Faculty Bibliography

BACKGROUND:Concerns about antipsychotic prescribing for children, particularly those enrolled in Medicaid and with Supplemental Security Income (SSI), continue despite recent calls for selective use within established guidelines. OBJECTIVES/OBJECTIVE:To (a) examine the application of 6 quality measures for antipsychotic medication prescribing in children and adolescents receiving Medicaid and (b) understand distinctive patterns across eligibility categories in order to inform ongoing quality management efforts to support judicious antipsychotic use. METHODS:Using data for 10 states from the 2008 Medicaid Analytic Extract (MAX), a cross-sectional assessment of 144,200 Medicaid beneficiaries aged < 21 years who received antipsychotics was conducted to calculate the prevalence of 6 quality measures for antipsychotic medication management, which were developed in 2012-2014 by the National Collaborative for Innovation in Quality Measurement. These measures addressed antipsychotic polypharmacy, higher-than-recommended doses of antipsychotics, use of psychosocial services before antipsychotic initiation, follow-up after initiation, baseline metabolic screening, and ongoing metabolic monitoring. RESULTS:Compared with children eligble for income-based Medicaid, children receiving SSI and in foster care were twice as likely to receive higher-than-recommended doses of antipsychotics (adjusted odds ratio [AOR] = 2.4, 95% CI = 2.3-2.6; AOR = 2.5, 95% CI = 2.4-2.6, respectively) and multiple concurrent antipsychotic medications (AOR = 2.2, 95% CI = 2.0-2.4; AOR = 2.2, 95% CI = 2.0-2.4, respectively). However, children receiving SSI and in foster care were more likely to have appropriate management, including psychosocial visits before initiating antipsychotic treatment and ongoing metabolic monitoring. While children in foster care were more likely to experience baseline metabolic screening, SSI children were no more likely than children eligible for income-based aid to receive baseline screening. CONCLUSIONS:While indicators of overuse were more common in SSI and foster care groups, access to follow-up, metabolic monitoring, and psychosocial services was somewhat better for these children. However, substantial quality shortfalls existed for all groups, particularly metabolic screening and monitoring. Renewed efforts are needed to improve antipsychotic medication management for all children. DISCLOSURES/UNASSIGNED:This project was supported by grant number U18HS020503 from the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS). Additional support for Rutgers-based participants was provided from AHRQ grants R18 HS019937 and U19HS021112, as well as the New York State Office of Mental Health. The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ, CMS, or the New York State Office of Mental Health. Finnerty has been the principle investigator on research grants/contracts from Bristol Myers Squibb and Sunovion, but her time on these projects is fully supported by the New York State Office of Mental Health. Scholle, Byron, and Morden work for the National Committee for Quality Assurance, a not-for-profit organization that develops and maintains quality measures. Neese-Todd was at Rutgers University at the time of this study and is now employed by the National Committee for Quality Assurance. The other authors have no financial relationships relevant to this article to disclose. Study concept and design were contributed by Finnerty, Neese-Todd, and Crystal, assisted by Scholle, Leckman-Westin, Horowitz, and Hoagwood. Scholle, Byron, Morden, and Hoagwood collected the data, and data interpretation was performed by Pritam, Bilder, Leckman-Westin, and Finnerty, with assistance from Scholle, Byron, Crystal, Kealey, and Neese-Todd. The manuscript was written by Leckman-Westin, Kealey, and Horowitz and revised by Layman, Crystal, Leckman-Westin, Finnerty, Scholle, Neese-Todd, and Horowitz, along with the other authors.

