John Weisz - US grants

To understand mental health problems of childhood, and corresponding clinical referral patterns, may require knowledge of the impact of culture. Culturally mediated values, and concomitant child-rearing practices, may influence the kinds of behavior problems children show. Cultural values may also influence adult attitudes toward child problems, with certain types of problems regarded as more serious and more in need of professional intervention in some cultures than in others. Adult attitudes are particularly important because it is adults (usually parents, teachers, or clinicians)--not children themselves--who make child referral decisions. The proposed research is designed to explore cultural differences in both prevalence patterns and adult attitudes. Some 118 clinically significant problem behaviors will be studied in all, but the pricipal focus will be on problems falling within two empirically-derived, broad-band child syndromes: Internalizing (e.g., worrying, somaticizing) and Externalizing (e.g., aggression, disobedience). The research will compare two cultures that appear to differ markedly in their orientation toward Internalizing and Externalizing child behavior. In contrast to U.S. culture, the heavily Buddhist, highly pacific culture of Thailand appears to condone and perhaps encourage diverse Internalizing behaviors, but actively discourage diverse Externalizing behaviors in children, especially boys. In the proposed research, Thai and U.S. patterns are to be compared in two ways. The Prevalence Study will address the question of whether child problems (Internalizing, Externalizing, and other) differ in prevalence across the two cultures and as a function of age and gender. Parents and teachers of Thai boys and girls aged 6-7, 8-9, and 10-11, will rate the children, using the Child Behavior Checklist; these ratings will be compared to parent and teacher ratings for U.S. children of the same gender and age. The Adult Attitudes Study will explore adult attitudes toward Internalizing and Externalizing behavior patterns as a function of culture and child gender. In Thailand and the U.S., parents, teachers, and clinical psychologists who work with children will rate the seriousness (e.g., likelihood of spontaneous improvement, need for treatment) of Internalizing and Externalizing problem patterns as presented in vignettes describing either boys or girls of their culture.

Most of the existing research on child and adolescent mental health care and its effects is derived from controlled experiments involving conditions quite unlike those in most clinics. To complement that experimental data base, the proposed research will focus on outpatient treatment of children and adolescents (here referred to as children) in community clinics. Children aged 8-15 (initial N=545) will be assessed at clinic intake using established measures of adjustment, diagnosis, and parent-child communication. The measures will be repeated at 6 months, l year, and 2 years after intake, for (ad-children who continue for a full course of treatment, (b) those who start treatment but drop out prematurely, and (c) those who drop out immediately after intake. The longitudinal data thus generated will be used to test predictions associated with a multi-factor model of child treatment outcome. This model is applied to the individualized, family-oriented, outpatient treatment provided in five participating nonprofit child mental health clinics in a representative target zone of Los Angeles County. In the model, child outcomes are hypothesized to differ as a function of gender (with greater treatment benefits for girls than boys), ethnicity (with Latino children benefiting more than others), parent-child communication style (with treatment effects influenced favorably by positive styles and adversely by negative styles), and parent pathology (with treatment mitigating the impact of parent pathology on child outcome). Specific aims of the study are (a) to identify groups that are being well-served by current outpatient treatment and other groups for whom services may need to be modified or improved, and (b) to generate suggestions for enhancing the effects of community-clinic-based outpatient treatment. A broad, long-term objective is to complement our field's large base of controlled, experimental evidence with information on outpatient child treatment in practicing community clinics.

This is a request for an ADAMHA Research Scientist Award. The overall objective of the research program is to strengthen the base of knowledge about mental health services for children and adolescents (herein referred to collectively as "children"). Research bearing on child services is often bifurcated into two insular streams: (a) Controlled, experimental research of modest ecological validity, and (b) Ecologically valid research of more modest experimental rigor. The research program described here is an attempt to bridge the gap, maximizing information by drawing from the strengths of both experimental and clinic-based research. The program is designed to generate a body of knowledge addressing the following questions: (l) What kinds of child problems and referral processes lead children into mental health services? (2) What factors are associated with children's persistence in, and attrition from, mental health care? (3) What are the effects of child mental health interventions? The program also explores whether answers to these questions differ as a function of child ethnicity and (where relevant) national culture. The questions are addressed through an array of methods: (a) A multi-site, longitudinal study of clinic-based child mental health care; (b) focused comparisons of mental health care data on Caucasian, Latino, and African- American youngsters; (c) complementary comparisons of data from Thailand and the U.S.; (d) multiple applications of a recently developed statistical procedure to referral problem data; and (e) multiple applications of meta-analysis to data on treatment attrition and treatment outcome. An overarching aim is to promote a conceptual synthesis, an integrated picture of how children gain access to mental health care, why they persist or drop out, and what impact services have on their functioning and adaptation. A longer-term goal is to find ways of improving children's access to mental health care, their persistence in it once they have access, and the benefits of the interventions they receive.

