Literature Collection

In 2021, the U.S. Surgeon General issued an advisory on youth mental health, stating that the challenges that youth are facing are unprecedented, hard to navigate, and significantly impacting their mental health.1 Through statewide quality improvement and collaborative learning models, the Care Transformation Collaborative of Rhode Island (CTC-RI) and PCMH-Kids have implemented innovative, pediatric integrated behavioral health (IBH) models to support pediatric medical homes in addressing youth mental health needs, reduce stigma, increase access, and improve care coordination. Early efforts focused on a traditional IBH model and practices were financially responsible for the IBH clinician; despite clinical successes, smaller practices could not sustain the model financially, so CTC-RI shifted its focus to an innovative model that removed financial risk from the practice. More recently, CTC-RI has launched initiatives to expand the pediatric team's capacity to manage the behavioral health needs of its patients and families by providing specialty skill building (e.g., sleep, anxiety, autism), and by adding community health workers to IBH teams. Results from these initiatives indicate that pediatric IBH models are an effective and essential element of advanced primary care.

OBJECTIVE: This study aimed to evaluate a theory-based measurement tool to assess primary care clinicians' (PCCs') knowledge, self-efficacy, and behavioral intentions across key pediatric mental health conditions. The authors used this tool to examine the impact of a comprehensive continuing medical education (CME) program. METHODS: The Patient-Centered Mental Health in Pediatric Primary Care (PPP) "mini-fellowship" included a 3-day interactive workshop and 12 follow-up coaching calls. PCCs (N=898) completed a 68-item assessment at baseline, postworkshop, and 6-month follow-up. Principal-components analysis identified 10 stable domains aligned with clinical priorities, distinguishing primary care-common disorders (PC-CDs; attention-deficit hyperactivity disorder, depression, anxiety, and suicidality) from specialty-level disorders (S-LDs; bipolar disorder, severe aggression, conduct disorders, etc.). All domains showed strong internal consistency (α≥0.77). Mixed-effects regression models examined change over time and predictors of behavioral intentions. RESULTS: Significant improvements in knowledge, self-efficacy, and behavioral intentions were observed postworkshop, with sustained gains at the 6-month follow-up for PC-CDs. Improvements in knowledge of and comfort with S-LDs predicted stronger behavioral intentions across both common and specialty conditions. No baseline differences were observed between those who completed the 6-month follow-up (N=416) and those who did not. PCCs who completed training after the onset of the COVID-19 pandemic had slightly larger and more persistent improvements. CONCLUSIONS: This CME model produced durable improvements in PCCs' readiness to deliver pediatric mental health care. The accompanying theory-informed measurement tool reliably captured these changes and may offer a practical, domain-specific framework for evaluating multidisorder pediatric mental health training initiatives in primary care.

Pediatric obsessive-compulsive disorder (OCD) is a complex condition that typically emerges in childhood or adolescence and is closely linked to developmental changes in cognitive and emotional control. This mini-review offers a clinically oriented synthesis of pediatric OCD from a developmental and transdiagnostic perspective, framing it as a disturbance of flexibility, inhibition, and distress regulation that organizes its clinical presentation. Variations in these control processes across development shape the content and form of obsessive-compulsive symptoms and contribute to their frequent overlap with conditions such as autism spectrum disorder, tic disorders and Tourettic OCD, ADHD, bipolar disorder, and psychosis-risk presentations, which share similar regulatory vulnerabilities. Within this framework, family accommodation is conceptualized as an interpersonal extension of the child's regulatory difficulties, temporarily reducing distress while reinforcing reliance on external control. A transdiagnostic focus on underlying regulatory mechanisms also helps to clarify why interventions such as developmentally adapted cognitive-behavioral therapy with exposure and response prevention, family-focused treatments, and process-based transdiagnostic protocols can promote more flexible cognitive-emotional regulation in both the child and the family system. Taken together, these elements support a developmental, family-integrated, and transdiagnostic conceptualization of pediatric OCD centered on cognitive-emotional control.

PURPOSE: Excessive narcotization in pediatric surgical patients has not been well characterized. This report describes the use of postoperative naloxone in pediatric patients. METHODS: Pediatric surgical patients from January 1, 2010, through June 30, 2016, who underwent general anesthesia and received naloxone within 48 h postoperatively were identified and matched 1:1 with controls by age, sex, and procedure. Cases and controls underwent retrospective chart review. RESULTS: Forty-seven patients received naloxone, with a rate of 2.0 (95% CI 1.5-2.7) per 1000 anesthetics. Indications were respiratory depression (n = 19), facilitating extubation (n = 15), and reversing sedation (n = 13), and 44 cases received naloxone in a monitored environment. The median (interquartile range) naloxone dose was 4.0 (2.0-23.5) mcg/kg, and five patients (11%) later required subsequent naloxone treatments. Their characteristics were similar to controls, including opioid medications, except cases that had signs of respiratory depression before naloxone administration. The outcomes were similar, although more cases were admitted to the intensive care unit before naloxone administration. One patient died 13 days postoperatively of unrelated causes. CONCLUSION: Postoperative naloxone administration in pediatric patients is rare. The observation that most administrations occurred in a monitored setting implies that at-risk patients had been appropriately identified and kept under closer surveillance.