The intersectionality of professional and personal identity formation in a virtual pre-health pathway program.

BACKGROUND AND PURPOSE: To describe the development and implementation of professional and personal identity formation content in a virtual pre-health pathway program. EDUCATIONAL ACTIVITY AND SETTING: Content within a six-week pre-health program for underrepresented and/or disadvantaged college students was redesigned to a virtual format with enhanced focus on professional and personal identity formation. Sessions on personal identity formation were also enhanced through a partnership with local mental health clinicians specializing in trauma-informed care and culturally relevant practices and strategies. FINDINGS: The 2020 and 2021 programs were restructured to include pharmacy professional identity formation content around the following weekly themes: Roadmap to Pharmacy, What Does it Mean to be a Pharmacist?, Expanding Knowledge of Pharmacy, Gaining Insight and Dispelling Myths, Practicing Knowledge and Exploration, and Moving Forward. These pre-pharmacy components emphasized diversity of career paths, pharmacy-based clinical services, and the pharmacist's role in promoting health equity. Overarching components of interprofessional collaboration coupled with health policy applications further emphasized the professional identity of a pharmacist in the collaborative design and delivery of health care. New personal identity formation sessions were implemented in tandem with this content and centering around the following themes: Supporting Scholars in Self-Authorship, Building a Community among Peers, and Strategies for Coping in Times of Challenge. SUMMARY: This project has the potential to serve as a model for the implementation of both personal and professional identity formation initiatives at other programs to promote pharmacy as a desirable and attainable career to pre-health students.

Use of the Child Opportunity Index to Examine Racial Variations in Outpatient Antibiotic Prescribing to Children.

To examine further racial and ethnic variations in antibiotic prescribing to children, we used the Child Opportunity Index. Black children were less likely to be prescribed an antibiotic. Low- and moderate-opportunity areas were associated with greater rates of antibiotic prescribing, after adjusting for race and other factors.

Examination of U.S. national rates of emergency department visits and hospitalizations for depression and suicidal behaviors after the release of the 13 Reasons Why Netflix series by demographic characteristics.

BACKGROUND: To evaluate the impact of the series 13Reasons Why on depression and suicidal behaviors in children and adolescents. METHODS: Data from the 2016 to 2018 Nationwide Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS) of the Healthcare Cost and Utilization Project (HCUP) from 2016 to 2018 was used to determine the presentation in both settings for depression and suicidal thoughts and behavior. This was compared to predictive modeling for presentations in the same time frame. RESULTS: Following the release of 13 Reasons Why both hospital admissions and presentations to the Emergency Department (ED) increased for complaints of worsening depression or suicidal thoughts and behavior. This was more pronounced for youth aged 10-17 years, Black race, and female sex. There were no significant findings, overall, for females 6-9 years, but in-patient visits for depression increased in May 2017 for Black females 6-9 years. Males 6-9 years had higher rates of ED visits for depression and both ED and in-patient visits for suicidal behaviors. LIMITATIONS: Secondary data analyses have known limitations including inability to track over time, inclusion of only visit-level data, and failure to collect variables of interest. CONCLUSIONS: The series 13 Reasons Why was likely associated with exacerbations of both depressive illnesses and suicidal behavior in youth, particularly for female and Black youth from 10 to 17 years. This study adds to known concerns regarding the role of media in influencing suicidal behavioral in vulnerable children and has important implications for youth monitoring and parent and youth education. More research is needed to identify specific targets for prevention.

Antipsychotic Medications for Low-Income Preschoolers: Long Duration and Psychotropic Medication Polypharmacy.

