Barriers to access and participation in community mental health treatment for anxious children

Barriers to access and participation in community mental health treatment for anxious children

Author’s Accepted Manuscript Barriers to Access and Participation in Community Mental Health Treatment for Anxious Children Alison Salloum, Carly John...

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Author’s Accepted Manuscript Barriers to Access and Participation in Community Mental Health Treatment for Anxious Children Alison Salloum, Carly Johnco, Adam B. Lewin, Nicole M. McBride, Eric A. Storch www.elsevier.com/locate/jad

PII: DOI: Reference:

S0165-0327(15)30967-8 http://dx.doi.org/10.1016/j.jad.2016.02.026 JAD8044

To appear in: Journal of Affective Disorders Received date: 18 September 2015 Revised date: 1 December 2015 Accepted date: 7 February 2016 Cite this article as: Alison Salloum, Carly Johnco, Adam B. Lewin, Nicole M. McBride and Eric A. Storch, Barriers to Access and Participation in Community Mental Health Treatment for Anxious Children, Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2016.02.026 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Barriers to Access and Participation in Community Mental Health Treatment for Anxious Children Alison Salloum, Ph.D.,1 Carly Johnco, Ph.D .,2 Adam B. Lewin, Ph.D., ABPP 2,4, 5 Nicole M. McBride, B.S.,2 Eric A. Storch, Ph.D. 2-7

1

Department of Social Work, University of South Florida 2

Department of Pediatrics, University of South Florida 3

4

Department of Health Policy and Management

Department of Psychiatry and Behavioral Neurosciences, University of South Florida 5

Department of Psychology, University of South Florida 6

7

Rogers Behavioral Health – Tampa Bay

All Children’s Hospital – Johns Hopkins Medicine

Correspondence concerning this article should be addressed to Alison Salloum, Ph.D. University of South Florida, 13301 Bruce B. Downs Blvd., MHC1400, Tampa, FL 33612-3807; phone: 813- 974-1535; email: [email protected]

Abstract Background: Anxiety disorders are the most common psychiatric disorders among children in the United States; yet many children do not receive treatment due to barriers to treatment access and participation. This study examined common barriers to treatment access and participation among anxious children who participated in computer-assisted cognitive behavioral therapy. Differences in barriers reported by treatment completers/non-completers were examined, as was the association with sociodemographic characteristics, anxiety severity, and impairment. The impact of barriers on treatment response was assessed, as well as the relationship with treatment expectancy and satisfaction. Method: Barriers to access and participation, demographics, anxiety severity /impairment, treatment credibility and satisfaction were assessed among parents and children with anxiety (N=100; ages 7-13) who were enrolled in a community-based randomized clinical trial. Results: The most common access barrier was parents not knowing where or from whom to seek services (66%). Differences among completers and non-completers were related to stigma, confidentiality, satisfaction and costs. The most common parent-reported barrier to participating was stress (32.4%) and child-reported barrier to participation was not having enough time to complete homework (22.1%). Of the sociodemographic, clinical and treatment characteristics, minority status, satisfaction, and treatment response were associated with barriers to treatment participation, although these associations varied by barriers related to treatment and external factors. Limitations: Cross sectional design and lack of well-established psychometric properties for barriers measures were limitations. Conclusion: Findings suggest that accessible, time-efficient, cost-effective service delivery methods that minimize stigma and maximize engagement when delivering evidence-based treatment for pediatric anxiety are needed. Keywords: Barriers to treatment, children, anxiety, mental health, computer-assisted cognitive-behavioral therapy

Introduction Understanding treatment barriers for children with mental health needs is critical, especially for children with anxiety disorders since these are the most common psychiatric conditions affecting youth (Merikangas et al., 2010). Pediatric anxiety can cause considerable suffering and impairment in children (Beesdo et al., 2009), and frequently persists into adulthood, increasing the likelihood of negative outcomes later in life (e.g., depression, substance abuse; Benjamin et al., 2013; Kendall et al., 2004). Despite the development of evidence-based practices (EBP) for childhood anxiety (Silverman et al., 2008), only 17.8% of children with an anxiety disorder receive treatment in the United States (Merikangas et al., 2011). Barriers to accessing effective treatments and barriers that affect youth and parent participation in treatment can delay or prevent children from receiving much needed mental health care. Identifying barriers that affect treatment access and participation among parents of children with anxiety disorders may help provide guidance on how to improve strategies for service utilization, treatment dissemination and implementation efforts for this population. There are many reasons why parents may not access mental health treatment for their child (Kazdin, 2000; Kazdin et al., 1997), both tangible (e.g., logistical, cost, difficulty identifying a suitable service) and intangible (e.g., attitudes about treatment, urgency of the child’s problem, stigma, motivation). In a study of parents of seventh-grade children who indicated that their child needed mental health services, the most commonly endorsed barriers to accessing treatment were parents not thinking the child’s problem was serious (20.7%), wanting to solve the child’s problem on their own (17.2%), and not knowing where to go (15.5%; Owens et al., 2002). About 10% of this sample also indicated barriers relating to cost, lack of confidence in recommended providers, not being recommended help by those they trusted, and the child not

wanting to go to therapy. Perceptions about the severity and urgency of the child’s problem may influence how motivated parents are to overcome other logistical obstacles to access care, with parents who perceived their child’s problem to be more serious more likely to access services (Teagle, 2002). However, when intangible barriers (e.g., stigma, poor perceptions of treatment) are significant, parents may be less likely to access treatment (Larson et al., 2013). Despite anxiety being one of the most common mental health issues in childhood, there has been surprisingly little research examining barriers to accessing treatment. Given low service utilization amongst this population (Merikangas et al., 2011), there is a clear need to examine and address treatment access barriers for this population. Even if parents and children are able to access treatment, there may be additional barriers that impact their continued treatment participation. Psychological treatments are often timeconsuming and require ongoing participation and effort by the child and parent to ensure progress. Treatment-related variables, such as a poor relationship between the therapist and parent and/or child, may lead to families dropping out of treatment prematurely (de Haan et al., 2013; Stevens et al., 2006). Similarly, families who do not perceive the treatment to be relevant or credible may be more likely to discontinue treatment ((Lewin et al., 2011; Wergeland et al., 2015). Conversely, barriers that affect treatment participation may also influence perceptions about treatment credibility and satisfaction and treatment outcome (Kazdin, 2000). There are mixed findings in regards to the effect of sociodemographic characteristics and barriers to treatment participation. Some studies have suggested that low-income and racial/ethnic minority children are disadvantaged in regards to accessing effective mental health care due to treatment barriers (Alegria et al., 2010; Bringewatt and Gershoff, 2010; Young and Rabiner, 2015). Although Thurston and Phares (2008) found no racial differences in attitudes

