Bridging K-12 Student Mental Health Policy to Practice Gaps with a Multi-Component Framework.

K-12 schools are a major sector for efforts to prevent and treat student mental health problems. In the United States, these efforts have led to the emergence of the MultiTiered System of Supports (MTSS) universal prevention, early intervention, and treatment policy framework. With a major focus on behavioral and mental health, MTSS has been adopted by all fifty state education departments. However, multi-level complexities of addressing student mental health within and across organizational structures complicate MTSS and broader policy development, implementation, and evaluation; disconnects between policy writers and practitioners obstruct progress, limiting positive outcomes. To bridge these policy-to-practice gaps, a multi-component solution is needed. The authors propose integrating the following elements: the Massachusetts School Mental Health Consortium's Five Guiding Principles for Building a Coordinated School Mental Health System, the comprehensive school improvement methodology Evolutionary Systems Improvement (ESI); and the ontological framework of BioPsychoSocioTechnical Systems Theory (BPST). Individual application of these components has already yielded systems-level improvements outperforming compliance-driven procedures. Used together, these components offer a multi-level solution for establishing conceptually-guided, measurement-based loops that transcend the restrictions of uninformed policy, supporting stakeholders as they work to systematically eliminate barriers and improve student mental health.

Identifying Youth at Risk for Suicidal Thoughts and Behaviors Using the "p" factor in Primary Care: An Exploratory Study.

Suicide is a major, preventable public health problem. The general factor of psychopathology ("p" factor) might help improve detection and prediction of individuals at risk for suicide. This cross-sectional proof-of-concept study tests whether the p-factor score is associated with suicidal thoughts and behaviors (STB) better than a depression scale alone. Youth (N = 841; mean age 18.02, SD = 3.36) in primary care were universally screened using the Behavioral Health Screen (BHS). Factor analysis and ROC results showed the BHS assesses the p-factor, and the p-factor score demonstrates higher classification accuracy of several types of STB than a depression scale. The p-factor could help clinicians in the identification of youths with STB.

Validation of a parent report on externalizing symptoms scale: A downward extension of the behavioral health screen.

Externalizing problems are common in children ages 6-14, can have lifelong consequences, and may pose a particular risk when combined with other risk factors and symptoms (like depression and anxiety). Schools are uniquely positioned to assess and address these types of behavioral health concerns, but many school-based assessments do not focus on mental health distress (partially because they often lack the infrastructure for identification, screening, and referral). To address this gap, the Behavioral Health Works program student mental health software system has integrated teacher training, psychometrically strong assessments, feedback, and referral tools. However, this self-report tool for adolescents needed to be adapted for younger children. Thus, a parent-report version was added as well as new scales for better assessing this age group. The present study examines the psychometric properties of the new parent-report attention-deficit hyperactivity disorder (ADHD) and oppositional defiant/conduct scales within a sample of 440 children referred for school-based assessments. Overall, the new scales demonstrated good structural validity, measurement invariance across most demographic groups, discrimination in item response theory analyses, and evidence of convergent validity and good classification accuracy in relation to a validation battery. These externalizing scales are distinct and precise and show promise for improving the effectiveness of school-based programs for identifying at-risk children. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Differentiating Between Youth with a History of Suicidal Thoughts, Plans, and Attempts.

Limited research has examined factors distinguishing between patterns of adolescent suicidal thoughts and behaviors. The current study examined demographic, school, family, and mental health differences across patterns identified by Romanelli and colleagues (2022): history of thoughts only, plans with thoughts, attempt with thoughts and/or plans, and attempt without thoughts. The current study includes 4,233 students (M age = 14.65 years, SD = 2.06) with a history of suicide risk referred to school Student Assistance Program teams. The sample was approximately 60.7% female, 59.8% White (16.0% Black, 15.4% multiracial, 8.8% other), and 14.4% Hispanic. Results indicated that the "attempt without thoughts" group was small with no differentiating characteristics. However, membership in the other three groups was predicted by demographic, school, family, and mental health factors. These results support the importance of examining suicidal thoughts, plans, and attempts as distinct indicators and assessing key biopsychosocial factors. Further research could improve how behavioral health systems identify at risk youth.

