Sociodemographic characteristics of youth in a trauma focused-cognitive behavioral therapy effectiveness trial in the city of Philadelphia

While randomized controlled trials of trauma-focused cognitive behavioral therapy (TF-CBT) have demonstrated efficacy for youth with posttraumatic stress disorder, TF-CBT effectiveness trials typically show attenuated outcomes. This decrease in effectiveness may be due to the differences in sociodemographic characteristics of youth in these trials; youth in efficacy trials are more often white and middle-income, whereas youth in effectiveness trials are more often racial/ethnic minorities, of low socioeconomic status (SES) and live in high crime neighborhoods. In this study-drawn from an effectiveness trial of TF-CBT in community mental health clinics across Philadelphia-we describe the sociodemographic characteristics of enrolled youth. We measured neighborhood SES by matching participants' addresses to American Community Survey data from their Census tracts, housing stability using the National Outcomes Measurement System, and neighborhood violence using police department crime statistics. Our results suggest that the majority of youth presenting for TF-CBT in mental health clinics in the City of Philadelphia live in poor and high-crime neighborhoods, experience substantial housing instability, and are predominantly ethnic and racial minorities. Thus, youth presenting for treatment experience significant racial and socioeconomic adversity. We also explored the association between these characteristics and youth symptom severity upon presenting for treatment. These factors were not associated with youth symptom severity or overall mental health functioning in our sample (with small effect sizes and p > .05 for all). Implications for future research, such as the need for efficacy and effectiveness trials to more fully characterize their samples and the need for pragmatic trials are discussed.

Acceptability and Use of Evidence-Based Practices for Firearm Storage in Pediatric Primary Care

OBJECTIVE

Promoting safe firearm storage in pediatric primary care is one way to address youth suicide by firearm. The study objective was to determine the perspectives of primary care physicians (PCPs) and leaders of primary care practices regarding the acceptability and use of screening, counseling, and firearm locks-all components of an adapted evidence-based intervention known as the Firearm Safety Check.

METHODS

In 2016, an online survey was conducted in two large US health systems. PCPs (n = 204) and leaders (n = 57) from 83 clinics were invited to participate. Respondents included 71 clinics (86%), 103 PCPs (50%), and 40 leaders (70%). Main outcomes included acceptability (6-point Likert scale, with higher scores indicating better acceptability) and use of the 3 intervention components (4-point Likert scale, with higher scores indicating greater use), as measured by an adapted validated instrument.

RESULTS

Analyses were conducted in 2017. PCP acceptability of screening (mean = 4.28; standard deviation [SD] = 1.12) and counseling (mean = 4.56; SD = 0.89) were high, but acceptability for firearm lock provision was more neutral (mean = 3.78; SD = 1.16). Most PCPs endorsed sometimes screening (85%) and counseling (80%). Few PCPs offered firearm locks to caregivers (15%). Leaders reported consistent information.

CONCLUSION

The acceptability of screening for firearms and safe storage counseling was high; both components were used commonly but not routinely. The acceptability of providing firearm locks was neutral, and use was rarely endorsed. This study provides important insights about areas of focus for future implementation efforts from policy and research perspectives.

Stakeholder Perspectives on Implementing a Firearm Safety Intervention in Pediatric Primary Care as a Universal Suicide Prevention Strategy: A Qualitative Study

IMPORTANCE

The rate of youth suicide has increased steadily over the past several decades due, in part, to an increase in suicide by firearm. Implementation of evidence-based approaches to increase safe firearm storage practices are important for reducing youth suicide.

OBJECTIVE

To assess the needs of stakeholders who would be affected by implementing an evidence-based approach to firearm safety promotion-Firearm Safety Check, which includes screening for the presence of firearms in the home, brief motivational interviewing-informed counseling regarding safe firearm storage, and provision of free firearm locks-in pediatric primary care settings.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative study, 58 stakeholders were interviewed over a 7-month period across 9 stakeholder groups from 2 large and diverse health systems. Participants included parents of youth; physicians; nurses and nurse practitioners; leaders of pediatric primary care practices, behavioral health, and quality improvement; system leaders; third-party payers; and members of national credentialing bodies. Data analysis were conducted from September 2017 to April 2018.

MAIN OUTCOMES AND MEASURES

Interview guides were informed by the Consolidated Framework for Implementation Research. An integrated analysis approach was used in which a priori attributes of interest were identified (Consolidated Framework for Implementation Research constructs, eg, intervention characteristics), and an inductive approach was used with regard to new themes that emerged.

RESULTS

A total of 58 stakeholders were interviewed (mean [SD] age, 48.38 [10.65] years; 27 men and 31 women). Stakeholders indicated that firearm safety promotion is a health system priority and reported favorable perceptions of the Firearm Safety Check approach for suicide prevention. The importance of leveraging existing infrastructures, such as electronic health record systems and brevity, were frequently noted. Distribution of firearm locks was endorsed as the most complicated component to implement.

CONCLUSIONS AND RELEVANCE

By including multiple service system stakeholder perspectives, these results support the development of implementation strategies to change clinician, organization, and system behaviors around firearm safety promotion in pediatric primary care as a universal suicide prevention strategy.