Addressing Adolescent Suicidality in Pediatric Primary Care.

OBJECTIVE: This study examines prevalence rates of reported suicidal ideation (SI) in 2107 adolescents, characterizes recommendations and interventions given by primary care providers (PCPs) and behavioral health clinicians (BHCs) in response to SI on the Patient Health Questionnaire 9-Item Modified for Adolescents (PHQ-9A) for 140 adolescents, and identifies factors associated with a decrease in the frequency of SI at follow-up visits for 85 adolescents. METHODS: A retrospective mixed-method approach was taken. Clinical informatics was used to extract visit data, demographics, and PHQ-9A scores for all visits between January 3, 2017, and August 31, 2018. Conventional content analysis of electronic medical records was used to examine qualitative results, and qualitative codes were then analyzed using point-biserial correlations. The setting includes a fully integrated behavioral health team within the primary care clinic. RESULTS: Of the 2107 adolescents, 140 (7%) endorsed SI within the past 2 weeks. Content analysis yielded 40 actions (17 PCP codes and 23 BHC codes) used in response to SI. Significant correlations were found between decreased SI frequency and the PCP referring to integrated behavioral health ( r = 0.24) and family navigators ( r = 0.26) and BHCs conducting a risk assessment ( r = 0.24), completing a safety plan ( r = 0.21), involving caregivers ( r = 0.29), sending the adolescent to the emergency department ( r = 0.28), and referring to family navigators ( r = 0.21; all p values < 0.05). CONCLUSION: The findings from this study support screening for SI and highlight specific multidisciplinary and family-centered interventions and recommendations to address adolescent endorsement of SI in pediatric primary care settings.

Clinicians' Cognitive and Affective Biases and the Practice of Psychotherapy.

OBJECTIVE: Cognitive and affective biases are essentially connected to heuristic shortcuts in thinking. These biases ordinarily function outside of conscious awareness and potentially affect clinical assessment, reasoning, and decision making in general medicine. However, little consideration has been given to how they may affect clinicians in the conduct of psychotherapy. This article aims to illustrate how such biases may affect assessment, formulation, and conduct of psychotherapy; describe strategies to mitigate these influences; and draw attention to the need for systematic research in this area. METHODS: Cognitive and affective biases potentially influencing clinical assessment, reasoning, and decision making in medicine were identified in a selective literature review. The authors drew from their experiences as psychotherapists and psychotherapy supervisors to consider how key biases may influence psychotherapists' conduct of psychotherapy sessions. RESULTS: The authors reached consensus in selecting illustrative biases pertinent to psychotherapy. Included biases related to anchoring, ascertainment, availability, base-rate neglect, commission, confirmation, framing, fundamental attribution error, omission, overconfidence, premature closure, sunk costs, and visceral reactions. Vignettes based on the authors' combined experiences are provided to illustrate how these biases could influence the conduct of psychotherapy. CONCLUSIONS: Cognitive and affective biases are likely to play important roles in psychotherapy. Clinicians may reduce the potentially deleterious effects of biases by using a variety of mitigating strategies, including education about biases, reflective review, supervision, and feedback. How extensively these biases appear among psychotherapists and across types of psychotherapy and how their adverse effects may be most effectively alleviated to minimize harm deserve systematic study.

Addressing Adolescent Depression in Primary Care: Building Capacity Through Psychologist and Pediatrician Partnership.

Early identification and treatment of depression during adolescence can contribute to healthier outcomes across the lifespan, yet adolescent depression has been underidentified and undertreated. The American Academy of Pediatrics' (AAP) Guidelines for Adolescent Depression in Primary Care (GLAD-PC) were created to enhance the identification and treatment of adolescent depression. Integrated psychologists in a pediatric primary care setting partnered with providers and clinic staff to implement an adolescent depression screening initiative and transform primary care practice around identification and management. From January 2017 through August 2018, 2107 adolescents between the ages of 11 and 18 were screened using the PHQ-9A. Eleven percent (n = 226) of adolescents had an elevated screen with a score of ≥ 10 and 7% (n = 151) screened positive for suicidal ideation. Identification of depressive symptoms led to increased integrated behavioral health services delivered by psychologists, psychiatrists, and psychology trainees. Psychologists integrated in primary care can support primary care practices to develop service delivery systems aligned with AAP's GLAD-PC and address the diverse implementation barriers associated with incorporating clinical practice guidelines in real-world settings. Universal screening for adolescent depression and response protocols were successfully implemented in a pediatric primary care clinic under the leadership of psychologists and pediatrician partners.

Incorporating Trainees' Development into a Multidisciplinary Training Model for Integrated Behavioral Health Within a Pediatric Continuity Clinic.

Integrated behavioral and mental health systems of care for children require multidisciplinary team members to have specific competencies and knowledge of the other disciplines' strengths and practice needs. Training models for multidisciplinary professionals should consider the developmental level of trainees. The authors describe a model of flexible scaffolding, increasing intensity, and depth of experience as trainees gain skills and knowledge.

Thought Disorder in Preschool Children with Attention Deficit/Hyperactivity Disorder (ADHD).