toward seeking services for their children between African American and Caucasian parents, African American parents experienced more barriers to treatment utilization (i.e., costs, limited service choices, having to travel too far). Owens et al. (2002) did not find any sociodemographic effects (e.g., child gender, child ethnicity, poverty, mother’s age and education level) on parentreported barriers to accessing mental health care; however, this may be reflective of their sample being primarily African American (82%), with more than half living in poverty (59%). Given the range of barriers that can be encountered in traditional face-to-face treatment models, computer-based and computer-assisted treatments have been developed as one approach to overcome some of the barriers to treatment participation (e.g., Ebert et al., 2015). Results from pilot studies on a computer-based treatment for pediatric anxiety (e.g., Cool Teens) suggest potential barriers to youth participation are finding time to complete the modules, being bored, not wanting to practice therapy tasks, having to disclose too much personal information, not having enough therapist support, not understanding the tasks, and losing interest (Cunningham et al., 2006; Cunningham and Wuthrich, 2008; Wuthrich et al., 2012). In a small open pilot trial of a computer-assisted program for children with anxiety, Camp-Cope-A-Lot (CCAL; Khanna and Kendall, 2010), two of six children thought the program was boring, two lost interest coming to sessions, and two children endorsed that they thought the program was too long. Encouragingly, in another open trial with 6 children receiving CCAL, all of the children felt supported by the therapist and other potential barriers (e.g., homework time, technical problems, understanding tasks and information, treatment relevance, time for practicing) were infrequently endorsed (Salloum et al., 2015). The current study expands the knowledge from these pilot studies of computer-assisted cognitive behavioral therapy (CBT) by examining feedback on treatment participation barriers in a much larger sample of anxious children treated with CCAL.

The aims of the current study were to examine: 1a) parents’ perceptions of barriers they encountered to access treatment for their child with anxiety, and 1b) to compare whether those who dropped out of treatment were more likely to endorse specific access barriers than those who completed treatment; 2) parent and child perceptions of barriers to treatment participation amongst families who received CCAL; 3) associations between parents’ perception of barriers to treatment participation and sociodemographic characteristics, anxiety severity and impairment, as well as the relationship with treatment expectancy and satisfaction; and 4) whether barriers to treatment participation were associated with treatment response. Method Participants Children (aged 7 to 13) were recruited from three community outpatient mental health clinics located throughout Florida (Panhandle, Central Coast, and Southeastern Florida) to participate in a randomized clinical trial comparing CCAL to a treatment as usual (TAU; Storch et al., 2015). After TAU children were offered CCAL. As previously reported (Storch et al., 2015), inclusion criteria was a primary anxiety diagnosis (e.g., separation anxiety, generalized anxiety, specific phobia, or panic disorder) based upon a clinical interview with the child and parent. Baseline data from this study has been reported in unrelated studies (Hamblin et al., 2015; Johnco et al., 2015a; Johnco et al., 2015b; Johnco et al., in press; Johnco et al., 2015c). The most common primary disorders were generalized anxiety (40%), social phobia (26%), separation anxiety (24%), specific phobia (9%), and panic disorder (1%). Children were excluded if they were receiving concurrent counseling for anxiety, had recently initiated antidepressant or antipsychotic medication, were actively suicidal or psychotic, or had a diagnosis of bipolar disorder or autism (Storch et al., 2015). The study sample consisted of 100

children and their parents. Demographic information is presented in Table 1 for the 100 children who completed the baseline assessment and 85 who received CCAL either immediately or after completion of a TAU period. Procedures This study was approved by the relevant Institutional Review Board. Parents were recruited to participate when they called one of the community clinics seeking services. Parents provided written informed consent and children provided assent. A trained blinded independent evaluator (IE) conducted diagnostic assessments via a secure internet platform where a web camera was used with the parent and child. Children and parents completed self-report measures via an online questionnaire platform. Data for the current study was collected at baseline, and post-CCAL treatment. Parents were compensated $30.00 for each assessment. Parents did not pay for therapy; non-participants were usually charged for services or a third party paid for services. The sample used in analysis for the four aims varied. Barriers to accessing treatment were examined using baseline data for 100 children and their parents who met inclusion criteria for the randomized control trial. Of these youth, 85 completed at least one session of CCAL, and we examined group differences in barriers to accessing treatment amongst those who completed CCAL (n=70) and treatment non-completers (n=15). The remaining 15 participants from the original baseline sample were randomized to TAU and either elected not to participate in CCAL, or no longer met study inclusion criteria at the start of CCAL. At the end of treatment we examined participant perceptions of barriers to participating in treatment amongst 68 youth who completed CCAL sessions and completed a post-treatment assessment. As noted above, 70 participants completed CCAL treatment; however, two

participants did not complete the primary barriers measure so were excluded. Of this sample of 68, 25 (36.8%) completed CCAL after 12 weeks in the TAU condition. All TAU participants continued to meet study inclusion criteria at entry to CCAL. There was no significant difference in anxiety severity, impairment or barriers to treatment participation reported by youth who completed CCAL immediately and those who completed it after TAU. Similarly, there was no significant difference in barriers to treatment participation reported by parents of youth who completed CCAL immediately, or after TAU. As such, this treatment sample was combined for analyses examining barriers to treatment participation. CCAL Treatment For a detailed description of CCAL, see Hamblin et al., 2015 and Khanna and Kendall, 2010. Briefly, CCAL is a 12-session (50 minute) interactive computer-assisted CBT therapy program where the first 6-sessions are completed on a computer with minimal therapist assistance, and the remaining sessions involve therapist-led graded exposure to feared stimuli. Parents meet briefly with the therapist and child at the beginning of each session before the child completes the computerized program, and meet individually with the therapist during sessions three and seven. The main purpose of the parent meetings is psychoeducation, to provide parent support and to explain the rationale of the gradual exposure so that the parent can support exposures tasks at home. Measures Anxiety Disorders Interview Schedule (ADIS-IV-C/P). The ADIS-IV-C/P (Silverman and Albano, 1996) is a clinician-administered semi-structured interview that was used to assess the presence and severity of DSM-IV anxiety and related disorders.

