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OBJECTIVE: To evaluate the effects of behavioral health interventions delivered within pediatric integrated primary care models on clinical outcomes. METHODS: We searched Medline, EMBASE, CENTRAL, PsycINFO, and SCOPUS for studies published from January 1, 1998, to September 20, 2023. We included studies that evaluated onsite behavioral health integration in pediatric primary care using a comparator condition (usual, enhanced usual care, or waitlist). Outcome data on symptom change, impairment/quality of life, health indicator, and behavior change were extracted using Covidence software. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed Risk of bias analysis was conducted using the Cochrane Risk of Bias tool. We used multilevel meta-analysis to synthesize multiple outcomes nested within studies. Open Science Foundation pre-registration: #10.17605/OSF.IO/WV7XP. RESULTS: In total, 33 papers representing 27 studies involving 6,879 children and caregivers were included. Twenty-four studies were randomized controlled trials and three were quasi-experimental designs. Seventeen papers reported on treatment trials and 16 reported on prevention trials. We found a small overall effect size (SMD = 0.19, 95% confidence interval [0.11, 0.27]) supporting the superiority of integrated primary care to usual or enhanced usual care. Moderator analyses suggested similar effectiveness between co-located and integrated models and no statistically significant differences were found between treatment and prevention trials. CONCLUSIONS: Results suggest that integrated primary care is superior to usual and enhanced usual care at improving behavior, quality of life, and symptoms. Integrated primary care research needs improved standards for reporting to promote better synthesis and understanding of the literature.
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INTRODUCTION: Suicide is the second leading cause of death for youth 12 to 18 years of age. Suicidal ideation can be predictive of suicide attempt, so screening for suicidal ideation by emergency nurses can help identify those at risk and facilitate timely intervention. This study evaluates the use of a universal suicide screening using the Patient Safety Screener 3 and the Columbia Suicide Severity Rating Scale to identify youth ages 12 to 18 years experiencing suicide risk and assess factors predictive of suicide risk level. METHODS: We conducted a retrospective cohort study using data from patients presenting to the emergency department at an acute care hospital that uses a universal screening program for suicide risk. We determined the frequency of positive screens and performed multivariate analyses to identify predictive factors of scoring high on the Columbia Suicide Severity Rating Scale. RESULTS: Notably, 9.1% of patients were experiencing some level of suicide risk; 10% of those with positive scores had no mental health history and were not presenting for a mental health reason. After controlling for other independent variables, insurance status, mental health presentation, and known mental health history were significantly associated with Columbia Suicide Severity Rating Scale score. DISCUSSION: Universal screening for suicide risk in pediatric emergency departments by nurses is critical for all patients older than 12 years, given that we identified patients at risk of suicide who presented for non-mental health reasons. These patients may not have been identified or referred to treatment if they were not screened for suicidality increasing risk of future suicide attempt.
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Enfermería de Urgencia , Servicio de Urgencia en Hospital , Tamizaje Masivo , Ideación Suicida , Humanos , Masculino , Femenino , Adolescente , Estudios Retrospectivos , Niño , Tamizaje Masivo/métodos , Enfermería de Urgencia/métodos , Medición de Riesgo/métodos , Prevención del Suicidio , Intento de Suicidio/estadística & datos numéricos , Factores de Riesgo , Estudios de CohortesRESUMEN
The articles in this special issue collectively provide important information about engagement, perceptions, and experiences that enhance our understanding of the current context of educational and health care delivery across systems of care; the importance of perspectives of collaboration and engagement in collaborations; and the direct benefits of interagency collaboration (IAC) on improving mental health among students. Moreover, these articles highlight the importance of specific training and interprofessional collaboration (IPC) and the importance of ethical considerations in IPC and IAC. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Conducta Cooperativa , Relaciones Interprofesionales , Estudiantes , Humanos , Estudiantes/psicología , Atención a la SaludRESUMEN
PURPOSE: The goal of the current study was to conduct a substantive validity review of four autism knowledge assessments with prior psychometric support (Gillespie-Lynch in J Autism and Dev Disord 45(8):2553-2566, 2015; Harrison in J Autism and Dev Disord 47(10):3281-3295, 2017; McClain in J Autism and Dev Disord 50(3):998-1006, 2020; McMahon in Res Autism Spectr Disord 71:101499, 2020). 69 autism experts who served on the editorial board of one or more peer-reviewed autism journals evaluated the accuracy and ambiguity of autism knowledge questions. 34% of the questions were flagged as "potentially problematic" for accuracy, and 17% of the questions were flagged as "potentially problematic" for ambiguity. Autism expert feedback revealed three themes across ambiguous questions: (1) an oversimplification of mixed or still-evolving research literature, (2) an insufficient recognition of the heterogeneity of the autism spectrum, and (3) a lack of clarity in the question/answer prompt. Substantive validity of future autism knowledge assessments should be carefully evaluated via feedback from a diverse group of autism experts and/or potential respondents. Potentially problematic questions can be removed or modified to improve the validity of autism knowledge assessments.
