Family Engagement in Services During COVID-19: A Mixed-Methods Study of Caregiver and Staff Perspectives.

INTRODUCTION: We examined changes in family engagement before versus during the pandemic in pediatric and family services and perceived facilitators and barriers to family engagement. METHOD: We employed a mixed-methods assessment of staff and caregiver perspectives related to pediatric and family medicine clinics and family resource centers in rural northern New England. We used narrative synthesis to analyze qualitative interviews (n = 29) and descriptive statistics for quantitative surveys (n = 108). RESULTS: Staff felt they were not doing as well at engaging families during versus prepandemic, identifying numerous facilitators and barriers. We found differences in resources used by families before versus during the pandemic. We identified discordant perspectives between caregivers and staff regarding how well clinics and centers identified and responded to family needs. DISCUSSION: Leaders in pediatrics, advanced practice nursing, and related fields can draw on our findings to decide what services and modalities they provide for postpandemic.

Difficulty Obtaining Behavioral Health Services for Children: A National Survey of Multiphysician Practices.

PURPOSE: In the United States, primary care practices rely on scarce resources to deliver evidence-based care for children with behavioral health disorders such as depression, anxiety, other mental illness, or substance use disorders. We estimated the proportion of practices that have difficulty accessing these resources and whether practices owned by a health system or participating in Medicaid accountable care organizations (ACOs) report less difficulty. METHODS: This national cross-sectional study examined how difficult it is for practices to obtain pediatric (1) medication advice, (2) evidence-based psychotherapy, and (3) family-based therapy. We used the National Survey of Healthcare Organizations and Systems 2017-2018 (46.9% response rate), which sampled multiphysician primary and multispecialty care practices including 1,410 practices that care for children. We characterized practices' experience as "difficult" relative to "not at all difficult" using a 4-point ordinal scale. We used mixed-effects generalized linear models to estimate differences comparing system-owned vs independent practices and Medicaid ACO participants vs nonparticipants, adjusting for practice attributes. RESULTS: More than 85% of practices found it difficult to obtain help with evidence-based elements of pediatric behavioral health care. Adjusting for practice attributes, the percent experiencing difficulty was similar between system-owned and independent practices but was less for Medicaid ACO participants for medication advice (81% vs 89%; P = .021) and evidence-based psychotherapy (81% vs 90%; P = .006); differences were not significant for family-based treatment (85% vs 91%; P = .107). CONCLUSIONS: Most multiphysician practices struggle to obtain advice and services for child behavioral health needs, which are increasing nationally. Future studies should investigate the source of observed associations.

Psychotropic Polypharmacy and Antipsychotics in Children: A Survey of Caregiver's Perspectives.

OBJECTIVE: We examined caregiver's knowledge, attitudes, and concerns about their child's psychotropic medication regimen and the potential side effects, describe how they seek information regarding treatment, and ascertain their perspectives toward deprescribing. METHODS: We surveyed 48 caregivers of children 6-17 years old treated with two or more psychotropic medications or an antipsychotic medication, analyzing outcomes using descriptive statistics. RESULTS: Almost all (N = 44, 92%) participants reported feeling very knowledgeable about why medications were prescribed, but only one-third (N = 16, 33%) reported feeling very knowledgeable about potential problems with long-term use or polypharmacy. Half of respondents (N = 24, 50%) reported asking their provider about reducing/stopping medications due to concerns about harmful effects, and nearly half (N = 20, 42%) reported stopping medications earlier than recommended. CONCLUSIONS: Interventions to engage caregivers in shared decision-making about complex medication regimens and to support prescribers to safely deprescribe psychotropic medications are needed to address caregivers' concerns regarding psychotropic medication use.

Difficult binds: A systematic review of facilitators and barriers to treatment among mothers with substance use disorders.

