Clinician Note Documentation of Parental Justice Involvement: Preliminary Evidence from Pediatric Electronic Health Records.

Little is known about clinical documentation for youth exposed to parental justiceinvolvement (e.g., parole, probation, jail, prison). We reviewed the electronic health records of 100 youth with at least one mention of parental incarceration between 2011-2019 from a large Midwestern pediatric hospital-based institution to describe clinical documentation and health characteristics. Within the sample, youth more commonly experienced incarceration of a father-identified figure (68%) as opposed to a mother-identified figure (32%). Seventeen percent (17%) of the youth were between zero and four years of age when clinicians documented exposure to a parent's incarceration. Nearly one-third of youth charts had no documentation regarding service referrals or follow-up from providers upon disclosure of parental incarceration. Few clinician documentation details were present related to the context of parental justice involvement (timing, type, and duration). Future research is needed to better understand the intersection of parental justice involvement and child health and service connection.

Housing and supportive services for young mothers experiencing substance use disorder and homelessness: Cost-effectiveness analysis of a randomized trial.

BACKGROUND: Mothers experiencing homelessness and caring for young children struggle with high rates of substance use and mental health problems. A comprehensive supportive housing intervention was implemented to assist young mothers experiencing substance use disorder (SUD) and homelessness. The cost-effectiveness of this intensive intervention could inform future dissemination. METHODS: A cost-effectiveness analysis was conducted alongside a randomized controlled trial that lasted from May 2015 to October 2018. Mothers experiencing homelessness between the ages of 18-24 years with a SUD were randomly assigned to housing+support services (HOU + SS) (n = 80), housing-only (HOU) (n = 80), or services as usual SAU (n = 80). Using incremental cost-effectiveness ratios (ICERs), the study compared the costs of HOU + SS and HOU to SAU for three outcomes: housing stability (percent days of stable housing), substance use (percent days of substance use), and depressive symptoms (Beck Depression Inventory score). Direct intervention costs of HOU + SS and HOU from both payor and societal perspectives were estimated. Cost data were collected from detailed study financial records. Outcomes were taken from 6-month assessments. RESULTS: The average societal cost of HOU + SS per participant was $5114 [CI 95 %, $4949-5278], while the average societal cost of HOU was $3248 [CI 95 %, $3248-$3341] (2019 U.S. dollars). The calculated ICERs show that HOU was more cost-effective than HOU + SS and SAU for housing outcome. For illicit drug use, HOU + SS was more cost-effective than HOU. Finally, for depressive symptoms, neither HOU + SS or HOU were more cost effective than SAU. CONCLUSION: While HOU is more cost-effective for increasing housing, HOU + SS is more cost-effective for reducing illicit drug use. However, housing without improvements in substance use may not be sustainable, and supportive services are likely essential for improved well-being overall beyond the housing outcome alone.

Learning competing risks across multiple hospitals: one-shot distributed algorithms.

OBJECTIVES: To characterize the complex interplay between multiple clinical conditions in a time-to-event analysis framework using data from multiple hospitals, we developed two novel one-shot distributed algorithms for competing risk models (ODACoR). By applying our algorithms to the EHR data from eight national children's hospitals, we quantified the impacts of a wide range of risk factors on the risk of post-acute sequelae of SARS-COV-2 (PASC) among children and adolescents. MATERIALS AND METHODS: Our ODACoR algorithms are effectively executed due to their devised simplicity and communication efficiency. We evaluated our algorithms via extensive simulation studies as applications to quantification of the impacts of risk factors for PASC among children and adolescents using data from eight children's hospitals including the Children's Hospital of Philadelphia, Cincinnati Children's Hospital Medical Center, Children's Hospital of Colorado covering over 6.5 million pediatric patients. The accuracy of the estimation was assessed by comparing the results from our ODACoR algorithms with the estimators derived from the meta-analysis and the pooled data. RESULTS: The meta-analysis estimator showed a high relative bias (∼40%) when the clinical condition is relatively rare (∼0.5%), whereas ODACoR algorithms exhibited a substantially lower relative bias (∼0.2%). The estimated effects from our ODACoR algorithms were identical on par with the estimates from the pooled data, suggesting the high reliability of our federated learning algorithms. In contrast, the meta-analysis estimate failed to identify risk factors such as age, gender, chronic conditions history, and obesity, compared to the pooled data. DISCUSSION: Our proposed ODACoR algorithms are communication-efficient, highly accurate, and suitable to characterize the complex interplay between multiple clinical conditions. CONCLUSION: Our study demonstrates that our ODACoR algorithms are communication-efficient and can be widely applicable for analyzing multiple clinical conditions in a time-to-event analysis framework.

