Journal of Clinical Child & Adolescent Psychology

Objective: The family environment of adolescents with body dysmorphic disorder (BDD) is under researched. The current study aimed to investigate family psychiatric history, as well as parental distress, rearing practices, accommodation of appearance concerns, and appearance messages in a clinical sample of adolescents with BDD. Method: Twenty-six adolescents (12-17 years) with BDD were compared to 27 adolescents with anxiety disorders and 25 adolescents without mental disorders. Adolescents and their primary caregivers completed self-report measures and participated in a discussion task that was independently coded for parental rearing styles. Results: Parents of adolescents with BDD reported experiencing significantly more emotional distress than parents in the non-clinical group (p = .003, d = 1.02). The majority (92%) of parents in the BDD group reported accommodating their child's appearance concerns and reported performing significantly more frequent appearance accommodations than parents of anxious adolescents (p < .001, d = 1.40) and the non-clinical group (p < .001, d = 1.83). An independent observer rated parents of adolescents with BDD (p = .002, d = 1.19) and anxiety disorders (p = .008, d = 0.87) as more critical than parents in the non-clinical group during a body-image related discussion, but parents of adolescents with BDD were not rated as more critical in other discussion scenarios. There were no significant differences in parental warmth, overprotection, or appearance messages between parents in the BDD group and comparison groups. Conclusions: Results of the study can inform cognitive-behavioral models of adolescent BDD as well as family-based treatment approaches.

Objective: This study examined youth-serving community mental health clinicians' multicultural counseling knowledge and awareness and their perceived barriers and facilitators in discussing race and racism with clients. Additionally, the study explored how clinicians' knowledge and awareness were related to their reports of barriers and facilitators in addressing race and racism. Methods: The current study is a mixed-method study of 119 youth-serving community mental health clinicians across Washington State. We explore qualitative themes in clinicians' reports of perceived barriers and facilitators in broaching topics of race and racism. We also examine if reported barriers and facilitators correlate with the Multicultural Counseling Knowledge and Awareness Scale. Results: Qualitative themes emerged at the client-, clinician-, organizational-, and societal-levels. Barriers included clinicians not engaging in racism-related discussions unless clients initiated them, clinicians' discomfort or lack of confidence, and clinicians' perceptions of harm or limitations because of their racial identification. Clinicians were more willing to broach topics of race or racism with older clients, with stronger perceptions of rapport, and when topics were broached earlier in therapy. There was no statistically significant correlation between the count of perceived barriers or facilitators' and clinicians' multicultural counseling knowledge and awareness. Conclusion: Qualitative and quantitative data highlight considerations for assessing and supporting clinicians' cultural humility. Enhancing multicultural competency and humility can help clinicians recognize their strengths and limitations, fostering a deeper understanding of clients' cultural backgrounds. Encouraging clinicians to facilitate open discussions about race and racism is a key step in this process.

Objective: Youth frequently miss meals and experience hunger, yet no studies have assessed how these experiences relate to changes in daily emotional states. This daily diary study examined associations of missing breakfast, missing lunch, and hunger with daily positive and negative affect among young adolescents. Methods: A community sample of 133 grade 5 and 6 students (50.4% boys, Mage = 10.77, 19.5% BIPOC) from two public schools completed baseline socio-demographic measures at the beginning of the study and daily measures at the end of the school day over 5 consecutive days. Measures included positive and negative affect, breakfast, lunch, and hunger. Multilevel regression models were constructed to test the associations. Results: Among participating youth, 27.8% missed breakfast at least once, 15.0% missed lunch at least once, and 26.3% felt hungry at least once. Missing breakfast was associated with increased negative affect (B = 0.36, p = .030) and missing lunch was related to both increased negative affect (B = 0.52, p = .019) and decreased positive affect (B = -0.80, p = .002). Hunger was not related to daily affect. Conclusion: This study provides a unique view of youths' experiences of missing meals, hunger, and daily emotional states. The findings underscore the importance of youth being adequately nourished through school meal programs. Clinicians should screen for and address missing meals among their young patients.

