Modifiable Lifestyle Activities Affect Cognition in Cognitively Healthy Middle-Aged Individuals at Risk for Late-Life Alzheimer's Disease.

BACKGROUND: It is now acknowledged that Alzheimer's disease (AD) processes are present decades before the onset of clinical symptoms, but it remains unknown whether lifestyle factors can protect against these early AD processes in mid-life. OBJECTIVE: We asked whether modifiable lifestyle activities impact cognition in middle-aged individuals who are cognitively healthy, but at risk for late life AD. Participants (40-59 years) completed cognitive and clinical assessments at baseline (N = 206) and two years follow-up (N = 174). METHODS: Mid-life activities were measured with the Lifetime of Experiences Questionnaire. We assessed the impact of lifestyle activities, known risk factors for sporadic late-onset AD (Apolipoprotein E ɛ4 allele status, family history of dementia, and the Cardiovascular Risk Factors Aging and Dementia score), and their interactions on cognition. RESULTS: More frequent engagement in physically, socially, and intellectually stimulating activities was associated with better cognition (verbal, spatial, and relational memory), at baseline and follow-up. Critically, more frequent engagement in these activities was associated with stronger cognition (verbal and visuospatial functions, and conjunctive short-term memory binding) in individuals with family history of dementia. Impaired visuospatial function is one of the earliest cognitive deficits in AD and has previously associated with increased AD risk in this cohort. Additionally, conjunctive memory functions have been found impaired in the pre-symptomatic stages of AD. CONCLUSION: These findings suggest that modifiable lifestyle activities offset cognitive decrements due to AD risk in mid-life and support the targeting of modifiable lifestyle activities for the prevention of AD.

Primary care provider utilization and satisfaction with a health system navigation program for adolescents with behavioral health needs.

Approximately 49.5% of the adolescents report a mental health disorder; only about half of the children and adolescents with mental health disorders seek treatment from a mental health professional. Stigma and poor access to behavioral health providers are leading barriers to care. A large ambulatory health system implemented a BH navigation program to facilitate referrals from primary care physicians (PCPs), including pediatricians and family physicians, to BH providers. We studied PCP adoption of BH navigation services over a 4-year period, from July 2014 to June 2018. We retrieved operational data regarding service utilization, patient information from electronic health records and PCP information from administrative data, and surveyed PCPs for their appraisals of navigation services. Four thousand five hundred and fifty-five referrals were made for 3,912 patients from 290 PCPs (71% of PCPs in the health system). Depression (39%), anxiety (25%), and attention-deficit hyperactivity disorder (7%) were the most frequent reasons for referral. Referrals increased dramatically in the first half of the study period and decreased afterwards. Ninety-one percent of the PCPs agreed or strongly agreed that navigation enhanced their clinical care at 12-month survey. More than 90% of the PCPs rated the referral process, communication with navigation staff, and the overall experience as above average or excellent at 12 months. There was a decrease in these evaluation indicators after 2.5 years. The initial high referral volume reflects a need for BH navigation services. However, challenges remain to maintain positive PCP assessment in the face of such demand.

For Better or Worse? Change in Service Use by Children Investigated by Child Welfare Over a Decade.

BACKGROUND: Children, particularly minority children, referred to child welfare because of suspected maltreatment are vulnerable and need many services. We sought to assess whether service use has improved over the past decade and whether racial-ethnic disparities in service use have decreased. METHODS: We used 2 national data sets (the National Survey of Child and Adolescent Well-Being [NSCAW] I and II) collected a decade apart to assess changes over time in health, education, mental health (MH), and dental services and overall service use. RESULTS: In NSCAW II more children were young, had lower Child Behavior Checklist (CBCL) scores, and were Hispanic. We found significant increases in dental services, a decrease in special education services, and a decrease in MH services on the bivariate level (all P < .01). A large proportion of the change in MH services occurred in school settings, but the pattern continued when examining only those services delivered outside of school. The greatest decrease occurred for children with CBCL scores <64. However, in multivariate analyses, older children, white non-Hispanic children, and children placed out of the home were significantly more likely to receive MH services. Rates of MH services controlling for CBCL scores showed no improvement over the decade, nor was there a decrease in racial and ethnic disparities. CONCLUSIONS: These data showed no change in MH services over time for children referred for child welfare evaluation, but improvement in dental services was noted. Racial and ethnic disparities persist. Decrease in MH services occurred predominantly among children whose MH symptoms were below the clinical range.

