State Insurance Mandates and the Workforce for Children With Autism.

BACKGROUND: State mandates have required insurance companies to provide coverage for autism-related child health care services; however, it has not been determined if insurance mandates have improved the supply of child health care providers. We investigate the effect of state insurance mandates on the supply of child psychiatrists, pediatricians, and board-certified behavioral analysts (BCBAs). METHODS: We used data from the National Conference of State Legislatures and Health Resources and Services Administration's Area Health Resource Files to examine child psychiatrists, pediatricians, and BCBAs in all 50 states from 2003 to 2017. Fixed-effects regression models compared change in workforce density before versus one year after mandate implementation and the effect of mandate generosity across 44 US states implementing mandates between 2003 and 2017. RESULTS: From 2003 to 2017, child psychiatrists increased from 7.40 to 10.03 per 100 000 children, pediatricians from 62.35 to 68.86, and BCBAs from 1.34 to 29.88. Mandate introduction was associated with an additional increase of 0.77 BCBAs per 100 000 children (95% confidence interval [CI]: 0.18 to 1.42) one year after mandate enactment. Mandate introduction was also associated with a more modest increase among child psychiatrists (95% CI: 0.10 to 0.91) and was not associated with the prevalence of pediatricians (95% CI: -0.76 to 1.13). We also found evidence that more generous mandate benefits were associated with larger effects on workforce supply. CONCLUSIONS: State insurance mandates were associated with an ∼16% increase in BCBAs from 2003 to 2017, but the association with child psychiatrists was smaller and nonsignificant among pediatricians. In these findings, it is suggested that policies are needed that specifically address workforce constraints in the provision of services for children with autism spectrum disorder.

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.

Availability of Outpatient Mental Health Care by Pediatricians and Child Psychiatrists in Five U.S. Cities.

The authors sought to assess the availability of outpatient mental health care through pediatrician and child psychiatrist offices in the United States and to characterize differences in appointment availability by location, provider type, and insurance across five cities. To do so, the authors posed as parents of a 12-year-old child with depression, gave a predetermined insurance type, and asked to make the first available appointment with the specified provider. They called the offices of 601 individual pediatricians and 312 child psychiatrists located in five U.S. cities and listed as in-network by Blue Cross Blue Shield, one of the largest private insurers in the United States. Appointments were obtained with 40% of the pediatricians and 17% of the child psychiatrists. The mean wait time for psychiatry appointments was 30 days longer than for pediatric appointments. Providers were less likely to have available appointments for children on Medicaid, which is public insurance for low-income people. The most common reason for being unable to make an appointment was that the listed phone number was incorrect. Pediatricians were twice as likely to see new patients and to see them sooner than child psychiatrists. Increasing the number of both types of providers may be necessary to increase access to mental health care for children.

Decrease in Statewide Antipsychotic Prescribing after Implementation of Child and Adolescent Psychiatry Consultation Services.

OBJECTIVE: To learn if a quality of care Medicaid child psychiatric consultation service implemented in three different steps was linked to changes in statewide child antipsychotic utilization. DATA SOURCES/STUDY SETTING: Washington State child psychiatry consultation program primary data and Medicaid pharmacy division antipsychotic utilization secondary data from July 1, 2006, through December 31, 2013. STUDY DESIGN: Observational study in which consult program data were analyzed with a time series analysis of statewide antipsychotic utilization. DATA COLLECTION/EXTRACTION METHODS: All consultation program database information involving antipsychotics was compared to Medicaid pharmacy division database information involving antipsychotic utilization. PRINCIPAL FINDINGS: Washington State's total child Medicaid antipsychotic utilization fell from 0.51 to 0.25 percent. The monthly prevalence of use fell by a mean of 0.022 per thousand per month following the initiation of elective consults (p = .004), by 0.065 following the initiation of age/dose triggered mandatory reviews (p < .001), then by another 0.022 following the initiation of two or more concurrent antipsychotic mandatory reviews (p = .001). High-dose antipsychotic use fell by 57.8 percent in children 6- to 12-year old and fell by 52.1 percent in teens. CONCLUSIONS: Statewide antipsychotic prescribing for Medicaid clients fell significantly at different rates following each implementation step of a multilevel consultation and best-practice education service.

