The Relationship Between First-Grade Psychosocial Functioning and Educational Outcomes through Eighth Grade in a Large Sample of Chilean Youth.

BACKGROUND: The association between early childhood psychosocial problems and poorer educational outcomes is well-documented, but the extent to which this association persists is less understood. The current study assessed the correlations between first-grade psychosocial functioning and educational outcomes through eighth grade in a large longitudinal sample of Chilean students. METHODS: The Pediatric Symptom Checklist-Chilean (PSC-CL) and Teacher Observation of Classroom Adaptation Re-Revised (TOCA-RR) assessed psychosocial functioning for 9736 students who were screened four times from first through eighth grade through the Skills for Life program. Adjusted linear mixed effects models assessed the association between first grade PSC-CL and TOCA-RR risk and third, sixth, and eighth grade GPA and school attendance. RESULTS: First-grade PSC-CL and TOCA-RR risk both significantly predicted lower third, sixth, and eighth grade GPAs; all p < .001. The relationships between first-grade psychosocial functioning and later school attendance rates were less consistent but still significant at certain time points. CONCLUSIONS: First-grade psychosocial risk was persistently associated with lower academic performance in a longitudinal sample of Chilean students followed through elementary and middle school. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Early school-based psychosocial screening and follow-up interventions have the potential to improve students' long-term educational outcomes.

Changes in psychosocial functioning among urban, school-age children during the COVID-19 pandemic.

BACKGROUND: There is concern about the effect of the COVID-19 pandemic on psychosocial functioning among school-age children, who have faced unusual stressors during this time. Our goal was to assess mental health symptoms and social risks during COVID-19, compared to before the pandemic, for urban, racial and ethnic minority school-age children, and investigate the relationship between mental health and social risks. METHODS: We conducted a cohort study from September 2019 until January 2021 of children age 5-11 years old recruited from an urban safety net hospital-based pediatric primary care practice. We measured emotional and behavioral symptoms (including attention, internalizing, and externalizing symptoms) before and during the pandemic with the Pediatric Symptom Checklist (PSC-17). We measured social risks (including food and housing insecurity) before and during the pandemic with the THRIVE screener. We measured additional mid-pandemic COVID-related stressors with items on school participation, screens/media use, illness exposure, and caregiver mental health. We compared pre- and mid-pandemic PSC-17 symptom scores across 4 domains (total, attention, internalizing, and externalizing) and used path analysis to examine the relationship between mental health and social risks pre- and mid-pandemic. RESULTS: Caregivers of 168 children (54% non-Hispanic Black, 29% Hispanic, and 22% non-English speaking) completed the study. Children had significantly higher levels of emotional and behavioral symptoms midpandemic- vs. pre-pandemic in all domains. Significantly more children had a positive PSC-17 total score (18% vs. 8%, p < 0.01) and internalizing (depression and anxiety) score (18% vs. 5%, p < 0.001) during the pandemic vs. before, indicating clinical concerns in these areas. Caregivers reported significantly more social risks during vs. before the pandemic (p < 0.001). Mental health symptoms significantly correlated with number of social risks before the pandemic, but not during the pandemic. Less school assignment completion, increased screen time, and caregiver depression were all significantly associated with worse mid-pandemic mental health in children. CONCLUSION: The COVID-19 pandemic has led to a dramatic increase in depression/anxiety problems and social risks among urban, racial and ethnic minority school-age children compared to before the pandemic. More research is needed to understand if these changes will persist.

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.

Utilization of Child Psychiatry Consultation Embedded in Primary Care for an Urban, Latino Population.

OBJECTIVE: In a novel model of embedded primary care child psychiatry serving an urban Latino population, we examined determinants of successful referral and relationship between clinical need and service intensity. METHODS: We conducted a chart review of referred patients from July 2013-March 2015. We used multiple logistic regressions controlling for confounders to identify determinants of successful referral. We examined the relationship between service intensity and clinical need using Poisson regression, adjusting for exposure time, age, sex, ethnicity, and language. RESULTS: Seventy-four percent of patients completed an evaluation. Younger children (p=.0397) and those with a history of therapy (p=.0077) were more likely to make initial contact. The markers of clinical need included PSC-35 Global Scores (p=.0027) and number of psychiatric diagnoses (p=.0178) predicted number of visits. CONCLUSIONS: Our findings support early referral to improve engagement, and provide initial evidence that embedded child psychiatry consultation is feasible and may increase access to care.

Hospital-Based Quality Measures for Pediatric Mental Health Care.

