Jack Stevens

Ethnic and Regional Differences in Primary Care Visits for Attention-Deficit Hyperactivity Disorder

ABSTRACT. The ethnic and regional differences in primary care visits for children regarding the frequency of attention-deficit hyperactivity disorder (ADHD) diagnoses, stimulant prescriptions, and other mental health diagnoses were examined. The authors analyzed 6 years (1995-2000) of data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey and found that an ADHD diagnosis and/or a stimulant prescription were less likely to be recorded during visits by Hispanic-American youths relative to visits by white-American youths. The authors also found that stimulant prescriptions were given more frequently for visits of children with ADHD in the south and west than in the northeast. Finally, no ethnic differences were found in the likelihood of receiving a psychotropic medication once an ADHD diagnosis was given or receiving a mental health diagnosis other than ADHD. Ethnic disparities in primary mental health care appear to exist for ADHD and not for other mental disorders pooled together.

Trial of computerized screening for adolescent behavioral concerns.

OBJECTIVE. Injury risk, depressive symptoms, and substance use are the leading causes of adolescent morbidity and death. The goal of this randomized, controlled trial was to determine whether computerized screening with real-time printing of results for pediatricians increased the identification of these adolescent behavioral concerns. METHODS. A total of 878 primary care patients 11 to 20 years of age participated in computerized behavioral screening (the Health eTouch system) in waiting rooms of 9 urban clinics. These clinics all served predominantly low-income patients. The clinics were randomly assigned to have pediatricians receive screening results either just before face-to-face encounters with patients (immediate-results condition) or 2 to 3 business days later (delayed-results condition). RESULTS. Fifty-nine percent of Health eTouch respondents had positive results for ≥1 of the following behavioral concerns: injury risk behaviors, significant depressive symptoms, or substance use. Sixty-eight percent of youths in the immediate-results condition who screened positive were identified as having a problem by their pediatrician. This was significantly higher than the recognition rate of 52% for youths in the delayed-results condition. CONCLUSION. Immediate provision of an adolescents self-report of behavioral concerns to a pediatrician increased recognition of those problems, compared with the delayed provision of results.

Changes in depressive symptoms in first time mothers in home visitation

OBJECTIVE The expansion of Home Visitation Programs for at-risk, first-time mothers and their young children has drawn attention to the potential impact of depression on program outcomes, yet little research has examined depression in the context of home visitation. The purpose of this study was to determine the prevalence of and changes in depressive symptoms in mothers enrolled in home visitation and identify predictors of change in symptoms over the first 9 months of service. METHODS Subjects consisted of 806 at-risk, first-time mothers enrolled in a Home Visitation Program. Self-reported depression was measured at enrollment and again 9 months later. Established clinical cutoffs were used to identify clinically elevated levels of depression. Additional measures were taken of interpersonal trauma history, concurrent intimate partner violence, and social support. RESULTS Results indicated that: (1) 45.3% of mothers had clinically elevated symptoms of depression at some point during the first 9 months of service, (2) 25.9% of mothers had elevated symptoms at both time points or at the 9-month assessment, and (3) 74.1% experienced an interpersonal trauma prior to enrollment. Lack of improvement or worsening of depressive symptoms from enrollment to 9 months was best predicted by pre-enrollment interpersonal trauma history, young maternal age, being African American, and symptoms severe enough to have led to mental health treatment. CONCLUSIONS Findings suggest that maternal depressive symptoms are a significant problem in home visitation. The role of interpersonal trauma in depressive symptoms, and how to best address these clinical issues in home visitation, warrants further examination. PRACTICE IMPLICATIONS Maternal depression is prevalent in Home Visitation Programs, and many mothers exhibit elevated symptoms at multiple time points over the first year of service. Interpersonal trauma history is also prevalent, and is predictive of increased depressive symptoms over time. Home Visitation Programs should note that mothers with interpersonal trauma history, young maternal age, and being African American have an increased likelihood of persistent depressive symptoms, which may in turn pose significant challenges to providing services.

