Spotlight on Juvenile Justice: Intersecting the Child Welfare System.

The authors disclose that this is a fictional case created by the authors. Julian, a 16-year-old adolescent who entered the juvenile justice system facing armed robbery charges, was 8 years old when he entered the child welfare system. He and his younger sister, Jessica, were placed in protective custody after school staff discovered that they were physically abused and witnessed domestic violence. Jessica further disclosed sexual abuse by the mother's boyfriend who was subsequently incarcerated. The siblings were placed together in several foster homes until a biological aunt assumed custody for 2 years. Both children struggled with behavioral problems in school and at home and responded to mental health treatment. The mother participated in substance use treatment, and the children reunified with her by the time Julian was 11 years old.

Editorial: Justice-Involved Youth: A National State of Emergency in Children's Mental Health.

In 2020, an estimated 424,300 youth were arrested and nearly 128,000 youth were detained in the United States, with disproportionately higher rates for minoritized youth when compared to White youth.1 Although the number of youth in detention facilities has decreased since the late 1990s, a staggering number of children and adolescents enter the justice system each year. This remains a critical issue for child and adolescent psychiatrists. By the time youth enter juvenile detention, individual mental health needs are already exceptionally high.

The patient experience of skill mix changes in primary care: an in-depth study of patient 'work' when accessing primary care.

BACKGROUND: This paper presents insights into patient experiences of changes in workforce composition due to increasing deployment in general practice of practitioners from a number of different professional disciplines (skill mix). We explore these experiences via the concept of 'patient illness work'; how a patient's capacity for action is linked to the work arising from healthcare. METHODS: We conducted four focus group interviews with Patient Participation Group members across participating English general practitioner practices. Thematic analysis and a theoretical lens of illness work were used to explore patients' attempts to understand and navigate new structures, roles and ways to access healthcare. RESULTS: Participants' lack of knowledge about incoming practitioners constrained their agency in accessing primary care. They reported both increased and burdensome illness work as they were given responsibility for navigating and understanding new systems of access while simultaneously understanding new practitioner roles. CONCLUSIONS: While skill mix changes were not resisted by patients, they were keen to improve their agency in capacity to access, by being better informed about newer practitioners to accept and trust them. Some patients require support to navigate change, especially where new systems demand specific capacities such as technological skills and adaptation to unfamiliar practitioners.

General practice managers' motivations for skill mix change in primary care: Results from a cross-sectional survey in England.

OBJECTIVES: The objectives are to determine the factors that motivated GP practice managers in England to employ non-medical roles, and to identify an ideal hypothetical GP practice workforce. METHODS: Cross-sectional survey of GP practice managers in England (n = 1205). The survey focused on six non-medical roles: advanced nurse practitioner, specialist nurse, health care assistant, physician associate, paramedic and pharmacist. RESULTS: The three most commonly selected motivating factors were: (i) to achieve a better match between what patients need and what the practitioner team can deliver; (ii) to increase overall appointment availability and (iii) to release GP time. Employment of pharmacists and physician associates was most commonly supported by additional funding. Practice managers preferred accessing new non-medical roles through a primary care network or similar, while there was a clear preference for direct employment of additional GPs, advanced nurse practitioners or practice nurses. The ideal practice workforce would comprise over 70% of GPs and nurses, containing, on average, fewer GPs than the current GP practice workforce. CONCLUSION: This study confirms that more diverse teams of practitioners are playing an increasing role in providing primary care in England. Managers prefer not to employ all new roles directly within the practice. A more detailed investigation of future workforce requirements is necessary to ensure that health policy supports the funding (whether practice or population based), recruitment, training, deployment and workloads associated with the mix of roles needed in an effective primary care workforce.

Spotlight on Juvenile Justice: How Did We Get Here?

Structural racism and inequity permeate the juvenile justice system. The earliest delinquency programs were developed at a time when slavery was still legal in the United States and Indigenous Americans were considered "savages," representing dehumanizing systems and beliefs that left lasting structural racism.1 Nearly 200 years later, racism continues to shape and structure our juvenile justice system both directly and indirectly. This article will underscore the historical legacy of structural racism in the juvenile justice system, an understanding necessary to address systemic change.

