Outpatient Visits and Medication Prescribing for US Children With Mental Health Conditions

Greater Frontoparietal Connectivity During Task Engagement Among Toddlers With Parent-Reported Inattention

Attention-deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with lifelong impairments. ADHD-related behaviors have been observed as early as toddlerhood for children who later develop ADHD. Children with ADHD have disrupted connectivity in neural circuitry involved in executive control of attention, including the prefrontal cortex (PFC) and dorsal attention network (DAN). It is not known if these alterations in connectivity can be identified before the onset of ADHD. Children (N = 51) 1.5-3 years old were assessed using functional near-infrared spectroscopy while engaging with a book. The relation between mother-reported ADHD-related behaviors and neural connectivity, computed using robust innovation-based correlation, was examined. Task engagement was high across the sample and unrelated to ADHD-related behaviors. Observed attention was associated with greater connectivity between the right lateral PFC and the right temporal parietal junction (TPJ). Children with greater ADHD-related behaviors had greater frontoparietal connectivity, particularly between the PFC bilaterally and the right TPJ. Toddlers at risk for developing ADHD may require increased frontoparietal connectivity to sustain attention. Future work is needed to examine early interventions that enhance developing attention and their effect on neural connectivity between the PFC and attention networks.

A pre-visit video/question prompt list intervention to increase youth question-asking about attention deficit hyperactivity disorder during pediatric visits

OBJECTIVE

To conduct a pragmatic randomized controlled trial to test the effectiveness of an ADHD question prompt list with video intervention to increase youth question-asking and provider education about ADHD during visits.

METHODS

English-speaking youth ages 11-17 with ADHD and their caregivers were enrolled from two pediatric clinics. Youth were randomized to intervention or usual care groups. Intervention group adolescents watched the video and then completed an ADHD question prompt list before their visits. Multivariable regression was used to analyze the data.

RESULTS

Twenty-one providers and 102 of their patients participated. Intervention group youth were significantly more likely to ask one or more questions about ADHD and its treatment than usual care youth (odds ratio=5.4, 95 % Confidence Interval (CI)= 1.8, 15.9). Providers were significantly more likely to educate youth who asked one or more questions during visits about more ADHD medication areas (unstandardized beta=0.98, 95 % CI=0.31 to 1.64) and more non-medication strategies for ADHD (unstandardized beta=0.50, 95 % CI=0.13 to 0.88).

CONCLUSION

The intervention increased youth question-asking about ADHD and its treatment. Providers provided more education to youth who asked one or more questions about ADHD and its treatment.

PRACTICE IMPLICATIONS

Providers and practices should consider having youth complete ADHD question prompt lists and watch the video before visits to increase youth question-asking during visits.

Association Between Neighborhood Context and Psychotropic Polypharmacy Use Among High-Need Children

OBJECTIVE

The authors explored whether neighborhood context is associated with psychotropic polypharmacy and psychotherapy among a cohort of children with high needs for psychiatric and general medical care.

METHODS

Electronic health record data from a large health care system were used in a cross-sectional design to examine psychotropic polypharmacy and psychotherapy in 2015-2019 among children ages 2-17 years (N=4,017) with geocoded addresses. Inclusion criteria were a diagnosis of a mental health condition, an intellectual and developmental disability, or a complex medical condition and one or more clinical encounters annually over the study period. Polypharmacy was defined as two or more psychotropic drug class prescriptions concurrently for ≥60 days. Psychotherapy was defined as receipt of any psychotherapy or adaptive behavior treatment. Neighborhood context (health, environment, education, and wealth) was measured with the Child Opportunity Index. Multilevel generalized linear mixed models with random intercept for census tracts were used to assess the associations between individual and neighborhood characteristics and psychotropic polypharmacy and psychotherapy.

RESULTS

Moderate (vs. low) child opportunity was associated with higher odds of polypharmacy (adjusted OR [AOR]=1.79, 95% CI=1.19-2.67). High (vs. low) child opportunity was associated with higher odds of psychotherapy (AOR=2.15, 95% CI=1.43-3.21). Black (vs. White) race (AOR=0.51, 95% CI=0.37-0.71) and Hispanic ethnicity (AOR=0.44, 95% CI=0.26-0.73) were associated with lower odds of polypharmacy.

CONCLUSIONS

Among high-need children, neighborhood Child Opportunity Index, race, and ethnicity were significantly associated with treatment outcomes in analyses adjusted for clinical factors. The findings underscore concerns about structural disparities and systemic racism and raise questions about access.

Depression Part 2: Treatment

Depression treatment strategies are within the scope of pediatric practice and among the competencies recommended by the Academy of Pediatrics and The American Board of Pediatrics. Treatments that may be provided through collaborative care include nonpharmacologic therapies such as psychosocial treatments and evidence-based psychotherapies, and pharmacotherapy and monitoring processes for depression. Abundant support and guidance are available to pediatricians in depression care, including mental health consultation and online materials.

Depression Part 1: Evaluation

By young adulthood, 1 in 5 teens will experience an episode of major depression. The second leading cause of death among youths aged 15 to 24 years is suicide, most of which will have been caused by untreated or undiagnosed depression. Depression is a highly heritable condition: depressed children often have depressed parents. Support to caregivers is important because depressed parents can have negative effects on children's development and future mental health. Groups more vulnerable to mental health disorders such as depression include Black, Indigenous, and persons of color and lesbian, gay, bisexual, transgender, or queer/questioning, who in recent years have the highest rate of suicide attempts (Black teens, sexual minority youth), the highest increases in suicide rates (Black children and youths), and the highest suicide rates (American Indian/Alaskan native). They frequently experience more adverse childhood events, which increases the risk of depression and suicide attempts. Pediatricians are most likely to care for these vulnerable youths, who often are less engaged in specialty mental health care for a variety of reasons, including stigma and barriers to access. By offering behavioral and mental health care to vulnerable populations in primary care, mental health equity may be achieved. Screening for depression and assessment for suicide are within the scope of pediatric practice and among the competencies recommended by the American Academy of Pediatrics and The American Board of Pediatrics.

Children in Mental Health Crisis: Pediatric Primary Care Providers' Role in Bridging Treatment Following Higher Levels of Care

The current study examines the role of pediatric PCPs in bridging treatment for youth who have experienced mental health crises and the characteristics of these patients for whom PCPs sought psychiatric consultation and referral support from a child psychiatry access program, Maryland Behavioral Health Integration in Pediatric Primary Care. Psychiatric consultation and referral calls between 2012 and 2021 were included if a) the patient was recently seen in a higher level of care and b) the PCP was bridging treatment following the patient's discharge; 208 calls met criteria. The most common mental health concerns included depressed mood, suicidal thoughts/gestures, and anxiety. Acute concerns of aggression, suicide attempts, and hallucinations were also reported. Over half of the patients had two or more mental health diagnoses. At the time of the call, only one quarter of these patients had outpatient therapy services while about half were receiving medication treatment. Most of these patients were discharged from the higher level of care without a care plan. Pediatric PCPs are managing their patients' complex mental health concerns following receipt of higher levels of care. Improvements in collaboration and care coordination between pediatric PCPs and emergency department providers are needed.

