Short report: Integrated evaluations for autism spectrum disorder in pediatric primary care clinics.

LAY ABSTRACT: Primary care providers often screen for autism during well child visits in the first few years of life and refer children for diagnostic evaluations when needed. However, most children do not receive a diagnosis until years later which delays access to services. Racism, socioeconomic status, and other systemic inequalities that limit access to health care further delay diagnostic evaluations. Mental health clinicians who work in primary care clinics can help address barriers to accessing diagnostic evaluation services once they are recommended by their primary care provider. However, mental health clinicians who work in primary care typically do not have training in diagnosing autism. The goal of this study was to evaluate a program training mental health professionals working in an urban primary care setting, primarily serving Black and Latinx families insured by Medicaid, to provide autism diagnostic evaluations. Two hundred and fifty children completed evaluations through the Autism in Primary Care (APC) program. The wait time to access an evaluation through APC was significantly shorter than through standard avenues of care (e.g. referring to a separate autism clinic). Referring primary care providers and caregivers endorsed high levels of satisfaction with the program. Conducting autism evaluations in primary care settings offers a promising opportunity to improve earlier diagnosis and treatment access for families, reduce inequities in care, and increase caregiver and child well-being.

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

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

A Multisystem Approach to Improving Autism Care.

Children with autism face significant barriers to accessing evaluations and intervention services often because of confusing referral processes, lack of centralized coordination across organizations serving children with autism, insurance coverage gaps, multiyear waitlists for diagnostic services, and limited provider knowledge about autism. Racism and systemic inequities exist and persist in autism care across the United States. This article reviews targeted initiatives implemented by a multidisciplinary team to advocate for, and address barriers faced, by autistic children and their families in Washington, DC. We describe initiatives across multiple levels of the health care system including: 1. infrastructure-building initiatives (eg, coalition-building, policy, and advocacy); 2. enabling services (eg, population- and community-level supports that increase provider capacity to serve children's and families' needs); and 3. direct services (eg, innovative, gap-filling programs that directly serve children and families). We review outcomes and describe lessons learned.

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

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

Mental Health Screening in Pediatric Primary Care: Factors Associated With Screening Completion and Elevated Scores.

This study aimed to examine predictors of complete and elevated youth mental health screens. Parents of 4- to 11-year-old children completed the Strengths and Difficulties Questionnaire (SDQ) during a routine, universal mental health screening initiative in primary care. Bivariate logistic regressions were run to examine associations between independent (visit age, sex, race/ethnicity, language, insurance, and guardian) and dependent variables (screening completion and elevated SDQ score). Parents of younger and Spanish-speaking (vs English-speaking) children were less likely to have a complete SDQ screen. Among those with complete SDQ screens, older children, male children, those with public or no insurance, and those who had a mother (vs father) complete the screener were more likely to have an elevated score. Understanding patterns of screening completion rates and predictors of elevated screens provides valuable information to improve resource mapping and planning. Findings can inform mental health screening implementation and optimization within primary care.

Factors Associated With Psychiatric Readmission of Youths in a Racially Diverse and Urban Hospital Setting.

OBJECTIVE: This study examined predictors of readmission to a psychiatric inpatient unit of an urban children's hospital within 1 year of discharge among a racially diverse sample of youths. METHODS: The authors retrospectively analyzed 2 years of electronic health record data of inpatient psychiatric unit admissions (N=1,604). Multivariate logistic regression and random-effects multinomial logistic regression were used for analyses. RESULTS: The estimated odds ratios for any readmission within 1 year of discharge were significantly higher for Black youths, youths insured by Medicaid, and youths with a length of stay longer than 7 days. Factors remained strongly predictive when examining multiple readmissions versus no readmissions. CONCLUSIONS: Black youths, youths insured by Medicaid, and youths with longer stays were more likely than other youths to be readmitted. Findings suggest the need for interventions such as care coordination to target predictors of readmission and the need to examine inequities in the health care system.

Pediatric Provider Experiences with Implementation of Routine Mental Health Screening.

