Collaborative care outcomes for pediatric behavioral health problems: a cluster randomized trial

The influence of familial networks and stigma on prison-based medication initiation for individuals with opioid use disorder: Clinicians' perceptions

INTRODUCTION

Individuals with criminal legal system (CLS) involvement experience opioid use disorder (OUD) at elevated rates when compared to their non-justice involved counterparts. Medications for opioid use disorder (MOUD) are efficacious but underutilized within this population. Interpersonal relationships and stigma play salient roles in the outcomes of OUD treatment. This study examines prison-based treatment staff perspectives on how familial networks and stigma interact to impact one's decision of whether to initiate MOUD while in prison in Kentucky.

METHODS

A coding team analyzed qualitative interviews with prison-based clinicians (n = 23) and administrators (n = 9) collected from the Geographic variation in Addiction Treatment Experiences (GATE) study using NVivo software. The study analyzed excerpts associated with the primary codes of "stigma" and "social networks" and the secondary code of "family" in order to assess the relationship between familial stigma and MOUD initiation from treatment staff viewpoints.

RESULTS

Arising themes suggest that clients' families' lack of MOUD knowledge plays a crucial role in perpetuating related stigma, that this stigma often materializes as a belief that MOUD is a continuation of illicit substance use and that stigma levels vary across MOUD forms (e.g., more stigma towards agonists than antagonists).

CONCLUSIONS

These findings carry implications for better understanding how intervention stigma within one's familial network impacts prison-based medication initiation decisions. Resulting themes suggest support for continued expansion of efforts by Kentucky Department of Corrections to involve participant families in education and treatment initiatives to reduce intervention stigma and increase treatment utilization.

Reducing disparities in behavioral health treatment in pediatric primary care: a randomized controlled trial comparing Partnering to Achieve School Success (PASS) to usual ADHD care for children ages 5 to 11 - study protocol

BACKGROUND

Integrating behavioral health services into pediatric primary care can improve access to care, especially for children marginalized by poverty and racial/ethnic minority status. In primary care, a common presenting concern is attention-deficit/hyperactivity disorder (ADHD). Services in primary care for marginalized children with ADHD typically include medication alone; therapy to improve skills and build relationships is less available. This study evaluates the effectiveness of a behavioral intervention offered through primary care for marginalized families coping with ADHD (Partnering to Achieve School Success, PASS) compared to treatment as usual (TAU).

METHOD

Three hundred participants will be randomly assigned to PASS or TAU. Participants include children ages 5 to 11 who have ADHD and are from economically marginalized families. PASS is a personalized, enhanced behavioral intervention that includes evidence-based behavior therapy strategies and enhancements to promote family engagement, increase caregiver distress tolerance, and provide team-based care to improve academic and behavioral functioning. TAU includes services offered by primary care providers and referral for integrated behavioral health or community mental health services. Outcomes will be assessed at mid-treatment (8 weeks after baseline), post-treatment (16 weeks), and follow-up (32 weeks) using parent- and teacher-report measures of service use, child academic, behavioral, and social functioning, parenting practices, family empowerment, and team-based care. Mixed effects models will examine between-group differences at post-treatment and follow-up. Analyses will examine the mediating role of parenting practices, family empowerment, and team-based care. Subgroup analyses will examine differential effects of intervention by child clinical characteristics and socioeconomic factors.

DISCUSSION

This study is unique in targeting a population of children with ADHD marginalized by low socioeconomic resources and examining an intervention designed to address the challenges of families coping with chronic stress related to poverty.

TRIAL REGISTRATION

This study was registered on clinicaltrials.gov (NCT04082234) on September 5, 2019, prior to enrollment of the first participant. The current version of the protocol and IRB approval date is October 4, 2023. Results will be submitted to ClinicalTrials.gov no later than 30 days prior to the due date for the submission of the draft of the final research report to the Patient-Centered Outcomes Research Institute.

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

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

Real-World Depression Screening Practices Among Primary Care Providers Across Patient-Level and Provider-Level Characteristics

This study examined primary care provider (PCP) alignment with guideline-based care for adolescent depression screening and identified factors associated with post-screening responses. A retrospective chart review was conducted across 17 primary care clinics. Logistical regressions were estimated across provider specialties, sociodemographic factors, and patient clinical histories. Significant differences in follow-up and identification of depression were found among patients with more severe depression presentation. Follow-up screening was also more likely to be completed among patients with private insurance and less likely to occur among Black patients. Patients with significant mental health history of a mood concern, history of being prescribed psychotropic medication, were currently on medications at the time of the screening, or had a history of an internal mental health referral had a higher predicted probability of being identified as depressed on the patient problem list.

Quantifying Potential Bias Resulting From Child Age on Screening for Hyperactive/Impulsive Presentations of ADHD

OBJECTIVE

This study aims to quantify the potential age bias in screening of hyperactive/impulsive presentations of ADHD in children ages 5 to 12 through comparison of age-based and overall percentiles in screening.

METHOD

A referred clinical sample of 307 children ages 5 to 12 with behavioral concerns completed the Vanderbilt Attention Deficit-Hyperactivity Disorder Diagnostic Parent Rating Scale (VADPRS) and were formally evaluated for ADHD with a diagnostic interview. Analysis utilizing logistic regression and receiver operating characteristic (ROC) curves was performed to compare the screening performance of agebased and overall percentiles.

RESULTS

The age-based percentiles demonstrated no improvement in the analyzed models compared to overall percentiles in hyperactive presentation ADHD screening. This finding was present in the overall sample and in the sub analysis of the 5 to 6 year old children.

CONCLUSIONS

This study identifies no improvement in modeling of hyperactive/impulsive ADHD screening when considering a child's age using age-based percentiles.

The effectiveness of collaborative care delivered via telehealth in a pediatric primary care population

Introduction

The prevalence of mental health conditions among children and adolescents in the United States has become a pressing concern, exacerbated by the COVID-19 pandemic. Collaborative care is an evidence-based model for identifying and treating depression and anxiety in healthcare settings, with additional promise for remote healthcare delivery. This study aims to evaluate the impact of a telehealth collaborative care model for adolescents with depression and anxiety in pediatric and primary care settings.

