Physician "costs" in providing behavioral health in primary care

Assessing Strengths and Well-Being in Primary Care for Adolescents With Mental Health and Substance Use Concerns

As the COVID-19 pandemic highlighted gaps in meeting adolescent behavioral health needs, primary care providers (PCPs) were a locus for interventions to address adolescent mental health and substance use concerns. Strength-based approaches may support PCP promotion of positive behavioral health in adolescents, but competing priorities or other factors may inhibit their use. We analyzed health record review data from 31 primary care practices to assess utilization of strength-based approaches during the health supervision visit (HSV) for adolescents with and without behavioral health concerns. We found that most had strengths identified (78%) or well-being topics addressed (83%). However, adolescents screening positive for depression were 40% less likely to have strengths identified, whereas those screening positive for anxiety or substance use were 89% and 163%, respectively, more likely to have well-being topics addressed. Primary care providers may need support for integrating strength-based approaches when managing adolescents screening positive for depression.

Increasing Access to and Utilization of Behavioral Health Care Through Integrated Primary Care

OBJECTIVES

To evaluate changes in access to and utilization of behavioral health (BH) services after the integration of psychologists into primary care clinics compared with clinics without integrated psychologists.

METHODS

We integrated 4 of 12 primary care clinics within our academic health system. We used the median wait time for BH services as a proxy for changes in access and defined BH utilization as the percentage of primary care visits that resulted in contact with a BH clinician within 180 days. We compared changes in access and utilization from the year before integration (September 2015 to September 2016) with the 2 years after integration (October 2016 to October 2018) within integrated clinics and between integrated and nonintegrated clinics. We used difference-in-difference analysis to test the association of study outcomes with the presence of integrated psychologists.

RESULTS

Access and utilization were similar across all practices before integration. After integration, BH utilization increased by 143% in integrated clinics compared with 12% in nonintegrated clinics. The utilization of BH services outside of the medical home (ie, specialty BH service) decreased for integrated clinics only. In clinics with integrated psychologists, 93% of initial BH visits happened on the same day as a need was identified. The median wait time for the 7% in integrated clinics who were not seen on the same day was 11.4 days (interquartile range = 5.3-17.7) compared with 48.3 days (interquartile range = 20.4-93.6) for nonintegrated clinics.

CONCLUSIONS

A team-based integration model increased BH utilization and access.

Cost-effectiveness analysis of robot-assisted laparoscopic surgery for complex pediatric surgical conditions

BACKGROUND

Robotics has been used safely and successfully in a variety of adult surgeries and is gradually gaining ground in pediatrics. While the benefits of robotic-assisted surgery in disease treatment are well recognized, its high cost has led to questions. To investigate whether robotic-assisted laparoscopic surgery (RALS) is cost-effective compared to conventional laparoscopic surgery (LS) in pediatric surgery, we attempted to construct a model to perform an analysis of these two surgical approaches using Python statistical analysis software.

METHODS

We selected four common complex pediatric surgical conditions (choledochal cyst, Hirschsprung's disease, vesicoureteral reflux, and congenital hydronephrosis) from three systems (pediatric hepatobiliary, gastroenterology, and urology). Models were constructed using Python statistical software to compare hospital costs and surgical outcomes for RALS and LS. In addition, we performed a preferred strategy analysis for both surgical modalities while assessing model uncertainty using one-way sensitivity analysis.

RESULTS

For the four diseases, the operative time decreased sequentially. The total inpatient costs of RALS were 10,816.72, 9145.44, 8414.29, 7973.58 dollars, respectively, yielding 1.789, 1.712, 1.749, 1.792 quality adjustment life years (QALYs) over two years post-operatively. The incremental cost of RALS relative to LS for each disease was 3523.44, 3200.20, 3049.79, 3043.66 dollars, respectively, with an incremental utility of 0.060, 0.054, 0.051, 0.050 QALYs. The incremental cost-effectiveness ratios (ICERs) for RALS for each of the four diseases were 58,724.01, 59,262.95, 59,799.79, 60,873.20 dollars/QALY, all less than 100,000 dollars/QALY. The cost of robot consumables was the main incremental cost of RALS and had the most significant impact on the model.

CONCLUSION

For the four pediatric surgical conditions described above, RALS has higher inpatient costs than LS, but it has better postoperative outcomes, and all four RALS treatments are cost-effective. Children with complex diseases and long operative times appear to benefit more from RALS.

Effects of Training on Use of Stimulant Diversion Prevention Strategies by Pediatric Primary Care Providers: Results from a Cluster-Randomized Trial

Pediatric primary care is a promising setting for reducing diversion of stimulant medications for ADHD. We tested if training pediatric primary care providers (PCPs) increased use of diversion prevention strategies with adolescents with ADHD. The study was a cluster-randomized trial in 7 pediatric primary care practices. Participants were pediatric PCPs (N = 76) at participating practices. Practices were randomized to a 1-h training in stimulant diversion prevention or treatment-as-usual. At baseline, 6 months, 12 months, and 18 months, PCPs rated how often they used four categories of strategies: patient/family education, medication management/monitoring, assessment of mental health symptoms/functioning, and assessment of risky behaviors. They completed measures of attitudes, implementation climate, knowledge/skill, and resource constraints. Generalized Estimating Equations estimated differences in outcomes by condition. Mediation analyses tested if changes in knowledge/skill mediated training effects on strategy use. PCPs in the intervention condition reported significantly greater use of patient/family education strategies at all follow-up time points. There were no differences between conditions in medication management, assessment of mental health symptoms/functioning, or assessment of risky behaviors. At 6 months, PCPs in the intervention condition reported more positive attitudes toward diversion prevention, stronger implementation climate, greater knowledge/skill, and less resource constraints. Differences in knowledge/skill persisted at 12 months and 18 months. Brief training in stimulant diversion had substantial and enduring effects on PCPs' self-reported knowledge/skill and use of patient/family education strategies to prevent diversion. Training had modest effects on attitudes, implementation climate, and resource constraints and did not change use of strategies related to medication management and assessment of mental health symptoms/functioning and risky behaviors. Changes in knowledge/skill accounted for 49% of the total effect of training on use of patient/family education strategies. Trial registration This trial is registered on ClinicalTrials.gov (NCT03080259). Posted March 15, 2017.

