Improving access to care and clinical outcome for pediatric behavioral problems: a randomized trial of a nurse-administered intervention in primary care

Evaluation of practice nurses' management of paediatric psychosocial problems in general practice

BACKGROUND

Child mental health services are under major pressure worldwide. In the Netherlands, Youth Mental Health Practice Nurses (YMHPNs) have been introduced in general practice to improve access to care. In this study, we evaluated care delivered by YMHPNs.

METHODS

We used medical records of a population-based cohort (21 717 children, 0-17 years). Characteristics of children consulting a YMHPN, type of problem, care delivered by YMHPNs and referrals were assessed using quantitative content analysis.

RESULTS

Records of 375 children (mean age 12.9 years, 59.2% girl) were analysed. These children were often in their adolescence (57.3% was between 13 and 17 years), and more often female than male (59.2% vs 40.8%). YMHPNs had a median of four consultations (IQR 2-7) with the child. YMHPNs managed a variety of psychosocial problems. YMHPNs managed 22.4% of children without need of referral, 52.0% were eventually referred for additional care. 13.3% of children dropped out during the treatment trajectory. In the remaining 12.3% of children, the treatment trajectory was stopped because the child was already attending specialized services, the treatment trajectory was still ongoing or the medical record was inconclusive.

CONCLUSIONS

YMHPNs successfully managed one in four children with psychosocial problems without need for referral. Nevertheless, most children were eventually referred for additional care.

Core Components and Implementation Determinants of Multilevel Service Delivery Frameworks Across Child Mental Health Service Settings

Multilevel service delivery frameworks are approaches to structuring and organizing a spectrum of evidence-based services and supports, focused on assessment, prevention, and intervention designed for the local context. Exemplar frameworks in child mental health include positive behavioral interventions and supports in education, collaborative care in primary care, and systems of care in community mental health settings. Yet, their high-quality implementation has lagged. This work proposes a conceptual foundation for multilevel service delivery frameworks spanning diverse mental health service settings that can inform development of strategic implementation supports. We draw upon the existing literature for three exemplar multilevel service delivery frameworks in different child mental health service settings to (1) identify core components common to each framework, and (2) to highlight prominent implementation determinants that interface with each core component. Six interrelated components of multilevel service delivery frameworks were identified, including, (1) a systems-level approach, (2) data-driven problem solving and decision-making, (3) multiple levels of service intensity using evidence-based practices, (4) cross-linking service sectors, (5) multiple providers working together, including in teams, and (6) built-in implementation strategies that facilitate delivery of the overall model. Implementation determinants that interface with core components were identified at each contextual level. The conceptual foundation provided in this paper has the potential to facilitate cross-sector knowledge sharing, promote generalization across service settings, and provide direction for researchers, system leaders, and implementation intermediaries/practitioners working to strategically support the high-quality implementation of these frameworks.

Changes Over Time in Outcomes of School-Age Children and Parents Receiving Integrated Mental Health Care in Federally Qualified Health Centers

OBJECTIVE

The purpose of this study is to understand change in parent-reported outcomes of mental health symptoms, health-related quality of life (QoL), and school-related functioning among children receiving mental health care at 3 federally qualified health centers engaging in a comprehensive pediatric mental health integration model.

METHODS

Trained personnel enrolled English- or Spanish-speaking families of 6- to 12-year-old children who had recently started receiving integrated mental health care and surveyed their parent/caregiver at 3 time points: entry into the cohort, 6-month follow-up, and 12-month follow-up (unique N = 51). Primary outcomes included validated measures of child symptoms, child health-related QoL, and child school-related functioning. Secondary outcomes focused on parental functioning and included validated measures of parental stress and depressive and internalizing symptoms. A multilevel mixed-effects generalized linear model was used to estimate the change in parent-reported outcomes over time, with inverse probability weights used to address attrition. Additional analyses were conducted to determine the degree to which changes in symptoms over time were associated with improvements in school-related functioning.

RESULTS

Over 12 months, children's mental health symptoms, health-related QoL, and school-related functional outcomes significantly improved. No changes in parental functioning were observed. In addition, improvements in mental health symptoms and health-related QoL were associated with improvements in school-related functional outcomes over time.

CONCLUSION

Findings demonstrate that outcomes of children who received integrated mental health care improved over time, both in regard to mental health and school functioning.

Carer perspectives of a transition to adult care model for adolescents with an intellectual disability and/or autism spectrum disorder with mental health comorbidities

BACKGROUND

Transition to adult care for adolescents with an intellectual disability and/or autism spectrum disorder with coexisting mental health disorders, often termed 'dual disability', is complex. It requires a family-centred approach, with collaboration among health, disability and social services and early planning.

AIM

To describe carer perspectives of transition to adult care and the outcomes of a transition support intervention, Fearless, Tearless Transition, for adolescents with dual disabilities piloted at a tertiary children's hospital.

METHODS

Carers of adolescents with a dual disability were invited to complete a survey at the commencement of their participation in the Fearless, Tearless Transition model, and again at the conclusion of the project. Within this intervention, carers and adolescents were encouraged to attend dedicated transition clinics and participate in a shared care general practitioner (GP) and paediatrician process.

RESULTS

One hundred and fifty-one carers of adolescents with dual disabilities were included in Fearless, Tearless Transition. Of this cohort, 138 adolescents and their carers received support in a dedicated transition clinic with 99 carers completing the initial survey at the commencement of the model. Eighty-two per cent of carers reported moderate to high levels of anxiety about transitioning from paediatric to adult care with 39% feeling 'unprepared' about transition. Eighty-one per cent reported having inadequate access to respite care with 47% reporting a lack of access to services in the community and 56% expressing dissatisfaction with their GPs. One hundred and two families participated in the shared care process with 80 GPs and 33 paediatricians. Twenty-two carers completed the second survey reporting a modest but significant improvement in preparedness for transition to adult care.

CONCLUSION

This study highlights the potential to improve transition outcomes for adolescents with dual disabilities and their carers through early, centralized transition planning, consistent methods of assessing adolescent and carer needs and shared care.

Antipsychotics in the Management of Disruptive Behavior Disorders in Children and Adolescents: An Update and Critical Review

Disruptive behaviour disorders (DBDs) in childhood include conduct disorder (CD) and oppositional defiant disorder (ODD). Though psychological therapies are considered to be the first-line treatment for DBDs, many patients require adjunctive pharmacotherapy for the control of specific symptoms, such as aggression. Three prior systematic reviews have examined the evidence for the use of antipsychotics in DBDs and have concluded that their efficacy is marginal and limited by adverse effects. This paper has two objectives: (i) to summarize the findings of existing systematic reviews of antipsychotics for the management of DBDs in children and adolescents (2012-2017), and (ii) to provide an update to these reviews by examining recent clinical trials of antipsychotics in this population, published in the period from 2 January 2017 to 10 October 2022. The PubMed, Scopus and ScienceDirect databases were searched for relevant citations using the search terms "disruptive behaviour disorder", "oppositional defiant disorder", "conduct disorder" and their variants, along with "antipsychotic", "atypical antipsychotic" and the generic names of all currently approved atypical antipsychotics. Six relevant trials were identified during this period, including five randomized controlled trials and one naturalistic open-label trial. These trials were critically evaluated in terms of outcome measures, efficacy and safety. Overall, the data from these trials suggests that of all available antipsychotics, risperidone appears to be effective in the short-term management of DBDs. All available antipsychotics are associated with significant metabolic adverse effects in this population. These results are discussed in the light of global trends towards increasing off-label prescription of antipsychotic medication in children and adolescents and of recent literature on the neuropharmacology of aggression in this patient population. The need for rational, short-term use of these drugs is highlighted, as well as the importance of post-marketing surveillance for long-term or severe adverse events.

