Ardis L. Olson

Primary Care Pediatricians' Roles and Perceived Responsibilities in the Identification and Management of Depression in Children and Adolescents

OBJECTIVEnTo describe primary care pediatricians 1) approach to the identification and management of childhood and adolescent depression and 2) perception of their skills, responsibilities, and barriers in recognizing and managing depression in children and adolescents.nnnDESIGN AND METHODSnNational cross-sectional survey of randomly selected primary care pediatricians that assessed the management of recalled last case of child or adolescent depression, attitudes, limitations to care from barriers and skills, and willingness to implement new educational or intervention strategies to improve care.nnnRESULTSnThere were 280 completed surveys about child and adolescent depression (63% response rate). Pediatricians overwhelmingly reported it was their responsibility to recognize depression in both children and adolescents (90%) but were unlikely to feel responsible for treating children or adolescents (26%-27%). Those with most of their practice in capitated managed care were less likely to feel responsible for recognizing depression in either children or adolescents. Forty-six percent of pediatricians lacked confidence in their skills to recognize depression in children, and few of them (10%-14%) had confidence in their skills in different aspects of treatment with children or adolescents. Diagnostic, assessment, and management details for their last recalled case of depression in a child or adolescent were provided by 248 of these pediatricians. In addition to referring 78%-79% of the cases to mental health care professionals, 77% of pediatricians provided a wide range of brief interventions. Only 19%-20% prescribed medication. Major factors cited that limited their diagnosis or management were time (56%-68%) and training or knowledge of issues (38%-56%). Fewer pediatricians noted limitations due to insurer or financial issues (8%-39%) or patient issues (19%-31%). The 35% of pediatricians who were motivated to change their recognition and management of suspected depression were significantly more interested in implementing in the future a variety of new strategies to improve care.nnnCONCLUSIONnPrimary care pediatricians felt responsible for recognizing but not for treating child and adolescent depression. Although the lack of confidence and lack of knowledge and/or skills and time issues are major barriers that limit pediatricians in their treatment of childhood and adolescent depression, pediatricians varied in their readiness to change, with some being more willing to implement new strategies to care for depression. Educational and practice interventions need to focus on how to assist all pediatricians in diagnosis and to prepare these motivated pediatricians to manage depression in primary care settings.

Brief maternal depression screening at well-child visits

OBJECTIVES. The goals were (1) to determine the feasibility and yield of maternal depression screening during all well-child visits, (2) to understand how pediatricians and mothers respond to depression screening information, and (3) to assess the time required for discussion of screening results. METHODS. Implementation of brief depression screening of mothers at well-child visits for children of all ages was studied in 3 rural pediatric practices. Two screening trials introduced screening (1 month) and then determined whether screening could be sustained (6 months). Screening used the 2-question Patient Health Questionnaire. Practices tracked the proportions of visits screened and provided data about the screening process. RESULTS. Practices were able to screen in the majority of well-child visits (74% in trial 1 and 67% in trial 2). Of 1398 mothers screened, 17% had 1 of the depressive symptoms and 6% (n = 88) scored as being at risk for a major depressive disorder. During discussion, 5.7% of all mothers thought they might be depressed and 4.7% thought they were stressed but not depressed. Pediatric clinicians intervened with 62.4% of mothers who screened positive and 38.2% of mothers with lesser symptoms. Pediatrician actions included discussion of the impact on the child, a follow-up visit or call, and referral to an adult primary care provider, a mental health clinician, or community supports. Pediatrician time needed to discuss screening results decreased in the second trial. Prolonged discussion time was uncommon (5–10 minutes in 3% of all well-child visits and >10 minutes in 2%). CONCLUSIONS. Routine, brief, maternal depression screening conducted during well-child visits was feasible and detected mothers who were willing to discuss depression and stress issues with their pediatrician. The discussion after screening revealed additional mothers who felt depressed among those with lesser symptoms. The additional discussion time was usually brief and resulted in specific pediatrician actions.

