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.

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.

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 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.

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.

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.

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.

In the moment: attitudinal measure of pediatrician management of maternal depression.

OBJECTIVE: Pediatricians are in a good position to identify women who struggle with depression, but studies show low rates of pediatrician identification and management. It is likely that pediatricians' management of maternal depression may vary on the basis of their attitudes, but no instrument has been developed to measure these attitudes. We sought to develop a measure of pediatricians' attitudes about managing maternal depression and to identify characteristics associated with pediatricians' attitudes about managing maternal depression. METHODS: We conducted a cross-sectional analysis of data provided by 651 practicing, nontrainee pediatricians (response rate 57.5%) surveyed through an American Academy of Pediatrics 2004 Periodic Survey. An exploratory principal components analysis was used to investigate the interrelationships among the attitudinal items. Multivariable linear regression was used to assess the adjusted associations between physician and practice characteristics and attitudes. RESULTS: The attitudinal measure consisted of 3 subscales: acknowledging maternal depression, perceptions of mothers' beliefs, and treating maternal depression. Clinical approaches (eg, interest in further education on identifying or treating maternal depression) and training and work characteristics were significantly related to pediatricians' attitudes; patient characteristics (eg, type of insurance and ethnicity/race) were not significantly associated with pediatricians' attitudes. CONCLUSIONS: We developed a measure to assess pediatricians' attitudes about managing maternal depression. The findings from this study can be used to develop and assess interventions that improve pediatricians' attitudes about acknowledging maternal depression, perceptions of mothers' beliefs, and treating maternal depression.

Factors associated with identification and management of maternal depression by pediatricians.

OBJECTIVE: We sought to identify characteristics of pediatricians that were associated with identification or management (referral and/or treatment) of mothers with depression. METHODS: A cross-sectional survey was mailed to a random sample of 1600 of the 50,818 US nonretired members of the American Academy of Pediatrics. Overall, 832 responded, with 745 responses from nontrainee members. The 662 fellow nontrainee members who engaged in direct patient care and completed information on identifying, referring, and treating maternal depression were included in the analyses. RESULTS: A total of 511 of 662 respondents reported identifying maternal depression; of those who reported identifying maternal depression, 421 indicated they referred and 29 that they treated maternal depression in their practices. Pediatricians who are older, work in practices that provide child mental health services, see primarily (> or = 75%) white patients, use > or = 1 method to address maternal depression, agree that pediatricians should be responsible for identifying maternal depression, think that maternal depression has an extreme effect on children's mental health, and are attitudinally more inclined to identify or manage maternal depression had significantly higher odds of reporting identification of maternal depression. Positive correlates of identification and management of maternal depression included practicing in the Midwest, using > or = 1 method to address maternal depression, working in a practice that provides child mental health services, thinking that caregiving problems attributable to maternal health have an extreme effect on children's physical health, having attitudes that are more inclined to identify and to manage maternal depression, and usually inquiring about symptoms routinely to identify maternal depression. CONCLUSIONS: Pediatricians' practice characteristics and attitudes are associated with their identification and management of mothers with depression.

Barriers to the identification and management of psychosocial issues in children and maternal depression.

CONTEXT: Child psychosocial issues and maternal depression are underidentified and undertreated, but we know surprisingly little about the barriers to identification and treatment of these problems by primary care pediatricians. OBJECTIVES: The purpose of this work was to determine whether (1) perceived barriers to care for children's psychosocial issues and maternal depression aggregate into patient, physician, and organizational domains, (2) barrier domains are distinct for mothers and children, and (3) physician, patient, and practice/organizational characteristics are associated with different barrier domains for children and mothers. METHODS: We conducted a cross-sectional survey of the 50,818 US nonretired members of the American Academy of Pediatrics. Of a random sample of 1600 members, 832 (745 nontrainee members) responded. This was a mailed 8-page survey with no patients and no intervention. We measured physician assessment of barriers to providing psychosocial care for children's psychosocial problems and maternal depression. RESULTS: Pediatricians frequently endorse the lack of time to treat mental health problems (77.0%) and long waiting periods to see mental health providers (74.0%) as the most important barriers to the identification and treatment of children's psychosocial problems. For maternal depression, pediatricians most often endorsed lack of training in treatment (74.5%) and lack of time to treat (64.3%) as important barriers. Pediatricians' reports of barriers clustered into physician and organizational domains. Physician domains were distinct for children and mothers, but organizational domains were not. Several physician and practice characteristics are significantly associated with the 4 barrier scales, and different characteristics (eg, sociodemographic, attitudinal, and practice features) were related to each barrier area. CONCLUSIONS: Pediatricians endorse a wide range of barriers with respect to the diagnosis and treatment of children's mental health problems and maternal depression. The specificity of factors relating to various barrier areas suggests that overcoming barriers to the identification and treatment of child mental health problems and maternal depression in primary care pediatrics is likely to require a multifaceted approach that spans organizational, physician, and patient issues. In addition, comprehensive interventions will likely require social marketing approaches designed to engage diverse audiences of clinicians and their patients to participate.