Pediatric Anxiety Rating Scale (PARS). The PARS (RUPP, 2002), a measure of anxiety severity across disorders, was used to assess symptom frequency, severity, severity of physical symptoms, avoidance, and interference at home and outside of the home. The 6-item total score (excluding the symptom count item) ranges from 0 to 30, with higher scores indicating greater severity. The PARS was administered at baseline and post-treatment. Clinical Global Impressions-Improvement (CGI-Improvement). The CGI-Improvement (Guy, 1976) was administered at post-treatment to assess the degree of improvement in anxiety symptoms relative to baseline. It is a single-item rating made by the IE indicating degree of improvement in anxiety, with ratings on a 7-point scale ranging from ‘very much worse’ to ‘very much improved’. Children who were rated as ‘much improved’ or ‘very much improved’ were considered treatment responders. Columbia Impairment Scale-Parent version (CIS-P). The CIS-P (Bird et al., 1996) is a 13-item parent-report measure that was administered at baseline and post-treatment to assess the child’s impairment in school, social and family/home functioning. Items are answered on a 5point scale ranging from 0=no problem to 4=very bad problem. Barriers to Treatment Questionnaire-Parent version (BTQ-P). The BTQ-P is a 28-item parent-rated measure administered at baseline to assess perceived barriers to accessing treatment (e.g., logistic and financial barriers, stigma, shame and discrimination barriers, and treatment perception and satisfaction barriers; see Table 2 for items). This measure was adapted from the BTQ (Marques et al., 2010) to reflect the extent to which parents endorsed their experience of each barrier as impacting their ability to obtain treatment for their child’s anxiety where 0=not at all true, 1=somewhat true, and 2=mostly true.

Barrier to Treatment Participation Scale (BTPS). The BTPS (Kazdin et al., 1997) is a 44-item parent-rated measure of barriers to engaging and participating in treatment that is rated post-treatment on a 5-point Likert scale (1=never a problem, 5=very often a problem). Based on the work of Colonna-Pydyn (2007), two subscales were used in the current study in addition to the total score: treatment expectations (e.g., treatment relevance, therapeutic relationship, understanding of treatment and other aspects of the actual treatment) and external demands (e.g., scheduling conflicts, unexpected illness, time commitment, logistical issues, parental stress, and other circumstances that place a burden on treatment participation). Internal consistency was good for the total score (α=.90), Treatment Expectations subscale (α=.82) and External Demands subscales (α=.86) in this sample. Adapted Barrier to Treatment Participation Scale - Child version. An adapted 10-item version of the child-BTPS (Wuthrich et al. 2012) was used, consistent with Salloum et al. (2015), to examine youth perceptions of barriers to treatment participation specific to the CCAL protocol (see Table 3 for items). Expectancy/Credibility Questionnaire (ECQ). We used an adapted version of the ECQ (Borkovec and Nau, 1972) consisting of 4-items about parents’ perceptions of treatment credibility and expectation of improvement rated at the start of treatment on a 10-point rating scale. Total scores range from 4 to 40, with higher scores indicating greater parental perception of treatment credibility and expectations for symptom change at the end of treatment. Client Satisfaction Questionnaire-8 (CSQ-8). The CSQ-8 (Larsen et al., 1979) is an 8item, 4-point measure of treatment satisfaction that was completed by parents at post-treatment. Higher scores indicate greater satisfaction (range 0-32).

Data Analysis Descriptive statistics were used to report demographic data. The percentage of the sample who endorsed barrier items as ‘mostly true’ or ‘somewhat true’ on the BTQ-P and as present ‘sometimes’ to ‘very often’ on the BTPS and child-BTPS were reported. To examine whether treatment access barriers impacted treatment completion, we examined group differences in barriers to accessing treatment amongst children who completed treatment (n=70) and those who did not (n=15) using chi-squared tests or Fisher’s exact test in cases where cell sizes had less than 5 cases. Pearson correlation coefficients were used to examine the relationship between continuous variables (e.g., age, anxiety severity, impairment) and BTPS scores. Independent samples t-tests were used to examine group differences in BTPS scores based on gender, ethnic minority status and treatment responder status. Analysis of variance (ANOVA) was used to examine group differences where there were more than two groups (e.g., family income status). Linear mixed models using maximum likelihood estimation were used to examine whether BTPS scores moderated change in anxiety (PARS). Models included the random effect of intercept, and fixed factors of intercept, time, and BTPS, and controlled for baseline PARS severity. Continuous predictor variables were centered around the mean. To assess moderation, it is the time by BTPS interaction result that is of interest to assess whether barriers affected how anxiety changed over treatment. In this context, a negative beta value indicates a predictor that is associated with greater reduction in anxiety over treatment, while a positive beta value indicates a predictor that is associated with less reduction in anxiety over treatment. Due to the exploratory and descriptive nature of the current study, a two-tailed alpha rate of .05 was used for all analyses.

Results Aim 1. Table 2 reports the percentage of parents who endorsed the presence of each barrier to accessing treatment on the BTQ as ‘mostly true’ or ‘somewhat true’ at pre-treatment. The most commonly endorsed barriers were parents being unsure of who to see or where to go, not knowing that their child’s problem was a genuine mental health condition and the child being worried about others knowing they were in treatment. Least commonly endorsed barriers were parents not thinking mental health treatments work, and not being comfortable discussing their child’s problems with a health professional. Differences in the barriers endorsed by children who completed treatment and those who dropped out of treatment are summarized in Table 4. There was a significantly higher proportion of children who felt uncomfortable discussing their problems with a health professional, and who felt ashamed of needing help that dropped out of treatment in comparison to children who completed treatment. There was a significantly higher proportion of parents who were not satisfied with the services in the non-completers group. Interestingly, there was a higher proportion of parents among treatment completers who reported that they were worried about the cost of treatment in comparison to non-completers. Aim 2. Parent endorsement at post-treatment of treatment participation barriers on the BTPS is reported in Table 5. The most common parent-reported treatment participation barriers were experiencing a lot of stress in their life, the therapist not calling enough, conflicts arising from other activities and the scheduling of an appointment time. Child endorsement of treatment participation barriers at post-treatment on the child-BTPS are reported in Table 3. The most common barriers reported were not having time for the therapy homework and practice tasks, the

