Youth Mental Health Screening and Linkage to Care

One Mind, in partnership with Meadows Mental Health Policy Institute, convened several virtual meetings of mental health researchers, clinicians, and other stakeholders in 2020 to identify first steps toward creating an initiative for early screening and linkage to care for youths (individuals in early adolescence through early adulthood, ages 10-24 years) with mental health difficulties, including serious mental illness, in the United States. This article synthesizes and builds on discussions from those meetings by outlining and recommending potential steps and considerations for the development and integration of a novel measurement-based screening process in youth-facing school and medical settings to increase early identification of mental health needs and linkage to evidence-based care. Meeting attendees agreed on an initiative incorporating a staged assessment process that includes a first-stage brief screener for several domains of psychopathology. Individuals who meet threshold criteria on the first-stage screener would then complete an interview, a second-stage in-depth screening, or both. Screening must be followed by recommendations and linkage to an appropriate level of evidence-based care based on acuity of symptoms endorsed during the staged assessment. Meeting attendees proposed steps and discussed additional considerations for creating the first nationwide initiative for screening and linkage to care, an initiative that could transform access of youths to mental health screening and care.

Effect of General Practitioner Training in a Collaborative Child Mental Health Care Program on Children's Mental Health Outcomes in a Low-Resource Setting: A Cluster Randomized Trial

IMPORTANCE

Integrated care for children is rarely studied, especially in low- and middle-income countries, where generalists often provide mental health care.

OBJECTIVES

To explore the effect of adding a child and youth component to an existing adult collaborative care program on mental health outcomes and receipt of care.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized trial was conducted within an adult collaborative care program in Tehran, Iran. General practitioners (GPs), their 5- to 15-year-old patients, and patients' parents were included. Children and youths coming for routine medical visits who scored greater than the cutoff on the Strengths and Difficulties Questionnaire (SDQ) were followed up for 6 months. The study was conducted from May 2018 to October 2019, and analysis was conducted from March 2020 to August 2021.

INTERVENTIONS

GPs were randomized to either a 2.5-day training on managing common child mental health problems (intervention) or refresher training on identification and referral (control).

MAIN OUTCOMES AND MEASURES

Primary outcome was change in SDQ total problems score; secondary outcomes included discussion of psychosocial issues by the GPs and receipt of mental health care during the follow-up period.

RESULTS

Overall, 49 GPs cared for 389 children who scored greater than the cutoff on the SDQ (216 children in intervention group, 173 in control group). Patients' mean (SD) age was 8.9 (2.9) years (range, 5 to 15 years), and 182 (47%) were female patients. At 6 months, children in the intervention group had greater odds of receiving mental health care during the study (odds ratio [OR], 3.0; 95% CI, 1.1 to 7.7), parents were more likely to report that intervention GPs had discussed parent (OR, 2.1; 95% Cl, 1.1 to 3.8) and child (OR, 2.0; 95% Cl, 0.9 to 4.8) psychosocial issues, and intervention GPs were more likely to say they had provided counseling (OR, 1.8; 95% Cl, 1.02 to 3.3). However, there was no greater improvement in SDQ scores among children seen by intervention vs control GPs. Adjusted for clustering within GP, the variables used for balanced allocation (practice size, practice ownership, and study wave), and the other variables associated with change in SDQ scores over time, there was not a significant time-treatment interaction at either the 3- or 6-month follow-up points (linear combination of coefficients for intervention, 0.57 [95% CI, -1.07 to 2.22] and -0.08 [95%CI, -1.76 to 1.56], respectively). In a subgroup of GPs with practices composed of 50% or more children, children seen by intervention GPs improved to a significantly greater extent (-3.6 points; 95% CI, -6.7 to -0.46 points; effect size d = 0.66; 95% CI, 0.30 to 1.01) compared with those seen by control GPs.

CONCLUSIONS AND RELEVANCE

In this cluster randomized trial, GP training on managing common child mental health problems did not demonstrate greater improvement in child SDQ scores. Child mental health training for GPs in collaborative care can improve children's access to mental health care, but prior experience working with children and their families may be required for GPs to use a brief training in a way that improves child outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03144739.

Ineligibility for and Refusal to Participate in Randomized Controlled Trials That Have Studied Impact on Suicide-Related Outcomes in the United States: A Meta-Analysis

Objective: Ineligibility for and refusal to participate in randomized controlled trials (RCTs) can potentially lead to unrepresentative study samples and limited generalizability of findings. We examined the rates of exclusion and refusal in RCTs that have studied impact on suicide-related outcomes in the US. Data Sources: PubMed, the Cochrane Library, the Campbell Collaboration Library of Systematic Reviews, CINAHL, PsycINFO, and Education Resources Information Center were searched from January 1990 to May 2020 using the terms (suicide prevention) AND (clinical trial). Study Selection: Of 8,403 studies retrieved, 36 RCTs assessing effectiveness on suicide-related outcomes in youth (≤ 25 years old) conducted in the US were included. Data Extraction: Study-level data were extracted by 2 independent investigators for a random-effects meta-analysis and meta-regression. Results: The study participants (N = 13,264) had a mean (SD) age of 14.87 (1.58) years and were 50% male, 23% African American, and 24% Hispanic. The exclusion rate was 36.4%, while the refusal rate was 25.5%. The exclusion rate was significantly higher in the studies excluding individuals not exceeding specified cutoff points of suicide screening tools (51.2%; adjusted linear coefficient [β] = 1.30, standard error [SE] = 0.15; P = .041) and individuals not meeting the age or school grade criterion (45.9%; β = 1.37, SE = 0.13; P = .005). Conclusions: The rates of exclusion and refusal in youth prevention interventions studying impact on suicide-related outcomes were not as high compared to the rates found in other mental and behavioral interventions. While there was strong racial/ethnic group representation in RCTs examining youth suicide-related outcomes, suicide severity and age limited eligibility.

Efficacy and cost-effectiveness of task-shared care for people with severe mental disorders in Ethiopia (TaSCS): a single-blind, randomised, controlled, phase 3 non-inferiority trial

BACKGROUND

There have been no trials of task-shared care (TSC) using WHO's mental health Gap Action Programme for people with severe mental disorders (psychosis or affective disorder) in low-income or middle-income countries. We aimed to evaluate the efficacy and cost-effectiveness of TSC compared with enhanced specialist mental health care in rural Ethiopia.

METHODS

In this single-blind, phase 3, randomised, controlled, non-inferiority trial, participants had a confirmed diagnosis of a severe mental disorder, recruited from either the community or a local outpatient psychiatric clinic. The intervention was TSC, delivered by supervised, non-physician primary health care workers trained in the mental health Gap Action Programme and working with community health workers. The active comparison group was outpatient psychiatric nurse care augmented with community lay workers (PSY). Our primary endpoint was whether TSC would be non-inferior to PSY at 12 months for the primary outcome of clinical symptom severity using the Brief Psychiatric Rating Scale, Expanded version (BPRS-E; non-inferiority margin of 6 points). Randomisation was stratified by health facility using random permuted blocks. Independent clinicians allocated groups using sealed envelopes with concealment and outcome assessors and investigators were masked. We analysed the primary outcome in the modified intention-to-treat group and safety in the per-protocol group. This trial is registered with ClinicalTrials.gov, number NCT02308956.

