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Purpose The aim of this study is to test the effects of an electronic screening and feedback tool and training for primary care clinicians on care and adolescent health behaviors. Methods We conducted a stepped-wedge cluster randomized trial with six clinics randomly assigned to sequential crossover from control to intervention periods with clinician training between periods. Adolescents (ages 13–18) with a well visit during the control periods (n = 135) received usual care, while adolescents during the intervention periods (n = 167) received the electronic screening and feedback tool prior to their well visit, with results sent to their clinicians. Adolescents completed surveys at baseline, 1 day, 3 months, 6 months, and 12 months. Linear mixed effects models were used to examine associations between outcomes and treatment, controlling for time as a fixed effect and clinic as a random effect. All analyses employed intent-to-treat analyses and utilized multiple imputations for missing data. Results Adolescents who received the intervention had a higher rate of counseling for their endorsed risk behaviors during the well visit (45% vs. 33%, Wald’s T = 2.29, p = .02). There were no significant intervention effects on adolescent satisfaction with the clinician or perception of patient centeredness. The intervention was associated with a small but statistically significant reduction in overall risk score relative to control at 3 months (−.63, 95% confidence interval [−1.07, −.19], Cohen’s d = .21), but not at 6 or 12 months. Conclusions The results suggest that electronic screening and feedback may be associated with small reductions in risk behaviors at 3 months but that changes do not persist at longer term follow-up.

Introduction: This study examined mental health, substance use, and sexual health across sexual attraction groups. Methods: 428 adolescents recruited from school-based health centers completed self-report measures. 72% were only opposite-sex attracted, 19% both-sex attracted, 3% same-sex attracted, 4% not sure. Results: Reported partners did not always align with reported attraction. Compared to opposite-sex attracted youth, 1) both-sex attracted youth had significantly higher rates of marijuana use (OR = 1.75, p =.04), depressive symptoms (OR = 2.62, p =.001) and inconsistent condom use (OR = 1.71, p =.05); 2) the “not sure” group had higher anxiety symptoms (OR = 4, p =.01). Conclusion: This study highlights the importance of considering sexual attraction in providing quality care to young people.

Introduction To test whether sexual minority males and females report lower satisfaction with primary care providers and lower health self-efficacy relative to heterosexual males and females. Methods Data from 535 adolescents who participated in one of two randomized clinical trials conducted in a primary care setting were analyzed. Multiple linear regressions controlling for demographic characteristics and treatment condition were used to examine sexual attraction differences in indicators of satisfaction with provider and health self-efficacy. Results Sexual minority and heterosexual youth both endorsed high satisfaction with providers. Relative to heterosexual males, sexual minority males reported lower self-efficacy in reaching their health goals. Relative to heterosexual females, sexual minority females reported lower confidence in positively impacting their own health, and lower self-efficacy in setting goals and working actively to improve their health. Conclusions Sexual minority youth may benefit from additional support from health care providers to enhance their health self-efficacy and reach their health goals.

BACKGROUND Access to gender-affirming care services for transgender and gender diverse (TGD) youth is limited, in part because it is currently provided primarily by specialists. Telehealth platforms that facilitate specialist to primary care provider (PCP) education and consultation may help improve access, however little is known about PCPs preferences regarding receiving this support. OBJECTIVE The purpose of this study was to explore pediatric PCPs’ perspectives regarding optimal ways to provide telehealth-based support to facilitate gender-affirming care provision in the primary care setting. METHODS PCPs who had previously requested support from the Seattle Children’s Gender Clinic were recruited to participate in a semi-structured, one-hour interviews over Zoom. Three different PCP-to-specialist telehealth modalities (tele-education, electronic consultation, telephonic consultation) were described and participants were invited to share their perspectives on 1) the benefits and drawbacks of each modality, 2) which modality would be most effective, and 3) the most important characteristics or outcomes of a successful platform. Interviews were transcribed and analyzed using Dedoose qualitative analysis software using an inductive thematic analysis framework. RESULTS Interviews were completed with 15 pediatric PCPs. Benefits of the tele-education platform included developing a network with other PCPs to facilitate shared learning, receiving comprehensive didactic and case-based education, occurring at a scheduled time and increasing provider confidence. Drawbacks included requiring a significant time commitment and not allowing for real-time, patient-specific consultation. Benefits of the electronic consultation platform included convenient and efficient communication, documentation in the electronic health record (EHR), ability to bill for provider time and sufficient time to synthesize information. Drawbacks of this platform included EHR-related difficulties, text-based communication challenges, not receiving an answer in real time, forced conversations with patients about billing and limitations for providers who lack baseline knowledge. With respect to telephonic consultation, benefits included having a dialogue with a specialist, compensation for PCP time and helping with high acuity or complex cases. Drawbacks included challenges associate with using the phone for communication, the limited expertise of responding providers, and lack of utility for non-emergent issues. Regarding the most effective platform, responses were mixed with 27% preferring the electronic consultation, 27% tele-education, 20% telephonic consultation, and the remaining 27% suggesting a hybrid of the three models. The ten factors important to the development of a successful PCP-to-specialist telehealth platform included: reliable, timely, engaging, non-judgmental, scalable, practical, adaptable, comprehensive, integrated and accessible. CONCLUSIONS We must develop a diverse suite of telehealth-based training and consultation services to meet the needs of PCPs with different levels of experience and training in gender-affirming care. Beyond the widely used telephonic consultation model, electronic consultation and tele-education may provide important alternative training and consultation opportunities to facilitate greater PCP independence promote more widespread access. CLINICALTRIAL n/a

