Diagnoses and Treatment in Juvenile Detention Before and After Evaluation by Facility-Based Mental Health Service.

As of 2018, more than 37,000 American youth were residing in juvenile detention or residential placement facilities.1 Prevalence studies have demonstrated high rates of psychiatric illness in this population, with estimates ranging from 50% to 75%.2,3 Comorbidity is common: Abram et al. found that 75% of juvenile detainees meeting criteria for one disorder met criteria for two or more disorders.4 Compared to psychiatric morbidity in justice-involved youth, there is a paucity of data describing mental health services within juvenile justice settings, treatments delivered by these services, or outcomes following treatment. We performed a retrospective study to compare diagnoses and medications prescribed to youth in the community prior to detention with those received after evaluation by the facility-based juvenile justice mental health service (JJMHS) staffing secure detention facilities in New York, NY.

Promoting Early Brain and Child Development: Perceived Barriers and the Utilization of Resources to Address Them.

OBJECTIVE: Efforts to promote early brain and child development (EBCD) include initiatives to support healthy parent-child relationships, tools to identify family social-emotional risk factors, and referrals to community programs to address family risk factors. We sought to examine if pediatricians perceive barriers to implementing these activities, and if they utilize resources to address those barriers. METHODS: Data were analyzed from 304 nontrainee pediatricians who practice general pediatrics and completed a 2013 American Academy of Pediatrics Periodic Survey. Sample weights were used to decrease nonresponse bias. Bivariate comparisons and multivariable regression analyses were conducted. RESULTS: At least half of the pediatricians agreed that barriers to promoting EBCD include: a lack of tools to promote healthy parent-child relationships, a lack of tools to assess the family environment for social-emotional risk factors, and a lack of local resources to address family risks. Endorsing a lack of tools to assess the family environment as a barrier was associated with using fewer screening tools and community resources. Endorsing a lack of local resources as a barrier was associated with using fewer community resources and fewer initiatives to promote parent-child relationships. Interest in pediatric mental health was associated with using more initiatives to promote healthy parent-child relationships, screening tools, and community resources. CONCLUSIONS: Although the majority of pediatricians perceive barriers to promoting EBCD, few are routinely using available resources to address these barriers. Addressing pediatricians' perceived barriers and encouraging interest in pediatric mental health may increase resource utilization and enhance efforts to promote EBCD.

Factors Associated With Whether Pediatricians Inquire About Parents' Adverse Childhood Experiences.

OBJECTIVE: Cumulative adverse childhood experiences (ACE) can have profound and lasting effects on parenting. Parents with a history of multiple ACE have greater challenges modulating their own stress responses and helping their children adapt to life stressors. We examined pediatric practice in inquiring about parents' childhood adversities as of 2013. METHODS: Using data from the 85th Periodic Survey of the American Academy of Pediatrics (AAP), we restricted analyses to the 302 pediatricians exclusively practicing general pediatrics who answered questions regarding their beliefs about childhood stressors, their role in advising parents, and whether they asked about parents' ACEs. Weighted descriptive and logistic regression analyses were conducted. RESULTS: Despite endorsing the influence of positive parenting on a child's life-course trajectory (96%), that their advice can impact parenting skills (79%), and that screening for social-emotional risks is within their scope of practice (81%), most pediatricians (61%) did not inquire about parents' ACE. Pediatricians who believed that their advice influences positive parenting skills inquired about more parents' ACE. CONCLUSIONS: As of 2013, few pediatricians inquired about parents' ACEs despite recognizing their negative impact on parenting behaviors and child development. Research is needed regarding the best approaches to the prevention and amelioration of ACEs and the promotion of family and child resilience. Pediatricians need resources and education about the AAP's proposed dyadic approach to assessing family and child risk factors and strengths and to providing guidance and management.

Do On-Site Mental Health Professionals Change Pediatricians' Responses to Children's Mental Health Problems?

OBJECTIVE: To assess the availability of on-site mental health professionals (MHPs) in primary care; to examine practice/pediatrician characteristics associated with on-site MHPs; and to determine whether the presence of on-site MHPs is related to pediatricians' comanaging or more frequently identifying, treating/managing, or referring mental health (MH) problems. METHODS: Analyses included American Academy of Pediatrics (AAP) members who participated in an AAP Periodic Survey in 2013 and who practiced general pediatrics (n = 321). Measures included sociodemographics, practice characteristics, questions about on-site MHPs, comanagement of MH problems, and pediatricians' behaviors in response to 5 prevalent MH problems. Weighted univariate, bivariate, and multivariable analyses were performed. RESULTS: Thirty-five percent reported on-site MHPs. Practice characteristics (medical schools, universities, health maintenance organizations, <100 visits per week, <80% of patients privately insured) and interactions of practice location (urban) with visits and patient insurance were associated with on-site MHPs. There was no overall association between colocation and comanagement, or whether pediatricians usually identified, treated/managed, or referred 5 common child MH problems. Among the subset of pediatricians who reported comanaging, there was an association with comanagement when the on-site MHP was a child psychiatrist, substance abuse counselor, or social worker. CONCLUSIONS: On-site MHPs are more frequent in settings where low-income children are served and where pediatricians train. Pediatricians who comanage MH problems are more likely to do so when the on-site MHP is a child psychiatrist, substance abuse counselor, or social worker. Overall, on-site MHPs were not associated with comanagement or increased likelihood of pediatricians identifying, treating/managing, or referring children with 5 common child MH problems.

Beyond ADHD: How Well Are We Doing?

BACKGROUND AND OBJECTIVE: There has been increasing emphasis on the role of the pediatrician with respect to behavioral, learning, and mental health (MH) issues, and developmental behavioral rotations are now required in pediatric residency programs. We sought to examine whether this newer emphasis on MH is reflected in pediatricians' reports of their current practices. METHODS: Data from 2 periodic surveys conducted in 2004 and 2013 by the American Academy of Pediatrics were examined to see whether there were differences in self-reported behaviors of usually inquiring/screening, treating/managing/comanaging, or referring patients for attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, behavioral problems, or learning problems. We examined patterns for all practicing members and for those who practiced general pediatrics exclusively. RESULTS: There were few changes over the decade in the percentage who inquired or screened among all clinicians; among those exclusively practicing general pediatrics, the percentage who inquired or screened increased about 10% for ADHD and depression. ADHD remained the only condition for which the majority of respondents treated/managed/comanaged (57%). While there was some increase in the percentages who treated other conditions, the other conditions were usually treated by <30% of respondents. A similar pattern of results was observed in analyses adjusted for physician, practice, and patient characteristics. CONCLUSIONS: Despite the changing nature of pediatric practice and increased efforts to emphasize the importance of behavior, learning, and MH, the pediatric community appears to be making little progress toward providing for the long-term behavioral, learning, and MH needs of children and adolescents in its care.

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 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.

Exploring perceptions and experiences of maternal depression in Latinas: a qualitative study.

Understanding how depression is conceptualized is key to designing effective screening and treatment procedures. Of particular concern is maternal depression in Latinas, given the high Latina birthrate. We conducted two focus groups of pregnant Latinas to elicit their perceptions of and experiences with maternal depression. Women reported familiarity with the concept of maternal depression and that their experiences with depression were linked to social support from family and friends. Women also indicated that they felt responsible for coping and recovering from depression independently. How experiences with depression interact with traditional Latino idioms of distress, needs further investigation.

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.

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.