The relationship between manual coordination and mental health.

Motor coordination impairments frequently co-occur with other developmental disorders and mental health problems in clinically referred populations. But does this reflect a broader dimensional relationship within the general population? A clearer understanding of this relationship might inform improvements in mental health service provision. However, ascertainment and referral bias means that there is limited value in conducting further research with clinically referred samples. We, therefore, conducted a cross-sectional population-based study investigating children's manual coordination using an objective computerised test. These measures were related to teacher-completed responses on a behavioural screening questionnaire [the Strength and Difficulties Questionnaire (SDQ)]. We sampled 298 children (4-11 years old; 136 males) recruited from the general population. Hierarchical (logistic and linear) regression modelling indicated significant categorical and continuous relationships between manual coordination and overall SDQ score (a dimensional measure of psychopathology). Even after controlling for gender and age, manual coordination explained 15 % of the variance in total SDQ score. This dropped to 9 % after exclusion of participants whose SDQ responses indicated potential mental health problems. These results: (1) indicate that there is a clear relationship between children's motor and mental health development in community-based samples; (2) demonstrate the relationship's dimensional nature; and (3) have implications for service provision.

[Need for youth welfare services following child and adolescent psychiatry treatment- a descriptive analysis]. / Jugendhilfebedarf nach (teil-)stationärer kinder- und jugendpsychiatrischer Behandlung.

OBJECTIVE: Cooperation between health and youth welfare services plays a prominent role in the psychosocial healthcare of children and adolescents with mental disorders. The need analysis presented here measured how many children and adolescents engaged youth welfare services before and after inpatient or daycare treatment. METHOD: The number of completed treatments from 36 Bavarian daycare and inpatient child and adolescent psychiatric clinics were recorded over a period of 6 months. Besides sociodemographic and diagnostic data, information was collected about indicated and subsequently realized measures of youth welfare following clinical and day care treatment. RESULTS: 33 %of the clinically treated children and adolescents participated in a youth-welfare measure after psychiatric treatment. In the run-up to clinical treatment, 38 % of the treated children and adolescents had engaged services of youth welfare. Half of the children and adolescents contacted both youth welfare services as well as child and adolescent psychiatric services. The residential setting of youth care is of major importance to the cooperative treatment. CONCLUSIONS: The provision of both youth welfare services and child and adolescent psychiatry treatment is usually not a matter of going from one system to another, but rather consists of different constellations of complex processes of mutual assistance. The goal is to carry out a structured survey of the common clientele and to develop a crossover system and common care structures in order to improve the overall cooperation.

[The treatment needs of migrant children according to child and adolescent psychiatrists from medical clinics and in private practice]. / Anforderungen an die Behandlung von Migrantenkindern aus Sicht niedergelassener und leitender Ärzte für Kinder- und Jugendpsychiatrie.

OBJECTIVE: How does the German child and adolescent psychiatry system respond to the increasing number of migrant children and adolescents? METHOD: Senior doctors from German child and adolescent psychiatric hospitals (Association of Medical Hospital Directors in Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy in Germany, BAG) completed a specially constructed questionnaire about the treatment needs of migrant children, while a «random, representative¼ sample of child and adolescent psychiatrists in private practice (German Professional Association for Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, BKJPP) was administered a slightly modified version. RESULTS: The 100 psychiatrists in private practice represented only about one-eighth of their group, whereas the 55 medical directors comprised a representative sample. One-third of the hospitals has treatments tailored to the specific needs of migrants. In both settings, however, competent interpreters were rarely found, despite the treatment problems arising from the understanding the illness by the parents, language problems, and the clinical knowledge of the patient. Cultural diversity is perceived as enriching. The migration background and the sex of child and adolescent psychiatrists influence the treatment of migrants. CONCLUSION: Facilitating the process of «cultural opening¼ in child and adolescent psychiatry involves enacting concrete steps, such as the funding of interpreter costs.

