Leader and Provider Perspectives on Implementing Safe Alternatives for Teens and Youth - Acute (SAFETY-A) in Public School Districts Serving Racial/ethnic Minoritized Youth.

Racial/ethnic minoritized (REM) youth represent a high-risk group for suicide, yet there are striking disparities in their use of mental health services (MHS) even after risk is identified in schools. Prior research suggests that school-based risk assessments and hospitalization encounters can be negatively experienced by REM youth and families, thus deterring likelihood of seeking follow-up care. The Safe Alternatives for Teens and Youth-Acute (SAFETY-A) is a brief, strengths-based, cognitive-behavioral family intervention demonstrated to increase linkage to MHS when implemented in emergency departments. With its focus on strengths and family engagement, SAFETY-A may cultivate a positive therapeutic encounter suited to addressing disparities in MHS by enhancing trust and family collaboration, if appropriately adapted for schools. Thirty-seven school district leaders and frontline school MHS providers from districts serving primarily socioeconomically disadvantaged REM communities participated in key informant interviews and focus groups. First, interviews were conducted to understand usual care processes for responding to students with suicidal thoughts and behaviors, and perspectives on the strengths and disadvantages of current practices. An as-is process analysis was used to describe current practices spanning risk assessment, crisis intervention, and follow-up. Second, focus groups were conducted to solicit perceptions of the fit of SAFETY-A for these school contexts. Thematic analysis of the interviews and focus groups was used to identify multilevel facilitators and barriers to SAFETY-A implementation, and potential tailoring variables for implementation strategies across school districts.

Factors Associated With Attendance for Cardiac Neurodevelopmental Evaluation.

BACKGROUND AND OBJECTIVES: Neurodevelopmental evaluation of toddlers with complex congenital heart disease is recommended but reported frequency is low. Data on barriers to attending neurodevelopmental follow-up are limited. This study aims to estimate the attendance rate for a toddler neurodevelopmental evaluation in a contemporary multicenter cohort and to assess patient and center level factors associated with attending this evaluation. METHODS: This is a retrospective cohort study of children born between September 2017 and September 2018 who underwent cardiopulmonary bypass in their first year of life at a center contributing data to the Cardiac Neurodevelopmental Outcome Collaborative and Pediatric Cardiac Critical Care Consortium clinical registries. The primary outcome was attendance for a neurodevelopmental evaluation between 11 and 30 months of age. Sociodemographic and medical characteristics and center factors specific to neurodevelopmental program design were considered as predictors for attendance. RESULTS: Among 2385 patients eligible from 16 cardiac centers, the attendance rate was 29.0% (692 of 2385), with a range of 7.8% to 54.3% across individual centers. In multivariable logistic regression models, hospital-initiated (versus family-initiated) scheduling for neurodevelopmental evaluation had the largest odds ratio in predicting attendance (odds ratio = 4.24, 95% confidence interval, 2.74-6.55). Other predictors of attendance included antenatal diagnosis, absence of Trisomy 21, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category, longer postoperative length of stay, private insurance, and residing a shorter distance from the hospital. CONCLUSIONS: Attendance rates reflect some improvement but remain low. Changes to program infrastructure and design and minimizing barriers affecting access to care are essential components for improving neurodevelopmental care and outcomes for children with congenital heart disease.

Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative.

Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.

Predictors of behavioural and emotional outcomes in toddlers with congenital heart disease.

OBJECTIVES: Children with congenital heart disease (CHD) are at risk for psychological challenges, including internalising (e.g., depression, anxiety) and externalising (e.g., aggression, inattention) problems. The present study aimed to investigate the development of psychological concerns in early childhood by identifying predictors of behavioural and emotional problems in toddlers with CHD. METHODS: Children with CHD who were seen for neurodevelopmental (ND) evaluation at 12 ± 3 months of age, who completed the Bayley Scales of Infant Development-III (BSID-III) and whose parents completed the Child Behavior Checklist (CBCL), a standardised measure of emotional/behavioural problems at age 24-36 months, were included in the study (n = 144). CBCL scores were compared to test norms and classified as normal or abnormal. A classification tree was used to assess the association between CBCL scores and demographic and clinical variables. RESULTS: Multi-variable tree analyses revealed lower BSID-III language composite scores at age 9-15 months predicted clinical CBCL internalising (p < 0.001), externalising (p = 0.004) and total scores (p < 0.001) at age 24-36 months. Lower maternal education levels also predicted clinical CBCL internalising (p < 0.0001), externalising (p < 0.001) and total scores (p < 0.0001). CONCLUSIONS: Lower language abilities and lower maternal education predict increased behavioural and emotional problems in toddlers with CHD. These risk factors should be considered during routine ND evaluations to allow for earlier identification of children with CHD and their families who may benefit from psychological support.

