Child Health Needs and the Developmental-Behavioral Pediatrics Workforce Supply: 2020-2040.

Developmental-behavioral pediatrics (DBP) subspecialists care for children with complex neurodevelopmental and behavioral health conditions; additional roles include education and training, advocacy, and research. In 2023, there were 1.0 DBP subspecialists per 100 000 US children aged 0 to 17 years (range 0.0-3.8), with wide variability in DBP subspecialist distribution. Given the prevalence of DB conditions, the current workforce is markedly inadequate to meet the needs of patients and families. The American Board of Pediatrics Foundation led a modeling project to forecast the US pediatric subspecialty workforce from 2020 to 2040 using current trends in each subspecialty. The model predicts workforce supply at baseline and across alternative scenarios and reports results in headcount (HC) and HC adjusted for percent time spent in clinical care, termed "clinical workforce equivalent." For DBP, the baseline model predicts HC growth nationally (+45%, from 669 to 958), but these extremely low numbers translate to minimal patient care impact. Adjusting for population growth over time, projected HC increases from 0.8 to 1.0 and clinical workforce equivalent from 0.5 to 0.6 DBP subspecialists per 100 000 children aged 0 to 18 years by 2040. Even in the best-case scenario (+12.5% in fellows by 2030 and +7% in time in clinical care), the overall numbers would be minimally affected. These current and forecasted trends should be used to shape much-needed solutions in education, training, practice, policy, and workforce research to increase the DBP workforce and improve overall child health.

Treatment Using Both Voclosporin and Belimumab in Four Patients With Lupus Nephritis.

Nearly 50% of patients with systemic lupus erythematosus (SLE) will develop lupus nephritis (LN). Current treatment regimens for LN are suboptimal as the majority of patients fail to achieve complete renal response after several months of treatment and there are high rates of relapse. We report outcomes in four LN patients who were treated with both voclosporin and belimumab. These patients had no serious infections, and we were able to taper glucocorticoids and reduce proteinuria.

Descriptive Analysis of Documentation Time for the National Developmental-Behavioral Pediatric Physician Workforce Using a Commercial Electronic Health Record System.

OBJECTIVE: The national developmental-behavioral pediatric (DBP) workforce struggles to meet current service demands because of several factors. Lengthy and inefficient documentation processes are likely to contribute to service demand challenges, but DBP documentation patterns have not been sufficiently studied. Identifying clinical practice patterns may inform strategies to address documentation burden in DBP practice. METHODS: Nearly 500 DBP physicians in the United States use a single commercial electronic health record (EHR) system (EpicCare Ambulatory, Epic Systems Corporation, Verona WI). We evaluated descriptive statistics using the US Epic DBP provider data set. We then compared DBP documentation metrics against those of pediatric primary care and selected pediatric subspecialty providers who provide similar types of care. One-way analyses of variance (ANOVAs) were conducted to determine whether outcomes differed among provider specialties. RESULTS: We identified 4 groups for analysis from November 2019 through February 2020: DBP (n = 483), primary care (n = 76,423), pediatric psychiatry (n = 783), and child neurology (n = 8589). Post hoc pairwise comparisons revealed statistically significant differences between multiple outcome-specialty combinations. Time in notes per appointment and progress note length demonstrated the strongest evidence of an increased burden on DBP providers compared with other similar provider groups. CONCLUSION: DBP providers spend a significant amount of time documenting progress notes both during and outside of normal clinic hours. This preliminary analysis highlights the utility of using EHR user activity data to quantitatively measure documentation burden.

Defining Developmental-Behavioral Pediatrics.