FINDINGS

We recruited participants between March 13, 2015 and May 21, 2016. We randomly assigned 329 participants (111 female and 218 male) who were aged 25-72 years and were predominantly of Gurage (198 [60%]), Silte (58 [18%]), and Mareko (53 [16%]) ethnicity. Five participants were found to be ineligible after randomisation, giving a modified intention-to-treat sample of 324. Of these, 12-month assessments were completed in 155 (98%) of 158 in the TSC group and in 158 (95%) of 166 in the PSY group. For the primary outcome, there was no evidence of inferiority of TSC compared with PSY. The mean BPRS-E score was 27·7 (SD 4·7) for TSC and 27·8 (SD 4·6) for PSY, with an adjusted mean difference of 0·06 (90% CI -0·80 to 0·89). Per-protocol analyses (n=291) were similar. There were 47 serious adverse events (18 in the TSC group, 29 in the PSY group), affecting 28 participants. These included 17 episodes of perpetrated violence and seven episodes of violent victimisation leading to injury, ten suicide attempts, six hospital admissions for physical health conditions, four psychiatric admissions, and three deaths (one in the TSC group, two in the PSY group). The incremental cost-effectiveness ratio for TSC indicated lower cost of -US$299·82 (95% CI -454·95 to -144·69) per unit increase in BPRS-E scores from a health care sector perspective at 12 months.

INTERPRETATION

WHO's mental health Gap Action Programme for people with severe mental disorders is as cost-effective as existing specialist models of care and can be implemented effectively and safely by supervised non-specialists in resource-poor settings.

FUNDING

US National Institute of Mental Health.

Correction to: Task sharing for the care of severe mental disorders in a low-income country (TaSCS): study protocol for a randomised, controlled, non-inferiority trial

An amendment to this paper has been published and can be accessed via the original article.

Identifying pathways for large-scale implementation of a school-based mental health programme in the Eastern Mediterranean Region: a theory-driven approach

Globally there is a substantial burden of mental health problems among children and adolescents. Task-shifting/task-sharing mental health services to non-specialists, e.g. teachers in school settings, provide a unique opportunity for the implementation of mental health interventions at scale in low- and middle-income countries (LMICs). There is scant information to guide the large-scale implementation of school-based mental health programme in LMICs. This article describes pathways for large-scale implementation of a School Mental Health Program (SMHP) in the Eastern Mediterranean Region (EMR). A collaborative learning group (CLG) comprising stakeholders involved in implementing the SMHP including policymakers, programme managers and researchers from EMR countries was established. Participants in the CLG applied the theory of change (ToC) methodology to identify sets of preconditions, assumptions and hypothesized pathways for improving the mental health outcomes of school-aged children in public schools through implementation of the SMHP. The proposed pathways were then validated through multiple regional and national ToC workshops held between January 2017 and September 2019, as the SMHP was being rolled out in three EMR countries: Egypt, Pakistan and Iran. Preconditions, strategies and programmatic/contextual adaptations that apply across these three countries were drawn from qualitative narrative summaries of programme implementation processes and facilitated discussions during biannual CLG meetings. The ToC for large-scale implementation of the SMHP in the EMR suggests that identifying national champions, formulating dedicated cross-sectoral (including the health and education sector) implementation teams, sustained policy advocacy and stakeholders engagement across multiple levels, and effective co-ordination among education and health systems especially at the local level are among the critical factors for large-scale programme implementation. The pathways described in this paper are useful for facilitating effective implementation of the SMHP at scale and provide a theory-based framework for evaluating the SMHP and similar programmes in the EMR and other LMICs.

Erratum: Measuring functional disability in children with developmental disorders in low-resource settings: validation of Developmental Disorders-Children Disability Assessment Schedule (DD-CDAS) in rural Pakistan

[This corrects the article DOI: 10.1017/gmh.2020.10.].

Measuring functional disability in children with developmental disorders in low-resource settings: validation of Developmental Disorders-Children Disability Assessment Schedule (DD-CDAS) in rural Pakistan

BACKGROUND

Developmental disorders (DDs) in children are a priority condition and guidelines have been developed for their management within low-resource community settings. However, a key obstacle is lack of open access, reliable and valid tools that lay health workers can use to evaluate the impact of such programmes on child outcomes. We adapted and validated the World Health Organization's Disability Assessment Schedule for children (WHODAS-Child), a lay health worker-administered functioning-related tool, for children with DDs in Pakistan.

METHODS

Lay health workers administered a version of the WHODAS-Child to parents of children with DDs (N = 400) and without DDs (N = 400), aged 2-12 years, after it was adapted using qualitative study. Factor analysis, validity, reliability and sensitivity to change analyses were conducted to evaluate the psychometric properties of the adapted outcome measure.

RESULTS

Among 800 children, 58% of children were male [mean (s.d.) age 6.68 (s.d. = 2.89)]. Confirmatory Factor Analysis showed a robust factor structure [χ2/df 2.86, RMSEA 0.068 (90% CI 0.064-0.073); Tucker-Lewis Index (TLI) 0.92; Comparative Fit Index (CFI) 0.93; Incremental Fit Index (IFI) 0.93]. The tool demonstrated high internal consistency (α 0.82-0.94), test-retest [Intra-class Correlation Coefficient (ICC) 0.71-0.98] and inter-data collector (ICC 0.97-0.99) reliabilities; good criterion (r -0.71), convergent (r -0.35 to 0.71) and discriminative [M (s.d.) 52.00 (s.d. = 21.97) v. 2.14 (s.d. = 4.00); 95% CI -52.05 to -47.67] validities; and adequate sensitivity to change over time (ES 0.19-0.23).

CONCLUSIONS

The lay health worker administrated version of adapted WHODAS-Child is a reliable, valid and sensitive-to-change measure of functional disability in children aged 2-12 years with DDs in rural community settings of Pakistan.

Implementation of Off-Site Integrated Care for Children: A Scoping Review

BACKGROUND

As an alternative to co-located integrated care, off-site integration (partnerships between primary care and non-embedded specialty mental health providers) can address the growing need for pediatric mental health services. Our goal is to review the existing literature on implementing off-site pediatric integrated care.

METHODS

We systematically searched the literature for peer-reviewed publications on off-site pediatric integrated care interventions. We included studies that involved systematic data collection and analysis, both qualitative and quantitative, of implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability).

RESULTS

We found 39 original articles from 24 off-site programs with a variety of study designs, most with secondary implementation outcomes. Models of off-site integration varied primarily along two dimensions: direct vs. indirect, and in-person vs. remote. Overall, off-site models were acceptable to providers, particularly when the following were present: strong interdisciplinary communication, timely availability and reliability of services, additional support beyond one-time consultation, and standardized care algorithms. Adoption and penetration were facilitated by enhanced program visibility, including on-site champions. Certain clinical populations (e.g., school-age, less complicated ADHD) seemed more amenable to off-site integrated models than others (e.g., preschool-age, conduct disorders). Lack of funding and inadequate reimbursement limited sustainability in all models.

CONCLUSIONS

Off-site interventions are feasible, acceptable, and often adopted widely with adequate planning, administrative support, and interprofessional communication. Studies that focus primarily on implementation and that consider the perspectives of specialty providers and patients are needed.

Collaborative care for child and youth mental health problems in a middle-income country: study protocol for a randomized controlled trial training general practitioners

BACKGROUND

Child and youth mental health problems are leading causes of disability and particular problems in low- and middle-income countries where populations are young and child mental health services are in short supply. Collaborative care models that support primary care providers' efforts to detect and treat child mental health problems offer one way to address this need. However, collaborative care for child mental health can be more complex than collaboration for adults for a number of reasons, including two-generational aspects of care, high degrees of co-morbidity, and variations in presentation across developmental stages.

METHODS

The study takes advantage of an existing collaborative care network in Tehran, Iran, in which general practitioners are supported by community mental health centers to care for adult mental health problems. At present, those practitioners are asked to refer children with mental health problems to the collaborating centers rather than treating them themselves. We are conducting a cluster randomized trial in which practitioners in the network will be randomized to receive training in child/youth mental health treatment or a booster training on recognition and referral. Children/youth aged 5-15 years making visits to the practitioners will be screened using the Strengths and Difficulties Questionnaire; those found positive will be followed for six months to compare outcomes between those treated by trained or control practitioners.

DISCUSSION

If the trial demonstrates superior outcomes among children treated by trained practitioners, it will support the feasibility of expanding collaborative care networks to include children.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03144739 . Registered on 8 May 2017.

Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice

Perinatal depression (PND) is the most common obstetric complication in the United States. Even when screening results are positive, mothers often do not receive further evaluation, and even when PND is diagnosed, mothers do not receive evidence-based treatments. Studies reveal that postpartum depression (PPD), a subset of PND, leads to increased costs of medical care, inappropriate medical treatment of the infant, discontinuation of breastfeeding, family dysfunction, and an increased risk of abuse and neglect. PPD, specifically, adversely affects this critical early period of infant brain development. PND is an example of an adverse childhood experience that has potential long-term adverse health complications for the mother, her partner, the infant, and the mother-infant dyad. However, PND can be treated effectively, and the stress on the infant can be buffered. Pediatric medical homes should coordinate care more effectively with prenatal providers for women with prenatally diagnosed maternal depression; establish a system to implement PPD screening at the 1-, 2-, 4-, and 6-month well-child visits; use community resources for the treatment and referral of the mother with depression; and provide support for the maternal-child (dyad) relationship, including breastfeeding support. State chapters of the American Academy of Pediatrics, working with state departments of public health, public and private payers, and maternal and child health programs, should advocate for payment and for increased training for PND screening and treatment. American Academy of Pediatrics recommends advocacy for workforce development for mental health professionals who care for young children and mother-infant dyads, and for promotion of evidence-based interventions focused on healthy attachment and parent-child relationships.

The study of effect moderation in youth suicide-prevention studies

PURPOSE

Suicide is now the second leading cause of death among persons between the ages of adolescents and emerging adults and rates have increased despite more funding and broader implementation of youth suicide-prevention programs. A systematic review was conducted focusing on identifying youth suicide-prevention studies within the United States. This paper reports on the methods utilized for understanding possible moderators of suicide-prevention program outcomes.

METHODS

We searched six databases from 1990 through August 2017 to identify studies of suicide-preventive interventions among those under age 26 years. Two independent team members screened search results and sequentially extracted information related to statistical methods of moderation analyses.

RESULTS

69 articles were included in the systematic review of which only 17 (24.6%) explored treatment effect heterogeneity using moderation analysis. The most commonly used analytic tool was regression with an interaction term. The moderators studied included demographic characteristics such as gender and ethnicity as well as individual characteristics such as traumatic stress exposure and multiple prior suicide attempts.

CONCLUSIONS

With a greater emphasis from the federal government and funding agencies on precision prevention, understanding which prevention programs work for specific subgroups is essential. Only a small percentage of the reviewed articles assessed moderation effects. This is a substantial research gap driven by sample size or other limitations which have impeded the identification of intervention effect heterogeneity.

The Power of Play: A Pediatric Role in Enhancing Development in Young Children

Children need to develop a variety of skill sets to optimize their development and manage toxic stress. Research demonstrates that developmentally appropriate play with parents and peers is a singular opportunity to promote the social-emotional, cognitive, language, and self-regulation skills that build executive function and a prosocial brain. Furthermore, play supports the formation of the safe, stable, and nurturing relationships with all caregivers that children need to thrive.Play is not frivolous: it enhances brain structure and function and promotes executive function (ie, the process of learning, rather than the content), which allow us to pursue goals and ignore distractions.When play and safe, stable, nurturing relationships are missing in a child's life, toxic stress can disrupt the development of executive function and the learning of prosocial behavior; in the presence of childhood adversity, play becomes even more important. The mutual joy and shared communication and attunement (harmonious serve and return interactions) that parents and children can experience during play regulate the body's stress response. This clinical report provides pediatric providers with the information they need to promote the benefits of play and and to write a prescription for play at well visits to complement reach out and read. At a time when early childhood programs are pressured to add more didactic components and less playful learning, pediatricians can play an important role in emphasizing the role of a balanced curriculum that includes the importance of playful learning for the promotion of healthy child development.

The Mental Health Training Intervention for School Nurses and Other Health Providers in Schools

School nurses encounter many students presenting with mental health needs. However, school nurses report that they need additional training and resources to be able to support student mental health. This study involved a multilevel, stakeholder-driven process to refine the Mental Health Training Intervention for Health Providers in Schools (MH-TIPS), an in-service training and implementation support system for school health providers, including school nurses, to increase their competence in addressing student mental health concerns. Findings highlighted the importance of mental health content including assessment, common factors of positive therapeutic mental health interactions, common elements of evidence-based mental health practice, and resource and referral mapping. Additionally, multifaceted ongoing professional development processes were indicated. Study findings indicate that, with recommended modifications, the MH-TIPS holds promise as a feasible, useful intervention to support school nurse practice and ultimately impact student mental health and educational outcomes.

Correlates of Patterns of Health Values of African Americans Living With HIV/AIDS: Implications for Advance Care Planning and HIV Palliative Care

CONTEXT

Advance care planning rates remain low, especially among people who are HIV positive, disadvantaged, and African American. Although advance care planning can be a sensitive topic for clinicians and patients to discuss, health values clarification can be an important initial step.

OBJECTIVES

The purpose of the study was to explore health values of African Americans living with HIV/AIDS and to examine correlates of these values.

METHODS

Data were from the first 325 participants in the AFFIRM Care study, which enrolled adults living with HIV/AIDS in Baltimore, Maryland, who had histories of illicit drug use. Respondents were asked whether (yes/no) they thought any of six health states would be worse than death: severe unremitting pain, total dependency on others, irreversible coma, being on mechanical ventilation, nursing home residence, and severe dementia. Latent class analysis was used to group individuals by their pattern of responses, interpretable as preference for aggressive (life-sustaining) or nonaggressive (palliative) end-of-life care. Latent class regression analysis was used to examine associations between class membership and background, health status, and social variables.

RESULTS

We found statistical support for a three-class latent class analysis model: 1) the nonaggressive treatment class, comprising 43% of cases, in which members perceived that every state was worse than death; 2) the aggressive treatment class, comprising 33% of cases, in which members perceived that none of the states was worse than death; and 3) the mixed class (24% of cases), in which members perceived that only four of the six states were worse than death.

CONCLUSION

Three-quarters of participant response patterns had clear preferences for treatment decisions. Further research is needed to ensure inclusion of end-of-life scenarios relevant to this population.

Surveillance or Engagement: Children's Conflicts During Health Maintenance Visits

OBJECTIVE

School-aged health maintenance visits seek to prevent or intervene early with health issues of lifelong importance. Little is known about what children expect to happen in these visits or how they experience them, factors related to their engagement as active collaborators in care.

METHODS

Thirty children (53% Latino, 27% African-American, and 20% white) ages 7 to 11 years were video recorded during a health maintenance visit and then interviewed while reviewing the videos. Interview transcripts were analyzed for understanding the purpose of the visit, feelings of comfort and discomfort, and decisions about how much to participate.

RESULTS

Children expected doctors to be helpful, caring, and a source of important information. They anticipated visits to include immunizations, a physical examination, and praise for accomplishments, but could be surprised by questions about behavior, family function, and lifestyle. During visits, feelings varied from warmth toward providers to embarrassment, wariness, irritation, and boredom. Even when bored or irritated, children hesitated to interrupt parent-provider conversations or correct perceived provider misunderstandings, not wanting to be seen as inappropriate or rude. When asked questions they considered off topic, likely to reveal sensitive information, or that could lead to changes in their lifestyle, some were silent or answered evasively. Some said they would have spoken more freely without their parent present but valued parental support and wanted parents to make important decisions.

CONCLUSIONS

School-aged children's limited knowledge of what to expect in health maintenance visits, uncertainty about conversational norms with adults, and desire to assert control over their lives compete with their desire to access expert advice and form bonds with providers. Engaging children in health maintenance visits might require more relationship-building and education about the visit's goals.

Data Linkage Strategies to Advance Youth Suicide Prevention: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop

BACKGROUND

Linking national, state, and community data systems to data from prevention programs could allow for longer-term assessment of outcomes and evaluation of interventions to prevent suicide.

PURPOSE

To identify and describe data systems that can be linked to data from prevention studies to advance youth suicide prevention research.