length of the program, not understanding the tasks, finding the program boring and losing interest. Aim 3. Child age and gender were not associated with BTPS Total score (r=.08, p=.536 and t(66)=.62, p=.536 respectively), BTPS Treatment Expectation subscale (r=.03, p=.822 and t(66)=.07, p=.944) or BTPS External Demands subscale (r=.10, p=.400 and t(66)=.89, p=.375). Similarly, there was no difference in BTPS scores based on whether participants came from low income (<$25,000; n=18, 26.5%), middle income ($25,001-$90,000; n=33, 48.5%) or high income (>$90,001; n=13, 19.1%) families (BTPS Total score: F(2,61)=.13, p=.882; BTPS Treatment Expectations subscale: F(2, 61)=.14, p=.866; BTPS External Demands: F(2,61)=.17, p=.84). Parents of children from minority backgrounds (n=18, 26.5%; M=23.61, SD=2.00) reported less barriers on the BTPS Treatment Expectations subscale (t(66)=1.92, p=.004) than parents of youth from white/Caucasian backgrounds (n=50, 73.5%; M=26.98, SD=7.33), however there was no significant difference on the BTPS Total score or BTPS External Demands subscale (t(66)=1.56, p=.125 and t(66)=.74, p=.329 respectively). The BTPS Total score, BTPS Treatment Demands, and BTPS External Demands subscales were not associated with anxiety severity on the PARS at pre-treatment (r=.02, p=.878; r=-.07, p=.597 and r=.10, p=.432 respectively) or post-treatment (r=.23, p=.059, r=.22, p=.076 and r=.21, p=.089 respectively). Similarly, there was no relationship between scores on the BTPS Total score, BTPS Treatment Expectations, and BTPS External Demands subscales and the level of functional impairment reported on the CIS-P at pre-treatment (r=-.04, p=.776, r=-.13, p=.305, and r=.04, p=.748) or post-treatment (r=.21, p=.083, r=.17, p=.174 and r=.21, p=.089). Treatment expectancy and credibility was not related to treatment participation barriers on the BTPS Total score, Treatment Expectations subscale, or External Demands subscale

(r=.04, p=.752, r=-.02, p=.898 and r=.09, p=.491). However, greater treatment participation barriers were associated with poorer treatment satisfaction on all subscales, with the BTPS Total score and BTPS Treatment Expectations showing a strong negative relationship with treatment satisfaction (r=-.56, p<.001 and r=-.67, p<.001), and BTPS External Demands showing a moderate negative relationship with treatment satisfaction (r=-.37, p=.002). Aim 4. Treatment responders had significantly lower barriers on the BTPS Total score (M=.55.54, SD=10.15) compared to non-responders (M=.63.20, SD=17.01), t(66)=2.30, p=.025. They also had significantly lower barriers on the BTPS Treatment Expectations subscale (M=25.02, SD=4.82 compared to M=28.65, SD=9.11), t(66)=2.15, p=.036. However, there was no significant difference in barriers on the BTPS External Demands subscale, t(66)=1.95, p=.056. Linear mixed models were conducted as secondary analyses to examine whether BTPS scores predicted change in anxiety on the PARS over treatment. There was a significant time by BTPS Treatment Expectations interaction (B=1.23, SE=.61, p=.046), indicating that children who experienced greater barriers experienced less change in their anxiety. The time by BTPS Total score and Time by External Demands interactions were not significant (p>.05). Discussion The most commonly endorsed barriers to access were related to poor recognition of pediatric anxiety and knowledge of available services, high levels of (especially child-focused) stigma about seeking treatment for anxiety, and financial concerns. Improving psychoeducation about how to identify anxiety and the available EBP options within the community, decreasing stigma and lowering costs may be important strategies to increasing access. Researchers have called for primary care physicians to take an active role in identifying childhood anxiety and making referrals to treatment (e.g., Piacentini and Roblek, 2002). Integrating anxiety screenings

and EBP into primary care settings (Ramsawh et al., 2010; Sakolsky and Birmaher, 2008) may be one approach to helping parents recognize pediatric anxiety and access services. Parents’ comfort level talking with professionals, as well as their belief that mental health treatments work and that the treatment would work for their child, were the least commonly endorsed barriers to access and participation. It is promising that parental perception of the helpfulness of therapy was not indicated as a major barrier for anxious children, although this may also be reflective of the sample being assessed after having already sought psychological treatment. Barriers relating to child worries about stigma associated with psychotherapy, parental satisfaction and cost were more commonly endorsed by those who subsequently dropped out of treatment. The current findings related to stigma is consistent with findings from a national sample of youth ages 13 to 18 that found approximately 30 percent dropped out of treatment due to fear of what others would think (Sylwestrzak et al., 2015). However, research is needed to examine differences in treatment participation barriers between children and adolescents as older youth may have increased demands in school workload or be more sensitive to stigma. It may be helpful for clinicians to assess the child’s worries about treatment participation so that these fears can be addressed openly within the therapeutic context. Cost has been cited previously as a barrier to accessing and continuing treatment (Bringewatt and Gershoff, 2010) and in the current study was one of the top endorsed barriers to treatment access. It may have been expected that there would have been more non-completers who worried about costs when initiating treatment, but there may be differences among completers and non-completers in factors related to payment for treatment that contributed to these results. We did not collect data related to how much, if any, parents would have had to pay for treatment external to study participation. Of note, none of

the parents endorsed cost as a barrier to participation at the completion of treatment, most likely because they did not have to pay for treatment. Parental stress was endorsed as the number one barrier to treatment participation. Parental stress may intensify external demands, such as arranging time to attend the sessions, as well as treatment expectations in that if parental stress remains high, it may be difficult to endorse that the treatment is effective and that they feel supported. High parental stress may lead to dropping out of treatment, consistent with previous findings that high levels of parental internalizing symptoms predicted dropout for anxious youth receiving CBT (Wergeland et al., 2015). Parental stress has also been associated with the child’s severity of symptoms and impairment, family accommodation and caregiver strain (Storch et al., 2009), as well as low parental treatment expectations for child therapy (Nock and Kazdin, 2001). Given the findings of parental stress being the most endorsed barrier, additional research is needed to understand the interaction of parental stress, barriers to participation and child outcomes. Although the therapist not calling enough was the second most commonly rated barrier, in the treatment provided phone calls were not a regular component of the treatment, and in most cases would have been discouraged by busy clinicians and by the research staff. As such, this finding is unsurprising, however it is also possible that parents of anxious children expect and/or need more contact and support from therapists (particularly given that anxiety is common in parents of anxious youth; Festa and Ginsburg, 2011), or that the parents might have felt that they did not get enough support. Consistent with results from pilot trials of computer-assisted CBT with small samples (Cunningham and Wuthrich, 2008), finding time to complete the program was the main barrier endorsed by youth, although promisingly, only 20% endorsed this barrier. The computer-assisted

