Implementing an APRN-Led Integrated Behavioral Health Clinic in a Rural Community.

OBJECTIVE: A rural primary care clinic implemented an advance practice providers, including nurse practitioner (APRN)-led integrated behavioral health program to facilitate holistic health care delivery. METHODS: Implementation was facilitated by Health Resources and Services Administration Grant funding to a state University College of Nursing. The College formed an academic-practice partnership with a Federally Qualified Health Center (FQHC) to implement integrated care in a rural satellite clinic administered by the FQHC. An interdisciplinary team (two family APRNs, a psychiatric APRN, a licensed behavioral health provider, and the Grant Project Director who is a Psychiatric APRN and a licensed Psychologist) provided the integrated care based on the University of Washington's Collaborative Care Model. RESULTS: This brief report describes the implementation of integrated care during the clinic's first year, services provided, lessons learned, community response, and improvement in anxiety and depressive symptoms for patients who were treated for behavioral health problems. An exemplar illustrates how collaborative care addressed one patient's behavioral health and primary care needs. CONCLUSIONS: APRN-led collaborative care can expand access to holistic, affordable care in rural areas to improve mental health. Adaptation and flexibility in traditional roles may be necessary and determining post-grant access to funding for services will be necessary for sustainability.

Improving Integrated Mental Health Care Through an Advanced Practice Registered Nurse-Led Program: Challenges and Successes.

Integrated and collaborative care delivery models have demonstrated efficacy for the management of psychiatric conditions in the primary care environment, yet organizations struggle with implementation of integrated efforts in clinical practice. Delivering care with a population focus versus face-to-face encounters with individual patients requires financial investment and adjustment in care delivery. We discuss the early implementation process of an advanced practice registered nurse (APRN)-led integrated behavioral health care program, including the challenges, barriers, and successes in the first 9 months of the program (January-September 2021), for an academic institution in the Midwest. A total of 161 Patient Health Questionnaire 9 (PHQ-9) and 162 Generalized Anxiety Disorder (GAD-7) rating scales were completed on 86 patients. The mean PHQ-9 score at the initial visit was 11.3 (moderate depression); after 5 visits, it decreased significantly to 8.6 (mild depression) (P < .001). The mean GAD-7 score at the initial visit was 10.9 (moderate anxiety); after 5 visits, it decreased significantly to 7.6 (mild anxiety) (P < .001). A survey completed by 14 primary care physicians 9 months after program launch revealed improvements in satisfaction with collaboration but, most notably, in perception of access to and overall satisfaction with behavioral health consultation/patient care services. Program challenges included adapting the environment to enhance leadership roles for the program and adjusting to virtual availability of psychiatric support. A case example highlights the value of integrated care along with improved depression and anxiety-related outcomes. Next steps should include efforts that capitalize on nursing leadership strengths while also promoting equity among integrated populations.

Maternal-Child Microbiome and Impact on Growth and Neurodevelopment in Infants and Children: A Scoping Review.

BACKGROUND: Pathologic changes in the microbiome (dysbiosis) have been implicated in affecting the growth and neurodevelopment of infants and children. There is evidence to suggest that prenatal and postnatal stressors may be a factor in dysbiosis and there is also a growing body of evidence to suggest that interventions may reduce this negative impact. A scoping review was undertaken to identify association between maternal and/or child microbiome with child growth and neurodevelopment. Additionally, intervention studies such as use of nutritional supplementation and its impact on the microbiome, growth and neurodevelopment were reviewed. METHODS: An exhaustive literature search identified 654 relevant citations. After review of abstracts, 557 were eliminated, and 97 remained for full text review. We identified and reported on 42 articles which met inclusion criteria. RESULTS: Seven studies examined associations between microbiome and neurodevelopment and 36 studies evaluated anthropometric measurements, most commonly weight, and microbiota relationships. One study evaluated both growth and neurodevelopment and microbiota. Fourteen studies evaluated supplemental nutrients. Preterm, low birth weight (LBW), and very low birth weight (VLBW) infants were most studied. Findings were inconclusive for consistent associations between microbiota and growth and neurodevelopment. Further, there were no consistent conclusive changes with prescribed treatment interventions. DISCUSSION: There is a need for high-quality longitudinal studies evaluating repeated developmental assessment measures using consistent microbial analysis techniques to inform conclusions regarding the association between microbiome and infant and child growth and neurodevelopment. Additional intervention studies that may mitigate dysbiosis are warranted.