BACKGROUND: The United States and Canada have observed sharp increases in substance use disorder among women of child-bearing or child-rearing age. Substance use disorder can have deleterious effects on children, families, and communities. Many evidence-based treatments exist, but engaging mothers in treatment is difficult. No recent review is available to help systems and providers understand the facilitators of and barriers to treatment for mothers. OBJECTIVE: To systematically identify facilitators and barriers to substance use and mental health treatment for mothers with substance use disorder who are pregnant or parenting young children in the United States and Canada. METHODS: We systematically searched the literature using five online databases and performed a gray literature search. We included studies published in the past two decades focused on parent or provider perspectives. RESULTS: Our search identified 23 high-quality papers. The majority of papers qualitatively examined the perspectives of treatment-seeking pregnant women and mothers diverse in race/ethnicity, region, and treatment settings. Our synthesis of findings revealed the compelling and complex centrality of motherhood, which served as both a facilitator and barrier. Motherhood often interacted with relational (e.g., perceiving stigma vs. support from providers, family, friends, partners) and structural (e.g., time commitments, childcare) factors to both hinder and help engagement in treatment. CONCLUSIONS: Our findings can help policy-makers and practitioners make tangible improvements to the financing and delivery of substance use treatment for mothers. Our review points to specific areas for future research, including an examination of the relationships between various structural factors and treatment outcomes.

Deprescribing psychotropic medications in children: results of a national qualitative study.

BACKGROUND AND OBJECTIVE: Prescriptions for psychotropic medications to children have risen dramatically in recent years despite few regulatory approvals and growing concerns about side effects. Government policy and numerous programmes are attempting to curb this problem. However, the perspectives of practising clinicians have not been explored. To characterise the perspectives and experiences of paediatric primary care clinicians and mental health specialists regarding overprescribing and deprescribing psychotropic medications in children. METHODS: We conducted 24 semistructured interviews with clinicians representing diverse geographic regions and practice settings in the USA. Interview questions focused on clinician perspectives surrounding overprescribing and experiences with deprescribing. We transcribed audio files verbatim and verified them for accuracy. We analysed transcripts using a grounded theory approach, identifying emergent themes and developing a conceptual model using axial coding. RESULTS: Analysis yielded themes within four domains: social and clinical contextual factors contributing to overprescribing, opportunities for deprescribing, and facilitators and barriers to deprescribing in paediatric outpatient settings. Most participants recognised the problem of overprescribing, and they described complex clinical and social contextual factors, as well as internal and external pressures, that contribute to overprescribing. Opportunities for deprescribing included identification of high-risk medications, routine reassessment of medication needs and recognition of the broader social needs of vulnerable children. Facilitators and barriers to deprescribing were both internal (eg, providing psychoeducation to families) and external (eg, parent and child preferences) to clinicians. CONCLUSION: Our findings highlight a discrepancy between clinicians' concerns about overprescribing and a lack of resources to support deprescribing in outpatient paediatric settings. To successfully initiate deprescribing, clinicians will need practical tools and organisational supports, as well as social resources for vulnerable families.

State-wide implementation and clinical outcomes associated with evidence-based psychotherapies for traumatized youth.

BACKGROUND: Highly efficacious evidence-based psychotherapies (EBPs) exist for children and youth exposed to trauma, yet very few who need the treatments in the community receive them. Research within real-world settings is needed to better understand what is required to translate treatments into the community. PURPOSE: We aimed to examine the implementation and clinical outcomes of a multiyear project installing 2 EBPs for trauma-exposed youth in community agencies across the state of New Hampshire. METHOD: We invited clinicians to 2 days of training plus weekly group consultation calls for 9 or 12 months in Trauma-Focused Cognitive Behavioral Therapy or Child Parent Psychotherapy. Implementation metrics included clinician adherence to training, consultation, and treatment delivery expectations. Clinical outcomes included treatment dropout, as well as posttraumatic stress (PTS) symptoms. RESULTS: Of the 292 clinicians meeting eligibility and agreeing to participate, 243 (83%) attended trainings, 168 (58%) began consultation calls, and 70 (24%) adhered to implementation expectations by attending 80% of consultation calls and beginning the treatment with 2 youths. According to (completing) clinicians' reports, of the 363 youths tracked over the 9 to 12 month consultation periods, 47% dropped out of treatment and 44% were ongoing. Pre-post PTS scores (n = 82) demonstrated clinically meaningful reductions for 59% of youth. CONCLUSIONS: Clinical outcomes were robust for those who completed treatment, rivaling those of highly controlled trials. However, implementation outcomes indicate an uphill battle in reaching youth who need the treatment. Implementation outcomes were mixed compared with those of more resource-intensive implementation models. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Children's behavioral health needs and satisfaction and commitment of foster and adoptive parents: Do trauma-informed services make a difference?

