Mind the Gap(s): Reflective supervision/consultation as a mechanism for addressing implicit bias and reducing our knowledge gaps

Mental health-related professions, like many fields, have begun reexamining common practices and opportunities following the 2020 reawakening to the need for antiracist practices/policies. This push includes encouraging both seasoned professionals and newer trainees to do inward and outward work to increase self- and other-awareness and recognize biases. Often, it is unclear where to begin, and this deeper reflection can bring up uncomfortable realizations about oneself, colleagues, and even broader professions. Doing this deep work is most beneficial when done in a community that can provide support and further challenge. Thus, the practice of reflective supervision/consultation (RSC) is well-suited for integration of conversations about bias (implicit and explicit) as well as racism/antiracism. The current paper provides background on these concepts, the model of RSC, and specific examples of diversity, equity, and inclusion principles within the infant and early childhood mental health (IECMH) field. Parallels are drawn to existing "key concepts" of reflective supervision to provide examples for integrating conversations about bias into reflective supervision. Finally, specific tools and strategies for use are offered as starting points, with encouragement for supervisors to continue to generate ideas and tools for these important conversations. Next steps and implications for broader practice are also discussed.

Diversity, Equity, and Inclusion Efforts at a Departmental Level: Building a Committee as a Vehicle for Advancing Progress

Academic Health Centers (AHCs) across the nation are experiencing a reawakening to the importance of Diversity, Equity, and Inclusion (DEI). Such work impacts both employees and patients served by healthcare institutions. Yet, for departments without previously existing formal channels for this work, it is not always apparent where to begin. The current manuscript details a process for creating a committee as a vehicle for championing DEI efforts at the department level within an AHC. The authors present a six-step model for forming a DEI Committee and progress monitoring measures to remain accountable to identified objectives. In each step, the authors provide examples of their work with the goal for readers to tailor and apply each step to their own departments’ DEI efforts. The current paper also identifies lessons learned with regard to barriers and facilitators of department-level DEI work. Reflections and next steps for DEI work beyond the proposed model are also discussed.

Health and adverse childhood experiences among homeless youth

BACKGROUND

Homelessness is associated with health problems and with adverse childhood experiences (ACEs). The risk of chronic health conditions for homeless compared to housed youth, and how this risk interacts with ACEs remains unclear. This study investigated the relationship between ACEs, housing, and child health, and whether: 1) ACEs and health vary by housing context; 2) ACEs and homelessness confer independent health risks; and 3) ACEs interact with housing with regard to adolescent health.

METHODS

Using data from 119,254 8th-11th graders, we tested independent and joint effects of ACEs and past-year housing status (housed, family homelessness, unaccompanied homelessness) on overall health and chronic health conditions, controlling for sociodemographic covariates.

RESULTS

The prevalence of ACEs varied by housing status, with 34.1% of housed youth experiencing ≥1 ACE vs. 56.3% of family-homeless and 85.5% of unaccompanied-homeless youth. Health status varied similarly. Homelessness and ACEs were independently associated with low overall health and chronic health conditions, after adjusting for covariates. Compared to housed youth, both family-homeless youth and unaccompanied-homeless youth had increased odds of low overall health and chronic physical and/or mental health conditions. All ACE x housing-status interactions were significant (all p < 0.001), such that ACE-related health risks were moderated by housing status.

CONCLUSIONS

ACEs and housing status independently predict health status during adolescence beyond other sociodemographic risks. Experiencing homelessness, whether unaccomapnied or with family, is associated with increased health risk, and every additional ACE increases this risk. Clinicians and health systems should advocate for policies that include stable housing as a protective factor.

Talking With Children About Race and Racism

Children notice race from an early age. They also observe and can understand injustices among people. However, research shows that not all caregivers discuss race, identity, and racism. Some avoid the topic altogether. There are significant repercussions when we do not provide space for these formative conversations. Silence allows stereotypes, biases, and racism to be reinforced. There is a role and a responsibility for mental health practitioners to undertake these sometimes difficult conversations and practices with patients and parents. Illustrative examples to use with children of different ages are presented as a means of supporting parents in their discussion of race and racism with their children.

