Ethnically diverse mothers' views on the acceptability of screening for maternal depressive symptoms during pediatric well-child visits

Factors Associated with Early Intervention Intensity for Children Who Are Deaf or Hard of Hearing

We quantified the intensity of early intervention (EI) services allocated to 1262 children who were deaf or hard of hearing (DHH) within a state program and identified factors associated with intervention intensity. Child specific data were collected on children born between 2008 and 2014. Data from Individualized Family Service Plans of children enrolled in Part C EI programming were evaluated for the type and duration of services during their EI enrollment. Associations between EI intensity and child/family variables were examined. Median age of EI enrollment was 5.3 months. The most frequently received services included primary service coordination, specialized DHH service, special instruction, language therapy, and family training; 60% of children received 4 or more different EI services. The median service intensity was 138.1 min per month across all EI years. The factors associated with higher EI intensity included severe hearing loss, bilateral hearing loss and presence of a disability. Children enrolled in EI at later ages received higher intensity of specialized DHH services, suggesting a need to "catch up" due to late acquisition of services. Evaluating EI service intensity broadens our understanding of effective components of state-based programs that support the developmental needs of children who are DHH.

When Families Do Not Request Help: Assessing a Social Determinants of Health Screening Tool in Practice

INTRODUCTION

Using pediatric social determinants of health screening data from a large medical system, we explored social needs dislosures and identified which needs were associated with resource connection requests.

METHOD

Data came from records of outpatient pediatric patients (0-18 years) seen between October 2018 and March 2020 (39,251 encounters). We assessed percent of encounters where families (1) indicated a social need, and (2) requested a resource connection. We conducted multivariable logistic regression to identify which needs were associated with resource connection requests.

RESULTS

Among all encounters, 8% indicated a need and 2% requested a resource connection. Among families indicating a need, needs associated with resource requests included: housing (odds ratio [OR], 3.49 [2.42-5.03]), employment (OR, 3.15 [2.21-4.50]), food (OR, 1.89 [1.41-2.52]), and transportation (OR, 1.82 [1.30-2.56]).

DISCUSSION

Families seldom requested resource connections to address social needs. Better understanding families' interests in receiving assistance is an important next step in pediatric social determinants of health screening system development.

Postpartum Depression Screening and Referral in a Pediatric Emergency Department

OBJECTIVES

The aim of this study was to determine the (1) proportion of screened postpartum depression (PPD)-positive mothers, (2) associated risk factors, and (3) impact of PPD screening in a pediatric emergency department (PED).

STUDY DESIGN

We performed a pilot cohort study using a convenience sample of mothers (n = 209, all ages) of infant patients 6 months or younger presenting to a PED. Mothers completed a computerized survey that included the Edinburgh Postnatal Depression Scale. We assessed frequency of positive screens and performed multivariable logistic regression to identify associated risk factors. We assessed maternal attitudes toward screening at enrollment and 1-month follow-up with positive-screen mothers. Differences in ED utilization were measured.

RESULTS

Fifty-seven of 209 mothers (27%; 95% confidence interval [CI], 21%-33%) screened positive for PPD, with 14 (7%) reporting suicidal thoughts. Forty-seven percent (97/209) had never previously been screened, including 58% (33/57) of PPD screen-positive mothers. Current unemployment status (adjusted odds ratio [aOR], 2.76; 95% CI, 1.25-6.13) and first-time motherhood (aOR, 3.92; 95% CI, 1.72-8.91) were associated with a positive screen. At 1-month follow-up, mothers (35/37) reported PED-based PPD screening was important. After adjustment for sociodemographic factors, PPD screen-positive mothers had increased PED utilization (aOR, 1.29; 95% CI, 1.03-1.61).

CONCLUSIONS

Approximately 1 in 4 mothers screened positive for PPD in a PED, with almost 1 in 10 reporting suicidal thoughts. The majority of PPD screen-positive mothers had not been screened previously. Our study helps to inform future efforts for interventions to support mothers of young infants who use the PED for care.

