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Children and adolescents with serious emotional disturbance represent 7-12 percent of all youth in the United States. In 2017, the State of Idaho implemented the Youth Empowerment Service program, which allows youth with serious emotional disturbance who are younger than age eighteen living in households with income up to 300 percent of the federal poverty level to qualify for Medicaid and receive intensive, community-based treatment. A uniquely detailed method was used to assess the need for services: the Child and Adolescent Needs and Strengths tool, a ninety-seven-indicator instrument administered by a clinician. We used these indicators and Idaho's 2018-22 administrative Medicaid claims data to study the association between children and adolescents' clinical needs complexity and their actual Medicaid behavioral and mental health service use. Our findings show that there was a substantial proportion of youth who were underusing Medicaid behavioral and mental health care services, and there were virtually no overusers. Our findings have implications for the appropriateness of Medicaid utilization management in behavioral health care and program efforts to maintain families with youth having serious emotional disturbance in the Youth Empowerment Service program.

Background: Complex social determinants of health may not be easily recognized by health care providers and pose a unique challenge in the vulnerable pediatric population where patients may not be able to advocate for themselves. The goal of this study was to examine the acceptability and feasibility of health care providers using an integrated brief pediatric screening tool in primary care and hospital settings., Methods: The framework of the Child and Adolescent Needs and Strengths (CANS) and Pediatric Intermed tools was used to inform the selection of items for the 9-item Child and Adolescent Needs and Strengths-Pediatric Complexity Indicator (CANS-PCI). The tool consisted of three domains: biological, psychological, and social. Semi-structured interviews were conducted with health care providers in pediatric medical facilities in Ottawa, Canada. A low inference and iterative thematic synthesis approach was used to analyze the qualitative interview data specific to acceptability and feasibility., Results: Thirteen health care providers participated in interviews. Six overarching themes were identified: acceptability, logistics, feasibility, pros/cons, risk, and privacy. Overall, participants agreed that a routine, trained provider-led pediatric tool for the screening of social determinants of health is important (n = 10, 76.9%), acceptable (n = 11; 84.6%), and feasible (n = 7, 53.8%)., Interpretation: Though the importance of social determinants of health are widely recognized, there are limited systematic methods of assessing, describing, and communicating amongst health care providers about the biomedical and psychosocial complexities of pediatric patients. Based on this study's findings, implementation of a brief provider-led screening tool into pediatric care practices may contribute to this gap., (© 2024. The Author(s).)

Understanding and addressing the impact of adverse life events is an important priority in the design of helping systems. However, creating trauma-informed systems requires efforts to embed effective trauma-informed work in routine practice. This article discusses a model for developing trauma-informed systems using the Transformational Collaborative Outcomes Management (TCOM) framework, a strategy for engineering person-centered care. Person-centered care is naturally congruent with trauma-informed care. We describe the initial stages of implementation of a trauma-informed standardized assessment process to support the sustained evolution of trauma-informed care. Distinguishing between traumatic experiences and traumatic stress is fundamental to an effective trauma-informed system. We describe two sets of analyses-one in a statewide child welfare system and the other in a statewide behavioral health system. These projects found opportunities in the analysis of the detection of traumatic stress based on traumatic experiences to inform practice and policy. Being trauma-informed in child welfare is distinct from being trauma-informed in behavioral health. In child welfare, it appears that a number of children are resilient in the face of traumatic experiences and do not require trauma treatment interventions. However, delayed and missed traumatic stress responses are common. In behavioral health, misses often occur among adolescents, particularly boys, who engage in acting out behavior. Opportunities for the ongoing development of trauma-informed systems using the TCOM framework are discussed., Competing Interests: JL is the president of the Praed Foundation. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Lyons and Fernando.)

Objective: The authors quantified the impact of the use of telehealth services on patient-level clinical outcomes among children with complex behavioral and emotional needs in Idaho during the COVID-19 pandemic by comparing data collected in 2020 with data for the same months in 2019., Methods: Longitudinal statewide data of Child and Adolescent Needs and Strengths (CANS) assessments were extracted from Idaho's mental and behavioral health system. Prepandemic assessments were matched to midpandemic assessments. A linear mixed-effect model was used to explore four child-level outcomes: psychosocial strengths-building rate, rate of need resolution within a life-functioning domain, rate of need resolution within a behavior-emotional domain, and rate of need resolution within a high-risk behaviors domain., Results: The number of new patients admitted to Idaho's state-funded mental and behavioral health program decreased almost twofold from April-December 2019 to April-December 2020 (N=4,458 vs. 2,794). For most children with complex needs, the use of telehealth was as effective in terms of strengths building and needs resolution as in-person services; for children whose caregivers had issues with access to transportation, availability of telehealth services improved outcomes for the children., Conclusions: The COVID-19 pandemic in 2020 was associated with a dramatic drop in the number of children served by Idaho's mental health program. Telehealth may effectively bridge mental health service delivery while patients and providers work toward the resolution of transportation issues or may serve as a more acceptable permanent format of service delivery for some populations.

