Initial development of tools to identify child abuse and neglect in pediatric primary care.

BACKGROUND: Child abuse and neglect (CAN) is prevalent, associated with long-term adversities, and often undetected. Primary care settings offer a unique opportunity to identify CAN and facilitate referrals, when warranted. Electronic health records (EHR) contain extensive information to support healthcare decisions, yet time constraints preclude most providers from thorough EHR reviews that could indicate CAN. Strategies that summarize EHR data to identify CAN and convey this to providers has potential to mitigate CAN-related sequelae. This study used expert review/consensus and Natural Language Processing (NLP) to develop and test a lexicon to characterize children who have experienced or are at risk for CAN and compared machine learning methods to the lexicon + NLP approach to determine the algorithm's performance for identifying CAN. METHODS: Study investigators identified 90 CAN terms and invited an interdisciplinary group of child abuse experts for review and validation. We then used NLP to develop pipelines to finalize the CAN lexicon. Data for pipeline development and refinement were drawn from a randomly selected sample of EHR from patients seen at pediatric primary care clinics within a U.S. academic health center. To explore a machine learning approach for CAN identification, we used Support Vector Machine algorithms. RESULTS: The investigator-generated list of 90 CAN terms were reviewed and validated by 25 invited experts, resulting in a final pool of 133 terms. NLP utilized a randomly selected sample of 14,393 clinical notes from 153 patients to test the lexicon, and .03% of notes were identified as CAN positive. CAN identification varied by clinical note type, with few differences found by provider type (physicians versus nurses, social workers, etc.). An evaluation of the final NLP pipelines indicated 93.8% positive CAN rate for the training set and 71.4% for the test set, with decreased precision attributed primarily to false positives. For the machine learning approach, SVM pipeline performance was 92% for CAN + and 100% for non-CAN, indicating higher sensitivity than specificity. CONCLUSIONS: The NLP algorithm's development and refinement suggest that innovative tools can identify youth at risk for CAN. The next key step is to refine the NLP algorithm to eventually funnel this information to care providers to guide clinical decision making.

Factores asociados a la adherencia al tratamiento farmacológico del trastorno por déficit de atención e hiperactividad (TDAH): revisión preliminar / Factors associated with adherence to pharmacological treatment of attention deficit hyperactivity disorder (ADHD): preliminary review

Resumen Introducción: El tratamiento del TDAH es seguro y eficaz, pero con frecuencia existen bajos niveles de adherencia al tratamiento. En este artículo describimos factores asociados a la adherencia des critos en la literatura disponible. Métodos: Realizamos una búsqueda bibliográfica no sistemática sobre artículos recientes sobre la adherencia a la medicación en niños y adolescentes con TDAH. Resultados: Hay factores asociados al propio trastorno, al paciente, al sistema de salud, factores socio-económicos, a la medicación y al entorno que pueden reducir o aumentar la adherencia a la medicación. Algunos factores que mejoran la adhe rencia incluyen: el conocimiento sobre el TDAH, la medicación y sus beneficios y efectos adversos potenciales. Regímenes de medicación sencillos, una vez al día y de liberación prolongada. Edad del paciente menor de 12 años y sexo femenino. Menos barreras de acceso al sistema de salud. Actitud positiva y proactiva de los padres respecto al TDAH y el uso de medicación. Discusión: Se podría optimizar la adherencia y por lo tanto mejorar el pronóstico a largo plazo del TDAH reforzando estos factores que aumentan la adherencia, y reduciendo los sesgos y desconocimiento sobre el TDAH.

Abstract Introduction: ADHD treatment is safe and effective, but often, adherence to t reatment is suboptimal. We studied factors associated to adherence to treatment in ADHD described in the literature. Methods: We conducted a non-systematic bibliographic search on recent articles on medication adherence in children and adolescents with ADHD. Results: There are factors associated with the disorder itself, the patient, the health system, socio-economic factors, the medication and the environment that can reduce/improve medication adherence. Some factors that improve adherence include: knowledge about ADHD, medication and its benefits and potential adverse effects. Simple, once-daily, extended-release medication regimens. Age of the patient less than 12 years and female sex. Fewer barriers to access the health system. Positive and proactive attitude of parents regarding ADHD and the use of medication. Discussion: Adherence could be optimized and therefore the long-term prognosis of ADHD improved by reinforcingfactors that increase adherence, and reducing biases and ignorance about ADHD.