Methods

Secondary analysis was conducted using de-identified national data from Concert Health, a behavioral health medical group offering remote collaborative care across 17 states. Baseline, 90-day, and 120-day assessments of the PHQ-9 and GAD-7 were collected, along with baseline covariates. Stepwise regression analysis was performed to determine the contribution of select covariates to improvement rates.

Results

Among the analyzed data, 263 participants had complete PHQ-9 data, and 230 had complete GAD-7 data. In both the PHQ-9 and GAD-7 groups, over 50% of patients experienced treatment success based on success at discharge, as well as 90- and 120-day improvement rates. Predictors of success at discharge for the GAD-7 group included age at enrollment (OR 1.2258, 95% CI 1.01-1.496), clinical touchpoints (OR 1.1469, 95% CI 1.086-1.218), and lower baseline GAD-7 score (OR 0.9319, 95% CI 0.874-0.992). For the PHQ-9 group, Medicaid was significantly associated with not achieving a 50% reduction in PHQ-9 score at 120 days (OR 0.5874, 95% CI 0.349-0.979).

Discussion

Collaborative care has demonstrated its effectiveness in treating adolescent populations, providing an opportunity to expand access to evidence-based behavioral health treatment for young individuals. Notably, collaborative care is already integrated into the Medicaid fee schedule for 22 states and accepted by all commercial payers. Given that individuals often turn to their trusted primary care providers for behavioral health care, offering collaborative care to adolescents can play a crucial role in addressing the ongoing mental health crisis.

Advancing Collaborative Care for Autistic Children and Adolescents

This Viewpoint discusses an implementation strategy for the Collaborative Care Model to address the need for proper evaluation and treatment for autistic children with a co-occurring mental health condition.

Using session recordings to understand the content of community-based treatment for childhood anxiety disorders and response to technology-based training

OBJECTIVE

The goal of the current study is to advance efforts to increase the quality of care for childhood anxiety disorder (CADs) through (1) detailing the content of community-based treatment sessions, (2) exploring the validity of therapist surveys, (3) examining the influence of setting differences, and (4) testing the effects of a technology-based training on use of nonexposure strategies.

METHODS

Thirteen therapists were randomly assigned to technology-based training in the use of exposure therapy or treatment as usual (TAU) for CADs. Therapeutic techniques were coded from 125 community-based treatment sessions.

RESULTS

Consistent with survey responses community therapists spent the majority of session time reviewing symptoms (34% of session time), implementing nonexposure cognitive behavioral therapy (CBT; 36%), and rarely engaged in exposure (3%). An integrated behavioral health setting was associated with greater endorsement of exposure on survey, p < 0.05, although this difference was not significant in session recordings, p = 0.14. Multilevel models indicated that technology-based training that has been shown to increase exposure, also decreased use of nonexposure CBT techniques (2% vs. 29%, p < 0.001).

CONCLUSION

The study supports the validity of survey-based findings that community-based care for CADs consists of non-exposure CBT techniques. Efforts should be invested in dissemination of within-session exposure.

Effects of a Primary Care-Based Engagement Intervention for Improving Use of ADHD Treatments

INTRODUCTION

Uptake of attention deficit hyperactivity disorder (ADHD) treatments is low in primary care. A quasi-experimental study assessed the impact of a primary care-based engagement intervention to improve ADHD treatment use.

METHOD

Families of children with ADHD from four pediatric clinics were invited to participate in a two-stage intervention. The first step was an assessment battery to assess functioning and identify goals, followed by an in-office engagement session run by primary care staff.

RESULTS

Of the 636 invited families, 184 (28.9%) completed ratings, with 95 (51%) families completing the engagement session. ADHD office visits varied based on the number of steps completed (0-2). ADHD prescriptions decreased over time in families completing neither step but increased for children previously unmedicated whose parents completed either step. Families completing both steps had the highest rates of nonmedication ADHD treatments.

DISCUSSION

A brief two-step engagement intervention was associated with increased uptake of ADHD treatments.

Principles of Child Health Care Financing

The American Academy of Pediatrics believes that the United States can and should ensure that all children, adolescents, and young adults from birth through the age of 26 years who reside within its borders have affordable access to high-quality comprehensive health care. Comprehensive, high-quality care addresses issues, challenges, and opportunities unique to children and young adults and addresses the effects of historic and present inequities. All families should have equitable access to professionals and facilities with expertise in the care of children within a reasonable distance of their residence. Payment methodologies should be structured to guarantee the economic viability of the pediatric medical home and of pediatric specialty and subspecialty practices. The recent increase in child uninsurance over the last several years is a threat to the well-being of children and families in the short- and long-term. Deficiencies in plans currently covering insured children pose similar threats. The AAP believes that the United States must not sacrifice recent hard-won gains for our children and that child health care financing should be based on the following guiding principles: (1) coverage with quality, affordable health insurance should be universal; (2) comprehensive pediatric services should be covered; (3) cost sharing should be affordable and should not negatively affect care; (4) payment should be adequate to strengthen family- and patient-centered medical homes; (5) child health financing policy should promote equity and address longstanding health and health care disparities; and (6) the unique characteristics and needs of children should be reflected.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A randomized controlled clinical trial to improve health outcomes in youth with type 1 diabetes: Study design and baseline characteristics

Most adolescents with T1D do not meet glycemic recommendations or consistently perform the required self-management behaviors to prevent acute- and long-term deleterious health outcomes. In addition, most youth with T1D do not have access to behavioral health services to address T1D management barriers. Thus, delivering behavioral interventions during routine medical appointments may hold promise for improving T1D outcomes in adolescents. The overall objective of this study was to examine the effect of behavioral interventions, either a Personalized T1D Self-Management Behaviors Feedback Report or Problem-Solving Skills, delivered by a T1D behavioral health provider and a T1D medical provider during a joint, fully integrated appointment to improve health outcomes in youth with T1D. This paper describes the study rationale, design, and baseline characteristics for the 109 adolescent-caregiver dyads who participated. Primary and secondary outcomes include hemoglobin A1c (A1C), T1D self-management behaviors, and biological indicators of complications.

