The Needs-to-Goals Gap: How informant discrepancies in youth mental health assessments impact service delivery.

2021

102114

2021 Dec 21

1873-7811

<p>Over 60&nbsp;years of research reveal that informants who observe youth in clinically relevant contexts (e.g., home, school)-typically parents, teachers, and youth clients themselves-often hold discrepant views about that client's needs for mental health services (i.e., informant discrepancies). The last 10&nbsp;years of research reveal that these discrepancies reflect the reality that (a) youth clients' needs may vary within and across contexts and (b) informants may vary in their expertise for observing youth clients within specific contexts. Accordingly, collecting and interpreting multi-informant data comprise "best practices" in research and clinical care. Yet, professionals across settings (e.g., health, mental health, school) vary in their use of multi-informant data. Specifically, professionals differ in how or to what degree they leverage multi-informant data to determine the goals of services designed to meet youth clients' needs. Further, even when professionals have access to multiple informants' reports, their clinical decisions often signal reliance on one informant's report, thereby omitting reports from other informants. Together, these issues highlight an understudied research-to-practice gap that limits the quality of services for youth. We advance a framework-the Needs-to-Goals Gap-to characterize the role of informant discrepancies in identifying youth clients' needs and the goals of services to meet those needs. This framework connects the utility of multi-informant data with the reality that services often target an array of needs within and across contexts, and that making decisions without accurately integrating multiple informants' reports may result in suboptimal care. We review evidence supporting the framework and outline directions for future research.</p>

10.1016/j.cpr.2021.102114

Clin Psychol Rev

35066239

Sleep Well! An adapted behavioral sleep intervention implemented in urban primary care.

2021

2021 Dec 16

1550-9397

<p><strong>STUDY OBJECTIVES: </strong>To describe the adaptation, feasibility, and initial outcomes of <em>Sleep Well!</em>, an intervention for early childhood insomnia and insufficient sleep, designed for families from lower-socioeconomic status (SES) backgrounds presenting to large metropolitan primary care sites.</p>

<p><strong>METHODS: </strong>Fifteen caregiver-child dyads (caregivers: 92.3% mothers; 80.0% Black; 53.3% ≤125% US poverty level; children: 73.3% female; 86.7% Black; age = 3.0 years) participated this multi-method, single-arm trial. A family advisory board of caregivers (N = 4) and a clinician advisory board of sleep experts, primary care clinicians, and psychologists (N = 13) provided intervention feedback throughout the pilot. Most adaptations were related to intervention delivery methods, with some related to sleep strategies. At post-intervention, caregivers completed surveys on intervention acceptability and cultural humility (primary outcomes) and completed semi-structured interviews. Caregivers also reported on child sleep pre- and post-intervention.</p>

<p><strong>RESULTS: </strong>Thirteen (86.6%) families completed <em>Sleep Well!&nbsp;</em>and 12 (80.0%) completed pre- and post-intervention measures. Caregivers reported strong intervention acceptability and cultural humility. There were pre-to-post reductions in child sleep problems, bedroom electronics, sleep onset latency, and night awakening frequency and duration. Nighttime sleep duration and overall insufficient sleep also improved. Qualitative data also showed strong intervention acceptability and perceived flexibility, with few participation barriers.</p>

<p><strong>CONCLUSIONS: </strong>A brief, early childhood behavioral sleep intervention delivered in primary care with families from primarily lower-SES and/or racially minoritized backgrounds is feasible to implement, with strong retention rates, acceptability, and perceptions of cultural humility. Child sleep improvements are positive, and warrant replication in a randomized controlled trial.</p>

10.5664/jcsm.9822

J Clin Sleep Med

34910624

Improving Care Management in Attention-Deficit/Hyperactivity Disorder: An RCT.

2021

2021 Jul 19

1098-4275

<p><strong>OBJECTIVES: </strong>To compare the effectiveness of care management combined with a patient portal versus a portal alone for communication among children with attention-deficit/hyperactivity disorder (ADHD).</p>

<p><strong>METHODS: </strong>Randomized controlled trial conducted at 11 primary care practices. Children aged 5 to 12 years old with ADHD were randomly assigned to care management + portal or portal alone. The portal included parent-reported treatment preferences and goals, medication side effects, and parent- and teacher-reported ADHD symptom scales. Care managers provided education to families; communicated quarterly with parents, teachers, and clinicians; and coordinated care. The main outcome, changes in the Vanderbilt Parent Rating Scale (VPRS) score as a measure of ADHD symptoms, was assessed using intention-to-treat analysis.</p>