Enhancing the primary care pediatrician's role in managing psychosocial issues: a cross sectional study of pediatricians and parents in Israel

Background

Psychosocial issues are an integral part of children's health and well-being, and it is widely acknowledged that pediatricians should be involved in their management. We examined the current perception of the pediatrician’s role in the management of psychosocial problems in Israel from the perspective of parents and pediatricians, and identified possible barriers.

Methods

We assessed parents' and pediatricians' perspectives through a cross sectional survey. 1000 parents with children under 10 were randomly selected from a large database representing the Israeli population and phone-surveyed by a polling company. Due to a low response-rate (5.4%), there was an overrepresentation of married parents and underrepresentation of parents with primary or secondary education. 173 Pediatricians were recruited both at a medical conference and by a web-based questionnaire.

Results

55% of the parents reported they were concerned with at least one psychosocial problem, yet less than 50% of them discussed these issues with the pediatrician. 59.9% of the parents did not perceive psychosocial problems as relevant to the pediatrician's role. Pediatricians with some previous training related to psychosocial issues were more likely to report on a lack of professional confidence (p = .037) and insufficient available resources (p = .022) as barriers to their involvement, while pediatricians who had no training were more likely to report on the parents' perception of their role as the barrier to involvement (p = .035).

Conclusions

Parents tend to avoid the discussion of psychosocial concerns in pediatric settings due to their perception that it's irrelevant to the pediatrician's role. Trained pediatricians feel unconfident in their ability to manage psychosocial issues and report on a lack of suitable resources. These findings suggest current pediatric mental-health training is insufficient to equip pediatricians with the knowledge and skills required to their involvement in psychosocial problems, and imply necessary changes to environment of community-based pediatrics. In order to change the practice of pediatricians in the community to enable them to address a variety of psychological issues, appropriate training is needed, through all stages of the pediatrician’s professional life, including medical school, pediatric residency and continuous medical education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-022-00537-6.

Scope of Practice and Principles of Care of Naturopathic Medicine in North America: A Commentary

Naturopathic medicine is a growing profession in North America that provides expertise in complementary and alternative, or integrative care to pediatric patients. It is imperative that healthcare providers have an understanding of the training and scope of other health professionals in order to effectively make decisions regarding research, collaborative clinical care, and policy. Given the prevalence of use of complementary and alternative medicine by children and families in North America, and the growing interest in "integrative" medicine, we aim to offer an overview of naturopathic care for children. This document describes the principles, training, and scope of naturopathic medicine, including health promotion, disease prevention, and illness management. It describes the process by which naturopathic doctors create an integrative healthcare plan for children, evaluate and apply evidence, and integrate ethical issues in practice management, and speaks to the role naturopathic doctors have regarding advocacy for community and planetary health as it relates to pediatrics.

Funding and Billing for Integrated Behavioral Health Care

Integrated behavioral health care (IBHC) improves patient outcomes, decreases cost, and increases patient satisfaction. It has become increasingly evident that IBHC must be incorporated into the US health care system. Although most health care providers agree that IBHC is beneficial, there is great debate regarding financial sustainability. Some studies have shown that incorporating BHCs into primary care clinics allows providers to see more patients, thus generating more revenue indirectly. In this article, the authors discuss funding and billing for IBHC. The authors truly believe that once properly implemented, IBHC will lower costs and improve patient care in the long run.

Need for Integrated Behavior Health Model in Primary Care

Children and adolescents with clinically concerning behavioral health conditions face several barriers to accessing specialized mental health care. One proposed solution is to improve and expand integrated care provided in the primary health care provider's office. Several strategies can increase pediatrician comfort and willingness to collaborate in diagnosing and treating behavioral health conditions, and increased utilization of new technologies (such as telehealth) are likely to play an increasingly important role in the process.

Use of Stimulant Diversion Prevention Strategies in Pediatric Primary Care and Associations With Provider Characteristics

PURPOSE

Diversion of stimulant medications for ADHD is a prevalent problem. Pediatric primary care providers (PCPs) are well-positioned to reduce diversion risk among adolescents prescribed stimulants, but little is known about their use of prevention strategies. The objectives of this study were to describe the frequency with which pediatric PCPs use diversion prevention strategies and examine potential determinants (facilitators and barriers) of strategy use.

METHODS

Participants were pediatric PCPs (N = 76) participating in a randomized controlled trial of stimulant diversion prevention strategies. At baseline, before randomization, PCPs rated the frequency with which they used specific strategies in each of four categories: patient/family education, medication management/monitoring, assessment of mental health symptoms/functioning, and assessment of risky behaviors. They completed measures of attitudes toward diversion prevention, subjective norms (i.e., implementation climate), and perceived behavioral control (i.e., knowledge/skill, resource constraints). Associations between determinants and strategy use were tested with correlational and regression analyses.

RESULTS

PCPs used strategies for assessing mental health symptoms/functioning most frequently and patient/family education strategies least frequently. Attitudes about the effectiveness of diversion prevention, implementation climate, knowledge/skill, and resource constraints were positively correlated with the use of at least one category of strategies. In regression analysis, PCP knowledge/skill was positively associated with patient/family education, medication management, and risk assessment strategies.

CONCLUSIONS

Findings suggest that improving knowledge and skill may increase the use of diversion prevention strategies by PCPs. Identifying provider-level determinants of strategy use informs implementation efforts in pediatric primary care and can facilitate efforts to prevent stimulant diversion among adolescents.

A pediatrician-friendly review of three common behavioral health screeners in pediatric practice: Findings and recommendations

Behavioral health concerns are surging in pediatric practices. Fortunately, integrated behavioral/medical health clinics are growing and child psychiatrists/psychologists are increasingly embedded in these care settings to help shoulder the clinical load. Routine screening of behavioral health problems in primary care facilities enables early identification and treatment. However, deciding on sound, efficient, and scalable screening measures is sometimes arduous. Accordingly, this article presents a clinician-friendly review of three common instruments useful in screening pediatric behavioral health concerns including anxiety, depression, and conduct problems. Psychometric findings and clinical applications of the Pediatric Symptom Checklist-17 (PSC-17), the Patient Health Questionnaire-9 (PHQ-9), and the Screen for Child Anxiety Related Emotional Disorders (SCARED) are delineated. Finally, clinical implications and recommendations for practicing pediatricians and child psychiatrists are offered.

