Family-Focused Universal Substance Use Prevention in Primary Care: Advancing a Pragmatic National Healthcare Agenda.

This article advances ideas presented at a National Academies of Sciences, Engineering, and Medicine workshop in 2022 that highlighted clinical practice and policy recommendations for delivering universal, family-focused substance use preventive interventions in pediatric primary care. Pediatric primary care is a natural setting in which to offer families universal anticipatory guidance and links to systematic prevention programming; also, several studies have shown that offering effective parenting programs in primary care is feasible. The article describes a blueprint for designing a pragmatic national agenda for universal substance use prevention in primary care that builds on prior work. Blueprint practice schematics leverage efficacious family-focused prevention programs, identify key program implementation challenges and resources, and emphasize adopting a core element approach and utilizing digital interventions. Blueprint policy schematics specify avenues for improving cross-sector policy and resource alignment and collaboration; expanding, diversifying, and strengthening the prevention workforce; and enhancing financing for family-focused prevention approaches. The article then draws from these schematics to assemble a candidate universal prevention toolkit tailored for adolescent patients that contains four interlocking components: education in positive parenting practices, parent and youth education in substance use risks, a parent-youth structured interaction task, and parent and youth linkage to in-person and web-based prevention resources.

Health Care Anchors' Responsibilities and Approaches to Achieving Child Health Equity.

This article provides an overview of the anchor institution concept, recommended strategies for embracing an anchor mission, and the challenges that can arise in the process. An anchor mission centers on advocacy, social justice, and health equity. Hospitals and health systems are anchor institutions that are uniquely positioned to utilize their economic and intellectual resources in partnership with communities to mutually benefit the long-term well-being of both. Anchor institutions have a responsibility to invest in the education and development of their leaders, staff, and clinicians in health equity, diversity, inclusion, and anti-racism.

Faculty Perspectives on Diversity, Equity, and Inclusion: Building a Foundation for Pediatrics.

ABSTRACT: Pediatric departments and children's hospitals (hereafter pediatric academic settings) increasingly promote the tenets of diversity, equity, and inclusion (DEI) as guiding principles to shape the mission areas of clinical care, education, research, and advocacy. Integrating DEI across these domains has the potential to advance health equity and workforce diversity. Historically, initiatives toward DEI have been fragmented with efforts predominantly led by individual faculty or subgroups of faculty with little institutional investment or strategic guidance. In many instances, there is a lack of understanding or consensus regarding what constitutes DEI activities, who engages in DEI activities, how faculty feel about their engagement, and what is an appropriate level of support. Concerns also exist that DEI work falls disproportionately to racial and ethnic groups underrepresented in medicine, exacerbating what is termed the minority tax. Despite these concerns, current literature lacks quantitative data characterizing such efforts and their potential impact on the minority tax. As pediatric academic settings invest in DEI programs and leadership roles, there is imperative to develop and use tools that can survey faculty perspectives, assess efforts, and align DEI efforts between academic faculty and health systems. Our exploratory assessment among academic pediatric faculty demonstrates that much of the DEI work in pediatric academic settings is done by a small number of individuals, predominantly Black faculty, with limited institutional support or recognition. Future efforts should focus on expanding participation among all groups and increasing institutional engagement.

Adolescent Suicide Risk Screening: A Secondary Analysis of the SHIELD Randomized Clinical Trial.

OBJECTIVE: To evaluate the effectiveness of adolescent suicide risk screening to increase initiation of mental health services via a secondary analysis using data from the SHIELD (Screening in High Schools to Identify, Evaluate and Lower Depression) randomized clinical trial, which evaluated school-based screening for major depressive disorder (MDD). STUDY DESIGN: Students in 14 Pennsylvania high schools were randomized by grade to either the usual school practice of targeted referral for behavior raising a concern for suicide risk or universal screening using the Patient Health Questionnaire-9 (PHQ-9), with any response >0 to item 9 regarding suicide risk considered positive. Students identified in either arm were referred to the Student Assistance Program (SAP), which is mandated in all Pennsylvania schools. The SAP determined follow-up. Study groups were compared using mixed-effects logistic regression. RESULTS: The participants comprised 12 909 students, with 6473 (50.1%) randomized to universal screening. The study group was 46% female and 43% Hispanic or non-Hispanic Black. Adolescents in the universal screening arm had 7.1-fold greater odds (95% CI, 5.7-8.8) of being identified as at risk for suicide, 7.8-fold greater odds (95% CI, 4.6-13.1) of follow-up needs, and 4.0-fold greater odds (95% CI, 2.0-7.9) of initiating mental health treatment. CONCLUSIONS: Although the PHQ-9 is a MDD screening tool, its use in universal screening increased identification and treatment initiation for adolescents at risk for suicide. This confirms the value of universal screening and suggests that a suicide-specific risk assessment would have even greater impact on treatment initiation for identified youth. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03716869.

