Rachel Haine-Schlagel

Mental Health Care for Children With Disruptive Behavior Problems: A View Inside Therapists' Offices

OBJECTIVES In the United States, more money is spent on treatment for childrens mental health problems than for any other childhood medical condition, yet little is known about usual care treatment for children. Objectives of this study were to characterize usual care outpatient psychotherapy for children with disruptive behavior problems and to identify consistencies and inconsistencies between usual care and common elements of evidence-based practices in order to inform efforts to implement evidence-based practices in usual care. METHODS Participants included 96 psychotherapists and 191 children aged four to 13 who were presenting for treatment for disruptive behavior to one of six usual care clinics. An adapted version of the Therapy Process Observational Coding System for Child Psychotherapy-Strategies scale (TPOCS-S) was used to assess psychotherapy processes in 1,215 randomly selected (out of 3,241 collected) videotaped treatment sessions; treatment sessions were recorded for up to 16 months. RESULTS Most children received a large amount of treatment (mean number of sessions=22, plus children received other auxiliary services), and there was great variability in the amount and type of care received. Therapists employed a wide array of treatment strategies directed toward children and parents within and across sessions, but on average all strategies were delivered at a low intensity. Several strategies that were conceptually consistent with evidence-based practices were observed frequently (for example, affect education and using positive reinforcement); however, others were observed rarely (for example, assigning or reviewing homework and role-playing). CONCLUSIONS Usual care treatment for these youths reflected great breadth but not depth. The results highlight specific discrepancies between evidence-based care and usual care, thus identifying potentially potent targets for improving the effectiveness of usual care.

Improving Community-Based Mental Health Care for Children: Translating Knowledge into Action

There is urgent need for improvement in community-based mental health care for children and families. Multiple studies have documented serious limitations in the effectiveness of “usual care.” Fortunately, many empirically-supported strategies to improve care have been developed, and thus there is now a great deal of knowledge available to address this significant public health problem. The goal of this selective review is to highlight and synthesize that empirically-supported knowledge to stimulate and facilitate the needed translation of knowledge into action. The review provides a sound foundation for constructing improved services by consolidating descriptive data on the status quo in children’s mental health care, as well as evidence for an array of promising strategies to improve (a) Service access and engagement; (b) Delivery of evidence-based practices; and (c) Outcome accountability. A multi-level framework is used to highlight recommended care improvement targets.

A Review of Parent Participation Engagement in Child and Family Mental Health Treatment

Engagement in child and family mental health treatment has critically important clinical, implementation, and policy implications for efforts to improve the quality and effectiveness of care. This article describes a review of the existing literature on one understudied element of engagement, parent participation. Twenty-three published articles were identified. Questions asked of the literature include what terms are used to represent parent participation engagement, how parent participation engagement is measured, what are the rates of parent participation engagement reported in studies of child and family mental health treatment, whether parent participation engagement has been found to overlap with attendance engagement, what factors have been identified as associated with parent participation engagement, whether parent participation engagement is associated with improved outcomes, and what strategies have been designed to improve PPE and whether such strategies are associated with improved outcomes. Results indicate varied terms and measures of parent participation engagement, moderate overall rates, and high overlap with measures of attendance engagement. The extant literature on factors associated with parent participation engagement was somewhat limited and focused primarily on parent-/family-level factors. Evidence of links between parent participation engagement and outcome improvements was found across some outcome domains, and strategies designed to target parent participation engagement were found to be effective overall. A framework for organizing efforts to examine the different elements of engagement is described, and findings are discussed in terms of suggestions for consistent terminology, clinical implications, and areas for the future research.

EEG and video-EEG seizure monitoring has limited utility in patients with hypothalamic hamartoma and epilepsy

Purpose:  Hypothalamic hamartomas (HHs) are a malformation of the ventral hypothalamus and tuber cinereum, associated with gelastic seizures and epilepsy. We sought to determine the spectrum of electroencephalography (EEG) abnormalities in a large cohort of HH patients.

Searching for Elements of Evidence-Based Practices in Children's Usual Care and Examining Their Impact

Most of the knowledge generated to bridge the research–practice gap has been derived from experimental studies implementing specific treatment models. Alternatively, this study uses observational methods to generate knowledge about community-based treatment processes and outcomes. Aims are to (a) describe outcome trajectories for children with disruptive behavior problems (DBPs), and (b) test how observed delivery of a benchmark set of practice elements common in evidence-based treatments may be associated with outcome change while accounting for potential confounding variables. Participants included 190 children ages 4 to 13 with DBPs and their caregivers, plus 85 psychotherapists, recruited from six clinics. All treatment sessions were videotaped and a random sample of 4 sessions in the first 4 months of treatment was reliably coded for intensity on 27 practice elements (benchmark set and others). Three outcomes (child symptom severity, parent discipline, and family functioning) were assessed by parent report at intake, 4, and 8 months. Data were collected on several potential covariates including child, parent, therapist, and service use characteristics. Multilevel modeling was used to assess relationships between observed practice and outcome slopes while accounting for covariates. Children and families demonstrated improvements in all 3 outcomes, but few significant associations between treatment processes and outcome change were identified. Families receiving greater intensity on the benchmark practice elements did demonstrate greater improvement in the parental discipline outcome. Observed changes in outcomes for families in community care were generally not strongly associated with the type or amount of treatment received.