Processes supporting effective skill-mix implementation in general practice: A qualitative study.

OBJECTIVES: Health policy and funding initiatives have addressed increasing workloads in general practice through the deployment of clinicians from different disciplinary backgrounds. This study examines how general practices in England operate with increasingly diverse groups of practitioners. METHODS: Five general practices were selected for maximum variation of the duration and diversity of skill-mix in their workforce. Individual interviews were recorded with management and administrative staff and different types of practitioner. Patient surveys and focus groups gathered patients' perspectives of consulting with different practitioners. Researchers collaborated during coding and thematic analysis of transcripts of audio recordings. RESULTS: The introduction of a wide range of practitioners required significant changes in how practices dealt with patients requesting treatment, and these changes were not necessarily straightforward. The matching of patients with practitioners required effective categorization of health care patients' reported problem(s) and an understanding of practitioners' capabilities. We identified individual and organizational responses that could minimize the impact on patients, practitioners and practices of imperfections in the matching process. CONCLUSIONS: The processes underpinning the redistribution of tasks from GPs to non-GP practitioners are complex. As practitioner employment under the Primary Care Network contracts continues to increase, it is not clear how the necessarily fine-grained adjustments will be made for practitioners working across multiple practices.

Assessment of health and welfare in a small sample of dogs owned by people who are homeless.

BACKGROUND: Pet ownership is common among homeless people, with dogs the most frequently reported pets. However, homeless people receive considerable criticism for keeping pets due to public perception of poor care provision. MATERIALS AND METHODS: A convenience, cross-sectional sample of 19 homeless people, owning a total of 21 dogs were recruited, and their dogs' health and wellbeing assessed using the PDSA Petwise MOT (P-MOT). RESULTS: The dogs compared favourably with conventionally owned pets in most areas, including exercise and companionship. Problems included being overweight/obese (although at lower prevalence than the general population). Some owners had difficulty in accessing veterinary care. Behavioural concerns were reported for 61.9% of the dogs, most commonly separation-related distress. DISCUSSION: Being unable to safely leave their pets may impair owners' access to services. Provision of accessible veterinary care, behavioural support and pet-friendly services could improve the health of homeless owners and their pets.

Editors' Note and Special Communication: Research Priorities in Child and Adolescent Mental Health Emerging From the COVID-19 Pandemic.

Over the last year, the coronavirus disease 2019 (COVID-19) pandemic has resulted in profound disruptions across the globe, with school closures, social isolation, job loss, illness, and death affecting the lives of children and families in myriad ways. In an Editors' Note in our June 2020 issue,1 our senior editorial team described this Journal's role in advancing knowledge in child and adolescent mental health during the pandemic and outlined areas we identified as important for science and practice in our field. Since then, the Journal has published articles on the impacts of the pandemic on child and adolescent mental health and service systems,2-5 which are available in a special collection accessible through the Journal's website.6 Alongside many opinion papers, the pace of publication of empirical research in this area is rapidly expanding, covering important issues such as increased frequency of mental health symptoms among children and adolescents3,5,7-10 and changes in patterns of clinical service use such as emergency department visits.11-14 As the Senior Editors prepared that Editors' Note, they were acutely aware that the priorities that they identified were broad and generated by only a small group of scientists and clinicians. Although this had the advantage of enabling us to get this information out to readers quickly, we decided that a more systematic approach to developing recommendations for research priorities would be of greater long-term value. We were particularly influenced by the efforts of the partnership between the UK Academy of Medical Scientists and a UK mental health research charity (MQ: Transforming Mental Health) to detail COVID-19-related research priorities for "Mental Health Science" that was published online by Holmes et al. in The Lancet Psychiatry in April 2020.15 Consistent with its focus on mental health research across the lifespan, several recommendations highlighted child development and children's mental health. However, a more detailed assessment of research priorities related to child and adolescent mental health was beyond the scope of that paper. Furthermore, the publication of that position paper preceded the death of George Floyd at the hands of Minneapolis police on May 25, 2020, which re-energized efforts to acknowledge and to address racism and healthcare disparities in the United States and many other countries. To build upon the JAACAP Editors' Note1 and the work of Holmes et al.,15 we conducted an international survey of professionals-practitioners and researchers-working on child and adolescent development and pediatric mental health to identify concerns about the impact of the pandemic on children, adolescents, and their families, as well as what is helping families navigate these impacts, and the specific research topics that are of greatest importance.