Adverse Childhood Experiences and Mental Health, Chronic Medical Conditions, and Development in Young Children.

OBJECTIVE: To determine the relationships between adverse childhood experiences (ACEs) and mental health, chronic medical conditions, and social development among young children in the child welfare system. METHODS: This cross-sectional study used a nationally representative sample of children investigated by child welfare (National Survey of Child and Adolescent Well-Being II) from 2008 to 2009. Our analysis included caregiver interviews and caseworker reports about children aged 18 to 71 months who were not in out-of-home care (n = 912). We examined the associations between ACEs and mental health (measured by the Child Behavior Checklist [CBCL]), reported chronic medical conditions, and social development (measured by the Vineland Socialization Scale) in bivariate and multivariate analyses. RESULTS: Nearly all children (98.1%) were reported to have had an ACE in their lifetime; the average number of ACEs was 3.6. For every additional reported ACE, there was a 32% increased odds of having a problem score on the CBCL (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.14, 1.53) and a 21% increased odds of having a chronic medical condition (OR 1.21, 95% CI 1.05, 1.40). Among children aged 36 to 71 months, for every additional reported ACE, there was a 77% increased odds of a low Vineland Socialization score (OR 1.77, 95% CI 1.12, 2.78). CONCLUSIONS: ACEs were associated with poor early childhood mental health and chronic medical conditions, and, among children aged 3 to 5, social development. Efforts are needed to examine whether providing early intervention to families with multiple stressors mitigates the impact of ACEs on children's outcomes.

Health-risk behaviors in teens investigated by U.S. Child Welfare Agencies.

PURPOSE: The aim of this study was to examine prevalence and correlates of health-risk behaviors in 12- to 17.5-year-olds investigated by child welfare and compare risk-taking over time and with a national school-based sample. METHODS: Data from the National Survey of Child and Adolescent Well-Being (NSCAW II) were analyzed to examine substance use, sexual activity, conduct behaviors, and suicidality. In a weighted sample of 815 adolescents aged 12-17.5 years, prevalence and correlates for each health-risk behavior were calculated using bivariate analyses. Comparisons to data from NSCAW I and the Youth Risk Behavior Survey were made for each health-risk behavior. RESULTS: Overall, 65.6% of teens reported at least one health-risk behavior with significantly more teens in the 15- to 17.5-year age group reporting such behaviors (81.2% vs. 54.4%; p ≤ .001). Almost 75% of teens with a prior out-of-home placement and 77% of teens with child behavior checklist scores ≥64 reported at least one health-risk behavior. The prevalence of smoking was lower than in NSCAW I (10.5% vs. 23.2%; p ≤ .05) as was that of sexual activity (18.0% vs. 28.8%; p ≤ .05). Prevalence of health-risk behaviors was lower among older teens in the NSCAW II sample (n = 358) compared with those of the 2011 Youth Risk Behavior Surveillance System high school-based sample with the exception of suicidality, which was approximately 1.5 times higher (11.3% [95% confidence interval, 6.5-19.0] vs. 7.8% [95% confidence interval, 7.1-8.5]). CONCLUSIONS: Health-risk behaviors in this population of vulnerable teens are highly prevalent. Early efforts for screening and interventions should be part of routine child welfare services monitoring.

Health status and type of out-of-home placement: informal kinship care in an investigated sample.

OBJECTIVE: To assess the sociodemographic, health, and mental health of children in different types of out-of-home placements after investigation by child welfare agencies; to determine whether there are systematic differences in the children and their caregivers by type of out-of-home placements; and to provide the first description of these characteristics in a nationally representative sample for children in informal kinship care after child welfare involvement. METHODS: Using data from the National Survey of Child and Adolescent Well-being (NSCAW II), we compared children (0-17.5 years) in formal nonkinship foster care, formal kinship foster care, and informal kinship care shortly after a child welfare investigation. All analyses were weighted to reflect the sampling design. RESULTS: Children in informal kinship care are at comparable risk of having chronic health conditions and poorer health but are less likely to receive school-based services. All children in kinship care (formal and informal) are less likely to be reported to have mental health problems and are more likely to live with older caregivers whose educational level is low and whose health is reportedly poorer. CONCLUSIONS: Although children in kinship care have health problems similar to children in nonkinship foster care, they are likely to live in families with fewer economic and educational resources. This mismatch between need and access has implications for the long-term well-being of the children who are living in informal kinship arrangements without system-level support of formal foster care.