There is an insufficient number of specialty developmental-behavioral pediatrics (DBP) physicians, despite nearly 25% of children and adolescents having a developmental, learning, behavioral, or emotional problem. In the nearly 20 years since becoming a board-certified subspecialty, the definition of DBP clinical practice remains somewhat unclear. This lack of clarity likely contributes to recruitment challenges and workforce issues, and limited visibility of DBP among parents, other professionals, payors, and administrators. Defining DBP is therefore an important step in the survival and growth of the field. In this paper, we describe the methodology used to develop this definition along with the origins of DBP, the persistent challenges to defining its scope, what training in DBP involves, and what distinguishes DBP from other overlapping fields of medicine. We propose the following definition of DBP: developmental-behavioral pediatrics (DBP) is a board-certified, medical subspecialty that cares for children with complex and severe DBP problems by recognizing the multifaceted influences on the development and behavior of children and addressing them through systems-based practice and a neurodevelopmental, strength-based approach that optimizes functioning. Developmental behavioral pediatricians care for children from birth through young adulthood along a continuum including those suspected of, at risk for, or known to have developmental and behavioral disorders.

Changes in Provider Type and Prescription Refills Among Privately Insured Children and Youth With ADHD.

OBJECTIVE: The aim of this paper is to understand associations between age and health care provider type in medication continuation among transition-aged youth with ADHD. METHOD: Using an employer-sponsored insurance claims database, we identified patients with likely ADHD and receipt of ADHD medications. Among patients who had an outpatient physician visit at baseline and maintained enrollment at follow-up 3 years later, we evaluated which ones continued to fill prescriptions for ADHD medications. RESULTS: Patients who were younger at follow-up more frequently continued medication (77% of 11-12 year-olds vs. 52% of 19-20 year-olds). Those who saw a pediatric provider at baseline and follow-up more frequently continued to fill ADHD medication prescriptions than those who saw a pediatric provider at baseline and non-pediatric providers at follow-up (71% vs. 53% among those ages 15-16 years at follow-up). CONCLUSION: Adolescents and young adults with ADHD who changed from pediatric to exclusively non-pediatric providers less frequently continued to receive ADHD medications.

Using Practice Facilitation to Improve Depression Management in Rural Pediatric Primary Care Practices.

INTRODUCTION: Depression is a common and serious mental health condition frequently encountered in pediatric primary care. Pediatricians report discomfort in managing depression due in part to limited training and limited access to mental health care, which is accentuated in rural areas. METHODS: We developed an evidence-based, quality improvement project designed to help pediatricians increase screening and initial management of depression in the primary care setting. We recruited practices from a pediatric accountable care organization as part of a larger quality improvement portfolio that used a practice facilitation model to support practices with data collection and project management. Practitioners received training on quality improvement, depression screening, and a depression management plan (referred to as the depression management bundle). Practices completed Plan-Do-Study-Act cycles to improve their performance. RESULTS: We recruited 4 practices in rural Ohio to participate. Screening increased from 0% to 81% within 6 months. All 4 practices measured documentation of the depression management bundle for patients diagnosed with depression. Composite data from these practices showed an increase in documentation from 59% to 86% by month 6. CONCLUSIONS: This study provides preliminary support for the use of practice facilitation combined with skills training to increase screening and improve documentation of depression management in rural primary care practices, where specialty mental health resources may be limited. Further research is needed to determine if this approach can be successfully disseminated and if patient outcomes improved.

The early local and systemic Type I interferon responses to ultraviolet B light exposure are cGAS dependent.

Most systemic lupus erythematosus (SLE) patients are photosensitive and ultraviolet B light (UVB) exposure worsens cutaneous disease and precipitates systemic flares of disease. The pathogenic link between skin disease and systemic exacerbations in SLE remains elusive. In an acute model of UVB-triggered inflammation, we observed that a single UV exposure triggered a striking IFN-I signature not only in the skin, but also in the blood and kidneys. The early IFN-I signature was significantly higher in female compared to male mice. The early IFN-I response in the skin was almost entirely, and in the blood partly, dependent on the presence of cGAS, as was skin inflammatory cell infiltration. Inhibition of cGAMP hydrolysis augmented the UVB-triggered IFN-I response. UVB skin exposure leads to cGAS-activation and both local and systemic IFN-I signature and could contribute to acute flares of disease in susceptible subjects such as patients with SLE.

