Predictors and moderators of agreement between clinical and research diagnoses for children and adolescents.

Diagnoses play an important role in treatment planning and monitoring, but extensive research has shown low agreement between clinician-generated diagnoses and those from structured diagnostic interviews. However, most prior studies of agreement have not used research diagnoses based on gold standard methods, and research needs to identify characteristics of diagnostically challenging clients. This study examined agreement between youth diagnoses generated through the research-based LEAD (Longitudinal, Expert, and All Data) Standard to clinician diagnoses

Clinician Training, Then What? Randomized Clinical Trial of Child STEPs Psychotherapy Using Lower-Cost Implementation Supports with versus without Expert Consultation

Objective: Implementation of evidence-based treatments in funded trials is often supported by expert case consultation for clinicians; this may be financially and logistically difficult in clinical practice. Might less costly implementation support produce acceptable treatment fidelity and clinical outcomes? Method: To find out, we trained 42 community clinicians from four community clinics in Modular Approach to Therapy for Children (MATCH), then randomly assigned them to receive multiple lower-cost implementation supports (LC) or expert MATCH consultation plus lower-cost supports (CLC). Clinically referred youths (N = 200; ages 7–15 years, M = 10.73; 53.5% male; 32.5% White, 27.5% Black, 24.0% Latinx, 1.0% Asian, 13.5% multiracial, 1.5% other) were randomly assigned to LC (n = 101) or CLC (n = 99) clinicians, and groups were compared on MATCH adherence and competence, as well as on multiple clinical outcomes using standardized measures (e.g., Child Behavior Checklist, Youth Self-Report) and idiographic problem ratings (Top Problems Assessment). Results: Coding of therapy sessions revealed substantial therapist adherence to MATCH in both conditions, with significantly stronger adherence in CLC; however, LC and CLC did not differ significantly in MATCH competence. Trajectories of change on all outcome measures were steep, positive, and highly similar for LC and CLC youths, with no significant differences; a supplemental analysis of posttreatment outcomes also showed similar LC and CLC posttreatment scores, with most LC–CLC differences nonsignificant. Conclusions: The findings suggest that effective implementation of a complex intervention in clinical practice may be supported by procedures that are less costly and logistically challenging than expert consultation

Evaluating a Modular Approach to Therapy for Children With Anxiety, Depression, Trauma, or Conduct Problems (MATCH) in School-Based Mental Health Care: Study Protocol for a Randomized Controlled Trial

Introduction: Schools have become a primary setting for providing mental health care to youths in the U.S. School-based interventions have proliferated, but their effects on mental health and academic outcomes remain understudied. In this study we will implement and evaluate the effects of a flexible multidiagnostic treatment called Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH) on students' mental health and academic outcomes. Methods and Analysis: This is an assessor-blind randomized controlled effectiveness trial conducted across five school districts. School clinicians are randomized to either MATCH or usual care (UC) treatment conditions. The target sample includes 168 youths (ages 7-14) referred for mental health services and presenting with elevated symptoms of anxiety, depression, trauma, and/or conduct problems. Clinicians randomly assigned to MATCH or UC treat the youths who are assigned to them through normal school referral procedures. The project will evaluate the effectiveness of MATCH compared to UC on youths' mental health and school related outcomes and assess whether changes in school outcomes are mediated by changes in youth mental health. Ethics and Dissemination: This study was approved by the Harvard University Institutional Review Board (IRB14-3365). We plan to publish the findings in peer-reviewed journals and present them at academic conferences. Clinical Trial Registration: ClinicalTrials.gov ID: NCT02877875. Registered on August 24, 2016

What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice

Across 5 decades, hundreds of randomized trials have tested psychological therapies for youth internalizing (anxiety, depression) and externalizing (misconduct, attention deficit and hyperactivity disorder) disorders and problems. Since the last broad-based youth metaanalysis in 1995, the number of trials has almost tripled and data-analytic methods have been refined. We applied these methods to the expanded study pool (447 studies; 30,431 youths), synthesizing 50 years of findings and identifying implications for research and practice. We assessed overall effect size (ES) and moderator effects using multilevel modeling to address ES dependency that is common, but typically not modeled, in meta-analyses. Mean posttreatment ES was 0.46; the probability that a youth in the treatment condition would fare better than a youth in the control condition was 63%. Effects varied according to multiple moderators, including the problem targeted in treatment: Mean ES at posttreatment was strongest for anxiety (0.61), weakest for depression (0.29), and nonsignificant for multiprob lem treatment (0.15). ESs differed across control conditions, with "usual care" emerging as a potent comparison condition, and across informants, highlighting the need to obtain and integrate multiple perspectives on outcome. Effects of therapy type varied by informant; only youth-focused behavioral therapies (including cognitive-behavioral therapy) showed similar and robust effects across youth, parent, and teacher reports. Effects did not differ for Caucasian versus minority samples, but more diverse samples are needed. The findings underscore the benefits of psychological treatments as well as the need for improved therapies and more representative, informative, and rigorous intervention science

Shared Decision-Making in Youth Mental Health Care: Using the Evidence to Plan Treatments Collaboratively

The shared decision-making (SDM) model is one in which providers and consumers of health care come together as collaborators in determining the course of care. The model is especially relevant to youth mental health care, when planning a treatment frequently entails coordinating both youth and parent perspectives, preferences, and goals. The present article first provides the historical context of the SDM model and the rationale for increasing our field's use of SDM when planning psychosocial treatments for youth and families. Having established the potential utility of SDM, the article then discusses how to apply the SDM model to treatment planning for youth psychotherapy, proposing a set of steps consistent with the model and considerations when conducting SDM with youth and families