DATA SOURCES

A systematic review, an environmental scan, and a targeted search were conducted to identify prevention studies and potentially linkable external data systems with suicide outcomes from January 1990 through December 2015.

STUDY SELECTION

Studies and data systems had to be U.S.-based and include persons aged 25 years or younger. Data systems also had to include data on suicide, suicide attempt, or suicidal ideation.

DATA EXTRACTION

Information about participants, intervention type, suicide outcomes, primary analytic method used for linkage, statistical approach, analyses performed, and characteristics of data systems was abstracted by 2 reviewers.

DATA SYNTHESIS

Of 47 studies (described in 59 articles) identified in the systematic review, only 6 were already linked to data systems. A total of 153 unique and potentially linkable data systems were identified, but only 66 were classified as "fairly accessible" and had data dictionaries available. Of the data systems identified, 19% were established primarily for research, 11% for clinical care or operations, 29% for administrative services (such as billing), and 52% for surveillance. About one third (37%) provided national data, 12% provided regional data, 63% provided state data, and 41% provided data below the state level (some provided coverage for >1 geographic unit).

LIMITATION

Only U.S.-based studies published in English were included.

CONCLUSION

There is untapped potential to evaluate and enhance suicide prevention efforts by linking suicide prevention data with existing data systems. However, sparse availability of data dictionaries and lack of adherence to standard data elements limit this potential.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Psychosocial interventions for use in pediatric primary care: An examination of providers' perspectives

INTRODUCTION

The integration of psychosocial interventions in primary care settings is 1 mechanism to increase access to mental health care to youth in need. Although the delivery of psychosocial interventions by primary care providers (PCPs) reflects 1 example of this integration, research indicates that various barriers to implementation by PCPs exist. With the goal of informing a framework to guide the selection of treatments amenable to PCP practice, the authors sought to examine which criteria might influence a PCP's intention to use a given psychosocial intervention.

METHOD

Using survey methodology, 49 PCPs ranked characteristics of interventions for feasibility and applicability to their patient populations and setting.

RESULTS

Survey respondents found the following characteristics most important: time to employ, applicability to multiple disorders, ease of use, and ease of learning. Providers who endorsed more negative beliefs and attitudes toward addressing psychosocial concerns in youth were more likely to see certain criteria, such as ease of use and ease of learning, as more important.

DISCUSSION

The authors illustrate the potential application of these findings to the selection of psychosocial interventions for use in primary care and discuss future research directions. (PsycINFO Database Record

Child and Adolescent Mental Health Care in Iran: Current Status and Future Directions

BACKGROUND

The need for mental health care among children and adolescents in Iran, as in other low and middle income countries (LAMIC) remains mostly unmet. In this paper, we sought to provide an overview of the extent of unmet need and mental health services in Iran. We also aimed to propose approaches to address this gap.

METHOD

We reviewed the published epidemiologic studies of child and adolescent mental and behavioral health problems in Iran. We also examined the current status of child mental health services and the gaps between current needs and available services based on published literature that included papers published in scientific journals, as well as governmental and other administrative reports. The contextual issues relevant to child mental health care were also explored, as well as the possibilities to introduce new or scale up promising services.

RESULTS

Child and adolescent mental and behavioral health problems are highly prevalent in Iran. Different studies have estimated that 16.7% to 36.4% of children and adolescents suffer from one or more mental health problems. However, there is a serious scarcity of resources to meet this need. Available services are delivered by independent public organizations (e.g., Ministry of Health, Welfare Organization, and Ministry of Education) or private sector with inefficient communication and collaboration among them and no mandatory national mental health policy. Available specialized child and adolescent services are mostly confined to small inpatient units and university outpatient facilities in larger cities, and there is a scarce evidence for  the effectiveness of the available services.

CONCLUSIONS

Expansion of primary care's role in timely detection and management of child and adolescent mental health problems, implementation of task-shifting and -sharing initiatives, as well as improved collaboration among responsible governmental and non-governmental sectors are some of the most promising future venues to improve mental health care for the Iranian youth.

Development process of an assessment tool for disruptive behavior problems in cross-cultural settings: the Disruptive Behavior International Scale - Nepal version (DBIS-N)

Systematic processes are needed to develop valid measurement instruments for disruptive behavior disorders (DBDs) in cross-cultural settings. We employed a four-step process in Nepal to identify and select items for a culturally valid assessment instrument: 1) We extracted items from validated scales and local free-list interviews. 2) Parents, teachers, and peers (n=30) rated the perceived relevance and importance of behavior problems. 3) Highly rated items were piloted with children (n=60) in Nepal. 4) We evaluated internal consistency of the final scale. We identified 49 symptoms from 11 scales, and 39 behavior problems from free-list interviews (n=72). After dropping items for low ratings of relevance and severity and for poor item-test correlation, low frequency, and/or poor acceptability in pilot testing, 16 items remained for the Disruptive Behavior International Scale-Nepali version (DBIS-N). The final scale had good internal consistency (α=0.86). A 4-step systematic approach to scale development including local participation yielded an internally consistent scale that included culturally relevant behavior problems.

Data Linkage Strategies to Advance Youth Suicide Prevention

OBJECTIVES

Linking national, State, and community data systems, such as those used for medical service billing, to existing data from suicide prevention efforts could facilitate the assessment of longer term outcomes. Our objective was to identify and describe data systems that can be linked to data from studies of youth suicide prevention interventions and to identify analytic approaches to advance youth suicide prevention research.

DATA SOURCES

We conducted a systematic review to identify studies of suicide prevention interventions and three types of searches to identify data systems providing suicide-related outcomes: (1) a literature search, (2) an environmental scan of gray literature, and (3) a targeted search, through contact with relevant individuals, in six States, two cities, and one tribal community.

REVIEW METHODS

Two independent reviewers screened all results. Studies and data systems had to be based in the United States; include individuals between 0 and 25 years of age; and include suicide, suicide attempt, or suicide ideation as an outcome.

RESULTS

Of the 47 studies (described in 59 articles) of suicide prevention interventions identified in our systematic review, only 6 studied outcomes by linking to external data systems and only 12 explored treatment heterogeneity through the effects of moderators such as gender or race/ethnicity. We identified 153 unique and potentially linkable external data systems, 66 of which we classified as "fairly accessible" with data dictionaries available.

CONCLUSIONS

There is potential for linking existing data systems with suicide prevention efforts to assess the broader and extended impact of suicide prevention interventions. However, sparse availability of data dictionaries and lack of adherence to standard data elements limit the potential utility of linking prevention efforts with data systems.

Pediatric Use of Emergency Medical Services: The Role of Chronic Illnesses and Behavioral Health Problems

OBJECTIVE

The increasing use of prehospital emergency medical services (EMS) and its contribution to rising emergency department use and healthcare costs point to the need for better understanding factors associated with EMS use to inform preventive interventions. Understanding patient factors associated with pediatric use of EMS will inform pediatric-specific intervention. We examined pediatric patient demographic and health factors associated with one-time and repeat use of EMS.

METHODS

We reviewed data from Baltimore City Fire Department EMS patient records over a 23-month period (2008-10) for patients under 21 years of age (n = 24,760). Repeat use was defined as involvement in more than one EMS incident during the observation period. Analyses compared demographics of EMS users to the city population and demographics and health problems of repeat and one-time EMS users. Health comparisons were conducted at the patient and incident levels of analysis.

RESULTS

Repeat users (n = 1,931) accounted for 9.0% of pediatric users and 20.8% of pediatric incidents, and were over-represented among the 18-20 year age group and among females. While trauma accounted for approximately one-quarter of incidents, repeat versus one-time users had a lower proportion of trauma-related incidents (7.2% vs. 26.7%) and higher proportion of medical-related incidents (92.6% vs. 71.4%), including higher proportions of incidents related to asthma, seizures, and obstetric/gynecologic issues. In patient-level analysis, based on provider or patient reports, greater proportions of repeat compared to one-time users had asthma, behavioral health problems (mental, conduct and substance use problems), seizures, and diabetes.

