Psychosocial morbidity: the economic burden in a pediatric health maintenance organization sample

Associations Between Patient-Reported Outcome Measures of Asthma Control and Psychosocial Symptoms

There is growing emphasis on using patient-reported outcome measures to enhance clinical practice. This study was a retrospective review of scores on the Childhood Asthma Control Test (C-ACT) and the Pediatric Symptom Checklist-17 (PSC-17) at a pediatric primary care center in Boston, Massachusetts. A total of 218 patients were selected at random using billing codes for well-child (WC) care and asthma, excluding complex medical conditions. Cutoff scores were used to identify uncontrolled asthma (C-ACT ⩽19) and clinically significant psychosocial symptoms (+PSC-17). Multiple logistic regression was used to measure associations between C-ACT ⩽19 and +PSC-17, adjusting for covariates. In multivariable analysis, C-ACT ⩽19 at WC visits was associated with +PSC-17 at WC visits (adjusted odds ratio = 3.2 [95% confidence interval = 1.3-8.6]). C-ACT ⩽19 at non-WC visits was also associated with +PSC-17 at WC visits (adjusted odds ratio = 3.1 [95% confidence interval = 1.2-8.9]). Patient-reported outcome measures of asthma control and psychosocial symptoms were positively correlated in this sample.

Medical and Psychosocial Experiences of Family Caregivers With Children Fed Enterally at Home

BACKGROUND

Pediatric home enteral nutrition (HEN) studies that evaluate the psychosocial aspects of caregiving are limited. Overlooking the psychosocial needs of the caregiver may result in negative outcomes such as lack of adherence to the HEN regimen. This study determined whether caregivers report psychosocial situations more frequent and difficult to manage than medical situations.

METHODS

A questionnaire, which identified 10 psychosocial and 10 medical issues related to pediatric HEN, was mailed to 150 caregivers (37 responded), who rated the statements for frequency and difficulty. Each statement was ranked from most frequent/difficult to least frequent/difficult by mean cross-product score (frequency x difficulty). To indicate overall burden, a medical total composite score (MTCS) and a psychosocial total composite score (PTCS) were calculated by summing the cross-products of the respective problems. Paired t tests compared MTCS to PTCS and also the psychosocial frequency means and difficulty means to the same for the medical problems.

RESULTS

Of the top 10 problems, 7 were psychosocial, whereas 3 were medical. Caregivers reported incidences of psychosocial problems more frequently (p < .003) than medical problems, and they had more difficulty (p < .001) with the psychosocial situations than with the medical ones. The PTCS was significantly higher (p < .001) than the MTCS.

CONCLUSIONS

The psychosocial situations were perceived as causing a greater burden and greater difficulty in coping with everyday life. Health professionals need to understand and address the psychosocial difficulties of the caregiver in order to provide support for the caregiver and promote positive growth and development of the child.

Psychological Factors Influencing the Decision of Urban Adolescents With Undiagnosed Asthma to Obtain Medical Care

PURPOSE

Adolescents are low users of medical care. Psychological factors and perceived reasons to not seek routine medical care may increase risk of nonuse by adolescents with undiagnosed asthma. This study tests if psychological factors were associated with seeing a medical provider for asthma-like symptoms; identifies adolescents' perceived reasons for not obtaining care; explores if psychological factors are associated with these perceptions; and explores if asthma severity moderates the relationships with psychological factors.

METHODS

We analyzed cross-sectional data from a baseline assessment of 349 urban, primarily ethnic minority adolescents with moderate to severe asthma-like symptoms but no asthma diagnosis who were enrolled in a controlled trial.

RESULTS

The odds of seeing a provider for their asthma-like symptoms were significantly higher for those with asthma-related anxiety (odds ratio [OR]: 1.644; 95% confidence interval [CI]: 1.242-2.176) and depressive symptoms (OR: 1.031; 95% CI: 1.004-1.059). The most commonly endorsed reason for noncare included a characterization of symptoms as not serious, past medical visits not diagnosed as asthma, fear of diagnosis, busy lifestyles, and not wanting medication. Psychological factors were not related to the number of reasons or to most of the commonly endorsed reasons. Adolescents with more asthma-related anxiety were less likely to characterize their breathing problems as serious (OR = .0583; 95% CI: .424-.802) and were more likely to report busy lifestyles (OR = 1.593; 95% CI: 1.122-2.261).

CONCLUSIONS

Adolescent-perceived reasons for noncare were not pragmatic, but instead highlighted denial. Asthma-related anxiety was the most robust psychological factor associated with the decision to seek medical care.

Game for health: How eHealth approaches might address the psychological needs of children and young people with long-term physical conditions

AIM

The aim of this study was to describe the psychological experiences of children and young people with long term physical conditions, their families and clinicians and to explore if these may be improved using eHealth interventions, including online information, support and e-therapy.

METHODS

Totally 11 children (7-12 years), 11 young people (13-18 years), 7 parents, 11 paediatricians and 10 general practitioners participated in a series of seven semi-structured digitally recorded focus groups. A general inductive approach was used to analyse interview data.

RESULTS

Feedback consisted of five main themes: (i) the experience of long-term physical conditions as an anxiety-provoking journey, (ii) limited access to information and eHealth-related interventions to support this journey, (iii) desires for interventions that assist with multiple aspects of the illness experience, (iv) diversity of preferences regarding the format and vehicle of such interventions, (v) the importance of trust regarding the source of interventions for children, young people and families and the sustainability of new interventions for clinicians.

CONCLUSIONS

eHealth interventions are currently being used in a limited manner by children and young people with long-term physical conditions and their families. Despite some concern expressed mainly by clinicians, there is overall support from all groups for the future development of eHealth interventions to address psychological issues for this audience, particularly anxiety. Relatable content, technological appeal and ease of access/referral to such interventions are likely to improve the uptake of these relatively new interventions.

