Discordant and Concordant Substance Use and Daily Partner Violence in Adolescent and Young Adult Relationships With Baseline Dating Violence.

PURPOSE: Intimate partner violence (IPV) and substance use in adolescents and young adults (AYAs) are significant public health issues in the United States. Together, they can harm emotional regulation and romantic relationship functioning. This study examines the role of concordant and discordant substance use on IPV within AYA relationships. METHODS: A prospective cohort of community-recruited AYA women in a heterosexual dating relationship with past-month IPV completed four months of daily surveys via a cell phone. Each day, participants reported any IPV perpetration and/or victimization, their alcohol and drug use, and observed partner substance use. Concordant substance use was coded when the participant and partner used drugs or alcohol on the same day. Discordant use was coded when only the participant or partner used drugs or alcohol on a given day. Alcohol and drug use were modeled separately. Generalized estimating equations accounted for the correlation of repeated measures. RESULTS: Participants (N = 143) were 18.2 (1.1) years old, 93% African American race. Discordant alcohol and drug use was associated with same-day victimization, perpetration, and co-occurring violence compared to concordant nonuse. Similarly, concordant alcohol use, drug use, and alcohol/drug use were associated with increased odds of victimization, perpetration, and co-occurring violence compared to concordant nonuse. DISCUSSION: Daily data illustrated that dyadic patterns of substance use are associated with IPV. These findings may facilitate the development of effective and developmentally appropriate IPV intervention programs for AYA that also integrate strategies to reduce substance use.

Conceptualizations of health, ability to act upon those definitions and desire for supports among families from historically marginalized communities.

Respect for parents' values and clinician-parent collaboration is less common among families from historically marginalized communities. We investigated how parents from marginalized communities operationalize health and their preferences for paediatric primary care. We recruited families who spoke English, Haitian Creole or Spanish with at least one child younger than 6 years old. Staff queried families' values and life experiences, perspectives on health and healthcare, social supports and resources. Fourteen interviews with the parents of 26 children were thematically analysed. Interviews revealed the following four themes: (1) parents' definitions of 'health' extend beyond physical health; (2) families' ability to actuate health definitions is complicated by poverty's impact on agency; (3) parents engage in ongoing problem recognition and identify solutions, but enacting solutions can be derailed by barriers and (4) parents want support from professionals and peers who acknowledged the hard work of parenting. Eliciting parents' multidimensional conceptualizations of health can support families' goal achievement and concern identification in the context of isolation, limited agency and few resources. Efforts to improve family centred care and reduce disparities in paediatric primary care must be responsive to the strengths, challenges, resources and priorities of marginalized families.

Changes Over Time in Outcomes of School-Age Children and Parents Receiving Integrated Mental Health Care in Federally Qualified Health Centers.

OBJECTIVE: The purpose of this study is to understand change in parent-reported outcomes of mental health symptoms, health-related quality of life (QoL), and school-related functioning among children receiving mental health care at 3 federally qualified health centers engaging in a comprehensive pediatric mental health integration model. METHODS: Trained personnel enrolled English- or Spanish-speaking families of 6- to 12-year-old children who had recently started receiving integrated mental health care and surveyed their parent/caregiver at 3 time points: entry into the cohort, 6-month follow-up, and 12-month follow-up (unique N = 51). Primary outcomes included validated measures of child symptoms, child health-related QoL, and child school-related functioning. Secondary outcomes focused on parental functioning and included validated measures of parental stress and depressive and internalizing symptoms. A multilevel mixed-effects generalized linear model was used to estimate the change in parent-reported outcomes over time, with inverse probability weights used to address attrition. Additional analyses were conducted to determine the degree to which changes in symptoms over time were associated with improvements in school-related functioning. RESULTS: Over 12 months, children's mental health symptoms, health-related QoL, and school-related functional outcomes significantly improved. No changes in parental functioning were observed. In addition, improvements in mental health symptoms and health-related QoL were associated with improvements in school-related functional outcomes over time. CONCLUSION: Findings demonstrate that outcomes of children who received integrated mental health care improved over time, both in regard to mental health and school functioning.