Treatment for Anxiety Disorders in the Pediatric Primary Care Setting

Anxiety disorders are among the most diagnosed mental health problems in children and adolescents. Without intervention, anxiety disorders in youth are chronic, debilitating, and amplify risk of negative sequelae. Youth with anxiety present to primary care frequently and often families choose to first discuss mental health concerns with their pediatricians. Both behavioral and pharmacologic interventions can be effectively implemented in primary care, and research demonstrates the effectiveness of both approaches.

Stemming the tide of mental health problems in young people: Challenges and potential solutions

One in five people experience clinically relevant mental health problems before the age of 25 years. Furthermore, in Australia, one in seven children are reported to experience a mental health disorder. Consequently, there has been a steady increase in demand for mental health services for children and young people, and this has been compounded by the COVID-19 pandemic. Unfortunately, currently many children and young people with mental health difficulties are not accessing appropriate and/or timely care, with individuals and families finding it increasingly difficult to access and navigate suitable services. In part, this is related to the fragmented and isolated manner in which child mental health services are operating. To address the current issues in access to appropriate child and adolescent mental health care in Australia, a novel Integrated Continuum of Connect and Care model is proposed to integrate relevant services along a tiered care pathway. The aim of this model is to facilitate timely access to mental health services that meet the specific needs of each child/young person and their family. This model will function within co-located service hubs that integrate health care through a comprehensive assessment followed by a link up to relevant services. The Integrated Continuum of Connect and Care has the potential to pave the way for unifying the fragmented child and youth mental health system in Australia.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care

OBJECTIVE

The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of collaborative mental health care in the pediatric primary care setting.

METHOD

A search of the literature on this topic from 2001was conducted initially in 2016, yielding 2,279 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 2,467 total citations, of which 1,962 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 219 based on topic relevance. A follow-up search from 2016 was conducted in 2021, yielding 2 additional citations based on nonduplication from initial search and topic relevance.

RESULTS

The collaborative care approach, arising in the 1990s and gaining momentum in the 2000s, aims to extend behavioral health care to the primary care setting. The goal of collaborative care is to conserve the sparse specialty care workforce for severe and complex psychiatric disorders through shifting certain specialty mental health tasks (eg, assessment; patient self-management; brief psychosocial intervention; basic psychopharmacology; care coordination) to primary care. Collaborative care can be delivered on a spectrum ranging from coordinated to co-located to integrated care. Although each of these models has some empirical support, integrated care-a multidisciplinary team-based approach-has the strongest evidence base in improving clinical outcomes and patient satisfaction while constraining costs. Challenges to integrated care implementation include insufficient mental health education and insufficient specialist consultative and care coordination support for primary care practitioners; space, time, and reimbursement constraints in the primary care setting; discomfort among primary care practitioners in assuming mental health tasks previously undertaken by specialists; and continuing need for and unavailability of ongoing specialty mental health care for severe and complex cases. Essential supporting activities for effective collaborative care include patient and family engagement, professional education and training, evaluation/demonstration of impact, fiscal sustainability, and advocacy for model dissemination.

CONCLUSION

Health professionals who are educated in the collaborative care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.

Referring Attention-Deficit/Hyperactivity Disorder: Gaining Perspective From Advanced Practice Providers in Primary Care

The objective of the current study is to identify provider, patient, and family characteristics associated with pediatric advanced practice provider (APP) decisions to refer to a subspecialist for diagnosis and management of attention-deficit/hyperactivity disorder (ADHD). We conducted a cross-sectional electronic survey of pediatric primary care APPs using member lists of professional organizations. T tests and chi-square analysis were conducted to identify group differences. Most respondents rated themselves as comfortable diagnosing and managing ADHD. We found no significant difference between groups based on comfort level or likelihood to refer. APPs working in suburban settings report significantly lower levels of comfort. Self-designation as the practice's primary provider for behavioral/mental health concerns had significantly higher levels of comfort and were less likely to refer. In a limited sample, most APPs reported comfort diagnosing and managing ADHD. Activities to identify and ameliorate gaps in ADHD knowledge and care need to consider this growing part of the workforce.

Clinical decision support methods for children and youths with mental health disorders in primary care

BACKGROUND

Mental health disorders among children and youths are common and often have negative consequences for children, youths, and families if unrecognized and untreated. With the goal of early recognition, primary care physicians (PCPs) play a significant role in the detection and referral of mental disorders. However, PCPs report several barriers related to confidence, knowledge, and interdisciplinary collaboration. Therefore, initiatives have been taken to assist PCPs in their clinical decision-making through clinical decision support methods (CDSMs).

OBJECTIVES

This review aimed to identify CDSMs in the literature and describe their functionalities and quality.

METHODS

In this review, a search strategy was performed to access all available studies in PubMed, PsychINFO, Embase, Web of Science, and COCHRANE using keywords. Studies that involved CDSMs for PCP clinical decision-making regarding psychosocial or psychiatric problems among children and youths (0-24 years old) were included. The search was conducted according to PRISMA-Protocols.

RESULTS

Of 1,294 studies identified, 25 were eligible for inclusion and varied in quality. Eighteen CDSMs were described. Fourteen studies described computer-based methods with decision support, focusing on self-help, probable diagnosis, and treatment suggestions. Nine studies described telecommunication methods, which offered support through interdisciplinary (video) calls. Two studies described CDSMs with a combination of components related to the two CDSM categories.

CONCLUSION

Easy-to-use CDSMs of good quality are valuable for advising PCPs on the detection and referral of children and youths with mental health disorders. However, valid multicentre research on a combination of computer-based methods and telecommunication is still needed.

The Role of Psychologists in Sport Medicine Practice

Young athletes face a unique set of stressors from nonathletes that require careful screening and management. Internalizing disorders, substance use, overtraining, eating disorders, the female athlete triad, and sport-related injury are some psychological issues related to sports participation. Young athletes experiencing these conditions may experience functional impairment and distress on and off the field and management of these concerns includes routine screening and intervention. Embedding a psychologist within a pediatric sports medicine clinic improves patients' access to psychological screenings, early identification, and early intervention for these concerns athletes face.