Characterisation of neurodevelopmental and psychological outcomes in CHD: a research agenda and recommendations from the cardiac neurodevelopmental outcome collaborative.

The Neurodevelopmental and Psychological Outcomes Working Group of the Cardiac Neurodevelopmental Outcome Collaborative was formed in 2018 through support from an R13 grant from the National Heart, Lung, and Blood Institute with the goals of identifying knowledge gaps regarding the neurodevelopmental and psychological outcomes of individuals with CHD and investigations needed to advance science, policy, clinical care, and patient/family outcomes. Accurate characterisation of neurodevelopmental and psychological outcomes in children with CHD will drive improvements in patient and family outcomes through targeted intervention. Decades of research have produced a generalised perspective about neurodevelopmental and psychological outcomes in this heterogeneous population. Future investigations need to shift towards improving methods, measurement, and analyses of outcomes to better inform early identification, prevention, and intervention. Improved definition of underlying developmental, neuropsychological, and social-emotional constructs is needed, with an emphasis on symptom networks and dimensions. Identification of clinically meaningful outcomes that are most important to key stakeholders, including patients, families, schools and providers, is essential, specifically how and which neurodevelopmental differences across the developmental trajectory impact stakeholders. A better understanding of the discontinuity and patterns of neurodevelopment across the lifespan is critical as well, with some areas being more impactful at some ages than others. Finally, the field needs to account for the impact of race/ethnicity, socio-economic status, cultural and linguistic diversity on our measurement, interpretation of data, and approach to intervention and how to improve generalisability to the larger worldwide population of patients and families living with CHD.

A Randomized Trial Evaluating School-Based Mindfulness Intervention for Ethnic Minority Youth: Exploring Mediators and Moderators of Intervention Effects.

The study examined the efficacy of a school-based mindfulness intervention on mental health and emotion regulation outcomes among adolescents in a wait-list controlled trial. The study also explored mediators and moderators of intervention effects. A total of 145 predominantly ethnic minority (Asian and Latino) 9th grade students with elevated mood symptoms were randomized to receive a 12-week mindfulness intervention at the start of the academic year, or in the second semester of the year. Students completed measures of emotion regulation and mental health symptoms at baseline, post-intervention, and 3-month follow-up. Intent-to-treat analyses revealed significant treatment effects of the mindfulness intervention for internalizing symptoms and perceived stress at post-treatment. Pooled pre-to-post treatment analyses of the entire sample revealed a small effect size for attention problems, medium for internalizing and externalizing problems, and large for perceived stress. We also found a small effect size for cognitive reappraisal, medium for expressive suppression, emotional processing, emotional expression, and rumination and large for avoidance fusion. Mediation analyses showed that treatment effects on internalizing symptoms and perceived stress were mediated by reductions in expressive suppression and rumination. Moderation analyses revealed that treatment effects were larger among youth with more severe problems at baseline for internalizing problems, externalizing problems, and perceived stress. However, for attention problems, students with lower severity at baseline appeared to have larger treatment gains. The study provided evidence that mindfulness intervention was beneficial for low-income ethnic minority youth in reducing perceived stress and internalizing problems, and improving emotion regulation outcomes. Furthermore, mindfulness training was associated with reduced mental health symptoms via improvements in emotion regulation.

Neurodevelopmental outcomes at 2 and 4 years in children with congenital heart disease.

