Faculty Bibliography

The dramatic rise in pediatric mental health visits to emergency departments that started in the 1990s continues, reflecting an ongoing youth mental health crisis. There is an urgent need for a comprehensive care continuum with accessible outpatient services capable of identifying and supporting the mental health needs of children regardless of acuity, payor, and geographic setting. A fully realized child mental health continuum of care meets children where they are; adequately funds services from the outpatient clinic to the inpatient unit; delivers evidence-based treatments targeted to reduce mental health symptoms; and supports the development of a skilled behavioral health workforce.

Exposure to trauma is common and frequently overlooked in behaviorally dysregulated youth. Common trauma-related symptoms, such as exaggerated startle responses, dissociative episodes, and irritability, may resemble behavioral dysregulation. These responses may not be recognized as being related to trauma. As a result, traumatized young people are often misdiagnosed and treated with antipsychotics. Trauma-informed care in health care settings, which includes systematic screening, staff training, trauma skills groups, and ongoing monitoring, is one way of addressing the effects of trauma and ensuring that young people receive access to the evidence-based care they deserve.

The purpose of this study was to examine the impact of childhood trauma exposure, posttraumatic stress disorder, and trauma-related comorbid diagnoses on the risk for readmission to juvenile detention among youth in a large metropolitan area (N = 1282). The following research questions were addressed: 1) Does a greater number of childhood traumas increase the risk for readmission to detention following release? 2) Does the risk for readmission differ by type of trauma? 3) Do PTSD and other co-morbid diagnoses increase the risk for readmission? and 4) What role do demographic factors play in the relationship between trauma-related variables and risk for readmission? This study utilized the screening results of 1282 youth who were voluntarily screened for PTSD, depressive symptoms and substance use during their initial intake to detention. More than half of the sample was readmitted during the three-year study period, with readmissions most likely to occur within one year of release. Returning to detention within one year was also associated with increased risk for multiple readmissions. Youth readmitted to detention were more likely to have a history of sexual abuse and problematic substance use. No other significant relationships were found between risk for readmission and trauma-related variables. Although trauma-related symptoms may be crucial targets for treatment, focusing solely on trauma exposure and traumatic stress symptoms without considering the impact of other risk factors may not be enough to decrease the likelihood of readmission for youth of color in a large urban environment.

Numerous recommendations have been made to address the high rates of mental health disorders among justice-involved youth. Few data are available on the use, quality, appropriateness, or availability of services to address these needs. This study examined the relationship between trauma-informed mental health screening, other referral pathways for diagnostic evaluation, subsequent DSM-5 diagnoses, and treatments for evaluated youth. Eligible participants were all youth admitted to New York City secure juvenile detention facilities from September 17, 2015 to October 30, 2016 who remained in the facility for at least five days (N = 786). Of those, 581 (73.9%) were voluntarily screened and 309 (53.2%) later received a diagnostic evaluation. Youth who screened positive for depression, posttraumatic stress disorder, and problematic substance use were more likely to be evaluated. Treatment received was related to diagnosis rather than reason for referral. For youth who were referred for behavioral or emotional concerns, 99.1 percent (114 of 115) of those diagnosed with a neurodevelopmental disorder had attention-deficit/hyperactivity disorder (ADHD). These data are among the first to describe DSM-5 diagnoses and treatment among youth detainees. They highlight the prevalence of ADHD in detained youth and argue for the coordination of universal trauma-informed mental health screening and a structured referral system for this population.