A qualitative study of expert and team cognition on complex patients in the pediatric intensive care unit.

OBJECTIVES: To understand expert and team cognition of complex patients in the pediatric intensive care unit through the use of cognitive task analysis. DESIGN: Qualitative study with semistructured interviews. SETTING: Academic medical center pediatric intensive care unit. PARTICIPANTS: Physicians, nurses, and nurse practitioners. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Semistructured interviews were conducted with members of the critical care team involved with the care of seven complex patients. Interviews were transcribed and themes were identified based on grounded theory and further divided into categories. A focus group of critical care team members further refined and validated the findings. From the interviews, 177 verbal fragments were sorted into 11 themes. Four broad thematic categories were identified and a cognitive framework for the care of complex patients was formulated. We found that at the center of this framework, critical care teams attempt to create and share mental models of their patients. These mental models serve as the framework for delivery of longitudinal care across handovers and shift changes. The analysis revealed that this process is limited by a number of factors such that team members utilize a variety of techniques to overcome these limitations and develop more complete and shared mental models. CONCLUSIONS: An inadequately developed or inadequately shared mental model is a substantial cognitive limitation for expert and team cognition in the complex environment of the pediatric intensive care unit. Providers utilize techniques that may avoid or decrease the variable interpretations of patient condition that would otherwise impair mental model formation and sharing. Future studies should be designed to enhance mental model formation and communication in the pediatric intensive care unit and other environments that deal with complex patients.

Acceptability and Usability of a Reward-Based Mobile App for Opioid Treatment Settings: Mixed Methods Pilot Study.

BACKGROUND: Contingency management is an evidence-based yet underutilized approach for opioid use disorder (OUD). Reasons for limited adoption in real-world practice include ethical, moral, and philosophical concerns regarding use of monetary incentives, and lack of technological innovation. In light of surging opioid overdose deaths, there is a need for development of technology-enabled solutions leveraging the power of contingency management in a way that is viewed by both patients and providers as acceptable and feasible. OBJECTIVE: This mixed methods pilot study sought to determine the perceived acceptability and usability of PROCare Recovery, a reward-based, technology-enabled recovery monitoring smartphone app designed to automate contingency management by immediately delivering micropayments to patients for achieving recovery goals via smart debit card with blocking capabilities. METHODS: Participants included patients receiving buprenorphine for OUD (n=10) and licensed prescribers (n=5). Qualitative interviews were conducted by 2 PhD-level researchers via video conferencing to explore a priori hypotheses. Thematic analysis of interviews was conducted and synthesized into major themes. RESULTS: Participants were overwhelmingly in favor of microrewards (eg, US $1) to incentivize treatment participation (up to US $150 monthly). Participants reported high acceptability of the planned debit card spending restrictions (blocking cash withdrawals and purchases at bars or liquor stores, casinos or online gambling). Quantitative data revealed a high level of perceived usability of the PROCare Recovery app. CONCLUSIONS: Patients and providers alike appear receptive to microfinancial incentives in standard OUD treatment practices. Further pilot testing of PROCare is underway to determine acceptability, feasibility, and preliminary effectiveness in a rigorous randomized controlled trial.

Primary Care Practice Redesign: Challenges in Improving Behavioral Health Care for a Vulnerable Patient Population.

This study examined a program focused on integrating mental health in a family medicine practice in an economically challenged urban setting. The program included using a behavioral health technology platform, a behavioral health collaborative composed of community mental health agencies, and a community health worker (CHW). Of the 202 patients screened, 196 were used for analysis; 56% were positive for anxiety, 38% had scores consistent with moderate to severe depression, and 34% were positive for post-traumatic stress disorder. There was a statistically significant difference in the diagnosis of depression when comparing the screened group to a control group. Only 27% of patients followed through with behavioral health referrals despite navigational assistance provided by a CHW and assured access to care through a community agency engaged with the Behavioral Health Alliance. Further qualitative analysis revealed that there were complex patient factors that affected patient decision making regarding follow-up with behavioral health care.

Computer-assisted assessment of depression and function in older primary care patients.

