Association Between Social Determinants of Health, COVID-19 Stressors, and Mental Health Among New York Residents Early in the Pandemic.

OBJECTIVE: The COVID-19 pandemic is a disaster event. Exposure to stressors during and after disaster events is associated with negative mental health symptoms. To inform targeted COVID-19 recovery efforts, data are needed to understand which stressors play a key role in this relationship. METHODS: Cross-sectional survey data (demographics, impacts of COVID-19, social determinants of health, depression, and anxiety) were collected online from adults living in New York state between May and June 2020. Differences in the proportion of stressors (COVID-19 and social determinants) experienced by race/ethnicity were assessed using chi-square analyses. Logistic regression was used to assess which factors were associated with increased odds of depression and anxiety. RESULTS: A majority (n = 258, 62.2%) of the 415 respondents reported being directly impacted by the pandemic. Non-white respondents reported a significantly larger proportion of stressors compared to white respondents. Under half of respondents reported depression (n = 171, 41.2%) and anxiety (n = 164, 39.5%). Healthcare and food concerns were associated with increased odds of depression and anxiety, and economic concerns were associated with increased odds of anxiety. CONCLUSIONS: Findings underscore the need to respond to the COVID-19 mental health crisis by addressing social determinants of health.

Population-level effects of Hurricane Sandy on adolescent health.

BACKGROUND: Disasters are increasing in frequency and intensity due to climate change. Youth are the largest and most vulnerable group exposed to disasters. More evidence is needed regarding how youth mental health and health behaviors vary based on disaster exposure, how mental health influences health behaviors, and how diverse groups of youth may be differentially affected. METHODS: Using data from the Youth Risk Behavior Survey and Federal Emergency Management Agency, we examined the impact of Hurricane Sandy (2012) on mental health (sadness, suicidality) and health behaviors (substance use, physical activity, screen time, sexual behaviors) of 240,365 youth. Difference-in-differences regression analyses evaluated pre-disaster (2005-2011) and post-disaster (2013-2019) changes. RESULTS: There were 83,442 (34.7 %) adolescents (51.2 % female, 18.1 % non-Hispanic White) located in 6 districts exposed to Hurricane Sandy and 156,923 (65.3 %) adolescents located in 13 non-exposed districts. Exposure was associated with differences in substance use, physical (in)activity, and risky sexual behaviors, but not mental health outcomes. Mental health did not moderate the association between disaster exposure and health behaviors. Hispanic adolescents and those identifying as Other races/ethnicities were most vulnerable to post-disaster negative health outcomes. LIMITATIONS: Study limitations include questionnaire design, cross-sectional data, sampling, and possible response biases. CONCLUSIONS: Findings provide critical information about youth mental health and health behaviors following disasters, as well as how youth may differ in their responses. Findings provide guidance for early identification and resource allocation for youth at higher risk for post-disaster health issues.

Parental Influence on Child Mental Health Post-Hurricane Harvey.

Purpose: Many children who face natural disasters experience significant mental health consequences. Parents play a prominent role in the likelihood of child mental health outcomes after a weather-related disaster. This study aimed to examine the relationship between parent risk factors and children's psychological well-being post Hurricane Harvey. Methods: Parents (n = 140) completed a survey that measured hurricane exposure, parental depression and anxiety, parenting behaviors, and assistance given and received during or after Hurricane Harvey. Additionally, parents were asked to complete questionnaires assessing one of their children's post-disaster psychosocial functioning and distress. Results: Results indicated that heightened parent anxiety was significantly associated with an increased risk for emotional symptoms, conduct problems, and hyperactivity-inattention symptoms in children. Additionally, inconsistency in parental discipline was significantly associated with an increased risk of child conduct problems. Further, higher numbers of assistance types received by parents-a proxy indicator of resource loss-was associated with higher child emotional distress scores. Conclusions: Broader systems-level interventions that address parents' physical and emotional needs may help mitigate maladaptive reactions in children and facilitate greater post-disaster psychosocial adjustment.

