Bruno J. Anthony

A review of cultural adaptations of screening tools for autism spectrum disorders

Screening children to determine risk for Autism Spectrum Disorders has become more common, although some question the advisability of such a strategy. The purpose of this systematic review is to identify autism screening tools that have been adapted for use in cultures different from that in which they were developed, evaluate the cultural adaptation process, report on the psychometric properties of the adapted instruments, and describe the implications for further research and clinical practice. A total of 21 articles met criteria for inclusion, reporting on the cultural adaptation of autism screening in 19 countries and in 10 languages. The cultural adaptation process was not always clearly outlined and often did not include the recommended guidelines. Cultural/linguistic modifications to the translated tools tended to increase with the rigor of the adaptation process. Differences between the psychometric properties of the original and adapted versions were common, indicating the need to obtain normative data on populations to increase the utility of the translated tool.

Commentary: Guiding a Public Health Approach to Bullying

Tragic events have served to focus the nation on possible profound and damaging effects of bullying on victims, on bystanders and on the school and community environments. Although a reliance on self-report and issues of definition and survey structure are concerns (Sawyer, Bradshaw & O’Brennan, 2008), recent analyses of national representative samples estimate about 30% of adolescents are involved in bullying with about half as victims (Wang, Ianotti & Nansel, 2009). The report by Wang et al. (2010) uses latent class analyses of a nationally representative sample of youth who completed the Health Behavior in School-aged Children (HBSC) study to identify a group of adolescents (All Types) who appear likely to be victimized by all types of bullying, including cyberbullying. The strong support for the relation between this type of victimization and a variety of psychological and physical sequelae suggest that intervening carefully at an individual level may be a useful strategy; however, such a strategy needs to be applied cautiously to avoid possible negative consequences and represents only one component of a comprehensive approach to this underestimated public health crisis.

Advancing the Selection of Neurodevelopmental Measures in Epidemiological Studies of Environmental Chemical Exposure and Health Effects

With research suggesting increasing incidence of pediatric neurodevelopmental disorders, questions regarding etiology continue to be raised. Neurodevelopmental function tests have been used in epidemiology studies to evaluate relationships between environmental chemical exposures and neurodevelopmental deficits. Limitations of currently used tests and difficulties with their interpretation have been described, but a comprehensive critical examination of tests commonly used in studies of environmental chemicals and pediatric neurodevelopmental disorders has not been conducted. We provide here a listing and critical evaluation of commonly used neurodevelopmental tests in studies exploring effects from chemical exposures and recommend measures that are not often used, but should be considered. We also discuss important considerations in selecting appropriate tests and provide a case study by reviewing the literature on polychlorinated biphenyls.

A Technical Assistance Model for Guiding Service and Systems Change

Technical assistance (TA) has been a ubiquitous part of the implementation of policies, programs, and services across public and private enterprise for decades. There have been few attempts to identify critical components of TA and evaluate its effectiveness. Qualitative analysis of interviews with experienced TA providers suggested a continuum of practice anchored at each end by approaches termed content-driven and relationship-based. Content-driven approaches focus on information transfer and referral whereas relationship-based approaches center on the facilitation of behavior and systems change. TA is almost always a mix of these approaches. Fitting the right approach to each situation is the key to success. The structure of TA is conceptualized as a three-phase set of activities (decision-making, implementation, and evaluation) supported by an effective partnership and informed by the overarching context. The strategies for effective TA are consistent with major theories of behavior change but need to be further evaluated and refined.

Lessons learned: Engaging culturally diverse families in neurodevelopmental disorders intervention research

Low-income and ethnic minority families continue to face critical disparities in access to diagnostic and treatment services for neurodevelopmental conditions, such as autism spectrum disorder and attention deficit hyperactivity disorder. Despite the growing cultural diversity of the United States, ethnic minority children and families continue to be substantially underrepresented across research on neurodevelopmental disorders, and there is a particularly concerning lack of research on the treatment of these conditions in low-income and ethnic minority communities. Of note, there are currently no published studies on adapting autism spectrum disorder treatment for low-income Latino communities and relatively few studies documenting adapted treatments for children with attention deficit hyperactivity disorder in these communities. This article describes methodological considerations and adaptations made to research procedures using a Diffusion of Innovation framework in order to effectively recruit and engage low-income, ethnic minority, particularly Latino, families of children with neurodevelopmental disorders, in a comparative effectiveness trial of two school-based interventions for executive dysfunction.

