Integration of the Safe Environment for Every Kid (SEEK) Model Across Primary Care Settings.

This project sought to assess the generalizability, barriers, and facilitators of implementing the Safe Environment for Every Kid (SEEK) model for addressing psychosocial risk factors for maltreatment across multiple primary care settings, including a pediatric practice, federally qualified health center, and family medicine practice. The SEEK model includes screening caregivers for psychosocial risk factors at well-child visits age 0 to 5 years, brief intervention incorporating principles of motivational interviewing to engage caregivers, and referral to treatment. All practices successfully implemented SEEK, with screening completion rates from 75% to 93% and brief intervention rates from 61% to 81%. Major parental stress (14%) and food insecurity (11%) were the most common risk factors. Providers found SEEK worthwhile for improving their knowledge, skills, and ability to address psychosocial concerns and provide whole person care. Barriers included limited time and resources, incomplete resource knowledge, and lack of follow-up. Facilitators included on-site support staff to assist with communication and referrals.

Assessing psychosocial risk in pediatric inflammatory bowel disease: validation of the Psychosocial Assessment Tool 2.0_General.

AIM: The aim of this study was to present the preliminary psychometric properties of the Psychosocial Assessment Tool 2.0_General (PAT2.0_GEN), a brief screener for psychosocial risk in families of children with inflammatory bowel disease (IBD). METHODS: Caregivers of 42 youth with IBD were recruited and administered a battery of measures including the PAT2.0_GEN and well-validated measures of child emotional and behavioral functioning at baseline and at a 6-month follow-up. RESULTS: Internal consistency for the PAT2.0_GEN total score was good (α=0.82). Baseline was significantly associated with the 6-month follow-up (r=0.79, P<0.001). Significant correlations between the baseline PAT2.0 _GEN total score and caregiver-reported Child Behavior Checklist total scores at baseline (r=0.74, P<0.001) and at a 6-month follow-up (r=0.62, P<0.001) support the content and predictive validity of the PAT2.0_GEN. Baseline PAT2.0_GEN was also significantly correlated with youth-reported Child Behavior Checklist total scores at baseline (r=0.37, P=0.02) but not at the 6-month follow-up (r=0.23, P=0.17). CONCLUSIONS: A number of indicators support the concurrent and predictive utility of the PAT2.0_GEN. The PAT2.0_GEN is a promising tool for screening psychosocial risk that could facilitate the provision of psychosocial services to those patients most in need.

The clinical utility of health-related quality of life screening in a pediatric inflammatory bowel disease clinic.

BACKGROUND: Adjusting to symptom flares, treatment regimens, and side effects places youth with inflammatory bowel disease (IBD) at increased risk for emotional and behavioral problems and adverse disease outcomes. Implementation of psychosocial screening into clinical practice remains a challenge. This study examines the clinical utility of health-related quality of life (HRQOL) screening in predicting disease outcome and healthcare utilization. METHODS: One hundred twelve youth of 7 to 18 years diagnosed with IBD and their parents. Youth completed standardized measures of HRQOL and depression. Parents completed a proxy report of HRQOL. Pediatric gastroenterologists provided the Physician Global Assessment. Families were recruited from a pediatric gastroenterology clinic. Retrospective chart reviews examined disease outcome and healthcare utilization for 12 months after baseline measurement. RESULTS: Linear regressions, controlling for demographic and disease parameters, revealed that baseline measurement of youth and parent proxy-reported HRQOL predicted the number of IBD-related hospital admissions, gastroenterology clinic visits, emergency department visits, psychology clinic visits, telephone contacts, and pain management referrals over the next 12 months. Disease outcome was not significant. CONCLUSIONS: Lower HRQOL was predictive of increased healthcare utilization among youth with IBD. Regular HRQOL screening may be the impetus to providing better case management and allocating resources based on ongoing care needs and costs. Proactive interventions focused on patients with poor HRQOL may be an efficient approach to saving on healthcare costs and resource utilization.

Behavioral functioning and treatment adherence in pediatric eosinophilic gastrointestinal disorders.

