Faculty Bibliography

OBJECTIVE: Maternal depression affects 10% to 40% of mothers with young children and has negative consequences for children's health and development. The American Academy of Pediatrics (AAP) recommends that pediatricians identify women with maternal depression. The authors examined trends in inquiring about (asking informal questions) or screening for (using a standardized instrument) maternal depression by pediatricians in 2004 and 2013 and identified correlates of usually inquiring/screening to identify maternal depression. METHODS: Data were ascertained from 778 nontrainee pediatricians exclusively practicing general pediatrics who completed the 2004 (n = 457) and 2013 (n = 321) AAP Periodic Surveys. Pediatricians answered questions about physician and practice characteristics, training, attitudes, and inquiring/screening to identify maternal depression. Sample weights were used to reduce nonresponse bias. Weighted descriptive and logistic regression analyses were conducted. RESULTS: The prevalence of usually inquiring/screening to identify maternal depression increased from 33% to 44% (p < .01). In both years, pediatricians who usually inquired about child/adolescent depression had increased odds of usually inquiring/screening to identify maternal depression. Patient race/ethnicity and training in adult Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria for depression were associated with inquiring/screening in 2004, and believing that family screening is within the scope of the pediatrician was associated with inquiring/screening in 2013. CONCLUSION: Although inquiring/screening about maternal depression has increased since 2004, less than half of pediatricians usually screen or inquire about maternal depression, representing a missed opportunity to identify depression and manage or refer women for treatment. Further training on the importance of mental and family health to children's health may increase identification of maternal depression in pediatric primary care.

OBJECTIVE: Pediatricians report many barriers to caring for children with mental health (MH) problems. The American Academy of Pediatrics (AAP) has focused attention on MH problems, but the impact on perceived barriers is unknown. We examined whether perceived barriers and their correlates changed from 2004 to 2013. METHODS: In 2004, 832 (52%) of 1600 and in 2013, 594 (36.7%) of 1617 of randomly selected AAP members surveyed responded to periodic surveys, answering questions about sociodemographics, practice characteristics, and 7 barriers to identifying, treating/managing, and referring child/adolescent MH problems. To reduce nonresponse bias, weighted descriptive and logistic regression analyses were conducted. RESULTS: Lack of training in treatment of child MH problems ( approximately 66%) and lack of confidence treating children with counseling ( approximately 60%) did not differ across surveys. Five barriers (lack of training in identifying MH problems, lack of confidence diagnosing, lack of confidence treating with medications, inadequate reimbursement, and lack of time) were less frequently endorsed in 2013 (all P < .01), although lack of time was still endorsed by 70% in 2013. In 2004, 34% of pediatricians endorsed 6 or 7 barriers compared to 26% in 2013 (P < .005). Practicing general pediatrics exclusively was associated with endorsing 6 or 7 barriers in both years (P < .001). CONCLUSIONS: Although fewer barriers were endorsed in 2013, most pediatricians believe that they have inadequate training in treating child MH problems, a lack of confidence to counsel children, and limited time for these problems. These findings suggest significant barriers still exist, highlighting the need for improved developmental and behavioral pediatrics training.

OBJECTIVE: To determine the relationships between adverse childhood experiences (ACEs) and mental health, chronic medical conditions, and social development among young children in the child welfare system. METHODS: This cross-sectional study used a nationally representative sample of children investigated by child welfare (National Survey of Child and Adolescent Well-Being II) from 2008 to 2009. Our analysis included caregiver interviews and caseworker reports about children aged 18 to 71 months who were not in out-of-home care (n = 912). We examined the associations between ACEs and mental health (measured by the Child Behavior Checklist [CBCL]), reported chronic medical conditions, and social development (measured by the Vineland Socialization Scale) in bivariate and multivariate analyses. RESULTS: Nearly all children (98.1%) were reported to have had an ACE in their lifetime; the average number of ACEs was 3.6. For every additional reported ACE, there was a 32% increased odds of having a problem score on the CBCL (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.14, 1.53) and a 21% increased odds of having a chronic medical condition (OR 1.21, 95% CI 1.05, 1.40). Among children aged 36 to 71 months, for every additional reported ACE, there was a 77% increased odds of a low Vineland Socialization score (OR 1.77, 95% CI 1.12, 2.78). CONCLUSIONS: ACEs were associated with poor early childhood mental health and chronic medical conditions, and, among children aged 3 to 5, social development. Efforts are needed to examine whether providing early intervention to families with multiple stressors mitigates the impact of ACEs on children's outcomes.

