Nathan L. Hollinsaid Awards & Honors

List of academic honors/awards and research grants (11-15-2020)

Transgender-specific Adolescent Mental Health Provider Availability Is Lower in States with More Restrictive Policies

Objective: Transgender adolescents experience adversity accessing mental healthcare, which is exacerbated by transgender-specific mental health provider shortages in the United States. Factors associated with variability in transgender-specific mental health provider availability across states—especially at the macro-social level—have yet to be identified, hindering efforts to address these shortages. To remedy this gap, we queried whether transgender-specific adolescent mental health provider availability varied by states’ transgender-specific policy climate. Method: We quantified states’ policy climate by factor-analyzing tallies of the presence/absence of 33 transgender-specific state laws/policies in six domains: parental/relationship recognition, nondiscrimination, education, healthcare, criminal justice, and identity documentation. We then tested whether states’ transgender-specific policy climate was associated with rates of transgender-specific adolescent mental health providers—identified via Psychology Today—per transgender adolescent in all 50 states and the District of Columbia. Results: Transgender-specific adolescent mental health provider availability was substantially lower in states with more restrictive laws/policies for transgender people (rate ratio=0.65, 95% CI [0.52, 0.81], p=0.00017), controlling for state-level conservatism, religiosity, and urbanicity. States’ transgender-specific policy climate was unrelated to rates of adolescent Attention-Deficit/Hyperactivity Disorder-specialty providers, Oppositional Defiant Disorder-specialty providers, and youth mental health provider shortages broadly, providing evidence for result specificity. Conclusions: Transgender adolescents appear to have access to considerably fewer transgender-specific mental health providers in states with more restrictive laws/policies for transgender people, which may compound their already high mental health burden in these contexts. Intervention and policy efforts are needed to address these shortages, particularly in states with increasingly prohibitive laws/policies targeting transgender adolescents

Future Directions in Mental Health Treatment with Stigmatized Youth

Stigma refers to societally-deemed inferiority associated with a circumstance, behavior, status, or identity. It manifests internally, interpersonally, and structurally. Decades of research indicate that all forms of stigma are associated with heightened risk for mental health problems (e.g., depression, PTSD, suicidality) in stigmatized youth (i.e., children, adolescents, and young adults with one or more stigmatized identities, such as youth of Color, transgender youth). Notably, studies find that stigmatized youth living in places with high structural stigma – defined as laws/policies and norms/attitudes that hurt stigmatized people – have a harder time accessing mental health treatment and are less able to benefit from it. In order to reduce youth mental health inequities, it is imperative for our field to better understand, and ultimately address, stigma at each of these levels. To facilitate this endeavor, we briefly review research on stigma and youth mental health treatment, with an emphasis on structural stigma, and present three future directions for research in this area: (1) directly addressing stigma in treatment, (2) training therapists in culturally responsive care, and (3) structural interventions. We conclude with recommendations for best practices in broader mental health treatment research

Transgender-specific Adolescent Mental Health Provider Availability Is Substantially Lower in States with More Restrictive Policies

Objective: Transgender adolescents experience adversity accessing mental healthcare, which is exacerbated by transgender-specific mental health provider shortages in the United States. Factors associated with variability in transgender-specific mental health provider availability across states—especially at the macro-social level—have yet to be identified, hindering efforts to address these shortages. To remedy this gap, we queried whether transgender-specific adolescent mental health provider availability varied by states’ transgender-specific policy climate. Method: We quantified states’ policy climate by factor-analyzing tallies of the presence/absence of 33 transgender-specific state laws/policies in six domains: parental/relationship recognition, nondiscrimination, education, healthcare, criminal justice, and identity documentation. We then tested whether states’ transgender-specific policy climate was associated with rates of transgender-specific adolescent mental health providers—identified via Psychology Today—per transgender adolescent in all 50 states and the District of Columbia. Results: Transgender-specific adolescent mental health provider availability was substantially lower in states with more restrictive laws/policies for transgender people (rate ratio=0.65, 95% CI [0.52, 0.81], p=0.00017), controlling for state-level conservatism, religiosity, and urbanicity. States’ transgender-specific policy climate was unrelated to rates of adolescent Attention-Deficit/Hyperactivity Disorder-specialty providers, Oppositional Defiant Disorder-specialty providers, and youth mental health provider shortages broadly, providing evidence for result specificity. Conclusions: Transgender adolescents appear to have access to considerably fewer transgender-specific mental health providers in states with more restrictive laws/policies for transgender people, which may compound their already high mental health burden in these contexts. Intervention and policy efforts are needed to address these shortages, particularly in states with increasingly prohibitive laws/policies targeting transgender adolescents