Screening for pediatric behavioral health in primary care in rural and urban clinics.

INTRODUCTION: The prevalence of behavioral health disorders in children is approximately 15%-20%, yet less than half of the children ever receive treatment for these conditions. The lack of access to behavioral health care is common in urban areas but even more difficult to access in rural areas. Screening for behavioral health in a primary care setting is one of the first strategies to reduce this problem and improve access to care. The primary goal of this study was to examine behavioral health screening practices of pediatric primary care providers in a rural midwestern state. METHOD: A survey that queried family practice/internal medicine and pediatric providers who provide care to pediatric patients was delivered to over 300 primary care providers across the state. The number of surveys returned was 112. RESULTS: The Modified Checklist for Autism tool was administered by 80% of pediatric providers and 30% of family practice primary care providers. The Patient Health Questionnaire for depression was administered by 72% of pediatric and 80% of family practice providers. Most of the primary care providers had a behavioral health provider present in the clinic, which likely resulted in higher screening rates compared to the national average. DISCUSSION: The screening practices of the family practice and pediatric subspecialities reflect their respective current professional organization recommendations. Although most providers believe it is important to screen for developmental and behavioral disorders, further system changes are needed to support screening for development and broader behavioral problems along with depression among family practice providers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Addressing the Need for Training More School Psychologists to Serve Toddlers and Preschoolers with Autism Spectrum Disorders.

The prevalence of autism spectrum disorder (ASD) has risen significantly in the past two decades. Unfortunately, there is a shortage of mental health providers who have specialized training in delivering evidenced-based services to this population. Early intensive behavioral intervention (EIBI) is an evidenced-based treatment recommended for toddlers with ASD, and school psychologists are uniquely positioned to help children with ASD receive it. However, many school psychologists do not receive adequate training in this subspecialty. This paper makes recommendations to school psychology training programs about how to add or improve training in this subspecialty based on the results of an Office of Special Education Programs grant-funded ASD training program which involved collaboration between a NASP-approved and APA-accredited school psychology training program and a community-based early intensive behavioral intervention (EIBI) clinic. The grant supported development of an interdisciplinary didactic and clinical training program to increase the ASD knowledge, skills, and competencies of school psychology graduate students, with the broader goals of developing a replicable training model and increasing the workforce of trained providers for this underserved population. Fifteen graduate students completed the training program. Outcomes related to trainee knowledge, skills, and competencies, trainee satisfaction, and lessons learned over time analyzed within a logic model that guided the project's development and execution can be informative for other school psychology programs undertaking training in this subspecialty.

Evaluation of Caregiver Training Procedures to Teach Activities of Daily Living Skills.

Caregivers of children with an autism spectrum disorder are often responsible for assisting their children to complete activities of daily living skills. Effective and efficient caregiver training methods are needed to train caregivers. The present study used two concurrent multiple-baseline across-participants designs to evaluate the effects of real-time feedback and behavioral skills training on training eight caregivers to implement teaching procedures for activities of daily living skills with their child. We assessed caregivers' accuracy and correct implementation of the six-component teaching procedure after they received either real-time feedback or behavioral skills training. Caregivers from both groups mastered and maintained correct implementation of the teaching procedures with their child. The overall results suggest that real-time feedback and behavioral skills training are efficacious to train caregivers to implement activities of daily living skills procedures with their children, and that real-time feedback may be an efficient alternative method to train caregivers. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40617-020-00513-z.

Systematic Review: Feasibility, Reliability, and Validity of Maternal/Caregiver Attachment and Bonding Screening Tools for Clinical Use.