<p><strong>RESULTS: </strong>A total of 303 eligible children (69% male; 46% Black) were randomly assigned, and 273 (90%) completed the study. During the 9-month study, parents in the care management + portal arm communicated inconsistently with care managers (mean 2.2; range 0-6) but similarly used the portal (mean 2.3 vs 2.2) as parents in the portal alone arm. In multivariate models, VPRS scores decreased over time (Adjusted β = -.015; 95% confidence interval -0.023 to -0.07) in both groups, but there were no intervention-by-time effects (Adjusted β = .000; 95% confidence interval -0.011 to 0.012) between groups. Children who received ≥2 care management sessions had greater reductions in VPRS scores than those with fewer sessions.</p>

<p><strong>CONCLUSIONS: </strong>Results did not provide evidence that care management combined with a patient portal was different from portal use alone among children with ADHD. Both groups demonstrated similar reductions in ADHD symptoms. Those families with greater care management engagement demonstrated greater reductions than those with less engagement.</p>

10.1542/peds.2020-031518

Pediatrics

34281997

Early Childhood Sleep Intervention in Urban Primary Care: Clinician and Caregiver Perspectives.

2020

2020 May 20

1465-735X

<p><strong>BACKGROUND: </strong>Despite significant income-related disparities in pediatric sleep, few early childhood sleep interventions have been tailored for or tested with families of lower socio-economic status (SES). This qualitative study assessed caregiver and clinician perspectives to inform adaptation and implementation of evidence-based behavioral sleep interventions in urban primary care with families who are predominantly of lower SES.</p>

<p><strong>METHODS: </strong>Semi-structured interviews were conducted with (a) 23 caregivers (96% mothers; 83% Black; 65% ≤125% U.S. poverty level) of toddlers and preschoolers with insomnia or insufficient sleep and (b) 22 urban primary care clinicians (physicians, nurse practitioners, social workers, and psychologists; 87% female; 73% White). Guided by the Consolidated Framework for Implementation Research, the interview guide assessed multilevel factors across five domains related to intervention implementation. Qualitative data were analyzed using an integrated approach to identify thematic patterns across participants and domains.</p>

<p><strong>RESULTS: </strong>Patterns of convergence and divergence in stakeholder perspectives emerged across themes. Participants agreed upon the importance of child sleep and intervention barriers (family work schedules; household and neighborhood factors). Perspectives aligned on intervention (flexibility; collaborative and empowering care) and implementation (caregiver-to-caregiver support and use of technology) facilitators. Clinicians identified many family barriers to treatment engagement, but caregivers perceived few barriers. Clinicians also raised healthcare setting factors that could support (integrated care) or hinder (space and resources) implementation.</p>

<p><strong>CONCLUSIONS: </strong>Findings point to adaptations to evidence-based early childhood sleep intervention that may be necessary for effective implementation in urban primary care. Such adaptations could potentially reduce significant pediatric sleep-related health disparities.</p>

10.1093/jpepsy/jsaa024

J Pediatr Psychol

32430496

Sharing of ADHD Information between Parents and Teachers Using an EHR-Linked Application.

2018

892-904

2018 Oct

1869-0327

<p><strong>BACKGROUND: </strong> Appropriate management of attention-deficit/hyperactivity disorder (ADHD) involves parents, clinicians, and teachers. Fragmentation of interventions between different settings can lead to suboptimal care and outcomes. Electronic systems can bridge gaps across settings. Our institution developed an email-based software to collect ADHD information from parents and teachers, which delivered data directly to the clinician within the electronic health record (EHR).</p>

<p><strong>OBJECTIVE: </strong> We sought to adapt our institution's existing EHR-linked system for ADHD symptom monitoring to support communication between parents and teachers and then to assess child characteristics associated with sharing of ADHD information.</p>

<p><strong>METHODS: </strong> We updated our software to support automated sharing of ADHD information between parents and teachers. Sharing was optional for parents but obligatory for teachers. We conducted a retrospective cohort study involving 590 patients at 31 primary care sites to evaluate a system for sharing of ADHD-specific health information between parents and teachers. We used multivariable logistic regression to estimate associations between child characteristics and parental sharing. We further investigated the association between child characteristics and viewing of survey results delivered through the electronic communication system.</p>

<p><strong>RESULTS: </strong> Most parents (64%) elected to share survey results with teachers at the first opportunity and the vast majority (80%) elected to share all possible information. Parents who elected to share usually continue sharing at subsequent opportunities (89%). Younger child age and performance impairments were associated with increased likelihood of sharing. However, parents viewed only 16% of teacher submitted surveys and teachers only viewed 30% of surveys shared by parents.</p>

<p><strong>CONCLUSION: </strong> This study demonstrates that electronic systems to capture ADHD information from parents and teachers can be adapted to support communication between them, and that parents are amenable to sharing ADHD information with teachers. However, strategies are needed to encourage viewing of shared information.</p>

10.1055/s-0038-1676087

Appl Clin Inform

30566963

Distance-Learning, ADHD Quality Improvement in Primary Care: A Cluster-Randomized Trial.

