levels of SI.

Conclusions

Findings demonstrate the importance of examining COVID-19-related changes in functioning and broadening repertoire of coping strategies among adolescents at high risk for SI.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10566-021-09641-1.

Social media use and self-injurious thoughts and behaviors: A systematic review and meta-analysis

Despite considerable public and scholarly debate about the role of social media in self-injurious thoughts and behaviors (SITBs), no comprehensive, quantitative synthesis of this literature has previously been undertaken. The current systematic review and meta-analysis examines associations between social media use and SITBs, including suicidal ideation, suicide plans, suicide attempts, and nonsuicidal self-injury (NSSI). A range of social media behaviors and experiences were identified, including cybervictimization and perpetration, exposure to and generation of SITB-related content, problematic use, sexting, social media importance, and frequency of use. A systematic search of PsycINFO, Medline, CINAHL, and the references of prior reviews yielded 61 eligible studies. Results largely suggested medium effect sizes for associations between specific social media constructs (cybervictimization, SITB-related social media use, problematic social media use) and SITBs. There was no association between frequency of social media use and SITBs; however, studies on this topic were limited. The majority of studies identified focused on cybervictimization, and results suggested positive associations with all SITBs, with the association between cybervictimization and suicidal ideation stronger for adolescents than adults. Overall, findings highlight the utility of examining specific social media behaviors and experiences, and point to the need for more research in this area.

Teens' perspectives on yoga as a treatment for stress and depression

OBJECTIVE

To understand adolescents' experiences and attitudes toward yoga, with a particular focus on acceptability and feasibility of a yoga intervention for depressed adolescents.

DESIGN

Qualitative analysis of data from three focus groups and eight individual interviews, for a total of 22 teen participants.

SETTING

Outpatient setting in a psychiatric hospital in the U.S.

MAIN OUTCOME MEASURES

Teens were asked about their own and their peers' attitudes toward, and experiences with, hatha yoga; reactions to a study-created yoga video; and opinions on class logistics.

RESULTS

Teens had both positive and negative attitudes toward, and experiences with, hatha yoga. They commented on "who does yoga;" many responses suggested a limited group (e.g., moms; people with money and time). Participants agreed that yoga could be potentially beneficial for depressed or stressed teens. Self-consciousness while being in a yoga class was a major concern. Overall, teens reacted favorably to the study-created yoga video. Teens had varied opinions about class logistics including class duration and size. Teens cited barriers to class, such as transportation, as well as barriers to home yoga practice.

CONCLUSIONS

Key points for developing a yoga class that might be appealing to depressed or stressed teens include: creating a class with variety that teens will find interesting; taking concrete steps to decrease teen self-consciousness; incorporating messages relevant for teens and consistent with yoga philosophy; and actively countering stereotypes about who practices yoga. Limitations of this study include the lack of data from male teens.

Suicidal Mental Imagery in Psychiatrically Hospitalized Adolescents

Suicide is the second leading cause of death in adolescents and suicide rates in this population have increased in recent years. A critical step in preventing suicide is improving the accuracy of suicide risk assessment. Measurement of suicidal cognitions typically emphasizes assessment of verbal thoughts about suicide. Recent research suggests, however, that suicidal mental imagery, or mentally imagining suicide-related content, may be even more strongly associated with suicidal behavior. No research has evaluated suicidal mental imagery in adolescents, however. The present study evaluated suicidal mental imagery and suicidal verbal thoughts in a sample of adolescents (N = 159) admitted to an adolescent psychiatric inpatient unit. Of those adolescents who reported suicidal cognitions, 63.73% reported suicidal mental imagery. Adolescents who reported suicidal mental imagery had 2.40 greater odds of having made a suicide attempt, after accounting for history of suicidal verbal thoughts and relevant covariates. Findings suggest that suicidal mental imagery should be directly assessed when evaluating suicide risk, and that treatments may be optimized by targeting both suicidal verbal thoughts and suicidal mental imagery.