Family-Based Prevention of Child Traumatic Stress

Most children experience potentially traumatic events, and some develop significant emotional and behavioral difficulties in response. Although the field has mainly focused on treatment, a prevention framework provides an alternate approach to reducing the public health burden of trauma. Because parents and families can affect children's trauma exposure and reactions, family-based preventive interventions represent a unique opportunity to address child traumatic stress. This article discusses family-based programs that address child traumatic stress across 3 categories: preventing children's exposure to traumatic events, preventing traumatic stress reactions following exposure, and preventing negative long-term sequelae of trauma.

Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial

BACKGROUND

Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms.

METHODS

We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life.

DISCUSSION

This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Revisiting caregiver satisfaction with children's mental health services in the United States

Nearly four decades ago, Unclaimed Children documented the gaps in the United States between mental health programs and caregivers’ perspectives about those services for their children. This absence of attention to parent or caregiver perspectives, including their satisfaction with these services, was a key finding of the report, which detailed system failure in caring for youth with mental health needs. Since then, the focus on caregiver satisfaction with children’s mental health services has been largely overlooked in research, and when examined has been mostly included as an indicator of the feasibility of program implementation. In striking contrast, overall healthcare system reforms have highlighted the importance of improving consumer’s direct experience of care. However, caregiver satisfaction remains largely disconnected to these overall health system reforms, even as reforms focus increasingly on value-based, coordinated and integrated care. In this paper, we review literature from 2010 to 2020, revisit the measurement of caregiver satisfaction, identify how and when it is being measured, and delineate a research agenda to both realign it with health system improvements, refine its focus on expectancies and appropriateness, and root it more firmly in the principles of user experience (UX) and human-centered design (HCD).

Co-located Parent Coaching Services Within Pediatric Primary Care: Feasibility and Acceptability

INTRODUCTION

This project assessed the feasibility and acceptability of Parent Connext, a positive parenting program that integrates screening and co-located parent coaching within pediatric primary care.

METHOD

Eleven practices implemented Parent Connext in phases between November 1, 2016, and July 31, 2019. Screening and surveillance for parenting and family psychosocial concerns were performed during patient visits. Providers responded with brief motivational interviewing and referral. Parenting Specialists provided individualized parent coaching to referred caregivers.

RESULTS

Screens were completed at 13,346 (65%) targeted visits, with 26% positive for concerns. Parent coaching was provided to 1,301 of 2,711 (48%) referred families (average 2.2 sessions per family). Providers and staff felt significantly more supported, confident, and knowledgeable about addressing parenting and family psychosocial concerns after implementing Parent Connext and felt the program improved their relationships with families and quality of care.

DISCUSSION

Co-located parent coaching was found to be a feasible and worthwhile addition to pediatric primary care.

Evaluation of a Web-Based ADHD Awareness Training in Primary Care: Pilot Randomized Controlled Trial With Nested Interviews

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting up to 5% of children and adults. Undiagnosed and untreated ADHD can result in adverse long-term health, educational, and social impacts for affected individuals. Therefore, it is important to identify this disorder as early as possible. General practitioners (GPs) frequently play a gatekeeper role in access to specialist services in charge of diagnosis and treatment. Studies have shown that their lack of knowledge and understanding about ADHD can create barriers to care.

OBJECTIVE

This pilot randomized controlled trial assesses the efficacy of a web-based psychoeducation program on ADHD tailored for GPs.

METHODS

A total of 221 participants were randomized to either a sham intervention control or an awareness training intervention and they completed questionnaires on ADHD knowledge, confidence, and attitude at 3 time points (preintervention, postintervention, and 2-week follow-up). Participants in the intervention arm were invited to participate in a survey and follow-up interview between 3 and 6 months after the intervention.

RESULTS

The responses of 109 GPs were included in the analysis. The knowledge (P<.001) and confidence (P<.001) of the GPs increased after the intervention, whereas misconceptions decreased (P=.04); this was maintained at the 2-week follow-up (knowledge, P<.001; confidence, P<.001; misconceptions, P=.03). Interviews and surveys also confirmed a change in practice over time.

CONCLUSIONS

These findings demonstrate that a short web-based intervention can increase GPs' understanding, attitude, and practice toward ADHD, potentially improving patients' access to care.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number ISRCTN45400501; http://www.isrctn.com/ISRCTN45400501.

A Systematic Review of External Validity in Pediatric Integrated Primary Care Trials

OBJECTIVE

We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to conduct a systematic review of external validity reporting in integrated primary care (IPC) interventions for mental health concerns.

METHODS

We searched Medline, CINAHL, PsycINFO, the Cochrane Center Register of Controlled Trials, and relevant literature to identify publications from 1998 to 2018 reporting on open, randomized, or quasi-randomized trials of IPC interventions that targeted child (ages 0-18 years) psychological symptoms. For each publication, we extracted the information reported in each RE-AIM domain and calculated the proportion of the total studies reviewed.

RESULTS

Thirty-nine publications describing 25 studies were included in the review. Publications rarely reported some indicators of external validity, including the representativeness of participants (12%), rate of adoption clinics or providers (16%), cost of implementation (8%), or evidence of maintenance (16%). Few studies reported on key pragmatic factors such as cost or organizational change processes related to implementation and maintenance. Strengths of some studies included comparisons of multiple active treatments, use of tailorable interventions, and implementation in "real world" settings.

CONCLUSIONS

Although IPC interventions appear efficacious under research conditions, there are significant knowledge gaps regarding the degree to which they reach and engage target recipients, what factors impact adoption and implementation of IPC interventions by clinicians, how fidelity can be maintained over time, and cost-effectiveness. Pediatric IPC researchers should embrace dissemination and implementation science methods to balance internal and external validity concerns moving forward.

Pediatric Anxiety in Practice: A Knowledge and Needs Assessment of Pediatricians and Nurses

OBJECTIVE

To assess pediatric primary care providers' (PCPs) knowledge, perceived barriers, and needs related to child and adolescent anxiety in their practice.

METHODS

Primary care providers licensed and practicing in the state of Colorado were invited to complete an online knowledge and needs assessment. The survey queried their knowledge of pediatric anxiety, experience in assessing and treating anxiety, perceived barriers in their practice setting to adequately addressing youth anxiety, and interest in additional training on this topic.

RESULTS

Survey completers included 115 PCPs (51 medical doctors and 64 nurses/nurse practitioners). PCPs had been practicing with their current medical license with pediatric patients for an average of 14 years (SD = 10.45), and 70% reported that they regularly discuss anxiety with patients and parents. Although PCPs had a basic knowledge of youth anxiety, there appeared to be significant gaps in PCP knowledge. Specifically, knowledge gaps included evidence-based assessment and treatment, how to differentiate between developmentally appropriate, transient episodes of anxiety versus anxiety disorders, and where and how to refer youth for specialty services. Nearly all (80%) PCPs indicated that they would be "extremely interested" in additional training in pediatric anxiety, particularly if it occurred in their organizational setting, at a nearby community setting, or online.