Young Minds: Mental Health and Transitional Care in Adolescent and Young Adult Rheumatology

Consideration of the mental health and emotional wellbeing is an important component of health care for all young people, irrespective of setting. Mental health disorders are common during adolescence and young adulthood and young people with rheumatic musculoskeletal diseases (RMD) are not exempt. For such young people, risks of poor outcomes are related to both mental health as well as their RMD. Times of change during adolescence and young adulthood-transitions-are potentially vulnerable life stages for young people with RMD and warrant specific attention in health care provision. Such transitions include those occurring at puberty, during education, training, and employment, socially with moves away from the parental home, as well as from child to adult-centered health services. There is great potential for rheumatology professionals to support young people with RMD at these transitions in view of their frequent encounters and ongoing therapeutic relationships. In this review, we aim to assess the impact of mental health on RMD during adolescence and young adulthood with particular reference to transitional care provision and how rheumatology professionals can be involved in addressing mental health issues during this time of change.

Exploring Predictors of Treatment Engagement in Urban Integrated Primary Care

Objective

Integrated primary care (IPC) is intended to address the gap in access to behavioral health care. This may be particularly true in urban settings; however, there is a paucity of research on treatment engagement in urban IPC. This study explored factors associated with treatment engagement.

Method

Data were collected via retrospective chart review for 410 patients of diverse backgrounds who received an IPC referral in an urban primary care site. Patient-related factors included having multiple types of referral concerns, patient primary care show rate, and number of visits with referring clinician. Service-related factors included referral type (warm handoff/ electronic), number of days between referral and intake, and average number of days between IPC treatment sessions. Engagement outcomes included attendance at IPC intake, total IPC sessions attended, overall IPC show rate, and IPC treatment attrition.

Results

Of referred patients, 348 (84.9%) were encouraged to or scheduled an intake. Of those, 289 (83.1%) scheduled and 57.2% attended; the average number of sessions attended was 1.73. Patients who had more primary care office visits and higher primary care show rates were more likely to attend an IPC intake. Shorter average duration between follow-up sessions was associated with higher overall IPC show rates for those who initiated IPC follow-up care.

Conclusions

Supporting engagement in primary care broadly and building scheduling capacity for IPC treatment may increase IPC service engagement in an urban primary care context.

Assessing feasibility of routine identification tools for mental health disorder in neurology clinics

OBJECTIVE

We aimed to test the feasibility of using an online parent-completed diagnostic assessment for detecting common mental health disorders in children attending neurology clinics. The assessment does not require intervention by a mental health professional or additional time in the clinic appointment.

SETTING

Two parallel and related screening studies were undertaken: Study 1: Tertiary paediatric neurology clinics. Study 2: Secondary and tertiary paediatric neurology clinics.

PATIENTS

Study 1: 406 Young people aged 7-18 attending paediatric neurology clinics. Study 2: 225 Young people aged 3-18 attending paediatric epilepsy clinics.

INTERVENTIONS

Parents completed online versions of the Strengths and Difficulties Questionnaire (SDQ) and Development and Well-being Assessment (DAWBA).

MAIN OUTCOME MEASURES

We investigated: the willingness of families to complete the measures, proportion identified as having mental health disorders, time taken to complete the measures and acceptability to families and clinicians.

RESULTS

The mean total difficulties score of those that had completed the SDQ fell in the 'high' and 'very high' ranges. 60% and 70% of the DAWBAS completed met criteria for at least one DSM-IV disorder in study 1 and 2 respectively. 98% of the parents reported that the screening methods used were acceptable.

National Referral and Treatment Patterns Among Mental Health Pediatric Primary Care Visits

The current study explored factors that predict referral from pediatric primary care to mental health specialty care among a nationally representative sample of visits (N = 2056). Results of a logistic regression indicated that patient visits that included rarer/serious diagnoses (e.g., bipolar disorder) were more likely to receive a referral in comparison to those with ADHD (OR = 4.75, SE = 1.37). Other characteristics associated with increased likelihood of referral were those with comorbid mental health conditions (OR = 2.20, SE = 0.84) and those from a metropolitan area (OR = 2.23, SE = 0.75). Implications are discussed.

Five-Year Outcomes of Behavioral Health Integration in Pediatric Primary Care

BACKGROUND AND OBJECTIVES

In the context of protracted shortages of pediatric behavioral health (BH) specialists, BH integration in pediatric primary care can increase access to BH services. The objectives of this study were to assess the structure and process of pediatric BH integration and outcomes in patient experience (access and quality), cost, and provider satisfaction.

METHODS

In 2013, we launched a multicomponent, transdiagnostic integrated BH model (Behavioral Health Integration Program [BHIP]) in a large pediatric primary care network in Massachusetts. Study participants comprised the first 13 practices to enroll in BHIP (Phase-1). Phase-1 practices are distributed across Greater Boston, with ∼105 primary care practitioners serving ∼114 000 patients. Intervention components comprised in-depth BH education, on-demand psychiatric consultation, operational support for integrated practice transformation, and on-site clinical BH service.

RESULTS

Over 5 years, BHIP was associated with increased practice-level BH integration (P < .001), psychotherapy (P < .001), and medical (P = .04) BH visits and guideline-congruent medication prescriptions for anxiety and depression (P = .05) and attention-deficit/hyperactivity disorder (P = .05). Total ambulatory BH spending increased by 8% in constant dollars over 5 years, mainly attributable to task-shifting from specialty to primary care. Although an initial decline in emergency BH visits from BHIP practices was not sustained, total emergency BH spending decreased by 19%. BHIP providers reported high BH self-efficacy and professional satisfaction from BHIP participation.

CONCLUSIONS

Findings from this study suggest that integrating BH in the pediatric setting can increase access to quality BH services while engendering provider confidence and satisfaction and averting substantial increases in cost.

The impact of behavioral health consultations on medical encounter duration in pediatric primary care: A retrospective match-controlled study

INTRODUCTION

The disproportionate time required to effectively manage psychosocial concerns is a key barrier to advancing delivery of behavioral care by primary care providers. Improved time efficiency is one potential benefit of the integration of behavioral health consultants (BHCs) into pediatric care, but few studies have systematically studied this outcome. We examined the impact of embedded BHCs on duration of medical encounters in a pediatric primary care clinic.

METHOD

We conducted a retrospective matched-pairs analysis of encounters involving behavioral consultations versus encounters for similar patients that did not include a consultation (N = 114) using electronic health record timestamp data. We examined both medical duration (i.e., medical provider services) and total duration (i.e., medical services + behavioral consultation).