Persistence of mental health problems in very young children investigated by US child welfare agencies.

OBJECTIVE: To document the persistence and predictors of mental health problems in children aged 12 to 18 months investigated for alleged maltreatment. METHODS: Data came from the second National Survey of Child and Adolescent Well-being (NSCAW II), a longitudinal study of youth 0 to 17.5 years referred to US child welfare agencies. These analyses involved children 12 to 18 months. Baseline sociodemographic, social services, developmental data, and health data were collected on children and caregivers. Potential social-emotional problems at baseline were assessed with the Brief Infant-Toddler Social and Emotional (BITSEA) scales. Outcomes were scores over the clinical cutoff on the Child Behavior Checklist (CBCL) 1.5-5 assessed at 18 months after study entry. RESULTS: The multivariable analyses showed that an elevated BITSEA score at baseline (odds ratio 9.18, 95% confidence interval 1.49, 56.64; P = .018) and living with a depressed caregiver (odds ratio 13.54, 95% confidence interval 2.50, 73.46; P = .003) were associated with CBCL scores in the clinical range at the 18-month follow-up. For children who scored both positive on the BITSEA and lived with a depressed caregiver, 62.5% scored positive on the CBCL compared to 10.7% of the children with one risk factor and 3.8% of the children with neither risk factor. Only 23.9% of children and/or their caregivers received any service. CONCLUSIONS: Data show considerable persistence of mental health problems in very young children that 2 factors could identify. Lack of services to these children is a tremendous missed opportunity for identification and treatment that could potentially prevent more serious mental health problems.

Chronic conditions among children investigated by child welfare: a national sample.

OBJECTIVE: To assess the presence of chronic health conditions (CHCs) among a nationally representative sample of children investigated by child welfare agencies. METHODS: The study included 5872 children, aged 0 to 17.5 years, whose families were investigated for maltreatment between February 2008 and April 2009. Using data from the second National Survey of Child and Adolescent Well-Being, we examined the proportion of children who had CHC. We developed 2 categorical and 2 noncategorical measures of CHC from the available data and analyzed them by using bivariate and multivariable analyses. RESULTS: Depending on the measure used, 30.6% to 49.0% of all children investigated were reported by their caregivers to have a CHC. Furthermore, the children identified by using diverse methods were not entirely overlapping. In the multivariable analyses, children with poorer health were more likely to be male, older, and receiving special educational services but not more likely to be in out-of-home placements. CONCLUSIONS: The finding that a much higher proportion of these children have CHC than in the general population underscores the substantial health problems of children investigated by child welfare agencies and the need to monitor their health carefully, regardless of their placement postinvestigation.

Mental health problems in teens investigated by U.S. child welfare agencies.

PURPOSE: To examine prevalence and correlates of five mental health (MH) problems among 12-17.5 year olds investigated by child welfare. METHODS: Data from the National Survey on Child and Adolescent Well-being (NSCAW II) were analyzed to examine depression, anxiety, substance use/abuse, suicidality, and attention deficit hyperactivity disorder (ADHD) as reported by teens and their caregivers. In a sample of 815 adolescents, prevalence for each MH problem and correlates (e.g., age, placement location) were identified using bivariate and multivariable logistic analyses. RESULTS: After investigation for maltreatment, 42.7% of teens reported at least one MH problem, regardless of placement. Nine percent reported depression, 13.9% reported suicidality, 23% had substance use/abuse, 13.5% reported anxiety, and 18.6% had ADHD. Of 332 teens with any MH problem, 52.1% reported only one problem, 28.3% had two problems, and 19.6% had ≥ three problems. Teens with prior out-of-home placement had odds 2.29 times higher of reporting a MH problem and odds 2.12 times higher of reporting substance use/abuse. Males were significantly less likely to report depression. Older teens were more likely to report substance use/abuse. Black teens were significantly less likely to report suicidality and ADHD and almost half as likely to report anxiety. Teens with a chronic health condition and teens whose caregiver reported depression had more than twice the odds of reporting anxiety. CONCLUSIONS: This study highlights high rates of MH problems in teens of all ages and placement locations and suggests that all teens involved with child welfare should be screened for MH problems, regardless of initial placement status.