Barriers to managing child and adolescent mental health problems: a systematic review of primary care practitioners' perceptions

BACKGROUND

Mental health problems are common and typically have an early onset. Effective treatments for mental health problems in childhood and adolescence are available, yet only a minority of children who are affected access them. This is of serious concern, considering the far-reaching and long-term negative consequences of such problems. Primary care is usually the first port of call for concerned parents so it is important to understand how primary care practitioners manage child and adolescent mental health problems and the barriers they face.

AIM

To ascertain primary care practitioners' perceptions of the barriers that prevent effective management of child and adolescent mental health problems.

DESIGN AND SETTING

A systematic review of qualitative and quantitative literature in a primary care setting.

METHOD

A database search of peer-reviewed articles using PsycINFO, MEDLINE(®), Embase, and Web of Science, from inception (earliest 1806) until October 2014, was conducted. Additional studies were identified through hand searches and forward-citation searches. Studies needed to have at least one search term in four categories: primary care, childhood/adolescence, mental health, and barriers.

RESULTS

A total of 4151 articles were identified, of which 43 were included (30 quantitative studies and 13 qualitative studies). The majority of the barriers related to identification, management, and/or referral. Considerable barriers included a lack of providers and resources, extensive waiting lists, and financial restrictions.

CONCLUSION

The identification of a broad range of significant barriers highlights the need to strengthen the ability to deal with these common difficulties in primary care. There is a particular need for tools and training to aid accurate identification and management, and for more efficient access to specialist services.

Twelve-Month Effects of the COPE Healthy Lifestyles TEEN Program on Overweight and Depressive Symptoms in High School Adolescents

BACKGROUND

We evaluated the 12-month effects of the COPE (Creating Opportunities for Personal Empowerment) Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, Nutrition) program versus an attention control program (Healthy Teens) on overweight/obesity and depressive symptoms in high school adolescents.

METHODS

A cluster randomized controlled trial was conducted. Participants were 779 culturally diverse adolescents in the US Southwest. COPE is a cognitive-behavioral skills-building intervention with 20 min of physical activity integrated into a health course and taught by teachers once a week for 15 weeks. Outcome measures included body mass index (BMI) and depressive symptoms.

RESULTS

COPE teens had a significantly lower BMI at 12 months (F(1,698)  = 11.22, p = .001) than Healthy Teens (24.95 versus 25.48). There was a significant decrease in the proportion of overweight and obese COPE teens from baseline to 12 months (χ(2)  = 5.40, p = .02) as compared with Healthy Teens. For youth who began the study with extremely elevated depressive symptoms, COPE teens had significantly lower depression at 12 months compared with Healthy Teens (COPE M = 42.39; Healthy Teens M = 57.90); (F(1 ,12)  = 5.78, p = .03).

CONCLUSIONS

COPE can improve long-term physical and mental health outcomes in teens.

Factor analysis of the pediatric symptom checklist in a population of children with voiding dysfunction and/or nocturnal enuresis

The research objective was to identify the factor structure of the pediatric symptom checklist (PSC) in children with voiding dysfunction and/or nocturnal enuresis who were seen in a pediatric urology clinic. Retrospective chart reviews were conducted for 498 consecutive patients, ages 6-16, who were seen over a 13-month period. The PSC, a 35-item measure used to screen for psychosocial difficulties, was completed by the patient's caregiver. Confirmatory factor analyses using three previous models were conducted. A four factor model comprised of internalizing, externalizing, attention problems, and chronic illness factors represented the best fit to the data. Within this population, the PSC appears to capture internalizing and externalizing problems, difficulties with attention, and possible side effects of a medical condition. This information could aid clinicians in assessing adjustment difficulties within this population and concurrently allow researchers to examine whether these specific factors are related to other relevant outcomes.

That's what friends are for: adolescent peer social status, health-related quality of life and healthcare costs

BACKGROUND

Social connections at all stages of life are essential for physical and mental well-being. Of particular importance are social relationships during adolescence that shape adult health behaviors and health outcomes.

OBJECTIVE

The aim of this study was to estimate the association between adolescent peer status in school and later-life quality-adjusted life-years (QALYs) and healthcare costs.

METHODS

This study used social network and health outcomes data from Wave I (ages 12-18 years) and Wave III (ages 18-24 years) of the US National Longitudinal Study of Adolescent Health (n = 10,578) to compare QALYs and healthcare costs (in 2012 US$) by adolescent peer status in US schools. Generalized linear models controlled for school fixed effects, individual and family characteristics, and US census block neighborhood effects. Non-parametric bootstrapping accounted for residual skewness in QALYs and healthcare costs. Net monetary benefit (NMB) was calculated by converting adjusted 5-year QALYs into US$ values and subtracting 5-year healthcare costs. NMB was then compared across quintiles of adolescent peer status in school at Wave I.

RESULTS

Results obtained from non-parametric bootstrapping indicate that adolescents with higher peer status in school experience significantly better health and lower healthcare costs over the next 5 years. At US$50,000 per QALY, adolescents with 8 or more friends achieved NMB of US$214,300 (95 % CI 212,800-215,800) over a 5-year span, in comparison to adolescents with 0-1 friends, who attained US$209,900 (95 % CI 207,900-211,700) NMB. This difference translates into approximately US$4,440 (95 % CI 2,036-6,825) per socially disengaged adolescent in additional health costs and/or reduced QALYs over 5 years.

CONCLUSION

The study calls for randomized controlled trials targeting adolescent peer group structures in schools as a means to promote better health and lower healthcare costs in adulthood.

Screening for behavioral health issues in children enrolled in Massachusetts Medicaid

OBJECTIVES

To understand mandated behavioral health (BH) screening in Massachusetts Medicaid including characteristics of screened children, predictors of positive screens, and whether screening identifies children without a previous BH history.