Pediatric Provider and Staff Burnout in Federally Qualified Community Health Centers.

This study examined changes in provider and staff burnout in 4 Boston-area federally qualified community health centers (FQHCs) participating in a pediatric behavioral health integration project. Utilizing the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSSMP), the study found that emotional exhaustion among primary care providers ( M = 20.5; confidence interval [CI], 17.8-23.2) was higher ( P = .001) than that among behavioral health clinicians ( M = 13.6; CI, 10.4-16.8) and ( P = .00005) community health workers ( M = 10.8; CI, 7.3-14.2). Emotional exhaustion among staff increased ( P = .04) from baseline ( M = 16.8; CI, 15.0-18.6) to follow-up ( M = 20.8; CI, 17.5-24.2), but burnout at follow-up was lower than national averages. FQHCs are integral in caring for marginalized patients; therefore, supporting a stable workforce by minimizing burnout is essential.

Association of Integrating Mental Health Into Pediatric Primary Care at Federally Qualified Health Centers With Utilization and Follow-up Care.

Importance: More than 1 in 5 children in low-income families report a mental health (MH) problem, yet most face barriers accessing MH services. Integrating MH services into primary care at pediatric practices such as federally qualified health centers (FQHCs) may address these barriers. Objective: To examine the association of a comprehensive MH integration model with health care utilization, psychotropic medication use, and MH follow-up care among Medicaid-enrolled children at FQHCs. Design, Setting, and Participants: This retrospective cohort study used Massachusetts claims data from 2014 to 2017 to conduct difference-in-differences (DID) analyses before vs after implementation of a complete FQHC-based MH integration model. The sample included Medicaid-enrolled children aged 3 to 17 years who received primary care at 3 intervention FQHCs or 6 geographically proximal nonintervention FQHCs in Massachusetts. Data were analyzed in July 2022. Exposures: Receipt of care at an FQHC implementing the Transforming and Expanding Access to Mental Health Care in Urban Pediatrics (TEAM UP) model, which began fully integrating MH care into pediatrics in mid-2016. Main Outcomes and Measures: Utilization outcomes included primary care visits, MH service visits, emergency department (ED) visits, inpatient admissions, and psychotropic medication use. Follow-up visits within 7 days of a MH-related ED visit or hospitalization were also examined. Results: Among the 20 170 unique children in the study sample, at baseline (2014), their mean (SD) age was 9.0 (4.1) years, and 4876 (51.2%) were female. In contrast to nonintervention FQHCs, TEAM UP was positively associated with primary care visits with MH diagnoses (DID, 4.35 visits per 1000 patients per quarter; 95% CI, 0.02 to 8.67 visits per 1000 patients per quarter) and MH service use (DID, 54.86 visits per 1000 patients per quarter; 95% CI, 1.29 to 108.43 visits per 1000 patients per quarter) and was negatively associated with rates of psychotropic medication use (DID, -0.4%; 95% CI -0.7% to -0.01%) and polypharmacy (DID, -0.3%; 95% CI, -0.4% to -0.1%). TEAM UP was positively associated with ED visits without MH diagnoses (DID, 9.45 visits per 1000 patients per quarter; 95% CI, 1.06 to 17.84 visits per 1000 patients per quarter), but was not significantly associated with ED visits with MH diagnoses. No statistically significant changes were observed in inpatient admissions, follow-up visits after MH ED visits, or follow-up visits after MH hospitalizations. Conclusions and Relevance: The first 1.5 years of MH integration enhanced access to pediatric MH services while limiting the use of psychotropic medications. Additional implementation time is necessary to determine whether these changes will translate into reductions in avoidable utilization.

Implementation of a Novel Pediatric Behavioral Health Integration Initiative.

