Widening Our Lane: How Child and Adolescent Psychiatrists Can Embrace the Full Spectrum of Mental Health.

The majority of a psychiatrist's training and clinical attention is devoted to mental illness rather than mental health. This article suggests a broader understanding and application of mental well-being that can benefit both those already struggling with mental health challenges and those trying to stay well. Recommendations for being a well-being-oriented psychiatrist include increasing one's knowledge about well-being and health promotion and adjusting one's practice to incorporate these principles. Recommendations at the level of the field of psychiatry include revising the definition of a psychiatrist, increasing research on well-being and health promotion, improving financial incentives, expanding efforts in schools and community settings, and providing additional training.

Reaching "The Other Half": Teacher Referral Increases Inclusivity in Intervention Research for Neurodivergent School-Age Children.

OBJECTIVE: Researchers employed two recruitment strategies in a school-based comparative effectiveness trial for students with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) or autism. This study assessed the: 1) effectiveness of school-based referrals for identifying students meeting diagnostic criteria and 2) impact of eliminating requirements for existing diagnoses on recruitment, sample characteristics, and intervention response. METHOD: Autistic students and students with ADHD in schools serving underresourced communities were recruited for an executive functioning (EF) intervention trial over 2 years. In Year 1, school staff nominated students with previous diagnoses. In Year 2, school staff nominated students demonstrating EF challenges associated with ADHD or autism; previous diagnosis was not required. Study staff then confirmed diagnoses. RESULTS: More students were included in Year 2 (N = 106) than Year 1 (N = 37). In Year 2, 96% of students referred by school staff met diagnostic criteria for ADHD or autism, 53% of whom were not previously diagnosed. Newly identified students were less likely than previously diagnosed students to be receiving services and, for those with ADHD, were more likely to speak primarily Spanish at home. Previously diagnosed and newly identified students did not differ on other demographic variables or intervention response. Caregivers of previously diagnosed students reported more symptoms than caregivers of newly identified students for both diagnostic groups. Previously diagnosed students with ADHD had more researcher-rated symptoms than newly identified students. CONCLUSIONS: Recruitment for an intervention study using behavior-based referrals from school staff enhanced enrollment without compromising the sample's diagnostic integrity and engaged children who otherwise would have been excluded.

Linking Primary Care to Community-Based Mental Health Resources via Family Navigation and Phone-Based Care Coordination.

Family navigation (FN) and phone-based care coordination may improve linkages from primary care to community-based mental health referrals, but research on their differential impact is limited. This mixed-methods study compared FN and phone-based care coordination in connecting families to mental health services from primary care. Families of children (56.3% male, mean age = 10.4 years, 85.4% Black) were sequentially assigned to either receive FN through a family-run organization or phone-based coordination via the child psychiatry access program (CPAP). Caregiver-reported children's mental health improved in both groups and both groups were satisfied with services. More families in the CPAP group had appointments made or completed (87%) than families in the FN group (71%) though the difference was not statistically significant. Future research with a larger sample that matches family needs and preferences (e.g., level and type of support) with navigation services would be beneficial.

Editorial: Cash Transfers to Families Living in Poverty: Can Benefits for Children Extend to the Next Generation?

Childhood poverty is the most widespread and important modifiable risk factor for the development of a range of health outcomes, including childhood-onset mental health problems.1 In the United States, 30 million children are growing up impoverished, which ranks among the highest per capita rates of child poverty among high-income countries.2 As a nation, the United States does less to support its poor children and their families than any other wealthy country, despite scientific evidence that growing up in poverty significantly increases lifetime risk of physical and mental health problems, reduces likelihood of academic and vocational success, and leads to poorer social outcomes for children.1 Meanwhile, 2 decades of research in low- and middle-income countries has demonstrated that directly providing poor families with financial support (commonly referred to as cash transfer programs)-delivered as one-time lump sum or smaller payments over time-produces reliably positive effects on a range of outcomes, including improved parental mental health, food security, housing security, educational and vocational attainment, female empowerment within families, as well as family savings and ownership of durable goods.3-6 Critics of cash transfer programs, who argue that poor families will exhibit temptation spending patterns (ie, alcohol, entertainment, etc), are increasingly being proven wrong by this literature, as studies have shown that recipient families tend to invest in the supports their children need to thrive.7.