A Clinical Trial of In-Home CBT for Depressed Mothers in Home Visitation

Despite negative outcomes for depressed mothers and their children, no treatment specifically designed to address maternal depression in the context of home visitation has emerged. In-Home Cognitive Behavioral Therapy (IH-CBT) is an adapted treatment that is delivered in the home, focuses on the needs of new mothers, and leverages ongoing home visiting to optimize engagement and outcomes. This study examined the efficacy of IH-CBT using a randomized clinical trial. Subjects were 93 new mothers in a home visiting program. Mothers with major depressive disorder identified at 3months postpartum were randomized into IH-CBT and ongoing home visitation (n=47) or standard home visitation (SHV; n=46) in which they received home visitation alone and could obtain treatment in the community. Depression was measured at pre- and posttreatment, and 3-month follow-up using interviews, clinician ratings, and self-report. Mothers receiving IH-CBT showed improvements in all indicators of depression relative to the SHV condition and these gains were maintained at follow-up. For example, 70.7% of mothers receiving IH-CBT were no longer depressed at posttreatment in terms of meeting criteria for major depressive disorder compared to 30.2% in the SHV group. These findings suggest that IH-CBT is an efficacious treatment for depressed mothers in home visitation programs.

An open trial of in-home CBT for depressed mothers in home visitation.

Research has demonstrated that low income mothers participating in home visitation programs have high rates of depression. This study used an open trial design to evaluate In-Home Cognitive Behavioral Therapy (IH-CBT), an evidence-based treatment for depression that is delivered in the home setting and has been adapted to address the needs of low income mothers participating in home visitation. 64 depressed mothers recruited from a home visitation program and who had completed IH-CBT were compared to 241 mothers from the same setting who met identical screening criteria at enrollment but did not receive the treatment. In addition, pre- and post-treatment measures of depression and related clinical features were contrasted in the 64 mothers receiving IH-CBT. There was a significantly greater reduction in depressive symptoms in the IH-CBT group relative to their counterparts who did not receive the treatment. Results from pre-post comparisons showed that treated mothers had decreased diagnosis of major depression, lower reported stress, increased coping and social support, and increased positive views of motherhood at post-treatment. Findings suggest that IH-CBT is a promising approach to addressing maternal depression in the context of home visitation and warrants further study. Public health implications for home visiting programs are discussed.

Perceived Barriers to Treatment and Psychotherapy Attendance in Child Community Mental Health Centers

Poor psychotherapy attendance is a major problem facing most child community mental health centers. However, post-treatment perspectives on reasons for premature termination are rarely sought from either families or clinicians. In the present study, we collected parent data and clinician data regarding 72 and 153 clients, respectively, from four child and adolescent community mental health centers serving diverse families. Problems regarding (a) the perceived relevance of treatment and (b) the quality of the therapist–family relationship emerged as the two most consistent factors related to premature dropout. Possible interventions to increase psychotherapy attendance are highlighted.

PTSD in Depressed Mothers in Home Visitation.

Recent research has suggested that mothers participating in home visitation programs have a high incidence of mental health problems, particularly depression. Posttraumatic stress disorder (PTSD) is a common comorbidity with depression, yet its prevalence among home visiting populations and implications for parenting and maternal functioning have not been examined. This study contrasted depressed mothers with (n = 35) and without PTSD (n = 55) who were enrolled in a home visitation program. Results indicated that depressed mothers with comorbid PTSD were more likely to have experienced childhood sexual abuse, had greater severity of depressive symptoms, increased social isolation, and lower overall functioning than their counterparts without PTSD. Among PTSD mothers, greater severity of PTSD symptoms, in particular avoidance and emotional numbness, were associated with increased maternal psychopathology and parenting deficits even after controlling for depression severity. These findings add to the literature documenting the negative impacts of PTSD on maternal functioning and parenting. Implications for screening and treatment in the context of home visitation are discussed.