PURPOSE: Telemedicine holds potential to improve access to gender-affirming care for gender-diverse youth (GDY), but little is known about youth's perspectives regarding its use. The purpose of this study was to explore GDY's experiences and satisfaction with telemedicine for gender-affirming care during the COVID-19 pandemic. METHODS: An online, cross-sectional survey was completed by 12–17-year-old GDY after a telemedicine gender clinic visit. Demographic characteristics, responses to a 12-item telemedicine satisfaction scale, and items assessing interest in future telemedicine use were analyzed using descriptive statistics. Open-ended items exploring GDY's experiences were coded qualitatively to identify key themes. RESULTS: Participants' (n=57) mean age was 15.6 years. A majority were satisfied with telemedicine (85%) and willing to use it in the future (88%). Most GDY preferred in-person visits for their first gender care visit (79%), with fewer preferring in-person for follow-up visits (47%). Three key themes emerged from the open-ended comments: (1) benefits of telemedicine including saving time and feeling safe; (2) usability of telemedicine such as privacy concerns and technological difficulties; and (3) telemedicine acceptability, which included comfort, impact on anxiety, camera use, and patient preference. CONCLUSIONS: Despite their preference for in-person visits, a majority of GDY were satisfied and comfortable with telemedicine, and expressed their interest in continuing to have telemedicine as an option for care. Pediatric gender care providers should continue services through telemedicine while implementing protocols related to privacy and hesitation regarding camera use. While adolescents may find telemedicine acceptable, it remains unclear whether telemedicine can improve access to gender-affirming care.

To examine associations between reports of sensitive health behaviors and the provision of time alone by a clinician during adolescent well visits.Data were collected from 547 adolescents who completed a well visit at one of eight clinics. Adjusted mixed logistic regression was used to examine whether reports of sexual behavior, substance use, disordered eating, mental health concerns, and demographic characteristics were associated with time alone.Sexual behavior was found to be significantly associated with time alone, while substance use, disordered eating, a positive depression screen, and suicidal ideation were not. Older adolescents and males were more likely to report time alone, while race/ethnicity had no association with time alone.Clinicians may be prioritizing time alone for behavioral concerns differently than for other sensitive behaviors.

Background Collaborative care (CC) is a well-established approach for the delivery of accessible behavioral health services in integrated health care settings. Substantial evidence supports its effectiveness in improving the quality and outcomes of adult services, and growing research indicates utility with child and adolescent populations. Methods To date, studies examining CC models for youth have focused exclusively on primary-care settings. Nevertheless, as the most common integrated service delivery setting for youth, the education sector is an equally important context for improving access to behavioral health services for children and adolescents. Results We provide a narrative review of the literature on CC, describes the relevance of CC to schools, and details its alignment with contemporary movements in education and school-based behavioral health. Conclusions Potential adaptations of the CC model for use in schools are detailed to improve: (1) behavioral health service accessibility, (2) the capacity of schools to provide behavioral health services, and (3) school service effectiveness through use of evidence-based practices. Although little research has explored the applicability of CC in the education sector, the model holds potential promise to improve the quality and efficiency of school-based behavioral health services.

Background This study aimed to compare care delivery and alcohol and marijuana use for adolescents with risky alcohol use who received a school-based health center (SBHC) visit with and without the Check Yourself tool, an electronic tool that gives motivational feedback on substance use and summarizes results for providers. Methods We conducted a randomized controlled trial with 148 adolescents aged 13–18 who met criteria for moderate- to high- risk alcohol use, recruited from urban SBHCs. Participants were randomized to receive their SBHC visit with ( n = 73) or without ( n = 75) the Check Yourself screening and feedback tool. All SBHC providers received a brief training on motivational interviewing. Results Adolescents who received the Check Yourself tool + SBHC visit reported higher levels of alcohol (67%) and marijuana (73%) counseling from the provider during their visit, compared with those who received a SBHC visit without the tool (40% and 45%, respectively, Ps Conclusion When adolescent patients are given an electronic screening and feedback tool, it can prompt providers to increase counseling of adolescents with substance use risk. Overall, participants who had a visit with a trained provider reported high satisfaction with care and decreased the amount of alcohol use over 2 months, suggesting that SBHCs are an excellent venue for delivery of brief substance use interventions.

Creative collaborative approaches are required to meet the demands of managing depression in youth. Primary care providers are well positioned to engage depressed youth and their families, yet often lack the training, access to psychiatric providers, and the reimbursement structure to support their efforts. Child and adolescent psychiatrists are encouraged to support pediatricians in establishing more robust systems to provide screening and effective treatment interventions, particularly for youth at higher risk. Several models of collaborative care are described, in addition to their emerging evidence-base, in an effort to disseminate evolving treatment strategies that can drive implementation of effective collaborative approaches.

