Behavioral Health Needs, Barriers, and Parent Preferences in Rural Pediatric Primary Care

A comparison of two strategies to assess sexual violence: general vs. specialised trauma screening strategies in two high-risk substance use health disparity samples

Background/Objective: Using two different high-risk samples, the present study compared and contrasted two different strategies/questionnaire types for assessing a history of sexual violence: a general trauma screening vs. specialised behaviourally-specific questionnaires.Methods: Sample 1 included 91 men and women seeking detoxification treatment services in a publicly funded, urban clinic who completed a trauma and substance use questionnaire battery during treatment. Sample 2 included 310 women at a rural college who completed a trauma and religious coping questionnaire battery for course credit. All participants completed both types of questionnaires: One general trauma screening questionnaire (i.e. the Life Events Checklist [LEC]) and two behaviourally-specific specialised questionnaires (i.e. the 2007 Sexual Experiences Survey [SES] and the Childhood Trauma Questionnaire [CTQ]).Results: There were large differences in the cases identified by the behaviourally-specific questionnaires (SES and CTQ) compared to the general trauma screening questionnaire (the LEC) in both samples but few differences in the prevalence rates of sexual violence detected by each questionnaire type. In the detoxification sample, the differences were especially notable for men. Follow-up analyses indicated that degree of traumatisation impacted results likely by increasing participant's willingness to endorse face-valid items on the LEC.Conclusions: For men, the behaviourally-specific questionnaires (SES/CTQ) were necessary to identify cases. For those with more severe trauma histories, the LEC was equivalent to the SES/CTQ in identifying a similar number of sexual violence cases. Thus, clinicians and researchers should consider the population when selecting assessments to identify sexual violence history.

Examining the measurement precision of behavior problems among a sample of primarily rural youth on juvenile probation and their parents

Accurate and timely intervention in the justice system is particularly critical in rural communities, given documented barriers to accessible, evidence-based services for youth. As youth in the juvenile justice system have a high prevalence of behavioral health needs, accurate assessment of those needs is a critical first step in linking youth to appropriate care. The goal of the current study is to examine the reliability of a brief assessment (the Brief Problem Checklist [BPC]) among a sample of 222 justice-involved youth and their caregivers who primarily reside in rural communities in the United States. Using a series of reliability analyses and tests of agreement, we examined whether youth and caregiver BPC produces reliable scales, the strength of the convergence among each of the BPC scales, and youth and caregiver agreement on the BPC scales. Findings support the reliability of the BPC, but not inter-rater reliability. Poor agreement between youth and caregiver reports exists for both youth internalizing and externalizing problems. Additionally, the BPC was significantly related to several theoretically relevant constructs, including treatment, substance use disorder severity, and family history of substance use. These findings lend merit to discussions about the need for more research on the reliability and validity of assessment instruments before their widespread use in guiding youth- and agency case planning decisions, along with informing conclusions about program effectiveness.

Pediatric Primary-Care Integrated Behavioral Health: A Framework for Reducing Inequities in Behavioral Health Care and Outcomes for Children

Nearly half of US children and adolescents will suffer a behavioral health (BH) disorder, with substantially higher rates among more disadvantaged children such as racial/ethnic minorities, LGBTQ + youth, and poor children. The current specialty pediatric BH workforce is inadequate to meet the need and the uneven distribution of specialists as well as other barriers to care, such as insurance coverage and systemic racism/bias, further exacerbate disparities in BH care and outcomes. Integrating BH care into the pediatric primary care medical home has the potential to expand access to BH care and reduce the disparities inherent in the current system.

Reducing Anxiety and Stress among Youth in a CBT-Based Equine-Assisted Adaptive Riding Program

Simple Summary

Reining in Anxiety (RiA) is a therapeutic program for youth with mild-to-moderate anxiety delivered in a therapeutic riding setting by Certified Therapeutic Riding Instructors. RiA is based on five foundational components of Cognitive Behavioral Therapy (CBT): in vivo exposure, cognitive restructuring, youth psychoeducation, relaxation, and caregiver psychoeducation about anxiety. The intervention sought to support youth between the ages of 6–17 with self-identified anxiety. Due to global pandemic trauma, in the second iteration of the protocol, researchers also included two evidence-based trauma components: maintenance and personal safety skills. All instructors were trained in the RiA curriculum and delivered the same lessons. In addition to assessing the youth’s perception and changes over time, the researchers also assessed changes in the horses, both through saliva sampling. The authors learned that RiA may be a promising approach for reducing anxiety and stress among youth and that the intervention can be delivered by adaptive/therapeutic horseback riding instructors in a non-clinic setting.