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INTRODUCTION: This study aimed to review approaches to health-related social needs (HRSN) screening and referral in pediatric primary care. METHOD: PsycINFO, PubMed, and Google Scholar databases were searched to include peer-reviewed studies conducted in the U.S. over the last 30 years that reported HRSN screening and/or referral outcomes in primary care up to age 18. Studies included multiple HRSN domains and a variety of study designs. Data were summarized descriptively. RESULTS: 20 studies met inclusion criteria. A variety of screening targets and modalities were employed in addition to referral support methods. Positive screens among the domains reported varied depending on the screening process and sample. DISCUSSION: This review highlights a range of patient-centered innovations for HRSN screening and referral that may be adaptable to a range of local needs and capacities. Ongoing rigorous evaluation of these models is needed.
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Animal-assisted therapies have been increasingly used as part of treatment for a range of emotional-behavioral conditions and have more recently been incorporated into treatment for children with symptoms associated with autism spectrum disorder. Autism spectrum disorder affects one in 36 children and early interventions can be very effective. The aims of this paper are to: 1) provide background into animal-assisted therapies including a breakdown on the subtypes of therapies, 2) report broad summaries of research outcomes across various domains: social-emotional, physical, quality of life, behavioral skills, and adaptive skills, and 3) summarize key takeaways for pediatric practitioners when supporting families of youth with autism spectrum disorder who are interested in participating in animal-assisted therapy. This paper is not a systematic review or meta-analysis as several rigorous review studies have been published already. This paper is an overview of the background and research for pediatric practitioners when advising families on treatment options. Implications for future research are covered.
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Terapia Asistida por Animales , Trastorno del Espectro Autista , Trastorno Autístico , Adolescente , Animales , Humanos , Niño , Trastorno Autístico/terapia , Trastorno del Espectro Autista/terapia , Calidad de Vida , Intervención Educativa PrecozRESUMEN
CASE: Sam is an 11-year-old young boy with autism spectrum disorder (ASD), unspecified anxiety disorder, and attention-deficit/hyperactivity disorder, combined presentation. He was initially diagnosed with ASD at 6 years of age after evaluation by a developmental-behavioral (DB) pediatrician. He presents to the DB pediatrics clinic to reestablish care. He established care with psychiatry 5 months ago after his school referred him to a hospital-school-community telepartnership bridge program following statements of self-harm and numerous concerns with his behavior, including elopement.Sam currently receives special education support under the classifications of "Emotional Disturbance" and "Speech Impairment." His parents report significant challenges with having his medical diagnosis of autism recognized by the school, which has impeded him receiving educational support as a student with autism. This has resulted in Sam being penalized for challenging behaviors related to his neurodevelopmental disorder. He is not currently making meaningful progress in the school setting. Sam currently demonstrates avoidance, physical and verbal aggression, and difficulty adapting to change across settings. In addition to difficulties advocating for more individualized support at school, Sam has never received applied behavior analysis (ABA) therapy because of challenges obtaining insurance approval. There are no additional barriers to accessing care, such as language, geographic, or socioeconomic factors.Sam's visit to reestablish care with DB pediatrics consisted of an individual clinician evaluation model. The Childhood Autism Rating Scale, Second Edition, (CARS-2) and Vineland Adaptive Behavior Scales, Third Edition (Vineland-3), were administered, and Sam continued to meet DSM-5 criteria for ASD following re-evaluation. A new referral for ABA therapy was submitted. Shortly afterward, his family received an insurance denial letter specifying that additional developmental testing was needed before ABA therapy would be approved. His clinician called the insurance company to appeal this decision but was unsuccessful. Sam was then seen by the DB pediatrics embedded psychologist, who completed additional testing, including assessment of cognitive functioning, administration of the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2), and autism-specific rating scales. This process led to further delays in access to ABA services. Throughout this process, the parents reported feeling helpless and frustrated given the barriers faced in receiving appropriate services. What are your next steps to advocate for supports through the school and insurance company?