DESCRIPTION (Adapted from applicant's abstract): Structured, manualized treatments have been developed for numerous mental health problems and disorders among children and adolescents, and a number of these have shown strong beneficial effects in clinical trials. Such findings have led to proposals that the empirically supported treatments be used to improve outcomes of conventional clinic treatment, which some research suggests may not be very effective. But can these lab-tested treatments actually work in service-oriented clinics with referred youth? Available evidence cannot tell us, because the therapists, conditions, and clientele in the laboratory efficacy tests tend to differ so markedly from those of clinical practice. To assess the clinical potential of efficacy-tested treatments, we need effectiveness research that tests these treatments in the crucible of clinical practice. To help begin this process, the proposed research focuses on a specific treatment program for a specific cluster of disorders: Kendall's (1994) cognitive-behavioral "Coping Cat" program for child and adolescent anxiety disorders. The program has shown unusually positive effects across a series of clinical trials in the U.S. and Australia, but it has never been tested in real-world clinical conditions. The proposed study will test the effectiveness of the treatment with clinic-referred youth, treated in community clinics, with the treatment carried out by clinic staff therapists. Some 128 youth, aged 9-14, referred for anxiety and diagnosed with anxiety disorders, will be randomly assigned to receive either the usual treatment in the clinic, or the Kendall program, carried out by clinic staff who have been trained to proficiency. Therapists for the two treatment conditions will also be chosen randomly, from a pool of volunteers. Outcome assessment at immediate post-treatment, 1-year, and 2-year follow-ups, will test effects across four domains of the Hoagwood, Jensen, Petti, and Burns (1996) services outcome model: (1) symptoms and diagnosis, (2) functioning, (3) consumer perspectives, and (4) systems (i.e., degree to which treatment reduces further service use).

DESCRIPTION: (adapted from Investigator's abstract) Depressive disorders are among the most common mental health concerns for adolescents and are associated with serious and enduring functional impairments. Although mounting evidence indicates that prevention of depressive disorders is possible, research-supported programs are not widely available to at risk youth. A primary barrier to program dissemination has been the need for a level of leader training and supervision that cannot be sustained outside the context of a research program. The goal of this collaborative study between UCLA and the United Behavioral Health managed care company is to develop and test a robust youth depression prevention program intended for use in real-world settings. The video-guided Primary and Secondary Control Enhancement Training (PASCET) Preventive Intervention is a cognitive-behavioral group intervention designed for reliable implementation with minimal group leader training. This proposal is a response to PA-99-1 34: Exploratory/Development Grants for MH Intervention Research. The project consists of two phases designed to set the stage for a subsequent large-scale effectiveness trial. Program development work in Phase 1 will include video production and use of focus groups to improve the clarity and appeal of the intervention. Feedback from youth aged 10-14 will be used to create a final version of the video, leader's manual and participant workbook. Assessment of the intervention effect in Phase 2 will include pilot testing procedures for training group leaders and assessment of leader adherence to protocol. Participants will be 160 children of depressed parents, aged 10-14, selected due to their elevated biological, psychological, and social risk for depression. In keeping with the goal of real-world sustainability, group leaders will be clinicians on the UBH provider panel, not members of the research team. Pilot implementation of the intervention will include estimation of intervention effect size to determine the sample size required for a full test of the program and preliminary identification of potential intervention mediators and moderators.

DESCRIPTION (provided by applicant): Youth depression is a serious, impairing condition. Its prevalence increases sharply following puberty, highlighting the public health significance of treatment in early adolescence. Our long-term goal is to develop and refine treatment for youth depression that is effective and deployable in a variety of youth settings. Here we focus on the setting in which evidence suggests most youth mental health care occurs: the school. Efforts to disseminate empirically supported cognitive behavioral therapies (CBTs) to schools have not been very successful to date, perhaps for at least 2 reasons: (a) the design of most CBT programs may have limited user appeal, and (b) CBT programs have not been shown to outperform current school-based interventions, so there is not a compelling logical case for change. In this application, we address both potential problems. To address the user appeal issue, we have drawn from the literature on robust design to restructure our own CBT program--Primary and Secondary Control Enhancement Training (PASCET) as a video-guided treatment. To address the case for change issue, we propose a trial of our video-guided treatment with a commonly used school-based treatment approach as the comparison condition. In the trial, 6th and 7th graders who meet diagnostic criteria for depressive disorders will be randomly assigned to the two conditions, matched for group format and treatment dose, and all treatment will take place in middle schools. Depression and other outcomes will be assessed at post-treatment and a 1-year follow-up.