Don't Get Lost in Translation: Integrating Developmental and Implementation Sciences to Accelerate Real-World Impact on Children's Development, Health, and Wellbeing

Predictive Utility of Irritability "In Context": Proof-of-Principle for an Early Childhood Mental Health Risk Calculator

OBJECTIVE

We provide proof-of-principle for a mental health risk calculator advancing clinical utility of the irritability construct for identification of young children at high risk for common, early onsetting syndromes.

METHOD

Data were harmonized from two longitudinal early childhood subsamples (total N = 403; 50.1% Male; 66.7% Nonwhite; Mage = 4.3 years). The independent subsamples were clinically enriched via disruptive behavior and violence (Subsample 1) and depression (Subsample 2). In longitudinal models, epidemiologic risk prediction methods for risk calculators were applied to test the utility of the transdiagnostic indicator, early childhood irritability, in the context of other developmental and social-ecological indicators to predict risk of internalizing/externalizing disorders at preadolescence (Mage = 9.9 years). Predictors were retained when they improved model discrimination (area under the receiver operating characteristic curve [AUC] and integrated discrimination index [IDI]) beyond the base demographic model.

RESULTS

Compared to the base model, the addition of early childhood irritability and adverse childhood experiences significantly improved the AUC (0.765) and IDI slope (0.192). Overall, 23% of preschoolers went on to develop a preadolescent internalizing/externalizing disorder. For preschoolers with both elevated irritability and adverse childhood experiences, the likelihood of an internalizing/externalizing disorder was 39-66%.

CONCLUSIONS

Predictive analytic tools enable personalized prediction of psychopathological risk for irritable young children, holding transformative potential for clinical translation.

Possible unintended consequences of pediatric clinician strategies for communicating about social-emotional and developmental concerns in diverse young children

INTRODUCTION

Screening to promote social-emotional well-being in toddlers has positive effects on long-term health and functioning. Communication about social-emotional well-being can be challenging for primary care clinicians for various reasons including lack of time, training and expertise, resource constraints, and cognitive burden. Therefore, we explored clinicians' perspectives on identifying and communicating with caregivers about social-emotional risk in toddlers.

METHOD

In 2021, semistructured interviews were conducted with pediatric clinicians (N = 20) practicing in Federally Qualified Health Centers in a single metropolitan area. Most participants identified as female (n = 15; 75%), white non-Hispanic/Latino (n = 14; 70%), and were Doctors of Medicine or Osteopathic Medicine (n = 14; 70%). Thematic analysis was conducted on audio-recorded interview transcripts.

RESULTS

Clinicians used various approaches to identify social-emotional concerns which were sometimes difficult to distinguish from other developmental concerns. The clinician-caregiver relationship guided identification and communication practices and cut-across themes. Themes include: starting with caregivers' concerns, communicating concerns with data and sensitivity, navigating labels, culture, and stigma, and limiting communication based on family capacity and interest.

DISCUSSION

Prioritizing the clinician-caregiver relationship is consistent with best practice and family-centered care. Yet, the dearth of standardized decision support may undermine clinician confidence and impede timely conversations about social-emotional concerns. An evidence-based approach with developmentally based culturally informed quantitative tools and standardized decision supports could help ensure equitable management and decision making about young children's social and emotional well-being and development. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Engaging primary care clinicians in the selection of implementation strategies for toddler social-emotional health promotion in community health centers

BACKGROUND

Social-emotional risk for subsequent behavioral health problems can be identified at toddler age, a period where prevention has a heightened impact. This study aimed to meaningfully engage pediatric clinicians, given the emphasis on health promotion and broad reach of primary care, to prepare an Implementation Research Logic Model to guide the implementation of a screening and referral process for toddlers with elevated social-emotional risk.

METHOD

Using an adaptation of a previously published community partner engagement method, six pediatricians from community health centers (CHCs) comprised a Clinical Partner Work Group. The group was engaged in identifying determinants (barriers/facilitators), selecting and specifying strategies, strategy-determinant matching, a modified Delphi approach for strategy prioritization, and user-centered design methods. The data gathered from individual interviews, two group sessions, and a follow-up survey resulted in a completed Implementation Research Logic Model.

RESULTS

The Clinical Partner Work Group identified 16 determinants, including barriers (e.g., patient access to electronic devices) and facilitators (e.g., clinician buy-in). They then selected and specified 14 strategies, which were prioritized based on ratings of feasibility, effectiveness, and priority. The highest-rated strategies (e.g., integration of the screener into the electronic health record) provided coverage of all identified barriers and comprised the primary implementation strategy "package" to be used and tested.

