Youth Mental Health Screening and Linkage to Care.

One Mind, in partnership with Meadows Mental Health Policy Institute, convened several virtual meetings of mental health researchers, clinicians, and other stakeholders in 2020 to identify first steps toward creating an initiative for early screening and linkage to care for youths (individuals in early adolescence through early adulthood, ages 10-24 years) with mental health difficulties, including serious mental illness, in the United States. This article synthesizes and builds on discussions from those meetings by outlining and recommending potential steps and considerations for the development and integration of a novel measurement-based screening process in youth-facing school and medical settings to increase early identification of mental health needs and linkage to evidence-based care. Meeting attendees agreed on an initiative incorporating a staged assessment process that includes a first-stage brief screener for several domains of psychopathology. Individuals who meet threshold criteria on the first-stage screener would then complete an interview, a second-stage in-depth screening, or both. Screening must be followed by recommendations and linkage to an appropriate level of evidence-based care based on acuity of symptoms endorsed during the staged assessment. Meeting attendees proposed steps and discussed additional considerations for creating the first nationwide initiative for screening and linkage to care, an initiative that could transform access of youths to mental health screening and care.

Multistage Adolescent Depression Screening: A Comparison of 11-Year-Olds to 12-Year-Olds.

INTRODUCTION: Adolescent depression screening is recommended starting at age 12 years, but younger children experience depression as well. Our objective was to determine whether screening for depression at age 11 years yields similar results to screening at age 12 years. METHODS: We conducted a retrospective chart review of 1000 11- and 12-year-olds in multiple pediatric offices of a large-group practice associated with a health maintenance organization in Southern California. All offices used a multistage depression screening process during well-child visits using the Patient Health Questionnaire for Adolescents, the global depression inquiry within a parent questionnaire, a chart-based review of mental health history, and brief patient/parent interview informed by the first 3 elements. RESULTS: The 11- and 12-year-old cohorts had similar completion rates for the Patient Health Questionnaire for Adolescents (99.2% vs 97.8%, P = 0.06), with similar mean total Patient Health Questionnaire for Adolescents scores (2.12 vs 2.22, P = 0.48). There was no significant difference for positive screenings determined by the pediatrician (12.0% vs 16.0%, P = 0.07), but parents of 12-year-olds were more likely have concerns for their child's mood (6.8% vs 10.5%, P = 0.04). There were similar percentages of referrals (6.2% vs 8.8%, P = 0.12), beneficial conversations related to depression and anxiety, (4.5% vs 4.8%, P = 0.85), and new mental health diagnoses (2.0% vs 2.3%, P = 0.79). DISCUSSION: The process, results, and outcomes of screenings are similar for 11- and 12-year-olds, with a tendency toward more positive findings in 12-year-olds. CONCLUSION: Multistage depression screening in 11-year-olds can be applied successfully in clinical practice, with most cases identifying youths without a prior mental health diagnosis.

Correlates of Patterns of Health Values of African Americans Living With HIV/AIDS: Implications for Advance Care Planning and HIV Palliative Care.

CONTEXT: Advance care planning rates remain low, especially among people who are HIV positive, disadvantaged, and African American. Although advance care planning can be a sensitive topic for clinicians and patients to discuss, health values clarification can be an important initial step. OBJECTIVES: The purpose of the study was to explore health values of African Americans living with HIV/AIDS and to examine correlates of these values. METHODS: Data were from the first 325 participants in the AFFIRM Care study, which enrolled adults living with HIV/AIDS in Baltimore, Maryland, who had histories of illicit drug use. Respondents were asked whether (yes/no) they thought any of six health states would be worse than death: severe unremitting pain, total dependency on others, irreversible coma, being on mechanical ventilation, nursing home residence, and severe dementia. Latent class analysis was used to group individuals by their pattern of responses, interpretable as preference for aggressive (life-sustaining) or nonaggressive (palliative) end-of-life care. Latent class regression analysis was used to examine associations between class membership and background, health status, and social variables. RESULTS: We found statistical support for a three-class latent class analysis model: 1) the nonaggressive treatment class, comprising 43% of cases, in which members perceived that every state was worse than death; 2) the aggressive treatment class, comprising 33% of cases, in which members perceived that none of the states was worse than death; and 3) the mixed class (24% of cases), in which members perceived that only four of the six states were worse than death. CONCLUSION: Three-quarters of participant response patterns had clear preferences for treatment decisions. Further research is needed to ensure inclusion of end-of-life scenarios relevant to this population.