Preschool identification of and intervention for psychiatric symptoms has the potential for lifelong benefits. However, preschool identification of thought disorder, a symptom associated with long term risk for social and cognitive dysfunction, has received little attention with previous work limited to examining preschoolers with severe emotional and behavioral dysregulation. Using story-stem methodology, 12 children with ADHD and 12 children without ADHD, ages 4.0-6.0 years were evaluated for thought disorder. Thought disorder was reliably assessed (Cronbach's alpha = .958). Children with ADHD were significantly more likely than children without ADHD to exhibit thought disorder (75 vs 25 %; Fischer's Exact Test = .0391). Thought disorder can be reliably assessed in preschool children and is present in preschool children with psychiatric illness including preschool children with ADHD. Thought disorder may be identifiable in preschool years across a broad range of psychiatric illnesses and thus may be an appropriate target of intervention.

Addressing psychosocial aspects of atopic dermatitis.

Moderate to severe atopic dermatitis (AD) negatively affects patients and their families. Pruritus, scratching, and sleep problems are common complaints linked to disturbed quality of life. Treatment is complex, and nonadherence rates are high. This article reviews the effect of AD on patients and their families and intervention strategies that have some success in improving quality of life. A treatment model for addressing the psychosocial effect of moderate to severe AD within a multidisciplinary setting is suggested herein.

The Atopic Dermatitis Quickscore (ADQ): validation of a new parent-administered atopic dermatitis scoring tool.

BACKGROUND: Atopic dermatitis (AD) severity is assessed using relatively elaborate scoring systems administered by health care practitioners; modification for parent assessment or self-assessment is limited. For ongoing home-based evaluation of pediatric AD treatment and outcomes, a quick, easy-to-use, parent-administered scoring tool is essential. OBJECTIVE: To evaluate the validity and responsiveness to change of the Atopic Dermatitis Quickscore (ADQ) compared with the established, widely used Scoring Atopic Dermatitis Severity Index (SCORAD). METHODS: The ADQ was developed for parent report and was validated against the SCORAD. The SCORAD assesses percentage of body surface area involved, intensity of a "representative area," pruritus, and insomnia. The ADQ assesses involvement and pruritus of 7 body parts. Sixty-eight children entering a pediatric day treatment program for moderate to severe AD were recruited. Skin severity was scored at admission by a physician assistant using the SCORAD and by a parent using the ADQ. Pearson correlations of the 2 scales were assessed. RESULTS: The ADQ total score correlates with the SCORAD total score (r = 0.64, P < .001). The ADQ pruritus score correlates with the SCORAD pruritus score (r = 0.62, P < .001). Correlation at the end of treatment was also seen for ADQ and SCORAD total and pruritus scores (r = 0.39, P = .02, and r = 0.66, P < .001, respectively). Responsiveness of both scales to change in skin condition was demonstrated, with significant decreases in total and pruritus scores (P < .001). CONCLUSIONS: The parent-administered ADQ takes 5 minutes to complete. Scores from the ADQ and the SCORAD are well correlated and are responsive to changes in skin condition, supporting the validity of the ADQ.

Posttraumatic stress in adolescents with asthma and their parents.

OBJECTIVE: To assess posttraumatic stress (PTS) symptoms in adolescents with and without asthma and their parents and the relationship between PTS symptoms and asthma morbidity. METHOD: Three groups of adolescents (12-18 years) participated: adolescents who had experienced a life-threatening asthma episode (n=49), asthma controls (n=71), and healthy controls (n=80). Adolescents completed the UCLA PTSD Reaction Index, Multidimensional Anxiety Scale for Children, and Reynolds Depression Inventory. Parents completed the Impact of Events Scale-Revised, Brief Symptom Inventory, and Asthma Functional Morbidity Scale. RESULTS: Twenty percent of adolescents with life-threatening asthma met criteria for PTSD compared with 11% of the asthma controls and 8% of the normal controls. Twenty-nine percent of parents of adolescents with life-threatening asthma met criteria for PTSD compared with 14% of parents of asthma controls and 2% of normal controls. Adolescent PTS symptoms accounted for 5% of the variance in functional asthma morbidity even after controlling for disease severity and other anxiety and depressive symptoms (beta=.26). CONCLUSIONS: Adolescents with asthma and their parents, particularly those who have experienced a life-threatening event, have high levels of PTS symptoms that are linked to asthma morbidity. Interventions to improve asthma outcomes should include assessment and treatment of trauma and PTS symptoms.

Predictors of body dissatisfaction in boys and girls with asthma.

BACKGROUND: Body satisfaction is an important issue for youth. Youth with more severe asthma may have experiences and emotions associated with less body satisfaction; however, this has not been studied. OBJECTIVE: To identify correlates of body dissatisfaction in youth with asthma. METHODS: Sixty-three females and 60 males, ages 8-18 years with asthma, completed measures of body dissatisfaction, anxiety, depression, asthma symptoms, and behaviors. Parents completed measures of asthma limitations; clinicians rated asthma severity. RESULTS: Anxiety, depression, and body mass index (BMI) accounted for 21 and 15% of the variance in body dissatisfaction for females and males, respectively. Physical activity added 13% variance to the above model for females. Asthma symptoms added 14% for males. Of note, neither parent ratings of asthma limitations nor clinician ratings of asthma severity contributed additional variance. CONCLUSION: This study increases our understanding of youth with asthma and provides future research directions.