Online Self-Injury Activities among Psychiatrically Hospitalized Adolescents: Prevalence, Functions, and Perceived Consequences

The majority of adolescents with psychiatric disorders use social media, engaging in a range of online activities that may confer both risks and benefits. Very little work, however, has examined engagement in online activities related to self-injury among these youth, such as posting about self-injury, viewing self-injury related content, or messaging about self-injury with online or offline friends. This study examined the frequency and types of online self-injury activities in which adolescents engage, perceived functions that these activities serve, and associated risk for self-injurious thoughts and behaviors (SITBs). Participants were 589 psychiatrically-hospitalized adolescents (M_age = 14.88), who completed self-report measures assessing online self-injury activities, perceived functions and consequences of these activities, and SITBs. Results indicated that 43.3% of the sample had engaged in online self-injury activities, that the majority (74.8%) used social networking sites (e.g., Snapchat, Instagram) to do so, and that these activities were significantly more common among sexual and gender minority youth. Adolescents who talked about self-injury with friends met online were more likely to report a history of suicide attempt(s). A latent profile analysis revealed three distinct subgroups of youth based on their perceived functions of engaging in online self-injury activities. Subgroups reporting higher levels of engagement for purposes of identity exploration, self-expression, and aiding recovery were at heightened risk for negative perceived consequences of these activities and reported greater suicidal ideation severity. Findings offer new insights for identifying youth who may be at heightened risk for SITBs in the context of social media use.

Application of the actor-partner interdependence model in parent-adolescent emotion regulation and depression

BACKGROUND

The family environment is an important context for the development and maintenance of depressive symptoms within families. In this study, we evaluated whether parent and adolescent self-reports of emotion regulation constructs are linked with their own (actor effects) and each other's (partner effects) depressive symptoms.

METHODS

Participants were 123 adolescent-parent dyads, recruited from adolescent inpatient and partial hospitalization programs, who completed self-report assessments of emotion dysregulation and depression.

RESULTS

Using the Actor-Partner Interdependence Model (APIM), results revealed expected actor effects for emotion regulation strategies, but not impulsiveness. A significant partner effect for parents' impulsiveness and adolescents' depressive symptoms was observed, demonstrating the interdependent nature of these characteristics in the sample. Interpretation of APIM model coefficients indicated that greater parent impulsiveness was associated with less adolescent depression symptom severity.

LIMITATIONS

Limitations include a small sample of primarily Caucasian adolescents who were receiving intensive psychiatric services making generalizability more challenging. The sample also consisted of largely mothers which is important to consider given there are known gender differences in rates of depression and sensitivity to interpersonal processes.

CONCLUSIONS

Overall, findings shed light on the nature of these characteristics within the families of depressed adolescents and the role of emotion regulation in the parent-child relationship. Implications of this work and future studies are discussed.

Prevalence and clinical indices of risk for sexual and gender minority youth in an adolescent inpatient sample

OBJECTIVE

Rates of self-injurious thoughts and behaviors have increased in adolescents over the past two decades. Sexual and gender minority (SGM) youth report elevated rates of self-injurious thoughts and behaviors compared to heterosexual and cisgender youth. Studies of factors influencing suicide risk in SGM youth remain limited, however, and have largely been conducted in community or epidemiological samples.

METHOD

The present study aimed to address these limitations by examining the prevalence and clinical characteristics of sexual and gender minority youth in a sample of 515 youth admitted to an adolescent inpatient unit. In addition, the present study aimed to compare rates of self-reported self-injurious thoughts and behaviors, adverse early childhood experiences, and rates of rehospitalization in sexual and gender minority compared to non-sexual and gender minority youth.

RESULTS

Results show that nearly 40% of the sample identified as sexual and/or gender minority. Sexual minority youth reported higher rates of suicidal ideation (t = -6.19, p < .001), higher rates of prior suicidal behavior (Chi2 = 27.44, p < .001) and non-suicidal self-injury (Chi2 = 48.09, p < .001), and greater numbers of adverse childhood experiences (t = -3.99, p < .001); gender minority youth reported higher rates of suicidal ideation (t = -3.91 p = .001). There were no group differences for SGM youth in rates of rehospitalization in the 6-months following initial admission. These results held when controlling for sex assigned at birth and current depression status in multi-variate analyses.

