Evolution of child mental health services in primary care

Predicting Adolescent Depression and Suicide Risk Based on Preadolescent Behavioral Health Screening in Primary Care

OBJECTIVE

To examine the degree to which a broadband behavioral health screener administered in preadolescence in primary care (PC) could serve as an early risk indicator for depression and suicide risk in adolescence.

METHODS

Participants included 9329 patients who attended well visits at 9 and 12 years old in a large pediatric PC network. The sample was 49% female, 64% White, 18% Black, 4% Asian, 14% other races, and 6% Hispanic/Latinx. Caregivers completed the Pediatric Symptom Checklist (PSC-17) about their child at age 9; youth completed the Patient Health Questionnaire-9 Modified for Teens (PHQ-9-M) at age 12.

RESULTS

After adjusting for demographic covariates, patients scoring above the risk cutoffs on the PSC-17 total scale and subscales (internalizing, externalizing, and attention) at age 9 had significantly greater odds of elevated depression and/or suicide risk on the PHQ-9-M at age 12 (odds ratios: 2.41-4.23, P < .001). Approximately one third of patients with depression (sensitivity: 37.1%) or suicide (sensitivity: 33.3%) risk at age 12 were identified as at risk on the PSC-17 at age 9.

CONCLUSIONS

Results suggest that the PSC-17, a well-researched screener widely used in pediatrics, has moderate predictive value with respect to depression and suicide risk during adolescence. More research is needed on the feasibility and potential benefits of broadband behavioral health screening in preadolescence to promote early identification and prevention efforts.

The Influence of Project ECHO and Integrated Behavioral Health in Primary Care on Emergency Department Visits Among Youth Diagnosed with Depression

Rates of depression among youth and emergency department (ED) visits for un- or under-treated symptoms are on the rise. Early identification and treatment of depression is imperative at the patient, program, system, and population levels. This paper examines the individual and cumulative impact of Project ECHO and the inclusion of IBH services in pediatric primary care practices on mental health-related ED rates among youth diagnosed with depression for those practices. Twenty-eight practices participated and provided data on 5,388 patients diagnosed with depression who were seen between 2019 and 2022. A binominal mixed effect model was used to examine the impact of Project ECHO and IBH on mental health-related ED rates among youth diagnosed with depression per month within each practice. Compared to practices without an IBH program, those who implemented IBH had a significantly lower rate of mental health-related ED visits among this patient population (Incident Rate Ratio (IRR) = 0.80, p = .005, 95% Confidence Intervale (CI) = 0.68, 0.93). No significant differences were found between practices regardless of participation in Project ECHO, nor was there a significant interaction effect between practices that employed Project ECHO and IBH in combination. This study shows promising results with IBH having a positive impact on practice outcomes compared to treatment as usual, while Project ECHO in isolation or combined with IBH did not significantly affect rates of mental health-related ED visits.

Integrated Behavioral Health: A Guide to Practical Implementation

Integrating behavioral health providers in primary care settings is an effective model for increasing access to mental and behavioral health services for youth. Resources and subject matter experts can be leveraged by pediatric practices to identify the components of a successful model and to support implementation in community practices. Integrated behavioral health approaches vary in scope and components of the models can be selected and implemented to meet the needs of each practice and the patient population served.

Subjective achievement from psychiatry rotation in the Japanese postgraduate residency system: a longitudinal questionnaire study

BACKGROUND

Psychiatry rotation has been mandatory in the Japanese postgraduate residency system since 2020. Some psychiatry-related competency items are stipulated as mandatory for residents. The current study aimed to clarify whether psychiatry rotation affected residents' subjective achievement of these competency items.

METHODS

This longitudinal study was conducted among postgraduate residents who completed a rotation in the psychiatry department at Nagasaki University Hospital across two academic years (2020-2021). The survey was administered at the start and at the end of the psychiatry rotation. Residents evaluated their subjective understanding and confidence regarding initiating treatment for these competency items using a six-point Likert scale. The average scores for each item were compared between pre-rotation and post-rotation.

RESULTS

In total, 99 residents (91.7%) responded to this survey. Residents had significantly higher scores at post-rotation compared with pre-rotation in all psychiatry-related competency items in both subjective understanding and confidence in initiating treatment. Additionally, strong effect sizes were found for many items.

CONCLUSION

Residents improved learning about psychiatry-related competency items through psychiatry rotation. This finding suggests that it is reasonable for psychiatry rotation to be mandatory in the current Japanese postgraduate residency system. The importance of psychiatry is likely to increase in both undergraduate and postgraduate medical education in the future. It is necessary to continuously update educational strategies to meet changing social needs over time. As this study was conducted at a single institution, a multi-center study is needed to expand the current findings.

Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial

BACKGROUND

Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms.

METHODS

We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life.

DISCUSSION

This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.

Adherence to Child Attention-Deficit/Hyperactivity Disorder Treatment Guidelines in Medical Homes-Results from a National Survey

OBJECTIVE

Having primary care delivered through a medical home is believed to improve mental health care delivery to children. Children with attention-deficit/hyperactivity disorder (ADHD) are commonly treated in pediatric practices, yet little is known about ADHD treatment patterns in medical homes. Our objective was to assess for treatment variation depending on parent-perceived medical home (PPMH) status. We hypothesized that having a PPMH would be associated with receiving ADHD treatments recommended by clinical guidelines.

