Literature Collection

IMPORTANCE: Given that the Patient Health Questionnaire (PHQ) item 9 is commonly used to screen for risk of self-harm and suicide, it is important that clinicians recognize circumstances when at-risk adolescents may go undetected. OBJECTIVE: To understand characteristics of adolescents with a history of depression who do not endorse the PHQ item 9 before a near-term intentional self-harm event or suicide. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study design using electronic health record and claims data from January 2009 through September 2017. Settings included primary care and mental health specialty clinics across 7 integrated US health care systems. Included in the study were adolescents aged 13 to 17 years with history of depression who completed the PHQ item 9 within 30 or 90 days before self-harm or suicide. Study data were analyzed September 2022 to April 2023. EXPOSURES: Demographic, diagnostic, treatment, and health care utilization characteristics. MAIN OUTCOME(S) AND MEASURE(S): Responded "not at all" (score = 0) to PHQ item 9 regarding thoughts of death or self-harm within 30 or 90 days before self-harm or suicide. RESULTS: The study included 691 adolescents (mean [SD] age, 15.3 [1.3] years; 541 female [78.3%]) in the 30-day cohort and 1024 adolescents (mean [SD] age, 15.3 [1.3] years; 791 female [77.2%]) in the 90-day cohort. A total of 197 of 691 adolescents (29%) and 330 of 1024 adolescents (32%), respectively, scored 0 before self-harm or suicide on the PHQ item 9 in the 30- and 90-day cohorts. Adolescents seen in primary care (odds ratio [OR], 1.5; 95% CI, 1.0-2.1; P = .03) and older adolescents (OR, 1.2; 95% CI, 1.0-1.3; P = .02) had increased odds of scoring 0 within 90 days of a self-harm event or suicide, and adolescents with a history of inpatient hospitalization and a mental health diagnosis had twice the odds (OR, 2.0; 95% CI, 1.3-3.0; P = .001) of scoring 0 within 30 days. Conversely, adolescents with diagnoses of eating disorders were significantly less likely to score 0 on item 9 (OR, 0.4; 95% CI, 0.2-0.8; P = .007) within 90 days. CONCLUSIONS AND RELEVANCE: Study results suggest that older age, history of an inpatient mental health encounter, or being screened in primary care were associated with at-risk adolescents being less likely to endorse having thoughts of death and self-harm on the PHQ item 9 before a self-harm event or suicide death. As use of the PHQ becomes more widespread in practice, additional research is needed for understanding reasons why many at-risk adolescents do not endorse thoughts of death and self-harm.

The World Health Organization reports that more than 390 million children and adolescents have obesity, with the US facing a prevalence of 14 million among this population and incurring an annual medical cost of $1.3 billion. Childhood and adolescent obesity stems from genetic, environmental, and socioecological factors, indicating the need for an evolving approach to pediatric obesity management. The updated 2023 American Academy of Pediatrics guideline for evaluation and treatment of pediatric obesity advocates for a child-centric strategy, considering health equity, racism, weight bias stigmatism, and adverse childhood experiences. Management includes intensive health behavior and lifestyle treatment, partnership with communities to build comprehensive treatment programs, promotion of early intervention, consideration of pharmacotherapy for children age 12 years and older, selective use of bariatric surgery, screening for and treatment of comorbidities, integration of mental health treatment, and use of motivational interviewing to engage patients in their care. Pediatric primary care providers play a key role in identification of obesity and encouragement of obesity treatment. Proactive management of childhood obesity benefits individuals, families, and the nation. Early intervention holds the promise of substantial cost savings on obesity-related healthcare. Healthcare providers wield significant influence in reducing childhood morbidity and enhancing the overall health of US children and adolescents.