Paediatric integrated care in the primary care setting: A scoping review of populations served, models used and outcomes measured

BACKGROUND

Paediatric integrated care (PIC), which involves primary care and behavioural health clinicians working together with patients and families, has been promoted as a best practice in the provision of care. In this context, behavioural health includes behavioural elements in the care of mental health and substance abuse conditions, chronic illness and physical symptoms associated with stress, and addressing health behaviours. Models of and contexts in which PIC has been applied vary, as do the outcomes and measures used to determine its value. Thus, this study seeks to better understand (1) what paediatric subpopulations are receiving integrated care, (2) which models of PIC are being studied, (3) what PIC outcomes are being explored and what measures and strategies are being used to assess those outcomes, and (4) whether the various models are resulting in positive outcomes. These questions have significant policy and clinical implications, given current national- and state-level efforts aimed at promoting integrated health care.

METHODS

This study utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews to identify relevant articles published between January 1994 and 30 June 2020. The search utilized three databases: PubMed, PsycInfo and CINAHL. A total of 28 articles met the eligibility criteria for inclusion.

RESULTS

Overall, acceptability of PIC appears to be high for patients and providers, with access, screening and engagement generally increasing. However, several gaps in the knowledge base on PIC were uncovered, and for some studies, ascertaining which models of integrated care were being implemented proved difficult.

CONCLUSION

PIC has the potential to improve access to and quality of behavioural health care, but more research is needed to understand what models of PIC prove most beneficial and which policies and conditions promote cost efficiency. Rigorous evaluation of patient outcomes, provider training, institutional buy-in and system-level changes are needed.

Association of Behavioral and Mental Health Professionals in Continuity Clinic with Resident-Reported Competence

OBJECTIVE

To assess whether residents who trained with a colocated or integrated behavioral/mental health professional (B/MHP) reported greater competence in the assessment and management of behavioral/mental health (B/MH) conditions than those who trained without an onsite B/MHP. We hypothesized that having an onsite B/MHP would be associated with greater self-reported competence, especially if integrated into clinic.

STUDY DESIGN

Cross-sectional survey of applicants for the initial American Board of Pediatrics (ABP) certifying examination. The independent variable was training in a continuity clinic with no onsite B/MHP, a colocated B/MHP, or an integrated B/MHP. Outcome variables were self-reported competence in 7 B/MH assessment skills and 9 treatment skills, summarized as 2 composite measures. Competence was rated on a 5-point scale; high competence was defined as mean scores ≥4. Logistic regression assessed relationships between independent and outcome variables adjusting for covariates including individual and residency program characteristics.

RESULTS

Of 1503 eligible respondents, 645 (42.9%) reported no onsite B/MHP, 390 (26.0%) a colocated B/MHP, and 468 (31.1%) an integrated B/MHP. In multivariable models, respondents with a colocated B/MHP reported greater levels of B/MH assessment competence (aOR 1.40, 95% CI1.06-1.86) and treatment competence (aOR 1.45, 95% CI 1.03-2.05) compared with those with no B/MHP. Respondents with an integrated B/MHP similarly reported greater odds of assessment (aOR 1.33, 95%CI 1.02-1.74) and treatment competence (aOR 1.53, 95% CI 1.10-2.13) than the reference group.

CONCLUSIONS

Although specific mechanisms were not tested, training with an onsite B/MHP within a continuity clinic may improve pediatric trainees' competence for addressing B/MH conditions.

Developing and applying synergistic multilevel implementation strategies to promote reach of an evidence-based parenting intervention in primary care

Background: This practical implementation report describes a primary care-based group parenting intervention—Child–Adult Relationship Enhancement in Primary Care (PriCARE)—and the approach taken to understand and strengthen the referral process for PriCARE within a pediatric primary care clinic through the deployment of synergistic implementation strategies to promote physician referrals. PriCARE has evidence of effectiveness for reducing child behavior problems, harsh and permissive parenting, and parent stress from three randomized controlled trials (RCTs). The integration of evidence-based parenting interventions into pediatric primary care is a promising means for widespread dissemination. Yet, even when integrated into this setting, the true reach will depend on parents knowing about and attending the intervention. A key factor in this process is the endorsement of and referral to the intervention by the child's pediatrician. Therefore, identifying strategies to improve physician referrals to parenting interventions embedded in primary care is worthy of investigation. Method: Through lessons learned from the RCTs and key informant interviews with stakeholders, we identified barriers and facilitators to physician referrals of eligible parent–child dyads to PriCARE. Based on this data, we selected and implemented five strategies to increase the PriCARE referral rate. We outline the selection process, the postulated synergistic interactions, and the results of these efforts. Conclusions: The following five discrete strategies were implemented: physician reminders, direct advertising to patients, incentives/public recognition, interpersonal patient narratives, and audit and feedback. These discrete strategies were synergistically combined to create a multifaceted approach to improve physician referrals. Following implementation, referrals increased from 13% to 55%. Continued development, application, and evaluation of implementation strategies to promote the uptake of evidence-based parenting interventions into general use in the primary care setting are discussed.

Plain Language Summary

There is strong evidence that parenting interventions are effective at improving child behavioral health outcomes when delivered in coordination with pediatric primary care. However, there is a lack of focus on the implementation, including the screening and referral process, of parenting interventions in the primary care setting. This is contributing to the delay in the scale-up of parenting interventions and to achieving public health impact. To address this gap, we identified barriers and facilitators to physician screening and referrals to a primary care-based parenting intervention, and selected and piloted five synergistic strategies to improve this critical process. This effort successfully increased physician referrals of eligible patients to the intervention from 13% to 55%. This demonstration project may help advance the implementation of evidence-based interventions by providing an example of how to develop and execute multilevel strategies to improve intervention referrals in a local context.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

International perspective on integrated care models in child and adult mental health

The dearth of child and adolescent mental health services (CAMHS) is a global problem. Integrating CAMHS in primary care has been offered as a solution. We sampled integrated care perspectives from colleagues around the world. Our findings include various models of integrated care namely: the stepped care model in Australia; shared care in the United Kingdom (UK) and Spain; school-based collaborative care in Qatar, Singapore and the state of Texas in the US; collaborative care in Canada, Brazil, US, and Uruguay; coordinated care in the US; and, developing collaborative care models in low-resource settings, like Kenya and Micronesia. These findings provide insights into training initiatives necessary to build CAMHS workforce capacity using integrated care models, each with the ultimate goal of improving access to care. Despite variations and progress in implementing integrated care models internationally, common challenges exist: funding within complex healthcare systems, limited training mechanisms, and geopolitical/policy issues. Supportive healthcare policy, robust training initiatives, ongoing quality improvement and measurement of outcomes across programs would provide data-driven support for the expansion of integrated care and ensure its sustainability.