Screening Children for Social Determinants of Health: A Systematic Review

CONTEXT

Screening children for social determinants of health (SDOHs) has gained attention in recent years, but there is a deficit in understanding the present state of the science.

OBJECTIVE

To systematically review SDOH screening tools used with children, examine their psychometric properties, and evaluate how they detect early indicators of risk and inform care.

DATA SOURCES

Comprehensive electronic search of PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection.

STUDY SELECTION

Studies in which a tool that screened children for multiple SDOHs (defined according to Healthy People 2020) was developed, tested, and/or employed.

DATA EXTRACTION

Extraction domains included study characteristics, screening tool characteristics, SDOHs screened, and follow-up procedures.

RESULTS

The search returned 6274 studies. We retained 17 studies encompassing 11 screeners. Study samples were diverse with respect to biological sex and race and/or ethnicity. Screening was primarily conducted in clinical settings with a parent or caregiver being the primary informant for all screeners. Psychometric properties were assessed for only 3 screeners. The most common SDOH domains screened included the family context and economic stability. Authors of the majority of studies described referrals and/or interventions that followed screening to address identified SDOHs.

LIMITATIONS

Following the Healthy People 2020 SDOH definition may have excluded articles that other definitions would have captured.

CONCLUSIONS

The extent to which SDOH screening accurately assessed a child's SDOHs was largely unevaluated. Authors of future research should also evaluate if referrals and interventions after the screening effectively address SDOHs and improve child well-being.

Embedded Maternal Mental Health Care in a Pediatric Primary Care Clinic: A Qualitative Exploration of Mothers' Experiences

OBJECTIVE

The American Academy of Pediatrics recommends screening parents for postpartum depression during pediatric primary care visits. Unfortunately, many women who screen positive do not obtain treatment. Providing mental health services for women in the same location as their children's primary care may facilitate treatment, but few such clinics exist. We designed a qualitative study to evaluate women's perceptions and experiences with receiving mental health services from psychiatrists embedded in a safety-net pediatric primary care clinic.

METHODS

Semistructured interviews were conducted with women receiving mental health care from embedded psychiatrists in a safety-net pediatric clinic. Data were analyzed using an inductive approach.

RESULTS

Twenty women participated. Five major themes emerged: 1) barriers to maternal mental health care, including psychiatric symptoms impairing access, stigma, and fear of Child Protective Services; 2) benefits of embedded care, including convenience, low barrier to entry and trust; 3) motherhood as facilitator to care, with early motherhood described as a time of vulnerability to relapse; 4) focus on parenting, including appreciation for parenting skills and normalization of the mothering experience; 5) treatment modality preferences, including concerns about medications and a preference for psychotherapy.

CONCLUSIONS

Postpartum women face many barriers to psychiatric care. Mental health care embedded within the pediatric setting lowers barriers to care during this critical period. These insights should inform further collaboration between adult psychiatrists and pediatric care providers.

Exploring Expressions of Depression in Black Single Mothers

PROBLEM

This study investigates the experience of depression from the perspective of Black single mothers, an understudied diverse-sub-group who consistently report high levels of depressive symptoms that go undetected and untreated.

PARTICIPANTS

The sample consisted of 210 Black single mothers aged 18-45 who reside in urban communities.

METHODS

A descriptive, cross-sectional design was used to categorize the responses of Black single mothers to an open-ended question that asks about feelings of depression according to the four domains of the Centers for Epidemiologic Studies Depression Scale. Percentages and frequencies were used to describe the results of the analysis.

FINDINGS

The 303 usable responses were most consistent with the depressed affect domain (N = 172), followed by somatic activity (N = 108), interpersonal symptoms (N = 21), and lack of positive affect (N = 2). The most prevalent raw responses included sadness (N = 59), forms of anger (N = 48), depressed (N = 24), cry (N = 23), do not want to be around people (N = 21), lonely (N = 17), tired (N = 16), and stressed (N = 12).

CONCLUSIONS/IMPLICATIONS

Consider culture and individualized assessments to explore feelings of anger and sadness when screening for depressive symptoms in specific sub-groups of Black single mothers. Consider the use of appropriate screening tools.

