Racial and ethnic disparities in pediatric mental health

Disparities in Pharmacologic Restraint for Children Hospitalized in Mental Health Crisis

BACKGROUND AND OBJECTIVES

Children hospitalized with a mental health crisis often receive pharmacologic restraint for management of acute agitation. We examined associations between pharmacologic restraint use and race and ethnicity among children admitted for mental health conditions to acute care nonpsychiatric children's hospitals.

METHODS

We performed a retrospective cohort study of children (aged 5-≤18 years) admitted for a primary mental health condition from 2018 to 2022 at 41 US children's hospitals. Pharmacologic restraint use was defined as parenteral administration of medications for acute agitation. The association of race and ethnicity and pharmacologic restraint was assessed using generalized linear multivariable mixed models adjusted for clinical and demographic factors. Stratified analyses were performed based on significant interaction analyses between covariates and race and ethnicity.

RESULTS

The cohort included 61 503 hospitalizations. Compared with non-Hispanic Black children, children of non-Hispanic White (adjusted odds ratio [aOR], 0.81; 95% confidence interval [CI], 0.72-0.92), Asian (aOR, 0.82; 95% CI, 0.68-0.99), or other race and ethnicity (aOR, 0.68; 95% CI, 0.57-0.82) were less likely to receive pharmacologic restraint. There was no significant difference with Hispanic children. When stratified by sex, racial/ethnic differences were magnified in males (aORs, 0.49-0.68), except for Hispanic males, and not found in females (aORs, 0.83-0.93). Sensitivity analysis revealed amplified disparities for all racial/ethnic groups, including Hispanic youth (aOR, 0.65; 95% CI, 0.47-0.91).

CONCLUSIONS

Non-Hispanic Black children were significantly more likely to receive pharmacologic restraint. More research is needed to understand reasons for these disparities, which may be secondary to implicit bias and systemic and interpersonal racism.

AI as a Mental Health Therapist for Adolescents

This Viewpoint discusses benefits and risks of using conversational artificial intelligence platforms to deliver psychotherapy to adolescents.

Parent-Child Nativity, Race, Ethnicity, and Common Mental Health Conditions Among United States Children and Adolescents

OBJECTIVE

To examine associations between race, ethnicity, and parent-child nativity, and common mental health conditions among U.S. children and adolescents.

METHODS

Data were from 2016 to 2019 National Survey of Children's Health, a US population-based, serial cross-sectional survey, and restricted to children who had access to health care. We used weighted multivariable logistic regression to examine the associations between race and ethnicity (Asian, Black, Hispanic, White, Other-race); mental health outcomes (depression, anxiety, and behavior/conduct problems) stratified by household generation; and between household generation and outcomes stratified by race and ethnicity, adjusting for demographics (age, sex, family income to poverty ratio, parental education), and an adverse childhood experience (ACE) score.

RESULTS

When stratifying by household generation, racial and ethnic minority children generally had similar to lower odds of outcomes compared with White children, with the exception of higher odds of behavior/conduct problems among third + -generation Black children. When stratifying by race and ethnicity, third + generation children had increased odds of depression compared to their first-generation counterparts. Third + generation, racial and ethnic minority children had increased odds of anxiety and behavior/conduct problems compared with their first-generation counterparts. The associations generally remained significant after adjusting for the ACE score.

CONCLUSIONS

Lower odds of common mental health conditions in racial and ethnic minority children could be due to factors such as differential reporting, and higher estimates, including those in third + generation children, could be due to factors including discrimination; systemic racism; and other factors that vary by generation and need further investigation to advance health equity.

Racial Disparities in the Impact of Head Start on Health Outcomes Among Low-Income Head Start-Eligible Children and Parents

This study examined racial disparities in Head Start's impact on health outcomes for families with young children in poverty. Research questions were as follows: (a) are there racial disparities in health outcomes among low-income families? (b) Does Head Start participation promote better health outcomes? And (c) does Head Start's impact on health outcomes differ by race and ethnicity? Logistic regression analysis found that African American and Hispanic children experience lower health outcomes than their white peers, including lower rates of dental screening, more frequent injury-related care, lower overall health status, and lower rates of health insurance coverage. In comparison to White parents, African American and Hispanic parents reported lower levels of cigarette smoking. Children enrolled in Head Start received significantly more dental screening than their non-Head Start peers, regardless of race and ethnicity. The positive impacts of Head Start were particularly pronounced for African American and Hispanic children when compared to White children. Families that do not speak English as their primary language and those with lower household incomes experienced worse health outcomes. The positive impact of Head Start on the health outcomes of marginalized populations highlights the need for continued expansion of Head Start programs, as they strive to provide equal opportunities for improvements in academic, socio-emotional, and health outcomes for children and their parents in low-income households. The recruitment and enrollment process for Head Start should provide eligibility and application information in multiple languages for families in deep poverty.

Mental Health and Gender Affirmation of Black and Latine Transgender/Nonbinary Youth Compared to White Peers Prior to Hormone Initiation

PURPOSE

To compare baseline mental health symptoms and gender affirmation between Black/Latine versus White transgender/nonbinary youth (BLTY vs. WTY) and examine relationships between gender affirmation and mental health symptoms, and whether associations differed by race/ethnicity subgroup.

METHODS

Baseline data were analyzed from the gender-affirming hormone cohort of the Trans Youth Care United States Study-a 4-clinic site, observational study. Mental health symptoms assessed included depression, suicidality, and anxiety. Gender affirmation measures included the parental acceptance subscale from the perceived Parental Attitudes of Gender Expansiveness Scale-Youth Report; non-affirmation, internalized transphobia, and community connectedness subscales from the Gender Minority Stress and Resilience Measure-Adolescent; and self-reported living full time in affirmed gender. Fisher exact tests and independent sample t tests compared mental health symptoms and gender affirmation between subgroups. Logistic regression analyses evaluated associations between gender affirmation and mental health symptoms. Interaction analyses assessed differences in associations between subgroups.

RESULTS

The sample (mean age 16 years, range 12-20 years) included 92 BLTY (35%) and 170 WTY (65%). Subgroups had comparable prevalence of depression and anxiety symptoms. WTY had higher prevalence of lifetime suicidality (73% vs. 59%; p = .02). There were no differences in gender affirmation. Among the whole sample, higher parental acceptance decreased odds of depression symptoms. Not living in affirmed gender increased odds of depression symptoms. Higher non-affirmation and internalized transphobia increased odds of depression and anxiety symptoms and suicidality. Associations did not vary by subgroup.

DISCUSSION

BLTY and WTY had comparable mental health symptoms. For both subgroups, gender affirmation decreased odds of those symptoms.

An 18-week model of Parent-Child Interaction Therapy: clinical approaches, treatment formats, and predictors of success for predominantly minoritized families

Introduction

Disruptive behavior disorders are among the most prevalent pediatric mental health referrals for young children. However, families from historically minoritized social identities have experienced disparities in treatment access, retention, and outcomes. Evidence-based interventions such as Parent-Child Interaction Therapy (PCIT) have been found to be effective in reducing children's disruptive behaviors in minoritized families. However, variable treatment length as a result of skill-based graduation criteria (e.g., observed caregiver verbalizations) may slow and/or hinder treatment progress, particularly for families where expected treatment verbalizations are less linguistically relative (e.g., no exact English to Spanish translations) and/or culturally familiar. Time-limited PCIT has been proposed as a strategy for promoting equity in treatment completion and outcomes amongst minoritized families, because treatment progression and/ or completion is not contingent upon caregiver linguistic skill demonstration.

Methods

The current study evaluated the overall effectiveness of an 18-week model of PCIT and examined predictors of retention and treatment outcomes. Participants (N = 488 dyads) included predominantly racially, ethnically, linguistically, and socioeconomically diverse children aged two to eight years, and their caregivers.