Principles for Primary Care Screening in the Context of Population Health.

A key component of primary care pediatrics is health promotion through screening: applying a test or procedure to detect a previously unrecognized disease or disease risk. How do we decide whether to screen? In 1965, Wilson and Jungner published an influential set of screening principles focused on the health problem's importance, the screening tool's performance, and the evidence for treatment efficacy. However, if we want realistic estimates of the population effects of routine screening, we must also account for the health care system's real-world functioning and disparities in care. We offer revised principles to guide discussions about routine screening in the primary care setting. We add to Wilson and Jungner's principles: 1. A focus on life course epidemiology and its consequences for population health, 2. A need to screen for the early stages of chronic health problems, 3. A concern for screening's acceptability to providers and the community, 4. A recommendation for estimating the uncertainty in benefits and harms in evaluating screening, 5. Inclusion of systematic plans for population data collection and monitoring, and 6. Recognition that achieving population health improvement requires a high-performing system with sufficient throughput and monitoring to deliver accessible, affordable, and effective care, especially for the groups experiencing the greatest inequities in access. Above all, instead of assuming best practices in treatment delivery and monitoring after screening, we argue for realism about the health care system functioning in routine practice.

Suicide prevention for substance using youth experiencing homelessness: study protocol for a randomized controlled trial.

BACKGROUND: While research on substance using youth experiencing homelessness (YEH) is increasing, there is a dearth of information regarding effective prevention interventions for these youth. Suicide is the leading cause of death among YEH and most youth do not access services that may be available to them. Therefore, this study seeks to address this gap in the research literature with the goal to identify an effective suicide prevention intervention that can be readily adopted by communities that serve these youth. METHODS: Three hundred (N = 300) YEH with recent substance use and suicidal ideation or a recent suicide attempt will be recruited from the streets as well as a drop-in center serving YEH. After the baseline assessment, all youth will be randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Services as Usual (SAU) (N = 150) or to SAU alone (N = 150). SAU includes outreach, advocacy, and service linkage whereas YEH who receive CTSP will also receive ten CTSP sessions and an optional nine booster sessions. Follow-up assessments will be conducted at 3, 6, 9, and 12 months post-baseline. Theoretically derived mediators (e.g., cognitive distortions) will be tested to shed light on mechanisms associated with change, and the moderating effects of sex, race, sexual orientation, and baseline service connection will be examined. In order to ease future dissemination of the intervention to agencies serving YEH, we will rigorously assess acceptability, feasibility, fidelity, and cost associated with the delivery of our intervention approach using a mixed-methods approach. DISCUSSION: This study adds to a very small number of clinical trials seeking to prevent lethal suicide among a very high-risk group by addressing suicidal ideation directly rather than underlying conditions. It is hypothesized that youth receiving CTSP + SAU will show greater reductions in suicidal ideation (primary outcome), substance use, and depressive symptoms (secondary outcomes) over time compared to SAU alone, as well as improved risk and protective factors. TRIAL REGISTRATION: NCT05994612. Date of Registration: August 16, 2023.

A History Of The Impacts Of Discriminatory Policies On Housing And Maternal And Infant Health In An Ohio Neighborhood.

Community-level disinvestment and de facto segregation rooted in decades of discriminatory race-based policies and racism have resulted in unacceptably large infant mortality rates in racial minority neighborhoods across the US. Most community development and housing work, implemented with the goal of addressing health and social inequities, is designed to tackle current challenges in the condition of neighborhoods without a race-conscious lens assessing structural racism and discrimination. Using one historically segregated neighborhood-Linden, in Columbus, Ohio-we detail how state and local policies have affected the neighborhood and shaped neighborhood-level demographics and resources during the past 100 years. We explore how structural racism- and discrimination-informed strategic community reinvestment could provide a solution and yield lasting change.

Rural-urban differences in social and emotional protective factors and their association with child health and flourishing.