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

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

Are the voices of parents heard? A scoping review of satisfaction in parenting programs

Parenting programs are an effective approach to promote positive parenting. In evidence-based practice, client's values and preferences contribute to promoting quality, and are a crucial component of service evaluation. The current scoping review summarizes quantitative research that examines parental satisfaction with parent training for families with child conduct problems. We aimed to know how much research had been undertaken; what measures have been used; and what were the findings related to parental satisfaction. A scoping review was conducted to retrieve peer-reviewed original articles. Out of 420 papers 5.5 % obtained data on parental satisfaction. Seven different measures were used, mainly Therapy Attitude Inventory and Client Satisfaction Questionnaire. Out of 23 papers, ten studies reported Cronbach's alpha coefficients on the assessment that was used to evaluate parental satisfaction. All of the 23 included studies found that parents are very satisfied with the parenting program they have received. The findings indicate that only a few studies included parents' values and preferences in quantitative evaluation studies on parental programs. In addition, there is a limited arsenal of assessment tools to measure what matters to parents. There is a need to develop measures with high psychometric quality, which will promote more quality in service evaluation.

Screening for Anxiety in Pediatric Primary Care: A Systematic Review

CONTEXT

Anxiety is common, screening tools are available, and treatment can be effective. Recently, anxiety screening has been recommended for adolescent girls beginning at 13 years of age.

OBJECTIVE

To evaluate the evidence regarding anxiety screening test accuracy in primary care for children and adolescents and assess the effectiveness of treatment of individuals identified through screening.

DATA SOURCES

We searched PubMed, the Cochrane library, and references to potentially eligible studies cited in other articles.

STUDY SELECTION

Screening studies were included if they were conducted in primary care or a similar population and employed a reference standard based on DSM criteria. Treatment studies were included if subjects were identified through screening and there was at least 1 comparator intervention or a placebo arm.

DATA EXTRACTION

At least 2 reviewers evaluated each identified reference.

RESULTS

Two screening studies (1 with low risk of bias and 1 with high risk of bias) and 1 treatment study with a low risk of bias were included. The screening study with a low risk of bias reported a sensitivity of 56% and specificity of 80%. The treatment study found individual cognitive behavioral therapy to be effective for screen-detected adolescents with social phobia.

LIMITATIONS

This review only included screening or treatment studies with clear evidence that the study populations were derived from an unselected population reflective of typical primary care. Relevant studies not indexed in PubMed or the Cochrane library could have been missed.

CONCLUSIONS

There are significant gaps in evidence related to anxiety screening in the primary care setting.

The Use of Electronic Health Record Tools to Improve Evidence-Based Treatment of Adolescent Depression in Primary Care

OBJECTIVE

The aim of the current study was to evaluate primary care pediatrician (PCP) adoption of an electronic health record (EHR) documentation tool and their delivery of a behavioral activation (BA) intervention within their routine practice with adolescents who screened positive for depression.

METHODS

We used the RE-AIM framework to describe PCP adoption and implementation of EHR documentation tools and brief evidence-based protocols. Utilization was assessed using a customized toolbar (ie, actions toolbar) via retrospective chart review. A pre-post design was used to measure changes in PCP-reported knowledge, comfort, and feasibility managing depression before and after they were trained. A mixed-effects logistic regression model was used to analyze associations of resource utilization with depression severity.

RESULTS

PCPs used the actions toolbar to document responses to elevated Patient Health Questionnaire (PHQ-9) scores for 29.80% of encounters. The PCPs utilized the BA protocol for 10.5% of encounters with elevated PHQ-9 scores. Higher depression severity categories were associated with significantly higher odds of utilization relative to mild severity. The training was rated highly acceptable and PCPs reported significant post-training increases in comfort and feasibility.

CONCLUSION

This is the first study of its kind to implement and evaluate PCP utilization of an EHR documentation tool aimed to improve delivery of an evidence-based intervention for adolescent depression. Teaching PCPs to implement brief interventions has potential to increase access to evidence-based care; however, large-scale practice change requires an effective implementation strategy that does not increase provider burden and is fully integrated into physician documentation and workflow.

All together: Integrated care for youth with type 1 diabetes

OBJECTIVE

We describe the implementation and evaluation of an integrated, stepped care model aimed to identify and address the concerns of adolescents with type 1 diabetes (T1D) associated with diabetes-related quality of life (DRQoL), emotional well-being, and depression.

RESEARCH DESIGN AND METHODS

The care model with 4 steps: (1) Systematic identification and discussion of concerns salient to adolescents; (2) Secondary screening for depressive symptoms when indicated; (3) Developing collaborative treatment plans with joint physical and mental health goals; and (4) Psychiatric assessment and embedded mental health treatment; was implemented into an ambulatory pediatric diabetes clinic and evaluated using quantitative and qualitative methods.

RESULTS

There were 236 adolescents (aged 13-18 years) with T1D that were enrolled in the care model. On average adolescents identified three concerns associated with their DRQoL and 25% indicated low emotional well-being. Fifteen adolescents received a psychiatric assessment and embedded mental health treatment. Both adolescents and caregivers were appreciative of a broader, more holistic approach to their diabetes care and to the greater focus of the care model on adolescents, who were encouraged to self-direct the conversation. Parents also appreciated the extra level of support and the ability to receive mental health care for their adolescents from their own diabetes care team.

CONCLUSION

The initial findings from this project indicate the acceptability and, to limited extent, the feasibility of an integrated stepped care model embedded in an ambulatory pediatric diabetes clinic led by an interdisciplinary care team. The care model facilitated the identification and discussion of concerns salient to youth and provided a more holistic approach.

A new mechanism for purchasing through personal interactions: fairness, trust and social influence in online group buying

Purpose

The purpose of this article was to explore the influence of individual perception and social climate on consumer-initiated group-buying purchase decisions. An extended cross-level research model was used to explain how a new mechanism for purchasing through personal interactions could work.