This study explores healthcare professionals' perspectives about the impact of behavioral health integration (BHI) on pediatric primary care delivery in community health centers (CHCs). A concurrent, qualitative-dominant mixed methods empirical study design was utilized, applying semi-structured interviews with healthcare professionals at the end of the implementation phase of a 3-year co-development, implementation, and evaluation process. Surveys were also administered at three time points. Via thematic analysis, emergent qualitative themes were mapped onto the Relational Coordination (RC) conceptual framework to triangulate and complement final qualitative results with quantitative results. Interview findings reveal five emergent themes aligning with RC domains. Survey results show that healthcare professionals reported increased behavioral healthcare integration into clinic practice (p = 0.0002) and increased clinic readiness to address behavioral health needs (p = 0.0010). Effective pediatric BHI and care delivery at CHCs may rely on strong professional relationships and communication. Additional research from the patient/caregiver perspective is needed.

Validity of a three-item dating abuse victimization screening tool in a 11-21 year old sample.

BACKGROUND: Dating abuse (DA) is prevalent and consequential, but no brief DA screening tools are available for use in pediatric or other settings. This study was designed to determine the sensitivity, specificity, and predictive values of the MARSHA-C, which is a three-item DA victimization screening tool. METHODS: The participants were 224 U.S. youth ages 11-21 years old (20% male, 77% female, 3% non-binary gender). Youth completed an online questionnaire about adolescent relationship abuse. The survey included the Measure of Adolescent Relationship Harassment and Abuse (MARSHA), which is a comprehensive DA measurement instrument normed on a nationally representative sample. Of 34 DA victimization items from the MARSHA, the three most prevalent items were hypothesized to have good predictive validity of the full scale score as a brief, screening version (MARSHA-C). The sensitivity, specificity, positive predictive value, and negative predictive value of the MARSHA-C to identify victims of DA was calculated. RESULTS: Using the MARSHA as the reference standard, the cutpoint of 1 on the MARSHA-C screening tool was identified as optimal. The MARSHA-C had a sensitivity of 84%, a specificity of 91%, and positive predictive value of 91%. Thus, for youth who endorse ≥ 1 MARSHA-C items, there is a 91% probability that they have experienced DA in the past year. Exploratory analyses by demographic subgroups suggest that the predictive validity of the MARSHA-C is approximately equivalent for females and males, younger and older adolescents, Asian, Black, Latinx, Multiracial and White youth, and heterosexual and lesbian, gay, and bisexual youth. CONCLUSIONS: The MARSHA-C can be used to detect DA among 11-21-year-old youth via online surveys for research purposes, or in clinical care settings to facilitate proactive patient counseling or parent-oriented anticipatory guidance.

Mistreatment Experiences, Protective Workplace Systems, and Occupational Distress in Physicians.

Importance: Reducing physician occupational distress requires understanding workplace mistreatment, its relationship to occupational well-being, and how mistreatment differentially impacts physicians of diverse identities. Objectives: To assess the prevalence and sources of mistreatment among physicians and associations between mistreatment, occupational well-being, and physicians' perceptions of protective workplace systems. Design, Setting, and Participants: This survey study was administered in September and October 2020 to physicians at a large academic medical center. Statistical analysis was performed from May 2021 to February 2022. Main Outcomes and Measures: Primary measures were the Professional Fulfillment Index, a measure of intent to leave, and the Mistreatment, Protection, and Respect Measure (MPR). Main outcomes were the prevalence and sources of mistreatment. Secondary outcomes were the associations of mistreatment and perceptions of protective workplace systems with occupational well-being. Results: Of 1909 medical staff invited, 1505 (78.8%) completed the survey. Among respondents, 735 (48.8%) were women, 627 (47.1%) were men, and 143 (9.5%) did not share gender identity or chose "other"; 12 (0.8%) identified as African American or Black, 392 (26%) as Asian, 10 (0.7%) as multiracial, 736 (48.9%) as White, 63 (4.2%) as other, and 292 (19.4%) did not share race or ethnicity. Of the 1397 respondents who answered mistreatment questions, 327 (23.4%) reported experiencing mistreatment in the last 12 months. Patients and visitors were the most common source of mistreatment, reported by 232 physicians (16.6%). Women were more than twice as likely as men to experience mistreatment (31% [224 women] vs 15% [92 men]). On a scale of 0 to 10, mistreatment was associated with a 1.13 point increase in burnout (95% CI, 0.89 to 1.36), a 0.99-point decrease in professional fulfillment (95% CI, -1.24 to -0.73), and 129% higher odds of moderate or greater intent to leave (odds ratio, 2.29; 95% CI, 1.75 to 2.99). When compared with a perception that protective workplace systems are in place "to a very great extent," a perception that there are no protective workplace systems was associated with a 2.41-point increase in burnout (95% CI, 1.80 to 3.02), a 2.81-point lower professional fulfillment score (95% CI, -3.44 to -2.18), and 711% higher odds of intending to leave (odds ratio, 8.11; 95% CI, 3.67 to 18.35). Conclusions and Relevance: This survey study found that mistreatment was common among physicians, varied by gender, and was associated with occupational distress. Patients and visitors were the most frequent source, and perceptions of protective workplace systems were associated with better occupational well-being. These findings suggest that health care organizations should prioritize reducing workplace mistreatment.