Background Health risk behaviors are the most common sources of morbidity among adolescents. Adolescent health guidelines (Guidelines for Preventive Services by the AMA and Bright Futures by the Maternal Child Health Bureau) recommend screening and counseling, but the implementation is inconsistent. Objective This study aims to test the efficacy of electronic risk behavior screening with integrated patient-facing feedback on the delivery of adolescent-reported clinician counseling and risk behaviors over time. Methods This was a randomized controlled trial comparing an electronic tool to usual care in five pediatric clinics in the Pacific Northwest. A total of 300 participants aged 13-18 years who attended a well-care visit between September 30, 2016, and January 12, 2018, were included. Adolescents were randomized after consent by employing a 1:1 balanced age, sex, and clinic stratified schema with 150 adolescents in the intervention group and 150 in the control group. Intervention adolescents received electronic screening with integrated feedback, and the clinicians received a summary report of the results. Control adolescents received usual care. Outcomes, assessed via online survey methods, included adolescent-reported receipt of counseling during the visit (measured a day after the visit) and health risk behavior change (measured at 3 and 6 months after the visit). Results Of the original 300 participants, 94% (n=282), 94.3% (n=283), and 94.6% (n=284) completed follow-up surveys at 1 day, 3 months, and 6 months, respectively, with similar levels of attrition across study arms. The mean risk behavior score at baseline was 2.86 (SD 2.33) for intervention adolescents and 3.10 (SD 2.52) for control adolescents (score potential range 0-21). After adjusting for age, gender, and random effect of the clinic, intervention adolescents were 36% more likely to report having received counseling for endorsed risk behaviors than control adolescents (adjusted rate ratio 1.36, 95% CI 1.04 to 1.78) 1 day after the well-care visit. Both the intervention and control groups reported decreased risk behaviors at the 3- and 6-month follow-up assessments, with no significant group differences in risk behavior scores at either time point (3-month group difference: β=−.15, 95% CI −0.57 to −0.01, P=.05; 6-month group difference: β=−.12, 95% CI −0.29 to 0.52, P=.57). Conclusions Although electronic health screening with integrated feedback improves the delivery of counseling by clinicians, the impact on risk behaviors is modest and, in this study, not significantly different from usual care. More research is needed to identify effective strategies to reduce risk in the context of well-care. Trial Registration ClinicalTrials.gov NCT02882919; https://clinicaltrials.gov/ct2/show/NCT02882919

Purpose We aimed to examine transgender youths' interest in receiving gender-affirming care via telemedicine or through primary care with telehealth support. Methods We surveyed 12- to 26-year-old transgender youth receiving care in a multidisciplinary gender clinic. Descriptive statistics and bivariate analyses were used to assess relationships between demographic and gender-related characteristics and interest in receiving care via telemedicine. Results Almost half (47%) of the 204 youth surveyed expressed interest in receiving gender care via telemedicine. Additionally, youth with lower levels of perceived parental support were more likely to express an interest in utilizing telemedicine (p = .001). Approximately half (45%) of youth were interested in receiving gender care in the primary care setting, with a majority expressing willingness to do so if their primary care provider had telehealth support. Conclusions Many transgender youth expressed interest in receiving gender care via telehealth, particularly for ongoing care and monitoring. Increased interest in telemedicine was seen among youth with lower perceived parental support.

To develop, validate, and test the feasibility of implementation of 4 new quality measures assessing emergency department (ED) and inpatient care for suicidal youth.Four quality measures were developed to assess hospital-based care for suicidal youth. These measures, focused on counseling caregivers about restricting access to lethal means of self-harm and benefits and risks of antidepressant medications, were operationalized into 2 caregiver surveys that assessed ED and inpatient quality, respectively. Survey field tests included caregivers of youth who received inpatient and/or ED care for suicidality at 1 of 2 children's hospitals between July 2013 and June 2014. We examined the feasibility of obtaining measure scores and variation in scores. Multivariate models examined associations between quality measure scores and 4 validation metrics: modified Child Hospital Consumer Assessments of Health Care Providers and Systems, communication composites, hospital readmissions, and ED return visits.Response rates were 35% (ED) and 31% (inpatient). Most caregivers reported receiving counseling to restrict their child's access to lethal means of self-harm (90% in the ED and 96% in the inpatient setting). In the inpatient setting, caregivers reported higher rates of counseling on benefits (95%) of newly prescribed antidepressants than risks (physical adverse effects 85%, increased suicidality 72%). Higher scores on the latter measure were associated with higher nurse (P .001) and doctor (P .01) communication composite scores. Measure scores were not associated with readmissions or ED return visits.These new quality measures evaluate key aspects of care for suicidal youth, and they may facilitate assessing quality of care for this vulnerable population.

Aims Emerging evidence suggests that the consistency of provider counseling can be increased through training and the use of screening tools; yet, we know little about the downstream effect on adolescents’ sense of control over their health and on their risk behaviors. This study aimed to test whether primary care provider (PCP) training on motivational interviewing together with implementation of an electronic screening and feedback tool would impact provider counseling on health risks and adolescent risk behaviors. Methods We used a stepped wedge study design and recruited adolescents aged 13-18 from 6 clinics. In the control period, 135 youth received their usual primary care appointment. In the intervention period, 167 youth received an electronic screening and feedback tool prior to their visit, with results sent to the PCP. In between the control and intervention periods, PCPs participated in an online interactive training demonstrating motivational interviewing skills using video-based scenarios, and met to discuss clinic-level reports summarizing adolescent-reported receipt of counseling. Youth were surveyed at baseline and three months about their health risk behaviors, and following the well-child visit regarding the receipt of counseling. We calculated the total number of behaviors counseled on divided by the total number of risk behaviors endorsed and compared across groups using chi-squared analyses. An adjusted linear mixed model was conducted to examine whether the intervention was associated with changes in the mean risk score at the 3-month assessment, adjusting for clinic, age, gender, and baseline risk. Results Control group participants reported receiving counseling on 35% of moderate risk behaviors compared to 43% of behaviors for intervention participants (p=0.009). Likewise, adolescents reported receiving counseling on 23% of high risk behaviors in the control group compared to 36% of behaviors in the treatment group (p Conclusion Results show promise for electronic screening and feedback and brief provider training to improve the quality and results of healthcare to adolescent patients in primary care settings.