Pediatric Pharmacology for the Primary Care Provider: Advances and Limitations

Despite >1 in 5 children taking prescription drugs in the United States, off-label drug use is common. To increase the study of drugs in children, regulatory bodies have enacted legislation to incentivize and require pediatric drug studies. As a result of this legislation, novel trial approaches, and an increase in personnel with pediatric expertise, there have been numerous advancements in pediatric drug development. With this review, we aim to highlight developments in pediatric pharmacology over the past 6 years for the most common disease processes that may be treated pharmacologically by the pediatric primary care provider. Using information extracted from label changes between 2018 and 2023, the published literature, and Clinicaltrials.gov, we discuss advances across multiple therapeutic areas relevant to the pediatric primary care provider, including asthma, obesity and related disorders, mental health disorders, infections, and dermatologic conditions. We highlight instances in which new drugs have been developed on the basis of a deeper mechanistic understanding of illness and instances in which labels have been expanded in older drugs on the basis of newly available data. We then consider additional factors that affect pediatric drug use, including cost and nonpharmacologic therapies. Although there is work to be done, efforts focused on pediatric-specific drug development will increase the availability of evidence-based, labeled guidance for commonly prescribed drugs and improve outcomes through the safe and effective use of drugs in children.

A Case-Based, Longitudinal Curriculum in Pediatric Behavioral and Mental Health

Introduction

Pediatric behavioral and mental health (BMH) disorders are increasingly common, but most pediatricians feel inadequately trained to manage them. We implemented a case-based, longitudinal curriculum in BMH within a pediatric residency program to prepare trainees to diagnose and manage these conditions.

Methods

The pediatric residency program at Wright State University/Wright-Patterson Medical Center implemented a new BMH curriculum in 2020-2021. The curriculum consisted of five simulated cases involving depression, anxiety, attention deficit disorder with hyperactivity (ADHD), developmental delays, behavioral concerns, and autism. To reflect follow-up within a continuity clinic, cases included initial encounters and multiple follow-up visits. Faculty facilitators led residents in monthly small-group meetings over the academic year, with each session consisting of two to three simulated patient encounters. Residents completed pre-post surveys regarding their confidence in diagnosing and managing BMH conditions and pre- and posttests to evaluate the impact of the curriculum on knowledge gains.

Results

All 47 pediatric residents participated in the curriculum; 38 (81%) completed pre-post surveys. Upon completion of the curriculum, residents reported significantly increased confidence in managing ADHD, treating depression, creating safety plans for suicidality, recognizing autism, and counseling patients and families on special education services. Knowledge-based pre- and posttests completed by 25 residents (53%) also demonstrated significant improvement (M = 92.4, SD = 10.9, pre vs. M = 99.3, SD = 6.6, post, p = .009).

Discussion

This case-based, longitudinal curriculum in pediatric BMH simulating patient continuity improved residents' confidence and knowledge in diagnosing and managing common BMH conditions.

Universal and Trauma-Specific Care Suggestions for Pediatric Primary Care Settings

Trauma exposure and other adverse life events are common experiences among youth and present long-standing mental and physical health consequences. Given the ongoing lack of sufficient mental health services, pediatricians play a critical role in supporting trauma-exposed youth. We propose both universal precaution and trauma-specific strategies for pediatric primary care settings. Universal interventions include recommendations to make health care systems more trauma-informed, reduce trauma or re-traumatization in the medical setting, eliminate potential bias, and focus on a strengths-based approach to support diverse youth and families. Trauma-specific strategies include screening for trauma-related symptomatology and risk stratification to link youth to appropriate levels of care. Specific assessment tools, resources, and materials are provided. [Pediatr Ann. 2023;52(11):e418-e421.].

Systematic Review: Child Psychiatry Access Program Outcomes

Objective

There has been an increase in Child Psychiatry Access Programs (CPAP) across the United States to address the national child and adolescent psychiatry workforce shortage by supporting pediatric primary care providers (PCPs) in providing mental health services. The objective of this systematic review is to synthesize the expanding literature on CPAPs.

Method

A systematic literature search was conducted in PubMed, PsycInfo, Embase, and Web of Science databases to identify articles published from database inception to April 6, 2022, to identify CPAPs, defined as programs with mental health specialists providing rapid remote mental health consultation services to pediatric PCPs. Study outcomes included program adoption, provider experience, patient and caregiver experience, program cost, and patient mental health.

Results

None of the 33 included studies were randomized controlled trials. Most of the studies (n = 30) focused on program adoption and provider experience (n = 18). Few studies examined patient and caregiver experience (n = 2), program cost(n = 4), or patient mental health (n = 4) outcomes. CPAPs showed year-over-year growth in adoption and were generally well-received by providers and caregivers. Health care provision costs were quite varied. No articles reported on changes in patient mental health according to validated measures. Heterogeneity in the methodological quality, study design, and outcomes used to evaluate CPAPs hindered comparison among programs.

Conclusion

Rigorous research on the impact of CPAPs is lacking. Findings show high provider satisfaction with CPAPs, yet few studies examine patient-level mental health outcomes. CPAPs and funding agencies should consider prioritizing and investing in research to build the evidence base for CPAPs.

Diversity & Inclusion Statement

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science.

Clinical trial registration information

Child Psychiatry Access Programs: A Systematic Review; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020146410; CRD42020146410.

State of the Evidence for Use of Psychotropic Medications in School-Age Youth

Psychotropic medications are commonly prescribed to school-aged youth for the management of mental health concerns. This paper describes the current state of evidence for psychotropic medications in school-aged youth. More specifically, the following sections summarize relevant medication research trials and practice parameters pertaining to psychotropic medication prescribing as well as the specific medications indicated for a range of commonly presenting disorders and symptom clusters in school-aged youth. For each of these disorders and symptom clusters, key findings pertaining to the current state of science and practice are highlighted for the purpose of offering patients, clinicians, researchers, and policymakers with nuanced considerations for the role of psychopharmacology within the context of a larger "whole-child" approach to care that relies on the collaboration of providers and services across systems of care to promote optimal child and family health and wellness. The paper concludes with a discussion about supporting the use of medication treatments in schools, including considerations for ensuring effective family-school-health system collaboration to best meet youth mental health needs.

Anxiety and Depression Treatment in Primary Care Pediatrics

BACKGROUND AND OBJECTIVES

Primary care pediatricians (PCP) are often called on to manage child and adolescent anxiety and depression. The objective of this study was to describe PCP care practices around prescription of selective serotonin reuptake inhibitors (SSRI) for patients with anxiety and/or depression by using medical record review.

METHODS

We identified 1685 patients who had at least 1 visit with a diagnosis of anxiety and/or depression in a large primary care network and were prescribed an SSRI by a network PCP. We randomly selected 110 for chart review. We reviewed the visit when the SSRI was first prescribed (medication visit), immediately previous visit, and immediately subsequent visit. We abstracted rationale for prescribing medication, subspecialist involvement, referral for psychotherapy, and medication monitoring practices.