INTRODUCTION: Infant-caregiver attachment is crucial for an infant's immediate and long-term social-emotional development and health. Despite advocacy by the National Institute of Children's Health Quality for infant social-emotional development screening, there is a lack of identified tools for use in primary care. Therefore, we conducted a systematic review to identify caretaker-infant attachment self-report screening tools that would be feasible, reliable, and valid for use in primary care. METHOD: A systematic search identified 340 abstracts/articles, which were screened using inclusion and exclusion criteria. Twelve articles and six self-report attachment tools were examined for reliability, validity, and feasibility characteristics. RESULTS: Six caregiver-infant attachment self-report tools were identified. Establishment of feasibility, reliability, and validity are in the early stages. DISCUSSION: Potential infant-caretaker attachment screening tools were identified for use in primary care practices. Suggestions for research and practice include informal screening, additional psychometric testing, and development of policies supporting implementation of screening.

Interleukin-17A and Chronic Stress in Pregnant Women at 24-28 Weeks Gestation.

BACKGROUND: Allostatic load (AL) is a biopsychosocial model that suggests chronic psychosocial stress leads to physiological dysregulation and poor outcomes. The purpose of this study was to examine AL in pregnant women operationalized using proinflammatory cytokines and psychosocial indicators and perinatal outcomes. OBJECTIVES: The aim of the study was to identify relationships between circulating cytokines/chemokines and the Prenatal Distress Questionnaire, the Maternal Antenatal Attachment Scale, the Emotional Quotient Inventory, the Life Experiences Scale, and demographics in pregnant women. METHODS: A cross-sectional design was used to recruit pregnant women between 24 and 28 weeks of gestation. Blood and stress/emotional indicators were obtained after informed consent. Plasma was abstracted to simultaneously measure 29 cytokines/chemokines using a multiplex array. Cytokine/chemokine levels were compared with continuous variables using Spearman's rho and with categorical variables using Mann-Whitney U. RESULTS: Twenty-five women with medically high-risk (n = 16) and low-risk (n = 9) pregnancies consented. Most women were White (68%) with a mean age of 29 years (SD = 5.9). Although several cytokines and chemokines showed significant correlations with the stress/emotional indicators, only interleukin-17A (IL-17A) was significantly associated with all of the indicators (Prenatal Distress Questionnaire: rs = .528, p = .012; Maternal Antenatal Attachment Scale: rs = -.439, p = .036; Emotional Quotient Inventory total: rs = -.545, p = .007), Life Experiences Scale (rs = .458, p = .032), birth weight (rs = -.499, p = .013), and race (p = .01). DISCUSSION: Increased levels of IL-17A, a known cytokine associated with chronic stress and with poor perinatal outcomes, were associated with high prenatal distress, low maternal attachment, and lower emotional intelligence in pregnant women. Increased levels of IL-17A also were associated with lower birth weight and non-White race. Results support the model of AL in pregnant women and highlight IL-17A as a potential biomarker of AL during pregnancy.

Postpartum Depression Screening for New Mothers at Well Child Visits.

BACKGROUND: Postpartum depression (PPD) is a debilitating emotional experience that can affect mothers and their infants. Screening for PPD is encouraged during pediatric well-child visits (WCVs); however, the frequency, referral process, and documentation relative to screening in clinical practice require further study. OBJECTIVES: There were three purposes to this study: 1) determine prevalence of mothers who scored in the at-risk range using the Edinburgh Postnatal Depression Scale (EPDS) at each of the 2-, 4-, and 6-month WCVs in a pediatric outpatient practice; 2) examine feasibility factors relative to extending the current standard of care for PPD screening; and 3) examine visit documentation for at-risk mothers. DESIGN: A prospective cohort study design was used to screen mothers during their infants' 6-month WCV for PPD using the EPDS. Feasibility in adding the 6-month time frame was assessed using an investigator-designed clinical team survey. Visit documentation content was obtained through medical record review. RESULTS: Forty-three postpartum women were included in the study. Prevalence rates among participants were 10%, 12.5%, and 14% for 2-month, 4-month, and 6-month WCVs, respectively. The clinical team found the additional screening at the 6-month visit to be feasible. Documentation for mothers identified to be at-risk varied greatly. CONCLUSIONS: Prevalence of PPD among participants is consistent with previously reported rates. Areas identified for improved clinical practice include the content of the visit that is documented in the medical record and reviewed with mothers identified to be at-risk, time allotted for the clinical team to screen new mothers, and appropriate referral to outside sources.

