Rahil D. Briggs

Social-Emotional Screening for Infants and Toddlers in Primary Care

BACKGROUND AND OBJECTIVES: Recommendations in pediatrics call for general developmental screening of young children; however, research suggests social-emotional development, in particular, is important as an initial indicator of general well-being versus risk. We aim to describe a program designed to identify the social-emotional status of young children in the pediatric setting by using the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) as a universal screening tool, and to assess the effect of interventions by a colocated psychologist on changes in ASQ:SE scores over time. METHODS: In a prospective cohort design we analyzed scores on ASQ:SE surveys completed on children 6 to 36 months of age, to determine if children were at risk for problems in social-emotional development. The probability of remaining at risk over time was then compared between subjects receiving intervention by the psychologist, and those who declined intervention. Logit specifications were used in multivariate comparisons to control for a set of covariates. RESULTS: Three thousand one hundred and sixty-nine children were screened; 711 (22.4%) scored at or above the risk cutoff. Among the 711 at-risk children, 170 were rescreened. At the time of rescreening, those children who received intervention from the psychologist showed significant improvement on ASQ:SE scores compared with those who declined intervention (P = .01). CONCLUSIONS: Universal social-emotional screening in a busy pediatric practice is challenging. Significant percentages of children can be identified as being at risk for social-emotional problems, and colocation of a psychologist promotes the ability to effectively address young children’s social-emotional development within their medical home.

Maternal Depressive Symptoms and Child Obesity in Low-Income Urban Families

OBJECTIVE To characterize the relationship between maternal depressive symptoms and child weight status, obesity-promoting feeding practices, and activity-related behaviors in low-income urban families. METHODS We conducted a cross-sectional survey of mothers with 5-year-old children receiving pediatric care at a federally qualified community health center. We used regression analyses to examine the relationship between maternal depressive symptoms (trichotomized: none, mild, moderate to severe) and 1) child weight status; 2) obesity-promoting feeding practices, including mealtime practices and feeding styles; and 3) activity-related behaviors, including sleep time, screen time, and outdoor playtime. RESULTS The sample included 401 mother-child pairs (78.3% response rate), with 23.4% of mothers reporting depressive symptoms (15.7% mild, 7.7% moderate to severe). Mothers with moderate to severe depressive symptoms were more likely to have overweight and obese children than mothers without depressive symptoms (adjusted odds ratio 2.62; 95% confidence interval 1.02-6.70). Children of mildly depressed mothers were more likely to consume sweetened drinks and to eat out at restaurants and were less likely to eat breakfast than children of nondepressed mothers. Mothers with depressive symptoms were less likely to set limits, to use food as a reward, to restrict their childs intake, and to model healthy eating than nondepressed mothers. Children with depressed mothers had less sleep and outdoor playtime per day than children of nondepressed mothers. CONCLUSIONS Maternal depressive symptoms are associated with child overweight and obese status and with several obesity-promoting practices. These results support the need for maternal depression screening in pediatric obesity prevention programs. Further research should explore how to incorporate needed mental health support.

Preventive pediatric mental health care : A co-location model

Current practice recommendations in both the fields of infant mental health and pediatrics support the co-location of mental health professionals into the pediatric setting. Multiple policy reports and statements of the past 5 years have repeatedly argued the need for coordination and integration between mental health care and pediatrics (Halfon, Regalado, McLearn, Kuo, & Wright, 2003; Osofsky, 2004). The pediatric office is recognized as a universally accessed, nonstigmatized setting, ideal for the assessment and treatment of early childhood mental health problems. However, barriers to this type of care are rampant, including time limitations on the part of pediatricians, inadequate reimbursement structures, inadequate training of pediatricians, and insufficient connections between medical and mental health providers. An innovative response to these barriers is the co-location of a mental health professional in the pediatric practice to provide pediatrician education and appropriate screening, assessment, referral, and treatment of young patients. This article describes a successful program of this type situated in the Bronx, NY, where a psychologist with expertise in infant mental health spends 25 hours per week in a large pediatric practice to address the developmental and mental health needs of children aged 0-3 years old. Preliminary descriptive data regarding the patient population, screening scores, and disposition are presented.

Comparing Two Models of Integrated Behavioral Health Programs in Pediatric Primary Care

This study examined how to design, staff, and evaluate the feasibility of 2 different models of integrated behavioral health programs in pediatric primary care across primary care sites in the Bronx, NY. Results suggest that the Behavioral Health Integration Program model of pediatric integrated care is feasible and that hiring behavioral health staff with specific training in pediatric, evidence-informed behavioral health treatments may be a critical variable in increasing outcomes such as referral rates, self-reported competency, and satisfaction.