[Factors associated with adherence to pharmacological treatment of attention deficit hyperactivity disorder (ADHD): preliminary review]. / Factores asociados a la adherencia al tratamiento farmacológico del trastorno por déficit de atención e hiperactividad (TDAH): revisión preliminar.

INTRODUCTION: ADHD treatment is safe and effective, but often, adherence to t reatment is suboptimal. We studied factors associated to adherence to treatment in ADHD described in the literature. METHODS: We conducted a non-systematic bibliographic search on recent articles on medication adherence in children and adolescents with ADHD. RESULTS: There are factors associated with the disorder itself, the patient, the health system, socio-economic factors, the medication and the environment that can reduce/improve medication adherence. Some factors that improve adherence include: knowledge about ADHD, medication and its benefits and potential adverse effects. Simple, once-daily, extended-release medication regimens. Age of the patient less than 12 years and female sex. Fewer barriers to access the health system. Positive and proactive attitude of parents regarding ADHD and the use of medication. DISCUSSION: Adherence could be optimized and therefore the long-term prognosis of ADHD improved by reinforcingfactors that increase adherence, and reducing biases and ignorance about ADHD.

Introducción: El tratamiento del TDAH es seguro y eficaz, pero con frecuencia existen bajos niveles de adherencia al tratamiento. En este artículo describimos factores asociados a la adherencia descritos en la literatura disponible. Métodos: Realizamos una búsqueda bibliográfica no sistemática sobre artículos recientes sobre la adherencia a la medicación en niños y adolescentes con TDAH. Resultados: Hay factores asociados al propio trastorno, al paciente, al sistema de salud, factores socio-económicos, a la medicación y al entorno que pueden reducir o aumentar la adherencia a la medicación. Algunos factores que mejoran la adherencia incluyen: el conocimiento sobre el TDAH, la medicación y sus beneficios y efectos adversos potenciales. Regímenes de medicación sencillos, una vez al día y de liberación prolongada. Edad del paciente menor de 12 años y sexo femenino. Menos barreras de acceso al sistema de salud. Actitud positiva y proactiva de los padres respecto al TDAH y el uso de medicación. Discusión: Se podría optimizar la adherencia y por lo tanto mejorar el pronóstico a largo plazo del TDAH reforzando estos factores que aumentan la adherencia, y reduciendo los sesgos y desconocimiento sobre el TDAH.

Longitudinal Predictors of Mother- and Child-Report of Maternal Support Following Child Sexual Abuse.

Maternal support is theorized as a critical predictor of children's recovery from sexual abuse. However, following disclosure, several factors may cause maternal support to fluctuate over time. This study examined the effects of hypothesized risk factors, mother's relationship to the perpetrator and maternal psychological distress, as well as protective factors, maternal belief of disclosure, lower levels of child blame, and mother-child relationship quality, as predictors of change in maternal support over a 9 month period. Mothers (Mage = 38.42, SD = 8.99) and their children (Mage = 11.57, SD = 2.69; 85% female), recruited from a child advocacy center following sexual abuse disclosure, completed measures of maternal support. Mothers reported on their relationship to the perpetrator, psychological distress, belief of disclosure, child blame, and mother-child relationship quality. On average, mother- and child-reports of maternal support were stable across time. Belief of disclosure and child blame predicted mother- and child-report of maternal support. Psychological distress and mother-child relationship quality predicted change in mother-report, but not child-report of maternal support. Researchers and clinicians should consider potential fluctuations in maternal support in assessment and intervention following child sexual abuse.

