Evaluating the function and psychometric properties of a violence risk screening tool in a community sample of adolescents.

Youth violence continues to be widespread. Despite numerous evidence-based programs that reduce youth violence, objective ways to identify youth in need of services is lacking. Few screening tools are available that enables practitioners or community organizations to predict who may perpetrate serious violence. The Violence Injury Protection and Risk Screen (VIPRS) is a previously validated screening tool providing a framework to address youth violence. The purpose of this study is to evaluate the psychometric properties of the VIPRS in a community sample for use in multiple settings. Youth participating in a community-focused youth violence prevention intervention served as the study subjects. Households with youth ages 10-17 were eligible to participate. Study personnel verbally asked youth survey questions and recorded answers on a laptop. Multiple measures-including risk factors for violent behavior as well as, violence and delinquency scales, were asked. Eleven hundred youth participated. Mean age was 13.3; 53% female, 26% Black, 58% Hispanic, 11% more than 1 race. Twenty percent screened positive on the VIPRS-28% male versus 13% female (p = .000). Violence-related behaviors were common: 33% were in a physical fight, 27% experienced cyberbullying victimization, and 9% perpetrated a minor assault. The VIPRS demonstrated robust criterion validity with significant correlation to multiple violence measures (0.3-0.6). Scoring positive on the VIPRS conveyed increased odds of reporting other violent behaviors, such as perpetrating physical aggression (OR: 7 [95% CI: 5.1-11.5]). Overall, the VIPRS performed well in a community sample of youth further validating its psychometric functioning while demonstrating the potential for use in settings beyond healthcare.

The Effects of an Electronic Medical Record Prompt on Documentation of Firearm Screening in and Adolescent Primary Care Setting.

PURPOSE: There is limited evidence as to how to facilitate health care providers (HCPs) addressing firearm injury prevention during routine visits. The purpose of this project was to examine whether including a screening question about firearms in the home in the routine care template increases the screening of youth access to firearms. METHODS: A pre-post approach chart review was conducted for youth 12-21 years old. Outcomes included HCP documentation of screening for the presence of firearms and whether counseling caregivers on safer storage practices was delivered. RESULTS: HCPs documented screening adolescents for firearms 85% after the addition of the prompt compared to 25% prior to the change (p < .001). The presence of the screening prompt also led to an increase in the delivery of safe storage counseling (p = .035). DISCUSSION: Altering the EMR template increased HCP documentation of the presence of firearms in the home while also increasing firearm injury prevention counseling delivered to caregivers.

Suicide and Suicide Risk in Adolescents.

Suicide is the second leading cause of death for 10- to 24-year-olds in the United States and is a global public health issue, with a recent declaration of a National State of Emergency in Children's Mental Health by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children's Hospital Association. This clinical report is an update to the previous American Academy of Pediatrics clinical report, "Suicide and Suicide Attempts in Adolescents." Because pediatricians and pediatric health care providers are at the front line of care for adolescents amid a child and adolescent mental health crisis, and because of the chronic and severe shortage of mental health specialists, it is important that pediatric health care providers become facile with recognizing risk factors associated with suicidality and at-risk populations, screening and further assessment of suicidality as indicated, and evidence-based interventions for patients with suicidal ideation and associated behaviors. Suicide risk can be mitigated by appropriate screening, bolstering of protective factors, indicated treatment, community resources, and referrals to mental health providers when available.

Which Types of Providers Have Firearm Discussions in a Pediatric Primary Care Clinic?

