Parents,friends, and depression: A multi-country study of adolescents in South Asia

PurposeThis study investigates the association between social support networks, as measured by parental involvement and close friendships, and depression among adolescents in South Asia.MethodsNationally representative samples of adolescents between the ages of 12 and 16 + years (n = 16,592) from the Global School Based Health Surveys from India, Sri Lanka, Pakistan, and Myanmar were analyzed to provide prevalence rates of depression. Additionally, differences in past year depressive symptoms were compared cross-sectionally by social support from parents and friends, separately. This was done by computing prevalence ratios adjusting for potential confounders and demographic factors.ResultsOf all adolescent respondents in the study, 14.5% met the criteria to be screened for depression, while 50% reported having three or more close friends, and 80% reported having very involved parents. Adjusted prevalence ratios indicated that those with close friendships were much less likely to be screened for depressive symptoms compared to their counterparts, as were adolescents with very involved parents. However, low and moderate levels of parent involvement were not found to be significantly associated with adolescents' propensity for being screened for depressive.ConclusionSocial support is a social determinant of adolescent mental health in South Asia that has received little scholarly attention to date. This study highlights the importance of research and interventions involving parents and close friends in building programs for adolescents that target mental health.     

Internalizing symptoms and safe sex intentions among adolescents in mental health treatment: Personal factors as mediators

Little is known about why some adolescents with internalizing symptoms engage in sexual behaviors that increase their risk for HIV. This study tested a mediation model of internalizing symptoms and safe sex intentions among adolescents receiving mental health treatment. Self-efficacy for HIV prevention, HIV knowledge, and worry about HIV were hypothesized to mediate associations between internalizing symptoms and safe sex intentions among sexually active and non-active adolescents receiving mental health treatment (N = 893, M age = 14.9). Significant indirect effects from internalizing symptoms to safe sex intentions varied according to sexual experience: for sexually non-active adolescents, HIV worry and knowledge mediated this link, whereas for sexually active adolescents, HIV self-efficacy was the significant mediator. Increasing both HIV knowledge and self-efficacy for HIV prevention are important targets for HIV prevention with adolescents with internalizing symptoms, and careful attention should be paid towards targeting these interventions to sexually experienced and inexperienced youth.     

Mental health outcomes among child welfare investigated children: In-home versus out-of-home care

BackgroundChild welfare has increasingly focused on alternatives to out-of-home (OOH) placement. In-home services, such as parent training, have increased and more maltreated children remain in-home. Yet, little is known about the effect on mental health of maintaining vulnerable children in-home vs placement in stable OOH care.ObjectiveTo evaluate and compare difference in mental health among children investigated by child welfare and who remained in-home vs. those who were placed in stable OOH care.Design/methodsWe examined a cohort of children (aged 1.5–18 years) from a nationally representative sample of children investigated by child welfare using the National Survey of Child and Adolescent Well-Being II (NSCAW II). We compared changes in mental health functioning over 18 months for children who remained in-home with parent training versus those placed in stable OOH care.ResultsAmong the 749 children in our sample, baseline characteristics of children who remained in-home with parent training and those placed in stable OOH care were similar. Among school-aged children placed in stable OOH care, mental health problems decreased from 26% to 13% (p = .003). This differed significantly from school-aged children who remained in home, for whom mental health problems increased (50% decrease stable OOH care vs. 23% increase in home; p = .007). Among pre-school aged children, mental health problems increased in both settings, particularly stable out-of-home care (p = .008).ConclusionsFor school aged children with a history of maltreatment, mental health outcomes improve following stable OOH placement, yet worsen when remaining in-home with parents. Pediatricians should be watchful for mental health problems among children who remain home after maltreatment and should advocate for high-quality stable OOH care when it is necessary. Child welfare may need to monitor the outcomes of children remaining at home more closely and provide more intensive preventive and treatment services to families.     