Rumination as a Mediator of the Association Between Racial Discrimination and Depression Among Black Youth.

BACKGROUND: Racial discrimination constitutes a significant risk factor for depressive symptoms among Black youth. Rumination, a maladaptive self-regulatory stress response, is a notable pathway by which racial discrimination contributes to depressive symptoms among racial/ethnic minority adults. Yet, examinations of the mechanistic nature of rumination in the context of racial discrimination among racial/ethnic minority youth remain limited. The present study investigated rumination as a mediator of the association between racial discrimination and depressive symptoms among Black youth. METHODS: Data for the current study were drawn from baseline questionnaire responses of community recruited Black pre-and-early adolescents (N = 158, 53% female, Mage = 11.50) in the southeast USA participating in an ongoing longitudinal study examining the effects of interpersonal stressors on youth mental health outcomes. RESULTS: After adjusting for age and gender, mediation analyses revealed a significant indirect effect of racial discrimination on depressive symptoms through rumination, estimate = 0.29, 95% confidence interval [0.12, 0.47]. Racial discrimination was positively associated with rumination (b = .74, SE = .23, p = .001), and rumination, in turn, was positively associated with depressive symptoms (b = .40, SE = .06, p < .001). CONCLUSION: Consistent with previous research, we found racial discrimination to be directly and indirectly associated with depressive symptoms among Black youth. Findings provide evidence of the cognitive burden of discriminatory experiences and suggest that rumination represents a potential pathway that can be targeted at early developmental stages to reduce the deleterious impact of racism-related stressors.

Therapists' Perceived Competence in Trauma-Focused Cognitive Behavioral Therapy and Client Outcomes: Findings From a Community-Based Learning Collaborative.

This study examined therapists' perceived competence in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and its association with youth treatment outcomes (posttraumatic stress and depression). Participants included 99 community therapists enrolled in a TF-CBT-focused Learning Collaborative (LC), along with one of their randomly selected TF-CBT training cases. Analyzed data included: 1) caregiver/youth-reported posttraumatic stress and depressive symptoms, pre- and post-treatment, and 2) therapist-perceived competence with TF-CBT components across treatment delivery. Youth- and caregiver-reports indicated large, significant pre- to post-treatment decreases in youth posttraumatic stress (ds = 1.10-1.30, ps < .001) and depressive symptoms (d = 1.01, p < .001). Higher therapist-perceived competence with TF-CBT predicted positive treatment responses for posttraumatic stress (ds = 0.38-0.39, ps = .03) and depression (d = 0.25), though only the former association was significant (ps = .03 vs. p = .15). Findings highlight the need to monitor and improve therapists' competencies to enhance clinical outcomes for trauma-exposed youth and suggest that LCs may be an effective training/implementation model to help achieve those critical goals.

Types of child maltreatment and child welfare involvement among opioid-using mothers involved in substance use treatment.

Although there is a significant link between maternal substance use and child maltreatment risk, extant literature has not investigated this link specifically among the growing number of parents abusing opioids. Underreporting of opioid use within child welfare presents further challenges in elucidating relations between maternal opioid use and child maltreatment. The purpose of the current study is to examine the link between maternal opioid use in women in substance use treatment and self-reported rates of child maltreatment and child welfare involvement of their children. We examined maternal substance use, severity of substance use, severity and type of child maltreatment of their children, and child welfare involvement across mothers who misuse opioids and misuse other substances using self-report surveys with 89 mothers. Results suggest similarities and differences among mothers who use opioids and other substances. Mothers who use opioids endorsed more significant and prolonged involvement with child welfare than mothers who use other substances. Participants did not endorse significant differences between rates of child maltreatment, and treatment engagement across groups. Given increased awareness of significant risks associated with opioid abuse, including greater risk for child maltreatment, a better understanding of its intersection with child welfare is necessary.

Healing Interpersonal and Racial Trauma: Integrating Racial Socialization Into Trauma-Focused Cognitive Behavioral Therapy for African American Youth.