METHODS

Massachusetts mandated BH screening in particularly among underidentified groups. 2008. Providers used a billing code and modifier to indicate a completed screen and whether a BH need was identified. Using MassHealth claims data, children with ≥ 300 days of eligibility in fiscal year (FY) 2009 were identified and categorized into groups based on first use of the modifier, screening code, or claim. Bivariate analyses were conducted to determine differences among groups. BH history was examined by limiting the sample to those continuously enrolled in FY 2008 and 2009. Multivariate logistic regression was used to determine predictors of positive screens.

RESULTS

Of 355,490 eligible children, 46% had evidence of screening. Of those with modifiers, 12% were positive. Among continuously enrolled children (FY 2008 and FY 2009) with evidence of screening, 43% with positive modifiers had no BH history. This "newly identified" group were more likely to be female, younger, minority, and from rural residences (P < .0001). Among children with modifiers; gender (male), age (5-7), being in foster care, recent BH history, and Hispanic ethnicity predicted having a positive modifier.

CONCLUSIONS

The high rate of newly identified Medicaid children with a BH need suggests that screening is performing well, particularly among underidentified groups. To better assess screening value, future work on cost-effectiveness and the impact on subsequent mental health treatment is needed.

Parental information, motivation, and adherence behaviors among children with sickle cell disease

BACKGROUND

Identification of psychosocial correlates of health care utilization has become an important strategy in improving clinical care. The objective of the study was to examine the fit of the Information-Motivation-Behavioral Skills (IMB) model, applied to health care utilization among children with sickle cell disease (SCD).

PROCEDURE

Participants were parents of 150 children, ages 1-17 years, receiving care in a sickle cell center. Parents completed questionnaires assessing information, motivation, adherence behaviors, and other factors with respect to SCD management. Data regarding health care utilization in the previous 12 months were obtained from parent report and electronic medical records. Stepwise multiple regression analysis was conducted to determine associations between IMB factors and health care use.

RESULTS

Parents rated highly in the domains of information, motivation, and adherence behaviors for managing their child's SCD. Children of parents reporting higher satisfaction with social supports had higher odds (OR 1.49, 95% CI 1.03-2.15) of two or more routine hematology visits in the previous 12 months. Neither information nor adherence behavior was associated with urgent or routine care use. Among other variables measured, high parental illness-related stress and child health status reported as fair/poor were the strongest predictors of urgent care use while private insurance type was the strongest predictor of routine care use.

CONCLUSIONS

Among IMB factors, social support was associated with routine health care utilization. Social support and parental illness-related stress may serve as important, modifiable targets in interventions to allocate needed resources to families and reduce unnecessary medical care.

Screening for adolescent anxiety disorders in a pediatric emergency department

OBJECTIVES

Adolescence is a time of increasing risk for some anxiety disorders. Scant data exist on adolescent anxiety in emergency department (ED) settings. We sought to characterize select clinical characteristics and health care use associated with anxiety disorders in a pediatric ED.

METHODS

We screened a convenience sample of 100 adolescent-parent dyads presenting to the ED for the presence of child anxiety disorders using the 5-item Screen for Child Anxiety Related Emotional Disorders, parent (SCARED-P) and child (SCARED-C) versions. Additional demographic and clinical data were also collected.

RESULTS

The SCARED-P and SCARED-C screens identified probable anxiety disorder(s) in 26% to 33% of adolescent participants, respectively. Correlates of positive SCARED-C screens were female sex, asthma, presenting complaint involving headache or migraine, and school absenteeism due to physical problems. Correlates of positive SCARED-P screens were lower parental educational level, presenting complaint involving headache or migraine, and more medical specialty and total medical visits. Few anxious adolescents had received mental health services in the past 6 months. In multivariate models, female sex was independently associated with SCARED-C total score, and presenting complaint involving headache or migraine was independently associated with SCARED-P total score.

CONCLUSIONS

The current pilot data suggest that anxiety disorders are more prevalent among adolescent ED patients than among the general population but largely untreated. Several demographic and clinical variables may help to identify occult anxiety disorders. Greater awareness of anxiety disorders in this population may assist in redirecting a pattern of low use of mental health services but higher overall health care use.

Perceived needs, self-reported health and disability among displaced persons during an armed conflict in Nepal

BACKGROUND

Most internally displaced persons (IDPs) live in low-income countries and have experienced war. Few studies have assessed their psychosocial needs and disability. We carried out a comprehensive assessment of perceived needs, self-reported health, and disability among IDPs in Nepal and examined factors associated with disability.

METHOD

A cross-sectional survey among 290 IDPs in Nepal was conducted between June and July 2003. We used the World Health Organization's Disability Assessment Schedule-II (WHO-DAS II) with additional local items to assess disability symptoms and a separate checklist to identify their perceived needs. Depression and anxiety symptoms were measured using the Hopkins Symptom Check List (HSCL-25), while the Posttraumatic Stress Disorder Checklist Civilian Version (PCL-C) was used to assess Posttraumatic Stress Disorder (PTSD) symptoms.

RESULTS

Different perceived needs such as financial help (70%), housing (40%), food and education for their children (20%) were expressed by the IDPs. Self-reported health status was strongly associated with distress and disability scores. Factors independently associated with disability were higher age, self-reported health, depression, anxiety but not PTSD. There was good correlation between WHO-DAS II and the locally identified items of disability measurement.

CONCLUSIONS

The reporting of findings only about psychiatric symptoms is insufficient in studying the mental health of displaced and potentially traumatized populations living in low-income countries. Assessments of perceived needs and factors associated with disability give a more comprehensive understanding of the underlying needs among crisis populations, and this can inform intervention programs. Depression and anxiety should be treated effectively to avoid disability.