RESULTS

Patient encounters involving behavioral consultation had a significantly longer (+11.23 min) total duration than matched controls, but significantly shorter (-11.67 min) medical duration.

DISCUSSION

The results indicate BHCs may improve primary care provider efficiency for patients with behavioral concerns, a notable finding given the impact of clinical time-constraints on important health care outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Promoting Earlier Access to Pediatric Behavioral Health Services with Colocated Care

OBJECTIVE

This study aimed to determine whether youth access behavioral health (BH) care earlier (i.e., when problems are less severe) when receiving services in colocated pediatric primary care clinics.

METHODS

Six primary care clinics in the Midwest with a colocated BH provider participated in this study. Data on number of sessions attended/not attended with the BH provider, BH symptom severity as measured by the Child Behavior Checklist, parent report of length of presenting problem, and improvement ratings were collected and compared for on-site referrals and off-site referrals. Descriptive, independent sample t tests and regression analyses compared those referred from on-site physicians versus off-site referral sources.

RESULTS

Results demonstrated that youth receiving BH services at their primary care physician's office accessed services when problems were less severe and had been impacting their functioning for a shorter duration.

CONCLUSION

This study is among the first to explore whether youth receiving BH services in primary care are accessing those services earlier than those who are referred from outside sources, resulting in improved patient outcomes.

The Primary Care Behavioral Health (PCBH) Model: An Overview and Operational Definition

The Primary Care Behavioral Health (PCBH) model is a prominent approach to the integration of behavioral health services into primary care settings. Implementation of the PCBH model has grown over the past two decades, yet research and training efforts have been slowed by inconsistent terminology and lack of a concise, operationalized definition of the model and its key components. This article provides the first concise operationalized definition of the PCBH model, developed from examination of multiple published resources and consultation with nationally recognized PCBH model experts. The definition frames the model as a team-based approach to managing biopsychosocial issues that present in primary care, with the over-arching goal of improving primary care in general. The article provides a description of the key components and strategies used in the model, the rationale for those strategies, a brief comparison of this model to other integration approaches, a focused summary of PCBH model outcomes, and an overview of common challenges to implementing the model.

Impacting Pediatric Primary Care: Opportunities and Challenges for Behavioral Research in a Shifting Healthcare Landscape

Behavior analysts have long recognized the potential of a partnership with pediatric medicine as an opportunity to expand the influence of behavior analysis and positively impact population health. Despite significant achievements in this domain, the impact of behavioral science on the daily practice of pediatrics has been limited. In this commentary, the authors argue that the current health care and research environments are ripe for a renewed focus on behavioral modification in pediatric primary care, with a particular emphasis on the study of high-frequency, low-intensity problems. They provide some analysis of why behavioral pediatrics has failed to gain traction in primary care, describe aspects of the current primary care practice and research landscapes that provide opportunities for an expanded portfolio of research, identify several exemplars from the behavior analytic literature that have influenced pediatric primary care or have the potential to do so, and make recommendations for producing influential data.

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.

Comparing primary care pediatricians' perceptions of clinics with and without integrated behavioral health

Objective: The purpose of this study was to investigate primary care pediatrician (PCP) perceptions of prevalence of, time spent in, and satisfaction with behavioral health services across clinics with and without on-site behavioral health providers (BHPs). Methods: A cross-sectional survey design was used to examine satisfaction across sites. Data were collected on PCP perceptions of behavioral health services among 60 pediatricians within two academic medical systems. Results: PCPs perceived behavioral health issues are prevalent and a time-consuming aspect of medical appointments and preferred to have on-site BHPs over off-site referral sources. Compared to sites without an on-site BHP, sites with on-site BHPs were more satisfied with behavioral health service availability and resources, felt they spent more time addressing medical concerns, and spent less time providing anticipatory guidance. Discussion: Study limitations included questions surrounding the validity of survey items to accurately assess PCP perceptions, lack of rigorous experimental design, and reliance on self-report data.

Enhancing Pediatricians' Behavioral Health Competencies Through Child Psychiatry Consultation and Education

The objective of this study was to assess feasibility, utilization, perceived value, and targeted behavioral health (BH) treatment self-efficacy associated with a collaborative child and adolescent psychiatry (CAP) consultation and BH education program for pediatric primary care practitioners (PCPs). Eighty-one PCPs from 41 member practices of a statewide pediatric practice association affiliated with an academic medical center participated in a program comprising on-demand telephonic CAP consultation supported by an extensive BH learning community. Findings after 2 years of implementation suggest that the program was feasible for large-scale implementation, was highly utilized and valued by PCPs, and was attributed by PCPs with enhancing their BH treatment self-efficacy and the quality of their BH care. After participation in the program, nearly all PCPs believed that mild to moderate presentations of common BH problems can be effectively managed in the primary care setting, and PCP consultation utilization was congruent with that belief.

Improving Data for Behavioral Health Workforce Planning: Development of a Minimum Data Set

The behavioral health workforce, which encompasses a broad range of professions providing prevention, treatment, and rehabilitation services for mental health conditions and substance use disorders, is in the midst of what is considered by many to be a workforce crisis. The workforce shortage can be attributed to both insufficient numbers and maldistribution of workers, leaving some communities with no behavioral health providers. In addition, demand for behavioral health services has increased more rapidly as a result of federal legislation over the past decade supporting mental health and substance use parity and by healthcare reform. In order to address workforce capacity issues that impact access to care, the field must engage in extensive planning; however, these efforts are limited by the lack of timely and useable data on the behavioral health workforce. One method for standardizing data collection efforts is the adoption of a Minimum Data Set. This article describes workforce data limitations, the need for standardizing data collection, and the development of a behavioral health workforce Minimum Data Set intended to address these gaps. The Minimum Data Set includes five categorical data themes to describe worker characteristics: demographics, licensure and certification, education and training, occupation and area of practice, and practice characteristics and settings. Some data sources align with Minimum Data Set themes, although deficiencies in the breadth and quality of data exist. Development of a Minimum Data Set is a foundational step for standardizing the collection of behavioral health workforce data. Key challenges for dissemination and implementation of the Minimum Data Set are also addressed.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Colocated Mental Health/Developmental Care

The inadequacy of mental health and developmental services for children is a widely recognized and growing problem. Although a variety of solutions have been proposed, none has been generally successful or feasible. This research describes models of colocation that have evolved in primary care settings in Massachusetts and reports on pediatricians' and their colocated colleagues' impressions of their benefits and challenges. Pediatricians in 18 practices that included a colocated mental health/developmental specialist (MH/DS) were identified through a survey administered through the state American Academy of Pediatrics Chapter, and interviewed. Practices varied widely in the professional expertise/training and roles of the MH/DSs, communication among providers, and financial arrangements. The majority of pediatricians and MH/DSs reported being pleased with their colocated arrangements, despite the costs rarely being supported by billing revenues. This study suggests that further development of such systems hold promise to meet the growing need for accessible pediatric mental and developmental health care.

