Sarah McCue Horwitz

Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors

Implementation science is a quickly growing discipline. Lessons learned from business and medical settings are being applied but it is unclear how well they translate to settings with different historical origins and customs (e.g., public mental health, social service, alcohol/drug sectors). The purpose of this paper is to propose a multi-level, four phase model of the implementation process (i.e., Exploration, Adoption/Preparation, Implementation, Sustainment), derived from extant literature, and apply it to public sector services. We highlight features of the model likely to be particularly important in each phase, while considering the outer and inner contexts (i.e., levels) of public sector service systems.

Examining the Proposed Disruptive Mood Dysregulation Disorder Diagnosis in Children in the Longitudinal Assessment of Manic Symptoms Study

OBJECTIVE To examine the proposed disruptive mood dysregulation disorder (DMDD) diagnosis in a child psychiatric outpatient population. Evaluation of DMDD included 4 domains: clinical phenomenology, delimitation from other diagnoses, longitudinal stability, and association with parental psychiatric disorders. METHOD Data were obtained from 706 children aged 6-12 years who participated in the Longitudinal Assessment of Manic Symptoms (LAMS) study (sample was accrued from November 2005 to November 2008). DSM-IV criteria were used, and assessments, which included diagnostic, symptomatic, and functional measures, were performed at intake and at 12 and 24 months of follow-up. For the current post hoc analyses, a retrospective diagnosis of DMDD was constructed using items from the K-SADS-PL-W, a version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children, which resulted in criteria closely matching the proposed DSM-5 criteria for DMDD. RESULTS At intake, 26% of participants met the operational DMDD criteria. DMDD+ vs DMDD- participants had higher rates of oppositional defiant disorder (relative risk [RR] = 3.9, P < .0001) and conduct disorder (RR = 4.5, P < .0001). On multivariate analysis, DMDD+ participants had higher rates of and more severe symptoms of oppositional defiant disorder (rate and symptom severity P values < .0001) and conduct disorder (rate, P < .0001; symptom severity, P = .01), but did not differ in the rates of mood, anxiety, or attention-deficit/hyperactivity disorders or in severity of inattentive, hyperactive, manic, depressive, or anxiety symptoms. Most of the participants with oppositional defiant disorder (58%) or conduct disorder (61%) met DMDD criteria, but those who were DMDD+ vs DMDD- did not differ in diagnostic comorbidity, symptom severity, or functional impairment. Over 2-year follow-up, 40% of the LAMS sample met DMDD criteria at least once, but 52% of these participants met criteria at only 1 assessment. DMDD was not associated with new onset of mood or anxiety disorders or with parental psychiatric history. CONCLUSIONS In this clinical sample, DMDD could not be delimited from oppositional defiant disorder and conduct disorder, had limited diagnostic stability, and was not associated with current, future-onset, or parental history of mood or anxiety disorders. These findings raise concerns about the diagnostic utility of DMDD in clinical populations.

Characteristics of children with elevated symptoms of mania: The Longitudinal Assessment of Manic Symptoms (LAMS) study

OBJECTIVE The aim of the Longitudinal Assessment of Manic Symptoms (LAMS) study is to examine differences in psychiatric symptomatology, diagnoses, demographics, functioning, and psychotropic medication exposure in children with elevated symptoms of mania (ESM) compared to youth without ESM. This article describes the initial demographic information, diagnostic and symptom prevalence, and medication exposure for the LAMS cohort that will be followed longitudinally. METHOD Guardians of consecutively ascertained new outpatients 6 to 12 years of age presenting for treatment at one of 10 university-affiliated mental health centers were asked to complete the Parent General Behavior Inventory-10-Item Mania Scale (PGBI-10M). Patients with scores ≥ 12 on the PGBI-10M (ESM+) and a matched sample of patients who screened negative (ESM-) were invited to participate. Patients were enrolled from December 13, 2005, to December 18, 2008. RESULTS 707 children (621 ESM+, 86 ESM-; mean [SD] age = 9.4 [2.0] years) were evaluated. The ESM+ group, compared to the ESM- group, more frequently met DSM-IV criteria for a mood disorder (P < .001), bipolar spectrum disorders (BPSD; P < .001), and disruptive behavior disorders (P < .01). Furthermore, they showed poorer overall functioning and more severe manic, depressive, attention-deficit/hyperactivity, disruptive behavioral, and anxiety symptoms. Nevertheless, rates of BPSD were relatively low in the ESM+ group (25%), with almost half of these BPSD patients (12.1% of ESM+ patients) meeting DSM-IV criteria for bipolar disorder not otherwise specified. ESM+ children with BPSD had significantly more of the following: current prescriptions for antipsychotics, mood stabilizers, and anticonvulsants (P < .001 for each); psychiatric hospitalizations (P < .001); and biological parents with elevated mood (P = .001 for mothers, P < .013 for fathers). ESM+ children with BPSD were also lower functioning compared to ESM+ children without BPSD. CONCLUSIONS Although ESM+ was associated with higher rates of BPSD than ESM-, 75% of ESM+ children did not meet criteria for BPSD. Results suggest that longitudinal assessment is needed to examine which factors are associated with diagnostic evolution to BPSD in children with elevated symptoms of mania.