METHODS

We used the 2016 National Survey of Children's Health-a nationally representative cross-sectional survey of children in the United States. Analyses included an unweighted sample of 4,252, representing 5.4 million children aged 3 to 17 years with parent-reported ADHD. Child characteristics were analyzed using descriptive statistics. Associations between ADHD treatment types and PPMH status were assessed using a multinomial logistic regression, adjusting for child characteristics.

RESULTS

Having a PPMH was associated with increased prevalence odds of children's receipt of medications alone for ADHD (vs no treatment). The prevalence odds of receiving behavioral treatment alone (vs medications alone) for ADHD decreased by 43% when children had a PPMH (95% confidence interval, 0.38-0.85, p = 0.01). PPMH status was not associated with a statistically significant difference in prevalence odds of receiving combination treatment (vs medications alone) for pediatric ADHD.

CONCLUSION

Having a PPMH was associated with children's receipt of ADHD medications alone, but not behavioral treatments. Our findings suggest that medical homes may need further improvement to ensure that children with ADHD receive treatments as recommended by clinical guidelines.

Increasing rate of diagnosed childhood mental illness in the United States: Incidence, prevalence and costs

Objective

This study examined the rate and economic burden of pediatric mental illness from 2012 to 2018.

Study design

Observational, retrospective analysis of administrative healthcare data.

Methods

This retrospective study of the MarketScan Commercial Research Database included calendar year-based samples (2012-2018) of children aged 4-17 with continuous medical, pharmacy, and mental health/substance abuse coverage for the year of interest and prior year. Incidence and prevalence rates of overall and specific mental illness diagnoses were calculated based on the appearance of diagnosis codes on claims: alcohol/substance abuse, depression, anxiety, eating disorders, bipolar, schizophrenia, developmental disorders, attention deficit/hyperactivity, and conduct disorders. Annual direct medical costs were compared between children with any mental illness and a matched non-mental illness control population.

Results

Between 2.4 and 4.1 million children qualified for each calendar year sample. From 2012 to 2018, there was a 34.6% increase in the prevalence of mental illness. Attention deficit/hyperactivity, conduct disorders, anxiety, and depression were the most common conditions, while eating disorders, anxiety, and depression presented the greatest increases at 96%, 95%, and 73% respectively. Children with a mental illness incurred significantly greater medical costs compared to matched controls in all years assessed (2018 comparison: $6,055±$27,198 vs. $1,629±$7,274; p < 0.001).

Conclusions

Childhood mental illness diagnoses have increased substantially in the United States from 2012 to 2018. In addition to patient impacts, mental health diagnoses also place a notable burden on the healthcare system via increased medical costs. As mental illness is known to be underdiagnosed, the true rate of mental illnesses among children is likely even greater.

Hospital Readmission of Adolescents and Young Adults With Complex Chronic Disease

IMPORTANCE

Adolescents and young adults (AYA) who have complex chronic disease (CCD) are a growing population that requires hospitalization to treat severe, acute health problems. These patients may have increased risk of readmission as demands on their self-management increase and as they transfer care from pediatric to adult health care practitioners.

OBJECTIVE

To assess variation across CCDs in the likelihood of readmission for AYA with increasing age.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective 1-year cross-sectional study of the 2014 Agency for Healthcare Research and Quality Nationwide Readmissions Database for all US hospitals. Participants were 215 580 hospitalized individuals aged 15 to 30 years with cystic fibrosis (n = 15 213), type 1 diabetes (n = 86 853), inflammatory bowel disease (n = 48 073), spina bifida (n = 7819), and sickle cell anemia (n = 57 622) from January 1, 2014, to December 1, 2014.

EXPOSURES

Increasing age at index admission.

MAIN OUTCOMES AND MEASURES

Unplanned 30-day hospital readmission. Readmission odds were compared by patients' ages in 2-year epochs (with age 15-16 years as the reference) using logistic regression, accounting for confounding patient characteristics and data clustering by hospital.

RESULTS

Of 215 580 participants, 115 982 (53.8%) were female; the median (interquartile range) age was 24 (20-27) years. Across CCDs, multimorbidity was common; the percentages of index hospitalizations with 4 or more coexisting conditions ranged from to 33.4% for inflammatory bowel disease to 74.2% for spina bifida. Thirty-day hospital readmission rates varied significantly across CCDs: 20.2% (cystic fibrosis), 19.8% (inflammatory bowel disease), 20.4% (spina bifida), 22.5% (type 1 diabetes), and 34.6% (sickle cell anemia). As age increased from 15 to 30 years, unadjusted, 30-day, unplanned hospital readmission rates increased significantly for all 5 CCD cohorts. In multivariable analysis, age trends in the adjusted odds of readmission varied across CCDs. For example, for AYA who had cystic fibrosis, the adjusted odds of readmission increased to 1.9 (95% CI, 1.5-2.3) by age 21 years and remained elevated through age 30 years. For AYA who had type 1 diabetes, the adjusted odds of readmission peaked at ages 23 to 24 years (odds ratio, 2.3; 95% CI, 2.1-2.6) and then declined through age 30 years.

CONCLUSIONS AND RELEVANCE

These findings suggest that hospitalized AYA who have CCDs have high rates of multimorbidity and 30-day readmission. The adjusted odds of readmission for AYA varied significantly across CCDs with increasing age. Further attention is needed to hospital discharge care, self-management, and prevention of readmission in AYA with CCD.

Promoção de parentalidade positiva nos cuidados de saúde primários: Formação de profissionais

Objetivo

Compreender o impacto de uma formação breve centrada em estratégias de parentalidade positiva e gestão do comportamento de crianças em idade pré-escolar no aconselhamento realizado por profissionais dos cuidados de saúde primários (CSP).

