Triadic Collaboration Between Adolescents, Caregivers, and Health-Care Providers to Promote Healthy Behavior.

PURPOSE: To further elucidate the various aspects of the triadic relationship between health-care providers (HCP), adolescents, and caregivers during adolescent health-care visits, with the goal of helping HCPs better understand how they can best support adolescents to choose healthy behaviors. METHODS: Adolescents (ages 13-18 years) and caregivers of adolescents were recruited to participate in qualitative interviews regarding preferences for provider interactions around health behavior change. Data analysis was conducted using inductive thematic analysis to identify and describe patterns of themes across the dataset. RESULTS: Thirty one adolescents and 30 caregivers participated. Fourteen themes emerged in the analysis regarding adolescent and caregiver preferences for direct and indirect relationships between adolescents, caregivers, and HCPs in promoting healthy behavior. These themes were organized into a triadic collaboration framework to promote healthy behavior using an adolescent-centered and caregiver-involved approach. DISCUSSION: This study supports findings of previous research on triadic interactions between HCPs, adolescents, and caregivers while deepening our understanding of the HCP's role in helping adolescents to choose healthy behaviors. These themes are representative of the continuing shift toward an adolescent-centered and caregiver-involved approach to adolescent health care and provide further guidance to HCPs on how to work collaboratively with both adolescents and caregivers to promote healthy behaviors and improve health outcomes.

Psychometric Properties and Validation of the General Anxiety Disorder 7-Item Scale Among Adolescents With Persistent Post-Concussive Symptoms.

The General Anxiety Disorder 7-Item (GAD-7) scale is commonly used in primary care as a self-report measure of general anxiety symptoms with adult populations. There is little psychometric research on this measure with adolescent populations, particularly those with persistent post-concussive symptoms (PPCS). This study examined the psychometrics properties of the GAD-7 among youth with PPCS. We used baseline data from a randomized controlled trial of collaborative care for treatment of PPCS among 200 sports-injured adolescents 11-18 years of age (Mage = 14.7 years, standard deviation = 1.7). Eligible adolescents had three or more PPCS that lasted for ≥1 month and spoke English. Adolescents reported on their anxious (GAD-7 and Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]; RCADS) and depressive (Patient Health Questionnaire-9; PHQ-9) symptoms. Parents used the RCADS to report on their adolescents' anxious symptoms. The GAD-7 had good internal validity (Cronbach's alpha = 0.87), and significant (p < 0.001) correlations were detected between the GAD-7 and youth and parent report of anxiety on RCADS (r = 0.73 and r = 0.29) and PHQ-9 (r = 0.77) scores. Confirmatory factor analysis suggested a one-factor solution. These results suggest that the GAD-7 is a valid measure of anxiety with good psychometric properties for youth experiencing PPCS. ClinicalTrials.gov identifier: NCT03034720.

Associations Between Sleep Duration and Positive Mental Health Screens During Adolescent Preventive Visits in Primary Care.

OBJECTIVE: The purpose of this paper was to understand associations between low sleep duration (<8.ßhours) and positive mental health screens among adolescents (ages 13...18) seen for preventive visits in primary care. METHODS: Data were from two randomized controlled trials testing the efficacy of an electronic health risk behavior screening and feedback tool for adolescent preventive visits. Participants (n.ß=.ß601) completed screeners at baseline, 3 months, and 6 months which included sleep duration in hours and the Patient Health Questionnaire 9 and Generalized Anxiety Disorder 7 screeners for depression and anxiety, respectively. Main analyses included adjusted logistic regressions testing associations between low sleep duration and positive mental health screens. RESULTS: Adjusted models showed that low sleep duration was associated with significantly greater odds of a positive depression screen (OR.ß=.ß1.58, 95% CI: 1.06...2.37) but not with a positive anxiety screen or co-occurring positive depression and anxiety screens. However, follow-up analyses indicated an interaction between sleep duration and anxiety in the association with a positive depression screen, such that the association between low sleep and a positive depression screen was driven by those who did not screen positive for anxiety. CONCLUSIONS: As pediatric primary care guidelines for sleep continue to evolve, further research, training, and support for sleep screening are warranted to ensure effective early intervention for sleep and mental health problems during adolescence.