It is well recognized that early experiences produce long-term impacts on health outcomes, yet many children are at risk of not achieving their full potential because of health and service disparities related largely to poverty and racism. Although many pediatric primary care (PPC) models address these needs, most are isolated, add-on efforts that struggle to be scalable and sustainable. We describe 3-2-1 IMPACT (Integrated Model for Parents and Children Together), an initiative to transform the model of PPC delivered within New York City Health + Hospitals, the largest public hospital system in the United States, to address the full range of child and family needs in early childhood. Taking advantage of the frequent contact with PPC in the early years and linking to prenatal services, the model assesses family mental, social, and physical health needs and offers evidence-based parenting supports and integrated mental health services. Launching and sustaining the model in our large health system has required coalition building and sustained advocacy at the state, city, and health system levels. Long-term sustainability of the IMPACT model will depend on the implementation of early childhood-focused advanced payment models, on which we have made substantial progress with our major contracted Medicaid managed care plans. By integrating multiple interventions into PPC and prenatal care across a large public-healthcare system, we hope to synergize evidence-based and evidence-informed interventions that individually have relatively small effect sizes, but combined, could substantially improve child and maternal health outcomes and positively impact health disparities.

Caring for individuals with autism spectrum disorder (ASD) can be complicated, especially when challenging behaviors are present. Providers may feel unprepared to work with these individuals because specialized training for medical and social service providers is limited. To increase access to specialized training, we modified an effective half-day ASD-Care Pathway training (Kuriakose et al. 2018) and disseminated it within five different settings. This short, focused training on strategies for preventing and reducing challenging behaviors of patients with ASD resulted in significant improvements in staff perceptions of challenging behaviors, increased comfort in working with the ASD population, and increased staff knowledge for evidence-informed practices. Implications, including the impact of sociodemographic characteristics on pre/post changes, and future directions are discussed.

Despite an increased focus on trauma-informed care within the juvenile justice system, we still know very little about the impact of trauma on juvenile justice professionals or their perceptions of trauma-informed interventions. To fill this gap, this study used an organizational assessment to examine perceptions of trauma-informed care among juvenile professionals in a juvenile detention setting. Participants included 204 staff members in two secure juvenile detention facilities. Staff who reported greater availability of trauma-informed practices were more likely to perceive that youth and families felt safe and those who reported that the facility was taking steps to address secondary trauma were more likely to report a sense of staff safety. Regarding individual factors, only age and gender were related to perceptions of youth and family safety. Frontline staff were more likely than supervisory staff to feel they had received adequate training in trauma and had the skills necessary to deescalate youth. These findings suggest that staff are open to trauma-informed practices in juvenile detention, but a greater focus on supervisory staff is needed. Shifting from individual-level strategies to facility-level improvements could have a greater impact on enhancing staff members"™ perceptions of safety, which improves their ability to care for youth.

As of 2018, more than 37,000 American youth were residing in juvenile detention or residential placement facilities.¹ Prevalence studies have demonstrated high rates of psychiatric illness in this population, with estimates ranging from 50% to 75%.²

BACKGROUND:Perinatal depression (PND) is a prevalent ailment that affects both the woman and her family. Addressing PND in primary health care, such as pediatrics and obstetric care settings, has been proposed as an effective way to identify and treat women. OBJECTIVE:The purpose of this study is to examine best practices for management of PND in obstetric and pediatric settings, as well as investigate the evidence that supports the guidelines. METHODS:Guidelines were identified through a literature search and discussion with experts in the field of perinatal depression, while evidence was examined through a literature search of reviews and thereafter experimental studies. RESULTS:Twenty-five guidelines, across 17 organizations were retained for analysis. Findings suggest that there is little or varied guidance on the management of PND, as well as a lack of specificity. Treatment was the topic most frequently reported, followed by screening. However best practices vary greatly and often contradict one another. Across all areas, there is inadequate or contrasting evidence to support these guidelines. CONCLUSIONS:Although there was consensus on the key steps in the pathway to care, the review revealed lack of consensus across guidelines on specific issues relating to identification and management of depression during the perinatal period. Clinicians may use these recommendations to guide their practice, but they should be aware of the limitations of the evidence supporting these guidelines and remain alert to new evidence. There is a clear need for researchers and policymakers to prioritize this area in order to develop evidence-based guidelines for managing perinatal depression.