The Impact of the Massachusetts Behavioral Health Child Screening Policy on Service Utilization.

OBJECTIVE: In 2008, Massachusetts Medicaid implemented a pediatric behavioral health (BH) screening mandate. This study conducted a population-level, longitudinal policy analysis to determine the impact of the policy on ambulatory, emergency, and inpatient BH care in comparison with use of these services in California, where no similar policy exists. METHODS: With Medicaid Analytic Extract (MAX) data, an interrupted time-series analysis with control series design was performed to assess changes in service utilization in the 18 months (January 2008-June 2009) after a BH screening policy was implemented in Massachusetts and to compare service utilization with California's. Outcomes included population rates of BH screening, BH-related outpatient visits, BH-related emergency department visits, BH-related hospitalizations, and psychotropic drug use. Medicaid-eligible children from January 1, 2006, to December 31, 2009, with at least ten months of Medicaid eligibility who were older than 4.5 years and younger than 18 years were included. RESULTS: Compared with rates in California, Massachusetts rates of BH screening and BH-related outpatient visits rose significantly after Massachusetts implemented its screening policy. BH screening rose about 13 per 1,000 youths per month during the first nine months, and BH-related outpatient visits rose to about 4.5 per 1,000 youths per month (p<.001). Although BH-related emergency department visits, hospitalization and psychotropic drug use increased, there was no difference between the states in rate of increase. CONCLUSIONS: The goal of BH screening is to identify previously unidentified children with BH issues and provide earlier treatment options. The short-term outcomes of the Massachusetts policy suggest that screening at preventive care visits led to more BH-related outpatient visits among vulnerable children.

Integrating mental health into adolescent annual visits: impact of previsit comprehensive screening on within-visit processes.

PURPOSE: To evaluate how a comprehensive, computerized, self-administered adolescent screener, the DartScreen, affects within-visit patient-doctor interactions such as data gathering, advice giving, counseling, and discussion of mental health issues. METHODS: Patient-doctor interaction was compared between visits without screening and those with the DartScreen completed before the visit. Teens, aged 15-19 years scheduled for an annual visit, were recruited at one urban and one rural pediatric primary care clinic. The doctor acted as his/her own control, first using his/her usual routine for five to six adolescent annual visits. Then, the DartScreen was introduced for five visits where at the beginning of the visit, the doctor received a summary report of the screening results. All visits were audio recorded and analyzed using the Roter interaction analysis system. Doctor and teen dialogue and topics discussed were compared between the two groups. RESULTS: Seven midcareer doctors and 72 adolescents participated; 37 visits without DartScreen and 35 with DartScreen were audio recorded. The Roter interaction analysis system defined medically related data gathering (mean, 36.8 vs. 32.7 statements; p = .03) and counseling (mean, 36.8 vs. 32.7 statements; p = .01) decreased with DartScreen; however, doctor responsiveness and engagement improved with DartScreen (mean, 4.8 vs. 5.1 statements; p = .00). Teens completing the DartScreen offered more psychosocial information (mean, 18.5 vs. 10.6 statements; p = .01), and mental health was discussed more after the DartScreen (mean, 93.7 vs. 43.5 statements; p = .03). Discussion of somatic and substance abuse topics did not change. Doctors reported that screening improved visit organization and efficiency. CONCLUSIONS: Use of the screener increased discussion of mental health but not at the expense of other adolescent health topics.