Improving the Mental Health of Children in Child Welfare Through the Implementation of Evidence-Based Parenting Interventions

Any comprehensive approach to children’s mental health should consider services systems such as Child Welfare that provide services to children with high rates of emotional and behavioral disorders. This paper will review what is known about efficacious parent-focused interventions that can improve the lives of children in Child Welfare and explore possible reasons why such interventions are rarely used by Child Welfare agencies. Data from a pilot study suggest key features for increasing the implementation of efficacious practices to improve children’s mental health.

Design Elements in Implementation Research: A Structured Review of Child Welfare and Child Mental Health Studies

Implementation science is an emerging field of research with considerable penetration in physical medicine and less in the fields of mental health and social services. There remains a lack of consensus on methodological approaches to the study of implementation processes and tests of implementation strategies. This paper addresses the need for methods development through a structured review that describes design elements in nine studies testing implementation strategies for evidence-based interventions addressing mental health problems of children in child welfare and child mental health settings. Randomized trial designs were dominant with considerable use of mixed method designs in the nine studies published since 2005. The findings are discussed in reference to the limitations of randomized designs in implementation science and the potential for use of alternative designs.

Mental Health Problems in Young Children Investigated by U.S. Child Welfare Agencies

OBJECTIVE To examine the prevalence/predictors of mental health (MH) problems and services use in 12- to 36-month-old children who had been investigated for maltreatment. METHOD Data came from the second National Survey of Child and Adolescent Well-Being (NSCAW II), a longitudinal study of youth ages 0 to 17.5 years referred to U.S. child welfare agencies. These analyses involved 1117 children 12 to 36 months of age. Sociodemographic, social services, developmental and health data were collected on the children and caregivers. Outcomes were scores over the clinical cutoffs on the Brief Infant Toddler Social and Emotional Assessment (BITSEA) Scales for 12- to 18-month-olds and the Child Behavior Checklist (CBCL) for 19- to 36-month-olds. RESULTS In all, 34.6% of 12 to 18 month-olds scored high on the Problem Scale of the BITSEA, and 20.9% on the Competence Scale, whereas 10.0% of 19- to 36-month-olds scored over the CBCL clinical cut-off. Children of black ethnicity were less likely to have elevated scores on the BITSEA Problem Scale, whereas children who lived with a never-married caregiver were five times more likely to have elevated scores. Competence problems were associated with prior child welfare history. Elevated CBCL scores were associated with living with a depressed caregiver. Few children with identified MH problems, 2.2%, received an MH service. When we added parenting skills training that might be related to the treatment of child problems, 19.2% received a service. CONCLUSIONS Identifiable MH problems are common, but few children receive services for those problems. The lack of services received by these young, multi-challenged children is a services systems and social policy failure.

Longitudinal Assessment of Manic Symptoms (LAMS) Study: Background, Design and Initial Screening Results