CONCLUSIONS

Chronic somatic conditions and behavioral health problems appear to contribute to a large proportion of the repeat pediatric use of this EMS system. Interventions may be needed to engage repeat users in primary care and behavioral health services, to train EMS providers on the recognition and management of behavioral health emergencies, and to improve family care and self-management of pediatric asthma and other chronic conditions.

Adverse Childhood Experiences, Resilience and Mindfulness-Based Approaches: Common Denominator Issues for Children with Emotional, Mental, or Behavioral Problems

US children with emotional, mental, or behavioral conditions (EMB) have disproportionate exposure to adverse childhood experiences (ACEs). There are theoretic and empirical explanations for early and lifelong physical, mental, emotional, educational, and social impacts of the resultant trauma and chronic stress. Using mindfulness-based, mind-body approaches (MBMB) may strengthen families and promote child resilience and success. This paper examines associations between EMB, ACEs, and protective factors, such as child resilience, parental coping/stress, and parent-child engagement. Findings encourage family-centered and mindfulness-based approaches to address social and emotional trauma and potentially interrupt cycles of ACEs and prevalence of EMB.

Task sharing for the care of severe mental disorders in a low-income country (TaSCS): study protocol for a randomised, controlled, non-inferiority trial

BACKGROUND

Task sharing mental health care through integration into primary health care (PHC) is advocated as a means of narrowing the treatment gap for mental disorders in low-income countries. However, the effectiveness, acceptability, feasibility and sustainability of this service model for people with a severe mental disorder (SMD) have not been evaluated in a low-income country.

METHODS/DESIGN

A randomised, controlled, non-inferiority trial will be carried out in a predominantly rural area of Ethiopia. A sample of 324 people with SMD (diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder or major depressive disorder) with an ongoing need for mental health care will be recruited from 1) participants in a population-based cohort study and 2) people attending a psychiatric nurse-led out-patient clinic. The intervention is a task-sharing model of locally delivered mental health care for people with SMD integrated into PHC delivered over 18 months. Participants in the active control arm will receive the established and effective model of specialist mental health care delivered by psychiatric nurses at an out-patient clinic within a centrally located general hospital. The hypothesis is that people with SMD who receive mental health care integrated into PHC will have a non-inferior clinical outcome, defined as a mean symptom score on the Brief Psychiatric Rating Scale, expanded version, of no more than six points higher, compared to participants who receive the psychiatric nurse-led service, after 12 months. The primary outcome is change in symptom severity. Secondary outcomes are functional status, relapse, service use costs, service satisfaction, drop-out and medication adherence, nutritional status, physical health care, quality of care, medication side effects, stigma, adverse events and cost-effectiveness. Sustainability and cost-effectiveness will be further evaluated at 18 months. Randomisation will be stratified by health centre catchment area using random permuted blocks. The outcome assessors and investigators will be masked to allocation status.

DISCUSSION

Evidence about the effectiveness of task sharing mental health care for people with SMD in a rural, low-income African country will inform the World Health Organisation's mental health Gap Action Programme to scale-up mental health care globally.

TRIAL REGISTRATION

NCT02308956 (ClinicalTrials.gov). Date of registration: 3 December 2014.

Yoga in Sedentary Adults with Arthritis: Effects of a Randomized Controlled Pragmatic Trial

OBJECTIVE

To evaluate the effect of Integral-based hatha yoga in sedentary people with arthritis.

METHODS

There were 75 sedentary adults aged 18+ years with rheumatoid arthritis (RA) or knee osteoarthritis randomly assigned to 8 weeks of yoga (two 60-min classes and 1 home practice/wk) or waitlist. Poses were modified for individual needs. The primary endpoint was physical health [Medical Outcomes Study Short Form-36 (SF-36) physical component summary (PCS)] adjusted for baseline; exploratory adjusted outcomes included fitness, mood, stress, self-efficacy, SF-36 health-related quality of life (HRQOL), and RA disease activity. In everyone completing yoga, we explored longterm effects at 9 months.

RESULTS

Participants were mostly female (96%), white (55%), and college-educated (51%), with a mean (SD) age of 52 years (12 yrs). Average disease duration was 9 years and 49% had RA. At 8 weeks, yoga was associated with significantly higher PCS (6.5, 95% CI 2.0-10.7), walking capacity (125 m, 95% CI 15-235), positive affect (5.2, 95% CI 1.4-8.9), and lower Center for Epidemiologic Studies Depression Scale (-3.0, 95% CI -4.8 - -1.3). Significant improvements (p < 0.05) were evident in SF-36 role physical, pain, general health, vitality, and mental health scales. Balance, grip strength, and flexibility were similar between groups. Twenty-two out of 28 in the waitlist group completed yoga. Among all yoga participants, significant (p < 0.05) improvements were observed in mean PCS, flexibility, 6-min walk, and all psychological and most HRQOL domains at 8 weeks with most still evident 9 months later. Of 7 adverse events, none were associated with yoga.

CONCLUSION

Preliminary evidence suggests yoga may help sedentary individuals with arthritis safely increase physical activity, and improve physical and psychological health and HRQOL. Clinical Trials NCT00349869.

Primary Care Interventions to Prevent or Treat Traumatic Stress in Childhood: A Systematic Review

OBJECTIVES

To systematically assess the evidence base for prevention and treatment of child traumatic stress in primary care settings.

DATA SOURCES

PubMed, Embase, PsycINFO, Scopus, Academic Search Complete, CINAHL, Web of Science, Cochrane Library, the National Registry of Evidence-based Programs and Practices, the National Child Traumatic Stress Network website, Google search.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Studies were eligible for inclusion if they described the results of intervention studies in a primary care setting addressing child traumatic stress. Study participants could include primary care providers, pediatric patients, and their parents or other caregivers.

STUDY APPRAISAL AND SYNTHESIS METHODS

Each study was assessed for inclusion, and each included study was assessed for risk of bias by 2 reviewers.

RESULTS

We found 12 articles describing 10 different studies that met the inclusion criteria. The intervention approaches taken in the studies were diverse and included the implementation of screening programs or tools, training clinicians to recognize and discuss psychosocial issues with patients and their families, and providing primary care professionals with community resource lists. Nine out of 10 studies included in the review reported favorable results.

LIMITATIONS

Studies included in the review had relatively short follow-up periods, and the diversity of studies identified precluded the possibility of conducting a meta-analysis.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Findings suggest that interventions in pediatric primary care settings are feasible and can favorably affect clinical practices and families' outcomes.

Patient demographic and health factors associated with frequent use of emergency medical services in a midsized city

OBJECTIVES

To optimize health care utilization, health outcomes, and costs, research is needed to improve an understanding of frequent users of emergency health services. Frequent use of emergency services is associated with high costs of health care and may be indicative of challenges accessing, or poor outcomes of, health care. Patient demographics and health factors related to frequent use of the emergency medical services (EMS) system of a midsized city were identified. Study findings will aid in the development of targeted interventions to improve population health.

METHODS

The authors reviewed 9-1-1 call dispatch data and Baltimore City Fire Department (BCFD) EMS records from 2008 through 2010. Frequent use was defined as six or more EMS incidents in the 23-month period. Analyses used census data to compare demographics of EMS users to their population distribution and examined differences in demographics and health problems of frequent EMS users compared to nonfrequent users.