Behavioral health services following implementation of screening in Massachusetts Medicaid children.

OBJECTIVES: To determine the relationship of child behavioral health (BH) screening results to receipt of BH services in Massachusetts Medicaid (MassHealth) children. METHODS: After a court decision, Massachusetts primary care providers were mandated to conduct BH screening at well-child visits and use a Current Procedural Terminology code along with a modifier indicating whether a BH need was identified. Using MassHealth claims data, a cohort of continuously enrolled (July 2007-June 2010) children was constructed. The salient visit (first use of the modifier, screening code, or claim in fiscal year 2009) was considered a reference point to examine BH history and postscreening BH services. Bivariate and multivariate logistic regression analyses were performed to determine predictors of postscreening BH services. RESULTS: Of 261,160 children in the cohort, 45% (118,464) were screened and 37% had modifiers. Fifty-seven percent of children screening positive received postscreening BH services compared with 22% of children screening negative. However, only 30% of newly identified children received BH services. The strongest predictors of postscreening BH services for children without a BH history were being in foster care (odds ratio, 10.38; 95% confidence interval, 9.22-11.68) and having a positive modifier (odds ratio, 3.79; 95% confidence interval, 3.53-4.06). CONCLUSIONS: Previous BH history, a positive modifier, and foster care predicted postscreening BH services. Only one-third of newly identified children received services. Thus although screening is associated with an increase in BH recognition, it may be insufficient to improve care. Additional strategies may be needed to enhance engagement in BH services.

Universal mental health screening in pediatric primary care: a systematic review.

OBJECTIVE: Universal mental health screening in pediatric primary care is recommended, but studies report slow uptake and low rates of patient follow-through after referral to specialized services. This review examined possible explanations related to the process of screening, focusing on how parents and youth are engaged, and how providers evaluate and use screening results. METHOD: A narrative synthesis was developed after a systematic review of 3 databases (plus follow-up of citations, expert recommendations, and checks for multiple publications about the same study). Searching identified 1,188 titles, and of these, 186 full-text articles were reviewed. Two authors extracted data from 45 articles meeting inclusion criteria. RESULTS: Published studies report few details about how mental health screens were administered, including how clinicians explain their purpose or confidentiality, or whether help was provided for language, literacy, or disability problems. Although they were not addressed directly in the studies reviewed, uptake and detection rates appeared to vary with means of administration. Screening framed as universal, confidential, and intended to optimize attention to patient concerns increased acceptability. Studies said little about how providers were taught to explore screen results. Screening increased referrals, but many still followed negative screens, in some cases because of parent concerns apparently not reflected by screen results but possibly stemming from screen-prompted discussions. CONCLUSIONS: Little research has addressed the process of engaging patients in mental health screening in pediatric primary care or how clinicians can best use screening results. The literature does offer suggestions for better clinical practice and research that may lead to improvements in uptake and outcome.

Assessing the impact of a web-based comprehensive somatic and mental health screening tool in pediatric primary care.

OBJECTIVE: To evaluate how parents and physicians perceive the utility of a comprehensive, electronic previsit screener, and to assess its impact on the visit. METHODS: A mixed methods design was used. English-speaking parents were recruited from 3 primary care systems (urban MD and rural NY and VT) when they presented for a well-child visit with a child 4 to 10 years of age. Parents completed an electronic previsit screen, which included somatic concerns, health risks, and 4 mental health tools (SCARED5, PHQ-2, SDQ Impact, and PSC-17). Parents completed an exit survey, and a subset were interviewed. All primary care providers (PCPs) were interviewed. RESULTS: A total of 120 parents and 16 PCPs participated. The exit surveys showed that nearly 90% of parents agreed or strongly agreed that the screener was easy to use and maintained confidentiality. During interviews, parents noted that the screener helped with recall, validated concerns, reframed issues they thought might not be appropriate for primary care, and raised new questions. PCPs thought that the screener enabled them to normalize sensitive issues, and it permitted them to simultaneously focus and be comprehensive during the visit. Parents and PCPs agreed that the screener helped guide discussion, promoted in-depth exchange, and increased efficiency. Findings were consistent across quantitative and qualitative methods and between parents and PCPs. CONCLUSIONS: A comprehensive electronic previsit screening tool is an acceptable and practical strategy to facilitate well-child visits. It may help with problem identification as well as with setting agendas, engaging the family, and balancing attention between somatic and psychosocial concerns.