CONCLUSIONS

The study illuminates the importance of assessing SGM status in clinical care and highlights the need to evaluate sexual and gender minority specific risk factors for self-injurious thoughts and behaviors in youth.

Safety Planning Intervention for Adolescents: Provider Attitudes and Response to Training in the Emergency Services Setting

OBJECTIVE

This study aimed to describe the implementation of the empirically supported Safety Planning Intervention (SPI) for adolescent suicidality in emergency services (ES) settings.

METHODS

Using an implementation science framework, the authors collaboratively evaluated the needs of ES providers; developed a plan; and trained ES psychiatrists, social workers, and mental health specialists for SPI implementation. The health care and social workers put the safety plan into practice in ES settings and, after involving stakeholders in addressing challenges during implementation, fully integrated the program into ES practice. This study examined providers' attitudes toward the structured SPI before and after training in this evidence-based intervention.

RESULTS

Providers reported a desire to learn evidence-based interventions for safety planning before the training. The effect of time from pre- to posttraining on provider attitudes and knowledge about the SPI was statistically significant (F=4.19, df=2 and 22, p=0.030), indicating that providers' attitudes toward using the structured SPI in their work improved after completing the training.

CONCLUSIONS

These findings are relevant for health care settings that seek to comply with new standards for hospital accreditation and improve overall patient care for suicidal youths. The results suggest that stakeholder collaboration and brief training in SPI may be effective for incorporating structured safety planning practices into pediatric ES settings.

Youth Self Report Thought Problems and Sleep Difficulties Are Linked to Suicidal Ideation Among Psychiatrically Hospitalized Adolescents

Objectives: Thought problems, such as hallucinations and delusional or disorganized ideas, have been associated with increased sleep problems and risk for suicidal ideation (SI). Sleep problems have also been linked directly to suicidality in adolescence. The nature of the relationship between these symptoms among adolescents with acute suicidality is not well understood. This study aims to examine the interrelationships between thought problems, sleep difficulties, and SI in adolescents psychiatrically hospitalized for safety concerns, with the goal of informing suicide risk screening and intervention for this population. Methods: Participants included adolescents (n = 690) aged 11-18. A retrospective chart review was used to obtain scores on study measures, including the Suicidal Ideation Questionnaire Junior (SIQ-Jr), the thought problems and sleep disturbance scales on the Youth Self Report (YSR), and mental health diagnoses using the Children's Interview for Psychiatric Syndromes (ChIPS). Results: Findings indicate that SIQ-Jr scores are moderately correlated with both YSR thought problems (r = 0.51, p < 0.001) and YSR sleep disturbance (r = 0.47, p < 0.001). Further, linear regression analyses support the hypotheses that thought problems (β = 0.28) and sleep difficulties (β = 0.11) are uniquely associated with SI, beyond the significant effects of depression (β = 0.36) and female sex (β = -0.07); R² = 0.43, F (8, 673) = 62.49, p < 0.001). Conclusions: These results suggest that sleep interventions and treatment of thought problems may be important for reducing SI, within and outside the context of depression. Furthermore, the adolescent version of the YSR may be a useful tool to evaluate these risk factors alongside other psychiatric concerns.

Parent-adolescent relationship characteristics and adolescent cannabis use: A growth curve analysis

Background: Adolescent cannabis misuse may be associated with serious academic, conduct, and health problems. Identifying factors associated with adolescent cannabis misuse over time may provide insight to address these factors in interventions. Parent-adolescent relationship characteristics (i.e., attachment, discipline) have been linked to adolescent cannabis misuse and may be important factors to study. Objectives: We investigated time-varying associations between parent-adolescent relationship domains and weekly adolescent-reported cannabis misuse. We hypothesized that during times when parents reported less positive aspects of their relationship with their adolescents, adolescents would report higher levels of cannabis misuse. Methods: Data were drawn from a community clinic treatment study for adolescents with substance use and co-occurring psychiatric disorders (n=110; average age=15.71; 57.3% male). Latent growth modeling with time-varying predictors (parent-adolescent relationship characteristics) was used to examine if the associations between adolescent cannabis misuse and relational frustration, discipline, and attachment varied across the study period (baseline, 3-, 6-, and 12-months). Results: Weekly cannabis misuse significantly increased over time, even after accounting for parental relationship characteristics. When parents rated higher levels of relational frustration relative to their average level of frustration, adolescents reported higher cannabis misuse at all study periods except 12-month follow-up. Conclusion: Results support the importance of considering how specific aspects of the parentadolescent relationship, in this case elevated parental frustration, are associated with adolescent cannabis misuse during treatment and after its completion. Findings suggest parental relationship frustration is a key factor to assess and address within individually tailored interventions for co-occurring cannabis misuse and psychiatric disorders.