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Trastorno por Déficit de Atención con Hiperactividad , Trastorno del Espectro Autista , Trastorno Autístico , Masculino , Niño , Humanos , Trastorno Autístico/psicología , Trastorno del Espectro Autista/diagnóstico , Trastorno del Espectro Autista/terapia , Trastorno por Déficit de Atención con Hiperactividad/terapia , Estudiantes , Accesibilidad a los Servicios de SaludRESUMEN
Psychotropic medications are commonly prescribed to school-aged youth for the management of mental health concerns. This paper describes the current state of evidence for psychotropic medications in school-aged youth. More specifically, the following sections summarize relevant medication research trials and practice parameters pertaining to psychotropic medication prescribing as well as the specific medications indicated for a range of commonly presenting disorders and symptom clusters in school-aged youth. For each of these disorders and symptom clusters, key findings pertaining to the current state of science and practice are highlighted for the purpose of offering patients, clinicians, researchers, and policymakers with nuanced considerations for the role of psychopharmacology within the context of a larger "whole-child" approach to care that relies on the collaboration of providers and services across systems of care to promote optimal child and family health and wellness. The paper concludes with a discussion about supporting the use of medication treatments in schools, including considerations for ensuring effective family-school-health system collaboration to best meet youth mental health needs.
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OBJECTIVE: We (a) describe the development of a hospital-school-community telepartnership (HSCT) program targeting suicidality crisis response implemented in the immediate aftermath of the COVID-19 pandemic, (b) report on service utilization outcomes from the first year and half of program implementation, and (c) share early lessons learned and implications for future directions. METHOD: Using program evaluation data collected from September 2020 to December 2021, demographic, usage outcomes, care coordination, and support outcomes are reported. Representative case vignettes are also illustrated. RESULTS: Students (N = 258) were referred to the HSCT program for suicidality from partnering school districts in the large metropolitan area of Austin, Texas. Students referred were adolescents, 12 years of age and older (n = 196, 76%). Sixty-two (24%) of the students referred for suicidal ideation entered the HSCT program through urgent same-day assessment. Medication evaluations were offered for 125 (48%) of the students. The most frequently prescribed medications included antidepressants (e.g., SSRIs; n = 29, 64%). Program clinicians referred 12 (5%) students identified as high risk for suicide for hospitalization. Of the 258 total students, 212 (82%) were referred to community providers for therapy. CONCLUSIONS: By providing rapid access to crisis response with mental health specialists and care coordinators, at-risk students received timely evidence-based care and referral to mental health resources in their communities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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This paper describes the (Sin Exclusión) Transdisciplinary Autism Assessment and Resources ([S]TAAR) model and presents early metrics tracking efficiency and equity in access to high-quality comprehensive autism evaluations for young children. Retrospective chart reviews over one year (08/2018-08/2019) with n = 173 children were reviewed. Through care coordination with community providers, the model was developed to meet local needs by increasing throughput of children (< 4 years old) evaluated by a transdisciplinary team. Team-based processes included pre-visit triage, synchronous evaluation procedures, case conferencing, huddles, and care coordination. The model led to increased patient throughput, reductions in waitlist and time to diagnosis, and improved provider satisfaction. Improvements in access to care were equitable across patient race, ethnicity, language, and insurance type.