CONCLUSION

Primary care providers reported that a substantial proportion of the patients they see struggle with anxiety. PCPs also reported a growing need for training in how to assess, treat, and refer anxious youth. This needs assessment supports a need for the development of easily accessible training and resources for PCPs to better support their pediatric patients.

Effects of Collaborative Care for Comorbid Attention Deficit Hyperactivity Disorder Among Children With Behavior Problems in Pediatric Primary Care

This study evaluates the impact of a 6-month care management intervention for 206 children diagnosed with comorbid attention deficit hyperactivity disorder (ADHD) from a sample of 321 five- to 12-year-old children recruited for treatment of behavior problems in 8 pediatric primary care offices. Practices were cluster-randomized to Doctor Office Collaboration Care (DOCC) or Enhanced Usual Care (EUC). Chart reviews documented higher rates of service delivery, prescription of medication for ADHD, and titration in DOCC (vs EUC). Based on complex conditional models, DOCC showed greater acute improvement in individualized ADHD treatment goals and follow-up improvements in quality of life and ADHD and oppositional defiant disorder goals. Medication use had a significant effect on acute and follow-up ADHD symptom reduction and quality of life. Medication continuity was associated with some long-term gains. A collaborative care intervention for behavior problems that incorporated treatment guidelines for ADHD in primary care was more effective than psychoeducation and facilitated referral to community treatment.

How can adolescent aggression be reduced? A multi-level meta-analysis

Aggressive behaviour among adolescents has significant social and economic costs. Numerous attempts have been made to intervene to reduce aggression in adolescents. However, little is known about what factors enhance or diminish intervention effectiveness. The present systematic review and meta-analysis, therefore, seeks to quantify the effectiveness of interventions to reduce aggressive behaviour in adolescents and to identify when and for whom such interventions work best. Sixteen databases were searched for randomised controlled trials that assessed interventions to reduce aggression among adolescents. After screening 9795 records, 95 studies were included. A multi-level meta-analysis found a significant overall small-to-medium effect size (d = 0.28; 95% CI [0.17, 0.39]). More effective interventions were of shorter duration, were conducted in the Middle East, were targeted at adolescents with higher levels of risk, and were facilitated by intervention professionals. Potentially active ingredients were classified using the Behaviour Change Technique Taxonomy. Behavioural practice and problem solving were components of more effective interventions targeted at the general population. Overall the findings indicate that psychosocial interventions are effective in reducing adolescent aggression. Future trials need to assess the effect of individual techniques and their combination to identify the key components that can reduce aggression in adolescents.

Key Components of Effective Pediatric Integrated Mental Health Care Models: A Systematic Review

IMPORTANCE

Emerging evidence suggests that integrated care models are associated with improved mental health care access and outcomes for youths (children ≤12 years and adolescents 12-21 years) served in pediatric primary care settings. However, the key components of these complex models remain unexamined.

OBJECTIVE

To identify and describe the key components of effective pediatric integrated mental health care models.

EVIDENCE REVIEW

The PubMed, Embase, PsycINFO, and Cochrane Controlled Register of Trials electronic databases were searched for relevant peer-reviewed articles published between January 1, 1985, and April 30, 2019. Articles were restricted to those published in the English language. Eligible articles reported original data on youths 17 years or younger, implemented an integrated mental health care model in a pediatric primary care setting, and assessed the model's association with primary outcomes (eg, mental health symptom severity) and secondary outcomes (eg, functional impairment and patient satisfaction). Articles that specified some degree of systematic coordination or collaboration between primary care and mental health professionals were included in the final review. Two independent reviewers extracted data on study design, model type, model components, level of integration, and outcomes. Study quality was assessed using the Jadad scale. Data were analyzed between January 1, 2018, and May 31, 2019.

FINDINGS

Eleven randomized clinical trials involving 2190 participants were included. Three studies focused on youths with depression, 3 on youths with attention-deficit/hyperactivity disorder, and 5 on youths with behavioral disorders. Most studies (9 of 11) implemented either the collaborative care model (n = 3), a slightly modified version of the collaborative care model (n = 2), or colocated care (n = 4). The most commonly reported components of effective pediatric integrated mental health care models were population-based care, measurement-based care, and delivery of evidence-based mental health services; all 3 components were present in studies reporting clinical improvement of mental health symptoms. Other model components, such as treatment-to-target or team-based care, were common in studies reporting specific outcomes, such as functional impairment.

CONCLUSIONS AND RELEVANCE

This review is the first to date to systematically search and qualitatively synthesize information on the key components of effective pediatric integrated mental health care models. This knowledge may be especially useful for pediatric primary care administrators in the selection of an integrated care model for their setting.

The Improvement of Individually Defined Problem Behaviors During a Telephone-Assisted Self-Help Intervention for Parents of Pharmacologically Treated Children with ADHD

Background: This study examined change in individually defined problem behaviors during a telephone-assisted self-help (TASH) intervention for parents of children with attention-deficit/hyperactivity disorder (ADHD). Method: Parents of children with ADHD and functional impairment despite methylphenidate treatment participated in a 12-month TASH intervention (8 self-help booklets plus up to 14 counseling telephone calls). The severity of three individually defined target problems, of ADHD symptoms, and oppositional symptoms were rated at baseline and after 6 and 12 months; parental satisfaction with the intervention was assessed after 12 months. The problems were categorized according to the type of behavior and the disorder to which they were related (ADHD vs. oppositional symptoms). Results: Repeated measures analyses of variance revealed a significant decrease in problem severity during the intervention. The change in problem severity was greater than the change in ADHD and oppositional symptoms. Correlations between problem severity and symptom severity were low to moderate. Correlations between the change in problem severity and parental satisfaction were moderate. Discussion: The decrease in the individual problem severity during TASH is stronger than the decrease in ADHD and oppositional symptoms. Individually defined problems should be attended to in psychotherapy research to avoid underestimating the benefit of interventions by solely considering standardized measures.

Pediatric Integrated Care Models: A Systematic Review

Psychiatric disorders are becoming more frequently diagnosed within the pediatric primary care setting. Despite increased diagnosis within primary care, only a minority of patients receive further psychiatric or specialty care. The integrated/collaborative care treatment model was designed to improve access within primary care. The purpose of this review is to identify randomized controlled trials and quasi-experimental studies that have investigated whether increased access improves treatment engagement, satisfaction, and improved mental health outcomes. Six studies met inclusion criteria. Studies reviewed indicated increased access to behavioral health treatment through use of the integrated/collaborative care model and improved mental health outcomes. Recommendations for screening and treatment are provided. Limitations of the reviewed studies include lack of generalizability to urban populations, minority youth, and youth younger than 4 years of age. Practice recommendations to address these limitations are identified.