OBJECTIVE: This study aimed to evaluate prescribing patterns of antipsychotic medication and factors that predict duration of use among low-income, preschool-age children. METHODS: State Medicaid claims from 2012 to 2017 were used to identify antipsychotic medication use for children <6 years old. ICD-9 and ICD-10 codes were used to describe child diagnoses. Descriptive and multivariable analyses were used to determine patterns of antipsychotic medication use and factors that predicted duration of use. RESULTS: In 2012, 316 children <6 years of age started an antipsychotic medication in a southeastern state. Most were non-Hispanic White (N=202, 64%) and boys (N=231, 73%). Diagnoses included attention-deficit hyperactivity disorder (N=288, 91%), neurodevelopmental disorders (N=208, 66%), anxiety and trauma-related diagnoses (N=202, 64%), and autism spectrum disorders (ASDs) (N=137, 43%). The mean±SD duration of exposure to antipsychotic medication for children in the cohort was 2.6±1.7 years, but 86 children (27%) had >4 years of exposure. Almost one-third (N=97, 31%) received polypharmacy of four or more medication classes, and 42% (N=131) received metabolic screening. Being male, being in foster care, and having a diagnosis of ASD or disruptive mood dysregulation disorder were significantly associated with duration of use of antipsychotic medications; race-ethnicity was not significantly associated with duration of use. Emergency department visits (N=277, 88%) and inpatient hospitalizations (N=107, 34%) were observed during the study period. CONCLUSIONS: Many preschoolers received antipsychotic medications for substantial periods. Further research is needed to identify evidence-based practices to reduce medication use and improve outcomes.

Recommendations and Guidelines for the Use of Simulation to Address Structural Racism and Implicit Bias.

SUMMARY STATEMENT: Simulation-based education is a particularly germane strategy for addressing the difficult topic of racism and implicit bias due to its immersive nature and the paradigm of structured debriefing. Researchers have proposed actionable frameworks for implicit bias education, particularly outlining the need to shift from recognition to transformation, with the goal of changing discriminatory behaviors and policies. As simulation educators tasked with training health care professionals, we have an opportunity to meet this need for transformation. Simulation can shift behaviors, but missteps in design and implementation when used to address implicit bias can also lead to negative outcomes. The focus of this article is to provide recommendations to consider when designing simulation-based education to specifically address racism and implicit bias.

High-level psychotropic polypharmacy: a retrospective comparison of children in foster care to their peers on Medicaid.

BACKGROUND: The use of antipsychotic medication and psychotropic polypharmacy has increased in the United States over the last two decades especially for children from low-income families and those in foster care. Although attention has been paid to providing greater insight, prescribing patterns remain concerning since there is a lack of evidence related to safety and efficacy. High-level psychotropic polypharmacy has not been described. We aim to compare the use of HLPP for children receiving Medicaid services and those in foster care and identify factors associated with the duration of use of high-level psychotropic polypharmacy. Additionally, we will examine the frequency of laboratory metabolic screening and emergency department, inpatient, and outpatient visits. METHODS: A cross-sectional, secondary analysis of statewide data describes trends in high-level psychotropic polypharmacy from 2012 to 2017 and the prevalence and predictors of high-level psychotropic polypharmacy duration and resource use in 2017 for all children on Medicaid and those in foster care. High-level psychotropic polypharmacy included concurrent use, at least four classes of medications including an antipsychotic, and at least 30 days duration. RESULTS: High-level psychotropic polypharmacy increased from 2012 to 2014 for both groups but stabilized in 2015-2016. Children in foster care showed a slight increase compared to their peers in 2017. There was no association between duration and demographic characteristics or foster care status. Diagnoses predicted duration. Neither group received metabolic monitoring at an acceptable rate. CONCLUSIONS: Concerning patterns of high-level psychotropic polypharmacy and metabolic monitoring were identified. Cautious use of high-level psychotropic polypharmacy and greater oversight to ensure that these children are receiving comprehensive services like behavioral health, primary care, and primary prevention.

Disparities in ADHD Diagnosis and Treatment by Race/Ethnicity in Youth Receiving Kentucky Medicaid in 2017.