An Intersectional Examination of Identity-Based Disparities in the Mental Health Symptomatology of Clinically Referred Youth

Gender minority youth (“GMY”; i.e., children and adolescents whose gender identity or expression differs from societal expectations for their birth-assigned sex) report elevated rates of anxiety (Reisner et al., 2015), depression (Roberts et al., 2013), self-harm (Veale et al., 2017), suicidality (Toomey et al., 2018), and other mental health disorders (Becerra-Culqui et al., 2018). Stigma-related stressors, including disproportionate exposure to violence (e.g., physical/sexual assault; Johns et al., 2019), interpersonal victimization (e.g., bullying; Day et al., 2018), discrimination (Kosciw et al., 2018), and trauma (e.g., child abuse; Roberts et al., 2012), contribute to GMY’s psychological distress (Hatzenbuehler & Pachankis, 2016). However, these studies largely focus on internalizing difficulties in older GMY (i.e., adolescents/emerging adults) and, as a result, have not fully elucidated the range of mental health concerns, including externalizing behaviors, of younger (i.e., school-age) GMY. Similarly, little is known about mental health disparities facing gender minority youth of Color (GMYoC), particularly during childhood and early adolescence. Gender minority people of Color experience multiple forms of stigmatization (e.g., transprejudice, racism) related to their intersecting identities (Garofalo et al., 2006), which, in late adolescence and emerging adulthood, are associated with greater risk for mental and physical health problems, including anxiety, depression, PTSD, suicidal ideation, substance abuse, and HIV (Garofalo et al., 2006; Wilson et al., 2015; Swann et al., 2019). GMYoC may be particularly vulnerable to mental health difficulties, as they encounter disparate rates of victimization (e.g., school-bullying, verbal/physical harassment) compared to their White classmates (Hatchel & Marx, 2018). Though recent studies have examined the mental health of GMY (e.g., Becerra-Culqui et al., 2018), none has explored variations in symptomatology across race/ethnicity. To address this gap in the literature, the present study assessed group differences in the mental health of clinically referred school-age youth. First, we compared symptomatology between cisgender youth and GMY. Consistent with the extant literature, we expected to find greater internalizing problems for GMY. We anticipated higher externalizing behaviors as well, as they often precede or occur concomitantly with internalizing difficulties in children (Maughan, Collishaw, & Stringaris, 2013). Next, we examined potential mental health disparities across (non-Latinx) White GMY and GMYoC. Given the frequency with which GMYoC are victimized in school-based settings (Hatchel & Marx, 2018), we predicted that they too would have more internalizing and externalizing difficulties relative to White GMY. Participants were pooled across three randomized controlled trials (RCTs) of MATCH (the Modular Approach to Therapy for Children) in community outpatient clinics (Weisz et al., 2019; Chorpita et al., 2013; Weisz et al., 2018). The sample included N = 817 youth (age range: 7-15; M = 10.6, SD = 1.6) diverse with respect to birth-assigned sex (43.6% girls, 56.4% boys) and race/ethnicity (53.5% White, 12.6% Black, 11.0% Latinx, 1.7% Asian, 19.1% multiracial, 2.1% “other”). Pretreatment youth- and caregiver-reported mental health symptomatology was assessed via broad- (i.e., internalizing, externalizing) and narrow-band (i.e., DSM-oriented) scales of the Youth Self-Report (YSR) and Child Behavior Checklist (CBCL). As the RCTs did not collect gender identity data, gender minority status was identified from YSR Item 110 (“I wish I were of the opposite sex”), the utility of which is well supported across studies (e.g., van der Miesen et al., 2018). To begin, gender identity-based differences in symptomatology were examined between n = 755 cisgender youth and n = 62 GMY; subsamples did not differ in age, t(815) = 1.2, p = .23, or race/ethnicity, χ2(5, N = 817) = 9.3, p = .1. Subsequently, the GMY subsample was divided into groups of n = 24 (non-Latinx) White GMY and n = 38 GMYoC in order to explore mental health disparities across race/ethnicity. As in previous studies and national surveys of sexual and gender minority populations, Latinx youth were included in the GMYoC subsample (James & Salcedo, 2017; Toomey et al., 2017). To account for uneven subsample sizes and unequal variance (Delacre, Lakens, & Leys, 2017), Welch’s t-tests were employed, when indicated, to examine potential heterogeneity in symptomatology between cisgender youth and GMY on the YSR and CBCL. No significant group differences emerged in caregiver-reported problems across CBCL broad- and narrow-band scales. However, on the YSR, GMY endorsed more internalizing (M = 63.7, SD = 8.0) and externalizing (M = 57.1, SD = 10.6) difficulties relative to their cisgender peers (M = 54.2, SD = 11.6; M = 51.1, SD = 11.1), t(83.6) = 8.6, p < .001 and t(72.4) = 4.3, p < .001, respectively. These findings were ubiquitous across all YSR DSM-oriented scales (affective, anxiety, somatic, ADHD, and conduct problems, ps < .01), excluding oppositionality. Welch’s t-tests were also utilized to explore racial/ethnic variation in mental health symptomatology within the GMY subsample. On the CBCL, White GMY had marginally higher internalizing problems (M = 65.9, SD = 7.9) compared to GMYoC (M = 60.8, SD = 10.9), t(58.7) = 2.1, p = .04. Specifically, these youth had greater caregiver-reported DSM-oriented anxiety problems, t(45.7) = 2.2, p = .03. No other significant differences were found between White GMY and GMYoC on either the CBCL or YSR. In partial support of our first hypothesis, relative to cisgender youth, GMY had higher self-reported internalizing (i.e., affective, anxiety, somatic problems) and externalizing symptoms (i.e., ADHD, conduct problems). Interestingly, these findings were not reflected by their caregivers. Given that GMY often conceal their identities to avoid familial rejection (Aparicio-García et al., 2019), they may also withhold related mental health concerns. No support was found for our second hypothesis, as GMYoC were no more likely to report mental health problems than their White counterparts. Though multiply marginalized, GMYoC often draw on their intersectional identities as sources of resiliency (Singh, 2013), potentially moderating the compounding effects of stigmatization on well-being by embracing one identity in order to accept and empower of the other (i.e., positive intersectionality; Ghabrial et al., 2017). Because the sample was limited to clinically referred youth, study findings may not generalize to GMY without access to or not in need of mental health treatment. Moreover, some GMY may be underrepresented, as YSR Item 110 provides an exclusively binary measure of gender and does not explicitly ask about gender identity (Olson-Kennedy et al., 2016). Nonetheless, by elucidating the mental health concerns unique to GMY, the present study highlights the importance of developing interventions targeted to this at-risk population. Existing evidence-based practices might be adapted to address the specific stigma-related stressors encountered by GMY and to facilitate the protective role of resiliency for GMYoC