Sociodemographic and Obstetric Factors Related to Symptoms of Postpartum Depression in Hispanic Women in Rural California

OBJECTIVE

To investigate the relationships among sociodemographic and obstetric factors and symptoms of postpartum depression (PPD) in Hispanic women living in rural California.

DESIGN

Quantitative, cross-sectional, descriptive design.

SETTING

Rural southern California communities.

PARTICIPANTS

A convenience sample of 223 Hispanic women, ages 18 to 42 years old, with one living infant younger than 12 months old.

METHODS

Interviewer-administered Edinburgh Postnatal Depression Scale and sociodemographic and obstetric history survey (maternal age, marital status, education, annual household income, employment, sex of infant, birth type, and number of children). Chi-square and logistic regression analyses were used to determine associations and predictive relationships among sociodemographic and obstetric factors and symptoms of PPD.

RESULTS

Low education levels, unemployment, cesarean birth, and more than one young child were significantly related to PPD risk (Edinburgh Postnatal Depression Scale scores ≥ 10). Many of the factors associated with PPD symptoms in this sample of Hispanic women were similar to those previously reported in the literature.

CONCLUSION

Our findings highlighted the need for PPD care among Hispanic women in rural areas. Early assessment and intervention for symptoms of PPD are needed to enhance health equity and promote better health for women who live in rural communities.

Beyond Screening: A Stepped Care Pathway for Managing Postpartum Depression in Pediatric Settings

The negative consequences of untreated postpartum depression (PD) for both the woman and her infant are well established. The impact of maternal depression has led to recommendations on systematic perinatal depression screening. Unfortunately, large-scale initiatives on PD screening have found no benefit unless systems are in place to facilitate appropriate interventions for women who screen positive. Pediatric primary care has been a focus of efforts to support screening and management of PD because pediatric providers, unlike adult healthcare providers, have the most frequent contact with postpartum women through well-child visits. Well-child visits thus present an unparalleled opportunity to detect and intervene with PD. Literature reviews suggest that specific strategies are feasible within pediatric settings and could benefit both the woman and her child. In this article, we present a stepped care approach for screening and managing PD, integrating common elements found in existing pediatric-based models. A stepped care approach is ideal because PD is a heterogeneous condition, with a range of presentations and hence responsiveness to various interventions. This care pathway begins with systematic screening for depression symptoms, followed by a systematic risk assessment for women who screen positive and care management based on risk profiles and responsiveness. This approach allows pediatric providers to be optimally flexible and responsive in addressing the majority of women with PD within the context of the family-centered medical home to improve child well-being. Challenges to managing PD within pediatrics are discussed, including strategies for addressing them. Implications for research, policy, and practice are discussed.

Follow-up of Mothers with Suspected Postpartum Depression from Pediatrics Clinics

PURPOSE

Pediatric providers are increasingly screening for postpartum depression (PD), yet, it is unknown how often mothers comply with recommendations to seek treatment. The objectives were to describe the rate at which mothers with suspected PD seek treatment and explore factors that predict help-seeking behavior.

DESIGN AND METHODS

Mothers were recruited from four pediatric clinics after identification using the Child Health Improvement through Computer Automation (CHICA) system. Mothers with a positive screen were invited to participate in a telephone interview between January 2012 and December 2014. Mothers reported if they sought treatment or called a community resource.

RESULTS

73 of 133 eligible mothers participated (55% response rate). Fifty women recalled a recommendation to seek help. Only 43.8% (32/73) made a follow-up appointment with an adult provider and even fewer kept the appointment.

CONCLUSION

A majority of mothers suspected of having PD recalled a referral for further intervention; yet, less than half took action. Further investigation of barriers of help-seeking behavior is warranted.