Screening in High Schools to Identify, Evaluate, and Lower Depression Among Adolescents: A Randomized Clinical Trial.

Importance: Adolescent major depressive disorder (MDD) prevalence has nearly doubled in the past decade. The US Preventive Services Task Force endorses universal adolescent MDD screening in primary care; however, most adolescents lack preventive health care, resulting in worsening disparities in MDD screening and treatment. Objective: To evaluate the effectiveness of universal adolescent MDD screening in the school setting in an effort to reduce disparities and improve MDD identification and treatment initiation. Design, Setting, and Participants: This randomized clinical trial, conducted from November 6, 2018, to November 20, 2020, compared the usual school practice of targeted or selected screening based on observable behaviors of concern with universal MDD screening. Students within an identified school were randomized by grade to 1 of the 2 study groups. Study groups were compared using mixed-effects logistic regression. Participants included students in grades 9 through 12 enrolled at 1 of the 14 participating Pennsylvania public high schools. Interventions: In targeted screening, students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up recommendations. In universal screening, all students completed the Patient Health Questionnaire-9 (PHQ-9); students with positive scores proceeded to SAP. The universal screening group could also have targeted referral to SAP for concerning behavior independent of the PHQ-9. Main Outcomes and Measures: The primary outcome was initiation of MDD treatment or services based on data collected by school SAP teams during the academic year. Results: A total of 12 909 students were included (median age, 16 years [range, 13-21 years]; 6963 male [53.9%]), of whom 2687 (20.8%) were Hispanic, 2891 (22.4%) were non-Hispanic Black, 5842 (45.3%) were non-Hispanic White, and 1489 (11.5%) were multiracial or of other race or ethnicity. A total of 6473 students (50.1%) were randomized to universal screening, and 6436 (49.9%) were randomized to targeted screening. Adolescents in the universal screening group had 5.92 times higher odds (95% CI, 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of SAP confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of initiating MDD treatment. No differences were identified in initiation for planned subgroup analyses by sex or race and ethnicity. Conclusions and Relevance: In this randomized clinical trial, universal school-based MDD screening successfully increased identification of MDD symptoms and treatment initiation among adolescents, confirming the value of this approach to address this rising public health concern. Trial Registration: ClinicalTrials.gov identifier: NCT03716869.

Parent Views on School-Based Depression Screening: Findings From a National Survey.

PURPOSE: This study explored parent views on school involvement in screening and identification of adolescent depression. METHODS: This was a cross-sectional Internet-based survey with the C.S. Mott Children's Hospital National Poll on Children's Health. Of 2,004 parents (63.4% response rate), 770 had a middle/high school student and were eligible for this module. Poststratification weights were generated by survey vendor Ipsos. Descriptive and bivariate results were calculated; multinomial logistic regression models controlled for parent sex, race/ethnicity, education, employment status, and school level. RESULTS: Parent respondents were 54.8% female, 57.5% white, 64.3% above a high school education, and 79.7% employed; 76.2% were answering based on a high school student. Most parents supported school-based depression screens starting in sixth (46.7%) or seventh (15.1%) grades, although 15.9% responded no screening should be done. Among parent respondents, 93.2% wished to be informed of a positive screen. Regression analysis found parents of middle school students were 4.18 times more likely to prefer sixth versus 9th to 12th grade to start screening. CONCLUSIONS: Most parents support middle school depression screening but overwhelmingly wished to be informed of a positive result. Guidelines for maintaining adolescent confidentiality in a school-based depression screening program will require careful consideration.

Effectiveness of Universal School-Based Screening vs Targeted Screening for Major Depressive Disorder Among Adolescents: A Trial Protocol for the Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) Randomized Clinical Trial.

