Pediatrician Burnout Before and After the COVID-19 Pandemic.

OBJECTIVE: During the surge of the COVID-19 pandemic, burnout among physicians increased significantly. In the spring of 2023, the COVID national emergency was terminated in the U.S. To investigate whether provider burnout rates have returned to pre-pandemic levels, the current study compared dimensions of burnout among pediatricians pre- and post-pandemic. METHOD: As part of 2 separate behavioral health trainings held at a Midwest academic health center in 2019 and virtually in 2023, data on burnout was collected from 52 pediatricians pre-pandemic and 38 pediatricians post-pandemic. Participants completed an online survey during the trainings and responded to items reflecting 3 dimensions of burnout: emotional exhaustion, depersonalization, and personal accomplishment. RESULTS: There were no statistically significant differences in pre- and post-pandemic burnout amongst pediatricians in terms of total scores, number of pediatricians who met the clinical cutoff for each dimension, number of cutoffs met, or number of providers reporting elevated burnout on at least 1 dimension (p > .05 for all comparisons). Participants were 1.77 times more likely to meet the cutoff for emotional exhaustion post-pandemic than pre-pandemic. Over half of providers met this cutoff post-pandemic, compared to only 35% pre-pandemic. CONCLUSIONS: While post-pandemic rates of burnout among pediatricians appear to be statistically similar to pre-pandemic levels, there appear to be clinically significant differences in emotional exhaustion between groups. With 63% of the post-pandemic group meeting the cutoff score for at least 1 dimension, it is imperative for the healthcare system to consider ways to mitigate burnout.

The Use of Electronic Health Record Tools to Improve Evidence-Based Treatment of Adolescent Depression in Primary Care.

OBJECTIVE: The aim of the current study was to evaluate primary care pediatrician (PCP) adoption of an electronic health record (EHR) documentation tool and their delivery of a behavioral activation (BA) intervention within their routine practice with adolescents who screened positive for depression. METHODS: We used the RE-AIM framework to describe PCP adoption and implementation of EHR documentation tools and brief evidence-based protocols. Utilization was assessed using a customized toolbar (ie, actions toolbar) via retrospective chart review. A pre-post design was used to measure changes in PCP-reported knowledge, comfort, and feasibility managing depression before and after they were trained. A mixed-effects logistic regression model was used to analyze associations of resource utilization with depression severity. RESULTS: PCPs used the actions toolbar to document responses to elevated Patient Health Questionnaire (PHQ-9) scores for 29.80% of encounters. The PCPs utilized the BA protocol for 10.5% of encounters with elevated PHQ-9 scores. Higher depression severity categories were associated with significantly higher odds of utilization relative to mild severity. The training was rated highly acceptable and PCPs reported significant post-training increases in comfort and feasibility. CONCLUSION: This is the first study of its kind to implement and evaluate PCP utilization of an EHR documentation tool aimed to improve delivery of an evidence-based intervention for adolescent depression. Teaching PCPs to implement brief interventions has potential to increase access to evidence-based care; however, large-scale practice change requires an effective implementation strategy that does not increase provider burden and is fully integrated into physician documentation and workflow.

Notes from the Field: Results from the Parent Acceptance of Pediatric Integrated Care Survey.

OBJECTIVE: To collect data and gain an understanding of parental satisfaction with and attitudes toward treatment in a pediatric integrated primary care (IPC) model. DATA SOURCES: Primary data were collected across the United States over the course of a few months. STUDY DESIGN: The 35-item, Parent Acceptance of Pediatric Integrated Care Survey (PAPICS) was developed by a panel of IPC experts. The survey was then distributed through the Qualtrics Panels Service with recruited participants (i.e., parents with children under 18-years-old) receiving a $4.00 incentive for their involvement. DATA COLLECTION/EXTRACTION METHODS: A single exploratory factor analysis was performed along with four factor retention tests and clinical judgment to guide factor selection. A 5-factor structure was selected. PRINCIPAL FINDINGS: Parents reported a high level of comfort with an IPC model and a favorable attitude toward child therapy, with some concerns regarding psychological stigma and privacy. Notable variation in parents' beliefs regarding one-on-one psychological service delivery were observed. CONCLUSIONS: Results provided evidence for parental openness to an IPC model. Findings also highlighted potential fundamental misunderstandings regarding evidence-based psychological treatment methods for children and adolescents.

The Association Between Burnout and Pediatrician Management of Adolescent Depression.

