Jerry L. Rushton

Epidemiology of Depressive Symptoms in the National Longitudinal Study of Adolescent Health

OBJECTIVE To describe the range of depressive symptoms reported by adolescents in a nationally representative U.S. sample and to examine factors associated with persistent depressive symptoms. METHOD Secondary analysis was done on National Longitudinal Study of Adolescent Health (AddHealth) data from 13,568 adolescents who completed the initial survey in 1995 and follow-up 1 year later. Main outcomes of Center for Epidemiologic Studies-Depression Scale (CES-D) scores were analyzed by chi2 comparisons and sample-weighted logistic regression. RESULTS Over 9% of adolescents reported moderate/severe depressive symptoms at baseline (CES-D > or = 24). Females, older adolescents, and ethnic minority youths were more likely to report depressive symptoms at baseline. Only 3% of adolescents with low initial CES-D scores (CES-D < 16) developed moderate/severe depressive symptoms at follow-up. Factors associated with persistent depressive symptoms at 1-year follow-up included: female gender, fair/poor general health, school suspension, weaker family relationships, and health care utilization. Other factors, including race and socioeconomics, did not predict persistent depressive symptoms. CONCLUSIONS Depressive symptoms are common in adolescents and have a course that is difficult to predict. Most adolescents with minimal symptoms of depression maintain their status and appear to be at low risk for depression; however, adolescents with moderate/severe depressive symptoms warrant long-term follow-up and reevaluation.

Implementing practice guidelines for depression: applying a new framework to an old problem.

We discuss the challenges of implementing clinical practice guidelines for depression in the primary care setting. Multiple potential barriers can limit physician guideline adherence and translation of research into improved patient outcomes. Six primary barriers relate to providers (lack of awareness, lack of familiarity, lack of agreement, lack of self efficacy, lack of outcome expectancy, and inertia of previous practice). In addition, factors related to patient, guideline, and practice environment factors encompass external barriers to adherence. By delineating the underlying barriers to adherence, different interventions that are tailored to improve physician adherence to guidelines can be utilized. We review examples of these barriers, as well as interventions to improve guideline adherence. We also review characteristics of successful interventions to improve physician adherence to guidelines for depression. Since different physicians and practice settings may encounter a variety of barriers, multifaceted interventions that are not focused exclusively on the physician tend to be most effective.

Pediatricians' attitudes and practices on ADHD before and after the development of ADHD pediatric practice guidelines.

Purpose: The study aims to assess the changes in attitudes and practices about ADHD reported by AAP fellows between 1999 and 2005 during which AAP ADHD guidelines, training, and quality improvement initiatives occurred. Method: The study assesses AAP-initiated surveys that were conducted between 1999 and 2005 and involving a random sample of 1,000 and 1,603 pediatricians, respectively. Results: The findings reveal that significant, although modest, increases occurred in pediatric practitioners’ self-reported adherence to the guidelines. About 81% of respondents reported routine use of formal diagnostic criteria (up from 67%), and 67% of the respondents routinely use ADHD teacher rating scales (compared to 49% in the 1999 survey). Findings further reveal that treatment with stimulant medications was used extensively by pediatricians from both surveys; more pediatricians in the 2005 survey reported use of a second stimulant if the first did not work, and still more reported almost always providing parent training, although the estimated number remained only about a quarter of the total; and greater familiarity with the initiatives predicted better reported adherence to the guidelines. Conclusion: The reported behaviors of practitioners have moved in the direction of greater adherence with the recommended AAP ADHD guidelines, and there was a positive response to, and a greater use of, the materials developed to enhance practice. The authors infer that practice changes may be due to many factors, including AAP guidelines and associated implementation efforts. Changing physician practices needs to be sustained through a continuing process that requires multiple, varying, sustained efforts directed at physicians, other providers, and families.