The Central Role of Relationships With Trauma-Informed Integrated Care for Children and Youth

OBJECTIVE

Primary care plays an essential role in the primary and secondary prevention of children's mental health problems. A growing series of trials have shown the capacity of primary care providers to deliver care that specifically addresses risks to healthy social and emotional development by incorporating mental health services into their routines and integrating their work with the mental health care system. In this article elements common to various integration schemes that seem essential to their success are described.

METHODS

Narrative review, combining conclusions from 3 previous systematic reviews.

RESULTS

Trusting, personal relationships between patients and providers, and among collaborating providers, are a critical element of successful trauma-informed integrated care. Patient-provider relationships are essential to disclosure of sensitive concerns, to engaging patients in care, and to designing care that is responsive to individual patient needs. Studies of patient-centered care and psychotherapy suggest ways that these relationships can be built and maintained. Provider-provider relationships are, in turn, essential to coordinating the work of the range of providers and services needed to address trauma prevention and treatment. These relationships can form within a variety of organizational structures but building them might require staff training, redesign of work flows, and support from organizational structures and goals.

CONCLUSIONS

A variety of interventions at the patient-provider, clinical site, system, and policy levels can foster relationships and provide the foundation for care capable of addressing promotion of social and emotional well-being in general and trauma prevention and treatment in particular.

Adolescent Risk Screening Instruments for Primary Care: An Integrative Review Utilizing the Donabedian Framework

Adolescent risk-taking behavior choices can affect future health outcomes. The purpose of this integrative literature review is to evaluate adolescent risk screening instruments available to primary care providers in the United States using the Donabedian Framework of structure, process, and outcome. To examine the literature concerning multidimensional adolescent risk screening instruments available in the United States for use in the primary care setting, library searches, ancestry searches, and Internet searches were conducted. Library searches included a systematic search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Premier, Health Source Nursing Academic Ed, Medline, PsycINFO, the Psychology and Behavioral Sciences Collection, and PubMed databases with CINAHL headings using the following Boolean search terms: "primary care" and screening and pediatric. Criteria for inclusion consisted of studies conducted in the United States that involved broad multidimensional adolescent risk screening instruments for use in the pediatric primary care setting. Instruments that focused solely on one unhealthy behavior were excluded, as were developmental screens and screens not validated or designed for all ages of adolescents. In all 25 manuscripts reviewed, 16 screens met the inclusion criteria and were included in the study. These 16 screens were examined for factors associated with the Donabedian structure-process-outcome model. This review revealed that many screens contain structural issues related to cost and length that inhibit provider implementation in the primary care setting. Process limitations regarding the report method and administration format were also identified. The Pediatric Symptom Checklist was identified as a free, short tool that is valid and reliable.

Child-Adult Relationship Enhancement in Primary Care (PriCARE): A Randomized Trial of a Parent Training for Child Behavior Problems

OBJECTIVE

Child-Adult Relationship Enhancement in Primary Care (PriCARE) is a 6-session group parent training designed to teach positive parenting skills. Our objective was to measure PriCARE's impact on child behavior and parenting attitudes.

METHODS

Parents of children 2 to 6 years old with behavior concerns were randomized to PriCARE (n = 80) or control (n = 40). Child behavior and parenting attitudes were measured at baseline (0 weeks), program completion (9 weeks), and 7 weeks after program completion (16 weeks) using the Eyberg Child Behavior Inventory (ECBI) and the Adult Adolescent Parenting Inventory 2 (AAPI2). Linear regression models compared mean ECBI and AAPI2 change scores from 0 to 16 weeks in the PriCARE and control groups, adjusted for baseline scores.

RESULTS

Of those randomized to PriCARE, 43% attended 3 or more sessions. Decreases in mean ECBI intensity and problem scores between 0 and 16 weeks were greater in the PriCARE group, reflecting a larger improvement in behavior problems [intensity: -22 (-29, -16) vs -7 (-17, 2), P = .012; problem: -5 (-7, -4) vs -2 (-4, 0), P = .014]. Scores on 3 of the 5 AAPI2 subscales reflected greater improvements in parenting attitudes in the PriCARE group compared to control in the following areas: empathy toward children's needs [0.82 (0.51, 1.14) vs 0.25 (-0.19, 0.70), P = .04], corporal punishment [0.22 (0.00, 0.45) vs -0.30 (-0.61, 0.02), P = .009], and power and independence [0.37 (-0.02, 0.76) vs -0.64 (-1.19, -0.09), P = .003].

CONCLUSIONS

PriCARE shows promise in improving parent-reported child-behavior problems in preschool-aged children and increasing positive parenting attitudes.

Parent Use and Efficacy of a Self-Administered, Tablet-Based Parent Training Intervention: A Randomized Controlled Trial

Background

Parent training programs are traditionally delivered in face-to-face formats and require trained facilitators and weekly parent attendance. Implementing face-to-face sessions is challenging in busy primary care settings and many barriers exist for parents to attend these sessions. Tablet-based delivery of parent training offers an alternative to face-to-face delivery to make parent training programs easier to deliver in primary care settings and more convenient and accessible to parents. We adapted the group-based Chicago Parent Program (CPP) to be delivered as a self-administered, tablet-based program called the ezParentprogram.

Objective

The purpose of this study was to (1) assess the feasibility of the ezParentprogram by examining parent satisfaction with the program and the percent of modules completed, (2) test the efficacy of the ezParentprogram by examining the effects compared with a control condition for improving parenting and child behavior in a sample of low-income ethnic minority parents of young children recruited from a primary care setting, and (3) compare program completion and efficacy with prior studies of the group-based CPP.