INTRODUCTION: The management of pediatric inflammatory bowel disease (PIBD) has drastically changed in the last decade. The limited availability of new biologics or small molecule therapies, and concerns about durability in children has necessitated the development of other advances in management to optimize care. AREAS COVERED: This review covers guidance for management targets and advances in optimizing biologic therapies, new medical therapies, adjuvant therapies, precision medicine and mental health concerns in PIBD. This review focused on recent advances and was not intended as a complete overview of the investigations and management of pediatric IBD. EXPERT OPINION: Advancements include standardization of treatment goals via a treat-to-target strategy, optimizing anti-TNF biologics through combination therapy or proactive drug monitoring, earlier initiation of treatment for Crohn's disease, the emergence of new biologic/advanced therapies and a growing focus on adjuvant therapies targeting the microbiome. Future progress relies on the inclusion of children/adolescents in clinical trials to facilitate faster regulatory approval for pediatric therapies and the integration of precision medicine and mental health screening to improve patient care and outcomes.

The Strengthening Care for Children (SC4C) is a general practitioner (GP)-paediatrician integrated model of care that consists of co-consulting sessions and case discussions in the general practice setting, with email and telephone support provided by paediatricians to GPs during weekdays. This model was implemented in 21 general practices in Australia (11 Victoria and 10 New South Wales). Our study aimed to identify the factors moderating the implementation of SC4C from the perspectives of GPs, general practice personnel, paediatricians and families. We conducted a qualitative study as part of the mixed-methods implementation evaluation of the SC4C trial. We collected data through virtual and in-person focus groups at the general practices and phone, virtual and in-person interviews. Data was analysed using an iterative hybrid inductive-deductive thematic analysis. Twenty-one focus groups and thirty-seven interviews were conducted. Overall, participants found SC4C acceptable and suitable for general practices, with GPs willing to learn and expand their paediatric care role. GPs cited improved confidence and knowledge due to the model. Paediatricians reported an enhanced understanding of the general practice context and the strain under which GPs work. GPs and paediatricians reported that this model allowed them to build trust-based relationships with a common goal of improving care for children. Additionally, they felt some aspects, including the lack of remuneration and the work and effort required to deliver the model, need to be considered for the long-term success of the model. Families expressed their satisfaction with the shared knowledge and quality of care jointly delivered by GPs and paediatricians and highlighted that this model of care provides easy access to specialty services without out-of-pocket costs. Future research should focus on finding strategies to ensure the long-term Implementation of this model of care with a particular focus on the individual stressors in general practices.

PURPOSE: To examine the associations between adverse childhood experiences (ACEs) scores from routine screenings in pediatric checkups and timing of puberty in a diverse cohort of adolescents. METHODS: A retrospective cohort study of 52,573 pediatric members of Kaiser Permanente Northern California, an integrated healthcare delivery system. Exposure was the total ACEs score, determined using caregiver- and self-reported scores across all well-child visits, and categorized into 0, 1-3, 4-6, or 7-10 ACEs. Outcomes were age at menarche and pubertal onset, using physician-assessed Sexual Maturity Ratings. RESULTS: Girls with ACEs had a substantially higher risk of earlier menarche and pubertal onset compared to those without ACEs. There were no associations between ACEs and boys' pubertal timing. DISCUSSION: These results highlight the importance of screening for ACEs in a clinical setting to address adolescents' psychological well-being and healthy lifestyle habits, which in turn may prevent adverse health outcomes associated with early puberty.

A Workforce Crisis. Across the nation there is a high degree of concern about the state of the behavioral health workforce and pessimism about its future. Workforce problems have an impact on almost every aspect of prevention and treatment across all sectors of the diverse behavioral health field. The issues encompass difficulties in recruiting and retaining staff, the absence of career ladders for employees, marginal wages and benefits, limited access to relevant and effective training, the erosion of supervision, a vacuum with respect to future leaders, and financing systems that place enormous burdens on the workforce to meet high levels of demand with inadequate resources. Most critically, there are significant concerns about the capability of the workforce to provide quality care. The majority of the workforce is uninformed about and unengaged in health promotion and prevention activities. Too many in the workforce also lack familiarity with resilience- and recovery-oriented practices and are generally reluctant to engage children, youth, and adults, and their families, in collaborative relationships that involve shared decision-making about treatment options. It takes well over a decade for proven interventions to make their way into practice, since prevention and treatment services are driven more by tradition than by science. The workforce lacks the racial diversity of the populations it serves and is far too often insensitive to the needs of individuals, as these are affected by ethnicity, culture, and language. In large sections of rural America, there simply is no mental health or addictions workforce.There is overwhelming evidence that the behavioral health workforce is not equipped in skills or in numbers to respond adequately to the changing needs of the American population. While the incidence of co-occurring mental and addictive disorders among individuals has increased dramatically, most of the workforce lacks the array of skills needed to assess and treat persons with these co-occurring conditions.Training and education programs largely have ignored the need to alter their curricula to address this problem and, thus, the nation continues to prepare new members of the workforce who simply are underprepared from the moment they complete their training.