Objective: Given the increased demand for pediatric primary care providers to manage adolescent depression, the current study examines the association between burnout and provider comfort and perception of feasibility managing adolescent depression. Method: Data were collected from 52 pediatricians at a Midwest academic health center. Results: Higher scores on depersonalization were associated with lower provider-reported comfort managing adolescent depression. Emotional exhaustion and personal accomplishment were not associated with provider-reported comfort managing adolescent depression. None of the burnout domains were associated with the provider-reported perception of the feasibility managing adolescent depression in this setting. Limitations and recommendations for future research regarding the impact of behavioral health training on burnout are discussed. Conclusions: The interpersonal stress dimension of burnout is associated with less comfort managing depression. Adding positive systematic interventions, such as behavioral health trainings that support pediatricians in the management of behavioral health may have impact on burnout.

Comparing primary care pediatricians' perceptions of clinics with and without integrated behavioral health.

Objective: The purpose of this study was to investigate primary care pediatrician (PCP) perceptions of prevalence of, time spent in, and satisfaction with behavioral health services across clinics with and without on-site behavioral health providers (BHPs). Methods: A cross-sectional survey design was used to examine satisfaction across sites. Data were collected on PCP perceptions of behavioral health services among 60 pediatricians within two academic medical systems. Results: PCPs perceived behavioral health issues are prevalent and a time-consuming aspect of medical appointments and preferred to have on-site BHPs over off-site referral sources. Compared to sites without an on-site BHP, sites with on-site BHPs were more satisfied with behavioral health service availability and resources, felt they spent more time addressing medical concerns, and spent less time providing anticipatory guidance. Discussion: Study limitations included questions surrounding the validity of survey items to accurately assess PCP perceptions, lack of rigorous experimental design, and reliance on self-report data.

Integrated care models for ADHD in children and adolescents: A systematic review.

INTRODUCTION: Attention-deficit/hyperactivity disorder (ADHD) in children and adolescents is commonly managed in primary care. Changes in United States health care have led to the integration of behavioral health services within a patient's "medical home" to improve access to, engagement in, and continuity of quality health care. Despite proliferation of these integrated care models, no studies have specifically examined models for managing ADHD in children and adolescents within primary care. METHOD: We searched PsycINFO, MEDLINE, and Google Scholar databases, and found 8 studies describing 6 integrated care models (i.e., combined psychosocial and medication treatments with coordination of care between primary care clinicians and behavioral health clinicians). We reviewed characteristics (i.e., settings, target populations, providers, levels of integration, evaluation and treatment approaches, and methods of interprofessional collaboration) and outcomes (i.e., access, outcomes, and acceptability) of these models. RESULTS: The 6 integrated care models demonstrate the potential to improve access to and acceptability of ADHD care for children and adolescents. The models also demonstrate that behavioral health clinicians can integrate at various levels within primary care to achieve superior clinical outcomes compared with nonintegrated models. DISCUSSION: We identified 6 effective integrated care models for addressing ADHD in children and adolescents that may be adaptable to local needs and internal capacities. We discuss results of these models with regard to their implications for clinical practice and research. (PsycINFO Database Record

Association between diabetes treatment adherence and parent-child agreement regarding treatment responsibilities.

When primary responsibility for Type 1 diabetes (DM1) treatment adherence transfers from parents to adolescents, glycemic control often suffers. Low rates of treatment adherence during this transition are possibly attributable to decreased parental involvement, disagreements between parents and children regarding treatment responsibilities, and increased family conflict. The current investigation assessed the relationships between each of these variables and glycemic control among youth diagnosed with DM1. Parent and child report questionnaires were completed by 64 parent-child dyads (ages 8-18) with a child diagnosed with DM1. HbA1c readings served as measures of glycemic control. Parental involvement in their children's treatment was reported to decline with age, however absolute levels of parent involvement were not significantly correlated with youth HbA1c levels. Parent-child agreement regarding treatment responsibility and reports of diabetes-related conflict were significant predictors of glycemic control. Results support previous findings implicating parent-child agreement regarding treatment responsibilities and family conflict as predictors of treatment adherence among youth with DM1. The current study found this relationship to be significant for a larger population of children for which past research has failed to find such an effect. Taken together, these findings suggest further research is warranted to identify effective methods for transferring treatment responsibilities from parents to children.

Assessing treatment barriers in young adults with type 1 diabetes.