Abstract

Reining in Anxiety (RiA) is a therapeutic program for youth with mild to moderate anxiety delivered in a therapeutic riding setting by Certified Therapeutic Riding Instructors. RiA was developed after a review of the evidence base for youth anxiety, is manualized, and includes five core CBT components: in vivo exposure, cognitive restructuring, youth psychoeducation, relaxation, and caregiver psychoeducation about anxiety. This study extended findings from a prior RCT that examined (1) the feasibility of collecting saliva samples from horses and children to measure stress (cortisol) and relaxation (oxytocin); (2) whether changes in stress and relaxation occurred both during each lesson and over the course of the 10-week intervention for horses and youth; (3) whether changes in anxiety symptoms, emotional regulation, and self-efficacy found in the first trial were comparable; and (4) if fidelity to the program was reliable. Youth participants (n = 39) ages 6–17 with caregiver-identified mild-to-moderate anxiety participated in a ten-week therapeutic intervention (RiA), which combined adaptive riding and components of CBT. Physiological data and self-report measures were taken at weeks one, four, seven, and ten for the youth and horses. Saliva assays assessed cortisol as a physiological marker of stress and anxiety, and oxytocin as a measure of relaxation. Fidelity data were recorded per session. Anxiety, as measured by caregiver self-reporting, significantly decreased from pre- to post-test, while emotional regulation scores increased. No significant changes in self-efficacy from pre- to post-test were observed. Saliva samples obtained from participants before and after riding sessions showed a consistent decrease in cortisol and a significant increase in oxytocin at two of the four timepoints (Week 1 and Week 7), but no overall pre- to post-test changes. Horse saliva data were collected using a modified bit; there were no significant changes in oxytocin or cortisol, suggesting that the horses did not have an increase in stress from the intervention. RiA may be a promising approach for reducing anxiety and stress among youth, as measured both by self-reported and by physiological measures. Collection of salivary assays for both youth and horses is feasible, and the intervention does not increase stress in the horses. Importantly, RiA can be delivered by adaptive/therapeutic horseback riding instructors in naturalistic (e.g., non-clinic-based) settings. As youth anxiety is a growing public health problem, novel interventions, such as RiA, that can be delivered naturalistically may have the potential to reach more youth and thus improve their quality of life. Further research is needed to examine the comparative value of RiA with other animal-assisted interventions and to assess its cost-effectiveness.

Delinquency, Substance Use, and Risky Sexual Behaviors among Youth who are involved in the Justice System and Predominantly Reside in Rural Communities: Patterns and Associated Risk Factors

There is a significant gap in research examining the prevalence of problem behaviors among youth involved in the juvenile justice system in rural areas. The current study sought to address this gap by exploring the behavioral patterns of 210 youth who were on juvenile probation in predominantly rural counties and who were identified as having a substance use disorder. First, we examined the correlation among 7 problem behaviors representing different forms of substance use, delinquency, and sexual risk-taking and 8 risk factors related to recent service utilization, internalizing and externalizing difficulties, and social support networks. Then, we used latent class analysis (LCA) to identify distinct behavioral profiles based on the observed problem behaviors. LCA identified a 3-class model representing distinct groups labeled Experimenting (70%), Polysubstance Use + Delinquent Behaviors (24%), and Diverse Delinquent Behaviors (6%). Finally, we assessed differences (i.e., ANOVA, χ2) in each risk factor across the behavioral profiles. Important similarities and differences in the association among the problem behaviors, behavioral profiles, and the risk factors were revealed. These findings underscore the need for an interconnected behavioral health model within rural juvenile justice systems that is able to address youths' multidimensional needs including criminogenic, behavioral, and physical health needs.

Five-Year Trends in Pediatric Mental Health Emergency Department Visits in Massachusetts: A Population-Based Cohort Study

OBJECTIVES

To evaluate temporal changes in pediatric emergency department (ED) visits for mental health problems in Massachusetts based on diagnoses and patient characteristics and to assess trends in all-cause pediatric ED visits.