Self-report of health problems and health care use among maltreated and comparison adolescents

The study aims were to compare maltreated and comparison adolescents' health problems and to identify how individual, family and home characteristics and maltreatment status affect adolescents' self-report of health status and health care use. The sample was 224 maltreated adolescents (mean age = 18.3 years) and 128 comparison adolescents (mean age = 18.15 years). Comparison adolescents reported more cold and pain symptoms during the previous 30 days but no differences in other physical health problems, self-assessment of their physical and mental health or health care use compared to maltreated adolescents. Girls were more likely to have had a dental checkup, to have seen a psychological counselor, and to self-identify their physical health as poor compared to boys. Older adolescents were less likely to have had a medical checkup or seen a psychological counselor than younger adolescents. A history of maltreatment was not related to health or health care disparities for adolescents growing up in the same low-income environment as adolescents without a maltreatment report. The environmental context and geographical location in which these adolescents grew up may be the primary driver in their health behaviors and health problems and not the experience of maltreatment.     

Mental health services for children and caregivers remaining at home after suspected maltreatment

ObjectiveBehavioral problems are common among children remaining at home after suspected maltreatment, but the effectiveness of current mental health services to improve these behavioral problems is unknown. The objective was to determine whether receipt of child and caregiver mental health services was associated with improvements in behavioral problems in maltreated children remaining at home.MethodsWe retrospectively analyzed Second National Survey of Child and Adolescent Well-being data. We included 1117 children ages 2–17 remaining at home after a maltreatment investigation, excluding children with missing outcome, covariate, or survey weight data. We compared mean Child Behavioral Checklist (CBCL) change scores from baseline to 18 months between children who did and did not receive mental health services, before and after adjusting for child, caregiver, and child welfare agency factors using survey-weighted linear regression.ResultsNearly one-quarter (22.6%) of children and 16.0% of caregivers received mental health services. Children receiving services had worse unadjusted baseline and 18-month CBCL scores than children not receiving services (all P < 0.001). Adjusted CBCL change scores revealed behavioral worsening among children receiving services but improvement among children not receiving services (all P < 0.001). However, children had improved behavior, regardless of their own service receipt, if their caregivers received services and reported an absence of depression at 18 months.ConclusionsChildren receiving mental health services had worse behavioral changes than children not receiving services. Caregiver receipt of services was associated with improved child behavior, suggesting that a family-centered approach may be most influential in improving behavioral outcomes among this population.     

‘Reach Out,Rise Up’: The efficacy of text messaging in an intervention package for anxiety and depression severity in young people

BackgroundDepression and anxiety are among the most commonly experienced mental health issues faced by young people in Aotearoa, New Zealand. Considerable barriers exist that prevent young people from engaging with face-to-face mental health services. Young people's preference for technology-based counselling mediums such as text messaging opens up new pathways for intervention.ObjectiveA pilot text message-based intervention package was trialled for use by young people to evaluate the potential efficacy of the text package as an intervention for depression and anxiety symptoms.MethodThe text package was piloted using a 10-week longitudinal cohort pilot with 21 young participants (12–24 years) who demonstrated mild to moderate anxiety and/or depression symptoms.ResultsParticipants' post-package scores were significantly lower than their pre-package scores for both anxiety (Z = − 2.83, p = .005, r = − 0.65) and depression (Z = − 2.49, p = .013, r = −.056). ‘Feeling encouraged and supported’ increased as a result of receiving support from a trained supporter (Z = − 2.06, p = .039, r = − 0.45), but not from friends/family (Z = − 1.72, p = .130, r = − 0.37). Anxiety and depression scores did not change as a result of support from either trained supporters or friends/family.ConclusionsFindings support the potential efficacy of the text package, justify wider trials of the text package, and support the use of text message-based interventions as potentially effective therapies for young people.     