BACKGROUND AND OBJECTIVES: Children with congenital heart disease (CHD) are at risk for neurodevelopmental (ND) delays. The purpose of this study is to compare the ND testing results of children with CHD at 2 and 4 years of age and determine if rates of ND delays change over time. METHODS: Children with CHD completed the Bayley Scales of Infant Development-III (BSID-III) at 2 years of age, and standardized neuropsychological measures at 4 years. Scores were compared with test norms and were classified as: average (within one SD of test mean); at risk (1-2 SDs from the test mean); and delayed (>2 SD from test mean). Pearson correlations and McNemar's exact tests were performed to determine the relationship between test scores at the two times of assessment. RESULTS: Sixty-four patients completed evaluations at 24 ± 3 months of age and 4 years of age. BSID-III cognitive and fine motor scores were correlated with preschool IQ and fine motor scores, r = .75 to .87, P < .0001. Agreement in score categories was 79% for cognitive and 61% for fine motor. More patients had at risk or delayed scores at age 4 vs age 2 (P ≤ .01). CONCLUSION(S): Despite significant correlations between 2- and 4-year-old test scores, many patients who scored in the average range at age 2 showed deficits at age 4. BSID-III scores at age 2 may underestimate delays. Therefore, longitudinal ND assessment is recommended.

Does Depression Screening in Schools Reduce Adolescent Racial/Ethnic Disparities in Accessing Treatment?

Although placing mental health services in schools increases access to care, racial/ethnic disparities persist within the scope of school-based mental health services. Universal mental health screening is a potential strategy to increase problem detection and reduce disparities in care provision. However, no study has experimentally tested the effect of universal screening on patterns of service utilization across racial groups and the potential to reduce disparities. Using a cluster randomized design, we compared service linkage patterns among 7th- and 8th-grade Asian American and Latino students (N = 2,494; Mage = 13.65) in schools that either conducted or did not conduct universal depression screening. Multilevel analyses showed that enrollment in a universal screening school, Latino ethnicity, and low academic performance were associated with greater likelihood of referral. However, these factors were not related to caregiver consent or treatment initiation. Screening-triggered referrals were less likely to result in caregiver consent compared to routine referrals. Furthermore, universal screening did not result in a statistically significant reduction in racial/ethnic disparities in treatment referral. Implications for engaging ethnic minority families beyond the point of problem recognition and referral are discussed.

Preschool Neurodevelopmental Outcomes in Children with Congenital Heart Disease.

OBJECTIVE: To describe preschool neurodevelopmental outcomes of children with complex congenital heart disease (CHD), who were evaluated as part of a longitudinal cardiac neurodevelopmental follow-up program, as recommended by the American Heart Association and the American Academy of Pediatrics, and identify predictors of neurodevelopmental outcomes in these children. STUDY DESIGN: Children with CHD meeting the American Heart Association/American Academy of Pediatrics high-risk criteria for neurodevelopmental delay were evaluated at 4-5 years of age. Testing included standardized neuropsychological measures. Parents completed measures of child functioning. Scores were compared by group (single ventricle [1V]; 2 ventricles [2V]; CHD plus known genetic condition) to test norms and classified as: normal (within 1 SD of mean); at risk (1-2 SD from mean); and impaired (>2 SD from mean). RESULTS: Data on 102 patients were analyzed. Neurodevelopmental scores did not differ based on cardiac anatomy (1V vs 2V); both groups scored lower than norms on fine motor and adaptive behavior skills, but were within 1 SD of norms. Patients with genetic conditions scored significantly worse than 1V and 2V groups and test norms on most measures. CONCLUSIONS: Children with CHD and genetic conditions are at greatest neurodevelopmental risk. Deficits in children with CHD without genetic conditions were mild and may not be detected without formal longitudinal testing. Parents and providers need additional education regarding the importance of developmental follow-up for children with CHD.

Effect of Intercurrent Operation and Cerebral Oxygenation on Developmental Trajectory in Congenital Heart Disease.