Collaborative Training Efforts with Pediatric Providers in Addressing Mental Health Problems in Primary Care

In recent years, there has been an increasing recognition that pediatric primary care providers (PPCPs) play a key role in identifying and addressing mental health problems in children and adolescents [1]. This recognition stems from a number of factors, including the high prevalence of mental health problems in youth and the ongoing workforce shortage of child and adolescent psychiatrists and other pediatric mental health professionals [2–5]. Seventy-five percent of children with diagnosed mental health problems are seen in the pediatric primary care setting [6]. Early intervention is vital for these youth: recognition and treatment early in childhood can prevent social and academic failure and interrupt enduring symptomology into adulthood [7]. While these issues highlight the need for PPCPs to identify and address mental health problems, many PPCPs report a lack of confidence, knowledge, and training pertaining to these areas [8]. The Affordable Care Act and the emphasis on PatientCenteredMedical Homes have stressed the need to effectively integrate physical and mental health interventions within the primary care setting. This creates a significant driver to find effective ways to train and support PPCPs to increase knowledge of mental health problems and to build attuned, effective provider-family communication related to these critical topics. Particular attention must be paid to enhancing PPCPs’ efforts to address mental health problems in populations impacted by health disparities; this includes vulnerable populations such as children from low-income families and from racial and ethnic minority populations. The American Academy of Pediatrics has made an emphatic case for increasing pediatric primary care providers’ capacities to address mental health problems, urging training efforts both during graduate medical education as well as for providers in practice [9]. Training efforts within graduate medical education as well as for practicing PPCPs can be designed and led by child and adolescent psychiatrists and psychologists in close collaboration with PPCPs. In addition, training programs in child and adolescent psychiatry and in pediatrics should encourage collaborative, integrated clinical learning experiences that begin during residency training. These proposed training and learning relationships should be bidirectional: mental health clinicians have expertise in mental health problems, while PPCPs can educate mental health professionals about managing children’s health needs in the primary care setting. Effective collaborative training efforts must include multiple components, including content that engages PPCPs and addresses specific knowledge gaps, delivery methods that are accessible and effective for busy adult learners, and scaffolding that supports PPCPs efforts to maintain, enhance, and measure their own developing skills in addressing mental health problems within their practices. Various models of developmental and mental health training for PPCPs exist. For example, brief training for PPCPs in communication skills with patients and parents has been shown to correlate with reductions in minority children’s mental health problems and with reductions in parents’ report of child symptoms when compared with non-trained providers [10]. PPCP training that focuses on a core set of process-ofcare skills referred to as “common factors,” including provider interpersonal skills that build relationships with parents and youth, has been shown to influence behavior change across a range of mental health problems [11]. Other training has focused onmore problem-specific areas, such as identifying risk for autism spectrum disorders (ASD) or identifying and treating mild to moderate attention-deficit/hyperactivity * Matthew G. Biel MGB101@gunet.georgetown.edu

Systemwide Initiative Documents Robust Health Screening for Adults With Intellectual Disability.

It is well documented that adults with intellectual disability (ID) experience higher rates of a series of health conditions compared to their peers without disability. These health conditions include cardiovascular disease, obesity, diabetes, gastrointestinal disorders, and psychiatric and behavioral disorders. With life expectancy approximating the general population, adults with ID are also now experiencing health conditions related to aging, further increasing their risk for diminished function and well-being. This increased morbidity poses new challenges in geriatric healthcare planning for this population. Relatively simple health prevention practices, such as the implementation of a health screening tool, can substantially increase disease detection and clinical activities directed toward improved health outcomes for people with ID. This study examines data collected from the District of Columbia Developmental Disabilities Administrations (DC DDAs) health screening component of its Health and Wellness Standards. Findings are presented, along with recommendations and implications for improving preventive health screening practices in the ID population.

Mental Health Screening Quality Improvement Learning Collaborative in Pediatric Primary Care

This article describes the results of a QI Learning Collaborative designed to improve rates of mental health screening in pediatric practice. BACKGROUND: In the United States, up to 20% of children experience a mental health (MH) disorder in a given year, many of whom remain untreated. Routine screening during annual well visits is 1 strategy providers can use to identify concerns early and facilitate appropriate intervention. However, many barriers exist to the effective implementation of such screening. METHODS: A 15-month quality improvement learning collaborative was designed and implemented to improve screening practices in primary care. Participating practices completed a survey at 3 time points to assess preparedness and ability to promote and support MH issues. Monthly chart reviews were performed to assess the rates of screening at well visits, documentation of screening results, and appropriate coding practices. RESULTS: Ten practices (including 107 providers) were active participants for the duration of the project. Screening rates increased from 1% at baseline to 74% by the end of the project. For the 1 practice for which more comprehensive data were available, these screening rates were sustained over time. Documentation of results and appropriate billing for reimbursement mirrored the improvement seen in screening rates. CONCLUSIONS: The learning collaborative model can improve MH screening practices in pediatric primary care, an important first step toward early identification of children with concerns. More information is needed about the burden placed on practices and providers to implement these changes. Future research will be needed to determine if improved identification leads to improved access to care and outcomes.