Nationally, opioid overdose remains strikingly persistent among people experiencing homelessness and housing instability. Limited information is available about the characteristics of this phenomenon in economically disadvantaged communities of color. This study sought to evaluate the association between key contextual factors and experiencing a non-fatal opioid overdose among people who use heroin in Washington Heights, New York City. We conducted a cross-sectional survey (N = 101) among participants seeking harm reduction services who reported heroin use in the last three months. Binary logistic regression models examined the association between key social and structural factors and the likelihood of ever experiencing a non-fatal opioid overdose and recently experiencing a non-fatal opioid overdose. The majority of the sample reported housing instability and lived in poverty; almost 42% were homeless. After adjustment, participants who injected heroin were more likely to have ever experienced a non-fatal opioid overdose. Also, younger participants who reported hunger in the last six months were more likely to have experienced a non-fatal opioid overdose in the last three months. Findings suggest the role of structural vulnerability in shaping overdose risk among the participants. Overdose prevention strategies should consider factors of the social and economic environment to mitigate barriers to accessing health and social services within the context of the current opioid crisis.

The downregulation of sclerostin in osteocytes mediates bone formation in response to mechanical cues and parathyroid hormone (PTH). To date, the regulation of sclerostin has been attributed exclusively to the transcriptional downregulation of the Sost gene hours after stimulation. Using mouse models and rodent cell lines, we describe the rapid, minute-scale post-translational degradation of sclerostin protein by the lysosome following mechanical load and PTH. We present a model, integrating both new and established mechanically and hormonally activated effectors into the regulated degradation of sclerostin by lysosomes. Using a mouse forelimb mechanical loading model, we find transient inhibition of lysosomal degradation or the upstream mechano-signaling pathway controlling sclerostin abundance impairs subsequent load-induced bone formation by preventing sclerostin degradation. We also link dysfunctional lysosomes to aberrant sclerostin regulation using human Gaucher disease iPSCs. These results reveal how bone anabolic cues post-translationally regulate sclerostin abundance in osteocytes to regulate bone formation., Competing Interests: NG, KW, HJ, OT, JL, MS, MH, RF No competing interests declared, JL, JS Holds two patents related to this work. One for the custom fluid shear device used for these experiments (US Patent No US 2017/0276666 A1) and a second for the targeting microtubules (part of this mechano-transduction pathway) to improve bone mass (US Patent No US 2019/0351055 A1). RK Has a patent pending on colchicine analogs to treat musculoskeletal disorders (PCT/US2018/038300). Ramzi J. Khairallah is affiliated with Myologica, LLC. The author has no financial interests to declare. CW Holds two patents related to this work. One for the custom fluid shear device used for these experiments (US Patent No US 2017/0276666 A1) and a second for the targeting microtubules (part of this mechano-transduction pathway) to improve bone mass (US Patent No US 2019/0351055 A1). Another patent pending on colchicine analogs to treat musculoskeletal disorders (PCT/US2018/038300)., (© 2021, Gould et al.)

Skeletal remodeling is driven in part by the osteocyte's ability to respond to its mechanical environment by regulating the abundance of sclerostin, a negative regulator of bone mass. We have recently shown that the osteocyte responds to fluid shear stress via the microtubule network-dependent activation of NADPH oxidase 2 (NOX2)-generated reactive oxygen species and subsequent opening of TRPV4 cation channels, leading to calcium influx, activation of CaMKII, and rapid sclerostin protein downregulation. In addition to the initial calcium influx, purinergic receptor signaling and calcium oscillations occur in response to mechanical load and prior to rapid sclerostin protein loss. However, the independent contributions of TRPV4-mediated calcium influx and purinergic calcium oscillations to the rapid sclerostin protein downregulation remain unclear. Here, we showed that NOX2 and TRPV4-dependent calcium influx is required for calcium oscillations, and that TRPV4 activation is both necessary and sufficient for sclerostin degradation. In contrast, calcium oscillations are neither necessary nor sufficient to acutely decrease sclerostin protein abundance. However, blocking oscillations with apyrase prevented fluid shear stress induced changes in osterix (Sp7), osteoprotegerin (Tnfrsf11b), and sclerostin (Sost) gene expression. In total, these data provide key mechanistic insights into the way bone cells translate mechanical cues to target a key effector of bone formation, sclerostin., Competing Interests: Declaration of competing interest JSL, CWW, and JPS hold two patents related to this work. One for the custom fluid shear device used for these experiments (US Patent No US 2017/0276666 A1) and a second for the targeting of this osteocyte mechanotransduction pathway to improve bone mass (US Patent No US 2019/0351055 A1)., (Copyright © 2020. Published by Elsevier Inc.)