Treatment of depressed mothers in home visiting: Impact on psychological distress and social functioning

OBJECTIVES Depression is prevalent in mothers receiving home visiting. Little is known about the impact of treatment on associated features of maternal depression in this population. The purpose of this study was to examine the impact of a novel, adapted treatment for depressed mothers in home visiting on psychological distress and social functioning. METHODS In-Home Cognitive Behavioral Therapy (IH-CBT) was developed to treat depressed mothers in home visiting. A randomized clinical trial design was used in which subjects were 93 new mothers in a home visiting program. Mothers with major depressive disorder identified at 3 months postpartum were randomized into IH-CBT and ongoing home visiting (n = 47) or standard home visiting (SHV; n = 46) in which they received home visitation alone and could obtain treatment in the community. Measures of psychological distress, social support, and social network were measured at pre-treatment, post-treatment, and three-month follow-up. Clinical features of depression and home visiting parameters were examined as potential moderators. RESULTS Subjects receiving IH-CBT reported decreased psychological distress at post-treatment (ES = 0.77) and follow-up (ES = 0.73). Examination of types of psychological distress indicated broad improvements at both time points. Those receiving IH-CBT reported increased social support over time relative to those in the SHV condition. Effect sizes were modest at post-treatment (ES = 0.38) but increased at follow-up (ES = 0.65). Improvements were seen in affiliative and belonginess aspects of social support, in contrast to tangible support which was statistically non-significant. Findings were not moderated by clinical features of depression or home visiting parameters. No group differences were found in size of and involvement with social networks. CONCLUSIONS IH-CBT is effective in reducing psychological distress and improving perceived social support in depressed mothers receiving home visiting. To the extent that mothers are better adjusted and feel socially supported, they are more available to their children and more amenable to home visiting services. IH-CBT is a feasible, readily adopted treatment that is compatible with multiple home visiting models. As a result it is a promising approach to help depressed mothers in home visiting. Additional interventions may be needed to support depressed mothers in building sizable and stable social networks.

Facilitators and Barriers to Engagement in Home Visitation: A Qualitative Analysis of Maternal, Provider, and Supervisor Data

Abstract Given previous findings indicating a positive association between home visitation participation rates and family outcomes, the present study explored reasons for and barriers to engagement in the first six months of these parenting programs. Social support, psychoeducation, and tangible assistance emerged as consistent themes across informants as reasons for participation. Perceived invasiveness of the assessments, maternal concerns about being reported to child protective services, and mismatches between maternal needs and home visitor attributes emerged as recurrent themes regarding barriers to participation. Results of these qualitative analyses converge with previous quantitative research regarding factors associated with home visitation delivery and suggest new areas in need of further inquiry by researchers and practitioners to increase engagement.

Barriers to Successful Treatment Completion in Child Sexual Abuse Survivors

Child sexual abuse (CSA) often requires psychological treatment to address the symptoms of victim trauma. Barriers to entry and completion of counseling services can compromise long-term well-being. An integrated medical and mental health evaluation and treatment model of a child advocacy center (CAC) has the potential to reduce barriers to mental health treatment. Objective: (a) to describe characteristics between CSA patients who engage versus those who do not engage in mental health treatment and (b) to identify factors associated with successful completion of mental health treatment goals. For design/setting, a retrospective cohort study was conducted of CSA patients (ages 3-16 years) referred to mental health services following a CAC assessment. Outcome variables included linkage with treatment and completion of treatment. Independent variables included demographics, abuse characteristics, and therapist characteristics. Data were abstracted from the CAC and billing databases. Results: Four hundred ninety subjects were evaluated. Subjects were as follows: predominately female (74%), White (60%), and more than half received Medicaid (56%). Mean age was 8.4 years. About 52% linked with mental health services and 39% of patients that successfully linked with mental health services completed therapy. Successful linkage was independently associated with referrals to other counseling services (AOR 8.4 [2.5, 27.7]). Successful completion of therapy was independently associated with caregiver participation in therapy (AOR 3.2 [1.8, 6.0]) and if the patient was referred to other counseling services (AOR 4.1 [1.9, 8.5]). There were no differences between subjects that linked and/or completed therapy and those that did not with regard to demographic characteristics or abuse severity. Conclusion: In contrast to previous reports, efforts at our CAC seem to overcome linkage barriers in this population. However, there remain challenges in achieving successful completion of treatment goals in this population. Engaging caregivers’ involvement in therapy services had a positive effect with successfully achieving treatment goals.