Identifying Children and Adolescents at Elevated Mental Health Risk Before and During COVID-19.

OBJECTIVE: To determine whether the prevalence of psychosocial risk in children and adolescents changed from before to during the COVID-19 pandemic and whether these changes differed by age group, sex, and season, based on a standardized psychosocial measure completed as a routine part of primary care. METHODS: Children and adolescents aged 5.5 to 17.9 years were screened with a parent report Pediatric Symptom Checklist-17 (PSC-17P) between November 2017 and June 2022. Changes in the prevalence of psychosocial risk (global, internalizing, externalizing, and attention scales) from before to during the pandemic were compared by age group, sex, and season. RESULTS: In a sample of 459,767 health supervision visits, the prevalence of PSC-17P global, internalizing, and attention risk worsened significantly from before to during the pandemic, especially among female adolescents (ages 12.0-17.9). For a pediatrician seeing a hypothetical sample of 1000 adolescent girls, the expected number at risk would have increased from 103 to 131 on the global scale (26.6% increase), from 189 to 231 on the internalizing subscale (22.0% increase), and from 60 to 82 on the attention subscale (35.7% increase). Seasonality had a large effect, with significantly lower PSC-17P risk in the summer every year. CONCLUSION: Data from a large, national sample of pediatric visits suggested that global, internalizing, and attention concerns increased slightly overall from before to during the COVID-19 pandemic, with different patterns by age group and sex. Adolescent girls showed substantially increased global, internalizing, and attention problems. These increases support the need for further research and additional individual and system-level interventions.

Do Autism-Specific and General Developmental Screens Have Complementary Clinical Value?

Prior studies suggest autism-specific and general developmental screens are complementary for identifying both autism and developmental delay (DD). Parents completed autism and developmental screens before 18-month visits. Children with failed screens for autism (n = 167) and age, gender, and practice-matched children passing screens (n = 241) completed diagnostic evaluations for autism and developmental delay. When referral for autism and/or DD was considered, overall false positives from the autism screens were less frequent than for referral for autism alone. Presence of a failed communication subscale in the developmental screen was a red flag for autism and/or DD. An ordinally-scored autism screen had more favorable characteristics when considering autism and/or DD, yet none of the screens achieved recommended standards at 18 months, reinforcing the need for recurrent screening as autism emerges in early development.

Earthquake exposure, adverse childhood experiences, and psychosocial functioning in Chilean children: A longitudinal study.

The impact of an 8.8 magnitude Chilean earthquake on elementary school students' psychosocial functioning was assessed along with exposure to adverse childhood experiences (ACEs). Skills for Life, a national school-based mental health program in Chile, routinely assesses first- and third-grade students' psychosocial functioning and classroom adaptation. Students (N = 19,627) were screened before (2009) and after (2011) the 2010 earthquake with parent- and teacher-report measures and with a parent-report of four ACEs (family psychopathology, child chronic illness, family social isolation, father absence). Earthquake exposure was categorized as mild, moderate, or severe for Chile's 15 regions. Multilevel models analyzed the unadjusted and adjusted impacts of earthquake exposure and ACEs on functioning while clustering for school- and district-level effects. In covariate-adjusted models, earthquake exposure and three ACEs were significantly associated with worsened psychosocial functioning; earthquake exposure and all four ACEs were significantly associated with worsened classroom adaptation. New family psychopathology, B = 1.90, p < .001; chronic illness, B = 2.25, p < .001; and severe earthquake impact, B = 1.29, p < .001, held the strongest negative effects on psychosocial well-being. Moderate, B = 3.04, p = .011, and severe earthquake exposure, B = 2.53, p = .047, and new family psychopathology, B = 1.99, p < .001, were associated with the worst classroom functioning 1-year postdisaster. Findings suggest that both exogenous and home-based stressors can have significant consequences for children's psychosocial functioning and classroom adaptation, and routine screening helps quantify how individual students are affected by chronic versus acute stressors.

Suicidal Ideation in Adolescents: Understanding Results from Screening with the PHQ-9M and the PSC-17P.

