Racial and ethnic disparities in pediatric mental health

Developing a Set of Standardized Core Principles and Methods Across Multiple Training and Technical Assistance Centers

Despite a growing body of research demonstrating the value of using evidence-based programs and practices (EBPPs) to address health and education issues, the gap between research evidence and practice in education and human services continues to be a vexing problem. Technical assistance (TA) is widely accepted as a key strategy to support evidence-based programs and practices (EBPP) uptake and implementation. However, little is known about how TA practices are used in TA delivery. Moreover, little attention has been paid to building the capacity of TA providers and assessing the fidelity of the implementation of TA practices. The case example presented in this article describes one organization's efforts to develop common language and definitions of TA services, core principles, and methods, and to standardize the delivery of TA by enhancing the capacity and retention of TA providers. We conclude with recommendations about how like organizations can employ similar efforts to improve the quality and consistency of TA delivery, thereby establishing a foundation for building a strong evidence base.

Age of onset of major depressive episode and association with lifetime psychiatric disorders, health-related quality of life and impact of gender: A cross sectional and retrospective cohort study

OBJECTIVE

To assess the long-term impact of the age of onset (AOO) of the first major depressive episode (MDE) according to 3 age groups and considering gender.

METHODS

Data were extracted from NESARC III, a representative U.S.

SAMPLE

We included 8053 participants with an MDE history in a cross-sectional and retrospective cohort study. We defined 3 AOO groups: childhood-onset (< 13 yo), adolescence-onset (13-18 yo), and adult-onset (> 18 yo). We compared sociodemographic characteristics, lifetime psychiatric disorders per DSM-5 criteria, and health-related quality of life (HRQOL) in each group and performed gender-stratified analyses.

RESULTS

Prevalence of childhood-onset MDE was 10.03 %, adolescence-onset was 14.12 %, and adult-onset was 75.85 %. Suicide attempts (AOR = 3.61; 95 % CI 2.90-4.50), anxiety disorders (AOR = 1.92; 95 % CI 1.62-2.27), and personality disorders (AOR = 3.08; 95 % CI 2.56-3.71) were more frequent in the childhood-onset than in the adult-onset one. Adolescence-onset group showed similar results. Physical Disability scale (p < 0.001) and Mental Disability scale (p < 0.001) were significantly lower in the childhood-onset group. Results were more nuanced in the adolescence-onset group. Women in childhood-onset and adolescence-onset groups had poorer outcomes than the adult-onset group. Differences were less pronounced in men.

LIMITATIONS

Recall and classification biases inherent to survey design.

CONCLUSION

Individuals, particularly women, who experienced their first MDE during childhood or adolescence exhibit higher lifetime psychiatric disorder prevalence and poorer HRQOL than those with adult-onset MDE. These findings highlight the importance of preventive measures, early diagnosis, and treatment of youth depression.

Screen time and mental health: a prospective analysis of the Adolescent Brain Cognitive Development (ABCD) Study

BACKGROUND

Despite the ubiquity of adolescent screen use, there are limited longitudinal studies that examine the prospective relationships between screen time and child behavioral problems in a large, diverse nationwide sample of adolescents in the United States, which was the objective of the current study.

METHODS

We analyzed cohort data of 9,538 adolescents (9-10 years at baseline in 2016-2018) with two years of follow-up from the Adolescent Brain Cognitive Development (ABCD) Study. We used mixed-effects models to analyze associations between baseline self-reported screen time and parent-reported mental health symptoms using the Child Behavior Checklist, with random effects adjusted for age, sex, race/ethnicity, household income, parent education, and study site. We tested for effect modification by sex and race/ethnicity.

RESULTS

The sample was 48.8% female and racially/ethnically diverse (47.6% racial/ethnic minority). Higher total screen time was associated with all mental health symptoms in adjusted models, and the association was strongest for depressive (B = 0.10, 95% CI 0.06, 0.13, p < 0.001), conduct (B = 0.07, 95% CI 0.03, 0.10, p < 0.001), somatic (B = 0.06, 95% CI 0.01, 0.11, p = 0.026), and attention-deficit/hyperactivity symptoms (B = 0.06, 95% CI 0.01, 0.10, p = 0.013). The specific screen types with the greatest associations with depressive symptoms included video chat, texting, videos, and video games. The association between screen time and depressive, attention-deficit/hyperactivity, and oppositional defiant symptoms was stronger among White compared to Black adolescents. The association between screen time and depressive symptoms was stronger among White compared to Asian adolescents.

CONCLUSIONS

Screen time is prospectively associated with a range of mental health symptoms, especially depressive symptoms, though effect sizes are small. Video chat, texting, videos, and video games were the screen types with the greatest associations with depressive symptoms. Future research should examine potential mechanisms linking screen use with child behavior problems.

Potential Bias in Social Work Consultations in the Pediatric Inpatient Setting

BACKGROUND AND OBJECTIVES

Failure to thrive, brief resolved unexplained event, accidental ingestion, and drowning admissions commonly involve social work (SW) consultation. Care team biases likely influence SW consultation decisions. We examined whether SW consultations varied by patient race for these diagnoses.

METHODS

We conducted a retrospective cohort study of children <6 years of age admitted for failure to thrive, brief resolved unexplained event, accidental ingestion, and drowning between July 1, 2012 and June 30, 2020 at a single, academic, standalone children's hospital in an urban environment. The outcome was SW consultation; the predictor was patient race. We used multivariable logistic regression, adjusting for ethnicity, language, insurance, and diagnosis. We completed a supplemental chart review of a random sample of 10% of patients with SW consultation to determine the reasons that consultations were placed.

RESULTS

We included 1199 unique patients; 64% identified as white, and 22% identified as Black. Black patients had 1.61 times higher adjusted odds of SW consultation compared with white patients (95% confidence interval 1.14-2.29). Publicly insured, compared with privately insured, patients had 6.10 times higher adjusted odds of SW consultation (95% confidence interval 4.28-8.80). Upon supplemental chart review, Black patients had SW consultations that focused more often on abuse, neglect, and safety; this was also found for publicly insured patients. There was parity in consultation for resource needs across groups.

CONCLUSIONS

Black children were more likely than white children to receive SW consultation during hospitalization, as were publicly insured children compared with their privately insured peers; in supplemental review, this was not due to differences in consultations for resource needs. The standardization of SW consultation may promote equitable care.

Child mental health treatment access and retention in integrated primary care and traditional outpatient services

INTRODUCTION

There are disparities in child mental health treatment access and treatment retention in terms of race and ethnicity, socioeconomic status (SES), and insurance coverage. Institutions have invested in the integrated primary care (IPC) treatment model with the goal of improving treatment access and promoting child mental health equity.

OBJECTIVE

This study compared treatment attendance in an outpatient psychiatry clinic (OPC) versus an IPC clinic to assess whether the IPC was associated with reduced disparities in access to care and treatment retention.

METHODS

This study assessed whether there were differences in who is connected to care from the intake appointment to first follow-up appointment.

RESULTS

Results showed that the IPC clinic served a more diverse patient population than the OPC clinic in terms of SES, race, and ethnicity. Differences in treatment attendance in the IPC and OPC were also found. After controlling for race, ethnicity, insurance, and distance from patient's home zip code to clinic, the IPC treatment setting was associated with poorer intake and follow-up appointment attendance.

CONCLUSIONS

The IPC model may be more accessible to historically underserved youth, but the treatment setting does not inherently eliminate disparities in child mental health treatment retention. Replication of this study has the potential to contribute to the external validity of study findings, improve quality assurance policies, and develop equitable workflow policies. Future research is needed to identify factors that can improve treatment attendance for populations who face greater retention barriers and to shine light on ways that healthcare systems may inadvertently maintain disparity in treatment retention.