Factors associated with treatment attrition for Medicaid-enrolled youth with serious emotional disturbances

Premature discontinuation from treatment is a significant problem that undermines the delivery of effective mental health services and increases the risk for relapse and poor outcomes. However, factors associated with treatment attrition in children and adolescents are not well understood. This retrospective longitudinal cohort study examines factors associated with attrition for Medicaid-enrolled youth, aged 5 to 17 with “new episodes” of ICD-9-CM diagnosed serious emotional disturbance (N = 43,122). Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Multilevel modeling was used to assess the association between individual and contextual-level variables and attrition. Of the 43,122 youth in the study sample, 4056 (9.4%) discontinued treatment. The odds of treatment attrition were significantly higher for youth who were male (OR = 1.16, p < 0.001), black compared to white (OR = 1.19, p < 0.001), had a co-occurring substance abuse disorder (OR = 1.35, p = 0.01), and lived in a county with a larger percentage of minorities (OR = 1.02, p = 0.01). In contrast, youth diagnosed with bipolar and depressive disorders compared to ADHD (OR = 0.78, p < 0.001 and OR = 0.87, p = 0.01, respectively), with comorbid psychiatric (OR = 0.74, p < 0.001) and medical disorders (OR = 0.82, p < 0.001), and a prior history of two or more psychotropic medications compared to no medications (OR = 0.76, p < 0.001) had lower odds of attrition. Residence in a county with a larger number of pediatricians and psychologists also reduced the odds of attrition (OR = 0.97, p = 0.05 and OR = 0.99, p = 0.03 respectively). Overall, this study suggests that a combination of individual factors, demographic and clinical, and contextual factors impact attrition in children's mental health outpatient treatment.     

Assessment of the complex effects of trauma across child serving settings: Measurement properties of the CANS-Trauma Comprehensive

This study examined the measurement properties of the Child and Adolescent Needs and Strengths-Trauma Comprehensive Version (CANS-Trauma). This comprehensive, trauma-focused, and strengths-based assessment strategy is designed to assess the complex needs of traumatized children and adolescents across child-serving settings and support the treatment/service delivery process. The current study assessed 257 children and adolescents from three mental health agencies across the country that were partners in the National Child Traumatic Stress Network (NCTSN). Internal consistency and inter-rater reliability, convergent and discriminant validity, and scale properties of the CANS-Trauma were examined. Overall, measurement properties of the CANS-Trauma showed promising results. Internal consistency varied from marginally acceptable to excellent across most domain scores (α = 0.62–0.90); the traumatic stress symptoms domain demonstrated very good internal consistency (α = 0.82). Inter-rater reliability for the CANS-Trauma was good overall, while the traumatic stress symptoms domain had marginally acceptable reliability. There was evidence for convergent validity with more limited evidence for discriminant validity, based on the association between domains on the CANS-Trauma and subscales of the Trauma Symptom Checklist for Children-Alternate (TSCC-A) and the Child Behavioral Checklist for Children (CBCL). Rasch modeling analyses indicated that the CANS-Trauma had good scale properties overall, including item fit within each of the domains. These preliminary results also suggested that the various mental health and trauma symptom domains on the CANS-Trauma were more sensitive to populations with significant trauma symptoms and mental health difficulties compared to populations with lower to moderate difficulties in these areas. Implications of these findings are discussed in terms of the utility of a comprehensive, trauma-informed assessment strategy in practice settings.     

The implementation of SPARX-R computerized mental health program in alternative education: Exploring the factors contributing to engagement and dropout

BackgroundComputerized cognitive behavioral therapy (cCBT) has been shown to improve mental health and wellbeing in youth, however, high drop out and low engagement rates are reported in many studies. This study examined the factors that contribute to engagement and dropout with SPARX-R, cCBT program for preventing depression and improving wellbeing with a group of vulnerable 15–20 year olds attending alternative education (AE).MethodsStudents who took part in a randomized controlled trial (RCT) of SPARX-R completed a post-intervention implementation questionnaire (n = 28) and provided verbal or written feedback (n = 12) on their experience of the program. Furthermore, process evaluation questionnaires completed after each level of SPARX-R examined the views of participating students, including those who dropped out of the study. Staff views were also explored through a post-intervention questionnaire and interviews.ResultsThe majority of the students considered SPARX-R easy to use and agreed that the program made sense to them. However, less than half of the participants reported that they liked the look of the program or considered it fun, and only a third reported that they would recommend SPARX-R to a friend. Those categorized as being at risk for depression, as assessed on the Short Moods and Feelings Questionnaire, rated the program higher in terms of its relevance and usefulness in comparison to those with no symptoms or clinical symptoms of depression. Technical issues, lengthiness and the lack of positive focus were the main reasons reported for negative reactions and disengagement with SPARX-R. Staff expressed a need for increased flexibility in delivery and complementing computerized programs with face-to-face activities to improve student engagement.ConclusionsComputerized delivery can offer multiple benefits to mental health promotion and prevention in educational settings. Further research is needed to examine how such programs can be incorporated into existing approaches and made more positive and adaptable to support universal delivery for more vulnerable young people.     