Results

Overall findings indicate that the 18-week PCIT model is an effective intervention for reducing children's externalizing and internalizing behaviors and improving caregiver parenting skills for most treatment completers. Despite advances in treatment completion, some caregiver social identities and PCIT treatment characteristics were predictive of lower completion rates and/or less optimal treatment outcomes.

Discussion

Overall, this study provides strong support for widely disseminating use of the 18-week model of PCIT for most families served. Clinical implications and considerations for continued treatment inequity are discussed.

COVID-19 and children's behavioral health: An overview

The paper reviews the impact of the COVID-19 pandemic on children's and adolescents' well-being. A trauma-informed framework is employed to discuss the emerging evidence of notable changes in youth's psychological, developmental, academic, and social well-being since the start of the COVID-19 pandemic. Children and adolescents have been uniquely affected based on their age at the start of the pandemic. Despite multiple resiliency factors, COVID-19 and its ramifications have had an adverse effect on youth in general and have exacerbated preexisting racial and socioeconomic disparities. This review concludes with recommendations for child health clinicians.

Sleep and Fatigue as Mediators of Racial Discrimination and Internalizing Symptoms in Black Adolescent-Caregiver Dyads

While the association of racial discrimination and internalizing symptoms in Black individuals is well established, we still have a limited understanding of mechanisms and contextual factors influencing this association, such as sleep and the family context. The present study examined sleep and fatigue as mediators underlying the relationship between racial discrimination and internalizing symptoms within Black adolescent-caregiver dyads. Using data from a larger survey study of risk and resilience in Black adolescents (Mage= 14.36, 49.5% female) and their caregivers (Mage= 39.25, 75.9% female), we used the Actor-Partner Interdependence Model extended Mediation (APIMeM) to test associations of racial discrimination, sleep factors, and internalizing symptoms among 179 dyads. Significant actor effects revealed that sleep disturbance and fatigue independently mediated the association of racial discrimination and internalizing symptoms among adolescents and caregivers. Additionally, partner effects were found, such that adolescents' experiences of discrimination were indirectly associated with their caregivers' internalizing symptoms via caregiver fatigue. No direct or indirect effects of caregiver experiences of discrimination on adolescent outcomes were found. The findings highlight the important role sleep and fatigue play in the link between racial discrimination and internalizing symptoms among Black adolescents and adults; and the role that the family context may play in this association. Mental health and sleep interventions for Black individuals should address the impact of racial discrimination on internalizing symptoms, with an emphasis on family-focused interventions.

TF-CBT Training Augmented with a Self-Care Focus: Understanding Facilitators and Barriers to Treatment Implementation

Clinicians working with youth exposed to trauma may be at increased risk for experiencing elevated levels of stress and symptoms of secondary traumatic stress, which can negatively impact clinician wellbeing and ultimately contribute to reduced access to quality care for clients. An innovative Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) training incorporating self-care practices (i.e., Practice What You Preach; PWYP) was developed to help facilitate the implementation of TF-CBT and to enhance clinicians' coping and decrease stress. The primary purpose of this study was to determine whether the PWYP-augmented training met three Objectives: (1) increase clinicians' feelings of TF-CBT competency; (2) improve clinicians' coping abilities/reduce clinicians' stress; and (3) increase clinicians' insight into the benefits and/or challenges clients may experience in treatment. An exploratory aim was also developed to identify additional facilitators and barriers of TF-CBT implementation. The written reflections of 86 community-based clinicians who participated in the PWYP-augmented TF-CBT training were examined using qualitative methods. The majority of clinicians indicated increased feelings of competency and improved coping abilities and/or stress levels; almost half mentioned increased insight into clients' experiences. The most frequently mentioned additional facilitators were related to elements of the TF-CBT treatment model. Anxiety/self-doubt was the barrier most frequently mentioned, though all clinicians who mentioned this barrier indicated it lessened or resolved over the course of the training. Incorporating self-care strategies into trainings may serve as a facilitator for TF-CBT implementation by enhancing the competency and well-being of clinicians. The additional insights into barriers and facilitators can be used to further improve the PWYP initiative and future training and implementation efforts.

Exploring Service Use Disparities among Suicidal Black Youth in a Suicide Prevention Care Coordination Intervention

OBJECTIVE

The aim of this study is to examine service utilization disparities among Black youth participating in Linking Individuals Needing Care (LINC), a 90-day research-informed suicide care coordination intervention.

METHODS

An open trial pilot was conducted to examine the effectiveness of LINC in increasing access to and engagement in mental health and non-mental health services among suicidal youth (N = 587). Other variables of interest included service use facilitators and service use barriers. Generalized linear mixed models with binomial distribution and logit link were performed to ascertain if service use facilitators and barriers were associated with service utilization and if disparities in service use and engagement existed between Black and White suicidal youth through a comparative analysis.

RESULTS

Service utilization differences were found between Black and White youth. While Black and White youth were both likely to engage in individual therapy (OR = 1.398, p < .001) and non-mental health services (OR = 1.289, p < .001), utilization rates for mental health and medication management services were lower for Black (55.1% to 60.6%) youth compared to White (66.0% to 71.0%) youth. Specifically, Black youth were significantly less likely than Whites to receive medication management (OR = .466, p = .002). Systemic barriers such long waitlists for care (OR = 1.860, p = .039) and poor relationship with providers (OR = 7.680, p = .028) increased odds of engagement in non-mental health services. Clinical disorders and engagement in suicide-related behaviors increased the likelihood of obtaining care from both medication management and non-mental health services.

CONCLUSION

Care coordination services for suicidal youth can increase access and engagement in mental health and non-mental health services. Culturally adapted models attending to cultural and social assets of Black families are needed to reduce disparities and suicide risk among Black youth.

Racial/Ethnic Disparities and Women's Mental Health: Considerations for Providing Culturally Sensitive Care

Racial and ethnic disparities are apparent in many areas of health care. Within mental health, women experience increased rates of some mental health disorders particularly noted within the reproductive life cycle starting at puberty and ending with the menopause transition. Hormone and endocrine processes along with individual vulnerability and various stressors all likely play a major role. Among these women, a disproportionate number are racial and ethnic minorities in the United States. Cultural influences and systemic barriers are explored to provide competent and necessary mental health care for women.

Immersive and reflective recall of a suicidal episode: Implications for assessing and treating suicidal adolescents

OBJECTIVE

The present study tested the validity and clinical utility of adolescents' reports of two distinct modes of processing during the recall of a suicidal episode in the Suicide Narrative Interview (SNI). Recall Intensity (RI) items were designed to capture a tendency to become immersed in thoughts and feelings during the interview, while Meaning Making (MM) items were designed to assess more distant and reflective processing.

METHOD

The construct and predictive validity of pretreatment MM and RI was tested in a 16-week randomized clinical trial (RCT) for depressed and suicidal adolescents (N = 113, Mage = 14.95, 84.1% female, 51.8% Black/African American). Adolescents rated MM and RI immediately following the SNI during a baseline assessment.

RESULTS

Baseline MM was associated with protective factors related to reduced suicidality, and RI was associated with several risk factors for suicidal symptoms. Adolescents who reported high MM and low RI reported greater reductions in both suicidal ideation and depressive symptoms during the RCT.

CONCLUSIONS

The results support MM and RI as two distinct modes of how adolescents process memories of suicidal episodes and highlight the potential clinical utility of RI and MM in assessing and treating suicidal adolescents. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effects of Intersectionality Along the Pathway to Diagnosis for Autistic Children With and Without Co-occurring Attention Deficit Hyperactivity Disorder in a Nationally-Representative Sample

Children with complex behavioral profiles (e.g., ASD + ADHD) may experience delays in obtaining a final diagnosis. Low-resource or underrepresented groups may be at even greater risk for delayed diagnosis. We assessed the effect of sociodemographic factors, symptom complexity and co-occurring conditions, and identifier of first symptoms on diagnostic trajectories among children aged 3-17 years diagnosed with ASD (n = 52) or ASD + ADHD (n = 352) from a nationally-representative sample. Race/ethnicity and gender disparities were evident in both groups. Race, symptom complexity, and co-occuring conditions predicted age of final diagnosis and wait time between first concern and final diagnosis, both of which were staggeringly high. Results suggest a complex influence of sociodemographic factors on the diagnostic pathway, and risk of health disparities as a function of intersectionality.

