Implementation of an Electronic Approach to Psychosocial Screening in a Network of Pediatric Practices

Achieving RoutIne Screening for Emotional health (ARISE) in pediatric subspecialty clinics

OBJECTIVE

This study aims to describe the experience of implementing a psychosocial distress screening system for children with serious or chronic medical conditions.

METHODS

Achieving RoutIne Screening for Emotional health (ARISE) was developed to systematically evaluate psychosocial distress in children with serious medical or chronic medical illnesses, by integrating patient-reported outcome measures (PROM) into care delivery. ARISE was developed using a user-centered approach with extensive input from patients, families, and healthcare professionals to overcome barriers to routine PROM collection and integration into care as usual. It comprises a system to capture PROMs and then relay results to clinicians for changing care. We sought to implement ARISE at four subspecialty pediatric clinics caring for patients with cystic fibrosis, sickle cell disease, hemophilia, and neurological malignancy.

RESULTS

Problems with acceptability, appropriateness, and feasibility represented barriers to implementation which were overcome by modifying the intervention using stakeholder input during the planning phase, leading to broad program acceptance. ARISE was implemented in three of the four clinics, in which 79.8% of eligible children and their family completed PROMs.

CONCLUSION

The ARISE program demonstrated the feasibility and effectiveness of integrating psychosocial screenings into subspecialty pediatric clinics, thereby enhancing the identification and management of psychosocial issues in children with serious and chronic medical illnesses.

Discrepancies Between Caregiver Reported Early Childhood Sleep Problems and Clinician Documentation and Referral

OBJECTIVE

The American Academy of Pediatrics recommends routine sleep problem screenings during child well-visits. However, studies suggest a discrepancy between caregiver- and clinician-reported child sleep problems. The present study examines whether caregiver-reported child sleep problems (ie, habitual snoring, insomnia symptoms, poor sleep health) and clinician-documented child sleep problems and management are congruent.

METHODS

The sample included 170 caregiver-child dyads (child Mage = 3.3 years, range = 2-5 years; 56.5% girls; 64.1% Black, 20.0% non-Latinx White, and 4.1% Latinx; 86.5% maternal caregiver reporter). Caregivers' questionnaire-based reports of habitual snoring, insomnia symptoms, and sleep health behaviors (nighttime electronics, caffeine intake, insufficient sleep) were compared with clinician documentation in the electronic health record.

RESULTS

About 92.3% of children had at least 1 caregiver-reported sleep problem (66% insomnia symptoms, 64% electronics, 38% insufficient sleep, 21% caffeine, 17% snoring). In contrast, a substantially lower percent of children had a clinician documented sleep problem (20% overall; 10% insomnia symptoms, 7% electronics, 0% insufficient sleep, 3% caffeine, 4% snoring), sleep-related referral (1% overall; 0.6% Otolaryngology, 0.6% polysomnogram, 0% sleep clinic), or recommendation (12% overall; 8% insomnia symptoms, 4% electronics, 0% insufficient sleep, 1% caffeine).

CONCLUSIONS

There is a vast discrepancy between caregiver-reported child sleep problems and clinician-documented sleep problems and management, with a higher proportion of caregiver reports. To benefit overall child health and well-being, future research and quality improvement initiatives should focus on enhancing screening tools and educational opportunities to improve clinician documentation and enhance family conversations about early childhood sleep problems.

Identifying and responding to depression in adolescents in primary care: A quality improvement response

The American Academy of Pediatrics (AAP) recommends adolescent depression screening and subsequent follow-up for those scoring at-risk. The current study assessed the outcomes of a Quality Improvement (QI) project that implemented these guidelines during annual well-child visits in a network of pediatric practices. This project used a two-stage screening process. First, adolescents were screened with the Pediatric Symptom Checklist (PSC-17). Second, adolescents who screened at-risk on the PSC-17 were asked to complete the Patient Health Questionnaire (PHQ-9). QI-participating providers received training on how to categorize the severity of their patient's depression based on PHQ-9 cut-off scores and clinical interview, and to implement and document appropriate options for follow-up. Patients in the QI group were significantly more likely to be screened with both the PSC-17 (93.8% vs. 89.1%, p < .001) and the PHQ-9 (54.8% vs. 16.4%, p < .001) compared to those in the non-QI group. Of the 80 adolescents in the QI group at-risk on the PSC-17 and with a completed PHQ-9, 65 (81.3%) received at least one type of referral for mental health, ranging from behavioral health services to lifestyle interventions. Findings support the feasibility of adolescent depression screening and referrals within pediatric primary care.