Methods

The study used a two-group randomized controlled trial (RCT) design with repeated measures follow up. Subjects (n=79) were randomly assigned to an intervention or attention control condition. Data collection was at baseline and 12 and 24 weeks post baseline. Parents were recruited from a large, urban, primary care pediatric clinic. ezParentmodule completion was calculated as the percentage of the six modules completed by the intervention group parents. Attendance in the group-based CPP was calculated as the percentage of attendance at sessions 1 through 10. Satisfaction data were summarized using item frequencies. Parent and child data were analyzed using a repeated measures analysis of variance (RM-ANOVA) with simple contrasts to determine if there were significant intervention effects on the outcome measures. Effect sizes for between group comparisons were calculated for all outcome variables and compared with CPP group based archival data.

Results

ezParentmodule completion rate was 85.4% (34.2/40; 95% confidence interval [CI] = 78.4%-93.7%) and was significantly greater ( P<.05) than face-to-face CPP group attendance (135.2/267, 50.6%) attendance of sessions; 95% CI = 46.8%-55.6%). ezParentparticipants reported the program as very helpful (35/40, 88.0%) and they would highly recommend the program (33/40, 82.1%) to another parent. ezParentparticipants showed greater improvements in parenting warmth (F1,77 = 4.82, P<.05) from time 1 to 3. No other significant differences were found. Cohen’s d effect sizes for intervention group improvements in parenting warmth, use of corporal punishment, follow through, parenting stress, and intensity of child behavior problems were comparable or greater than those of the group-based CPP.

Conclusions

Data from this study indicate the feasibility and acceptability of the ezParentprogram in a low-income, ethnic minority population of parents and comparable effect sizes with face-to-face delivery for parents.

Phone Consultation for Behavioral Health–Related Referrals in Integrated Primary Care

Behavioral health (BH) providers add value to primary care teams. This descriptive study illustrates one such role that the BH provider can serve. The on-site BH provider responded to patient phone inquiries regarding BH topics for pediatricians over the course of 15 months. The majority of these calls were for children 10 years and younger and related to externalizing problems. Phone calls were relatively brief (ie, 11-15 minutes). More than half of these phone calls resulted in families scheduling an appointment with nearly 75% showing up for the initial session. Providing this type of adjunctive service may result in earlier access to care and efficiently assigning responsibilities to the appropriate team member.

Seeing Is Believing: Using Skype to Improve Diabetes Outcomes in Youth

OBJECTIVE

The objective of this study was to compare the relative effectiveness of two modes of delivering Behavioral Family Systems Therapy for Diabetes (BFST-D) to improve adherence and glycemic control among adolescents with type 1 diabetes with suboptimal glycemic control (HbA(1c) ≥9.0% [≥74.9 mmol/mol]): face to face in clinic (Clinic) and Internet videoconferencing (Skype) conditions.

RESEARCH DESIGN AND METHODS

Adolescents aged 12 to 18 years and at least one adult caregiver were randomized to receive BFST-D via the Clinic or Skype condition. Participants completed up to 10 therapy sessions within a 12-week period. Changes in youth- and parent-reported adherence and glycemic control were compared before and after the intervention and at follow-up assessment.

RESULTS

Using an intent-to-treat analytic approach, no significant between-group differences were identified between the before, after, and follow-up assessments. Groups were collapsed to examine the overall effects of BFST-D on adherence and glycemic control. Results identified that statistically significant improvements in adherence and glycemic control occurred from before to after the intervention; improvements were maintained at 3-month follow-up.

CONCLUSIONS

Delivery of BFST-D via Internet-based videoconferencing is viable for addressing nonadherence and suboptimal glycemic control in adolescents with type 1 diabetes, potentially reducing important barriers to care for youth and families.

Pediatric Nurse Practitioner Management of Child Anxiety in a Rural Primary Care Clinic With the Evidence-Based COPE Program

INTRODUCTION

Anxiety is the most common mental health disorder in children. Many communities have shortages of mental health providers, and the majority of children with anxiety are not receiving the evidence-based treatment they need. The purpose of this pilot study was to assess the feasibility and effects of a brief seven-session cognitive behavioral skills-building intervention, Creating Opportunities for Personal Empowerment (COPE), which was delivered to anxious children by a pediatric nurse practitioner in a primary care setting.

METHODS

A pre-experimental, one-group, pretest and post-test design was used.

RESULTS

Children who participated had a significant decrease in anxiety symptoms (13.88 points, SD = 17.96, 95% confidence interval [CI] = -1.13-28.89), as well as an increase in knowledge of cognitive-behavioral coping skills (M = 11.38, CI = 5.99-8.26, p = .00) and improved functioning (at school and at home). Evaluations by parents and children were positive.

DISCUSSION

COPE is a promising evidence-based intervention for children with anxiety with feasible delivery by pediatric nurse practitioners in primary care.

Integrating mental health into adolescent annual visits: impact of previsit comprehensive screening on within-visit processes

PURPOSE

To evaluate how a comprehensive, computerized, self-administered adolescent screener, the DartScreen, affects within-visit patient-doctor interactions such as data gathering, advice giving, counseling, and discussion of mental health issues.

METHODS

Patient-doctor interaction was compared between visits without screening and those with the DartScreen completed before the visit. Teens, aged 15-19 years scheduled for an annual visit, were recruited at one urban and one rural pediatric primary care clinic. The doctor acted as his/her own control, first using his/her usual routine for five to six adolescent annual visits. Then, the DartScreen was introduced for five visits where at the beginning of the visit, the doctor received a summary report of the screening results. All visits were audio recorded and analyzed using the Roter interaction analysis system. Doctor and teen dialogue and topics discussed were compared between the two groups.

RESULTS

Seven midcareer doctors and 72 adolescents participated; 37 visits without DartScreen and 35 with DartScreen were audio recorded. The Roter interaction analysis system defined medically related data gathering (mean, 36.8 vs. 32.7 statements; p = .03) and counseling (mean, 36.8 vs. 32.7 statements; p = .01) decreased with DartScreen; however, doctor responsiveness and engagement improved with DartScreen (mean, 4.8 vs. 5.1 statements; p = .00). Teens completing the DartScreen offered more psychosocial information (mean, 18.5 vs. 10.6 statements; p = .01), and mental health was discussed more after the DartScreen (mean, 93.7 vs. 43.5 statements; p = .03). Discussion of somatic and substance abuse topics did not change. Doctors reported that screening improved visit organization and efficiency.