Conduct disorder (CD) is a psychiatric diagnosis characterized by a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate social norms or rules are violated. This article presents information on CD with an emphasis on a new multispecifier personality model that could offer a valuable new perspective on CD by refining the way we specify CD. The multispecifier model may have the potential to clarify the considerable confusion that has occurred over past decades and improve our understanding of prevalence, etiology, course, and treatment of youth with conduct problems. In this paper, we present a new structure for CD designed to inspire new lines of research that may be needed to help the field more fully capitalize on this innovation. With additional research, it is hoped that the new multispecifier model will eventually buy clinicians additional information that cannot be gleaned from current diagnostic criteria and will help clinicians and researchers further uncover the factors that promote or protect against the development of CD. This paper delineates the areas of research that will be needed to fully realize the potential of a multispecifier model and ultimately to improve clinical care for children and adolescents with CD.

Objective: Co-occurring anxiety affects 40-80% of autistic individuals; however, little is understood about how anxiety manifests in young autistic children, especially those with intellectual disability (ID), partly due to the paucity of measures designed to assess anxiety symptoms in this population. The present study examined the utility of the Modified Anxiety Dimensional Observation Scale (M-Anx-DOS), an observational measure of anxiety-related behaviors, in preschool-aged autistic children with and without ID. Method: This study included 48 autistic children (Mean age = 43.96 months; 81.3% with ID) and 30 non-autistic (NA) controls (Mean age = 43.66 months). Anxiety-related behaviors were measured during the M-Anx-DOS. Parent-reported anxiety symptoms were assessed via the Preschool Anxiety Scale-Revised (PAS-R). Results: Groups exhibited comparable scores on both the M-Anx-DOS and PAS-R. Within the autism group, a subset of M-Anx-DOS scores were related to age, autistic features, or IQ. The M-Anx-DOS exhibited excellent inter-rater reliability and acceptable internal consistency. Convergent validity was promising, with specific M-Anx-DOS scores correlated with parent-reported social, separation, and overall anxiety symptoms. M-Anx-DOS scores were not correlated with parent-reported ADHD or externalizing symptoms, suggesting strong discriminant validity. Conclusions: This study provides preliminary evidence of the reliability and validity of the M-Anx-DOS. These findings are promising given the importance of observational measurement of anxiety and lack of existing measures for this critical developmental period. Given the sample size and the complexity of identifying prodromal signs of anxiety in young autistic preschoolers with ID, future longitudinal work is essential to replicate and extend this work.

Objective: Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA) and Medication Integration Protocol (MIP) are two family-based behavioral protocols designed to promote family solutions to academic problems and medication decision-making. Building on a randomized control trial examining these protocols, the current study examined how protocol dose, an indicator of treatment adherence, was associated with treatment outcomes. Method: The sample consisted of 145 adolescent clients (M age = 14.8, 72% male, 42% White, 37% Hispanic, 15% Black) and 49 community and hospital-based therapists (82% female, 63% White, 29% Hispanic). Latent growth curve models examined how therapist reports of minutes adolescents and their caregivers received CASH-AA and MIP predicted levels and change in inattentive and hyperactive symptoms (MINI-International Neuropsychiatric Interview); co-occurring symptoms (Youth Self Report/Child Behavior Checklist); homework problems (Homework Problems Checklist); and medication compliance at baseline, 3, 6, and 12-month follow-ups. Results: MIP minutes were prospectively associated with lower caregiver-reported inattentive and hyperactive symptoms, adolescent- and caregiver-reported externalizing symptoms and caregiver-reported homework problems at the 12-month follow-up (ẞ range = -.16 to -.39, p < .05), as well as faster decline in caregiver-reported inattentive symptoms (ẞ = -.29, p < .001). CASH-AA minutes were associated with greater caregiver-reported inattentive symptoms (ẞ = .11, p = .049) at 12-month follow-up and slower declines in homework problems (ẞ = -.39, p < .001). Neither MIP nor CASH-AA minutes were associated with internalizing symptoms or medication use. Conclusions: Findings further support MIP as an effective behavioral protocol for adolescent ADHD and indicate the need for increasing MIP implementation efforts in community settings.

