Effect of routine mental health screening in a low-resource pediatric primary care population

Increasing parent help-seeking for child mental health: A study protocol for the growing minds check-in, an online universal screening tool

BACKGROUND

Early identification and intervention for mental health (MH) problems in childhood offers lifelong benefits. Many children with MH problems do not receive appropriate help. To address this need, an online universal MH screening tool, the Growing Minds Check-In for parents/caregivers (GMCI-P), was developed to provide feedback to parents on their children's MH, identify children at risk of MH problems, and link parents to evidence-based online programs/information, with the goal of facilitating parent help-seeking, and ultimately reducing the prevalence of child MH problems.

METHODS/DESIGN

A randomised controlled trial (RCT) with 440 parents/caregivers will be conducted to 1) examine the efficacy of GMCI-P for increasing parent help-seeking; 2) explore acceptability; and 3) cost-effectiveness. Participants will be Australian parents/caregivers with a child aged from birth to 17 years, 6 months, who will be randomly allocated to GMCI-P (intervention) or waitlist control (WLC) group, and complete baseline measures. The intervention group will complete the GMCI-P immediately, the post-GMCI-P intervention questions, a three-month and six-month follow-up. The WLC group will receive access to GMCI-P after their three-month follow-up but will not be followed up further. The primary outcome is parent help-seeking behaviour for child MH, and secondary outcomes include child MH, parenting, parent wellbeing, acceptability, cost-effectiveness, and unintended negative effects.

DISCUSSION

The results from this study will provide efficacy, acceptability and cost-effectiveness data on a universal online, parent-report child MH Check-In. These results can be used to inform public policy on universal screening for child MH.

TRIAL REGISTRATION

ACTRN12624000098538.

Using a participatory method to test a strategy supporting the implementation of a state policy on screening children for adverse childhood experiences (ACEs) in a Federally Qualified Health Center system: a stepped-wedge cluster randomized trial

BACKGROUND

Adverse childhood experiences (ACEs) are potentially traumatic events occurring before age 18, such as maltreatment or exposure to violence. ACE screening is increasingly recommended to prevent and address physical and mental health conditions associated with ACEs. To promote ACE screening uptake, the state of California issued the "ACEs Aware" policy that provides Medicaid reimbursement for ACE screening annually for child primary care visits. However, policy directives alone often do not translate into effective screening efforts and greater access to care. Few rigorous studies have developed and tested implementation strategies for ACE pediatric screening policies. This study will fill this gap by testing a multifaceted implementation strategy in partnership with a Federally Qualified Health Center (FQHC) system serving low-income families in Southern California to support the ACE Aware policy.

METHODS

We will use Implementation Mapping, with study process and consideration of determinants and mechanisms guided by the EPIS framework, to co-create and refine an implementation strategy. The proposed strategy is comprised of online training videos, a customized algorithm and use of technology to improve workflow efficiency, implementation training to internal FQHC personnel, clinic support and coaching, and written implementation protocols. A hybrid type 2, stepped-wedge cluster randomized trial design with five primary care clinics will test whether a multifaceted implementation strategy improves (a) fidelity to the ACE screening protocol, (b) reach defined as the proportion of eligible children screened for ACEs, and (c) the impact of the ACE policy on child-level mental health referrals and symptom outcomes. The study will use mixed methods with data to include electronic health records, surveys, and interviews with clinic personnel and caregivers.

DISCUSSION

This study is designed to increase the capacity of FQHCs' inner context to successfully implement an outer context-initiated ACE policy designed to benefit pediatric patients. It capitalizes on a rare opportunity to use a co-creation approach to develop, adapt, refine, and pilot test an implementation strategy to maximize the impact of a new state-wide policy intended to improve ACE assessment and subsequent care to improve child health, particularly those from underserved communities.

TRIAL REGISTRATION

Trial # NCT04916587  registered at ClinicalTrials.gov on June 4, 2021.

