Impact of location and availability of behavioral health services for children

Nutrition and Health Programming and Outreach in Grocery Retail Settings: A Community Coalition in Action

Grocery stores can provide a conducive environment for interventions targeting healthy eating and access to health services, particularly in low-income communities. A wide array of organizations deliver nutrition and related programs in community settings, but rarely in a coordinated fashion. Collaboration of local health promotion organizations with grocery stores could increase consumers' access to and selection of healthy foods and related services. This evaluation of the In-Store Programming and Outreach Coalition (IPOC) uses thematic analysis of first-person accounts from coalition members. To our knowledge, this is the first study of such a coalition. We present perspectives from six stakeholders about the IPOC strengths, challenges, and recommendations for strengthening the delivery of in-store interventions. Themes identified include partnership, increased client reach and cross-referrals, conflicting work schedules, leadership, and recommendations to identify coalition leaders and expand services to other grocery stores. We conclude that grocery stores can offer a suitable setting for programming and community outreach through coalitions.

Role of neighbourhood social characteristics in children's use of mental health services between ages 9 and 13 years: a population-based cohort study in the Netherlands

OBJECTIVES

This study aims to investigate the association of neighbourhood socioeconomic status (SES) and social cohesion (SC) within the neighbourhood with mental health service use in children, independent of individual-level characteristics and mental health problems.

DESIGN, SETTING AND PARTICIPANTS

A longitudinal analysis was done using data from the Generation R Study, a prospective, population-based cohort of children born in Rotterdam, the Netherlands. These data were linked to the Neighbourhood Profile, containing registry and survey data on residents of Rotterdam. Data of 3403 children (mean age: 13.6 years, SD: 0.4) were used to study the associations between neighbourhood SES, SC (SC belonging and SC relations) and mental health service use, adjusted for mental health problems and sociodemographic characteristics.

OUTCOME MEASURES

Mental health service use was reported by the accompanying parent at the research centre using the question: 'Did your child visit a psychologist or psychiatrist between 9 and 13 years old?'.

RESULTS

Mental health services were used by 524 (15.4%) children between ages 9 and 13 years. No significant differences in mental health service use between neighbourhoods were identified (median OR: 1.07 (p=0.50)). The neighbourhood social characteristics were associated with mental health service use, but only when adjusted for each other. Children living in neighbourhoods with a low SES (OR 0.57 (95% CI 0.32 to 1.00)) or high SC belonging (OR 0.79 (95% CI 0.64 to 0.96)) were less likely to use services compared with children in a high SES or low SC belonging neighbourhood. SC relations was not associated with mental health service use.

CONCLUSIONS

Our findings indicate that children living in high SES neighbourhoods or in neighbourhoods where people feel less sense of belonging are more likely to use mental health services. As these associations were only present when studied jointly, more research is warranted on the complex associations of neighbourhood factors with children's mental health service use.

Developing and applying synergistic multilevel implementation strategies to promote reach of an evidence-based parenting intervention in primary care

Background: This practical implementation report describes a primary care-based group parenting intervention—Child–Adult Relationship Enhancement in Primary Care (PriCARE)—and the approach taken to understand and strengthen the referral process for PriCARE within a pediatric primary care clinic through the deployment of synergistic implementation strategies to promote physician referrals. PriCARE has evidence of effectiveness for reducing child behavior problems, harsh and permissive parenting, and parent stress from three randomized controlled trials (RCTs). The integration of evidence-based parenting interventions into pediatric primary care is a promising means for widespread dissemination. Yet, even when integrated into this setting, the true reach will depend on parents knowing about and attending the intervention. A key factor in this process is the endorsement of and referral to the intervention by the child's pediatrician. Therefore, identifying strategies to improve physician referrals to parenting interventions embedded in primary care is worthy of investigation. Method: Through lessons learned from the RCTs and key informant interviews with stakeholders, we identified barriers and facilitators to physician referrals of eligible parent–child dyads to PriCARE. Based on this data, we selected and implemented five strategies to increase the PriCARE referral rate. We outline the selection process, the postulated synergistic interactions, and the results of these efforts. Conclusions: The following five discrete strategies were implemented: physician reminders, direct advertising to patients, incentives/public recognition, interpersonal patient narratives, and audit and feedback. These discrete strategies were synergistically combined to create a multifaceted approach to improve physician referrals. Following implementation, referrals increased from 13% to 55%. Continued development, application, and evaluation of implementation strategies to promote the uptake of evidence-based parenting interventions into general use in the primary care setting are discussed.

