Assessment of the Smoke Free Families Tobacco Screening, Counseling, and Referral Program in Pediatric Primary Care Practices.

OBJECTIVE: The Smoke Free Families (SFF) program trained pediatric providers to use an SFF tool during well-child visits (WCVs) of infants ≤12 months to "Ask" caregivers about tobacco use, "Advise" smokers to quit, and "Refer" smokers to cessation services (AAR). The primary objectives were to assess the prevalence and changes in caregiver tobacco use after being screened and counseled by providers using the SFF tool. A secondary objective was to examine providers' AAR behavior facilitated by using the SFF tool. METHODS: Pediatric practices participated in 1 of 3 6-9-month SFF program waves. Over the 3 waves, all initial SFF tools completed on caregivers during their infant's WCV were evaluated for the caregiver and household tobacco use and providers' AAR rates. An infant's first and next WCV was matched to determine changes in caregiver tobacco product use. RESULTS: In total, the SFF tool was completed at 19,976 WCVs; 2081 (18.8%) infants were exposed to tobacco smoke. A total of 834 (74.1%) caregivers who smoked received counseling: 786 (69.9%) were advised to quit, 700 (62.2%) were given cessation resources, and 198 (17.6%) were referred to the Quitline. In total, 230 (27.6%) of caregivers who smoked had a second visit; 58 (25.2%) self-reported that they quit using tobacco. Among cigarette users (n = 183), 89 (48.6%) reported that they used fewer cigarettes or quit at their infants' second WCV. CONCLUSIONS: Systematic use of the SFF AAR tool during infants' WCVs could improve the health of caregivers and children, resulting in decreases in tobacco-related morbidity.

Neighborhood market potentials for alcohol use and rates of child abuse and neglect.

BACKGROUND: Alcohol use can lead to child abuse and neglect even if the person using alcohol does not use heavily. Yet relatively few measures that reflect alcohol use are available at smaller geographic units. We assess whether the estimated level of total alcohol use per capita is related to measures of child abuse and neglect that include substantiated reports of maltreatment, total entries into foster care, and alcohol-related entries into foster care. METHODS: Our sample consists of 326 Census block groups in Sacramento, California over three time points (978 space-time units). Administrative data for substantiations of child abuse and neglect and foster care entries are our outcomes. We create market potentials for alcohol use among 18- to 29-year-olds as our primary independent variable. Data are analyzed using Bayesian conditionally autoregressive spatio-temporal models. RESULTS: Higher alcohol use potentials (as measured by total volume per capita of 18- to 29-year olds) are related to more children entering foster care due to drinking-related concerns by a parent or caregiver (RR = 1.032, 95% CI = [1.013, 1.051]), but not total substantiations for foster care entries. Neighborhoods with higher total volume of alcohol per 18- to 29-year-olds had more foster care entries when we used number of substantiations as the denominator (RR = 1.012, 95% CI = [1.0001, 1.023]) but were not related to foster care entries with alcohol misuse as a concern as a subset of all foster care entries. CONCLUSIONS: Higher estimated volume of alcohol use per capita among young adults (aged 18 to 29) was related to more children entering foster care due to alcohol-related concerns. Reducing alcohol supply in alcohol outlets, specifically through off-premise establishments, might reduce rates for all entries into foster care or other out-of-home placement and substantiated child abuse and neglect.

Implementation and Mental Health Outcomes of a Service Cascade Linking Child Welfare and Children's Mental Health Systems: A Case Study of the Gateway CALL Demonstration.

The mental health needs of children and youth involved in the child welfare system remain largely unmet. Service cascades are an emerging approach to systematizing mental health screening, assessment, and treatment referral processes. However, evidence is minimal and inconsistent regarding the effectiveness of such approaches for improving mental health service access and outcomes. In an effort to address this gap, this study presents a case-study of the implementation fidelity and treatment outcomes of the Gateway CALL service cascade. Study analyses involved longitudinal data collected as part of a larger evaluation of Gateway CALL. Specifically, descriptive and linear mixed model analyses were conducted to assess the implementation of service cascade components, and changes in mental health outcomes (behavior problems) among 175 children placed out-of-home during the study. Study analyses found that although fidelity was strong early in the service cascade, implementation began to break down once components involved more than one service system (child welfare, mental health). However, results also indicated that parent-reported child behavior problems decreased significantly over time, despite later cascade components being implemented with poor fidelity to the Gateway CALL service model. For children and youth involved in child welfare systems, service cascades like Gateway CALL have the potential to significantly improve both mental health service receipt and outcomes. To maximize the effectiveness of such approaches, later phases of implementation may require increased attention and support, particularly regarding processes and outcomes that cross child welfare and mental health service systems.

Medical Marijuana Dispensaries and Referrals for Child Maltreatment Investigations.