What Caregivers Want: Preferences for Behavioral Health Screening Implementation Procedures in Pediatric Primary Care

There has been a national push for universal psychosocial prevention screening in pediatric primary care. Implementation science highlights the importance of considering patients' perspectives when developing such procedures; however, minimal studies have examined this. The present study employed a mixed-methods design to examine caregivers of pediatric patients' (n = 149) preferences and comfort with psychosocial screening procedures. A subset of participants (n = 20) were interviewed to better understand reasons for responses. Results indicated that caregivers rated screening for physical health, development, emotion and behavior, caregiver adverse childhood experiences (ACEs), and child ACEs within primary care as important or very important. The majority of caregivers were not comfortable completing screenings in the waiting room and preferred the exam room. Caregivers primarily preferred the primary care provider to administer screenings and communicate results and recommendations. Parents also preferred the behavioral health provider to provide recommendations on emotion and behavior, parent ACEs, and child ACEs. Qualitative reasons for responses included relationship quality, knowledge of child, expertise, and desire for direct communication. Findings have implications for developing family-centered, trauma-informed practices within primary care, particularly among those within under-resourced rural communities.

Identification of Preschool Children with Mental Health Problems in Primary Care: Systematic Review and Meta-analysis

OBJECTIVE

Primary care practitioners determine access to care for many preschool children with mental health (MH) problems. This study examined rates of mental health (MH) problem identification in preschoolers within primary healthcare settings, related service use, and MH status at follow-up. The findings may inform evidence-based policy and practice development for preschool MH.

METHOD

For this systematic review, MEDLINE®, EMBASE®, PsycInfo®, and ERIC ® were searched from inception to March 7, 2018 for reports in which a screening measure was used to identify MH problems in children aged 24-72 months, seen in primary and community health care settings. Meta-analyses, using random effects models to provide pooled estimates, were used when three or more studies examined identification rates. Findings on service use and persistence of disorders are summarized.

RESULTS

Thirty-five publications representing 21 studies met the inclusion criteria. MH problems were identified in 17.6% of preschoolers (95% Confidence Interval (CI): 11.1-24.1), Q = 4.9, p > 0.1 by primary/community healthcare practitioners. Psychiatric diagnoses were identified in 18.4% of preschoolers (95% CI: 12.3 - 24.4), Q= 1.6, p > 0.1. Based on three studies, parents of 67-72% of identified children received advice and 26-42% received specialist referrals. In the subset of studies examining persistence of MH disorders, 25-67% of identified children had MH disorders after one to three years.

CONCLUSION

While the identification rate by primary/community practitioners is similar to the diagnostic rate, these may not consistently be the same children. Substantial variability in management and outcomes indicate need for more rigorous evaluation of primary care services for this population.

The Relationship Between Linkages to Behavioral Health Services in Pediatric Primary Care and Reductions in Non-urgent Emergency Department Visits Among Vulnerable Children

The integration of behavioral health (BH) services within pediatric primary care has been utilized as a way to address young children's social-emotional needs. This study aimed to examine whether linking at-risk young children to BH services is associated with a reduction in "non-urgent" emergency department (ED) visits. BH teams integrated in a pediatric clinic conducted socio-emotional screening in children 6-65 months of age and tracked ED utilization for children with positive screening. The results indicated that children with positive screening are less likely to have a non-urgent ED visit than children with negative screening with concerns (NWC) and are more likely to be connected to services. Among children in the NWC group, those connected to services were less likely to have non-urgent ED visits than those not connected to services. These findings suggest that integrated behavioral health care has the potential to reduce non-urgent ED visits among at-risk children.

Screening for Both Child Behavior and Social Determinants of Health in Pediatric Primary Care

OBJECTIVE

To implement comprehensive screening for child behavior and social determinants of health in an urban pediatric practice and explore rates of referrals and follow-up for positive screens.