Validation of a Process for Shared Decision-Making in Pediatrics.

OBJECTIVE: We sought to confirm, refute, or modify a 4-step process for implementing shared decision-making (SDM) in pediatrics that involves determining 1) if the decision includes >1 medically reasonable option; 2) if one option has a favorable medical benefit-burden ratio compared to other options; and 3) parents' preferences regarding the options; then 4) calibrating the SDM approach based on other relevant decision characteristics. METHODS: We videotaped a purposive sample of pediatric inpatient and outpatient encounters at a single US children's hospital. Clinicians from 7 clinical services (craniofacial, neonatology, oncology, pulmonary, pediatric intensive care, hospital medicine, and sports medicine) were eligible. English-speaking parents of children who participated in inpatient family care conferences or outpatient problem-oriented encounters with participating clinicians were eligible. We conducted individual postencounter interviews with clinician and parent participants utilizing video-stimulated recall to facilitate reflection of decision-making that occurred during the encounter. We utilized direct content analysis with open coding of interview transcripts to determine the salience of the 4-step SDM process and identify themes that confirmed, refuted, or modified this process. RESULTS: We videotaped 30 encounters and conducted 53 interviews. We found that clinicians' and parents' experiences of decision-making confirmed each SDM step. However, there was variation in the interpretation of each step and a need for flexibility in implementing the process depending on specific decisional contexts. CONCLUSIONS: The 4-step SDM process for pediatrics appears to be salient and may benefit from further guidance about the interpretation of each step and contextual factors that support a modified approach.

Electronic Screening for Adolescent Risk Behaviors in the Emergency Department: A Randomized Controlled Trial.

INTRODUCTION: In this study we aimed to assess the impact of an electronic health assessment with individualized feedback for risk behaviors in adolescents seeking care in a pediatric emergency department (ED). METHODS: We conducted a randomized control trial using a tablet-based screening program with a study population of adolescents in a busy pediatric ED. The intervention group received the screening program with individualized feedback. The control group received the screening program without feedback. All participants received one-day and three-month follow-up surveys to assess behaviors and attitudes toward health behaviors. RESULTS: A total of 296 subjects were enrolled and randomized. There was no difference in changes in risky behaviors between the control and experimental groups. A higher proportion of participants in the intervention groups reported that the screener changed the way they thought about their health at one-day follow-up (27.0%, 36/133) compared to the control group (15.5%, 20/129, P = .02). CONCLUSION: This study successfully tested a multivariable electronic health screener in a real-world setting of a busy pediatric ED. The tool did not significantly change risky health behaviors in the adolescent population screened. However, our finding that the intervention changed adolescents' perceptions of their health opens a door to the continued development of electronic interventions to screen for and target risk behaviors in adolescents in the ED setting.

Same, opposite and both-sex attracted adolescents' mental health, safe-sex practices and substance use.

This study examined mental health, substance use, and sexual health across sexual attraction groups. 428 adolescents recruited from school-based health centers completed self-report measures. 72% were only opposite-sex attracted, 19% both-sex attracted, 3% same-sex attracted, 4% not sure. Reported partners did not always align with reported attraction. Compared to opposite-sex attracted youth, 1) both-sex attracted youth had significantly higher rates of marijuana use (OR=1.75, p=.04), depressive symptoms (OR=2.62, p=.001) and inconsistent condom use (OR=1.71, p=.05); 2) the "not sure" group had higher anxiety symptoms (OR=4, p=.01). This study highlights the importance of considering sexual attraction in providing quality care to young people.

Youth-Reported School Connection and Experiences of a Middle School-Based Screening, Brief Intervention, and Referral to Treatment Initiative: Preliminary Results From a Program Evaluation.