Identification and Utility of a Short Form of the Pediatric Symptom Checklist-Youth Self-Report (PSC-17-Y)

Abstract. The Pediatric Symptom Checklist-Youth self-report (PSC-Y) is a 35-item measure of adolescent psychosocial functioning that uses the same items as the original parent report version of the PSC. Since a briefer (17-item) version of the parent PSC has been validated, this paper explored whether a subset of items could be used to create a brief form of the PSC-Y. Data were collected on more than 19,000 youth who completed the PSC-Y online as a self-screen offered by Mental Health America. Exploratory factor analyses (EFAs) were first conducted to identify and evaluate candidate solutions and their factor structures. Confirmatory factor analyses (CFAs) were then conducted to determine how well the data fit the candidate models. Tests of measurement invariance across gender were conducted on the selected solution. The EFAs and CFAs suggested that a three-factor short form with 17 items is a viable and most parsimonious solution and met criteria for scalar invariance across gender. Since the 17 items used on the parent PSC short form were close to the best fit found for any subsets of items on the PSC-Y, the same items used on the parent PSC-17 are recommended for the PSC-Y short form.

Parents' Consumer Preferences for Early Childhood Behavioral Intervention in Primary Care

OBJECTIVE

Early childhood parenting interventions are increasingly delivered in primary care, but parental engagement with those interventions is often suboptimal. We sought to better understand parents' preferences for the content and delivery method of behavioral health guidance in pediatric primary care and to determine the relationship of those preferences with demographic characteristics, child behavior problems, and parenting style.

METHODS

Participants were 396 parents of young children recruited from primary care offices. We collected measures of parental preferences (including behavioral topics, intervention strategies, and methods of delivery) for behavioral intervention in primary care, child behavior symptoms, parenting style, and demographic characteristics. Descriptive statistics were used to identify parents' most preferred behavioral topics and intervention delivery methods. We used a hierarchical regression approach to determine whether parenting style predicted parents' preferences beyond demographic and child-level factors.

RESULTS

Nearly all parents (96%) endorsed a behavioral topic (e.g., aggression) as important. Most preferred to receive intervention during routine medical appointments. Child behavior problems correlated with parents' overall interest in behavioral guidance, but clinically significant symptoms did not differentiate interest in any single topic. Socioeconomic factors and negative parenting practices predicted some parental preferences. Notably, lax parenting generally predicted higher interest in behavioral intervention, whereas hostile and physically controlling parenting predicted lower interest.

CONCLUSION

Most parents are interested in behavioral guidance as part of primary care, but their preferences for the content and delivery of that guidance vary by known socioeconomic, child, and parenting risk factors. Tailoring intervention to parents' preferences may increase engagement with available interventions.

Impact of Stressful Climates on Provider Perceptions of Integrated Behavioral Health Services in Pediatric Primary Care: An Exploratory Study

OBJECTIVE

Pediatric primary care providers (PCPs) work in challenging environments and are increasingly called to implement complex interventions, such as behavioral health (BH) service integration. We explore how perceived stressful practice climates (1) change over time in and (2) influence provider perceptions of collaborative care versus usual care, 2 models of integrated BH care.

METHODS

Secondary exploratory analysis using hierarchical linear modeling was performed on an 18-month cluster-randomized trial of 8 pediatric primary care practices to Doctor-Office Collaborative Care (DOCC), where an on-site care manager delivered BH services in coordination with PCPs, or Enhanced Usual Care (EUC), where a care manager facilitated referrals to local BH providers. Various indicators of PCP perceptions of BH services, including satisfaction with practice, burdens and beliefs regarding psychosocial problems, and effectiveness in treating behavioral problems, were assessed as outcomes. Moderators were 2 domains of stressful climates, role conflict and role overload.

RESULTS

Role conflict and role overload stayed stable in both conditions. Role conflict strengthened the positive effect of DOCC on PCP perceived effectiveness in treating behavioral problems (β [SE], 0.04 [0.02]; p = 0.04) and improvement in managing oppositional/aggressive behavior (0.02 [0.01]; p = 0.02). Role overload strengthened the positive effect of DOCC on PCP-perceived improvement in managing attention-deficit hyperactivity disorder (0.03 [0.01]; p = 0.01). Stressful climates did not influence perceptions for EUC providers.

CONCLUSIONS

Providers experiencing more stressful practice climates developed more positive perceptions of collaborative care. This may encourage stressed providers to make effective practice changes and promote practice integration of BH services.

Collaborative Care to Improve Access and Quality in School-Based Behavioral Health

BACKGROUND

Collaborative care (CC) is a well-established approach for the delivery of accessible behavioral health services in integrated health care settings. Substantial evidence supports its effectiveness in improving the quality and outcomes of adult services, and growing research indicates utility with child and adolescent populations.

METHODS

To date, studies examining CC models for youth have focused exclusively on primary-care settings. Nevertheless, as the most common integrated service delivery setting for youth, the education sector is an equally important context for improving access to behavioral health services for children and adolescents.

RESULTS

We provide a narrative review of the literature on CC, describes the relevance of CC to schools, and details its alignment with contemporary movements in education and school-based behavioral health.

CONCLUSIONS

Potential adaptations of the CC model for use in schools are detailed to improve: (1) behavioral health service accessibility, (2) the capacity of schools to provide behavioral health services, and (3) school service effectiveness through use of evidence-based practices. Although little research has explored the applicability of CC in the education sector, the model holds potential promise to improve the quality and efficiency of school-based behavioral health services.

Collaborative care model for treatment of persistent symptoms after concussion among youth (CARE4PCS-II): Study protocol for a randomized, controlled trial

Background

Currently, there is limited evidence to guide intervention and service delivery coordination for youth who suffer a concussion and subsequently experience persistent post-concussive symptoms (PCS) (Lumba-Brown et al. JAMA Pediatr 172(11):e182853, 2018; Lumba-Brown A et al. JAMA Pediatr 172(11):e182847, 2018). We have developed a collaborative care intervention with embedded cognitive-behavioral therapy, care management, and stepped-up psychotropic medication consultation to address persistent PCS and related psychological comorbidities. The CARE4PCS-II study was designed to assess whether adolescents with persistent symptoms after sports-related concussion will demonstrate better outcomes when receiving this collaborative care intervention compared to a usual care (control) condition.

Methods/design

This investigation is a randomized comparative effectiveness trial to receive intervention (collaborative care) or control (usual care). Two hundred sports-injured male and female adolescents aged 11–18 years with three or more post-concussive symptoms that persist for at least 1 month but less than 9 months after injury will be recruited and randomized into the study. The trial focuses on the effects of the intervention on post-concussive, depressive, and anxiety symptoms measured 3, 6, and 12 months after baseline.

Discussion

The CARE4PCS II study is a large comparative effectiveness trial targeting symptomatic improvements in sports injured adolescents after concussion. The study is unique in its adaptation of the collaborative care model to a broad spectrum of primary care, sports medicine, and school settings. The investigation incorporates novel elements such as the delivery of CBT through HIPAA complaint video conferenceing technology and has excellent widespread dissemination potential should effectiveness be demonstrated.

Trial registration

ClinicalTrials.gov, NCT03034720. Registered on January 27, 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3662-3) contains supplementary material, which is available to authorized users.