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Trastorno del Espectro Autista , Trastorno Autístico , Niño , Humanos , Preescolar , Trastorno Autístico/diagnóstico , Trastorno Autístico/terapia , Trastorno del Espectro Autista/diagnóstico , Trastorno del Espectro Autista/terapia , Estudios Retrospectivos , Etnicidad , TriajeRESUMEN
Attention-deficit/hyperactivity disorder (ADHD) is a common presenting concern in primary care. This study examined the relationship between pediatric residency training program characteristics and residents' ADHD knowledge, attitudes, and comfort in providing ADHD services. Given the familiarity that pediatric chief residents have with the training and experiences within their residency programs, a 30-item survey was mailed to pediatric chief residents. A total of 100 residents returned their surveys (response rate 49.5%) and were included in the descriptive quantitative and thematic qualitative analyses. The majority of participants rated their ADHD knowledge as at least average. However, approximately half of the participants were comfortable with screening, and less than half were comfortable with managing stimulant medication or behavioral treatments. Participants emphasized the importance of interprofessional collaboration, clinical experiences, and integrated ADHD education throughout training. These results emphasize the importance of improved training in screening, diagnosing, and managing ADHD to increase resident comfort regarding these practices.
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Trastorno por Déficit de Atención con Hiperactividad , Internado y Residencia , Humanos , Niño , Trastorno por Déficit de Atención con Hiperactividad/diagnóstico , Trastorno por Déficit de Atención con Hiperactividad/terapia , Encuestas y Cuestionarios , EscolaridadRESUMEN
Child health disparities in terms of access to high-quality physical and behavioral health services and social needs supports are rampant and pernicious in the United States. These disparities reflect larger societal health inequities (social injustice in health) and lead to preventable population-specific differences in wellness outcomes with marginalized children facing substantial and systematically disproportionate health burdens. Primary care, and specifically the pediatric patient-centered medical home (P-PCMH) model, is a theoretically well-positioned platform to address whole-child health and wellness needs, yet often does so in a way that is inequitable for marginalized populations. This article delineates how the integration of psychologists within the P-PCMH can advance child health equity. This discussion emphasizes roles (i.e., clinician, consultant, trainer, administrator, researcher, and advocate) that psychologists can undertake with explicit intentionality toward promoting equity. These roles consider structural and ecological drivers of inequities and emphasize interprofessional collaboration within and across child-serving systems of care using community-partnered shared decision-making approaches. Owing to the multiple intersecting drivers implicated in health inequities-ecological (e.g., environmental and social determinants of health), biological (e.g., chronic illness, intergenerational morbidity), and developmental (e.g., developmental screening, support, and early intervention)-the ecobiodevelopmental model is used as an organizing framework for psychologists' roles in promoting health equity. This article aims to advance the platform of the P-PCMH to address and promote policy, practice, prevention, and research in child health equity and the important role of psychologists within this model. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Equidad en Salud , Humanos , Estados Unidos , Niño , Atención Dirigida al Paciente , PolíticasRESUMEN
Given existing barriers to a timely autism diagnosis, this study compares the efficiency and equity of diagnoses conducted in-person vs. telehealth in a developmental behavioral pediatrics setting. The transition to telehealth was prompted by the COVID-19 pandemic. Eleven months of clinic data in electronic medical records were retrospectively analyzed for children diagnosed with autism in-person (N = 71) vs. telehealth (N = 45). Time to autism diagnosis, patient demographics, and deferred diagnoses did not significantly differ across visit types. However, privately insured patients and families living farther from the clinic had a longer time to diagnosis via telehealth vs. in-person. Results of this exploratory study highlight the feasibility of telehealth evaluations for autism and which families may benefit from additional support to ensure a timely diagnosis.
