Therapeutic engagement of adolescents is critical to maximizing the success of any psychotherapy intervention. Therapists have found that engaging adolescents is especially challenging and that there are several reasons for this. Most psychotherapy models are based on treatments that work for adults. These methods are frequently not conducive to engaging adolescents because of their developmental immaturity, the stigma many adolescents associate with psychotherapy, and adolescents feeling forced into psychotherapy. Existing empirical and clinical knowledge about therapy process, adolescent development, and adolescent interactions with their social ecology can be used to guide psychotherapists working with this population. Engaging adolescents in psychotherapy and establishing a strong therapeutic alliance with adolescents require that therapists express empathy and genuineness, utilize developmentally appropriate interventions, address the stigma, and increase choice in therapy. The prevalence and impact of mental health issues among adolescents are astonishing. Recent reports indicate that 1 in 10 children and adolescents suffer from impairing mental illness (Kessler, McGonagle, & Shayang, 1994; U.S. Public Health Service, 2000). Depression and depressive syndromes are common among adolescents, with more than 25% of high school students reporting persistent dysphoria and hopelessness severe enough to affect social and academic functioning, and 8 to 9% of youths admitting to attempts at suicide (Centers for Disease Control and Prevention [CDC], 2002). Five percent of all high school youths report weight control strategies that indicate a potential eating disorder (CDC, 2002). Nearly 27% of eighth graders, increasing to nearly 54% of high school seniors, report illicit substance use (National Institute on Drug Abuse, 2001), with 11% of high school students having a substance abuse problem.These mental health problems lead to serious consequences that include impaired social, academic, and occupational functioning; increased risk for behavioral problems; and accidental injury and death. Yet, fewer than one in five youths in need of mental health services receive the needed treatment (National Institute of Mental Health [NIMH], 1999). So, while adolescent mental health problems are pervasive and increasing, access to treatment is decreasing (NIMH, 1999). Consequently, maximizing adolescent use of psychotherapy and providing effective mental health services to adolescents are significant concerns for therapists (Dakof, Tejeda, & Liddle, 2001). However, therapy with adolescents is thought to be difficult (Church,

BackgroundAcute rheumatic fever (ARF) rates have declined to near zero in nearly all developed countries. However, in New Zealand rates have not declined since the 1980s. Further, ARF diagnoses in New Zealand are inequitably distributed--occurring almost exclusively in Māori (the indigenous population) and Pacific children--with very low rates in the majority New Zealand European population. With ARF diagnosis, secondary prophylaxis is key to prevent recurrence. The purpose of this study was to identify the perceived enablers and barriers to secondary recurrence prophylaxis following ARF for Māori patients aged 14–21.MethodsThis study took a systems approach, was informed by patient voice and used a framework method to explore potential barriers and enablers to ongoing adherence with monthly antibiotic injections for secondary prophylaxis. Qualitative interviews were conducted with 19 Māori ARF patients receiving recurrence prophylaxis in the Waikato District Health Board region. Participants included those fully adherent to treatment, those with intermittent adherence or those who had been “lost to follow-up.”ResultsBarriers and enablers were presented around three factors: system (including access/resources), relational and individual. Access and resources included district nurses coming to patients as an enabler and lack of income and time off work as barriers. Relational characteristics included support from family and friends as enablers and district nurse communication as predominantly a positive although not enabling factor. Individual characteristics included understanding, personal responsibility and fear/pain of injections.ConclusionThis detailed exploration of barriers and enablers for ongoing secondary prophylaxis provides important new information for the prevention of recurrent ARF. Among other considerations, a national register, innovative engagement with youth and their families and a comprehensive pain management programme are likely to improve adherence to ongoing secondary prophylaxis and reduce the burden of RHD for New Zealand individuals, families and health system.

OBJECTIVE. To examine whether a quality improvement initiative aimed at medical providers in school-based health centers would improve the recognition and management of pediatric obesity.PARTICIPANTS AND METHODS. Thirteen school-based health centers, with a total of 22 providers and 6 clinical staff, were enrolled in the study. Quality improvement measures and best medical practices for assessing and treating pediatric obesity were provided during 1 learning collaborative and 2 on-site trainings. Measures included documentation of (1) a BMI percentile, (2) a corresponding weight-category diagnosis, (3) assessing readiness to change, (4) assessing readiness to change for patients with a BMI at Ն85th percentile, and (5) addressing 4 key messages that enhance a healthy lifestyle. RESULTS.Results of paired-sample t tests indicate that all 5 variables significantly increased from baseline to the midpoint data collection. From midpoint to the final data collection, documentation of BMI percentile and key messages increased, although not significantly. Documentation of weight-category diagnosis and readiness to change for patients with a BMI at Ն85th percentile decreased significantly, whereas documentation of readiness to change decreased, but not significantly.CONCLUSIONS. This study offers promising evidence that school-based health center providers trained in a quality improvement initiative demonstrate consistent improvement in implementing the guidelines for treatment of pediatric overweight. In response to the problem of obesity in children and youth, the governor of New Mexico, Bill Richardson, doubled the number of school-based health centers (SBHCs), creating at least 1 in every county (a total of 68 state-funded SBHCs). During the 2007 fiscal year, SBHCs in New Mexico provided care to ϳ35 400 children and adolescents. 2 An SBHC is a clinic based on school property that provides care to students during the school day. The model of health care is different from that of a typical physician's office or urgent care center. The team that provides care consists of both a medical provider and a mental/behavioral health provider and may include a health educator, nutritionist, and others. The medical provider is typically a nurse practitioner or physician's assistant. At the initial visit, each student is asked to fill out a comprehensive health assessment that includes questions about all of the major risk categories including nutrition, physical activity, home situation, risk for suicide and depression, pregnancy, and substance abuse. SBHCs are changing how school-aged children receive health care by focusing on prevention, early intervention, and access to care.Primary care providers have few tools for confronting the epidemic of obesity and are often hampered by a lack of knowledge, skills, and tools for dealing with their overweight and obese patients. 3 Many medical providers have never received specific training in counseling patients about obesity, diet, and exercise and are unfamiliar with recent nat...

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