RESULTS

At the medication visit, in 82% (n = 90) of cases, PCPs documented reasons for starting an SSRI, most commonly clinical change (57%, n = 63). Thirty percent (n = 33) of patients had documented involvement of developmental-behavioral pediatrics or psychiatry subspecialists at 1 of the 3 visits reviewed. Thirty-three percent (n = 37) were referred to unspecified psychotherapy; 4% (n = 4) were referred specifically for cognitive behavioral therapy. Of 69 patients with a subsequent visit, 48% (n = 33) had documentation of monitoring for side effects.

CONCLUSIONS

When prescribing SSRIs for children with anxiety and/or depression, PCPs in this network documented appropriate indications for starting medication and prescribed without subspecialist involvement. Continuing medical education for PCPs who care for children with these conditions should include information about evidence-based psychotherapy and strategies for monitoring potential side effects.

A Comparison of Pediatric Mental Health Diagnoses and Selective Serotonin Reuptake Inhibitor Prescribing Before and During the COVID-19 Pandemic

PURPOSE

To assess the rate of mental health diagnoses and selective serotonin reuptake inhibitor (SSRI) prescribing before and during the Coronavirus Disease 2019 pandemic.

METHODS

We conducted a cross-sectional study at an ambulatory pediatric clinic. A prepandemic (June 2018 to June 2019) and intrapandemic (June 2020 to June 2021) cohort were reviewed. The rate of mental health visits and new SSRI prescriptions were compared. Chi-squared analyses demonstrated a variance of statistical significance.

RESULTS

From 15,414 encounters (9,791 prepandemic and 5,623 intrapandemic), 397 mental health encounters were identified. 231 (4.1%) encounters occurred during the pandemic (vs. 1.7% prepandemic) and 63 (27.3%) SSRIs were prescribed (vs. 5.4% prepandemic). Mental health encounters (prevalence ratio 2.42, 95% confidence interval, 1.99-2.95, p < .001) and SSRI prescriptions (prevalence ratio 5.03, 95% confidence interval, 2.58-9.82, p < .001) were higher during the pandemic.

DISCUSSION

Our findings demonstrate increased rates of SSRI prescribing and mental health diagnoses during the Coronavirus Disease 2019 pandemic, suggesting an increased incidence of these conditions. Clinicians should be prepared to manage and screen for mental health conditions.

General practitioner-centred paediatric primary care reduces risk of hospitalisation for mental disorders in children and adolescents with ADHD: findings from a retrospective cohort study

Background

General practitioners (GPs) play an essential role in the sustainable management of attention-deficit/hyperactivity disorder (ADHD). To our knowledge, the healthcare programme described here is the first integrated care programme for paediatric ambulatory care embedded in GP-centred-healthcare in Germany.

Objectives

To compare the health-service-utilisation of patients with ADHD enrolled in a GP-centred-paediatric-primary-care-programme with usual care in terms of disease-related hospitalisation, pharmacotherapy and psychotherapy.

Methods

In 2018, we conducted a retrospective cohort study of 3- to 18-year-old patients with ADHD in Baden-Wuerttemberg, southern Germany. The intervention group (IG) comprised patients enrolled in a GP-centred-paediatric-primary-healthcare-programme and consulted a participating GP for ADHD at least once. GP-centred-paediatric-primary-care provides high continuity of care, facilitated access to specialist care, extended routine examinations and enhanced transition to adult healthcare. Patients in the control group (CG) received usual care, meaning they consulted a non-participating GP for ADHD at least once. Main outcomes were disease-related hospitalisation, pharmacotherapy and psychotherapy. Multivariable logistic regression was performed to compare groups.

Results

A total of 2317 patients were included in IG and 4177 patients in CG. Mean age was 8.9 ± 4.4. The risk of mental-disorder-related hospitalisations was lower in IG than CG (odds ratio (OR): 0.666, 95% confidence interval (CI): 0.509–0.871). The prescription rate for stimulants was lower in IG (OR: 0.817; 95% CI: 0.732–0.912). There was no statistically significant difference in the participation rate of patients in cognitive behavioural therapy between groups (OR: 0.752; 95% CI: 0.523–1.080).

Conclusion

Children and adolescents with ADHD enrolled in GP-centred-paediatric-primary-care are at lower risk of mental-disorder-related hospitalisation and less likely to receive stimulants.

Impact of pet dog or cat exposure during childhood on mental illness during adolescence: a cohort study

BACKGROUND

In our prior study of 643 children, ages 4-11 years, children with pet dogs had lower anxiety scores than children without pet dogs. This follow-up study examines whether exposure to pet dogs or cats during childhood reduces the risk of adolescent mental health (MH) disorders.

METHODS

Using a retrospective cohort study design, we merged our prior study database with electronic medical record (EMR) data to create an analytic database. Common MH diagnoses (anxiety, depression, ADHD) occurring from the time of prior study enrollment to 10/27/21 were identified using ICD-9 and ICD-10 codes. We used proportional hazards regression to compare time to MH diagnoses, between youths with and without pets. From 4/1/20 to 10/27/21, parents and youth in the prior study were interviewed about the amount of time the youth was exposed to a pet and how attached s/he was to the pet. Exposure included having a pet dog at baseline, cumulative exposure to a pet dog or cat during follow-up, and level of pet attachment. The main outcomes were anxiety diagnosis, any MH diagnosis, and MH diagnosis associated with a psychotropic prescription.

RESULTS

EMR review identified 571 youths with mean age of 14 years (range 11-19), 53% were male, 58% had a pet dog at baseline. During follow-up (mean of 7.8 years), 191 children received a MH diagnosis: 99 were diagnosed with anxiety (52%), 61 with ADHD (32%), 21 with depression (11%), 10 with combined MH diagnoses (5%). After adjusting for significant confounders, having a pet dog at baseline was associated with lower risk of any MH diagnosis (HR = 0.74, p = .04) but not for anxiety or MH diagnosis with a psychotropic prescription. Among the 241 (42%) youths contacted for follow-up, parent-reported cumulative exposure to pet dogs was borderline negatively associated with occurrence of any MH diagnosis (HR = 0.74, p = .06). Cumulative exposure to the most attached pet (dog or cat) was negatively associated with anxiety diagnosis (HR = 0.57, p = .006) and any MH diagnosis (HR = 0.64, p = .013).

CONCLUSION

Cumulative exposure to a highly attached pet dog or cat is associated with reduced risk of adolescent MH disorders.

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

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

Trend in rural-urban disparities in access to outpatient mental health services among US adults aged 18-64 with employer-sponsored insurance: 2005-2018

PURPOSE

This study estimates the rural-urban differences in outpatient service utilization and expenditures for depression, anxiety disorder, and substance use disorder, and the evolving mental health provider mix for privately insured US adults aged 18-64 during 2005-2018.

METHODS

We used the IBM MarketScan Commercial Claims and Encounters Database for individuals covered by employer-sponsored health insurance, from 2005 to 2018, with a yearly total number of beneficiaries ranging from 17.5 to 53.1 million. Claims for nonelderly adults with mental health and substance abuse coverage are included. Outcomes include rates of outpatient service utilization for depression, anxiety disorder, and substance use disorder; counts of outpatient visits; expenditure and share of the out-of-pocket cost; and the mental health services provider mix.