The changing legal status of marijuana in the United States has increased access to the drug through medical marijuana dispensaries. Limited research exists that examines the effects of these dispensaries on social problems including child maltreatment. The current study examines how medical marijuana dispensaries may affect referrals for child abuse and neglect investigations. Data are analyzed from 2,342 Census tracts in Los Angeles County, California. Locations of medical marijuana dispensaries were obtained through Weedmaps.com. Using conditionally autoregressive models, local and spatially lagged dispensaries show a positive relationship to rates of referrals in the unadjusted models. However, when we adjust for alcohol outlet density and measures of social disorganization, this relationship is no longer significant. Although this study does not find a relationship between medical marijuana dispensaries and referrals for investigations of child maltreatment, it should not be considered a definitive finding of this relationship. The increasing number of states that are allowing marijuana to be used for medical and recreational purposes is resulting in more people using the drug and the effects on parenting are still unknown.

Does mental health screening and assessment in child welfare improve mental health service receipt, child safety, and permanence for children in out-of-home care? An evaluation of the Gateway CALL demonstration.

BACKGROUND: Unmet mental health service needs among children in out-of-home care are sometimes attributed to poor assessments and referrals in child welfare. The Gateway CALL project implemented mental health screening, diagnostic assessment, and referral to treatment practices. OBJECTIVE: We examined the effectiveness of Gateway CALL for improving children's mental health service receipt, safety, and permanency outcomes. PARTICIPANTS AND SETTING: Participants included 538 children (birth to 18 years) in out-of-home placements through a county-based child welfare agency over a 17-month period. METHODS: We compared the mental health service receipt, safety, and permanency outcomes for 175 children who received Gateway CALL with 175 children who received "services as usual" identified through propensity score matching. Participant demographics, safety, and permanency outcomes were drawn from child welfare administrative records, and mental health service visits and diagnoses were drawn from Medicaid billing records. RESULTS: Gateway CALL appeared to increase the number of mental health service visits children received (z = 2.14, p = 0.032), although not the likelihood of receiving services. In terms of child safety, children in Gateway CALL had a greater number of screened-in calls after the intervention than those in the comparison group [t(348) = -1.92, p = 0.03]; there were no differences in substantiations. There were also no observed effects on permanency. CONCLUSIONS: Despite systematic efforts to identify, assess, and refer children to mental health services through the Gateway CALL intervention, substantial unmet mental health service needs among children persisted. Results have implications for designing interventions that promote cross-system service access.

Availability of medical cannabis dispensaries and cannabis abuse/dependence-related hospitalizations in California.

AIMS: To estimate associations between both current- and prior-year medical cannabis dispensary densities and hospitalizations for cannabis use disorder in California, USA between 2013 and 2016. DESIGN: Spatial analysis of ZIP code-level hospitalization discharge data using Bayesian Poisson hierarchical space-time models over 4 years. SETTING AND CASES: California, USA from 2013 to 2016 (6832 space-time ZIP code units). MEASUREMENTS: We assessed associations of annual hospitalizations for cannabis use disorder [assignment of a primary or secondary code for cannabis abuse and/or dependence using ICD-9-CM or ICD-10-CM (outcome)] with the total number of medical cannabis dispensaries per square mile in a ZIP code as well as dispensary temporal and spatial lags (primary exposures). Other exposure covariates included alcohol outlet densities, manual labor and retail sales densities and ZIP code-level economic and demographic conditions. FINDINGS: One additional dispensary per square mile was associated with a median risk ratio of 1.021 (95% credible interval 1.001, 1.041). Prior-year dispensary density did not appear to be associated with hospitalizations (median risk ratio = 1.006, 95% CrI = 0.986, 1.026). Higher median household income, higher unemployment, greater off-premises alcohol outlet density and lower on-premises alcohol outlet density and poverty were all associated with decreased ZIP code-level risk of cannabis abuse/dependence hospitalizations. CONCLUSIONS: In California, USA, the increasing density of medical cannabis dispensaries appears to be positively associated with same-year but not next-year hospitalizations for cannabis use disorder.

Opioid Misuse and the Availability of Medical Marijuana Through Dispensaries.

OBJECTIVE: In this study we assess whether changes in ZIP code-level density of medical marijuana facilities are related to changes in rates of opioid poisonings and opioid use disorder hospitalizations in California. METHOD: A panel study using California hospital discharge data was conducted to assess the relationship between density of medical marijuana dispensaries and opioid poisonings and use disorder. There were 8,536 space-time units at the ZIP code level. Outcome measures included ZIP code counts of opioid poisonings and opioid use disorder; independent variables were local- and adjacent-area medical marijuana dispensaries and demographic and economic characteristics. RESULTS: Independent of effects for covariates, densities of medical marijuana dispensaries were positively related to opioid use disorder (RR = 1.05, CI [1.03, 1.06]) and opioid poisonings (RR = 1.04, CI [1.02, 1.05]) in local areas, but negatively related to opioid misuse in spatially adjacent areas (RR = 0.91, CI [0.88, 0.94] for opioid use disorder, RR = 0.89, CI [0.86, 0.93] for opioid poisonings). CONCLUSIONS: Although state-level studies suggest that more liberal marijuana policies may result in fewer opioid overdose deaths, our results within one state suggest that local availability of medical marijuana may not reduce those deaths. The relationship appears to be more complex, possibly based on socioeconomic conditions within and adjacent to areas with higher densities of medical marijuana dispensaries.