RESULTS

Frequent EMS users (n = 1,969) had a range of six to 199 EMS incidents (mean = 11.2) during the observation period, and although they accounted for only 1.5% of EMS users, they were involved in 12.0% of incidents. Frequent users, compared to nonfrequent users and to the population, were more likely to be male, African American, and 45 years of age or older. Of frequent users, the modal age group was 45 to 54 years, accounting for 29.7% of frequent users, which represented twice this age group's population distribution. Furthermore, this age group had the greatest overrepresentation of males (63.0% of frequent users) and was the peak age group for incidents related to substance abuse (28.0% of frequent users' incidents in this age group). Frequent users, compared to nonfrequent users, had lower levels of incidents related to trauma (5.1% vs. 16.7%) and higher levels of medical incidents (94.8% vs. 82.9%). As proportions of EMS incidents among frequent versus nonfrequent users, respiratory, mental health, and seizure-related incidents were highest in the youngest age groups; substance abuse-related incidents were highest in those middle-aged (35 to 44 and 45 to 54 years). Of health problems, behavioral health (mental health or substance use) contributed most to frequent EMS use (23.4% of frequent users' incidents). Across all incidents, 65.8% of frequent users had indications of behavioral health problems, representing 6.6-fold higher odds than nonfrequent users (22.5%). Frequent compared to nonfrequent users also had higher levels of select chronic conditions (diabetes, 39.9% vs. 14.6%; asthma, 40.9% vs. 13.4%; and HIV, 9.1% vs. 2.4%), with unadjusted odds almost four to seven times higher.

CONCLUSIONS

The study findings revealed the major role of chronic somatic and behavioral health problems in frequent EMS use and that rates of frequent use were highest among those middle-aged, African American, and male. These results suggest the need for coordination of EMS with community-based, integrated medical and behavioral health services to improve access and use of preventive services, with implications for health outcomes and costs. This study demonstrates the value of EMS patient data in identifying at-risk populations and informing novel, targeted approaches to public health interventions.

How to improve the mental health care of children and adolescents in Brazil: actions needed in the public sector

INTRODUCTION

Child/adolescent mental health (CAMH) problems are associated with high burden and high costs across the patient's lifetime. Addressing mental health needs early on can be cost effective and improve the future quality of life.

OBJECTIVE/METHODS

Analyzing most relevant papers databases and policies, this paper discusses how to best address current gaps in CAMH services and presents strategies for improving access to quality care using existing resources.

RESULTS

The data suggest a notable scarcity of health services and providers to treat CAMH problems. Specialized services such as CAPSi (from Portuguese: Psychosocial Community Care Center for Children and Adolescents) are designed to assist severe cases; however, such services are insufficient in number and are unequally distributed. The majority of the population already has good access to primary care and further planning would allow them to become better equipped to address CAMH problems. Psychiatrists are scarce in the public health system, while psychologists and pediatricians are more available; but, additional specialized training in CAMH is recommended to optimize capabilities. Financial and career development incentives could be important drivers to motivate employment-seeking in the public health system.

CONCLUSIONS

Although a long-term, comprehensive strategy addressing barriers to quality CAMH care is still necessary, implementation of these strategies could make.

Informal care and reciprocity of support are associated with HAART adherence among men in Baltimore, MD, USA

Research suggests gender differences in interpersonal relationship factors important to health. This study examined relationship factors associated with HAART adherence among men. The sample (n = 154) comprised 95% African Americans and 48% current illicit drug users; 83% reported HAART adherence. Results revealed adherence was associated with comfort level taking HAART in the presence of close friends, and the interaction between informal care (having someone to care for oneself when sick in bed) and reciprocity of support. Among those with informal care, higher reciprocity of support to caregivers was associated with greater adherence. Promoting men's reciprocity of support to their caregivers and enhancing peer norms of medication taking are important strategies for improving men's adherence. The findings complement previous findings on relationship factors adversely associated with women's adherence. Results suggest the merit of interventions targeting men and their informal caregivers, particularly main partners, and gender-specific, contextually tailored strategies to promote HAART adherence.

How post-call resident doctors perform, feel and are perceived in out-patient clinics

CONTEXT

 Recently, in the U.S.A., the Accreditation Council for Graduate Medical Education guidelines limited residents' consecutive duty to 24 hours. In Europe, the European Working Time Directive limits the average working week to 48 hours.

OBJECTIVES

This study aimed to examine the performance of post-call residents in out-patient interviews using subjective and objective measures and to assess residents' subjective feelings.

METHODS

 We conducted a cross-sectional analysis of a systematic sample of 170 paediatric primary care consultations conducted during 117 clinic sessions served by 47 residents at a teaching hospital, including 34 consultations conducted during 23 sessions by 20 post-call residents. Interviews were audiotaped and quantitatively analysed using the Roter Interactional Analysis System (RIAS). Residents and patients' parents gave subjective appraisals of the visits using short questionnaires. Major covariates are resident gender and the timing of the clinic.

RESULTS

Results did not show significant differences between post-call residents and their peers who had left the hospital on time in most components of the out-patient interview. Subtle yet probably important differences emerged with findings that post-call residents were significantly less likely to ask a parent to repeat what she had just said, and parents seeing post-call residents were more likely to request the resident to repeat what he or she had just said and to check if the resident understood what they had said. Post-call residents were rated by objective coders as having better attitudes than their left-on-time counterparts, yet subjectively felt less satisfied and more fatigued. Female post-call residents felt less competent, less productive and less energetic; male post-call residents felt more challenged, more demoralised and busier.

CONCLUSIONS

The changes in activating and partnering talk that occur in post-call residents are consistent with findings concerning sleep deprivation and speech. Female and male residents tended to attribute their post-call performance to different factors. Setting limits on working hours might help to avoid potential negative impacts on post-call resident feelings, and the impact of working hours on resident performance warrants further exploration.

Main partner factors associated with worse adherence to HAART among women in Baltimore, Maryland: a preliminary study

Compared to US men, US women have worse HAART and HIV health outcomes. The study examined main partner factors associated with women's HAART adherence. The community sample comprised 85% African-Americans; 63% had a main partner and 32% relied on their partner for emotional support. Adherence was highest (92%) among those without a main partner and lowest (57%) among those with an HIV seropositive main partner. In adjusted analysis, adherence was 75% less likely among women with an HIV seropositive main partner and 78% less likely among those relying on their partner for emotional support. Furthermore, HIV seropositive versus other serostatus main partners were most likely to provide medication taking assistance and to be preferred in helping participants deal with HIV, yet were no more likely to be nominated as the most helpful to them. Findings reveal women's perceived unmet support needs from HIV seropositive main partners in this population and the need for interventions to promote their HAART adherence. Seroconcordant couples-focused intervention that enhances mutual support of HAART adherence may be an effective approach to improving women's HAART adherence and reducing US gender disparities in HIV health outcomes.

Aspects of mental health communication skills training that predict parent and child outcomes in pediatric primary care

OBJECTIVE

Training in communication can change clinician behaviors, but brief training may function by altering attitudes rather than teaching new skills. We used data from a trial of mental health training for office-based primary care to determine indicators of uptake that predicted parent and child outcomes.

METHODS

Clinicians (n=50) were randomized to be controls or receive training. Uptake was determined comparing pre- and post-training visits with standardized patients (SPs) coded for skills and patient centeredness. Clinical outcomes were assessed by recruiting and following 403 children/youth ages 5-16 making visits to participants. At 6 months, change in mental health was assessed by parent and youth reports using the Strengths and Difficulties Questionnaire.

RESULTS

Trained clinicians used more agenda setting, time, and anger management skills than controls and showed increased patient centeredness toward SP parents, but not adolescents. Increased patient-centeredness toward parents predicted improvement in child/youth symptoms and functioning (rated by parents), and improvement in youth-rated symptoms. Increased skills alone were not associated with improvement, but patients of clinicians above the mean for both skill and patient-centeredness change improved most.

Primary care and children's mental health in Brazil

OBJECTIVE

Primary care offers opportunities to expand children's access to mental health (MH) services, but a given practice's community context and staff attitudes may influence which integration models are feasible. The aim of this study was to explore the possibility of using community-based primary care to increase access to MH services in low-income communities in Brazil.

METHODS

A qualitative study was undertaken using focus groups with adolescents aged 11 to 16 (n = 46), parents (n = 40), and primary care clinicians and staff (n = 52) from public-sector health centers in 6 low-income Brazilian communities chosen for their geographic diversity.