Universal, School-Based Mental Health Program Implemented Among Racially and Ethnically Diverse Youth Yields Equitable Outcomes: Building Resilience for Healthy Kids

Although suicide is a leading cause of mortality among racial and ethnic minority youth, limited data exists regarding the impact of school-based mental health interventions on these populations, specifically. A single-arm pragmatic trial design was utilized to evaluate the equity of outcomes of the universal, school-based mental health coaching intervention, Building Resilience for Healthy Kids. All sixth-grade students at an urban middle school were invited to participate. Students attended six weekly sessions with a health coach discussing goal setting and other resilience strategies. 285 students (86%) participated with 252 (88%) completing both pre- and post-intervention surveys. Students were a mean age of 11.4 years with 55% identifying as girls, 69% as White, 13% as a racial minority, and 18% as Hispanic. Racial minority students exhibited greater improvements in personal and total resilience compared to White students, controlling for baseline scores.

Trends in Positive Depression and Suicide Risk Screens in Pediatric Primary Care During COVID-19

OBJECTIVE

Adolescent mental health concerns increased during COVID-19, but it is unknown whether early increases in depression and suicide risk have been sustained. We examined changes in positive screens for depression and suicide risk in a large pediatric primary care network through May 2022.

METHODS

Using an observational repeated cross-sectional design, we examined changes in depression and suicide risk during the pandemic using electronic health record data from adolescents. Segmented logistic regression was used to estimate risk differences (RD) for positive depression and suicide risk screens during the early pandemic (June 2020-May 2021) and late pandemic (June 2021-May 2022) relative to before the pandemic (March 2018-February 2020). Models adjusted for seasonality and standard errors accounted for clustering by practice.

RESULTS

Among 222,668 visits for 115,627 adolescents (mean age 15.7, 50% female), the risk of positive depression and suicide risk screens increased during the early pandemic period relative to the prepandemic period (RD, 3.8%; 95% CI, 2.9, 4.8; RD, 2.8%; 95% CI, 1.7, 3.8). Risk of depression returned to baseline during the late pandemic period, while suicide risk remained slightly elevated (RD, 0.7%; 95% CI, -0.4, 1.7; RD, 1.8%; 95% CI, 0.9%, 2.7%).

CONCLUSIONS

During the early months of the pandemic, there was an increase in positive depression and suicide risk screens, which later returned to prepandemic levels for depression but not suicide risk. Results suggest that pediatricians should continue to prioritize screening adolescents for depressive symptoms and suicide risk and connect them to treatment.

Screening for parent and child ADHD in urban pediatric primary care: pilot implementation and stakeholder perspectives

BACKGROUND

ADHD commonly co-occurs in children and parents. When ADHD is untreated in parents, it contributes to negative child developmental and treatment outcomes. Screening for parent and child ADHD co-occurrence in pediatric primary care may be an effective strategy for early identification and treatment. There is no data on whether this screening model can be implemented successfully and there exists limited guidance on how to effectively approach parents about their own ADHD in pediatric settings. Even greater sensitivity may be required when engaging with families living in urban, low SES communities due to systemic inequities, mistrust, and stigma.

METHODS

The current pilot study described the first 6 months of implementation of a parent and child ADHD screening protocol in urban pediatric primary care clinics serving a large population of families insured through Medicaid. Parents and children were screened for ADHD symptoms at annual well-child visits in pediatric primary care clinics as part of standard behavioral health screening. Independent stakeholder group meetings were held to gather feedback on factors influencing the implementation of the screening and treatment strategies. Mixed methods were used to examine initial screening completion rates and stakeholder perspectives (i.e., parents, primary care office staff, pediatricians, and behavioral health providers) on challenges of implementing the screening protocol within urban pediatric primary care.

RESULTS

Screening completion rates were low (19.28%) during the initial 6-month implementation period. Thematic analysis of stakeholder meetings provided elaboration on the low screening completion rates. Identified themes included: 1) divergence between provider enthusiasm and parent hesitation; 2) parent preference versus logistic reality of providers; 3) centering the experiences of people with marginalized identities; and 4) sensitivity when discussing parent mental health and medication.

CONCLUSIONS

Findings highlight the importance of developing flexible approaches to screening parent and child ADHD in urban pediatric health settings and emphasize the importance of cultural sensitivity when working with marginalized and under-resourced families.

TRIAL REGISTRATION

NCT04240756 (27/01/2020).

Psychiatric Diagnoses and Treatment in Nine- to Ten-Year-Old Participants in the ABCD Study

Objective

Psychiatric disorders commonly emerge prior to adulthood. Identification and intervention may vary significantly across populations. We leveraged a large population-based study to estimate the prevalence of psychiatric disorders and treatments, and evaluate predictors of treatment, in children ages 9-10 in the United States.

Method

We analyzed cross-sectional data from the Adolescent Brain Cognitive Developmental (ABCD) Study. The Computerized Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-COMP) was used to estimate clinical diagnoses, and the Child Behavior Checklist (CBCL) was used to assess internalizing and externalizing psychopathology. Parents reported on prescription medications and other mental health interventions. Prevalence rates of KSADS diagnoses and treatments were calculated. Logistic regression analyses estimated associations between clinical and sociodemographic predictors (sex at birth, race, ethnicity, income, education, urbanicity) and treatments.

Results

The most common KSADS diagnoses were anxiety disorders, followed by attention deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder. ADHD and depression diagnoses predicted stimulant and antidepressant medication use, respectively. Bipolar and ADHD diagnoses also predicted antidepressant medications, outpatient treatment and psychotherapy. The odds of reporting specific treatments varied by sex, ethnic and racial identities, urbanicity, and income.

Conclusion

Expected rates of KSADS-based psychiatric symptoms are present in the ABCD sample at ages 9-10, with treatment patterns broadly mapping onto psychopathology in expected ways. However, we observed important variations in reported treatment utilization across sociodemographic groups, likely reflecting societal and cultural influences. Findings are considered in the context of potential mental health disparities in U.S. children.

Bidirectional Associations of Mental Health with Self-Reported Criminal Offending Over Time for At-Risk Early Adult Men in the USA

Criminal offending and mental health problems often co-occur. This study examined competing models to understand bidirectional associations between crime and mental health problems over time among at-risk men in the U.S. It was hypothesized that there would be significant cross-lagged associations of offending and mental health problems in early adulthood. Longitudinal data were drawn from 206 at-risk men enrolled in the Oregon Youth Study. Random intercept cross-lagged models examined bidirectional associations between mental health problems (assessed with the 53-item Brief Symptom Inventory) and self-reported offending in early adulthood across 6 time points from ages 19-20 to 29-30 years. Sociodemographic factors, prior levels, and common risk factors (i.e., parents' criminality, mental health problems, and socioeconomic status, as well as child age, antisocial propensity, and internalizing behaviors) were controlled during analysis. A robust association between mental health problems and offending was found for the early adult period, especially for total and violence offenses. Findings did not support the hypothesized positive cross-lagged effects. Instead, two cross-lagged effects emerged indicating that offending was inversely related to subsequent mental health problems. Childhood antisocial propensity and internalizing behaviors emerged as important predictors of stable between-person level differences in offending and mental health problems, respectively, although results differed as a function of offense categories (total, violence, property, drug). Findings indicate that the relation between mental health problems and offending is unidirectional, temporal, and partially spurious. Preventing child internalizing behaviors and child antisocial behaviors holds promise for reducing early adult mental health problems and offending.