Interplay of Cyclic GMP-AMP Synthase/Stimulator of IFN Genes and Toll-Like Receptor Nucleic Acid Sensing Pathways in Autoinflammation and Abnormal Bone Formation due to DNaseII-Deficiency.

Nucleic acid (NA) sensing receptors were first described in the context of host defense. We now know that some endosomal NA sensors play a critical role in the development of systemic autoimmune diseases such as systemic lupus erythematosus, whereas cytosolic Cyclic GMP-AMP Synthase/Stimulator of IFN Genes (cGAS/STING) DNA-detecting pathway has been associated with monogenic autoinflammatory interferonopathies such as Aicardi-Goutieres and Education; collaboration; communication STING-associated vasculopathy with onset in infancy (SAVI). DNaseII hypomorphic patients and DNase-/- IFNaR-/- (double knockout [DKO]) mice also develop an autoinflammatory syndrome associated with an interferon signature. We now add to the description of an unusual clinical manifestation of DKO mice that involves the accrual of trabecular bone in long bone marrow and the formation of ectopic bone within the spleen. This aberrant bone formation is lost not only in STING-deficient but also in Unc93b1-deficient mice and, therefore, depends on the interplay of cells expressing cytosolic and endosomal NA sensing receptors.

When to Raise Our White Flag-A Discussion of Scope of Practice in a Resource Scarce World.

CASE: Thomas is a 13-year-old boy with autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder, separation anxiety disorder, and major depressive disorder who presented for a follow-up to his developmental and behavioral pediatrician (DBP). His mother describes an increase in symptoms of anxiety and depression for the last 6 weeks, accompanied by suicidal ideation and thoughts of self-mutilation.Before this increase in symptoms, he had been doing well for the last several months with the exception of increasing weight gain, and Abilify was decreased from 5 mg to 2.5 mg at his last visit. Other medications at that time included Zoloft 100 mg twice daily, Focalin XR 40 mg every morning, and Focalin 5 mg every night. Without seeking the guidance of our developmental and behavioral pediatrics clinic, his mother increased his intake of Zoloft to 150 mg each morning and continued 100 mg each evening because of worsening anxiety and depression.Religion is very important to Thomas and his family. He acknowledges that he does not want to die and feels badly because "suicide is against our religion."Helping Thomas receive appropriate care has been a challenge. He was diagnosed with ADHD and Asperger disorder at the age of 5. Thomas is homeschooled and is very attached to his mother. His parents have very different parenting styles, with his mother being more permissive and his father more authoritarian. At the time of initial diagnosis, the behavioral health services (BHS) in Thomas' community, which is about an hour away from the DBP, were limited to older children, and he was followed by a DBP for ADHD medication management. At the age of 11, he expressed passive suicidal ideation and described that he imagined his mother as "the devil with fire coming out of her eyes" when she corrected him. He was evaluated by BHS, diagnosed with anxiety disorder, and started on Lexapro. BHS linked to the DBP were out of network for his insurance. The family was unable to pay out of pocket, so care was subsequently transferred to a DBP clinic that was in network. Soon after, Thomas developed auditory hallucinations, and Abilify was added after consultation with BHS.Over the last few years, Thomas' symptoms have waxed and waned. He did well for a short time and then again developed auditory hallucinations, worsening symptoms of anxiety and depression, and increasing somatic symptoms including vomiting and penile pain. Medications were adjusted with input from BHS, and further attempts were made to link him to local BHS but were unsuccessful. With his current concerns of suicidal ideation and self-mutilation, what would be your next steps?

Comparison of Performance on ADHD Quality of Care Indicators: Practitioner Self-Report Versus Chart Review.