treatment in the current study involved 12 weekly in-office sessions with homework assignments and thus computerized delivery did not actually reduce weekly therapist-led treatment time. Service delivery approaches that reduce child and parent time are needed. A positive finding was that, similar to the three pilot trials of computer-assisted CBT with children with anxiety (e.g., Cunningham and Wuthrich, 2008; Salloum et al., 2015; Wuthrich et al., 2012), a computerassisted format of treatment delivery did not inflate barriers related to therapeutic alliance (e.g., the child feeling like the therapist supported them and their efforts, and that treatment focused on their life and problems). Similar to Owens et al. (2002), income was not associated with BTPS, nor was the child’s age or gender, but contrary to the findings in Owens et al., ethnicity was associated with BTPS. Parents of children from minority backgrounds reported less BTPS treatment expectations and demands than parents of youth from white/Caucasian backgrounds, and contrary to Thurston and Phares (2008) there were no significant differences in external demands barriers. These promising data suggest that youth from minority backgrounds were able to engage in CCAL, potentially more so than Caucasian youth in some contexts. The child’s severity level and impairment were not associated with BTPS in the current study, although given that all participants were treatment seeking, this may explain the null findings. It may be that severity and impairment are more related to access barriers (Teagle, 2002), but less so once the parent and child have initiated and begun anxiety-focused treatment. For example, in a nationally representative sample of adolescents in the United States, findings suggest that if youth did not perceive their problems were severe and causing impairment, they did not see the need to access treatment (Sylwestrzak et al., 2015).

Treatment expectations were not associated with barriers to treatment participation. However, at the end of treatment, parents who reported more barriers to treatment participation were less satisfied with treatment and were less likely to have a child who responded to treatment. It is not clear if the barriers resulted in less treatment satisfaction and improvement or if not being satisfied with services and improvement led to higher barriers. Study findings (e.g., treatment responders had lower treatment demand barriers than non-responders, no significant differences in external demands between responders/non-responders and treatment expectation predicted change in anxiety on the PARS) lend more support for the importance of parents’ and children’s attitudes about the treatment than external participation barriers. Research with adults has suggested that attitudinal barriers, especially for adults with mild mental health conditions, were more important than external demands for accessing and continuing participation in treatment (Andrade et al., 2014). Interestingly, while attitudinal barriers may prevent patients from participating in treatment, therapist attitudes toward specific EBP may prevent them from providing effective treatments (Reding et al., 2014). Research on how to best change patient and therapist attitudes may be pivotal in disseminating EBP. While a major strength of the current study was that treatment access barriers were assessed prior to treatment and treatment participation barriers were assessed at the end of treatment with a large sample from three community mental health clinics, there were several limitations. First, the BTQ-P could only be used descriptively due to not having well-developed psychometric properties, thus limiting analyses of study variables. Also, while the adaptation of the child BTPS has been used in other studies (Salloum et al., 2015; Wuthrich et al., 2012), the items were limited and were not comparable to the BTPS parent report. Second, cross-sectional design does not imply causation and the direction and timing of the relationships between the

variable studies could not be explored. Third, a significance level of .05 was used for all analyses given the exploratory nature of this study. Given the number of comparisons conducted, it is possible that some results may be spurious. Fourth, the current sample was a treatment seeking sample that did not have to pay for services. Barriers to access may vary based on non-treatment seeking samples and whether participants were charged for treatment. This study adds to the literature understanding barriers to accessing and participating in treatment for children with anxiety. With 66% of the parents indicating that they did not know who to see or where to go to get their child treatment, and almost half reporting that they did not identify their child’s problem as a genuine mental health condition, we must improve recognition of childhood anxiety and make treatment easy for parents to access. Findings from this study suggest that as we continue to develop and disseminate EBP in community-based settings, we must also consider ways to minimize barriers, such as developing service delivery methods that provide effective and time-efficient treatments, address stigma and confidentiality concerns for youth, and minimize costs to families in order to maximize engagement with effective treatment services for youth.

References Alegria, M., Vallas, M., Pumariega, A.J., 2010. Racial and ethnic disparities in pediatric mental health. Child Adolesc. Psychiatr. Clin. N. Am. 19, 759-774. Andrade, L.H., Alonso, J., Mneimneh, Z., Wells, J.E., Al-Hamzawi, A., ..., Kessler, R.C., 2014. Barriers to mental health treatment: results from the WHO World Mental Health surveys. Psychol. Med. 44, 1303-1317. Beesdo, K., Knappe, S., Pine, D.S., 2009. Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V. Psychiatr. Clin. North Am. 32, 483-524. Benjamin, C.L., Harrison, J.P., Settipani, C.A., Brodman, D.M., Kendall, P.C., 2013. Anxiety and related outcomes in young adults 7 to 19 years after receiving treatment for child anxiety. J. Consult Clin. Psychol. 81, 865-876. Bird, H.R., Andrews, H., Schwab-Stone, M., Goodman, S., Dulcan, M., Richters, J., RubioStipec, M., Moore, R.E., Chiang, P., Hoven, C., Canino, G., Fisher, P., Gould, M.S., 1996. Global measures of impairment for epidemiologic and clinical use with children and adolescents. Int. J. Methods Psychiatr Res. 6, 295-307. Borkovec, T.D., Nau, S.D., 1972. Credibility of analogue therapy rationales. J. Behav. Ther. Exp. Psychiatry 3, 257-260. Bringewatt, E.H., Gershoff, E.T., 2010. Falling through the cracks: Gaps and barriers in the mental health system for America's disadvantaged children. Child Youth Serv. Rev. 32, 1291-1299.