BACKGROUND: Children in rural communities experience higher mortality rates and less access to health care services than those in urban communities. Protective factors like social support also vary by geography, but their contribution to differences in child health is understudied. Understanding geographic variation in protective health factors could provide insight into their impact on health and guide future intervention strategies. RESEARCH OBJECTIVE: To examine protective factors' association with child flourishing and child health status in rural and urban communities. METHODS: Publicly available data from the National Survey of Children's Health, 2018-2021, with nonmissing geographic data (N = 150,493) were used to assess the relationship between protective factors and child flourishing and health by rurality. Multivariate survey-weighted probit models examined these relationships, adjusting for child and caregiver characteristics. FINDINGS: More than a third of children were not flourishing, according to parental report. An estimated 62% of rural children were flourishing compared to 66% of urban children (P<0.001). Urban caregivers also were more likely to report better adult mental and physical health status. Nevertheless, rural children were reported to receive more social support than urban children, while their caregivers reported more emotional support and living in supportive and safe neighborhoods (P<0.001). Rural caregivers reported more support from places of worship and less from counselors/other mental health care providers than urban caregivers. CONCLUSIONS: Despite higher reported caregiver emotional support and child social support, fewer rural children are flourishing. Health systems and community organizations able to leverage these existing social and emotional protective factors in rural communities could help close this gap.

Assessing Alternative Approaches for Wound Closure in a National Pediatric Learning Health System.

INTRODUCTION: Our objective was to perform a feasibility study using real-world data from a learning health system (LHS) to describe current practice patterns of wound closure and explore differences in outcomes associated with the use of tissue adhesives and other methods of wound closure in the pediatric surgical population to inform a potentially large study. METHODS: A multi-institutional cross-sectional study was performed of a random sample of patients <18 y-old who underwent laparoscopic appendectomy, open or laparoscopic inguinal hernia repair, umbilical hernia repair, or repair of traumatic laceration from January 1, 2019, to December 31, 2019. Sociodemographic and operative characteristics were obtained from 6 PEDSnet (a national pediatric LHS) children's hospitals and OneFlorida Clinical Research Consortium (a PCORnet collaboration across 14 academic health systems). Additional clinical data elements were collected via chart review. RESULTS: Of the 692 patients included, 182 (26.3%) had appendectomies, 155 (22.4%) inguinal hernia repairs, 163 (23.6%) umbilical hernia repairs, and 192 (27.8%) traumatic lacerations. Of the 500 surgical incisions, sutures with tissue adhesives were the most frequently used (n = 211, 42.2%), followed by sutures with adhesive strips (n = 176, 35.2%), and sutures only (n = 72, 14.4%). Most traumatic lacerations were repaired with sutures only (n = 127, 64.5%). The overall wound-related complication rate was 3.0% and resumption of normal activities was recommended at a median of 14 d (interquartile ranges 14-14). CONCLUSIONS: The LHS represents an efficient tool to identify cohorts of pediatric surgical patients to perform comparative effectiveness research using real-world data to support medical and surgical products/devices in children.

Electronic health records identify timely trends in childhood mental health conditions.

BACKGROUND: Electronic health records (EHRs) data provide an opportunity to collect patient information rapidly, efficiently and at scale. National collaborative research networks, such as PEDSnet, aggregate EHRs data across institutions, enabling rapid identification of pediatric disease cohorts and generating new knowledge for medical conditions. To date, aggregation of EHR data has had limited applications in advancing our understanding of mental health (MH) conditions, in part due to the limited research in clinical informatics, necessary for the translation of EHR data to child mental health research. METHODS: In this cohort study, a comprehensive EHR-based typology was developed by an interdisciplinary team, with expertise in informatics and child and adolescent psychiatry, to query aggregated, standardized EHR data for the full spectrum of MH conditions (disorders/symptoms and exposure to adverse childhood experiences (ACEs), across 13 years (2010-2023), from 9 PEDSnet centers. Patients with and without MH disorders/symptoms (without ACEs), were compared by age, gender, race/ethnicity, insurance, and chronic physical conditions. Patients with ACEs alone were compared with those that also had MH disorders/symptoms. Prevalence estimates for patients with 1+ disorder/symptoms and for specific disorders/symptoms and exposure to ACEs were calculated, as well as risk for developing MH disorder/symptoms. RESULTS: The EHR study data set included 7,852,081 patients < 21 years of age, of which 52.1% were male. Of this group, 1,552,726 (19.8%), without exposure to ACEs, had a lifetime MH disorders/symptoms, 56.5% being male. Annual prevalence estimates of MH disorders/symptoms (without exposure to ACEs) rose from 10.6% to 2010 to 15.1% in 2023, a 44% relative increase, peaking to 15.4% in 2019, prior to the Covid-19 pandemic. MH categories with the largest increases between 2010 and 2023 were exposure to ACEs (1.7, 95% CI 1.6-1.8), anxiety disorders (2.8, 95% CI 2.8-2.9), eating/feeding disorders (2.1, 95% CI 2.1-2.2), gender dysphoria/sexual dysfunction (43.6, 95% CI 35.8-53.0), and intentional self-harm/suicidality (3.3, 95% CI 3.2-3.5). White youths had the highest rates in most categories, except for disruptive behavior disorders, elimination disorders, psychotic disorders, and standalone symptoms which Black youths had higher rates. Median age of detection was 8.1 years (IQR 3.5-13.5) with all standalone symptoms recorded earlier than the corresponding MH disorder categories. CONCLUSIONS: These results support EHRs' capability in capturing the full spectrum of MH disorders/symptoms and exposure to ACEs, identifying the proportion of patients and groups at risk, and detecting trends throughout a 13-year period that included the Covid-19 pandemic. Standardized EHR data, which capture MH conditions is critical for health systems to examine past and current trends for future surveillance. Our publicly available EHR-mental health typology codes can be used in other studies to further advance research in this area.