Objective: This study compared practitioner self-report of ADHD quality of care measures with actual performance, as documented by chart review. Method: In total, 188 practitioners from 50 pediatric practices completed questionnaires in which they self-reported estimates of ADHD quality of care indicators. A total of 1,599 charts were reviewed. Results: The percentage of patients for whom practitioners self-reported that they used evidence-based care was higher in every performance category when compared with chart review, including higher use of parent and teacher rating scales during assessment and treatment compared with chart review. Self-reported use of Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria during assessment was also higher than by chart review. The actual number of days until the first contact after starting medication was nearly three times longer than self-report estimates. Conclusion: Practitioners overreport performance on quality of care indicators. These differences were large and consistent across ADHD diagnostic and treatment monitoring practices. Practitioner self-report of ADHD guideline adherence should not be considered a valid measure of performance.

Factors Associated with Attention Deficit Hyperactivity Disorder Medication Use in Community Care Settings.

OBJECTIVES: To examine patient- and provider-level factors associated with receiving attention-deficit/hyperactivity disorder (ADHD) medication treatment in a community care setting. We hypothesized that the likelihood of ADHD medication receipt would be lower in groups with specific patient sociodemographic (eg, female sex, race other than white) and clinical (eg, comorbid conditions) characteristics as well as physician characteristics (eg, older age, more years since completing training). STUDY DESIGN: A retrospective cohort study was conducted with 577 children (mean age, 7.8 years; 70% male) presenting for ADHD to 50 community-based practices. The bivariate relationship between each patient- and physician-level predictor and whether the child was prescribed ADHD medication was assessed. A multivariable model predicting ADHD medication prescription was conducted using predictors with significant (P < .05) bivariate associations. RESULTS: Sixty-nine percent of children were prescribed ADHD medication in the year after initial presentation for ADHD-related concerns. Eleven of 31 predictors demonstrated a significant (P < .05) bivariate relationship with medication prescription. In the multivariable model, being male (OR, 1.34; 95% CI, 1.01-1.78; P = .02), living in a neighborhood with higher medical expenditures (OR, 1.11 for every $100 increase; 95% CI, 1.03-1.21; P = .005), and higher scores on parent inattention ratings (OR, 1.06; 95% CI, 1.03-1.10; P < .0001) increased the likelihood of ADHD medication prescription. CONCLUSIONS: We found that some children, based on sociodemographic and clinical characteristics, are less likely to receive an ADHD medication prescription. An important next step will be to examine the source and reasons for these disparities in an effort to develop strategies for minimizing treatment barriers.

Outcomes of a Statewide Learning Collaborative to Implement Mental Health Services in Pediatric Primary Care.

OBJECTIVE: Mental health concerns are common in pediatric primary care, but practitioners report low levels of comfort managing them. A primary care intervention addressing organizational and individual factors was developed to improve the management of common mental health conditions. METHODS: Twenty-nine practices participated in a statewide learning collaborative over 18 months. On-site training was used to teach communication and brief intervention skills and develop an organizational context supportive of mental health. Clinician confidence was measured pre- and postintervention. Medicaid claims data were used to estimate the intervention's effects on identification of mental health conditions and prescribing practices. RESULTS: Mean clinician confidence scores increased by 20% (95% confidence interval [CI]=15% to 25%), from 2.92 at baseline to 3.55 postintervention. In the first month of the preintervention year, 6.65% of patients with an office visit had at least one visit for a mental health condition, rising to 9% postintervention; this trend was driven by detection and treatment of attention-deficit hyperactivity disorder (ADHD). Rates of prescribing ADHD medication to patients with visits for ADHD increased by 0.12 percentage points per month (CI=0.02 to 0.22, p=0.022). Rates of prescribing second-generation antipsychotics to all patients with office visits decreased by 0.014 percentage points per month (CI=-.03 to -.00, p=0.028), relative to preintervention trends. CONCLUSIONS: This study suggests that a multicomponent intervention addressing individual staff and organizational factors together can promote identification and treatment of child mental health conditions in primary care. Future research is required to better understand the core components, impact on health outcomes, and sustainability.