Collaborative Care is an innovative approach to integrated mental health service delivery that focuses on reducing access barriers, improving service quality, and lowering healthcare expenditures. A large body of evidence supports the effectiveness of Collaborative Care models with adults and, increasingly, for youth. Although existing studies examining these models for youth have focused exclusively on primary care, the education sector is also an appropriate analog for the accessibility that primary care offers to adults. Collaborative Care aligns closely with the practical realities of the education sector and may represent a strategy to achieve some of the objectives of increasingly popular multi-tiered systems of supports frameworks. Unfortunately, no resources exist to guide the application of Collaborative Care models in schools. Based on the existing evidence for Collaborative Care models, the current paper (1) provides a rationale for the adaptation of Collaborative Care models to improve mental health service accessibility and effectiveness in the education sector; (2) presents a preliminary Collaborative Care model for use in schools; and (3) describes avenues for research surrounding school-based Collaborative Care, including the currently funded Accessible, Collaborative Care for Effective School-based Services (ACCESS) project.

Adolescents' wide use of technology opens up opportunities to integrate technology into health visits and health care. In particular, technology has the potential to influence adolescent behavior change by offering new avenues for provider communication and support for healthy choices through many different platforms. However, little information exists to guide the integration of technology into adolescent health care, especially adolescents' perspectives and preferences for what they find useful.This qualitative study aimed to take a broad approach to understanding adolescents' use of technology for supporting their overall health and to understand whether and how adolescents envision using technology to enhance their health and clinical care, particularly in communicating with their provider.Adolescents (13-18 years) were recruited to participate in semi-structured, in-depth individual interviews. Potential participants were approached in-person through the Seattle Children's Hospital Adolescent Medicine Clinic while they were waiting for consultation appointments, through outreach to youth who expressed interest in other local research study activities, and via flyers in waiting rooms. Interviews were recorded, transcribed, and analyzed using a thematic analysis approach.Thirty-one adolescents (58% female, M= 15.2 years) were interviewed and described 3 main uses of technology: (1) to gather information, (2a) to share their own experiences and (2b) view others' experiences in order to gain social support or inspiration, and (3) to track behaviors and health goals. Perceived benefits and potential downsides were identified for technology use. Teens desired to use technology with their provider for 3 main reasons: (1) have questions answered outside of visits, (2) have greater access to providers as a way to build relationship/rapport, and (3) share data regarding behaviors in between visits. Social media was not a preferred method for communicating with providers for any of the youth due to concerns about privacy and intrusiveness.Although youth are avid users of technology in general, in regard to technology for health, they display specific use preferences especially in how they wish to use it to communicate with their primary care provider. Healthcare providers should offer guidance to youth with regard to how they have used and plan to use technology and how to balance potential positives and negatives of use. Technology developers should take youth preferences into account when designing new health technology and incorporate ways they can use it to communicate with their healthcare provider.

BACKGROUND AND OBJECTIVES: Patients with a primary mental health condition account for nearly 10% of pediatric hospitalizations nationally, but little is known about the quality of care provided for them in hospital settings. Our objective was to develop and test medical record–based measures used to assess quality of pediatric mental health care in the emergency department (ED) and inpatient settings. METHODS: We drafted an evidence-based set of pediatric mental health care quality measures for the ED and inpatient settings. We used the modified Delphi method to prioritize measures; 2 ED and 6 inpatient measures were operationalized and field-tested in 2 community and 3 children’s hospitals. Eligible patients were 5 to 19 years old and diagnosed with psychosis, suicidality, or substance use from January 2012 to December 2013. We used bivariate and multivariate models to examine measure performance by patient characteristics and by hospital. RESULTS: Eight hundred and seventeen records were abstracted with primary diagnoses of suicidality (n = 446), psychosis (n = 321), and substance use (n = 50). Performance varied across measures. Among patients with suicidality, male patients (adjusted odds ratio: 0.27, P < .001) and African American patients (adjusted odds ratio: 0.31, P = .02) were less likely to have documentation of caregiver counseling on lethal means restriction. Among admitted suicidal patients, 27% had documentation of communication with an outside provider, with variation across hospitals (0%–38%; P < .001). There was low overall performance on screening for comorbid substance abuse in ED patients with psychosis (mean: 30.3). CONCLUSIONS: These new pediatric mental health care quality measures were used to identify sex and race disparities and substantial hospital variation. These measures may be useful for assessing and improving hospital-based pediatric mental health care quality.

Screening adolescents for depression is recommended by the US Preventive Services Task Force. We sought to evaluate the impact of positive depression screens in an adolescent population on health care utilization and costs from a payer perspective.We conducted depression screening among 13- to 17-year-old adolescents enrolled in a large integrated care system using the 2- and 9-item Patient Health Questionnaires (PHQ). Health care utilization and cost data were obtained from administrative records. Chi-square, Wilcoxon rank sum, and t tests were used to test for statistical differences in outcomes between adolescents on the basis of screening status.Of the 4010 adolescents who completed depression screening, 3707 (92.4%) screened negative (PHQ-22 or PHQ-910), 186 (3.9%) screened positive for mild depression (PHQ-9 10-14), and 95 (2.4%) screened positive for moderate to severe depression (PHQ-9 ≥15). In the 12 months after screening, screen-positive adolescents were more likely than screen-negative adolescents to receive any emergency department visit or inpatient hospitalization, and they had significantly higher utilization of outpatient medical (mean ± SD, 8.3 ± 1.5 vs 3.5 ± 5.1) and mental health (3.8 ± 9.3 vs 0.7 ± 3.5) visits. Total health care system costs for screen-positive adolescents ($5083 ± $10,489) were more than twice as high as those of screen-negative adolescents ($2357 ± $7621).Adolescent depressive symptoms, even when mild, are associated with increased health care utilization and costs. Only a minority of the increased costs is attributable to mental health care. Implementing depression screening and evidence-based mental health services may help to better control health care costs among screen-positive adolescents.