Heterogeneity among adolescent mothers and home visiting program outcomes

Despite the challenges of early parenting, many adolescents navigate motherhood successfully, underscoring an overlooked heterogeneity among adolescent mothers. The present study used Latent Class Analysis (LCA) to identify subgroups of adolescent mothers (n = 704) enrolled in a randomized controlled trial (RCT) evaluation of a home visiting program for young parents. The model incorporated demographic and background characteristics, as well as indicators of psychological vulnerability. Analyses revealed four distinct subgroups: (a) non-Hispanic high vulnerability (n = 209, 30%); (b) Hispanic high vulnerability (n = 98, 14%); (c) non-Hispanic moderate vulnerability (n = 241, 34%); and (d) Hispanic moderate vulnerability (n = 156, 22%). Mothers in the two high vulnerability subgroups exhibited the poorest personal and parenting functioning outcomes measured approximately two years postpartum, particularly in terms of child maltreatment (non-Hispanic high vulnerability) and depressive symptoms (Hispanic high vulnerability). Analyses revealed positive effects of the home visiting program within specific latent classes on such outcomes as healthy baby at birth, high school or GED attainment, and repeat birth.     

Development of an innovative process evaluation approach for the Families Improving Together (FIT) for weight loss trial in African American adolescents

This study demonstrates how a multi-theoretical, multilevel process evaluation was used to assess implementation of the Families Improving Together (FIT) for weight loss intervention. FIT is a randomized controlled trial evaluating a culturally tailored, motivational plus family-based program on weight loss in African American adolescents and their parents. Social Cognitive, Self Determination, Family Systems theories and cultural tailoring principles guided the conceptualization of essential elements across individual/family, facilitator, and group levels. Data collection included an observational rating tool, attendance records, and a validated psychosocial measure.ResultsAttendance records (0 = absent, 1 = present, criteria = ≥70%) indicated that 71.5% of families attended each session. The survey (1 = false, 6 = true, criteria = ≥4.5) indicated that participants perceived a positive group climate (M = 5.16, SD = 0.69). A trained evaluator reported that facilitator dose delivered (0 = no, 1 = yes, criteria = ≥75%) was high (99.6%), and fidelity (1 = none to 4 = all, criteria = ≥3) was adequate at facilitator (M = 3.63, SD = 0.41) and group levels (M = 3.35, SD = 0.49). Five cultural topics were raised by participants related to eating (n = 3) and physical activity (n = 2) behaviors and were integrated as part of the final curriculum.DiscussionResults identify areas for program improvement related to delivery of multi-theoretical and cultural tailoring elements. Findings may inform future strategies for implementing effective weight loss programs for ethnic minority families.     

Cost effectiveness of a school readiness intervention for foster children

ObjectiveMany young children in foster care suffer from emotional and behavior problems due to neglect and abuse. These problems can lead to difficulties in school, and functioning in school is linked to long-term health and development. Early intervention to reduce emotional and behavioral issues can help children successfully transition to school, which can improve long-term outcomes. However, communities need information on relative costs and benefits associated with programs to make informed choices. The objective of this study was to assess cost effectiveness, over 12 months, of the Kids in Transition to School (KITS) intervention compared to usual services available to children in a foster care control group (FCC).MethodRandomized controlled trial of 192 children in foster care entering kindergarten who were randomized to KITS (n = 102) or FCC (n = 90). KITS includes school readiness groups and parent training over 4 months. Main outcomes were days free from internalizing symptoms (IFD), days free from externalizing behavior (EFD), intervention costs, public agency costs, and incremental cost effectiveness.ResultsKITS significantly increased IFD and EFD compared to FCC. Average total cost of the intervention was $932 per family. The intervention did not significantly impact usual services. Average incremental cost effectiveness was $64 per IFD and $63 per EFD.ConclusionsThe cost of KITS is comparable to, or less than, similar programs, and the intervention is likely to provide significant emotional and behavioral benefit and improvement in school readiness for young children in foster care.     