Ethnicity as a moderator of how parents' attitudes and perceived stigma influence intentions to seek child mental health services

Research has identified several variables that affect utilization of mental health services. However, more could be explored regarding ethnic differences among parents seeking help for their children. In our study, 238 caregivers were recruited from the southern United States to examine ethnic differences in intentions to access child mental health services with the Parental Attitudes Toward Psychological Services Inventory (Turner, 2012) as the primary measure. Group comparisons indicated that African-American parents reported less positive attitudes and more stigma than European-American or Hispanic-American parents. Moderation analyses found (a) attitudes were associated with a higher level of parental help-seeking intention among European Americans, but not among African Americans or Hispanic Americans and (b) stigma was associated with a lower parent-reported likelihood of help-seeking for Hispanic Americans, but not for European Americans or African Americans. Ethnicity deferentially impacts attitudes and stigma associated with seeking mental health services. Public education efforts to increase service use should be tailored toward under-served groups to be more effective

Treatment Engagement in Adolescents: The Associations of Sociodemographic Characteristics, Caregiver Perceived Barriers, and Clinical Impairment

To examine the associations between sociodemographic characteristics, perceived barriers to treatment, clinical impairment, and youth treatment engagement. Participants included 196 families (youth: ages 12 to 18; 64.3% cis-gender female; 23.5% Black, 60.7% White, and 12.2% Mixed/Other race; 41.3% Hispanic or Latinx ethnicity) recruited as part of a comparative effectiveness trial for adolescent anxiety and depression. Self-report measures of sociodemographic characteristics and caregiver perceived barriers were completed at intake. Youth clinical impairment was assessed at baseline via clinical interview. Measures of engagement were collected throughout treatment, including initiation status, session attendance, and termination status. Relationships were examined using analyses of variances and hierarchal linear and logistic modeling. Perceived barriers did not differ by sociodemographic characteristics. Greater perceived stressors and obstacles predicted fewer sessions attended and a lower likelihood of successful termination. Youth of caregivers with an advanced degree and those with caregivers who were employed part time attended more sessions and were more likely to initiate and terminate treatment successfully compared to youth with caregivers of a lower education level or student or unemployed status. At higher levels of youth clinical impairment, greater perceived treatment demands and issues predicted reduced likelihood of treatment initiation. Perceived barriers, sociodemographic characteristics, and clinical impairment were all associated with levels of engagement in the treatment process. Baseline and continued assessment of perceived and experienced barriers to treatment may promote individualized strategies for families identified as at-risk for reduced engagement

Predictors and moderators of agreement between clinical and research diagnoses for children and adolescents.

OBJECTIVE: Diagnoses play an important role in treatment planning and monitoring, but extensive research has shown low agreement between clinician-generated diagnoses and those from structured diagnostic interviews. However, most prior studies of agreement have not used research diagnoses based on gold standard methods, and research needs to identify characteristics of diagnostically challenging clients. This study examined agreement between youth diagnoses generated through the research-based LEAD (Longitudinal, Expert, and All Data) Standard to clinician diagnoses. METHOD: Participants were 391 families seeking outpatient community mental health services for youths ages 6-18 (39.1% female, 88.2% African American). Youths and parents completed research interviews and clinic diagnoses were extracted from clinic records. LEAD diagnoses synthesized results of the Schedule for Affective Disorders and Schizophrenia for School-Age Children- Present and Lifetime (KSADS-PL) and the youth's developmental, family, and psychiatric history. RESULTS: Agreement between the LEAD and chart diagnoses was low, not exceeding “poor” agreement for most diagnostic categories (κ = .10-.46, median = .37). Disagreement was largely driven by missed diagnoses, although clinicians also did assign extra diagnoses for some clients. Fewer diagnostic errors occurred when the youth's clinical picture was more clear (e.g., high or low symptom severity, lower comorbidity), when the youth was older, when the family was higher functioning, and when the parent had more depression. However, youth and family characteristics explained very little of the variability in diagnostic errors. CONCLUSIONS: Results support the need to investigate strategies to improve clinician diagnostic accuracy

Benchmarking Treatment Adherence and Therapist Competence in Individual Cognitive-Behavioral Treatment for Youth Anxiety Disorders

Evidence-based treatments (EBTs) for youth are typically developed and established through studies in research settings designed to ensure treatment integrity, that is, protocol adherence and competence by therapists. An important question for implementation science is how well integrity is maintained when these EBTs are delivered in community settings. The present study investigated whether the integrity achieved by therapists in community settings achieved a benchmark set by therapists in a research setting when they delivered the same EBT-an individual cognitive-behavioral treatment (ICBT) for youth anxiety. Therapists (N = 29; 68.97% White; 13.79% male) provided ICBT to 68 youths (M age = 10.60 years, SD = 2.03; 82.35% White; 52.94% male) diagnosed with a principal anxiety disorder in research or community settings. Training and supervision protocols were the same across settings. Two independent teams of trained coders rated 744 sessions using observational instruments designed to assess ICBT adherence and competence. Both adherence and competence were higher in the research setting. Group differences in competence were consistent across treatment, but differences in adherence were most pronounced when treatment shifted to exposure, widely viewed as the most critical component of ICBT. When using the benchmarks from the research setting, therapists from the community settings fell short for indices of adherence and competence. However, given differences between therapists and clients, as well as the fact that treatment outcomes were similar across settings, our findings raise questions about whether it is appropriate to use treatment integrity benchmarks from research settings for community