A Descriptive Analysis of Long-Term Treatment with Adolescent-Aged Foster Youth

Foster youth experience a complex combination of psychological symptoms associated with the experience of abuse and/or neglect. Among adolescents, psychological challenges can be magnified by an increased likelihood of placement disruption once in foster care, longer stays in the system, and numerous barriers that impede access and use of mainstream psychological intervention. This manuscript relies on two studies to learn more about the experience of adolescent-aged foster youth who utilize long-term mental health services coordinated through A Home Within, a national nonprofit committed to reducing treatment barriers by asking licensed therapists to provide pro bono therapy "for as long as it takes." Study 1 evaluates 84 therapist interviews about client demographics, trauma history, and mental health symptoms in an effort to learn more about the concerns and experiences of adolescent-aged youth participating in treatment. Study 2 examines 30 pre/post interviews with therapists to understand outcomes associated with treatment completion, as well as to describe treatment practices. Findings support a need for continued investigation of long-term psychotherapeutic services with foster youth focused on the needs of youth accessing care and best treatment practices with this population of vulnerable youth.

Physician Utilization of a Universal Psychosocial Screening Protocol in Pediatric Primary Care

This study evaluated physicians' utilization of a universal psychosocial screening protocol within a pediatric primary care setting. Pediatricians (n = 20) adopted a multitiered screening algorithm using the Pediatric Symptom Checklist-17 (PSC-17) within well-child checkups (WCC) for children, ages 7 and 11 years. Descriptive analyses were performed to evaluate the initial 3 years of physician screening protocol implementation to: (1) determine frequency and proportion of use and (2) examine patient outcomes associated with accessing behavioral health care. Physicians frequently initiated the protocol, administering the PSC-17 within 3678 WCC encounters, with frequency progressively increasing over the 3-year period. Results highlighted elements of screener utilization, cost-effectiveness, screening algorithm fidelity, and prevalence of psychosocial concerns identified. Secondary implementation challenges were observed after initial screening, specific to implementation of prescribed follow-up procedures. Primary care behavioral health collaborations appear helpful for improving universal screening utilization and cost-effectiveness, and for ensuring children with psychosocial problems are identified early and directed to follow-up care as needed.

Promoção de parentalidade positiva nos cuidados de saúde primários: Formação de profissionais

Objetivo

Compreender o impacto de uma formação breve centrada em estratégias de parentalidade positiva e gestão do comportamento de crianças em idade pré-escolar no aconselhamento realizado por profissionais dos cuidados de saúde primários (CSP).

Método

Participaram 152 profissionais (e.g., enfermeiros, médicos, psicólogos) de unidades dos CSP do distrito de Coimbra, numa ação de formação com duração de nove horas. O nível de satisfação com a formação, as estratégias recomendadas aos pais antes e três meses após a formação e a necessidade de formação percecionada foram avaliados através de três Inventários de Autorreflexão e de um Ficha de Avaliação de Satisfação.

Resultados

Observaram-se níveis elevados de adesão à formação e de satisfação com os respetivos conteúdos e estratégias de ensino/aprendizagem. Os profissionais reportaram ter passado a aconselhar com mais frequência aos pais as estratégias de parentalidade positiva abordadas na formação e referiram a necessidade de formação adicional.

Conclusão

Ações de formação junto de profissionais dos CSP poderão contribuir para preencher uma importante lacuna ao nível da literacia em saúde mental, capacitando estes profissionais de primeira linha para darem uma resposta de maior qualidade e baseada em evidência a questões colocadas pelos pais relativas à gestão do comportamento dos seus filhos.

Utilization of Child Psychiatry Consultation Embedded in Primary Care for an Urban, Latino Population

OBJECTIVE

In a novel model of embedded primary care child psychiatry serving an urban Latino population, we examined determinants of successful referral and relationship between clinical need and service intensity.

METHODS

We conducted a chart review of referred patients from July 2013-March 2015. We used multiple logistic regressions controlling for confounders to identify determinants of successful referral. We examined the relationship between service intensity and clinical need using Poisson regression, adjusting for exposure time, age, sex, ethnicity, and language.

RESULTS

Seventy-four percent of patients completed an evaluation. Younger children (p=.0397) and those with a history of therapy (p=.0077) were more likely to make initial contact. The markers of clinical need included PSC-35 Global Scores (p=.0027) and number of psychiatric diagnoses (p=.0178) predicted number of visits.

CONCLUSIONS

Our findings support early referral to improve engagement, and provide initial evidence that embedded child psychiatry consultation is feasible and may increase access to care.

What the patient wants: Addressing patients' treatment targets in an integrative group psychotherapy programme

OBJECTIVES

Limited empirical attention has been devoted to individualized treatment objectives in intensive group therapy for personality dysfunction. This study investigated patients' ratings of distress associated with individual therapy goals - referred to as target object severity - in an intensive Evening Treatment Programme for patients with personality dysfunction.

DESIGN

Change in target objective severity was examined in a sample of 81 patients who completed treatment in an intensive, integrative group therapy programme.

METHODS

Correlation and regression analyses were used to examine associations between change in target object severity and patients' pre-treatment diagnosis, symptom distress, and treatment outcome expectancy, and between change in target objective severity and patients' ratings of group therapy process (group climate, therapeutic alliance, group cohesion). The relationship between change in target objective severity and longer-range life satisfaction was also examined in a subsample of patients who rated life satisfaction at follow-up.

RESULTS

While change in target objective severity was not significantly related to pre-treatment variables, significant associations were found with several aspects of group therapy process. Patients' experience of a highly engaged group climate was uniquely associated with improvement in target object severity. Such improvement was significantly related to longer-term life satisfaction after controlling for general symptom change.

CONCLUSION

The working atmosphere in group therapy contributes to patients' progress regarding individual treatment targets, and such progress is an important factor in later satisfaction. Attention to individualized treatment targets deserves further clinical and research attention in the context of integrative group therapy for personality dysfunction.

PRACTITIONER POINTS

This study found that patients attending an integrative group treatment programme for personality dysfunction experienced significant improvement in severity of distress related to individual treatment objectives. Improvement in severity of distress related to individual treatment objectives was uniquely associated with patients' experience of an engaged, collaborative working atmosphere. Improvement in individual target objective severity was associated with patients' ratings of overall life satisfaction, rated an average of 9 months following termination, after controlling for change in general symptom severity.

Integrated Pediatric Health Care in Pennsylvania: A Survey of Primary Care and Behavioral Health Providers

This study reports on a statewide survey of medical and behavioral health professionals to advance the knowledge base on the benefits and obstacles to delivering integrated pediatric health care. Surveys distributed in 3 statewide provider networks were completed by 110 behavioral health specialists (BHSs) and 111 primary care physicians (PCPs). Survey content documented their perceptions about key services, benefits, barriers, and needed opportunities related to integrated care. Factor analyses identified 8 factors, and other items were examined individually. We compared responses by specialty group (BHS vs PCP) and integrated care experience (no vs yes). The findings revealed differences across domains by specialty subgroup. In several cases, BHS (vs PCP) respondents, especially those with integrated care experience, reported lower benefits, higher barriers, and fewer resource requests. The implications of these results for enhancing care integration development, delivery, training, and research are discussed along with the study's limitations and empirical literature.

Pediatric integrated behavioral health service delivery models: Using a federal framework to assess levels of integration

OBJECTIVE

To assess the level of integration of pediatric integrated behavioral health service delivery models (IBHSDM) since it has not been well established.

