The healthy teen project: tools to enhance adolescent health counseling

Workshop on Implementation Science and Digital Therapeutics for Behavioral Health

Digital therapeutics can overcome many of the barriers to translation of evidence-based treatment for substance use, mental health, and other behavioral health conditions. Delivered via nearly ubiquitous platforms such as the web, smartphone applications, text messaging, and videoconferencing, digital therapeutics can transcend the time and geographic boundaries of traditional clinical settings so that individuals can access care when and where they need it. There is strong empirical support for digital therapeutic approaches for behavioral health, yet implementation science with regard to scaling use of digital therapeutics for behavioral health is still in its early stages. In this paper, we summarize the proceedings of a day-long workshop, "Implementation Science and Digital Therapeutics," sponsored and hosted by the Center for Technology and Behavioral Health at Dartmouth College. The Center for Technology and Behavioral Health is an interdisciplinary P30 Center of Excellence funded by the National Institute on Drug Abuse, with the mission of promoting state-of-the-technology and state-of-the-science for the development, evaluation, and sustainable implementation of digital therapeutic approaches for substance use and related conditions. Workshop presentations were grounded in current models of implementation science. Directions and opportunities for collaborative implementation science research to promote broad adoption of digital therapeutics for behavioral health are offered.

Integrating mental health into adolescent annual visits: impact of previsit comprehensive screening on within-visit processes

PURPOSE

To evaluate how a comprehensive, computerized, self-administered adolescent screener, the DartScreen, affects within-visit patient-doctor interactions such as data gathering, advice giving, counseling, and discussion of mental health issues.

METHODS

Patient-doctor interaction was compared between visits without screening and those with the DartScreen completed before the visit. Teens, aged 15-19 years scheduled for an annual visit, were recruited at one urban and one rural pediatric primary care clinic. The doctor acted as his/her own control, first using his/her usual routine for five to six adolescent annual visits. Then, the DartScreen was introduced for five visits where at the beginning of the visit, the doctor received a summary report of the screening results. All visits were audio recorded and analyzed using the Roter interaction analysis system. Doctor and teen dialogue and topics discussed were compared between the two groups.

RESULTS

Seven midcareer doctors and 72 adolescents participated; 37 visits without DartScreen and 35 with DartScreen were audio recorded. The Roter interaction analysis system defined medically related data gathering (mean, 36.8 vs. 32.7 statements; p = .03) and counseling (mean, 36.8 vs. 32.7 statements; p = .01) decreased with DartScreen; however, doctor responsiveness and engagement improved with DartScreen (mean, 4.8 vs. 5.1 statements; p = .00). Teens completing the DartScreen offered more psychosocial information (mean, 18.5 vs. 10.6 statements; p = .01), and mental health was discussed more after the DartScreen (mean, 93.7 vs. 43.5 statements; p = .03). Discussion of somatic and substance abuse topics did not change. Doctors reported that screening improved visit organization and efficiency.

CONCLUSIONS

Use of the screener increased discussion of mental health but not at the expense of other adolescent health topics.

Automated conversation system before pediatric primary care visits: a randomized trial

BACKGROUND AND OBJECTIVES

Interactive voice response systems integrated with electronic health records have the potential to improve primary care by engaging parents outside clinical settings via spoken language. The objective of this study was to determine whether use of an interactive voice response system, the Personal Health Partner (PHP), before routine health care maintenance visits could improve the quality of primary care visits and be well accepted by parents and clinicians.

METHODS

English-speaking parents of children aged 4 months to 11 years called PHP before routine visits and were randomly assigned to groups by the system at the time of the call. Parents' spoken responses were used to provide tailored counseling and support goal setting for the upcoming visit. Data were transferred to the electronic health records for review during visits. The study occurred in an urban hospital-based pediatric primary care center. Participants were called after the visit to assess (1) comprehensiveness of screening and counseling, (2) assessment of medications and their management, and (3) parent and clinician satisfaction.

RESULTS

PHP was able to identify and counsel in multiple areas. A total of 9.7% of parents responded to the mailed invitation. Intervention parents were more likely to report discussing important issues such as depression (42.6% vs 25.4%; P < .01) and prescription medication use (85.7% vs 72.6%; P = .04) and to report being better prepared for visits. One hundred percent of clinicians reported that PHP improved the quality of their care.

CONCLUSIONS

Systems like PHP have the potential to improve clinical screening, counseling, and medication management.

Universal mental health screening in pediatric primary care: a systematic review

OBJECTIVE

Universal mental health screening in pediatric primary care is recommended, but studies report slow uptake and low rates of patient follow-through after referral to specialized services. This review examined possible explanations related to the process of screening, focusing on how parents and youth are engaged, and how providers evaluate and use screening results.

METHOD

A narrative synthesis was developed after a systematic review of 3 databases (plus follow-up of citations, expert recommendations, and checks for multiple publications about the same study). Searching identified 1,188 titles, and of these, 186 full-text articles were reviewed. Two authors extracted data from 45 articles meeting inclusion criteria.

RESULTS

Published studies report few details about how mental health screens were administered, including how clinicians explain their purpose or confidentiality, or whether help was provided for language, literacy, or disability problems. Although they were not addressed directly in the studies reviewed, uptake and detection rates appeared to vary with means of administration. Screening framed as universal, confidential, and intended to optimize attention to patient concerns increased acceptability. Studies said little about how providers were taught to explore screen results. Screening increased referrals, but many still followed negative screens, in some cases because of parent concerns apparently not reflected by screen results but possibly stemming from screen-prompted discussions.