BACKGROUND Adolescents’ wide use of technology opens up opportunities to integrate technology into health visits and health care. In particular, technology has the potential to influence adolescent behavior change by offering new avenues for provider communication and support for healthy choices through many different platforms. However, little information exists to guide the integration of technology into adolescent health care, especially adolescents’ perspectives and preferences for what they find useful. OBJECTIVE This qualitative study aimed to take a broad approach to understanding adolescents’ use of technology for supporting their overall health and to understand whether and how adolescents envision using technology to enhance their health and clinical care, particularly in communicating with their provider. METHODS Adolescents (13-18 years) were recruited to participate in semi-structured, in-depth individual interviews. Potential participants were approached in-person through the Seattle Children's Hospital Adolescent Medicine Clinic while they were waiting for consultation appointments, through outreach to youth who expressed interest in other local research study activities, and via flyers in waiting rooms. Interviews were recorded, transcribed, and analyzed using a thematic analysis approach. RESULTS Thirty-one adolescents (58% female, mean age 15.2 years) were interviewed and described 3 main uses of technology: (1) to gather information, (2a) to share their own experiences and (2b) view others’ experiences in order to gain social support or inspiration, and (3) to track behaviors and health goals. Perceived benefits and potential downsides were identified for technology use. Teens desired to use technology with their provider for 3 main reasons: (1) have questions answered outside of visits, (2) have greater access to providers as a way to build relationship/rapport, and (3) share data regarding behaviors in between visits. Social media was not a preferred method for communicating with providers for any of the youth due to concerns about privacy and intrusiveness. CONCLUSIONS Although youth are avid users of technology in general, in regard to technology for health, they display specific use preferences especially in how they wish to use it to communicate with their primary care provider. Health care providers should offer guidance to youth with regard to how they have used and plan to use technology and how to balance potential positives and negatives of use. Technology developers should take youth preferences into account when designing new health technology and incorporate ways they can use it to communicate with their health care provider.

Objective Evaluate determinants of mental health service use among depressed adolescents. Method We assessed mental health services use over the 12 months following screening among 113 adolescents (34 males, 79 females) from an integrated healthcare system who screened positive for depression (Patient Health Questionnaire-9 score ≥11). Youth characteristics (demographics, depression severity, and co-morbidity) and parent characteristics (parent history of depression, parent-report of youth externalizing and internalizing problems) were compared among youth who had received mental health services and those who had not. Multivariate regression was used to evaluate the strongest factors associated with mental health service use. Results Overall, 52% of adolescents who screened positive for depression received mental health service in the year following screening. Higher parent-reported youth internalizing problems (OR 5.37, CI 1.77–16.35), parental history of depression/anxiety (OR 4.12, CI 1.36–12.48) were significant factors associated with mental health service use. Suicidality and functional impairment were not associated with increased mental health services use. Conclusion Parental factors including recognition of the adolescent's internalizing symptoms and parental experience with depression/anxiety are strongly associated with mental health service use for depressed adolescents. This highlights the importance of educating parents about depression and developing systems to actively screen and engage youth in treatment for depression.

Importance Health risk behaviors are a leading cause of morbidity during adolescence. Screening and counseling for health risk behaviors are recommended but infrequently performed. Objective To test the effect of an electronic screening and feedback tool on clinician counseling and adolescent-reported health risk behaviors. Design, Setting, and Participants A randomized clinical trial compared electronic screening and feedback on an intention-to-treat basis with usual care among 300 youths 13 to 18 years of age at 5 pediatric clinics in the Pacific Northwest. Outcomes were assessed via electronic survey at 1 day and 3 months after the initial visit. Study data collection occurred from March 13, 2015, to November 29, 2016, and statistical analysis was conducted between February 6, 2017, and June 20, 2018. Interventions Youths in the intervention group (n = 147) received electronic screening and personalized feedback with clinician clinical decision support. Youths in the control group (n = 153) received standard screening and counseling as provided by their clinic. Main Outcomes and Measures Youths’ report of receipt of counseling during the visit and risk behaviors at 3 months. Results In the final study sample of 300 youths (intervention group, 75 girls and 72 boys; mean [SD] age, 14.5 [1.4 years]; and control group, 80 girls and 73 boys; mean [SD] age, 14.5 [1.4] years), 234 (78.0%) were aged 13 to 15 years. After adjusting for age, sex, and random effect of clinic, youths in the intervention group were more likely to receive counseling for each of their reported risk behaviors than were youths in the control group (adjusted rate ratio, 1.32; 95% CI, 1.07-1.63). Youths in the intervention group had a significantly greater reduction (β = –0.48; 95% CI, –0.89 to –0.02;P = .02) in their risk behavior scores at 3 months when compared with youths in the control group. Conclusions and Relevance Electronic screening of health risk behavior with clinical decision support and motivational feedback to teens can improve care delivery and outcomes. Trial Registration ClinicalTrials.gov identifier:NCT02360410