How to improve the mental health care of children and adolescents in Brazil: actions needed in the public sector / Como aprimorar a assistência à saúde mental de crianças e adolescentes brasileiros: ações recomendadas para o sistema público

INTRODUCTION: Child/adolescent mental health (CAMH) problems are associated with high burden and high costs across the patient's lifetime. Addressing mental health needs early on can be cost effective and improve the future quality of life. OBJECTIVE/METHODS: Analyzing most relevant papers databases and policies, this paper discusses how to best address current gaps in CAMH services and presents strategies for improving access to quality care using existing resources. RESULTS: The data suggest a notable scarcity of health services and providers to treat CAMH problems. Specialized services such as CAPSi (from Portuguese: Psychosocial Community Care Center for Children and Adolescents) are designed to assist severe cases; however, such services are insufficient in number and are unequally distributed. The majority of the population already has good access to primary care and further planning would allow them to become better equipped to address CAMH problems. Psychiatrists are scarce in the public health system, while psychologists and pediatricians are more available; but, additional specialized training in CAMH is recommended to optimize capabilities. Financial and career development incentives could be important drivers to motivate employment-seeking in the public health system. CONCLUSIONS: Although a long-term, comprehensive strategy addressing barriers to quality CAMH care is still necessary, implementation of these strategies could make.

INTRODUÇÃO: Problemas de saúde mental na infância/adolescência (SMIA) trazem diversos prejuízos e geram altos custos. A assistência precoce pode ser custo efetiva, levando a melhor qualidade de vida a longo prazo. OBJETIVOS/MÉTODO: Analisando os artigos mais relevantes, documentos do governo, base de dados e a política nacional, este artigo discute como melhor administrar a atual falta de serviços na área da SMIA e propõe estratégias para maximizar os serviços já existentes. RESULTADOS: Dados apontam evidente falta de serviços e de profissionais para tratar dos problemas de SMIA. Serviços especializados, como o CAPSi (Centro de Atenção Psicossocial Infanto-Juvenil) estão estruturados para assistir casos severos, mas são insuficientes e desigualmente distribuídos. A maioria da população já tem bom acesso às unidades básicas de saúde e um melhor planejamento ajudaria a prepará-las para melhor assistir indivíduos com problemas de SMIA. Psiquiatras são escassos no sistema público, enquanto psicólogos e pediatras estão mais disponíveis; para estes recomenda-se capacitação mais especializada em SMIA. Incentivos financeiros e de carreira motivariam profissionais a procurarem emprego no sistema público de saúde. CONCLUSÕES: Apesar de estratégias complexas e de longo prazo serem necessárias para lidar com as atuais barreiras no campo da SMIA, a implantação de certas propostas simples já poderiam trazer impacto imediato e positivo neste cenário.

How to improve the mental health care of children and adolescents in Brazil: actions needed in the public sector.