The relationship of depressive symptoms to parenting competence and social support in inner-city mothers of young children.

OBJECTIVE: Despite the high prevalence of maternal depression and its negative consequences for children, many pediatricians fail to identify this problem. Our goal was to determine whether simple questions about parenting competence and the adequacy of maternal social support might be useful to providers in determining which inner-city mothers are likely to be depressed. METHODS: We surveyed a convenience sample of 279 English-speaking mothers of children 6 months to 3 years old prior to a routine visit at an urban, hospital-based general pediatrics clinic. The mothers self-completed the Psychiatric Symptom Index (PSI) and the Parenting Stress Index Sense of Competence subscale, and rated the adequacy of their social support, and provided health and sociodemographic data by face-to-face interview. RESULTS: 41% of mothers had "high" PSI symptom levels and 22% had scores above a criterion that suggests major depressive disorder. In addition, 15% experienced high parenting stress (low competence) and 42% reported little or no social support. High distress was unrelated to a variety of sociodemographic risk factors, but significantly associated with a poor sense of parenting competence (Adj. OR = 3.3, 95% CI = 1.5, 7.0) and inadequate perceived social support (Adj. OR = 2.3, 95% CI = 1.2, 4.4), as well as with having health-related activity limitations (Adj. OR = 3.2, 95% CI = 1.1, 9.0). CONCLUSIONS: Negative ratings of parenting competence, low perceived social support, and presence of health-related activity restrictions can be useful markers of likely depression among inner-city mothers of young children. These factors are often assessed during routine pediatric visits and may be helpful to pediatricians in identifying mothers needing further evaluation or treatment by mental health specialists.

Will mothers discuss parenting stress and depressive symptoms with their child's pediatrician?

BACKGROUND: Parenting stress and maternal depressive symptoms are ubiquitous and have negative consequences for children. Pediatricians may be an underused resource to mothers regarding these issues. OBJECTIVE: To explore maternal beliefs and perceptions about discussing the stress of parenting and depressive symptoms with their child's pediatrician. DESIGN/METHODS: Mothers were recruited from 5 community-based pediatric practices and 1 hospital-based practice to ensure a diverse sample. An experienced, trained facilitator conducted focus groups by using open-ended questions and administered a standard questionnaire. Audiotapes and transcripts of the groups were reviewed for major themes by 3 independent researchers using grounded theory and immersion/crystallization technique. RESULTS: Seven focus groups (N = 44) were convened. Participants were 70% black and 30% white with a mean age of 27 years; 61% were single; 50% were educated beyond high school; and 43% received public assistance as their main source of income. The mean score on the Psychiatric Symptom Index was 26.3 (high > or =20). Within 2 overarching domains (maternal and interaction between mother and pediatrician), several themes emerged. Within the maternal domain, dominant themes included 1) emotional health: all respondents indicated that a mother's emotional health greatly affects her child's well being; 2) self-efficacy: mothers believed in the importance of accepting responsibility for monitoring their own well being and that of their child; and 3) support systems: all mothers expressed the need to share parenting experiences, stressors, and depressive symptoms with someone (most preferred to speak with family or friends rather than with their child's pediatrician). Within the interaction domain, 2 themes emerged: 1) communication: open communication with a pediatrician who listens well was perceived by mothers in all groups as very important, and 2) trust: mothers trust pediatricians with their child's health, but many were hesitant to discuss their own stress or depressive symptoms. Mothers in all socioeconomic groups expressed fear of judgment and possible referral to child protection if they talked about such issues. Both of these were mediated by the presence of an ongoing relationship between the pediatrician and mother. Mothers were more likely to discuss their own emotional health if they felt their child's pediatrician "knew them well." CONCLUSIONS: Mothers are aware that their own emotional health has consequences for their children. Although many mothers experienced lacks in their social support systems, many are reluctant to discuss parenting stress and depressive symptoms with their child's pediatrician because of mistrust and fear of judgment. Mothers are, however, generally receptive to the idea of open communication with their pediatricians and are interested in receiving supportive written communication about parenting stress and depressive symptoms from pediatricians. These qualitative data are valuable in developing an intervention to help pediatricians assist mothers at risk.