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ABSTRACT IntroductionThis study aimed to assess the prevalence of risk behaviors and the impact of electronic risk behavior screening with personalized feedback among adolescents seeking care in the emergency department (ED). MethodsRandomized control trial of tablet-based screening and feedback among adolescents presenting to the ED. Intervention youth received screening with individualized feedback. Control youth completed risk behavior screening only. All participants received 3-month online follow up surveys re-assessing health behaviors. Results296 subjects were enrolled and randomized. Approximately half were female (52.4%) and half white (54.4%) with a mean age of 15.4 years. The response rate at 3-month follow-up was 70.6%.  The most frequently reported risk behaviors were those negatively impacting long-term health: sleeping less than 8 hours per night (142/296=48%), drinking more than 2 sugary drinks per day (99/296=33.4%) and getting less than 3 days of physical activity per week (96/296=32.4%). The prevalence of high-risk behaviors with more immediate health consequences were depression (92/296 =31.1%); high alcohol (47/296=15.9%) or marijuana use (55/296=18.6%); texting when driving (41/296=13.8%) and inconsistent birth control or condom use (42/296=14.2%). There was no significant difference between groups in risk behavior changes from baseline to 3 months. ConclusionsWhile risk behavior prevalence was high in this population, electronic personalized feedback alone was insufficient to induce change in behaviors. More research is warranted to understand the best strategies for reducing risk among youth presenting to the ED.

Background: There is limited long-term data on the course of school-related problems and academic needs for youth with persistent post-concussive symptoms (PPCS). Methods: This was a randomized trial comparing collaborative care to usual care for 200 youth 11-18 years of age with PPCS. In this report, the main outcomes were academic functioning, GPA, school absences, date of return to school, and school days missed. Results: Youth were mean age of 14.7 (SD = 1.7), 62.0% female. New or worsening academic problems occurred in half of participants in both groups at 12 months after injury. Students were most concerned about grades and falling behind. There were no significant differences by study group on school problems or GPA, but number of days missed was lower in the collaborative care group compared at 3 months (12.5 [SD = 14.5] vs 16.1 days [20.4] adjusted relative risk [aRR] 0.67 [95% CI: 0.61, 0.74; p < 0.001]), 6 months (14.5 [22.1] vs 19.3 [26.6] aRR 0.77 [95% CI: 0.71, 0.84; p < 0.001]), and 12 months (16.9 [25.4] vs 19.6 [27.7], aRR 0.68 [95% CI: 0.62, 0.74; p < 0.001]). Conclusions: Youth with PPCS are at high risk of school problems in the year after injury.

Frequent formative assessment of students' functioning, or progress monitoring, is a critical component of multi-tiered systems of support as data inform data-driven decisions about response to treatment. Progress monitoring tools for students' academic and behavioral functioning are readily available and widely researched; however, despite the documented prevalence of depressive disorders among youth and that schools have been put forth as an ideal location for the delivery of mental health services, there are currently no progress monitoring tools to examine students' response to interventions that target depression. To address this gap, this study sought to develop a progress monitoring assessment of students' depressive symptoms using an empirically informed model for creating "Brief Behavior Rating Scales" (BBRS). Using this model, a four-item BBRS of depressive symptoms (BBRS-D) was created from the item pools of the "Beck Depression Inventory for Youth" (BDI-Y) and "Children's Depression Inventory" (CDI) administered during a treatment study of depression in female youth; the resulting short scale corresponds well to the full-length assessments (i.e., r = 0.65 and r = 0.59); however, the BBRS-D possessed lower than adequate internal consistency (alpha = 0.50) and test-retest reliability (r = 0.56). Limitations and future directions are discussed.