INTRODUCTION: Child/adolescent mental health (CAMH) problems are associated with high burden and high costs across the patient's lifetime. Addressing mental health needs early on can be cost effective and improve the future quality of life. OBJECTIVE/METHODS: Analyzing most relevant papers databases and policies, this paper discusses how to best address current gaps in CAMH services and presents strategies for improving access to quality care using existing resources. RESULTS: The data suggest a notable scarcity of health services and providers to treat CAMH problems. Specialized services such as CAPSi (from Portuguese: Psychosocial Community Care Center for Children and Adolescents) are designed to assist severe cases; however, such services are insufficient in number and are unequally distributed. The majority of the population already has good access to primary care and further planning would allow them to become better equipped to address CAMH problems. Psychiatrists are scarce in the public health system, while psychologists and pediatricians are more available; but, additional specialized training in CAMH is recommended to optimize capabilities. Financial and career development incentives could be important drivers to motivate employment-seeking in the public health system. CONCLUSIONS: Although a long-term, comprehensive strategy addressing barriers to quality CAMH care is still necessary, implementation of these strategies could make.

Medical residency: factors relating to "difficulty in helping" in the resident physician-patient relationship / Residência médica: fatores relacionados à "dificuldade para ajudar" na relação médico residente-paciente

CONTEXT AND OBJECTIVE: Previous studies have attempted to understand what leads physicians to label patients as 'difficult'. Understanding this process is particularly important for resident physicians, who are developing attitudes that may have long-term impact on their interactions with patients. The aim of this study was to distinguish between patients' self-rated emotional state (anxiety and depression) and residents' perceptions of that state as a predictor of patients being considered difficult. DESIGN AND SETTING: Cross-sectional survey conducted in the hospital of Universidade Federal de São Paulo (Unifesp). METHODS: The residents completed a sociodemographic questionnaire and rated their patients using the Hospital Anxiety and Depression Scale (HADS) and Difficulty in Helping the Patient Questionnaire (DTH). The patients completed HADS independently and were rated using the Karnofsky Performance Status scale. RESULTS: On average, the residents rated the patients as presenting little difficulty. The residents' ratings of difficulty presented an association with their ratings for patient depression (r = 0.35, P = 0.03) and anxiety (r = 0.46, P = 0.02), but not with patients' self-ratings for depression and anxiety. Residents from distant cities were more likely to rate patients as difficult to help than were residents from the city of the hospital (mean score of 1.93 versus 1.07; P = 0.04). CONCLUSIONS: Understanding what leads residents to label patients as having depression and anxiety problems may be a productive approach towards reducing perceived difficulty. Residents from distant cities may be more likely to find their patients difficult.

CONTEXTO E OBJETIVO: Estudos têm tentado compreender o que leva os médicos a rotularem pacientes como "difíceis". Entender este processo é particularmente importante para os médicos residentes, que estão desenvolvendo atitudes que podem ter impacto a longo prazo em suas interaç ões com pacientes. O objetivo deste estudo foi de distinguir entre o estado emocional (ansiedade e depressão) auto-avaliado pelos pacientes e a percepção dos residentes desse estado, como preditor de pacientes serem considerados difíceis. TIPO DE ESTUDO E LOCAL: Estudo transversal realizado no hospital da Universidade Federal de São Paulo (Unifesp). MÉTODOS: Os residentes responderam a um questionário sociodemográfico e pontuaram seus pacientes com a Hospital Anxiety and Depression Scale (HADS) e o Difficulty in Helping the Patient Questionnaire (DTH). Os pacientes completaram a HADS de forma independente e foram avaliados usando o Karnofsky Performance Status Scale. RESULTADOS: Em média, os residentes avaliaram seus pacientes como mobilizadores de pouca dificuldade. Os escores de dificuldade dos residentes apresentaram associação com os escores de depressão (r = 0.35, P = 0,03) e ansiedade (r = 0,46, P = 0,02) que atribuíram aos pacientes, mas não com os escores de ansiedade e depressão na auto-avaliação dos pacientes. Residentes provenientes de cidades distantes mostraram-se mais propensos a classificar os pacientes como difíceis de ajudar do que os residentes provenientes da mesma cidade do hospital (pontuação média de 1.93 versus 1.07, P = 0,04). CONCLUSÕES: Compreender o que leva os residentes a classificar pacientes como tendo problemas de ansiedade e depressão pode ser uma abordagem produtiva para reduzir a dificuldade percebida. Residentes de cidades distantes do local do hospital podem ser mais propensos a considerar seus pacientes como difíceis.