DATA SOURCES

A systematic review of journal databases (e.g., PubMed) and Google searches was used to identify publications.

STUDY SELECTION

Studies were included if they examined children who were treated in an IBHSDM.

DATA EXTRACTION

The authors extracted data from studies and assessed them for level of integration using a federal conceptual framework.

DATA SYNTHESIS

Guided by PRISMA standards, the authors identified 40 journal articles that described 32 integrated delivery models. Five models (15.6%) were rated at integration level 1 or 2 (coordinated care), eight models (25%) were rated level 3 and five models (15.6%) were rated level 4 (co-located care), and fourteen models (43.8%) were rated level 5 or 6 (integrated care).

CONCLUSIONS

In general, it is assumed that more completely integrated care will result in higher quality care and reduced costs. Thirteen of the models described (40.6%) had levels of integration of 3 or lower that may be too low to produce desired effects on quality and cost. Future research should address potential barriers that impede the development of models with higher degrees of integration.

Individual goal achievement in group psychotherapy: The roles of psychological mindedness and group process in interpretive and supportive therapy for complicated grief

The ability to infer psychological meaning in behaviour-referred to as psychological mindedness-has been posited as a patient characteristic that contributes to the therapy process and consequently to therapeutic success. The present study was developed to examine the relationship between patients' psychological mindedness and improvement in patients' personal treatment goals in interpretive and supportive group therapies for complicated grief, along with patients' importance to group process. The study was conducted with a clinical sample of 109 patients (79% female; average 45 years old) receiving treatment for complicated grief. Patients provided severity of distress ratings for individual target objectives at pretreatment and posttreatment. Psychological mindedness was assessed prior to treatment using the video-based, interviewer-rated Psychological Mindedness Assessment Procedure. Patients' importance to the therapy process was rated by therapists and other patients in interpretive and supportive group therapy for complicated grief. Conditional process modelling tested whether psychological mindedness would contribute to patients' goal achievement through patients' importance to group process, moderated by type of therapy. A significant, conditional indirect effect was observed for psychological mindedness as a predictor of improvement in individual target objectives, through patients' importance to group process as rated by therapists, specifically in interpretive therapy. The findings indicate that patients' psychological mindedness significantly contributes to their achievement of individual goals through their contributions to group process in interpretive group therapy. Further research is needed to understand the facilitation of individual goal achievement in supportive therapy.

Intervention Models for Increasing Access to Behavioral Health Services Among Youth: A Systematic Review

OBJECTIVE

The purpose of this systematic literature review is to examine interventions designed to improve access to behavioral health services among youth in the United States and to identify how the concept of access to health care has been measured and conceptualized in these studies.

METHOD

The review used a systematic search strategy to identify articles published in medical, nursing, and psychological literature. The search yielded 579 initial articles, of which 69 appeared to be candidates for inclusion in the review. In the end, 19 studies qualified for synthesis in the review. Studies were required to use an experimental or quasi-experimental design and include a comparison group.

RESULTS

Results indicated that access to behavioral health services can be improved by providing services in schools, using telehealth models, or delivering multicomponent interventions in clinical settings. Models that incorporated parental support, peer support from other parents, or other ways of engaging parents in the utilization process, as well as multicomponent and policy interventions, helped improve access to care. In the studies reviewed, access was operationalized primarily in terms of child behavioral health service utilization.

CONCLUSION

Interventions delivered in schools, engaging parents, or utilizing telehealth technology show promise for increasing access for youth affected by behavioral health disorders.

What's known about implementing co-located paediatric integrated care: a scoping review

Several studies have demonstrated clinical benefits of integrated care for a range of child and adolescent mental health outcomes. However, there is a significant gap between the evidence for efficacy of integrated care interventions vs their implementation in practice. While several studies have examined large-scale implementation of co-located integrated care for adults, much less is known for children. The goal of this scoping review was to understand how co-located mental health interventions targeting children and adolescents have been implemented and sustained. The literature was systematically searched for interventions targeting child and adolescent mental health that involved a mental health specialist co-located in a primary care setting. Studies reporting on the following implementation outcomes were included: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. This search identified 34 unique studies, including randomized controlled trials, observational studies, and survey/mixed method approaches. Components facilitating implementation of on-site integrated behavioural healthcare included interprofessional communication and collaboration at all stages of implementation; clear protocols to facilitate intervention delivery; and co-employment of integrated care providers by specialty clinics. Some studies found differences in service use by demographic factors, and others reported funding challenges affecting sustainability, warranting further study.

Shared decision-making and parental experiences with health services to meet their child's special health care needs: Racial and ethnic disparities

OBJECTIVES

Test the relationship between shared decision-making (SDM) and parental report of frustration with efforts to get services for their child and to address unmet health needs; assess SDM's influence on minority parents' service experiences.

METHODS

Performed secondary analysis using the 2009-2010 National Survey of Children with Special Health Care Needs (n = 40,242). Used multivariate logistic regressions to test the association between SDM and parent-reported service experiences, and whether SDM influenced the association between minorities and negative service experiences. Propensity scores accounted for observed selection bias.

RESULTS

Families engaged in SDM had lower odds of reporting service dissatisfaction. Fewer minority parents reported SDM engagement compared with Whites (between 62% and 66% versus 74%). Blacks engaged in SDM had higher odds of reporting negative service experiences compared with SDM-engaged Whites. This disparity was no longer significant after adjusting for covariates.

CONCLUSION

SDM is associated with lower reports of parental service dissatisfaction. Stratified analyses showed that SDM seems to be experienced differently across minority groups.

PRACTICE IMPLICATIONS

SDM may be a promising engagement strategy to improve parental service experiences. The role of SDM on increasing Black parents' reports of service dissatisfaction, perhaps due to increased awareness of service challenges, should be investigated.

An Exploration of Parent-Youth Agreement on Functional Impairment in Adolescents Utilizing Outpatient Mental Health Services

Parent-youth agreement on the youth’s functional impairment may have important implications for mental health service utilization, assessment, therapy goal development, and treatment engagement for adolescents. The present study examines parent-youth agreement on their perceptions of youth functional impairment in a predominantly racial/ethnic minority sample of adolescents utilizing outpatient mental health services. Parent and youth functional impairment ratings were compared, and agreement was estimated in multiple ways. On average, parents indicated higher levels of youth functional impairment compared to youth in their overall scores, and when differences existed between parents and youth at the functioning domain and item level. Although there was similarity in the proportion of parents and youth who reported total impairment above the clinical cut-off, actual agreement between parent-youth pairs was only slight. There appeared to be substantial variation in agreement levels when identifying problems in functional impairment at the domain and item levels, and some areas of strong consensus were identified. These findings highlight the need to consider parent-youth agreement in perceptions of functional impairment and the complexities that may underlie this agreement.

Integration of Pediatric Behavioral Health Services in Primary Care: Improving Access and Outcomes with Collaborative Care

OBJECTIVE

To examine collaborative care interventions to integrate pediatric mental health services into primary care as a means of addressing barriers to mental health service delivery, improving access to care, and improving health outcomes.

METHOD

Selective review of published literature addressing structural and attitudinal barriers to behavioural health service delivery and the integration of behavioural health services for pediatric mental problems and disorders into primary care settings, with a special focus on Canadian and U.S.