Caregiver Participation in Community-Based Mental Health Services for Children Receiving Outpatient Care

Caregiver participation in child mental health treatment has been associated with better youth outcomes, but little is known about the amount and type of caregiver participation in usual care services for children. This study examined 1,255 caregivers’ reports of their participation in the outpatient services their children received through a large, public mental health system in the Southwest. The majority of the caregivers reported that they participated in their child’s services. Extent of participation was associated with several factors including children’s physical health and caregivers’ primary language, satisfaction with the services, feelings of support, and perceptions of barriers to participation. The findings offer some encouragement for the contextual fit for many evidence-based interventions that focus on caregiver involvement, and highlight which caregivers may need greater encouragement to participate in their child’s care.

Factors Contributing to Reduced Caregiver Strain in a Publicly Funded Child Mental Health System

This study examined caregiver strain in families who initiated mental health services for their child. Predictors of strain and the bidirectional relation between strain and child symptoms were examined. Participants included 218 children aged 4 to 13 with disruptive behavior problems and their caregivers, plus 96 psychotherapists, recruited from six publicly funded clinics. Child disruptive behavior severity and caregiver strain were assessed at baseline, 4, and 8 months. Multilevel models were used to examine predictors of reduced caregiver strain, and autoregressive cross-lagged models were used to examine the bidirectional relations between change in caregiver strain and behavior problems over time. There were small to medium decreases in caregiver strain over the 8 months after the initiation of mental health services, but few factors predicted change other than initial behavior problem severity. Whereas more severe initial child symptoms predicted greater reductions in caregiver strain, greater child symptom severity sustained at 4 months predicted lesser improvements in caregiver strain. Simultaneously, greater caregiver strain predicted less improvement in child symptom severity, suggesting that child symptom severity and caregiver strain affect each other over time. These results suggest that attending to both child and caregiver factors may be important in maintaining improvements after initiating usual care.

Evaluating a Learning Collaborative to Implement Evidence-Informed Engagement Strategies in Community-Based Services for Young Children.

BackgroundGiven dismal attendance rates in community-based care for children and families, it is critical that evidence-informed attendance engagement strategies be implemented within community service systems. There is growing research on effective methods for training in evidence-based practices (EBPs), and one method that shows promise is the learning collaborative modeled after the Institute for Healthcare Improvement’s Breakthrough Series Collaborative framework.ObjectiveThis study examines implementation outcomes of a learning collaborative based on the Breakthrough Series Collaborative that was conducted to improve attendance engagement in community-based early childhood intervention programs using evidence-informed strategies.MethodsA total of 29 providers from four programs within a large regional hospital participated. Qualitative and quantitative data collected prior, during, and at the completion of the 9-month learning collaborative as part of a process evaluation. Data were analyzed to examine the feasibility, acceptability, adoption and fidelity, and planned sustainability of strategies to facilitate attendance engagement as a result of the learning collaborative.ResultsResults indicate that: (1) using a learning collaborative implementation method with early intervention providers was feasible; (2) the method was acceptable based on perceived improvements in attendance and a significant increase in attitudes towards EBPs; (3) the method supported successful self-reported adoption and fidelity of engagement strategies; and (4) the method facilitated planned sustainability of practice changes.ConclusionsThe learning collaborative can be a useful implementation strategy within early childhood intervention programs to promote the use of EBPs, including enhancing attendance engagement through evidence-informed strategies.

Randomized Trial of the Parent And Caregiver Active Participation Toolkit for Child Mental Health Treatment

The purpose of this pilot study was to examine preliminary feasibility, acceptability, and effectiveness of a toolkit (Parent And Caregiver Active Participation Toolkit) to increase parent participation in community-based child mental health services. Study participants included 29 therapists (93% female; M age = 34.1 years; 38% Latino) and 20 parent/child dyads (children 80% female; M age = 8.6 years; parents 40% Latino) in 6 diverse community mental health clinics. Therapists were randomly assigned to standard care or the toolkit with standard care. Therapist and parent survey data and observational coding of treatment sessions were utilized. Mean comparisons and repeated measures analyses were used to test differences between study conditions over 4 months. Results supported preliminary feasibility and acceptability of the toolkit, with therapists assigned to the toolkit participating in ongoing training, adhering to toolkit use, and perceiving the toolkit as feasible and acceptable within their setting. Results preliminarily demonstrated improvement in therapists’ job attitudes, as well as actual use of parent engagement strategies. Results also preliminarily demonstrated increases in parent participation in child therapy sessions and more regular attendance, as well as some indication of support for perceived treatment effectiveness. Overall, results suggest the feasibility, acceptability, and potential effectiveness of the toolkit to enhance therapist job attitudes; practices that support parent engagement, parent engagement itself, and consumer perspectives on treatment outcomes; and the potential promise of future research in the area of parent participation interventions in child mental health services.

The Parent Participation Engagement Measure (PPEM): Reliability and Validity in Child and Adolescent Community Mental Health Services

Parent participation in community-based child mental health services is an important yet understudied process associated with treatment effectiveness. This paper describes the development and psychometrics of the Parent Participation Engagement Measure in a sample of 1374 parents and 563 youth receiving publicly-funded mental health services. Analyses indicated excellent internal consistency, and model fit indices/factor loadings supported a one-factor model. Convergent and discriminant validity were supported, although some coefficients were modest in magnitude. Psychometric results were consistent for Caucasian versus Hispanic, parent versus youth, and English versus Spanish-language respondents. The clinical and research utility of this measure are discussed.