Perceptions of racism in a children's psychiatric inpatient unit: A qualitative study of entrenching and uprooting factors

WHAT IS KNOWN ON THE SUBJECT?: The impacts of racism on health are well documented and are greater for mental than for general health. Mental health professionals are well positioned to help dismantle racism and structural barriers compromising optimal patient care.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

We describe a systematic and orderly way to identify factors that contribute to entrenching racism as the status quo or that help to uproot it. By incorporating a racial equity lens, we can better understand daily racism and inform the optimal antiracist actions most relevant to an inpatient psychiatric setting. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Our two-domain/six-theme model may serve as a rubric for individuals to engage in structured self-reflection, for organizations in auditing or programmatic evaluation, or as scaffolding for difficult but frequently elided conversations. The unique strengths of a mental health environment can be harnessed toward the elimination of racism and racist practices in clinical care and in the workplace ABSTRACT: INTRODUCTION: It is well documented that racism plays a role in health care access and outcomes. However, discussions about racism in the inpatient psychiatric workplace are generally avoided. To address this gap, we incorporated a racial equity perspective into a qualitative study to better understand daily racism, its impact on patients and staff, and to inform optimal antiracist actions most relevant to inpatient psychiatric settings.

AIM/QUESTION

We sought to identify factors that may contribute to or deter from racism to inform interventions to sustain a psychologically supportive environment for patients and staff.

METHODS

We conducted semistructured interviews using a purposive sample of 22 individuals in an acute child psychiatric inpatient service. We analysed transcripts using thematic analysis guided by a constructivist grounded theory conceptual framework.

RESULTS

We identified two countervailing processes: (1) Entrenching-factors that sustain or increase racism: Predisposing, Precipitating, and Perpetuating and (2) Uprooting-factors that rectify or reduce racism: Preventing, Punctuating, and Prohibiting. We organized each of the elements into a '6P' model along a temporal sequence around sentinel racist events. For each of the six components we describe: Contributing Factors, Emotional Reactions, and Behavioural Responses as reported by participants.

IMPLICATIONS FOR PRACTICE

Identifying factors that entrench or uproot racism can inform specific steps to improve the care of all children and families on an inpatient child psychiatry unit. The two-domain/six-theme model we developed can serve as a rubric for individuals or milieu-based inpatient settings serving patients of any age to engage in structured self-reflection, auditing, program evaluation, or as scaffolding for difficult but frequently elided conversations.

Youth engagement to achieve health equity: Are healthcare organizations and leaders prepared?

Youth engagement in institutional decision-making is necessary to ensure policy and practice is responsive and relevant to youth and community needs. In particular, it is critical to engage the voices and experiences of youth of Color who have historically been marginalized by healthcare organizations. The present study used multiple methods to examine youth and adult perspectives on the facilitators and barriers to implementing a citywide youth advisory board of youths of Color for a safety net hospital. Data were analyzed using thematic analysis. The findings illustrate the need to employ an antiracist framework to ensure organizational and adult readiness to engage youth of Color in an advisory board. Organizational readiness included assessing organizational culture, clear expectation setting, and creating safe spaces for youth. Adult readiness included adult facilitators who are trained in antiracist and equity-focused practice and the youth-adult partnership model, and a recognition of the bidirectional benefits of youth engagement in decision-making. The implications and recommendations of this study are timely given the historical mistrust between healthcare organizations and communities of Color, as well as the racial health inequities that have been further exposed during the COVID-19 pandemic.

Identifying Methods to Select and Tailor Implementation Strategies to Context-Specific Determinants in Child Mental Health Settings: A Scoping Review

This scoping review describes the state of the literature regarding Implementation Strategy Mapping Methods (ISMMs) within the context of child mental health practice delivery. Goals included (a) identify and describe ISMMs addressing determinants of implementing mental health evidence-based interventions (MH-EBIs) for children and (b) describe the scope of the literature (e.g., outcomes, remaining gaps) related to identified ISMMs. Following PRISMA-ScR guidelines, 197 articles were identified. After removing 54 duplicates, 152 titles and abstracts were screened, yielding 36 articles that were screened during the full-text review. The final sample included four studies and two protocol papers (n = 6). A data charting codebook was developed a priori to capture relevant information (e.g., outcomes) and content analysis was utilized to synthesize findings. Six ISMMs were identified: innovation tournament, concept mapping, modified conjoint analysis, COAST-IS, focus group, and intervention mapping. ISMMs were successful in leading to the identification and selection of implementation strategies at participating organizations, and all ISMMs included stakeholders throughout these processes. Findings revealed the novelty of this research area and highlighted numerous areas for future investigation. Implications related to implementation, service, and client outcomes are discussed, including the possible impact of utilizing ISMMs to increase access to MH-EBIs for children receiving services in community settings. Overall, these findings contribute to our understanding of one of the five priority areas within implementation strategy research-enhancing methods used to design and tailor implementation strategies-by providing an overview of methods that may be utilized to facilitate MH-EBI implementation in child mental health care settings. Trial Registration: Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-023-00086-3.

Validation of the Psychosocial Assessment Tool Sibling Module Follow-Up Version

OBJECTIVE

Psychosocial screening is recommended to connect siblings of youth with cancer to psychosocial services, but the lack of validated sibling-specific screening tools is a barrier to routine screening. The current study aimed to validate and establish a clinical cutoff for the recently developed Psychosocial Assessment Tool (PAT) Sibling Module follow-up version to address this barrier.

METHODS

Parents (N = 246) completed the PAT Sibling Module follow-up version for all siblings within their families ages 0-17 years (N = 458) at three time points between 6- and 24-month post-cancer diagnosis. For one target sibling within each family aged 8-17 years, parents also completed the Strengths and Difficulties Questionnaire, and the target sibling completed the Child PTSD Symptom Scale. Cross-sectional and longitudinal analyses examined internal consistency and convergent and predictive validity. Receiver operator characteristic analyses were used to establish a maximally sensitive and specific clinical cutoff.

RESULTS

Internal consistency was acceptable for all age versions (Kuder-Richardson 20s ≥ 0.79), except for the ages 0-2 version, which had low internal consistency at 18 months post-diagnosis (Kuder-Richardson 20 = 0.57). Convergent (r values >0.7, p values <.001) and predictive (r values >0.6, p values <.001) validity were strong at each time point. An optimal clinical cutoff of 0.32 was identified (range: 0.00-1.00).

CONCLUSIONS

The PAT Sibling Module follow-up version is a reliable and valid screener for sibling psychosocial risk following cancer diagnosis. Validation of a sibling-specific screener and establishment of a clinical cutoff are necessary first steps to addressing siblings' unmet psychosocial needs and improving trajectories of sibling functioning.

Perceived Negative Political Climate Among Hispanic/Latino Adolescents Before and After the 2020 U.S. Presidential Election: Associations with Internalizing Symptoms and Substance Use

The political climate often changes following the installment of a new president. This volatility presents opportunities for examining how elections might affect vulnerable subgroups such as Hispanic/Latino (HL) adolescents. The present study explored the perception of negative political climate among HL adolescents before and after the 2020 U.S. presidential election and its association with internalizing symptoms and substance use. We conducted the study in Los Angeles and Miami between 2020-2021, with a sample of 304 HL adolescents (Females = 60.8%), aged 15.3 years on average. Participants completed measures of negative political climate (pre- post-election) and measures of depressive symptoms, anxiety, substance misuse, and substance use intentions after the election. We used paired tests and linear mixed-effects modeling to explore changes in perceived negative climate before and after the election. Structural equation modeling was used to determine predictors of negative political climate and its associations with internalizing symptoms and substance use. Results indicated that following the election negative political climate increased significantly in Miami and among Cuban-origin adolescents but not in Los Angeles or among Mexican-origin adolescents. Pre-election perceived negative political climate was significantly predicted by gender, study site, and mother's nativity. Pre-election negative political climate predicted post-election internalizing symptoms and substance use intentions indirectly through post-election negative political climate. HL youth's perceived political climate is a complex construct that might vary across different sociopolitical contexts and populational sub-groups. Exploring variations in politically-based cultural stressors and their role as mental health and substance use risk factors is crucial to addressing HL disparities. KEY WORDS: Adolescence, Hispanic/Latino, political climate, presidential election, internalizing symptoms, substance use.

