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Strengths and Behavioral Health among Youth with Serious Emotional Disturbance (SED): Preliminary
Findings from a State-Level System of Care
Maria Jose Horen, MS, MPH Theda Rose, PhD
John Cosgrove, MSW Bethany R. Lee, PhD
Children’s Mental Health Research and Policy Conference
March 4th, 2014
Maryland System of Care
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SOC Population of Focus
• MDC & RC
• Youth 10-21
• Diagnosed SED
• At-risk of out-of-home placement or disruption in placement
SOC Core Values
•Family driven and youth guided, with the strengths and needs determining services and supports
•Community based
•Culturally and linguistically competent
Results = individualized service plans
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Why Focus on Strengths
• Prior focus on problem identification and reduction in adverse symptoms
• Supports assumption that population has identifiable strengths
• Gives a more comprehensive picture of youth functioning
• Practitioners able to identify youth assets, better engage families, and track progress
• May be less stigmatizing for youth and families
Strengths and Emotional/Behavioral Problems
Studies show that greater strengths are related to:
– Lower likelihood of functional impairment among youth with SED1
– Fewer mental health problem symptoms among youth with emotional and behavioral disorders2
1Barksdale, Azur, & Daniels, 2010 2Oswald, Cohen, Best, Jenson, & Lyons, 2001
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Strengths and Prevention
• Prevention strategies include reduction of impairment severity and enhancement of yth capacity to function
• Strengths can act as a buffer against mental health problems3
• Prevention target for yth with SED can focus on fostering strengths to reduce negative impact of emotional and behavioral problems
3Seligman, 2002
Caregiver and Youth Perspectives
• Multiple informants help providers get a more holistic picture of youth functioning4
• Lower levels of agreement are usually found between adult-youth dyads compared to adult-adult dyads, particularly on assessments of problem behavior4,5
• For strengths, studies show: – Low to moderate agreement between youth and parents
on overall youth strengths and categories of strengths 5, 6
4Achenbach, McConaughy, & Howell, 1987 5Synhorst, Buckley, Reid, Epstein, & Ryser, 2005 6Sointu, Savolainen, Lappalainen, & Epstein, 2012
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Purpose of Study
• Examine relationship between cg and yth assessment of yth strengths and behavioral health problems at baseline
• Examine relationship between strengths and yth behavioral health problem outcomes at baseline
• Explore change in cg and yth reports of yth strengths over time
• Explore change in cg and yth reports of yth behavioral health problems over time; and role of strengths
Methods: Data
• Study encompasses two SOC sites in a mid-Atlantic state
• Caregivers and youth enrolled in SOC National evaluation
• Data includes caregiver and youth baseline, 6m, and 12m reports of youth strengths and behavioral health problems
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Methods: Sample (N=147) Socio-Demographic Characteristics
Mean Age (SD, range) 13.9 (3.14, 4-21)
Gender
Male 71 (48%)
Female 76 (52%)
Race
African American 93 (66%)
White 39 (28%)
Other 8 (6%)
Caregiver
Biological-adoptive parents 76 (53%)
Grandparents-other relatives 25 (18%)
Foster parent/staff/other 42 (29%)
Data from Enrollment and Demographic Information Form (EDIF), Living Situation Questionnaire (LSQ).