Plain Language Summary

There is strong evidence that parenting interventions are effective at improving child behavioral health outcomes when delivered in coordination with pediatric primary care. However, there is a lack of focus on the implementation, including the screening and referral process, of parenting interventions in the primary care setting. This is contributing to the delay in the scale-up of parenting interventions and to achieving public health impact. To address this gap, we identified barriers and facilitators to physician screening and referrals to a primary care-based parenting intervention, and selected and piloted five synergistic strategies to improve this critical process. This effort successfully increased physician referrals of eligible patients to the intervention from 13% to 55%. This demonstration project may help advance the implementation of evidence-based interventions by providing an example of how to develop and execute multilevel strategies to improve intervention referrals in a local context.

Improving Child Behaviors and Parental Stress: A Randomized Trial of Child Adult Relationship Enhancement in Primary Care

BACKGROUND

Prior single-site evaluations of Child Adult Relationship Enhancement in Primary Care (PriCARE), a 6-session group parent training, demonstrated reductions in child behavioral problems and improvements in positive parenting attitudes.

OBJECTIVE

To measure the impact of PriCARE on disruptive child behaviors, parenting stress, and parenting attitudes in a multisite study.

METHODS

Caregivers of children 2- to 6-year-old with behavior concerns recruited from 4 pediatric primary care practices were randomized 2:1 to PriCARE intervention (n = 119) or waitlist control (n = 55). Seventy-nine percent of caregivers identified as Black and 59% had annual household incomes under $22,000. Child behavior, parenting stress, and parenting attitudes were measured at baseline and 2 to 3 months after intervention using the Eyberg Child Behavior Inventory, Parenting Stress Index, and Adult-Adolescent Parenting Inventory-2. Marginal standardization implemented in a linear regression compared mean change scores from baseline to follow-up by treatment arm while accounting for clustering by site.

RESULTS

Mean change scores from baseline to follow-up demonstrated greater improvements (decreases) in Eyberg Child Behavior Inventory problem scores but not intensity scores in the PriCARE arm compared to control, (problem: -4.4 [-7.5, -1.2] vs -1.8 [-4.1, 0.4], P= .004; intensity: -17.6 [-28.3, -6.9] vs -10.4 [-18.1, -2.6], P= .255). Decreases in parenting stress were greater in the PriCARE arm compared to control (-3.3 [-4.3, -2.3] vs 0 [-2.5, 2.5], P= .025). Parenting attitudes showed no significant changes (all P> .10).

CONCLUSIONS

PriCARE showed promise in improving parental perceptions of the severity of child behaviors and decreasing parenting stress but did not have an observed impact on parenting attitudes.

Behavioral Health Needs, Barriers, and Parent Preferences in Rural Pediatric Primary Care

OBJECTIVE

The goal of this study was to examine modifiable factors related to health disparities by exploring the role of predisposing, need, and enabling characteristics on mental/behavioral health treatment-seeking behaviors in a rural sample. Parental treatment preferences and knowledge about treatment options were also examined.

METHODS

One hundred eighteen parents completed questionnaires assessing demographics, child prior psychological treatment, child psychological symptoms, barriers to care, mental health stigma, and willingness to seek services across settings. Questions also assessed preferences for treatment, awareness of behavioral/mental health services, and knowledge of community treatment options.