OBJECTIVE: Some mothers of preterm infants continue to view them as vulnerable after their health has improved. These exaggerated perceptions of vulnerability lead to poor parent-child interactions and, subsequently, to adverse child outcomes. However, there is no theoretical model to explain why these exaggerated perceptions develop in only some mother-child dyads. METHOD: Data for this study come from a randomized trial of an intervention to reduce distress in mothers of preterm infants. A total of 105 mothers older than 18 years of infants aged 25-34 weeks, weighing >600 g and with clinically significant anxiety, depression, or trauma symptoms, were recruited and randomized. Women were assessed at baseline, after intervention, and at 6 months after birth. The outcome for these analyses was perceptions of infant vulnerability as measured by the Vulnerable Baby Scale (VBS) at 6 months after birth. A theoretical model developed from the extant literature was tested using the MacArthur Mediator-Moderator Approach. RESULTS: A dysfunctional coping style, high depression, anxiety, or trauma symptoms in response to the preterm birth, and low social support were related to 6-month VBS scores. Maternal response to trauma was directly related to VBS, and an important precursor of maternal response to trauma was a dysfunctional coping style. CONCLUSIONS: This model suggests that maternal responses to trauma are critical in the formation of exaggerated perceptions of vulnerability as are dysfunctional coping styles and low social support. Women with these characteristics should be targeted for intervention to prevent poor parenting practices that result from exaggerated perceptions of vulnerability.

Objective: Characteristics associated with participation in training in evidence-informed business and clinical practices by 346 outpatient mental health clinics licensed to treat youths in New York State were examined. Methods: Clinic characteristics extracted from state administrative data were used as proxies for variables that have been linked with adoption of innovation (extraorganizational factors, agency factors, clinic provider-level profiles, and clinic client-level profiles). Multiple logistic regression models were used to assess the independent effects of theoretical variables on the clinics' participation in state-supported business and clinical trainings between September 2011 and August 2013 and on the intensity of participation (low or high). Interaction effects between clinic characteristics and outcomes were explored. Results: Clinic characteristics were predictive of any participation in trainings but were less useful in predicting intensity of participation. Clinics affiliated with larger (adjusted odds ratio [AOR]=.65, p<.01), more efficient agencies (AOR=.62, p<.05) and clinics that outsourced more clinical services (AOR=.60, p<.001) had lower odds of participating in any business-practice trainings. Participation in business trainings was associated with interaction effects between agency affiliation (hospital or community) and clinical staff capacity. Clinics with more full-time-equivalent clinical staff (AOR=1.52, p<.01) and a higher proportion of clients under age 18 (AOR=1.90, p<.001) had higher odds of participating in any clinical trainings. Participating clinics with larger proportions of youth clients had greater odds of being high adopters of clinical trainings (odds ratio=1.54, p<.01). Conclusions: Clinic characteristics associated with uptake of business and clinical training could be used to target state technical assistance efforts.

PURPOSE: The aim of this study was to examine prevalence and correlates of health-risk behaviors in 12- to 17.5-year-olds investigated by child welfare and compare risk-taking over time and with a national school-based sample. METHODS: Data from the National Survey of Child and Adolescent Well-Being (NSCAW II) were analyzed to examine substance use, sexual activity, conduct behaviors, and suicidality. In a weighted sample of 815 adolescents aged 12-17.5 years, prevalence and correlates for each health-risk behavior were calculated using bivariate analyses. Comparisons to data from NSCAW I and the Youth Risk Behavior Survey were made for each health-risk behavior. RESULTS: Overall, 65.6% of teens reported at least one health-risk behavior with significantly more teens in the 15- to 17.5-year age group reporting such behaviors (81.2% vs. 54.4%; p /=64 reported at least one health-risk behavior. The prevalence of smoking was lower than in NSCAW I (10.5% vs. 23.2%; p