African American youth are more likely than their peers from other racial and ethnic groups to experience interpersonal traumas and traumatic racist and discriminatory encounters. Unfortunately, evidence-based trauma treatments have been less effective among these youth likely due to these treatments not being culturally tailored to address both interpersonal and racial trauma. In this article, we utilize the racial encounter coping appraisal and socialization theory to propose suggestions for adapting trauma-focused cognitive behavioral therapy-an evidence-based trauma treatment for children and adolescents-to include racial socialization or the process of transmitting culture, attitudes, and values to help youth overcome stressors associated with ethnic minority status. We conclude by discussing implications for the research and clinical community to best promote healing from both interpersonal and racial trauma for African American youth.

Sustainment of Trauma-Focused and Evidence-Based Practices Following Learning Collaborative Implementation.

Given the need to develop and validate effective implementation models that lead to sustainable improvements, we prospectively examined changes in attitudes, behaviors, and perceived organizational support during and after statewide Community-Based Learning Collaboratives (CBLCs) promoting trauma-focused evidence-based practices (EBPs). Participants (N = 857; i.e., 492 clinicians, 218 brokers, and 139 senior leaders) from 10 CBLCs completed surveys pre- and post-CBLC; a subsample (n = 146) completed a follow-up survey approximately two years post-CBLC. Results indicated (a) medium, sustained increases in clinician-reported use of trauma-focused EBPs, (b) medium to large, sustained increases in perceived organizational support for trauma-focused EBPs, and (c) trivial to small, sustained increases in perceived organizational support for EBPs broadly. In contrast, clinician-reported overall attitudes towards EBPs decreased to a trivial degree pre- to post-CBLC, but then increased to a small, statistically significant degree from post-CBLC to follow-up. Notably, the degree of perceived improvements in organizational support for general and trauma-focused EBPs varied by professional role. Findings suggest the CBLC implementation strategies may both increase and sustain provider practices and organizational support towards EBPs, particularly those EBPs a CBLC explicitly targets.

Identification of differential item functioning by race and ethnicity in the Childhood Trauma Questionnaire.

BACKGROUND: The accurate assessment of childhood maltreatment (CM) is important in medical and mental health settings given its association to adverse psychological and physical outcomes. Reliable and valid assessment of CM is also of critical importance to research. Due to the potential of measurement bias when comparing CM across racial and ethnic groups, invariant measurement is an important psychometric property of such screening tools. OBJECTIVE: In this study, differential item function (DIF) by race and ethnicity was tested. Uniform DIF refers to the influence of bias on scores across all levels of childhood maltreatment, and non-uniform DIF refers to bias in favor of one group. METHOD: Participants were N=1,319 women and men (Mage=36.77, SDage=10.37) who completed the Child Trauma Questionnaire-Short Form; 42.7% were women, 57.3% were male; 58.9% were White-American, 22.1% Black-American, and 8.0% as other; 26.3% were Hispanic. RESULTS: Using empirical thresholds, non-uniform DIF was identified in five items by race, and no items by ethnicity. CONCLUSIONS: Uniform DIF is less problematic given that mathematical corrections can be made to adjust scores for DIF. However, non-uniform DIF can usually only be corrected by removing the DIF items from the scale. Further methodological research is needed to minimize measurement bias to effectively assess racially diverse populations.

Family Emotion Expressiveness Mediates the Relations Between Maternal Emotion Regulation and Child Emotion Regulation.

While there is a growing body of literature examining the influence of emotion socialization on children's emotional and social development, there is less research on what predicts emotion socialization behaviors among parents. The current study explores maternal emotion regulation difficulties as a predictor of emotion socialization practices, specifically, family emotion expressiveness. Further, the current study examines the role of family emotion expressiveness as a possible mediator of the relations between maternal and child emotion regulation in a community sample of 110 mother-child dyads with preschool-aged children. Analyses revealed that positive family expressiveness mediated the relations between maternal emotion dysregulation and child emotion regulation and thus presents important clinical implications for existing emotion socialization interventions.