Triagem cognitiva e comportamental de crianças com dificuldades de aprendizagem escolar: um estudo preliminar

OBJETIVO: Avaliar a aplicabilidade do Mini-Mental State Examination (MMSE) e da lista de sintomas pediátricos (LSP) como teste de triagem cognitiva e de problemas psicossociais em crianças com dificuldades de aprendizagem. MÉTODOS: Estudo descritivo e transversal envolvendo 103 crianças entre seis e nove anos de uma escola pública de Curitiba (PR) com prováveis dificuldades de aprendizagem, realizado de 1º de março de 2002 a 30 de junho de 2009. Os dados foram obtidos simultaneamente por uma equipe multidisciplinar na avaliação inicial, com a aplicação do MMSE, da LSP e do Wechsler Intelligence Scale for Children (WISC III). Após 2007 o Child Behavior Checklist (CBCL) e o Teacher's Report Form (TRF) foram utilizados, sendo também comparados à LSP. Os coeficientes de correlação entre os testes foram calculados, sendo significante p<0,05. RESULTADOS: Das crianças analisadas, 10% apresentavam algum tipo de dificuldade de aprendizagem, sendo 76% do sexo masculino e 24% do feminino. A faixa etária mais prevalente foi entre seis e sete anos de idade. História familiar positiva ocorreu em 45% dos casos e antecedentes obstétricos em 18%, sendo o baixo peso o mais frequente. O escore do MMSE mostrou correlação com o do WISC III (r=0,73) e o CBCL mostrou moderada correlação com o LSP (r=0,53). CONCLUSÕES: O MMSE e a LSP podem ser utilizados pelo pediatra como triagem cognitiva e de problemas psicossociais em crianças com dificuldade de aprendizagem.

Illness-specific anxiety: implications for functioning and utilization of medical services in adolescents with inflammatory bowel disease

PURPOSE. Adolescents with inflammatory bowel disease (IBD) may be at heightened risk for developing anxiety and depression. This cross-sectional pilot study examined the relationship between anxiety and depression and health-related behaviors. METHODS. Thirty-six adolescents with diagnosed IBD, ages 12-17, and their parents were recruited from two pediatric gastroenterology medical centers. RESULTS. Clinical levels of anxiety (22%) and depressive symptoms (30%) were reported by patients. Regression analyses revealed that IBD-specific anxiety was significantly associated with greater utilization of medical services and worsened psychosocial functioning. PRACTICE IMPLICATIONS. Results provide preliminary support that IBD-specific anxiety may play an important role in disease management, yet concerns are rarely systematically assessed by health professionals.

Mental health screening of adolescents in pediatric practice

This study examines routine computerized mental health screening for adolescents scheduled for a routine physical examination in a group pediatric practice. Medical records of adolescents aged 13 to 17 who were offered screening (n = 483) were reviewed. Approximately 44.7% (95% confidence interval (CI) 40.3-49.2) were screened, and 13.9% (95% CI 9.3-18.5) were identified as being at risk. Screening was associated with significantly increased odds of receiving either pediatric mental health care or a referral for specialty mental health care (adjusted odds ratio (AOR): 2.6 95% CI 1.2-5.6). Among patients who received either mental health intervention, those who were screened were significantly more likely to be referred to specialty care (AOR: 15.9 95% CI 2.5-100.4), though they were less likely to receive pediatric mental health care (AOR: 0.10 95% CI 0.02-0.54). The findings support the feasibility of routine mental health screening in pediatric practice. Screening is acceptable to many parents and adolescents, and it is associated with referral for specialized mental health care rather than care from the pediatrician.

Psychometric evaluation of the Turkish version of the Pediatric Symptom Checklist-17 for detecting psychosocial problems in low-income children

AIMS

To evaluate the usefulness of Pediatric Symptom Checklist-17 in identifying psychosocial problems in low-income, Turkish children.

BACKGROUND

Epidemiological data indicate that 10-20% of children in primary care settings exhibit significant psychosocial problems. Early detection and treatment of these problems may lead to considerable health benefits. However, the brief and valid screening tool for children with psychosocial problems is not available in Turkey.

DESIGN

Survey.

METHODS

A sample of 306 parents with children between 6-16 years of age who were attending primary schools in Istanbul was included. The psychometric properties of the scale were established by examining the content, convergent, discriminant, construct validity and internal consistency and stability. Receiver operating characteristic analysis was conducted to estimate the optimal cut-off score of scale using the Child Behaviour Checklist as the criterion standard.

RESULTS

Convergent validity was supported, and discriminant validity suggested that the scale successfully discriminated among the normal, borderline and clinical range groups. Although, exploratory factor analysis extracted three factors, confirmatory factor analysis did not meet the criteria for good model fit. Internal consistency was found to be 0·81; test-retest reliability was found to be 0·72. The area under curve was found to be 0·91 and optimal cut-off score was found to be 12 (sensitivity: 0·81; specificity: 0·86) for clinical range psychopathology.

CONCLUSION

The results provided an empirical support for extending the use of the Pediatric Symptom Checklist-17 in the primary care settings. The Turkish version of the Pediatric Symptom Checklist-17 showed an adequate reliability and validity for its use in low-income, Turkish children.

RELEVANCE TO CLINICAL PRACTICE

Primary care providers can use the Pediatric Symptom Checklist-17 for early identification of childhood psychosocial problems in primary care settings. This easy-to-use tool can provide guidance to care providers for further assessment of children.

Burden of anxiety disorders in pediatric medical settings: prevalence, phenomenology, and a research agenda

The current review describes the phenomenology of several common anxiety disorders in children and adolescents as they present in medical settings. Anxiety disorders and associated features in children are described, along with epidemiology, functional impairment, common somatic complaints, medical comorbidity, health care utilization, and presentation in general and in specialty pediatric medical settings. Recommendations for clinical management in pediatric settings are presented, and evidence-based interventions and emerging treatments for pediatric anxiety disorders are described. The review concludes with a discussion of future research directions that may lead to increased recognition and improved management of anxiety disorders in pediatric medical settings.