Polymorphisms of the serotonin transporter (SERT) gene have been shown to influence the risk for depression. The goal of this study was to investigate a possible effect of SERT polymorphisms on severity and course of depression symptoms in a community sample of adolescents.Community-dwelling adolescents (n=192) ages 13-17 years, who were at risk for depression, were followed for a period of 6 months. Subjects donated a saliva sample for genotyping of the 5-HTTLPR and STin2 VNTR polymorphisms of SERT.We found no associations between SERT genotype and severity of depressive symptoms at baseline. Depression symptom severity markedly decreased over time. For 5-HTTLPR, we observed a significant interaction between time and genotype, indicating the possibility that heterozygote genotype carriers (s/l) might experience a greater reduction in depression symptoms over time compared with adolescents with the 5-HTTLPR l/l genotype.Our study shows that for most community-dwelling adolescents, depressive symptoms decrease over time. A possible interaction effect of time and SERT genotype will require confirmation in larger studies.

© 2016 Society for Adolescent Health and Medicine Despite the recognition that behavioral and medical health conditions are frequently intertwined, the existing health care system divides management for these issues into separate settings. This separation results in increased barriers to receipt of care and contributes to problems of underdetection, inappropriate diagnosis, and lack of treatment engagement. Adolescents and young adults with mental health conditions have some of the lowest rates of treatment for their conditions of all age groups. Integration of behavioral health into primary care settings has the potential to address these barriers and improve outcomes for adolescents and young adults. In this paper, we review the current research literature for behavioral health integration in the adolescent and young adult population and make recommendations for needed research to move the field forward.

Importance Depression is one of the most common adolescent chronic health conditions and can lead to increased health care use. Collaborative care models have been shown to be effective in improving adolescent depressive symptoms, but there are few data on the effect of such a model on costs. Objective To evaluate the costs and cost-effectiveness of a collaborative care model for treatment of adolescent major depressive disorder in primary care settings. Design, Setting, and Participants This randomized clinical trial was conducted between April 1, 2010, and April 30, 2013, at 9 primary care clinics in the Group Health system in Washington State. Participants were adolescents (age range, 13-17 years) with depression who participated in the Reaching Out to Adolescents in Distress (ROAD) collaborative care intervention trial. Interventions A 12-month collaborative care intervention included an initial in-person engagement session, delivery of evidence-based treatments, and regular follow-up by master’s level clinicians. Youth in the usual care control condition received depression screening results and could access mental health services and obtain medications through Group Health. Main Outcomes and Measures Cost outcomes included intervention costs and per capita health plan costs, calculated from the payer perspective using administrative records. The primary effectiveness outcome was the difference in quality-adjusted life-years (QALYs) between groups from baseline to 12 months. The QALYs were calculated using Child Depression Rating Scale–Revised scores measured during the clinical trial. Cost and QALYs were used to calculate an incremental cost-effectiveness ratio. Results Of those screened, 105 youths met criteria for entry into the study, and 101 were randomized to the intervention (n = 50) and usual care (n = 51) groups. Overall health plan costs were not significantly different between the intervention ($5161; 95% CI, $3564-$7070) and usual care ($5752; 95% CI, $3814-$7952) groups. Intervention delivery cost an additional $1475 (95% CI, $1230-$1695) per person. The intervention group had a mean daily utility value of 0.78 (95% CI, 0.75-0.80) vs 0.73 (95% CI, 0.71-0.76) for the usual care group. The net mean difference in effectiveness was 0.04 (95% CI, 0.02-0.09) QALY at $883 above usual care. The mean incremental cost-effectiveness ratio was $18 239 (95% CI, dominant to $24 408) per QALY gained, with dominant indicating that the intervention resulted in both a net cost savings and a net increase in QALYs. Conclusions and Relevance Collaborative care for adolescent depression appears to be cost-effective, with 95% CIs far below the strictest willingness-to-pay thresholds. These findings support the use of collaborative care interventions to treat depression among adolescent youth. Trial Registration clinicaltrials.gov Identifier:NCT01140464

The purpose of this study was to examine the association between mental health disorders and subsequent risk for long-term opioid use among adolescents and young adults presenting with common chronic pain complaints (back pain, neck pain, headache, and arthritis/joint pain).Using claims data from January 1, 2001 to June 30, 2008, we conducted a longitudinal analysis of opioid use patterns among 13-24-year-old subjects presenting with a new episode of chronic pain. Long-term opioid use was defined as receiving90 days of opioids within a 6-month period with no gap of30 days in use of opioids in the 18 months after the first qualifying pain diagnosis. Mental health disorders were identified from claims in the 6 months before the first qualifying pain diagnosis.Fifty-nine thousand seventy-seven youth met criteria for a new episode of chronic pain. Among these youth, 321 (.5%) met criteria for long-term opioid use, and 16,172 (27.4%) had some opioid use. After controlling for demographic and clinical factors, youth with preexisting mental health diagnoses had a 2.4-fold increased risk of subsequently receiving long-term opioids versus no opioids (odds ratio = 2.36, 95% confidence interval = 1.73-3.23) and a 1.8-fold increased likelihood of receiving long-term opioids versus some opioids (odds ratio = 1.83, 95% confidence interval = 1.34-2.50).Mental health disorders are associated with increased risk for long-term opioid use among adolescents and emerging young adults. Further study is warranted to examine risks and benefits of long-term opioid use in this population.