The mediating role of self-regulation on the link between child maltreatment and later substance use among Latinx youth.

BACKGROUND: Children who experience maltreatment are at heightened risk for substance use initiation and mental health disorders later in life. Few studies have assessed the relationship between child maltreatment and substance use among Latinx youth. OBJECTIVE: The current study assessed the potential mediating effect of three aspects of self-regulation (emotional, behavioral, and cognitive) on the association between child maltreatment and substance use and examined whether effects varied depending on maltreatment type and severity. PARTICIPANTS AND SETTING: This study involved a random sample of 504 Latinx youth (52 % girls, 48 % boys) between the ages of 10-12 at the start of the study. METHODS: Study hypotheses were tested through structural equation modeling and bootstrapped random errors using the R programming language. RESULTS: Our results indicated that higher levels of child maltreatment predicted higher levels of later substance use, as mediated by emotional and behavioral dysregulation (ß = 0.09, p < 0.01), but not cognitive regulation. When separating maltreatment by subtype, we found the mediating effect was present for abuse (ß = 0.09, p < 0.01), but not neglect. CONCLUSIONS: Findings contribute to our understanding of potential causal mechanisms for the association between child maltreatment and substance use for Latinx youth.

Screening Infants Through Adolescents for Social/Emotional/Behavioral Problems in a Pediatric Network.

OBJECTIVE: To assess changes in screening completion in a diverse, 7-clinic network after making annual screening for social/emotional/behavioral (SEB) problems the standard of care for all infant through late adolescent-aged patients and rolling out a fully automated screening system tied to the electronic medical record and patient portal. METHODS: In 2017, the Massachusetts General Hospital made SEB screening using the age-appropriate version of the Pediatric Symptom Checklist the standard of care in its pediatric clinics for all patients aged 2.0 months to 17.9 years. Billing records identified all well-child visits between January 1, 2016 and December 31, 2019. For each visit, claims were searched for billing for an SEB screen and the electronic data warehouse was queried for an electronically administered screen. A random sample of charts was reviewed for other evidence of screening. Chi-square analyses and generalized estimating equations assessed differences in screening over time and across demographic groups. RESULTS: Screening completion (billing and/or electronic) significantly increased from 2016 (37.2%) through 2019 (2017 [46.2%] vs 2018 [66.8%] vs 2019 [70.9%]; χ2 (3) =112652.33, P < .001), with an even higher prevalence found after chart reviews. Most clinics achieved screening levels above 90% by the end of 2019. Differences among demographic groups were small and dependent on whether data were aggregated at the clinic or system level. CONCLUSIONS: Following adoption of a best-practice policy and implementation of an electronic system, SEB screening increased in all age groups and clinics. Findings demonstrate that the AAP recommendation for routine psychosocial assessment is feasible and sustainable.

Risk Factors for Intimate Partner Violence in the Context of Disasters: A Systematic Review.

Women are at increased risk for experiencing intimate partner violence (IPV) in the context of disasters. However, the factors that increase this risk are not well understood. The purpose of the current study was to systematically review the literature on IPV in the context of disasters. The first aim was to identify risk factors predicting women's exposure to IPV. The second aim was to identify disaster-specific risk factors for IPV. The third aim was to construct a social ecological framework of risk factors for IPV in disasters at the individual, relationship/household, community, and structural levels. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA; Moher et al., 2009). Articles were identified using keywords in seven ProQuest databases. Of the 67 articles identified for full-text review, 24 were eligible for inclusion. Studies were evaluated based on critical appraisal of methodology using an adapted version of the Mixed Methods Appraisals Tool (MMAT; Hong et al., 2018). Findings suggest that disasters give rise to unique risk factors across social ecologies which interact with pre-existing characteristics of social vulnerability to increase women's risk of IPV. Findings inform violence prevention strategies within the context of disaster response and therefore have implications for research, policy, and practice.

Identifying and responding to depression in adolescents in primary care: A quality improvement response.