We wanted to test the psychometric reliability and validity of self-reported information on psychological and functional status gathered by computer in a sample of primary care outpatients. Persons aged 65 years and older visiting a primary care medical practice in Baltimore (n=240) were approached. Complete baseline data were obtained for 54 patients and 34 patients completed 1-week retest follow-up. Standard instruments were administered by computer and also given as paper and pencil tests. Test-retest reliability estimates were calculated and comparisons across mode of administration were made. Separately, an interviewer administered a questionnaire to gauge patient attitudes and feelings after using the computer. Most participants (72%) reported no previous computer use. Nevertheless, inter-method reliability of the GDS15 at baseline (0.719, n=47), intra-method reliability of the computer in time (0.797, n=31), inter-method reliability of the CESDR20 at baseline (0.740, n=53), and the correlation between the CESDR20 computer version at baseline and follow-up (0.849, n=34) were all excellent. The inter-method reliability of the CESDR20 at follow-up (0.615, n=37) was lower but still acceptable. Although 28% were anxious prior to using the computer testing system, that percent decreased to 19% while using the system. The efficiency and reliability in comparison to the paper instruments were good or better. Even though most participants had not ever used a computer prior to participating in the study, they had generally favorable attitudes toward the use of computers, and also reported having favorable experience with the computer testing system.

Integrating technology into palliative care research.

PURPOSE OF REVIEW: As palliative care research evolves and grows within resource-strained environments, further integration of novel methods to assist in completing protocols is needed. Technology-assisted techniques, including the use of software and hardware, to aid in data collection, analysis and reporting are increasingly being incorporated into research investigations in palliative care. Reviewing reported successes of technology use in palliative care research is important to communicate lessons learned and principles to guide further implementation. RECENT FINDINGS: There is a growing body of evidence that technology can be effectively integrated into palliative care research. We review four diverse examples of the use of software and hardware technology for data collection from patients and other research participants. Early successes and challenges with technology are also discussed. In addition, seven guiding principles for technology design, implementation and upgrading are appraised to advise readers of the important pitfalls that can plague any well intentioned technology-based research programme. SUMMARY: Technology has been successfully integrated into some aspects of palliative care research. The growth of both palliative care research and use of electronic methods for data collection predict increased incorporation between the two fields.

Tell Us™: a Web-based tool for improving communication among patients, families, and providers in hospice and palliative care through systematic data specification, collection, and use.

CONTEXT: Routine electronic patient-reported outcome collection in patients with advanced disease could improve communication among patients, caregivers, and providers, the timeliness of identifying problems, and effectiveness of follow-up. OBJECTIVES: To develop a Web-based tool to collect symptoms and needed data and provide feedback to hospice and palliative care patients, caregivers, and providers. METHODS: We developed Tell Us™ based on an existing pure Web technology platform, the Medical Decision Logic, Inc., Health Science Process Framework. The software development process included eliciting information on systems and needs, mapping care processes with three diverse hospices, and soliciting ideas for the software from clinicians and researchers. We developed a prototype software product, incorporated the hospices' processes, assessment questions, and educational materials, and refined the product with feedback from other hospice and palliative care professionals. RESULTS: Tell Us™ includes modules for authoring and deploying clinical queries and completion schedules, for enrolling clinical sites and patients for patients and/or families to complete assigned assessments on a scheduled basis, and for providers to view patient-reported data. Tell Us™ provides customizable automated provider e-mail alerts based on patient responses (such as uncontrolled symptoms or need for medication refills) and provides educational materials targeted to patient needs. CONCLUSION: This Web-based toolset may be useful for improving communication among hospice and palliative care patients, caregivers, and providers, and proactive patient management. Future research will involve integrating the software into care and evaluating its feasibility and use for data collection, patient education, and improving outcomes.

Feasibility and effects of a Web-based adolescent psychiatric assessment administered by clinical staff in the pediatric emergency department.