Intersection of homelessness and mental health: A mixed methods study of young adults who accessed psychiatric emergency services

Young adults who experience homelessness have high rates of mental disorders, yet low rates of outpatient mental health service use. This mixed methods study examined the intersection of homelessness and mental health in a sample of 54 young adults (ages 18–25) who were hospitalized on a short-term, inpatient psychiatric unit. Nearly half (n = 26) reported being homeless in the prior year and more than a quarter were homeless at the time of admission (n = 15). Qualitative analyses identified key factors that contributed to both mental health problems and homelessness including disrupted support networks, fragile family relationships, foster care involvement, substance use and traumatic events. Homelessness was both a facilitator and a barrier to successfully accessing mental health services to manage mental health symptoms. Findings highlight the interconnection of homelessness and mental health and their common relationship with additional underlying risk factors. Providers across service settings need to recognize the overlap of client populations and provide integrated, trauma informed care to address housing instability, mental health, and substance use together.     

Using a community-based participatory research approach to evaluate resident predictors of involuntary exit from permanent supportive housing

ObjectiveThe aim of this study was to determine an association between resident characteristics at time of entry to permanent supportive housing and exit status.MethodsA community-based participatory research (CBPR) approach was the guiding framework for the design, implementation and evaluation of this project. This retrospective observational study used an administrative data source from a local permanent supportive housing provider to compare resident characteristics among those who left housing voluntarily or involuntarily.ResultsThe population based sample (n = 407) was comprised of 51% males and 47% African-Americans with a mean age of 40 years (SD = 11.8). Involuntary exits (IEs) occurred in 40% of the sample (n = 166). IE was less likely with receipt of mainstream benefits, compared to employment income (O.R. = .546, p = .032). IE was more likely for residents self-identifying as African-American (O.R. = 1.56, p = .037) and when children resided in the household (O.R. = 2.03, p = .013).ConclusionsDespite limitations of community-derived data, findings suggest that supportive housing providers consider income source and family status when designing interventions to decrease IEs. A CBPR approach is a promising framework to guide evaluation efforts for supportive housing programs.     

Societal factors impacting child welfare: Re-validating the Perceptions of Child Welfare Scale

ObjectiveThis research examines the psychometric properties of the Perceptions of Child Welfare Scale (PCWS) by seeking to understand the differences between workers' perceptions of how society views them based upon job title by revalidating the PCWS with a sample of administrators and clinicians.MethodsConfirmatory factor analysis was utilized to analyze data on 165 administrators and 153 clinical child welfare workers.ResultsThe final model consisted of three latent variables with ten indicators related to stigma, value, and respect ([X²] = 167.6, [p] = 0.00; [RMSEA] = 0.07; 90% [CI]: 0.06–0.09; [CFI] = 0.95; [TLI] = 0.95).DiscussionThe factors found in the previous study were confirmed using an entirely different sample of child welfare workers. The factors value, stigma, and respect were confirmed across the sample based upon whether the workers were administrators or clinicians. This provides reassurance that measuring how workers perceive they are viewed by those outside the child welfare system does not vary based upon job title.     