OBJECTIVE To describe the design of a longitudinal study of youth with elevated symptoms of mania (ESM), as well as the prevalence and correlates of manic symptoms. Bipolar disorder in youth is serious and is surrounded by controversy about its phenomenology, course, and treatment. Yet, there are no longitudinal studies of youth selected only for ESM, the phenomenological hallmark. The studys objective is to document the rate and sociodemographic correlates of ESM in children attending outpatient psychiatric clinics. METHOD Parents of 3,329 children aged 6-12 years visiting 10 outpatient clinics were asked to complete the Parent General Behavior Inventory 10-Item Mania Scale (PGBI-10M). Children with PGBI-10M scores ≥ 12 (ESM positive-screen [ESM+]) and a matched sample of ESM screen-negative (ESM-) children were invited to enroll in the longitudinal study. The sample was accrued from November 14, 2005, to November 28, 2008. RESULTS Most of the children whose parents filled out the PGBI-10M (N = 2,622, 78.8%) participated in the study. Nonparticipants were slightly younger (mean age = 9.1 years [SD = 2.0 years] versus 9.4 years [SD = 2.0 years] for participants; t3327 = 4.42, P < .001). Nearly half of the participants (43%) were ESM+; these were more likely to be Latino (4.2% versus 2.5% for ESM-; χ(2)1 = 5.45, P = .02), younger (mean age = 9.3 years [SD = 2.0 years] versus 9.6 years [SD = 1.9 years] for ESM-; t2620 = 3.8, P < .001), and insured by Medicaid (48.4% versus 35.4% for ESM-; χ(2)1 = 45.00, P < .001). There were no sociodemographic differences between those who did versus did not agree to enroll in the longitudinal portion (yes to enrollment: n = 621, 55.2%; no to enrollment: n = 503, 44.8%). Four items best discriminated ESM+ children from ESM- children. Three of the 4 items were not the most commonly endorsed items, but all were indicative of behavioral extremes. CONCLUSIONS Data suggest that ESM+ is not rare in 6- to 12-year-olds. Children who are ESM+ show behavioral extremes, including rapid mood shifts, compared to ESM- children.

Pediatric bipolar spectrum disorder and ADHD: Comparison and comorbidity in the LAMS clinical sample

Arnold LE, Demeter C, Mount K, Frazier TW, Youngstrom EA, Fristad M, Birmaher B, Findling RL, Horwitz SM, Kowatch R, Axelson DA. Pediatric bipolar spectrum disorder and ADHD: comparison and comorbidity in the LAMS clinical sample. Bipolar Disord 2011: 13: 509–521.

Parent Involvement Is Associated With Early Success in Obesity Treatment

Objective: The study examined the influence of parent involvement and family factors on body mass index (BMI) change in a pediatric obesity treatment program. Methods: A total of 104 children and their caregivers were examined during a 12-week obesity intervention. Participants (mean age = 11.42 years; SD = 2.83) and their caregivers completed measures of family environment and depression prior to enrollment. Children’s BMI and parental involvement were rated weekly during the intervention. Logistic regressions were conducted to examine the role of sociodemographic factors, family characteristics, and parent involvement on weight. Results: Children with the lowest parent involvement were less likely to lose any weight or have clinically significant (≥2 kg) weight loss. Demographics and family factors did not predict BMI change. Parent involvement related to ethnicity, absences and physical activity. Conclusions: Parental involvement may be helpful in identifying who is likely to do well in a weight loss program.

Mental Health Services Use by Children Investigated by Child Welfare Agencies

OBJECTIVE: To examine the rates and predictors of mental health services use for a nationally representative cohort of youths who had been investigated for alleged maltreatment. METHODS: Data came from caregiver and caseworker baseline and 18-month interviews in the second National Survey of Child and Adolescent Well-being. These interviews took place from March 2008 to September 2008 and September 2010 to March 2011. Data on family and child characteristics and service use were gathered and examined by using weighted univariate and multivariate analyses. RESULTS: Children had numerous challenges: 61.8% had a previous report of maltreatment, 46.3% had poor socialization skills, and 23.9% had a mental health problem measured by the Child Behavior Checklist (CBCL). At baseline, 33.3% received some mental health service and this varied by age, with younger children receiving fewer services. This percentage decreased to 30.9% at the 18-month follow-up, although the youngest children had increases in services use. For younger children, race/ethnicity, out-of-home placement, chronic physical health problems, low adaptive behaviors, and CBCL scores in the clinical range were related to use. For children ≥11, out-of-home placement, high CBCL scores, and family risk factors predicted services use at 18 months. CONCLUSIONS: Mental health services utilization increases as young children come into contact with schools and medical providers or have more intensive involvement with child welfare. Minority children receive fewer services adjusting for need. Over the 18-month follow-up, there was a decrease in service use that may be a result of the tremendous financial challenges taking place in the United States.