Effectiveness & Acceptability of ESTs in GM Youth Across 4 RCTs

We examined the effectiveness of empirically-supported mental health treatments for gender minority youths (who endorsed a wish to be the opposite sex) and cisgender youths. Gender minority youths reported more severe problems before treatment, demonstrated slower improvement in caregiver-reported behavior problems, and endorsed lower treatment satisfaction. Findings support the potential need for provider-focused trainings relevant to gender minority youths

Hypervigilance: An Understudied Mediator of the Longitudinal Relationship Between Stigma and Internalizing Psychopathology Among Sexual Minority Young Adults

Hypervigilance is often theoretically invoked as a psychological mechanism linking stigma to internalizing psychopathology among sexual minorities. Empirically, however, hypervigilance is rarely explicitly assessed, but is instead commonly conflated with putatively related constructs, including sexual orientation-related rejection sensitivity and rumination, hindering conceptual and mechanistic understandings of this process. We therefore embedded a hypervigilance measure within a longitudinal, population-based study of 811 Swedish sexual minority young adults (ages 17–34). Hypervigilance—but neither sexual orientation-related rejection sensitivity nor rumination, with which it was only weakly correlated (rs=0.23–0.24)— uniquely mediated prospective associations between perceived discrimination and internalizing symptoms two years later, explaining up to 40% of these effects. Sexual orientation-related rejection sensitivity and rumination prospectively predicted hypervigilance on these paths. Findings suggest that hypervigilance represents a distinct construct and transdiagnostic mechanism through which stigma-related experiences and processes undermine sexual minority mental health. We discuss implications for enhancing psychological interventions for sexual minorities by addressing hypervigilance

Are Psychotherapies Less Effective for Black Youth in Communities with Higher Levels of Anti-Black Racism?