Mental health services use by children investigated by child welfare agencies.

OBJECTIVE: To examine the rates and predictors of mental health services use for a nationally representative cohort of youths who had been investigated for alleged maltreatment. METHODS: Data came from caregiver and caseworker baseline and 18-month interviews in the second National Survey of Child and Adolescent Well-being. These interviews took place from March 2008 to September 2008 and September 2010 to March 2011. Data on family and child characteristics and service use were gathered and examined by using weighted univariate and multivariate analyses. RESULTS: Children had numerous challenges: 61.8% had a previous report of maltreatment, 46.3% had poor socialization skills, and 23.9% had a mental health problem measured by the Child Behavior Checklist (CBCL). At baseline, 33.3% received some mental health service and this varied by age, with younger children receiving fewer services. This percentage decreased to 30.9% at the 18-month follow-up, although the youngest children had increases in services use. For younger children, race/ethnicity, out-of-home placement, chronic physical health problems, low adaptive behaviors, and CBCL scores in the clinical range were related to use. For children ≥ 11, out-of-home placement, high CBCL scores, and family risk factors predicted services use at 18 months. CONCLUSIONS: Mental health services utilization increases as young children come into contact with schools and medical providers or have more intensive involvement with child welfare. Minority children receive fewer services adjusting for need. Over the 18-month follow-up, there was a decrease in service use that may be a result of the tremendous financial challenges taking place in the United States.

Mental health problems in young children investigated by U.S. child welfare agencies.

OBJECTIVE: To examine the prevalence/predictors of mental health (MH) problems and services use in 12- to 36-month-old children who had been investigated for maltreatment. METHOD: Data came from the second National Survey of Child and Adolescent Well-Being (NSCAW II), a longitudinal study of youth ages 0 to 17.5 years referred to U.S. child welfare agencies. These analyses involved 1117 children 12 to 36 months of age. Sociodemographic, social services, developmental and health data were collected on the children and caregivers. Outcomes were scores over the clinical cutoffs on the Brief Infant Toddler Social and Emotional Assessment (BITSEA) Scales for 12- to 18-month-olds and the Child Behavior Checklist (CBCL) for 19- to 36-month-olds. RESULTS: In all, 34.6% of 12 to 18 month-olds scored high on the Problem Scale of the BITSEA, and 20.9% on the Competence Scale, whereas 10.0% of 19- to 36-month-olds scored over the CBCL clinical cut-off. Children of black ethnicity were less likely to have elevated scores on the BITSEA Problem Scale, whereas children who lived with a never-married caregiver were five times more likely to have elevated scores. Competence problems were associated with prior child welfare history. Elevated CBCL scores were associated with living with a depressed caregiver. Few children with identified MH problems, 2.2%, received an MH service. When we added parenting skills training that might be related to the treatment of child problems, 19.2% received a service. CONCLUSIONS: Identifiable MH problems are common, but few children receive services for those problems. The lack of services received by these young, multi-challenged children is a services systems and social policy failure.

Mothers with positive or negative depression screens evaluate a maternal resource guide.

INTRODUCTION: Social isolation is common in mothers with high depressive symptoms. This study tested the hypothesis that a maternal resource guide that provided mothers with links to community human service agencies would be deemed more helpful by mothers with positive depression screens (PDS) compared with mothers with negative depression screens (NDS). METHOD: This investigation was a cross-sectional survey study of a convenience sample from a primary care practice-based research network, the Southwestern Ohio Ambulatory Research Network (SOAR-Net). English-speaking mothers who took their child(ren) to SOAR-Net practices were eligible to participate in the study. Data were collected between May 2006 and March 2009. A total of 1048 mothers completed the survey, and 234 mothers refused to participate. RESULTS: Mothers were more likely to report that "This guide is helpful to me" if they were single (odds ratio [OR] = 4.05; 95% confidence interval [CI]: 2.77-5.94), their child had public health insurance (OR = 3.59; 95% CI: 2.39-5.40), or they had PDS (OR = 3.57; 95% CI: 2.13-5.98). After adjusting for a number of demographic variables, PDS continued to be significantly associated with "This guide is helpful to me" (adjusted OR = 2.68; 95% CI: 1.58-4.56). DISCUSSION: Mothers with PDS were more likely to report that the maternal resource guide would be personally helpful compared with mothers with NDS.