Lessons learned from housing first, rapid rehousing trials with youth experiencing homelessness.

BACKGROUND: Youth, 18 to 24 years, experiencing homelessness (YEH) are recognized as having developmental challenges dissimilar to older adults. Yet, research on efforts to end homelessness and prevent or intervene in drug use and mental health problems among youth have lagged behind that of adults. The Housing First (HF) Model which underlies Permanent Supportive Housing (PSH) and Rapid Re-Housing (RRH) has become preferred over treatment-first models. METHODS AND RESULTS: We provide an overview of PSH and RRH studies to date and summarize our current understanding of their utility for use with YEH. Finally, we review our team's current and past randomized trials testing RRH with YEH, providing lessons learned and recommendations. CONCLUSION: Current research efforts to guide best practices are hampered by a lack of fidelity to HF principles, lack of randomized design, and lack of focus on youth. Lessons learned and recommendations from our work are offered to facilitate the future work of those who seek to end homelessness and address drug use and mental health problems among youth.

Hair Collection for Cortisol Among Youth Experiencing Homelessness.

BACKGROUND: Investigations of chronic physiological stress measured by hair cortisol are rapidly expanding among community samples of adolescents and adults. However, research examining physiological stress among youth experiencing homelessness is nascent despite the youth's increased risk for adverse exposures and subsequent impaired mental health. OBJECTIVE: This article aimed to examine the feasibility of collecting hair for measuring cortisol among diverse youth experiencing homelessness and gain an understanding of variation in participation. METHODS: Analysis of survey and hair participation data from three pilot studies among youth experiencing homelessness was conducted. Survey measures included sociodemographic characteristics (age, race and ethnicity, sex assigned at birth, and sexual orientation) and reasons for nonparticipation. Descriptive analysis examined participation rates in hair collection for cortisol measurement, including sociodemographic differences in participation. RESULTS: Participation in the hair sampling for cortisol was high for the combined sample (88.4%), with some variation across the three pilot studies. Insufficient hair for cutting was the most common reason for not participating; Black and multiracial youth, as well as male youth, had a higher prevalence of nonparticipation. DISCUSSION: The collection of hair for cortisol research among youth experiencing homelessness is feasible, and integration of physiological measures of stress into research with this vulnerable population should be considered, given their high risk for adversity and death by suicide and drug overdose. Methodological considerations and avenues for potential research are discussed.

Prevention of Opioid Use and Disorder Among Youth Involved in the Legal System: Innovation and Implementation of Four Studies Funded by the NIDA HEAL Initiative.

Youth involved in the legal system (YILS) experience rates of opioid and substance use disorders (OUD/SUDs) and overdose that is well above those in the general population. Despite the dire need, and the existing programs that focus on treatment of these problems in YILS, research on opioid initiation, and OUD prevention, including feasibility and sustainability, are severely limited. We present four studies testing interventions that, while not necessarily novel as SUD treatments, test novel structural and interpersonal strategies to prevent opioid initiation/OUD precursors: (1) ADAPT (Clinical Trial No. NCT04499079) provides real-time feedback using community-based treatment information system data to create a more effective mental health and SUD treatment cascade to prevent opioid use; (2) HOME (Clinical Trial No. NCT04135703) provides youth experiencing homelessness, including YILS, with direct access to shelter in independent living without prerequisites as an opioid initiation prevention strategy; (3) LeSA (Clinical Trial No. NCT04678960) uses the Trust-Based Relational Intervention® to equip YILS and their caregivers with self-regulatory and communication skills during the transition from secure confinement to reduce opioid initiation/re-initiation; and (4) POST (Clinical Trial No. NCT04901312) tests two interventions integrating interpersonal/drinking and drug refusal skills, case management, and goal setting among YILS in transitioning out of secure detention as opioid initiation prevention strategies. We discuss early implementation barriers and facilitators, including complexities of prevention research with YILS and adaptations due to COVID-19. We conclude by describing anticipated end products, including implementation of effective prevention interventions and integration of data from multiple projects to address larger, multi-site research questions.