Expanding Access to Clinical Services for Toddlers with Autism Spectrum Disorders.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder typically diagnosed in the toddler and preschool years. Intensive early intervention (EI) using applied behavior analytic procedures is the evidenced-based intervention most effective in improving developmental outcomes. Unfortunately, there are numerous barriers to accessing EI services for toddlers with ASD. This article addresses (a) the process of developing an EI program using primarily applied behavior analytic services with multidisciplinary health care providers, (b) a description of the service delivery provided, (c) educational and training programs to increase qualified staff, and (d) advocacy efforts to improve community capacity. The EI program has sustained growth, improved child developmental outcomes, served as a training ground for EI providers, and yielded high parent satisfaction ratings. Suggestions for continued advocacy, education, research, and policy development related to the lack of access to EI for children with ASD is offered for pediatric health care providers.

Parent-implemented behavioral skills training of social skills.

Impairment in social skills is a primary feature of Autism Spectrum Disorders (ASDs). Research indicates that social skills are intimately tied to social development and negative social consequences can persist if specific social behaviors are not acquired. The present study evaluated the effects of behavioral skills training (BST) on teaching four parents of children with ASDs to be social skills trainers. A nonconcurrent multiple baseline design across parent-child dyads was employed and direct observation was used to assess parent and child behaviors Results demonstrated substantial improvement in social skills teaching for all participants for trained and untrained skills. Ancillary measures of child performance indicated improvement in skills as well. High levels of correct teaching responses were maintained at a 1 month follow-up. This study extends current literature on BST while also providing a helpful, low-effort strategy to modify how parents can work with their children to improve their social skills.

Findings and implications of developmental screening for high-risk children referred to a tertiary developmental disability center.

INTRODUCTION: The primary goal of this article is to describe an intake process and results of screening for developmental and autism spectrum disorders in children referred to a tertiary center. A secondary analysis of abnormal screening results, demographic variables, and parental concerns of autism was conducted, along with a correlation analysis between developmental and autism-specific screening tools. METHODS: A total of 379 children younger than 6 years were "prescreened" with the Ages and Stages Questionnaire-3 and the Modified Checklist for Autism in Toddlers or the Social Communication Questionnaire. Medical records were reviewed to identify demographic variables and parental primary concerns. RESULTS: In approximately 11% of participants who screened positive for autism, no parental concerns of autism were present. Medium effect size correlations were found between the failed autism screening tools and delays in two domains on the Ages and Stages Questionnaire-3. DISCUSSION: Clinical implications are addressed concerning diligent use of developmental and autism-specific rating scales to identify children at risk.

"Girls take charge": a community-based participatory research program for adolescent girls.

BACKGROUND: Adolescent females are at high risk for health disparities. An approach to minimizing health disparities involves facilitating changes in the environment within the community. Community-based participatory research (CBPR) is an important method of producing community change. OBJECTIVES: The objectives were for adolescent females to learn the CBPR process, implement a community health change project, and build capacity by engaging community agencies. METHODS: After conducting an assessment of community problems, the adolescents formed a coalition of community partners and implemented a Lead Poisoning Awareness Fair and a "lock-in" to educate about child maltreatment. A pre- and post-test research design was used. RESULTS: The community changes that resulted were policy change for routine lead testing, a DVD about child maltreatment, and care packages for adolescent mothers. Modest increases in knowledge about lead poisoning and child maltreatment occurred. CONCLUSION: Adolescent females were successful in using CBPR to produce positive community changes.