CONCLUSIONS

Use of the screener increased discussion of mental health but not at the expense of other adolescent health topics.

Promoting optimal development: screening for behavioral and emotional problems

By current estimates, at any given time, approximately 11% to 20% of children in the United States have a behavioral or emotional disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Between 37% and 39% of children will have a behavioral or emotional disorder diagnosed by 16 years of age, regardless of geographic location in the United States. Behavioral and emotional problems and concerns in children and adolescents are not being reliably identified or treated in the US health system. This clinical report focuses on the need to increase behavioral screening and offers potential changes in practice and the health system, as well as the research needed to accomplish this. This report also (1) reviews the prevalence of behavioral and emotional disorders, (2) describes factors affecting the emergence of behavioral and emotional problems, (3) articulates the current state of detection of these problems in pediatric primary care, (4) describes barriers to screening and means to overcome those barriers, and (5) discusses potential changes at a practice and systems level that are needed to facilitate successful behavioral and emotional screening. Highlighted and discussed are the many factors at the level of the pediatric practice, health system, and society contributing to these behavioral and emotional problems.

Developing the eCPP: adapting an evidence-based parent training program for digital delivery in primary care settings

BACKGROUND

Developing innovative delivery methods is needed to overcome time and logistic barriers to in-person participation in evidence-based parent training (PT) programs.

PURPOSE

The purpose of this paper is to (a) describe the systematic process for adapting an evidence-based group PT program (the Chicago Parent Program) to a tablet-based delivery format, (b) present the adapted program, and (c) discuss opportunities and challenges of adapting evidence-based programs for alternative delivery methods.

METHODS

To ensure consistency with the original program and relevance to the intended program recipients, three groups-parents (n = 10), CPP developers (n = 3), and digital delivery experts- were engaged throughout the systematic steps of the delivery adaptation of the Chicago Parent Program (eCPP). Group meetings were used to identify the program's core components, develop the adaptation program model, assess potential mismatches for the new delivery context, and adapt the original program model and materials.

RESULTS

The final eCPP is a six-module Internet-based intervention that includes: interactive activities, video examples and explanations of parenting strategies, reflection questions, assessment of parent knowledge with feedback, and module practice assignments.

LINKING EVIDENCE TO ACTION

Developing innovative delivery approaches for evidenced-based interventions are promising to increase intervention sustainability and participant access and engagement. It is critical that these adaptations are systematic and developed with expert consultation and community input.

Internet guidance on time out: inaccuracies, omissions, and what to tell parents instead

OBJECTIVE

Pediatricians are frequently asked to address parents' behavioral concerns. Time out (TO) is one of the few discipline strategies with empirical support and is recommended by the American Academy of Pediatrics. However, correctly performed, TO can be a complex procedure requiring training difficult to provide in clinic due to time and cost constraints. The Internet may be a resource for parents to supplement information provided by pediatricians. The present study included evaluation of information on TO contained in websites frequently accessed by parents. It was hypothesized that significant differences exist between the empirically supported parameters of TO and website-based information.

METHODS

Predefined search terms were entered into commonly used search engines. The information contained in each webpage (n = 102) was evaluated for completeness and accuracy based on research on TO. Data were also collected on the consistency of information about TO on the Internet.

RESULTS

None of the pages reviewed included accurate information about all empirically supported TO parameters. Only 1 parameter was accurately recommended by a majority of webpages. Inconsistent information was found within 29% of the pages. The use of TO to decrease problem behavior was inaccurately portrayed as possibly or wholly ineffective on 30% of webpages.

CONCLUSIONS

A parent searching for information about TO on the Internet will find largely incomplete, inaccurate, and inconsistent information. Since nonadherence to any 1 parameter will decrease the efficacy of TO, it is not recommended that pediatricians suggest the Internet as a resource for supplemental information on TO. Alternative recommendations for pediatricians are provided.

Adolescents' preference for technology-based emergency department behavioral interventions: does it depend on risky behaviors?

OBJECTIVES

This study aimed to (1) determine the prevalence of technology use and interest in technology-based interventions among adolescent emergency department patients and (2) examine the association between interest in an intervention and self-reported risky behaviors.

METHODS

Adolescents (age, 13-17 years) presenting to an urban pediatric emergency department completed a survey regarding baseline technology use, risky behaviors, and interest in and preferred format for behavioral health interventions. Questions were drawn from validated measures when possible. Descriptive statistics and χ2 tests were calculated to identify whether self-reported risky behaviors were differentially associated with intervention preference.

RESULTS

Two hundred thirty-four patients (81.8% of eligible) consented to participate. Almost all used technology, including computers (98.7%), social networking (84.9%), and text messaging (95.1%). Adolescents reported high prevalence of risky behaviors as follows: unintentional injury (93.2%), peer violence exposure (29.3%), dating violence victimization (23.0%), depression or anxiety (30.0%), alcohol use (22.8%), drug use (36.1%), cigarette use (16.4%), and risky sexual behaviors (15.1%). Most were interested in receiving behavioral interventions (ranging from 93.6% interest in unintentional injury prevention, to 73.1% in smoking cessation); 45% to 93% preferred technology-based (vs in person, telephone call, or paper) interventions for each topic. Proportion interested in a specific topic and proportion preferring a technology-based intervention did not significantly differ by self-reported risky behaviors.

CONCLUSIONS

Among this sample of adolescent emergency department patients, high rates of multiple risky behaviors are reported. Patients endorsed interest in receiving interventions for these behaviors, regardless of whether they reported the behavior. Most used multiple forms of technology, and approximately 50% preferred a technology-based intervention format.

Attitudes toward technology-based health information among adult emergency department patients with drug or alcohol misuse

Technology-based screening and interventions are emerging solutions to the challenge of addressing substance use in the emergency department (ED). A standardized questionnaire of adult patients at a large-volume, urban, academic ED assessed interest in, and potential barriers to, technology-based substance use information. Questionnaire topics included substance use, access to technology, preferences for health information, and perceived barriers to technology interventions. Among the 430 participants, mean age was 39 years and 55% were female; 37% reported alcohol misuse and 52% drug misuse. Access to technology was high. Technology was preferred by 46% of alcohol misusers (vs. 43% non-misusers, p=0.65) but only 41.9% of drug misusers (vs. 56% non-drug misusers, p=0.005). In multivariate analyses, drug misuse was associated with decreased interest in receiving technology-based information. Cited barriers included confidentiality, complexity, and time. Our findings suggest that drug misusers in particular may wish to have reassurances about the confidentiality of technology-based interactions.