Método

Participaram 152 profissionais (e.g., enfermeiros, médicos, psicólogos) de unidades dos CSP do distrito de Coimbra, numa ação de formação com duração de nove horas. O nível de satisfação com a formação, as estratégias recomendadas aos pais antes e três meses após a formação e a necessidade de formação percecionada foram avaliados através de três Inventários de Autorreflexão e de um Ficha de Avaliação de Satisfação.

Resultados

Observaram-se níveis elevados de adesão à formação e de satisfação com os respetivos conteúdos e estratégias de ensino/aprendizagem. Os profissionais reportaram ter passado a aconselhar com mais frequência aos pais as estratégias de parentalidade positiva abordadas na formação e referiram a necessidade de formação adicional.

Conclusão

Ações de formação junto de profissionais dos CSP poderão contribuir para preencher uma importante lacuna ao nível da literacia em saúde mental, capacitando estes profissionais de primeira linha para darem uma resposta de maior qualidade e baseada em evidência a questões colocadas pelos pais relativas à gestão do comportamento dos seus filhos.

A Clinical Care Monitoring and Data Collection Tool (H3 Tracker) to Assess Uptake and Engagement in Mental Health Care Services in a Community-Based Pediatric Integrated Care Model: Longitudinal Cohort Study

BACKGROUND

National recommendations for pediatric integrated care models include improved capacity for care coordination and communication across primary care and specialty mental health providers using technology, yet few practical, short-term solutions are available for low-resource, community-based pediatric integrated care clinics.

OBJECTIVE

The goal of the paper is to describe the development and features of a Web-based tool designed for program evaluation and clinician monitoring of embedded pediatric mental health care using a community-partnered approach. In addition, a longitudinal study design was used to assess the implementation of the tool in program evaluation, including clinical monitoring and data collection.

METHODS

Biweekly meetings of the partnered evaluation team (clinic, academic, and funding partners) were convened over the course of 12 months to specify tool features using a participatory framework, followed by usability testing and further refinement during implementation.

RESULTS

A data collection tool was developed to collect clinic population characteristics as well as collect and display patient mental health outcomes and clinical care services from 277 eligible caregiver/child participants. Despite outreach, there was little uptake of the tool by either the behavioral health team or primary care provider.

CONCLUSIONS

Development of the H3 Tracker (Healthy Minds, Healthy Children, Healthy Chicago Tracker) in two community-based pediatric clinics with embedded mental health teams serving predominantly minority children is feasible and promising for on-site program evaluation data collection. Future research is needed to understand ways to improve clinic integration and examine whether promotion of primary care/mental health communication drives sustained use.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02699814; https://clinicaltrials.gov/ct2/show/NCT02699814 (Archived by WebCite at http://www.webcitation.org/772pV5rWW).

I heard it through the grapevine: Where and what parents learn about youth mental health treatments

OBJECTIVE

This study investigates where parents learn about, and what parents know about child mental health services. Parents who are better informed about mental health services may be more likely to utilize services for their children.

METHODS

In a national online survey, 196 parents of children between the ages of 4 and 17 years reported on their information-seeking behaviors and their familiarity and experience with psychosocial approaches.

RESULTS

Parents reported utilizing multiple information sources with mental health providers, pediatricians, and social networks being the most prominent. Parents' trust in different sources varied, with parents generally trusting healthcare professionals the most. Parents exposed to mental health services were more aware of specific therapeutic approaches.

CONCLUSIONS

Data on how parents receive and understand mental health-related information contributes to ongoing dissemination and implementation efforts.

Stepped Care Interpersonal Psychotherapy Treatment for Depressed Adolescents: A Pilot Study in Pediatric Clinics

Adolescents with depression are at risk for negative long-term consequences and recurrence of depression. Many do not receive nor access treatment, especially Latino youth. New treatment approaches are needed. This study examined the feasibility and acceptability of a stepped collaborative care treatment model (SCIPT-A) for adolescents with depression utilizing interpersonal psychotherapy for adolescents (IPT-A) and antidepressant medication (if needed) compared to Enhanced Treatment as Usual (E-TAU) in urban pediatric primary care clinics serving primarily Latino youth. Results suggest the SCIPT-A model is feasible, acceptable and potentially beneficial for urban Latino adolescents. Clinicians delivered the SCIPT-A model with fidelity using supervision successfully implemented in a community setting.

Evaluating Training Programs for Primary Care Providers in Child/Adolescent Mental Health in Canada: A Systematic Review

INTRODUCTION

The need for child/adolescent mental health care in Canada is growing. Primary care can play a key role in filling this gap, yet most providers feel they do not have adequate training. This paper reviews the Canadian literature on capacity building programs in child and adolescent psychiatry for primary care providers, to examine how these programs are being implemented and evaluated to contribute to evidence-based initiatives.

METHODS

A systematic literature review of peer-reviewed published articles of capacity building initiatives in child/adolescent mental health care for primary care practitioners that have been implemented in Canada.

RESULTS

Sixteen articles were identified that met inclusion criteria. Analysis revealed that capacity building initiatives in Canada are varied but rigorous evaluation methodology is lacking. Primary care providers welcome efforts to increase mental health care capacity and were satisfied with the implementation of most programs.

DISCUSSION

Objective conclusions regarding the effectiveness of these programs to increase mental health care capacity is challenging given the evaluation methodology of these studies.

