Ongoing Disparities in Digital and In-Person Access to Child Psychiatric Services in the United States

Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior

OBJECTIVE

To evaluate the prevalence, trends, and factors associated with psychotropic medication use and polypharmacy among children and adolescents initiating intensive behavioral therapy for severe challenging behavior over a 10-year period.

STUDY DESIGN

In this retrospective observational study, we examined data from caregiver interviews and patient medical records on the number and types of psychotropic medications prescribed to patients initiating intensive behavioral therapy between January 1, 2013, and December 31, 2022. Trends in medication use and polypharmacy across the 10-year period were analyzed using regression analysis, while differences in demographics and clinical factors for patients with use and polypharmacy were analyzed using nonparametric statistical analysis with odds ratios presented for significant factors.

RESULTS

Data from all 302 pediatric patients initiating intensive behavioral therapy across the 10-year period were analyzed. Among all patients and all years, 83.8% were taking at least 1 psychotropic medication and 68.2% experienced polypharmacy. There were no changes in the prevalence of use, mean number of medications taken, or polypharmacy across the 10-year period. Patients diagnosed with attention-deficit/hyperactivity disorder or anxiety disorder, as well as those exhibiting self-injurious behavior had higher use of psychotropic medication and polypharmacy and were taking more medications overall.

CONCLUSIONS

Psychotropic medication use and polypharmacy were extremely high for children and adolescents with severe challenging behavior, but use and polypharmacy did not change over the 10-year period of data collection. Further research is needed to establish the generality of these findings to other regions of the US.

Management of youth with suicidal ideation: Challenges and best practices for emergency departments

Suicide is a leading cause of death among youth, and emergency departments (EDs) play an important role in caring for youth with suicidality. Shortages in outpatient and inpatient mental and behavioral health capacity combined with a surge in ED visits for youth with suicidal ideation (SI) and self-harm challenge many EDs in the United States. This review highlights currently identified best practices that all EDs can implement in suicide screening, assessment of youth with self-harm and SI, care for patients awaiting inpatient psychiatric care, and discharge planning for youth determined not to require inpatient treatment. We will also highlight several controversies and challenges in implementation of these best practices in the ED. An enhanced continuum of care model recommended for youth with mental and behavioral health crises utilizes crisis lines, mobile crisis units, crisis receiving and stabilization units, and also maximizes interventions in home- and community-based settings. However, while local systems work to enhance continuum capacity, EDs remain a critical part of crisis care. Currently, EDs face barriers to providing optimal treatment for youth in crisis due to inadequate resources including the ability to obtain emergent mental health consultations via on-site professionals, telepsychiatry, and ED transfer agreements. To reduce ED utilization and better facilitate safe dispositions from EDs, the expansion of community- and home-based services, pediatric-receiving crisis stabilization units, inpatient psychiatric services, among other innovative solutions, is necessary.

Engaging primary care clinicians in the selection of implementation strategies for toddler social-emotional health promotion in community health centers

BACKGROUND

Social-emotional risk for subsequent behavioral health problems can be identified at toddler age, a period where prevention has a heightened impact. This study aimed to meaningfully engage pediatric clinicians, given the emphasis on health promotion and broad reach of primary care, to prepare an Implementation Research Logic Model to guide the implementation of a screening and referral process for toddlers with elevated social-emotional risk.

METHOD

Using an adaptation of a previously published community partner engagement method, six pediatricians from community health centers (CHCs) comprised a Clinical Partner Work Group. The group was engaged in identifying determinants (barriers/facilitators), selecting and specifying strategies, strategy-determinant matching, a modified Delphi approach for strategy prioritization, and user-centered design methods. The data gathered from individual interviews, two group sessions, and a follow-up survey resulted in a completed Implementation Research Logic Model.

RESULTS

The Clinical Partner Work Group identified 16 determinants, including barriers (e.g., patient access to electronic devices) and facilitators (e.g., clinician buy-in). They then selected and specified 14 strategies, which were prioritized based on ratings of feasibility, effectiveness, and priority. The highest-rated strategies (e.g., integration of the screener into the electronic health record) provided coverage of all identified barriers and comprised the primary implementation strategy "package" to be used and tested.