Purpose To evaluate the association between history of childhood sexual abuse (CSA) and having transactional sex among adolescents who have been in foster care. Methods We used an existing dataset of youth transitioning out of foster care. Independent CSA variables included self report of history of sexual molestation and rape when participants were, on average, 17 years of age. Our outcome variables were self-report of having transactional sex ever and in the past year, when participants were an average age of 19 years. Separate multiple logistic regression analyses were conducted to assess the associations between CSA variables and transactional sex variables. Initial analyses were performed on both genders; exploratory analyses were then performed evaluating each gender separately. Total N = 732; 574 were included in the main analyses. Results History of sexual molestation was significantly associated with increased odds of having transactional sex, both ever and in the past year (OR [95% CI]: 3.21 [1.26–8.18] and 4.07 [1.33, 12.52], respectively). History of rape was also significantly associated with increased odds of having had transactional sex ever and in the past year (ORs [95% CI]: 3.62 [1.38–9.52] and 3.78 [1.19, 12.01], respectively). Odds ratios in female-only analyses remained significant and were larger in magnitude compared with the main, non-stratified analyses; odds ratios in male-only analyses were non-significant and smaller in magnitude when compared with the main analyses. Conclusions Both CSA variables were associated with increased likelihood of transactional sex. This association appears to vary by gender. Our results suggest that policymakers for youth in foster care should consider the unique needs of young women with histories of CSA when developing programs to support healthy relationships. Health care providers should also consider adapting screening and counseling practices to reflect the increased risk of transactional sex for female youth in foster care with a history of CSA.

Objectives Opioids are among the most commonly abused drugs among adolescents, and the prescription of these drugs has increased over the last decade. The goal of the current study is to examine trends and factors associated with prescription opioid use among adolescents with common non-cancer pain (NCP) conditions, sampled from two contrasting populations. Methods We conducted a secondary data analysis examining time trends from 2001 to 2005 in opioid use in two dissimilar populations: a national, commercially insured population and a state Medicaid plan. We examined trends in mean dose prescribed, mean number of prescriptions and types of medications given, as well as clinical and demographic features of adolescents receiving opioids. Results In 2005, 21% of adolescents with common NCP conditions in HealthCore and 40.2% of adolescents with NCP in Arkansas Medicaid had received prescription opioids. The majority of opioid prescriptions in both 2001 and 2005 were for DEA Schedule II and III short-acting opioids. In both samples, rates of prescription were higher for adolescents with comorbid mental health diagnoses compared to those without and for adolescents with multiple pain conditions compared to a single pain condition. Discussion Prescription of opioids among adolescents with NCP is common, and the prescription rate is higher among adolescents with multiple pain conditions and comorbid mental health disorders. Further research is necessary to determine risk factors for abuse and misuse of opioids in adolescents to help develop guidelines for use in this age group.

We evaluated whether having a naturally acquired mentor during adolescence was associated with improved adult outcomes among youth with learning disabilities (YLD). Mentored youth were more likely to have graduated from high school, reported a higher level of self-esteem, and reported a higher overall number of positive outcomes than nonmentored youth. Mentorship by teachers/guidance counselors was associated with larger differences in high school graduation rates and self-esteem compared to nonmentored youth whereas mentorship by nonteachers was associated with smaller changes in self-esteem and no differences in high school completion rates. Future research should include more in-depth, objective assessments of youths’ learning disabilities, consideration of interactions with concurrent risk factors, and efforts to clarify optimal strategies for mentoring support of YLD.

To describe the differential completion rates and cost of sequential methods for a survey of adolescents enrolled in a regional health care delivery organization.Four thousand randomly selected enrollees were invited to complete a mailed health survey. Techniques used to boost response included (1) a follow-up mailing, (2) varying the appearance of the survey, (3) reminder calls, and (4) phone calls to obtain parent and child consent and to administer the survey. We evaluated the outcome and costs of these methods.Seven hundred eighty-three enrollees (20%) completed the first mailed survey and 521 completed the second, increasing the overall response rate to 33%. Completion was significantly higher among respondents who received only the plain survey than those receiving only the color survey (P.001). Reminder calls boosted response by 8%. Switching to administration of the survey by phone boosted response by 20% to 61%. The cost per completed survey was $29 for the first mailing, $26 after both mailings, $42 for mailings and reminder calls, and $48 for adding phone surveys.The response to mailings and reminder calls was low and the cost was high, with decreasing yield at each step, although some low-cost techniques were helpful. Results suggest phone surveys may be most effective among similar samples of adolescents.

Objective Although multiple studies of adolescents have examined the association of depression with individual health risk behaviors such as obesity or smoking, this is one of the few studies that examined the association between depression and multiple risk behaviors. Methods A brief mail questionnaire, which screened for age, gender, weight, height, sedentary behaviors, physical activity, perception of general health, functional impairment and depressive symptoms, was completed by a sample of 2291 youth (60.7% response rate) aged 13–17 enrolled in a health care plan. A subset of youth who screened positive on the two-item depression screen and a random sample of those screening negative were approached to participate in a telephone interview with more in-depth information obtained on smoking and at-risk behaviors associated with drug and alcohol use. Results Youth screening positive for high levels of depressive symptoms compared to those with few or no depressive symptoms were significantly more likely to meet criteria for obesity, had a poorer perception of health, spent more time on the computer, got along less well with parents and friends, had more problems completing school work and were more likely to have experimented with smoking and a wide array of behaviors associated with drug and alcohol use. Conclusions Because many adverse health behaviors that develop in adolescence continue into adulthood, the association of depressive symptoms with multiple risk behaviors and poor functioning suggest that early interventions are needed at an individual, school, community and primary care level.