Objective: Youth disruptive behavior disorders (DBDs) have a male preponderance, but the extent to which gender biases in clinical assessment influence this imbalance remains unclear. The present study investigates whether a child patient's gender affects clinicians' diagnostic decision-making regarding Oppositional Defiant Disorder (ODD), Conduct Dissocial Disorder (CDD), and Intermittent Explosive Disorder (IED). Method: Clinicians (N = 403; 57.1% male; Mage = 48.96 years, SD = 11.09) participated in a global ICD-11 field study. Following an experimental design, participants were asked to use ICD-10 or ICD-11 diagnostic guidelines to evaluate two clinical case vignettes, randomly manipulating the patients' gender (boy, girl) and symptom presentation (ODD-Defiant, ODD-Irritable, CDD, IED). Analyses tested whether clinicians' diagnostic accuracy and perceptions of impairment and severity were affected by the patient's gender. Results: Overall, clinicians identified the correct diagnosis 64.7% of the time. Patient gender was not associated with clinicians' diagnostic accuracy (ps= .090-.895, |φs| = 0.01-0.18) or severity or impairment ratings (ps = .079-.404, |ds| = 0.04-0.19). This pattern of nonsignificant differences and negligible/small effect sizes was consistent across all clinical presentations and analyses. Conclusions: We found no evidence of an association between patient gender, diagnostic accuracy, or perceived severity or impairment when assessing youth DBDs in the present study. Results suggest that diagnostic judgments may be driven by clinical presentation rather than gender and that the male DBD preponderance may not be due to gender diagnostic biases. Further research is needed to replicate these findings among youths in clinical settings, with diverse gender identities, and with other mental health conditions.

Objective: To examine differences in parenting factors among caregivers with children with and without externalizing behavior problems (EBP) in a community homeless shelter sample versus a stable housing sample. Method: Nine hundred and fourteen children (ages = 2.01-7.49 years, SD = 1.45 years, 40.8% female, 54.3% Black, 46.7% Hispanic) were recruited from a service-driven research project in a shelter setting (n = 638) and a longitudinal/clinical study (n = 276). Primary caregivers (97% mothers) completed a parenting stress questionnaire and an observational measure of parent-child interactions. Results: Logistic regression indicated that children who were Black and/or of Hispanic background were less likely to be identified as having elevated EBP but only in the homeless shelter sample. Multivariate analyses indicated that the homeless shelter-EBP group reported the highest levels of overall stress compared to the homeless shelter-typically developing (TD), stable housing-EBP and stable housing-TD groups. Mothers from the homeless shelter-EBP group exhibited a higher proportion of negative verbalizations relative to caregivers from all other groups while mothers from the homeless shelter-TD group exhibited a higher proportion of positive verbalizations relative to the caregivers from the homeless shelter-EBP group and the stable housing TD group. Both homeless shelter groups engaged in less total verbalizations relative to both stable housing samples, with the stable housing-EBP group exhibiting the most verbalizations. Conclusions: High levels of parenting stress and negative parent-child interactions within a homeless shelter sample are exacerbated by having a child with EBP. Embedding universal parenting programs in a homeless shelter setting to reduce parenting stress would be valuable to address health disparities in this vulnerable population.

Objective: Research to date has produced compelling evidence of the potentially traumatic consequences of racial discrimination among Black adolescents and adults. Seldom explored, however, is how the potentially traumatic effects of racial discrimination may be shared across the family context. To clarify the relevance of racial trauma across the family system, the current study examined the relationship between racial discrimination and trauma symptoms among a sample of Black adolescent-caregiver dyads. Method: Data were drawn from a larger self-report survey study examining Black family life experiences. For this study, data from 202 Black adolescents (Mage = 14.50, 52% female) and their caregiver (Mage = 41.63, 83% female) were used to test actor-partner interdependence models examining the associations of racial discrimination and trauma symptoms. Results: Significant actor effects revealed that racial discrimination was positively associated with self-reported trauma symptoms among adolescents and caregivers. Additionally, partner effects were found, such that adolescent and caregiver experiences of discrimination were positively associated with the trauma symptoms of their family member. Analyses also revealed that the association between racial discrimination and trauma symptoms among caregivers was dependent upon youth experiences of racial discrimination. Conclusion: The current study lends credence to theories linking racism and trauma-related symptomatology across the life course and family system. Collectively, study findings highlight the importance of understanding the effects of racism beyond the individual and underscores the value and need for family tailored interventions that can repudiate the shared impact and potential intergenerational effects of racial discrimination across Black families.