School belonging mediates the longitudinal effects of racial/ethnic identity on academic achievement and emotional well-being among Black and Latinx adolescents

Social Identity Theory proposes that a positive in-group social identification fosters students' academic motivation and psychological well-being. The present study, grounded in Social Identity Theory, investigated the roles of racial/ethnicity identity (REI) in the development of school adjustment among Black and Latinx youth as well as the psychological mechanisms underlying these longitudinal associations. We hypothesized that REI would positively predict the development of academic achievement and emotional symptoms. In addition, we hypothesized that the development of school belonging would mediate the predictive effects of REI on the growth of academic achievement and emotional symptoms. Participants were 475 (n = 182 Black, 48.9% female; 293 Latinx, 47.8% female) students in Grades 7-9. Students self-reported their REI, school belonging, and emotional symptoms. Academic achievement was assessed using standardized achievement test scores. The longitudinal mediation models indicated that REI indirectly predicted the development of academic achievement and emotional symptoms through students' sense of school belonging. Specifically, higher REI embedded achievement and lower REI awareness of racism predicted higher school belonging in Grade 7. Higher Grade 7 school belonging in turn predicted faster academic growth in Grade 7 to Grade 9 as well as lower emotional symptoms in Grade 7. In addition, the three dimensions of REI also directly predicted the growth of academic achievement and emotional symptoms in Grades 7-9. The mediated effects were smaller in size than the direct effects. These findings highlight the importance of fostering positive REI and a strong sense of school belonging in promoting school adjustment among racial/ethnic minoritized, academically at-risk youth.

Telehealth Utilization Among Adult Medicaid Beneficiaries in North Carolina with Behavioral Health Conditions During the COVID-19 Pandemic

OBJECTIVE

We examined factors associated with telehealth utilization during COVID-19 among adult Medicaid beneficiaries with behavioral health conditions.

DATA SOURCES AND STUDY SETTING

NC Medicaid 2019-2021 beneficiary and claims data.

STUDY DESIGN

This retrospective cohort study examined and compared behavioral health service use pre-COVID-19 (03/01/2019 to 02/28/2020) and during COVID-19 (04/01/2020 to 03/31/2021). Telehealth users included those with at least one behavioral health visit via telehealth during COVID-19. Descriptive statistics were calculated for overall sample and by telehealth status. Multilevel modified Poisson generalized estimating equation examined associations between telehealth use and patient- and area-level characteristics.

DATA COLLECTION/EXTRACTION METHODS

We identified individuals ages ≥ 21-64, diagnosed with a behavioral health condition, and had at least one behavioral-health specific visit before COVID-19.

PRINCIPAL FINDINGS

Almost two-thirds of the cohort received behavioral health services during COVID-19, with half of these beneficiaries using telehealth. Non-telehealth users had steeper declines in service use from pre- to during COVID-19 compared to telehealth users. Beneficiaries identifying as Black, multiracial or other were significantly less likely to use telehealth (ARR = 0.86; 95% CI: (0.83, 0.89)); (ARR = 0.92; 95% CI: (0.87, 0.96)) compared to White beneficiaries. Those eligible for Medicaid through the blind/disabled programs and who qualified for a state-specific specialized behavioral health plan were more likely to use telehealth (17% and 20%, respectively).

CONCLUSIONS

During the pandemic, telehealth facilitated continuity of care for beneficiaries with behavioral health conditions. Future research should aim to investigate how to reduce the digital divide and ensure equitable access to telehealth.

Understanding the Social Drivers for LGBTQIA+ Youth Suicide

LGBTQIA+ youth are disproportionately affected by mental health issues including suicidal ideation and suicide attempts. Minoritized youth have numerous social and structural factors influencing their health, including a lack of access to care and resources. However, these youth and their caregivers also have many unique and individual cultural strengths. Awareness of special considerations and work toward dismantling structural drivers is essential in improving the health of these youth. Additionally, it is important to support minoritized youth and their caregivers through tailored evidence-based treatments in addressing social and structural drivers to influence individual, community, educational, institutional, and policy levels and prevent suicide in achieving mental health equity.

Using a Culturally Responsive, Antiracist, and Equitable Approach to School Mental Health

Amidst a national youth mental health crisis, comprehensive school mental health systems offer an opportunity to promote positive mental health for all students. To advance health equity, schools benefit from a culturally responsive, antiracist, and equitable (CARE) framework to address the youth mental health crisis. This article describes how to integrate CARE practices within a multi-tiered system of support for mental health in schools. The strategies align with a trauma-informed approach and aim to enhance the capacity of comprehensive school mental health systems to promote positive mental health and well-being for all students.

An Epidemiological Study of Physical-Mental Multimorbidity in Youth: Une étude épidémiologique de la morbidité physique-mentale chez les jeunes

OBJECTIVE

This epidemiological study estimated the lifetime prevalence of chronic physical illness (i.e., an illness that lasted or was expected to last ≥6 months) and 6-month prevalence of mental disorder and multimorbidity (i.e., ≥1 physical illness and ≥1 mental disorder) in youth. Associations between physical illness and mental disorder were quantified, including the number of illnesses. Secondary objectives examined factors associated with mental disorder, after controlling for physical illness.

METHODS

Data come from 10,303 youth aged 4-17 years in the 2014 Ontario Child Health Study (OCHS). Physical illness was measured using a list of chronic conditions developed by Statistics Canada. Mental disorders were measured using the OCHS Emotional Behavioural Scales. The Health Utility Index Mark III assessed overall functional health.

RESULTS

Weighted prevalence estimates showed 550,090 (27.8%) youth had physical illness, 291,986 (14.8%) had mental disorder, and 108,435 (5.4%) had multimorbidity. Physical illness was not associated with mental disorder. However, youth with 2 physical illnesses, as compared to no physical illnesses, had increased odds of having any mental (OR = 1.75 [1.08, 2.85]), mood (OR = 2.50 [1.39, 4.48]) and anxiety disorders (OR = 2.40 [1.33, 4.31]). Mean functional health scores demonstrated a dose-response association across health status categories, with the highest scores among healthy youth and the lowest scores among multimorbid youth (all p < .05).

CONCLUSION

Chronic physical illness and mental disorders are prevalent in youth. Youths with 2 physical illnesses have a higher likelihood of mental disorders. Higher functional health scores protected against all mental disorders. Mental health interventions for youth should promote strong overall functional health.

PLAIN LANGUAGE SUMMARY TITLE

Physical-Mental Multimorbidity in Ontario Youth.

Stress interventions for immigrant parents in the United States: a scoping review protocol

OBJECTIVE

This review will map stress interventions designed for and implemented among immigrant parents in the United States (US) according to intervention characteristics, participant characteristics, and reported outcomes and measurement tools.

INTRODUCTION

In addition to parenting stressors shared with their non-immigrant counterparts, immigrant parents also face immigration stressors. Although stress interventions can effectively manage, reduce, or prevent stress among non-immigrant populations, we know little about stress interventions designed for immigrant parents in the US. This study will be the first to explore stress interventions implemented among immigrant parents in the US.

INCLUSION CRITERIA

This scoping review will include published, peer-reviewed quantitative, qualitative, and mixed methods studies that evaluate stress interventions designed specifically for US immigrant parents with at least 1 child under the age of 18 years. Reported interventions must include stress as a primary or secondary outcome or be labeled as a stress intervention. Stress interventions are broadly defined, with no restrictions on the type of stress targeted (eg, job, general, parenting) or the intervention's nature (ie, prevention vs. management/reduction vs. treatment).

METHODS

A literature search will be conducted in ProQuest's APA PsycINFO and PsycARTICLES, CINAHL Plus (EBSCOhost), ERIC (ProQuest), Embase, MEDLINE (Ovid), International Bibliography of Social Sciences (ProQuest), and the Cochrane Library. Only English-language publications will be eligible, with no date restrictions. Retrieved titles and abstracts will be screened by at least 2 independent reviewers in duplicate. Data will be extracted using a self-developed data extraction tool. Findings will be presented in tabular or diagrammatic format, accompanied by a narrative summary.

REVIEW REGISTRATION

Open Science Framework osf.io/ec39j.

Brief School-Based Interventions Targeting Student Mental Health or Well-Being: A Systematic Review and Meta-Analysis

Brief, school-based mental health interventions hold promise for reducing barriers to mental health support access, a critical endeavor in light of increasing rates of mental health concerns among youth. However, there is no consensus on whether or not brief school-based interventions are effective at reducing mental health concerns or improving well-being. This systematic review and meta-analysis aims to provide consensus and determine directions for future work. Articles were included if they examined a brief (≤ four sessions or 240 min of intervention time) psychosocial intervention, were conducted within a Pre-K through 12th-grade school setting, included at least one treatment outcome evaluating mental health or well-being, and were published since 2000. A total of 6,702 papers were identified through database searching, of which 81 papers (k studies = 75) were ultimately selected for inclusion. A total of 40,498 students were included across studies and a total of 75 unique interventions were examined. A total of 324 effect sizes were extracted. On average, interventions led to statistically significant improvements in mental health/well-being outcomes versus control conditions up to one-month (g = .18, p = .004), six-month (g = .15, p = .006), and one-year (g = .10, p = .03) post-intervention. There may be benefits to brief school-based interventions from a preventative public health standpoint; future research may focus on how to optimize their real-world utility. Prospero pre-registration: CRD42021255079.