CONCLUSIONS

Clinical partners provided important context and insights for implementation strategy selection and specification to support the implementation of social-emotional risk screening and referral in pediatric primary care. The methodology described herein can improve partner engagement in implementation efforts and increase the likelihood of success. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Toward an optimized assessment of adolescent psychopathology risk: Multilevel environmental profiles and child irritability as predictors

Background

Adolescence is a developmental period during which youth experience vulnerability to psychopathology. To build the foundation for a parsimonious psychopathology risk calculator while capturing the complexity and dynamic nature of the environment, the current study aimed to identify distinct risk and resilience profiles with a wide range of environmental factors guided by Bronfenbrenner's biopsychosocial ecological system theory. The association between the early-mid childhood risk profiles and psychopathology in adolescence were examined. Moreover, the predictive utility of early childhood irritability was evaluated in addition to the risk profiles.

Methods

The data from Future of Families and Child Wellbeing Study a nation-wide longitudinal study, were used in the latent profile analyses to identify the risk profiles with family, school, and neighborhood characteristics from 3 to 9 years old. To capture the socio-environmental and cultural nuances, we extracted three subsamples, including Black/African American (n = 2587), Hispanic/Latinx (n = 1577), and White (n = 776) for separate analyses. Risk profile memberships were used to predict adolescence psychopathology, including depression, anxiety, attention deficits, oppositional defiant disorder, and conduct disorder symptoms. The predictive utility of early childhood irritability above and beyond environmental risk profiles was evaluated using stepwise regression.

Results

Three risk profiles were identified in the Hispanic/Latinx and Black/African American subsamples, while four profiles were identified in White subsample. Almost all risk profile membership predicted both internalizing and externalizing psychopathology, while some profiles are predictive of externalizing symptoms only. Higher level of irritability predicted higher symptomatology in all five mental health outcomes above and beyond the environmental profiles.

Conclusions

Distinct risk and resilience profiles primarily driven by parent and family characteristics were identified for all three major race/ethnicity groups. Our findings lay the foundation for a more efficient multi-tiered information gathering process in mental health clinical settings to aid the decision making for intervention and prevention.

Modeling the normal:abnormal spectrum of early childhood internalizing behaviors: A clinical-developmental approach for the Multidimensional Assessment Profiles Internalizing Dimensions

BACKGROUND

We expanded the Multidimensional Assessment Profiles (MAPS) Scales developmental specification model to characterize the normal:abnormal spectrum of internalizing (anxious and depressive) behaviors in early childhood via the MAPS-Internalizing (MAPS-INT) scale.

METHODS

The MAPS-INT item pool was generated based on clinical expertise and prior research. Analyses were conducted on a sub-sample of families (n = 183) from the diverse When to Worry early childhood sample.

RESULTS

Normal:abnormal descriptive patterns for both anxious and depressive behaviors were consistent with prior work: (1) extremes of normative variation are abnormal when very frequent; and (2) pathognomonic indicators that most children do not engage in and are abnormal, even if infrequent. Factor analysis revealed a two-factor MAPS-INT Anxious Behaviors structure (Fearful-Worried and Separation Distress) and a unidimensional MAPS-INT Depressive Behaviors factor with good fit and good-to-excellent test-retest reliability and validity.

CONCLUSIONS

We characterized the normal:abnormal spectrum of internalizing behaviors in early childhood via the MAPS-INT. Future research in larger representative samples can replicate and extend findings, including clinical thresholds and predictive utility. The MAPS-INT helps lay the groundwork for dimensional characterization of the internalizing spectrum to advance neurodevelopmental approaches to emergent psychopathology and its earlier identification.

Advancing earlier transdiagnostic identification of mental health risk: A pragmatic approach at the transition to toddlerhood

OBJECTIVES

In light of the youth mental health crisis, as 1 in 5 children have a mental disorder diagnosis by age 3, identification of transdiagnostic behavioral vulnerability prior to impairing psychopathology must occur at an earlier phase of the clinical sequence. Here, we lay the groundwork for a pragmatic irritability measure to identify at-risk infant-toddlers.

METHODS

Data comprised N = 350 diverse infant-toddlers and their mothers assessed at ∼14 months old for irritability (Multidimensional Assessment Profiles- Temper Loss-Infant/Toddler (MAPS-TL-IT) and impairment (Early Childhood Irritability-Related Impairment Interview, E-CRI; and Family Life Impairment Scale (FLIS). Bimonthly follow-up surveys assessed impairment (FLIS) over the following year.