The study examined whether anti-Black cultural racism moderates the efficacy of youth psychotherapy interventions

Are Psychotherapies Less Effective for Black Youth in Communities with Higher Levels of Anti-Black Racism?

Objective: We examined whether anti-Black cultural racism moderates the efficacy of psychotherapy interventions among youth. Method: We analyzed a subset of studies from a previous meta-analysis of five decades of youth psychotherapy randomized controlled trials. Studies were published in English between 1963 and 2017 and identified through a systematic search. The 194 studies (N=14,081; ages 2-19) across 34 states comprised 2,678 effect sizes (ESs) measuring mental health problems (e.g., depression) targeted by interventions. Anti-Black cultural racism was operationalized using a composite index of 31 items measuring explicit racial attitudes (obtained from publicly available sources; e.g., General Social Survey), aggregated to the state level and linked to the meta-analytic database. Analyses were conducted with samples of majority (i.e., ≥50%) Black (n=36 studies) and majority-White (n=158 studies) youth. Results: Two-level random effects meta-regression analyses indicated that higher anti-Black cultural racism was associated with lower ESs for studies with majority-Black youth (β=-0.20, CI: -0.35, -0.04, p=0.02) but was unrelated to ESs for studies with majority-White youth (β=0.0004, CI: -0.03, 0.03, p=0.98), controlling for relevant area-level covariates. In studies with majority-Black youth, mean ESs were significantly lower in states with the highest anti-Black cultural racism (>1 SD above the mean; g=0.19) compared to states with the lowest racism (<1 SD below the mean; g=0.60). Conclusions: Psychotherapy randomized controlled trials with samples comprised of majority-Black youth were significantly less effective in states with higher (vs. lower) levels of anti-Black cultural racism, suggesting that anti-Black cultural racism may be one contextual moderator of treatment effect heterogeneity

Principle-Guided Psychotherapy for Children and Adolescents (FIRST): Study Protocol for a Randomized Controlled Effectiveness Trial in Outpatient Clinics

Background:Hundreds of youth psychotherapy randomized trials have generated scores of helpful empirically supported treatments (ESTs). However, the standardized structure of many ESTs and their focus on a single disorder or homogeneous cluster of problems may not be ideal for clinically referred youths who have comorbidity and whose treatment needs may shift from week to week. This concern has prompted development of flexible transdiagnostic, modular youth psychotherapies. One of these, designed for efficient training and implementation, is FIRST—a transdiagnostic intervention built on five empirically supported principles of change (i.e., feeling calm, increasing motivation, repairing thoughts, solving problems, and trying the opposite) and targeting common internalizing and externalizing youth mental health disorders and problems. FIRST has shown promise in improving youth mental health in three open trials. Now, in a more rigorous test, we seek to (1) conduct a randomized controlled trial comparing FIRST to usual care in real-world clinical practice settings; (2) examine a promising candidate mediator of change—regulation of negative emotions; and (3) explore variables that may influence clinicians’ treatment implementation.Methods:This is an assessor-naïve randomized controlled effectiveness trial in youth outpatient community clinics in New England and Texas. Using double randomization, clinic-employed clinicians and treatment-referred youths (7–15 years old) are independently randomly allocated (1:1) to FIRST or usual care. We aim to recruit 212 youth participants, all referred through normal community pathways, with elevated symptoms of anxiety, depression, conduct problems, or post-traumatic stress. This study will test the effectiveness of FIRST compared to usual care on mental health outcomes, examine whether those outcomes are mediated by regulation of negative emotions, and explore clinician factors that may be associated with FIRST implementation and outcomes. Session recordings are coded to assess treatment fidelity.Discussion: This study will evaluate the effectiveness of FIRST in youth community mental health settings, relative to the care usually provided in those settings. If FIRST is found to be effective, it could offer an efficient and practical method to increase use of empirically supported treatment principles in real-world practice contexts.Trial registration:NIH Clinical Trials Registry, NCT04725721. Registered 27 January 2021, https://clinicaltrials.gov/ct2/show/study/NCT0472572