Mental Health Crisis Responses and (In)Justice: Intrasystem and Intersystem Implications

Mental health crises among people who are marginalized merit special consideration. These groups are both overserved and underserved by mental health crisis systems: over-represented in acute treatment settings by number while facing inequities in outcomes. The predisposing, precipitating, and perpetuating factors that contribute to crises, however, neither begin nor end with the mental health system. Rather, these factors are multisystemic. As an illustration of this concept, this article highlights select marginalized groups, those that have faced inequities in mental health diagnosis and treatment due to race, medical complexity, age, and criminal justice system involvement.

Retrospective descriptive analysis of an urban pediatric collaborative care program

OBJECTIVE

The prevalence of mental health conditions in pediatric patients in the United States is approximately 15%. Concerningly, nearly half go untreated, with lower treatment rates among children of color. Collaborative care can increase access to care and has an emerging evidence base for pediatrics. We present retrospective results from a collaborative care program that accepted referrals for a variety of conditions.

METHODS

Pediatric patients seen in an academic, urban collaborative care program from July 2019 to December 2021 were tracked in a registry. Demographics, presenting problem(s), symptoms, treatment, and discharge dispositions were examined. Descriptive data were analyzed, including changes in reported symptoms via paired t-tests.

RESULTS

Three hundred nineteen patients were seen. Racial and ethnic diversity in our clinic's population was similar to that of the surrounding community, with half belonging to a minoritized racial or ethnic group. Symptom comparisons demonstrated clinically and statistically significant improvements from intake to discharge.

CONCLUSION

Collaborative care can improve access to care and outcomes for a diverse pediatric population. Our clinic served racial and ethnic patient populations that were representative of the demographics of the metropolitan area. Further study is necessary to determine if collaborative care increases access for these underserved groups.

The role of competency based medical education in addressing health inequities and cultivating inclusive learning environments

Pediatric health inequities are pervasive and reflect the confluence of social and structural determinants of health including racism in all its forms. Current approaches in graduate medical education that prepare trainees to address health inequities and improve population health are inadequate. Competency based medical education (CBME) can advance equity-oriented efforts to improve patient outcomes, optimize the learning environment and encourage lifelong learning. We briefly describe the impact of racism and discrimination on the clinical learning environment. We then highlight how to apply the 5 core principles of CBME to equip learners across the continuum to address health inequities. We provide specific examples including 1) how CBME can inform teaching, assessment and professional development activities to promote equitable pediatric health outcomes via enturstable professional activities, 2) competency-focused instruction that address racism and inequities, 3) multimodal learning approaches to facilitate the acquisition of the desired competencies to address health inequities, 4) sequenced learning approaches across the continuum of practicing pediatricians, and 5) tools and resources for programmatic assessment of trainee and program performance in addressing pediatric health inequities.

A Secret Shopper Study of Language Accessibility of Community-Based Behavioral Health Services for Children in Families Who Speak Spanish and English

OBJECTIVE

The objective of this study was to compare outpatient behavioral health scheduling for children in Spanish-speaking families in Pennsylvania with that for children in families who speak English.

STUDY DESIGN

We made paired English and Spanish telephone calls to outpatient behavioral health facilities using a standardized script, describing a simulated, stable, Medicaid-insured child. Facilities were identified using the Pennsylvania Department of Human Services Online Provider Directory for Mental Health and Substance Abuse Services, which had 288 outpatient facilities with nonduplicate telephone numbers. An English-language caller following a script made up to 2 call attempts per facility from December 2019 through February 2020. The 126 facilities that did not answer the phone, accept Medicaid, or see children were removed. A Spanish-language caller then made up to 2 scripted call attempts to the 162 remaining facilities. The primary outcome was whether the facility tried to schedule an appointment for the simulated adolescent.

RESULTS

A total of 125 facilities answered both English- and Spanish-language calls. For the English-language caller, 71% of facilities attempted to schedule an appointment and 100% communicated in the caller's preferred language. For the Spanish-language caller, 24% attempted to schedule an appointment (P < .001) and 25% communicated in the caller's preferred language (P < .001).

CONCLUSIONS

Among outpatient behavioral health facilities for Medicaid-insured children in Pennsylvania, there were inequities in access to appointments for families who speak Spanish compared with English. This is a modifiable barrier to care. Community-based behavioral health care for children should strengthen language access training, contracting, and oversight.

Characteristics Associated With Mental Health Treatment Prior to Suicide Among Youth in the United States

OBJECTIVE

To examine individual and contextual characteristics associated with receipt of mental health treatment prior to youth suicide.

METHOD

Data from the US National Violent Death Reporting System, Area Health Resource File, and Social Vulnerability Index were used to examine characteristics associated with receipt of mental health treatment within 2 months before death among youth suicide decedents aged 5 to 17 years from 2013 to 2020 (N = 6,229). The association between individual (demographic, precipitating circumstances, and clinical characteristics) and contextual-level variables (county health resources, Social Vulnerability Index) and mental health service use was modeled using logistic regression.

RESULTS

Mental health treatment was received by 31.6% of youth suicide decedents (n = 1,967) in the 2 months before suicide. Male individuals and youth from all racial and ethnic minority groups were less likely to receive mental health treatment in the 2 months prior to suicide, as were youth residing in non-metropolitan counties and living in counties characterized by high compared to low levels of social vulnerability. A history of family problems, a recent crisis, criminal/legal problems, and suicidal thoughts and attempts were associated with increased odds of receiving mental health services.

CONCLUSION

Youth suicide decedents who were male, members of a racial or ethnic minority group, and residing in counties that are non-metropolitan and/or socially disadvantaged were less likely to have received mental health services in the months prior to death. Suicide prevention efforts that focus on improving access to care are essential for these vulnerable populations at risk for suicide.

Risk and protective factors of asthma and mental health condition multimorbidity in a national sample of Canadian children

BACKGROUND

The coexistence of childhood asthma and mental health (MH) conditions can impact management and health outcomes but we need to better understand the etiology of multimorbidity. We investigated the association between childhood asthma and MH conditions as well as the determinants of their coexistence.

METHODS

We used data from the Canadian Health Survey of Children and Youth 2019 (3-17 years; n = 47,871), a cross-sectional, nationally representative Statistics Canada dataset. Our primary outcome was condition status (no asthma or MH condition; asthma only; MH condition only; both asthma, and a MH condition (AMHM)). Predictors of condition status were assessed using multiple multinomial logistic regression. Sensitivity analyses considered individual MH conditions.

RESULTS

MH condition prevalence was almost two-fold higher among those with asthma than those without asthma (21.1% vs. 11.6%, respectively). There were increased risks of each condition category associated with having allergies, other chronic conditions, and family members smoking in the home while there were protective associations with each condition status category for being female and born outside of Canada. Four additional variables were associated with AMHM and MH condition presence with one additional variable associated with both AMHM and asthma. In sensitivity analyses, the associations tended to be similar for most characteristics, although there was some variability.

CONCLUSION

There are common risk factors of asthma and MH conditions along with their multimorbidity with a tendency for MH risk factors to be associated with multimorbidity. MH condition presence is common and important to assess among children with asthma.

Anxiety, depression, and suicidal ideation among early adolescents during the COVID-19 pandemic

BACKGROUND

Anxiety and depression are among the most common and debilitating psychiatric disorders affecting youth, with both related to increased suicide risk. While rates of youth anxiety and depression were increasing before the COVID-19 pandemic, the pandemic further negatively impacted adolescent mental health. Unfortunately, few studies have examined prevalence of these concerns among early adolescents (ages 10-13) longitudinally during the pandemic.

METHOD

The current study examined self-reported anxiety and depression symptoms, and suicidal ideation amongst a general pediatrics population of 11- to 13-year-olds (n = 623) from March through September 2020 (early-pandemic) and approximately 7 months later (September 2020 through May 2021; mid-pandemic). Paired samples proportions were used to examine changes in prevalence of moderate to severe anxiety, depression, and suicidal ideation from early- to mid-pandemic.