BACKGROUND AND OBJECTIVES: Patients with a primary mental health condition account for nearly 10% of pediatric hospitalizations nationally, but little is known about the quality of care provided for them in hospital settings. Our objective was to develop and test medical record-based measures used to assess quality of pediatric mental health care in the emergency department (ED) and inpatient settings. METHODS: We drafted an evidence-based set of pediatric mental health care quality measures for the ED and inpatient settings. We used the modified Delphi method to prioritize measures; 2 ED and 6 inpatient measures were operationalized and field-tested in 2 community and 3 children's hospitals. Eligible patients were 5 to 19 years old and diagnosed with psychosis, suicidality, or substance use from January 2012 to December 2013. We used bivariate and multivariate models to examine measure performance by patient characteristics and by hospital. RESULTS: Eight hundred and seventeen records were abstracted with primary diagnoses of suicidality (n = 446), psychosis (n = 321), and substance use (n = 50). Performance varied across measures. Among patients with suicidality, male patients (adjusted odds ratio: 0.27, P < .001) and African American patients (adjusted odds ratio: 0.31, P = .02) were less likely to have documentation of caregiver counseling on lethal means restriction. Among admitted suicidal patients, 27% had documentation of communication with an outside provider, with variation across hospitals (0%-38%; P < .001). There was low overall performance on screening for comorbid substance abuse in ED patients with psychosis (mean: 30.3). CONCLUSIONS: These new pediatric mental health care quality measures were used to identify sex and race disparities and substantial hospital variation. These measures may be useful for assessing and improving hospital-based pediatric mental health care quality.

Development and Validation of a Method to Identify Children With Social Complexity Risk Factors.

OBJECTIVES: We sought to develop and validate a method to identify social complexity risk factors (eg, limited English proficiency) using Minnesota state administrative data. A secondary objective was to examine the relationship between social complexity and caregiver-reported need for care coordination. METHODS: A total of 460 caregivers of children with noncomplex chronic conditions enrolled in a Minnesota public health care program were surveyed and administrative data on these caregivers and children were obtained. We validated the administrative measures by examining their concordance with caregiver-reported indicators of social complexity risk factors using tetrachoric correlations. Logistic regression analyses subsequently assessed the association between social complexity risk factors identified using Minnesota's state administrative data and caregiver-reported need for care coordination, adjusting for child demographics. RESULTS: Concordance between administrative and caregiver-reported data was moderate to high (correlation range 0.31-0.94, all P values <.01), with only current homelessness (r = -0.01, P = .95) failing to align significantly between the data sources. The presence of any social complexity risk factor was significantly associated with need for care coordination before (unadjusted odds ratio = 1.65; 95% confidence interval, 1.07-2.53) but not after adjusting for child demographic factors (adjusted odds ratio = 1.53; 95% confidence interval, 0.98-2.37). CONCLUSIONS: Social complexity risk factors may be accurately obtained from state administrative data. The presence of these risk factors may heighten a family's need for care coordination and/or other services for children with chronic illness, even those not considered medically complex.

Common and costly hospitalizations for pediatric mental health disorders.

BACKGROUND AND OBJECTIVES: Inpatient pediatric mental health is a priority topic for national quality measurement and improvement, but nationally representative data on the patients admitted or their diagnoses are lacking. Our objectives were: to describe pediatric mental health hospitalizations at general medical facilities admitting children nationally; to assess which pediatric mental health diagnoses are frequent and costly at these hospitals; and to examine whether the most frequent diagnoses are similar to those at free-standing children's hospitals. METHODS: We examined all discharges in 2009 for patients aged 3 to 20 years in the nationally representative Kids' Inpatient Database (KID) and in the Pediatric Health Information System (free-standing children's hospitals). Main outcomes were frequency of International Classification of Diseases, Ninth Revision, Clinical Modification-defined mental health diagnostic groupings (primary and nonprimary diagnosis) and, using KID, resource utilization (defined by diagnostic grouping aggregate annual charges). RESULTS: Nearly 10% of pediatric hospitalizations nationally were for a primary mental health diagnosis, compared with 3% of hospitalizations at free-standing children's hospitals. Predictors of hospitalizations for a primary mental health problem were older age, male gender, white race, and insurance type. Nationally, the most frequent and costly primary mental health diagnoses were depression (44.1% of all mental health admissions; $1.33 billion), bipolar disorder (18.1%; $702 million), and psychosis (12.1%; $540 million). CONCLUSIONS: We identified the child mental health inpatient diagnoses with the highest frequency and highest costs as depression, bipolar disorder, and psychosis, with substance abuse an important comorbid diagnosis. These diagnoses can be used as priority conditions for pediatric mental health inpatient quality measurement.