CONCLUSION

Rigorous evaluation methods are needed to make evidence-based decisions on ways forward to be able to build child/adolescent mental health care capacity in primary care. Outcome measures need to move beyond self-report to more objective measures, and should expand the measurement of patient outcomes to ensure that these initiative are indeed leading to improved care for families.

Distress Responses in a Routine Vaccination Context: Relationships to Early Childhood Mental Health

Social and emotional competencies, such as distress regulation, are established in early childhood and are critical for the development of children’s mental health and wellbeing. Routine vaccinations in primary care provide a unique opportunity to relate responses to a universal, relatively standardized, distress regulation paradigm (i.e., pain-related distress) to key developmental outcomes. The current study sought to examine distress regulation during routine vaccination in infancy and preschool as predictors of outcomes related to socioemotional competence in preschool. It was hypothesized that children with poorer distress regulation abilities post-vaccination would have lower socioemotional development. Furthermore, it was hypothesized that insensitive parenting would exacerbate this relationship for children with poor distress regulation abilities. As part of an ongoing longitudinal cohort, 172 parent–child dyads were videotaped during vaccinations in infancy and preschool, and subsequently participated in a full-day psychological assessment in a university lab. Videotapes were coded for child pre-needle distress (baseline distress), immediate post-needle pain-related distress reactivity (immediate distress reactivity), and pain-related distress regulation (distress regulation). Parent sensitivity during the preschool vaccination was also coded. Baseline distress prior to vaccination predicted greater externalizing problems and behavioral symptoms. Parent sensitivity did not moderate the association between any child distress behaviors and socioemotional development indicators. Child distress behaviors prior to injection, regardless of parent behavior, during the vaccination context may provide valuable information to health care professionals about child socioemotional functioning in the behavioral and emotional domains.

Integrated Behavioral Health in Pediatric Primary Care

There are multiple barriers to accessing high quality, evidence-based behavioral health care for children and adolescents, including stigma, family beliefs, and the significant paucity of child and adolescent psychiatrists. Although equal access continues to be an unmet need in the USA, there is growing recognition that integrated behavioral health services in pediatric primary care have the potential to reduce health disparities and improve service utilization. In a joint position paper, the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) highlighted the multiple benefits of children receiving initial behavioral health screening, assessment, and evidence-based behavioral health treatments in the medical home. The purpose of this paper is to review the current state of the literature related to integrated behavioral health services in pediatric primary care. Specifically, innovative models of integrated behavioral health care are discussed.

Advancing the Measurement of Care Coordination in Pediatric Behavioral Health

OBJECTIVE

To describe the measure review and evaluation process used to identify new measures of care coordination for children with behavioral health needs conducted as part of Massachusetts' Children's Health Insurance Program Reauthorization Act Quality Demonstration Grant.

METHOD

The Massachusetts Child Health Quality Coalition identified a shortage of pediatric measures of care coordination in behavioral health. After an extensive literature review, the Measure Development Committee applied the Care Coordination Key Elements Framework (Framework), which was designed as part of the grant work, and used a modified RAND Delphi method to conduct feasibility and validity evaluation and propose the new candidate measures for further rigorous testing.

RESULTS

Thirty-two measures were evaluated. One existing Healthcare Effectiveness Data and Information Set and 8 newly proposed measures met the criteria for feasibility and reliability. These measures represented each of the key elements contained in the Framework. The measures need further testing to ensure scientific acceptability and wide usability.

CONCLUSION

A multipronged methodology was used to propose measures of care coordination in the space of pediatric behavioral health to fill the identified gaps in existing measures.

Future Directions for the Implementation and Dissemination of Statewide Developmental-Behavioral Pediatric Integrated Health Care

The integration of mental health and pediatric health care services has long been a goal for both research and practice. With the advent of federal policies developed to mandate clinical efficiency across the health care spectrum, this issue is becoming more salient. Applied literature on this topic is only recently emerging, however, and there are limited contextual examples to guide program development, research, and refinement. This article presents background information relevant to the development of such a program (the Center for Advancement of Youth). The cultural and organizational contexts for the project are discussed, with particular emphasis on models for cooperation among several institutions of varying size and scope. The implications for the future of tangible research in this area are also discussed, with attention to extending lessons learned to diverse settings motivated to integrate various aspects of health care service provision.

Comparison of Health Care Spending and Utilization Among Children With Medicaid Insurance

BACKGROUND AND OBJECTIVES

Opportunities to improve health care quality and contain spending may differ between high and low resource users. This study's objectives were to assess health care and spending among children with Medicaid insurance by their resource use.

METHODS

Retrospective cross-sectional analysis of 2012 Medicaid health administrative data from 10 states of children ages 11 months to 18 years. Subjects were categorized into 4 spending groups, each representing ∼25% of total spending: the least expensive 80% of children (n = 2,868,267), the next 15% expensive (n = 537,800), the next 4% expensive (n = 143,413), and the top 1% (n = 35,853). We compared per-member-per-month (PMPM) spending across the groups using the Kruskal-Wallis test.

RESULTS

PMPM spending was $68 (least expensive 80%), $349 (next 15%), $1200 (next 4%), and $6738 (top 1%). Between the least and most expensive groups, percentages of total spending were higher for inpatient (<1% vs 46%) and mental health (7% vs 24%) but lower for emergency (15% vs 1%) and primary (23% vs 1%) care (all Ps < .001). From the least to most expensive groups, increases in PMPM spending were smallest for primary care (from $15 to $33) and much larger for inpatient ($0.28 to $3129), mental health ($4 to $1609), specialty care ($8 to $768), and pharmacy ($4 to $699).