RESULTS

Results highlight high initial rates and stability in anxiety and suicidal ideation, as well as a significant increase in depression (42.9% increase; p < .05) among the full sample during the COVID-19 pandemic. Prevalance of concerns were greatest for females and Hispanic youth during the early-pandemic, and generally highest for females and Medicaid insured youth at mid-pandemic.

DISCUSSION

Results extend recent research and underscore the need for continued monitoring of mental health concerns across development for youth who grew up during the COVID-19 pandemic; highlighting the need for sustainable, effective, and accessible early detection, prevention, and intervention strategies. Improving these services is critical to support youth who experienced pandemic-related stressors, and to prepare for supporting youth during future disruptive and isolating events.

An Institutional Approach to Equity and Improvement in Child Health Outcomes

Pediatric health inequities are pervasive. Approaches by health care institutions to address inequities often, and increasingly, focus on social needs screening without linked, robust responses. Even when actions in pursuit of health equity do occur within health care institutions, efforts occur in isolation from each other, standing in the way of cross-learning and innovation. Learning network methods hold promise when institutions are confronted with complex, multidimensional challenges. Equity-oriented learning networks may therefore accelerate action to address complex factors that contribute to inequitable pediatric health outcomes, enabling rapid learning along the way. We established an institutional Health Equity Network (HEN) in pursuit of excellent and equitable health outcomes for children and adolescents in our region. The HEN supports action teams seeking to eliminate pediatric health inequities in their clinical settings. Teams deploy targeted interventions to meet patients' and families' needs, addressing both medical and social factors affecting health and wellbeing. The primary, shared HEN measure is the equity gap in hospitalization rates between Black patients and all other patients. The HEN currently has 10 action teams and promotes rapid learning and scaling of interventions via monthly "action period calls" and "solutions labs" focused on successes, challenges, and potential common solutions (eg, scaling of existing medical-legal partnership to subspecialty clinics). In this Advocacy Case Study, we detail the design, implementation, and early outcomes from the HEN, our equity-oriented learning network.

The Declaration of the National Emergency in Child and Adolescent Mental Health: It Takes a Village

Recognition of the high prevalence of children's mental health conditions and challenges to accessing needed care faced by children and their families have been long-standing concerns, emerging well before the onset of the COVID-19 pandemic. Global data examining the prevalence of at least one mental health and/or substance-use disorder for 2516 million people aged 5 to 24 years in 2019 found that at least 293 million people were affected by at least one mental health disorder and 31 million affected by a substance-use disorder.

Rethinking Racial Matching in Children's Mental Health: The Need for Racially Conscious Therapists

In a given year, 1 in 6 youth will experience a mental health disorder.1 Prevalence data reveal that anxiety (9.4%), attention-deficit/hyperactivity disorder (9.8%), and behavior problems (8.9%) are the most common mental disorders in youth.2 With the coronavirus disease (COVID-19) pandemic, psychiatric needs skyrocketed because of factors such as isolation from social networks, disruption in routines, reduction in physical activities, and increased social media use.3 As a result, symptoms of depression and anxiety doubled and suicide attempts rose, which illuminated the mental health crisis among children and adolescents.4,5 More concerning, this trend has had a disproportionate impact on racially minoritized communities, who also had to grapple with significant compounding stressors related to inequitable health care access, police brutality, xenophobia, and more.6 For instance, exposure to personal and indirect racial discrimination through channels such as social media resulted in elevated worry and stress among Black and Asian American youth.6 Furthermore, across different racial groups, the percentage of youth injured from a suicide attempt only increased for Black youth from 2019 to 2021.7 Despite these needs, mental health service use rates among racially minoritized youth remain low compared to those of their White counterparts. Moreover, once and if care is provided, racially minoritized youth report poorer quality services, contributing to premature termination and unmet mental health needs.8 Thus, strategies that promote racially minoritized youths' engagement in services are warranted to address mental health inequities.

Understanding Signs and Sources of Anxiety in Urban Elementary Schools Serving Predominately Ethnically/Racially Minoritized Children

OBJECTIVE

This mixed-methods study examined teachers' perceptions of student anxiety in urban elementary schools serving predominantly low-income and ethnically/racially minoritized youth.

METHOD

Most participating teachers were female (87.7%) and from minoritized backgrounds themselves (89.2%), teaching in schools serving predominantly Black/African American (40%) or Hispanic (60%) students, and in which > 70% of students are eligible for free meals. Teachers were asked in surveys (N = 82) and interviews (n = 12) about the nature of student anxiety, and cultural/contextual considerations that influence anxiety.

RESULTS

Overall, teachers reported prevalence and signs of student anxiety that were consistent with the literature, but they reported higher levels of impairment than in previous community samples. Regressions revealed that greater levels of student exposure to community violence and higher proportions of Black students were associated with higher teacher-perceived prevalence and concern about student anxiety, respectively. Moreover, greater emotional exhaustion in teachers was associated with higher reports of anxiety-related impairment in students. Thematic coding of interviews emphasized how teachers perceived 1) most student anxieties to be proportional responses to realistic threats and stress in students' lives (e.g. resource insecurity), 2) systems-level problems (e.g. pressure to perform on standardized tests) contribute to student anxiety, and 3) school-based anxiety sources often interact with traumas and stressors students experience outside of school (e.g. immigration experiences).

CONCLUSIONS

Relative to the predominant literature that has focused on biological, cognitive, and other intraindividual factors as sources of anxiety, the present work underscores the importance of considering how broader economic and systems-level influences exacerbate anxiety in marginalized youth.

Scope-of-Practice Expansions Associated with Reduced Racial Disparities in Pediatric Mental Health Care

To examine the association between scope-of-practice (SoP) regulations and racial disparities in pediatric mental health services. We used the National Survey of Children's Health (2016-2020; n = 33,790) to examine racial disparities in unmet mental health care needs and receipt of mental health medication between states with and without SoP expansions for psychologists and nurse practitioners (NP). Our primary outcomes were (1) unmet mental health care needs and (2) receipt of mental health medication. We examined heterogeneous treatment effects of SoP expansion on the outcomes using logistic regression with interaction terms between SoP expansion and race/ethnicity. We estimated population-level racial disparities for both outcomes stratified by SoP expansion to identify differences in racial disparities. The psychologist SoP expansion-associated reduction in unmet need was 15.8 percentage-points (CI= -25.3, -6.2) larger for Other-race children than for White children. The psychologist SoP expansion-associated increase in medication was 5.1%-points (CI=. 0.8, 9.4) larger for Black children and 5.6%-points (CI = 0.5, 10.8) for Other-race children. No differences were found for NP SoP expansion. Racial disparities in both outcomes were lower in psychologist SoP expansion states but varied in NP SoP states. Expanded SoP was generally associated with lower racial disparities in pediatric mental health care access.

Identifying Precise Targets to Improve Child Mental Health Care Equity: Leveraging Advances in Clinical Research Informatics and Lived Experience

To reduce child mental health disparities, it is imperative to improve the precision of targets and to expand our vision of social determinants of health as modifiable. Advancements in clinical research informatics and please state accurate measurement of child mental health service use and quality. Participatory action research promotes representation of underserved groups in informatics research and practice and may improve the effectiveness of interventions by informing research across all stages, including the identification of key variables, risk and protective factors, and data interpretation.

Black and White Adults' Racial and Gender Stereotypes of Psychopathology Symptoms in Black and White Children

Adults' judgments of children's behaviors play a critical role in assessment and treatment of childhood psychopathology. Judgments of children's psychiatric symptoms are likely influenced by racial biases, but little is known about the specific racial biases adults hold about children's psychiatric symptoms, which could play a critical role in childhood mental health disparities. This study examined one form of such biases, racial stereotypes, to determine if White and Black adults hold implicit and explicit racial stereotypes about common childhood psychopathology symptoms, and if these stereotypes vary by child gender and disorder type. Participants included 82 self-identified Black men, 84 Black woman, 1 Black transgender individual, 1 Black genderfluid individual, 81 White men, and 85 White women. Analyses of implicit stereotypes revealed that White adults associated psychopathology symptoms more strongly with Black children than did Black adults (p < .001). All adults held stronger implicit racial stereotypes for oppositional defiant disorder, anxiety, and depression than for attention-deficit/hyperactivity disorder (p < .001). For explicit stereotypes, White adults generally associated psychopathology symptoms more with Black children than did Black adults but effects varied across child gender and disorder type. As the first study to examine racial and gender stereotypes across common childhood psychopathology symptoms, these findings point to a need for further investigation of the presence and impact of racial biases in the mental healthcare system for Black youth and to identify interventions to mitigate the impacts of racial biases to inform racial equity in mental healthcare in the United States.