CONCLUSIONS

Clinical partners provided important context and insights for implementation strategy selection and specification to support the implementation of social-emotional risk screening and referral in pediatric primary care. The methodology described herein can improve partner engagement in implementation efforts and increase the likelihood of success. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Navigating healthier beverage consumption in adolescents using the "R-Ma Bot" chatbot: A usability and evaluation study

Objective

This pilot study aimed to evaluate the usability and effectiveness of a behavior change technique (BCT)-based chatbot developed to promote healthier beverage consumption among adolescents.

Methods

The Read and Manage your health roBot ("R-Ma Bot"), designed with 13 BCTs, was tested with 42 adolescents (13 men, 29 women, mean age 15.0 ± 0.7) for 2 weeks. Usability was assessed after the 2-week intervention using a chatbot usability questionnaire, recruitment, retention, participation, and engagement. Scores above 70 out of 100 were considered high usability. Qualitative data from open-ended questions were collected for evaluation. Effectiveness was measured by changes in knowledge, use and impact of nutrition labels, and weekly consumption of sugar, sodium, and caffeine from carbonated and/or energy drinks before and after the 2-week intervention.

Results

The score of R-Ma Bot's usability averaged 74.7, with participants addressing it useful, friendly, and easy to use, though they suggested improving unnatural conversation flow. All participants engaged with the chatbot for at least 13 out of 14 days, with over half using it daily for the entire period. After intervention, awareness of nutrition labels increased from 64.3% to 92.9%, and nonreaders decreased from 42.9% to 16.7%. Weekly sugar intake from beverages significantly decreased by 60%, from 13.1 ± 20.1 mg to 7.9 ± 12.8 mg.

Conclusions

R-Ma Bot's high usability contributed to high retention and behavioral changes, significantly reduced sugar consumption from beverages and improved awareness of nutrition labels. We suggest integrating strategies that enhance knowledge, motivation, and opportunities through BCTs with youth-friendly design elements in the development of interventions for adolescents.

The relationship between health and housing in low-income older adults: A secondary analysis of survey data

OBJECTIVE

To examine the health-housing relationship in low-income older adults, and differences by income and receipt of housing assistance.

DESIGN

Secondary analysis of longitudinal survey data.

SAMPLE

About 10,858 adults aged 62+ who completed at least one wave of the 2014 Survey of Income and Program Participation (SIPP) (n = 37,333 observations).

MEASUREMENTS

SIPP variables representing demographics and housing quality, affordability, stability, and neighborhood were analyzed. Low-income and higher-income participants were differentiated by the household income-to-poverty ratio.

RESULTS

Low-income participants were significantly more likely to be in poor health and report problems with housing quality, affordability, and neighborhood safety compared to higher-income participants (p < .001). Increased household size and problems with housing quality and neighborhood safety were associated with poor health in both groups (p < .05). Low-income participants who received housing assistance were significantly poorer, less healthy, and food insecure than participants not receiving assistance (p < .001); however, the health-housing relationship was not different in the two groups.

CONCLUSIONS

Results provide additional support for housing as a social determinant of older adult health. Though housing assistance programs reached a subset of low-income older adults, the results suggest a housing assistance shortfall. Implications for public health nurses and researchers are explored.

The Effects of Social Determinants of Health on Child and Family Mental Health: Implications of the COVID-19 Pandemic and Beyond

PURPOSE OF REVIEW

This review aims to expand understanding of the effect of SDOH on youth and family mental health outcomes. The review highlights significant findings from recent literature across SDOH categories (Economic Stability, Education Access/Quality, Health Care Access/Quality, Neighborhood/Built Environment, and Social/Community Context). This review also aims to demonstrate how the COVID-19 pandemic influences these effects.

RECENT FINDINGS

Economic instability (i.e., poverty, food insecurity) is associated with poorer MH outcomes. The COVID-19 pandemic limited access to mental health resources, including reduced opportunities for school-based mental health services and insurance barriers. Systemic factors, such as community violence and racism, exacerbate MH disparities. Policy decisions, especially those addressing poverty, can help youth and family exposures to SDOH, ACEs, and TS, which can help improve youth mental health outcomes at the population level. Findings on negative consequences of SDOH factors should be balanced with reporting findings of resiliency and other associated protective factors.