2017

2017 Aug 09

1536-7312

<p><strong>OBJECTIVE: </strong>To evaluate a distance-learning, quality improvement intervention to improve pediatric primary care provider use of attention-deficit/hyperactivity disorder (ADHD) rating scales.</p>

<p><strong>METHODS: </strong>Primary care practices were cluster randomized to a 3-part distance-learning, quality improvement intervention (web-based education, collaborative consultation with ADHD experts, and performance feedback reports/calls), qualifying for Maintenance of Certification (MOC) Part IV credit, or wait-list control. We compared changes relative to a baseline period in rating scale use by study arm using logistic regression clustered by practice (primary analysis) and examined effect modification by level of clinician participation. An electronic health record-linked system for gathering ADHD rating scales from parents and teachers was implemented before the intervention period at all sites. Rating scale use was ascertained by manual chart review.</p>

<p><strong>RESULTS: </strong>One hundred five clinicians at 19 sites participated. Differences between arms were not significant. From the baseline to intervention period and after implementation of the electronic system, clinicians in both study arms were significantly more likely to administer and receive parent and teacher rating scales. Among intervention clinicians, those who participated in at least 1 feedback call or qualified for MOC credit were more likely to give parents rating scales with differences of 14.2 (95% confidence interval [CI], 0.6-27.7) and 18.8 (95% CI, 1.9-35.7) percentage points, respectively.</p>

<p><strong>CONCLUSION: </strong>A 3-part clinician-focused distance-learning, quality improvement intervention did not improve rating scale use. Complementary strategies that support workflows and more fully engage clinicians may be needed to bolster care. Electronic systems that gather rating scales may help achieve this goal. Index terms: ADHD, primary care, quality improvement, clinical decision support.</p>

10.1097/DBP.0000000000000490

J Dev Behav Pediatr

28816912

A Social Media Peer Group for Mothers To Prevent Obesity from Infancy: The Grow2Gether Randomized Trial.

2017

2017 May 30

2153-2176

<p><strong>BACKGROUND: </strong>Few studies have addressed obesity prevention among low-income families whose infants are at increased obesity risk. We tested a Facebook peer-group intervention for low-income mothers to foster behaviors promoting healthy infant growth.</p>

<p><strong>METHODS: </strong>In this randomized controlled trial, 87 pregnant women (Medicaid insured, BMI ≥25 kg/m(2)) were randomized to the Grow2Gether intervention or text message appointment reminders. Grow2Gether participants joined a private Facebook group of 9-13 women from 2 months before delivery until infant age 9 months. A psychologist facilitated groups featuring a curriculum of weekly videos addressing feeding, sleep, parenting, and maternal well-being. Feasibility was assessed using the frequency and content of participation, and acceptability using surveys. Maternal beliefs and behaviors and infant growth were assessed at birth, 2, 4, 6, and 9 months. Differences in infant growth between study arms were explored. We conducted intention-to-treat analyses using quasi-least-squares regression.</p>

<p><strong>RESULTS: </strong>Eighty-eight percent (75/85) of intervention participants (42% (36/85) food insecure, 88% (75/85) black) reported the group was helpful. Participants posted 30 times/group/week on average. At 9 months, the intervention group had significant improvement in feeding behaviors (Infant Feeding Style Questionnaire) compared to the control group (p = 0.01, effect size = 0.45). Intervention group mothers were significantly less likely to pressure infants to finish food and, at age 6 months, give cereal in the bottle. Differences were not observed for other outcomes, including maternal feeding beliefs or infant weight-for-length.</p>

<p><strong>CONCLUSIONS: </strong>A social media peer-group intervention was engaging and significantly impacted certain feeding behaviors in families with infants at high risk of obesity.</p>

10.1089/chi.2017.0042

Child Obes

28557558

A Social Media Peer Group Intervention for Mothers to Prevent Obesity and Promote Healthy Growth from Infancy: Development and Pilot Trial.