PURPOSE: This study aimed (1) to evaluate the feasibility of a school-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) program that expands on traditional SBIRT to support the mental health and well-being of middle school students and (2) to assess its effects on students' connection with adults at school. METHODS: Focus group discussions were conducted with 26 students in grades 6-8 to understand student perspectives about an innovative school-based SBIRT program. A subset of middle school students from the SBIRT program who received a brief intervention (BI) after screening (n = 116) were asked to rate their experience meeting with the interventionist in terms of feeling comfortable, feeling listened to, and talking about their goals. Additionally, these students' ratings of connection to adults at school was compared from the time of screening (baseline) to following BI using two-sided paired t-tests. RESULTS: Students who participated in focus groups expressed favorable opinions about universal screening and this school-based SBIRT model and noted that relationship building with adults at school was an important factor for open communication and motivating behavior change for students. Nearly all students who completed the post-BI survey rated their experiences with interventionists during BI as "Excellent," "Very Good," or "Good" in all categories (98%). Students' reported mean school connection scores significantly higher after participation in school-based SBIRT than at baseline (5.9/8 vs. 7.0/8, p < .001). DISCUSSION: Middle school students were satisfied with the school-based SBIRT model and participation in the program resulted in increased student connection with adults at school. These findings improve our understanding of the experience of SBIRT intervention with middle school students and on school connection in particular.

Provider Use of Time Alone With Adolescents: Differences by Health Concern.

PURPOSE: To examine associations between reports of sensitive health behaviors and the provision of time alone by a clinician during adolescent well visits. METHODS: Data were collected from 547 adolescents who completed a well visit at one of eight clinics. Adjusted mixed logistic regression was used to examine whether reports of sexual behavior, substance use, disordered eating, mental health concerns, and demographic characteristics were associated with time alone. RESULTS: Sexual behavior was found to be significantly associated with time alone, while substance use, disordered eating, a positive depression screen, and suicidal ideation were not. Older adolescents and males were more likely to report time alone, while race/ethnicity had no association with time alone. DISCUSSION: Clinicians may be prioritizing time alone for behavioral concerns differently than for other sensitive behaviors.

Barriers to Implementing a Cannabis Focused SBIRT in Adolescent Primary Care.

Introduction: The current study investigated providers' perceived barriers, supports, and need for adopting a screening, brief intervention, and referral to treatment model (SBIRT) intervention related to cannabis reduction into their community based primary care clinics. Methods: Eleven pediatric primary care providers from regional community-based clinics participated in focus groups discussing a proposed adolescent cannabis use SBIRT reduction intervention, perceived need, and potential barriers to implementation within their clinic. Results: Seven primary themes emerged regarding barriers to implementing a cannabis reduction SBIRT in primary care including provider ambivalence to adolescent cannabis use. Conclusion: Further research is needed to understand evolving provider perceptions of adolescent cannabis use and how these views impact the adoption of SBIRT for the reduction of cannabis use among their adolescent patients.

Exploring Heterogeneity of Stepped Collaborative Care Treatment Response Trajectories after Adolescent Sports Injury Concussion.

Objective: Few clinical trials of posttraumatic interventions have utilized symptom trajectory modeling to explore heterogeneity of treatment responses. The goal of this investigation was to conduct a secondary analysis of a randomized clinical trial of stepped collaborative care for adolescents with sports and recreational related concussion and persistent symptoms of >1 month.Method: Trajectory modeling was used to examine the impact of randomization to the intervention as well as demographic, clinical, and injury characteristics on adolescent post-concussive symptom trajectories. Two hundred male and female adolescents were assessed >1 month after a concussion, and then 3-, 6- and 12-months later with a standardized measure of concussive symptoms, the Health and Behavior Inventory (HBI). Multinomial logistic regression was used to compare the association between intervention, demographic, clinical and injury characteristics with trajectory group membership.Results: Four post-concussive symptom trajectories emerged: recovery, remitting, low-persistent, and high-persistent. In adjusted analyses randomization to the intervention condition was associated with significantly greater odds of HBI recovery trajectory group membership (OR 3.29 95% CI 1.06-10.28). Female gender and prior concussion history were associated with significantly greater odds of high-persistent trajectory group membership relative to all other trajectories. Greater odds of high-persistent versus recovery group trajectory membership was observed for adolescents with a pre-injury history of anxiety and/or depressive disorders.Conclusions: Stepped collaborative care was associated with an increased odds of recovery versus high-persistent post-concussive symptom trajectories, while readily identifiable baseline characteristics were associated high-persistent symptoms. Future post-concussive clinical trials and practice improvement efforts could incorporate these observations.