Motivating factors behind skill mix change: results from a practice managers' survey in England.

BACKGROUND: The expansion of the primary care workforce by employing a varied range of practitioners ('skill mix') is a key component of the General Practice Forward View (GPFV). The extent of skill mix change and where that has occurred has been examined using publicly available practice level workforce data. However, such data does not provide information regarding specific motivating factors behind employment decisions for individual practices nor future workforce plans. AIM: To identify key motivating factors behind practice workforce decisions and their future workforce plans. METHOD: An online questionnaire was sent to practice managers in England. Data collection is ongoing; however, 1000 practices have responded to the survey so far. The questionnaire was composed of questions related to current workforce, motivating factors behind employment decisions, planned future workforce changes, financial assistance with employing staff (for example, HEE or CCG funding) and ideal workforce. RESULTS: Early results indicate that practices that have employed physician associates have done so to increase appointment availability (78% of practices) and release GP time (68%). Sixty-six per cent of practices who have employed pharmacists have received some form of financial assistance with 21% of practices still receiving assistance. When asked to construct an ideal workforce, 'new' roles accounted for 20% of that workforce on average, which is a significantly larger proportion than those roles currently account for. CONCLUSION: Although data collection and analysis are ongoing, the results of the survey provide novel insights into the underlying motivating factors behind employment decisions, specifically for new roles such as pharmacists, PAs and paramedics.

Caffeine-Induced Psychosis and a Review of Statutory Approaches to Involuntary Intoxication.

Caffeine is the most commonly ingested psychoactive substance in the world. Although caffeine-use disorder is not recognized as a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, five disorders related to caffeine use are enumerated therein. An evolving literature suggests that caffeine is one of many licit substances that may cause psychotic symptoms in higher doses. Here, we present a case in which a defendant ingested large quantities of caffeine, which result in transient psychosis and a successful affirmative defense of involuntary intoxication. The purpose of this article is to summarize states' statutory approaches to involuntary intoxication, given that the term is defined variably, if defined at all. Evaluators must be careful to apply jurisdictionally appropriate standards in involuntary intoxication defenses because the bar for this total defense differs across localities.

Opportunities for, and implications of, skill mix changes in health care pathways: Pay, productivity and practice variations in a needs-based planning framework.

Health workforce planning is traditionally based on demographically-driven 'silo-based' models in which future requirements for particular health professions are determined by applying estimates of the future population to the existing population-based level of workforce supply. Estimates of future workforce requirements are focused on, and constrained by population size and requirements increase monotonically. Key failures of existing models include (1) lack of integration between planning the health care workforce, health care services and health care funding and (2) lack of integration between planning different health care inputs and the potential for substitution between inputs. Hence planning models fail to incorporate emerging developments in healthcare delivery and workforce change. We present an integrated needs-based framework for health workforce planning and apply the framework using data from nine European countries to explore the workforce and financial implications of re-configuring the delivery of care through changes in the allocation of treatment tasks between health care professions (skill mix). We show that cost consequences depend not only on pay differences. Instead, workforce planning in rapidly changing workforce environments must consider and incorporate between-provider group differences in productivity (the number of patients that are served per fixed period of time) and practice style (the number and mix of tasks used in providing care to the same type of patient).

Regional variation in practitioner employment in general practices in England: a comparative analysis.