Objective Anxiety and depression are common among youth and are associated with significant morbidity. Few youth with depression are diagnosed and receive treatment for these disorders. The purpose of this study was to examine the rate of recognition and management among an insured population and the factors associated with evidence of detection among youth. Methods Structured mental health interviews assessing depression and anxiety diagnoses were completed with a random sample of 581 youth (age range 11–17 years) from an integrated health care system. Administrative data on medical and pharmacy services were used to examine any evidence of detection by the medical system in the prior 12 months. Results Fifty-one youth met criteria for an anxiety or depressive disorder. Twenty-two percent of these youth with an anxiety or depressive disorder as defined in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition had evidence of detection or treatment. Factors associated with detection and treatment included having diagnosis of a depressive disorder (with or without an anxiety disorder), more depressive symptoms, greater functional impairment, a higher number of primary care visits in the prior year, and higher parent-reported externalizing symptoms. On multivariate analysis, having more depressive symptoms and a higher number of primary care visits were significant predictors of detection and receipt of treatment. Conclusions The rate of detection and treatment of anxiety and depressive disorders is very low in this age group and suggests a need for increased focus on detection, particularly in light of recent evidence suggesting decreases in diagnosis and treatment among youth following the black box warning regarding antidepressant medications.

Objective The objectives of this study were to examine associations between depressive symptoms and body mass over 1 year during early adolescence and to assess how the associations might differ depending upon whether self-reported or directly measured height and weight were used. Method Participants were 446 sixth-grade Seattle students. Depressive symptoms were assessed using the Mood and Feelings Questionnaire. Regression models were used to examine whether baseline depression status was associated with 12-month body mass index (BMI; using self-reported height and weight) and whether baseline overweight status was associated with 12-month depressive symptom score. Analyses were rerun among a subsample ( n =165) who had height and weight directly measured. Results Using BMI derived from self-reported values, depressed males had a significantly lower BMI than nondepressed males, while depressed females had a significantly higher BMI than nondepressed females, after adjusting for covariates. Among a subsample using measured height and weight values, however, depression was no longer associated with BMI in either gender. Baseline overweight status did not predict 12-month depression score. Conclusions Observed associations between depression and subsequent BMI were explained by differential misclassification of self-reported height and weight by depression status and gender. Direct measurement of height and weight may be necessary to ensure validity in studies of adolescent depression and weight-related outcomes.

Objective Prior studies have shown a low rate of accurate identification by primary care physicians of mental health disorders in youth. This study tested the psychometric properties of 2 brief mental health screening questionnaires, the Mood and Feelings Questionnaire, short form, (MFQ-SF) and Childhood Anxiety Sensitivity Index (ASI), in a large sample of youth. Methods In a sample of 1375 youth aged 11 to 17 (779 with asthma, 596 randomly selected controls) enrolled in a health maintenance organization, the psychometric properties (optimum cutoffs on receiver operator characteristic (ROC) curves, sensitivity, specificity, positive and negative predictive values) of 2 brief anxiety and depression screens were compared with a gold standard–structured psychiatric interview. Results Both the MFQ-SF and ASI performed well on ROC analysis for screening youth for 1 or more Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) anxiety or depressive disorders. The MFQ-SF performed better on ROC analysis than the ASI for youth with major depression (area under the curve of 0.84 vs 0.77). For screening youth with anxiety disorders, ROC curves showed that both the MFQ-SF and ASI only performed in the fair range (area under the curve of 0.76). Conclusion The MFQ-SF and ASI are 2 relatively brief questionnaires that performed well for screening youth for 1 or more DSM-IV anxiety or depressive disorders. The MFQ-SF performed better than the ASI for screening youth with major depression. Use of these instruments could increase the accuracy of identification of mental health disorders in youth by primary care physicians.

Purpose To determine the prevalence of anxiety and depressive disorders in youth with asthma compared with a control sample of youth and to determine the sociodemographic and clinical characteristics associated with having one or more anxiety/depressive disorders among youth with asthma. Methods A telephone interview was offered to all youth aged 11–17 years with asthma (N = 781) and a random sample of similar aged controls (N = 598) enrolled in a Health Maintenance Organization. The C-DISC-4.0 was used to diagnose anxiety and depressive disorders and reliable and valid questionnaires were used to assess severity of anxiety and depressive symptoms. Automated diagnostic, pharmacy and health use data were used to measure asthma treatment intensity, asthma severity and nonasthmatic medical comorbidity. One parent was interviewed to assess sociodemographic variables, child/adolescent psychiatric symptoms and to confirm the asthma diagnosis. Results In all, 16.3% of youth with asthma compared with 8.6% of youth without asthma met DSM-IV criteria for one or more anxiety and depressive disorders (OR = 1.92, 95% CI=1.13–3.28). Independent factors associated with a significantly higher likelihood of meeting criteria for one or more anxiety or depressive disorders included female gender [OR = 1.96 (95% CI=1.27, 3.03)], living in a single-parent household, [OR = 1.96 (95% CI=1.26, 3.07)], more parent-reported externalizing behaviors [OR = 1.03 (95% CI=1.01, 1.05)], more recent diagnosis of asthma [OR = 0.94 (95% CI=0.89, 0.98)], and more impairment on the asthma physical health scale [OR = 0.95 (95% CI=0.94, 0.96)]. Conclusions Youth with asthma have an almost twofold higher prevalence of comorbid DSM-IV anxiety and depressive disorders compared with control youth. Clinical factors associated with meeting criteria for one or more anxiety and depressive included more recent asthma diagnosis, more impairment on the asthma physical health scale, and increased externalizing behaviors.