Pediatric primary care as a component of systems of care

Systems of care should be defined in a manner that includes primary care. The current definition of systems of care shares several attributes with the definition of primary care: both are defined as community-based services that are accessible, accountable, comprehensive, coordinated, culturally competent, and family focused. However, systems of care is defined as serving only children and youth with serious emotional disturbance and their families and does not fully embrace the concept of primary prevention. Although similarities in the definitions of primary care and systems of care may provide a theoretical foundation for including primary care within the systems of care framework, a definition of systems of care that incorporates the idea of prevention and takes into account the broad population served in primary care would provide communities with a definition that can be used to further the work of integrating primary care into systems of care.

Training clinicians in mental health communication skills: impact on primary care utilization

OBJECTIVE

Although it is known that children with mental health problems utilize primary care services more than most other children, it is unknown how addressing mental health problems in primary care affects children's subsequent services utilization. This study measures primary care utilization in the context of a randomized trial of a communication skills training program for primary care clinicians that had a positive impact on child mental health outcomes.

METHODS

From 2002 to 2005, 48 pediatric primary care clinicians at 13 sites in rural upstate New York, urban Maryland, and Washington, DC, were randomized to in-office training or to a control group. Consecutive primary care patients between the ages of 5 and 16 years were screened for mental health problems, as indicated by a possible or probable score on the Strengths and Difficulties Questionnaire (SDQ). For 397 screened children, primary care visits during the next 6 months were identified using chart review and administrative databases. Using generalized estimating equation regression to account for clustering at the clinician level, primary care utilization was compared by study group and SDQ status.

RESULTS

The number of primary care visits to the trained clinicians did not differ significantly from those made to control clinicians (2.5 for both groups; P = .63). Children with possible or probable SDQ scores made, on average, 0.38 or 0.65 more visits on a per child basis, respectively, during the 6-month follow-up period than SDQ unlikely children (P = .0002).

CONCLUSIONS

Seeing a trained clinician did not increase subsequent primary care utilization. However, primary care utilization was greater among children with mental health problems as measured by the SDQ. Addressing children's mental health in primary care does not increase the primary care visit burden. Research on overall health services utilization is needed.

Evolution of child mental health services in primary care

OBJECTIVE

Although the importance of mental health assessment and treatment in primary care is increasingly recognized, the research that underlies current practices largely stems from a considerable body of non-mental health primary care studies. Our purpose was to describe trends in research over the past 2 decades and to suggest further key items for the research agenda.

METHODS

We reviewed the literature broadly on health services research in pediatrics, especially studies of changes in primary care practice, and examined recent articles in primary care mental health services.

RESULTS

The evolution of primary care mental health services for children has been slow, but the focus of research has changed with the development of clinical improvements. Proposals to deliver more effective services have evolved over the past 40 years in a series of approaches that paralleled initiatives in the broader fields of medicine and pediatrics. Current trends in electronic technology, practice consolidation and coordination, and personalized medicine are likely to increase the pace of change in mental health services for primary care.

CONCLUSIONS

The evolution of pediatric mental health services in primary care suggests a continuing expansion from a focus initially on provider behavior and quality to a growing attention to patient and systems' behavior over time and within communities.

A common factors approach to improving the mental health capacity of pediatric primary care

To expand the mental health service capacity of pediatric primary care, we ask whether there are evidence-based skills to allow providers to 1) immediately begin treatment for children with emotional and behavioral problems while diagnostic procedures are being pursued, and 2) offer evidence-based care to children who do not meet criteria for a specific diagnosis. We discuss why the epidemiology of child mental health problems poses difficulties for disorder-specific mental health interventions, and review evidence that "common factors" contributing to the outcome of mental health treatments define a core set of skills that primary care providers might use to complement disorder-specific interventions.

A common factors approach to improving the mental health capacity of pediatric primary care

To expand the mental health service capacity of pediatric primary care, we ask whether there are evidence-based skills to allow providers to 1) immediately begin treatment for children with emotional and behavioral problems while diagnostic procedures are being pursued, and 2) offer evidence-based care to children who do not meet criteria for a specific diagnosis. We discuss why the epidemiology of child mental health problems poses difficulties for disorder-specific mental health interventions, and review evidence that "common factors" contributing to the outcome of mental health treatments define a core set of skills that primary care providers might use to complement disorder-specific interventions.

The predictive value of the pediatric symptom checklist in 5-year-old Austrian children

In this investigation the predictive value of the pediatric symptom checklist (PSC) in relation to the child behaviour checklist (CBCL) was studied in preschool children. Thirty nursery schools in the city and province of Salzburg participated in the study and a total of 179 correctly completed questionnaires (82 male and 97 female children) were analysed. Questionnaires were completed by the parents. Data were analysed using descriptive statistics (SPSS 11.0). Predictive validity was determined by non-parametric correlations and calculations of sensitivity and specificity, as well as an ROC analysis. The mean PSC at 10.74 +/- 6.8 was found to be below both international and Austrian values for this age group and was also found to differ significantly between girls (9.33 +/- 6.2) and boys (12.4 +/- 7.1; p < 0.01). The recommended international cut-off point at 24 is too high. CBCL analysis resulted in 12.6% impaired (T value between 60 and 64) and 8.2% pathological children (T value > 64). PSC sensitivity in relation to the CBCL total score was 15.7% and specificity 98.5%. The cut-off was optimized with the help of ROC analysis and optimum specificity (80.2%) and sensitivity (81.1%) were obtained at a cut-off value of 15.5. This cut-off would allow 24.6% to be detected as impaired, which is somewhat above the frequency (20.2%) found by CBCL.