OBJECTIVE: Caring for children in foster or adoptive care with behavioral health needs can severely stress parents, contributing to adverse outcomes for children and families. Trauma-informed services from the child welfare and mental health sectors may help prevent poor outcomes by helping children and parents identify and understand trauma and its impact on children's behavioral health and receive effective treatment. To help understand the role of trauma-informed services for the child welfare population, we examined whether trauma-informed child welfare and mental health services moderated the relationship between children's behavioral health needs and parent satisfaction and commitment. METHOD: The researchers analyzed data from a cross-sectional statewide survey of foster and adoptive parents (n = 512 respondents, 42% of 1,206 contacted) from one state. RESULTS: Foster (but not adoptive) parent ratings of trauma-informed mental health services significantly moderated the relationship between children's behavioral health needs and foster and adoptive parent satisfaction and commitment. As ratings of trauma-informed mental health services increased, the association between child behavioral health needs and parent satisfaction and commitment became nonsignificant, suggesting a buffering effect. Trauma-informed child welfare services did not moderate the relationship for foster or adoptive parents. CONCLUSIONS: Leaders and policymakers are urged to promote trauma-informed mental health services for children involved with child welfare to potentially buffer foster parents against lower parenting satisfaction and commitment. More research is needed to replicate and expand on these findings and to examine the effectiveness of trauma-informed services on other relevant child and family outcomes. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Effectiveness of a Trauma-Informed Care Initiative in a State Child Welfare System: A Randomized Study.

Trauma-informed care (TIC) initiatives in state child welfare agencies are receiving more attention, but little empirical evidence exists as to their efficacy. The purpose of this study was to assess changes in self-reported practices and perceptions of child welfare staff involved in a multifaceted, statewide TIC intervention. Ten child welfare offices were matched and randomized to an early or delayed cohort. Staff were surveyed at Time 1 prior to any intervention, Time 2 postintervention for Cohort 1, and Time 3 postintervention for Cohort 2. The survey covered six domains: trauma screening, case planning, mental health and family involvement, progress monitoring, collaboration, and perceptions of the state's overall system performance. Linear mixed modeling assessed the effect of the intervention. Cohort by time interaction was significant for three intervention targets. We demonstrate, using a rigorous study design, the mixed results of a multimodal intervention to improve trauma-informed attitudes, practices, and system performance. TIC initiatives must account for complex, dynamic contextual factors.

Psychotropic medications for highly vulnerable children.

INTRODUCTION: At least 20% of children in the U.S. are highly vulnerable because they lack healthcare and protection. Several factors produce vulnerability: trauma, disruptions of parenting, poverty, involvement in the juvenile justice and/or child welfare systems, residence in restrictive settings, and problems related to developmental disabilities. These children receive psychotropic medications at high rates, raising numerous concerns. AREAS COVERED: The authors begin this review with a description of the population of highly vulnerable children. They then follow this with a review of the effectiveness and side effects of psychotropic medications for their most common diagnoses, using the highest-quality systematic reviews identified by multiple database searches. EXPERT OPINION: Highly vulnerable children receive numerous psychotropic medications with high rates of polypharmacy, off-label use, and long-term use, typically in the absence of adjunctive psychosocial interventions. The current evidence contravenes these trends. Future studies of psychotropic medications in vulnerable children should include long-term effectiveness trials and polypharmacy in conjunction with evidence-based, family-centered, psychosocial treatments.

