Lee S. Beers

Addressing the Mental Health Needs of Pregnant and Parenting Adolescents

Adolescent parenthood is associated with a range of adverse outcomes for young mothers, including mental health problems such as depression, substance abuse, and posttraumatic stress disorder. Teen mothers are also more likely to be impoverished and reside in communities and families that are socially and economically disadvantaged. These circumstances can adversely affect maternal mental health, parenting, and behavior outcomes for their children. In this report, we provide an overview of the mental health challenges associated with teen parenthood, barriers that often prevent teen mothers from seeking mental health services, and interventions for this vulnerable population that can be integrated into primary care services. Pediatricians in the primary care setting are in a unique position to address the mental health needs of adolescent parents because teens often turn to them first for assistance with emotional and behavioral concerns. Consequently, pediatricians can play a pivotal role in facilitating and encouraging teen parents’ engagement in mental health treatment.

Patterns and Predictors of Involvement Among Fathers of Children Born to Adolescent Mothers

Father involvement may be an important support for children born to adolescent mothers. This study examines patterns and predictors of father involvement, as reported by adolescent mothers, from their childs infancy through toddlerhood. Data were collected from urban, primarily African American, adolescent mothers (N = 138) in four interviews, over a 24-month period. The percentage of fathers categorized as “highly involved” decreased significantly from baseline to 12-month follow-up and was stable through 24 months. The romantic status of the mother–father relationship was the strongest predictor of whether father involvement was consistently high, consistently low, or decreased over time.

Strengthening Positive Coparenting in Teen Parents: A Cultural Adaptation of an Evidence-Based Intervention

Teen childbearing is associated with a range of adverse outcomes for both mothers and children, and perpetuates an intergenerational cycle of socioeconomic disadvantage. Fathers may be an underappreciated source of support to teen mothers and their children. The strongest and most consistent predictor of positive father involvement is a positive coparenting relationship between the mother and father. Thus, strengthening the coparenting relationship of teen parents may be protective for both parents and children. This paper describes the rationale, the intervention model, and the cultural adaptation of Strong Foundations, an intervention designed to facilitate and enhance positive coparenting in teen parents. Adapted from an evidence-based coparenting program for adult, cohabiting parents, this intervention was modified to be developmentally and culturally appropriate, acceptable, and feasible for use with urban, low-income, minority expectant teen mothers and their male partners. The authors present lessons learned from the cultural adaptation of this innovative intervention. Pilot testing has shown that this model is both acceptable and feasible in this traditionally hard to reach population. Although recruitment and engagement in this population present specific challenges, young, urban minority parents are deeply interested in being effective coparents, and were open to learning skills to support this goal.

Coparenting in Teen Mothers and Their Children's Fathers: Evidence From the Early Childhood Longitudinal Study–Birth Cohort

OBJECTIVE (1) To describe coparenting among adolescent mothers and the biological fathers of their children. (2) To examine the effects of coparenting on young childrens social-emotional development and whether these effects vary by fathers residence status, parental education, and child characteristics. METHODS Secondary analysis was conducted with the Early Childhood Longitudinal Study-Birth Cohort, which is a nationally representative sample of U.S. children born in 2001. The subsample used in this study includes 400 children whose biological mothers, aged 15-19, participated when their children were 2 years and 4 years old and whose biological fathers (residential and nonresidential) participated at 4 years. Cooperative coparenting and coparenting conflict were measured at child age 2 years. Childrens social skills and problem behavior were measured at child age 4 years. RESULTS Mother- and father-reported coparenting conflict were associated with child behavior problems, more strongly among boys (b = 1.31, P < .01) than girls (b = -0.13, P > .05). Mother-reported coparenting conflict also predicted lower child social skills (b = -1.28, P < .05); the association of father-reported coparenting conflict with social skills was moderated by child race and father education. CONCLUSIONS Coparenting conflict between adolescent parents influences child adjustment. Practitioners working with teen mothers should encourage father participation at medical visits and other clinical contacts and should address the relationship between the parents, whether or not they are living together, as part of routine care.

Feasibility of an Audio Computer-Assisted Self-Interview Method to Self-Assess Sexual Maturation

PURPOSE Sexual maturation assessment using physical examination may no longer be feasible in some large epidemiologic surveys, such as National Health and Nutrition Examination Survey, because of the sensitivity of the examination and privacy concerns. This study tested the feasibility of a new automated audio computer-assisted self-interview (ACASI) module for children and adolescents for self-assessment of sexual maturation. METHODS A cross-sectional feasibility study was conducted at a large urban children/adolescent clinic in Washington D.C. Self-assessed sexual maturation (Tanner stages) was reported by 234 youths (119 boys and 115 girls) aged 8-18 years by using the ACASI module. Girls assessed their breast and pubic hair development, and boys assessed their genital and pubic hair development. Self-assessments were compared with Tanner stages recorded by clinical examiners during routine well-child physical examinations conducted on the same day. RESULTS There was good/excellent agreement between boys self-assessment and the examiners assessment of their genital stage (weighted κ: .65, 95% confidence interval [CI]: .55-.75) and pubic hair stage (weighted κ: .78, CI: .70-.86). There was excellent agreement between girls self-assessment and the examiners assessment of their breast stage (weighted κ: .81, CI: .74-.87) and pubic hair stage (weighted κ: .78, CI: .71-.86). CONCLUSION The ACASI method is a feasible method of pubertal self-assessment for participants as young as 8 years in large epidemiologic surveys. However, additional testing is needed to determine the validity of this ACASI module.

Parental Nurturance and the Mental Health and Parenting of Urban African American Adolescent Mothers

This study examined the relationship between a teen mothers perceptions of nurturance from her mother and father and her mental health and parenting attitudes. One-hundred and thirty-eight urban, primarily African American adolescent mothers were interviewed. Multivariate results indicate that teen mothers who felt nurtured by their mothers had greater empathy toward their own children, and those who felt nurtured by their fathers reported greater parenting satisfaction. These findings support the importance of interventions that include supporting nurturing parenting of adolescent mothers by their mothers and their fathers.

Improving Mental Health Access for Low-Income Children and Families in the Primary Care Setting

Poverty is a common experience for many children and families in the United States. Children <18 years old are disproportionately affected by poverty, making up 33% of all people in poverty. Living in a poor or low-income household has been linked to poor health and increased risk for mental health problems in both children and adults that can persist across the life span. Despite their high need for mental health services, children and families living in poverty are least likely to be connected with high-quality mental health care. Pediatric primary care providers are in a unique position to take a leading role in addressing disparities in access to mental health care, because many low-income families come to them first to address mental health concerns. In this report, we discuss the impact of poverty on mental health, barriers to care, and integrated behavioral health care models that show promise in improving access and outcomes for children and families residing in the contexts of poverty. We also offer practice recommendations, relevant to providers in the primary care setting, that can help improve access to mental health care in this population.

Behavioral Health Integration in Health Care Settings: Lessons Learned from a Pediatric Hospital Primary Care System

Behavioral health integration within primary care has been evolving, but literature traditionally focuses on smaller scale efforts. We detail how behavioral health has been integrated across a large, urban pediatric hospital system’s six primary care clinics (serving over 35,000 children annually and insured predominately through Medicaid) and discuss strategies for success in sustaining and expanding efforts to achieve effective integration of behavioral health into primary care. In a time span of 3 years, the clinics have implemented routine, universal behavioral health screening at well child visits, participated in a 15-month behavioral health screening quality improvement learning collaborative, and integrated the work of psychologists and psychiatrists. Additional work remains to be done in improving family engagement, further expanding services, and ensuring sustainability.

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

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.