A Medicaid Quality Improvement Collaborative on Psychotropic Medication Prescribing for Children.

A Medicaid statewide quality improvement (QI) collaborative was developed to improve antipsychotic prescribing practices for children. With use of a multistrategy approach that incorporated data-driven feedback and evidence-based recommendations, improvements were seen in three measures: antipsychotics prescribed to children under age six, prescription of two or more concomitant antipsychotics for longer than two months, and prescription of four or more psychotropic medications. Challenges and complexities are reviewed, including use of ongoing QI to address factors influencing antipsychotic prescribing behaviors, engagement of providers in QI efforts, and financial sustainability of such efforts.

A Learning Collaborative Approach to Improve Mental Health Service Delivery in Pediatric Primary Care.

BACKGROUND: Pediatric primary care practitioners (PPCPs) report inadequate training in the care of children with common mental health conditions. Although additional training is needed, system changes are also necessary to support improvements in care. METHODS: We developed the Building Mental Wellness Learning Collaborative to assist PPCPs in delivering better mental health services in primary care by targeting 5 focus areas: mental health promotion; early identification and screening; practitioner skills; collaboration and community linkages; and medication management. Aims were developed for each area. RESULTS: Twenty-one practices and 50 practitioners completed the collaborative in 2 seven-month waves. For mental health promotion, ≥85% of charts showed documentation in 3 of 4 preselected areas. For early identification/screening, screening increased, but the ≥85% goal was not met. For practitioner skills, a ≥20% increase in the proportion of children/youth ≥1 visits for anxiety or depression was achieved, from 0.70% of children/youth in the 12 months preintervention to 1.09% children/youth in the 12 months after. For collaboration/linkages, mental health referral completion was unchanged and below the 60% goal. For medication use, a ≥15% increase in selective serotonin reuptake inhibitor prescribing by Building Mental Wellness (BMW) practitioners was achieved from 0.72% children/youth with office visits pre-BMW to 0.92% post. Prescribing did not decrease for atypical antipsychotic medication use or for psychotropic medication use in children younger than 6 years, although there was a trend toward more appropriate prescribing. CONCLUSIONS: The BMW Learning Collaborative was effective in helping PPCPs implement certain aspects of a comprehensive approach to the delivery of mental health services in primary care.

The role of organizational context in the implementation of a statewide initiative to integrate mental health services into pediatric primary care.

BACKGROUND: Although there is evidence that mental health services can be delivered in pediatric primary care with good outcomes, few changes in service delivery have been seen over the past decade. Practices face a number of barriers, making interventions that address determinants of change at multiple levels a promising solution. However, these interventions may need appropriate organizational contexts in place to be successfully implemented. PURPOSE: The objective of this study was to test whether organizational context (culture, climate, structures/processes, and technologies) influenced uptake of a complex intervention to implement mental health services in pediatric primary care. METHODOLOGY/APPROACH: We incorporated our research into the implementation and evaluation of Ohio Building Mental Wellness Wave 3, a learning collaborative with on-site trainings and technical assistance supporting key drivers of mental health care implementation. Simple linear regression was used to test the effects of organizational context and external or fixed organizational characteristics on program uptake. RESULTS: Culture, structure/processes, and technologies scores indicating a more positive organizational context for mental health at the project's start, as well as general cultural values that were more group/developmental, were positively associated with uptake. Patient-centered medical home certification and use of electronic medical records were also associated with greater uptake. Changes in context over the course of Building Mental Wellness did not influence uptake. CONCLUSION: Organizational culture, structures/processes, and technologies are important determinants of the uptake of activities to implement mental health services in pediatric primary care. Interventions may be able to change these aspects of context to make them more favorable to integration, but baseline characteristics more heavily influence the more proximal uptake of program activities. PRACTICE IMPLICATIONS: Pediatric primary care practices would benefit from assessing their organizational context and taking steps to address it prior to or in a phased approach with mental health service implementation.