OBJECTIVE: The objective of the study was to help pediatricians understand and respond to suicidal ideation (SI) in adolescents based on data from 2 widely used screening measures that assessed SI and other psychosocial vulnerabilities in a large, national sample. METHODS: Adolescents (ages 11-17 years) completed the Patient Health Questionnaire Modified for Teenagers (PHQ-9M) using the Comprehensive Health and Decision Information System software before their well-child visits. Question 9 asks about past 2-week SI. Their parents filled out the Pediatric Symptom Checklist (PSC-17P), which screens for a broad range of psychosocial problems. Chi-square analyses and one-way analysis of variances assessed the relationship between SI and psychosocial problems. RESULTS: Among 5411 adolescents, 266 (4.9%) reported SI at least several days in the past 2 weeks. Among adolescents with SI, 187 (70.3%) reported moderate to very severe depression on the PHQ-9M (≥10), 68.1% were at risk on at least 1 PSC-17P problem subscale, 59.7% on the PSC-17P internalizing scale, 42.9% on PSC-17P overall, 20.6% on PSC-17P externalizing, and 18.5% on PSC-17P attention. Within the subsample endorsing SI nearly all days, 35.7% had a former suicide attempt. CONCLUSION: The PHQ-9M identifies a clinically heterogeneous subset of approximately 5% of adolescents who report occasional to frequent SI. The PSC-17P corroborates their high degree of overall risk and offers additional information that can help pediatricians assess clinical severity and range of psychosocial problems. Given our limited knowledge of how to predict and prevent an individual adolescent's suicide, the focus of screening should be to identify and help the subset of patients with chronic psychosocial vulnerability of any type.

Autism screening at 18 months of age: a comparison of the Q-CHAT-10 and M-CHAT screeners.

BACKGROUND: Autism screening is recommended at 18- and 24-month pediatric well visits. The Modified Checklist for Autism in Toddlers-Revised (M-CHAT-R) authors recommend a follow-up interview (M-CHAT-R/F) when positive. M-CHAT-R/F may be less accurate for 18-month-olds than 24-month-olds and accuracy for identification prior to two years is not known in samples that include children screening negative. Since autism symptoms may emerge gradually, ordinally scoring items based on the full range of response options, such as in the 10-item version of the Quantitative Checklist for Autism in Toddlers (Q-CHAT-10), might better capture autism signs than the dichotomous (i.e., yes/no) items in M-CHAT-R or the pass/fail scoring of Q-CHAT-10 items. The aims of this study were to determine and compare the accuracy of the M-CHAT-R/F and the Q-CHAT-10 and to describe the accuracy of the ordinally scored Q-CHAT-10 (Q-CHAT-10-O) for predicting autism in a sample of children who were screened at 18 months. METHODS: This is a community pediatrics validation study with screen positive (n = 167) and age- and practice-matched screen negative children (n = 241) recruited for diagnostic evaluations completed prior to 2 years old. Clinical diagnosis of autism was based on results of in-person diagnostic autism evaluations by research reliable testers blind to screening results and using the Autism Diagnostic Observation Schedule-Second Edition (ADOS-2) Toddler Module and Mullen Scales of Early Learning (MSEL) per standard guidelines. RESULTS: While the M-CHAT-R/F had higher specificity and PPV compared to M-CHAT-R, Q-CHAT-10-O showed higher sensitivity than M-CHAT-R/F and Q-CHAT-10. LIMITATIONS: Many parents declined participation and the sample is over-represented by higher educated parents. Results cannot be extended to older ages. CONCLUSIONS: Limitations of the currently recommended two-stage M-CHAT-R/F at the 18-month visit include low sensitivity with minimal balancing benefit of improved PPV from the follow-up interview. Ordinal, rather than dichotomous, scoring of autism screening items appears to be beneficial at this age. The Q-CHAT-10-O with ordinal scoring shows advantages to M-CHAT-R/F with half the number of items, no requirement for a follow-up interview, and improved sensitivity. Yet, Q-CHAT-10-O sensitivity is less than M-CHAT-R (without follow-up) and specificity is less than the two-stage procedure. Such limitations are consistent with recognition that screening needs to recur beyond this age.

Beyond Initial Screening: One-Year Follow-up of Adolescents with Internalizing Problems on the Pediatric Symptom Checklist.

OBJECTIVE: Screening for adolescent depression is a quality indicator for pediatric care, and the parent-completed, 17-item Pediatric Symptom Checklist's internalizing (PSC-17P-INT) subscale has been validated for this purpose. The current study assessed the feasibility of PSC-17P-INT screening, the prevalence of risk on 2 consecutive PSC-17P-INTs, and rates of behavioral health (BH) service use before and after screening. METHODS: The parent-report PSC-17 was completed on tablet devices before well-child visits (WCVs) with results instantaneously available to clinicians in the electronic health record. Billing data were used to identify adolescents with 2 consecutive WCVs and possible BH service utilization 6 months before and after their first screen. RESULTS: In 2017, 1,068 adolescents (12-17 years old) were seen for a WCV, and 637 (59.6%) of them had one in 2018. Most (93.9%; N = 604) completed a PSC at both visits. Patients who scored positively on their first PSC-17P-INT were about 9 times more likely to receive subsequent BH services than patients who screened negative (24.3% vs 2.6%, χ2 = 59.65, p < 0.001). However, risk prevalence increased from the first (11.6%) to the second (14.9%) screen, and only 37.1% of at-risk patients remitted. CONCLUSION: The current study demonstrated that screening adolescents for depression using the PSC-17P-INT was feasible and associated with a significant increase in BH treatment rates. The study also demonstrated that the PSC could be used to track adolescents at risk for depression, found that most youth who screened positive remained at risk 1 year later, and supported recent quality guidelines calling for annual depression screening and follow-up for adolescents with depression.