Objective: The adult INTERMED is used to determine case complexity and psychosocial needs. We developed and validated a pediatric version of the INTERMED for children and adolescents with inflammatory bowel disease (IBD) and assessed its utility in predicting healthcare utilization., Methods: We performed a cross-sectional study of children (aged 8-17 y) with IBD (n = 148) and their parents, seen in a hospital-based clinic. Subjects completed semi-structured interviews that were scored on the 34 pIBD-INTERMED items. To assess inter-rater reliability, 40 interviews were videotaped and scored by a second assessor. Convergent and predictive validity were assessed by examining the relation of the pIBD-INTERMED to standardized measures of psychological, social, and family functioning, disease activity, and healthcare utilization., Results: Correlational analyses supported the validity of all five pIBD-INTERMED domains with very good inter-rater reliability (median r = 0.87) and internal consistency (α = 0.91) for the total complexity index. Ratings of 2-3 on the pIBD-INTERMED "mental health/cognitive threat" item were associated with greater odds of behavior and social problems (CBCL-Internalizing scale OR = 7.27, 95% CI 2.17-24.36); CBCL-Externalizing scale OR = 24.79, 95% CI 5.00-122.84), depression (Children's Depression Inventory OR = 8.52, 95% CI 1.70-43.02) and anxiety (Multidimensional Anxiety for Children OR = 11.57, 95% CI 3.00-45.37). The pIBD-INTERMED complexity index added significantly to the prediction of healthcare utilization, beyond the contribution of disease severity., Conclusions: The pIBD-INTERMED is a reliable and valid tool for identifying psychosocial risks and needs of children with IBD. It can be used to guide planning of individualized care and enhance interdisciplinary pediatric IBD care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: The goal of this study was to examine the mental health needs of children and youth who present to the emergency department (ED) for mental health care and to describe the type of, and satisfaction with, follow-up mental health services accessed., Methods: A 6-month to 1.5-year prospective cohort study was conducted in three Canadian pediatric EDs and one general ED, with a 1-month follow-up post-ED discharge. Measures included 1) clinician rating of mental health needs, 2) patient and caregiver self-reports of follow-up services, and 3) interviews regarding follow-up satisfaction. Data analysis included descriptive statistics and the Fisher's exact test to compare sites., Results: The cohort consisted of 373 children and youth (61.1% female; mean age 15.1 years, 1.5 standard deviation). The main reason for ED presentations was a mental health crisis. The three most frequent areas of need requiring action were mood (43.8%), suicide risk (37.4%), and parent-child relational problems (34.6%). During the ED visit, 21.6% of patients received medical clearance, 40.9% received a psychiatric consult, and 19.4% were admitted to inpatient psychiatric care. At the 1-month post-ED visit, 84.3% of patients/caregivers received mental health follow-up. Ratings of service recommendations were generally positive, as 60.9% of patients obtained the recommended follow-up care and 13.9% were wait-listed., Conclusions: Children and youth and their families presenting to the ED with mental health needs had substantial clinical morbidity, were connected with services, were satisfied with their ED visit, and accessed follow-up care within 1-month with some variability.