RESULTS

Parents felt they had little support in parenting and attributed much of their children's behavior and mood problems to life in violent, poor communities. Parents thought that primary care could potentially be a source of MH care, but that clinicians often seemed rushed or uninterested. Clinicians classified many child problems as issues with parenting rather than MH. Nonprofessional staff was more likely to be a source of support to parents, except at one center that had a truly integrated MH service. Adolescents reported little need for MH services.

CONCLUSIONS

Expanding the role of primary care in child MH may require close attention to how parents, adolescents, and clinicians define their problems and on the causes to which they attribute them. These factors interact with differences in how centers organize MH care, and the extent to which they take advantage of patient interactions with nonprofessional staff.

Mid-life suicide: an increasing problem in U.S. Whites, 1999-2005

BACKGROUND

The overall suicide rate in the U.S. increased by 6% between 1981 and 1986 and declined by 18% between 1986 and 1999. Detailed descriptions of recent trends in suicide are lacking, especially with regard to the method of suicide. Information is needed on the major changes in rates of suicide in specific population groups in recent years (1999-2005).

METHODS

Mortality data came from the Web-based Injury Statistics Query and Reporting System. Suicide trends during 1981-2005 were analyzed by age, race, gender, and method, with an emphasis on increases between 1999 and 2005. Linear regression was used to examine the significance of trends in suicide mortality. The annual percentage change in rates was employed to measure the linear trend in suicide mortality.

RESULTS

The suicide rate increased after 1999, due primarily to an increase in suicide among whites aged 40-64 years, whose rate of completed suicide between 1999 and 2005 rose by 2.7% annually for men and by 3.9% annually for women,with increases of 6.3% and 2.3% for poisoning, 2.8% and 19.3% for hanging/suffocation, and 1.5% and 1.9% for firearms for men and women, respectively. Rates did not increase for other age or racial groups [corrected].

CONCLUSIONS

The differential increases by age, race, gender, and method underscore a change in the epidemiology of suicide.Whites aged 40-64 years have recently emerged as a new high-risk group for suicide. Although firearms remain the most common method of suicide, the notable increases in suicide by poisoning in men and hanging/suffocation in women deserve prevention attention [corrected].

Externalizing behaviors among children of HIV seropositive former and current drug users: parent support network factors as social ecological risks

Children affected by their parents' dual drug use and HIV/AIDS face considerable challenges to their psychosocial development, including parent dysfunction and foster care placement. While HIV/AIDS may increase parents' mobilization of social support, their drug use may restrict who is available to help them, with potential implications to the adjustment of their children with whom they remain in contact. This study sought to identify dually affected children's living situations, and parent and parent's support network factors as correlates of children's externalizing problem behaviors. An urban community sample of 462 HIV seropositive, current or former drug-using parents were queried about their children aged 5-15 years old. One hundred ninety-four children were reported by 119 parents. The outcome was children's externalizing behaviors of ever having been suspended or expelled from school, criminal-justice system involvement, or illicit drug or heavy alcohol use. Independent variables included kin and drug users in parent's support network. Generalized estimating equations were used to adjust for the potential correlation of children of the same parent. Among parents, 63% were mothers, 57% current opioid or cocaine users, 85% were African American, 35% had AIDS or CD<200, and 53% had high depressive symptoms (CES-D>or=16); median age was 38. Among children, median age was 12; 23% lived with the nominating parent, 65% with other family, and 11% in non-kin foster care. While only 34% of parents reported child custody, 43% reported daily contact with their child, and 90% reported high emotional closeness. Parents reported externalizing behaviors among 32% of the children. Logistic regression indicated that externalizing behavior was positively associated with parent's physical limitations and proportion of illicit drug users in parent's support network. A significant interaction was found indicating that the effect of parent's support network-level drug use was greater for children living with versus not living with the parent. The model adjusted for parent's current drug use and depressive symptoms, which were not significant. Results indicate that while only a minority of these dually affected children lived with the parent, the parents' physical limitations and embeddedness in drug using support networks, particularly if living with their children, was associated with the children's maladjustment. It is plausible that these factors interfere with parenting, expose the children to conflict or adverse social influences, or obligate children to assume caregiving for their parent. While dually affected children's contact with their parents may have important benefits, results suggest it presents ongoing needs for intervention with the children, their parents, and caregivers.

Gifts, bribes and solicitions: print media and the social construction of informal payments to doctors in Taiwan

The Taiwanese practice of patients giving informal payments to physicians to secure services is deeply rooted in social and cultural factors. This study examines the portrayal of informal payments by Taiwanese print news media over a period of 12 years-from prior to until after the implementation of national health insurance (NHI) in Taiwan in 1995. The goal of the study was to examine how the advent of NHI changed the rationale for and use of informal payments. Both before and after the introduction of NHI, Taiwanese newspapers portrayed informal payments as appropriate means to secure access to better health care. Newspaper accounts established that, although NHI reduced patients' financial barriers to care, it did not change deeply held cultural beliefs that good care depended on the development of a reciprocal sense of obligation between patients and physicians. Physicians may have also encouraged the ongoing use of informal payments to make up revenue lost when NHI standardized fees and limited income from dispensing medications. In 2002, seven years after the implementation of NHI, the use of informal payments, though illegal, was still being justified in the print media through allusions to its role in traditional Taiwanese culture.

Meaning shift: findings from wellness acupuncture

Wellness or holistic acupuncture places an emphasis on working with and developing the patient's understanding of health and illness. This research project examines changes in meaning in 367 letters from successful wellness acupuncture. Mentions of changes of the meaning of health and illness were categorized into themes using content analysis. Five main meaning shifts were identified in the data. These shifts are (1) from a goal of fixing the problem to a goal of increasing health, (2) from symptoms as problems to symptoms as teachers, (3) from healing as passive to healing as active, (4) from being dominated by illness to moving beyond the illness, and (5) from regarding the practitioner as a technician to regarding the practitioner as a healer or friend. The shifts in meaning seen in the data illustrate a potential pathway for bringing health benefits to patients and may provide a useful strategy for healing. Narrative (defined here as "first-person accounts by respondents of their experience") is thought to play a major role in the manifestation of symptoms and the ability of patients to cope with illness. Patients suffer not only from their primary symptoms, but also from the results and effects of their illnesses, such as depression and changes in their relationships. For the patient, symptoms often hold much meaning beyond physical sensation. A recurrence of symptoms can have other unpleasant results, such as additional trips to doctors, paying for medications, time off from work, not being able to play with children, or changes in relationships with family members. In many cases, the anxiety and depression surrounding the symptoms causes suffering which are greater than the suffering caused by the physical symptoms directly. These factors also change how the ill individual interacts socially, thereby reducing both instrumental and emotional social support, resulting in a downward spiral of suffering. By interacting with narrative, a path to improved health that augments conventional or alternative treatment can be used. Narrative is the point of access to the patient's mental state about illness; it is the manifestation of meaning. Patients express the meaning of their illness in their own narratives. By expressing narratives, patients articulate and develop the meaning of their illness. This process itself can be therapeutic. By shifting the individual's meaning from a detrimental to a beneficial one, a great deal of suffering may be eliminated without any change in the physical sensations. Certain individuals (eg, a socially-sanctioned healer) are given social roles in the ongoing story of someone's illness. These socially sanctioned individuals (ie, physicians) have an important role in interpreting and developing the individual's understanding of his or her illness. Therefore, in addition to physical interventions targeting the cause of the sensations, a great deal of suffering may potentially be alleviated through interacting with the patient's understanding and appraisal of symptoms. Patient meaning shift may be one of the most effective means by which to aid the patient. This article examines patient accounts of acupuncture experience for narrative concerning meaning shifts to gain insight into their role in wellness acupuncture practice.

