Clinical Practice Guidelines
These Clinical Practice Guidelines for Behavioral Health Treatment of Children and Youth, and their Families is to provide evidence-informed and culturally-responsive recommendations to improve the assessment, diagnosis, and treatment of mental health conditions in children and adolescents in San Francisco, where we serve primarily BIPOC clients including Latina/o/x/e; Black/African American; and Asian American, native Hawaiian, and Pacific Islander communities. Evidence-based treatments and practices are challenging to implement with fidelity in diverse communities and community mental health settings (Huey & Polo, 2008). As such, there is a need to ensure evidence-based practices are culturally adapted and made culturally-responsive (Bernal & Sáez-Santiago, 2006). The vision is for all youth, especially those from historically marginalized communities, to have equitable access to high-quality, effective, and culturally-affirming behavioral healthcare that leads to positive outcomes and addresses disparities.
These guidelines aim to synthesize current research and expertise from organizations like the American Psychological Association (APA), American Academy of Child and Adolescent Psychiatry (AACAP), American Academy of Pediatrics (AAP), National Institute of Mental Health (NIMH), the Child Mind Institute, and Substance Abuse and Mental Health Services Administration (SAMHSA) to inform clinical decision-making and establish standards of care that promote health equity. The rationale is that implementing clinical practice guidelines can enhance the appropriateness, quality, and consistency of care delivered across diverse settings and populations. The goal is to promote the wellbeing of children, youth, and families by optimizing mental healthcare practices in a culturally-responsive manner.
Please scroll down this page or click the following to access the practice guidelines:
Anxiety Intervention Clinical Practice Guidelines
1. Assessment
Conduct comprehensive assessment to establish diagnosis, comorbid conditions, symptom severity, child temperament and attachment history, trauma exposures, family context, developmental factors, and strengths/resilience.
Use clinical interviews.
Use rating scales.
Rule out medical causes.
Track outcomes over time.
2. Psychoeducation
Provide psychoeducation on anxiety to the client and their family.
Explain anxiety diagnosis, rationale for treatment, options for treatment, and prognosis.
Psychoeducation video series on anxiety and treatment for very young children:
Set reasonable expectations
Empower families to actively participate in treatment planning.
3. CBT Intervention
Cognitive Behavioral Therapy (CBT) has the strongest empirical support as the first-line psychological treatment.
Use CBT Models such as Coping Cat or C.A.T. Project (Kendall, 2006), or Transdiagnostic CBT Models such as F.I.R.S.T. (Weisz & Bearman, 2020)
Use Play-Based CBT for young children
CYF Training on a Transdiagnostic CBT Model for Anxiety is offered annually.
Deliver CBT individually or in groups over 12-16 sessions.
Incorporate strategies to increase parent/caregiver involvement. Coach them in CBT skills, and encourage modeling of approach behaviors.
Tailor treatment to developmental level, family context, culture, and preferences.
4. Other Interventions
For severe anxiety and marked impairment, combine CBT with an SSRI antidepressant. SSRIs are first-line medications due to efficacy and safety data.
Coordinate care closely with schools, medical providers, and community resources.
For inadequate progress, first optimize treatment fidelity, family engagement, and address comorbidities. Then consider adding meds, alternate CBT protocols, parent/family therapy, psychodynamic approaches, or group interventions.
Reassess symptoms and adjust treatment plan accordingly.
Transition to maintenance phase with periodic booster CBT sessions as indicated.
Practice Guides
Find below comprehensive practice guidelines from major professional organizations
Depression Intervention Clinical Practice Guidelines
1. Assessment
Conduct thorough biopsychosocial assessment including clinical interview, review of symptoms, family history, psychosocial factors, and suicide risk.
Use clinical interviews.
Use rating scales.
Rule out medical causes.
Track outcomes over time.
2. Psychoeducation
Provide psychoeducation to client and family about depression and evidence-based treatment options.
Set reasonable expectations
Empower families to actively participate in treatment planning.