Pediatric Primary-Care Integrated Behavioral Health: A Framework for Reducing Inequities in Behavioral Health Care and Outcomes for Children

Nearly half of US children and adolescents will suffer a behavioral health (BH) disorder, with substantially higher rates among more disadvantaged children such as racial/ethnic minorities, LGBTQ + youth, and poor children. The current specialty pediatric BH workforce is inadequate to meet the need and the uneven distribution of specialists as well as other barriers to care, such as insurance coverage and systemic racism/bias, further exacerbate disparities in BH care and outcomes. Integrating BH care into the pediatric primary care medical home has the potential to expand access to BH care and reduce the disparities inherent in the current system.

Spatial Analysis of Access to Psychiatrists for US Military Personnel and Their Families

IMPORTANCE

Military service members and their families have greater mental health care needs compared with their civilian counterparts. Some communities have inadequate access to psychiatrists for this population.

OBJECTIVES

To identify geographic variations in the availability of military and civilian psychiatrists within a 30-minute driving time of TRICARE (the US military's health care program) beneficiaries' communities and compare the likelihood of living in areas with inadequate access to psychiatrists for historically underserved and other communities.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of all zip code communities in the continental US, Hawaii, and Alaska with at least one TRICARE beneficiary between January 1, 2016, and September 30, 2020, combines data from the Defense Health Agency, the National Plan and Provider Enumeration System, and the US Census to estimate a logistic regression to compare differences between communities with and without a psychiatrist shortage. Data were analyzed from September 2021 to November 2022.

MAIN OUTCOMES AND MEASURES

A community's likelihood of having a shortage of military and civilian psychiatrists within a 30-minute driving time and a community's likelihood of having no psychiatrists. Odds ratios were calculated to estimate likelihood of the outcomes.

RESULTS

This study includes 39 487 unique communities where 13% of the population is Black and 14% of the population is Hispanic. During the study period, 35% of TRICARE beneficiaries lived in communities with a shortage of both military and civilian psychiatrists, and 6% lived in communities with no access to military or civilian psychiatrists. Low-income communities with high income inequality were 1.64 (95% CI, 1.30-2.07) times more likely to have inadequate access to psychiatrists and 2.59 (95% CI, 1.82-3.69) times more likely to have no access to psychiatrists, compared with reference communities (average income without high income inequality); low-income communities without high income inequality were 1.37 (95% CI, 1.05-1.78) times more likely to have inadequate access to psychiatrists and 1.93 (95% CI, 1.28-2.89) times more likely to have no access to psychiatrists. Rural communities were 6.65 (95% CI, 5.09-8.69) times more likely to have inadequate access to psychiatrists than urban communities.

CONCLUSIONS AND RELEVANCE

In this cohort study of US communities, 35% of TRICARE beneficiaries lived in communities with inadequate access to psychiatrists. Psychiatric capacity was structurally inequitable along 2 separate dimensions: the income gradient and rurality. Developing targeted strategies for these shortage areas could alleviate disparities.

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.

Editorial: Disparities in Access to Child Psychiatric Services: Can We Shift the Landscape?

A National Academy of Medicine report published in 1993 defined disparities in health care as "a difference in access or treatment provided to members of different racial or ethnic groups that is not justified by the underlying health conditions or treatment preferences of the groups."¹ Disparities in access to and quality of mental health services have persisted for racially minoritized children and for many rural communities in the United States. The global pandemic has taken an enormous toll on the mental health and well-being of youth and their families and has exacerbated preexisting needs.² The rapid expansion of telehealth capacity, providing services via text, telephone, or video, has provided access to a spectrum of services for individuals and expert consultation for partners in low-resource communities. Telehealth has demonstrated effectiveness for lowering the barriers to seeking treatment in rural communities for youth with suicidality, depression, and anxiety.³ However, disenfranchised, low-income populations lacking sufficient in-person care or internet broadband to support telepsychiatry services or who encounter other barriers, such as underinsurance or no insurance and limited cultural and linguistic matched services, continue to have poor access to care and are at risk for disparate outcomes.⁴ In the midst of a pandemic and an accelerated child and adolescent mental health emergency in the United States, disparities in access to services presents a crisis within a crisis. Is the services landscape shifting to address the need?