Amy Lewis Gilbert

Associations of Early Exposure to Intimate Partner Violence and Parental Depression With Subsequent Mental Health Outcomes

IMPORTANCE Children with known exposure to intimate partner violence (IPV) or maternal depression are at risk for negative mental health outcomes as early as preschool age. Active ongoing surveillance for these risk factors can lead to earlier mental health intervention for children. OBJECTIVE To examine the association between parent reports of IPV and depressive symptoms within the first 3 years of a childs life with subsequent mental health conditions and psychotropic drug treatment. DESIGN Prospective cohort study linking parental IPV and depression with subsequent billing and pharmacy data between November 1, 2004, and June 7, 2012. SETTING Four pediatric clinics. PARTICIPANTS A total of 2422 children receiving care from clinics that implemented the Child Health Improvement Through Computer Automation (CHICA) system. MAIN OUTCOME MEASURES Any report of IPV and/or parental depressive symptoms from birth to age 3 years, mental health diagnoses made with International Classification of Diseases, Ninth Revision criteria, and any psychotropic drug treatment between ages 3 and 6 years. RESULTS Fifty-eight caregivers (2.4%) reported both IPV and depressive symptoms before their children were aged 3 years, 69 (2.8%) reported IPV only, 704 (29.1%) reported depressive symptoms only, and 1591 (65.7%) reported neither exposure. Children of parents reporting both IPV and depressive symptoms were more likely to have a diagnosis of attention-deficit/hyperactivity disorder (adjusted odds ratio = 4.0; 95% CI, 1.5-10.9), even after adjusting for the childs sex, race/ethnicity, and insurance type. Children whose parents reported depressive symptoms were more likely to have been prescribed psychotropic medication (adjusted odds ratio = 1.9; 95%, CI 1.0-3.4). CONCLUSIONS AND RELEVANCE Exposure to both IPV and depression before age 3 years is associated with preschool-aged onset of attention-deficit/hyperactivity disorder; early exposure to parental depression is associated with being prescribed psychotropic medication. Pediatricians play a critical role in performing active, ongoing surveillance of families with these known social risk factors and providing early intervention to negate long-term sequelae.

Child exposure to parental violence and psychological distress associated with delayed milestones.

OBJECTIVE: To examine the association between parental report of intimate partner violence (IPV) and parental psychological distress (PPD) with child attainment of developmental milestones. METHODS: By using data collected from a large cohort of primary care patients, this cross-sectional study examined the relationship between parental report of IPV and/or PPD and the attainment of developmental milestones within the first 72 months of a child’s life. Multivariate logistic regression analyses were used to adjust for parental report of child abuse concern and sociodemographic characteristics. RESULTS: Our study population included 16 595 subjects. Children of parents reporting both IPV and PPD (n = 88; 0.5%) were more likely to fail at least 1 milestone across the following developmental domains: language (adjusted odds ratio [aOR] 2.1; 95% confidence interval [CI] 1.3–3.3), personal-social (aOR 1.9; 95% CI 1.2–2.9), and gross motor (aOR 3.0; 95% CI 1.8–5.0). Significant associations for those reporting IPV-only (n = 331; 2.0%) were found for language (aOR 1.4; 95% CI 1.1–1.9), personal-social (aOR 1.7; 95% CI 1.4–2.2), and fine motor-adaptive (aOR 1.7; 95% CI 1.0–2.7). Significant associations for those reporting PPD-only (n = 1920; 11.6%) were found for: language (aOR 1.5; 95% CI 1.3–1.7), personal-social (aOR 1.6; 95% CI 1.5–1.8), gross motor (aOR 1.6; 95% CI 1.4–1.8), and fine-motor adaptive (aOR 1.6; 95% CI 1.3–2.0). CONCLUSIONS: Screening children for IPV and PPD helps identify those at risk for poor developmental outcomes who may benefit from early intervention.

Adolescent Self-Consent for Biomedical Human Immunodeficiency Virus Prevention Research

PURPOSE The Adolescent Medicine Trials Network Protocol 113 (ATN113) is an open-label, multisite demonstration project and Phase II safety study of human immunodeficiency virus (HIV) preexposure prophylaxis with 15- to 17-year-old young men who have sex with men that requires adolescent consent for participation. The purpose of this study was to examine factors related to the process by which Institutional Review Boards (IRBs) and researchers made decisions regarding whether to approve and implement ATN113 so as to inform future biomedical HIV prevention research with high-risk adolescent populations. METHODS Participants included 17 researchers at 13 sites in 12 states considering ATN113 implementation. Qualitative descriptive methods were used. Data sources included interviews and documents generated during the initiation process. RESULTS A common process for initiating ATN113 emerged, and informants described how they identified and addressed practical, ethical, and legal challenges that arose. Informants described the process as responding to the protocol, preparing for IRB submission, abstaining from or proceeding with submission, responding to IRB concerns, and reacting to the outcomes. A complex array of factors impacting approval and implementation were identified, and ATN113 was ultimately implemented in seven of 13 sites. Informants also reflected on lessons learned that may help inform future biomedical HIV prevention research with high-risk adolescent populations. CONCLUSIONS The results illustrate factors for consideration in determining whether to implement such trials, demonstrate that such protocols have the potential to be approved, and highlight a need for clearer standards regarding biomedical HIV prevention research with high-risk adolescent populations.