A Statewide Evaluation of the Implementation of Evidence-Based Suicide Prevention Guidelines in Juvenile Detention Centers

This study aimed to explore suicide prevention in juvenile detention centers by conducting a case study of one state. Qualitative data from semistructured interviews were synthesized from 10 juvenile detention centers. Analytical techniques included thematic and content analysis and the integration of quantitative information and qualitative themes to illustrate key differences in suicide prevention practices and center characteristics among facilities with varying frequencies of crisis stabilization calls and critical incidents. Although the use of many suicide prevention practices was reported across the sample, the quality with which those practices were implemented was highly variable. The analysis suggests that facilities with higher-quality implementation of suicide prevention practices may have had leaders who acknowledged that their facility plays a role in suicide prevention. Moreover, preliminary evidence suggests that the quality of suicide prevention implementation may be associated with the number of crisis stabilization calls and critical incidents (i.e., variables related to suicidality) a facility experiences. Clear conceptualization of a juvenile detention center's role in suicide prevention may lead to better outcomes in suicide prevention implementation. High-quality implementation may reduce suicidality exhibited by youths in juvenile detention and save lives.

Disparities in Access to Mental Health Services Among Children Diagnosed with Anxiety and Depression in the United States

Child and adolescent mental health are major public health concerns in the US. Overall, 20% of US children have a reported mental health condition, while an estimated 40% will be diagnosed with one by age 18. Despite these concerns, little is known about factors associated with access to mental health services among children and adolescents. We analyzed data from a sample of 6655 children (aged 6 to 17 years) with either anxiety and/or depression drawn from the 2020-2021 National Survey of Children's Health (NSCH). A multivariable logistic regression model was fit to investigate predisposing, enabling, and need factors associated with caregiver's (i.e., parent or other guardian) perceived access to mental health services for their children. Approximately 50.8% of caregivers perceived obtaining mental health services for their children to be somewhat difficult, very difficult, or impossible. Children meeting criteria for having a medical home had lower odds of experiencing such difficulties (adjusted [a]OR = 0.38; 95% CI: 0.30-0.49). Further, compared to children who sometimes or never had health insurance coverage for mental or behavioral health needs, children who were always insured (aOR: 0.19; 95% CI 0.14, 0.25) and those who usually had coverage (aOR: 0.38; 95% CI 0.28, 0.51) had lower odds of experiencing perceived difficulties in obtaining care. The results indicate several enabling and need predictors of perceived access to mental health services--highlighting potential structural barriers to care access. Efforts to address access challenges should adopt a multifaceted approach and be tailored to families living in poverty, those with limited health coverage, and minoritized children with less than optimal general health.

Evaluation of Reliability Between Race and Ethnicity Data Obtained from Self-report Versus Electronic Health Record

INTRODUCTION

Disparities based on perceived race and ethnicity exist in all fields of medicine. Accurate data collection is crucial to addressing these disparities, yet few studies have evaluated the validity of data gathered. This study compares self-reported race and ethnicity data, considered the gold standard, with data documented in the electronic health record (EHR), to assess the validity of that data.

METHODS

Data from self-reported questionnaires was collected from adolescents admitted to a psychiatric inpatient unit from February 2019 to July 2022. Demographic questionnaires were self-administered as part of a larger battery completed during the admission process. Data was compared to demographic information collected from the hospital's EHR for the same patients and time.

RESULTS

In a sample of 1191 patients (ages 11-18, 61.9% female, 89% response rate), substantial agreement was observed for Hispanic ethnicity (κ = 0.64), while agreement for specific racial groups ranged from slight to substantial (κ = 0.10-0.63). In addition, it was noted that there was discrepancy between multiracial identification, with 17.1% of patients identifying as more than one race in self-reported data compared to 3.1% in EHR data.

CONCLUSIONS

The findings from this data set highlight the need for caution when using EHR data to draw conclusions about health disparities. It also suggests that the method of data collection meaningfully influences the responses patients provide. Addressing these challenges is essential for advancing equitable healthcare and mitigating disparities among patients.

Psychosocial Competencies Among Clinic-Referred and Community-Based Children: Known-Groups Validity of the Psychosocial Strengths Inventory for Children and Adolescents (PSICA)

Child psychosocial competencies protect against the development of psychopathology, ameliorate existing psychosocial problems, and predict positive long-term developmental cascades. Assessment of these competencies can improve identification of children in need of psychosocial services, enrich treatment planning, and improve treatment progress and outcome monitoring. Yet, appropriate measures are limited. One promising option is the Psychosocial Strengths Inventory for Children and Adolescents (PSICA), although its discriminative properties were formerly unknown. The present study evaluated the PSICA's sensitivity, specificity, and optimal cutoff scores with 228 youth (38 clinic-referred and 190 community-based youth with case-control matching) ages 2-10 years (Mage = 5.8, 71% boys, 77% White). Results indicated large, significant discrepancies, with clinic-referred youth rated as having less overall psychosocial competence overall and across domains of compliance, prosociality, and attention. Caregivers also reported significantly less satisfaction with the psychosocial competence of clinic-referred versus community youth. Discriminative accuracy of the PSICA's Frequency and Satisfaction scales, and its subscales, were good-to-excellent. Such discriminative accuracy and empirically derived, if preliminary, cutoff scores further support the PSICA as a pragmatic, psychometrically strong tool to screen children for referral into services, and potentiate future investigations into the PSICA's use in treatment planning and evaluation.

Racial/Ethnic Disparities in Psychiatric Traits and Diagnoses within a Community-based Sample of Children and Youth: Disparités raciales/ethniques dans les traits et diagnostics psychiatriques au sein d'un échantillon communautaire d'enfants et de jeunes

OBJECTIVE

Racial/ethnic disparities in the prevalence of psychiatric disorders have been reported, but have not accounted for the prevalence of the traits that underlie these disorders. Examining rates of diagnoses in relation to traits may yield a clearer understanding of the degree to which racial/ethnic minority youth in Canada differ in their access to care. We sought to examine differences in self/parent-reported rates of diagnoses for obsessive-compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders after adjusting for differences in trait levels between youth from three racial/ethnic groups: White, South Asian and East Asian.

METHOD

We collected parent or self-reported ratings of OCD, ADHD and anxiety traits and diagnoses for 6- to 17-year-olds from a Canadian general population sample (Spit for Science). We examined racial/ethnic differences in trait levels and the odds of reporting a diagnosis using mixed-effects linear models and logistic regression models.

RESULTS

East Asian (N = 1301) and South Asian (N = 730) youth reported significantly higher levels of OCD and anxiety traits than White youth (N = 6896). East Asian and South Asian youth had significantly lower odds of reporting a diagnosis for OCD (odds ratio [OR]East Asian = 0.08 [0.02, 0.41]; ORSouth Asian = 0.05 [0.00, 0.81]), ADHD (OREast Asian = 0.27 [0.16, 0.45]; ORSouth Asian = 0.09 [0.03, 0.30]) and anxiety (OREast Asian = 0.21 [0.11, 0.39]; ORSouth Asian = 0.12 [0.05, 0.32]) than White youth after accounting for psychiatric trait levels.

CONCLUSIONS

These results suggest a discrepancy between trait levels of OCD, ADHD and anxiety and rates of diagnoses for East Asian and South Asian youth. This discrepancy may be due to increased barriers for ethnically diverse youth to access mental health care. Efforts to understand and mitigate these barriers in Canada are needed.

Disparities in accessing specialty behavioral health services during the COVID-19 pandemic and why we need pediatric integrated primary care

Objective

Youth unmet behavioral health needs are at public health crisis status and have worsened since the onset of the coronavirus disease 2019 pandemic (Covid-19). Integrating behavioral health services into pediatric primary care has shown efficacy in addressing youth behavioral health needs. However, there is limited guidance on facilitating equitable access to care in this setting, including in triaging access to co-located services (i.e., onsite outpatient behavioral health services with only the behavioral health provider) or to specialty behavioral health services in other clinics within larger health systems.