Design/methodology/approach

This study utilised a questionnaire survey for data gathering. The subjects of the investigation were group-buying initiators. Hierarchical linear modelling (HLM) was used to experimentally examine the research hypotheses.

Findings

The empirical results of the study indicate that the social influence of critical mass can effectively promote positive attitudes and intentions towards consumer-initiated online group buying. An individuals' perception of an initiator's fairness influences their trust in the initiator. In addition, trust in the initiator can positively and significantly influence buyers' attitudes and intentions to online group buying.

Originality/value

Most previous studies on online group-buying focus on how social media influences group-buying behaviours. This study extends social media research by introducing an extended cross-level model to provide a comprehensive investigation into online-shopping. It is a preliminary attempt to systematically verify relationships at the individual and aggregate levels. The decision to group buying requires a relationship of trust to be formed before any transaction takes place, thereby increasing the intention to make a purchase. As a result, group buying is perceived as positive when interpersonal communication is very efficient, or when social influence is high.

A primary care modification of family-based treatment for adolescent restrictive eating disorders

Although eating disorders pose a significant threat to the health and well-being of children and adolescents, due to a profound scarcity of specialty providers, only a small percentage of patients receives evidence-based treatment. To improve access to care for restrictive eating disorders, we developed a modified version of Family-Based Treatment to be delivered by primary care providers (PCPs) and conducted a pilot study to evaluate the feasibility and preliminary outcomes of this intervention. Fifteen adolescents (mean age = 15.5 years) with restrictive eating disorders and their caregiver(s) were enrolled in Family-Based Treatment for Primary Care (FBT-PC), delivered by three trained PCPs. Retention for the intervention was high (n = 13, 86.7%). Over the course of 3 months, participants attended an average of 9.2 (SD = 2.8) sessions and experienced a significant increase in BMI percentile from 39.1 to 54.8 (t (13) = -6.71, p < .001; d = .61). FBT-PC appears to be feasible for implementation in the primary care setting and has the potential to improve access to treatment and yield positive outcomes for young patients with restrictive eating disorders.

Barriers for Ethnic Minorities and Low Socioeconomic Status Pediatric Patients for Behavioral Health Services and Benefits of an Integrated Behavioral Health Model

The integrated behavioral health care model in primary care has the potential to reduce barriers to care experienced by children and families from ethnic minorities and low socioeconomic status. Limited access to pediatric behavioral health care is a significant problem, with up to 40% of children and adolescents with identified mental disorders and only 30% of them receiving care. Barriers include transportation, insurance, and shortage of specialists. Primary care provider bias, decreased knowledge and feelings of competence, and cultural beliefs and stigma also affect earlier diagnosis and treatment, particularly for Hispanic families with low English proficiency and African Americans.

The Continuum of Intervention Models in Integrated Behavioral Health

The current models of clinical collaboration between physicians and psychologists/social workers in the pediatric outpatient primary care setting fall along a continuum of integration of services and philosophies of care. Domains of integration include physical office location, the targeted patient population, the level of professional adaptation to other professions' model of training, and the influence of current models of reimbursement. Included here is an analysis of those models based on each continuum of integration. Each model is discussed with respect to where it falls on each continuum.

Integrated Behavioral Health and Intervention Models

Accumulating evidence documenting the high percentage of patients who first discuss mental health needs with their primary care physician has accelerated the integration of physical and mental health care to a national priority. Several models have been developed describing how health care settings can integrate physical and mental health care and how training programs might better prepare clinicians to work in integrated behavioral health care settings. This article explores models of integrated behavioral health, highlights contributions of social work and psychology, and describes the training and experiences of social workers and psychologists working in integrated behavioral health.

Can adolescents with eating disorders be treated in primary care? A retrospective clinical cohort study

BACKGROUND

Family-Based Treatment (FBT) is considered the first-line intervention for adolescent anorexia nervosa. However, access to this treatment is limited. Treatment programs for other pediatric mental health conditions have successfully overcome barriers to accessing evidence-based intervention by integrating mental health services into primary care. This study evaluated the proof-of-concept of a novel modification of FBT, Family-Based Treatment for Primary Care (FBT-PC) for adolescent restrictive eating disorders designed for delivery by primary care providers in their practices.

METHODS

This retrospective clinical cohort study evaluated 15 adolescents with restrictive eating disorders receiving FBT-PC and 15 adolescents receiving standard FBT. We examined improvement in BMI percentile, reduction in weight suppression, and clinical benchmarks of eating disorder recovery including weight restoration to > 95% of expected body weight (EBW) and resolution of DSM-5 criteria for eating disorders.

RESULTS

In both groups, effect sizes for increased BMI percentile exceeded Cohen's convention for a large effect (FBT-PC: d = .94; standard FBT: d = 1.15) as did effect sizes for reduction in weight suppression (FBT-PC: d = 1.83; standard FBT: d = 1.21). At the end of treatment, 80% of the FBT-PC cohort and 87% in the standard FBT group achieved > 95%EBW and 67% in the FBT-PC group and 60% in the standard FBT group no longer met DSM-5 criteria for an eating disorder. There were no cohort differences in the number of treatment drop-outs or referrals to a more intensive level of eating disorder treatment.

CONCLUSIONS

Findings suggest that primary care providers have potential to improve weight and clinical status in adolescents with restrictive eating disorders. Based on these results, more rigorous testing of the FBT-PC model is warranted.

L’engagement dans les soins en collaboration en santé mentale jeunesse pour les familles migrantes : des lieux cliniques ancrés dans leurs contextes institutionnel et sociopolitique

Objectifs Cet article vise à combler certaines lacunes dans la littérature concernant les conditions propices à des soins en collaboration de qualité en santé mentale jeunesse (SMJ) pour les jeunes migrants et leurs familles, dans les services de première ligne. Il examine les facteurs susceptibles de favoriser l’engagement des familles migrantes dans les services, en tenant compte des dimensions liées à la rencontre clinique, aux enjeux systémiques et aux questions institutionnelles/sociopolitiques.

Méthode Utilisant un devis multiphase en méthodes mixtes, l’article présente séquentiellement les résultats qualitatifs et quantitatifs spécifiques aux familles migrantes, d’un vaste programme de recherche sur les soins en collaboration en SMJ dans des quartiers culturellement et socioéconomiquement diversifiés. Ces résultats proviennent de données collectées à Montréal au cours de la dernière décennie par le biais de questionnaires, d’entrevues semi-structurées, de groupes de discussion, d’observation participante et de documentation. Les participants à la recherche étaient des enfants, des adolescents et des parents de familles migrantes, des cliniciens et des gestionnaires.