Proactive parents are assets to the health and well-being of teens.

OBJECTIVES To analyze parents who self-identified themselves as being proactive parents (PPs) compared with non-PPs who were queried about their teens health to understand common adolescent health concerns, parenting practices/behaviors around health, and whether their adolescent had received a preventive care visit in the last year STUDY DESIGN Secondary analyses of parents (n = 504) from a nationally representative online panel were surveyed to assess health beliefs/attitudes, perceived adolescent health concerns, frequency of health discussions, topics that pediatricians should discuss, and their teens last annual visit. Demographics, parental beliefs, frequency of health conversations, and topics that physicians should discuss were compared. Logistic regression determined the likelihood of PPs compared with non-PPs reporting a teen annual health visit within the last year. RESULTS Greater education and having a single-child household were slightly more common among PPs. PPs expressed greater concern about their teens getting good grades, getting sick, and their teens future (P < .001). PPs indicated a greater severity of worry (P < .02) across all health topics and rated issues of sexual health, vaccines, and stress/mental health as very important for pediatricians to discuss (P < .01). Controlling for demographics, PPs were 3.4 (95% CI 2.06-5.56) times more likely to report an annual visit of their teen in the last year. CONCLUSION PPs are an asset to the health promotion and the well-being of their teens. PPs were more likely to have their teen receive an annual visit, report more frequent discussions about health, and place a high value on physician discussions about health.

Medical legal partnership and health informatics impacting child health: Interprofessional innovations.

Abstract Dramatic differences in health are closely related to degrees of social and economic disadvantage. Poverty-induced hardships such as food insecurity, utility shut-offs, and substandard housing, all have the potential to negatively impact the health of families. In an effort to better address social determinants of health in pediatric primary health care settings using the Medical Legal Partnership (MLP) model of health care delivery, an interprofessional team of investigators came together to design an innovative process for using computerized clinical decision support to identify health-harming legal and social needs, improve the delivery of appropriate physician counseling, and streamline access to legal and social service professionals when non-medical remedies are required. This article describes the interprofessional nature of the MLP model itself, illustrates the work that was done to craft this innovative health informatics approach to implementing MLP, and demonstrates how pediatricians, social workers and attorneys may work together to improve child health outcomes.

Parent and Adolescent Views on Barriers to Adolescent Preventive Health Care Utilization

OBJECTIVES To determine adolescent and parent views of barriers to annual adolescent preventive care. STUDY DESIGN A nationally recruited cross-sectional study of adolescents between ages 13 and 18 years, and parents of adolescents from different families, were recruited. The primary outcome was self-report of preventive care in the last 12 months. Demographic, family health discussions, physical/emotional health importance, and preventive care barriers were gathered from adolescents and parents. RESULTS The majority of the sample (500 adolescents and 504 parents in different families) reported a primary care visit within 12 months (parents = 78.7%; adolescents = 66.9%). Adolescent participants identified more barriers than parents (parents = 0.69; adolescents = 1.42). Adolescent who reported having discussions with parents about health (aOR 1.57, 95% CI 1.26-1.98) and seeing a subspecialist provider (aOR 3.72, CI 1.21-11.47) were more likely to report preventive visits. Barriers for parents and adolescents include the belief that an appointment is only needed when a child is sick (parent aOR 0.21, CI 0.08-0.61; adolescent aOR 0.29, CI 0.17-0.51) and family cannot afford cost (parent aOR 0.34, CI 0.15-0.81; adolescent aOR 0.50, CI 0.26-0.97). Barriers for parents include the child sees a specialist (aOR 0.26, CI 0.08-0.88) and their child does not need a checkup (aOR 0.12, CI 0.05-0.34). Lastly, a barrier for adolescents was parents never schedule preventive visits (aOR 0.31, CI 0.17-0.58). CONCLUSIONS The Affordable Care Act has the potential to limit preventive care barriers. The results of the current study find there are parental and adolescent issues regarding preventive services that should be addressed.

Moral conflict and competing duties in the initiation of a biomedical HIV prevention trial with minor adolescents

ABSTRACT Background: Biomedical HIV prevention research with minors is complicated by the requirement of parental consent, which may disclose sensitive information to parents. We examine the experience of principal investigators (PIs) and study personnel who faced this complex ethical issue in the first biomedical HIV prevention study that allowed minors to self-consent for enrollment. Methods: We conducted in-depth interviews with PIs and study personnel from 13 medical trial sites in cities across the United States. Data were analyzed using a conventional content analysis. Results: Participants experienced moral conflict as they struggled to fulfill conflicting duties in this trial involving minor adolescents with multiple vulnerabilities. Our participants experienced conflict between the two types of duties—protective and scientific—previously identified by Merritt. Protective duties were owed to the child, the parents, and the institution, and participants expressed tension between the actions that would protect these subgroups and the actions necessary to fulfill their scientific duties. Conclusions: Moral conflict was resolved in a variety of ways, including reflecting on the protocols alignment with federal regulations, modifying consent language, considering each individual for enrollment carefully, and accepting institutional review board (IRB) decisions. Potential solutions for future studies are discussed, and include flexible protocol consent procedures and centralized IRB reviews.