Intergenerational risk and resilience pathways from discrimination and acculturative stress to infant mental health

Preconception and prenatal stress impact fetal and infant development, and women of color are disproportionately exposed to sociocultural stressors like discrimination and acculturative stress. However, few studies examine links between mothers' exposure to these stressors and offspring mental health, or possible mitigating factors. Using linear regression, we tested associations between prenatally assessed maternal acculturative stress and discrimination on infant negative emotionality among 113 Latinx/Hispanic, Asian American, Black, and Multiethnic mothers and their children. Additionally, we tested interactions between stressors and potential pre- and postnatal resilience-promoting factors: community cohesion, social support, communalism, and parenting self-efficacy. Discrimination and acculturative stress were related to more infant negative emotionality at approximately 12 months old (M = 12.6, SD = .75). In contrast, maternal report of parenting self-efficacy when infants were 6 months old was related to lower levels of infant negative emotionality. Further, higher levels of parenting self-efficacy mitigated the relation between acculturative stress and negative emotionality. Preconception and prenatal exposure to sociocultural stress may be a risk factor for poor offspring mental health. Maternal and child health researchers, policymakers, and practitioners should prioritize further understanding these relations, reducing exposure to sociocultural stressors, and promoting resilience.

A Natural Helper Intervention to Address Disparities in Parent Child-Interaction Therapy: A Randomized Pilot Study

OBJECTIVE

Parent-child interaction therapy (PCIT) is an effective intervention to address child externalizing behaviors. However, disparities in access and retention are pervasive, which relate to the availability of PCIT in low-income communities, inadequate workforces to provide culturally appropriate care, and distrust in services due to systemic discrimination. This study incorporated natural helpers who had been trained as community health workers into PCIT delivery to improve disparities in engagement and outcomes.

METHOD

Families from three low-income, predominately Latino/a/x and Black neighborhoods in Miami qualified for services if they had a child aged 2-8 with clinically elevated externalizing behaviors. Families were randomly assigned into either Standard-PCIT group (N = 30 families; 80% boys, 57% Latino/a/x, 27% Black) or a PCIT plus Natural helper (PCIT+NH) group (N = 51 families; 66% boys, 76% Latino/a/x, 18% Black). Families in the PCIT+NH group received home visits and support addressing barriers to care from a natural helper. Path analyses within an intention-to-treat framework examined group-differences in treatment engagement, child behavior, and parenting skills and stress.

RESULTS

Families in both groups demonstrated large improvements in child externalizing behavior, caregiver stress, and parenting skills from pre-to-post-treatment. Externalizing behavior improved significantly more in the PCIT+NH group compared to the Standard-PCIT group. There were no significant group differences in parenting skills or caregiver stress. Though differences in engagement were not significant, the PCIT+NH group had a small effect on treatment retention.

CONCLUSIONS

Natural helpers may help to address structural barriers that systematically impact communities of color, apply treatment in naturalistic environments, and promote improved treatment outcomes.

Introduction to the Special Issue: Advancing Racial Justice in Clinical Child and Adolescent Psychology

Relative to White youth, racially and ethnically marginalized youth in the U.S. are less likely to initiate treatment, stay in treatment, and receive adequate care. This special issue attends to racial injustice in clinical child and adolescent psychology. While numerous factors drive these racial disparities, this special issue focuses specifically on opportunities and responsibilities we have as mental health providers, teachers, mentors, researchers, and gatekeepers to make our field more racially just. In this introduction to the special issue, we review barriers and solutions across multiple contexts including structural, institutional, and practice-based. We also discuss challenges and opportunities to diversify our field and increase the representation of racially and ethnically marginalized practitioners and scholars in clinical child and adolescent psychology. We then briefly review the special issue articles and make final recommendations for how to move the field forward.

Addressing Social Context in Adverse Childhood Experience Screening Policy: Implications for Children With Special Health Care Needs

Adverse childhood experiences (ACEs) disproportionately affect children with special health care needs, especially racial and ethnic minority children whose ACEs may be less likely to be identified. As awareness and understanding of the health impacts of ACEs have increased, heightened by the COVID-19 pandemic, several areas of the United States have initiated policy efforts to screen for and address ACEs. However, these policies do not always include mechanisms to account for context-specific adversity or contemporary stressors in the lives of children. Stressors most significant in a child's life may include adversities beyond those included in common ACE screening instruments. ACE policy in California will be discussed relative to addressing the social context in ACEs screening. By taking a holistic view of ACEs and thinking beyond deriving ACE scores alone, clinicians can ensure that ACE-related policies are implemented with maximum benefit to diverse children with special health care needs.

Follow-up After Pediatric Mental Health Emergency Visits

OBJECTIVES

To examine how outpatient mental health (MH) follow-up after a pediatric MH emergency department (ED) discharge varies by patient characteristics and to evaluate the association between timely follow-up and return encounters.

METHODS

We conducted a retrospective study of 28 551 children aged 6 to 17 years with MH ED discharges from January 2018 to June 2019, using the IBM Watson MarketScan Medicaid database. Odds of nonemergent outpatient follow-up, adjusted for sociodemographic and clinical characteristics, were estimated using logistic regression. Cox proportional hazard models were used to evaluate the association between timely follow-up and risk of return MH acute care encounters (ED visits and hospitalizations).

RESULTS

Following MH ED discharge, 31.2% and 55.8% of children had an outpatient MH visit within 7 and 30 days, respectively. The return rate was 26.5% within 6 months. Compared with children with no past-year outpatient MH visits, those with ≥14 past-year MH visits had 9.53 odds of accessing follow-up care within 30 days (95% confidence interval [CI], 8.75-10.38). Timely follow-up within 30 days was associated with a 26% decreased risk of return within 5 days of the index ED discharge (hazard ratio, 0.74; 95% CI, 0.63-0.91), followed by an increased risk of return thereafter.

CONCLUSIONS

Connection to outpatient care within 7 and 30 days of a MH ED discharge remains poor, and children without prior MH outpatient care are at highest risk for poor access to care. Interventions to link to outpatient MH care should prioritize follow-up within 5 days of an MH ED discharge.

Household Social Needs, Emotional Functioning, and Stress in Low-Income Latinx Children and their Mothers

Latinx families may be particularly vulnerable to emotional dysfunction, due to higher rates of economic hardship and complex social influences in this population. Little is known about the impact of environmental stressors such as unmet social needs and maternal stress on the emotional health of Latinx children from low-income families. We conducted secondary analyses using survey and biomarker data from 432 Latinx children and mothers collected in a separate study. We used binomial and multinomial logistic regression to test if household social needs, or maternal perceived stress or hair cortisol concentration (HCC), predicted child measures of emotional functioning or child HCC, independent of relevant sociodemographic factors. Approximately 40% of children in the sample had symptoms consistent with emotional dysfunction, and over 37% of households reported five or more social needs. High perceived maternal stress predicted higher odds of child emotional dysfunction (OR = 2.15; 95% CI [1.14, 4.04]; p = 0.01), and high maternal HCC was positively associated with high child HCC (OR = 10.60; 95% CI [4.20, 26.74]; p < 0.01). Most individual household social needs, as well as the level of household social need, were not independently associated with child emotional dysfunction or child HCC. Our findings begin to define a framework for understanding emotional health, stress, and resilience when caring for Latinx children and mothers living with high levels of social need, and the need for integrated mental health and social needs screening and interventions in settings that serve this population.