Beyond screening: a review of pediatric primary care models to address maternal depression

Depression is one of the most debilitating chronic disorders in the United States, affecting 15 million children in homes with depressed mothers, many of whom endure household chaos, inconsistent nurturing, inadequate safety practices, and harsh discipline. Depressed mothers are under diagnosed and undertreated, yet there is broad consensus about the importance of identifying and managing maternal depression, as reflected in recommendations by pediatric and obstetric professional organizations to routinely screen for perinatal depression. Screening was shown to be acceptable to women and most pediatric providers, and adding a screening component need not impair clinic efficiency. Screening, however, is not sufficient, and there are few models in the literature to guide medical practices in implementing successful interventions to identify, treat, and prevent maternal depression, particularly in the pediatric setting. We reviewed the literature and identified six studies that evaluated models for screening and managing mothers' depression in pediatric primary care settings. Some of these interventions have promise, but no studies characterized health outcomes of the depressed mothers and children. We discuss the components of these models, their implementation, and the practice and research needed to create effective pediatrics-based systems to reduce the negative effects of maternal depression on mothers, children, and families.

A systematic review on the acceptability of perinatal depression screening

BACKGROUND

Perinatal depression (PND) affects approximately 10-15% of women, worldwide. PND screening, using screening tools, has been undertaken by a broad range of healthcare professionals in different settings. Our objective was to explore the acceptability of PND screening and how acceptability was being assessed.

METHODS

A systematic literature review of studies that explored the acceptability of PND screening was carried out throughout MEDLINE, PsycINFO, PubMed, CINAHL, Embase, Maternity and Infant Care and Joanna Briggs Institute databases.

RESULTS

Twenty-eight out of twenty-nine publications reported PND screening to be acceptable to most participants. A wide range of terms, questions and statements was used to infer, assess or report on acceptability. There was no uniform, psychometrically tested tool used to measure acceptability across the studies.

LIMITATIONS

Broad inclusion criteria and methodological differences limited comparisons, but are overcome by the comprehensiveness of the data and the lack of uniformity across studies.

CONCLUSIONS

Even though PND screening appears acceptable, it is difficult to draw conclusions about PND screening acceptability as studies used different methods to infer, assess or report on acceptability. The lack of a uniform, psychometrically tested tool to measure acceptability is not unique to PND. Nonetheless, the majority of perinatal women and healthcare professionals reported positive attitudes towards PND screening using different tools in different settings, indicating that it may be the responsibility of all healthcare professionals who come into contact with perinatal women.

Pediatric-based intervention to motivate mothers to seek follow-up for depression screens: The Motivating Our Mothers (MOM) trial

OBJECTIVE

To determine the initial effectiveness of a novel, pediatric office-based intervention in motivating mothers to seek further assessment of positive depression screens.

METHODS

In this pilot randomized controlled trial, English-speaking mothers (n = 104) with positive 2-question depression screens and presenting with children 0 to 12 years old for well-child care to a general pediatric training clinic received interventions from a trained research assistant. The Motivating Our Mothers (MOM) intervention included office-based written and verbal targeted depression education and motivational messages encouraging further depression assessment and a semistructured telephone booster delivered 2 days later. The control intervention included nontargeted written and verbal messages and 2 days later, an attention control telephone survey. Both groups received a list of depression care resources. The primary outcome was the proportion of mothers in each group who reported trying to contact any of 6 types of resources to discuss the positive screen at 2 weeks after intervention (ClinicalTrials.gov NCT01453790).

RESULTS

Despite 6 contact attempts, 10 MOM and 9 control mothers were lost to follow-up. More mothers in the MOM intervention tried to contact a resource compared to control (73.8% vs 53.5%, difference 20.3%, 95% confidence interval for difference -0.1 to 38.5, P = .052).

CONCLUSIONS

Mothers receiving the MOM intervention made more attempts to contact a resource for follow-up of positive depression screens. If found effective in larger studies, MOM may prove a promising approach for motivating depression screen-positive mothers identified in general pediatric settings within and beyond the postpartum period to seek further depression assessment and support.