Methods: Measures • Behavioral and Emotional Rating Scale, Second Edition (BERS-2) (Epstein,
2004) 57-item scale –parent and youth reports Six domains - interpersonal strength, family involvement, intrapersonal
strength, school functioning, affective strengths, and career strength Higher scores indicate greater strengths: below 8 (below average), 8-12 (average), above 12 (above average)
• Child Behavioral Checklist (CBCL) 6-18 (Achenbach & Rescorla, 2001) 113 items –parent report Internalizing, externalizing, and total problem scores Responses classified into three groups by T-scores: below 60 (normal), 60-
63 (borderline), and 64 and above (clinical) • Clinical Impairment Scale (CIS) (Bird, Shaffer, Fisher, & Gould, 1993)
13 items-parent report Problems commonly encountered among children and youth Higher scores indicate greater impairment: 15 or above (clinically
impaired)
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Methods: Measures • Reynolds Adolescent Depression Scale, Second Edition (RADS-2)
(Reynolds, 1986) 30-item youth self-report Four domains and overall depression score Overall t-score; higher scores indicate greater depression: below 61
(normal), 61-64 (mild), 65-69 (moderate), 70 and above (severe)
• Revised Children’s Manifest Anxiety Scale, Second Edition (RCMAS-2) (Reynolds & Richmond, 1979) 49-item youth self-report Six scales and overall anxiety score Overall t-score; higher scores indicate greater anxiety: 61 and above
(anxiety problems)
Methods: Data Analysis
Are higher strengths
related to lower behavioral
health problems?
• Correlation between the two assessments at Baseline
• T-test of the mean difference between the two assessments
• Chi-square exploring categorical differences between the two assessments
• T-tests exploring differences on each BERS subscale
• Categorical distributions of all behavioral health measures
Are youth and caregiver reports of
strengths and behavioral
health problems different?
• Correlations between BERS Strengths Index and each behavioral health measure at Baseline:
-CBCL Internalizing -CBCL Externalizing -CBCL Total Problems
-Clinical Impairment Scale -RADS-2 Depression -RCMAS-2 Anxiety
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Methods: Data Analysis
• Paired samples t-tests examining change on the BERS Strengths Index from Baseline to six months, and Baseline to 12 months
• Repeated measures ANOVA examining change among all three time points
Is there change in strengths over
time?
• Paired samples t-tests examining change from Baseline to six months, and Baseline to 12 months, on all behavioral health measures
• Repeated measures ANOVAs examining change among all three time points, and the effect of Baseline strengths on this change
Is there a change in behavioral
health problems?
Do strengths have an effect on this
change?
Results: Comparing youth and caregiver report of strengths at baseline
Mean SD r p
Youth 91.36 16.15 .398 <.001
Caregiver 81.10 18.59
Relationship between youth- and caregiver-reported Strengths Index
• The relationship between the youth and caregiver reports of strengths at baseline was significant, but the correlation was only low-moderate (r=.398), despite being a comparison of the same instrument at the same time point.
• We felt that this correlation was low enough to further explore how the two respondents might differ.
N=91; <89 =below average, 90-110=average, >110=above average
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Results: Comparing youth and caregiver report of strengths at baseline
Mean SD t p Youth 91.36 16.15 5.11 <.001
Caregiver 81.10 18.59
Mean difference between youth- and caregiver-reported Strengths Index
Youth x2 (df) p
Caregiver Below
average Average
Above average
Total
Below average (<89) 39 (63%) 16 (26%) 7 (11%) 62 (100%) 9.58(4) .048
Average (90-110) 8 (33%) 9 (38%) 7 (29%) 24 (100%)
Above average (>110) 1 (20%) 3 (60%) 1 (20%) 5 (100%)
Total 48 (53%) 28 (31%) 15 (16%) 91 (100%)
Categorical relationships between youth- and caregiver-reported Strengths Index
N=91; <89 =below average, 90-110=average, >110=above average
Results: Comparing youth and caregiver report of strengths at baseline
BERS Strength Subscale
Caregiver score (SD) Youth score (SD) t (df=29), p