Behavioral health care for children: the massachusetts child psychiatry access project.

Access to behavioral health care for children is essential to achieving good health care outcomes. Pediatric primary care providers have an essential role to play in identifying and treating behavioral health problems in children. However, they lack adequate training and resources and thus have generally been unable to meet children's need for behavioral health care. The Massachusetts Child Psychiatry Access Project has addressed this problem by delivering telephone child psychiatry consultations and specialized care coordination support to over 95 percent of the pediatric primary care providers in Massachusetts. Established in 2004, the project consists of six regional hubs, each of which has one full-time-equivalent child psychiatrist, licensed therapist, and care coordinator. Collectively, the hubs are available to over 95 percent of the 1.5 million children in Massachusetts. In fiscal year 2013 the Massachusetts Child Psychiatry Access Project served 10,553 children. Pediatric primary care providers enrolled in the project reported a dramatic improvement in their ability to meet the psychiatric needs of their patients. Telephone child psychiatry consultation programs for pediatric primary care providers, many modeled after the Massachusetts project, have spread across the United States.

The current and ideal state of mental health training: pediatric program director perspectives.

OBJECTIVE: To assess pediatric residency program director (PD) perceptions of the current state of mental health (MH) training, their receptivity to curricular changes, and perceptions of their residents' knowledge and skills in MH care. METHODS: We performed a cross-sectional study utilizing a Web-based survey of pediatric residency PDs to assess program characteristics, learning modalities PDs currently had or would implement, and their knowledge of the new American Academy of Pediatrics' MH competencies. PDs then ranked their residents' knowledge and skills for 29 MH competencies. Analyses included descriptive statistics and bivariate and multivariate analyses to assess for associations between variables, particularly MH model of care and perceived competence. RESULTS: Ninety-nine PDs (51%) responded. A total of 87% of PDs reported that MH care was taught as part of another rotation, yet PDs were receptive to curricular changes. Only 45% of PDs were aware of the 2009 American Academy of Pediatrics competencies, and PDs infrequently rated their residents' MH skills and knowledge to be above average. Attention-deficit/hyperactivity disorder (ADHD) was an exception: 64% reported above-average ADHD knowledge in diagnoses and 57% in treatment. There was an association between enhanced MH services in continuity clinics and perceived resident systems-based practice (P < .01) and medical knowledge (P = .04). CONCLUSIONS: PDs acknowledged that MH training is not emphasized, leading to deficiencies in their residents' knowledge and skills in MH care. The receptivity of PDs suggests the need for targeted dissemination of national guidelines or curriculum. Integrated models of care may be one way to improve resident competencies, but this deserves further study.

Bibliometric assessment of publication output of child and adolescent psychiatric/psychological affiliations between 2005 and 2010 based on the databases PubMed and Scopus.

We aimed to determine the quantitative scientific publication output of child and adolescent psychiatric/psychological affiliations during 2005-2010 by country based on both, "PubMed" and "Scopus" and performed a bibliometric qualitative evaluation for 2009 using "PubMed". We performed our search by affiliation related to child and adolescent psychiatric/psychological institutions using "PubMed". For the quantitative analysis for 2005-2010, we counted the number of abstracts. For the qualitative analysis for 2009 we derived the impact factor of each abstract's journal from "Journal Citation Reports". We related total impact factor scores to the gross domestic product (GDP) and population size of each country. Additionally, we used "Scopus" to determine the number of abstracts for each country that was identified via "PubMed" for 2009 and compared the ranking of countries between the two databases. 61 % of the publications between 2005 and 2010 originated from European countries and 26 % from the USA. After adjustment for GDP and population size, the ranking positions changed in favor of smaller European countries with a population size of less than 20 million inhabitants. The ranking of countries for the count of articles in 2009 as derived from "Scopus" was similar to that identified via the "PubMed" search. The performed search revealed only minor differences between "Scopus" and "PubMed" related to the ranking of countries. Our data indicate a sharp difference between countries with a high versus low GDP with regard to scientific publication output in child and adolescent psychiatry/psychology.