Effects of food insecurity on asthma outcomes in the pediatric emergency department.

OBJECTIVES: Food insecurity is associated with a wide variety of adverse health conditions in adults and children, but its relationship to asthma outcomes in children has not been described. The objectives of this study were to assess and characterize the food security status of an inner-city asthmatic population and to determine whether and to what extent household food insecurity is independently associated with negative clinical outcomes in children presenting to a pediatric emergency department (ED) with asthma exacerbations. METHODS: This study is a cross-sectional survey of a convenience sample of families of children presenting to an urban children's hospital ED for asthma exacerbations. Data were gathered through structured chart review and interview, including a published food insecurity questionnaire. RESULTS: A total of 127 families were enrolled, with a median patient age of 6.6 years. Of all families, 81% were black and 10% were white. Of these families, 35% met criteria for household food insecurity. 78% of food-insecure and 46% of food-secure households received food stamps. Of all food-insecure households, 67% reported never using food pantries or free community meals. 36% of food-insecure and 31% of food-secure patients lacked an adequate home supply of asthma medications. The overall admission rate was 37%; no significant difference was found in admission rate or length of stay. CONCLUSIONS: The rate of household food insecurity in families of asthmatic children presenting to an urban ED is high, with relatively low participation in a number of safety net programs. This study failed to demonstrate an association between household food insecurity and negative asthma outcomes.

Disposition and health outcomes among infants born to mothers with no prenatal care.

OBJECTIVE: This study assessed infant disposition and health outcomes among offspring born to mothers without prenatal care, based on maternal characteristics and the reason for lack of prenatal care (i.e., denial of pregnancy, concealment of pregnancy, primary substance use, financial barriers and multiparity). METHODS: A retrospective record review was completed at an urban academic medical center. Subjects were women who presented at delivery or immediately postpartum with no history of prenatal care (N=211), and their infants. RESULTS: Infants of mothers with substance use problems had the highest rates of referral to child protective services and out-of-home placement at discharge, though mothers with other reasons for no prenatal care also experienced both referral and placement. Infants born to mothers using substances experienced the highest rates of neonatal intensive care unit admission, and the lowest mean birth weight. CONCLUSIONS: Though those without prenatal care experienced a variety of adverse outcomes, substance use problems were most frequently correlated with adverse infant outcomes. Mothers who either had lost custody of other children or with substance use problems were at highest risk of losing custody of their infants. Those who denied or concealed their pregnancy still frequently retained custody. PRACTICE IMPLICATIONS: Among mothers without prenatal care, those with substance use problems were least likely to retain custody of their infant at hospital discharge. Custody status of the mother's other children was also independently associated with infant custody. Mothers who denied or concealed their pregnancy still often retained custody. Referrals of mothers with no prenatal care for psychiatric evaluation were rare, though referrals to social work were frequent. Child protective services occasionally did not investigate referrals in the denial and concealment groups. Healthcare providers should be aware of the medical and psychological needs of this vulnerable population of infants and mothers.

Characteristics of women who do not seek prenatal care and implications for prevention.

OBJECTIVES: To describe characteristics of women without prenatal care and their reasons for not seeking prenatal care. DESIGN: Retrospective record review. SETTING: Urban, academic medical center. PARTICIPANTS: Women without prenatal care whose pregnancies reached the third trimester, who presented to the hospital for delivery or immediately postpartum for a 7 year period. METHODS: Records were reviewed for factors including socio-demographic factors, history of pregnancy/miscarriage/abortion, social supports, abuse history, history of substance use, toxicology results, history of mental illness or mental retardation, and the reason for lack of prenatal care. RESULTS: Among 211 women with no prenatal care, the primary reasons were noted: 30% had problems with substance use; 29% experienced denial of pregnancy; 18% had financial reasons; 9% concealed pregnancy; and 6% believed they did not need prenatal care due to multiparity. Women with substance use disorders were significantly more likely to be older, unemployed multigravidas. CONCLUSIONS: Nurses should target specific groups of women for education and intervention based on their rationale for not seeking prenatal care.