RESULTS

Integration of pediatric behavioural health services in primary care has potential to address structural and attitudinal barriers to care delivery, including shortages and the geographical misdistribution of behavioural health specialists. Integration challenges stigma by communicating that health cannot be compartmentalized into physical and mental components. Stepped collaborative care interventions have been demonstrated to be feasible and effective in improving access to behavioural health services, outcomes, and patient and family satisfaction relative to existing care models.

CONCLUSION

Collaborative integration of behavioural health services into primary care is a promising means of improving access to care and outcomes for children and adolescents struggling with mental problems and disorders. Dissemination to real-world practice settings will likely require changes to existing models of reimbursement and the culture of health service delivery.

Screening and support for emotional burdens of youth with type 1 diabetes: Strategies for diabetes care providers

Multiple sources of burden for youth with type 1 diabetes (T1D) impact key outcomes including quality of life, self-management, and glycemic control. Professional diabetes organizations recommend diabetes care providers screen for psychosocial and behavioral challenges and implement strategies to support youth with T1D. The purpose of this article is to review the literature and recommend practical strategies medical providers can use for screening and behavioral support for youth with diabetes and their families. As part of their routine medical care, diabetes care providers are well-positioned to identify and intervene to address emotional distress related to the burdens of living with diabetes. In collaboration with multidisciplinary team members, including psychologists and mental health professionals, medical providers may be able to successfully implement brief behavioral strategies for screening and providing emotional support.

Adolescent Self-Screening for Mental Health Problems; Demonstration of an Internet-Based Approach

OBJECTIVE

To examine the prevalence of positive screening scores, construct validity, and opportunities for follow-up in a large sample of adolescents who chose to fill out the Pediatric Symptom Checklist-Youth Form (PSC-Y) through the Mental Health America (MHA) Web site.

METHODS

MHA sent researchers a deidentified data set of all PSC-Y data submitted to MHA from May 15, 2015 to May 14, 2016. The analytic data set contained 29,886 PSC-Y forms from youth aged 11 to 17 years who sought out the Web site and chose to fill out the PSC-Y anonymously and independently online. The prevalence of impairment on the PSC-Y was calculated overall and for various subgroups. Next steps reported by at-risk youth were also examined.

RESULTS

Of all respondents, 77.4% of youth screened positive on the PSC-Y. Significant associations between positive screening and self-ratings of a need for help, previous history of mental health treatment, and low family income provided construct validation for the online PSC-Y. Almost two-thirds of positively screened youth stated that they planned to get some kind of help in the future and 10% indicated that they planned to seek professional treatment.

CONCLUSIONS

The large number of respondents suggested that many adolescents use the Internet to learn about mental health and that a very high percentage of them might be at risk. The availability of brief, free Internet-based psychosocial screens might offer a viable way to identify at-risk youth and provide them with pathways to additional support and/or treatment.

Evidence Base Update for Psychosocial Treatments for Disruptive Behaviors in Children

This article reviews the state of the science on psychosocial treatments for disruptive behaviors in children, as an update to Eyberg, Nelson, and Boggs (2008). We followed procedures for literature searching, study inclusion, and treatment classification as laid out in Southam-Gerow and Prinstein (2014), focusing on treatments for children 12 years of age and younger. Two treatments (group parent behavior therapy, and individual parent behavior therapy with child participation) had sufficient empirical support to be classified as well-established treatments. Thirteen other treatments were classified as probably efficacious. Substantial variability in effectiveness of different programs within the same treatment family has been previously documented; thus, a particular level of evidence might not hold true for every individual program in a treatment family. Systematic investigations of implementation, dissemination, and uptake are needed to ensure that children and families have access to effective treatments. Investigations into how to blend the strengths of the effective approaches into even more effective treatment might also lead to greater impact.

Collaborative mental health care for pediatric behavior disorders in primary care: Does it reduce mental health care costs?

OVERVIEW

One recently completed randomized controlled trial (RCT) demonstrated the effectiveness of a doctor-office collaborative care (DOCC), relative to enhanced usual care (EUC), for pediatric behavior problems and attention-deficit/hyperactivity disorder. In this study, we sought to extend the literature by incorporating a cost-analysis component at the conclusion of the aforementioned trial. To our knowledge, it was the first study to examine whether the DOCC model leads to lower costs of mental health services for children.

METHOD

Financial records from the RCT provided cost information about all the 321 child study participants in the 6-month intervention period, and claims data from insurance plans provided cost information about community mental health services for 57 children, whose parents consented to release their claims data, in both pre- and postintervention periods. Both descriptive and multivariate analyses were performed.

RESULTS

The DOCC group had higher intervention costs, but the cost per patient treated in the DOCC group was lower than the EUC group during the 6-month intervention period. In terms of costs of community mental health services, although the 2 groups had similar costs in the 6 months before the RCT intervention, the DOCC group had significantly lower costs during the 6-month intervention period and 6 or 12 months after the intervention, but not in the 18 or 24 months after the intervention.

DISCUSSION

The DOCC model has the potential for cost savings during the intervention period and the follow-up periods immediately after the intervention while improving clinical effectiveness. (PsycINFO Database Record

Provider Training to Screen and Initiate Evidence-Based Pediatric Obesity Treatment in Routine Practice Settings: A Randomized Pilot Trial

INTRODUCTION

This randomized pilot trial evaluated two training modalities for first-line, evidence-based pediatric obesity services (screening and goal setting) among nursing students.

METHOD

Participants (N = 63) were randomized to live interactive training or Web-facilitated self-study training. Pretraining, post-training, and 1-month follow-up assessments evaluated training feasibility, acceptability, and impact (knowledge and skill via simulation). Moderator (previous experience) and predictor (content engagement) analyses were conducted.

RESULTS

Nearly all participants (98%) completed assessments. Both types of training were acceptable, with higher ratings for live training and participants with previous experience (ps < .05). Knowledge and skill improved from pretraining to post-training and follow-up in both conditions (ps < .001). Live training demonstrated greater content engagement (p < .01).

CONCLUSIONS

The training package was feasible, acceptable, and efficacious among nursing students. Given that live training had higher acceptability and engagement and online training offers greater scalability, integrating interactive live training components within Web-based training may optimize outcomes, which may enhance practitioners' delivery of pediatric obesity services.

Practitioner Review: Psychological treatments for children and adolescents with conduct disorder problems - a systematic review and meta-analysis

BACKGROUND

This meta-analysis evaluates the efficacy of nonpharmacological treatments for conduct disorder (CD) problems in children and adolescents, based on child, parent and teacher report.

METHODS

PubMed, PsycINFO and EMBASE were searched for peer-reviewed articles published between January 1970 and March 2015. Main inclusion criteria were nonpharmacological treatment, participants younger than 18 years, clinical CD problems/diagnosis, randomized controlled trials and inclusion of at least one CD problem-related outcome. Treatment efficacy is expressed in effect sizes (ESs) calculated for each rater (parent, teacher, self and blinded observer).