Recognizing Adolescent Depression with Parent- and Youth-Report Screens in Pediatric Primary Care.

OBJECTIVES: To compare the use of the parent-report Pediatric Symptom Checklist (PSC-17P) and youth-report Patient Health Questionnaire-9 Modified for Teens (PHQ-9M) in compliance with recent quality standards for adolescent depression screening. STUDY DESIGN: Parents of 5411 pediatric outpatients (11.0-17.9 years old) completed the PSC-17P, which contains scales that assign categorical risk for overall (PSC-17P-OVR), internalizing (PSC-17P-INT), externalizing (PSC-17P-EXT), and attention (PSC-17P-ATT) problems. Adolescents completed the PHQ-9M, which assesses depressive symptoms. Both forms were completed online within 24 hours of each other before pediatric well-child visits. RESULTS: A total of 9.9% of patients (n = 535) were at risk on the PSC-17P-OVR, 14.3% (n = 775) were at risk on the PSC-17P-INT, and 17.0% (n = 992) were at risk on either or both scales (PSC-17P-OVR and/or PSC-17P-INT). Using the PHQ-9M cut-off score of 10 (moderate-very severe depression), an additional 2.4% (n = 131) were classified as at risk, with 66.8% (n = 263) of all PHQ-9M positives (n = 394) also coded as at risk by the PSC-17P-OVR and/or PSC-17P-INT scales. Using a PHQ-9M cut-off score of 15 (severe-very severe depression), only 29 patients (21.8% of the PHQ-9M positives) not identified by the PSC-17P-OVR and/or PSC-17P-INT were classified as being at risk. CONCLUSIONS: The combined PSC-17P-OVR and/or PSC-17P-INT scales identified 17% of adolescents as at risk for depression, including about two-thirds to three-quarters of adolescents classified as at risk on the PHQ-9M. These findings support using the PSC-17P to meet quality standards for depression as well as overall screening in pediatrics. Primary care clinicians can add the PHQ-9M to identify additional adolescents who may self-report depressive symptoms.

Accurate Autism Screening at the 18-Month Well-Child Visit Requires Different Strategies than at 24 Months.

Accuracy of autism screening using M-CHAT plus the follow-up interview (M-CHAT/F) for children screened positive at 18-months was compared to screening at 24-months. Formal ASD testing was criterion for a community sample of M-CHAT positive children (n = 98), positive predictive value (PPV) was 0.40 for the M-CHAT and 0.58 for the M-CHAT/F. MCHAT/F PPV was 0.69 among children 20+ months compared to 0.36 for <20 months. Multivariate analyses incorporating data from the Ages and Stages Questionnaire, MacArthur-Bates Communicative Development Inventory, M-CHAT and M-CHAT/F results, and M-CHAT items suggest language variables carry greatest relative importance in contributing to an age-based algorithm with potential to improve PPV for toddlers <20 months to the same level as observed in older toddlers.

Comparison of Autism Screening in Younger and Older Toddlers.

This study examined the effect of age at completion of an autism screening test on item failure rates contrasting older (>20 months) with younger (<20 months) toddlers in a community primary care sample of 73,564 children. Items related to social development were categorized into one of three age sets per criteria from Inada et al. (Research in Autism Spectrum Disorders 4(4):605-611, 2010). Younger toddlers produced higher rates of item failure than older toddlers and items in both of the later acquired item sets had higher probability rates for failure than the earliest acquired item set (prior to 8 months). Use of the same items and the same scoring throughout the target age range for autism screening may not be the best strategy for identifying the youngest toddlers at risk for autism.

School-based Screening to Identify Children At Risk for Attention-Deficit/Hyperactivity Disorder: Barriers and Implications.

This report describes a school-based screening project to improve early identification of children at risk for attention-deficit/hyperactivity disorder (ADHD) and communicate these concerns to parents, recommending that they contact their child's primary care provider (PCP). Of 17,440 eligible children in first through fifth grades in five school districts, 47.0% of parents provided required written consent, and teachers completed 70.4% of the online screeners (using the Vanderbilt AD/HD Diagnostic Teacher Rating Scale). Of 5,772 screeners completed, 18.1% of children (n = 1,044) were identified as at risk. Parents of at-risk children were contacted to explain risk status and recommended to visit their child's PCP for further evaluation. It was not possible to contact 39.1% of parents of at-risk children. Of the 636 parents of at-risk children who could be contacted, 53.1% (n = 338) verbally accepted the recommendation to follow-up with their PCP, which was not related to ADHD symptom severity. Parents of children with IEPs or related services were more likely to accept the recommendation to visit the PCP. Our exploration of the potential for school-based screening for ADHD identified a number of barriers to successful execution, but the data also indicated that this is an important problem to address.