METHOD

Quality improvement methodology was used to implement routine screening using an adapted version of the Survey of Well Being of Young Children, a child behavior and social screen, for all children aged 6 months to 10 years. Rates of screen administration and documentation were assessed for 18 months. Medical records of a convenience sample (N = 349) were reviewed to track referrals and follow-up for positive screens. A secondary analysis explored associations between reported parental concern for their child's behavior and both child behavior symptoms and social stressors.

RESULTS

Over 18 months, 2028 screens were administered. Screening rates reached 90% after introducing a tablet for screening. Provider documentation of screens averaged 62%. In the convenience sample, 28% scored positive for a behavioral problem, and 25% reported at least 1 social stressor. Of those with positive child behavior or social stressor screens, approximately 80% followed up with their primary medical doctor, and approximately 50% completed referrals to the clinic social worker. Further analysis indicated that referral and follow-up rates varied depending on whether the family identified child behavior or social issues. Logistic regression revealed that parental concern was independently associated with child behavior symptoms (p = 0.001) and social stressors (p = 0.002).

CONCLUSION

Implementing a comprehensive psychosocial screen is feasible in pediatric primary care and may help target referrals to address psychosocial health needs.

Mental Health Screening Quality Improvement Learning Collaborative in Pediatric Primary Care

BACKGROUND

In the United States, up to 20% of children experience a mental health (MH) disorder in a given year, many of whom remain untreated. Routine screening during annual well visits is 1 strategy providers can use to identify concerns early and facilitate appropriate intervention. However, many barriers exist to the effective implementation of such screening.

METHODS

A 15-month quality improvement learning collaborative was designed and implemented to improve screening practices in primary care. Participating practices completed a survey at 3 time points to assess preparedness and ability to promote and support MH issues. Monthly chart reviews were performed to assess the rates of screening at well visits, documentation of screening results, and appropriate coding practices.

RESULTS

Ten practices (including 107 providers) were active participants for the duration of the project. Screening rates increased from 1% at baseline to 74% by the end of the project. For the 1 practice for which more comprehensive data were available, these screening rates were sustained over time. Documentation of results and appropriate billing for reimbursement mirrored the improvement seen in screening rates.

CONCLUSIONS

The learning collaborative model can improve MH screening practices in pediatric primary care, an important first step toward early identification of children with concerns. More information is needed about the burden placed on practices and providers to implement these changes. Future research will be needed to determine if improved identification leads to improved access to care and outcomes.

Addressing the Mental Health Needs of Latino Children in Immigrant Families

Latino children in the United States, whether immigrants themselves or children in immigrant families, are at high risk for mental health disorders stemming from poverty, exposure to trauma, assimilation stressors, and discrimination. The timely identification and treatment of mental health disorders in Latino children are compromised by limited healthcare access and quality as well as the lack of routine mental health screening in pediatric primary care. Here we review Spanish-language validity and implementation studies of Bright Futures previsit mental health screening tools and models of care. We identify strengths and weaknesses in the literature and suggest tools for use in mental health care assessment, management, and treatment for Latino children in pediatric primary care. Pediatricians can improve care of Latino children through awareness of risk factors for mental health disorders, integration of evidence-based screening tools, and advocacy for culturally tailored mental health resources.

Childhood Maltreatment and Health Impact: The Examples of Cardiovascular Disease and Type 2 Diabetes Mellitus in Adults

Child maltreatment is associated with increased risk for an array of mental and physical health problems. We reviewed studies examining associations of child maltreatment, assessed either alone or in combination with other adversities, with cardiovascular disease (CVD) and Type 2 Diabetes. PubMed was searched for relevant studies until December, 2015. Forty publications met inclusion criteria. Consistent positive associations were noted across a range of childhood adversities. Child maltreatment was associated with CVD (myocardial infarction, stroke, ischemic heart disease, coronary heart disease) in 91.7% of studies, with diabetes in 88.2% of studies, and with blood pressure/hypertension in 61.5% of studies. Inclusion of mental disorders tended to attenuate associations. Sex-related differences were under-examined. Implications for future research and intervention efforts are discussed.

