Faculty Bibliography

This review examines empirically based studies of school-based mental health interventions. The review identified 64 out of more than 2,000 articles published between 1990 and 2006 that met methodologically rigorous criteria for inclusion. Of these 64 articles, only 24 examined both mental health and educational outcomes. The majority of school-based mental health intervention studies failed to include even rudimentary measures of school-related outcomes. Analysis of the 24 studies yielded several key findings; The types of mental health outcomes most frequently assessed included self-, peer-, teacher-, or parent-reported measures of social competence, aggression, or problem behaviors. Academic scores and school attendance were the types of educational outcomes most frequently assessed. The majority of interventions focused on elementary students, had a preventive focus, and targeted prosocial, aggressive, and antisocial behaviors. Only 15 of the 24 studies demonstrated a positive impact on both educational and mental health outcomes, 11 of which included intensive interventions targeting both parents and teachers. The studies that had an impact only on mental health outcomes tended to be less intensive with more limited family involvement. This review discusses the implications of these findings for schoolbased mental health services and identifies directions for future research.

BACKGROUND: While studies have increasingly investigated deficits in reaction time (RT) and RT variability in children with attention deficit/hyperactivity disorder (ADHD), few studies have examined the effects of stimulant medication on these important neuropsychological outcome measures. METHODS: 316 children who participated in the Multimodal Treatment Study of Children with ADHD (MTA) completed the Conners' Continuous Performance Test (CPT) at the 24-month assessment point. Outcome measures included standard CPT outcomes (e.g., errors of commission, mean hit reaction time (RT)) and RT indicators derived from an Ex-Gaussian distributional model (i.e., mu, sigma, and tau). RESULTS: Analyses revealed significant effects of medication across all neuropsychological outcome measures. Results on the Ex-Gaussian outcome measures revealed that stimulant medication slows RT and reduces RT variability. CONCLUSIONS: This demonstrates the importance of including analytic strategies that can accurately model the actual distributional pattern, including the positive skew. Further, the results of the study relate to several theoretical models of ADHD

Implementation of evidence-based assessment and intervention approaches for youth with behavioral and/or emotional problems is rising to recognition worldwide. Feasibility research is critical to examine what characteristics of systems allow for success or barriers to the implementation of evidence-based practices into real-world settings, especially when working cross-culturally. This paper briefly reviews the experience of 4 international sites to understand how the overall structure and specific site variables directed the implementation of the World Health Organization and the World Psychiatry Association project. Discussion includes a thematic summary of the successes and challenges experienced by the sites, and future directions of feasibility studies.

OBJECTIVE: The present study examined implementation issues in adopting cognitive-behavioral therapies in routine clinical settings in four countries reflecting diverse cultures, languages, settings, and traditions. METHOD: A Director's Systems Survey was administered prior to program implementation and one year later. Therapist ratings on attitudes about evidence-based practices and satisfaction were also gathered. RESULTS: All sites reported successful adoption of the program, although significant variations existed in fiscal support, family involvement, prior experience with cognitive-behavioral therapies, and plans for sustainability. Therapists' ratings indicated overall satisfaction with the implementation of the project. Findings from the Director's Systems Survey pointed to five factors facilitating implementation: 1) early adoption and guidance by innovative leaders (i.e., the Directors); 2) attention to the "fit" between the intervention model and local practices; 3) attention to front-end implementation processes (e.g., cultural adaptation, translation, training, fiscal issues); 4) attention to back-end processes early in the project (e.g., sustainability); and 5) establishing strong relationships with multiple stakeholders within the program setting. CONCLUSIONS: The implementation issues here mirror those identified in other studies of evidence-based practices uptake. Some of the obstacles to implementation of evidence-based practices may be generic, whereas issues such as the impact of political/economic instability, availability of translated materials, constitute unique stressors that differentially affect implementation efforts within specific countries.