CONCLUSIONS

As resource use increases in children with Medicaid, spending rises unevenly across health services: Spending on primary care rises modestly compared with other health services. Future studies should assess whether more spending on primary care leads to better quality and cost containment for high resource users.

Effect of Pediatric Behavioral Health Screening and Colocated Services on Ambulatory and Inpatient Utilization

OBJECTIVE

The study sought to determine the impact of a pediatric behavioral health screening and colocation model on utilization of behavioral health care.

METHODS

In 2003, Cambridge Health Alliance, a Massachusetts public health system, introduced behavioral health screening and colocation of social workers sequentially within its pediatric practices. An interrupted time-series study was conducted to determine the impact on behavioral health care utilization in the 30 months after model implementation compared with the 18 months prior. Specifically, the change in trends of ambulatory, emergency, and inpatient behavioral health utilization was examined. Utilization data for 11,223 children ages ≥4 years 9 months to <18 years 3 months seen from 2003 to 2008 contributed to the study.

RESULTS

In the 30 months after implementation of pediatric behavioral health screening and colocation, there was a 20.4% cumulative increase in specialty behavioral health visit rates (trend of .013% per month, p=.049) and a 67.7% cumulative increase in behavioral health primary care visit rates (trend of .019% per month, p<.001) compared with the expected rates predicted by the 18-month preintervention trend. In addition, behavioral health emergency department visit rates increased 245% compared with the expected rate (trend .01% per month, p=.002).

CONCLUSIONS

After the implementation of a behavioral health screening and colocation model, more children received behavioral health treatment. Contrary to expectations, behavioral health emergency department visits also increased. Further study is needed to determine whether this is an effect of how care was organized for children newly engaged in behavioral health care or a reflection of secular trends in behavioral health utilization or both.

Detecting initiation or risk for initiation of substance use before high school during pediatric well-child check-ups

BACKGROUND

Youth substance use (SU) is prevalent and costly, affecting mental and physical health. American Academy of Pediatrics and Affordable Care Act call for SU screening and prevention. The Youth Risk Index(©) (YRI) was tested as a screening tool for having initiated and propensity to initiate SU before high school (which forecasts SU disorder). YRI was hypothesized to have good to excellent psychometrics, feasibility and stakeholder acceptability for use during well-child check-ups.

DESIGN

A high-risk longitudinal design with two cross-sectional replication samples, ages 9-13 was used. Analyses included receiver operating characteristics and regression analyses.

PARTICIPANTS

A one-year longitudinal sample (N=640) was used for YRI derivation. Replication samples were a cross-sectional sample (N=345) and well-child check-up patients (N=105) for testing feasibility, validity and acceptability as a screening tool.

RESULTS

YRI has excellent test-retest reliability and good sensitivity and specificity for concurrent and one-year-later SU (odds ratios=7.44, CI=4.3-13.0) and conduct problems (odds ratios=7.33, CI=3.9-13.7). Results were replicated in both cross-sectional samples. Well-child patients, parents and pediatric staff rated YRI screening as important, acceptable, and a needed service.

CONCLUSIONS

Identifying at-risk youth prior to age 13 could reap years of opportunity to intervene before onset of SU disorder. Most results pertained to YRI's association with concurrent or recent past risky behaviors; further replication ought to specify its predictive validity, especially adolescent-onset risky behaviors. YRI well identifies youth at risk for SU and conduct problems prior to high school, is feasible and valid for screening during well-child check-ups, and is acceptable to stakeholders.

The medical home and integrated behavioral health: advancing the policy agenda

There has been a considerable expansion of the patient-centered medical home model of primary care delivery, in an effort to reduce health care costs and to improve patient experience and population health. To attain these goals, it is essential to integrate behavioral health services into the patient-centered medical home, because behavioral health problems often first present in the primary care setting, and they significantly affect physical health. At the 2013 Patient-Centered Medical Home Research Conference, an expert workgroup convened to determine policy recommendations to promote the integration of primary care and behavioral health. In this article we present these recommendations: Build demonstration projects to test existing approaches of integration, develop interdisciplinary training programs to support members of the integrated care team, implement population-based strategies to improve behavioral health, eliminate behavioral health carve-outs and test innovative payment models, and develop population-based measures to evaluate integration.

Promoting optimal development: screening for behavioral and emotional problems

By current estimates, at any given time, approximately 11% to 20% of children in the United States have a behavioral or emotional disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Between 37% and 39% of children will have a behavioral or emotional disorder diagnosed by 16 years of age, regardless of geographic location in the United States. Behavioral and emotional problems and concerns in children and adolescents are not being reliably identified or treated in the US health system. This clinical report focuses on the need to increase behavioral screening and offers potential changes in practice and the health system, as well as the research needed to accomplish this. This report also (1) reviews the prevalence of behavioral and emotional disorders, (2) describes factors affecting the emergence of behavioral and emotional problems, (3) articulates the current state of detection of these problems in pediatric primary care, (4) describes barriers to screening and means to overcome those barriers, and (5) discusses potential changes at a practice and systems level that are needed to facilitate successful behavioral and emotional screening. Highlighted and discussed are the many factors at the level of the pediatric practice, health system, and society contributing to these behavioral and emotional problems.