Foster and Adoptive Parent Perspectives on Needs and Services: a Mixed Methods Study.

Caring for children with complex needs severely stresses foster and adoptive parents, but few studies have examined their perspectives on needs and services. To examine parental views, the authors analyzed four focus groups (n = 27 participants) and one state-wide survey (n = 512 respondents, 42% of 1206 contacted) of foster and adoptive parents in one state. Results highlighted inadequate communication between providers and families, cultural and legal barriers, needs for parent training and preparation, the importance of several types of parent supports, and needs for specialized mental health treatment for the children. Surveyed parents identified children's behavior problems as their top challenge, and over half rated the availability of mental health providers who treat attachment and family as insufficient. The findings suggest specific areas in which state leaders could enhance training and supports for child welfare staff and foster and adoptive parents and improve mental health services for children in foster and adoptive care.

Supporting Shared Decision-making for Children's Complex Behavioral Problems: Development and User Testing of an Option Grid™ Decision Aid.

There is a lack of research to guide collaborative treatment decision-making for children who have complex behavioral problems, despite the extensive use of mental health services in this population. We developed and pilot-tested a one-page Option Grid™ patient decision aid to facilitate shared decision-making for these situations. An editorial team of parents, child psychiatrists, researchers, and other stakeholders developed the scope and structure of the decision aid. Researchers included information about a carefully chosen number of psychosocial and pharmacological treatment options, using descriptions based on the best available evidence. Using semi-structured qualitative interviews (n = 18), we conducted user testing with four parents and four clinical prescribers and field testing with four parents, four clinical prescribers, and two clinic administrators. The researchers coded and synthesized the interview responses using mixed inductive and deductive methods. Parents, clinicians, and administrators felt the Option Grid had significant value, although they reported that additional training and other support would be required in order to successfully implement the Option Grid and achieve shared decision-making in clinical practice.

Prescribing clinicians' perspectives on evidence-based psychotherapy for posttraumatic stress disorder.

Evidence-based psychotherapies (EBP) for Posttraumatic Stress Disorder are not utilized to their full extent within the Department of Veterans Affairs (VA). VA provides care to many persons with PTSD and has been in the forefront of clinical practice guidelines and EBP training and dissemination. Yet VA continues to find EBP implementation difficult. Veterans with PTSD often initially present to prescribing clinicians, who then help make care decisions. It is therefore critical that these clinicians correctly screen and triage appropriate mental health care. The purpose of this study was to assess VA prescribing clinicians' knowledge, perceptions, and referral behaviors related to EBPs for PTSD and to identify facilitators and barriers to implementing EBPs within VA. We conducted qualitative interviews with 26 VA prescribing clinicians. Limited access to EBPs was the most commonly noted barrier. The clinicians we interviewed also held specific beliefs and behaviors that may delay or deter EBPs. Strategies to improve utilization also emerged. Findings suggest the need for increased access to EBPs, training to optimize the role of prescribing clinicians in helping Veterans with PTSD make appropriate care decisions, and specific organizational changes to facilitate access and effective referral systems for EBPs.

Innovations in Practice: Dissemination and implementation of child-parent psychotherapy in rural public health agencies.

BACKGROUND: Early trauma exposure can have long-term negative health effects. Few young children receive evidence-based trauma treatment. This article explores the feasibility of implementing Child-Parent Psychotherapy (CPP), an evidence-based intervention, in rural public health agencies. METHOD: Twenty-three clinicians across four agencies were trained. Training outcomes and implementation barriers and facilitators were assessed. RESULTS: One hundred twelve client-caregiver dyads began the year-long treatment; 50% are currently enrolled or have completed treatment. Barriers and facilitators to implementation were identified. CONCLUSIONS: CPP is feasible to implement in rural community mental health agencies. Important lessons were learned related to planning, implementation, and sustainability.