Screening to identify mental health problems in pediatric primary care: considerations for practice.

OBJECTIVE: Few pediatric primary care providers routinely use mental health screening tools, in part because they may have concerns about whether screening is useful and how it will affect their practice. This study examined the extent to which screening in primary care would increase the identification of mental health problems among a diverse population of children and youth. METHODS: Prior to the visit, the parents of 767 patients age 5 to 16 completed the Strengths and Difficulties Questionnaire to report their child's mental health symptoms and impairment. Without viewing the screening results, each child's provider (N = 53) completed a questionnaire to report whether the child or youth demonstrated a mental health problem. RESULTS: Compared with providers, the screen identified twice as many patients with moderate symptoms and nearly 28% more patients with high symptoms. Among patients with high symptoms, providers failed to identify a problem among 78% of those who were Latino/Other and 55% of those who were African American compared with 27% of Caucasian patients (p < 0.001). Providers were not more likely to identify patients with externalizing versus internalizing symptoms but were more likely to identify patients who demonstrated symptoms across multiple domains of functioning. CONCLUSIONS: Screening substantially increased the number of children and youth who would be identified as possibly having a mental health problem. Screening may have the most potential to increase the identification of problems among patients who have moderate mental health symptoms and those who are African American or Latino.

Discussion of sensitive health topics with youth during primary care visits: relationship to youth perceptions of care.

PURPOSE: Youth have concerns about sensitive health topics, such as drugs, sex, and mental health, and many wish to discuss those concerns with a primary care provider. Research has not determined whether the discussion of sensitive health topics during primary care visits is independently associated with youth perceptions of care. This study examined whether the discussion of sensitive health topics during primary care visits was associated with youth's perceptions of the provider and of participation in treatment. METHODS: Directly after visits to 54 primary care providers in 13 geographically diverse offices and clinics, youth age 11-16 years old (N = 358) reported whether the visit included the discussion of mood, behavior, getting along with others, drugs, tobacco, alcohol, sexuality, birth control, parent mood, or family problems. Youth also reported whether the provider understood their problems, eased their worries, allowed them to make decisions about treatment, gave them some control over treatment, and asked them to take some responsibility for treatment. Providers reported confidence in their ability to offer counseling for nonmedical concerns and their beliefs and attitudes toward treating nonmedical concerns. RESULTS: Youth had more positive perceptions of the provider and were more likely to report taking an active role in treatment when the visit included the discussion of a sensitive health topic. Results from multivariate random effects logistic regression suggested that youth were more likely to report that the provider understood their problems (OR = 3.62, CI = 1.57-8.31), eased their worries (OR = 2.13, CI = 1.06-3.92), allowed them to make decisions about treatment (OR = 2.71, CI = 1.44-5.10), gave them some control over treatment (OR = 2.51, CI = 1.32-4.71), and asked them to take some responsibility for treatment (OR = 2.00, CI = 1.04-3.86) when the visit included the discussion of one or more sensitive health topics. The odds of each of these outcomes were also higher when the visit included the discussion of a greater number of sensitive topics. Youth also had more positive perceptions of female providers. Youth demographics, mental health status, and other provider characteristics were unrelated to youth perceptions of care. CONCLUSIONS: The discussion of sensitive health topics during primary care visits may have a positive impact on youth perceptions of care. Future research is needed to understand the relationship between the discussion of sensitive health topics and health outcomes among youth.

Gifts, bribes and solicitions: print media and the social construction of informal payments to doctors in Taiwan.