Background: Kentucky has among the highest rate of attention deficit/hyperactivity disorder (ADHD) and stimulant use in the United States. Little is known about this use by race/ethnicity and geography. This article describes patterns of diagnosis of ADHD and receipt of stimulants and psychosocial interventions for children aged 6-17 years receiving Kentucky Medicaid in 2017 and identifies factors associated with diagnosis and treatment. Methods: Using Medicaid claims, children with and without ADHD (ICD-10 codes F90.0, F90.1, F90.2, F90.8, and F90.9) were compared and predictors of diagnosis and treatment type were examined. Psychosocial interventions were defined as having at least one relevant CPT code. Chi-squared tests and logistic regression models were used for univariate and multivariable analysis, respectively. Results: The rates of ADHD, stimulant use, and psychosocial interventions in our study population exceeded the national average (14% vs 9%; 75% vs 65.5%; and 51% vs 46.5%, respectively). The distributions varied by sex, race/ethnicity, sex among race/ethnicities, and population density. In general, race/ethnicity predicted ADHD diagnosis, stimulant use, and receipt of psychosocial interventions with non-Hispanic White children being more likely to receive diagnosis and medication, but less likely to receive psychosocial therapy than other children. Differences were also shown for rural compared with urban residence, sex, and sex within racial/ethnic groups. Conclusions: Diagnosis and treatment modalities differed for children by race/ethnicity, population density, and sex. More data are needed to better understand whether differences are due to provider bias, child characteristics, or cultural variations impacting the utilization of different treatment options.

Epidemiology of Treatment for Preschoolers on Kentucky Medicaid Diagnosed with Attention-Deficit/Hyperactivity Disorder.

Objectives: The National Survey of Children's Health reported a concerning increase in children 2-5 years being diagnosed with attention-deficit/hyperactivity disorder (ADHD) in 2016. Concerns include both the increase in diagnosing and potential deviations from published guidelines for the treatment of ADHD in preschoolers. The present study aims to describe the epidemiology and factors associated with receiving the diagnosis and treatment types for low-income preschoolers. Methods: Using Kentucky Medicaid claims from 2012 to 2017, a retrospective cohort study of children 2-5 years of age (n = 337,631) with a diagnosis of ADHD (n = 11,712) was completed. Trends in demographics, comorbidities, and treatment and provider types are presented. Multinomial logistic regression was used to determine predictors of receipt of the diagnosis and treatment type (a stimulant only, an alpha-2 agonist [A2A] only, both, or neither) based on nonmissing 2017 data (n = 2394). Results: The number of children in the cohort diagnosed with ADHD and receiving a stimulant decreased from 2012 to 2017, but the use of A2As increased. Primary care physicians were the most frequent prescribers of both medications. The adjusted odds ratios (AORs) of receipt of an A2A alone, stimulant alone, or both medications over receiving no ADHD medication were associated with specific demographics and comorbid conditions for each medication regimen. Race/ethnicity is associated with receiving the diagnosis of ADHD and treatment with A2A. Comorbid mental health conditions and provider type are associated with treatment type. Conclusion: Use of stimulants for preschoolers in Kentucky has decreased and A2A use has increased since 2012. Continued vigilance and long-term follow-up of preschoolers with ADHD are warranted. The appropriateness of the diagnosis and treatment type could not be determined.

Trends in diagnosis of bipolar and disruptive mood dysregulation disorders in children and youth.

OBJECTIVE: Rates of pediatric bipolar disorders have increased and some are concerned about diagnostic accuracy. Disruptive mood dysregulation disorder (DMDD) was added to the DSM-5 in 2013. The purpose of this study was to assess diagnostic trends of bipolar disorders and DMDD and to identify predictors of receiving the DMDD diagnosis since implementation of DSM-5. METHOD: Kentucky Medicaid claims from 2012-2017 for children under 18 years (N = 814,919; 2012 n = 473,389; 2013 n = 470,918; 2014 n = 499,094; 2015 n = 517,199; 2016 n = 529,048; 2017 n = 535,814) were used. Logistic regression was used to identify predictors of a diagnosis of DMDD in 2015-2017 for a sub-sample (n = 5,071). RESULTS: The use of DMDD rose after 2013 and mood disorder NOS decreased steadily through 2017. This decrease was seen when there was a diagnosis of bipolar and oppositional defiant disorder (ODD) combined with mood disorder NOS. A diagnosis of only mood disorder NOS in 2012 did not predict DMDD in 2015-2017, but the same diagnosis in 2013 was predictive (OR 2.14, p = 0.049). The reverse is true for a diagnosis of only ADHD in 2013, which did not predict DMDD in later years, but its presence in 2012 was predictive (OR 1.36, p = 0.010). CONCLUSIONS: DMDD increased after 2013, and this was associated with a diagnosis of mood disorder NOS, ADHD, as well as with bipolar disorders comorbid with ODD. Given the complexity of comorbid diagnoses, DMDD may be more accurate in classifying some children. Administrative claims data have limitations, which are discussed; and the data represent only children living in Kentucky.