The American Academy of Pediatrics (AAP) recommends adolescent depression screening and subsequent follow-up for those scoring at-risk. The current study assessed the outcomes of a Quality Improvement (QI) project that implemented these guidelines during annual well-child visits in a network of pediatric practices. This project used a two-stage screening process. First, adolescents were screened with the Pediatric Symptom Checklist (PSC-17). Second, adolescents who screened at-risk on the PSC-17 were asked to complete the Patient Health Questionnaire (PHQ-9). QI-participating providers received training on how to categorize the severity of their patient's depression based on PHQ-9 cut-off scores and clinical interview, and to implement and document appropriate options for follow-up. Patients in the QI group were significantly more likely to be screened with both the PSC-17 (93.8% vs. 89.1%, p < .001) and the PHQ-9 (54.8% vs. 16.4%, p < .001) compared to those in the non-QI group. Of the 80 adolescents in the QI group at-risk on the PSC-17 and with a completed PHQ-9, 65 (81.3%) received at least one type of referral for mental health, ranging from behavioral health services to lifestyle interventions. Findings support the feasibility of adolescent depression screening and referrals within pediatric primary care.

Earthquake exposure, adverse childhood experiences, and psychosocial functioning in Chilean children: A longitudinal study.

The impact of an 8.8 magnitude Chilean earthquake on elementary school students' psychosocial functioning was assessed along with exposure to adverse childhood experiences (ACEs). Skills for Life, a national school-based mental health program in Chile, routinely assesses first- and third-grade students' psychosocial functioning and classroom adaptation. Students (N = 19,627) were screened before (2009) and after (2011) the 2010 earthquake with parent- and teacher-report measures and with a parent-report of four ACEs (family psychopathology, child chronic illness, family social isolation, father absence). Earthquake exposure was categorized as mild, moderate, or severe for Chile's 15 regions. Multilevel models analyzed the unadjusted and adjusted impacts of earthquake exposure and ACEs on functioning while clustering for school- and district-level effects. In covariate-adjusted models, earthquake exposure and three ACEs were significantly associated with worsened psychosocial functioning; earthquake exposure and all four ACEs were significantly associated with worsened classroom adaptation. New family psychopathology, B = 1.90, p < .001; chronic illness, B = 2.25, p < .001; and severe earthquake impact, B = 1.29, p < .001, held the strongest negative effects on psychosocial well-being. Moderate, B = 3.04, p = .011, and severe earthquake exposure, B = 2.53, p = .047, and new family psychopathology, B = 1.99, p < .001, were associated with the worst classroom functioning 1-year postdisaster. Findings suggest that both exogenous and home-based stressors can have significant consequences for children's psychosocial functioning and classroom adaptation, and routine screening helps quantify how individual students are affected by chronic versus acute stressors.

Suicidal Ideation in Adolescents: Understanding Results from Screening with the PHQ-9M and the PSC-17P.

OBJECTIVE: The objective of the study was to help pediatricians understand and respond to suicidal ideation (SI) in adolescents based on data from 2 widely used screening measures that assessed SI and other psychosocial vulnerabilities in a large, national sample. METHODS: Adolescents (ages 11-17 years) completed the Patient Health Questionnaire Modified for Teenagers (PHQ-9M) using the Comprehensive Health and Decision Information System software before their well-child visits. Question 9 asks about past 2-week SI. Their parents filled out the Pediatric Symptom Checklist (PSC-17P), which screens for a broad range of psychosocial problems. Chi-square analyses and one-way analysis of variances assessed the relationship between SI and psychosocial problems. RESULTS: Among 5411 adolescents, 266 (4.9%) reported SI at least several days in the past 2 weeks. Among adolescents with SI, 187 (70.3%) reported moderate to very severe depression on the PHQ-9M (≥10), 68.1% were at risk on at least 1 PSC-17P problem subscale, 59.7% on the PSC-17P internalizing scale, 42.9% on PSC-17P overall, 20.6% on PSC-17P externalizing, and 18.5% on PSC-17P attention. Within the subsample endorsing SI nearly all days, 35.7% had a former suicide attempt. CONCLUSION: The PHQ-9M identifies a clinically heterogeneous subset of approximately 5% of adolescents who report occasional to frequent SI. The PSC-17P corroborates their high degree of overall risk and offers additional information that can help pediatricians assess clinical severity and range of psychosocial problems. Given our limited knowledge of how to predict and prevent an individual adolescent's suicide, the focus of screening should be to identify and help the subset of patients with chronic psychosocial vulnerability of any type.