BACKGROUND: In recent years, UK health policy makers have responded to a GP shortage by introducing measures to support increased healthcare delivery by practitioners from a wider range of backgrounds. AIM: To ascertain the composition of the primary care workforce in England at a time when policy changes affecting deployment of different practitioner types are being introduced. DESIGN AND SETTING: This study was a comparative analysis of workforce data reported to NHS Digital by GP practices in England. METHOD: Statistics are reported using practice-level data from the NHS Digital June 2019 data extract. Because of the role played by Health Education England (HEE) in training and increasing the skills of a healthcare workforce that meets the needs of each region, the analysis compares average workforce composition across the 13 HEE regions in England RESULTS: The workforce participation in terms of full-time equivalent of each staff group across HEE regions demonstrates regional variation. Differences persist when expressed as mean full-time equivalent per thousand patients. Despite policy changes, most workers are employed in long-established primary care roles, with only a small proportion of newer types of practitioner, such as pharmacists, paramedics, physiotherapists, and physician associates. CONCLUSION: This study provides analysis of a more detailed and complete primary care workforce dataset than has previously been available in England. In describing the workforce composition at this time, the study provides a foundation for future comparative analyses of changing practitioner deployment before the introduction of primary care networks, and for evaluating outcomes and costs that may be associated with these changes.

Violence and Suicide Risk Assessment in Youth with Psychotic Disorders: Practical Considerations for Community Clinicians.

Psychosis is a unique and significant risk factor associated with violent and suicidal behavior and warrants special consideration. This article presents a careful review of the literature on violence risk and psychosis and suicide risk and psychosis as it pertains to youth or those who have been newly diagnosed with or are at high risk for psychotic disorders. Each topic is covered in reference to general considerations and specific psychotic symptoms (eg, hallucinations, delusions, paranoia). The reader can refer to practical boxes to assist in identifying relevant risk factors and examples of questions to ask the patient and family.

Understanding how and why de-implementation works in health and care: research protocol for a realist synthesis of evidence.

BACKGROUND: Strategies to improve the effectiveness and quality of health and care have predominantly emphasised the implementation of new research and evidence into service organisation and delivery. A parallel, but less understood issue is how clinicians and service leaders stop existing practices and interventions that are no longer evidence based, where new evidence supersedes old evidence, or interventions are replaced with those that are more cost effective. The aim of this evidence synthesis is to produce meaningful programme theory and practical guidance for policy makers, managers and clinicians to understand how and why de-implementation processes and procedures can work. METHODS AND ANALYSIS: The synthesis will examine the attributes or characteristics that constitute the concept of de-implementation. The research team will then draw on the principles of realist inquiry to provide an explanatory account of how, in what context and for whom to explain the successful processes and impacts of de-implementation. The review will be conducted in four phases over 18 months. Phase 1: develop a framework to map the preliminary programme theories through an initial scoping of the literature and consultation with key stakeholders. Phase 2: systematic searches of the evidence to develop the theories identified in phase 1. Phase 3: validation and refinement of programme theories through stakeholder interviews. Phase 4: formulating actionable recommendations for managers, commissioners and service leaders about what works through different approaches to de-implementation. DISCUSSION: This evidence synthesis will address gaps in knowledge about de-implementation across health and care services and ensure that guidance about strategies and approaches accounts for contextual factors, which may be operating at different organisational and decision-making levels. Through the development of the programme theory, which explains what works, how and under which circumstances, findings from the evidence synthesis will support managers and service leaders to make measured decisions about de-implementation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017081030.

Skill-mix change in general practice: a qualitative comparison of three 'new' non-medical roles in English primary care.

BACKGROUND: General practice is currently facing a significant workforce challenge. Changing the general practice skill mix by introducing new non-medical roles is recommended as one solution; the literature highlights that organisational and/or operational difficulties are associated with skill-mix changes. AIM: To compare how three non-medical roles were being established in general practice, understand common implementation barriers, and identify measurable impacts or unintended consequences. DESIGN AND SETTING: In-depth qualitative comparison of three role initiatives in general practices in one area of Greater Manchester, England; that is, advanced practitioner and physician associate training schemes, and a locally commissioned practice pharmacist service. METHOD: Semi-structured interviews and focus groups with a purposive sample of stakeholders involved in the implementation of each role initiative were conducted. Template analysis enabled the production of pre-determined and researcher-generated codes, categories, and themes. RESULTS: The final sample contained 38 stakeholders comprising training/service leads, role holders, and host practice staff. Three key themes captured participants' perspectives: purpose and place of new roles in general practice, involving unclear role definition and tension at professional boundaries; transition of new roles into general practice, involving risk management, closing training-practice gaps and managing expectations; and future of new roles in general practice, involving demonstrating impact and questions about sustainability. CONCLUSION: This in-depth, in-context comparative study highlights that introducing new roles to general practice is not a simple process. Recognition of factors affecting the assimilation of roles may help to better align them with the goals of general practice and harness the commitment of individual practices to enable role sustainability.