OBJECTIVE: Despite the utility of universal screening, most pediatric providers rarely use mental health (MH) screening tools. As such, provider descriptions of their experiences with universal screening are limited. The goal of this study was to describe barriers to, and facilitators of, universal MH screening implementation, the perceived impact of such screening, impressions of a screening-focused quality improvement (QI) Learning Collaborative, and lessons learned. METHOD: We invited primary care clinicians participating in a large-scale QI Learning Collaborative on MH screening (n = 107) to complete postproject interviews. Interviews were transcribed and analyzed using constant comparative qualitative analysis, an inductive, iterative process. RESULTS: Eleven interviews were completed and analyzed. Practice sites included academic health centers, a private practice, and a federally qualified health center. Providers described the positive impact of screening (increased identification of MH concerns) and barriers and facilitators of screening at the practice level (clinic and leadership buy-in and electronic medical record integration), the provider level (provider beliefs about the importance of screening), and the patient level (parent literacy). Challenges of linking families with care after screening included lack of adequate referrals, long wait lists, limited bilingual providers, insurance gaps, and inadequate feedback loops. Access to on-site MH clinicians and participation in the Learning Collaborative were described as beneficial. CONCLUSION: Findings elucidate how universal MH screening can be sustainably integrated into real-world primary care settings and may facilitate the uptake of American Academy of Pediatrics recommendations for best practices in screening for MH concerns.

Increasing Mental Health Engagement From Primary Care: The Potential Role of Family Navigation.

Early engagement in mental health intervention is critical, yet the vast majority of children who are experiencing mental health concerns are not receiving needed services. Pediatric primary care clinics have been recognized as an ideal setting in which to identify and address mental health problems early, although engagement in mental health services within primary care and in community-based settings remains low. Navigators, or individuals with experience in navigating the mental health system, have been highlighted as promising partners in efforts to improve engagement in mental health services. Navigation has a growing body of research support among adults and in targeting medical concerns, but there has been limited research on integrating family navigators into pediatric primary care settings to address mental health concerns. Despite this gap in the evidence base, we believe there is significant promise for the use of this model in addressing children's mental health needs. In this report, we discuss factors contributing to high levels of unmet mental health needs and low levels of engagement in mental health services, the role that navigators can play in increasing engagement in mental health care, and implications and recommendations related to integrating mental health-focused family navigators into pediatric primary care settings.

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

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

Behavioral Health Integration in Health Care Settings: Lessons Learned from a Pediatric Hospital Primary Care System.

Behavioral health integration within primary care has been evolving, but literature traditionally focuses on smaller scale efforts. We detail how behavioral health has been integrated across a large, urban pediatric hospital system's six primary care clinics (serving over 35,000 children annually and insured predominately through Medicaid) and discuss strategies for success in sustaining and expanding efforts to achieve effective integration of behavioral health into primary care. In a time span of 3 years, the clinics have implemented routine, universal behavioral health screening at well child visits, participated in a 15-month behavioral health screening quality improvement learning collaborative, and integrated the work of psychologists and psychiatrists. Additional work remains to be done in improving family engagement, further expanding services, and ensuring sustainability.

Using Effective Public Private Collaboration to Advance Integrated Care.

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

Improving Mental Health Access for Low-Income Children and Families in the Primary Care Setting.

Poverty is a common experience for many children and families in the United States. Children <18 years old are disproportionately affected by poverty, making up 33% of all people in poverty. Living in a poor or low-income household has been linked to poor health and increased risk for mental health problems in both children and adults that can persist across the life span. Despite their high need for mental health services, children and families living in poverty are least likely to be connected with high-quality mental health care. Pediatric primary care providers are in a unique position to take a leading role in addressing disparities in access to mental health care, because many low-income families come to them first to address mental health concerns. In this report, we discuss the impact of poverty on mental health, barriers to care, and integrated behavioral health care models that show promise in improving access and outcomes for children and families residing in the contexts of poverty. We also offer practice recommendations, relevant to providers in the primary care setting, that can help improve access to mental health care in this population.

Prevention Services for Externalizing and Anxiety Symptoms in Low-Income Children: the Role of Parent Preferences in Early Childhood.