Trends in Office-Based Anxiety Treatment Among US Children, Youth, and Young Adults: 2006-2018.

BACKGROUND AND OBJECTIVES: Anxiety disorder diagnoses in office-based settings increased for children through the mid-2010s, but recent changes in diagnosis and treatment are not well understood. The objectives of the current study were to evaluate recent trends in anxiety disorder diagnosis and treatment among children, adolescents, and young adults. METHODS: This study used serial cross-sectional data from the National Ambulatory Medical Care Survey (2006-2018), a nationally representative annual survey of US office-based visits. Changes in anxiety disorder diagnosis and 4 treatment categories (therapy alone, therapy and medications, medications alone, or neither) are described across 3 periods (2006-2009, 2010-2013, 2014-2018). Multinomial logistic regression compared differences in treatment categories, adjusting for age group, sex, and race/ethnicity, contrasting the last and middle periods with the first. RESULTS: The overall proportion of office visits with an anxiety disorder diagnosis significantly increased from 1.4% (95% confidence interval [CI] 1.2-1.7; n = 9 246 921 visits) in 2006 to 2009 to 4.2% (95% CI 3.4-5.2; n = 23 120 958 visits) in 2014 to 2018. The proportion of visits with any therapy decreased from 48.8% (95% CI 40.1-57.6) to 32.6% (95% CI 24.5-41.8), but there was no significant change in the overall use of medications. The likelihood of receiving medication alone during office visits was significantly higher in the last, relative to the first period (relative risk ratio = 2.42, 95% CI 1.24-4.72). CONCLUSIONS: The proportion of outpatient visits that included a diagnosis of anxiety increased over time, accompanied by a decrease in the proportion of visits with therapy.

Multidisciplinary Strategies for Preventing Opioid Misuse and Escalation by Targeting Mental Health Symptoms and Conditions.

We aim to review the association between childhood-onset mental health conditions and increased risk for early substance use including opioid misuse and opioid use disorders (OUD). The association between mental health conditions and opioid misuse suggests youth with mental health conditions may benefit from opioid prevention efforts that concurrently address mental health. To aid in the identification of youth with mental health conditions who could benefit from interventions, we will review opportunities and challenges associated with screening for mental health symptoms or substance use in settings where youth at high risk for mental health conditions present. We will also review how research projects within the National Institutes of Health's Helping to End Addiction Long-term (HEAL) Prevention Cooperative are addressing mental health within opioid misuse and OUD prevention interventions for youth.

Social Needs as a Risk Factor for Positive Postpartum Depression Screens in Pediatric Primary Care.

OBJECTIVE: The goal of this study was to examine the association between self-reported social needs and postpartum depression (PPD) symptoms of mothers screened in pediatric primary care clinics. METHODS: This retrospective cohort study used electronic health record data from 3616 pediatric patients (age 0-6 months), whose mothers completed the Edinburgh Postpartum Depression Scale (EPDS) and a social needs screening in a large pediatric primary care network between April 2021 and February 2022. Mothers were screened for four self-reported social needs (food, housing, transportation, and utilities). Logistic regression evaluated the association between the report of any social need and a positive EPDS screen (≥ 10), adjusting for demographic and clinical characteristics and ZIP code-level poverty. RESULTS: Overall, 8.6% of mothers screened positive for PPD and 10.0% reported any social needs. The odds of a positive depression screen were significantly higher among mothers who reported any social need compared to those not reporting a social need (OR 4.18, 95% CI 3.11-5.61). The prevalence of all depressive symptoms on the EPDS was significantly higher among those who reported any social need, relative to those reporting no needs. Mothers reporting any social needs were significantly more likely to report thoughts of self-harm (6.9% vs 1.5%, P < .005). CONCLUSIONS: Self-report of social need was significantly associated with positive PPD screens during infant well-child visits. Social needs may be a target of future interventions addressing PPD in pediatric settings. Improving care for social needs may have added benefit of alleviating the risk of PPD.