OBJECTIVES: To determine the adoption rate of the Web-based Behavioral Health Screening-Emergency Department (BHS-ED) system during routine clinical practice in a pediatric ED, and to assess this system's effect on identification and assessment of psychiatric problems. DESIGN: Descriptive design to evaluate the feasibility of a clinical innovation. SETTING: The ED of an urban tertiary care children's hospital. PARTICIPANTS: Adolescents from 14 to 18 years of age, without acute or critical injuries or illness, presenting with nonpsychiatric symptoms. INTERVENTION: The ED clinical staff initiated the use of the BHS-ED system, which identifies and assesses adolescents for depression, suicidal ideation, posttraumatic stress, substance use, and exposure to violence. Treating clinicians reviewed results and followed routine care practices thereafter. MAIN OUTCOME MEASURES: Adoption rate of the BHS-ED system by nursing staff, identification rates of occult psychiatric problems, and social worker or psychiatrist assessment. Data were collected for 19 months before implementation of the BHS-ED system and for 9 months during implementation. RESULTS: Of 3979 eligible patients, 1327 (33.4%) were asked by clinical staff to get screened using the BHS-ED; of these 1327 patients, 857 (64.6%) completed the screening and 470 (35.4%) refused. During implementation, identification of adolescents with psychiatric problems increased significantly (4.2% vs 2.5%; odds ratio [OR], 1.70; 95% confidence interval [CI], 1.38-2.10), as did ED assessments by a social worker or psychiatrist (2.5% vs 1.7%; OR, 1.47; 95% CI, 1.13-1.90). Of the 857 patients who were screened with the BHS-ED, 90 (10.5%) were identified as having psychiatric problems (OR, 4.58; 95% CI, 3.53-5.94), and 71 (8.3%) were assessed (OR, 5.12; 95% CI, 3.80-6.88). CONCLUSIONS: In a busy pediatric ED, computerized, self-administered adolescent behavioral health screening can be incorporated into routine clinical practice. This can lead to small but significant increases in the identification of unrecognized psychiatric problems.

Development, validation, and utility of internet-based, behavioral health screen for adolescents.

OBJECTIVES: The goals were to develop and to validate the Internet-based, Behavioral Health Screen (BHS) for adolescents and young adults in primary care. METHODS: Items assessing risk behaviors and psychiatric symptoms were built into a Internet-based platform with broad functionality. Practicality and acceptability were examined with 24 patients. For psychometric validation, 415 adolescents completed the BHS and well-established rating scales. Participants recruited from primary care waiting rooms were 12 to 21 years of age (mean: 15.8 years); 66.5% were female and 77.5% black. RESULTS: The BHS screens in 13 domains by using 54 required items and 39 follow-up items. The administration time was 8 to 15 minutes (mean: 12.4 minutes). The scales are unidimensional, are internally consistent (Cronbach's alpha = 0.75-0.87), and discriminate among adolescents with a range of diagnostic syndromes. Sensitivity and specificity were high, with overall accuracy ranging from 78% to 85%. Patients with scores above scale cutoff values for depression, suicide risk, anxiety, and posttraumatic stress disorder symptoms were > or =4 times more likely to endorse other risk behaviors or stressors. CONCLUSIONS: The BHS addresses practical and clinical barriers to behavioral health screening in primary care. It is a brief but comprehensive, self-report, biopsychosocial assessment. The psychiatric scales are valid and predictive of risk behaviors, which facilitates exclusion of false-positive results, as well as assessment and triage.

Electronic health record - public health (EHR-PH) system prototype for interoperability in 21st century healthcare systems.

Information exchange, enabled by computable interoperability, is the key to many of the initiatives underway including the development of Regional Health Information Exchanges, Regional Health Information Organizations, and the National Health Information Network. These initiatives must include public health as a full partner in the emerging transformation of our nation's healthcare system through the adoption and use of information technology. An electronic health record - public health (EHR-PH)system prototype was developed to demonstrate the feasibility of electronic data transfer from a health care provider, i.e. hospital or ambulatory care settings, to multiple customized public health systems which include a Newborn Metabolic Screening Registry, a Newborn Hearing Screening Registry, an Immunization Registry and a Communicable Disease Registry, using HL7 messaging standards. Our EHR-PH system prototype can be considered a distributed EHR-based RHIE/RHIO model - a principal element for a potential technical architecture for a NHIN.