Physician recommended school accommodations and student outcomes following a mild traumatic brain injury among youth with persistent post-concussive symptoms.

BACKGROUND: Post-concussion return-to-learn (RTL) guidelines include implementation of school accommodations. Yet, little is known about physician recommendations for school accommodations and their impact, particularly among youth experiencing persistent post-concussive symptoms (PPCS). OBJECTIVE: We examined the association between physician recommended school accommodations and student outcomes among youth experiencing PPCS. METHODS: Data from a randomized comparative effectiveness trial was used. Physician recommended school accommodations (≤90 days post-injury) were collected via chart abstraction. Grade point average was extracted from school records. Reports of problems at school, concussion symptoms, health-related quality of life (HRQOL), anxiety symptoms, and depressive symptoms were collected by survey (at baseline, three months, and 12 months post study entry). RESULTS: Of 200 participants (Mage = 14.7, 62% female), 86% were recommended school accommodations. Number of recommended school accommodations was positively associated with number of school problems at three months (aRR 1.18, 95% CI:1.12-1.24) and 12 months (aRR 1.11, 95% CI:1.05-1.18). No significant associations were found between recommended school accommodations and GPA, HRQOL, anxiety symptoms, or depressive symptoms. CONCLUSIONS: Physicians recommend more school accommodations for students experiencing more school problems post-concussion. Appropriate implementation of RTL recommendations made by physicians by fostering partnerships among physicians, students, and schools may be needed to achieve student-centered RTL.

Electronic Screening, Feedback, and Clinician Training in Adolescent Primary Care: A Stepped-Wedge Cluster Randomized Trial.

PURPOSE: The aim of this study is to test the effects of an electronic screening and feedback tool and training for primary care clinicians on care and adolescent health behaviors. METHODS: We conducted a stepped-wedge cluster randomized trial with six clinics randomly assigned to sequential crossover from control to intervention periods with clinician training between periods. Adolescents (ages 13-18) with a well visit during the control periods (n = 135) received usual care, while adolescents during the intervention periods (n = 167) received the electronic screening and feedback tool prior to their well visit, with results sent to their clinicians. Adolescents completed surveys at baseline, 1 day, 3 months, 6 months, and 12 months. Linear mixed effects models were used to examine associations between outcomes and treatment, controlling for time as a fixed effect and clinic as a random effect. All analyses employed intent-to-treat analyses and utilized multiple imputations for missing data. RESULTS: Adolescents who received the intervention had a higher rate of counseling for their endorsed risk behaviors during the well visit (45% vs. 33%, Wald's T = 2.29, p = .02). There were no significant intervention effects on adolescent satisfaction with the clinician or perception of patient centeredness. The intervention was associated with a small but statistically significant reduction in overall risk score relative to control at 3 months (-.63, 95% confidence interval [-1.07, -.19], Cohen's d = .21), but not at 6 or 12 months. CONCLUSIONS: The results suggest that electronic screening and feedback may be associated with small reductions in risk behaviors at 3 months but that changes do not persist at longer term follow-up.

Barriers to Increasing Access to Brief Pediatric Mental Health Treatment From Primary Care.

A quality improvement process targeted mental health care uptake and system capacity in an underserved region. The pediatric program created pathways for rapid referral from primary care and schools to four sessions of evidence-based treatments for disruptive behavior and depression with community clinicians. Of 250 referrals, 46 families enrolled in treatments for disruptive behavior and 21 for depression. Many families did not respond or required more intensive treatment. Acceptability of the program was high for participating families, referrers, and clinicians. Brief treatment met most participating families' needs. The process demonstrated barriers to mental health care access and delivery and the need for integrated and multitiered care delivery.

Effect of Collaborative Care for Persistent Postconcussive Symptoms on Academic Function: A Randomized Clinical Trial.