Assessment of Suny Upstate Medical University's child telepsychiatry consultation program.

OBJECTIVES: The project assesses the child telepsychiatry services provided by SUNY Upstate psychiatrists to several county mental health clinics in central New York State. METHOD: Data for 45 patients was extracted from pre-consultation forms completed by the referring clinic and postconsultation summaries completed by the Upstate psychiatrists that occurred between July 13, 2009 and May 12, 2010. The study identified characteristics of patients for whom telepsychiatry consultations were sought, why they were sought, and reviewed recommended changes in therapy and medication provided by the telepsychiatry consultant. RESULTS: Analysis of the data showed that there was a large variation in patient characteristics such as age (from age 3 to 17), current living situation, and psychological symptoms. In addition to a family history of mental illness (80%), the most common symptoms were physical aggression (60.0%), defiant/oppositional behavior (57.8%), and attentional problems (55.6%). The most common reason for referral was diagnostic clarification (67%). The child telepsychiatrist recommended a change in medication for most (80.8%) of the patients who were on medications, and to begin medications for most (63.2%) who were not receiving medication at the time of consult. Further, the telepsychiatrist often recommended the addition of family therapy (71.1%) and counseling at school (17.8%). CONCLUSION: The child telepsychiatric program at Upstate seemed effective. It reached a large variety of children with significant mental disorders. The consultants provided diagnostic clarification and recommended modification of treatment for most. However, this assessment is limited as examined as it did not include follow-up information on whether consultant recommendations were followed and, if they were, whether they were effective.

[Evolution and description of a complete hospitalisation unity in child and teenager psychiatry]. / Hospitalisation en pédopsychiatrie : description et évolution d'une unité.

The university department of child and adolescent psychiatry of Brest Hospital (a medium size town of 200,000 inhabitants) has at disposal a 14 in-patient emergency care unit, where young people under 16, mostly in crisis (individual and/or family and/or institutional crisis) are admitted. This unit opens 24h a day throughout the year, and patients with any type of pathology are admitted for a short stay, mainly with no demand for care. After a description of this unit with its modalities of functioning, the authors will report on its activity assessed from sets of data pertinent to the last 8 years. One thousand two hundred and twenty-five admittances were recorded over these 8 years. A very strong increase in the number of hospitalisation over the years (+201.4%) was also noticed. However, the sex-ratio remained quite alike with a majority of boys (55.3%), as well as the average stay duration (15.5 days in 2007). About the age at admittance, one should note that, after the relative stability observed in the first years, the average age has been decreasing regularly for the last 3 years to pass from 13.2 years for girls and 12.7years for boys in 2005 to 12.6 years (girls) and 11.2 years (boys) in 2007. Despite a rise in the number of children under placement in this region (Finistère) between 2001 and 2006, the origin of the admittances has remained quite stable over 8 years: in 2007, 64.9% of the accepted children were living in their family, 24.6% in a foster care and 10.4% in a foster family. The evaluation of this hospitable cohort over several years allowed the authors to highlight various trends such as the explosion of the demand for medical care in both sexes, the rejuvenation of mental disorders, evolution in the motives for admittance with an important increase of psychomotor instability and externalised behavioural problems as well as the occurrence of new demands for care, e.g. the weaning of "on-line" video games or Internet. The growing expansion of NICT (new information and communication technologies) would invite them to appropriate them as tools in the meetings and to reconsider their restrictive position with respect to them. Finally, this rejuvenation of mental disorder(s), the occurrence of adolescent problems at an earlier age, together with their observation of the lengthening of the oedipian phase, whose elaboration seems more problematic than previously, have made them wonder about the contemporary characteristics of the phase of latency and the modalities of negotiation of this stage by their cohort of young people. These modifications have incited the authors to reconsider their offer of care and to propose alternatives to the hospitalisation through the recent development of a structure of home psychiatric-care. This new unit caused no arrest in the massive influx of the patients in complete hospitalisation, but it allowed them to optimise the care for some young people in complex situations through improvement of relationships with their various partners of the sanitary and socio-educational world (listening and support by the partners, exchanges of know-how in full awareness of complementarity, and work in the continuity during the stay at hospital [better prepared hospitalisation together with a better understanding of its interest by the child/teenager and the partners]).