Importance: The prevalence of annual major depressive disorder (MDD) episodes among adolescents in the United States rose from 8.3% in 2008 to 12.8% in 2016. Despite the US Preventive Services Task Force 2009 endorsement and 2016 reaffirmation of universal adolescent MDD screening in primary care, many adolescents are missed, as more than 60% lack annual preventive health visits and MDD screening remains inconsistent. Objective: To compare the effectiveness of universal school-based screening for adolescent MDD vs the existing process of targeted screening based on observable behavior. Design, Setting, and Participants: Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) is a randomized clinical trial that will take place in at least 8 Pennsylvania public high schools among at least 9650 students enrolled in 9th through 12th grade. Students will be randomized by grade to either targeted screening (current process) or universal screening (intervention). Students in the targeted screening arm will complete mandated school health screenings, which do not include an MDD screening. These students will be observed through the academic year for referral to the Student Assistance Program (SAP), required in all Pennsylvania schools. If a student exhibits behavior concerning for MDD raised by any contact (eg, teacher, parent, peer, or self-referral), SAP will triage the student and provide follow-up recommendations. Students in the universal screening arm will complete the validated Patient Health Questionnaire-9 (PHQ-9) from September through December of the academic year. The PHQ-9 includes 9 close-ended questions and is scored from 0 to 27. Students with a positive result (ie, score >10) will proceed to SAP triage. Students in the intervention arm will also be observed for behavior concerning for MDD during the school year, potentially prompting SAP triage referral. The primary outcome will be the proportion of adolescents referred to SAP triage who are recommended for additional MDD-related services and successfully engage with at least 1 SAP recommendation. Observers will not be blinded to patient groups, and an intention-to-treat analysis will be used. Discussion: The SHIELD trial began with 3 schools during the 2018-2019 academic year. Screening in the intervention arm with the PHQ-9 is currently underway for the remaining schools, with a goal of completion of all PHQ-9 screenings by December 2019. This trial addresses the US Preventive Services Task Force call for large, high-quality randomized clinical trials to better understand the effects of MDD screening and quantify the proportion of adolescents with screen-detected MDD successfully referred and treated. Trial Registration: ClinicalTrials.gov identifier: NCT03716869.

Introduction to the special issue on child and family health: the role of behavioral medicine in understanding and optimizing child health.

Health promotion during early life and childhood can reduce the prevalence and impact of acute and chronic health conditions later in life. Research regarding factors that influence child and family health, prevention, and intervention programs that address them, and policies that promote implementation of best practices are needed to efficiently and effectively address the multi-faceted, biopsychosocial influences on child health, especially among youth from underserved backgrounds. The current special issue dedicated to child and family health offers a series of articles that illustrate how explanatory studies and targeted intervention programs for children, families, health care providers, and communities can be used to improve child health. Articles in this special issue are organized into three areas related to child and family health: (i) diet and nutrition, (ii) cancer prevention and control, and (iii) social determinants of health and health care. The articles included in this special issue underscore that behavioral medicine practitioners, researchers, and policy makers are well poised to lead innovative efforts to promote child health across clinical, community, health care, and population settings.

Potential solutions for pediatric weight loss programs in the treatment of obesity in rural communities.

Pediatric obesity remains disproportionately more prevalent in rural communities; however, multidisciplinary, pediatric weight loss programs, which are often located in tertiary-care centers, may not be accessible to rural families. Limited models to specifically address pediatric obesity in rural communities exist. Therefore, innovative solutions are required for expanded treatment of pediatric obesity in rural communities. This article discusses potential solutions for multidisciplinary, tertiary-care pediatric weight loss programs to improve access and treatment of pediatric obesity in rural communities. A selected review of the literature suggests that strategies to overcome barriers to treatment in rural communities include telephone calls and telemedicine conferencing by obesity specialists from academic centers (obesity medicine specialists, endocrinologists, dietitians, and psychotherapists) as well as training local primary care providers in rural communities to screen, diagnose, and treat patients with obesity. Multidisciplinary, tertiary-care pediatric weight loss programs have a profound opportunity to impact the treatment of pediatric obesity in rural communities by training practicing rural primary care providers as well as strengthening their commitment to educate future generations of clinicians on the treatment of pediatric obesity through medical training including physician assistant, nurse practitioner, and pediatric and family medicine resident education and skill building. This article identifies potential mechanisms for expansive treatment of pediatric obesity in rural communities by multidisciplinary, tertiary-care weight loss programs and highlights areas of specific focus needed for future investigation.