Integrating Pediatric Universal Behavioral Health Care at Federally Qualified Health Centers.

BACKGROUND: Research supports integrated pediatric behavioral health (BH), but evidence gaps remain in ensuring equitable care for children of all ages. In response, an interdisciplinary team codeveloped a stepped care model that expands BH services at 3 federally qualified health centers (FQHCs). METHODS: FQHCs reported monthly electronic medical record data regarding detection of BH issues, receipt of services, and psychotropic medications. Study staff reviewed charts of children with attention-deficit/hyperactivity disorder (ADHD) before and after implementation. RESULTS: Across 47 437 well-child visits, >80% included a complete BH screen, significantly higher than the state's long-term average (67.5%; P < .001). Primary care providers identified >30% of children as having BH issues. Of these, 11.2% of children <5 years, 53.8% of 5-12 years, and 74.6% >12 years were referred for care. Children seen by BH staff on the day of referral (ie, "warm hand-off") were more likely to complete an additional BH visit than children seen later (hazard ratio = 1.37; P < .0001). There was no change in the proportion of children prescribed psychotropic medications, but polypharmacy declined (from 9.5% to 5.7%; P < .001). After implementation, diagnostic rates for ADHD more than doubled compared with baseline, follow-up with a clinician within 30 days of diagnosis increased (62.9% before vs 78.3% after; P = .03) and prescriptions for psychotropic medication decreased (61.4% before vs 43.9% after; P = .03). CONCLUSIONS: Adding to a growing literature, results demonstrate that integrated BH care can improve services for children of all ages in FQHCs that predominantly serve marginalized populations.

Five-Year Trends in Pediatric Mental Health Emergency Department Visits in Massachusetts: A Population-Based Cohort Study.

OBJECTIVES: To evaluate temporal changes in pediatric emergency department (ED) visits for mental health problems in Massachusetts based on diagnoses and patient characteristics and to assess trends in all-cause pediatric ED visits. STUDY DESIGN: This statewide population-based retrospective cohort study used the Massachusetts All-Payer Claims Database, which includes almost all Massachusetts residents. The study sample consisted of residents aged <21 years who were enrolled in a health plan between 2013 and 2017. Using multivariate regression, we examined temporal trends in mental health-related and all-cause ED visits in 2013-2017, with person-quarter as the unit of analysis; we also estimated differential trends by sociodemographic and diagnostic subgroups. The outcomes were number of mental health-related (any diagnosis, plus 14 individual diagnoses) and all-cause ED visits/1000 patients/quarter. RESULTS: Of the 967 590 Massachusetts residents in our study (representing 14.8 million person-quarters), the mean age was 8.1 years, 48% were female, and 57% had Medicaid coverage. For this population, mental health-related (any) and all-cause ED visits decreased from 2013 to 2017 (P < .001). Persons aged 18-21 years experienced the largest declines in mental health-related (63.0% decrease) and all-cause (60.9% decrease) ED visits. Although mental health-related ED visits declined across most diagnostic subgroups, ED visits related to autism spectrum disorder-related and suicide-related diagnoses increased by 108% and 44%, respectively. CONCLUSIONS: Overall rates of pediatric ED visits with mental health diagnoses in Massachusetts declined from 2013 to 2017, although ED visits with autism- and suicide-related diagnoses increased. Massachusetts' policies and care delivery models aimed at pediatric mental health may hold promise, although there are important opportunities for improvement.