How impaired are children and adolescents by mental health problems? Results of the BELLA study.

BACKGROUND: The consideration of impairment plays a crucial role in detecting significant mental health problems in children whose symptoms do not meet diagnostic criteria. The assessment of impairment may be particularly relevant when only short screening instruments are applied in epidemiological surveys. Furthermore, differences between childrens' and parents' perceptions of present impairment and impairing symptoms are of interest with respect to treatment-seeking behaviour. OBJECTIVES: The objectives were to assess parent- and self-reported impairment due to mental health problems in a representative sample of children and adolescents; to describe the characteristics of highly impaired children with normal symptom scores; and to investigate the associations between symptoms in different problem areas and impairment. METHODS: The mental health module of the German Health Interview and Examination Survey for Children and Adolescents (the BELLA study) examined mental health in a representative sub-sample of 2,863 families with children aged 7-17. Self-reported and parent-reported symptoms of mental health problems and associated impairment were identified by the extended version of the strengths and difficulties questionnaire (SDQ) in children 11 years and older. RESULTS: Considerable levels of distress and functional impairment were found with 14.1% of the boys and 9.9% of the girls being severely impaired according to the parental reports. However, self-reported data shows a reversed gender-difference as well as lower levels of severe impairment (6.1% in boys; 10.0% in girls). Six percent of the sampled children suffer from pronounced impairment due to mental health problems but were not detected by screening for overall symptoms. Childrens' and parents' reports differed in regard to the association between reported symptom scores and associated impairment with children reporting higher impairment due to emotional problems. CONCLUSIONS: The assessment of impairment caused by mental health problems provides important information beyond the knowledge of symptoms and helps to identify an otherwise undetected high risk group. In the assessment of impairment, gender-specific issues have to be taken into account. Regarding the systematic differences between childrens' and parents' reports in the assessment of impairment, the child's perspective should be given special attention.

Depressive symptoms of children and adolescents in a German representative sample: results of the BELLA study.

BACKGROUND: In Europe, a considerable proportion of children and adolescents is affected by depressive symptoms, impairing their everyday life and social functioning. OBJECTIVES: The aim of this paper is to provide an overview of the depressive symptoms in children and adolescents in Germany, addressing risk factors, comorbidity, and impact of depressive symptoms on everyday life. METHODS: In the BELLA study, the mental health module of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), a representative sample of young people aged 7-17 years was enrolled. Depressiveness, assessed by the CES-DC, as well as other mental health problems were examined in the context of risk and protective factors. RESULTS: Depressive symptoms showed high prevalence in parent- and self-reports. Higher depression scores were found in those with a high number of psychosocial risks existing in the family, and they decreased as the number of protective factors the children and adolescents had at their disposal increased. Although only half of the boys and girls with high depression scores were regarded as significantly impaired, all of them had a much higher risk for additional mental health problems. Furthermore, their health-related quality of life was limited compared to their peers who had low depression scores. CONCLUSIONS: To differentiate between clinically significant depression and milder forms, it is necessary to take into account the different perspectives of children and their parents. Prevention and intervention should acknowledge the widespread distribution of depressive symptoms in children and adolescents, the high comorbidity of depressive and other mental health problems and the impact of depression on the aspects of everyday life.

Health-related quality of life in children and adolescents in Germany: results of the BELLA study.