"It was Just Good to Have an Outlet for Other Parents to Talk to": Feasibility and Acceptability of Integrating Mental Health and Wellness Services into Predominantly Black Early Childhood Education Centers During the COVID-19 Pandemic.

Racial disparities in mental health care access and quality are associated with higher levels of unmet need for Black parents and families, a population disproportionately affected by the COVID-19 pandemic. Integrating services within early childhood education centers may increase mental health care access for Black families with young children. The current study examined the feasibility, acceptability, and perceived impact of an integrated program offering mental health care for parents, children, and dyads during the pandemic. Black parents (N = 61) completed measures of program satisfaction and perceived benefits of participation, and 47 parents also participated in focus groups further assessing perceptions of the program. Results demonstrated high levels of satisfaction and perceived benefit of the program for parents and children. Themes generated through analysis included: social support, creating a safe space, prioritizing self-care, and sharing parenting strategies. Parents' feedback provides preliminary feasibility and acceptability for the integrated mental health program.

Leveraging the Expertise of the Community: A Case for Expansion of a Peer Workforce in Child, Adolescent, and Family Mental Health.

The rise in child and adolescent mental health concerns has led to the need for an expanded workforce to meet the needs of our nation's families. Peer paraprofessionals (PPs) have proven to be impactful in the areas of adult mental health (MH) and substance use disorders, and for persons with chronic medical conditions. PPs can contribute to addressing child, adolescent, and family MH needs by being deployed in community settings and providing both emotional and tangible support to families and children. Additional use of PPs can address equity gaps in MH services by improving access to support and enhancing the cultural acceptability of MH interventions. A concentrated effort to expand and develop this workforce may help to alleviate the strain on the current MH system. The Georgetown University Infant and Early Childhood Certificate program is a paraprofessional training program that prepares community members to meet the MH needs of families with young children. The authors will describe the results of a qualitative study examining the landscape of peer paraprofessional services in DC that was conducted to support the expansion of the peer workforce to include individuals with expertise in infant and early childhood mental health.

DC Mental Health Access in Pediatrics: Evaluating a Child Psychiatry Access Program in Washington, DC.

INTRODUCTION: Child psychiatry access programs (CPAPs) provide primary care providers (PCPs) with assistance in mental health diagnosis, management, and resource navigation. METHOD: Data collected from DC Mental Health Access in Pediatrics (MAP) included PCPs and patient demographics, clinical encounter information, and provider satisfaction. RESULTS: DC MAP consult volume increased 349.3% over the first 5 years. Services requested included care coordination (85.8%), psychiatric consultation (21.4%), and psychology/social work consultation (9.9%). Of psychiatry-involved consultations, PCPs managed patient medication care with DC MAP support 50.5% of the time. Most (94.1%) PCPs said they would recommend colleagues use DC MAP, and 29.6% reported diverting patients from the emergency departments using DC MAP. DISCUSSION: DC MAP grew quickly, highlighting program impact and need. Demand for care coordination required flexible staffing and highlighted the need for coordination in pediatrics. Child psychiatry access programs offer an innovative way to enhance PCP management of their patients' mental health needs.

The Family is the Patient: Promoting Early Childhood Mental Health in Pediatric Care.

Advances in developmental psychology, child psychiatry, and allied disciplines have pointed to events and experiences in the early years as the origin of many adult mental health challenges. Yet, children's mental health services still largely lack a developmental or prevention-focused orientation, with most referrals to mental health professionals occurring late, once problems are well established. An early childhood mental health system rooted in the principles of life-course health development would take a very different approach to designing, testing, and implementing prevention and intervention strategies directed toward early child mental health. Priorities for such a system include supporting healthy family environments, parent-child and family relationships, parents' emotional/behavioral health, and family routines as a means of providing the best possible neurobiological foundation for mental health across the life span. The system would include proactive, trauma-informed, multidisciplinary care, with integrated mental health and social services support embedded in pediatric primary care settings. Novel intervention approaches in need of further research include 2-generational dyadic interventions designed to improve the mental health of parents and children, mental health-oriented telemedicine, and contingency management (CM) strategies. Integral to this Life Course Health Development reformulation is a commitment by all organizations supporting children to primordial and primary prevention strategies to reduce racial and socioeconomic disparities in all settings. We contend that it is the family, not the individual child, that ought to be the identified target of these redesigned approaches, delivered through a transformed pediatric system with anticipated benefits for multiple health outcomes across the life course.