Cunningham, M.J., Rapee, R.M., Lyneham, H.J., Schniering, C.A., Hudson, J.L., Wuthrich, V., 2006. The Cool Teens CD-ROM - An anxiety management program for young people. Macquarie University Anxiety Macquarie University Anxiety Research Unit (MUARU):

Sydney. Cunningham, M.J., Wuthrich, V.M., 2008. Examination of barriers to treatment and user preferences With computer-based therapy using The Cool Teens CD for adolescent anxiety. E. J. Appl. Psychol. 4, 12-17. de Haan, A.M., Boon, A.E., de Jong, J.T., Hoeve, M., Vermeiren, R.R., 2013. A meta-analytic review on treatment dropout in child and adolescent outpatient mental health care. Clin Psychol Rev. 33, 698-711. Ebert, D.D., Zarski, A.C., Christensen, H., Stikkelbroek, Y., Cuijpers, P., Berking, M., Riper, H., 2015. Internet and computer-based cognitive behavioral therapy for anxiety and depression in youth: a meta-analysis of randomized controlled outcome trials. PloS one 10, e0119895. Festa, C.C., Ginsburg, G.S., 2011. Parental and peer predictors of social anxiety in youth. Child Psychiatry Hum. Dev. 42, 291-306. Guy, W., 1976. Clinical Global Impressions, ECDEU Assessment Manual for Psychopharmacology. National Institute for Mental Health, Rockville, MD, pp. 218-222. Hamblin, R.J., Lewin, A.B., Salloum, A., Crawford, E.A., McBride, N.M., Storch, E.A., 2015. Clinical characteristics and predictors of hoarding in children with anxiety disorders. J. Anxiety Disord. 36, 9-14.

Johnco, C., Lewin, A.B., Salloum, A., Murphy, T.K., Crawford, E.A., Dane, B.F., McBride, N.M., Storch, E.A., 2015a. Adverse prenatal, perinatal and neonatal experiences in children with anxiety disorders. Child Psychiatry Hum. Dev. [Epub ahead of print] Johnco, C., Salloum, A., De Nadai, A.S., Lewin, A.B., McBride, N., Crawford, E.A., Storch, E.A., 2015b. Incidence, clinical correlates and treatment effect of rage in childhood anxiety disorders. Psychiatry Research. 229, 63-69. Johnco, C., Salloum, A., Lewin., A.B., Storch, E.A., in press. Refining clinical judgment of treatment response and symptom remission identification in childhood anxiety usinga signal detection analysis on the Pediatric Anxiety Rating Scale. J. Child Adolesc. Psychopharmacol. Johnco, C.J., Salloum, A., Lewin, A.B., McBride, N.M., Storch, E.A., 2015c. The impact of comorbidity profiles on clinical and psychosocial functioning in childhood anxiety disorders. Psychiatry Research. 229, 237-244. Kazdin, A.E., 2000. Perceived barriers to treatment participation and treatment acceptability among antisocial children and their families. J. Child Fam. Stud. 9, 157-174. Kazdin, A.E., Holland, L., Crowley, M., Breton, S., 1997. Barriers to Treatment Participation Scale: evaluation and validation in the context of child outpatient treatment. J. Child Psychol. Psychiatry 38, 1051-1062. Kendall, P.C., Safford, S., Flannery-Schroeder, E., Webb, A., 2004. Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4-year followup. J. Consult Clin. Psychol. 72, 276-287. Khanna, M.S., Kendall, P.C., 2010. Computer-assisted cognitive behavioral therapy for child anxiety: results of a randomized clinical trial. J. Consult. Clin. Psychol. 78, 737-745.

Larsen, D.L., Attkisson, C.C., Hargreaves, W.A., Nguyen, T.D., 1979. Assessment of client/patient satisfaction: development of a general scale. Eval. Program Plann. 2, 197207. Larson, J., dosReis, S., Stewart, M., Kushner, R., Frosch, E., Solomon, B., 2013. Barriers to mental health care for urban, lower income families referred from pediatric primary care. Adm. Policy Ment. Health 40, 159-167. Lewin, A.B., Peris, T.S., Bergman, R.L., McCracken, J.T., Piacentini, J., 2011. The role of treatment expectancy in youth receiving exposure-based CBT for obsessive compulsive disorder. Behav. Res. Ther. 49, 536-543. Marques, L., LeBlanc, N.J., Weingarden, H.M., Timpano, K.R., Jenike, M., Wilhelm, S., 2010. Barriers to treatment and service utilization in an internet sample of individuals with obsessive-compulsive symptoms. Depress. Anxiety 27, 470-475. Merikangas, K.R., He, J.P., Burstein, M., Swanson, S.A., Avenevoli, S., Cui, L., Benjet, C., Georgiades, K., Swendsen, J., 2010. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). J. Am. Acad. Child Adolesc. Psychiatry. 49, 980-989. Merikangas, K.R., He, J.P., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., Georgiades, K., Heaton, L., Swanson, S., Olfson, M., 2011. Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J. Am. Acad. Child Adolesc. Psychiatry 50, 32-45. Nock, M.K., Kazdin, A.E., 2001. Parent expectancies for child therapy: Assessment and relation to participation in treatment. J. Child Fam. Stud. 10, 155-180.

Owens, P.L., Hoagwood, K., Horwitz, S.M., Leaf, P.J., Poduska, J.M., Kellam, S.G., Ialongo, N.S., 2002. Barriers to children's mental health services J. Am. Acad. Child Adolesc. Psychiatry 41, 731-738. Piacentini, J., Roblek, T., 2002. Recognizing and treating childhood anxiety disorders. West. J. Med. 176, 149-151. Ramsawh, H.J., Chavira, D.A., Stein, M.B., 2010. Burden of anxiety disorders in pediatric medical settings: prevalence, phenomenology, and a research agenda. Arch. Pediatr. Adolesc. Med. 164, 965-972. Reding, M.E., Chorpita, B.F., Lau, A.S., Innes-Gomberg, D., 2014. Providers' attitudes toward evidence-based practices: is it just about providers, or do practices matter, too? Adm. Policy Ment. Health 41, 767-776. RUPP, 2002. The Pediatric Anxiety Rating Scale (PARS): development and psychometric properties. J. Am. Acad. Child Adolesc. Psychiatry 41, 1061-1069. Sakolsky, D., Birmaher, B., 2008. Pediatric anxiety disorders: management in primary care. Curr. Opin. Pediatr. 20, 538-543. Salloum, A., Crawford, E.A., Lewin, A.B., Storch, E.A., 2015. Consumers' and providers' perceptions of utilizing a computer-assisted cognitive behavioral therapy for childhood anxiety. Behav. Cogn. Psychother. 43, 31-41. Silverman, W.K., Albano, A.M., 1996. The Anxiety Disorders Interview Schedule for DSM-IVChild and Parent Versions. Graywind., San Antonio, TX. Silverman, W.K., Pina, A.A., Viswesvaran, C., 2008. Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. J. Clin. Child Adolesc. Psychol. 37, 105-130.