RESULTS

Stepwise logistic regression indicated that 5 MAPS-TL-IT items were most informative for differentiating concurrent impairment on the FLIS: "frustrated about small things"; "hit, bite, or kick during tantrums"; "trouble cheering up when grumpy"; "grumpy during fun activities" and "tantrums in public". With this summed score, Receiver Operating Characteristics analysis differentiating concurrent impairment on the E-CRI indicated good classification accuracy for (Area under the curve = 0.755, p < 0.05), with a cutoff of 5 maximizing sensitivity (71.4%) and specificity (70.6%). Elevated irritability on this MAPS-TL-IT clinically optimized screener increased likelihood of persistently elevated FLIS impairment trajectories over the following year more than fourfold (OR = 4.37; Confidence intervals = 2.40-7.97, p < 0.001).

CONCLUSIONS

Our findings represent the first step toward a pragmatic tool for screening for transdiagnostic mental health risk in toddlers, optimized for feasibility in clinical care. This has potential to strengthen resilience pathways via earlier identification of mental health risk and corollary prevention in toddlers.

Characterizing the spectrum of irritability in preadolescence: Dimensional and pragmatic applications

OBJECTIVES

Characterize the dimensional spectrum of preadolescent (PA) irritability, a robust transdiagnostic vulnerability marker, using the youth version of the Multidimensional Assessment Profiles Temper Loss (MAPS-TL-Youth) scale including common and with developmentally specific items. Based on this, derive and validate a clinically optimized irritability screener to flag psychopathology risk in preadolescents.

METHODS

The normal:abnormal irritability spectrum was modeled using MAPS-TL-Youth data from the Multidimensional Assessment of Preschoolers Study (MAPS) Study PA wave (n = 340) via item response theory. Both cross-cutting core items from the MAPS scales and developmentally specific items were used to generate this dimension. Stepwise logistic regression was then used to optimize MAPS-TL-Youth irritability items in relation to Kiddie Schedule of Affective Disorders and Schizophrenia impairment to generate a clinically optimized irritability screener. Receiver operator characteristic analysis identified the irritability threshold for the screener. For the first time, youth self-report of their own irritability on the MAPS-TL was also modeled via the MAPS-TL-Youth-Self-Report (MAPS-TL-Youth-SR).

RESULTS

Irritability was unidimensional and ranged from mild and common to severe and rare behaviors. Developmentally specific items allowed detection of more severe irritability. Items for the screener were identified in relation to concurrent impairment. These included low frustration tolerance and pathognomonic severe behaviors. The clinically optimized screener demonstrated very good sensitively (87%) and specificity (81%) in regard to concurrent irritability-related DSM disorders. Modeling of the MAPS-TL-Youth-SR yielded similar results.

CONCLUSION

Characterizing the normal: abnormal spectrum of irritability in preadolescence advances application of Research Domain Criteria methods to this developmental period. This foundational work yielded two developmentally specified tools for irritability characterization in preadolescence: a nuanced dimensional scale to precisely characterize the full normal-abnormal irritability spectrum, and a pragmatic, clinically optimized screener suitable for real world use. Future application in mechanistic and clinical studies will be important for establishing validity and incremental utility.

Pediatric clinicians' perspectives on assessing concerns about young children's social-emotional wellbeing in primary care

We surveyed pediatric primary care clinicians working in Federally Qualified Health Centers about their perceptions of children's social-emotional wellbeing. We identified clinician's current methods for assessing social-emotional wellbeing in practices, perceived implementation barriers to providing behavioral health care, and interest in adopting a validated, low-burden developmentally sensitive parent-report instrument for screening for social-emotional wellbeing in young children. We surveyed 72 PCCs working in FQHCs from 9 US states. Analyses included examining central tendencies, correlations, analysis of variance, and group differences via t-tests. Average PCC perceptions of social-emotional wellbeing importance for overall health were statistically significantly higher than their confidence in providing care for common social-emotional wellbeing concerns (mean difference = 1.31, 95% CI = 1.13-1.49). PCCs expressed low satisfaction with currently available screening measures for identifying concerns in social-emotional wellbeing. Fewer than half of clinicians reported using any standardized parent-reported measure for identifying concerns in social-emotional wellbeing. Assessment methods and decision tools that improve clinician confidence concerning risk indications are needed, particularly at the critical early childhood period. Policymakers and payers ought to facilitate funding mechanisms that support pediatric PCCs in identifying early concerns in social-emotional wellbeing and providing referral guidance to evidence-based interventions to support parents and caregivers.