Paediatric integrated care in the primary care setting: A scoping review of populations served, models used and outcomes measured.

BACKGROUND: Paediatric integrated care (PIC), which involves primary care and behavioural health clinicians working together with patients and families, has been promoted as a best practice in the provision of care. In this context, behavioural health includes behavioural elements in the care of mental health and substance abuse conditions, chronic illness and physical symptoms associated with stress, and addressing health behaviours. Models of and contexts in which PIC has been applied vary, as do the outcomes and measures used to determine its value. Thus, this study seeks to better understand (1) what paediatric subpopulations are receiving integrated care, (2) which models of PIC are being studied, (3) what PIC outcomes are being explored and what measures and strategies are being used to assess those outcomes, and (4) whether the various models are resulting in positive outcomes. These questions have significant policy and clinical implications, given current national- and state-level efforts aimed at promoting integrated health care. METHODS: This study utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews to identify relevant articles published between January 1994 and 30 June 2020. The search utilized three databases: PubMed, PsycInfo and CINAHL. A total of 28 articles met the eligibility criteria for inclusion. RESULTS: Overall, acceptability of PIC appears to be high for patients and providers, with access, screening and engagement generally increasing. However, several gaps in the knowledge base on PIC were uncovered, and for some studies, ascertaining which models of integrated care were being implemented proved difficult. CONCLUSION: PIC has the potential to improve access to and quality of behavioural health care, but more research is needed to understand what models of PIC prove most beneficial and which policies and conditions promote cost efficiency. Rigorous evaluation of patient outcomes, provider training, institutional buy-in and system-level changes are needed.

Perceived Collective Efficacy and Parenting Competence: The Roles of Quality of Life and Hope.

Parents' perceptions of their parenting competence predict successful implementation of parenting tasks and contribute to their interest and involvement in parenting and to their children's development. Thus, identifying factors that contribute to parents' perceptions of parenting competence can help inform efforts to promote children's safety and well-being. The present study employs social disorganization theory to examine the relationship between collective efficacy and parents' sense of competence, measured along two dimensions: parental efficacy and parental satisfaction. It examines the direct association between the two constructs and whether the association is mediated by parent perceptions of their quality of life (QOL) and sense of hope. Data were collected from 198 parents residing in a neighborhood in southern Tel Aviv, Israel. The analyses indicated that high collective efficacy was directly associated with high parental efficacy, but not with high parental satisfaction. Using structural equation modeling, a mediation model was found whereby higher collective efficacy was associated with (a) higher QOL, which in turn was related to a greater sense of hope, which was linked with higher parental efficacy; and (b) higher QOL, which was directly associated with higher parental satisfaction. The findings provide further support to the idea that neighborhood characteristics play an important role in parents' ability to care for their children.

Las percepciones de los padres de su competencia en la crianza predicen la implementación satisfactoria de las tareas de crianza y contribuyen a su interés y participación en la crianza y al desarrollo de sus hijos. Por ende, los factores identificadores que contribuyen a las percepciones de los padres de su competencia en la crianza pueden ayudar a orientar las iniciativas para promover la seguridad y el bienestar de los niños. El presente estudio emplea la teoría de la desorganización social a fin de analizar la relación entre la eficacia colectiva y la percepción de competencia de los padres evaluadas en dos dimensiones: la eficacia parental y la satisfacción parental. Además, examina la asociación directa entre los dos constructos y si la asociación está mediada por las percepciones de los padres de su calidad de vida y su sensación de esperanza. Se recopilaron datos de 198 padres que viven en un barrio del sur de Tel Aviv, Israel. Los análisis indicaron que una eficacia colectiva alta estuvo directamente asociada con una eficacia parental alta, pero no con una satisfacción parental alta. Utilizando modelos de ecuaciones estructurales, se descubrió un modelo de mediación por el cual una eficacia colectiva más alta estuvo asociada con (a) una calidad de vida más alta, la cual a su vez estuvo relacionada con una mayor sensación de esperanza, que estuvo ligada con una eficacia parental más alta; y (b) una calidad de vida más alta, que estuvo directamente asociada con una satisfacción parental más alta. Los resultados ofrecen mayor respaldo de la idea de que las características de un barrio desempeñan un papel importante en la capacidad de los padres para preocuparse por sus hijos.

The Cultural Adaptation of a Community-Based Child Maltreatment Prevention Initiative.