Evaluating Burn Recovery Outcomes in Children With Neurodevelopmental Symptoms.

Neurodevelopmental symptoms (NS) including attention and behavioral problems, developmental delays, intellectual disabilities, and learning problems are prevalent in children with burn injuries. The presence of NS may predispose children to poorer burn injury recovery outcomes compared to children without these symptoms (non-NS). The Multicenter Benchmarking Study (MCBS) monitored recovery outcomes in children with burn injuries in real time using the Burn Outcomes Questionnaire (BOQ). The objective of this study was to retrospectively assess the long-term burn recovery outcomes in NS patients vs non-NS patients from the MCBS population. This study assessed parent-reported BOQ outcomes in a sample of 563 patients aged 5 to 18 years who were admitted for burn injuries to a pediatric burn center. A subsample of patients had reported NS (n = 181). Analyses compared BOQ outcomes within the NS subsample and the non-NS subsample (n = 382) across three longitudinal points postdischarge. The prevalence rate of NS was 32.1% in the full sample. Findings revealed statistically significant improvement in the recovery curves in all five BOQ subscales for the non-NS group and all subscales except for Compliance for the NS group across all longitudinal points. When compared to non-NS patients, NS patients had significantly poorer burn recovery outcomes on the Satisfaction and Compliance subscales. Although it is important to educate all clinicians, parents, and children on burn prevention efforts, targeted education is necessary for children with NS because they may be at greater risk for burn injury as well as worse recovery outcomes.

Beyond Initial Screening: One-Year Follow-up of Adolescents with Internalizing Problems on the Pediatric Symptom Checklist.

OBJECTIVE: Screening for adolescent depression is a quality indicator for pediatric care, and the parent-completed, 17-item Pediatric Symptom Checklist's internalizing (PSC-17P-INT) subscale has been validated for this purpose. The current study assessed the feasibility of PSC-17P-INT screening, the prevalence of risk on 2 consecutive PSC-17P-INTs, and rates of behavioral health (BH) service use before and after screening. METHODS: The parent-report PSC-17 was completed on tablet devices before well-child visits (WCVs) with results instantaneously available to clinicians in the electronic health record. Billing data were used to identify adolescents with 2 consecutive WCVs and possible BH service utilization 6 months before and after their first screen. RESULTS: In 2017, 1,068 adolescents (12-17 years old) were seen for a WCV, and 637 (59.6%) of them had one in 2018. Most (93.9%; N = 604) completed a PSC at both visits. Patients who scored positively on their first PSC-17P-INT were about 9 times more likely to receive subsequent BH services than patients who screened negative (24.3% vs 2.6%, χ2 = 59.65, p < 0.001). However, risk prevalence increased from the first (11.6%) to the second (14.9%) screen, and only 37.1% of at-risk patients remitted. CONCLUSION: The current study demonstrated that screening adolescents for depression using the PSC-17P-INT was feasible and associated with a significant increase in BH treatment rates. The study also demonstrated that the PSC could be used to track adolescents at risk for depression, found that most youth who screened positive remained at risk 1 year later, and supported recent quality guidelines calling for annual depression screening and follow-up for adolescents with depression.

Recognizing Adolescent Depression with Parent- and Youth-Report Screens in Pediatric Primary Care.