Intimate Partner Violence and the Pediatric Electronic Health Record: A Qualitative Study.

OBJECTIVES: To explore expert perspectives on risks associated with the pediatric electronic health record (EHR) for intimate partner violence (IPV) survivors and their children and to identify strategies that may mitigate these risks. METHODS: We conducted semistructured interviews with multidisciplinary pediatric IPV experts (nursing, physicians, social workers, hospital security, IPV advocates) recruited via snowball sampling. We coded interview transcripts using thematic analysis, then consolidated codes into themes. RESULTS: Twenty-eight participants completed interviews. Participants identified the primary source of risk as an abuser's potential access to a child's EHR by legal and illegal means. They noted that abuser's access to multiple pediatric EHR components (eg, online health portals, clinical notes, contact information) may result in escalated violence, stalking, and manipulation of IPV survivors. Suggested risk mitigation strategies included limited and coded documentation, limiting EHR access, and discussing documentation with the IPV survivor. Challenges to using these strategies included healthcare providers' usual practice of detailed documentation and that information documented may confer both risk and benefit concurrently. Reported potential benefits of the pediatric EHR for IPV survivors included ensuring continuity of care, decreasing need to repeatedly talk about trauma histories, and communication of safety plans. CONCLUSIONS: Our findings suggest the pediatric EHR may confer both risks and benefits for IPV survivors and their children. Further work is needed to develop best practices to address IPV risks related to the pediatric EHR, to ensure consistent use of these practices, and to include these practices as standard functionalities of the pediatric EHR.

Anti-Poverty Medicine Through Medical-Financial Partnerships: A New Approach to Child Poverty.

Poverty threatens child health. In the United States, financial strain, which encompasses income and asset poverty, is common with many complex etiologies. Even relatively successful antipoverty programs and policies fall short of serving all families in need, endangering health. We describe a new approach to address this pervasive health problem: antipoverty medicine. Historically, medicine has viewed poverty as a social problem outside of its scope. Increasingly, health care has addressed poverty's downstream effects, such as food and housing insecurity. However, strong evidence now shows that poverty affects biology, and thus, merits treatment as a medical problem. A new approach uses Medical-Financial Partnerships (MFPs), in which healthcare systems and financial service organizations collaborate to improve health by reducing family financial strain. MFPs help families grow assets by increasing savings, decreasing debt, and improving credit and economic opportunity while building a solid foundation for lifelong financial, physical, and mental health. We review evidence-based approaches to poverty alleviation, including conditional and unconditional cash transfers, savings vehicles, debt relief, credit repair, financial coaching, and employment assistance. We describe current national MFPs and highlight different applications of these evidence-based clinical financial interventions. Current MFP models reveal implementation opportunities and challenges, including time and space constraints, time-sensitive processes, lack of familiarity among patients and communities served, and sustainability in traditional medical settings. We conclude that pediatric health care practices can intervene upon poverty and should consider embracing antipoverty medicine as an essential part of the future of pediatric care.

Adolescent and Young Women's Daily Reports of Emotional Context and Episodes of Dating Violence.

PURPOSE: To investigate same day, previous day, and next day associations between trust, closeness, commitment, jealousy and provision of instrumental support with dating violence victimization and perpetration. METHOD: A convenience sample of young women, 16-19 years, in a heterosexual dating relationship with at least one act (past month) of physical or psychological victimization or perpetration, were recruited from urban public locations. Participants answered questions daily via text continuously for four months on dating violence and partner-specific emotions. Daily surveys asked about trust, closeness, commitment for their partner, jealousy, perceptions of partner's jealousy and provision of instrumental support to and from partner, and dating violence victimization and perpetration. Multilevel modeling examined within-relationship associations over time. RESULTS: Mean (sd) age for the full sample was 18.1 (1.1) years. Same-day emotional context (trust, closeness, commitment, jealousy and provision of instrumental support) was more strongly associated with victimization and perpetration compared to previous day emotions. Strongest same-day positive associations were with partner's perpetration, both partner's jealousy, and females' instrumental support. Partner's jealousy and increased trust were best predictors of next day victimization. Closeness, commitment and trust went down on the day of violence. Perpetration was positively associated with next day commitment. Victimization was positively associated with next day trust. CONCLUSIONS: This event-level analysis demonstrates the role and timing that emotional aspects of adolescent relationships - including positive feelings - have surrounding episodes of dating violence. This granular understanding of the emotional context of dating violence has the potential to facilitate development of effective, developmentally appropriate interventions.