Standardized training and credentialing is increasingly important to states and healthcare systems. Workforce shortages in children's mental health can be addressed through training and credentialing of professional peer parents (called family peer advocates or FPAs), who deliver a range of services to caregivers. A theory-based training program for FPAs targeting skills and knowledge about childhood mental health services (Parent Empowerment Program, or PEP) was developed through a partnership among a statewide family-run organization, state policy leaders, and academic researchers. Prior studies by this team using highly-experienced family peer advocates (who were also co-developers of the training program) as trainers found improvements in knowledge about mental health services and self-efficacy. In 2010, to meet demands and scale the model, a training of trainers (TOT) model was developed to build a cohort of locally-trained FPAs to deliver PEP training. A pre/post design was used to evaluate the impact of TOT model on knowledge and self-efficacy among 318 FPAs across the state. Participants showed significant pre-post (6 month) changes in knowledge about mental health services and self-efficacy. There were no significant associations between any FPA demographic characteristics and their knowledge or self-efficacy scores. A theory-based training model for professional peer parents working in the children's mental health system can be taught to local FPAs, and it improves knowledge about the mental health system and self-efficacy. Studies that evaluate the effectiveness of different training modalities are critical to ensure that high-quality trainings are maintained.

Background: Partnership, engagement, and collaboration (PEC) are critical factors in dissemination and implementation (D&I) research. Despite a growing recognition that incorporating PEC strategies in D&I research is likely to increase the relevance, feasibility, impacts, and of evidence-based interventions or practices (EBIs, EBPs), conceptual frameworks and methodologies to guide the development and testing of PEC strategies in D&I research are lacking. To address this methodological gap, a review was conducted to summarize what we know, what we think we know, and what we need to know about PEC to inform D&I research. Methods: A cross-field scoping review, drawing upon a broad range of PEC related literature in health, was conducted. Publications reviewed focused on factors influencing PEC, and processes, mechanisms and strategies for promoting effective PEC. The review was conducted separately for three forms of partnerships that are commonly used in D&I research: (1) consumer-provider or patient-implementer partnership; (2) delivery system or implementation team partnership; and (3) sustainment/support or interagency/community partnership. A total of 39 studies, of which 21 were review articles, were selected for an in-depth review. Results: Across three forms of partnerships, four domains (cognitive, interpersonal/affective, behavioral, and contextual domains) were consistently identified as factors and strategies for promoting PEC. Depending on the stage (preparation or execution) and purpose of the partnership (regulating performance or managing maintenance), certain PEC strategies are more or less relevant. Recent developments of PEC frameworks, such as Partnership Stage of Change and multiple dynamic processes, provide more comprehensive conceptual explanations for PEC mechanisms, which can better guide PEC strategies selection and integration in D&I research. Conclusions: This review contributes to D&I knowledge by identifying critical domain factors, processes, or mechanisms, and key strategies for PEC, and offers a multi-level PEC framework for future research to build the evidence base. However, more research is needed to test PEC mechanisms.

OBJECTIVE: The U.S. Department of Justice has called for the creation of trauma-informed juvenile justice systems in order to combat the negative impact of trauma on youth offenders and frontline staff. Definitions of trauma-informed care have been proposed for various service systems, yet there is not currently a widely accepted definition for juvenile justice. The current systematic review examined published definitions of a trauma-informed juvenile justice system in an effort to identify the most commonly named core elements and specific interventions or policies. METHOD: A systematic literature search was conducted in 10 databases to identify publications that defined trauma-informed care or recommended specific practices or policies for the juvenile justice system. RESULTS: We reviewed 950 unique records, of which 10 met criteria for inclusion. The 10 publications included 71 different recommended interventions or policies that reflected 10 core domains of trauma-informed practice. We found 8 specific practice or policy recommendations with relative consensus, including staff training on trauma and trauma-specific treatment, while most recommendations were included in 2 or less definitions. CONCLUSION: The extant literature offers relative consensus around the core domains of a trauma-informed juvenile justice system, but much less agreement on the specific practices and policies. A logical next step is a review of the empirical research to determine which practices or policies produce positive impacts on outcomes for youth, staff, and the broader agency environment, which will help refine the core definitional elements that comprise a unified theory of trauma-informed practice for juvenile justice. (PsycINFO Database Record