RESULTS

Of 1,549 articles retrieved, 17 (published between June 2004 and January 2014) describing 19 interventions met the inclusion criteria. All studies used psychological treatments; only three studies included a blinded observer to rate CD problems. Most studies were of very poor to fair quality. ESs were significant but small for parent-reported outcomes (0.36, 95% CI = 0.27-0.47), teacher-reported outcomes (0.26, 95% CI = 0.12-0.49) and blinded observer outcomes (0.26, 95% CI = 0.06-0.47), and they were nonsignificant for self-reported outcomes (-0.01, 95% CI = -0.25 to 0.23). Comorbidity, gender, age, number of sessions, duration, intervention type, setting, medication use or dropout percentage did not influence the effect of treatment.

CONCLUSIONS

Psychological treatments have a small effect in reducing parent-, teacher- and observer-rated CD problems in children and adolescents with clinical CD problems/diagnosis. There is not enough evidence to support one specific psychological treatment over another. Future studies should investigate the influence of participant characteristics (e.g. age of CD onset), use more homogeneous outcome measures and allow better evaluation of study quality. Many reports failed to provide detailed information to allow optimization of psychological treatment strategies.

Psychosocial interventions for use in pediatric primary care: An examination of providers' perspectives

INTRODUCTION

The integration of psychosocial interventions in primary care settings is 1 mechanism to increase access to mental health care to youth in need. Although the delivery of psychosocial interventions by primary care providers (PCPs) reflects 1 example of this integration, research indicates that various barriers to implementation by PCPs exist. With the goal of informing a framework to guide the selection of treatments amenable to PCP practice, the authors sought to examine which criteria might influence a PCP's intention to use a given psychosocial intervention.

METHOD

Using survey methodology, 49 PCPs ranked characteristics of interventions for feasibility and applicability to their patient populations and setting.

RESULTS

Survey respondents found the following characteristics most important: time to employ, applicability to multiple disorders, ease of use, and ease of learning. Providers who endorsed more negative beliefs and attitudes toward addressing psychosocial concerns in youth were more likely to see certain criteria, such as ease of use and ease of learning, as more important.

DISCUSSION

The authors illustrate the potential application of these findings to the selection of psychosocial interventions for use in primary care and discuss future research directions. (PsycINFO Database Record

Addressing Early Childhood Emotional and Behavioral Problems

Emotional, behavioral, and relationship problems can develop in very young children, especially those living in high-risk families or communities. These early problems interfere with the normative activities of young children and their families and predict long-lasting problems across multiple domains. A growing evidence base demonstrates the efficacy of specific family-focused therapies in reducing the symptoms of emotional, behavioral, and relationship symptoms, with effects lasting years after the therapy has ended. Pediatricians are usually the primary health care providers for children with emotional or behavioral difficulties, and awareness of emerging research about evidence-based treatments will enhance this care. In most communities, access to these interventions is insufficient. Pediatricians can improve the care of young children with emotional, behavioral, and relationship problems by calling for the following: increased access to care; increased research identifying alternative approaches, including primary care delivery of treatments; adequate payment for pediatric providers who serve these young children; and improved education for pediatric providers about the principles of evidence-based interventions.

The PSC-17: Subscale Scores, Reliability, and Factor Structure in a New National Sample

BACKGROUND

The Pediatric Symptom Checklist-17 (PSC-17) is a widely used, briefer version of the PSC-35, a parent-completed measure of children's psychosocial functioning. Despite the extensive use of the PSC-17 over the past 15 years there has not been a large-scale replication of the original derivation study.

OBJECTIVE

To examine the prevalence of positive screens, reliability, and factor structure of PSC-17 scores in a new national sample and compare them with the derivation sample.

METHODS

Data were collected on 80 680 pediatric outpatients, ages 4 to 15 years, whose parents filled out the PSC-17 from 2006 to 2015 via the Child Health and Development Interactive System, an electronic system that presents and scores clinical measures.

RESULTS

The rates of positive screening on the overall PSC-17 (11.6%) and on the internalizing (10.4%) and attention (9.1%) subscales were comparable to rates found in the original sample, although the rate of externalizing problems (10.2%) was lower than in the derivation study. Reliability was high (internal consistency 0.89; test-retest 0.85), and a confirmatory factor analysis provided support for the original 3-factor model.

CONCLUSIONS

Fifteen years after the PSC-17 was derived in a large nationally representative outpatient pediatric sample, a new and larger national sample found rates of positive screening, reliability, and factor structure that were comparable. Findings from this study support the continued use of the PSC-17 clinically as a screening tool in pediatric settings and in research.

Collaborative Care in Schools: Enhancing Integration and Impact in Youth Mental Health

Collaborative Care is an innovative approach to integrated mental health service delivery that focuses on reducing access barriers, improving service quality, and lowering healthcare expenditures. A large body of evidence supports the effectiveness of Collaborative Care models with adults and, increasingly, for youth. Although existing studies examining these models for youth have focused exclusively on primary care, the education sector is also an appropriate analog for the accessibility that primary care offers to adults. Collaborative Care aligns closely with the practical realities of the education sector and may represent a strategy to achieve some of the objectives of increasingly popular multi-tiered systems of supports frameworks. Unfortunately, no resources exist to guide the application of Collaborative Care models in schools. Based on the existing evidence for Collaborative Care models, the current paper (1) provides a rationale for the adaptation of Collaborative Care models to improve mental health service accessibility and effectiveness in the education sector; (2) presents a preliminary Collaborative Care model for use in schools; and (3) describes avenues for research surrounding school-based Collaborative Care, including the currently funded Accessible, Collaborative Care for Effective School-based Services (ACCESS) project.

[Modular psychotherapy with children and adolescents]

The implementation of evidence-based psychotherapy with children and adolescents has been limited so far. This is mainly due to the fact that patients in service settings tend to have higher rates of comorbidities and more frequently changing therapy needs than those in research settings. Thus, modular psychotherapies are promising, as they allow the treatment protocol to be adapted to patients’ individual needs. Because no review on modular psychotherapy for children and adolescents exists, we conducted a systematic literature research. The results of the 15 randomized controlled trials identified demonstrate that modular psychotherapy is associated with significant reductions in symptom levels as well as with higher rates of diagnostic remission compared to control conditions. Because of the lack of evidence, future studies should investigate the incremental efficacy of modular approaches and test the validity of underlying theoretical models as well as of decision flowcharts. Modular psychotherapy approaches have the potential to personalize evidence-based interventions for children and adolescents across various therapeutical traditions, and to facilitate their implementation into clinical practice.

Using Clinical Data to Predict Accurate ADHD Diagnoses Among Urban Children

Diagnosing attention deficit hyperactivity disorder (ADHD) requires reports of child behavior from 2 settings-most commonly home and school. Obtaining this information from teachers, however, is often challenging. We sought to determine if clinical data, supplementary to parent symptom scales, could be useful in predicting DSM-compliant diagnoses. Parents and teachers reported ADHD symptoms for 156 children using Vanderbilt scales; care managers collected clinical data; a team of specialists determined whether children met diagnostic criteria for ADHD. The ability of a parent Vanderbilt alone to predict an ADHD diagnosis was 56% (95% confidence interval = 45%, 67%). By adding child age and grade retention history to the multivariable model, the probability rose to 78% (95% confidence interval = 59%, 93%). In the maximally predictive model-which included 5 covariates-the predictive validity rose to 84% (95% confidence interval = 52%, 99%). Supplementing parent symptom reports with clinical data may be a viable alternative in certain cases when teacher reports are unavailable.