CONCLUSION

To summarize, the PSC is a valid psychosocial screening instrument, at least for this age group, and thus applicable for German-speaking countries.

A comparison of health care utilization and costs of children with and without autism spectrum disorders in a large group-model health plan

OBJECTIVE

Data on the current costs of medical services for children with autism spectrum disorders are lacking. Our purpose for this study was to compare health care utilization and costs of children with and without autism spectrum disorders in the same health plan.

PATIENTS AND METHODS

Participants included all 2- to 18-year-old children with autism spectrum disorders (n = 3053) and a random sample of children without autism spectrum disorders (n = 30529) who were continuously enrolled in the Kaiser Permanente Medical Care Program in northern California between July 1, 2003, and June 30, 2004. Data on health care utilization and costs were derived from health plan administrative databases.

MAIN OUTCOME MEASURES

Outcome measures included mean annual utilization and costs of health services per child.

RESULTS

Children with autism spectrum disorders had a higher annual mean number of total clinic (5.6 vs 2.8), pediatric (2.3 vs 1.6), and psychiatric (2.2 vs 0.3) outpatient visits. A higher percentage of children with autism spectrum disorders experienced inpatient (3% vs 1%) and outpatient (5% vs 2%) hospitalizations. Children with autism spectrum disorders were nearly 9 times more likely to use psychotherapeutic medications and twice as likely to use gastrointestinal agents than children without autism spectrum disorders. Mean annual member costs for hospitalizations (550 dollars vs 208 dollars), clinic visits (1373 dollars vs 540 dollars), and prescription medications (724 dollars vs 96 dollars) were more than double for children with autism spectrum disorders compared with children without autism spectrum disorders. The mean annual age- and gender-adjusted total cost per member was more than threefold higher for children with autism spectrum disorders (2757 dollars vs 892 dollars). Among the subgroup of children with other psychiatric conditions, total mean annual costs were 45% higher for children with autism spectrum disorders compared with children without autism spectrum disorders; excess costs were largely explained by the increased use of psychotherapeutic medications.

CONCLUSIONS

The utilization and costs of health care are substantially higher for children with autism spectrum disorders compared with children without autism spectrum disorders. Research is needed to evaluate the impact of improvements in the management of children with autism spectrum disorders on health care utilization and costs.

Interventions for adolescent depression in primary care

BACKGROUND

Depression in adolescents is underrecognized and undertreated despite its poor long-term outcomes, including risk for suicide. Primary care settings may be critical venues for the identification of depression, but there is little information about the usefulness of primary care interventions.

OBJECTIVE

We sought to examine the evidence for the treatment of depression in primary care settings, focusing on evidence concerning psychosocial, educational, and/or supportive intervention strategies.

METHODS

Available data on brief psychosocial treatments for adolescent depression in primary settings were reviewed. Given the paucity of direct studies, we also drew on related literature to summarize available evidence whether brief, psychosocial support from a member of the primary care team, with or without medication, might improve depression outcomes.

RESULTS

We identified 37 studies relevant to treating adolescent depression in primary care settings. Only 4 studies directly examined the impact of primary care-delivered psychosocial interventions for adolescent depression, but they suggest that such interventions can be effective. Indirect evidence from other psychosocial/behavioral interventions, including anticipatory guidance and efforts to enhance treatment adherence, and adult depression studies also show benefits of primary care-delivered interventions as well as the impact of provider training to enhance psychosocial skills.

CONCLUSIONS

There is potential for successful treatment of adolescent depression in primary care, in view of evidence that brief, psychosocial support, with or without medication, has been shown to improve a range of outcomes, including adolescent depression itself. Given the great public health problem posed by adolescent depression, the likelihood that most depressed adolescents will not receive specialty services, and new guidelines for managing adolescent depression in primary care, clinicians may usefully consider initiation of supportive interventions in their primary care practices.

Children's health services in a "system of care": patterns of mental health, primary and specialty use

OBJECTIVES

This study was designed to investigate demonstrable impacts of the Mental Health Services Program for Youth (MHSPY), a highly coordinated, intentionally integrated "system of care," on patterns of health service utilization for youth with multiple needs.

METHODS

The MHSPY intervention is available to a target population of urban youth who face barriers to health care and are at risk for out-of-home placement. These youth are enrolled in a non-profit managed care organization (MCO). Patterns of medical, pharmacy, and mental health and substance abuse service use were compared for children aged 3 to 19 across insurance categories.

RESULTS

Despite risks for access and engagement barriers to care, and for greater medical expense due to greater morbidity, MHSPY enrollees received significantly more ambulatory care per person-year than either the privately insured population or the Medicaid Standard population, and medical expense for MHSPY members was significantly lower than expected. During the four years studied, individuals in the privately insured and Medicaid Standard populations were less likely than MHSPY enrollees to have had an ambulatory pediatric visit (odds ratio [OR] 0.833, 95% confidence interval [CI] 0.765, 0.908 and OR 0.823, 95% CI 0.775, 0.897, respectively). Medical expenses per member per month for MHSPY enrollees were significantly less than that for the similarly impaired Medicaid Disabled population with any medical claim (p < 0.001) or with any outpatient mental health claim (p < 0.01).

CONCLUSIONS

Patterns of health care for subpopulations with known risk are important to identify to evaluate system-of-care effectiveness. The service utilization patterns for youth enrolled in the MHSYP system of care vs. those for similar MCO youth suggest health care access for individuals can be affected by delivery system design variables.

Adolescent quality of life and satisfaction with care

PURPOSE

1) To describe adolescents' responses to a client satisfaction and family-centered care survey; 2) to examine the relationship between satisfaction with health care and health-related quality of life (HRQL) among these adolescents; and 3) to determine if adolescents and their parents differ in their satisfaction with services.