STUDY DESIGN

This statewide population-based retrospective cohort study used the Massachusetts All-Payer Claims Database, which includes almost all Massachusetts residents. The study sample consisted of residents aged <21 years who were enrolled in a health plan between 2013 and 2017. Using multivariate regression, we examined temporal trends in mental health-related and all-cause ED visits in 2013-2017, with person-quarter as the unit of analysis; we also estimated differential trends by sociodemographic and diagnostic subgroups. The outcomes were number of mental health-related (any diagnosis, plus 14 individual diagnoses) and all-cause ED visits/1000 patients/quarter.

RESULTS

Of the 967 590 Massachusetts residents in our study (representing 14.8 million person-quarters), the mean age was 8.1 years, 48% were female, and 57% had Medicaid coverage. For this population, mental health-related (any) and all-cause ED visits decreased from 2013 to 2017 (P < .001). Persons aged 18-21 years experienced the largest declines in mental health-related (63.0% decrease) and all-cause (60.9% decrease) ED visits. Although mental health-related ED visits declined across most diagnostic subgroups, ED visits related to autism spectrum disorder-related and suicide-related diagnoses increased by 108% and 44%, respectively.

CONCLUSIONS

Overall rates of pediatric ED visits with mental health diagnoses in Massachusetts declined from 2013 to 2017, although ED visits with autism- and suicide-related diagnoses increased. Massachusetts' policies and care delivery models aimed at pediatric mental health may hold promise, although there are important opportunities for improvement.

COVID-19 and the Acceleration of Behavioral Parent Training Telehealth: Current Status and Future Directions

The SARS-COV-2 (COVID-19) pandemic and associated social distancing guidelines have accelerated the telehealth transition in mental health. For those providing Behavioral Parent Training (BPT), this transition has called for moving sessions that are traditionally clinic-based, active, and directive to engaging, supporting, and treating families of children with behavior disorders remotely in their homes. Whereas many difficulties accompany this transition, the lessons learned during the current public health crisis have the potential to transform BPT service delivery on a large scale in ways that address many of its long-standing limitations. We describe both challenges and opportunities and consider the possibilities inherent in a large scale BPT service delivery model capable of increasing the reach and impact of evidence-based treatment for all families.

A Mixed-Method Investigation of Parent Perspectives on Early Childhood Behavioral Services in Primary Care

Primary care is a key setting for the delivery of parent-focused behavioral interventions. Various methods of intervention show promising efficacy but fail to engage adequate parental participation. This study used a sequential-explanatory mixed-method design to understand factors underlying parents' attitudes toward the content, sources, and delivery methods of behavioral guidance in primary care. Fifteen parents who previously participated in a larger survey study participated in interviews about their experiences and attitudes toward integrated primary care. Qualitative data were analyzed and sorted by quantitative data of interest to identify demographic, child, and parental factors that shape attitudes toward integrated care. Parents emphasized a need for tailored behavioral guidance, and multiple interconnected factors (e.g., trust of providers, perceived convenience of delivery modalities, stigma associated with behavioral health services) drove parents' attitudes toward behavioral primary care. These attitudes varied based on socioeconomic status, child behavior symptoms, and reported use of corporal punishment.

Introduction to the Special Issue: Addressing Health Disparities in Pediatric Psychology

This introduction to the special issue on Addressing Health Disparities in Pediatric Psychology provides context for why this special issue is needed, reviews key findings of the accepted articles, and discusses future directions for advancing the field. This special issue, one of three on this topic area that has been put forth in the history of this journal, comes at a critical point in our world. This is a time when the COVID-19 pandemic is systematically infecting Black, Indigenous, and People of Color and when there has been increased attention to systemic racism and intersecting violence inherent in multiple systems, including the justice, health, and educational systems. Using Kilbourne et al. (2016) framework, this special issue focuses on Phase 2 and Phase 3 research. Rather than only identifying health disparities (Phase 1), this issue focuses on understanding mechanisms and translating such understanding into interventions and policy changes. The accepted articles span a wide gamut from obesity to autism to rural populations. Furthermore, the articles provide methods for advancing the field beyond simply noting that systematic differences exist toward strategies to address these inequities. We conclude this introduction by discussing next steps for future research, with hopes that it inspires the next generation to study issues of disparities and inequity in deeper, more meaningful, and impactful ways.