Keys to academic success for under-represented minority young investigators: recommendations from the Research in Academic Pediatrics Initiative on Diversity (RAPID) National Advisory Committee.

BACKGROUND: Although Latinos, African-Americans, and American Indians/Alaska Natives comprise 34% of Americans, these under-represented minorities (URMs) account for only 7% of US medical-school faculty. Even when URMs become faculty, they face many substantial challenges to success. Little has been published, however, on keys to academic success for URM young faculty investigators. METHODS: The Research in Academic Pediatrics Initiative on Diversity (RAPID) goal is to enhance the professional advancement of URM junior faculty pursuing research careers in general academic pediatrics. One important RAPID component is the annual mentoring/career-development conference, which targets URM residents, fellows, and junior faculty, and has included 62 URM participants since its 2013 inception. A conference highlight is the panel discussion on keys to academic success for URM young investigators, conducted by the RAPID National Advisory Committee, a diverse group of leading senior researchers. The article aim was to provide a guide to academic success for URM young investigators using the 2018 RAPID Conference panel discussion. A modified Delphi technique was used to provide a systematic approach to obtaining answers to six key questions using an expert panel: the single most important key to success for URM young investigators; ensuring optimal mentorship; how to respond when patients/families say, "I don't want you to see my child because you are ____"; best strategies for maximizing funding success; how to balance serving on time-consuming committees with enough time to advance research/career objectives; and the single thing you wish someone had told you which would have substantially enhanced your success early on. RESULTS/CONCLUSIONS: This is the first published practical guide on keys to academic success for URM young investigators. Identified keys to success included having multiple mentors, writing prolifically, being tenaciously persistent, having mentors who are invested in you, dealing with families who do not want you to care for their child because of your race/ethnicity by seeking to understand the reasons and debriefing with colleagues, seeking non-traditional funding streams, balancing committee work with having enough time to advance one's research and career by using these opportunities to generate scholarly products, and asking for all needed resources when negotiating for new jobs.

Longitudinal Trends in the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Stimulant Use in Preschool Children on Medicaid.

OBJECTIVES: To describe trends in the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and prescribing of stimulants in preschool-age children receiving Medicaid and to identify factors associated with the receipt of psychosocial care. STUDY DESIGN: Data were extracted from 2012-2016 Kentucky Medicaid claims for children aged <6 years. ADHD was identified using International Classification of Diseases, Tenth Revision codes F90.0, F90.1, F90.2, F90.8, and F90.9. Psychosocial therapy was defined as having at least 1 relevant Current Procedural Terminology code in a claim within the year. A generalized linear model with a logit link and binomial distribution was used to assess factors associated with receipt of psychosocial treatment in 2016. RESULTS: More than 2500 (1.24%) preschool-aged children receiving Medicaid had a diagnosis of ADHD in 2016, with 988 (38.2%) of those receiving a stimulant medication. Children in foster care were diagnosed with and/or treated for ADHD 4 times more often than other Medicaid recipients. Of the 1091 preschoolers receiving stimulants, 99 (9%) did not have a diagnosis of ADHD. There were no significant differences in diagnoses by race/ethnicity, but children reported to be black, Hispanic, or other race/ethnicity received stimulants at a lower rate than white children. Positive predictors for receiving psychosocial therapy in 2016 included having the diagnosis but not receiving a stimulant, having at least 1 prescription written by a psychiatrist, having comorbidities, and age. The use of stimulants in children aged <6 years declined from 0.9% in 2012 to 0.5% in 2016. CONCLUSIONS: Promising trends demonstrate a decreasing use of stimulants in preschoolers; however, continued vigilance is needed to promote the optimal use of psychosocial interventions.

Engaging the Transgender Community to Improve Medical Education and Prioritize Healthcare Initiatives.