The Influence of Culture on Healthy Relationship Formation and Teen Dating Violence: A Qualitative Analysis of South Asian Female Youth Residing in the United States.

Teen dating violence (TDV) has well-documented detrimental health effects. Scant research has examined the perspectives of ethnically diverse youth about the impact of culture on TDV. We sought to explore the intersection between culture and TDV specifically for South Asian youth residing in the United States. We conducted semi-structured interviews with South Asian youth aged 16 to 21 years. Interviews included three aims: (a) exploring participants' perspectives on TDV and healthy relationships within the South Asian community, (b) examining how different components of their cultural identity affect their romantic relationships, and (c) understanding ideas for TDV prevention programs for South Asian youth. Interview transcripts were coded using thematic analysis. Twenty-five adolescent females participated; the majority (76%) trace their heritage to India, were born abroad (62%), and are in college (80%). The majority believed that dating was stigmatized within the South Asian community, forcing youth to hide relationships from their parents. Participants described aspects of culture that may negatively impact relationships (e.g., patriarchal attitudes and fear of stigma), as well as those that may protect teens (e.g., close-knit community). Conflicts about dating due to generational differences were also discussed. Participants suggested programs for South Asian youth focused on engaging parents in conversations about TDV and promoting gender equity. About half thought TDV prevention programs should be culturally tailored for South Asian youth, while others believed multicultural programs would be more effective. Although South Asian culture may confer some protection for youth experiencing TDV, stigma against dating and generational differences may create unique challenges. Future work should examine how to mediate parent-adolescent cultural conflicts around dating.

Evaluation of a Multi-Session Group Designed to Prevent Commercial Sexual Exploitation of Minors: The "My Life My Choice" Curriculum.

The commercial sexual exploitation (CSE) of children is a consequential public health and criminal justice problem, but no CSE prevention programs have been evaluated. The Boston-based My Life My Choice (MLMC) program offers a multisession psychoeducation group to girls who are identified as "at-disproportionate-risk" for CSE victimization and trains other agencies throughout the U.S. to offer this curriculum. The curriculum was designed to improve knowledge about the commercial sex industry and shift-related attitudes and behaviors. The current project was a multi-year, multi-site evaluation to assess the effectiveness of the MLMC prevention group. Using a one-group longitudinal design, changes in participant behavior and CSE knowledge were measured at baseline (n = 354), upon group completion (n = 296), and 3 months after group completion (n = 241). The sample was 95% female-identified, 28% Black/African American, 26% White/non-Hispanic, 25% Hispanic/Latina, and 22% other race. The mean age of participants was 15.6 years old. Approximately 28% identified as bisexual, and 10% identified as lesbian, asexual, pansexual, or other. In multivariable-adjusted models, participants reported fewer episodes of sexually explicit behavior at follow up as compared to baseline (relative risk [RR]: 0.52, 95% confidence interval [CI]: 0.37-0.72 at Follow-up 1, and 0.53, 95% CI: 0.35-0.82 at Follow-up 2). Participants were 24% less likely to report dating abuse at Follow-up 2 as compared to baseline (p = .06). In addition, as compared to baseline, participants were 40% more likely to have given help or information about CSE to a friend at Follow-up 2, and participants demonstrated increased knowledge and awareness about CSE and its harms over the follow-up period. Although additional evaluation using a comparison group and long-term follow up would increase confidence that observed changes are attributable to the group instead of other factors, results suggest that the MLMC curriculum may be effective in reducing the risk of CSE and improving other conditions for youth who are at-disproportionate-risk of CSE.