OBJECTIVE: Safe firearm storage decreases self-inflicted and unintentional firearm injury in youth. Medical providers are well-positioned to discuss safe firearm storage with families. The primary objective of this study was to determine which providers are most likely to discuss firearms with their patients. Our secondary objective was to determine whether providers were more likely to discuss firearms with patients at elevated suicide risk. METHODS: This was a retrospective chart review of primary care well child visits occurring January-December 2019 in a large, urban academic clinic. We documented provider-type and training level (exposure); any documentation of firearms in the chart (counseling, screening) was considered as having a firearm discussion (outcome). We also collected demographics, patient mental health history, PHQ-9 scores, and assessed suicide risk. RESULTS: Of the 743 charts reviewed, firearms were discussed in 9% (n=66). Medical students were most likely to discuss firearms (15%), attending physicians were least likely (1%, p < 0.001). Providers did not discuss firearms more frequently among youth at elevated suicide risk. CONCLUSION: Though providers do not frequently discuss and document firearm discussions overall, the higher rates among medical students is promising. Given the lethality of firearms in a suicide attempt, the lack of firearm safety discussions with those at elevated suicide risk was concerning. Further study should evaluate factors that facilitate discussions in this cohort and identify strategies to improve counseling among more senior providers. WHAT'S NEW: Pediatric providers have an opportunity to counsel families about the risk of firearm access. We found that trainees are most likely to counsel families about firearms, and that providers are not more likely to counsel youth at elevated suicide risk.

Utilizing the Electronic Medical Record to Enhance Health Care Provider Delivery of Messages About the Safe Storage of Firearms.

The goal of this project was to determine whether screening youth and parents for firearm presence and imbedding those results in the electronic medical record (EMR) increased health care provider (HCP) documentation of firearms and subsequent delivery of a safe storage message. The study took place in a large adolescent medicine practice. Fifty-six dyads (40% of eligible) were randomized to usual care or the intervention, in which screening results for firearms were imbedded in the EMR. Health care providers delivered a safe storage message to 20% of controls and 51.2% in the intervention (P = .04). When HCPs documented the delivery of a safe storage message, 64% of parents recalled hearing it, compared with only 36% when there was no documentation (P = .012). Therefore, we found that incorporating firearm screening into the EMR increases the attention HCPs give to delivering a firearm safe storage message and correlates with parents recalling having heard a safe storage message.

Gun Carrying Among Military-Connected Youth With Past-Year Suicidal Ideation and Suicide Plans.

This cross-sectional study compares gun carrying practices and participation in violence prevention programs among youth with vs without a parent in the US military.

Building an evidence-based multitiered system of supports for high-risk youth and communities.

The mental, emotional and behavioral health problems of high-risk youth and youth living in high-risk communities are not inevitable and can be prevented. A shift from the nation's focus on treating disease and illness after it occurs to a concentrated effort on preventing the root causes of these problems is needed. Prevention science suggests a comprehensive multitiered approach that provides evidence-based prevention supports for children and youth at each developmental stage and across multiple social contexts is likely to result in the greatest health impact and return on investment. However, actually implementing this approach at a neighborhood level has remained a challenge and an ongoing research gap especially in high-risk communities. This article describes a process and provides a case study example for implementing a comprehensive, multitiered approach in a high-risk community. This includes assessing and prioritizing the specific needs of individuals and communities; selecting evidence-based programs based upon assessed needs; and creating a continuum of programs to improve the health and well-being of youth across developmental age spans, social contexts, and levels of risk. Operational details and challenges for organizing and implementing this comprehensive approach are also described. We estimate that the collective impact of a multitiered evidence-based approach, implemented with fidelity, could conservatively result in a 30 to 40% reduction in problem behaviors. (PsycINFO Database Record

Use of Psychopharmacologic Medications in Adolescents With Restrictive Eating Disorders: Analysis of Data From the National Eating Disorder Quality Improvement Collaborative.