Methods

A retrospective, comparative study was conducted to examine variability in access to co-located and specialty behavioral health (SBH) services for a pre-Covid-19 cohort (April 2019 to March 2020; n = 367) and a mid-Covid-19 cohort (April 2020 to March 2021; n = 328), while accounting for integrated primary care consultation services. The sample included children 1-18 years old served through a large, inner-city primary care clinic. Logistic regression models were used to examine the association between scheduled and attended co-located and SBH visits, pre- and mid-Covid-19 effects, and sociodemographic factors of race and ethnicity, language, health insurance (SES proxy), age, and sex.

Results

The majority of youth were not directly scheduled for a co-located or SBH visit but the majority of those scheduled attended their visit(s). The odds of not being directly scheduled for a co-located or SBH visit were greater for the mid-Covid-19 cohort, Black youth, and older youth. Accounting for integrated primary care consultation visits addressed these disparities, with the exception of persisting significant differences in scheduled and attended co-located and SBH visits for Black youth even while accounting for IPC consultation.

Implication

Findings from the current study highlight the effective role of integrated primary care consultation services as facilitating access to initial behavioral health services, especially given that referrals to integrated primary care co-located and SBH services within the larger health system often involve barriers to care such as longer wait-times and increased lack of referral follow through. Ongoing research and equitable program development are needed to further this work.

Racial-Ethnic Discrimination and Early Adolescents' Behavioral Problems: The Protective Role of Parental Warmth

OBJECTIVE

The purpose of the study was to investigate the association between discrimination by multiple sources (ie, teachers, students, and other adults) and early adolescents' behavioral problems (ie, internalizing, externalizing, and attention problems), also considering the protective role of parental warmth in the association.

METHOD

Cross-sectional analyses were conducted with 3,245 early adolescents of color obtained from the Adolescent Brain Cognitive Development Study (ABCD Study) at year 1 follow-up (Y1), a large and diverse sample of children (mean age = 9.48 years) in the United States. Racially-ethnically minoritized adolescents reported sources of discrimination, parental warmth, and symptoms of psychopathology. Regression with interaction terms was conducted to investigate the associations among sources of discrimination, parental warmth, and behavioral problems among racially-ethnically minority adolescents. Sensitivity analyses were conducted to examine (1) race/ethnicity and sex/gender variations; (2) whether the associations between different sources of discrimination and behavioral problems were reliably different; and (3) effects of discrimination, parental warmth, and their interplay at Y1 in predicting adolescents' behavioral problems at year 2 follow-up.

RESULTS

Early adolescents experiencing interpersonal racial-ethnic discrimination by multiple sources, including teachers, students, and other adults, reported higher levels of attention, internalizing, and externalizing problems. Parental warmth was protective for the association between interpersonal racial-ethnic discrimination and early adolescents' behavioral problems.

CONCLUSION

Experiencing interpersonal racial-ethnic discrimination from teachers, peers, and other adults is related to heightened attention, internalizing, and externalizing problems among racially-ethnically minoritized early adolescents. Parental warmth may reduce the risk of developing behavioral problems among early adolescents who experience interpersonal racial-ethnic discrimination from students, teachers, and other adults outside of school.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. One or more of the authors of this paper received support from a program designed to increase minority representation in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. We actively worked to promote sex and gender balance in our author group. While citing references scientifically relevant for this work, we also actively worked to promote sex and gender balance in our reference list.

The State School Mental Health Profile: Findings from 25 States

BACKGROUND

State-level leadership and conditions are instrumental to local and regional comprehensive school mental health system (CSMHS) quality, sustainability, and growth. However, systematic documentation of state-level school mental health (SMH) policy, infrastructure, funding, and practice is limited.

METHODS

Using a multi-phase, multi-method process, we developed the State School Mental Health Profile (State Profile) to offer a comprehensive landscape of state SMH efforts. State leaders in 25 states completed the State Profile once over a 3-year data collection period. Mixed methods results are reported in 8 domains.

RESULTS

State education agencies were reportedly most involved in SMH technical assistance, advocacy, leadership, funding, and service provision, with mental health agencies reported as second most involved. Nearly half of state respondents reported having a state-level SMH director or coordinator. Policies with the greatest perceived impact require implementation of and funding for SMH services and supports. Despite leveraging multiple sources of funding, most states emphasized lack of funding as a primary barrier to establishing CSMHSs. All states reported staffing shortages.

CONCLUSION

The State Profile can assist multi-agency state leadership teams to self-assess policy, infrastructure, and resources to support CSMHSs statewide. Findings point to areas of opportunity to advance equity across resource allocation, service provision, and policy development.

Parent-Led Cognitive Behavioral Teletherapy for Anxiety in Autistic Youth: A Randomized Trial Comparing Two Levels of Therapist Support

Parent-led cognitive behavioral therapy (CBT) is an efficient, promising form of therapy that may be well suited for autistic youth with anxiety disorders, though to date it has been minimally tested. In this study, 87 autistic youth (7 to 13 years old) with anxiety disorders and their parents were randomized to two forms of parent-led CBT in which parents led their child through a guided CBT workbook across 12 weeks: one with low therapist contact (four 30-minute telehealth calls), and one with standard therapist contact (ten 60-minute telehealth calls). Anxiety, functional impairment, and autism features significantly declined across therapy, without differences between groups. High satisfaction was reported in both groups, though significantly higher satisfaction ratings were reported in standard-contact CBT. Responder rates were 69% of completers at posttreatment (70% in standard contact, 68% in low contact) and 86% at 3-month follow-up (86% in standard contact, 87% in low contact). Low-contact CBT was estimated to incur an average cost of $755.70 per family compared with $1,978.34 in standard-contact CBT. Parent-led CBT with minimal or standard therapist contact both appear to be effective CBT delivery formats for autistic youth with anxiety disorders, with significant cost savings for low-contact CBT.

Factors Associated With Prolonged Mental Health Admissions at US Children's Hospitals

BACKGROUND AND OBJECTIVES

Mental health (MH) hospitalizations at medical hospitals are associated with longer length of stay (LOS) compared with non-MH hospitalizations, but patient factors and costs associated with prolonged MH hospitalizations are unknown. The objective of this paper is to assess patient clinical and demographic factors associated with prolonged MH hospitalizations and describe variation in MH LOS across US children's hospitals.

METHODS

We studied children aged 5 to 20 years hospitalized with a primary MH diagnosis during 2021 and 2022 across 46 children's hospitals using the Pediatric Health Information System database. Generalized estimating equations, clustered on hospital, tested associations between patient characteristics with prolonged MH hospitalization, defined as those in the 95th percentile or above (>14 days).

RESULTS

Among 42 654 primary MH hospitalizations, most were aged 14 to 18 (62.4%), female (68.5%), and non-Hispanic white (53.8%). The most common primary MH diagnoses were suicide/self-injury (37.4%), depressive disorders (16.6%), and eating disorders (10.9%). The median (interquartile range) LOS was 2 days (1-5), but 2169 (5.1%) experienced a hospitalization >14 days. In adjusted analyses, race and ethnicity, category of MH diagnosis, and increasing medical and MH complexity were associated with prolonged hospitalization.

CONCLUSIONS

Our results emphasize several diagnoses and clinical descriptors for targeted interventions, such as behavioral and inpatient MH resources and discharge planning. Expanded investment in both community and inpatient MH supports have the potential to improve health equity and reduce prolonged MH hospitalizations.

Assessing Access to Trauma-Informed Outpatient Mental Health Services for Adolescents: A Mystery Shopper Study

OBJECTIVE

The authors aimed to examine how access to trauma-informed mental health services in safety-net health centers varies by insurance type and race-ethnicity of the care seeker.

METHODS

In this mystery shopper study, three women (White, Latina, and Black voice actresses) called community mental health centers (CMHCs) and federally qualified health centers (FQHCs) (N=229) in Cook County, Illinois, posing as mothers requesting a mental health appointment for their traumatized adolescent child. Each health center was called twice-once in the spring and once in the summer of 2021-with alternating insurance types reported (Medicaid or private insurance). Ability to schedule an appointment, barriers to access, wait times, and availability of trauma-specific treatment were assessed.

RESULTS

Callers could schedule an appointment in only 17% (N=78 of 451) of contacts. Reasons for appointment denial varied by organization type: the primary reasons for denial were capacity constraints (67%) at CMHCs and administrative requirements to switch to in-network primary care providers (62%) at FQHCs. Insurance and organization type did not predict successful appointment scheduling. Non-White callers were significantly less likely (incidence rate ratio=1.18) to be offered an appointment than the White caller (p=0.019). The average wait time was 12 days; CMHCs had significantly shorter wait times than FQHCs (p=0.019). Only 38% of schedulers reported that their health center offered trauma-informed therapy.