Phenomenon: Transgender patients experience discrimination, limited access to care, and inadequate provider knowledge in healthcare settings. Medical education to address transgender-specific disparities is lacking. Research that engages transgender community members may help address health disparities by empowering patients, increasing trust, and informing medical curricula to increase competence. APPROACH: A 2015 Community Forum on Transgender Health Care was hosted at the University of Louisville School of Medicine, which included healthcare professionals and transgender community members to facilitate dialogue among mixed-participant groups using a World Café model. Fifty-nine participants discussed the status of transgender healthcare and made recommendations for local improvements. A follow-up survey was administered to 100 individuals, including forum participants and their referrals. The forum discussion and survey responses were analyzed to determine common perceptions of transgender healthcare, priorities for improvement interventions, and themes to inform curriculum. FINDINGS: The community forum discussion showed that local transgender care is overwhelmingly underdeveloped and unresponsive to the needs of the transgender community. The follow-up survey revealed that priorities to improve transgender care included a multidisciplinary clinic for lesbian, gay, bisexual, and transgender (LGBT) patients, an LGBT-friendly network of physicians, and more training for providers and support staff. This mutually constructive engagement experience influenced reform in undergraduate curricula and continuing education opportunities. Insights: Community engagement in healthcare disparities research can cultivate improbable discussions, yield innovative insight from marginalized populations, and build relationships with community members for future collaborations and interventions. Societal acceptance of transgender identities, which could be promoted through healthcare providers, could stimulate significant progress in transgender healthcare. Supplemental educational interventions for practicing physicians will improve the current conditions of transgender healthcare, but a comprehensive medical school curriculum specifically for transgender health that includes interactions between the transgender community and medical students could be particularly impactful.

Changes in medical student implicit attitudes following a health equity curricular intervention.

PURPOSE: This study assessed the: (1) effect of an LGBTQI + health equity curriculum (eQuality) on implicit attitudes among first (M1) and second year (M2) medical students and (2) utility of dedicated time to explore implicit bias. METHOD: Implicit biases were assessed at baseline using implicit association tests (IAT) for all M2s and a random sample of first years (M1A). These students were then debriefed on strategies to mitigate bias. Following eQuality, all M1 and M2s completed post-intervention IATs. The remaining first years (M1B) were then debriefed. Paired sample t-tests assessed differences between pre/post. Independent sample t-tests assessed differences in post-IATs between M1 groups. RESULTS: IATs indicated preferences for "Straight," "White," and "Thin" at both pre and post. M2s demonstrated statistically significant improvements pre to post for sexuality (p = 0.01) and race (p = 0.03). There were significant differences in post-intervention IAT scores between M1As who received the IAT and debriefing prior to eQuality and M1Bs for sexuality (p = 0.002) and race (p = 0.046). There were no significant changes for weight. CONCLUSION: eQuality reduced implicit preference for "Straight" and "White." Differences in M1 post-intervention IAT scores between groups suggest dedicating time to debrief implicit attitudes enhances bias mitigation.

Culturally Effective Care for Refugee Populations: Interprofessional, Interactive Case Studies.

Introduction: Within health sciences education literature, the majority of reported student experiences with refugee populations are limited to traditional, professionally independent, elective courses and extracurricular volunteer opportunities. A simulated patient exercise is a learning opportunity that helps participants engage with material in real time in a realistic environment, demanding higher levels of learning. This session utilized a simulated patient facilitator in interprofessional small groups to explore common health needs and barriers to care among refugee populations. Methods: Health professions students from nine degree programs participated in a refugee health session in interprofessional teams of nine to 10 students to explore patient cases. The session concluded with a debriefing discussing the outcomes of the student-patient interaction, best practices, and exemplary practice models as takeaways. The simulated patient facilitators completed an Observation Checklist to assess students' grasp of learning objectives. Results: Five hundred twenty-four students participated in the refugee session, divided into 61 groups. Observation Checklists were completed for 58 groups (95%). Assessment of student engagement focused on general health needs common to refugee populations: barriers to health care, team and individual roles, bias, consequences of nontreatment, and social determinants of health. Most of the groups (95%) reported engagement between the simulated patient facilitator and the group of student providers. Qualitative data indicated student groups were knowledgeable in each of the overarching learning objectives. Discussion: This session allowed health sciences students to focus on culturally effective patient care for refugee populations as a part of an interprofessional team.

Interprofessional LGBT Health Equity Education for Early Learners.

