Sara M. Buckelew

Predictors of Outcome at 1 Year in Adolescents With DSM-5 Restrictive Eating Disorders: Report of the National Eating Disorders Quality Improvement Collaborative

PURPOSE The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year. METHODS Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed. RESULTS At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration. CONCLUSIONS The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.

Increasing clinician self-efficacy for screening and counseling adolescents for risky health behaviors: results of an intervention.

This study evaluates a training and tools intervention to increase provider self-efficacy to screen and counsel adolescents for risky behavior. Two clinics within a health maintenance organization served as intervention sites, and two as comparison sites. Self-efficacy to deliver adolescent services increased significantly in the intervention group relative to the comparison group.

An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses.

PURPOSE This quality improvement project collected and analyzed short-term weight gain data for patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED programs nationally. METHODS Data on presentation and treatment of low-weight ED patients aged 9-21 years presenting in 2006 were retrospectively collected from 11 independent ED programs at intake and at 1-year follow-up. Low-weight was defined as < 90% median body weight (MBW) which is specific to age. Treatment components at each program were analyzed. Risk adjustment was performed for weight gain at 1 year for each site, accounting for clinical variables identified as significant in bivariate analyses. RESULTS The sites contained 6-51 patients per site (total N = 267); the mean age was 14.1-17.1 years; duration of illness before intake was 5.7-18.6 months; % MBW at intake was 77.5-83.0; and % MBW at follow-up was 88.8-93.8. In general, 40%-63% of low weight ED subjects reached ≥90% MBW at 1-year follow-up. At intake, patients with higher % MBW (p = .0002) and shorter duration of illness (p = .01) were more likely to be ≥90% MBW at follow-up. Risk-adjusted odds ratios controlled for % MBW and duration of illness were .8 (.5, 1.4)-1.3 (.3, 3.8), with no significant differences among sites. CONCLUSION A total of 11 ED programs successfully compared quality improvement data. Shorter duration of illness before intake and higher % MBW predicted improved weight outcomes at 1 year. After adjusting for risk factors, program outcomes did not differ significantly. All adolescent medicine-based ED programs were effective in assisting patients to gain weight.

What Fathers Need: A Countywide Assessment of the Needs of Fathers of Young Children

Objective: Realizing the paucity of data available concerning fatherhood, the Fatherhood Collaborative of San Mateo County, a public-private community partnership with leadership from the local Maternal, Child and Adolescent Health (MCAH) program, conducted a countywide needs assessment to ask fathers of young children about their personal and service-related needs in order to assist local stakeholders in expanding and improving services for families. Methods: Both quantitative and qualitative data were collected. A total of 204 fathers of children aged 0 to 5 years completed a 35-question survey. In addition, 80 fathers and community representatives participated in nine focus groups. Results: A complex set of needed services for fathers in the county emerged from the assessment, including: father-child activities; parks and recreational activities; better schools; parenting classes; support groups; high quality, affordable childcare; and general legal assistance. Only one-half felt the county was doing a good or excellent job in supporting fathers. Conclusions: This assessment is one countys effort to collect data about fathers, from fathers, in order to shape MCAH programming to better serve families. This assessment may serve as a model for other MCAH programs interested in improving services for fathers and families.

Addressing Adolescent Substance Use: Teaching Screening, Brief Intervention, and Referral to Treatment (SBIRT) and Motivational Interviewing (MI) to Residents

BACKGROUND The American Academy of Pediatrics Committee on Substance Use recommends screening, brief intervention, and referral to treatment (SBIRT) at every adolescent preventive and all appropriate urgent visits. We designed an SBIRT curriculum as part of the adolescent block of a pediatric residency that combined online modules with an in-person workshop, faculty feedback on resident interactions with patients, and resident self-reflection on their motivational interviewing (MI) skills. METHODS To evaluate the curriculum, we measured resident satisfaction and self-reported confidence in using SBIRT and MI with teens using a retrospective pre/post questionnaire. We used qualitative analysis to evaluate the written comments from faculty observations of patient-trainee interactions and comments from resident self-reflection(s) on patient interactions. RESULTS Thirty-two residents completed the curriculum. Residents reported high satisfaction with the training. Comparing retrospective pre/post scores on the survey of resident self-reported confidence, measures increased significantly in all domains, including for both alcohol and other drug use. Regarding self-reported MI, skillfulness also increased significantly. Analysis of specific faculty feedback to residents revealed subthemes such as normalizing confidentiality and focusing more on the patients perspectives on substance use. Resident reflections on their own abilities with SBIRT/MI focused on using the ruler tool and on adapting the MI style of shared decision-making. CONCLUSIONS A curriculum that combines online training, small-group practice, clinical observations, and self-reflection is valued by residents and can increase resident self-reported confidence in using SBIRT and MI in adolescent encounters. Future studies should examine to what extent confidence predicts performance using standardized measures of MI skillfulness in patient encounters.

Innovations in preventive mental health care services for adolescents.

PURPOSE This descriptive study examined programs designed to provide mental health-related preventive services to at-risk adolescents. METHODS Qualitative interviews were conducted with state and local program directors and key personnel in public health and mental health departments and academic researchers who have initiated preventive services. RESULTS States and local communities offer varied mental health-related preventive services for high-risk adolescents in diverse settings. Services include public education, screening, early intervention for adolescents, and educational programs for primary care providers. Funding mechanisms include state general funds, foundation grants, and Medicaid and the State Childrens Health Insurance Program dollars. Evaluation is essential to maintain services and to persuade funders and other stakeholders to sustain these efforts. CONCLUSIONS State and local prevention-related mental health programs have been implemented with limited funding, but significant local advocacy and community support. More extensive evaluation and cost effectiveness studies may encourage policymakers to expand services. Further data are necessary to determine how prevention-related mental health programs can best serve vulnerable youth.

The Prevalence of Social and Behavioral Topics and Related Educational Opportunities During Attending Rounds

Purpose To quantify the prevalence of social and behavioral sciences (SBS) topics during patient care and to rate team response to these topics once introduced. Method This cross-sectional study used five independent raters to observe 80 inpatient ward teams on internal medicine and pediatric services during attending rounds at two academic hospitals over a five-month period. Patient-level primary outcomes—prevalence of SBS topic discussions and rate of positive responses to discussions—were captured using an observational tool and summarized at the team level using hierarchical models. Teams were scored on patient- and learner-centered behaviors. Results Observations were made of 80 attendings, 83 residents, 75 interns, 78 medical students, and 113 allied health providers. Teams saw a median of 8.0 patients per round (collectively, 622 patients), and 97.1% had at least one SBS topic arise (mean = 5.3 topics per patient). Common topics were pain (62%), nutrition (53%), social support (52%), and resources (39%). After adjusting for team characteristics, the number of discussion topics raised varied significantly among the four services and was associated with greater patient-centeredness. When topics were raised, 38% of teams’ responses were positive. Services varied with respect to learner- and patient-centeredness, with most services above average for learner-centered, and below average for patient-centered behaviors. Conclusions Of 30 SBS topics tracked, some were addressed commonly and others rarely. Multivariable analyses suggest that medium-sized teams can address SBS concerns by increasing time per patient and consistently adopting patient-centered behaviors.

Teaching paediatric transgender care

We aimed to evaluate the effect of online modules – as stand‐alone training – on paediatric transgender‐related self‐perceived knowledge, objective knowledge, and clinical self‐efficacy of learners. We previously evaluated the online modules as part of a larger curriculum that included observation in a paediatric transgender clinic, and assessed change in self‐perceived knowledge.