A unique primary prevention effort, Strong Communities for Children (Strong Communities), focuses on changing attitudes and expectations regarding communities' collective responsibilities for the safety of children. Findings from a 6-year pilot of the initiative in South Carolina have shown promise in reducing child maltreatment, but efforts to adapt the initiative to different cultural contexts have been lacking. No models exist for adapting an initiative that takes a community-level approach to ensuring children's safety. Thus, this article addresses the gap by providing an overview of the original initiative, how the initiative was adapted to the Israeli context, and lessons learned from the experience. Building on conceptualizations of cultural adaptation by Castro et al. (Prevention Science, 5, 2004, 41) and Resnicow et al. (Ethnicity and Disease, 9, 1999, 11), sources of nonfit (i.e., sociodemographic traits, political conflict, government services, and the presence and role of community organizations) were identified and deep and surface structure modifications were made to the content and delivery. Ultimately, this article describes the adaption and dissemination of a community-based child maltreatment prevention initiative in Tel Aviv, Israel, and addresses researchers' calls for more publications describing the adaptation of interventions and the procedures that need to be implemented to achieve cultural relevance.

The Impact of Health Status on Health Care Utilization of Children in Foster Care.

OBJECTIVES: This study sought to understand the health status of children in foster care; the relationship between their health status and health care utilization; and demographic and placement factors associated with health care utilization. METHODS: To estimate relationships between health status and health care utilization, this study used electronic health records from 4976 children in foster care seen at a children's hospital in the southwestern United States, 2017 to 2020. An algorithm classified patients' health status as nonchronic, noncomplex chronic, or complex chronic. Descriptive statistics were used to describe patients and utilization. The χ2, Kruskal-Wallis, and pairwise comparison post hoc tests were used to examine relationships between health status and health care utilization. Zero-inflated negative binomial (ZINB) regression further estimated relationships between health status and health care utilization while factoring in demographic and placement characteristics. RESULTS: Within the sample, 35.6% had complex chronic health status. Significant differences were found among health status groups in age, gender, ethnicity, and maltreatment exposure. Both nonparametric pairwise comparisons and the ZINB regression model showed that having complex chronic health was associated with higher utilization of all hospital resources: emergency, admission, primary and specialty care, and various therapies, relative to having noncomplex chronic and nonchronic health. CONCLUSION: A high percentage of children in foster care had complex chronic health, and these patients used significantly more resources. This study suggests that hospital-based health clinics focused on children in foster care and care coordination may be warranted.

Examining the Feasibility of Telehealth Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) with Young People in Foster Care.

Purpose: Despite the high rate of trauma exposure among young people with child welfare involvement, various systematic and patient barriers exist that inhibit utilization of evidence-based trauma treatments. One strategy for alleviating barriers to such treatments is using telehealth. A few studies have found that the clinical outcomes of telehealth TF-CBT are comparable to those found from clinic-based, in-person treatment administration. Studies have yet to examine the feasibility of telehealth TF-CBT with young people in care. The current study sought to address this gap by examining outcomes for patients who received telehealth TF-CBT, along with factors that may have impacted successful completion, at an integrated primary care clinic exclusively serving young people in care. Methods: Patient data were collected retrospectively from the electronic health records of 46 patients who received telehealth TF-CBT between March 2020 and April 2021, and feedback was sought via focus group from 7 of the clinic's mental health providers. A paired-sample t-test was conducted to evaluate the impact of the intervention for the 14 patients who completed treatment. Results: Responses from the Child and Adolescent Trauma Screen showed a significant decrease in posttraumatic stress symptoms when comparing pre-treatment scores (M = 25.64, SD = 7.85) to post-treatment scores (13.57, SD = 5.30), t(13) = 7.50, p < .001. The mean decrease in scores was 12.07 with a 95% confidence interval ranging from 8.60 to 15.55. Themes emerging from the focus group centered on home environment, caregiver participation, and systemic topics. Conclusions: Findings suggest that telehealth TF-CBT with young people in care is feasible but relatively low completion rates suggest that barriers to treatment completion remain.

Mental Health Disorders and Psychotropic Medication: Prevalence and Related Characteristics Among Individuals in Foster Care.