3. Interventions
Evidence-based psychotherapies such as Cognitive Behavioral Therapy (CBT), Interpersonal Therapy (IPT), or family therapy (e.g., ABFT) are first-line treatment for adolescents. There is insufficient evidence to recommend specific psychotherapy for children.
Consider the use of Transdiagnostic CBT Models such as F.I.R.S.T. (Weisz & Bearman, 2020)
Use Play-Based CBT for young children
Monitor for treatment response, side effects, and suicide risk regularly in first 6 weeks and ongoing.
Incorporate strategies to increase parent/caregiver involvement.
Adapt treatment planning and monitoring based on developmental stage and diversity factors
4. Other Interventions
For moderate-severe depression, recommend pharmacotherapy with selective serotonin reuptake inhibitor (SSRI) concurrently with psychotherapy.
Assess for suicide risk at every visit and implement safety plan if needed.
Coordinate care across treatment team including mental health provider(s), primary care provider, school supports, and family.
Continue maintenance treatment for 6-12 months after remission of acute symptoms
Practice Guides
Suicide Prevention and Intervention Clinical Practice Guidelines
1. Assessment
Conduct universal screening for suicide risk using a validated tool like the Ask Suicide-Screening Questions (ASQ), the Columbia Suicide Severity Rating Scale (C-SSRS), or the Patient Health Questionnaire-9 Modified for Teens (PHQ-A):
You can also use the Crisis Assessment Tool (CAT-SF), which has a Level of Care (LoC) Decision Support Tool
Use the Cultural Assessment for Risk of Suicide Measure-Adolescents (CARS-A) for BIPOC and LGBTQIA2S+ Youth
For positive screens, complete a comprehensive suicide risk assessment evaluating current suicidal ideation, intent, plans and means. Also assess past suicide attempts and non-suicidal self-injury
2. Psychoeducation
Provide psychoeducation to client and family about causes, risk factors, warning signs and treatments for suicidality and self-harm.
Provide families with information on warning signs:
Educate families on the importance of lethal means restriction, safety planning, monitoring youth behaviors, and supporting participation in treatment.
Provide families with a list of national and local resources
3. Safety Planning
Address any immediate safety concerns.
Develop a safety plan collaboratively with the client and family, outlining coping strategies and sources of support. Include means restriction and 24/7 crisis phone numbers. Update regularly.
SAFETY-Acute, is a developmentally-informed safety planning family intervention for youth.
Other options include increased monitoring or supervision, removing access to lethal means, and hospitalization if high risk.
Tailor treatment to developmental level, family context, culture, and preferences.
4. Other Interventions
Use evidence-based therapies tailored to client needs, such as:
Dialectical Behavior Therapy (DBT), specifically the DBT-A module for adolescents, which has demonstrated effectiveness for reducing suicidal ideation and self-harm behaviors.
Cognitive Behavioral Therapy (CBT) focused on problem-solving skills training and building reasons for living
Monitor symptoms and modify treatment plan as needed. Continue follow-up contacts after crisis resolution.
Practice Guides
Trauma-Focused Intervention Clinical Practice Guidelines
1. Assessment
Conduct a thorough trauma-informed assessment including questions about trauma exposure and PTSD symptoms as part of routine evaluations. Obtain information from multiple informants including child/youth and parents/caregivers.
Screen for exposure to multiple, chronic, and prolonged trauma to assess for complex trauma.
Assess experiences of race-based trauma, discrimination, or ethnic violence. You can use the UConn Racial/Ethnic Stress & Trauma Scale (UnRESTS).
If screening is positive, conduct a formal evaluation to determine presence of PTSD/complex trauma, symptom severity, degree of functional impairment, and differential diagnosis. Use validated structured interviews and rating scales
Consider differential diagnoses that may mimic PTSD symptoms such as ADHD, depression, anxiety disorders, and physical conditions.
Conduct medical evaluation for somatic complaints.
Track outcomes over time.