Psychiatric Services

Deinstitutionalization in the 1960s shifted the care of the mentally ill from state-funded institutions to community settings. Unfortunately, funding to support the treatment needs of this population has continued to be minimized, and countless individuals have not received much needed care. This has resulted in a large increase in mentally ill patients surfacing in jails, homeless shelters, and emergency departments. Subsequently, the federal government has begun to prioritize funding to address the mental health needs of our communities. Pharmacists are in a unique position to influence treatment outcomes for patients with mental illnesses, and the current state of health reform provides avenues for the pharmacist to become an essential part of the health care delivery team in numerous ambulatory care clinical settings. The challenges with adherence, medical and psychiatric comorbidities, polypharmacy with psychotropics, potential for life-threatening adverse effects, and the ever-present need for patient education are but a few reasons why pharmacists can be utilized to provide Medication Therapy Management services for these patients.

The current and ideal state of mental health training: pediatric resident perspectives

PHENOMENON: Mental health (MH) problems are prevalent in the pediatric population, and in a setting of limited resources, pediatricians need to provide MH care in the primary medical home yet are uncomfortable doing so citing a lack of training during residency as one barrier.

APPROACH

The purpose of this study is to describe pediatric residents' experiences and perspectives on the current and ideal states of MH training and ideas for curriculum development to bridge this gap. A qualitative study using focus groups of pediatric residents from an urban academic medical center was performed. Audio recordings were transcribed and analyzed using a grounded theory approach.

FINDINGS

Twenty-six residents participated in three focus groups, which is when thematic saturation was achieved. The team generated five major themes: capabilities, comfort, organizational capacity, coping, and education. Residents expressed uncertainty at every step of an MH visit. Internal barriers identified included low levels of comfort and negative emotional responses. External barriers included a lack of MH resources and mentorship in MH care, or an inadequate organizational capacity. These internal and external barriers resulted in a lack of perceived capability in handling MH issues. In response, residents reported inadequate coping strategies, such as ignoring MH concerns. To build knowledge and skills, residents prefer educational modalities including didactics, experiential learning through collaborations with MH specialists, and tools built into patient care flow. Insights: Pediatric residency programs need to evolve in order to improve resident training in MH care. The skills and knowledge requested by residents parallel the American Academy of Pediatrics statement on MH competencies. Models of collaborative care provide similar modalities of learning requested by residents. These national efforts have not been operationalized in training programs yet may be useful for curriculum development and dissemination to enhance trainees' MH knowledge and skills to provide optimal MH care for children.

Brief approaches to developmental-behavioral promotion in primary care: updates on methods and technology

Well-child visits are a critical opportunity to promote learning and development, encourage positive parenting practices, help children acquire behavioral self-control, enhance the development and well-being of children and their families, identify problems not amenable to brief in-office counseling, and refer for services when needed. This article outlines the communication skills, instructional methods, and resource options that enable clinicians to best assist families. Also covered is how to monitor progress and outcomes. A total of 239 articles and 52 Web sites on parent/patient education were reviewed for this study. Providers require a veritable armamentarium of instructional methods. Skills in nonverbal and verbal communication are needed to elicit the parent/patient agenda, winnow topics to a manageable subset, and create the "teachable moment." Verbal suggestions, with or without standardized spoken instructions, are useful for conveying simple messages. However, for complex issues, such as discipline, it is necessary to use a combination of verbal advice, written information, and "teach-back," aided by role-playing/modeling or multimedia approaches. Selecting the approaches most likely to be effective depends on the topic and family characteristics (eg, parental literacy and language skills, family psychosocial risk and resilience factors, children's developmental-behavioral status). When providers collaborate well (with parents, patients, and other service providers) and select appropriate educational methods, families are better able to act on advice, leading to improvements in children's well-being, health, and developmental-behavioral outcomes. Provided are descriptions of methods, links to parenting resources such as cell phone applications, Web sites (in multiple languages), interactive technology, and parent training courses.

The integration of behavioral health interventions in children's health care: services, science, and suggestions

Because the integration of mental or behavioral health services in pediatric primary care is a national priority, a description and evaluation of the interventions applied in the healthcare setting is warranted. This article examines several intervention research studies based on alternative models for delivering behavioral health care in conjunction with comprehensive pediatric care. This review describes the diverse methods applied to different clinical problems, such as brief mental health skills, clinical guidelines, and evidence-based practices, and the empirical outcomes of this research literature. Next, several key treatment considerations are discussed to maximize the efficiency and effectiveness of these interventions. Some practical suggestions for overcoming key service barriers are provided to enhance the capacity of the practice to deliver behavioral health care. There is moderate empirical support for the feasibility, acceptability, and clinical utility of these interventions for treating internalizing and externalizing behavior problems. Practical strategies to extend this work and address methodological limitations are provided that draw upon recent frameworks designed to simplify the treatment enterprise (e.g., common elements). Pediatric primary care has become an important venue for providing mental health services to children and adolescents due, in part, to its many desirable features (e.g., no stigma, local setting, familiar providers). Further adaptation of existing delivery models may promote the delivery of effective integrated interventions with primary care providers as partners designed to address mental health problems in pediatric healthcare.