The Taiwanese practice of patients giving informal payments to physicians to secure services is deeply rooted in social and cultural factors. This study examines the portrayal of informal payments by Taiwanese print news media over a period of 12 years-from prior to until after the implementation of national health insurance (NHI) in Taiwan in 1995. The goal of the study was to examine how the advent of NHI changed the rationale for and use of informal payments. Both before and after the introduction of NHI, Taiwanese newspapers portrayed informal payments as appropriate means to secure access to better health care. Newspaper accounts established that, although NHI reduced patients' financial barriers to care, it did not change deeply held cultural beliefs that good care depended on the development of a reciprocal sense of obligation between patients and physicians. Physicians may have also encouraged the ongoing use of informal payments to make up revenue lost when NHI standardized fees and limited income from dispensing medications. In 2002, seven years after the implementation of NHI, the use of informal payments, though illegal, was still being justified in the print media through allusions to its role in traditional Taiwanese culture.

Informed consent for enrolling minors in genetic susceptibility research: a qualitative study of at-risk children's and parents' views about children's role in decision-making.

PURPOSE: To better understand the process by which families at increased risk of disease would decide to enroll their children in genetic susceptibility research in order to develop recommendations regarding the informed consent process by which at-risk children are enrolled in such research in the future [corrected]. METHODS: Parents and children (ages 10-17 years) from families at increased risk for heart disease (n = 21 dyads) or breast cancer (n = 16 dyads) participated in two face-to-face, audio-taped, semi-structured interviews: Initial interviews were conducted with parents and children separately, and follow-up family interviews were conducted 1 year later. Interview transcripts were coded based on common themes. RESULTS: Families vary in the stage at which, and degree to which, children would be involved in decision-making about research participation. In general, the older/more mature the child, the less risky the research and the more open the communication style, the greater the likelihood that decisions would be made jointly. Most children wanted some parental input, but still thought the final decision should be theirs. Most parents would want to make the initial decision about whether it would be reasonable to consider enrolling their child in the research being proposed, but none opposed the child having some time alone with the researcher. All parents and children in our study placed extreme importance on not forcing children to participate in nontherapeutic research if they do not want to. CONCLUSIONS: Decision-making about enrolling children in genetic susceptibility research should be based on an informed consent process that (a) gives parents and children sufficient opportunity to ask questions of the researcher(s) and to communicate with one another, and (b) gives children the opportunity to exercise their right to refuse participation without parental influence. This process should be tailored to the child's maturity level and style of communication in the family.

Parents' and children's attitudes toward the enrollment of minors in genetic susceptibility research: implications for informed consent.

PURPOSE: Children at high risk of future disease may be recruited for participation in disease susceptibility research involving genetic testing. This study was aimed at assessing parents' and children's reactions to such research, and their perceptions of risks and benefits of participating. METHODS: Parents and children (ages 10-17) from families at increased risk for breast cancer (n = 16 dyads) and heart disease (n = 21 dyads) participated in separate audiotaped interviews and a follow-up family interview one year later. We asked about reactions, risks and benefits, and informational needs regarding participation in hypothetical research involving genetic testing on a saliva sample. Audiotape transcripts were analyzed qualitatively. RESULTS: All children would initially participate because they viewed the research as low risk. When thinking about learning their test result and sharing it with others, or the uncertainties of testing, many children became hesitant about participating. Many parents thought their child might worry about a positive result, making them unlikely to enroll their child, or to choose not to tell the child test results. Both children and parents thought the benefits of participating included early detection or treatment (breast cancer families), prevention (heart disease families) and helping others. Children's questions about research participation centered on details of the study design and purpose, while parents' questions related to the genetic test itself. CONCLUSIONS: Children's first reaction to participating in research involving genetic susceptibility testing research may not indicate an adequate appreciation of risks and benefits; if encouraged to personalize the impact of genetic testing, children are able to engage in a more informed decision-making process.