This study sought to provide prevalence data for mental health (MH) diagnoses and psychotropic medication prescriptions among individuals in foster care and to examine their relationships with physical health status, maltreatment type, placement type, and demographic variables. Data were retrieved from electronic health records for 3,067 patients seen at integrated pediatric primary care clinics serving individuals in care. Descriptive and bivariate statistics for presence of MH diagnoses and psychotropic medication prescription were calculated. Multivariable zero-inflated negative binomial regressions were used to assess relationships. Half (50.0%) of patients had at least one MH diagnosis; trauma and stressor-related (31.5%) and attention deficit hyperactivity (22.6%) disorders were most common. 27.8% of patients were prescribed at least 1 psychotropic medication. Complex chronic physical health, having 1 and 2 or more maltreatment exposures, and being 6-11 and 12-20 years of age had significantly higher rates of having a MH diagnosis while being female, Black, Hispanic, and other race were significantly associated with lower rates. Patients with at least 1 MH diagnosis that had complex chronic physical health status, experienced sexual abuse, and were 6-11 and 12-20 years of age had significantly higher rates of psychotropic medication prescription while shelter and kinship placement and female gender were significantly associated with lower rates. Findings suggest that initial and ongoing MH screening is vital for individuals in care so that appropriate interventions can be offered. Results support implementing strategies designed to increase access to MH services for this population, such as integrated care and child psychiatry consult programs. Supplementary Information: The online version contains supplementary material available at 10.1007/s40653-023-00547-9.

Healthcare utilization among children with a history of neonatal opioid withdrawal syndrome: A matched cohort study.

OBJECTIVES: Compare longitudinal healthcare utilization patterns in children with and without a history of neonatal opioid withdrawal syndrome (NOWS). STUDY DESIGN: A retrospective matched cohort study was conducted using billing data extracted from between 2003 and 2016 in North Texas hospitals. The sample included 595 pediatric patients diagnosed with NOWS (i.e. exposed). The unexposed were patients not diagnosed with NOWS and matched 4:1 on sex, age at first encounter, and ethnicity to the exposed who received care during the same period. Multi-level regression models (accounting for clustered data structure of multiple visits per patient) compared number of hospitalizations, number of outpatient visits, number of emergency department (ED) visits, average length of stay, and healthcare expenditures across patients with and without NOWS. RESULTS: Hospitalizations were significantly lower among exposed (Incidence Rate Ratio [IRR] = 0.58, 95 % Confidence Interval [CI] = 0.44-0.77) compared to unexposed. Outpatient visits, ED visits, and average length of stay was significantly higher among exposed compared to unexposed (IRR = 1.19, 95 % CI = 1.04-1.36; IRR = 1.22, 95 % CI = 1.04-1.42; IRR = 2.21, 95 % CI = 2.03-2.42, respectively). Overall healthcare expenditure was greater among exposed, as well as for patients with neurologic, endocrine, cardiac, mental disorders, respiratory, perinatal, infectious disease, eye, ear, digestive, congenital anomaly, and skin diagnoses. CONCLUSIONS: Children with a diagnosis of NOWS have significantly higher healthcare expenditures, and with the exception of hospitalizations, higher healthcare utilization beyond the newborn visit. These findings suggest the needs for interventions for children with NOWS beyond the immediate neonatal period.

Developmental Status of Young Children in Foster Care.

OBJECTIVE: Children in foster care (CFC) may be at higher risk for developmental problems. This study sought to determine (1) the percentage of CFC with developmental problems seen at an integrated primary care clinic and (2) whether the presence of various risk factors was associated with increased odds of developmental problems in general and across developmental domains. METHOD: This cross-sectional study used the Ages and Stages Questionnaire, Third Edition, demographic, and health-related data retrieved from electronic health records. The study included 796 children aged 1 to 66 months seen at an integrated primary care clinic exclusively serving CFC. Frequencies and percentages of children with developmental problems were calculated, and relationships between developmental status and potential risk factors were accessed using χ2 and bivariate logistic regression analyses. RESULTS: Overall, 68.5% had scores indicative of developmental concern (DC), and 39.8% had scores indicating developmental delay (DD). After adjusting for other risk factors, analysis suggested that being male (odds ratio [OR] 2.169, 95% confidence interval [CI] 1.595-2.950) and exhibiting trauma symptoms (OR 1.51, 95% CI 0.993-2.295) were associated with higher odds of exhibiting DC, whereas being in a kinship placement (OR 0.55, 95% CI 0.359-0.842) was associated with lower odds. Odds were higher for exhibiting DD for children who were male (OR 1.716, 95% CI 1.278-2.303), born prematurely (OR 2.165, 95% CI 1.438-3.259), experienced physical abuse (OR 1.541, 95% CI 1.040-2.283), and presented trauma symptoms (OR 1.441, 95% CI 0.975-2.130). CONCLUSION: The findings suggest that early screening is vital for CFC to identify developmental impairment so that appropriate education and interventions can be offered.

Establishing a path to unity: Recommendations for the Biden/Harris administration.