The integration of behavioral health interventions in children's health care: services, science, and suggestions

Because the integration of mental or behavioral health services in pediatric primary care is a national priority, a description and evaluation of the interventions applied in the healthcare setting is warranted. This article examines several intervention research studies based on alternative models for delivering behavioral health care in conjunction with comprehensive pediatric care. This review describes the diverse methods applied to different clinical problems, such as brief mental health skills, clinical guidelines, and evidence-based practices, and the empirical outcomes of this research literature. Next, several key treatment considerations are discussed to maximize the efficiency and effectiveness of these interventions. Some practical suggestions for overcoming key service barriers are provided to enhance the capacity of the practice to deliver behavioral health care. There is moderate empirical support for the feasibility, acceptability, and clinical utility of these interventions for treating internalizing and externalizing behavior problems. Practical strategies to extend this work and address methodological limitations are provided that draw upon recent frameworks designed to simplify the treatment enterprise (e.g., common elements). Pediatric primary care has become an important venue for providing mental health services to children and adolescents due, in part, to its many desirable features (e.g., no stigma, local setting, familiar providers). Further adaptation of existing delivery models may promote the delivery of effective integrated interventions with primary care providers as partners designed to address mental health problems in pediatric healthcare.

The impact of long-acting medications on attention-deficit/hyperactivity disorder treatment disparities

OBJECTIVE

Long-acting stimulants have increased medication adherence for many children diagnosed with attention deficit/hyperactivity disorder (ADHD), but it is unknown whether the increase has been similar across racial/ethnic groups. Our objective was to determine whether differences in medication utilization and adherence among white, black, and Hispanic ADHD-diagnosed children and adolescents narrowed following the introduction of long-acting stimulants in the 1990s.

METHODS

We conducted a retrospective analysis of Florida Medicaid claims data from fiscal years 1996-2005. At each of three cross sections, we identified children and adolescents 3-17 years of age with at least two claims with an ADHD diagnosis. We used linear regression to model disparities over the study period in utilization of any ADHD medications (utilization of long-acting medication specifically) and medication adherence, and identified patient level, treatment setting, and geographic contributors to disparities.

RESULTS

Although ADHD medication utilization was lower for ADHD-diagnosed minorities than whites in all years, minorities were as likely as whites to switch to long-acting medications. The increase in prescribed days following long-acting medication diffusion was comparable for white and black medication users (40 and 43 days, respectively), but lower for Hispanics (27 days). Geography and provider setting helped to explain disparities in medication utilization overall, but disparities in adherence were not explained by any of the covariates.

CONCLUSIONS

Despite equivalent switching to long-acting medications in the study period, minorities continued to utilize all ADHD medications less than did whites, and for shorter periods. Provider setting helps explain the ADHD medication utilization gap. High-volume, minority-serving providers are potential targets for future interventions related to improved communication about medication and follow-up after medication initiation.

Mental health communications skills training for medical assistants in pediatric primary care

Paraprofessional medical assistants (MAs) could help to promote pediatric primary care as a source of mental health services, particularly among patient populations who receive disparate mental health care. This project piloted a brief training to enhance the ability of MAs to have therapeutic encounters with Latino families who have mental health concerns in pediatric primary care. The evaluation of the pilot found that MAs were able to master most of the skills taught during the training, which improved their ability to have patient-centered encounters with families during standardized patient visits coded with the Roter Interaction Analysis System. Parents interviewed 1 and 6 months following the training were more than twice as willing as parents interviewed 1 month before the training to discuss mental health concerns with MAs, and they had better perceptions of their interactions with MAs (all p < 0.01) even after controlling for a range of patient and visit characteristics. Before training, 10.2% of parents discussed a mental health concern with the MA but not the physician; this never happened 6 months after training. This pilot provides preliminary evidence that training MAs holds potential to supplement other educational and organizational interventions aimed at improving mental health services in pediatric primary care, but further research is necessary to test this type of training in other settings and among different patient populations.

John K. Referral Patterns and Training Needs in Psychiatry among Primary Care Physicians in Canadian Rural/Remote Areas

OBJECTIVES

This study examined the referral patterns of rural/remote primary care physicians (PCPs) as well as their needs and interests for further training in child/adolescent mental health.

METHODS

Surveys were mailed to Canadian rural/remote PCPs requesting participants' demographic information, training and qualifications, referral patterns, and identification of needs and interests for continuing medical education (CME).

RESULTS

PCPs were most likely to refer to mental health programs, and excessive wait times are the most common deterrent. Major reasons for referral were to obtain recommendations regarding medications and assessing non-responsive patients. While PCPs expressed higher levels of confidence in making appropriate referrals, they were much less confident in their knowledge and skills in managing mental health problems. Professional development in child/adolescent psychiatry is a moderate or highly perceived CME need. Overall, attention deficit/hyperactivity disorder (ADHD) was the most commonly chosen topic of interest and CME in the community was preferred, but some regional differences emerged.

CONCLUSIONS

PCPs viewed limited community resources and self-identified gaps in skills as barriers to service provision. Professional development in child and adolescent mental health for PCPs by preferred modes appears desired.

Moderators and predictors of clinical outcome in a randomized trial for behavior problems in pediatric primary care

OBJECTIVES

To evaluate putative moderator, predictor, and treatment parameter variables in relation to three outcomes in a clinical trial that compared a modular protocol for on-site, nurse-administered intervention (PONI) and enhanced usual care (EUC) for pediatric behavioral problems in primary care.

METHODS

Patients were 163 clinically referred children for behavior problems in six primary care offices. PONI consisted of seven treatment modules adapted from prior treatment trials with this population, whereas EUC involved a facilitated referral to a community provider. Outcome measures were based on standardized scales reflecting one parent-rated aggregate (child dysfunction) and one child-rated aggregate (child health), and diagnostic interviews with both informants (remission in oppositional defiant disorder).