Background: Electronic health screening tools for primary care present an opportunity to go beyond data collection to provide education and feedback to adolescents in order to motivate behavior change. However, there is limited research to guide feedback message development.Objective: The aim of this study was to explore youth perceptions of and preferences for receiving personalized feedback for multiple health risk behaviors and reinforcement for health promoting behaviors from an electronic health screening tool for primary care settings, using qualitative methodology.Methods: In total, 31 adolescents aged 13-18 years completed the screening tool, received the electronic feedback, and subsequently participated in individual, semistructured, qualitative interviews lasting approximately 60 min. Participants were queried about their overall impressions of the tool, perceptions regarding various types of feedback messages, and additional features that would help motivate health behavior change. Using thematic analysis, interview transcripts were coded to identify common themes expressed across participants.Results: Overall, the tool was well-received by participants who perceived it as a way to enhance—but not replace—their interactions with providers. They appreciated receiving nonjudgmental feedback from the tool and responded positively to information regarding the consequences of behaviors, comparisons with peer norms and health guidelines, tips for behavior change, and reinforcement of healthy choices. A small but noteworthy minority of participants dismissed the peer norms as not real or relevant and national guidelines as not valid or reasonable. When prompted for possible adaptations to the tool, adolescents expressed interest in receiving follow-up information, setting health-related goals, tracking their behaviors over time, and communicating with providers electronically between appointments.Conclusions: Adolescents in this qualitative study desired feedback that validates their healthy behavior choices and supports them as independent decision makers by neutrally presenting health information, facilitating goal setting, and offering ongoing technological supports.

Despite the recognition that behavioral and medical health conditions are frequently intertwined, the existing health care system divides management for these issues into separate settings. This separation results in increased barriers to receipt of care and contributes to problems of underdetection, inappropriate diagnosis, and lack of treatment engagement. Adolescents and young adults with mental health conditions have some of the lowest rates of treatment for their conditions of all age groups. Integration of behavioral health into primary care settings has the potential to address these barriers and improve outcomes for adolescents and young adults. In this paper, we review the current research literature for behavioral health integration in the adolescent and young adult population and make recommendations for needed research to move the field forward.

BackgroundHealth risk behaviors are the most common sources of morbidity among adolescents. Adolescent health guidelines (Guidelines for Preventive Services by the AMA and Bright Futures by the Maternal Child Health Bureau) recommend screening and counseling, but the implementation is inconsistent. ObjectiveThis study aims to test the efficacy of electronic risk behavior screening with integrated patient-facing feedback on the delivery of adolescent-reported clinician counseling and risk behaviors over time. MethodsThis was a randomized controlled trial comparing an electronic tool to usual care in five pediatric clinics in the Pacific Northwest. A total of 300 participants aged 13-18 years who attended a well-care visit between September 30, 2016, and January 12, 2018, were included. Adolescents were randomized after consent by employing a 1:1 balanced age, sex, and clinic stratified schema with 150 adolescents in the intervention group and 150 in the control group. Intervention adolescents received electronic screening with integrated feedback, and the clinicians received a summary report of the results. Control adolescents received usual care. Outcomes, assessed via online survey methods, included adolescent-reported receipt of counseling during the visit (measured a day after the visit) and health risk behavior change (measured at 3 and 6 months after the visit). ResultsOf the original 300 participants, 94% (n=282), 94.3% (n=283), and 94.6% (n=284) completed follow-up surveys at 1 day, 3 months, and 6 months, respectively, with similar levels of attrition across study arms. The mean risk behavior score at baseline was 2.86 (SD 2.33) for intervention adolescents and 3.10 (SD 2.52) for control adolescents (score potential range 0-21). After adjusting for age, gender, and random effect of the clinic, intervention adolescents were 36% more likely to report having received counseling for endorsed risk behaviors than control adolescents (adjusted rate ratio 1.36, 95% CI 1.04 to 1.78) 1 day after the well-care visit. Both the intervention and control groups reported decreased risk behaviors at the 3- and 6-month follow-up assessments, with no significant group differences in risk behavior scores at either time point (3-month group difference: β=−.15, 95% CI −0.57 to −0.01, P=.05; 6-month group difference: β=−.12, 95% CI −0.29 to 0.52, P=.57). ConclusionsAlthough electronic health screening with integrated feedback improves the delivery of counseling by clinicians, the impact on risk behaviors is modest and, in this study, not significantly different from usual care. More research is needed to identify effective strategies to reduce risk in the context of well-care. Trial RegistrationClinicalTrials.gov NCT02882919; https://clinicaltrials.gov/ct2/show/NCT02882919

In an effort to better understand possible pathways that lead to a relatively high incidence of depressive symptoms among Mexican American youth, an interpersonal stress model of depression was tested using a community sample of 674 Mexican American mothers and their 5th grade children. Structural equation analyses revealed that maternal depression was positively related to mothers' interpersonal stress in their relationships. Additionally, maternal poor parenting quality was associated with three child outcomes: lower social competence, higher interpersonal stress, and higher depressive symptoms. Child difficulties with peers, however, were not related to child depression. Overall, evidence suggests that familial factors, rather than peer factors, were related to child depression for these study participants.