BACKGROUND: The self-perceived health or health-related quality of life of children and adolescents is increasingly recognised as a relevant outcome in medical practice and public health research. Identifying children and adolescents with particularly low health-related quality of life allows for an early detection of hidden morbidity and health care needs. OBJECTIVES: The present study investigates health-related quality of life in children and adolescents in Germany. METHODS: In the Mental Health Module (BELLA study) of the German National Health Interview and Examination Survey for Children and Adolescents (KiGGS), the parents of 2,863 children and adolescents aged 7-17 years, and 1,700 children and adolescents aged 11-17 years completed the KINDL-R quality of life questionnaire. RESULTS: The reliability (Cronbach's alpha=0.86) and validity of the measurements using the parent-reported KINDL-R were confirmed. Means and percentiles were calculated for the total sample as well as for strata defined by age, sex, geographical region (east/west), migration status and socioeconomic status. Expected differences in health-related quality of life of children and adolescents from different social backgrounds and with different health statuses were demonstrated by differences in the KINDL-R scores (effect size d up to 1.29). CONCLUSION: This study provides representative, normative data (self-report and parent-report) on the test scores of health-related quality of life (KINDL-R) for the population of children and adolescents in Germany in general, as well as in sociodemographic and socioeconomic subpopulations.

Videoconferencing in child and adolescent psychiatry in Finland--an inadequately exploited resource.

To assess the current role of videoconferencing and the purposes for which it has been used in child and adolescent psychiatry in Finland, we sent a 16-item questionnaire to all providers of child and adolescent psychiatry services in specialised health care in Finland, i.e. the 42 child and adolescent units in 21 hospital districts. All service providers responded. The responses to both open-ended and structured questions were analysed manually and classified quantitatively and qualitatively. Use of videoconferencing was reported by 16 of the 21 hospital districts in Finland. Videoconferencing had been used for more than 5.5 years in only three hospital districts, for 3-5 years in 14 units and for 1-3 years in six units. Videoconferencing was used for clinical work in 12 and for distance education in another 12 hospital districts. Videoconferencing was used weekly for clinical work and for supervision by two districts; it was used for education by three districts. Although the workers' experiences of and attitudes towards videoconferencing were favourable, it has not been widely used in child and adolescent psychiatry. The implementation of videoconferencing seems to depend more on the activity of service providers than on the number of people involved.

The EU-regulation on medicinal products for paediatric use: impacts on child and adolescent psychiatry and clinical research with minors.

BACKGROUND: At present the EU-regulation on medicinal products for paediatric use is in the final legislation phase. The Regulation will bring essential changes to the policy of research with minors, to funding and to regulations of drug development in Europe. METHOD: The article analyses contents of the regulation and possible effects on research with and treatment of mentally ill minors. RESULTS: The regulation seems to be a chance to improve pharmacological treatment for children and bring similar research conditions to Europe as they already exist in the US. Some terms of the regulation must be considered as critical due to vague definitions and ambiguously defined policies in some articles. The designated expert committee will be a powerful institution, but it remains to be seen whether this committee will act in the intended way. It is an existing and real danger that European child and adolescent psychiatry will be neglected by the new regulation, if there is no participation of scientists of this discipline in committees. The regulation makes it necessary for child and adolescent psychiatry to strengthen research in clinical trials and developmental psychopharmacology to get benefits from new legislation and improve health care for mentally ill minors.

Practice patterns in pediatric consultation-liaison psychiatry: a national survey.

The purpose of this survey was to describe the current status of pediatric consultation-liaison (C-L) services in the United States. A total of 144 pediatric C-L programs were surveyed, with a response rate of 33%. Financial and staffing constraints were cited as common problems; 61% of programs reported an increase in consultation requests over the past 5 years, however, 30% of services reported a decrease in funding. Collection rates for professional billings average 30%; 57% of services reported an increase in clinical service demands at the expense of teaching and liaison activities. Discussion includes recommendations based on the results of the survey.