RESULTS

Moderator analyses revealed that PONI was more effective than EUC in reducing child dysfunction by 12-month follow-up among Caucasian children, whereas EUC was more effective than PONI among non-Caucasian children. In the full sample, child health improvement was predicted by the severity of the child's depression and anxiety, and level of family conflict. Duration of child exposure to cognitive-behavioral treatment in PONI was related to greater improvement in overall child health, but other treatment parameters were unrelated to outcome.

CONCLUSIONS

These few significant relationships notwithstanding the findings indicate that the two treatments had robust effects on several outcomes and across selected child, parent, family, and treatment variables. The findings extend efforts to incorporate mental health services in pediatric practice.

Educating residents in behavioral health care and collaboration: integrated clinical training of pediatric residents and psychology fellows

Pediatric residency practices face the challenge of providing both behavioral health (BH) training for pediatricians and psychosocial care for children. The University of Rochester School of Medicine and Dentistry and Rochester General Hospital developed a joint training program and continuity clinic infrastructure in which pediatric residents and postdoctoral psychology fellows train and practice together. The integrated program provides children access to BH care in a primary care setting and gives trainees the opportunity to integrate collaborative BH care into their regular practice routines. During 1998-2008, 48 pediatric residents and 8 psychology fellows trained in this integrated clinical environment. The program's accomplishments include longevity, faculty and fiscal stability, sustained support from pediatric leadership and community payers, the development in residents and faculty of greater comfort in addressing BH problems and collaborating with BH specialists, and replication of the model in two other primary care settings. In addition to quantitative program outcomes data, the authors present a case example that illustrates how the integrated program works and achieves its goals. They propose that educating residents and psychology trainees side by side in collaborative BH care is clinically and educationally valuable and potentially applicable to other settings. A companion report published in this issue provides results from a study comparing the perceptions of pediatric residents whose primary care continuity clinic took place in this integrated setting with those of residents from the same pediatric residency who had their continuity clinic training in a nonintegrated setting.

Primary health care quality in a national sample of children and youth with mental health impairment

OBJECTIVE

To examine the general pediatric health care quality experiences of children and youth with mental health impairment.

METHODS

We conducted a cross-sectional analysis of 2006 Medical Expenditures Panel Survey data for children and youth aged 5 to 17 years (n = 7263). Mental health impairment was defined using the recommended cut-point (score ≥ 16) on the parent version of the Columbia Impairment Scale. Health care quality was measured with the Consumer Assessment of Healthcare Providers and Systems including parent ratings in 3 domains: provider communication, getting needed care, and getting care quickly. Logistic regression was used to test associations between mental health impairment and dichotomized Consumer Assessment of Healthcare Providers and Systems measures (poor vs good quality) adjusted for demographic characteristics, health insurance, and socioeconomic status. Analysis was conducted with Stata, Version 10.1 SE, and all estimates accounted for the Medical Expenditures Panel Survey complex sampling design.

RESULTS

In multivariable analysis, health care experiences of children with mental health impairment (versus those without) were consistently rated less favorably by parents, with greater odds of inferior quality of care ratings in all domains: getting needed care (odds ratio [OR] = 2.35), getting care quickly (OR = 1.41), physician communication (OR = 1.72), and overall health care quality (OR = 1.63).

CONCLUSIONS

Further research is needed to identify specific aspects of care that families find problematic in relation to the organization and delivery of care within each quality domain. Interventions are needed to improve service systems for children and youth with mental health impairment, especially to support access to needed care.

Improving access to care and clinical outcome for pediatric behavioral problems: a randomized trial of a nurse-administered intervention in primary care

OBJECTIVE

To determine the effectiveness of an on-site modular intervention in improving access to mental health services and outcomes for children with behavioral problems in primary care relative to enhanced usual care. The study includes boys and girls from six primary care offices in metropolitan Pittsburgh, PA.

METHODS

One hundred sixty-three clinically referred children who met a modest clinical cutoff (75th percentile) on the externalizing behavior scale of the Pediatric Symptom Checklist-17 were randomized to a protocol for on-site, nurse-administered intervention or to enhanced usual care. Protocol for on-site, nurse-administered intervention applied treatment modules from an evidence-based specialty mental health treatment for children with disruptive behavior disorders that were adapted for delivery in the primary care setting; enhanced usual care offered diagnostic assessment, recommendations, and facilitated referral to a specialty mental health provider in the community. The main outcome measures such as standardized rating scales, including the Pediatric Symptom Checklist-17, individualized target behavior ratings, treatment termination reports, and diagnostic interviews were collected.

RESULTS

Protocol for on-site, nurse-administered intervention cases were significantly more likely to receive and complete mental health services, reported fewer service barriers and more consumer satisfaction, and showed greater, albeit modest, improvements on just a few clinical outcomes that included remission for categorical behavioral disorders at 1-year follow-up. Both conditions also reported several significant improvements on several clinical outcomes over time.

CONCLUSIONS

A psychosocial intervention for behavior problems that was delivered by nurses in the primary care setting is feasible, improves access to mental health services, and has some clinical efficacy. Options for enhancing clinical outcome include the use of multifaceted collaborative care interventions in the pediatric practice.

Integration of child mental health services to primary care: challenges and opportunities

In the first decade of this new millennium, health professionals are faced with a rapidly increasing need for child mental health services and changing models of service provision. This gives us a unique opportunity to make provision for services where it has not been available before, or to improve upon the existing services. This paper examines the challenges and opportunities while attempting to integrate child mental health services to primary care.