This study tests the predictive associations between externalizing behaviors and internalizing symptoms and examines the mediating roles of social competence, parent-child conflicts, and academic achievement. Using youth-, parent-, and teacher-reported longitudinal data on a sample of 523 boys and 460 girls from late childhood to early adolescence, we found evidence for pathways between externalizing behaviors and internalizing symptoms in both directions. Parent-child conflict, but not social competence and academic achievement, was found to be a significant mediator such that externalizing behaviors predicted parent-child conflicts, which in turn, predicted internalizing symptoms. Internalizing symptoms showed more continuity during early adolescence for girls than boys. For boys, academic achievement was unexpectedly, positively predictive of internalizing symptoms. The results highlight the importance of facilitating positive parental and caregiver involvement during adolescence in alleviating the risk of co-occurring psychopathology.

Youth with elevated conduct disorder (CD) symptoms who also have callous-unemotional (CU) traits exhibit more antisocial behavior than youth without CU traits. However, evidence regarding whether CU traits increase risk of substance use over and above CD symptoms, and whether these associations differ for boys and girls, is scarce. Using the Developmental Pathways Project sample of 521 middle school students, we examined whether adolescent- and parent-reported CU traits measured in 6th grade prospectively predicted the onset and recurrence of substance use and use-related impairment by 9th grade. We also examined the degree to which CU traits uniquely predicted substance use and impairment over and above CD symptoms, as well as whether gender moderated these associations. Results indicated that adolescent-reported CU traits increased the likelihood of substance use and impairment onset and recurrence by 9th grade. Analyses revealed that CD symptoms accounted for prospective associations between adolescent-reported CU and substance use, but gender moderated these associations. Boys with elevated CU traits and CD symptoms were not more likely to report alcohol use onset or recurrence, but they were at highest risk of recurrent marijuana use, use of both alcohol and marijuana, and use-related impairment by 9th grade. Girls with low CU traits and high CD symptoms were most likely to report onset and recurrent use of alcohol, as well as recurrent marijuana use, use of both substances and impairment. Study findings highlight the importance of accounting for CD symptoms and gender when examining links between CU traits and substance use in early adolescence.

Purpose: To evaluate the association between history of childhood sexual abuse (CSA) and having transactional sex among adolescents who have been in foster care. Methods: We used an existing dataset of youth transitioning out of foster care. Independent CSA variables included self report of history of sexual molestation and rape when participants were, on average, 17 years of age. Our outcome variables were self-report of having transactional sex ever and in the past year, when participants were an average age of 19 years. Separate multiple logistic regression analyses were conducted to assess the associations between CSA variables and transactional sex variables. Initial analyses were performed on both genders; exploratory analyses were then performed evaluating each gender separately. Total N = 732; 574 were included in the main analyses. Results: History of sexual molestation was significantly associated with increased odds of having transactional sex, both ever and in the past year (OR [95% CI]: 3.21 [1.26-8.18] and 4.07 [1.33, 12.52], respectively). History of rape was also significantly associated with increased odds of having had transactional sex ever and in the past year (ORs [95% CI]: 3.62 [1.38-9.52] and 3.78 [1.19, 12.01], respectively). Odds ratios in female-only analyses remained significant and were larger in magnitude compared with the main, non-stratified analyses; odds ratios in male-only analyses were non-significant and smaller in magnitude when compared with the main analyses. Conclusions: Both CSA variables were associated with increased likelihood of transactional sex. This association appears to vary by gender. Our results suggest that policymakers for youth in foster care should consider the unique needs of young women with histories of CSA when developing programs to support healthy relationships. Health care providers should also consider adapting screening and counseling practices to reflect the increased risk of transactional sex for female youth in foster care with a history of CSA. (Contains 2 tables.)

In this study we examined cognitive features that have been posited to contribute to depressive vulnerability in adolescents. Using a longitudinal sample of 331 young adolescents followed from 6th to 7th grade, cross-lagged structural equation analyses were conducted. Controlling for baseline levels of depressive, conduct, and anxiety symptoms, low self-worth was associated with a vulnerability to both depressive symptoms and conduct problems, whereas rejection sensitivity was uniquely predictive of increases in anxiety. In support of cognitive "scar" models, baseline depressive and conduct problems were both predictive of a more negative attributional style. Depressive symptoms also predicted more rejection sensitivity, whereas conduct problems predicted lower self-esteem.