Bridging Primary Care Practices and Communities to Promote Healthy Behaviors

BACKGROUNDnPrimary care practices able to create linkages with community resources may be more successful at helping patients to make and sustain health behavior changes.nnnMETHODSnHealth behavior-change interventions in eight practice-based research networks were examined. Data were collected July 2005-October 2007. A comparative analysis of the data was conducted to identify and understand strategies used for linking primary care practices with community resources.nnnRESULTSnIntervention practices developed three strategies to initiate and/or implement linkages with community resources: pre-identified resource options, referral guides, and people external to the practice who offered support and connection to resources. To initiate linkages, practices required the capacity to identify patients, make referrals, and know area resources. Linkage implementation could still be defeated if resources were not available, accessible, affordable, and perceived as valuable. Linkages were facilitated by boundary-spanning strategies that compensated for the lack of infrastructure between practices and resources, and by brokering strategies that identified interested community partners and aided mutually beneficial connections with them. Linkages were stronger when they incorporated practice or resource abilities to motivate the patient, such as brief counseling or postreferral outreach. Further, data suggested that sustaining linkages requires continuous attention and ongoing communication between practices and resources.nnnCONCLUSIONSnCreating linkages between primary care practices and community resources has the potential to benefit both patients and clinicians and to lessen the burden on the U.S. healthcare system resulting from poor health behaviors. Infrastructure support and communication systems must be developed to foster sustainable linkages between practices and local resources.

Multi-institutional development and utilization of a computer-assisted learning program for the pediatrics clerkship: The CLIPP project

Computer-assisted instruction (CAI) holds significant promise for meeting the current challenges of medical education by providing consistent and quality teaching materials regardless of training site. The Computer-assisted Learning in Pediatrics Project (CLIPP) was created over three years (2000–2003) to meet this potential through multi-institutional development of interactive Internet-based patient simulations that comprehensively teach the North American core pediatrics clerkship curriculum. Project development adhered to four objectives: (1) comprehensive coverage of the core curriculum; (2) uniform approach to CAI pedagogy; (3) multi-institutional development by educators; and (4) extensive evaluation by users. Pediatrics clerkship directors from 30 institutions worked in teams to develop a series of 31 patient case simulations. An iterative process of case content and pedagogy development, case authoring, peer review, and pilot-testing ensured that the needs of clerkship directors and medical students were met. Fifty medical schools in the United States and Canada are presently using CLIPP. More than 8,000 students have completed over 98,000 case sessions, with an average of 2,000 case sessions completed per week at this time. Each CLIPP case has been completed by more than 3,000 students. The current cost of CLIPP development is approximately

Two approaches to maternal depression screening during well child visits.

70 per student user, or

SunSafe in the Middle School Years: A Community-wide Intervention to Change Early-Adolescent Sun Protection

6 per case session. The project’s success demonstrates that multi-institutional development and implementation of a peer-reviewed comprehensive CAI learning program by medical educators is feasible and provides a useful model for other organizations to develop similar programs. Although CAI development is both time-consuming and costly, the initial investment decreases significantly with broad use over time.

Use of Inexpensive Technology to Enhance Adolescent Health Screening and Counseling

ABSTRACT. The US Preventive Services Task Force (USPSTF) has recommended depression screening for adults. Screening mothers has special importance to pediatricians because of the impact of maternal depression on children. The two screening questions endorsed by the USPSTF may allow pediatricians to screen mothers during routine well child care. This study explores the feasibility and yield of interview- and paper-based pediatric screening for maternal depression during well child visits. A structured interview script was developed to inquire about maternal depression. It included the two-question screen and required less than 1 minute to administer. An alternative paper-based screen asked the two questions after a brief written introduction providing the rationale. Four community pediatric practices in New Hampshire and Maine were trained in both screening approaches and developed plans on how to respond to positive screens (either question positive). The 11 providers at these sites tested the two approaches on two different series of mothers at well child visits. The pediatricians also reported barriers to the screening inquiries, maternal responses, and subsequent clinician actions and referrals. The pediatricians screened 250 mothers via the scripted interview. In a second trial, 223 women had paper-based depression screening. Yields from the paper-based screen were 22.9% versus 5.7% for the interview-based screener. Pediatricians also took on the new role of discussion of possible depression in about two thirds of cases. Subsequently, 7.6% of all women with paper-based screening were referred to mental health versus 1.6% with the interview-based screening. With the interview, mothers of children younger than 1 year of age were less likely to screen positive than those with older children (1.9% vs. 8.5%, p = .04). With the paper-based screener, no age differences in positive screen rates occurred. While both approaches to screening were feasible in primary care, the yield from the two different approaches differed substantially. This finding deserves exploration in future studies. With either of these screening approaches, pediatricians could enhance their detection of mothers at risk of depression. The outcomes of pediatrician screening and the best approach to follow-up care still need to be determined.