Dissemination of prevention programs targeting young children is impeded by challenges with parent engagement. Matching program characteristics to parent preferences is associated with increased retention in clinical/intervention settings, but little is known about the types of prevention programs that interest parents. The objectives of this study were to better understand parents' preferences for services designed to prevent externalizing and anxiety disorders and to identify factors associated with preferences. Ethnically diverse, low-income caregivers (n = 485) of young children (11-60 months) completed surveys on child anxiety and externalizing symptoms, parental worry about their children, parent anxiety symptoms, and preferences for prevention group topics. Parents were more likely to prefer a group targeting externalizing behaviors compared to anxiety. Cluster analysis revealed four groups of children: low symptoms, moderate anxiety-low externalizing, moderate externalizing-low anxiety, and high anxiety and externalizing. Parents' preferences varied according to co-occurrence of child anxiety and externalizing symptoms; interest in a program targeting externalizing problems was associated with elevated externalizing problems (regardless of anxiety symptom level), parent anxiety symptoms, and parent worry about their child. Only parent anxiety symptoms predicted parents' interest in an anxiety-focused program, and preference for an anxiety-focused program was actually reduced if children had co-occurring anxiety and externalizing symptoms versus only anxiety symptoms. Results suggest that parents' interest in a program to prevent externalizing problems was well-aligned with the presenting problem, whereas preferences for anxiety programming suggest a more complex interplay among factors. Parent preferences for targeted programming are discussed within a broader framework of parent engagement.

Which African American mothers disclose psychosocial issues to their pediatric providers?

OBJECTIVE: To determine if parents' self-efficacy in communicating with their child's pediatrician is associated with African American mothers' disclosure of psychosocial concerns during pediatric primary care visits. METHODS: Self-identified African American mothers (n = 231) of children 2 to 5 years were recruited from 8 urban pediatric primary care practices in the Washington, DC, metropolitan area. Visits were audiorecorded, and parents completed phone surveys within 24 hours. Maternal disclosure of psychosocial issues and self-efficacy in communicating with their child's provider were measured using the Roter Interactional Analysis System (RIAS) and the Perceived Efficacy in Patient-Physician Interactions (PEPPI), respectively. RESULTS: Thirty-two percent of mothers disclosed psychosocial issues. Mothers who disclosed were more likely to report maximum levels of self-efficacy in communicating with their child's provider compared to those who did not disclose (50% vs 35%; P = .02). During visits in which mothers disclosed psychosocial issues, providers were observed to provide more psychosocial information (mean 1.52 vs 1.08 utterances per minute, P = .002) and ask fewer medical questions (mean 1.76 vs 1.99 utterances per minute, P = .05) than during visits in which mothers did not disclose. The association between self-efficacy and disclosure was significant among low-income mothers (odds ratio 5.62, P < .01), but not higher-income mothers. CONCLUSIONS: Findings suggest that efforts to increase parental self-efficacy in communicating with their child's pediatrician may increase parents' likelihood of disclosing psychosocial concerns. Such efforts may enhance rates of identifying and addressing psychosocial issues, particularly among lower-income African American patients.

Mental health screening and consultation in primary care: The role of child age and parental concerns [corrected].

OBJECTIVE: To determine (1) how child age relates to parent concerns about child behavior and (2) how child age and parent concerns correlate with provider referrals and family attendance at mental health consultant (MHC) appointments. METHODS: Data were obtained from Rhode Island's Project, Linking Actions for Unmet Needs in Children's Health, in which universal developmental and behavioral screening and MHCs were embedded within primary care sites serving low-income diverse families. Children 9 months to 8 years of age were eligible for the study if they had a scheduled screening well-child visit in 2010 (N = 1451). Families completing screening and/or those referred for a MHC appointment were included in analyses (n = 700). Outcome measures included parent-reported concerns about child behavior, referral status following screening, and family attendance at the MHC appointment. RESULTS: For every 1-month increase in child age, there was a 1.02 times increase in the likelihood of parent behavioral concern and a 1.04 times increase in the likelihood of mental health referral, even when controlling for child behavior. MHC-referred children older than 5 years were 2.61 times more likely to attend than children less than 5 years. When examining parent behavioral concerns and child age jointly, only concerns remained significant. CONCLUSIONS: Infants and toddlers, who have the highest rates of unmet mental health needs, may be least likely to benefit from universal screening and on-site MHC support. Efforts to incorporate behaviorally based screening tools and increase parent concerns where appropriate appear warranted, particularly for families with very young children.

Randomized trial of a health communication intervention for parents of children with asthma.