Stevens, J., Kelleher, K.J., Ward-Estes, J., Hayes, J., 2006. Perceived barriers to treatment and psychotherapy attendance in child community mental health centers. Community Ment. Health J. 42, 449-458. Storch, E.A., Lehmkuhl, H., Pence, S.L., Geffken, G.R., Ricketts, E., Storch, J.F., Murphy, T.K., 2009. Parental experiences of having a child with obsessive-compulsive disorder: Associations with clinical characteristics and caregiver adjustment. J. Child Fam. Stud. 18, 249-258. Storch, E.A., Salloum, A., King, M.A., Crawford, E.A., Andel, R., McBride, N.M., Lewin, A.B., 2015. A randomized controlled trial in community mental health centers of computerassisted cognitive behavioral therapy versus treatment as usual for children with anxiety. Depress. Anxiety 32, 843-852. Sylwestrzak, A., Overholt, C.E., Ristau, K.I., Coker, K.L., 2015. Self-reported Barriers to Treatment Engagement: Adolescent Perspectives from the National Comorbidity SurveyAdolescent Supplement (NCS-A). Community Ment. Health J. 51, 775-781. Teagle, S.E., 2002. Parental problem recognition and child mental health service use. Ment. Health Serv. Res. 4, 257-266. Thurston, I.B., Phares, V., 2008. Mental health service utilization among African American and Caucasian mothers and fathers. J. Consult. Clin. Psychol. 76, 1058-1067. Wergeland, G.J., Fjermestad, K.W., Marin, C.E., Haugland, B.S., Silverman, W.K., Ost, L.G., Havik, O.E., Heiervang, E.R., 2015. Predictors of dropout from community clinic child CBT for anxiety disorders. J.Anxiety Disord. 31, 1-10.

Wuthrich, V.M., Rapee, R.M., Cunningham, M.J., Lyneham, H.J., Hudson, J.L., Schniering, C.A., 2012. A randomized controlled trial of the Cool Teens CD-ROM computerized program for adolescent anxiety. J. Am. Acad. Child Adolesc. Psychiatry 51, 261-270. Young, A.S., Rabiner, D., 2015. Racial/ethnic differences in parent-reported barriers to accessing children's health services. Psychol. Serv. 12, 267-273. Table 1. Sample Demographic Information

Age Gender Female Male

Baseline Sample (N = 100) Range M (SD) 7-13 9.82 (1.82)

Treatment Sample (N = 68) Range M (SD) 7-13 9.71 (1.88)

N

%

N

%

44 56

44.0 56.0

33 35

48.5 51.5

t .92 χ2 1.77

.03 Ethnicity White Minority (African American, Hispanic, Asian, Other)

73 27

73.0 27.0

50 18

73.5 26.5 .17

Family Income Low (<$25,000 Middle ($25,001-$90,000) High (>$90,001) Not specified

28 48 19 5

28.0 48.0 19.0 5.0

18 33 13 4

26.5 48.5 19.1 5.9

Table 2. Barriers to accessing treatment (N = 100) Barrier %a Unsure of who to see or where to go 66 Parent did not know that child’s problem was a genuine mental health condition 46 Child worried that people would know s/he was in treatment 42 Child not comfortable discussing problems with a health professional 37 Health insurance wouldn’t cover cost/service 37 Worried about the cost 35 Child did not think s/he had a problem 35 Parent was concerned that child would be put on medication 29 Child felt ashamed of needing help 20 Couldn’t get off work 20 Child felt ashamed of his/her problems 21 Parent wanted to handle on own 19 Couldn’t choose provider 18 Child wanted to handle on own 17 Transportation/scheduling problems 17 Parent was not satisfied with the services that were available 14 Parent afraid of being criticized by family for seeking help 12 Couldn’t get an appointment 11 Child was scared that they could be hospitalized against their will 10 Parent felt ashamed of needing help 9 Child has received treatment before and it didn’t work 8 Child is too busy 7 Too inconvenient 7 Parent worried what other people would think if they knew child was in treatment 7 Parent was scared that child could be hospitalized against their will 7 Parent not comfortable discussing child’s problems with a health professional 5 Parent did not think mental health treatments work 2 Parent did not think treatment would work to help child 1 a Percentage of sample endorsing barriers as ‘mostly true’ or ‘somewhat true’. Items are from the Barriers to Treatment Questionnaire- Parent version (BTQ-P; Marques et al., 2010).

Table 3. Child-Rated Barriers to Treatment Participation (N = 68) 1. I did not have time for the assigned homework and totem pole challenges 2. I had technical problems with the computerized program, Camp-Cope-ALot 3. I lost interest in coming to sessions 4. I did not understand the tasks (or things that I was supposed to do in the Camp-Cope-A-Lot treatment) 5. I did not feel that the therapist supported me and my efforts 6. I thought the Camp-Cope-A-Lot program was boring 7. I feel treatment did not focus on my life and problems 8. I did not want to practice the tasks (or to do my homework and totem pole challenges at home) 9. I think the Camp-Cope-A-Lot program lasted to long (too many weeks) 10. Information in the sessions seemed confusing. a Proportion of sample reporting barrier present ‘sometimes’ to ‘very often’

n (%)a 15 (22.1) 10 (14.7) 11 (16.2) 12 (17.6) 4 (5.9) 11 (16.2) 5 (7.4) 8 (11.8) 14 (20.6) 10 (14.7)

Table 4. Comparison of Barriers between CBT Treatment Completers and Non-Completers.

Barrier Unsure of who to see or where to go Parent did not know that child’s problem was a genuine mental health condition Child worried that people would know s/he was in treatment Child not comfortable discussing problems with a health professional Health insurance wouldn’t cover cost/service Worried about the cost Child did not think s/he had a problem Parent was concerned that child would be put on medication Child felt ashamed of needing help Couldn’t get off work Child felt ashamed of his/her problems Parent wanted to handle on own Couldn’t choose provider Child wanted to handle on own Transportation/scheduling problems Parent was not satisfied with the services that were available Parent afraid of being criticized by family for seeking help Couldn’t get an appointment Child was scared that they could be hospitalized against their will Parent felt ashamed of needing help Child has received treatment before and it didn’t work Child is too busy Too inconvenient Parent worried what other people would think if they knew child was in treatment Parent was scared that child could be hospitalized against their will Parent not comfortable discussing child’s problems with a health professional Parent did not think mental health treatments work Parent did not think treatment would work to help child a

Completers (n = 70)

Noncompleters (n = 15)

n (%)a

n (%)a

47 (67.1)

9 (60.0)

χ2/Fisher’s Exact Test .28

32 (45.7)

6 (40.0)