Purpose: We evaluated the hypothesis that abusive parents' reports may exaggerate rates of child behavior problems in a clinical sample. Method: The association between parental ratings of behavior problems and independent observations of child behaviors was examined in a sample of 205 clinic-referred families, 58 of which had a reported history of physical abuse. Results: Relative to the comparison group, parents in the abuse group reported more externalizing problems in their children after controlling for parental psychopathology, and displayed more emotionally controlling and less supportive behavior during parent-child interactions. However, there was no association between abuse history and observed child behaviors during the interaction tasks. Abuse status significantly moderated the association between parent-reported externalizing behaviors and observed demanding behavior by the child; the association was significant among comparison families, but not in the abuse group families. Conclusions: Results indicate that abusive parents may over-report externalizing behavior problems in their children.

Serious sequelae of youth depression, plus recent concerns over medication safety, prompt growing interest in the effects of youth psychotherapy. In previous meta-analyses, effect sizes (ESs) have averaged 0.99, well above conventional standards for a large effect and well above mean ES for other conditions. The authors applied rigorous analytic methods to the largest study sample to date and found a mean ES of 0.34, not superior but significantly inferior to mean ES for other conditions. Cognitive treatments (e.g., cognitive-behavioral therapy) fared no better than noncognitive approaches. Effects showed both generality (anxiety was reduced) and specificity (externalizing problems were not), plus short- but not long-term holding power. Youth depression treatments appear to produce effects that are significant but modest in their strength, breadth, and durability.

Research on parent risk factors, family environment, and familial involvement in the treatment of depression in children and adolescents is integrated, providing an update to prior reviews on the topic. First, the psychosocial parent and family factors associated with youth depression are examined. The literature indicates that a broad array of parent and family factors is associated with youth risk for depression, ranging from parental pathology to parental cognitive style to family emotional climate. Next, treatment approaches for youth depression that have been empirically tested are described and then summarized in terms of their level of parent inclusion, including cognitive-behavioral therapy, interpersonal therapy, and family systems approaches. Families have mostly "not" been incorporated into clinical treatment research with depressed adolescents, with only 32% of treatments including parents in treatment in "any" capacity. Nonetheless, the overall effectiveness of treatments that involve children and adolescents exclusively is very similar to that of treatments that include parents as agents or facilitators of change. The article concludes with a discussion of the implications of these findings and directions for further research.

Juvenile fire setting is a serious, dangerous, and costly behavior. The majority of research examining youth fire setting has been cross-sectional. We sought to examine early risk attributes that could differentiate fire setters from non-fire setters, in addition to examining their association with the developmental continuity of fire-setting behavior into late childhood. Using a sample of 361 youth drawn from 4 different U.S. communities, this study examined the association between a broad array of risk variables from the child, parent, and family domains, and fire-setting behavior over the course of 2 developmental periods: prior to 4th grade, and between 4th and 6th grade. Youth were classified into 1 of 4 groups (non-fire setters, desisters, later-onset fire setters, and persisters) based on their reported fire-setting behavior during these periods. Children who set fires had higher levels of risk on most of the variables assessed. Persistence of fire setting was associated with elevated parental depressive symptoms and more interparental conflict and ineffective discipline. The findings highlight the need for multicomponent preventive interventions to address the breadth of risk experienced by fire-setting youth and their families.

Expressed emotion measures, encompassing dimensions of criticism (CRIT), and emotional over-involvement (EOI) are increasingly being used to assess the parent-child relationship in child clinical populations, despite the lack of studies assessing their validity. We examined the correspondence between CRIT, EOI, and parent-child interactions as observed by neutral coders in a sample of 252 clinic-referred children and adolescents, ages 7-17 years. We found support for the validity of the CRIT code, with high critical parents showing more antagonism, negativity, disgust, harshness, and less responsiveness, compared to parents who scored in the low or borderline ranges. In contrast, none of the observed behaviors were found to correspond with parental EOI, suggesting either that this construct lacks validity with juvenile samples or that behaviors that correspond to EOI are difficult to observe. We conclude that high parental CRIT can be used as an index of problematic parent-child interactions.

The TIES [Training, Intervention, Education, and Services] for Adoption program in Los Angeles, attempts to reduce obstacles to adoption of children in out-of-home care who experienced prenatal substance exposure. Interviews with parents conducted at intervals following home placement reveal experiences and concerns, parenting aspects and adoption process, prenatal substance-exposure effects, and evaluation of support and resources. (LBT)