FINDINGS

Rural enrollees were less likely than urban enrollees to use outpatient mental health services for depression by 1.2% (percentage points) in 2005 and 0.6% in 2018. Among those who used outpatient mental health services, rural enrollees had fewer outpatient visits than their urban counterparts (difference: 1.8-2.4 visits for depression, 1.2-1.7 visits for anxiety disorder, and 0.7-2.1 visits for substance use disorder). Rural patients paid less per year for mental health outpatient visits of the 3 conditions but incurred a higher share of out-of-pocket expenses. Rural and urban patients differ in the mix of mental health providers, with rural enrollees relying more on primary care providers than urban enrollees.

CONCLUSIONS

Rural-urban disparities in access to mental health services persist during 2005-2018 among a population with private insurance.

Pediatric Primary Care Perspectives of Mental Health Services Delivery during the COVID-19 Pandemic

Due to a national shortage of child and adolescent psychiatrists, pediatric primary care providers (PCPs) are often responsible for the screening, evaluation, and treatment of mental health disorders. COVID-19 pandemic stay-at-home orders decreased access to mental health care and increased behavioral and emotional difficulties in children and adolescents. Despite increased demand upon clinicians, little is known about mental health care delivery in the pediatric primary care setting during the pandemic. This focus group study explored the experiences of pediatric PCPs and clinical staff delivering mental health care during the pandemic. Transcripts from nine focus groups with San Francisco Bay Area primary care practices between April and August 2020 were analyzed using a thematic analysis approach. Providers expressed challenges at the patient-, provider-, and system-levels. Many providers reported increased patient mental health symptomatology during the pandemic, which was often intertwined with patients’ social determinants of health. Clinicians discussed the burden of the pandemic their own wellness, and how the rapid shift to telehealth primary care and mental health services seemed to hinder the availability and effectiveness of many resources. The findings from this study can inform the creation of new supports for PCPs and clinical staff providing mental health care.

How to Mitigate Risk of Premature Cardiovascular Disease Among Children and Adolescents with Mental Health Conditions

PURPOSE OF REVIEW

The goal of this article is to characterize the myriad of ways that children with mental health conditions can be at risk for premature cardiovascular disease (CVD) and various modalities to ameliorate this risk in childhood in order to improve the life course of these children.

REVIEW FINDINGS

Child and adolescent mental health conditions are a common yet underrecognized risk factor for premature CVD. The American Heart Association has recently included psychiatric conditions as a CVD risk factor (CVDRF) and the evidence linking childhood adversity to cardiometabolic disease. There are bidirectional and additive effects from the intrinsic emotional dysregulation and inflammatory changes from the mental health condition, the associations with risky health behaviors, and in some cases, metabolic side effects from pharmacotherapy. These pathways can be potentiated by toxic stress, a physiologic response to stressors from childhood adversity. Toxic stress is also associated with development of mental health conditions with epigenetic effects that can result in transgenerational inheritance of cardiometabolic risk. Exposure to toxic stress and mental health conditions in isolation sometimes compounded by pharmacotherapies used in treatment increase the risk of cardiometabolic diseases in childhood. The multiple pathways, which adversely influence cardiometabolic outcomes, encourage clinicians to consider strategies to mitigate these factors and justify the importance of early screening and treatment for CVDRFs. Mental health, health behaviors, and environmental factors co-occur and intersect in complex pathways that can increase CVD risk over the lifespan. Early detection and response can mitigate the risks associated with premature development of CVD.

Pharmacotherapy interventions for adolescent co-occurring substance use and mental health disorders: a systematic review

BACKGROUND

Co-occurring mental health and substance use (SU) disorders among adolescents are common, with two-thirds of adolescents who seek SU treatment also requiring support for mental health. Primary care physicians play a key role in the pharmacological treatment of mental health disorders among adolescents, however, little is known about the impact of these treatments on SU outcomes.

OBJECTIVES

This systematic review summarizes the evidence regarding commonly used pharmacotherapy interventions for mental health and their impact on adolescent SU.

METHODS

Literature searches were conducted across five databases as part of a larger systematic review of adolescent SU interventions. Studies were screened for eligibility by two researchers, and study data were extracted regarding study design, patient and treatment characteristics and results. Risk of bias analyses and qualitative syntheses were completed to evaluate the strength of the evidence and the impact of pharmacotherapy on SU outcomes.

RESULTS

Ten randomized controlled trials exploring seven pharmacotherapies met criteria for inclusion. All studies had low to moderate risk of bias. Four studies evaluated pharmacotherapy for co-occurring depression and SU, three evaluated attention deficit hyperactivity disorder and SU, and three evaluated bipolar disorder and SU. Five of the 10 studies also included a behavioural intervention. We found no evidence that pharmacotherapy for co-occurring mental health diagnoses impacted SU.

CONCLUSION

Family medicine clinicians prescribing pharmacotherapy for mental health should be aware that additional interventions will likely be needed to address co-occurring SU.

Medication Management of Anxiety and Depression by Primary Care Pediatrics Providers: A Retrospective Electronic Health Record Study

Objectives

To describe medication management of children diagnosed with anxiety and/or depression by primary care providers within a primary care network.

Study Design/Methods

We performed a retrospective cross-sectional analysis of electronic health record (EHR) structured data from all children seen at least twice in a 4-year observation period within a network of primary care clinics in Northern California. For children who had visit diagnoses of anxiety, depression, anxiety+depression or symptoms characteristic of these conditions, we analyzed the rates and types of medications prescribed. A logistic regression model considered patient variables for the combined sample.

Results

Of all patients 6-18 years old (N = 59,484), 4.4% (n = 2,635) had a diagnosis of anxiety only, 2.4% (n = 1,433) depression only, and 1.2% (n = 737) both anxiety and depression (anxiety + depression); 18% of children with anxiety and/or depression had comorbid ADHD. A total of 15.0% with anxiety only (n = 357), 20.5% with depression only (n = 285), and 47.4% with anxiety+depression (n=343) were prescribed a psychoactive non-stimulant medication. For anxiety and depression only, the top three medications prescribed were sertraline, fluoxetine, and citalopram. For anxiety + depression, the top three medications prescribed were citalopram, sertraline, and escitalopram. Frequently prescribed medications also included benzodiazepines. Logistic regression modeling showed that the depression only and anxety + depression categories had increased likelihood of medication prescription. Older age and mental health comorbidities were independently associated with increased likelihood of medication prescription.

Conclusions

In this network, ~8% of children carried a diagnosis of anxiety and/or depression. Medication choices generally aligned with current recommendations with the exception of use of benzodiazepines.

Trazodone Prescribing for Children With Attention Deficit Hyperactivity Disorder on Medicaid in Oregon

OBJECTIVE

To examine trazodone prescribing to Medicaid-insured children with a diagnosis of attention deficit hyperactivity disorder (ADHD) from 2012 to 2016 for patient-level factors, including coexisting diagnoses associated with trazodone prescriptions.

METHODS

A retrospective cohort study used de-identified claims data from the Oregon Health Authority to analyze associations, frequency, and likelihood of new trazodone fills.

