Oliver J. Lindhiem, Ph.D. - US grants

DESCRIPTION (provided by applicant): The current proposal seeks to improve rates of response to evidence-based psychosocial treatments for childhood disruptive behavior disorders (Oppositional Defiant Disorder and Conduct Disorder) by focusing on the acquisition and utilization of specific skills (parent-management skills and cognitive-behavioral skills) learned during the course of treatment. Aim 1 is to develop measures and a methodology for assessing skill acquisition and skill utilization during the course of treatment, using performance based assessments and ecological assessment (electronic diary) strategies. Aim 2 is to assess determinates, correlates, and sequelae of skill acquisition and utilization. Aim 3 is to develop a pilot protocol for enhancing skill utilization by augmenting existing evidence-based treatments for childhood disruptive behavior disorders through the use of interactive health technologies. The current proposal will also allow the PI to gain additional training in 1) performance based assessment, 2) ecological assessment (electronic diary) approaches, 3) interactive health technologies, and 4) advanced training in treatment outcome research and related statistical analyses. These training goals, together with the specific aims of the research plan, will contribute to the PI's long-term career goal of becoming an independent investigator in applied clinical research and the treatment of children with disruptive behavior disorders in community settings. The research aims of this proposal are consistent with Strategic Objective 3 of the NIMH Strategic Plan, which is to, "develop new and better interventions for mental disorders that incorporate the diverse needs and circumstances of people with mental illness." Specifically, Strategy 3.1 of the NIMH Strategic Plan is to, "further develop innovative interventions and designs for intervention studies." Strategy 3.4 is to, "identify and systematically study elements of personalized mental health care." The current proposal is consistent with both of these strategies. PUBLIC HEALTH RELEVANCE: The findings from the current proposal will 1) provide the field with measures and methods for assessing skill- specific factors of change during the course of evidence-based psychosocial treatments for disruptive behavior disorders, 2) increase our understanding of the link between skill acquisition/utilization and treatment outcome, and 3) promote the routine use of digital technologies to enhance treatment delivery and optimize treatment outcome. It is expected that this project will have an important and lasting impact on the field of child and adolescent treatment research and that the findings will have wide-reaching applications for skills-based treatments for other mental health disorders.

? DESCRIPTION (provided by applicant): Unlike most medical conditions, mental health disorders have no definitive diagnostic or screening tools (e.g., blood tests, x-rays) to verify thir presence or absence. In primary care settings, pediatricians and family medicine doctors often lack confidence in their ability to screen for significant mental health problems such as pediatric bipolar disorder, and refer out for most mental and behavioral health concerns. Unfortunately, many patients either do not follow through on referrals or do not receive appropriate referrals. As a result, both under-referrals and over-referrals are all too common in primary care settings. Over-referrals cause inefficiency while under-referrals result in prolonged patient suffering, burden on family members, and a huge cost to society. The Posterior Probability of Diagnosis (PPOD) Index has recently been proposed as a unique step towards solving these problems. The PPOD Index is a Bayesian method that quantifies the probability that a patient meets or exceeds a diagnostic threshold for a particular disorder. The method has two advantages over traditional screening approaches. First, the PPOD Index is based on a patient's individual pattern of symptoms rather than on traditional symptom counts. Second, the method quantifies the likelihood that a patient meets criteria for a particular diagnosis in probabilistic terms (0-100%). The goal of this SBIR project is to develop and test a Bayesian screening tool using PPOD Index software for tablets. In Phase I, we will focus prototype development and testing on pediatric (ages 5-17) bipolar disorder, a disorder that is particularly likely to be misdiagnosed, resulting in tremendous costs for the person and society. The proposed software system will enhance screening to improve the precision and quality of referrals for pediatric bipolar disorder in primary- care settings. The following three specific aims will be accomplished during Phase I: 1) create a fully functioning working prototype of a Bayesian screening tool for pediatric bipolar disorder using PPOD Index software for tablets to run on a tablet PC, 2) perform usability testing with physicians and families, and 3) assess the product value, innovation, feasibility, acceptability, and quality. The technology will have far- reaching generalizability to a variety of patient populations. We envision a final product (Phase II) that will include modules for other mental health disorders such as ADHD, Autism, and PTSD. By improving the efficiency and screening of mental health problems in primary-care settings, we can significantly improve the mental health outcomes of children and their families, alleviating suffering, burden on families, and cost to society.