BACKGROUND: There is limited long-term data on the course of school-related problems and academic needs for youth with persistent post-concussive symptoms (PPCS). METHODS: This was a randomized trial comparing collaborative care to usual care for 200 youth 11-18 years of age with PPCS. In this report, the main outcomes were academic functioning, GPA, school absences, date of return to school, and school days missed. RESULTS: Youth were mean age of 14.7 (SD = 1.7), 62.0% female. New or worsening academic problems occurred in half of participants in both groups at 12 months after injury. Students were most concerned about grades and falling behind. There were no significant differences by study group on school problems or GPA, but number of days missed was lower in the collaborative care group compared at 3 months (12.5 [SD = 14.5] vs 16.1 days [20.4] adjusted relative risk [aRR] 0.67 [95% CI: 0.61, 0.74; p < .001]), 6 months (14.5 [22.1] vs 19.3 [26.6] aRR 0.77 [95% CI: 0.71, 0.84; p < .001]), and 12 months (16.9 [25.4] vs 19.6 [27.7], aRR 0.68 [95% CI: 0.62, 0.74; p < .001]). CONCLUSIONS: Youth with PPCS are at high risk of school problems in the year after injury.

Prevalence and risk factors for depression, anxiety and suicidal ideation in youth with persistent post-concussive symptoms (PPCS).

Objectives: To assess the prevalence and risk factors for emotional distress in youth with persistent post-concussive symptoms (PPCS) greater than one month.Methods: We used baseline data from an intervention study for youth with PPCS, utilizing Poisson regression to examine factors associated with exceeding clinical cut-points on measures of depression, anxiety, self-harm and suicidal ideation. Predictors included: age, sex, socioeconomic status, mental health history, duration of concussion symptoms, history of prior concussion, trauma history and sleep quality.Results: The sample included 200 youth with PPCS, (mean 14.7 SD 1.7 years, 82% white, 62% female). Forty percent reported clinically significant depressive symptoms, 25% anxiety, 14% thoughts of self-harm and 8% thoughts of suicide. History of depression was associated with 3-fold higher risk for thoughts of self-harm (95% CI:1.82-6.99) and 6-fold higher risk for suicidal ideation (95% CI:1.74-24.46). Better sleep quality was associated with lower risk for all outcomes. History of prior concussion and duration of PPCS were not significantly associated with any outcomes.Conclusions: Suicidal thoughts are common post-concussion, and history of depression is a strong risk factor. Tailored interventions may be needed to address mental health in this population.

Child- compared with parent-report ratings on psychosocial measures following a mild traumatic brain injury among youth with persistent post-concussion symptoms.

Primary Objective: To compare child- and parent-report ratings on the Health Behavior Inventory, Revised Child Anxiety and Depression Scale-Short Version (anxiety subscale), Patient Health Questionnaire-9, and Pediatric Quality of Life InventoryTM among children with persistent post-concussive symptoms following a sports- or recreation-related concussion, overall and by child age and gender.Research Design: Cross-sectional study examining baseline data from a randomized, comparative effectiveness trial.Methods and Procedures: Inter-rater reliability was assessed using two-way random effects model (absolute agreement) intraclass correlations, correlations were examined using Spearman's rho, mean differences were determined using paired t-tests, and agreement was examined using Bland-Altman plots.Main Outcomes and Results: The final analytic sample was 200 parent-child dyads [child Mage = 14.7 (95% CI: 14.5, 15.0)]. Reliability and correlations were modest overall. When considering child age and gender, reliability ranged from poor to excellent (-1.01-0.95) and correlations ranged from weak to strong (-0.64-0.94). Overall, children reported more symptoms but better functioning than parents, and mean differences in scores were greater among females (versus males) and ages 16-18 (versus younger groups).Conclusions: Findings should inform the use and interpretation of psychosocial measures when developing appropriate youth concussion treatment plans.

Effect of Collaborative Care on Persistent Postconcussive Symptoms in Adolescents: A Randomized Clinical Trial.