Depression Prevention in Pediatric Primary Care: Implementation and Outcomes of Interpersonal Psychotherapy-Adolescent Skills Training

This study evaluated the fidelity, feasibility, acceptability, and preliminary outcomes of a depression prevention program, interpersonal psychotherapy-adolescent skills training (IPT-AST), in urban pediatric primary care (PC) with a sample of primarily Black youth. Twenty-two adolescents with elevated depressive symptoms participated in this open clinical trial. Adolescents were identified through a screening questionnaire completed at well visits. Ratings of IPT-AST fidelity and session attendance were recorded. Youth and caregivers reported on their attitudes toward the intervention and completed measures of adolescents' symptoms and functioning pre- and post-intervention. Results demonstrated high levels of fidelity, attendance, and acceptability, despite some difficulties with recruitment. Adolescents and caregivers reported significant improvements in functioning. There were marginally significant reductions in self-reported depression, anxiety, and total mental health symptoms. Caregivers reported a significant decrease in total mental health symptoms. Findings provide preliminary information regarding the implementation and effects of IPT-AST when delivered in PC.

How can pediatric surgeons address racism and become actively anti-racist?

BACKGROUND/PURPOSE

This is an article submitted on behalf of the Canadian Association of Pediatric Surgeons. We assert that Pediatric Surgeons must work to dismantle systemic racism. Pediatric Surgeons have expertise in both common and rare surgical diseases affecting patients ranging from premature neonates to adolescents. Thus, our professional obligation is to transform our health and social systems to prevent the harms of racism to our patients.

METHODS

Specific to the Canadian context, we describe a brief history, the ongoing impact on individuals and communities, and the harmful effect on the surgical community and trainees. Finally, we developed a series of practical recommendations to help surgeons become actively anti-racist.

RESULTS

Four primary recommendations are made: (1) Increasing and supporting anti-racism education; (2) Changing individual behaviours to combat racism; (3) Developing strategies for organizational change; and (4) Committing to diversity in leadership.

CONCLUSION

As surgeons, we are actors of change, and we can take meaningful steps to combat racism in our health systems.

LEVEL OF EVIDENCE

V.

Examining Patterns of Psychotherapy Service Utilization Among Medicaid-Enrolled Adolescents

OBJECTIVE

Adolescents with behavioral health disorders (i.e., mental health disorders and substance use) often experience frequent recurrence of symptoms, suggesting a need for an ongoing behavioral health intervention, rather than a single course of treatment. However, little is known about mental health care service use among adolescents over longer periods. The authors examined longitudinal patterns of outpatient behavioral health service utilization in a large sample of adolescents.

METHODS

Medicaid claims for 8,197 adolescents (ages 10.0-13.9 years, mean±SD=11.5±1.2; 61% male) from one Indiana county between 2006 and 2017 were examined, with a focus on outpatient psychotherapy visits. Latent class analysis (LCA) was used to detect clusters of longitudinal patterns of outpatient psychotherapy visits across 5 years, beginning with an adolescent's first behavioral health visit.

RESULTS

A five-class LCA model emerged with unique classes of service use based on duration and level of engagement (frequency) of monthly outpatient psychotherapy visits. Most adolescents fell in the nonuse class (38.7% of the sample). Additional classes were defined as late-onset low engagement (17.1%), early-onset high engagement (15.5%), early-onset moderate engagement (16.7%), and continuously high engagement (11.9%). Statistically significant differences were found across the classes in average duration and frequency of involvement (p<0.001), as well as in demographic characteristics (race, age, gender, and ethnicity) and behavioral health diagnoses (p<0.001).

CONCLUSIONS

These findings confirm that adolescents with behavioral health diagnoses do not follow a uniform pattern of psychotherapy utilization. The distinct patterns of service use point toward the need to identify appropriate long-term service recommendations for adolescents.

Can We Expand the Pool of Youth Who Receive Telehealth Assessments for ADHD? Covariates of Service Utilization

BACKGROUND

During the COVID-19 pandemic, telehealth became widely utilized for healthcare, including psychological evaluations. However, whether telehealth has reduced or exacerbated healthcare disparities for children with Attention-Deficit/Hyperactivity Disorder (ADHD) remains unclear.

METHODS

Data (race, ethnicity, age, insurance type, ADHD presentation, comorbidities, and distance to clinic) for youth with ADHD (Mage = 10.97, SDage = 3.42; 63.71% male; 51.62% White) were extracted from the medical record at an urban academic medical center. Three naturally occurring groups were compared: those evaluated in person prior to COVID-19 (n =780), in person during COVID-19 (n = 839), and via telehealth during COVID-19 (n = 638).

RESULTS

Children seen via telehealth were significantly more likely to be older, White, have fewer comorbid conditions, and live farther from the clinic than those seen in person.

CONCLUSIONS

The current study suggests that telehealth has not eliminated barriers to care for disadvantaged populations. Providers and institutions must take action to encourage telehealth use among these groups.

Factors Associated With Psychiatric Readmission of Youths in a Racially Diverse and Urban Hospital Setting

OBJECTIVE

This study examined predictors of readmission to a psychiatric inpatient unit of an urban children's hospital within 1 year of discharge among a racially diverse sample of youths.

METHODS

The authors retrospectively analyzed 2 years of electronic health record data of inpatient psychiatric unit admissions (N=1,604). Multivariate logistic regression and random-effects multinomial logistic regression were used for analyses.

RESULTS

The estimated odds ratios for any readmission within 1 year of discharge were significantly higher for Black youths, youths insured by Medicaid, and youths with a length of stay longer than 7 days. Factors remained strongly predictive when examining multiple readmissions versus no readmissions.

CONCLUSIONS

Black youths, youths insured by Medicaid, and youths with longer stays were more likely than other youths to be readmitted. Findings suggest the need for interventions such as care coordination to target predictors of readmission and the need to examine inequities in the health care system.

Mental Health Care Utilization Among Children and Adolescents With a Firearm Injury

Importance

Firearm injuries are a leading cause of morbidity and mortality among US children and adolescents. Despite evidence demonstrating mental health sequelae for children and adolescents who have experienced a firearm injury, little is known about mental health care utilization after a firearm injury.

Objective

To evaluate mental health care utilization in the 12 months after a firearm injury among Medicaid-insured and commercially insured children and adolescents compared with propensity score-matched controls.

Design, Setting, and Participants

This propensity score-matched retrospective cohort analysis assessed 2127 children and adolescents, aged 0 to 17 years, with a firearm injury that occurred between January 1, 2016, and December 31, 2017, compared with 2127 matched controls using MarketScan Medicaid and commercial claims data. Claims data were analyzed 12 months before and after injury, with the total study period spanning from January 1, 2015, to December 31, 2018.

Exposure

Nonfatal firearm injury.

Main Outcomes and Measures

The primary outcome of interest was a dichotomous variable representing any mental health care utilization in the 12 months after injury. Secondary outcomes included psychotherapy utilization, substance use-related utilization, and a psychotropic medication prescription. Logistic regression modeling was used to estimate relative risks with adjusted analyses of dichotomous outcomes.