A Process Evaluation of a Substance Use Brief Intervention for Adolescents in a Psychiatric Inpatient Program

The present study represents a two-phase process evaluation of the implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT) on an adolescent psychiatric inpatient unit. The first phase analyzed uptake efforts using chart review data, which revealed that 158 (16.8%) of 942 hospitalized patients (Mean age = 15.81, SD = 1.24) were eligible to receive the brief intervention; however, only 30 (19%) adolescents received the intervention, 15 (9.5%) declined treatment, and 113 (71.5%) were never offered. The second phase involved directed content analyses of clinical staff and providers’ perceived facilitators and barriers to the implementation. Qualitative findings revealed that providers and staff accepted and agreed with the use of the brief substance use intervention, though perceived time constraints, competing demands, and insufficient staffing interfered with implementation across disciplines. Barriers included patients’ length of stay and competing treatment priorities. Several recommendations emerged including, utilization of non-clinical staff, a clear administration protocol, and the use of computer-based interventions. Findings from the present study shed light on the need to consider alternate or more streamlined substance use treatments such as computerized approaches and focus on ways in which protocol can be modified to fit the needs within an acute, short-term setting.

Feasibility of decision rule-based treatment of comorbid youth: A pilot randomized control trial

This study examined the feasibility, acceptability, and preliminary efficacy of a decision rule driven treatment for youth with comorbid conduct problems and depression. A randomized, controlled, repeated measures design was used to compare two treatment approaches: Decision-Rule Based Treatment (DR) and Sequential Treatment (SEQ). Participants included 30 children (ages 8-14; 66% female; 80% Caucasian) who met criteria for a depressive disorder (major depressive disorder and/or dysthymia) and a conduct problem disorder (oppositional defiant disorder and/or conduct disorder). Assessments were conducted at baseline, post-treatment, and six-month follow-up. Treatment adherence, attendance, and session evaluations ratings indicate that the treatments were feasible to implement and acceptable to parents and youth in both conditions. Both treatments showed similar remission of internalizing and externalizing diagnoses. Participants in DR showed significantly greater improvements at six-month follow-up in child-reported depressive symptom severity compared to SEQ. Both DR and SEQ conditions showed significantly lower behavior problems at end of treatment and six-month follow-up. DR showed significant reductions in emotion dysregulation at 6-month follow-up, while SEQ did not. Findings suggest that a decision rule based intervention holds promise as a feasible and acceptable treatment with high rates of remittance.

Piloting of COPES: An Empirically Informed Psychosocial Intervention on an Adolescent Psychiatric Inpatient Unit

OBJECTIVES

This study evaluated the feasibility and initial efficacy of an empirically informed psychosocial intervention on an adolescent psychiatric inpatient unit.

METHODS

Data were obtained for 463 adolescents 12-16 years of age on a psychiatric inpatient unit. Information collected included demographics, psychiatric diagnoses, length of inpatient stay, completion of four treatment modules, rehospitalizations, and emergency room visits during 12 months after discharge from index admission.

RESULTS

Around 98.70% of patients completed at least one out of the four treatment modules and 93.95% of patients completed two modules. There were no significant barriers to completing treatment modules on the basis of participant characteristics (demographics, psychiatric diagnosis, number of diagnoses, or length of stay). Completion of the four treatment modules, particularly modules on developing a safety plan and enhancing life, predicted lower risk for rehospitalization and emergency room contact in the 12 months postdischarge.