Parenting and physical punishment: primary care interventions in Latin America / https://www.scielosp.org/pdf/rpsp/2000.v8n4/257-267/en

Physical punishment is a form of intrafamilial violence associated with short - and long - term adverse mental health outcomes. Despite these possible consequences, it is among the most common forms of violent interpersonal behavior. For many children it begins within the first year of life. The goal of this study was to determine the feasibility of involving public sector primary health care providers to inform parents about alternatives to phuysical punishment. The study used a qualitative design utilizing focus groups and survey questionnaires with parents and providers at six clinic sites chosen to be representative of public sector practice settings in Costa Rica and in metropolitan Santiago, Chile. The data were collected during 1998 and 1999. In the focus groups and surveys the parents voiced a range of opinions about physical punishment. Most acknowledged its common use but listed it among their least preferred means of discipline. Frequency of its use correlated positively with the parents' belief in its effectiveness and inversely with their satisfaction with their children's behavior. Some parents wanted to learn more about discipline; others wanted help with life stresses they felt led them to use physical punishment. Parents reported they chose other family memebers more frequently as a source of parenting information than they did health care providers. Some parents saw providers as too rushed and not knowledgeable enough to give good advice. Providers, in turn, felt ill equipped to handle parents' questions, but many of the health professionals expressed interest in more training. Parents and providers agreed that problems of time, space, and resources were barriers to talking about child discipline in the clinics. Many parents and providers would welcome a primary-care-based program on physical punishment. Such a program would need to be customized to accommodate local differences in parent and provider atitudes and in clinic organization. Health care professionals need more training in child discipline and in the skills required to interact with parents on issues relating to child behavior

El castigo corporal representa una forma de violencia que acarrea consecuencias mentales adversas en el corto y largo plazo. No obstante, es una de las formas más frecuentes de violencia personal y en muchos casos comienza cuando el niño aún no ha cumplido un año de edad. El objetivo del presente estudio fue determinar la factibilidad de utilizar a proveedores de atención primaria del sector público para explicar a los padres que hay otras opciones diferentes del castigo corporal. El estudio tuvo un diseño cualitativo y se valió de grupos de enfoque y formularios de encuesta para padres y proveedores de atención en seis centros ambulatorios que fueron elegidos como muestra representativa de los consultorios públicos de Costa Rica y de la zona metropolitana de Santiago, Chile. Los datos se recolectaron en 1998 y 1999. En los grupos de enfoque y las encuestas los padres expresaron diferentes opiniones sobre el castigo corporal. La mayoría reconocieron que la práctica estaba difundida, pero la colocaron en la lista de conductas punitivas que menos les gustaban. Su frecuencia mostró una correlación positiva con la creencia en su efectividad por parte de los padres y una correlación inversa con la satisfacción de los padres con la conducta de sus hijos. Algunos padres querían aprender más acerca de las formas de disciplinar a los hijos; otros querían que se les ayudara a sobrellevar las presiones de la vida que, según ellos, los hacían recurrir al castigo corporal. Los padres dijeron haber acudido a otros miembros de la familia como fuentes de información sobre la disciplina de los hijos con mayor frecuencia que a proveedores de atención de salud. A algunos padres les parecía que estos proveedores siempre andaban con demasiada prisa y que no poseían conocimientos suficientes para darles buenos consejos. Por otra parte, los proveedores de atención se sentían poco preparados para contestar las preguntas de los padres, pero muchos expresaron el deseo de recibir capacitación adicional. Tanto los padres como los proveedores de servicios estuvieron de acuerdo en que las limitaciones de tiempo, espacio y recursos planteaban barreras que impedían que se hablara del castigo de los hijos en el consultorio. A muchos padres y proveedores les gustaría que se creara un programa sobre el castigo corporal en el contexto de la atención primaria. Un programa de esa naturaleza tendría que adaptarse a las diferencias locales en cuanto a las actitudes de los padres y el personal y a la organización de los consultorios. Los proveedores de atención de salud necesitan un mayor adiestramiento sobre la disciplina de los niños y deben adquirir las habilidades indispensables para comunicarse con los padres sobre la conducta de sus hijos.