Overall Function in Rural Childhood Cancer Survivors The Role of Social Competence and Emotional Health

OBJECTIVE. Rising rates of skin cancer associated with early-life sun exposure make it important to improve adolescent sun-protection practices. Our study objective was to determine if a multicomponent community-wide intervention could alter the decline in sun protection that begins in early adolescence. METHODS. A randomized, controlled trial was conducted in 10 communities to assess the impact of the SunSafe in the Middle School Years program. The intervention sought to (1) educate and activate adults and peers to role model and actively promote sun-protection practices and (2) create a pro–sun protection community environment. It targeted school personnel, athletic coaches, lifeguards, and clinicians and enlisted teens as peer advocates. Annual observations of cross-sectional samples of teens at community beach/pool sites were used to assess the impact of 1 and 2 years of intervention exposure compared to grade-matched controls. The outcome was percent of body surface protected by sunscreen, clothing, or shade. RESULTS. Observers determined the sun protection level of 1927 adolescents entering 6th to 8th grades. After 2 years of intervention exposure, adolescents at the beach/pool in intervention communities were significantly better protected than those in control communities. Over 2 years, the percent of body surface area protected declined by 23% in the control arm but only 8% in intervention arm. After intervention, the average percent of body surface protected at intervention sites (66.1%) was significantly greater than control sites (56.8%). Teens in intervention communities reported sun-protection advice from more adult sources, were more likely to use sunscreen, and applied it more thoroughly than control-site teens. CONCLUSIONS. Our multicomponent model addressing adolescent sun protection shows the power of engaging teens and adults from across the community as role models and educators. This new ecological approach shows promise in changing adolescent sun protection behaviors and reducing skin cancer risks.

Changing Adolescent Health Behaviors The Healthy Teens Counseling Approach

OBJECTIVESnTo describe the health issues reported using a personal digital assistant (PDA) to conduct screening at adolescent well visits, and to determine the effect of a PDA screening tool on the content and quality of the clinical interaction.nnnDESIGNnThe PDA screening tool was used to record adolescent health risk behaviors, and cross-sectional exit surveys were administered before and after PDA introduction.nnnSETTINGnFive primary care practices in New England.nnnPARTICIPANTSnThe PDA screening was completed by 1052 youth aged 11 to 19 years. In addition, youth seen before (n = 65) and after (n = 98) PDA screening implementation completed exit surveys. Intervention Adolescents completed the PDA screening immediately before the well visit. Branching questions explored risk behaviors in more depth, including motivation to change. Physicians viewed the summarized findings before the adolescent health visit.nnnMAIN OUTCOME MEASURESnHealth risk behaviors based on PDA data. Exit surveys assessed the quality of the visit and of any discussion of nutrition, exercise, screen time, tobacco use, alcohol and other drug use, and mood.nnnRESULTSnMultiple risk behaviors (n = 3-9) were reported by 30% of 11- to 14-year-olds and 45% of 15- to 19-year-olds. Exit surveys showed that, with PDA use, the proportion of visits that included discussions of health risk behaviors increased for fruit/vegetable intake (60.4% vs 41.7% without PDA use; P =.03), tobacco use (54.9% vs 40.0%; P = .07), and alcohol use (53.9% vs 38.0%; P =.05). With PDA use, more adolescents rated the visit as confidential (83.7% vs 61.5%; P =.002), more thought they were listened to carefully (87.8% vs 64.6%; P <.001), and more were very satisfied (87.8% vs 63.1%; P < .001).nnnCONCLUSIONnUse of a PDA-based screening tool enhances physician counseling and improves adolescents perceptions of the well visit.

Measuring Nonsolar Tanning Behavior : Indoor and Sunless Tanning

This study compared the functioning of 20 rural cancer survivors, aged 6 to 16 years, with that of 40 age- and gender-matched school peers. Social competence and emotional health were evaluated, along with academic performance and physical limitations. Eight measures were used: the teacher and parent Child Behavior Check Lists, the Health Resources Inventory, the Vineland Revised Scale of Social Maturity, the Piers-Harris Childs Self-Concept Scale, the Parcel and Meyers Health Locus of Control, the Moos Family Environment Scale, and the Functional Status II (r) . Cancer survivors and controls had similar attitudes about self-esteem, family conflicts, physical functioning, social skills, independence, and sense of control over health. Both parents and teachers noted poorer social competence among the cancer survivors than among controls, but parents of survivors reported more behavior problems, whereas teachers stressed poorer school performance. Routine screening for emotional health, social competence, and academic performance should be part of the follow-up care of pediatric cancer survivors.