Clinical Presentation and Treatment of Amniotic Fluid Embolism.

Obstetric emergencies often require intensive care intervention. Amniotic fluid embolism is a rare, unpredictable, and often catastrophic complication of pregnancy that is suspected in a woman who experiences cardiac arrest after a cesarean section. The condition occurs in approximately 1 in 40 000 births and has an average case-fatality rate of 16%. This complication may result from activation of an inflammatory response to fetal tissue in the maternal circulation. Risk factors may include maternal age over 35 years and conditions in which fluid can exchange between the maternal and fetal circulations. The presentation is abrupt, with profound cardiovascular and respiratory compromise, encephalopathy, fetal distress, and disseminated intravascular coagulopathy. Diagnosis is by exclusion and clinical presentation. Treatment is supportive, with a focus on reversal of hypoxia and hypotension, delivery of the fetus, and correction of coagulopathy. Staff debriefing and psychological support for the woman and family are vital.

Implementing new care models: learning from the Greater Manchester demonstrator pilot experience.

BACKGROUND: Current health policy focuses on improving accessibility, increasing integration and shifting resources from hospitals to community and primary care. Initiatives aimed at achieving these policy aims have supported the implementation of various 'new models of care', including general practice offering 'additional availability' appointments during evenings and at weekends. In Greater Manchester, six 'demonstrator sites' were funded: four sites delivered additional availability appointments, other services included case management and rapid response. The aim of this paper is to explore the factors influencing the implementation of services within a programme designed to improve access to primary care. The paper consists of a qualitative process evaluation undertaken within provider organisations, including general practices, hospitals and care homes. METHODS: Semi-structured interviews, with the data subjected to thematic analysis. RESULTS: Ninety-one people participated in interviews. Six key factors were identified as important for the establishment and running of the demonstrators: information technology; information governance; workforce and organisational development; communications and engagement; supporting infrastructure; federations and alliances. These factors brought to light challenges in the attempt to provide new or modify existing services. Underpinning all factors was the issue of trust; there was consensus amongst our participants that trusting relationships, particularly between general practices, were vital for collaboration. It was also crucial that general practices trusted in the integrity of anyone external who was to work with the practice, particularly if they were to access data on the practice computer system. A dialogical approach was required, which enabled staff to see themselves as active rather than passive participants. CONCLUSIONS: The research highlights various challenges presented by the context within which extended access is implemented. Trust was the fundamental underlying issue; there was consensus amongst participants that trusting relationships were vital for effective collaboration in primary care.

Messenger RNA transport in the opportunistic fungal pathogen Candida albicans.

Candida albicans, a common commensal fungus, can cause disease in immunocompromised hosts ranging from mild mucosal infections to severe bloodstream infections with high mortality rates. The ability of C. albicans cells to switch between a budding yeast form and an elongated hyphal form is linked to pathogenicity in animal models. Hyphal-specific proteins such as cell-surface adhesins and secreted hydrolases facilitate tissue invasion and host cell damage, but the specific mechanisms leading to asymmetric protein localization in hyphae remain poorly understood. In many eukaryotes, directional cytoplasmic transport of messenger RNAs that encode asymmetrically localized proteins allows efficient local translation at the site of protein function. Over the past two decades, detailed mechanisms for polarized mRNA transport have been elucidated in the budding yeast Saccharomyces cerevisiae and the filamentous fungus Ustilago maydis. This review highlights recent studies of RNA-binding proteins in C. albicans that have revealed intriguing similarities to and differences from known fungal mRNA transport systems. I also discuss outstanding questions that will need to be answered to reach an in-depth understanding of C. albicans mRNA transport mechanisms and the roles of asymmetric mRNA localization in polarized growth, hyphal function, and virulence of this opportunistic pathogen.