Résultats Les résultats suggèrent que le macrosystème sociopolitique et institutionnel structure l’espace de la clinique et influence le processus de soins. En particulier, les réformes successives du système de santé posent des défis de taille aux institutions et aux équipes en SMJ quant à leur capacité à créer un environnement favorable à la continuité des soins et au partenariat interinstitutionnel et à la collaboration interprofessionnelle, des facteurs associés à l’engagement des familles dans les soins. Cet engagement est également tributaire des représentations que les familles migrantes se font de la santé mentale et des services. Ces représentations sont façonnées par leur expérience des soins, mais aussi par ce que leur environnement socioculturel et les discours publics leur permettent d’imaginer de ces services. Cela invite à considérer une intégration de dimensions culturelles et sociopolitiques dans le concept d’engagement. Enfin, les résultats suggèrent également que les écoles jouent un rôle important pour favoriser l’engagement dans les soins de santé mentale.

Conclusion La qualité des soins de santé mentale pour les enfants et adolescents migrants dépend de l’engagement des familles dans les services, et aussi de l’engagement réciproque des cliniciens et des institutions. Les contextes politiques où des tensions entre les groupes majoritaires et minoritaires sont présentes peuvent également faire obstacle aux soins. Étant donné que les familles migrantes s’engagent moins dans les services par rapport aux familles non migrantes, ces considérations appellent à un examen important des moyens pour faciliter l’engagement des familles migrantes dans les soins en collaboration en SMJ. L’article propose certaines avenues pour favoriser cet engagement.

Notes from the Field: Results from the Parent Acceptance of Pediatric Integrated Care Survey

Objective:

To collect data and gain an understanding of parental satisfaction with and attitudes toward treatment in a pediatric integrated primary care (IPC) model.

Data Sources:

Primary data were collected across the United States over the course of a few months.

Study Design:

The 35-item, Parent Acceptance of Pediatric Integrated Care Survey (PAPICS) was developed by a panel of IPC experts. The survey was then distributed through the Qualtrics Panels Service with recruited participants (i.e., parents with children under 18-years-old) receiving a $4.00 incentive for their involvement.

Data Collection/Extraction Methods:

A single exploratory factor analysis was performed along with four factor retention tests and clinical judgment to guide factor selection. A 5-factor structure was selected.

Principal Findings:

Parents reported a high level of comfort with an IPC model and a favorable attitude toward child therapy, with some concerns regarding psychological stigma and privacy. Notable variation in parents’ beliefs regarding one-on-one psychological service delivery were observed.

Conclusions:

Results provided evidence for parental openness to an IPC model. Findings also highlighted potential fundamental misunderstandings regarding evidence-based psychological treatment methods for children and adolescents.

Measures of Organizational Culture and Climate in Primary Care: a Systematic Review

BACKGROUND

Primary care is increasingly contributing to improving the quality of patient care. This has imposed significant demands on clinicians with rising needs and limited resources. Organizational culture and climate have been found to be crucial in improving workforce well-being and hence quality of care. The objectives of this study are to identify organizational culture and climate measures used in primary care from 2008 to 2019 and evaluate their psychometric properties.

METHODS

Data sources include PubMed, PsycINFO, HAPI, CINAHL, and Mental Measurements Yearbook. Bibliographies of relevant articles were reviewed and a cited reference search in Scopus was performed. Eligibility criteria include primary health care professionals, primary care settings, and use of measures representing the general concept of organizational culture and climate. Consensus-Based Standards for the selection of health Measurement Instruments (COSMIN) guidelines were followed to evaluate individual studies for methodological quality, rate results of measurement properties, qualitatively pool studies by measure, and grade evidence.

RESULTS

Of 1745 initial studies, 42 studies met key study inclusion criteria, with 27 measures available for review (16 for organizational culture, 11 for organizational climate). There was considerable variability in measures, both conceptually and in psychometric quality. Many reported limited or no psychometric information.

DISCUSSION

Notable measures selected for frequent use and strength and applicability of measurement properties include the Culture Questionnaire adapted for health care settings, Practice Culture Assessment, and Medical Group Practice Culture Assessment for organizational culture. Notable climate measures include the Nurse Practitioner Primary Care Organizational Climate Questionnaire, Practice Climate Survey, and Task and Relational Climate Scale. This synthesis and appraisal of organizational culture and climate measures can help investigators make informed decisions in choosing a measure or deciding to develop a new one. In terms of limitations, ratings should be considered conservative due to adaptations of the COSMIN protocol for clinician populations.

PROSPERO REGISTRATION NUMBER

CRD 42019133117.

Behavioural, emotional and rhythm-related disturbances in toddlers: Preliminary findings from a community-based study in Kerala, India

PURPOSE

The need to enhance mental health in primary care settings for infants and toddlers is increasingly becoming apparent. However, the lack of trained healthcare personnel and culturally appropriate measures makes it a challenge in low- and middle-income countries. A needs-based assessment of the extent of the problems in toddlers will help address the lacunae in providing mental health services.

METHODS

A needs-based assessment was carried out of a community sample of 9,287 mothers with toddlers aged between 13 and 25 months in Kerala, India. This assessment was conducted by junior public health nurses using an indigenously developed checklist titled 'Screening checklist for Behavioural, Emotional and Rhythm-related disturbances in Toddlers' (S-BERT).

RESULTS

According to the mothers surveyed, 30.4% of toddlers had concerning or distress causing behaviours. Three factors, namely behavioural, rhythm-related and emotional disturbances, were deemed significant when the item response theory was used to examine the factor structure of S-BERT.

CONCLUSION

This study suggests that behaviours that cause distress to mothers of toddlers are common, if queried specifically. Given the constraints in health resources as the cultural factors in operation, use of indigenous tools and principles of collaborative stepped care may be the way forward.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

DISCUSSION

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

Provider Specialty and Receipt of Metabolic Monitoring for Children Taking Antipsychotics

BACKGROUND AND OBJECTIVES

Metabolic monitoring is important for children taking antipsychotic medication, given the risk for increased BMI, impaired glucose metabolism, and hyperlipidemia. The purpose was to examine the influence of provider specialty on the receipt of metabolic monitoring. Specifically, differences in the receipt of recommended care when a child receives outpatient care from a primary care provider (PCP), a mental health provider with prescribing privileges, or both was examined.