The Biden/Harris Administration faces many challenges, from systems and policies that do not work for or benefit all Americans to stark social and political divisions. Multiple courses of action will be necessary, and there must be commitment and investment for the "long haul." When considering the nation's challenges, overarching themes emerge that must be addressed. For instance, recommendations for justice reform cannot be followed without significant focus on race and equity. This focus will also be needed in considering solutions to affordable housing shortages, economic crises, and social and economic immobility concerns. In a similar vein, if the interests and rights of our nation's children are not recognized now, the social consequences will impact every aspect of their livelihoods-and those of future generations. The recommendations put forward by the Global Alliance are bold and will take time to fully implement. The implementation of these recommendations will challenge our systems and our policymakers to acknowledge our past and reenvision the future-and they will help address the multifaceted behavioral health and well-being needs of our nation, its communities, and its people. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Research Participation of Minor Adolescents in Foster Care.

STUDY OBJECTIVE: In this study we evaluated published studies about foster care to: (1) determine the types of data used; (2) describe the degree to which a sexual/reproductive health topic was addressed; and (3) describe the consent process. DESIGN: Analysis of published literature. SETTING: PubMed was searched using "foster care" for English articles published between January 1, 2017 and September 4, 2019. PARTICIPANTS: None. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Articles were coded into 4 data source categories: primary, secondary, peripheral, or perspective data. Articles with a primary data source were coded for participant ages: only 9 years old and younger, 10- to 17-year-olds (minor adolescents), and only 18 years old and older. Articles using a secondary data source were coded for the source of the data registry. All articles were coded for presence of a sexual/reproductive health outcome. The primary data articles that included minor adolescents were coded for the study topic and consent process. RESULTS: Of the 176 articles about foster care, 72/176 (41%) used primary data, 53/176 (30%) used secondary data, and 51/176 (29%) used peripheral/perspective data. Forty-eight of the primary data articles included minor adolescents. Secondary data sources included few national research surveys. Sexual/reproductive health outcomes were measured in 17 articles, 4 of which used primary data. The consent process for minor adolescents varied and had no consistent pattern across studies. CONCLUSION: Research on best practices for consent processes and use of registries could be developed to increase research on sexual/reproductive health outcomes among adolescents in foster care.

The role of religious institutions in preventing, eradicating, and mitigating violence against children.

When religious institutions are discussed in the context of child maltreatment, the topic is typically sources of danger for children. Although some religious institutions are counted among the formal organizations in which child abuse has occurred and in which accusations have been covered up, to focus solely on religion and its institutions as sources of threat or to exclude them from discussions of addressing, preventing, and eradicating violence against children, would be a mistake. Throughout the world, there exist communities of faith that provide formal and informal resources, supports, and opportunities to children and families in their midst. This article provides a rationale for including religious institutions in conversations about and in efforts to protect children, examples of efforts by religious institutions to provide protection to children, a discussion of religion and its institutions as potential sources of risk for children, and suggestions for research on the role of religious institutions in child protection.

The Nature, Logic, and Significance of Strong Communities for Children.

High levels of stress and low levels of support for parents have significant implications for child safety, particularly for families living in neighborhoods which are dangerous and disadvantaged. Building on this knowledge about the causes and correlates of child maltreatment, the U.S. Advisory Board on Child Abuse and Neglect (1993) recommended a neighborhood-based child protection strategy. This article describes Strong Communities for Children, a community-based child maltreatment prevention intervention designed to carry out the Board's recommendations. During an initial period of development and evaluation (lasting more than 7 years) of the first such initiative (located in communities near Greenville, SC), Strong Communities added substantially to the knowledge base on the role of community factors in children's safety. It also advanced understanding of ways to operationalize some of the ideas underlying the Board's proposed strategy. This article (a) describes the conceptual foundation, the logic model, and the engagement strategies that comprise Strong Communities; (b) provides an overview of the results from the first comprehensive initiative; (c) discusses their significance; and (d) concludes with discussion of the possibilities for Strong Communities in the current context.

Effecting social change across contexts: Needs and mechanisms-An introduction to the special section.