A system dynamics model of clinical decision thresholds for the detection of developmental-behavioral disorders

Background

Clinical decision-making has been conceptualized as a sequence of two separate processes: assessment of patients’ functioning and application of a decision threshold to determine whether the evidence is sufficient to justify a given decision. A range of factors, including use of evidence-based screening instruments, has the potential to influence either or both processes. However, implementation studies seldom specify or assess the mechanism by which screening is hypothesized to influence clinical decision-making, thus limiting their ability to address unexpected findings regarding clinicians’ behavior. Building on prior theory and empirical evidence, we created a system dynamics (SD) model of how physicians’ clinical decisions are influenced by their assessments of patients and by factors that may influence decision thresholds, such as knowledge of past patient outcomes. Using developmental-behavioral disorders as a case example, we then explore how referral decisions may be influenced by changes in context. Specifically, we compare predictions from the SD model to published implementation trials of evidence-based screening to understand physicians’ management of positive screening results and changes in referral rates. We also conduct virtual experiments regarding the influence of a variety of interventions that may influence physicians’ thresholds, including improved access to co-located mental health care and improved feedback systems regarding patient outcomes.

Results

Results of the SD model were consistent with recent implementation trials. For example, the SD model suggests that if screening improves physicians’ accuracy of assessment without also influencing decision thresholds, then a significant proportion of children with positive screens will not be referred and the effect of screening implementation on referral rates will be modest—results that are consistent with a large proportion of published screening trials. Consistent with prior theory, virtual experiments suggest that physicians’ decision thresholds can be influenced and detection of disabilities improved by increasing access to referral sources and enhancing feedback regarding false negative cases.

Conclusions

The SD model of clinical decision-making offers a theoretically based framework to improve understanding of physicians’ behavior and the results of screening implementation trials. The SD model is also useful for initial testing of hypothesized strategies to increase detection of under-identified medical conditions.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0517-0) contains supplementary material, which is available to authorized users.

Impact of pediatric mental health screening on clinical discussion and referral for services

OBJECTIVE

This study discusses the impact of mental health screening in pediatric primary care on the management of mental health concerns.

METHODS

Youth aged 11 years and their parents completed the Pediatric Symptom Checklist and chart reviews were used to gather information about discussion of mental health concerns and connection with mental health services. The study design was a post-intervention study with a concurrent comparison group of youth aged 12 years who were not offered a screening. The χ(2) or Fisher's exact tests and logistic regression were used to compare groups on outcome variables.

RESULTS

Parents who completed a mental health screening for their child were more likely to be referred and attend mental health services, attend a psychiatrist appointment, and discuss their concerns with the primary care provider compared with the comparison group.

CONCLUSIONS

Screening by parents improves detection of problems and fosters conversations with providers and subsequent connection with services.

Have rates of behavioral health assessment and treatment increased for Massachusetts children since the Rosie D. decision? A report from two primary care practices

Following a court decision (Rosie D. v. Romney), the Medicaid program in Massachusetts launched the statewide Children's Behavioral Health Initiative in 2008 to increase the recognition and treatment of behavioral health problems in pediatrics. We reviewed billing data (n = 64,194) and electronic medical records (n = 600) for well child visits in pediatrics in 2 practices to examine rates of behavioral health screening, problem identification, and treatment among children seen during the year before and 2 years after the program's implementation. According to electronic medical records, the percentage of well child visits that included any form of behavioral health assessment increased significantly during the first 2 years of the program, and pediatricians significantly increased their use of standardized screens. According to billing data, behavioral health treatment increased significantly. These findings suggest that behavioral health screening and treatment have increased following the Rosie D. decision.

Pediatric provider processes for behavioral health screening, decision making, and referral in sites with colocated mental health services

OBJECTIVE

Validated behavioral health (BH) screens are recommended for use at well-child visits. This study aimed to explore how pediatricians experience and use these screens for subsequent care decisions in primary care.