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OBJECTIVE: Minimal guidance is available in the literature to develop protocols for training non-clinician raters to administer semi-structured psychiatric interviews in large, multi-site studies. Previous work has not produced standardized methods for maintaining rater quality control or estimating interrater reliability (IRR) in such studies. Our objective is to describe the multi-site Texas Childhood Trauma Research Network (TX-CTRN) rater training protocol and activities used to maintain rater calibration and evaluate protocol effectiveness. METHODS: Rater training utilized synchronous and asynchronous didactic learning modules, and certification involved critique of videotaped mock scale administration. Certified raters attended monthly review meetings and completed ongoing scoring exercises for quality assurance purposes. Training protocol effectiveness was evaluated using individual measure and pooled estimated IRRs for three key study measures (TESI-C, CAPS-CA-5, MINI-KID [Major Depressive Episodes - MDE & Posttraumatic Stress Disorder - PTSD modules]). A random selection of video-recorded administrations of these measures was evaluated by three certified raters to estimate agreement statistics, with jackknife (on the videos) used for confidence interval estimation. Kappa, weighted kappa and intraclass correlations were calculated for study measure ratings. RESULTS: IRR agreement across all measures was strong (TESI-C median kappa 0.79, lower 95% CB 0.66; CAPS-CA-5 median weighted kappa 0.71 (0.62), MINI-MDE median kappa 0.71 (0.62), MINI-PTSD median kappa 0.91 (0.9). The combined estimated ICC was ≥0.86 (lower CBs ≥0.69). CONCLUSIONS: The protocol developed by TX-CTRN may serve as a model for other multi-site studies that require comprehensive non-clinician rater training, quality assurance guidelines, and a system for assessing and estimating IRR.
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Experiencias Adversas de la Infancia , Trastorno Depresivo Mayor , Humanos , Reproducibilidad de los Resultados , Texas , Aprendizaje , Variaciones Dependientes del ObservadorRESUMEN
OBJECTIVE: Previous work investigating the impact of childhood trauma on substance use and co-occurring psychiatric disorders has primarily been conducted in adults or on specific trauma types. This limits understanding of traumas impact in childhood and how different types of traumas play a role. We sought to characterize substance use in a sample of trauma-exposed youth in the context of psychiatric comorbidities. METHOD: 1152 youth from the Texas Childhood Trauma Research Network (TX-CTRN) that were exposed to at least one trauma meeting DSM-5 Criterion A were assessed for current substance use and psychiatric diagnoses. Latent class analysis was used to identify patterns of substance use. To characterize these patterns, we examined if demographics, number of trauma types experienced, or childhood psychiatric disorders predicted class membership. RESULTS: We identified four primary patterns of substance use: Non-use (66.1%), predominantly alcohol use (19.7%), predominantly cannabis use (4.5%), and polysubstance use (9.7%). Compared to the non-users, polysubstance users tended to be older, Non-Hispanic White, have experienced more types of trauma. They were also more likely to have fulfilled diagnostic criteria for suicidality and ADHD. Comparisons among the substance using classes were more nuanced. CONCLUSION: The findings highlight the need for universal assessments of trauma, substance misuse, and mental health symptoms in youth as the presence or absence of their co-occurrence has implications for treatment.