RESULTS

A total of 16,547 trazodone prescriptions were identified, representing 8.4% (n = 2,705) of 32,134 children. Most were filled for children ages 10 years and older. Children with ADHD were predominantly male (70.7%); however, more female children had a filled trazodone prescription compared with males (10.1% vs 7.7%). Female and male children with a filled trazodone prescription shared common diagnoses in the top 10 rank, although episodic mood disorders, such as bipolar disorder (International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis code 296) were only noted for female children. Female children were significantly older at the time of the first filled trazodone prescription (12.5 years; 95% CI, 12.3–12.7) compared with male children (12.0 years; 95% CI, 11.8–12.1). Modified Poisson regression models found children with ADHD and a filled trazodone prescription were 3 times more likely to have a sleep-related diagnosis as their most common diagnosis (excluding ADHD), compared with those of the same age and sex without a trazodone prescription (RR, 2.94; 95% CI, 2.44–3.54).

CONCLUSIONS

Children with ADHD are prescribed trazodone off label and for conditions with no national guidelines or clinical evidence of efficacy. Female children on Medicaid may be prescribed trazodone for concurrent mental health conditions, and further research is warranted regarding potential correlates.

Stakeholder perspectives on digital behavioral health applications targeting adolescent depression and suicidality: Policymaker, provider, and community insights

Background

With adolescent depression and suicidality increasing, technology-based interventions may help address mental health needs. The Enhancing Treatment and Utilization for Depression and Emergent Suicidality (ETUDES) Center supports development of technology interventions to help primary care providers target these problems. To successfully develop and integrate such interventions into primary care, iterative engagement of stakeholders is necessary. This paper outlines our stakeholder engagement process, a qualitative analysis of feedback and outcomes, and how feedback was incorporated to develop Center interventions.

Methods

Stakeholder panels represented key end-users of ETUDES Center interventions (adolescents, young adults, parents, and healthcare providers) and their advocates at the organizational/policy level. Meetings were held throughout intervention development and at annual retreats. Detailed meeting notes were collected and summarized by the stakeholder engagement team in real time, after which action items were generated and reviewed by the full research team. Using a content analysis approach, all stakeholder feedback summaries were coded using a prespecified codebook organized by recurring topics. Codes were organized under the Consolidated Framework for Implementation Research (CFIR). Anonymous stakeholder feedback surveys assessed relevance of topics, meeting effectiveness, and stakeholder involvement.

Results

Stakeholder meetings provided feedback on topics such as representation, language, access to care, and stigma. Relevant feedback and recommendations were incorporated into subsequent iterations of the interventions and their implementation. Mean stakeholder ratings of meeting proceedings on a 0–3 Likert scale ranged from 1.70 ( SD  =  0.10) for participation to 2.43 ( SD  =  0.08) for effectiveness in addressing meeting agenda.

Conclusions

The iterative engagement approach yielded practical feedback from stakeholders about ETUDES Center interventions. The team organized feedback to identify barriers and facilitators to using Center interventions and to generate action items, which were transposed onto components of an implementation strategy, supplemented by the CFIR-ERIC Implementation Strategy Matching Tool. Stakeholder feedback will direct the future development of an integrated intervention and guide further stakeholder engagement in developing technologies for adolescent mental health. Plain Language Summary: Depression and suicide in teens have been on the rise for the past several years. Primary care may be an ideal place to address these concerns because most teens have a primary care provider (PCP) who can offer a confidential place for both teens and their caregivers. Our Center develops technology-based interventions to help PCPs address teen depression and suicidality. Multiple barriers may hinder PCPs in addressing teen depression and suicidality. This paper describes how we engaged multiple types of stakeholders—or individuals with an interest in adolescent mental health—to ask for their feedback over a series of meetings, to help us improve the fit of our interventions to this population. Stakeholders included providers, community members like parents and mental health advocates, youth, and policymakers. We learned what was most important to them—including concerns about equitable access (e.g., providing broadband internet to families who do not have it so they can still participate) and legal risks or failures for the technology to identify suicidality. In this paper, we describe our process for not only recruiting and engaging stakeholders but also for planning action based on their feedback. Similar processes could be used by other researchers and clinical organizations seeking to incorporate technology into mental health interventions.

The Impact of a New On-site Inpatient Psychiatric Unit in an Urban Pediatric Emergency Department

OBJECTIVE

The objective of this study was to describe the impact of opening an inpatient child psychiatric unit in an urban tertiary care pediatric emergency department (PED).

DESIGN/METHODS

A retrospective chart review was performed of pediatric patients seen in the PED at a large tertiary care center who presented for a primary psychiatric concern before opening of the inpatient psychiatric unit within the same hospital and 6 months following, allowing for a 6-month adjustment period. Patients were identified via query of the ED Cube model, an institutional database by a "behavioral health" flag that is documented in triage. Patients were excluded if subsequent chart review did not reveal a psychiatric concern and the patient did not undergo psychiatric evaluation during the PED visit. Charts were reviewed for baseline patient demographics, psychiatric interventions performed, and disposition. Additional flow metrics obtained were PED volume, percentage of psychiatric visits, and length of stay for both psychiatric-related visits compared with the general population.

RESULTS

Visits to the PED for psychiatric evaluation increased 135% from 91 to 226 after initiation of an inpatient psychiatric unit. There was no difference in baseline patient demographics or rate of medical/mechanical restraints used. Percentage of behavioral health patients admitted to medical units decreased, although overall admission rate remained stable. Length of stay for behavioral health patients was longer after opening of the unit and remained significantly higher than the general population before opening of the inpatient unit, 363 minutes versus 177 minutes, respectively, and further lengthened after to 418 minutes versus 188 minutes.

DISCUSSION

Patients presenting for psychiatric evaluation are a significant burden to PED flow both in volume and time for evaluation and boarding. This is to the detriment of patients seeking appropriate mental health services and to the rest of patients in the PED. Both inpatient and outpatient psychiatric services are overwhelmed creating a downstream affect; limited resources delays disposition and increases boarding in the PED. Further resources are needed to appropriately address psychiatric concerns, such as dedicated psychiatric holding units and brief PED interventions targeted to safety planning and interventions.

Association Between Insurance and the Transfer of Children With Mental Health Emergencies

OBJECTIVES

This study sought to investigate the association between a patient's insurance coverage and a hospital's decision to admit or transfer pediatric patients presenting to the emergency department (ED) with a mental health disorder.

METHODS

This is a cross-sectional study of pediatric mental health ED admission and transfer events using the Healthcare Cost and Utilization Project 2014 Nationwide Emergency Department Sample. Children presenting to an ED with a primary mental health disorder who were either admitted locally or transferred to another hospital were included. Multivariable logistic regression models were used to adjust for confounders.

RESULTS

Nineteem thousand eighty-one acute mental health ED events among children were included in the analyses. The odds of transfer relative to admission were higher for children without insurance (odds ratio, 3.30; 95% confidence interval, 1.73-6.31) compared with patients with private insurance. The odds of transfer were similar for children with Medicaid compared with children with private insurance (odds ratio, 1.23; 95% confidence interval, 0.80-1.88). Transfer rates also varied across mental health diagnostic categories. Patients without insurance had higher odds of transfer compared with those with private insurance when they presented with depressive disorder, bipolar disorder, attention-deficit/conduct disorders, and schizophrenia.