RESULTS

Prior treatment use and stigma significantly predicted willingness to seek services in a doctor's office after controlling for predisposing (demographic) and need characteristics (psychological symptoms). Symptom severity and barriers significantly differentiated between parents who previously sought treatment or reported an unmet treatment need from those who reported no prior treatment and no treatment need. Families overwhelmingly (94%) reported a preference for individual versus group treatment, and up to 10 sessions were most commonly reported (38%) as the ideal number of sessions. Forty percent of respondents reported no knowledge of treatment options in their community.

CONCLUSIONS

These results highlight the role of enabling characteristics (i.e., stigma, barriers to care, psychological symptoms) and prior service use in understanding parental treatment seeking in a rural sample. Overall, these results support integrated behavioral health in rural settings. Understanding modifiable factors and parent treatment preferences and knowledge may be important to increase access to services and reduce health disparities in rural areas. Future research directions are discussed.

Collaborative and Integrated Care for Adolescent Depression

Creative collaborative approaches are required to meet the demands of managing depression in youth. Primary care providers are well positioned to engage depressed youth and their families, yet often lack the training, access to psychiatric providers, and the reimbursement structure to support their efforts. Child and adolescent psychiatrists are encouraged to support pediatricians in establishing more robust systems to provide screening and effective treatment interventions, particularly for youth at higher risk. Several models of collaborative care are described, in addition to their emerging evidence-base, in an effort to disseminate evolving treatment strategies that can drive implementation of effective collaborative approaches.

Increasing Mental Health Engagement From Primary Care: The Potential Role of Family Navigation

Early engagement in mental health intervention is critical, yet the vast majority of children who are experiencing mental health concerns are not receiving needed services. Pediatric primary care clinics have been recognized as an ideal setting in which to identify and address mental health problems early, although engagement in mental health services within primary care and in community-based settings remains low. Navigators, or individuals with experience in navigating the mental health system, have been highlighted as promising partners in efforts to improve engagement in mental health services. Navigation has a growing body of research support among adults and in targeting medical concerns, but there has been limited research on integrating family navigators into pediatric primary care settings to address mental health concerns. Despite this gap in the evidence base, we believe there is significant promise for the use of this model in addressing children's mental health needs. In this report, we discuss factors contributing to high levels of unmet mental health needs and low levels of engagement in mental health services, the role that navigators can play in increasing engagement in mental health care, and implications and recommendations related to integrating mental health-focused family navigators into pediatric primary care settings.

Brief, Rapid Response, Parenting Interventions Within Primary Care Settings

Opportunities created by the Patient Protection and Affordable Care Act along with the increased prevalence of pediatric behavioral and mental health concerns provide new challenges for pediatric health care providers. To address these matters, providers need to change the manner by which they provide health care to families. A novel approach is providing brief, rapid response, evidence-based parenting interventions within the pediatric primary care setting. Family-focused parenting programs support the American Academy of Pediatrics recommendations of improving mental health via supports in pediatric primary care to maximize the social and psychological well-being of families. A considerable body of research indicates that parenting interventions reduce the severity and frequency of disruptive behavior disorders in children and provide support to parent by bolstering parental resilience and improving overall family functioning. Providing these services within the pediatric primary care setting addresses the need for fully integrated health services that are family-centered and easily accessible.

Preventive Behavioral Health Programs in Primary Care: A Systematic Review

CONTEXT

Early childhood is a critical period for socioemotional development. Primary care is a promising setting for behavioral health programs.

OBJECTIVES

To identify gaps in the literature on effectiveness and readiness for scale-up of behavioral health programs in primary care.

DATA SOURCES

PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Embase, Evidence-Based Medicine Reviews, and Scopus databases were searched for articles published in English in the past 15 years. Search terms included terms to describe intervention content, setting, target population, and names of specific programs known to fit inclusion criteria.

STUDY SELECTION

Inclusion criteria were: (1) enrolled children 0 to 5 years old, (2) primary care setting, (3) measured parenting or child behavior outcomes, and (4) clinical trial, quasi-experimental trial, pilot study, or pre-post design.