Perinatal antidepressant use: understanding women's preferences and concerns

Perinatal depression is prevalent and linked with a host of adverse consequences for women and newborns. Rates of engagement in depression treatment are, however, strikingly low among pregnant and postpartum women, with the majority of affected women receiving no mental health treatment. Research indicates that perinatal women are extremely reluctant to take antidepressant medications, yet the nature of women's concerns and treatment decision- making patterns have not been well documented. Developing a clearer understanding of women's treatment preferences and behaviors may help identify solutions to the under-treatment of perinatal depression. In this mixed methods study, we conducted in-depth interviews with 61 pregnant women, approximately half of whom were experiencing clinical levels of depression. In addition to assessing psychiatric diagnoses, symptoms, and functional impairment, we conducted qualitative interviews addressing women's preferences for depression treatment, concerns, and decision-making patterns. Consistent with prior reports, women were significantly more likely to voice a preference for non-pharmacologic depression treatments, as opposed to antidepressant medications. Many depressed women reported a great degree of uncertainty regarding how to treat their depression, and those with more severe depression symptoms were more likely to endorse decisional conflict. Analysis of qualitative comments yielded detailed information about the nature of women's concerns and preferences related to use of antidepressant medications and other aspects of treatment engagement. We discuss findings in the context of improving patient-centered care for perinatal depression.

Adaptation of problem-solving treatment for prevention of depression among low-income, culturally diverse mothers

Adapting evidence-based interventions to be more accessible and culturally sensitive to the needs of diverse populations is a potential strategy to address disparities in mental health care. We adapted an evidence-based depression-treatment strategy, Problem-Solving Treatment, to prevent depression among low-income mothers with vulnerable children. Intervention adaptations spanned 3 domains: (1) the intervention's new prevention focus, (2) conducting a parent-focused intervention in venues oriented to children; and (3) cultural competency. The feasibility of adaptations was assessed through 2 pilot-randomized trials (n = 93), which demonstrated high participant adherence, satisfaction, and retention, demonstrating the feasibility of our adaptations.

Racial and ethnic disparities in postpartum depression care among low-income women

OBJECTIVE

The goal of this study was to characterize racial-ethnic differences in mental health care utilization associated with postpartum depression in a multiethnic cohort of Medicaid recipients.

METHODS

In a retrospective cohort study, administrative claims data from New Jersey's Medicaid program were obtained for 29,601 women (13,001 whites, 13,416 blacks, and 3,184 Latinas) who delivered babies between July 2004 and October 2007. Racial-ethnic differences were estimated with logistic regression for initiation of antidepressant medication or outpatient mental health visits within six months of delivery, follow-up (a prescription refill or second visit), and continued mental health care (at least three visits or three filled antidepressant prescriptions within 120 days).

RESULTS

Nine percent (N=1,120) of white women initiated postpartum mental health care, compared with 4% (N=568) of black women and 5% (N=162) of Latinas. With analyses controlling for clinical factors, the odds of initiating treatment after delivery were significantly (p<.001) lower for blacks (adjusted odds ratio [AOR]=.43) and Latinas (AOR=.59) compared with whites. Among those who initiated treatment, blacks and Latinas were less likely than whites to receive follow-up treatment (blacks, AOR=.66, p<.001; Latinas, AOR=.67, p<.05) or continued care (blacks, AOR=.81, p=.069; Latinas, AOR=.67, p<.05). Among those who initiated antidepressant treatment, black women and Latinas were less likely than whites to refill a prescription.

CONCLUSIONS

There were significant racial-ethnic differences in depression-related mental health care after delivery. Suboptimal treatment was prevalent among all low-income women in the study. However, racial and ethnic disparities in the initiation and continuation of postpartum depression care were particularly troubling and warrant clinical and policy attention.

Racial and ethnic disparities in postpartum depression care among low-income women

OBJECTIVE

The goal of this study was to characterize racial-ethnic differences in mental health care utilization associated with postpartum depression in a multiethnic cohort of Medicaid recipients.

METHODS

In a retrospective cohort study, administrative claims data from New Jersey's Medicaid program were obtained for 29,601 women (13,001 whites, 13,416 blacks, and 3,184 Latinas) who delivered babies between July 2004 and October 2007. Racial-ethnic differences were estimated with logistic regression for initiation of antidepressant medication or outpatient mental health visits within six months of delivery, follow-up (a prescription refill or second visit), and continued mental health care (at least three visits or three filled antidepressant prescriptions within 120 days).