.16

32 (45.7)

6 (40.0)

.16

23 (32.9)

9 (60.0)

3.88*

25 (35.7) 29 (41.4) 19 (27.1)

7 (46.7) 2 (13.3) 7 (46.7)

.63 4.21* 2.22

24 (34.3)

2 (13.3)

2.55

12 (17.1) 16 (22.9) 14 (20.0) 15 (21.4) 13 (18.6) 14 (20.0) 12 (17.1)

6 (40.0) 1 (6.7) 6 (40.0) 3 (20.0) 4 (26.7) 3 (20.0) 4 (26.7)

3.87* 2.02 2.85 .02 .51 <.01 .73

6 (8.6)

4 (26.7)

3.90*

11 (15.7)

1 (6.7)

.83

7 (10.0)

3 (20.0)

1.19

6 (8.6)

3 (20.0)

1.70

8 (11.4) 3 (4.3) 5 (7.1) 6 (8.6)

1 (6.7) 2 (13.3) 1 (6.7) 1 (6.7)

.30 1.83 <.01 .06

6 (8.6)

0 (0.0)

1.38

5 (7.1)

2 (13.3)

.63

4 (5.7)

0 (0.0)

.90

1 (1.4) 1 (1.4)

0 (0.0) 0 (0.0)

.22 .22

Proportion of sample endorsing barriers as ‘mostly true’ or ‘somewhat true’

Group comparison

Table 5. Barriers to Treatment Participation (N = 68) Barrier 1. My child refused to come to the sessions 2. Transportation to the clinic 3. My child was in other activities that made it hard to come to a session 4. Scheduling of appointment times for treatment 5. Treatment lasted too long (too many weeks) 6. Treatment was in conflict with another of my activities (classes, job, friends) 7. Treatment did not seem necessary 8. I did not like the therapist 9. I felt that treatment cost too much 10. I was billed for the wrong amount 11. Treatment was not what I expected 12. Information in the session and handouts seemed confusing 13. My child had trouble understanding treatment 14. During the course of treatment I experienced a lot of stress in my life 15. I lost interest in coming to sessions 16. I was sick on the day when treatment was scheduled 17. My child was sick on the day when treatment was scheduled 18. Crises at home made it hard for me to get to a session 19. I felt I had to give too much personal information to the therapist 20. Treatment added another stressor to my life 21. I felt treatment did not seem as important as the sessions continued 22. I felt this treatment was more work than expected 23. The atmosphere at the clinic made it uncomfortable for appointments 24. I did not feel that I had enough to say about what goes on in treatment 25. I feel treatment did not focus on my life and problems 26. The therapist did not seem confident that treatment would work for my child 27. The therapist did not seem confident in my ability to carry out programs 28. My child now has new or different problems 29. My child's behavior seems to have improved; treatment no longer seems necessary 30. Treatment did not seem to be working 31. There was bad weather and this made coming to treatment a problem 32. I do not feel the therapist supported me or my efforts 33. The assigned work for me to do as part of this treatment was much too difficult 34. I did not have time for the assigned work 35. My child was never home to do the assigned homework 36. There was always someone sick in my home 37. The therapist did not call often enough 38. Getting a baby-sitter so I could come to the sessions 39. Finding a place to park at the clinic 40. I had a disagreement with my husband, boyfriend, or partner about whether we should come to treatment at all 41. I was too tired after work to come to a session 42. My job got in the way of coming to a session 43. Treatment took time away from spending time with my children 44. I had trouble with other children at home which made it hard to come to treatment a Proportion of sample reporting barrier present ‘sometimes’ to ‘very often’

n (%)a 7 (10.3) 7 (10.3) 9 (13.2) 14 (20.6) 2 (2.9) 16 (23.5) 4 (5.9) 1 (1.5) 0 (0.0) 0 (0.0) 9 (13.2) 2 (2.9) 4 (5.9) 22 (32.4) 1 (1.5) 5 (7.4) 2 (2.9) 4 (5.9) 0 (0.0) 5 (7.4) 1 (1.5) 7 (10.3) 2 (2.9) 0 (0.0) 4 (5.9) 1 (1.5) 1 (1.5) 5 (7.4) 12 (17.6) 11 (16.2) 1 (1.5) 3 (4.4) 2 (2.9) 5 (7.4) 1 (1.5) 2 (2.9) 19 (27.9) 1 (1.5) 7 (10.3) 1 (1.5) 4 (5.9) 8 (11.8) 0 (0.0) 3 (4.4)

Highlights

Not knowing where or from whom to seek services prevents access to treatment. Stress for parents and time for children was a treatment participation barrier. Stigma, confidentiality, satisfaction may contribute to treatment non-completion. Computerized treatment for pediatric anxiety may be one approach to addressing treatment barriers.

Author Disclosure Funding This work was supported by a grant to the last author from the Agency for Healthcare Research and Quality (1R18HS018665-01A1). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Agency for Healthcare Research and Quality. Acknowledgements The contributions of Tyne Pierce, Amanda Krucke, Christin Cooper, Wendy Kubar, Stephanie Dobbs, and April Lott at Directions for Living in Largo, FL; Ashley Holden, Elise Ward, Sonya Hernandez, Bhagirat Sahas, Nathalie Miniscalco Paquette and Pamela Galan at Henderson Behavioral Health in Ft. Lauderdale, FL; Tanya White, Lori Olsen, Shannon Massingale, Ruqayyah Gaber, John Bilbrey, Carol Clark, Shaun Dahle, Ed Mobley, and Larry Williams at Lakeview Center Inc. in Pensacola, FL; Michael Sulkowski, Elysse Arnold, Alessandro de Nadai, Joshua Nadeau, Anna Jones, Brittany Kugler, Joseph McGuire, Tanya Murphy, Danielle Ung, Jennifer Park, Marie McPherson, Brittany Dane, Erica Crawford, Morgan King and Robert

Constantine at the University of South Florida; Nick Dewan of BayCare Health System; and Muniya Khanna at the University of Pennsylvania are gratefully acknowledged. Contributions Alison Salloum wrote the first draft of the literature review, methods section and discussion. Carly Johnco conducted the statistical analysis for the result section, wrote the first draft of the result section, and assisted with editing. Adam Lewin oversaw the administration of assessments and assisted with editing. Nicole M. McBride assisted with method section and editing the manuscript. Eric Storch the principle investigator for the randomized clinical trial assisted with development of the current study aims and assisted with editing. All authors contributed to and have approved the final manuscript.