METHODS

We recruited 104 adolescents who attended the Alberta Children's Hospital pediatric neurology clinic. Each family completed the Client Satisfaction Questionnaire (CSQ), the Family Centered Care Survey (FCCS), the Measure of Processes of Care (MPOC) survey, the Give Youth a Voice (GYV) survey, and the Pediatric Quality of Life Inventory (PedsQL).

RESULTS

Of 116 eligible families, 104 (90%) completed the study. The majority (83%) of adolescents were satisfied with services provided. Adolescents who were very satisfied on the CSQ and the FCCS had higher PedsQL psychosocial scores (p = .009 and .013, respectively). Multivariate analysis revealed that adolescents' psychosocial HRQL was the most significant predictor of their satisfaction with care (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01 to 1.06). There was a difference between parents' and adolescents' responses to the FCCS (p = .02), with adolescents being less satisfied overall.

CONCLUSIONS

Given that adolescents and parents differ in their satisfaction with health care, it is helpful to have direct input from adolescents on health services surveys. The positive relationship between adolescents' psychosocial HRQL and satisfaction with care highlights the potential impact of emotional health on subjective rating of services. Further studies should determine if improvement in adolescents' mental health is associated with greater satisfaction with health care and/or increased adherence with medical treatments.

Preventing depression among early adolescents in the primary care setting: a randomized controlled study of the Penn Resiliency Program

This study evaluated the Penn Resiliency Program's effectiveness in preventing depression when delivered by therapists in a primary care setting. Two-hundred and seventy-one 11- and 12-year-olds, with elevated depressive symptoms, were randomized to PRP or usual care. Over the 2-year follow-up, PRP improved explanatory style for positive events. PRP's effects on depressive symptoms and explanatory style for negative events were moderated by sex, with girls benefiting more than boys. Stronger effects were seen in high-fidelity groups than low-fidelity groups. PRP did not significantly prevent depressive disorders but significantly prevented depression, anxiety, and adjustment disorders (when combined) among high-symptom participants. Findings are discussed in relation to previous PRP studies and research on the dissemination of psychological interventions.

Medical Problems among Adolescents in U.S. Mental Health Services: Relationship to Functional Impairment

This study provides information about the extent of comorbidity between medical and behavioral problems among adolescents in mental health services, describes the clinical and sociodemographic characteristics of adolescents with both problems, and discusses the consequences or comorbidity for service delivery. Nationally representative mental health service use data for adolescents (age 12-17) in inpatient, outpatient, and residential mental health service settings (weighted N=296,755) were used. Close to one fifth (18.9%) of the adolescents had a medical problem, and adolescents with anxiety and pervasive developmental disorders had the highest rates of medical problems. In multivariate logistic regressions, having a medical problem significantly increased the odds of serious functional impairment; having a secondary or dual psychiatric diagnosis was only significant in interaction with a medical problem. The results underscore the need for adolescent behavioral health research and practice to attend to multiple influences on functioning.

Cost-of-illness studies : a review of current methods

The number of cost-of-illness (COI) studies has expanded considerably over time. One outcome of this growth is that the reported COI estimates are inconsistent across studies, thereby raising concerns over the validity of the estimates and methods. Several factors have been identified in the literature as reasons for the observed variation in COI estimates. To date, the variation in the methods used to calculate costs has not been examined in great detail even though the variations in methods are a major driver of variation in COI estimates. The objective of this review was to document the variation in the methodologies employed in COI studies and to highlight the benefits and limitations of these methods. The review of COI studies was implemented following a four-step procedure: (i) a structured literature search of MEDLINE, JSTOR and EconLit; (ii) a review of abstracts using pre-defined inclusion and exclusion criteria; (iii) a full-text review using pre-defined inclusion and exclusion criteria; and (iv) classification of articles according to the methods used to calculate costs. This review identified four COI estimation methods (Sum_All Medical, Sum_Diagnosis Specific, Matched Control and Regression) that were used in categorising articles. Also, six components of direct medical costs and five components of indirect/non-medical costs were identified and used in categorising articles.365 full-length articles were reflected in the current review following the structured literature search. The top five cost components were emergency room/inpatient hospital costs, outpatient physician costs, drug costs, productivity losses and laboratory costs. The dominant method, Sum_Diagnosis Specific, was a total costing approach that restricted the summation of medical expenditures to those related to a diagnosis of the disease of interest. There was considerable variation in the methods used within disease subcategories. In several disease subcategories (e.g. asthma, dementia, diabetes mellitus), all four estimation methods were represented, and in other cases (e.g. HIV/AIDS, obesity, stroke, urinary incontinence, schizophrenia), three of the four estimation methods were represented. There was also evidence to suggest that the strengths and weaknesses of each method were considered when applying a method to a specific illness. Comparisons and assessments of COI estimates should consider the method used to estimate costs both as an important source of variation in the reported COI estimates and as a marker of the reliability of the COI estimate.

Factor analysis of the Pediatric Symptom Checklist with a chronically ill pediatric population

The psychometric properties and factor structure of a widely used screening measure for behavioral and emotional dysfunction, the Pediatric Symptom Checklist (PSC), was extended to a population of chronically ill children. Parents of 404 children ranging from 6 to 17 years of age and diagnosed with either insulin-dependent diabetes mellitus (IDDM) or sickle cell disease (SCD) completed the PSC while waiting for a routine medical appointment. The measure's internal consistency was found to be high, Cronbach's alpha = .89, and test-retest reliability across 4 months was observed to be acceptable, r = .77. A principal components analysis with an oblique (promax) rotation yielded a four-factor solution with factors that included items representative of internalizing, externalizing, attention, and chronic illness-related problems, respectively. Cronbach alpha estimates ranged from .78 to .83 for the first three factors but was lower for the chronic illness-related problems factor (Cronbach's alpha = .60). A three-factor solution and reliability estimates were recomputed without the chronic illness items that yielded the same reliability estimates for each of the three factors and for the full scale. The three-factor solution was also found to be similar to a published factor structure obtained with a primary care sample, r(c) = .90-.91. The findings lend support to extending the PSC's clinical utility to tertiary care pediatric settings. Further research is recommended with a broader range of chronic illness groups to increase generalizability.