Screening Infants Through Adolescents for Social/Emotional/Behavioral Problems in a Pediatric Network

OBJECTIVE

To assess changes in screening completion in a diverse, 7-clinic network after making annual screening for social/emotional/behavioral (SEB) problems the standard of care for all infant through late adolescent-aged patients and rolling out a fully automated screening system tied to the electronic medical record and patient portal.

METHODS

In 2017, the Massachusetts General Hospital made SEB screening using the age-appropriate version of the Pediatric Symptom Checklist the standard of care in its pediatric clinics for all patients aged 2.0 months to 17.9 years. Billing records identified all well-child visits between January 1, 2016 and December 31, 2019. For each visit, claims were searched for billing for an SEB screen and the electronic data warehouse was queried for an electronically administered screen. A random sample of charts was reviewed for other evidence of screening. Chi-square analyses and generalized estimating equations assessed differences in screening over time and across demographic groups.

RESULTS

Screening completion (billing and/or electronic) significantly increased from 2016 (37.2%) through 2019 (2017 [46.2%] vs 2018 [66.8%] vs 2019 [70.9%]; χ² (3) =112652.33, P < .001), with an even higher prevalence found after chart reviews. Most clinics achieved screening levels above 90% by the end of 2019. Differences among demographic groups were small and dependent on whether data were aggregated at the clinic or system level.

CONCLUSIONS

Following adoption of a best-practice policy and implementation of an electronic system, SEB screening increased in all age groups and clinics. Findings demonstrate that the AAP recommendation for routine psychosocial assessment is feasible and sustainable.

Disparities in Pediatric Mental and Behavioral Health Conditions

Mental and behavioral health conditions are common among children and adolescents in the United States. The purpose of this state-of the-art review article is to describe inequities in mental and behavioral health care access and outcomes for children and adolescents, characterize mechanisms behind the inequities, and discuss strategies to decrease them. Understanding the mechanisms underlying these inequities is essential to inform strategies to mitigate these health disparities. Half of United States children with a treatable mental health disorder do not receive treatment from a mental health professional. Children and adolescents in racial, ethnic, sexual, sex, and other minority groups experience inequities in access to care and disparities in outcomes for mental and behavioral health conditions. Suicide rates are nearly twice as high in Black compared to White boys 5 to 11 years old and have been increasing disproportionately among adolescent Black girls 12 to 17 years old. Children identifying as a sexual minority have >3 times increased odds of attempting suicide compared to heterosexual peers. Adverse experiences of children living as part of a minority group, including racism and discrimination, have immediate and lasting effects on mental health. Poverty and an uneven geographic distribution of resources also contribute to inequities in access and disparities in outcomes for mental and behavioral health conditions. Strategies to address inequities in mental and behavioral health among United States children include investing in a diverse workforce of mental health professionals, improving access to school-based services, ensuring equitable access to telehealth, and conducting quality improvement with rigorous attention to equity.

Diagnoses and Treatment After Depression Screening in Primary Care Among Youth

INTRODUCTION

Depression screening is universally recommended for adolescents presenting in primary care settings in the U.S. However, little is known about how depression screening affects the likelihood of being diagnosed with a mental disorder or accessing mental health care over time.

METHODS

This longitudinal cohort study used insurance claims data from adolescents who attended a well-visit between 2014 and 2017. Propensity score matching was used to compare adolescents who were screened for depression with similar unscreened adolescents. Diagnoses and treatment uptake were examined over a 6-month follow-up and included depression diagnoses, mood-related diagnoses, antidepressant medications, any mental health medication, and psychotherapy. Heterogeneity of associations by sex was also examined. Analyses were conducted from December 2020 to June 2021.

RESULTS

The sample included 57,732 adolescents (mean age, 14.26 years; 48.9% female). Compared with adolescents who were not screened for depression, adolescents screened for depression were 30% more likely to be diagnosed with depression (risk ratio=1.30, 95% CI=1.11, 1.52) and 17% more likely to receive a mood-related diagnosis (risk ratio=1.17, 95% CI=1.08, 1.27) but were not more likely to be treated with an antidepressant medication (risk ratio=1.11, 95% CI=0.82, 1.51), any mental health medication (risk ratio=1.15, 95% CI=0.87, 1.53), or psychotherapy (risk ratio=1.13, 95% CI=0.98, 1.31). Associations were generally stronger among female adolescents.

CONCLUSIONS

Adolescents who were screened for depression during a well-visit were more likely to receive a diagnosis of depression or a mood-related disorder in the 6 months after screening. Future research should explore methods for increasing treatment uptake after screening.