AIMS: The current study was designed to identify barriers that prevent young adults with DM1 from achieving glycemic control. METHODS: Eighty-three young adult patients with DM1 [age 22.2 ± 2.8 years (mean ± SD), duration diabetes 11.3 ± 5.6 years, HbA1c 8.8 ± 2.1%] completed a battery of surveys assessing potential barriers to achieving glycemic control. Results of questionnaires were correlated with the patient's most recent HbA1c, and a multiple regression analysis was conducted to determine what barriers were significantly associated with HbA1c levels. RESULTS: Questionnaires that significantly correlated with HbA1c levels included the Conflict Subscale of the Diabetes Responsibility and Conflict Scale (r = .55, p < .01), the Modified Barriers to Adherence Questionnaire (r = .42, p < .01), and the Hospital Anxiety and Depression Scale (r = .31, p < .05). An item analysis of the Modified Barriers to Adherence Scale suggested that patient confidence with carbohydrate counting was most statistically associated with HbA1c [F(3, 80) = 12.95, p < .01, R²=.35]. CONCLUSIONS: Results suggest that despite attempts to educate patients; barriers such as family conflict, psychological issues, and carbohydrate counting remain obstacles impeding glycemic control in young adults with DM1.

Parental report of medication acceptance among youth: implications for everyday practice.

OBJECTIVE: Evidence-based interventions for pill swallowing training exist but are primarily implemented in pediatric specialty hospitals. Given increasing interest in the translation of brief and effective interventions to the wider population, there is a need to examine medication acceptance in a normative sample. METHODS: Participants (N = 304) completed the Medication Acceptance Survey, which assessed child/adolescent liquid and pill medication history and acceptance as well as parental interest in pill swallowing training. RESULTS: Results showed that 30-40% of youth had rejected/refused a pill or liquid formulation. Over half were unable to swallow a standard size pill or small capsule. Despite these difficulties, most parents did not express interest in an empirically supported pill swallowing training intervention. CONCLUSIONS: The results provide directions for future research as well as the translation of pill swallowing interventions to primary care.

Assessment and treatment of autism.

Physicians are often the first health care professionals to encounter children that display symptoms associated with developmental disorders such as autism. Unfortunately, there is lack of information regarding what strategies physicians should adopt in treating these symptoms and where they should look to refer individuals who present with severe symptoms of autism. This paper provides some preliminary information regarding the current behavioral assessment and treatment strategies in order to help physicians identify and make appropriate recommendations for successful treatment when working with autistic children. The essential components of successful treatment for autism are outlined; some preliminary treatment methodologies that physicians can recommend parents or caregivers attempt are also highlighted. In addition, the current behavioral treatment strategies used for acquisition of social skills and language are covered as well as methodologies for the reduction of maladaptive behavior in children with autism.

Functional analysis and treatment of the bizarre speech of dually diagnosed adults.

Nine behavior-analytic studies, each reporting data for a single participant, have shown that bizarre speech can be maintained by social reinforcement. In the current study, we controlled for a possible referral bias in this literature by including nonreferred participants with dual diagnoses. Functional analyses identified attention functions for 2 participants and nonsocial functions for the others. Noncontingent reinforcement decreased the bizarre speech of both participants who displayed attention-maintained bizarre speech.

Using video modeling and reinforcement to teach perspective-taking skills to children with autism.

We evaluated video modeling and reinforcement for teaching perspective-taking skills to 3 children with autism using a multiple baseline design. Video modeling and reinforcement were effective; however, only 2 children were able to pass an untrained task, indicating limited generalization. The findings suggest that video modeling may be an effective technology for teaching perspective taking if researchers can continue to develop strategies for enhancing the generalization of these new skills.

An evaluation of simultaneous and sequential presentation of preferred and nonpreferred food to treat food selectivity.

In the current investigation, we compared two methods of food presentation (simultaneous vs. sequential) to increase consumption of nonpreferred food for 3 children with food selectivity. In the simultaneous condition, preferred foods were presented at the same time as nonpreferred food (e.g., a piece of broccoli was presented on a chip). In the sequential condition, acceptance of the nonpreferred food resulted in presentation of the preferred food. Increases in consumption occurred immediately during the simultaneous condition for 2 of the 3 participants. For 1 participant, increases in consumption occurred in the simultaneous condition relative to the sequential condition, but only after physical guidance and re-presentation were added to treatment. Finally, consumption increased for 1 participant in the sequential condition, but only after several sessions. These results are discussed in terms of possible mechanisms that may alter preferences for food (i.e., establishing operations, flavor-flavor conditioning).