OBJECTIVE: To determine if a health communication intervention targeting parents of high-risk, urban, minority children with asthma could (i) improve parental perceptions of connectedness to and communication with their child's primary care providers (PCP) and (ii) decrease reliance on emergency departments (EDs) and other urgent care services for their child's asthma-related care. METHODS: The design was a single blind, parallel groups, randomized controlled trial. Parents were recruited from an ED-based asthma clinic serving primarily low-income, minority children in Washington, DC. The intervention involved face-to-face education on effective communication followed by a single booster call. Standardized instruments were administered to assess primary care connectedness and healthcare utilization at baseline and 2- and 6-months post-enrollment. RESULTS: A total of 150 parents of children 1-12 years old were randomized (77 intervention and 73 usual care), and 137 (91%) were successfully followed for six months. Only at the two-month follow-up time-point, parents in the intervention group were significantly more likely to identify a PCP as the main source of their child's asthma care (adjusted odds ratio: 12.6, 95% confidence interval: 1.1-142.1) and to report a significant reduction in ED visits for asthma care (adjusted incidence rate ratio: 0.3, 95% confidence interval: 0.1-0.8). There was no significant effect on parent communication self-efficacy or number of PCP visits. CONCLUSIONS: A brief, in-person health communication intervention for parents of high-risk children with asthma resulted in improved identification of PCPs as the usual source of asthma care and reduced reliance on EDs for asthma care, albeit only for two months post-intervention.

Internet and mobile technology use among urban African American parents: survey study of a clinical population.

BACKGROUND: There is considerable potential for mobile technologies to empower pediatric patients and families by improving their communication with health professionals. National surveys suggest minority parents frequently communicate via mobile technology, but it is uncertain how amenable they are to receiving health care information in this format. Although the low cost and far reach characteristics of mobile health (mHealth) technology makes it advantageous for communication with minority parents, data on acceptance are needed. OBJECTIVE: The objective of the study was to determine utilization of mobile and Internet technology by African American parents in an urban, underserved population, and to assess their interest in receiving health information via text messaging or other technologies (eg, social media and the Internet). METHODS: A survey was administered to parents of children aged 1-12 years covered by public insurance receiving care at 3 pediatric primary care centers in Washington, DC. RESULTS: The African American sample (N=302) was composed of primarily single (75.8%, 229/302) mothers. Almost half had more than a high school education (47.7%, 144/302) and incomes above US $25,000 per year (43.0%, 130/302). Most (97.0%, 293/302) reported owning a cell phone, of which 91.1% (275/302) used it to text and 78.5% (237/302) used it to access the Internet. Most had service plans with unlimited text and data, but 26.5% (80/302) experienced service interruptions in the previous year. Home Internet access was more prevalent among those with higher income (86.2%, 112/130), but it was still relatively pervasive among lower income families (66.9%, 83/124). In adjusted logistic regression models, African American mothers with income greater than US $25,000 annually were 4 times as likely to own a tablet computer than their lower income counterparts. Of the participants, 80.8% (244/302) used social networking, primarily Facebook, and 74.2% (224/302) were interested in joining a social networking group about a health topic concerning their child. Although relatively few African American mothers (17.9%, 54/302) shared health information via texting, there was strong interest in receiving health information via mobile phones (87.4%, 264/302). There was no significant difference in Internet/mobile device use or interest in using these outlets to send/receive information about their children's health between parents of healthy children and parents of children with chronic health conditions. CONCLUSIONS: Urban African American parents are active users of the Internet and mobile technology for social interactions, but they are less likely to use it for accessing or communicating health information. However, most parents expressed an interest in receiving health information or utilizing social networking to learn more about health topics. Mobile technology and social networks may be an underutilized method of providing health information to underserved minority populations.

Pathways to service receipt: modeling parent help-seeking for childhood mental health problems.

Understanding parent appraisals of child behavior problems and parental help-seeking can reduce unmet mental health needs. Research has examined individual contributors to help-seeking and service receipt, but use of structural equation modeling (SEM) is rare. SEM was used to examine parents' appraisal of child behavior, thoughts about seeking help, and receipt of professional services in a diverse, urban sample (N = 189) recruited from women infant and children offices. Parents of children 11-60 months completed questionnaires about child behavior and development, parent well-being, help-seeking experiences, and service receipt. Child internalizing, externalizing, and dysregulation problems, language delay, and parent worry about child behavior loaded onto parent appraisal of child behavior. Parent stress and depression were positively associated with parent appraisal (and help-seeking). Parent appraisal and help-seeking were similar across child sex and age. In a final model, parent appraisals were significantly associated with parent thoughts about seeking help, which was significantly associated with service receipt.