PURPOSE: Psychopharmacologic medications are often prescribed to patients with restrictive eating disorders (EDs), and little is known about the frequency of use in adolescents. We examined the use of psychopharmacologic medications in adolescents referred for treatment of restrictive ED, potential factors associated with their use, and reported psychiatric comorbidities. METHODS: Retrospective data from the initial and 1-year visits were collected for patients referred for evaluation of restrictive ED at 12 adolescent-based ED programs during 2010 (Group 1), including diagnosis, demographic information, body mass index, prior treatment modalities, and psychopharmacologic medications. Additional data regarding patients' comorbid psychiatric conditions and classes of psychopharmacologic medications were obtained from six sites (Group 2). RESULTS: Overall, 635 patients met inclusion criteria and 359 had 1-year follow-up (Group 1). At intake, 20.4% of Group 1 was taking psychopharmacologic medication and 58.7% at 1 year (p ≤ .0001). White, non-Hispanic race (p = .020), and prior higher level of care (p < .0001) were positively associated with medication use at 1 year. Among Group 2 (n = 256), serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors use was most common, and 62.6% had a reported psychiatric comorbidity. Presence of any psychiatric comorbidity was highly associated with medication use; odds ratio, 10.0 (5.6, 18.0). CONCLUSIONS: Adolescents with restrictive ED treated at referral centers have high rates of reported psychopharmacologic medication use and psychiatric comorbidity. As more than half of this referral population were reported to be taking medication, continued investigation is warranted to ensure the desired outcomes of the medications are being met.

Predictors of outcome at 1 year in adolescents with DSM-5 restrictive eating disorders: report of the national eating disorders quality improvement collaborative.

PURPOSE: The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year. METHODS: Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed. RESULTS: At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration. CONCLUSIONS: The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.

Primary care practitioners' detection of youth violence involvement.

BACKGROUND: Youth violence is a widespread public health problem. Despite recommendations to address youth violence by the American Academy of Pediatrics, it is unclear how often primary care practitioners (PCPs) do so. PURPOSE: To determine PCPs' documentation of violence involvement. METHODS: Children 11 to 17 years old were enrolled while attending a clinic. They completed questionnaires assessing violence involvement confidentially without the knowledge of the PCP. The primary outcome, documented reference to violence involvement, was determined by chart review. RESULTS: A total of 165 youth participated: mean age = 14.5 years (standard deviation = 1.7), 43% male, 46% white. In all, 14.5% of charts documented any violence involvement. Of the 20% of youth who reported serious violence involvement, PCPs documented violence issues 19.4% of the time. Factors associated with documentation included nonwhite race (P < .05), having public (or no) insurance (P < .001), visit type (routine checkup (P < .05), and clinic site (P < .001). CONCLUSION: PCPs infrequently document discussion of violence-related issues, specifically in youth who are demonstrating risk.

An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses.

PURPOSE: This quality improvement project collected and analyzed short-term weight gain data for patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED programs nationally. METHODS: Data on presentation and treatment of low-weight ED patients aged 9-21 years presenting in 2006 were retrospectively collected from 11 independent ED programs at intake and at 1-year follow-up. Low-weight was defined as < 90% median body weight (MBW) which is specific to age. Treatment components at each program were analyzed. Risk adjustment was performed for weight gain at 1 year for each site, accounting for clinical variables identified as significant in bivariate analyses. RESULTS: The sites contained 6-51 patients per site (total N = 267); the mean age was 14.1-17.1 years; duration of illness before intake was 5.7-18.6 months; % MBW at intake was 77.5-83.0; and % MBW at follow-up was 88.8-93.8. In general, 40%-63% of low weight ED subjects reached ≥90% MBW at 1-year follow-up. At intake, patients with higher % MBW (p = .0002) and shorter duration of illness (p = .01) were more likely to be ≥90% MBW at follow-up. Risk-adjusted odds ratios controlled for % MBW and duration of illness were .8 (.5, 1.4)-1.3 (.3, 3.8), with no significant differences among sites. CONCLUSION: A total of 11 ED programs successfully compared quality improvement data. Shorter duration of illness before intake and higher % MBW predicted improved weight outcomes at 1 year. After adjusting for risk factors, program outcomes did not differ significantly. All adolescent medicine-based ED programs were effective in assisting patients to gain weight.