? DESCRIPTION (provided by applicant): Although existing treatments benefit many families of children with disruptive behavior problems, a substantial proportion do not respond to treatment. A better understanding of treatment mechanisms will illuminate reasons for nonresponse and point to strategies for improving treatment. To achieve this goal, systematic research on specific treatment targets (not just symptom reduction) is needed. This application focuses on skill acquisition and utilization as specific treatment targets or hypothesized mechanisms of therapeutic action for cognitive behavioral therapy (CBT) for childhood disruptive behavior problems. Specifically, this project consists of a small pilot RCT to examine target engagement and validation (acquisition and utilization of specific CBT skills) of a smartphone based mobile health (mHealth) system called UseIt! (Understanding Skill- use to Enhance the Impact of Treatment). The project will also establish the feasibility of this novel research protocol and refine the smartphone applications (apps) and secure online clinician portal. The parent and child UseIt! apps include both content and features to promote the use of CBT skills in day-to-day life including a library of skills, an interactive trouble-shooting guide, an electronic diary,a secure messaging system, and a skill-use reminder alarm. The project will also establish the feasibility of incorporating recently developed measures of skill acquisition (Skill Acquisition Measure [SAM]) and skill utilization (Skill-use Internet Diary [SID]) into a treatment trial. Childen with significant disruptive behavior problems (ages 8-12) and their parents will be recruited directly from partnering community agencies. Aim 1 of the project is to assess target engagement and validation in the context of a preliminary RCT comparing CBT + UseIt! protocol (N=18) to CBT only (N=18). Aim 2 is to assess the feasibility of a future full-scale effectiveness RCT comparing these treatments, and incorporating measures of skill acquisition and skill utilization into a treatment trial. Aim 3 is to refine the UseIt! apps and clinician portal, and to integrate the technology seamlessly with treatment delivery, based on feedback obtained from clinicians and families. This approach is consistent with treatment development pathways recommended in the R34 mechanism and also responsive to strategies outlined in the NIMH Strategic Plan for improving personalization of treatments by providing customized in vivo skills coaching, and for improving potential dissemination of child psychosocial treatments by making them more efficient, interactive, and engaging. This will provide the preliminary data necessary to prepare for a full-scale effectiveness RCT (R01).

Project Summary/Abstract Effective parenting is a critical component of healthy child development and deficits in parenting skills have been implicated as both pathogenic and maintaining factors for childhood disruptive behavior problems and subsequent behavioral and emotional problems extending into adulthood. Parenting measures are still needed that are brief, low-cost, have strong psychometrics and established norms, are bias free, and are sensitive to change. We have recently developed a set of measures to address these limitations. The Skill Acquisition Measure (SAM), a measure of parenting knowledge and skill acquisition, is a computerized assessment during which respondents answer questions in response to video-clip vignettes of both common and challenging parenting scenarios. The Skill-use Internet Diary (SID), a measure of parenting skill utilization, is an internet- based diary used to document the use of various parenting behaviors in daily life. Both measures focus specifically on the domains of parenting that are known to be associated with childhood disruptive behavior problems. The measures cover content including, age-appropriate expectations, effective communication, planned ignoring, rewards, consequences, time-outs, attending to positive behavior, and praise. This project will allow us to evaluate the psychometric properties of these two measures and establish norms and optimal clinical cut-scores using a using a large, nationally representative sample (N = 1,000). This project will result in psychometric and normative data for a set of promising new parenting measures that will contribute to both developmental research and intervention research. Aim 1 is to examine the reliability and validity of the SAM and SID using data obtained from a nationally representative sample. Aim 2 is to establish norms and optimal clinical cut-off scores for the SAM and SID using data from a nationally representative sample. Aim 3 is to use item response theory (IRT) to establish a brief (10-item) and unbiased version of the SAM (no differential item functioning [DIF] for any of the items) of the SAM that will enhance its utility as a research tool for both longitudinal and early-intervention research. This proposed project is consistent with both the R21 mechanism (development of novel techniques, agents, methodologies, models, or applications that could have a major impact) and NICHD?s mission to ensure, ?that all children have the chance to achieve their full potential for healthy and productive lives.?

Study One, ?Screening Guru? Abstract The adolescent suicide rate has increased by more than 20% in the past decade and is now the second leading cause of death for adolescents. Depression is the single most important contributor to suicidal ideation, attempt, and death by suicide among adolescents aged 12-17.11. Screening for mental health problems in general, and for depression and suicidality in particular, is a national priority. Even when routine screening is implemented, initiation of treatment is low. One critical barrier to starting depression treatment is whether adolescents and their parent(s) perceive a need for mental health treatment. Perceived need for mental health care services is a known predictor of service use, but may be low when depression is not the presenting concern but rather is identified on a routine screening questionnaire. This project seeks to increase the rate of appropriate referrals by primary care providers and treatment initiation among adolescents who screen positive for depression or suicidal ideation by: 1) assessing adolescents? and their parents? barriers to following through with clinician-recommended care prior to the start of treatment; and 2) providing clinicians with decision- support recommendations that are personalized to the adolescent?s clinical presentation, treatment preferences, and barriers. This will be accomplished through three specific aims. Aim 1 is to develop an automated decision-support system (DSS) that will guide primary care providers in making personalized treatment recommendations to adolescents presenting with symptoms of depression and risk for suicide at the time of the office encounter. Aim 2 is to test the effectiveness of the DSS, using a stepped wedge design, at increasing primary care providers? rate of personalized referrals in a pilot trial (N = 120) of adolescents aged 12-17.11 years who screen positive for depression and/or suicidality during a routine primary care visit. Aim 3 is to explore the impact of the DSS on service utilization and symptom reduction. This project is innovative because there currently is no support tool for PCPs assessing depressed adolescents, the tool integrates information about suicidal risk using an adaptive screen, severity of depression, and patient and parent motivation, barriers, and treatment preferences to provide the PCP with a personalized recommendation for the patient. The study has the potential to improve care following depression screening by reducing variability in PCPs? treatment recommendations, and increasing PCPs? awareness of potential barriers to care so as to provide a referral that reflects the patient?s clinical needs and also increases patients? engagement with recommended care.