Interpersonal 6.57 (2.78) 11.43 (2.86) t=-8.71, p<.001
Intrapersonal 7.83 (3.49) 11.60 (2.21) t=-5.81, p<.001
Family involvement 7.17 (2.15) 11.10 (2.72) t=-8.33, p<.001
School functioning 6.33 (3.18) 9.73 (2.85) t=-8.63, p<.001
Affective 8.07 (2.97) 11.17 (2.73) t=-4.66, p<.001
Career 11.27 (3.08) 10.90 (2.48) t=.58, p.569
Mean differences between youth and caregiver reports on BERS subscales (of the 30 cases where youth scores were in a higher category)
N=30; <8=below average, 8-12=average, >12=above average
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Results: Caregiver- and youth-reported behavioral health measures at baseline
Caregiver-reported measures
Baseline N (%) Baseline Mean
CBCL Internalizing N=138
65.8 (9.43) Normal (<60) 34 (25%)
Borderline (60-63) 22 (16%)
Clinical (>63) 82 (59%)
CBCL Externalizing N=138
69.6 (10.36) Normal (<60) 21 (14%)
Borderline (60-63) 18 (13%)
Clinical (>63) 99 (72%)
CBCL Total Problem N=138
70.0 (9.34) Normal (<60) 19 (14%)
Borderline (60-63) 16 (12%)
Clinical (>63) 103 (75%)
Clinical Impairment N=139
22.8 (10.07) Normal (<15) 29 (21%)
Impaired (15+) 110 (79%)
Youth-reported measures
Baseline N (%) Baseline Mean
RADS-2 Depression N=107
52.0 (9.86)
Normal (<61) 84 (79%)
Mild (61-63) 14 (13%)
Moderate (65-69) 5 (5%)
Severe (70+) 4 (4%)
RCMAS-2 Anxiety N=97
50.8 (11.73) Non-impaired (<61) 74 (76%)
Impairment (61+) 23 (24%)
Results: The relationship between strengths and behavioral health measures at baseline
r p
CBCL Internalizing -.382 <.001
CBCL Externalizing -.523 <.001
CBCL Total Problem Score -.521 <.001
Clinical Impairment Scale -.639 <.001
N=127
r p
RADS-2 Depression (N=97) -.530 <.001
RCMAS-2 Anxiety (N=93) -.206 .047
Youth-reported measures
Caregiver-reported measures
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Results: Change in strengths and behavioral health over time
• No significant changes in Strengths Index at 6m or 12m
• No significant changes in any behavioral health measure at 6m or 12m
• No main effects, so unable to interpret interaction with strengths
Discussion: Youth Strengths • All youth have some level of strengths
• Low to moderate correlation of youth and parent report of overall strengths; youth report of overall strengths and their subscales were significantly different from caregivers
• No change in strengths over time - behavioral health challenges of population?
• Important for providers to understand there are differences – Reasons why
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Discussion: Behavioral Health Outcomes
• Behavioral health differences in reporting
caregiver report - clinical range
youth report - normal range
• No change in behavioral health measures over time may be indicative of population needs combined with length of time
• Reducing caregiver strain to focus on strengths could lead to better relationships and positive outcomes
Discussion: Strengths as a Possible Prevention Target
• Correlations showed that strengths were significantly and negatively related to behavioral health measures at baseline
• Strengths could potentially serve as a buffer against an increase in problem outcomes or reduce impact of outcomes in population
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Limitations
• Small sample
• Single state data
• Different behavioral health problem assessments for caregiver and youth
• Could only examine up to 12 months
Future Research • Replicate study with larger sample (other SOC sites)
• Identify behavioral health measures comparable for caregiver and youth report
• Include other perspectives of youth strengths (e.g., teacher, provider)
• Examine changes over a longer period of time
• Examine relationships of caregiver strain and their report of youth’s strengths
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Questions?
Contact Information
Maria Jose Horen
Theda Rose
John Cosgrove
Bethany Lee
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Acknowledgements
• Funded by SAMHSA, CMHS, Cooperative Agreements for Comprehensive Community Mental Health Services for Children and Their Families Program, Grants 1U79SM058522-01, 1U79SM059052-01
• MD CARES and Rural CARES Staff
• National Evaluation Team, ICF International
• Institute for Innovation and Implementation, School of Social Work, University of Maryland