Today's era of integrated working seeks to bring together different professionals to work in patient-centered teams. As a result leadership perspectives have changed. We now seek leaders who recognize the complexity of moderating across different health, social care and other public and private sector organizations for collective patient/community focussed service. This research focuses on the role of leaders in the UK who were asked to lead a range of practitioners working from Children's Centers. These centers brought together a myriad of practitioners from health, social care, and education to meet the needs of children from wide and diverse backgrounds. We share a qualitative study, exploring the experiences of Children's Center leaders, using critical theory and constructivism. The study explored how leaders enable integrated working to flourish. The research was conducted in two stages: In Stage One, five strategic Children's Center managers were interviewed to illuminate the key ingredients felt to support good leaders. Stage Two brought together 10 Children's Center leaders from across different areas of the UK, to share their experiences using Participatory Action Research. The final synthesis identified four main processes which could help leaders to enable integrated working to flourish. These were: i) Thinking Systematically; ii) Building and re-building relationships; ii) Nourishing self-actualization and; iv) Utilizing alternative approaches to problem solving. Four borderline processes were identified: Interaction, Integrity, Flow and Sensitivity. The final model articulates the skills required to lead integrated services which bring together a wide range of practitioners. The outcomes help leaders to explore new ways of leading and require further testing. The outcomes may apply to other clinical areas of integrated working.

As treatment expansion in the opioid epidemic continues, it is important to examine how the makeup of individuals with opioid use disorder (OUD) is evolving. Treatment programs are increasingly utilizing buprenorphine, an effective OUD medication. This exploratory study examines sex and gender differences in psychosocial, clinical and substance use treatment characteristics of a clinical population in outpatient medication treatment for OUD with buprenorphine. This is a secondary data analysis from a cross-sectional survey study with retrospective medical record review conducted with patients recruited from an office-based opioid treatment clinic between July-September 2019. Participants on buprenorphine for at least 28 days at time of survey completion were included (n=133). Differences between men and women were explored with Pearson χ(2) and Fisher's Exact Tests for categorical variables and T-Tests for continuous variables. The sample was 55.6% women and nearly three-fourths Black (70.7%). Mean days in current treatment episode was 431.6 (SD=244.82). Women were younger and more likely to be unemployed, identify as a sexual minority, and live alone with children than men. More women than men had a psychiatric comorbidity. Women reported more prescription opioid misuse while men had more heroin only opioid use. More men reported comorbid alcohol use and a history of drug overdose. One-third of participants reported recent discrimination in a healthcare setting due to substance use. As buprenorphine-based outpatient treatment programs continue to expand, present study findings support evaluation of the unique needs of men and women in order to better tailor OUD-related services and improve treatment outcomes.

This paper documents an innovative research approach undertaken to co-develop an integrated assessment, diagnosis, and support service trajectory for children suspected of having a developmental disability. It employed data-driven practices and involved multiple stakeholders such as parents, professionals, managers, and researchers. It emphasized the importance of incorporating experiential knowledge adopting an integrated care and service trajectory perspective, and using an implementation science framework. The first part of this article presents the theoretical roots and the collaborative method used to co-construct the model trajectory. The second part of this article presents the results of a survey in which participating stakeholders shared their point of view on the value and impact of this approach Overall, this article provides a step-by-step operationalization of participative research in the context of public health and social services. This may help guide future initiatives to improve services for developmental disabilities in partnership with those directly concerned by these services.