DATA EXTRACTION

Data were abstracted from 44 studies. The rigor of individual studies and evidence base as a whole were compared with the Society of Prevention Research's standards for efficacy, effectiveness, and scale-up research.

RESULTS

Gaps in the literature include: study findings do not always support hypotheses about interventions' mechanisms, trust in primary care as a mediator has not been sufficiently studied, it is unclear to which target populations study findings can be applied, parent participation remains an important challenge, and the long-term impact requires further evaluation.

LIMITATIONS

Potential limitations include publication bias, selective reporting within studies, and an incomplete search.

CONCLUSIONS

Targeting gaps in the literature could enhance understanding of the efficacy, effectiveness, and readiness for scale-up of these programs.

Attendance at Fragile X Specialty Clinics: Facilitators and Barriers

The objectives were to describe the demographic characteristics of children with Fragile X syndrome (FXS) and to determine predictors of attendance at Fragile X (FX) clinics. Findings from the Community Support Network (CSN) and Our Fragile X World (OFXW) samples showed that children who attended FX Clinics were mostly male, high-school aged or younger, and white, non-Hispanic. Using logistic regression models, awareness about FX Clinic services, guardian education, and income (CSN), and child age, family income, and total number of co-occurring conditions (OFXW) were predictors of clinic attendance. Demographic and child characteristics accounted for a large portion of the explained variance. Importantly, symptom severity and parent knowledge about services were independent predictors beyond the demographic characteristics of families.

Quality improvement, implementation, and dissemination strategies to improve mental health care for children and adolescents: a systematic review

BACKGROUND

Some outcomes for children with mental health problems remain suboptimal because of poor access to care and the failure of systems and providers to adopt established quality improvement strategies and interventions with proven effectiveness. This review had three goals: (1) assess the effectiveness of quality improvement, implementation, and dissemination strategies intended to improve the mental health care of children and adolescents; (2) examine harms associated with these strategies; and (3) determine whether effectiveness or harms differ for subgroups based on system, organizational, practitioner, or patient characteristics.

METHODS

Sources included MEDLINE®, the Cochrane Library, PsycINFO, and CINAHL, from database inception through February 17, 2017. Additional sources included gray literature, additional studies from reference lists, and technical experts. Two reviewers selected relevant randomized controlled trials (RCTs) and observational studies, extracted data, and assessed risk of bias. Dual analysis, synthesis, and grading of the strength of evidence for each outcome followed for studies meeting inclusion criteria. We also used qualitative comparative analysis to examine relationships between combinations of strategy components and improvements in outcomes.

RESULTS

We identified 18 strategies described in 19 studies. Eleven strategies significantly improved at least one measure of intermediate outcomes, final health outcomes, or resource use. Moderate strength of evidence (from one RCT) supported using provider financial incentives such as pay for performance to improve the competence with which practitioners can implement evidence-based practices (EBPs). We found inconsistent evidence involving strategies with educational meetings, materials, and outreach; programs appeared to be successful in combination with reminders or providing practitioners with newly collected clinical information. We also found low strength of evidence for no benefit for initiatives that included only educational materials or meetings (or both), or only educational materials and outreach components. Evidence was insufficient to draw conclusions on harms and moderators of interventions.

CONCLUSIONS

Several strategies can improve both intermediate and final health outcomes and resource use. This complex and heterogeneous body of evidence does not permit us to have a high degree of confidence about the efficacy of any one strategy because we generally found only a single study testing each strategy.

TRIAL REGISTRATION

PROSPERO, CRD42015024759 .