An intensive mental health home visiting model for two at-risk early childhood populations

This study examined proximal outcomes of a mental health home visiting model for two populations at risk for child maltreatment: families with young children referred by child protective services (CPS) and at-risk pregnant women (Prenatal) referred by community agencies. Family- and caregiver-level outcomes were measured using the Family Assessment Form (FAF). Families (n = 215) showed significant improvement in all eight family functioning factors over the course of their participation in mental health home visiting services. Initially, CPS-referred families (n = 84) scored higher on the FAF measure of Interactions between Caregivers, indicating greater conflict between caregivers in the family. Prenatal referred families (n = 131) were at greater risk initially on Housing. Prenatal-referred families demonstrated greater risk reduction on measures of Supports to Caregivers, Developmental Stimulation, Caregiver Personal Characteristics and Housing. In addition, all families demonstrated significant improvements in functioning on 11 of 12 items comprising the Caregiver Personal Characteristics factor. Overall, CPS-referred families scored at higher risk on items reflecting externalizing problems, while Prenatal-referred families showed greater improvement on items reflecting internalizing problems. This model was successful in reducing risk factors and promoting protective factors for CPS-referred and Prenatal at-risk families. Implications and future directions are discussed.     

Differences between risk factors for truancy and delinquency in Dutch adolescents

The present study examined differences in risk factors for truancy and delinquency. Research questions were: (1) Which risk factors are significantly different between truants and delinquents? (2) Which risk factors make the strongest distinction between truancy and delinquency? Participants were Dutch adolescents (N = 365) who received a penal sanction in the Netherlands. 83% (n = 304) of them had violated the penal law, and 17% (n = 62) received the penalty for truancy. Differences in risk factors for truancy and delinquency were found for age and parental punishment. Binary logistic regression showed that only parental punishment retained its predictive effects when controlling for other differences. Truants experienced more parental punishment than delinquent adolescents. The present study shows that addressing dysfunctional home circumstances could be more important for truants, indicating that existing interventions do not differentiate enough between truants and delinquents.     

A comparison of outcomes for children and youth in foster and residential group care across agencies

Working collaboratively with two state associations and their member (nonprofit) agencies providing out-of-home care to children and youth, University researchers conducted a multi-site project to examine whether there were any differences in individual child-level outcomes between children placed in residential group care and those placed in foster. The study employed a quasi-experimental repeated measures design, with data collected at a minimum of two intervals (at intake and 3-month follow-up) and at subsequent intervals of 6 and 12 months for children remaining in care. Samples for analyses were drawn from 1082 youth in either residential group care (n = 903) or foster care (n = 179), in one of 37 agency sites across two southeastern states, who participated in a broader evaluation project. The average ages of participating youth in residential and foster care were 13.97 (SD = 2.43) and 13.65 (SD = 2.73), respectively. Based on his or her score on the Children's Global Assessment Scale (CGAS) at intake, each participant was also assigned to the low functioning group (n = 526; 53.1%), the borderline group (n = 232; 23.4%), or the high functioning group (n = 232; 23.4%). Analyses confirmed that youth in foster care tended to have higher levels of general functioning at baseline than did youth placed in group care. However, the degree to which youth progressed in care on measures of general functioning and mental and behavioral health problems did not differ based on placement setting; youth in residential group care settings progressed at the same rate as youth in community-based settings, regardless of their level of functioning at intake. The only exception to this pattern was in regard to anxiety; there was an observable, but non-significant trend of youth in foster care reporting decreases in anxiety levels, while those in group care reported increased anxiety.     

A randomized controlled trial of the effectiveness of the youth crime prevention program ‘New Perspectives’ (NP): Post-treatment changes and moderator effects

ObjectivesNew Perspectives (NP) aims to prevent that youth at onset of a criminal career will develop a more persistent criminal behavior pattern. The study aim was to examine whether NP was effective relative to care as usual in preventing and reducing (persistent) delinquency. Moreover, we examined improvements in secondary outcomes (e.g., peer and parent relationships and cognitive distortions) and other outcomes (e.g., substance use and self-esteem).MethodsAt-risk youth (N = 101) aged 12 to 19 years were randomly assigned to the intervention group (NP, n = 47) or control group (‘care as usual’, n = 54). The effects of the NP intensive phase (3 months after program start) and aftercare phase (6 months after program start) were analyzed.ResultsNP and care as usual did not differ on any of the outcome measures at both post-test occasions. The effects of NP were the same for boys and girls, different age groups, and ethnic groups.ConclusionsThe overall null-effects are discussed, including implications for further research, policy, and practice.