BACKGROUND: Children with congenital heart disease are at increased risk of abnormal neurodevelopment (ND). Demographic and perioperative physiologic factors have both been associated with developmental outcome. The acute physiologic effect of a surgical procedure, anesthesia, and hospitalization may offset any potential advantage gained from anatomic correction and circulatory palliation. The specific risk/benefit balance on ND outcome of the insult of the operation, offset by the benefit of improved anatomy and physiology, has not been addressed. We therefore sought to identify interval procedural and physiologic factors assessed at outpatient ND evaluation visits that were associated with outcome. METHODS: The study included children with congenital heart disease at high risk for impaired ND performance with at least three ND assessments using the Bayley Scales of Infant Development-III during the first 3 years of life. The number of cardiac procedures, duration of hospitalization, feeding status, height, weight, and arterial, cerebral, and somatic oxygen saturations by near-infrared spectroscopy were recorded at each visit and used as predictors of language, motor, and cognitive composite scores and slopes (change over time) in general linear models. RESULTS: Data on 178 children derived from 632 visits (median, 4 visits/child) were analyzed, with ages at first and last assessment of 7.7 and 30.2 months. Fifty-one had 1 ventricle (1V), 88 had 2 ventricles, and 39 had genetic syndrome conditions. Motor performance increased with age in all diagnostic categories. Cognitive and language performance increased with age in 1V patients but exhibited no significant change in 2-ventricle and genetic syndrome groups. At the first visit, 1V patients performed less well than 2-ventricle patients in the motor domain, but the rate of improvement was higher for 1V patients; by 24 months, there were no differences, and both groups were normal in all domains. Performance in genetic syndrome patients was below normal in all domains at the first visit and did not improve. Higher arterial saturation and narrower arterial-cerebral and arterial-somatic near-infrared spectroscopy saturation differences were associated with better or improving motor performance. Incremental cardiopulmonary bypass time, cumulative hospital length of stay, and tube feedings were risk factors in all domains. Total and incremental times for deep hypothermic circulatory arrest, extracorporeal membrane oxygenation, total open and total surgical procedures, and birth weight were not risk factors. CONCLUSIONS: Patient physiologic status assessed by cerebral and somatic near-infrared spectroscopy is associated with ND performance. Incremental surgical procedures are not associated with ND performance when adjusted for cardiopulmonary bypass time and physiologic status. Treatment strategies that target improved physiologic status may also improve ND outcome.

Risk Factors for Abnormal Developmental Trajectories in Young Children With Congenital Heart Disease.

BACKGROUND: Children with congenital heart disease are at risk for developmental delay. This study sought to identify early risk factors for abnormal developmental trajectories in children with congenital heart disease. METHODS AND RESULTS: Children with congenital heart disease at high risk for developmental delay, without known genetic abnormality, and with ≥3 assessments by the use of the Bayley Scales of Infant and Toddler Development, Third Edition, were studied. Logistic regression was used to assess the impact of patient and clinical factors on cognitive, language, and motor score trajectories; classified as: average or improved if all scores were ≥85 (<1 standard deviation below the mean) or increased to ≥85 and never decreased; or abnormal if all scores were <85, fell to <85 and never improved, or fluctuated above and below 85. Data on 131 children with 527 Bayley Scales of Infant and Toddler Development, Third Edition assessments were analyzed. Subject age was 5.5 to 37.4 months. Overall, 56% had cognitive, language, and motor development in the average range. Delays occurred in single domains in 23%. Multiple domains were delayed in 21%. More cardiac surgeries, longer hospital stay, poorer linear growth, and tube feeding were associated with worse outcomes in all domains (P<0.05). In the multivariable model, the need for tube feeding was a risk factor for having an abnormal developmental trajectory (odds ratio, 5.1-7.9). Minority race and lack of private insurance had significant relationships with individual domains. CONCLUSIONS: Longitudinal developmental surveillance identified early factors that can help quantify the risk of developmental delay over time. Strategies to improve modifiable factors and early therapeutic intervention can be targeted to children at highest risk.

Building the gateway to success: an appraisal of progress in reaching underserved families and reducing racial disparities in school-based mental health.

School-based mental health (SBMH) services hold the promise of reducing barriers to care among underserved children and families in need, which can in turn reduce racial disparities in care. Yet, questions remain about the potential of SBMH for equitably reaching diverse communities. In particular, reaching Asian American youth in SBMH may remain a challenge even compared with other immigrant and ethnic minority groups, such as Latinos. This article describes the development and evaluates the service capacity of a SBMH platform in a medium-sized public school district serving predominantly low-income Latino and Asian American families. Service capacity was built through the creation and coordination of a system of community partnerships. Analyses of needs assessment and service referral and utilization patterns revealed no significant racial/ethnic differences in overall rates of mental health need between Latino and Asian American students; yet, Asian Americans were underrepresented in referrals to SBMH. However, once referred to care, there was no difference in the likelihood that Asian American and Latino students received treatment. Although there was an increase in capacity to link students to care, work remains to improve processes of identification to reduce unmet need across diverse groups.