Have rates of behavioral health assessment and treatment increased for Massachusetts children since the Rosie D. decision? A report from two primary care practices.

Following a court decision (Rosie D. v. Romney), the Medicaid program in Massachusetts launched the statewide Children's Behavioral Health Initiative in 2008 to increase the recognition and treatment of behavioral health problems in pediatrics. We reviewed billing data (n = 64,194) and electronic medical records (n = 600) for well child visits in pediatrics in 2 practices to examine rates of behavioral health screening, problem identification, and treatment among children seen during the year before and 2 years after the program's implementation. According to electronic medical records, the percentage of well child visits that included any form of behavioral health assessment increased significantly during the first 2 years of the program, and pediatricians significantly increased their use of standardized screens. According to billing data, behavioral health treatment increased significantly. These findings suggest that behavioral health screening and treatment have increased following the Rosie D. decision.

Child and parental poor health among families at risk for hunger attending a community health center.

BACKGROUND: Hunger is prevalent in low-income families. Community clinics offer an opportunity to identify families who experience hunger and to address hunger-related health problems. METHODS: Parents of pediatric patients seen in an urban clinic completed a single question hunger screen. A subsample of parents participated in an interview. Patient and parental medical and mental health diagnoses were collected from medical records. RESULTS: Children from families reporting hunger were more likely than those from families not reporting hunger to be obese and to have more documented medical diagnoses. Parents reporting hunger were also more likely to have mental health problems noted and to describe poor health status. CONCLUSION: Hunger is associated with specific health problems among children and parents in a low-income community clinic. A simple screen to identify hungry families in clinics may assist in recognition of hunger's contribution to child and parental poor health and development of targeted interventions.

Use of a single-question screening tool to detect hunger in families attending a neighborhood health center.

OBJECTIVE: To examine the use and accuracy of a brief screening tool to identify family hunger, administered in an inner-city primary health care setting and the use of food assistance programs by families in this setting. METHODS: Parents were asked to complete a screening tool for hunger during a routine visit with their children to their neighborhood health center. To evaluate the accuracy of the single-question screening, a subsample of parents who completed the screening participated in an extended interview. Patients were from a neighborhood health center in Chelsea, Massachusetts. A total of 1750 families were screened, and 122 parents completed extended interviews. The US Department of Agriculture (USDA) Household Food Security Scale (HFSS) was used as the standard to assess the accuracy of the brief hunger screening tool. The USDA Food Assistance Program Participation Survey was used to gather information about food program use. RESULTS: The brief hunger screening tool showed 83% sensitivity and 80% specificity (kappa = .62) compared with the HFSS. The screening also had significant time-to-time reliability (77%). Among families screened as hungry, no food assistance programs were fully used. CONCLUSIONS: The single-question screening tool had acceptable sensitivity, specificity, and reliability. Hungry families underused all types of food assistance programs. Taken together, these findings suggest that screening for hunger could become an important addition to routine pediatric health care in low-income neighborhoods.

Validation of the Preschool and Early Childhood Functional Assessment Scale (PECFAS).

Efforts to determine the prevalence of serious emotional disturbance in preschool-aged children have been hampered by the lack of a validated measure. The Preschool and Early Childhood Functional Assessment Scale (PECFAS) is a multi-dimensional measure that assesses the psychosocial functioning of children aged 3-7 years. The concurrent validity and reliability of the PECFAS were assessed in a sample of 30 preschool-aged children in a large Head Start program in Ventura, California. PECFAS ratings based on in-depth interviews were significantly related to parental ratings that the children had mental health problems, psychiatric diagnoses, teacher ratings of the child's need for mental health evaluations, teacher ratings of behavior problems on a standardized screening inventory (DIAL-R), and actual referrals for mental health evaluations. Interrater reliability for the total PECFAS score was high (r = .90) as was internal consistency of the five subscales (alpha = .86). Using the PECFAS scores as a standard, the weighted prevalence of serious emotional disturbance in this West Coast Head Start program was 17%, at the lower end of the current estimated rate of SED for older children in low income samples (18-26%).

Screening for psychosocial dysfunction in economically disadvantaged and minority group children: further validation of the Pediatric Symptom Checklist.

This study assessed the validity and reliability of the Pediatric Symptom Checklist (PSC) for screening lower-middle-class and minority group children. PSCs were collected from parents of 300 pediatric outpatients aged six to 12 years and 48 of these children and their parents were interviewed in depth. The rate of positive screening was higher for poorer children. Comprehensive interview evaluations and statistical indices suggested that this higher rate was valid.