Importance: Despite the high level of impairment for adolescents with persistent postconcussive symptoms, few studies have tested whether such problems can be remediated. Objective: To examine whether collaborative care treatment is associated with improvements in postconcussive, quality of life, anxiety, and depressive symptoms over 1 year, compared with usual care. Design, Setting, and Participants: The Collaborative Care Model for Treatment of Persistent Symptoms After Concussion Among Youth II Trial was a randomized clinical trial conducted from March 2017 to May 2020 with follow-up assessments at 3, 6, and 12 months. Participants were recruited from pediatric primary care, sports medicine, neurology, and rehabilitation clinics in western Washington. Adolescents aged 11 to 18 years with a diagnosed sports-related or recreational-related concussion within the past 9 months and with at least 3 symptoms persisting at least 1 month after injury were eligible. Data analysis was performed from June to September 2020. Interventions: The collaborative care intervention included cognitive behavioral therapy and care management, delivered mostly through telehealth, throughout the 6-month treatment period, with enhanced medication consultation when warranted. The comparator group was usual care provided in specialty clinics. Main Outcomes and Measures: Primary outcomes were adolescents' reports of postconcussive, quality of life, anxiety, and depressive symptoms. Secondary outcomes were parent-reported symptoms. Results: Of the 390 eligible adolescents, 201 (51.5%) agreed to participate, and 200 were enrolled (mean [SD] age, 14.7 [1.7] years; 124 girls [62.0%]), with 96% to 98% 3- to 12-month retention. Ninety-nine participants were randomized to usual care, and 101 were randomized to collaborative care. Adolescents who received collaborative care reported significant improvements in Health Behavior Inventory scores compared with usual care at 3 months (3.4 point decrease; 95% CI, -6.6 to -0.1 point decrease) and 12 months (4.1 point decrease; 95% CI, -7.7 to -0.4 point decrease). In addition, youth-reported Pediatric Quality of Life Inventory scores at 12 months improved by a mean of 4.7 points (95% CI, 0.05 to 9.3 points) in the intervention group compared with the control group. No differences emerged by group over time for adolescent depressive or anxiety symptoms or for parent-reported outcomes. Conclusions and Relevance: Although both groups improved over time, youth receiving the collaborative care intervention had fewer symptoms and better quality of life over 1 year. Intervention delivery through telehealth broadens the reach of this treatment. Trial Registration: ClinicalTrials.gov Identifier: NCT03034720.

Parent Traumatic Events and Adolescent Internalizing Symptoms: The Mediating Role of Parental Depression Among Youth with Persistent Post-concussive Symptoms.

OBJECTIVE: Research has demonstrated associations between parental depression (PD) and negative psychological outcomes among their children. However, little is known about the pathways through which lifetime parent traumatic events (PTEs) influence their adolescents' internalizing symptoms. Our study examined whether PD mediates the association between PTE and adolescent depressive and anxious symptoms among youth with persistent postconcussive symptoms (PPCS). METHODS: We used baseline data from a randomized effectiveness trial of collaborative care for treatment of persistent postconcussive symptoms among sports-injured adolescents aged 11-18 years. Parent-adolescent dyads were recruited from pediatric clinics throughout western Washington. Eligible adolescents had three or more PPCS that lasted for at least 1 month but <9 months and spoke English. Of 1,870 potentially eligible adolescents, 1,480 (79%) were excluded for not meeting the inclusion criteria. Of the eligible 390 adolescents, 189 (49%) declined to participate/consent. Participants included 200 parent-adolescent dyads (adolescent Mage = 14.7 years, SD = 1.7). Parent respondents were mostly female (83%) and mothers (81%). Adolescents reported on their depressive (Patient Health Questionnaire-9; PHQ-9) and anxious symptoms (Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]) and parents reported on their depressive symptoms (M = 3.7, SD = 3.7; PHQ-9). RESULTS: Mediation analyses revealed two (out of four) significant indirect effects of PTE on both adolescent and parent report of depressive symptoms, but not anxiety. CONCLUSIONS: This study elucidates one pathway (PD) through which PTE history influences adolescent depressive symptoms, supporting a two-generation approach to pediatric patient care for youth experiencing PPCS.