RESULTS

Nine percent (N=1,120) of white women initiated postpartum mental health care, compared with 4% (N=568) of black women and 5% (N=162) of Latinas. With analyses controlling for clinical factors, the odds of initiating treatment after delivery were significantly (p<.001) lower for blacks (adjusted odds ratio [AOR]=.43) and Latinas (AOR=.59) compared with whites. Among those who initiated treatment, blacks and Latinas were less likely than whites to receive follow-up treatment (blacks, AOR=.66, p<.001; Latinas, AOR=.67, p<.05) or continued care (blacks, AOR=.81, p=.069; Latinas, AOR=.67, p<.05). Among those who initiated antidepressant treatment, black women and Latinas were less likely than whites to refill a prescription.

CONCLUSIONS

There were significant racial-ethnic differences in depression-related mental health care after delivery. Suboptimal treatment was prevalent among all low-income women in the study. However, racial and ethnic disparities in the initiation and continuation of postpartum depression care were particularly troubling and warrant clinical and policy attention.

The impact of race on participation in part C early intervention services

OBJECTIVE

To quantify racial differences in receipt of early intervention (EI) services among children ages birth to 3 years.

METHODS

Multivariable analyses of a nationally representative sample of children eligible for EI services using data from the Early Child Longitudinal Study, Birth Cohort was conducted. Birth weight <1000 g, genetic and medical conditions associated with developmental delay, or low scores on a standardized measure of developmental performance defined EI eligibility. Receipt of EI services was ascertained from parent self-report. The effect of race on receipt of EI services was examined in main effect models and models stratified by EI qualifying condition, which was defined as either established medical condition or developmental delay in the absence of an underlying medical diagnosis.

RESULTS

At 9 months of age, among the 1000 children eligible for EI services, 9% of children received services; there were no black-white racial differences in receipt of services. At 24 months of age, among the 1000 children eligible for EI services, 12% received services; black children were 5 times less likely to receive services than white children (adjusted odds ratio [aOR] 0.19; 95% confidence interval [CI] 0.09, 0.39). In models stratified by qualifying condition, black children who qualified for services at 24 months based on developmental delay alone were less likely to receive services (aOR 0.09; 95% CI 0.02, 0.39); there were no differences by race among children who qualified based on established medical conditions (aOR 0.56; 95% CI 0.18, 1.72).

CONCLUSIONS

Racial disparities in EI service receipt, which were not present during infancy, emerged as children became toddlers. These disparities were found most consistently among children who qualified for services based on developmental delay alone.

Screening and counseling for postpartum depression by nurses: the women's views

PURPOSE

In this part 2 article of research examining a model of care in which nurses screen and counsel postpartum women for postpartum depression, acceptability of such a model to postpartum patients was evaluated with a diverse sample of American women.

STUDY DESIGN AND METHODS

Descriptive survey of two groups: 691 predominately white postpartum women with relatively high annual incomes (Sample 1) and 132 low-income women, some of whom were ethnic minorities (Sample 2). The surveys were distributed and needed to be mailed back to the investigators. The response rate was 72% in Sample 1 and 30% in Sample 2.

RESULTS

The overwhelming majority in both groups (>90%) felt that it was acceptable for nurses to perform screening for postpartum depression and for nurses to do the necessary counseling. More than half in each sample were "definitely willing" to see a nurse for counseling. Although women in both samples had positive views, when compared with each other, women with higher incomes (Sample 1) had more positive views of nurse-delivered mental healthcare. More than half in each sample were "definitely willing" to see a nurse for counseling. For Sample 1, 15% reported having taken medications for postpartum depression; in Sample 2 this number was 22.3%.

CLINICAL IMPLICATIONS

Nurses have frequent contact with postpartum women; as such, they are well positioned to provide depression screening and counseling. Nurse-delivered mental healthcare has the potential to obviate many barriers that prevent the detection and treatment of depression, and ultimately improve outcomes for infant and children.