States are restructuring health care delivery with a focus on cost savings and care quality. Building on lessons learned from the first statewide roll-out of the NY State Managing and Adapting Practice (MAP) program, we targeted adaptations to the MAP trainings with the goal of addressing key factors related to clinician dropout. We describe these adaptations made to MAP version 2, using Damschroder et al.'s (2009) theoretical model of the consolidated Framework for Implementation Research (CFIR). our adaptations were connected with each of the five domains: intervention characteristics, outer setting (incentives and cost), inner setting (leadership/champions), characteristics of the individuals, and the process of training implementation (planning, engaging, executing, and reflecting and evaluating. Next, we compared dropout rates between MAP version 1 (v1) and MAP version 2 (v2). Because the structural adaptations aimed to increase retention rate by targeting factors hypothesized to be associated with empirically derived predictors of dropout, we expected that the dropout rate would be significantly lower in MAP v2. We then examined associations of clinician sociodemographic characteristics, clinical characteristics, and attitudes with dropout. Although older participant age was significantly associated with dropout in MAP v1, we hypothesized that participant age will not be a significant predictor of dropout in MAP v2 because MAP v2 adaptations focused on age-related factors. However, we expected clinic region, which is immutable, to remain a significant predictor of dropout.

The negative consequences of untreated postpartum depression (PD) for both the woman and her infant are well established. The impact of maternal depression has led to recommendations on systematic perinatal depression screening. Unfortunately, large-scale initiatives on PD screening have found no benefit unless systems are in place to facilitate appropriate interventions for women who screen positive. Pediatric primary care has been a focus of efforts to support screening and management of PD because pediatric providers, unlike adult healthcare providers, have the most frequent contact with postpartum women through well-child visits. Well-child visits thus present an unparalleled opportunity to detect and intervene with PD. Literature reviews suggest that specific strategies are feasible within pediatric settings and could benefit both the woman and her child. In this article, we present a stepped care approach for screening and managing PD, integrating common elements found in existing pediatric-based models. A stepped care approach is ideal because PD is a heterogeneous condition, with a range of presentations and hence responsiveness to various interventions. This care pathway begins with systematic screening for depression symptoms, followed by a systematic risk assessment for women who screen positive and care management based on risk profiles and responsiveness. This approach allows pediatric providers to be optimally flexible and responsive in addressing the majority of women with PD within the context of the family-centered medical home to improve child well-being. Challenges to managing PD within pediatrics are discussed, including strategies for addressing them. Implications for research, policy, and practice are discussed.

OBJECTIVE: Efforts to promote early brain and child development (EBCD) include initiatives to support healthy parent-child relationships, tools to identify family social-emotional risk factors, and referrals to community programs to address family risk factors. We sought to examine if pediatricians perceive barriers to implementing these activities, and if they utilize resources to address those barriers. METHOD: Data were analyzed from 304 non-trainee pediatricians who practice general pediatrics and completed a 2013 American Academy of Pediatrics Periodic Survey. Sample weights were used to decrease non-response bias. Bivariate comparisons and multivariable regression analyses were conducted. RESULTS: At least half of the pediatricians agreed that barriers to promoting EBCD include: a lack of tools to promote healthy parent-child relationships, a lack of tools to assess the family environment for social-emotional risk factors, and a lack of local resources to address family risks. Endorsing a lack of tools to assess the family environment as a barrier was associated with using fewer screening tools and community resources. Endorsing a lack of local resources as a barrier was associated with using fewer community resources and fewer initiatives to promote parent-child relationships. Interest in pediatric mental health was associated with using more initiatives to promote healthy parent-child relationships, screening tools, and community resources. CONCLUSION: Although the majority of pediatricians perceive barriers to promoting EBCD, few are routinely using available resources to address these barriers. Addressing pediatricians' perceived barriers and encouraging interest in pediatric mental health may increase resource utilization and enhance efforts to promote EBCD.

This paper describes a systematic approach to assessing community services post-Sandy Hook shooting. An evaluation team was invited to develop a sustainability plan for community services in Newtown. Service organizations, providers and families were interviewed. Descriptive statistics were used to characterize the range of services; respondent perspectives were coded using content analysis. We found that Newtown has a broad array of community services, but respondent groups varied in their perceptions of service adequacy. Consensus existed about core components of an ideal service system, including centralizing access; coordinating care; personalizing and tailoring services for families; and providing evidence-based care. The strategic community assessment approach developed here may inform how communities examine their service capacity and develop sustainability plans post-disaster.