Autism Screening With Online Decision Support by Primary Care Pediatricians Aided by M-CHAT/F.

BACKGROUND AND OBJECTIVE: Autism spectrum disorders (ASDs) often go undetected in toddlers. The Modified Checklist for Autism in Toddlers (M-CHAT) With Follow-up Interview (M-CHAT/F) has been shown to improve detection and reduce over-referral. However, there is little evidence supporting the administration of the interview by a primary care pediatrician (PCP) during typical checkups. The goal of this study was to evaluate the feasibility, validity, and reliability of the M-CHAT/F by PCPs with online prompts at the time of a positive M-CHAT screen. DESIGN: Forty-seven PCPs from 22 clinics completed 197 M-CHAT/Fs triggered by positive M-CHAT screens via the same secure Web-based platform that parents used to complete M-CHATs before an 18- or 24-month well-child visit. A second M-CHAT/F was administered live or by telephone by trained research assistants (RAs) at the Kennedy Krieger Institute Center for Autism and Related Disorders. The Autism Diagnostic Observation Schedule, Second Edition, and the Mullen Scales of Early Learning were administered as criterion measures. Measures of agreement between PCPs and RAs were calculated, and measures of test performance compared. RESULTS: There was 86.6% agreement between PCPs and RAs, with a Cohen's κ of 0.72. Comparison of sensitivity, specificity, positive predictive value (PPV), and overall accuracy for M-CHAT/F between PCPs and RAs showed significant equivalence for all measures. Use of the M-CHAT/F by PCPs resulted in significant improvement in PPV compared with the M-CHAT alone. CONCLUSIONS: Minimally trained PCPs can administer the M-CHAT/F reliably and efficiently during regular well-child visits, increasing PPV without compromising detection.

The PSC-17: Subscale Scores, Reliability, and Factor Structure in a New National Sample.

BACKGROUND: The Pediatric Symptom Checklist-17 (PSC-17) is a widely used, briefer version of the PSC-35, a parent-completed measure of children's psychosocial functioning. Despite the extensive use of the PSC-17 over the past 15 years there has not been a large-scale replication of the original derivation study. OBJECTIVE: To examine the prevalence of positive screens, reliability, and factor structure of PSC-17 scores in a new national sample and compare them with the derivation sample. METHODS: Data were collected on 80 680 pediatric outpatients, ages 4 to 15 years, whose parents filled out the PSC-17 from 2006 to 2015 via the Child Health and Development Interactive System, an electronic system that presents and scores clinical measures. RESULTS: The rates of positive screening on the overall PSC-17 (11.6%) and on the internalizing (10.4%) and attention (9.1%) subscales were comparable to rates found in the original sample, although the rate of externalizing problems (10.2%) was lower than in the derivation study. Reliability was high (internal consistency 0.89; test-retest 0.85), and a confirmatory factor analysis provided support for the original 3-factor model. CONCLUSIONS: Fifteen years after the PSC-17 was derived in a large nationally representative outpatient pediatric sample, a new and larger national sample found rates of positive screening, reliability, and factor structure that were comparable. Findings from this study support the continued use of the PSC-17 clinically as a screening tool in pediatric settings and in research.

Cerebellar Transcriptome Profiles of ATXN1 Transgenic Mice Reveal SCA1 Disease Progression and Protection Pathways.

SCA1, a fatal neurodegenerative disorder, is caused by a CAG expansion encoding a polyglutamine stretch in the protein ATXN1. We used RNA sequencing to profile cerebellar gene expression in Pcp2-ATXN1[82Q] mice with ataxia and progressive pathology and Pcp2-ATXN1[30Q]D776 animals having ataxia in absence of Purkinje cell progressive pathology. Weighted Gene Coexpression Network Analysis of the cerebellar expression data revealed two gene networks that significantly correlated with disease and have an expression profile correlating with disease progression in ATXN1[82Q] Purkinje cells. The Magenta Module provides a signature of suppressed transcriptional programs reflecting disease progression in Purkinje cells, while the Lt Yellow Module reflects transcriptional programs activated in response to disease in Purkinje cells as well as other cerebellar cell types. Furthermore, we found that upregulation of cholecystokinin (Cck) and subsequent interaction with the Cck1 receptor likely underlies the lack of progressive Purkinje cell pathology in Pcp2-ATXN1[30Q]D776 mice.