CONCLUSIONS

Children presenting to an ED with a mental health emergency who do not have insurance are more likely to be transferred to another hospital than to be admitted and treated locally compared with those with private insurance. Future studies are needed to determine factors that may protect patients without insurance from disparities in access to care.

Diagnostic and Medication Treatment Disparities in African American Children with ADHD: a Literature Review

BACKGROUND

Despite a national focus on achieving health equity, limited attention has been paid to behavioral and pediatric health disparities. As the most common pediatric neurobehavioral disorder, attention-deficit/hyperactivity disorder (ADHD) provides an opportunity to assess the status of pediatric behavior health disparities. The purpose of this literature review is to provide a synthesis of existing research on ADHD diagnostic and treatment disparities between African American and White children.

METHODS

Studies were systematically identified through searches in PubMed, CINAHL, and APA PsycInfo using the terms attention-deficit/hyperactivity disorder, disparity, race, ethnicity, diagnosis, medication, and treatment. Summary calculations were conducted to report the proportions of studies with statistically significant differences in ADHD diagnosis and treatment between White and African American children, and to describe trends in disparities over time.

RESULTS

Forty-one studies were included in this review. The majority of studies identified significant disparities in ADHD diagnosis and medication treatment between African American and White children. While diagnostic disparities show a trend toward reduction over time, a similar trend was not observed in medication treatment disparities. This synthesis provides a critique of the existing literature and recommendations for practice and future research.

Colocated Developmental-Behavioral Pediatrics in Primary Care: Improved Outcome Across Settings

OBJECTIVE

We developed a colocation "Rapid Developmental Evaluation" (RDE) model for Developmental-Behavioral Pediatrics (DBP) to evaluate young children for developmental concerns raised during routine developmental surveillance and screening in a pediatric primary care Federally Qualified Health Center (FQHC). In this low-income patient population, we anticipated that colocation would improve patient access to DBP and decrease time from referral to first developmental evaluation and therapeutic services.

METHODS

Children were assessed at the FQHC by a DBP pediatrician, who made recommendations for therapeutic services and further diagnostic evaluations. A retrospective chart review over 27 months (N = 151) investigated dates of referral and visit, primary concern, diagnosis, and referral to tertiary DBP center and associated tertiary DBP center dates of service and diagnoses if appropriate. We surveyed primary care clinicians (PCCs) for satisfaction.

RESULTS

The DBP pediatrician recommended that 51% of children be referred to the tertiary DBP center for further diagnostic evaluation or routine DBP follow-up. Average wait from referral to an RDE visit was 57 days compared with 137.3 days for the tertiary DBP center. Children referred from RDE to the tertiary DBP center completed visits at a higher rate (77%) than those referred from other sites (54%). RDE-recommended therapeutic services were initiated for 73% of children by the tertiary visit. Fidelity of diagnosis between RDE and the tertiary DBP center was high, as was PCC satisfaction.

CONCLUSION

Colocation of a DBP pediatrician in an FQHC primary care pediatrics program decreased time to first developmental assessment and referral for early intervention services for an at-risk, low-income patient population.

The Challenges of Children with Bipolar Disorder

Childhood onset bipolar disorder (CO-BD) presents a panoply of difficulties associated with early recognition and treatment. CO-BD is associated with a variety of precursors and comorbidities that have been inadequately studied, so treatment remains obscure. The earlier the onset, the longer is the delay to first treatment, and both early onset and treatment delay are associated with more depressive episodes and a poor prognosis in adulthood. Ultra-rapid and ultradian cycling, consistent with a diagnosis of BP-NOS, are highly prevalent in the youngest children and take long periods of time and complex treatment regimens to achieve euthymia. Lithium and atypical antipsychotics are effective in mania, but treatment of depression remains obscure, with the exception of lurasidone, for children ages 10-17. Treatment of the common comorbid anxiety disorders, oppositional defiant disorders, pathological habits, and substance abuse are all poorly studied and are off-label. Cognitive dysfunction after a first manic hospitalization improves over the next year only on the condition that no further episodes occur. Yet comprehensive expert treatment after an initial manic hospitalization results in many fewer relapses than traditional treatment as usual, emphasizing the need for combined pharmacological, psychosocial, and psycho-educational approaches to this difficult and highly recurrent illness.

Community-Based Prevalence of Externalizing and Internalizing Disorders among School-Aged Children and Adolescents in Four Geographically Dispersed School Districts in the United States

The Project to Learn About Youth-Mental Health (PLAY-MH; 2014-2018) is a school-based, two-stage study designed to estimate the prevalence of selected mental disorders among K-12 students in four U.S.-based sites (Colorado, Florida, Ohio, and South Carolina). In Stage 1, teachers completed validated screeners to determine student risk status for externalizing or internalizing problems or tics; the percentage of students identified as being at high risk ranged from 17.8% to 34.4%. In Stage 2, parents completed a structured diagnostic interview to determine whether their child met criteria for fourteen externalizing or internalizing disorders; weighted prevalence estimates of meeting criteria for any disorder were similar in three sites (14.8%-17.8%) and higher in Ohio (33.3%). PLAY-MH produced point-in-time estimates of mental disorders in K-12 students, which may be used to supplement estimates from other modes of mental disorder surveillance and inform mental health screening and healthcare and educational services.

Need for Integrated Behavior Health Model in Primary Care

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

Lack of pediatric mental health clinical experiences among FNP students

BACKGROUND

Mental health disorders accounted for approximately 5% of outpatient child and adolescent visits between 2008 and 2011, and 34.8% of these children were seen by a primary care provider. As primary care providers, family nurse practitioners (FNP) are positioned to address mental health issues across the lifespan; however, they require appropriate training and experience.

AIM

The study examined pediatric mental health assessment clinical experiences in a national survey of FNP students.

METHODS

A secondary analysis was performed on a data set of FNP students (N = 3940). Frequencies and chi-square analyses were performed to examine pediatric mental health assessment clinical experiences.

RESULTS

Nearly 30% (n = 1118) of FNP students reported experiencing two or fewer pediatric mental health assessments during their clinical rotations. More than half (53%) of these students were required to set up their own preceptors and clinical sites.

CONCLUSION

Despite the growing need for mental health care in the U.S, students reported lacking pediatric mental health assessment clinical opportunities. Moreover, students who set up their own clinical sites and preceptors were even less likely to assess pediatric patients' mental health. FNP educators and programs are encouraged to provide students with the support and opportunity for adequate pediatric practice, including mental health assessment.

Psychotropic Medication Prescribing in Primary Care: Pediatric Chief Resident Perspectives

OBJECTIVE

Evidence-based treatments for mental health concerns include psychopharmacological and psychosocial approaches. Pediatrics organizations indicate psychopharmacology needs to be a component of training. This study investigated the status of training in psychotropic medication prescribing through a national survey of pediatric chief residents.