Attention-deficit/hyperactivity disorder: how much responsibility are pediatricians taking?

BACKGROUND: Attention-deficit/hyperactivity disorder, the most common childhood behavioral condition, is one that pediatricians think they should identify and treat/manage. OBJECTIVE: Our goals were to explore the relationships between pediatricians' self-reports of their practice behaviors concerning usually inquiring about and treating/managing attention-deficit/hyperactivity disorder and (1) attitudes regarding perceived responsibility for attention-deficit/hyperactivity disorder and (2) personal and practice characteristics. METHODS: We analyzed data from the 59th Periodic Survey of the American Academy of Pediatrics for the 447 respondents who practice exclusively in general pediatrics. Bivariate and logistic regression analyses were used to identify attitudes and personal and practice characteristics associated with usually identifying and treating/managing attention-deficit/hyperactivity disorder. RESULTS: A total of 67% reported that they usually inquire about and 65% reported that they usually treat/manage attention-deficit/hyperactivity disorder. Factors positively associated with usually inquiring about attention-deficit/hyperactivity disorder in adjusted multivariable analyses include perceived high prevalence among current patients, attendance at a lecture/conference on child mental health in the past 2 years, having patients who are assigned or can select a specific pediatrician, practicing in suburban communities, practicing for > or =10 years, and being female. Pediatricians' attitudes about responsibility for identification of attention-deficit/hyperactivity disorder were not associated with usually inquiring about attention-deficit/hyperactivity disorder in either unadjusted or adjusted analyses. Attitudes about treating/managing attention-deficit/hyperactivity disorder were significantly associated with usually treating/managing attention-deficit/hyperactivity disorder in unadjusted and adjusted analyses. Those who perceived that pediatricians should be responsible for treating/managing had almost 12 times the odds of reporting treating/managing attention-deficit/hyperactivity disorder, whereas those who believe physicians should refer had threefold decreased odds of treating/managing. Other physician/practice characteristics significantly associated with the odds of usually treating/managing attention-deficit/hyperactivity disorder include belief that attention-deficit/hyperactivity disorder is very prevalent among current patients, seeing patients who are assigned or can select a specific pediatrician, and practice location. CONCLUSIONS: Taking responsibility for treating attention-deficit/hyperactivity disorder and practice characteristics seem to be important correlates of pediatrician self-reported behavior toward caring for children with attention-deficit/hyperactivity disorder.

Pediatricians' role in providing mental health care for children and adolescents: do pediatricians and child and adolescent psychiatrists agree?

BACKGROUND: Many children who have a mental health disorder do not receive mental health services and are seen only in primary care settings. Perceptions of pediatricians and mental health specialists regarding the role that pediatricians should have in diagnosing and managing children's mental health problems have not been studied. OBJECTIVE: To examine whether primary care pediatricians (PCPs) and child and adolescent psychiatrists (CAPs) agree about: (1) the pediatrician's role in identification, referral, and treatment of childhood mental health (MH) disorders; and (2) barriers to the identification, referral, and treatment of childhood MH disorders. METHODS: Surveys were mailed in 2005 to 338 PCPs and 75 CAPs in 7 counties surrounding Cleveland, Ohio. Each group was asked whether they agreed that PCPs should be responsible for identifying, treating, or referring 7 prevalent childhood MH problems. Barriers that PCPs face in identification, referral, and treatment of MH problems were also assessed. Analyses were weighted for nonresponse; group differences were assessed via Rao-Scott chi test and weighted regression analyses. RESULTS: Approximately half of PCPs and CAPs returned the survey. With the exception of attention deficit hyperactivity disorder (ADHD), the majority of PCPs and CAPs agreed that pediatricians should be responsible for identifying and referring, but not treating child MH conditions. For ADHD, PCPs were more likely than CAPs to agree that pediatricians should identify and treat affected children. PCPs were more likely than CAPs to agree that pediatricians should be responsible for identifying child/adolescent depression and anxiety disorders; the majority of both groups agree that PCPs should be responsible for referring, but not treating these conditions. Both groups agree that lack of MH services is a barrier to identification, treatment, and referral of child MH problems for PCPs. CAPs were more likely to agree that pediatrician's lack of training in identifying child mental health problems was a barrier, whereas PCPs were more likely to endorse lack of confidence in their ability to treat child MH problems with counseling, long waiting periods to see MH providers, family failure to follow through on referrals, and billing/reimbursement issues as barriers. CONCLUSIONS: Most PCPs and CAPs believe it is pediatricians' responsibility to identify and refer, but not treat, the majority of children's mental health problems. Both groups agree that mental health services are not readily available. Future efforts are needed to support PCPs and CAPs in their combined effort to address the mental health needs of children.