Aggressive cellular phenotypes such as uncontrolled proliferation and increased migration capacity engender cellular transformation, malignancy and metastasis. While genetic mutations are undisputed drivers of cancer initiation and progression, it is increasingly accepted that external factors are also playing a major role. Two recently studied modulators of breast cancer are changes in the cellular mechanical microenvironment and alterations in calcium homeostasis. While many studies investigate these factors separately in breast cancer cells, very few do so in combination. This current work sets a foundation to explore mechano-calcium relationships driving malignant progression in breast cancer. Utilizing real-time imaging of an in vitro scratch assay, we were able to resolve mechanically-sensitive calcium signaling in human breast cancer cells. We observed rapid initiation of intracellular calcium elevations within seconds in cells at the immediate wound edge, followed by a time-dependent increase in calcium in cells at distances up to 500μm from the scratch wound. Calcium signaling to neighboring cells away from the wound edge returned to baseline within seconds. Calcium elevations at the wound edge however, persisted for up to 50 minutes. Rigorous quantification showed that extracellular calcium was necessary for persistent calcium elevation at the wound edge, but intercellular signal propagation was dependent on internal calcium stores. In addition, intercellular signaling required extracellular ATP and activation of P2Y 2 receptors. Through comparison of scratch-induced signaling from multiple cell lines, we report drastic reductions in response from aggressively tumorigenic and metastatic cells. The real-time scratch assay established here provides quantitative data on the molecular mechanisms that support rapid scratch-induced calcium signaling in breast cancer cells. These mechanisms now provide a clear framework for investigating which short-term calcium signals promote long-term changes in cancer cell biology., Competing Interests: CONFLICTS OF INTEREST The authors declare no conflicts of interest.

The adaptation of the skeleton to its mechanical environment is orchestrated by mechanosensitive osteocytes, largely by regulating the abundance of sclerostin, a secreted inhibitor of bone formation. We defined a microtubule-dependent mechanotransduction pathway that linked fluid shear stress to reactive oxygen species (ROS) and calcium (Ca 2+ ) signals that led to a reduction in sclerostin abundance in cultured osteocytes. We demonstrated that microtubules stabilized by detyrosination, a reversible posttranslational modification of polymerized α-tubulin, determined the stiffness of the cytoskeleton, which set the mechanoresponsive range of cultured osteocytes to fluid shear stress. We showed that fluid shear stress through the microtubule network activated NADPH oxidase 2 (NOX2)-generated ROS that target the Ca 2+ channel TRPV4 to elicit Ca 2+ influx. Furthermore, tuning the abundance of detyrosinated tubulin affected cytoskeletal stiffness to define the mechanoresponsive range of cultured osteocytes to fluid shear stress. Finally, we demonstrated that NOX2-ROS elicited Ca 2+ signals that activated the kinase CaMKII to decrease the abundance of sclerostin protein. Together, these discoveries may identify potentially druggable targets for regulating osteocyte mechanotransduction to affect bone quality., (Copyright © 2017 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Cells respond to their mechanical environment by initiating multiple mechanotransduction signaling pathways. Defects in mechanotransduction have been implicated in a number of pathologies; thus, there is need for convenient and efficient methods for studying the mechanisms underlying these processes. A widely used and accepted technique for mechanically stimulating cells in culture is the introduction of fluid flow on cell monolayers. Here, we describe a novel, multifunctional fluid flow device for exposing cells to fluid flow in culture. This device integrates with common lab equipment including routine cell culture plates and peristaltic pumps. Further, it allows the fluid flow treated cells to be examined with outcomes at the cell and molecular level. We validated the device using the biologic response of cultured UMR-106 osteoblast-like cells in comparison to a commercially available system of laminar sheer stress to track live cell calcium influx in response to fluid flow. In addition, we demonstrate the fluid flow-dependent activation of phospho-ERK in these cells, consistent with the findings in other fluid flow devices. This device provides a low cost, multi-functional alternative to currently available systems, while still providing the ability to generate physiologically relevant conditions for studying processes involved in mechanotransduction in vitro., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

After children enter the child welfare system, subsequent out-of-home placement decisions and their impact on children's well-being are complex and under-researched. This study examined two placement decision-making models: a multidisciplinary team approach, and a decision support algorithm using a standardized assessment. Based on 3,911 placement records in the Illinois child welfare system over 4 years, concordant (agreement) and discordant (disagreement) decisions between the two models were compared. Concordant decisions consistently predicted improvement in children's well-being regardless of placement type. Discordant decisions showed greater variability. In general, placing children in settings less restrictive than the algorithm suggested ("under-placing") was associated with less severe baseline functioning but also less improvement over time than placing children according to the algorithm. "Over-placing" children in settings more restrictive than the algorithm recommended was associated with more severe baseline functioning but fewer significant results in rate of improvement than predicted by concordant decisions. The importance of placement decision-making on policy, restrictiveness of placement, and delivery of treatments and services in child welfare are discussed.