Evaluation of Mental Health First Aid USA Using the Mental Health Beliefs and Literacy Scale

Purpose: This study assessed the impact of Mental Health First Aid (MHFA) in the United States with a theoretically based and psychometrically sound measure, the Mental Health Beliefs and Literacy Scale (MBLS). Design: Online MBLS surveys were administered pre-MHFA training, 3-weeks post-training, and 6-months posttraining. Setting: Mental Health First Aid trainings carried out across the United States. Participants: Six hundred sixty-two trainees were contacted, and 273 (41%) completed the presurvey. Of those, 63% filled out the postsurvey and 35% completed the 6-month survey. Seventy-six individuals completed all 3 surveys. Intervention: Mental Health First Aid is an 8-hour education program to help the general public identify, understand, and respond to signs of mental illness and substance abuse; to date, almost 1 million people have been trained. Measure: The MLBS, based on the Unified Theory of Behavior Change framework, consists of attitudinal, social-, and skill-based constructs affecting the intention to perform and achievement of MHFA actions and reports of their actual completion. Analysis: Change across time points was assessed using multivariate repeated measures analysis of variance. Results: Significant short- and longer term changes were found in internally consistent constructs tapping positive beliefs about MHFA actions, the confidence and intention to perform them as well as mental health literacy. Conclusion: The MBLS documented strong positive effects of MHFA training that were greater in individuals without prior mental health training, the intended targets of MHFA efforts.

Authors’ Response to Comment on “Collaborative Training Efforts with Pediatric Providers in Addressing Mental Health Problems in Primary Care”

To the Editor: We are grateful for Dr. Regalado’s careful consideration of our recent research article, “Collaborative Training Efforts with Pediatric Provider in Addressing Mental Health Problems in Primary Care.” Both the concerns that he raises and the path forward that he illuminates resonate with our current thinking—clearly, we are “speaking the same language,” and the collaboration that he proposes could have a galvanizing impact upon our shared work. We entirely concur with the opinion that in many pediatric and family practice training programs, inadequate time is dedicated to learning experiences devoted to mental and developmental health. Recent evidence from the field suggests that pediatric primary care providers spend a considerable amount of clinical time addressing these issues with patients [1, 2]. However, postgraduate training in pediatric and family practice residencies tend to dedicate very limited hours to these topics. We see reasons for cautious optimism related to this concern: many training programs in our region, metropolitan Washington, D.C., have significantly bolstered their training in developmental and mental health in the last several years, and the American Academy of Pediatrics has emphasized this area as well [3]. Training directors in pediatrics and family medicine, as well as teaching faculty from child and adolescent psychiatry and developmental and behavioral pediatrics, must continue to push for deeper and broader training experiences in these areas. In addition, we see a great benefit to interdisciplinary clinical services: in a number of training programs nationwide, inpatient and outpatient clinical rotations in which trainees in pediatrics, child and adolescent psychiatry, social work, and clinical psychologywork side by side have been launched or are in development [4]. These approaches can build the foundations for effective collaborative practice that Dr. Regalado hopes to achieve, and are entirely consonant with the widespread efforts to integrate mental health care into pediatric primary care settings. We agree with his concern that in the training strategies that we describe, the impact of teaching and consultation about mental and developmental health screening and intervention might fade with time in the absence of periodic reinforcement. In addition, we share his interest in assuring that the skills that pediatric primary care providers develop in the realm of mental and developmental health aren’t limited to merely following screening protocols and other simple approaches that require minimal expertise. We have several responses to these valid concerns. First, we see real value in the introduction of consistent, effective mental and developmental screening into pediatric primary care. While “simple” as an intervention strategy, universal mental health screening accomplishes several key goals including reducing stigma around conversations about mental health among both providers and families, as well as alerting providers to key developmental and mental health challenges that typically go unnoticed in the absence of established screening protocols. Second, we emphasize in our article the “relationship-based” nature of our collaborative training efforts. We intend to emphasize that the trainings we have designed and delivered in Washington have been true collaborations between mental health clinicians and pediatric primary care providers rather than unidirectional “let us train you” approaches. By building and maintaining strong relationships between trainer/consultants and primary care providers, we intend to foster collaborative partnerships that will continue * Matthew G. Biel mgb33@georgetown.edu