Integrated Behavioral Health in Pediatric Primary Care

There are multiple barriers to accessing high quality, evidence-based behavioral health care for children and adolescents, including stigma, family beliefs, and the significant paucity of child and adolescent psychiatrists. Although equal access continues to be an unmet need in the USA, there is growing recognition that integrated behavioral health services in pediatric primary care have the potential to reduce health disparities and improve service utilization. In a joint position paper, the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) highlighted the multiple benefits of children receiving initial behavioral health screening, assessment, and evidence-based behavioral health treatments in the medical home. The purpose of this paper is to review the current state of the literature related to integrated behavioral health services in pediatric primary care. Specifically, innovative models of integrated behavioral health care are discussed.

Variations in Mental Health Diagnosis and Prescribing Across Pediatric Primary Care Practices

BACKGROUND

Primary care pediatricians increasingly care for children's mental health problems, but little is known about practice-level variation in diagnosis and psychotropic medication prescribing practices.

METHODS

This retrospective review of electronic heath records from 43 US primary care practices included children aged 4 to 18 years with ≥1 office visit from January 1, 2009, to June 30, 2014. We examined variability in diagnosis and psychotropic prescribing across practices using logistic regression with practice fixed effects and evaluated associations of the availability of colocated or community-based mental health providers or the proportion of children in foster care with diagnosis and prescribing using generalized linear mixed models.

RESULTS

Among 294 748 children, 40 932 (15%) received a mental health diagnosis and 39 695 (14%) were prescribed psychotropic medication. Attention deficit/hyperactivity disorder was most commonly diagnosed (1%-16% per practice). The proportion of children receiving any psychotropic medication (4%-26%) and the proportion receiving ≥2 medication classes (1%-12%) varied across practices. Prescribing of specific medication classes also varied (stimulants, 3%-18%; antidepressants, 1%-12%; α-agonists, 0%-8%; second-generation antipsychotics, 0%-5%). Variability was partially explained by community availability of psychiatrists (significantly higher odds of a diagnosis or prescription when not available) but not by colocation of mental health professionals or percentage of children in foster care.

CONCLUSIONS

The prevalence of mental health diagnosis and psychotropic medication prescribing varies substantially across practices and is only partially explained by psychiatrist availability. Research is needed to better define the causes of variable practice-level diagnosis and prescribing and implications for child mental health outcomes.

The role of psychology in a pediatric outpatient cardiology setting: preliminary results from a new clinical program

The aim of this study was to provide a descriptive analysis of a new clinical program integrating psychology services within a pediatric outpatient cardiology clinic. Patients with congenital heart disease (CHD) (n = 79) were referred for psychological services by their pediatric cardiologist. Parents completed the child behavior checklist, and the pediatric quality of life inventory generic core scales (PedsQL parent report). Teachers completed the teacher report form. Reasons for referral included: emotional problems (29%); attention problems (25%); learning problems (22%); behavior problems (16%); and developmental delay (8%). Parents and teachers reported higher rates of behavior problems and lower quality of life scores than the general population. Psychological evaluation suggested that incorporating a psychologist within a pediatric cardiology clinic may be beneficial for children with CHD in order to optimize their psychosocial functioning. Practice implications for implementing psychology services within a pediatric outpatient cardiology program are discussed.

Perception of primary care pediatricians of effectiveness, acceptability, and availability of mental health services

Approximately 20% of children in the United States meet the criteria for a psychosocial disorder; however, less than 25% of these children receive psychosocial services. A questionnaire assessed primary care pediatricians' (PCPs) perceptions of effectiveness, availability, and burden of treatment options for children's psychosocial difficulties and parents' acceptance and adherence with these treatments. Repeated measures analysis of variance found that PCPs are more likely to refer children with psychosocial problems to a mental health professional than to prescribe medication. PCPs prescribe medications more than counseling parents themselves or watchful waiting. PCPs reported children's behavior is more likely to improve with mental health services than with medication, though medication is the most available treatment. PCPs believe parent training programs are very effective for treating children's behavior problems, but believe parents are more accepting and compliant with other treatments. Findings indicate PCPs' perceptions of availability and acceptability of treatment options drive their treatment recommendations of psychosocial problems.