CONCLUSION

Findings suggest that the intervention is feasible to implement regardless of common barriers in an inpatient psychiatric setting, such as complex psychopathology and brief duration of hospitalization. Completion of treatment modules significantly reduces risk for subsequent emergency intensive service utilization, suggesting this intervention may be an effective method for reducing acute clinical events.

Family-focused cognitive behavioral treatment for depressed adolescents in suicidal crisis with co-occurring risk factors: a randomized trial

BACKGROUND

Suicide is the second leading cause of death among adolescents. The purpose of this study was to test a family-focused outpatient cognitive behavioral treatment (F-CBT) protocol for depressed adolescents following psychiatric hospitalization for a suicide attempt or suicidal ideation, and who had a co-occurring risk factor (suicidal behavior prior to the index admission, nonsuicidal self-injury, and/or a substance use disorder), in a randomized Phase 2 efficacy trial.

METHOD

One hundred forty-seven adolescents (mean age = 14.91 years; 76.2% female, 85.5% White) and their families, recruited primarily from an inpatient psychiatric hospitalization program, were randomly assigned to F-CBT or enhanced treatment-as-usual (E-TAU). A suicide attempt was the primary outcome variable. Depression, suicidal ideation, and nonsuicidal self-injury are also reported here. Assessments were completed at pretreatment as well as 6, 12, and 18-months postrandomization (Trial Registration ClinicalTrials.gov Identifier: NCT01732601).

RESULTS

In the sample as a whole, rates of attempts decreased from 20% at 6 months to 9% at 12 months to 7% at 18 months. There was no evidence of a significant difference between treatment arms in rates of suicide attempts, major depressive disorder, suicidal ideation, or nonsuicidal self-injury at any of the postrandomization assessment points.

CONCLUSIONS

Though F-CBT was associated with reductions in suicidality, depression, and nonsuicidal self-injury, E-TAU showed an equally strong effect. Greater frequency of F-CBT treatment sessions, particularly at the start of care, and alternative approaches to transitioning to care at 12 months, may be necessary when using F-CBT with this population.

Patterns of Social Media Use Among Adolescents Who Are Psychiatrically Hospitalized

Adolescents' use of social media (SM) has increased drastically in recent years, with more than 80% of teens now belonging to sites such as Instagram, Snapchat, and Facebook.¹ This has critical implications for youths' psychosocial development. Research increasingly supports a differential susceptibility model of media effects,² whereby certain adolescents show increased risk for negative effects of SM use. Emerging research with community samples of youth suggest that mental health concerns may be one factor that heightens vulnerability to adverse SM experiences. In particular, youth with internalizing symptoms are more likely to report negative emotional responses to SM activity.³ In addition, youth with suicidal thoughts or behaviors are more likely to experience cybervictimization, and may be at risk for exposure to suicide-related SM content.⁴ Despite this preliminary evidence, almost no research to date has examined SM use among youth with clinically severe psychiatric presentations. This has significantly limited our understanding of a central feature in the lives of youth with mental illness. To address this limitation, we examined SM experiences among a large sample of psychiatrically hospitalized adolescents. We sought to determine the prevalence of positive and negative SM experiences in this population, and to explore differences in SM use based on diagnostic presentation.

Emotion dysregulation and non-suicidal self-injury: A systematic review and meta-analysis

BACKGROUND

Over the past several years there has been considerable interest in the relation between emotion dysregulation and non-suicidal self-injury (NSSI), particularly given that rates of NSSI have been increasing and NSSI is a critical risk factor for suicidal behavior. To date, however, no synthesis of empirical findings exists.

METHODS

The present study presents a comprehensive meta-analytic review of the literature on the association between NSSI and emotion dysregulation. A total of 48 publications, including 49 independent samples, were included in this analysis.

RESULTS

Overall, a significant association was found between emotion dysregulation and NSSI (pooled OR = 3.03 [95% CI = 2.56-3.59]). This association was reduced but remained significant (OR = 2.40 [95% CI = 2.01-2.86]) after adjustment for publication bias. Emotion dysregulation subscales most strongly associated with NSSI included limited access to regulation strategies, non-acceptance of emotional responses, impulse control difficulties, and difficulties engaging goal-directed behavior. Lack of emotional awareness/clarity and cognitive aspects of dysregulation yielded weaker, yet significant, positive associations with NSSI.