Identifying adverse childhood experiences in pediatrics to prevent chronic health conditions

Despite evidence that over 40% of youth in the United States have one or more adverse childhood experiences (ACEs), and that ACEs have cumulative, pernicious effects on lifelong health, few primary care clinicians routinely ask about ACEs. Lack of standardized and accurate clinical assessments for ACEs, combined with no point-of-care biomarkers of the "toxic stress" caused by ACEs, hampers prevention of the health consequences of ACEs. Thus, there is no consensus regarding how to identify, screen, and track ACEs, and whether early identification of toxic stress can prevent disease. In this review, we aim to clarify why, for whom, when, and how to identify ACEs in pediatric clinical care. To do so, we examine the evidence for such identification; describe the efficacy and accuracy of potential screening instruments; discuss current trends in, and potential barriers to, the identification of ACEs and the prevention of downstream effects; and recommend next steps for research, practice, and policy.

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

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

The Role of Preschool Relational and Physical Aggression in the Transition to Kindergarten: Links with Social-Psychological Adjustment

RESEARCH FINDINGS

The transition to kindergarten has important ramifications for future achievement and psychosocial outcomes. Research suggests that physical aggression may be related to difficulty during school transitions, yet no studies to date have examined the role of relational aggression in these transitions. This paper examined how engagement in preschool physical and relational aggression predicted psychosocial adjustment during the kindergarten school year. Observations and teacher reports of aggression were collected in preschool, and kindergarten teachers reported on student-teacher relationship quality, child internalizing problems, and peer acceptance in kindergarten. Results suggested that preschool physical aggression predicted reduced peer acceptance and increased conflict with the kindergarten teacher. High levels of relational aggression, when not combined with physical aggression, were related to more positive transitions to kindergarten in the domains assessed.

PRACTICE OR POLICY

These data lend support to the need for interventions among physically aggressive preschoolers to target not only concurrent behavior but also future aggression and adjustment in kindergarten. Thus, educators should work to encourage social influence in more prosocial ways amongst aggressive preschoolers.

Risk, Vulnerability, and Protective Processes of Parental Expressed Emotion for Children's Peer Relationships in Contexts of Parental Violence

This study examined risk, vulnerability, and protective processes of parental expressed emotion for children's peer relationships in families living in emergency shelters with high rates of exposure to parental violence (EPV). Parental criticism and negativity were hypothesized to exacerbate the association between EPV and poorer peer relations, whereas parental warmth was expected to buffer this association. Participants included 138 homeless parents (M = 30.77 years, SD = 6.33, range = 20.51-57.32 years; 64% African American, 12% Caucasian, 24% other) and their 4-to 6-year-old children (43.5% male; M = 4.83, SD = .58, range = 4.83-6.92 years; 67% African American, 2% Caucasian, 31% other). Families were assessed during the summer at three urban shelters, with parents completing the Five-Minute Speech Sample (FMSS), later scored for criticism, negativity, and warmth, and interview items about EPV. Teachers were subsequently contacted in the fall about children's classroom behavior, and they provided ratings of peer relations. Demographic factors, parental internalizing symptoms, and observed parental harshness were examined as covariates. Regression analyses indicated an interaction of EPV and warmth, consistent with a moderating effect of expressed emotion for EPV and peer relations, although no interactions were found for criticism or negativity. Observed harshness also directly predicted worse peer relations. Parental warmth may be protective for positive peer relations among impoverished families with high levels of EPV. The FMSS is discussed as an efficient tool with potential for both basic clinical research and preventative interventions designed to target or assess change in parental expressed emotion.

Relations of inattention and hyperactivity/impulsivity to preadolescent peer functioning: the mediating roles of aggressive and prosocial behaviors

This study examined the structural relations of preadolescents' inattention and hyperactivity/impulsivity, aggressive and prosocial behaviors, and peer functioning. There were 739 fourth (n = 239) and fifth (n = 500) graders (52.23% boys) in Taiwan who participated in this study. Preadolescents' inattention and hyperactivity/impulsivity were assessed using parent reports on the Swanson, Nolan, and Pelham IV Rating Scale. Aggressive behaviors, including physical aggression and relational aggression, and prosocial behaviors were assessed using teacher and peer reports. Peer acceptance and the number of reciprocated friendships were obtained through peer nomination administered 6 months later after initial assessment and were combined to assess children's peer functioning. Results of structural equation modeling demonstrated that inattention was indirectly linked to impaired peer functioning through low levels of prosocial behavior, regardless of gender. In addition, inattention was directly related to less optimal peer functioning only for girls. Hyperactivity/impulsivity was neither directly nor indirectly related to impaired peer functioning in boys, although it was related to more physical and relational aggression. However, for girls, a positive and direct path existed between hyperactivity and peer functioning. Further, hyperactivity in girls was associated with more physical aggression, which in turn led to poorer peer functioning. These findings suggested that the processes related to each core domain of ADHD and peer functioning may be varied, depending on the mediating factors (e.g., aggression or prosocial behavior) and gender.