Risk and prevalence of developmental delay in young children with congenital heart disease.

BACKGROUND AND OBJECTIVE: Children with congenital heart disease (CHD) are at risk for developmental delay (DD). Changes in cognitive, language, and motor skills in early childhood have not been described. We report the results of a structured approach using longitudinal testing to identify problems and ensure early intervention in accordance with published guidelines. METHODS: Bayley Scales of Infant Development, Third Edition, were used to assess cognitive, language, and motor skills in 99 children with CHD. Subjects were evaluated 3 to 6 times in the first 3 years of life. DD was defined as scores >1 SD below the population mean. RESULTS: Cardiac anatomy was single ventricle (1V) in 34 subjects and 2 ventricles (2V) in 65. Medical comorbidities were present in 21% and genetic syndromes in 19%. Most subjects (75%) had DD in ≥1 area at ≥1 assessments. Subjects with 1V anatomy had equivalent outcomes to those with 2V. Cognitive and language scores declined in subjects with genetic syndromes but were stable and within the average range for subjects with 1V and 2V. Motor scores improved for subjects with 1V and 2V but remained low for those with genetic syndromes. In addition to age, need for supplemental tube feeding, longer cardiopulmonary bypass time, and shorter time since last hospitalization were significant predictors of developmental outcomes. CONCLUSIONS: DDs in young children with CHD are both common and dynamic. Providers should encourage longitudinal surveillance for children with CHD because exposure to risk and prevalence of DD change over time.

Implementation of a routine developmental follow-up program for children with congenital heart disease: early results.

OBJECTIVE: To describe the implementation of a routine developmental follow-up program for children with congenital heart disease, summarize the developmental outcomes of the first clinic visits of the referred patients, and determine what factors predict variability in early developmental outcomes. DESIGN: Infants with congenital heart disease who had cardiac surgery within the first 30 days of life, had a cyanotic lesion (with or without surgery) or were believed to be at risk for developmental delay due to comorbid conditions or perioperative complications such as seizures or stroke were referred to the program as part of standard clinical care. Patients were evaluated using the Bayley Scales of Infant and Toddler Development-III. This study reports results from 95 patients (January 2007-October 2009) who had their first developmental follow-up visit at less than 1 year of age. RESULTS: Patients were 7.2 ± 1.2 months at their first evaluation. Bayley scores (mean/standard deviation) for the entire group were: Cognitive 100.8 ± 11.9; Language 96.3 ± 12.7; and Motor 88.6 ± 18.6. Scores for language and motor achievement were significantly lower than population norms. 44% of children had at least one low score (defined as > 1 standard deviation below the mean). Of children meeting state criteria for early intervention services, 31% were not receiving any early intervention services. Risk factors for worse developmental outcomes (P < .05) included more open heart procedures, the presence of additional medical/genetic conditions, and the need for supplemental tube feedings. Developmental outcomes were not significantly related to gestational age, prenatal diagnosis, diagnostic category, or age at first surgery. CONCLUSIONS: Implementation of a routine developmental follow-up program for congenital heart disease patients is possible and useful in identifying those patients who would benefit most from early intervention.

Early identification of infants at risk for developmental disabilities.

Early identification of infants at risk for developmental delay is of the utmost importance to initiate appropriate intervention. Although early detection can be a challenge, the primary care practitioner is in the ideal position to recognize and refer these children. Early recognition requires an in-depth knowledge of the child's history, general physical examination, and developmental level and an understanding of the expected developmental precursors of a skill. Referral to appropriate interventional resources leads to a formalized developmental and neurologic evaluation. If necessary, the development of an interdisciplinary comprehensive plan of remediation can occur and a definitive diagnosis can be made. If no significant problem is found, a decision to provide expectant observation is warranted.