METHODS

The study took place at 4 safety net health centers. Fourteen interviews were conducted with pediatricians who were mandated to use validated BH screens at well-child visits. Interview questions focused on key domains, including clinic BH context, screening processes, assessment of screening scores, and decision making about referral to mental health services. Qualitative analysis used the Framework Approach.

RESULTS

A variety of themes emerged: BH screens were well accepted and valued for the way they facilitated discussion of mental health issues. However, screening results were not always used in the way that instrument designers intended. Providers' beliefs about the face validity of the instruments, and their observations about performance of instruments, led to discounting scored results. As a result, clinical decisions were made based on a variety of evidence, including individual item responses, parent or patient concerns, and perceived readiness for treatment. Additionally, providers, although interested in expanding their mental health discussions, perceived a lack of time and of their own skills to be major obstacles in this pursuit.

CONCLUSIONS

Screens act as important prompts to stimulate discussion of BH problems, but their actual scored results play a variable role in problem identification and treatment decisions. Modifications to scheduling policies, additional provider training, and enhanced collaboration with mental health professionals could support better BH integration in pediatric primary care.

Universal mental health screening in pediatric primary care: a systematic review

OBJECTIVE

Universal mental health screening in pediatric primary care is recommended, but studies report slow uptake and low rates of patient follow-through after referral to specialized services. This review examined possible explanations related to the process of screening, focusing on how parents and youth are engaged, and how providers evaluate and use screening results.

METHOD

A narrative synthesis was developed after a systematic review of 3 databases (plus follow-up of citations, expert recommendations, and checks for multiple publications about the same study). Searching identified 1,188 titles, and of these, 186 full-text articles were reviewed. Two authors extracted data from 45 articles meeting inclusion criteria.

RESULTS

Published studies report few details about how mental health screens were administered, including how clinicians explain their purpose or confidentiality, or whether help was provided for language, literacy, or disability problems. Although they were not addressed directly in the studies reviewed, uptake and detection rates appeared to vary with means of administration. Screening framed as universal, confidential, and intended to optimize attention to patient concerns increased acceptability. Studies said little about how providers were taught to explore screen results. Screening increased referrals, but many still followed negative screens, in some cases because of parent concerns apparently not reflected by screen results but possibly stemming from screen-prompted discussions.

CONCLUSIONS

Little research has addressed the process of engaging patients in mental health screening in pediatric primary care or how clinicians can best use screening results. The literature does offer suggestions for better clinical practice and research that may lead to improvements in uptake and outcome.

Assessing the impact of a web-based comprehensive somatic and mental health screening tool in pediatric primary care

OBJECTIVE

To evaluate how parents and physicians perceive the utility of a comprehensive, electronic previsit screener, and to assess its impact on the visit.

METHODS

A mixed methods design was used. English-speaking parents were recruited from 3 primary care systems (urban MD and rural NY and VT) when they presented for a well-child visit with a child 4 to 10 years of age. Parents completed an electronic previsit screen, which included somatic concerns, health risks, and 4 mental health tools (SCARED5, PHQ-2, SDQ Impact, and PSC-17). Parents completed an exit survey, and a subset were interviewed. All primary care providers (PCPs) were interviewed.

RESULTS

A total of 120 parents and 16 PCPs participated. The exit surveys showed that nearly 90% of parents agreed or strongly agreed that the screener was easy to use and maintained confidentiality. During interviews, parents noted that the screener helped with recall, validated concerns, reframed issues they thought might not be appropriate for primary care, and raised new questions. PCPs thought that the screener enabled them to normalize sensitive issues, and it permitted them to simultaneously focus and be comprehensive during the visit. Parents and PCPs agreed that the screener helped guide discussion, promoted in-depth exchange, and increased efficiency. Findings were consistent across quantitative and qualitative methods and between parents and PCPs.

CONCLUSIONS

A comprehensive electronic previsit screening tool is an acceptable and practical strategy to facilitate well-child visits. It may help with problem identification as well as with setting agendas, engaging the family, and balancing attention between somatic and psychosocial concerns.