INTRODUCTION: The eQuality project at the University of Louisville aims to train future physicians to deliver equitable quality care for all people by creating an integrated educational model utilizing the competencies identified in the AAMC's Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born With DSD. This foundational interprofessional health equity session for early learners addresses knowledge and attitude milestones relating to interprofessional collaboration, professionalism, and systems-based practice competencies for lesbian, gay, bisexual, and transgender (LGBT) populations. METHODS: First-year medical students were assigned to interprofessional teams of approximately 10 health sciences students each. Students participated in a 75-minute session utilizing a group case study activity, including a systems lecture exploring social determinants and community resources related to LGBT health. Students collaboratively discussed the case and recorded strategies for optimal patient care. The Readiness for Interprofessional Learning Scale and health disparities attitudes and knowledge scales were administered pre-/postsession. RESULTS: One hundred fifty-eight first-year medical students participated in the session. Posttest scores reflected an improvement for all disparities knowledge items (p < .001), and an increased interest in working with other health professions students on future projects (p < .001). Changes in attitudes toward systemic and social factors affecting health were also observed. However, content analysis of worksheets revealed that only 36% of teams identified specific action steps for the case scenarios. DISCUSSION: This session was effective in improving knowledge and attitudes related to LGBT health equity and interprofessional education.

Mental Health Issues in Foster Care.

Children in foster care have exceptional needs due to their histories of abuse, neglect, and increased exposure to violence. The rates of psychiatric symptoms and disorders, such as attention-deficit/hyperactivity disorder, posttraumatic stress disorder, and reactive attachment disorder, are much higher in children in foster care; furthermore, the rate of these children receiving psychotropic medications is 3 times that of children who are not in foster care. Pediatricians, in their role of providing a medical home, play a central role in safeguarding the physical and mental health of these children. By taking a trauma-informed approach to understanding the unique needs and gaps in their health care, pediatricians can improve the mental health and maximize outcome for children in foster care. [Pediatr Ann. 2016;45(10):e342-e348.].

First We Have to Engage Them: A Mixed Methods Assessment of Low-Income Parents' Preferences for and Barriers to Receiving Child Health Promotion Information.

INTRODUCTION: The aim of this study is to understand low-income parents' preferences for and barriers to receiving child health promotion information. METHODS: A mixed-methods approach was used. Data were collected in an urban pediatric primary care setting serving predominantly low-income African American families. Parents (n = 190) of 3- to 8-year-old children completed a survey; a randomly selected subset participated in focus groups. RESULTS: The quantitative and qualitative samples differed with regard to whether they would like to get parenting information from their doctors. The most commonly cited obstacles to attending parenting classes were time (50.6%), work schedule (40.6%), transportation (37.7%), and own health (22.4%). DISCUSSION: New and creative methods are needed to promote child health and development that do not increase the burden associated with raising children in the context of limited resources.

Health promotion in pediatric primary care: importance of health literacy and communication practices.

Health literacy has been shown to predict health behaviors and outcomes above the effects of education or socioeconomic status. Much remains unknown about the health literacy of parents and the role it plays in children's health outcomes or in health disparities. The current study explored the health communication needs and health literacy indicators in a diverse sample of parents (n = 75) to identify potential areas for future interventions. The sample consisted of parents of children 18 to 36 months old who were visiting 3 different pediatric medical offices, 2 of which served low-income families and 1 located in an affluent suburb. When comparisons were made between 2 educational attainment groups, there were variations in indicators of health literacy and health communication needs. These data can be used to guide the development of interventions by primary care providers to improve parent education.

An exploratory study of 2 parenting styles and family health behaviors.

OBJECTIVE: To examine the relationships between 2 parenting styles and family nutrition and physical activity. METHODS: Parents of elementary/primary school children in the southeastern United States (N = 145) completed surveys regarding family relationships and health behaviors. RESULTS: Parents exhibiting a laissez-faire parenting style reported lower levels of family nutrition and physical activity. In addition, parent BMI moderated the relationship between laissez-faire parenting and these health behaviors. CONCLUSIONS: This study indicates that family-oriented nutrition and physical activity programs may benefit from including a focus on decreasing laissez-faire parenting, as well as helping overweight parents reduce their BMIs.