OBJECTIVES: To compare the use of the parent-report Pediatric Symptom Checklist (PSC-17P) and youth-report Patient Health Questionnaire-9 Modified for Teens (PHQ-9M) in compliance with recent quality standards for adolescent depression screening. STUDY DESIGN: Parents of 5411 pediatric outpatients (11.0-17.9 years old) completed the PSC-17P, which contains scales that assign categorical risk for overall (PSC-17P-OVR), internalizing (PSC-17P-INT), externalizing (PSC-17P-EXT), and attention (PSC-17P-ATT) problems. Adolescents completed the PHQ-9M, which assesses depressive symptoms. Both forms were completed online within 24 hours of each other before pediatric well-child visits. RESULTS: A total of 9.9% of patients (n = 535) were at risk on the PSC-17P-OVR, 14.3% (n = 775) were at risk on the PSC-17P-INT, and 17.0% (n = 992) were at risk on either or both scales (PSC-17P-OVR and/or PSC-17P-INT). Using the PHQ-9M cut-off score of 10 (moderate-very severe depression), an additional 2.4% (n = 131) were classified as at risk, with 66.8% (n = 263) of all PHQ-9M positives (n = 394) also coded as at risk by the PSC-17P-OVR and/or PSC-17P-INT scales. Using a PHQ-9M cut-off score of 15 (severe-very severe depression), only 29 patients (21.8% of the PHQ-9M positives) not identified by the PSC-17P-OVR and/or PSC-17P-INT were classified as being at risk. CONCLUSIONS: The combined PSC-17P-OVR and/or PSC-17P-INT scales identified 17% of adolescents as at risk for depression, including about two-thirds to three-quarters of adolescents classified as at risk on the PHQ-9M. These findings support using the PSC-17P to meet quality standards for depression as well as overall screening in pediatrics. Primary care clinicians can add the PHQ-9M to identify additional adolescents who may self-report depressive symptoms.

Appearance Concerns, Psychosocial Outcomes, and the Feasibility of Implementing an Online Intervention for Adolescents Receiving Outpatient Burn Care.

The current study assessed the prevalence of appearance concerns, psychosocial difficulty, and use of an appearance-focused social and psychological support resource (Young Person's Face IT; YPF) within a population of teens (12-17 year-olds) receiving outpatient burn care with the goal to assess the feasibility of routine use of the resource in outpatient burn care. The study sample included 78 patients ages 12 to 17 receiving outpatient care for burns at one hospital. Appearance concerns were measured via the Burn Outcomes Questionnaire Appearance Subscale, the Appearance Subscale of the Body Esteem Scale for Adolescents, and a 2-part question which asked participants directly about appearance concerns related to the burn injury. A large majority (70.0%) of study participants reported appearance concerns on at least one appearance measure and girls reported more burn-related appearance concerns compared with boys. Psychosocial difficulty was measured via the Pediatric Symptom Checklist-17 (PSC-17) and measures of social functioning were collected and compared within the sample by burn size, burn location, sex, and appearance concerns. Internalizing symptoms were prevalent on the PSC-17 (18.6% risk) and decreased self-worth and increased social anxiety symptoms were significantly associated with having appearance concerns. Although interest in YPF was high (78.3%), actual use of the resource among those who signed up to pilot it (n = 46 participants) was low (19.4% use). Results indicate that there is a need for and interest in appearance-focused social anxiety resources for adolescents with burn injuries such as YPF, but more research is needed to understand its feasibility in clinical practice.

Implementation of an Electronic Approach to Psychosocial Screening in a Network of Pediatric Practices.