CONCLUSIONS

Fewer than one in five contacts resulted in a mental health appointment, and an apparent bias against non-White callers raises concern that racial discrimination may occur during scheduling. For equitable access to care, antidiscrimination policies should be implemented.

Disparities by Race and Ethnicity in Inpatient Hospitalizations Among Autistic Adults

This study examined hospitalizations in a large, all-payer, nationally representative sample of inpatient hospitalizations in the US and identified differences in rates of hospitalization for conditions by race and ethnicity in autistic adults. Conditions examined included mood disorders, epilepsy, schizophrenia, and ambulatory care sensitive conditions (ACSCs). Compared to white, non-Hispanic autistic adults, Black, Hispanic, Asian or Pacific Islander (API), and autistic adults of another race had lower prevalence of admission for a principal diagnosis of a mood disorder. Conversely, Black, Hispanic, API, and autistic adults of another race had higher odds of admission for epilepsy than white autistic adults. Black and Hispanic autistic adults were more likely to have schizophrenia as a principal diagnosis compared to white autistic adults, but only Black autistic adults had increased odds for admission for an ACSCs compared to white autistic adults. Differences in diagnosis prevalence among hospitalized autistic adults may suggest differential access to comprehensive outpatient care that could prevent such hospitalizations, while also pointing to concerns of differential validity of diagnostic tools and treatment approaches. Insurance policy and programs should prioritize optimizing outpatient care to ensure access to care and emphasize the need for equitable treatment.

Differences in schizophrenia treatments by race and ethnicity-analysis of electronic health records

Racial disparities in prescriptions of anti-psychotics have been highlighted before. However, (i) the evidence on other medications, including anti-depressant or mood stabilizing medications is lacking, and (ii) the role of potentially confounding factors and (iii) specificity of such disparities to schizophrenia (SCZ), are still unknown. We used electronic health records (EHRs) from 224,212 adults to estimate the odds ratios of receiving a prescription for different nervous system medications among patients with SCZ of different race/ethnicity, and analogous linear models to investigate differences in prescribed medication doses. To verify specificity of the observed patterns to SCZ, we conducted analogous analyses in depression and bipolar disorder (BD) patients. We found that Black/African American (AA) and Hispanic patients with SCZ were more likely to be prescribed haloperidol (Black/AA: OR = 1.52 (1.33-1.74); Hispanic: OR = 1.32 (1.12-1.55)) or risperidone (Black/AA: OR = 1.27 (1.11-1.45); Hispanic: OR = 1.40 (1.19-1.64)), but less likely to be prescribed clozapine (Black/AA: OR = 0.40 (0.33-0.49); Hispanic: OR = 0.45 (0.35-0.58)), compared to white patients. There were no race/ethnicity-related differences in the prescribed medication doses. These patterns were not specific to SCZ: Asian, Hispanic and Black/AA patients with BD or depression were more likely to be prescribed anti-psychotics, but less likely to be prescribed antidepressants or mood-stabilizers. In conclusion, we found racial/ethnic disparities in the medications prescribed to patients with SCZ and other psychiatric conditions. We discuss the potential implications for the quality of care for patients of diverse races/ethnicities.

Differential Risk: Gender and Racial Differences in the Relationship between Trauma, Discrimination, and Schizotypy

Traumatic experiences are associated with increased experiences of positive schizotypy. This may be especially important for People of Color, who experience higher rates of trauma and racial discrimination. No study to date has examined how racial disparities in traumatic experiences may impact schizotypy. Furthermore, of the studies that have examined the relationship between trauma and schizotypy, none have examined racial discrimination as a potential moderator. The present study examined if racial discrimination moderates the relationship between trauma and multidimensional (positive, negative, and disorganized) schizotypy. In a sample of 770 college students, we conducted chi-squared analyses, analyses of variance, and stepwise regressions. We found that Black students experienced significantly higher racial discrimination and trauma than Latinx and Asian students. Furthermore, Black and Latinx students experienced significantly more multidimensional schizotypy items than Asian students. Trauma and racial discrimination explained 8 to 23% of the variance in each dimension of schizotypy. Racial discrimination did not moderate the relationships between trauma and multidimensional schizotypy. Our findings suggest that we need to examine risk factors that may prevent recovery from psychotic disorders. Additionally, disorganized schizotypy showed the most robust associations and may be a critical site of intervention.

Implementing trauma-informed care in a special education setting: An initial exploration of a multi-tiered model

Implementing trauma-informed care in a special education environment serving youth from historically marginalized communities with high levels of exposure to potentially traumatic events (PTEs) requires a systematic tiered approach consistent with public health guidelines. Little is known about the implementation of this framework in special education settings where youth have significant emotional and behavioral difficulties. To address this need, a consultant-community partnership was forged between a hospital providing mental health services and a therapeutic day school that serves a special education cooperative. The current case study explores the design and implementation of a three-tiered model of trauma-informed care in a special education setting. This study will address the specific practices implemented at each tier, discuss successes and challenges, and summarize future directions for research, practice, and policy.

Racial and ethnic trends in mental health service utilisation and perceived unmet need in the USA

BACKGROUND

Two decades ago, the Surgeon General issued a report highlighting concerning disparities in mental healthcare among racial and ethnic minority populations. The present study characterised national trends in mental health treatment utilisation by race and ethnicity across a 13-year period.

METHODS

Nationally representative data were drawn from the National Survey on Drug Use and Health from 2008 through 2020 (unweighted n=4 41 993). Trends in mental health treatment utilisation and perceived unmet treatment need among individuals with and without psychiatric illness were stratified by race and ethnicity.

RESULTS

Logistic regression analyses revealed most racial/ethnic minority groups were less likely to receive treatment than white individuals, regardless of mental health status. Treatment utilisation increased among those with (annual per cent change (APC)=0.83, 95% CI=0.41 to 1.26) and without psychiatric illness (APC=1.39, 95% CI=0.53 to 2.26). Among individuals with psychiatric illness, treatment use increased among white (APC=0.88, 95% CI=0.51 to 1.24), Hispanic (APC=2.12, 95% CI=0.70 to 3.57) and black adults (APC=1.07, 95% CI=0.11 to 2.04). White (APC=1.88, 95% CI=0.86 to 2.91) and Hispanic (APC=2.45, 95% CI=0.02 to 4.93) individuals without psychiatric illness also saw increased treatment use. Although increases in perceived unmet treatment need were observed for all racial and ethnic groups except blacks and Native Americans with psychiatric illness, rates remained low across all groups.

CONCLUSIONS

Although national rates of mental health treatment utilisation have risen, this was almost entirely observed among white and Hispanic individuals with and without psychiatric illness, highlighting the limited progress made towards eliminating disparities in care.

Suicide prevention programming across ecological levels: Recommendations from Latinx immigrant origin youth and their parents

INTRODUCTION

Latinx immigrant-origin youth (IOY) have unique risks for suicidal thoughts and behaviors. It has been suggested that these risks should be addressed from an ecological perspective, addressing cultural and family context as well as structural and systemic barriers to prevention. This study sought to explore perspectives of immigrant-origin Latinx adolescents and their caregivers on suicide and its prevention, including the potential impact of stressors specific to immigrant status.

METHOD

Focus groups were conducted in 2018-2019 with Latinx immigrant-origin caregivers (N = 41, 97.5% female) and adolescents (ages = 14-19, N = 56, 50% female). Participants were recruited from community-based organizations in two different cities. A codebook approach to thematic analysis was used to identify themes, which were subsequently mapped onto levels of the Center for Disease Control's Social-Ecological Framework for Violence Prevention.

RESULTS

Participants identified both contributors to suicidal behavior and potential components of prevention programming across ecological levels. Specific recommendations for suicide prevention included engaging in recreation, parenting education and support, enhancing academic supports for adolescents, and enhancing school-family communication. Structural barriers (e.g., caregiver work schedules) to implementing recommendations were described.