Asking fathers: a study of psychosocial adaptation

Although few contemporary studies specifically address paternal adaptation, the theme of paternal estrangement from medical care and from family relationships is pervasive in the psychosocial literature on haemophilia. This estrangement has been shown to have a negative effect on fathers' psychological well-being, marital relationships and the adaptive outcome of their sons who have haemophilia. The goals of this study were to provide contemporary data on the psychosocial adaptation of fathers of boys with haemophilia and to examine specific variables that might influence their adjustment. Eighty-three eligible fathers returned a survey instrument that collected demographic and medical information, as well as scores on self-measures of adaptation in marital and parenting roles. Statistically significant direct correlations (P < 0.01) were found between fathers' scores on the Marital Adjustment Test and the Parenting Sense of Competence subscales (parenting efficacy and satisfaction). Variables specific to rearing a son with haemophilia that negatively affected fathers' marital adjustment scores included: feeling left out of medical decision making by their wives or partners, worry about their sons' having limited activity, and the presence of a secondary diagnosis in the affected child. Scores on the parenting efficacy subscale of the PSOC were statistically significantly reduced (i.e. fathers felt less effective in the parenting role) in men who 'rarely' or 'never' infused their sons (42/80, 53%). Variables that negatively affected scores on the parenting satisfaction subscale included frustrating interactions with medical staff and concern about their sons' potential to contract an infection or secondary diagnosis. This paper presents a model to examine the interrelationships among the data and discusses the clinical implications.

Disclosure of HIV diagnosis to children: when, where, why, and how

Despite recent recommendations by the American Academy of Pediatrics that strongly encourage disclosure of human immunodeficiency virus (HIV) infection to school-age children, health care providers vary widely in their actual disclosure practices. Concrete guidelines for accomplishing disclosure are not currently available. Nondisclosure can result in a variety of problems, including anxiety, depression, phobias, and exclusion from peer support groups and medical camps. This article reviews the available literature on disclosure of HIV infection to children and describes the disclosure process used in a large, urban pediatric HIV clinic.

The impact of barriers and self-efficacy on self-care behaviors in type 2 diabetes

PURPOSE

This cross-sectional, correlational study examined the relationships of diabetes-specific treatment barriers and self-efficacy with self-care behaviors.

METHODS

A total of 309 people with type 2 diabetes participated in this study. All of the factors were assessed by self-report questionnaires. Self-care behaviors included exercise, diet, skipping medication, testing blood for glucose, adjusting insulin to avoid or correct hyperglycemia, and adjusting diet to avoid or correct hypoglycemia.

RESULTS

Perceived barriers to carrying out self-care behaviors were associated with worse diet and exercise behavior. Greater self-efficacy predicted more frequent blood glucose testing, less frequent skipping of medication and binge eating, and closer adherence to an ideal diet. Nontraditional dimensions of self-efficacy were associated with worse self-care. Self-efficacy explained 4% to 10% of the variance in diabetes self-care behaviors beyond that accounted for by patient characteristics and health beliefs about barriers.

CONCLUSIONS

The findings of this study provided support for Rosenstock's proposal that a person's self-perceived capability to carry out a behavior should be incorporated into an expanded health belief model.

Children affected by HIV. Clinical experience and research findings

This article describes the plight of HIV affected children, and the work of mental health professionals with HIV affected children and their families, and presents pertinent research findings on the topics. The concepts of prevention, resilience, and family and child development are applied to the organizing of mental health care for HIV affected children.

Pediatric asthma care in the emergency department: measuring the quality of history-taking and discharge planning

The National Asthma Education and Prevention Program NAEPP Guidelines include recommendations for history-taking and discharge planning during an asthma visit, but there are no tools to measure performance. The objectives of this study were to define and operationalize key elements of history-taking and discharge planning, to develop a tool for measuring these elements, and to evaluate the quality of history-taking and discharge planning in the emergency department (ED) during visits for asthma using the new tool. Expert opinion and extensive literature review were used to develop a 13-item checklist containing items that should be documented during history-taking and provided during discharge planning for an ED visit for an acute asthma exacerbation by children. A convenience sample of 90 pediatric emergency medicine physicians and allergists rated each item in the checklist. The checklist was used to score audiotapes of asthma visits in the ED. Subjects were 154 parents of asthmatic children aged 4-9 years seeking care in nine inner-city EDs affiliated with asthma centers participating in the National Cooperative Inner-City Asthma Study and the physician/providers who delivered care. Seven of the 13 items on the checklist were rated as required to be performed by more than 90% of the allergist/pediatric emergency medicine physicians. Only 10% of the 154 visits included all seven of the highly rated items, whereas 19% of the visits included three or fewer. Only 7 of the 13 items (54%) were performed in more than 50% of the visits, and 4 items were performed in fewer than 25% of visits. Based on expert ratings, the checklist for measuring elements of history-taking and discharge planning during asthma visits appears to have considerable face validity. In the visits studied, the overall performance of these elements was low. Interventions to improve performance on the checklist might lead to improved care for children with asthma who frequent the ED.

Injury prevention counseling in an urban pediatric clinic. Analysis of audiotaped visits

OBJECTIVE

To determine the content of injury prevention counseling (an expected component of pediatric anticipatory guidance) and the communication methods used with data from an urban pediatric clinic that serves low-income families.

DESIGN

Audiotapes of well-child visits with 52 pediatric residents were analyzed for 178 children aged 0 to 4 years. A specific coding methodology was developed to analyze counseling by injury topics, prevention strategies, and communication methods.

RESULTS

Less than half (ie, 47%) of the visits included injury prevention counseling. During the 83 visits that included counseling, an average of 1.96 injury topics were discussed. The average time spent on injury topics was 1.08 minutes per visit and 33 seconds per injury topic. An average of 2.68 prevention strategies were mentioned, although a statement specifically recommending their use was made for only 35% of the prevention strategies. The most frequently discussed injury topics were ingestion, falls, and pedestrian safety, house fires and firearms were never discussed. The most frequently mentioned prevention strategies were storing dangerous substances and items out of reach, using cabinet locks, calling the poison-control center, having outlet covers, using stair gates, and using car seats. Information-giving by the resident was the most frequently used communication method. Physician elicitation of information from parents was associated with more parental participation in the discussion.

CONCLUSIONS

Pediatric residents in this sample spent little time discussing injury prevention, and problems thought to be important to the specific population being served were never mentioned. Communication methods to enhance compliance other than eliciting and giving information (ie, soliciting feedback, obtaining a commitment, and giving reinforcements) were rarely or never used. Priorities need to be defined so that the most important injury prevention topics and strategies are discussed effectively in the limited time available. Further research about pediatric injury prevention counseling is needed to examine the feasibility and effect of resident training in communication methods that enhance compliance.

In-home injury prevention practices for infants and toddlers: the role of parental beliefs, barriers, and housing quality

The present research was designed to contribute to the empirical literature on the scope and determinants of parents' injury prevention practices among families living in disadvantaged, urban areas. One hundred fifty mothers were interviewed about their living environment when they brought their children (ages 6-36 months) to a hospital-based, pediatric primary care clinic. Only 37% of respondents reported that they knew their hot water temperature was 125 degrees or less. A majority (59%) of families reported that they did not use stair gates. More than one fourth (27%) of respondents said they did not have smoke detectors. Mothers uniformly reported very favorable attitudes and beliefs and strong support from others for in-home injury prevention practices. Factors significantly associated with the number of injury prevention practices implemented were family income, housing quality, and environmental barriers. Instead of attempting solely to persuade parents about the value of injury prevention practices, skill-based interventions are needed to help parents overcome specific barriers that result from living in substandard housing and having very limited financial resources.

Partial trisomy 6q, due to balanced maternal translocation (6;22) (q21; p13) or (q21; pter)

We report a stillborn infant with partial trisomy 6q who had several major congenital malformations not previously associated with the chromosomal aberration. These included occipital encephalocele, ambiguous genitalia with imperforate anus, omphalocele and unilateral hydronephrosis. The infant's karyotype was 46,XY,-22,der(22),t(6;22)(q21; p13) or (q21;pter)mat. The mother and maternal grandmother are balanced translocation carriers.