Results

The overall cohort consisted of 4254 children and adolescents, of whom 2127 (mean [SD] age, 13.5 [4.1] years; 1722 [81.0%] male) had an initial encounter for a firearm injury and an equal number of matched controls (mean [SD] age, 13.5 [4.1] years; 1720 [80.9%] male). Children and adolescents with a firearm injury had a 1.40 times greater risk (95% CI, 1.25-1.56; P < .001) of utilizing mental health services in the 12 months after their injury compared with children and adolescents without a firearm injury, after controlling for potential confounders. Children and adolescents with a firearm injury had a 1.23 times greater risk (95% CI, 1.06-1.43; P = .007) of utilizing psychotherapy and a 1.40 times greater risk (95% CI, 1.19-1.64; P < .001) of substance use-related utilization. Among those who experienced a firearm injury, Black children and adolescents were 1.64 times more likely (95% CI, 1.23-2.19; P < .001) to utilize mental health care compared with White children and adolescents.

Conclusions and Relevance

This propensity score-matched cohort study found that children and adolescents with a firearm injury had a greater risk of utilizing mental health services in the 12 months after their injury compared with those without an injury, and significant racial disparities were associated with use of mental health services. The findings suggest that health care practitioners should be aware of this increased risk and ensure adequate mental health follow-up for these patients.

Community Health Workers and Stigma Associated with Mental Illness: An Integrative Literature Review

Community health workers (CHWs) are facilitators between health services and service users, providing essential and effective support to those seeking health care. However, stigmatizing attitudes towards people with mental illness also exist among CHWs and are based on prejudicial and biasedopinions. This integrative review critically assessed evidence regarding CHWs approaches for addressing mental health issues. In total, 19 studies were included in this review. The results revealed that CHWs have limited knowledge about mental illness and also stigmatizing attitudes towards people with mental illness or substance use problems. Despite feeling unprepared, CHWs are favorable resources for mental health care and can contribute to reducing stigma due to the similarities they share with the communities that they serve. Task-sharing between health professionals and CHWs is an important strategy to improve access to health services and reducing stigma towards people with mental illness, provided that receive adequate training to perform the duties.

Longitudinal assessment of anxiety and depression symptoms in U.S. adolescents across six months of the coronavirus pandemic

BACKGROUND

The present study aimed to describe anxiety and depression symptoms at two timepoints during the coronavirus pandemic and evaluate demographic predictors.

METHODS

U.S. high school students 13-19 years old completed a self-report online survey in May 2020 and November 2020-January 2021. The Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Depression and Anxiety short forms queried depression and anxiety symptoms.

RESULTS

The final sample consisted of 694 participants (87% White, 67% female, 16.2 ± 1.1 years). Nearly 40% of participants reported a pre-pandemic depression diagnosis and 49% reported a pre-pandemic anxiety diagnosis. Negative affect, defined as both moderate to severe depression and anxiety PROMIS scores, was found in ~ 45% of participants at both timepoints. Female and other gender identities and higher community distress score were associated with more depression and anxiety symptoms. Depression symptoms T-score decreased slightly (- 1.3, p-value  ≤ 0.001).

CONCLUSION

Adolescent mental health screening and treatment should be a priority as the pandemic continues to impact the lives of youth.

The Development and Pilot Evaluation of a Family-Based Education to Strengthen Latinx Adolescent Mental Health in the United States: The Familias Activas Experience

Adolescent years are a time of joy and can represent a challenge for parents and youth, especially for immigrants to the US who are adjusting to their host country. Programs focusing on family skills and positive youth development (PYD) can contribute to youth wellbeing especially, however, few exist for low-income immigrant families. (1) Background: The major goals of this project are to strengthen both PYD and healthy parenting practices by implementing an evidence-informed program, Familias Activas. A theory of change guided the development of Familias Activas in which three factors: parent training, positive youth development, and youth physical activity sessions (soccer) aimed to improve Latinx youth mental health. Youth participated in weekly soccer practices led by trained soccer coaches while parents/caregivers attended parent education. Both sessions lasted eight weeks. (2) Method: We describe the formative stage of the research project as well as the pilot implementation of the Familias Activas program, which provides critical insights for the development of a PYD program. (3) Results: Evaluation surveys were administered to youth and their parents. Thirty youths and sixteen parents completed the survey. The Kidscreen scale had a mean for most items ranging from 3.6 to 4.2. Participating youth were 11 years old and most affirmed they were Latinx. The feasibility program quality mean was 4.2 indicating an overall positive result for the pilot program.. Implications of PYD programs for Latinx youth are discussed. (4) Conclusions: The current paper presents a model for positively influencing the physical and mental wellbeing of Latinx youth and their parents. The model is culturally responsive in its involvement of both parents and youth in programming.

Racial/ethnic differences in receipt of surgery among children in the United States

BACKGROUND

It is unknown whether racial/ethnic disparities exist in surgical utilization for children. The aim, therefore, was to evaluate the odds of surgery among children in the US by race/ethnicity to test the hypothesis that minority children have less surgery.

METHODS

Cross-sectional data were analyzed on children 0-18 years old from the 1999 to 2018 National Health Interview Survey, a large, nationally representative survey. The primary outcome was odds of surgery in the prior 12 months for non Latino African-American, Asian, and Latino children, compared with non Latino White children, after adjustment for relevant covariates. The National Surgical Quality Improvement Program Pediatric Dataset was used to analyze the odds of emergent/urgent surgery by race/ethnicity.

RESULTS

Data for 219,098 children were analyzed, of whom 10,644 (4.9%) received surgery. After adjustment for relevant covariates, African-American (AOR, 0.54; 95% CI, 0.50-0.59), Asian (AOR, 0.39; 95% CI, 0.33-0.46), and Latino (AOR, 0.62; 95% CI, 0.57-0.67) children had lower odds of surgery than White children. Latino children were more likely to require emergent or urgent surgery (AOR, 1.71; 95% CI, 1.68-1.74).

CONCLUSIONS

Latino, African-American, and Asian children have significantly lower adjusted odds of having surgery than White children in America, and Latino children were more likely to have emergent or urgent surgery. These racial/ethnic differences in surgery may reflect disparities in healthcare access which should be addressed through further research, ongoing monitoring, targeted interventions, and quality-improvement efforts.

LEVEL OF EVIDENCE

II.

TYPE OF STUDY

Prognosis study.

Effects of a brief parenting intervention on Latinx mothers and their children

Parent-Child Interactions (PCI) is a home visit parenting intervention designed to promote positive parenting and deter punitive approaches to child behavior management. With attention to the importance of providing efficacious interventions for families from diverse backgrounds, this study used a subsample from a larger randomized controlled trial (RCT) to examine the efficacy of PCI intervention among Latinx participants. PCI was offered to 170 at-risk Latinx mother-child dyads, of whom the majority were primarily Spanish speaking. Dyads were randomly assigned to an intervention or a wait-list control condition. Path analysis modeling was used to examine parenting outcomes as a mediator of program efficacy between group assignment and children's long-term functioning. Results suggest that Latinx parent and child functioning benefited from PCI intervention 6 months following intervention. Specifically, model results indicated significant indirect effects of the PCI intervention on (1) cooperative child behavior and (2) children's externalizing behaviors 6-months posttreatment via parenting at post test, with mother-child dyads assigned to the treatment condition, relative to the control, demonstrating better functioning 6-months posttreatment. Overall, findings contribute to increased understanding of parenting intervention implementation among Latinx families. Recommendations for future study are discussed.

Racial and Ethnic Differences in Psychotropic Prescription Receipt Among Pediatric Patients Enrolled in North Carolina Medicaid

OBJECTIVE

The authors aimed to examine racial-ethnic differences in filled psychotropic prescriptions among a pediatric Medicaid population.

METHODS

This retrospective cohort study included patients ages 0-21 with at least one North Carolina Medicaid claim from October 1, 2017, through September 30, 2018 (N=983,886). The primary outcome was a filled psychotropic prescription. Separate multivariable modified Poisson regression models generated adjusted risk ratios (ARRs) and 95% confidence intervals (CIs), adjusted for patient demographic characteristics.