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INTRODUCTION: Despite increased prevalence and identification of pediatric behavioral health concerns, families face many barriers when attempting to access behavioral health services. System navigators, or individuals experienced in navigating the health system, help to engage families in services by helping individuals overcome barriers for accessing care. However, limited research to date has systematically reviewed the implementation and effectiveness of navigation models in pediatric populations. METHOD: We systematically reviewed published studies examining navigation models for pediatric populations (up to age 18) referred to behavioral health services. We searched PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO for studies that evaluated a navigation model and included service use outcomes. We aggregated data pertaining to characteristics of the study and navigation model, service use outcomes, and implementation outcomes. RESULTS: Eight studies met inclusion criteria. Families who participated in navigation services were more likely to complete diagnostic assessments and received an increased dosage (e.g., time spent, services completed) of behavioral health treatments. There was notable variability across studies in terms of processes involved in the navigation models. DISCUSSION: Findings indicate that system navigation is a promising method for improving service use for pediatric populations referred to behavioral health services. Future research may continue to examine the effectiveness and implementation of the model, to best understand its benefits and what processes may contribute to improved service outcomes. Public Significance Statement: This paper reviews the effectiveness of system navigator models, which are designed to engage children and families in behavioral health services. The interventions reviewed are associated with increased behavioral health service use in children and show promise as a method of overcoming barriers to accessing behavioral health care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Trabajo Infantil , Servicios de Salud Mental , Adolescente , Niño , Humanos , Navegación de PacientesRESUMEN
INTRODUCTION: Despite increasing evidence that use of the "common factors" and "common elements" approaches are effective in improving patient outcomes, and calls for pediatricians to address patient behavioral health concerns, little is known about pediatrician knowledge, perceptions, and use of these approaches. METHOD: Pediatric chief residents from all 210 pediatric residency programs in the United States were surveyed to investigate their knowledge, attitudes, practices, and training related to use of engagement and treatment strategies that comprise the common factors and common elements approaches to delivering behavioral health care. RESULTS: The usable response rate was 38%. Most respondents indicated they believe pediatricians should address behavioral health issues and that common factors and common elements would be useful and feasible in clinical practice. Most indicated low levels of familiarity with common factors and common elements and dissatisfaction with training in these areas. CONCLUSION: Additional training and other implementation supports, such as dissemination of implementation guidelines and mechanisms for technical assistance, will be needed in order to increase pediatrician use of these approaches. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Internado y Residencia , Psiquiatría , Niño , Humanos , Pediatras , Encuestas y Cuestionarios , Estados UnidosRESUMEN
ABSTRACT: The transition to virtual and hybrid schooling given the COVID-19 pandemic in the United States has upended the education system and may be widening gaps in service disparities, particularly for children with disabilities. Schools often function as "de facto" service systems for most children with disabilities, particularly those from racially and ethnically minoritized, economically vulnerable, and bilingual populations. The impact of school closures on children with disabilities poses significant ramifications for the medical, behavioral health, and educational systems in which they are served, necessitating the need for pediatric clinicians to collaborate with schools in purposeful ways. This commentary (1) presents an overview of the current guidance for providing school-based services to children with disabilities during the COVID context with many schools operating in virtual or hybrid formats, (2) reviews potential service inequities exacerbated by school closures and lack of on-site services, and (3) offers recommendations for collaborating with school staff and community agencies in support of children and families with disabilities.
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COVID-19/epidemiología , Niños con Discapacidad/educación , Relaciones Interinstitucionales , Instituciones Académicas/organización & administración , Niño , Educación a Distancia/métodos , Educación a Distancia/organización & administración , Humanos , Estados UnidosRESUMEN
BACKGROUND: Interagency collaboration between community and school settings is one mechanism to serve the complex needs of pediatric patients with autism spectrum disorder (ASD). PURPOSE: We surveyed a national sample of community-based providers to examine their perspectives on interagency collaboration with school-based providers when serving pediatric patients with ASD. METHOD: Medical and behavioral/mental health professionals practicing in community settings were recruited. Participants (N = 116) completed an online survey about their interagency collaboration experiences with schools. RESULTS: The majority of the sample reported engaging in interagency collaboration with school-based providers; however, the frequency was limited and was associated with the number of years working in the field. Community-based providers wanted more didactic and hands-on experiences in collaboration. Barriers and facilitators were related to schools' administration, school personnels' training in ASD, information exchange, and delineating between identification systems. DISCUSSION AND CONCLUSION: Our findings highlight the importance of leadership support and the need for innovative training experiences to support school-community interagency collaboration.