(PS5-17) Focus on Externalizing Over Internalizing Difficulties for Youth With Comorbidity in School-Based Behavioral Health Settings

Abstract Text: Youth experience relatively high rates of comorbidity across internalizing and externalizing difficulties (Merikangas et al., 2010). Therapists tend to disproportionately attend to externalizing treatment targets (ExtTTs) rather than internalizing treatment targets (IntTTs) when there is diagnostic comorbidity (Milette-Winfree et al., 2018). However, little is known about the comorbidity, and even less about its treatment, in school-based behavioral health (SBBH) settings. Therefore, our study aims to (1) describe and compare the proportionate focus on ExtTTs and IntTTs for all youth receiving SBBH services, (2) examine ExtTT and IntTT endorsement in the treatment of youth with comorbidity, and (3) investigate evidence-based practice (EBP) utilization for IntTTs and ExtTTs in the treatment of youth with comorbidity.

Students (N=8509; Mage=13.1, SD=3.7) who received SBBH services from Hawai’i public schools in the 2023-2024 academic year were primarily male (62.7%; 5331), Native Hawaiian or Other Pacific Islander (27.3%; 2319), and received free or reduced lunch (56.7%; 4823). For each of the 163,239 SBBH sessions, therapists selected one primary IntTT (e.g., Anxiety, Depressed Mood), ExtTT (e.g., Attention Problems), or Other target (Children and Adolescent Mental Health Division Hawai‛i Department of Health, 2023). Similarly, therapists selected one primary practice element (PE) for each session. Leveraging the PracticeWise Evidence-Based Services Database, a PE was only designated as an EBP if it was supported by the treatment protocol literature for the relevant problem area (e.g., Exposure PE for Anxiety, Commands PE for Disruptive Behavior). These session-by-session data were aggregated into one treatment episode per student for the 2023-2024 academic year. Comorbidity for a youth was defined as at least one ExtTT and at least one IntTT during a treatment episode.

Across all students that engaged in SBBH services, the most common targets endorsed within a treatment episode were Other targets (56.3%), ExtTTs (24.9%), and IntTTs (18.8%). Results indicated a heavier focus on ExtTTs than IntTTs in SBBH settings (Wilcoxon signed-rank test, Z = 15.1, p < 0.001). Of the 1906 (22.4%) students with comorbid conditions, ExtTTs (29.7% of sessions) were also endorsed more frequently than IntTTs (23.1%; Wilcoxon signed-rank test, Z = 8.38, p < 0.001). Furthermore, therapists utilized more EBPs for externalizing (13.8% of sessions) than for internalizing difficulties (9.1% of sessions) within treatment episodes for students with comorbid conditions (Wilcoxon signed-rank test, Z = 10.7, p < 0.001).

Greater attention was paid to externalizing relative to internalizing targets in treatment episodes of all students and students with comorbid difficulties treated in SBBH settings, replicating prior literature with similar findings in a state youth system of care (Milette-Winfree et al., 2018). Students with comorbidity also received more evidence-based treatment for externalizing difficulties than internalizing difficulties, further highlighting the focus on externalizing difficulties. Future directions, including recommendations for addressing comorbidity in school-based treatment settings, will be reviewed.