Advancing Antiracism in Community-Based Research Practices in Early Childhood and Family Mental Health.

Structural racism-the ways that institutional policies, practices, and other norms operate to create and sustain race-based inequities1-has historically been foundational to the operations of academic medical centers and research institutions. Since its inception, academic medicine has depended on the exploitation of vulnerable communities to achieve medical, educational, and research goals.2 Research practices have long ignored or taken advantage of the individuals purportedly benefiting from the research, a dynamic most manifestly true for Black, Indigenous, and People of Color (BIPOC) communities in the United States. Reflecting current practices in racial justice work, we intentionally use the term "BIPOC" to highlight shared experiences within racially and ethnically minoritized communities, given the history of White supremacy in the United States. We acknowledge limitations of this term, which collapses myriad unique communities and histories into one construct. Specifically, child and adolescent psychiatry has historically been driven by Eurocentric approaches, paradigms, and methodology. These nonparticipatory dominant research practices have contributed to a lack of culturally responsive interventions for BIPOC communities, a paucity of evidence-based practices with demonstrated effectiveness within BIPOC communities, and disparities in access and quality of care.3 Mental health research involving BIPOC communities has been replete with exploitation and inequality.2.

Editorial: Learning From the Pandemic: "Building Back Better" Through Research on Risk and Resilience With Diverse Populations.

The COVID-19 pandemic is responsible for over 2 million deaths and unprecedented disruption in the daily lives of people in communities worldwide. Efforts to slow viral transmission including quarantine and school closures have introduced profound changes in children's lives. Decreased opportunities for social interaction and physical activity, reduced instruction time impacting academic progress, changing nutritional habits and soaring rates of hunger, and increasing digital media use are just several of the myriad ways in which young people's lives have been altered. Emerging studies suggest that health and emotional wellbeing has been negatively impacted across developmental. There are many reasons to suspect that minoritized communities are particularly vulnerable, given the disproportionate toll COVID-19 has taken on the physical health and economic stability of Black, Latinx/Hispanic, and Native American communities who have experienced generations of structural racism and related health disparities. These indications of a percolating national and global crisis in children's mental health occur against a pre-COVID backdrop of inadequate health care infrastructure to meet the needs of children and families requiring mental health support. With these deeply concerning trends in mind, this month's Journal features new research from Penner et al.1 in which investigators found a protective effect of stay-at-home regulations on the mental health of a cohort of middle school students in the United States early in the pandemic. This study deserves our attention as we seek to understand the complex and evolving impacts of the pandemic upon youth mental health, and raises important questions about cultural, biological, and social factors that might contribute to resilience in specific youth and communities.

Editorial: Sharpening Our Focus on Early Adversity, Development, and Resilience Through Cross-National Research.

The impacts of the Adverse Childhood Experiences (ACEs) Study continue to reverberate across medicine, influencing clinical practice, research, and public policy, prompting reexamination of the original ACEs research, and generating a range of new research questions that are critical for understanding health and development across the lifespan.1,2 Within child and adolescent psychiatry, this explosion of interest in childhood trauma and its consequences is generating rich new areas of inquiry: how does adversity become biologically embedded in brain structure and functioning? What familial, environmental, and genetic factors influence resilience and risk? How should we update and adapt the original ACEs framework to account for cultural, ethnic, and geographic differences across populations with various exposures during childhood and distinct ways of experiencing and understanding these exposures? What positive experiences during childhood might have equally profound lifelong health impacts? In this issue of the Journal, Salhi et al.3 present findings from a large cross-national survey of parents of young children to examine their hypotheses that particular household exposures, physical discipline, and lack of cognitive stimulation represent adverse experiences associated with specific developmental outcomes in young children. Like much related research emerging in this area, the present study may provoke more new questions than it answers, and the article sharpens our focus to better understand the developmental science of early adversity and its implications for mental health promotion and clinical care.

Applying Mindfulness-Based Practices in Child Psychiatry.