Objective: Impulsivity has been recognized as an important factor in suicidal thoughts and behaviors (STBs). However, previous research linking impulsivity to STBs has largely relied on cross-sectional designs, considered only a subset of impulsivity measures, and typically focused on middle-to-older adolescents. Here, we explored multiple measures of impulsivity and assessed their predictive relation to suicidal ideation and suicide attempts. Method: In a sample of 10,286 adolescents (ages 9-12; 47.4% female, 76.4% White, 19.4% Black, 6.4% Asian, 3.5% American Indian/Alaskan Native, 0.6% Native Hawaiian/Pacific Islander, 6.4% Other, 19.4% Hispanic, 12.1% Mixed/Multiple Race) from the Adolescent Brain Cognitive Development℠ Study (ABCD Study®), we assessed impulsivity when youth were 9-10 years old, and suicidal ideation and attempts when youth were 11-12 years old. We measured impulsivity in three ways: a trait-like measure (UPPS-P Impulsive Behavior Scale), a behavioral measure (delay discounting task), and a neural measure (Cortical Delay Discounting [C-DD]). Suicidal ideation and attempts were assessed using the Kiddie Schedule for Affective Disorder and Schizophrenia (KSADS) suicide module. Results: Negative urgency and lack of perseverance (at ages 9-10) significantly predicted a higher likelihood of suicidal ideation (Negative Urgency: Odds Ratio [OR] = 1.254, p < .001; Lack of Perseverance: OR = 1.152, p = .035) and suicide attempts (Negative Urgency: OR = 1.328, p = .009; Lack of Perseverance: OR = 1.270, p = .009) when youth were 11-12 years old. Conclusions: Negative urgency and lack of perseverance are robust predictors of future suicidal ideation and suicide attempts in young adolescents. These findings highlight the importance of assessing for and targeting these dimensions of impulsivity in clinical settings.

Objective: The purpose of this systematic review and meta-analysis is to provide an updated examination of the adolescent Dialectical Behavioral Therapy (DBT) literature and synthesize study findings across treatment settings (e.g. inpatient, outpatient, school), and treatment levels (e.g. clinical intervention, targeted, universal prevention). We also provide meta-analytic findings of the impact of DBT across key problem behaviors: depression, emotion dysregulation, suicidal and self-harm behaviors, externalizing problems, and eating disorders. Method: A reference database search was used to identify studies conducted on adolescent DBT interventions from 2000 through 2023 (N = 72). In addition to ensuring that the review process conformed to the PRISMA statement, we independently verified that each study met inclusion criteria before triple coding each article to examine variables of interest and extracted outcome data needed to conduct meta-analyses. Results: DBT appears to demonstrate effectiveness in improving mental health outcomes in adolescents across a range of psychiatric problems. To meet these treatment needs, DBT interventions have been appropriately adapted based on care setting, suggesting empirical support in inpatient, residential, partial hospitalization, and intensive outpatient programs, as well as in outpatient settings, juvenile correctional facilities, and schools. Conclusions: The growing evidence base for adolescent DBT appears to reflect its promise and versatile clinical utility. Clinical implications and recommendations for future directions are discussed, including the need for more randomized controls and representation of diverse communities.

Objective: Regularly administering outcome measures, measurement-based care (MBC), informs clinical decision-making and improves youth mental health. Understanding predictors of high- fidelity MBC delivery helps ensure all youth can benefit from this evidence-based practice. Research on client and clinician predictors of MBC fidelity has mixed findings. Method: Participants included 53 clinicians and 115 adolescents from a randomized controlled effectiveness trial with MBC only and MBC + Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders in Adolescents (UPA) conditions. Clients and clinicians reported demographic information. Clinicians completed broad- and narrow-band attitude measures. MBC fidelity was operationalized using the implementation index, combining rates of administering and viewing questionnaires, using objective MBC data. Results and Discussion: The average MBC fidelity was 56.75% (SD = 30.36) and was significantly higher in the MBC only condition (M = 67.46%, SD = 27.63%) than in MBC + UPA condition (M = 46.58%, SD = 29.52%; p = .012). Clients identifying as White received significantly higher MBC fidelity than youth not identifying as White. Youth ethnicity, family income, age, severity, and number of sessions did not significantly predict MBC fidelity. Clinicians with less experience at their agency, less confidence, and who found manualized treatments less appealing, had significantly higher MBC fidelity than other clinicians. These results can inform future efforts to increase fidelity and equity in MBC delivery.