CONCLUSIONS

Findings support the notion that greater emotion dysregulation is associated with higher risk for NSSI among individuals across settings, regardless of age or sex. Furthermore, findings reveal facets of dysregulation that may have unique implications for NSSI. This meta-analysis highlights the importance of better understanding emotion dysregulation as a treatment target for preventing NSSI.

Emotion Dysregulation Mediates the Relationship Between Child Maltreatment and Non-Suicidal Self-Injury

One risk factor for non-suicidal self-injury (NSSI) in adolescents is exposure to traumatic experiences, particularly child maltreatment. However, the mechanisms through which childhood maltreatment predicts NSSI are largely unknown. Emotion dysregulation (ED) is likely an important mechanism in this relationship. Therefore, this study examined the relationship between childhood maltreatment, ED, and NSSI in a sample of adolescent inpatients (n= 53). Results demonstrated that child physical and emotional maltreatment, but not child sexual abuse, was significantly associated with NSSI frequency. More specifically, ED mediated the relationship between child physical and emotional maltreatment and NSSI frequency. Findings support the importance of ED as a mediating factor in the relationship between childhood maltreatment and NSSI behaviors and highlight the need for teaching emotion regulation skills to youth affected by trauma.

Interactive Effect of Parent and Adolescent Psychiatric Symptoms on Substance Use among Adolescents in Community Treatment

Both adolescent and parent psychiatric symptoms are well-established risk factors for adolescent substance use (SU), but the ways that these symptoms interact are not well understood. This study examined the interactive effects of parent and adolescent psychiatric symptoms on adolescent frequency of alcohol and marijuana use, over and above the effects of parental SU. Seventy adolescents presenting to a community mental health center (CMHC) participated. Parent and adolescent psychiatric symptoms were measured with the brief symptom inventory (BSI) and child behavior checklist (CBCL), respectively. Hierarchical regressions revealed different patterns for adolescent alcohol and marijuana use. For alcohol, the BSI parent phobic anxiety subscale predicted increased adolescent use while the parent interpersonal sensitivity subscale predicted decreased use: the effects of these parental symptoms were strongest among adolescents with higher levels of externalizing problems on the CBCL. For marijuana, the BSI parent psychoticism subscale predicted increased adolescent use, whereas paranoid ideation predicted decreased use. Results suggest that adolescent SU treatment and assessment should attend to both adolescent and parent psychiatric symptoms.

Characteristics of Children With ADHD and Comorbid Anxiety

OBJECTIVE

The following comorbid subgroups of ADHD have been proposed: ADHD Only, ADHD + anxiety disorders (ANX), ADHD + oppositional defiant disorder/conduct disorder (ODD/CD), and ADHD + ODD/CD + ANX. The current study examined a subset of these groups.

METHOD

A total of 134 children and adolescents (M age = 9.92; range = 6-17) from a clinic-referred sample (n = 407) were grouped based on a semistructured diagnostic interview: ADHD only (n = 41), ADHD + ANX (n = 31), and ANX Only (n = 62).

RESULTS

Findings supported greater parent-reported anxiety symptoms in anxiety groups, and greater parent- and teacher-reported attention problems in ADHD groups. ADHD groups performed worse on a continuous performance test, whereas ADHD + ANX performed worse on working memory than ADHD Only. ADHD + ANX reported more physical anxiety symptoms than ADHD Only.

CONCLUSION

Comorbid anxiety should be considered in ADHD assessment and treatment.