Mindfulness-based interventions for adults, children, and families have grown considerably, and burgeoning evidence supports use of these approaches for a range of clinical presentations, including anxiety, depression, ADHD, and addiction. Research into the mechanisms of mindfulness suggests improvements in key brain-based functions including attentional control and emotional regulation. Mindfulness may be relevant for improving emotional and behavioral symptoms in children and families presenting for psychiatric care and also may be an important universal strategy to promote brain health. Child psychiatrists should be familiar with mindfulness-based clinical programs and also may seek to develop mindfulness-based strategies to use in clinical practice.

Where Do We Go from Here? Additional Opportunities to Address Well-Being in Child Psychiatry Clinical Practice and Advocacy for Children and Families.

Child psychiatrists should play an active role in helping parents and children to develop healthy media use habits and can introduce uses of technology including mobile applications and telepsychiatry to enhance clinical care. Strength-based approaches in clinical assessment and treatment build patient and family engagement and enhance outcomes in child psychiatry. Focusing on supporting youths' strengths and enhancing emotional and behavioral well-being are critical strategies for child psychiatrists working in consultation with schools and other community settings, and in advocating for optimal environments for children and families.

Parental Psychiatric Symptoms and Children's Outcomes: Toward Understanding and Responding to Intergenerational Risk in Child Psychiatry.

Family history of psychiatric illness is a core feature of any competent clinical history taken in a child and adolescent psychiatry clinical setting, and this history is often limited to reviewing caregivers' reports of diagnosed or suspected mental disorders in biological parents and relatives across several generations. Less commonly included is a detailed inquiry into parents' and caregivers' current mental health, including psychiatric symptoms at the time that their child is presenting for evaluation. Recent evidence is a strong reminder that parental mental illness is an important adversity that critically affects lifelong mental well-being in offspring, and that maternal depression in particular is an established factor influencing offspring mental health.1-3 In this issue of the Journal, Wesseldijk et al. present their article "Do Parental Psychiatric Symptoms Predict Outcome in Children With Psychiatric Disorders? A Naturalistic Clinical Study," an effort to examine relationships between parental psychiatric symptoms and clinical outcomes in child psychiatric patients.4 The study moves beyond a focus on maternal depression as a risk factor for offspring psychopathology to include a range of active psychiatric symptomatology in both mothers and fathers at the time that children are presenting for clinical evaluation, and again at follow-up over a year and a half later.

Mental Health Screening Quality Improvement Learning Collaborative in Pediatric Primary Care.

BACKGROUND: In the United States, up to 20% of children experience a mental health (MH) disorder in a given year, many of whom remain untreated. Routine screening during annual well visits is 1 strategy providers can use to identify concerns early and facilitate appropriate intervention. However, many barriers exist to the effective implementation of such screening. METHODS: A 15-month quality improvement learning collaborative was designed and implemented to improve screening practices in primary care. Participating practices completed a survey at 3 time points to assess preparedness and ability to promote and support MH issues. Monthly chart reviews were performed to assess the rates of screening at well visits, documentation of screening results, and appropriate coding practices. RESULTS: Ten practices (including 107 providers) were active participants for the duration of the project. Screening rates increased from 1% at baseline to 74% by the end of the project. For the 1 practice for which more comprehensive data were available, these screening rates were sustained over time. Documentation of results and appropriate billing for reimbursement mirrored the improvement seen in screening rates. CONCLUSIONS: The learning collaborative model can improve MH screening practices in pediatric primary care, an important first step toward early identification of children with concerns. More information is needed about the burden placed on practices and providers to implement these changes. Future research will be needed to determine if improved identification leads to improved access to care and outcomes.

Using Effective Public Private Collaboration to Advance Integrated Care.

Integrated mental health services within health care settings have many benefits; however, several key barriers pose challenges to fully implemented and coordinated care. Collaborative, multistakeholder efforts, such as health networks, have the potential to overcome prevalent obstacles and to accelerate the dissemination of innovative clinical strategies. In addition to engaging clinical experts, efforts should also include the perspectives of families and communities, a grounding in data and evaluation, and a focus on policy and advocacy. This article describes how one community, Washington, DC, implemented a health network to improve the integration of mental health services into pediatric primary care.