OBJECTIVE: A network of 18 pediatric practice locations serving predominantly commercially insured patients implemented the electronic administration of the Pediatric Symptom Checklist-17 parent-report (PSC-17P) for all 5.50- to 17.99-year-old children seen for well child visits (WCVs) and wrote up the results as a quality improvement project. The current study investigated this screening over 2 years to assess its implementation and risk rates over time. METHODS: Parents completed the PSC-17P electronically before the visit and the scored data were immediately available in the patient's chart. Using billing and screening data, the study tracked rates of overall and positive screening during the first-year baseline (4 months) and full implementation phases of the project in the first (8 months) and second (12 months) year. RESULTS: A total of 35,237 patients completed a WCV in the first year. There was a significant improvement in PSC-17P screening rates from the first-year baseline (26.3%) to full implementation (89.3%; P < .001) phases. In the second year, a total of 40,969 patients completed a WCV and 77.9% (n = 31,901) were screened, including 18,024 patients with screens in both years. PSC-17P screening rates varied significantly across the 18 locations and rates of PSC-17P risk differed significantly by practice, insurance type, sex, and age. CONCLUSIONS: The current study demonstrated the feasibility of routine psychosocial screening over 2 years using the electronically administered PSC-17P in a network of pediatric practices. This study also corroborated past reports that PSC-17 risk rates differed significantly by insurance type (Medicaid vs commercial), sex, and age group.

How an Electronic Medical Record System Facilitates and Demonstrates Effective Psychosocial Screening in Pediatric Primary Care.

Using questionnaires, administrative claims, and chart review data, the current study explored the impact of using an electronic medical record system to administer, score, and store the Pediatric Symptom Checklist (PSC-17) during annual pediatric well-child visits. Within a sample of 1773 Medicaid-insured outpatients, the electronic system demonstrated that 90.5% of cases completed a PSC-17 screen electronically, billing codes indicating a screen was administered agreed with the existence of a questionnaire in the chart in 98.8% of cases, the classification of risk based on PSC-17 scores agreed with the classification of risk based on the Current Procedural Terminology code modifiers in 72.9% of cases, and 90.0% of clinicians' progress notes mentioned PSC-17 score in treatment planning. Using an electronic approach to psychosocial screening in pediatrics facilitated the use of screening information gathered during the clinical visit and allowed for enhanced tracking of outcomes and quality monitoring.

Usefulness of a Novel System for Feedback of Patient-Reported Outcome Measures in Children Recovering From Burns.

The Burn Outcomes Questionnaire for children ages 5-18 years (BOQ5-18) is a widely used, reliable, and valid parent-reported outcome measure designed to assess children's recovery from burn injuries in 12 physical and psychosocial domains. This study evaluated the feasibility, acceptability, and usefulness of a feedback system that delivered BOQ and Pediatric Symptom Checklist (PSC-17; a widely used measure of psychosocial functioning) results to burn care clinicians prior to an outpatient appointment or a postoperative surgical encounter. The BOQ and the PSC-17 were administered to the parents of 147 children receiving outpatient or surgical care in two pediatric burn hospitals. Clinician and parent perceptions of the feedback system were evaluated using debriefing questionnaires. Over half of all patients were at-risk on at least one BOQ subscale, and risk on three or more BOQ domains was significantly associated with a higher likelihood of poor psychological scores on the PSC-17 (P < .001). Significant differences in BOQ scores were found between the two hospital sites on four BOQ subscales, three related to physical ability and one to psychosocial well-being. Parent ratings of the feedback system were positive, with 90% of parents in both settings agreeing that the BOQ tablet experience was easy and helpful. Clinician attitudes differed across the two settings with more positive clinician ratings of the system in the outpatient setting (P < .001). Clinician interviews revealed that the data was especially useful in bringing to light psychosocial aspects of functioning relevant to long-term recovery from burn injuries.

Development of the social brain from age three to twelve years.

Human adults recruit distinct networks of brain regions to think about the bodies and minds of others. This study characterizes the development of these networks, and tests for relationships between neural development and behavioral changes in reasoning about others' minds ('theory of mind', ToM). A large sample of children (n = 122, 3-12 years), and adults (n = 33), watched a short movie while undergoing fMRI. The movie highlights the characters' bodily sensations (often pain) and mental states (beliefs, desires, emotions), and is a feasible experiment for young children. Here we report three main findings: (1) ToM and pain networks are functionally distinct by age 3 years, (2) functional specialization increases throughout childhood, and (3) functional maturity of each network is related to increasingly anti-correlated responses between the networks. Furthermore, the most studied milestone in ToM development, passing explicit false-belief tasks, does not correspond to discontinuities in the development of the social brain.