Does education influence pediatricians' perceptions of physician-specific barriers for maternal depression?

Pediatric residency reforms have increased emphasis on psychosocial issues, but we do not know whether this has changed pediatricians' perceptions of barriers to addressing maternal depression. A survey of 1600 members of the American Academy of Pediatrics investigated whether training in adult mental health issues and perceived barriers to addressing maternal depression differed for current pediatric residents, pediatricians in practice <5 years, and those in practice >or=5 years. Training did not differ for respondents who were currently in training, in practice <5 years, or in practice >or=5 years. Those in practice >or=5 years reported more barriers to addressing maternal depression compared with current residents. Current residents with training in adult mental techniques reported fewer barriers to the care of maternal depression. However, in spite of residency reforms, 81% of current residents reported no training in adult mental health issues.

Do pediatricians think they are responsible for identification and management of child mental health problems? Results of the AAP periodic survey.

OBJECTIVE: Childhood psychosocial problems have profound effects on development, functioning, and long-term mental health. The pediatrician is often the only health professional who regularly comes in contact with young children, and it is recommended that health care supervision should include care of behavioral and emotional issues. However, it is unknown whether pediatricians believe they should be responsible for this aspect of care. Our objective was to report the proportion of physicians who agree that pediatricians should be responsible for identifying, treating/managing, and referring a range of behavioral issues in their practices, and to examine the personal physician and practice characteristics associated with agreeing that pediatricians should be responsible for treating/managing 7 behavioral issues. METHODS: The 59th Periodic Survey of members of the American Academy of Pediatrics was sent to a random sample of 1600 members. The data that are presented are based on the responses of 659 members in current practice and no longer in training who completed the attitude questions. RESULTS: More than 80% of respondents agreed that pediatricians should be responsible for identification, especially for attention-deficit/hyperactivity disorder (ADHD), eating disorders, child depression, child substance abuse, and behavior problems. In contrast, only 59% agreed that pediatricians were responsible for identifying learning problems. Seventy percent thought that pediatricians should treat/manage ADHD; but for other conditions, most thought that their responsibility should be to refer. Few factors were consistently associated with higher odds of agreement that pediatricians should be responsible for treating/managing these problems, except for not spending their professional time exclusively in general pediatrics. CONCLUSIONS: These data suggest that pediatricians think that they should identify patients for mental health issues, but less than one-third agreed that it is their responsibility to treat/manage such problems, except for children with ADHD. Those not working exclusively in general pediatrics were more likely to agree that pediatricians should be responsible for treating and managing children's mental health problems.

Use of selective serotonin reuptake inhibitors by pediatricians: comparing attitudes of primary care pediatricians and child and adolescent psychiatrists.

To compare attitudes regarding a pediatrician's role in prescribing selective serotonin reuptake inhibitors for children and adolescents, surveys were mailed to 338 primary care pediatricians and 75 child and adolescent psychiatrists; half responded. Child and adolescent psychiatrists were significantly more likely than primary care pediatricians to agree that selective serotonin reuptake inhibitors are safe and effective when used for children and adolescents. Primary care pediatricians were significantly more likely than child and adolescent psychiatrists to agree that black box warnings have changed their prescribing practices. Both had similar beliefs about whether antidepressants should be prescribed only by psychiatrists and whether pediatricians should initiate selective serotonin reuptake inhibitor therapy, without or after consulting a psychiatrist. These data suggest that among child and adolescent psychiatrists and primary care pediatricians, agreement about the pediatrician's role in using selective serotonin reuptake inhibitors therapy is lacking. Strategies that enhance communication and endorse support for defined roles of primary care pediatricians and child and adolescent psychiatrists will ensure that children with mental health needs are treated safely and appropriately.