The articles in this Special Section provide some grounds for optimism. Although their specific topics, approaches, and mechanisms for action vary, they reflect efforts designed to inform change initiatives or foster health and wellness utilizing data-driven strategies and conceptual models. These articles shed light on salient issues and point to strategies for building capacity to take action. Their recommendations are targeted and well founded. It is clear that a comprehensive approach to resource development, program implementation, and policy change-informed by applied research and evaluation-is necessary. Indeed, today's challenges require the engagement of diverse stakeholders, from community members to system leaders and policymakers, and lead researchers, practitioners, and policymakers to grapple with a range of related questions: How can we effect changes in our systems to maximize our reach and impact, particularly for groups that have been traditionally disadvantaged and underserved? How can we foster more responsive community systems, engage in innovative prevention strategies, and improve our programs? How do we address social determinants of health-from poverty or economic stability to race-related challenges, from access to safe and stable housing, health care, or adequate food to educational opportunities, transportation, and park access-to promote well-being? How can we create contexts for connectedness and support in individuals', children's, and families' natural settings, whether their neighborhoods, their faith communities, or their schools? How can we shape practice and policy to support behavioral health and well-being and social justice? (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Changing norms, strategies, and systems to support behavioral health and social justice: A call to action and introduction to the special section.

This editorial introduces this special section of the American Journal of Orthopsychiatry. The Global Alliance for Behavioral Health and Social Justice (formerly the American Orthopsychiatric Association) has developed the theme for its track at the 2016 Annual Research and Policy Conference on Child, Adolescent, and Young Adult Behavioral Health. The Global Alliance, the parent organization of the American Journal of Orthopsychiatry, has long sought to address prevailing social conditions by treating them as problems to be solved through multilevel, contextually grounded social interventions. Indeed, throughout the organization's history, it has advocated for focusing on the effects of social determinants of health (e.g., racism, violence, poverty, oppression, war) on behavioral health and for doing so across contexts, such as the family, community, and broader social environment. In keeping with the organization's history and the current social context, the theme for the Global Alliance's track was "Changing norms, strategies, and systems to support behavioral health and social justice." This special section includes articles that build on four of the presentations and two award addresses delivered as part of the Global Alliance's track. (PsycINFO Database Record

Addressing mental health challenges facing the "Next America": A call for culture change.

Provides an editorial addressing future mental health challenges. The articles in this issue highlight the need to create environments conducive to promoting the well-being of future generations. The articles build on symposia held by the American Orthopsychiatric Association in 2015, which focused on the effects on well-being of changing sociodemographics and labor market trends. Included in these pages are articles that lay out some of the challenges young people today face and strategies for helping them transition to adulthood successfully.

Millennial children of immigrant parents: Transnationalism, disparities, policy, and potential.

At 11% of their generational cohort, second-generation millennials account for the larger number of children of immigrants than any other generation before them. Second-generation millennials belong to a cohort that comprises about 80 million people, the largest cohort of young people that the United States has ever seen. The "creators" of the millennial generation, Neil Howe and William Strauss, proposed seven core millennials' traits that are now overwhelmingly accepted as being factual: They are special, sheltered, confident, team-oriented, conventional, achieving, and pressured. In contemporary discourse, millennials have been described as tech savvy, open to change, compassionate, inclusive, and politically active, but also self-centered and lacking attachment or direction. Although it is true that many second-generation millennials fit these descriptions and are doing as well financially and educationally as their nonimmigrant peers, a significant proportion are struggling. The diverse outcomes raise questions about why some children of immigrant parents fare better than others. If these factors can be identified, efforts can be undertaken to promote the wellbeing of these young adults

Community differences in the implementation of Strong Communities for Children.

In 1993, the U.S. Advisory Board on Child Abuse and Neglect recommended a neighborhood-based strategy to prevent child abuse and neglect. The Board further recommended the development of Prevention Zones to allow for testing of the effectiveness of community-wide child protection efforts in neighborhoods of differing population density, ethnic and cultural composition, and social and economic resources. Following the Board's recommendation, this article presents the results of a trial of the effectiveness of a neighborhood-based strategy in low- and high-resource communities. Using management, survey, and administrative data, the research showed that both community types experienced declines in founded cases of and injuries suggesting child maltreatment for children under age 5. Low-resource communities experienced greater levels of mobilization, as measured by community and institutional engagement, and a greater number of positive outcomes related to changes in the quality of life for families and community norms relative to child and family well-being. In particular, the low-resource communities experienced the largest increases in receiving help from neighbors, neighboring, perceived household safety for neighborhood children, and observed positive parenting. High-resource communities experienced greater increases in intermediate outcomes related to self-reported parenting practices. The findings suggest that, ultimately, community mobilization can occur and be an effective means of preventing child maltreatment across community types. It appears, however, that community mobilization may play a more significant role in low-resource communities.

Young adults in conflict: confident but struggling, networked but disconnected.

This article discusses the conflict the cohort of adults known as the Millennials has been affected by. More specifically this article takes a look at how changes in the economy and society have influenced Millennials and what can be done to promote their well-being and that of future generations.