Early child social-emotional problems and child obesity: Exploring the protective role of a primary care-based general parenting intervention

Objective: To determine whether early social-emotional problems are associated with child feeding practices, maternal-child feeding styles, and child obesity at age 5 years, in the context of a primary care–based brief general parenting intervention led by an integrated behavioral health specialist to offer developmental monitoring, on-site intervention, and/or referrals. Methods: A retrospective cohort study was conducted of mothers with 5-year-old children previously screened using the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) during the first 3 years of life. ASQ:SE scores were dichotomized “not at risk” versus “at risk.” “At risk” subjects were further classified as participating or not participating in the intervention. Regression analyses were performed to determine relationships between social-emotional problems and feeding practices, feeding styles, and weight status at age 5 years based on participation, controlling for potential confounders and using “not at risk” as a reference group. Results: Compared with children “not at risk,” children “at risk—no participation” were more likely to be obese at age 5 years (adjusted odds ratio, 3.12; 95% confidence interval, 1.03 to 9.45). Their mothers were less likely to exhibit restriction and limit setting and more likely to pressure to eat than mothers in the “not at risk” group. Children “at risk—participation” did not demonstrate differences in weight status compared with children “not at risk.” Conclusion: Early social-emotional problems, unmitigated by intervention, were related to several feeding styles and to obesity at age 5 years. Further study is needed to understand how a general parenting intervention may be protective against obesity.

Parental perspectives of screening for adverse childhood experiences in pediatric primary care

Introduction: Pediatricians recognize a need to mitigate the negative impact that adverse childhood experiences (ACEs) can have on health and development. However, ACEs screening and interventions in primary care pediatrics may be inhibited by concerns about parental perceptions. We assessed parent perspectives of screening for ACEs in the pediatric primary care setting, to understand their views on the potential impact of their ACEs on their parenting and to identify opportunities for pediatric anticipatory guidance. Method: We used purposive sampling to recruit parents of children <6 years receiving care at an urban, pediatric clinic. Semistructured questions guided 1:1 interviews that were later coded by multiple researchers to verify reliability. A thematic framework approach guided analysis and identified main themes and subthemes. Results: We reached thematic saturation after 15 parent interviews, which consistently revealed 3 interrelated themes. First, parents strongly supported ACEs screening as a bridge to needed services, and they recommended using a trauma-sensitive, person-centered approach in pediatric practices. Second, parents understood the intergenerational impact of ACEs and expressed a desire to break the cycle of adversity. Finally, parents saw their child’s pediatrician as a potential change-agent who could provide support to meet their parenting goals. Discussion: Parents want to discuss their ACEs and receive help and guidance from pediatricians. Furthermore, they perceive their child’s pediatrician as having an important role to play in meeting their parenting goals. It is important to ensure that pediatricians have the training, skills and familiarity with available resources to meet parental expectations.

A Learning Collaborative Approach to Improve Primary Care STI Screening

The Bronx Ongoing Pediatric Screening (BOPS) project sought to improve screening for sexual activity and sexually transmitted infections (gonorrhea and chlamydia [GCC] and HIV) in a primary care network, employing a modified learning collaborative, real-time clinical data feedback to practices, improvement coaching, and a pay-for-quality monetary incentive. Outcomes are compared for 11 BOPS-participating sites and 10 non-participating sites. The quarterly median rate for documenting sexual activity status increased from 55% to 88% (BOPS sites) and from 13% to 74% (non-BOPS sites). GCC screening of sexually active youth increased at BOPS and non-BOPS sites. Screening at non–health care maintenance visits improved more at BOPS than non-BOPS sites. Data from nonparticipating sites suggests that introduction of an adolescent EMR template or other factors improved screening rates regardless of BOPS participation; BOPS activities appear to promote additional improvement of screening during non–health maintenance visits.

The Goodness of Fit between Evidence-Based Early Childhood Mental Health Programs and the Primary Care Setting

With numerous evidence-based early childhood behavioral health programs, it is important to choose wisely when deciding to integrate a particular program into primary care. Most programs were designed for implementation outside of the primary care setting, and may not be a good fit, due to the unique nature of primary care (busy, episodic visits, heterogeneous populations, etc.). In this chapter, we propose five critical elements to be considered when evaluating the goodness of fit between a particular program and the primary care setting, including the evidence base, the required elements (i.e., groups, technology), educational qualifications of practitioners, the target population served, and cost. We review seven common programs, assess them according to these metrics, and present recommendations for guiding program choice.

Healthy Steps at Montefiore: Our Journey from Start Up to Scale

With a decade of experience in integrated early childhood behavioral health programming, we present our lessons learned from Montefiore. We begin with our program model and chart the progression of the model as we expanded. We note why we made certain changes to the model, and how taking the model to scale throughout our system required modifications. We share our top three lessons learned: breaking down silos while respecting the medical hierarchy, navigating thorny issues of privacy related to documentation and communication, and the need to battle isolation as integrated behavioral health providers.

Workforce Development for Integrated Early Childhood Behavioral Health

When looking to implement an early childhood integrated behavioral health program, it is critical to consider issues related to workforce development. In this chapter, we outline the suggested areas of knowledge and particular skill sets necessary for early childhood integrated behavior health specialists to be effective in this role. We also raise questions primary care pediatric practices need to address when determining who best to fill this position, particular to their type and scope of service. Practical examples are used to illustrate important topics, and strategies for incorporating ongoing interdisciplinary training are discussed.