Perspectives of family medicine physicians on the importance of adolescent preventive care: a multivariate analysis

BackgroundThe study objective was to identify commonalities amongst family medicine physicians who endorse annual adolescent visits.MethodsA nationally weighted representative on-line survey was used to explore pediatrician (N = 204) and family medicine physicians (N = 221) beliefs and behaviors surrounding adolescent wellness. Our primary outcome was endorsement that adolescents should receive annual preventive care visits.ResultsPediatricians were significantly more likely (p < .01) to endorse annual well visits. Among family medicine physicians, bivariate comparisons were conducted between those who endorsed an annual visit (N = 164) compared to those who did not (N = 57) with significant predictors combined into two multivariate logistic regression models.Model 1 controlled for: patient race, proportion of 13-17 year olds in provider’s practice, discussion beliefs scale and discussion behaviors with parents scale. Model 2 controlled for the same first three variables as well as discussion behaviors with adolescents scale. Model 1 showed for each discussion beliefs scale topic selected, family medicine physicians had 1.14 increased odds of endorsing annual visits (p < .001) and had 1.11 greater odds of endorsing annual visits with each one-point increase in discussion behaviors with parents scale (p = .51). Model 2 showed for each discussion beliefs scale topic selected, family medicine physicians had 1.15 increased odds of also endorsing the importance of annual visits (p < .001).ConclusionsFamily medicine physicians that endorse annual visits are significantly more likely to affirm they hold strong beliefs about topics that should be discussed during the annual exam. They also act on these beliefs by talking to parents of teens about these topics. This group appears to focus on quality of care in thought and deed.

Characteristics Associated with Confidential Consultation for Adolescents in Primary Care

Objective To examine how provider report of confidential consultation in the electronic health record is associated with adolescent characteristics, health risk factors, and provider training. Study design This prospective cohort study was conducted as part of a larger study implementing computerized clinical decision support in 2 urban primary care clinics. Adolescents used tablets to complete screening questions for specified risk factors in the waiting room. Adolescent‐reported risk factors included sexual activity, substance use, and depressive symptoms. Providers were prompted on encounter forms to address identified risk factors and indicate whether confidential consultation was provided. Provider types included adolescent medicine board certified pediatrics and general pediatrics. Differences in proportions of adolescents reporting risk factors by provider type were assessed using χ2 tests. Associations between adolescent characteristics, risk factors, and provider‐reported confidential consultation were examined using logistic regression analyses. Results The sample included 1233 English and Spanish‐speaking adolescents 12‐20 years of age (52% female; 60% black; 50% early adolescent). Patients seen by adolescent medicine board certified providers reported sexual activity, depressive symptoms, and substance use significantly more often than those seen by general pediatric providers. Among patients seen by board certified adolescent medicine providers, confidential consultation was provided to 90%. For those seen by general pediatric providers, confidential consultation was provided to 53%. Results of multiple logistic regression demonstrated that female sex, later adolescence, and clinic location were significantly associated with confidential consultation. Conclusions Provider training is needed to reinforce the importance of confidential consultation for all adolescents.

Suicide Screening in Primary Care: Use of an Electronic Screener to Assess Suicidality and Improve Provider Follow-Up for Adolescents

PURPOSE The purpose of this study was to assess the feasibility of using an existing computer decision support system to screen adolescent patients for suicidality and provide follow-up guidance to clinicians in a primary care setting. Predictors of patient endorsement of suicidality and provider documentation of follow-up were examined. METHODS A prospective cohort study was conducted to examine the implementation of a CDSS that screened adolescent patients for suicidality and provided follow-up recommendations to providers. The intervention was implemented for patients aged 12-20 years in two primary care clinics in Indianapolis, Indiana. RESULTS The sample included 2,134 adolescent patients (51% female; 60% black; mean age = 14.6 years [standard deviation = 2.1]). Just over 6% of patients screened positive for suicidality. A positive endorsement of suicidality was more common among patients who were female, depressed, and seen by an adolescent-medicine board-certified provider as opposed to general pediatric provider. Providers documented follow-up action for 83% of patients who screened positive for suicidality. Documentation of follow-up action was correlated with clinic site and Hispanic race. The majority of patients who endorsed suicidality (71%) were deemed not actively suicidal after assessment by their provider. CONCLUSIONS Incorporating adolescent suicide screening and provider follow-up guidance into an existing computer decision support system in primary care is feasible and well utilized by providers. Female gender and depressive symptoms are consistently associated with suicidality among adolescents, although not all suicidal adolescents are depressed. Universal use of a multi-item suicide screener that assesses recency might more effectively identify suicidal adolescents.