2016

e159

2016

1929-0748

<p><strong>BACKGROUND: </strong>Evidence increasingly indicates that childhood obesity prevention efforts should begin as early as infancy. However, few interventions meet the needs of families whose infants are at increased obesity risk due to factors including income and maternal body mass index (BMI). Social media peer groups may offer a promising new way to provide these families with the knowledge, strategies, and support they need to adopt obesity prevention behaviors.</p>

<p><strong>OBJECTIVE: </strong>The aim of this study is to develop and pilot test a Facebook-based peer group intervention for mothers, designed to prevent pediatric obesity and promote health beginning in infancy.</p>

<p><strong>METHODS: </strong>We conducted in-depth semi-structured interviews with 29 mothers of infants and focus groups with 30 pediatric clinicians, to inform the development of a theory-based intervention. We then conducted a single-group pilot trial with 8 mothers to assess its feasibility and acceptability. All participants were recruited offline at pediatric primary care practices. Participants in the pilot trial joined a private Facebook group, moderated by a psychologist, with a weekly video-based curriculum, and also had the option to meet at a face-to-face event. Within the Facebook group, mothers were encouraged to chat, ask questions, and share photos and videos of themselves and babies practicing healthy behaviors. Consistent with the literature on obesity prevention, the curriculum addressed infant feeding, sleep, activity, and maternal well-being. Feasibility was assessed using the frequency and content of group participation by mothers, and acceptability was measured using online surveys and phone interviews.</p>

<p><strong>RESULTS: </strong>Based on preferences of mothers interviewed (mean BMI 35 kg/m(2), all Medicaid-insured, mean age 27, all Black), we designed the intervention to include frequent posts with new information, videos showing parents of infants demonstrating healthy behaviors, and an optional face-to-face meeting. We developed a privacy and safety plan that met the needs of participants as well as the requirements of the local institutional review board (IRB), which included use of a "secret" group and frequent screening of participant posts. Clinicians, 97% (29/30) women and 87% (26/30) pediatricians, preferred no direct involvement in the intervention, but were supportive of their patients' participation. In our 8-week, single group pilot trial, all participants (mean BMI 35 kg/m(2), all Medicaid-insured, mean age 28, all Black) viewed every weekly video post, and interacted frequently, with a weekly average of 4.4 posts/comments from each participant. All participant posts were related to parenting topics. Participants initiated conversations about behaviors related to healthy infant growth including solid food introduction, feeding volume, and managing stress. All 8 pilot group participants reported that they found the group helpful and would recommend it to others.</p>

<p><strong>CONCLUSIONS: </strong>Our methodology was feasible and acceptable to low-income mothers of infants at high risk of obesity, and could be adapted to implement peer groups through social media for underserved populations in varied settings.</p>

<p><strong>CLINICALTRIAL: </strong>ClinicalTrials.gov NCT01977105; https://clinicaltrials.gov/ct2/show/NCT01977105 (Archived by WebCite at http://www.webcitation.org/6iMFfOBat).</p>

10.2196/resprot.5276

JMIR Res Protoc

27485934

Mothers' and Clinicians' Priorities for Obesity Prevention Among Black, High-Risk Infants.

2016

2016 Mar 2

1873-2607

<p><strong>INTRODUCTION: </strong>Despite many recommended strategies for obesity prevention during infancy, effectively delivering recommendations to parents in clinical settings is challenging, especially among high-risk populations. This study describes and compares mothers' and clinicians' priorities for obesity prevention during infancy, to facilitate more-effective obesity prevention messaging.</p>

<p><strong>METHODS: </strong>A discrete choice experiment using maximum difference scaling was administered in 2013 and analyzed in 2013-2014. Twenty-nine low-income, obese mothers of infants and 30 pediatric clinicians from three urban primary care practices rated the relative importance of 16 items relevant to obesity prevention during infancy, in response to this question: Which topic would be most helpful [for new mothers] to learn about to prevent your [their] child from becoming overweight? Response options encompassed the domains of feeding, sleep, parenting (including physical activity and screen time), and maternal self-care.</p>

<p><strong>RESULTS: </strong>Mothers (all Medicaid-enrolled and black; mean age, 27 years; mean BMI, 35 kg/m(2)) and clinicians (97% female, 87% pediatricians, 13% nurse practitioners) both highly prioritized recognizing infant satiety and hunger cues, and appropriate feeding volume. Mothers rated infant physical activity and maintaining regular routines as 3.5 times more important than clinicians did (p&lt;0.001). Clinicians rated breastfeeding as 3.4 times more important than mothers did (p&lt;0.001). Neither group prioritized learning about screen time or maternal self-care.</p>

<p><strong>CONCLUSIONS: </strong>Low-income, obese, black mothers of infants highly prioritized learning about many effective obesity prevention strategies, including recognizing hunger and satiety cues, promoting infant activity, and maintaining regular routines. Clinicians may frame preventive guidance to be responsive to these priorities.</p>

10.1016/j.amepre.2015.12.015

Am J Prev Med

26947214