CONCLUSIONS

Little research has addressed the process of engaging patients in mental health screening in pediatric primary care or how clinicians can best use screening results. The literature does offer suggestions for better clinical practice and research that may lead to improvements in uptake and outcome.

Assessing the impact of a web-based comprehensive somatic and mental health screening tool in pediatric primary care

OBJECTIVE

To evaluate how parents and physicians perceive the utility of a comprehensive, electronic previsit screener, and to assess its impact on the visit.

METHODS

A mixed methods design was used. English-speaking parents were recruited from 3 primary care systems (urban MD and rural NY and VT) when they presented for a well-child visit with a child 4 to 10 years of age. Parents completed an electronic previsit screen, which included somatic concerns, health risks, and 4 mental health tools (SCARED5, PHQ-2, SDQ Impact, and PSC-17). Parents completed an exit survey, and a subset were interviewed. All primary care providers (PCPs) were interviewed.

RESULTS

A total of 120 parents and 16 PCPs participated. The exit surveys showed that nearly 90% of parents agreed or strongly agreed that the screener was easy to use and maintained confidentiality. During interviews, parents noted that the screener helped with recall, validated concerns, reframed issues they thought might not be appropriate for primary care, and raised new questions. PCPs thought that the screener enabled them to normalize sensitive issues, and it permitted them to simultaneously focus and be comprehensive during the visit. Parents and PCPs agreed that the screener helped guide discussion, promoted in-depth exchange, and increased efficiency. Findings were consistent across quantitative and qualitative methods and between parents and PCPs.

CONCLUSIONS

A comprehensive electronic previsit screening tool is an acceptable and practical strategy to facilitate well-child visits. It may help with problem identification as well as with setting agendas, engaging the family, and balancing attention between somatic and psychosocial concerns.

Designing computerized decision support that works for clinicians and families

Evidence-based decision-making is central to the practice of pediatrics. Clinical trials and other biomedical research provide a foundation for this process, and practice guidelines, drawing from their results, inform the optimal management of an increasing number of childhood health problems. However, many clinicians fail to adhere to guidelines. Clinical decision support delivered using health information technology, often in the form of electronic health records, provides a tool to deliver evidence-based information to the point of care and has the potential to overcome barriers to evidence-based practice. An increasing literature now informs how these systems should be designed and implemented to most effectively improve outcomes in pediatrics. Through the examples of computerized physician order entry, as well as the impact of alerts at the point of care on immunization rates, the delivery of evidence-based asthma care, and the follow-up of children with attention deficit hyperactivity disorder, the following review addresses strategies for success in using these tools. The following review argues that, as decision support evolves, the clinician should no longer be the sole target of information and alerts. Through the Internet and other technologies, families are increasingly seeking health information and gathering input to guide health decisions. By enlisting clinical decision support systems to deliver evidence-based information to both clinicians and families, help families express their preferences and goals, and connect families to the medical home, clinical decision support may ultimately be most effective in improving outcomes.

Changing adolescent health behaviors: the healthy teens counseling approach

BACKGROUND

Brief motivational interventions that have been provided in addition to routine primary care have changed adolescent health behaviors. Whether health screening and motivational-interviewing-based counseling provided by clinicians during routine care can change behaviors is unknown.

METHODS

Healthy Teens was a primary care, office-system intervention to support efficient, patient-centered counseling at well visits. Healthy Teens utilized a personal digital assistant (PDA)-based screener that provided the clinician with information about a teen's health risks and motivation to change. Changes in adolescent self-report of diet and activity health behaviors 6 months later were assessed in two cross-sectional samples of teens from five rural practices in 2005 and 2006. Usual-care subjects (N=148) were recruited at well visits prior to the intervention, and the Healthy Teens subjects (N=136) were recruited at well visits after the Healthy Teens system was well established.

RESULTS

At 6-month follow-up, the Healthy Teens group had significantly increased self-reported exercise levels and milk-product intake. In the models exploring covariates, the only significant predictors for improvement in exercise levels were intervention-group status (p=0.009) and post-visit interest in making a change (p=0.015). Interest in changing predicted increased milk intake (p=0.028) in both groups. When teens planned an action related to nutrition, physical activity, or both after a well visit, Healthy Teens participants were more likely to report multiple planned actions (68% Healthy Teens vs 32% usual care, p<0.05).

CONCLUSIONS

Changes in office systems using low-cost technology to screen adolescents and promote patient-centered counseling appear to influence teens to increase exercise and milk intake.

Themed Review: Clinical Interventions to Promote Physical Activity in Youth

National recommendations call for children and adolescents to accumulate at least 60 minutes of moderate to vigorous physical activity on most days of the week and for physicians to counsel their patients about physical activity. Physical inactivity tracks from childhood into adulthood, and among youth, it is associated with unfavorable risk factor profiles that promote the development of cardiovascular and metabolic chronic diseases. Few studies of clinical interventions to promote physical activity in children and youth have been published, and the paucity of evidence describing effective interventions and significant barriers limit delivery of counseling. However, existing studies provide evidence about elements of counseling most likely to be effective to guide clinical interventions and inform future research. Based on a literature review, this article offers guidance for incorporating physical activity promotion into clinical care, identifies gaps in current evidence, and suggests methodologic considerations for future research.