Cognitive-Behavioral Therapy Plus Healthy Lifestyle Enhancement for Depressed, Overweight/Obese Adolescents: Results of a Pilot Trial

The objective of this article was to conduct a treatment development study to examine the feasibility, acceptability, and preliminary efficacy of treating depressed, overweight/obese adolescents using both an exercise regimen and a Cognitive Behavioral Therapy (CBT) protocol modified to address aspects of healthy living and nutrition (CBT plus healthy lifestyle; CBT-HL). A randomized controlled repeated measures design was used to test the hypothesis that CBT-HL would lead to greater reductions in depressed mood and weight compared to CBT for Depression Only (CBT). Participants (n=33; 24 in CBT-HL condition) included 33 adolescents (median age 15, 73% female, 61% white, 36% Hispanic) who met DSM-IV criteria for Current Major Depressive Episode (MDE) and had BMI ≥ 85th percentile. CBT-HL was found to be feasible to implement with most adolescents. Both conditions resulted in improvement in depressed mood. The CBT-HL protocol was more effective in stabilizing weight status as assessed by BMI. Percent time spent in MVPA was increased at 12 weeks for adolescents in CBT-HL compared to those in CBT. The CBT-HL protocol was acceptable to most, but not all, adolescents, and resulted in an improvement in depressed mood as well as stabilization of weight status. A larger study to test efficacy and moderators of treatment outcome is necessary to better understand which adolescents would benefit most from the increased demands of exercise and adhering to nutrition recommendations in addition to standard CBT for depression. Revisions to the treatment protocol to support weight loss, not just stabilization, are also suggested.

Parent Management Training and Collaborative & Proactive Solutions: A Randomized Control Trial for Oppositional Youth

This study examined the efficacy of Collaborative & Proactive Solutions (CPS) in treating oppositional defiant disorder (ODD) in youth by comparing this novel treatment to Parent Management Training (PMT), a well-established treatment, and a waitlist control (WLC) group. One hundred thirty-four youth (ages 7-14, 61.9% male, 83.6% White) who fulfilled Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for ODD were randomized to CPS, PMT, or WLC groups. ODD was assessed with semistructured diagnostic interviews, clinical global severity and improvement ratings, and parent report measures. Assessments were completed pretreatment, posttreatment, and at 6 months following treatment. Responder and remitter analyses were undertaken using intent-to-treat mixed-models analyses. Chronological age, gender, and socioeconomic status as well as the presence of comorbid attention deficit/hyperactivity and anxiety disorders were examined as predictors of treatment outcome. Both treatment conditions were superior to the WLC condition but did not differ from one another in either our responder or remitter analyses. Approximately 50% of youth in both active treatments were diagnosis free and were judged to be much or very much improved at posttreatment, compared to 0% in the waitlist condition. Younger age and presence of an anxiety disorder predicted better treatment outcomes for both PMT and CPS. Treatment gains were maintained at 6-month follow-up. CPS proved to be equivalent to PMT and can be considered an evidence-based, alternative treatment for youth with ODD and their families.

Concurrent treatment for adolescent and parent depressed mood and suicidality: feasibility, acceptability, and preliminary findings

OBJECTIVE

The purpose of this study was to conduct a treatment development study to examine the feasibility, acceptability, and preliminary efficacy of treating depressed, suicidal adolescents and their depressed parent concurrently in a cognitive behavioral therapy (CBT) protocol (Parent-Adolescent-CBT [PA-CBT]).

METHODS

A randomized, controlled, repeated measures design was used to test the hypothesis that PA-CBT would lead to greater reductions in suicidality and depression compared with Adolescent Only CBT (AO-CBT). Participants included 24 adolescent and parent dyads in which the adolescent met American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for current major depressive episode (MDE) and the parent met DSM-IV criteria for current or past MDE.

RESULTS

The concurrent protocol was found to be feasible to implement with most depressed adolescents and parents. Adolescent ratings of program satisfaction were somewhat lower in PA-CBT, suggesting that some teens view treatment negatively when they are required to participate with a parent. The concurrent treatment protocol was more effective in reducing depressed mood in the parent-adolescent dyad at the end of maintenance treatment (24 weeks) than treating an adolescent alone for depression; the largest effect was on parental depressed mood. This difference between dyads was no longer significant, however, at the 48 week follow-up. Adolescent and parent suicidal ideation improved equally in both groups during active and maintenance treatment, and remained low at follow-up in both groups.