A Longitudinal Examination Predicting Emergency Room Use in Children with Sickle Cell Disease and Their Caregivers

OBJECTIVE

To examine in a longitudinal investigation perceptions of disease severity among children and adolescents with sickle cell disease (SCD) and their caregivers and to determine whether perceptions of disease severity and self-reported adjustment would account for a greater percentage of the variance in emergency room (ER) use than objective measures of disease severity.

METHODS

Participants were 58 African-American children (ages 8-18 years) diagnosed with SCD who were recruited from an outpatient clinic. Children and their caregivers were administered a series of measures designed to assess caregivers' adjustment and perceptions of children's disease severity. Frequency of ER visits was tabulated over an average 4-year period.

RESULTS

Caregivers' and children's social adjustment accounted for a unique portion of the variance beyond that accounted by subjective perceptions of disease severity, demographic, and objective biological markers of disease severity. Poorer psychological adjustment of caregivers as well as communication patterns among children were associated with ER use frequency after controlling for objective disease severity variables and demographic factors. Child social adjustment, specifically friendship quality, accounted for variance in children's use of the ER beyond that accounted for by social class and objective markers of disease severity.

CONCLUSIONS

Support is provided for the notion that ER use for children with SCD may be independent of disease severity and predicted by caregivers' psychological adjustment and children's peer adjustment.

Pediatricians' training and identification and management of psychosocial problems

This study evaluated the association of pediatrician training on the identification and management of current and ongoing emotional or behavioral problems among children ages 4-8 years in 19 practices in south-central Connecticut. Pediatricians with advanced training in psychosocial issues were more likely to identify children's psychosocial problems and use multiple management strategies compared with pediatricians with no specialized training. Although pediatricians with moderate training in psychosocial issues were more likely to identify psychosocial problems compared with pediatricians with no training, there was no relationship between moderate training and management of psychosocial problems. These results suggest that identification and management of young children's psychosocial problems demands advanced training and support the American Academy of Pediatrics' call for more extensive training.

Psychiatric disorders of children living with drug-abusing, alcohol-abusing, and non-substance-abusing fathers

OBJECTIVE

The present study examined lifetime psychiatric disorders and current emotional and behavioral problems of 8- to 12-year-old children living with drug-abusing (DA) fathers compared to children living in demographically matched homes with alcohol-abusing (AA) or non-substance-abusing fathers.

METHOD

Children's lifetime psychiatric diagnoses were determined using the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version. In addition, both parents completed the Pediatric Symptom Checklist. Substance-abusing fathers were recruited from an outpatient treatment program.

RESULTS

Children who lived with DA fathers were more likely to have a lifetime psychiatric diagnosis (i.e., 53% versus 25% in AA homes and 10% in non-substance-abusing homes). Compared to children in the other groups, children in DA homes were more than twice as likely to exhibit clinical levels of behavioral symptoms.

CONCLUSIONS

Children living with DA fathers were more likely to experience a lifetime psychiatric disorder and more negative behaviors compared to children living with an AA father or non-substance-abusing parents.

Parent reported longstanding health problems in early childhood: a cohort study

AIM

To study changing prevalence and correlates of longstanding health problems across early childhood.

METHODS

Of 2576 infants enrolled in the Coventry Cohort Study at birth, parents of 2157 at 8 weeks, 1752 at 8 months, 1521 at 18 months, and 1182 at 3 years completed the Warwick Child Health and Morbidity Profile.

RESULTS

The prevalence of parent reported longstanding health problems was 4.3% at 8 months, 6.9% at 18 months, and 9.7% at 3 years. Congenital anomalies accounted for 42.1% of longstanding health problems at 8 months, 40.0% at 18 months, and 27.8% at 3 years. The proportion accounted for by asthma was 17.1% at 8 months, 21.9% at 18 months, and 24.3% at 3 years. In each age period, children reported to have longstanding health problems were at increased risk of impaired functional health, poorer general health, and reduced health related quality of life. Low birthweight infants were most at risk of longstanding health problems at 8 months. By 3 years, risk of longstanding health problems was associated with living in rented accommodation and living in a smoking household.

CONCLUSIONS

The prevalence of parent reported longstanding health problems increased across early childhood. Congenital anomalies constituted the major cause, particularly in infancy, with asthma and developmental delay becoming more prominent by 3 years of age. Social patterning of longstanding health problems and the association with smoking were clearly established by 3 years of age but the relation may have been mediated by low birth weight earlier in infancy.

Psychosocial issues in the child with chronic conditions

Psychosocial issues in children, adolescents and families who suffer with chronic illnesses require careful identification and treatment. Since more of these young people survive into adulthood, their risk of psychosocial distress and psychiatric illness is increased, although many adapt well. The literature is vast, but limited in its usefulness: criteria for the variables described, including chronicity and severity, are poorly defined; outcome measures are not standardized; and few randomized controlled clinical trials exist. This chapter focuses the attention of physicians on overt and covert signs of psychosocial distress in the patient and family with chronic illness. Common issues for all chronic diseases are discussed and a non-categorical approach is taken. The importance of the family as a focus of intervention is highlighted. The meaning and treatment of unexplained medical symptoms, non- adherence with treatment recommendations, school refusal, sexuality and substance use and abuse are discussed.