OBJECTIVE: To examine behavioral predictors of treatment adherence in patients with eosinophilic gastrointestinal disorders (EGID). METHODS: Participants were 96 patients 2.5-18 yr of age with eosinophilic esophagitis or eosinophilic gastroenteritis and their caregivers (mother, father). We assessed maternal and paternal report of child/adolescent internalizing symptoms (e.g., anxiety, depression) and externalizing symptoms (e.g., aggression, anger) using the Behavior assessment system for children, 2nd edition (BASC-2). A multi-informant adherence assessment approach and an 80% cut point were used to classify patients as adherent or non-adherent. RESULTS: Sociodemographic predictors did not distinguish between adherent and non-adherent patients. Maternal report of internalizing symptoms significantly correlated with non-adherence (p < 0.001). Post hoc probing revealed a significant contribution of depression, with depressed patients being more likely (OR = 7.27; p < 0.05) to be non-adherent than non-depressed patients. Paternal report of internalizing and externalizing symptoms was not associated with non-adherence. CONCLUSIONS: Maternal report of patient internalizing behavioral symptoms, particularly depression, is significantly associated with non-adherence in patients with EGID. These symptoms are potential risk factors and should be considered when assessing and treating non-adherence. Clinical care of patients with EGID should include routine screening for depression.

Evaluation of a group-based behavioral intervention to promote adherence in adolescents with inflammatory bowel disease.

OBJECTIVE: To pilot test the feasibility and acceptability of a family-based group behavioral intervention and to improve medication adherence in adolescents diagnosed with inflammatory bowel disease. METHODS: Participants were 40 adolescents aged 11-18 years diagnosed with inflammatory bowel disease and their primary caregivers, who were randomized to either a four-session Family-Based Group Behavioral Treatment or Usual Care over a 6-week period. Adherence was measured using a multi-method, multi-informant assessment involving caregiver-report and patient-report, pill count data, and electronic monitoring. RESULTS: Adherence rates ranged from 66 to 89% for 6-mercaptopurine/azathioprine and 51 to 93% for mesalamine across assessment methods. The intervention was feasible, as evidenced by the 99% treatment session attendance rate, and acceptable based on patient and caregiver report. Repeated measures analysis of variance tests revealed nonsignificant differences between the conditions from baseline to post-treatment assessments for pill count, electronic monitor, and primary caregiver-reported adherence (P's>0.05). There was a statistically significant improvement in patient-reported mesalamine adherence represented by a significant main effect for Condition (F=22.24, P<0.01; δ=0.79) and Condition×Time interaction (F=13.32, P<0.05; δ=0.69). CONCLUSION: Findings suggest potential for use of behavioral intervention to improve medication adherence in this population. This intervention may be more effective with more complex regimens (e.g. multiple doses per day) such as those prescribed with mesalamine. Further research is needed to examine this type of intervention in more diverse samples with more active disease. Use of alternative adherence measurement approaches, including electronic pill boxes and/or real-time self-report (e.g. by text messaging, electronic diaries, etc.) is also recommended.

Treatment adherence in pediatric eosinophilic gastrointestinal disorders.

OBJECTIVE: Examine treatment adherence rates in pediatric eosinophilic gastrointestinal disorders (EGID). METHODS: Participants were children aged 2.5-18 years with eosinophilic esophagitis or eosinophilic gastroenteritis (EGE) and their caregivers. A multimethod, multi-informant assessment including parent report and electronic monitoring was utilized, with a 90% cut point for nonadherence. RESULTS: Medication nonadherence prevalence was 30%. Adherence frequency was 91% ± 14% (0-100%) per parent report and 100% ± 69% (0-194%) per electronic monitors. Tube-feeding adherence was 99% ± 3%. Food allergen exposures were less than 1 per 2 weeks, with 33% nonadherence prevalence. Patients with EGE and toddlers with both conditions demonstrated poorer medication adherence (p's < .05). Caregivers reported higher number of missed medication doses than food exposures (p < .05). CONCLUSIONS: The prevalence and range of nonadherence demonstrates that subsets of these patients are nonadherent. Adherence to treatment in EGID is complex and multifaceted, with nonadherence varying across treatments.