METHODS

Medicaid enrollment and health care and pharmacy claims data from 2 states were used in the analyses. Providers were assigned to specialties by using a crosswalk of the National Provider Identifier numbers to specialty type. A total of 41 078 children were included.

RESULTS

For both states, 61% of children saw ≥1 provider type and had adjusted odds ratios for receiving metabolic monitoring that were significantly higher than those of children seeing PCPs only. For example, children seeing a PCP and a mental health provider with prescribing privileges during the year had adjusted odds of receiving metabolic monitoring that were 42% higher than those seeing a PCP alone (P < .001).

CONCLUSIONS

Shared care arrangements significantly increased the chances that metabolic monitoring would be done. For states, health plans, and clinicians to develop meaningful quality improvement strategies, identifying the multiple providers caring for the children and potentially responsible for ordering tests consistent with evidence-based care is essential. Provider attribution in the context of shared care arrangements plays a critical role in driving quality improvement efforts.

Utilization of Integrated and Colocated Behavioral Health Models in Pediatric Primary Care

Integrating behavioral health services within pediatric primary care may help address barriers to these services for youth, especially the underserved. Models of primary care behavioral health include coordinated, colocated, integrated, and collaborative care. This study began exploring the comparative utility of these models by investigating differences in the demographics and diagnoses of patients seen for a behavioral health warm handoff (integrated model) and a scheduled behavioral health visit (colocated model) across 3 pediatric primary care sites. The 3 sites differed in their rates of warm handoff usage, and there were differences in certain diagnoses given at warm handoffs versus scheduled visits. Depression diagnoses were more likely to be given in warm handoffs, and disruptive behavior, trauma/adjustment, and attention-deficit/hyperactivity disorder-related diagnoses were more likely to be given in scheduled visits. These results have implications for the influence of office structure and standardized procedures on behavioral health models used in pediatric primary care.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rates of Mental Health Service Utilization by Children and Adolescents in Schools and Other Common Service Settings: A Systematic Review and Meta-Analysis

A meta-analysis was conducted to examine the relative rates of youth mental health service utilization across settings among the general population and among those with elevated mental health symptoms or clinical diagnoses. Rates of school-based mental health were compared to outpatient, primary care, child welfare, juvenile justice, and inpatient. Nine studies presented rates of mental health service use for general-population youth in the U.S., and 14 studies presented rates for youth with elevated symptoms or clinical diagnoses. Random effects meta-analysis was used to calculate mean proportions of youth receiving care in each sector. Of general population youth, 7.28% received school mental health services. Rates for other sectors are as follows: 7.26% in outpatient settings, 1.76% in primary care, 1.80% in inpatient, 1.35% in child welfare, and 0.90% juvenile justice. For youth with elevated mental health symptoms or diagnoses, 22.10% of youth were served by school-based mental health services, 20.56% outpatient settings, 9.93% primary care, 9.05% inpatient, 7.90% child welfare, and 4.50% juvenile justice. Schools and outpatient settings are the most common loci of mental health care for both the general population and samples of youth with elevated symptoms or clinical diagnoses, although substantial amounts of care are also provided in a range of other settings. Results hold potential for informing resource allocation, legislation and policy, intervention development, and research. Given that mental health services are delivered across many settings, findings also point to the need for interconnection across child-serving sectors, particularly schools and outpatient clinics.

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

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

Parenting Interventions in Pediatric Primary Care: A Systematic Review

CONTEXT

More than 4 decades of research indicate that parenting interventions are effective at preventing and treating mental, emotional, and behavioral disorders in children and adolescents. Pediatric primary care is a viable setting for delivery of these interventions.

OBJECTIVE

Previous meta-analyses have shown that behavioral interventions in primary care can improve clinical outcomes, but few reviews have been focused specifically on the implementation of parenting interventions in primary care. We aimed to fill this gap.

DATA SOURCES

We reviewed 6532 unique peer-reviewed articles published in PubMed, the Cumulative Index to Nursing and Allied Health Literature, and PsycInfo.

STUDY SELECTION

Articles were included if at least part of the intervention was delivered in or through primary care; parenting was targeted; and child-specific mental, emotional, and behavioral health outcomes were reported.

DATA EXTRACTION

Articles were reviewed in Covidence by 2 trained coders, with a third coder arbitrating discrepancies.

RESULTS

In our review of 40 studies, most studies were coded as a primary. Few researchers collected implementation outcomes, particularly those at the service delivery system level.

LIMITATIONS

Including only published articles could have resulted in underrepresentation of implementation-related data.

CONCLUSIONS

Parenting interventions delivered and implemented with fidelity in pediatric primary care could result in positive and equitable impacts on mental, emotional, and behavioral health outcomes for both parents and their children. Future research on the implementation strategies that can support adoption and sustained delivery of parenting interventions in primary care is needed if the field is to achieve population-level impact.

Towards Integrated Youth Care: A Systematic Review of Facilitators and Barriers for Professionals

To overcome fragmentation in support for children and their families with multiple and enduring problems across life domains, professionals increasingly try to organize integrated care. However, it is unclear what facilitators and barriers professionals experience when providing this integrated care. Our systematic review, including 55 studies from a broad variety of settings in Youth Care, showed that integrated care on a professional level is a multi-component entity consisting of several facilitators and barriers. Findings were clustered in seven general themes: ‘Child’s environment’, ‘Preconditions’, ‘Care process’, ‘Expertise’, ‘Interprofessional collaboration’, ‘Information exchange’, and ‘Professional identity’. The identified facilitators and barriers were generally consistent across studies, indicating broad applicability across settings and professional disciplines. This review clearly shows that when Youth Care professionals address a broad spectrum of problems, a variety of facilitators and barriers should be considered.

Registration PROSPERO, registration number CRD42018084527.

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

IMPORTANCE

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

OBJECTIVE

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSIONS AND RELEVANCE

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