Screening for adolescent alcohol and drug use in pediatric health-care settings: predictors and implications for practice and policy

OBJECTIVE

This paper used data from a study of pediatric primary care provider (PCP) screening practices to examine barriers to and facilitators of adolescent alcohol and other drug (AOD) screening in pediatric primary care.

METHODS

A web-based survey (N = 437) was used to examine the influence of PCP factors (attitudes and knowledge, training, self-efficacy, comfort with alcohol and drug issues); patient characteristics (age, gender, ethnicity, comorbidities and risk factors); and organizational factors (screening barriers, staffing resources, confidentiality issues) on AOD screening practices. Self-reported and electronic medical record (EMR)-recorded screening rates were also assessed.

RESULTS

More PCPs felt unprepared to diagnose alcohol abuse (42%) and other drug abuse (56%) than depression (29%) (p < 0.001). Overall, PCPs were more likely to screen boys than girls, and male PCPs were even more likely than female PCPs to screen boys (23% versus 6%, p < 0.0001). Having more time and having other staff screen and review results were identified as potential screening facilitators. Self-reported screening rates were significantly higher than actual (EMR-recorded) rates for all substances. Feeling prepared to diagnose AOD problems predicted higher self-reported screening rates (OR = 1.02, p < 0.001), and identifying time constraints as a barrier to screening predicted lower self-reported screening rates (OR = 0.91, p < 0.001). Higher average panel age was a significant predictor of increased EMR-recorded screening rates (OR = 1.11, p < 0.001).

CONCLUSIONS

Organizational factors, lack of training, and discomfort with AOD screening may impact adolescent substance-abuse screening and intervention, but organizational approaches (e.g., EMR tools and workflow) may matter more than PCP or patient factors in determining screening.

Cross-cultural aspects of depression management in primary care

Major depressive disorder (MDD) is a prevalent illness in minority populations. Minority patients with MDD are often unrecognized and untreated. This review examines promising interventions to address MDD in primary care settings, where minority groups are more likely to seek care. Since 2010, eleven interventions have been developed to address patient-specific and provider-specific barriers, many of which are adaptations of the collaborative care model. Other promising interventions include cultural tailoring of the collaborative care model, as well as the addition of telepsychiatry, motivational interviewing, cultural consultation, and innovations in interpreting. Overall, collaborative care was found feasible and improved satisfaction and treatment engagement of depressed minority patients in primary care. It remains inconclusive whether these newer intervention models improve MDD treatment outcomes. Future research will be needed to establish the effectiveness of these intervention models in improving the treatment outcomes of minority populations with MDD.

Emergency department patients' preferences for technology-based behavioral interventions

STUDY OBJECTIVE

To assess emergency department (ED) patients' preferences for technology-based behavioral interventions, and the demographic factors associated with these preferences.

METHODS

A cross-sectional survey of a random sample of urban ED patients (≥13 years) from a representative sample of shifts, with oversampling of adolescents/young adults (aged 13 to 24 years). Participants self-administered the survey about baseline technology use, concerns about technology-based interventions, and preferred intervention format for 7 behavioral health topics. We performed descriptive statistics and multivariate logistic regression (controlling for demographics and then additionally for baseline technology use) to identify factors differentially associated with technology preference for each behavioral topic.

RESULTS

Of patients presenting during research assistant shifts, 1,429 (≈59%) were screened and 664 (68.2% of eligible) consented to participate. Mean age was 31 years (SD 0.69); 54.5% were female, 64.1% were white, 23.2% were Hispanic, and 46.6% reported low income. Baseline use of computers (91.2%), Internet (70.7%), social networking (66.9%), mobile phones (95.0%), and text messaging (73.8%) was high. Participants reported interest in receiving interventions on each behavioral topic. Ninety percent preferred a technology-based intervention for at least 1 topic. Patients expressed greatest concerns about Internet (51.5%) and social networking (57.6%), particularly about confidentiality. Adjusting for sex, race, ethnicity, and income, younger age associated with preference for technology-based interventions for unintentional injuries (odds ratio 0.63 for technology preference if adult versus youth; 95% confidence interval 0.45 to 0.89) and peer violence (odds ratio 0.63 if adult; 95% confidence interval 0.43 to 0.92). Additionally adjusting for baseline technology usage, only baseline usage was associated with preference for technology-based interventions.

CONCLUSION

ED patients reported high baseline technology use, high interest in behavioral health interventions, and varying preferences for technology-based interventions. Future studies should address actual feasibility and acceptability of technology-based interventions in a more generalized population and ways to alleviate concerns about these interventions.

Antipsychotic medication prescribing trends in children and adolescents

The Food and Drug Administration has approved the use of antipsychotic medications in some children and adolescents with severe emotional and behavioral disorders. However, recent national data show a dramatic rise in off-label and Food and Drug Administration-approved uses of these medications. Of particular note is a twofold to fivefold increase in the use of antipsychotic medications in preschool children, despite little information on their long-term effects. This article describes the trend in pediatric antipsychotic medication use, possible explanations for the increase, implications for children's health, and recommendations for pediatric providers who work with parents of children and adolescents who seek or receive antipsychotic medication treatments.

Intimate partner violence, mental health disorders, and sexually transmitted infections: important screening opportunities for pediatric healthcare providers

PURPOSE OF REVIEW

This article addresses three critical areas where pediatric healthcare providers must employ effective screening techniques to ensure the best care for patients: intimate partner violence (IPV), mental health issues, and sexually transmitted infections (STIs).

RECENT FINDINGS

IPV is now recognized as an important issue impacting the health of children. While long-term outcomes secondary to positive screening results are not known, routine, sensitive questioning can identify at-risk children and help connect families to resources in the community. Routine use of validated screening tools for mental health disorders (MHDs) in the office setting is now recommended. STIs disproportionately affect adolescents and young adults, yet timely diagnosis is often challenging because infections are frequently asymptomatic and adolescents may not be forthcoming about risk-taking behaviors. There is significant opportunity for pediatricians to improve screening rates of adolescents.

SUMMARY

Screening is an essential aspect of healthcare for pediatricians. An understanding of current screening recommendations for IPV, MHDs, and STIs will assist providers in earlier detection of medical problems in their patients and will likely improve patient outcomes.