METHOD

Pediatric chief residents (one per residency program) completed a survey (response rate = 60.2%, 127/211) about their attitudes, knowledge, comfort, practice, and training around prescribing psychotropic medication in primary care. Quantitative data included descriptive statistics and correlational analyses to explore relationships between variables; qualitative data were examined through classical content analysis.

RESULTS

Almost half of respondents reported prescribing sometimes or often. Frequency of prescribing varied by mental health condition, with highest frequency for attention-deficit/hyperactivity disorder. About two-thirds of respondents reported having at least some/average knowledge. About half of respondents reported being uncomfortable with prescribing; respondents were most uncomfortable with prescribing antianxiety, mood stabilizing, and antipsychotic medications, and with discontinuing medication; about half indicated their competence in progress-monitoring needed improvement. Concurrent psychosocial treatment was perceived as very useful, although often inaccessible to patients. Prescribing frequency was related to knowledge, comfort, progress-monitoring competence, and training quality; training quality was related to knowledge and comfort. Over 60% rated their training as not at all or only somewhat adequate.

CONCLUSIONS

Pediatric chief residents reported having knowledge of psychotropic medication issues, but experience a general discomfort, especially with discontinuing medication, and with medications other than stimulants. Most thought their training needed improvement in terms of comprehensiveness and clinical practice experiences.

Mental Health Care Costs Among Youth with Comorbid Mental Disorders

This exploratory study described the distribution of mental health service costs in youth with mental disorder and determined if costs differed for youth with comorbid internalizing and externalizing disorder compared to those with comorbid internalizing disorders. Data come from youth (8-17 years; n=75) receiving mental health services at a children's hospital in Canada. Billing amounts specified in the Health Insurance Act of Ontario were used to estimate costs. Overall, past-year service use costs were $7436.63. Hospitalizations represented the largest cost. Youth with comorbid internalizing and externalizing disorders had higher total (β=0.81 [0.17, 1.45]), hospital (β=0.93 [0.03, 1.84]), and professional (β=0.87 [0.04, 1.69]) costs. These preliminary findings suggest that comorbidity type is associated with the costs of past-year mental health services used by youth. Research is needed to understand the reasons for elevated costs and whether the increased services used by youth with comorbid internalizing and externalizing disorders are effective.

25 Years of the International Bipolar Collaborative Network (BCN)

BACKGROUND

The Stanley Foundation Bipolar Treatment Outcome Network (SFBN) recruited more than 900 outpatients from 1995 to 2002 from 4 sites in the United States (US) and 3 in the Netherlands and Germany (abbreviated as Europe). When funding was discontinued, the international group of investigators continued to work together as the Bipolar Collaborative Network (BCN), publishing so far 87 peer-reviewed manuscripts. On the 25th year anniversary of its founding, publication of a brief summary of some of the major findings appeared appropriate. Important insights into the course and treatment of adult outpatients with bipolar disorder were revealed and some methodological issues and lessons learned will be discussed.

RESULTS

The illness is recurrent and pernicious and difficult to bring to a long-term remission. Virtually all aspects of the illness were more prevalent in the US compared to Europe. This included vastly more patients with early onset illness and those with more psychosocial adversity in childhood; more genetic vulnerability; more anxiety and substance abuse comorbidity; more episodes and rapid cycling; and more treatment non-responsiveness.

CONCLUSIONS

The findings provide a road map for a new round of much needed clinical treatment research studies. They also emphasize the need for the formation of a new network focusing on child and youth onset of mood disorders with a goal to achieve early precision diagnostics for intervention and prevention in attempting to make the course of bipolar illness more benign.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Attention-Deficit/Hyperactivity Disorder in 2- to 5-Year-Olds: A Primary Care Network Experience

OBJECTIVE

To assess 1) rates of primary care provider (PCP) diagnosis of attention-deficit/hyperactivity disorder (ADHD) in young children, 2) documented PCP adherence to ADHD clinical practice guidelines, and 3) patient factors influencing PCP variation in diagnosis and management.

METHODS

Retrospective cohort study of electronic health records from all office visits of children aged 2 to 5 years, seen ≥2 times between 2015 and 2019, in 10 practices of a community-based primary health care network. Outcomes included ADHD diagnosis (symptom or disorder), and adherence to guidelines in 1) comorbidity documentation at or after ADHD diagnosis, 2) ADHD medication choice, and 3) follow-up of medicated patients. Logistic regressions assessed associations between outcomes and patient characteristics.

RESULTS

Of 29,408 eligible children, 195 (0.7%) had ADHD diagnoses. Of those, 56% had solely symptom-level diagnoses (eg, hyperactivity); 54% had documented comorbidities. ADHD medications were prescribed only to 4- to 5-year olds (40 of 195 [21%]); 85% received stimulants as first-line medication; 48% had follow-up visits within 2 months. Likelihood of ADHD diagnosis was higher for children with public or military insurance (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.40-2.66; OR 3.17; 95% CI 1.93-4.96). Likelihood of comorbidity documentation was lower for older ADHD patients (OR 0.48; 95% CI 0.32-0.71) and higher for those with military insurance (OR 3.11; 95% CI 1.13-9.58).

CONCLUSION

PCPs in this network frequently used symptom-level ADHD diagnoses in 2- to 5-year olds; ADHD diagnosis rates were below estimated population prevalence, with evidence for sociodemographic disparities. PCP comorbidity documentation and choice of stimulant medications were consistent with guidelines. Rates of timely follow-up were low.

Hospitalization Outcomes for Rural Children with Mental Health Conditions

OBJECTIVE

To identify where rural children with mental health conditions are hospitalized and to determine differences in outcomes based on location of hospitalization.

STUDY DESIGN

This is a retrospective cohort analysis of US rural children aged 0-18 years with a mental health hospitalization between January 1, 2014, and November 30, 2014, using the 2014 Agency for Healthcare Research and Quality's Nationwide Readmissions Database. Hospitalizations for rural children were categorized by children's hospitals, metropolitan non-children's hospitals, or rural hospitals. Associations between hospital location and outcomes were assessed with logistic (readmission) and negative binomial regression (length of stay [LOS]) models. Classification and regression trees (CART) were used to describe the characteristics of most common hospitalizations at a rural hospital.

RESULTS

Of 21 666 mental health hospitalizations of rural children, 20.6% were at rural hospitals. After adjustment for clinical and demographic characteristics, LOS was higher at metropolitan non-children's and children's hospitals compared with rural hospitals (LOS: adjusted rate ratio [aRR], 1.35 [95% CI 1.29-1.41] and 1.33 [95% CI, 1.25-1.41]; P < .01 for all). The 30-day readmission was lower at metropolitan non-children's and children's hospitals compared with rural hospitals (aOR, 0.73 [95% CI, 0.63-0.84] and 0.59 [95% CI, 0.48-0.71]; P < .001 for all). Adolescent males living in poverty with externalizing behavior disorder had the highest percentage of hospitalization at rural hospitals (69.4%).

CONCLUSIONS

Although hospitalizations at children's and metropolitan non-children's hospitals were longer, patient outcomes were more favorable.