Receipt of Asthma Subspecialty Care by Children in a Managed Care Organization

BACKGROUND Although proper outpatient asthma management sometimes requires care from subspecialists, there is little information on factors affecting receipt of subspecialty care in a managed care setting. OBJECTIVE To determine factors associated with receipt of subspecialty care for children with asthma in a managed care organization. METHODS We conducted an analysis of the claims from 3163 children with asthma enrolled in a university-based managed care organization from January 1998 to October 2000. We used logistic regression analysis to determine factors associated with an outpatient asthma visit with an allergist or pulmonologist. RESULTS Of the 3163 patients, 443 (14%) had at least 1 subspecialist visit for asthma; 354 (80%) were seen by an allergist, 63 (14%) were seen by a pulmonologist, and 26 (6%) were seen by both. In multivariate analysis, patients with more severe asthma (odds ratio [OR], 3.81; 95% confidence interval [CI], 2.99-4.86) and older patients (OR, 1.04; 95% CI, 1.02-1.07) were more likely to receive care from a subspecialist. Compared with Medicaid patients, both non-Medicaid patients with copayment (OR, 2.52; 95% CI, 1.85-4.43) and non-Medicaid patients without any copayment (OR, 3.40; 95% CI, 2.35-4.93) were more likely to receive care from an asthma subspecialist. CONCLUSIONS Children insured by Medicaid are less likely to receive care from subspecialists for asthma. Reasons may be due to health care system-related factors, such as accessibility of subspecialists, to physician referral decisions, and/or to patient factors, such as adherence to recommendations to see a subspecialist. Our findings suggest a need to further investigate health care system barriers, physician referral, and patient acceptance and completion of subspecialty referral.

Resident work duty hour requirements: medical educators' perspectives.

From the Association of Pediatric Program Directors (Drs Burke, Rushton, Guralnick, Hicks); Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, Ohio (Dr Burke); Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Ind (Dr Rushton); Winthrop University Hospital, Mineola, NY (Dr Guralnick); and The Children’s Hospital of Philadelphia, Department of Pediatrics, the University of Pennsylvania School of Medicine, Philadelphia, Pa (Dr Hicks) Address correspondence to Ann E. Burke, MD, Dayton Children’s Medical Center, Medical Education Department, One Children’s Plaza, Dayton, Ohio 45419 (e-mail: Ann.burke@wright.edu).

Examining Mental Health Service Needs in Pediatric Primary Care Settings

Abstract While integration of the primary health care system and mental health system is viewed as a way to improve early detection of emotional and behavioral problems in children and increase their access to mental health services, less is known about the extent to which parents bring concerns about their childs mental health to pediatricians. In this study, we assessed the mental health needs and service use of a diverse sample of 228 youth, ages 4-17, in pediatric primary care settings. The central research question examined whether parents who identify child mental health concerns talk about these concerns with pediatricians.

Pediatric Mental Health Services: Complex Problems Demand Comprehensive Solutions

IT IS WELL recognized that mental health is no longer the so-called new morbidity. Issues of the new millennium have only broadened the complexity of issues threatening child health. Despite progress in the last 4 decades since the landmark book by Bob Haggerty, many children with mental health needs are still unrecognized and undertreated, or falling through the cracks in health systems. Mental health issues are difficult to diagnose, treat, and manage in childhood, adolescence, and the transition to adulthood. The tipping point in meeting the challenges of mental health services may be the realization that we cannot disentangle pediatric mental health from overall child health or medical systems. Those of us who care for families struggling to care for children and adolescents with mental health issues are well aware of the complexity of these conditions. Targeted efforts have allowed us to realize some limited success, but until we have more comprehensive system solutions, we risk a plateau in improved outcomes without integrated identification, treatment, and long-term management. The 4 articles in this issue of the Journal demonstrate how mental health is an inextricable part of medical utilization, social services, education, and public health. Mental health in pediatrics encompasses a breadth of diverse issues like substance use, attention-deficit/ hyperactivity disorder (ADHD), mood disorders, and suicidality. These 4 articles also highlight the depth of mental health conditions with effects on all aspects of child health, family functioning, and health service utilization. Population effects are broad as well; these studies examine a wide pool of data for children of all ages, from diverse demographics across the country. Whether children are in foster care or are members of an insured population like Group Health, mental health issues are a major part of health care. How can we use these findings to consider next steps? Clearly the first part is recognition. Each step of mental health services loses patients to attrition by insurance barriers, compliance issues, and other individual or system factors. If we do not even identify children in need, we will never begin to initiate the process to engagement in effective treatment. The article by Jee and colleagues shows that recognition in primary care is possible, even in a complex population of youth in foster care. Primary care pediatrics has often focused more narrowly on early childhood issues like development. Mundt reports on the important effects of alcohol use in adolescents. Issues like substance use