BACKGROUND/OBJECTIVE: The use of antipsychotics in children and adolescents in the Texas Medicaid program has increased with the introduction of newer atypical antipsychotics. The purpose of this study was to examine physician specialty associated with antipsychotic prescribing from 1996 to 2001. METHODS: All antipsychotic prescription claims records for children and adolescents younger than the age of 20 years from 1996 to 2001 were extracted from the Texas Medicaid Drug Vendor prescription database. Physician specialty associated with youths receiving all, atypical, and conventional antipsychotic prescriptions was examined for time trends. Physician specialty categories included psychiatry, primary care, neurology, other, and unspecified. RESULTS: Psychiatrists accounted for more than 80% of youths receiving antipsychotic prescriptions from 1996 to 2001. The proportion of youths receiving antipsychotic prescriptions from primary care physicians remained fairly steady over the course of time (1996: 19%; 2001: 16%). The number of youths prescribed conventional antipsychotics decreased in all specialty groups, whereas the number prescribed atypical antipsychotic prescriptions increased dramatically. CONCLUSIONS: Although the majority of children and adolescents in the Texas Medicaid program were prescribed antipsychotics by psychiatrists and child and adolescent psychiatrists, youths may often receive treatment within the primary care setting. Future research is necessary to evaluate patient outcomes associated with antipsychotic treatment across different treatment settings.

A systematic review was undertaken of scientifically rigorous studies of family-based services in children's health and mental health. From a pool of over 4000 articles since 1980 in health and mental health that examined either specific family-based interventions for families of children or the processes of involvement, 41 studies were identified that met the methodological criteria for inclusion. These 41 studies encompassed 3 distinct categories: families as recipients of interventions (e.g., family education, support, engagement, empowerment); (b) families as co-therapists; and (c) studies of the processes of involvement (e.g., therapeutic alliance, engagement, empowerment, expectancies, and choice). Too few experimental studies exist to conclude decisively that family-based services improve youth clinical outcomes. However, those studies that have been rigorously examined demonstrate unequivocal improvements in other types of outcomes, such as retention in services, knowledge about mental health issues, self-efficacy, and improved family interactions - all outcomes that are essential ingredients of quality care. Four implications are drawn from this review. (1) Effective family education and support interventions from studies of adults with mental illnesses and from studies of families of high-risk infants exist and can be imported into the field of children's mental health. (2) The range of outcomes that are typically assessed in clinical treatment studies is too narrow to afford an adequate view of the impact of family-based interventions. A broader view of outcomes is needed. (3) The absence of a robust literature on process variables other than therapeutic alliance limits conclusions about how and why interventions are effective. Attention to the processes by which families become involved in services will require a more robust and nuanced range of studies that attend simultaneously to processes of change and to outcome improvement. (4) Linkage of effective family-based interventions to delivery of evidence-based services is likely to amplify the impact of those services and improve outcomes for youth and families.

OBJECTIVE: To estimate prevalence rates of antipsychotic use in children and adolescents from 1996 to 2001 in three state Medicaid programs (midwestern [MM], southern [SM], and western [WM]) and one private managed care organization (MCO). METHOD: Prescription claims were used to evaluate antipsychotic prevalence, defined as the number of children and adolescents up to the age of 19 years with at least one prescription claim for an antipsychotic per 1,000 enrolled youths. RESULTS: From 1996 to 2001, the prevalence of total antipsychotic use increased in each program (MM: 4.7 to 14.3 per 1,000; SM: 6.3 to 15.5; WM: 4.5 to 6.9; and MCO: 1.5 to 3.4). Typical antipsychotic use decreased (MM: 3.7 to 2.0 per 1,000; SM: 4.6 to 1.5; WM: 4.4 to 1.3; and MCO: 1.2 to 0.9), while atypical antipsychotic use dramatically increased (MM: 1.4 to 13.1 per 1,000; SM: 2.5 to 14.9; WM: 0.3 to 6.2; and MCO: 0.4 to 2.7). CONCLUSIONS: The increased prevalence of antipsychotic use in children and adolescents from 1996 to 2001 was attributed to increased use of atypical antipsychotics. Given the limited data with atypical antipsychotics in youths, this emphasizes the need for additional studies of these agents and other treatment modalities in this population.