The Kindling/Sensitization Model and Early Life Stress

INTRODUCTION

Few animal models address the characteristics of the longitudinal course of bipolar disorder. However, behavioral sensitization (to recurrent stressors and psychomotor stimulants) and kindling of seizures both provide clues to mechanisms in the progressive course of bipolar disorder.

METHODS

We describe aspects of bipolar illness that show sensitization and kindling-like increases reactivity to the recurrence of stressors, mood episodes, and bouts of substance abuse. Mechanisms of these events and clinical implications for treatment are discussed.

RESULTS

Early life stress is a risk factor for the development of episodes of unipolar depression and bipolar disorder and the acquisition of substance abuse. Initial affective episodes are often triggered by the recurrence of psychosocial stressors in adulthood, but after many episodes have occurred, episodes may also begin to emerge spontaneously in a kindling-like progression. More prior episodes are associated with faster recurrences, dysfunction, disability, frontal cortical abnormalities, cognitive impairment, shorter telomeres, treatment refractoriness, and an increased risk of a diagnosis of dementia in old age. Sensitization to stressors, episodes, and substances of abuse each appear driven by epigenetic mechanisms and their accumulation on DNA, histones, and microRNA. Patients with bipolar illness in the USA are more ill than those from Europe and experience more sensitization to stressors, episodes, substance abuse, as well as more genetic vulnerability across four generations.

DISCUSSION

The sensitization and kindling models highlight the importance of early intervention and prevention in order to limit or halt the downhill progression of bipolar disorder and its multiple comorbidities toward treatment refractoriness. Clinical data support this conclusion as well but have not been sufficient to change practice in the direction of early intervention. It is hoped that a better understanding of sensitization and kindling-like mechanisms will add neurobiological rationales for the importance of prevention and sustained prophylactic intervention in rendering bipolar disorder a more benign illness.

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.

Implementing the Behavioral and Mental Health Entrustable Professional Activity: Insights for a Path Forward

OBJECTIVE

Mental health problems in children are growing exponentially. General pediatricians, while in a unique position to address these issues as they arise, report they lack adequate training in assessing and managing behavioral/mental health (B/MH) problems. Underscoring the importance of this area, the American Board of Pediatrics has defined B/MH as one of only 17 foundational entrustable professional activities (EPAs) for general pediatric practice. Our goal was to explore the facilitators and barriers associated with implementing and assessing the B/MH EPA among pediatric residency programs in order to identify best practices and potential solutions to common barriers.

METHODS

In this qualitative study, 18 key faculty members from 4 residency programs with 3 years' experience implementing and assessing their residents on the B/MH EPA were purposively sampled. Semistructured interviews were conducted with each participant, and interviews were analyzed utilizing a thematic analysis.

RESULTS

Five themes were defined in the thematic analysis 1) B/MH training: who's responsible? 2) local context can serve as a barrier or facilitator, 3) B/MH may require longitudinal, integrated, and multidisciplinary training, 4) B/MH specialists: indispensable, yet a hurdle?, and 5) resident and faculty confidence and skill impact B/MH training.

CONCLUSIONS

The need for robust training to prepare pediatric residency graduates to meet the needs of patients with B/MH problems has never been greater. This study provides important insights about gaps in B/MH training. These should inform future directions focused on addressing this need.

Screening for Mental Health Problems in Pediatric Primary Care

Systematic mental health screening is a recommended but controversial process in the pediatricians' behavioral health tool kit. Although the American Academy of Pediatrics and other organizations promote routine behavioral health screening, implementing an effective and sustainable screening program can be challenging. We discuss the rationale for and barriers to screening in pediatric settings, identify accessible validated tools that can be easily incorporated into practice, and suggest a practical strategy for implementing a more accurate screening system for common mental health concerns in pediatric primary care. [Pediatr Ann. 2020;49(10):e421-e425.].

Exploring Predictors of Treatment Engagement in Urban Integrated Primary Care

Objective

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

Method

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

Results

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

Conclusions

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

Mind-Body Skills Groups for Adolescents With Depression in Primary Care: A Pilot Study

INTRODUCTION

The objective of this study was to determine the acceptability and preliminary effectiveness of Mind-Body Skills Groups (MBSGs) as a treatment for depressed adolescents in primary care.

METHOD

A single-arm clinical trial was conducted. A 10-week MBSG program was implemented in primary care. Participants completed self-report measures at baseline, postintervention, and 3 months following the MBSGs. Measures included the Children's Depression Inventory-2, Suicidal Ideation Questionnaire, Mindful Attention Awareness Scale, Self-Efficacy for Depressed Adolescents, rumination subscale of the Children's Response Style Questionnaire, and a short acceptability questionnaire.

RESULTS

Participants included 43 adolescents. The total depression scores significantly improved following the MBSG intervention and continued to improve significantly from posttreatment to follow-up. Mindfulness, self-efficacy, rumination, and suicidal ideation all had significant improvement following the intervention. Acceptability of the program was strong, and attendance was excellent.

DISCUSSION

Preliminary evidence suggests that MBSGs are an acceptable treatment for primary care settings and lead to improved depression symptoms in adolescents.

Preliminary evaluation of the utility of parental ratings in a Child Network

INTRODUCTION

Children in the US have a high incidence of psychiatric disorders, but the symptoms of these illnesses are often poorly recognized and treated. We thus created a Child Network for parents of children aged 2-12 to rate their child on a weekly basis on a secure website so that longitudinal ratings could be easily visualized.

METHODS

After giving informed consent, parents filled out: a one-time questionnaire and a 97 item Child Checklist; and then rated the severity of depression, anxiety, ADHD, oppositional behavior, and mania each week. The new Checklist ratings were correlated with the 23 previous validated in adults (the M-3), and symptom burden was compared with diagnoses received in the community.

RESULTS

The 23 item M-3 ratings were highly correlated with the more extensive Child Checklist. Symptom severity also corresponded to diagnoses received in the community. An example of the longitudinal weekly ratings of a child with a dysphoric mania is also presented.

CONCLUSIONS

The convergence of scores on the adult and child portions of the Child Checklist and the ease of visualization of symptoms and response to treatment suggest the utility of the ratings in the Child Network.

Toward prevention of bipolar disorder in at-risk children: Potential strategies ahead of the data

BACKGROUND

Despite the well-documented negative impact of untreated bipolar illness, approaches to early intervention in childhood-onset bipolar and related disorders are not well delineated.

METHODS

We reviewed the extant treatment literature on children at high risk for bipolar disorder, with definitions based on family history, childhood adversity, and prodromal symptoms.

RESULTS

A panoply of approaches have been described, but most interventions are based on an inadequate database to support their routine implementation. We classify early stage interventions as a function of their safety and tolerability with the hope that these might generate more rigorous study and a stronger database.

LIMITATIONS

Critics may rightly argue that identifying viable treatment methods is premature given our lack of ability to reliably predict illness trajectory in very young children. However, many of the psychosocial and pharmacological interventions we present could have nonspecific positive effects across a variety of symptoms, syndromes, and diagnoses, further enhancing the rationale for more rigorous study.

CONCLUSIONS

Early stage interventions have the potential to improve functioning in prodromal illness and exert long-term positive effects on the course of illness. Many of the safest interventions deserve consideration for implementation and dissemination studies.