DISCUSSION

Our results highlight the potential role of access to school and community-based supports as public health-oriented suicide prevention strategies and suggest a need to address barriers faced by immigrant families in accessing these supports alongside addressing barriers to mental health treatment. Policies impacting immigrant families' financial stability and increasing the availability of recreational and academic opportunities may promote mental health and prevent suicidal thoughts and behavior among IOY. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Perceived Parent Needs for Improving Parent Participation in School-Based Therapies for Children with Disabilities Using the Parent-Therapist Partnership Survey

Rehabilitative and habilitative therapies can help children with disabilities increase independence and overall wellbeing. However, children and their caregivers face many barriers to accessing these therapies and often rely on the school for therapy access. Given the limited resources available within the special education system, increasing parent involvement in special education therapies could improve service delivery. However, providers must first understand what parents need to participate in therapies before attempting to engage families. 217 parents completed an online survey consisting of the Parent-Therapist Partnership Survey and demographic questionnaires about theirfamiliesand their child[ren] with disabilities. The percentage of needs parents endorsed as important and thepercentageofimportantneedsendorsedasunmetwere calculated. Differences across demographic variables were assessed. Overall, parents reported an average of 75% of needs as important with significantly more needs endorsed as important regarding being an informed, engaged member of the child's care team (M = 83%) than needs related to support and guidance (M = 65%, p < 0.001). Furthermore, parentsreportedan average of 58% of important needs as unmet, with no significant differences in subscale averages. Significant associations were found for race/ethnicity, education, income, partner availability, number of children with disabilities in the household, transportation access, neighborhood opportunities, parent efficacy and social, emotional, and behavioral concerns. Parents reported a high percentage of needs as important, but a large percentage of these important needs were considered unmet. Significant disparities based on racial/ethnic identities and access to resources were found. In order to successfully engage parents in special education therapy activities, providers must work to understand and address parents' engagement needs, paying special attention to each family's unique circumstances to optimize engagement.

The next generation of developmental psychopathology research: Including broader perspectives and becoming more precise

The current Special Issue marks a major milestone in the history of developmental psychopathology; as the final issue edited by Cicchetti, we have an opportunity to reflect on the remarkable progress of the discipline across the last four decades, as well as challenges and future directions for the field. With contemporary issues in mind, including rising rates of psychopathology, health disparities, and international conflict, as well as rapid growth and accessibility of digital and mobile technologies, the discipline of developmental psychopathology is poised to advance multidisciplinary, developmentally- and contextually- informed research, and to make substantial progress in supporting the healthy development of individuals around the world. We highlight key future directions and challenges for the next generation of developmental psychopathology research including further investigation of culture at multiple levels of analysis, incorporation of macro-level influences into developmental psychopathology research, methods advances to address heterogeneity in translational research, precision mental health, and the extension of developmental psychopathology research across the lifespan.

Gestational diabetes mellitus and risk of neurodevelopmental disorders in young offspring: does the risk differ by race and ethnicity?

BACKGROUND

Previous studies examined the associations of gestational diabetes mellitus with autism spectrum disorder and attention deficit hyperactivity disorder. However, the associations between gestational diabetes mellitus and other neurodevelopmental disorders, such as the common speech/language disorder and developmental coordination disorder, are rarely studied, and whether the associations vary by race/ethnicity remains unknown.

OBJECTIVE

This study aimed to examine the associations of gestational diabetes mellitus with individual neurodevelopmental disorders in young offspring, and to investigate whether the associations vary by race/ethnicity.

STUDY DESIGN

This retrospective cohort study (Glucose in Relation to Women and Babies' Health [GrownB]) included 14,480 mother-offspring pairs in a large medical center in the United States from March 1, 2013 to August 31, 2021. We ascertained gestational diabetes mellitus using the validated ICD (International Classification of Diseases) codes (ICD-9: 648.8x; ICD-10: O24.4x), and identified neurodevelopmental disorders (speech/language disorder, developmental coordination disorder, autism spectrum disorder, and other neurodevelopmental disorders [attention deficit hyperactivity disorder, behavioral disorder, intellectual disability, and learning difficulty]) and their combinations using validated algorithms. We compared the hazard of neurodevelopmental disorders during the entire follow-up period between offspring born to mothers with and without gestational diabetes mellitus using multivariable Cox regression models.

RESULTS

Among all mothers, 19.9% were Asian, 21.8% were Hispanic, 41.0% were non-Hispanic White, and 17.3% were of other/unknown race/ethnicity. During the median follow-up of 3.5 years (range, 1.0-6.3 years) after birth, 8.7% of offspring developed at least 1 neurodevelopmental disorder. Gestational diabetes mellitus was associated with a higher risk of speech/language disorder (adjusted hazard ratio, 1.59 [95% confidence interval, 1.07-2.35]), developmental coordination disorder (2.36 [1.37-4.04]), autism spectrum disorder (3.16 [1.36-7.37]), other neurodevelopmental disorders (3.12 [1.51-6.47]), any neurodevelopmental disorder (1.86 [1.36-2.53]), the combination of speech/language disorder and autism spectrum disorder (3.79 [1.35-10.61]), and the combination of speech/language disorder and developmental coordination disorder (4.22 [1.69-10.51]) among offspring born to non-Hispanic White mothers. No associations between gestational diabetes mellitus and any neurodevelopmental disorders or their combinations were observed among offspring born to mothers of other racial/ethnic groups.

CONCLUSION

We observed an elevated risk of neurodevelopmental disorders among young offspring born to non-Hispanic White mothers with gestational diabetes mellitus, but not among other racial/ethnic groups.

The Built Environment and Pediatric Health

Buildings, parks, and roads are all elements of the "built environment," which can be described as the human-made structures that comprise the neighborhoods and communities where people live, work, learn, and recreate (https://www.epa.gov/smm/basic-information-about-built-environment). The design of communities where children and adolescents live, learn, and play has a profound impact on their health. Moreover, the policies and practices that determine community design and the built environment are a root cause of disparities in the social determinants of health that contribute to health inequity. An understanding of the links between the built environment and pediatric health will help to inform pediatricians' and other pediatric health professionals' care for patients and advocacy on their behalf. This technical report describes the range of pediatric physical and mental health conditions influenced by the built environment, as well as historical and persistent effects of the built environment on health disparities. The accompanying policy statement outlines community design solutions that can improve pediatric health and health equity, including opportunities for pediatricians and the health care sector to incorporate this knowledge in patient care, as well as to play a role in advancing a health-promoting built environment for all children and families.

Assessment and management of anxiety and depression in a pediatric high-risk asthma clinic

OBJECTIVE

The aims of this study were to determine the prevalence of positive mental health (MH) screens in a pediatric high-risk asthma (HRA) clinic population, and to determine the success rate of engagement in MH services before and after adding a clinical psychologist to our multidisciplinary clinic.

HYPOTHESIS

We hypothesized that the HRA population would have a higher prevalence of anxiety/depression symptoms than that previously reported for the general pediatric asthma population. We anticipated that the presence of an embedded psychologist in HRA clinic would facilitate successful connection to MH services.

METHODS

Pediatric patients in the HRA clinic were prospectively screened for anxiety and depression using validated screening instruments. Positive scores were referred for MH services. Time to MH service engagement was recorded before and after the addition of a clinical psychologist.

RESULTS

A total of 186 patients were screened; 60% had a positive MH screen. Female sex was associated with higher median scores on both screening tools and higher likelihood of engagement in MH services. After addition of a clinical psychologist, new engagement in MH services increased (20% vs. 80%, p < 0.0001), and median time to engagement decreased (14.5 vs. 0.0 months, p = 0.003).

CONCLUSION

There is a high prevalence of anxiety and depression in this pediatric HRA population. Success of engagement in MH services improved after a clinical psychologist joined our multidisciplinary team, suggesting access to care as a primary barrier to engagement.

Availability and Accessibility of Mental Health Services for Youth: A Descriptive Survey of Safety-Net Health Centers During the COVID-19 Pandemic

Community Mental Health Centers (CMHCs) and Federally Qualified Health Centers (FQHCs) are critical access points for families with adolescents needing mental health care, especially those enrolled in Medicaid. However, barriers exist which may reduce their accessibility. This study aims to describe the availability and accessibility of outpatient mental health services for children and adolescents at safety-net health centers in a large metropolitan county. Approximately one year after the COVID-19 pandemic began in the U.S., a comprehensive sample of 117 CMHCs and 117 FQHCs were called and administered a 5-minute survey. Approximately 10% of health centers were closed, and 20% (28.2% of FQHCs and 7.7% of CMHCs) reported not offering outpatient mental health services. Despite CMHCs having 5.4 more clinicians on staff on average, reported wait times were longer at CMHCs than FQHCs. These findings indicate that online directories intended to be a comprehensive and accessible resource, such as the SAMHSA Treatment Locator, are often inaccurate or out-of-date.