RESULTS

Black and Hispanic patients were significantly less likely to receive any filled psychotropic prescription (ARR=0.61, 95% CI=0.60-0.62; ARR=0.29, 95% CI=0.28-0.29, respectively) compared with White and non-Hispanic patients. Furthermore, Black and Hispanic patients were less likely to receive filled prescriptions in the four included drug classes compared with White and non-Hispanic patients.

CONCLUSIONS

Future studies should focus on understanding the factors contributing to racial and ethnic differences among pediatric patients receiving filled psychotropic prescriptions.

Rapid and Deferred Help Seeking Among African American Parents of Children With Emotional and Behavioral Difficulties

OBJECTIVE

Little is known about the factors African American parents consider when seeking care for their child after emotional and behavioral difficulties emerge. This study aimed to examine factors associated with seeking professional care within 30 days after identifying a child's need (i.e., rapid care seeking) and with deferring care for ≥1 year.

METHODS

This cross-sectional study surveyed African American parents raising a child with emotional or developmental challenges (N=289). Logistic regression was used to examine associations of parent activation, medical mistrust, and care-seeking barriers with two outcomes: rapidly seeking care and deferring care seeking.

RESULTS

About 22% of parents rapidly sought care, and 49% deferred care for 1 year or longer. Parents were more likely to rapidly seek care if they had higher parent activation scores; lived with other adults with mental health challenges; or, contrary to the authors' hypothesis, mistrusted doctors. Parents were less likely to rapidly seek care if the challenge did not initially bother them much or if their health insurance would not cover the service. Parents were more likely to defer care if they feared involuntary hospitalization for their child or if their health insurance would not cover the service. Parents were less likely to defer care if they had at least some college education or lived with other adults with mental health challenges.

CONCLUSIONS

Community-based pediatric and child welfare professionals should be informed about facilitators and barriers to mental health care seeking as part of efforts to develop interventions that support African American families.

The Socioeconomic Indicators Linked to Parent Health-Related Technology Use: Cross-sectional Survey

Background

Despite the prevalence of parent health information seeking on the internet and its impact on parenting behavior, there is a paucity of research on parents of young children (ages 3 to 8 years). Given the importance of this developmental period, exploring how family socioeconomic indicators linked to the digital divide and health inequities affect parent proxy- and self-seeking is critical to further understanding variability in health information seeking and associated outcomes.

Objective

This study aimed to explore parental health-related technology use (HTU), the process by which parents engage in support, advice, and information-seeking behavior related to their (self-seeking) and their children’s (proxy seeking) health across a range of hardware devices (eg, tablet, wearable, smartphone, laptop, and desktop computer) and sources (eg, search engines, mobile applications, social media, and other digital media).

Methods

A cross-sectional study including 313 parents and guardians of children ages 3 to 8 years recruited through Amazon Mechanical Turk (MTurk) was conducted. Parents were asked to complete a self-administered questionnaire on a broad range of parenting and parent-related constructs, including sociodemographic information, technology device ownership, and engagement in and use, features, and perceptions of HTU. Descriptive and bivariate analyses (chi-square tests) were performed to identify patterns and investigate associations between family socioeconomic indicators and parent HTU.

Results

The overwhelming majority (301/313, 96%) of parents of young children reported engaging in HTU, of which 99% (300/301) reported using search engines (eg, Google), followed by social media (62%, 188/301), other forms of digital media (eg, podcasts; 145/301, 48%), and mobile applications (114/301, 38%). Parents who engaged in HTU reported seeking information about their child’s behavior and discipline practices (260/313, 83%), mental or physical health (181/313, 58%), and academic performance (142/313, 45%). Additionally, nearly half (134/313, 43%) of parents reported searching for advice on managing their stress. Among parents who reported using each source, an overwhelming majority (280/300, 93%) indicated that search engines were a helpful online source for proxy- and self-seeking, followed by social media (89%, 167/188), other digital media (120/145, 83%), and mobile apps (87/114, 76%). Among parents who reported using any technology source, approximately one-fifth reported that technology sources were most comfortable (61/311, 20%), most understanding (69/311, 22%), and most influential toward behavior change (73/312, 23%) compared to traditional sources of health information–seeking, including mental health professionals, other health care professionals, school professionals, community leaders, friends, and family members. Indicators of family socioeconomic status were differentially associated with frequency and perceptions of and search content associated with parent HTU across technology sources.

Conclusions

The findings of this study underscore critical considerations in the design and dissemination of digital resources, programs, and interventions targeting parent and child health, especially for families in traditionally underserved communities.

Incidence of anxiety and depression in children and young people with life-limiting conditions

BACKGROUND

The aim of this study was to investigate the incidence of anxiety and depression in children and young people with life-limiting conditions.

METHODS

A comparative cohort study was conducted, using primary and secondary care data from the Clinical Practice Research Datalink (CPRD) in England. Anxiety and depression codes were identified using diagnostic, symptom and prescription codes. Incidence rates of anxiety and depression were compared across condition groups using Poisson regression, adjusting for sex, age, ethnicity, and deprivation status.

RESULTS

A total of 25,313 children and young people were included in the study: 5527 with life-limiting conditions, 6729 with chronic conditions, and 13,057 with no long-term conditions. The incidence of anxiety (IRR_adj: 1.39, 95% CI: 1.09-1.77) and depression (IRR_adj: 1.41, 95% CI: 1.08-1.83) was significantly higher in children and young people with life-limiting conditions, compared to children and young people with no long-term conditions.

CONCLUSIONS

The higher incidence of anxiety and depression observed among children and young people with life-limiting conditions highlights the need for psychological support in this population, including further efforts to prevent, identify, and treat anxiety and depression.

IMPACT

The analysis of primary and secondary healthcare data from England revealed that the incidence of anxiety and depression was higher among children and young people with life-limiting conditions, compared to those with no long-term conditions. This is the first study to investigate the incidence of anxiety and depression in children and young people with a wide range of life-limiting conditions. The higher incidence of anxiety and depression observed in children and young people with life-limiting conditions highlights the need for psychological support aiming to prevent, identify, and treat anxiety and depression in this population group.

School Mental Health Professionals' Knowledge of Stereotypes and Implicit Bias Toward Black and Latinx Youths

Clinician bias is a contributor to health care inequities, but research on racial-ethnic bias among mental health professionals, especially toward minoritized youths, is limited. This column describes two studies involving mental health clinicians in schools, where most youths access mental health services. Study 1 used a mixed-methods approach to identify stereotypes about Black and Latinx youths salient to clinicians (e.g., academic failure; anger and aggression). In study 2, the authors developed four Implicit Association Tests to assess clinicians' implicit prejudice and stereotyping of Black and Latinx youths and found pro-White and anti-Black/Latinx bias at levels similar to those of other health care providers and the general population.

Social Determinants of Health, Structural Racism, and the Impact on Child and Adolescent Mental Health

In recent years, there has been a greater emphasis on examining the factors, particularly the social factors, that affect health outcomes and contribute to population health inequities. The social determinants of health, as defined by the World Health Organization, are "the conditions in which people are born, grow, work, live, and develop, and the wider set of forces, including economic policies, social norms, and political systems, that shape the conditions of daily life and impact health outcomes."¹ The social determinants of mental health (SDoMH) are similar, but include the added societal stigma associated with mental health and substance use disorders. The SDoMH often receive less focus and study, particularly in youth. Table 1 lists several examples of social determinants of mental health for children and adolescents and examples of how to address them in the clinical setting.¹ The SDoMH are particularly relevant for children, as they are reliant on the adults who care for them and have even less control over these societal factors. Additionally, the physical, cognitive, emotional, and social development that occurs during this critical time lays the foundation for mental health and well-being into adulthood. It is important that mental health providers recognize these SDoMH, as they invariably impact the clinical presentation of the children they treat. However, to truly address the SDoMH and improve outcomes for all children, clinicians must understand the major driving force behind them-structural racism.