CONCLUSIONS

The PA-CBT protocol is feasible to conduct and acceptable to most but not all adolescents. The strongest effect was on parental depressed mood. A larger study that has sufficient power to test efficacy and moderators of treatment outcome is necessary to better understand which adolescents would benefit most from concurrent treatment with a parent.

Negative cognitive style and perceived social support mediate the relationship between aggression and NSSI in hospitalized adolescents

Despite the well-documented association between aggression and NSSI among adolescents, relatively little research has been conducted on the mechanisms underlying this relationship. The purpose of this study was to investigate potential socio-cognitive mechanisms through which aggression and NSSI are related. Participants were 186 adolescents (ages 13-18) recruited from a psychiatric inpatient facility in the northeastern United States. According to teen report, 57.5% of the sample endorsed NSSI in the previous year. Mediation was tested using the modern bootstrapping technique described by Hayes, using 5000 resamples with replacement, including sex and depression diagnosis as covariates. Results demonstrated that greater negative self-talk, a more negative cognitive style, and lower perceived family support were all significant mediators of the relationship between aggression and greater frequency of NSSI, whereas perceived social support from friends was not a significant mediator. Limitations, clinical implications, and future research directions of the current research are discussed.

Psychological, peer, and family influences on smoking among an adolescent psychiatric sample

Although much is known about adolescent cigarette use and initiation in community samples, less is known about these factors among adolescents in clinic-referred populations or those with severe psychopathology. Data were collected from 106 adolescents aged 12 to 15 years (M = 13.6, SD = 0.74) recruited from a psychiatric inpatient facility. Hierarchical logistic regressions assessed the relationship among psychological, peer, and family environment factors and smoking at baseline and 18 months posthospitalization. Conduct problem symptoms, friends' cigarette use, and friends' marijuana use were associated with greater odds of lifetime and current smoking at baseline but not at follow-up. After accounting for the significant effect of baseline use, greater family conflict predicted decreased odds of having initiated smoking at the 18-month follow-up. The period following inpatient psychiatric hospitalization may represent an important window for smoking cessation and prevention efforts targeting peer and family factors, especially for youth with externalizing problems.

Temporal relationship between substance use and delinquent behavior among young psychiatrically hospitalized adolescents

There is considerable evidence linking substance use and delinquent behavior among adolescents. However, the nature and temporal ordering of this relationship remain uncertain, particularly among early adolescents and those with significant psychopathology. This study examined the temporal ordering of substance use and delinquent behavior in a sample of psychiatrically hospitalized early adolescents. Youth (N = 108) between the ages of 12 and 15 years completed three assessments over 18 months following hospitalization. Separate cross-lagged panel models examined the reciprocal relationship between delinquent behavior and two types of substance use (e.g., alcohol and marijuana). Results provided evidence of cross-lagged effects for marijuana: Delinquent behavior at 9 months predicted marijuana use at 18 months. No predictive effects were found between alcohol use and delinquent behavior over time. Findings demonstrate the stability of delinquent behavior and substance use among young adolescents with psychiatric concerns. Furthermore, results highlight the value of examining alcohol and marijuana use outcomes separately to better understand the complex pathways between substance use and delinquent behavior among early adolescents.

The Comorbidity of Conduct Problems and Depression in Childhood and Adolescence

An extensive body of research documents the high prevalence of comorbidity among child and adolescent disorders in general and between conduct problems and depression in particular. These problems co-occur at significantly higher rates than would be expected by chance and their comorbidity may have significant implications for nosology, treatment, and prognosis. Four main hypotheses have been put forth to account for these high rates of comorbidity. First, comorbidity may be a result of shortcomings associated with referral or informant biases. Second, comorbidity may be an artifact of overlapping definitional criteria. Third, one disorder may cause the other disorder by influencing the developmental trajectory and placing an individual at increased risk for further difficulties. Finally, comorbidity between two disorders may be explained by shared underlying causal or risk factors. The purpose of this review is to explore these possibilities, concentrating primarily on the common risk factors of parent psychopathology, emotion regulation, and cognitive biases that may underlie the co-occurrence of these two disorders. Based on our review, we propose a model for the development of comorbidity between these two disorders.