2. Psychoeducation
Provide education to the child/youth and family about common trauma reactions and the process of recovery.
Normalize symptoms as adaptive coping attempts
Teach about the process of recovery
Discuss available treatment options
Set reasonable expectations
Empower families to actively participate in treatment planning.
3. Interventions
Trauma-focused CBT (TF-CBT) should be considered a first-line treatment. It facilitates processing of traumatic memories and faulty trauma-related cognitions through anxiety management, trauma exposure, cognitive restructuring, and parenting skills training.
Integrative Treatment of Complex Trauma for Adolescents (ITCT-A) is a component-based, assessment-driven, multi-modal treatment.
Child-Parent Psychotherapy (CPP) is a dyadic treatment facilitating joint trauma narrative creation and addressing attachment disruptions in very young children.
Prolonged Exposure Therapy (PET) involves repeated exposure to trauma reminders in a safe environment to reduce fear and avoidance.
Tailor treatment to developmental level, family context, culture, and preferences.
4. Other Interventions
Narrative Exposure Therapy facilitates organization and integration of traumatic memories through repeated re-telling of coherent narratives.
Consider psychodynamic play therapy, and expressive arts approaches appropriate to age and development.
Eye Movement Desensitization and Reprocessing (EMDR) utilizes bilateral stimulation to integrate traumatic experiences.
Provide integrated treatment for any comorbid disorders. Use evidence-based models such as Seeking Safety for PTSD with SUD.
Medications such as SSRIs may be used as adjunctive treatment for severe symptoms.
Monitor symptoms, functioning, risk factors, and treatment progress continually.
Practice Guides
ADHD Intervention Clinical Practice Guidelines
1. Assessment
Conduct a clinical interview with parents/caregivers, teachers, and child/adolescent to gather developmental, medical, family, social, school, and mental health history.
Obtain rating scales or checklists from parents, teachers, and youth to quantify and characterize ADHD symptoms and impairment across settings. Recommended evidence-based scales include the ADHD Rating Scale-5, Conners 3, and Vanderbilt ADHD Diagnostic Rating Scales
Screen for common comorbid conditions including learning disabilities, developmental delay, depression, anxiety, ODD, substance use.
Review academic records and conduct cognitive, achievement or other neuropsychological testing as needed to assess learning.
Rule out alternative causes or mimics of ADHD symptoms.
2. Psychoeducation
Provide education about ADHD to clients, families, and teachers to promote understanding and improve treatment outcomes.
Psychoeducation should cover ADHD symptoms, developmental course, impairments, causes like biology rather than parenting, treatment options like behavioral approaches and medications, the importance of structure and routines at home, emotional impact and self-esteem, partnering with schools for academic support, and making healthy lifestyle choices.
Providing education about ADHD promotes greater understanding and aids treatment.
Set reasonable and developmentally appropriate expectations.
Empower families to actively participate in treatment planning.
3. Interventions
A multimodal approach is recommended for ADHD treatment.
Behavioral interventions like parent training, classroom accommodations, and organizational skills training provide environmental supports and teach compensatory strategies.
Behavioral Parent Training are manualized programs that teach parents and caregivers strategies for reinforcing positive behaviors and reducing problematic behaviors. Parents or caregivers attend weekly training sessions over several months.
Classroom Behavioral Interventions are accommodations implemented by teachers in the classroom, such as a daily report card, planned ignoring of minor misbehaviors, and preferential seating near the teacher.
4. Other Interventions
First-line medication options include stimulants like methylphenidate and amphetamines as well as non-stimulants like atomoxetine, guanfacine and clonidine.
Ongoing communication between the prescriber, family, teachers and clinician is key to successful medication management.
Additional therapies such as cognitive behavioral therapy, mindfulness, family therapy, or social skills training may also be beneficial.
Treatment should be tailored to the individual's symptoms, impairments, preferences, culture, and access to services.
Monitoring should track symptoms, impairments, treatment response, medication effects, academic progress, emergence of comorbidities, and social functioning.
Practice Guides
