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Integrating behavioral health into primary care ambulatory clinics can improve management of patients presenting with suicidality in medical practices. To date, financial outcomes associated with managing suicidality in integrated care have not been documented.This study sought to evaluate both course of treatment (e.g., the patient is discharged home and referred to emergency departments [EDs]) and financial outcomes (e.g., cost to medical center) for patients presenting with suicidality in integrated pediatric primary care.Medical record review was conducted across a 6-month period. Demographics, course of treatment, and financial data were collected. Financial data were extracted using EPSi software using a cost accounting model. We documented the amount in dollars billed to the patient/insurance company and the amount reimbursed to the medical center and then calculated net margins associated with each course of treatment.Participants were 103 youth (aged 7-24 years). The results demonstrate that the integrated model of care diverted 93% of participants from the ED and that the highlighted model of care yielded cost savings for the medical center. After reimbursement, patients seen in the ED for suicide evaluations cost the medical center an average of 16 times more than patients who were managed in the primary care setting.The results document the magnitude of cost savings associated with an integrated care model for treating high-risk youth.

The publication of the Thompson et al. competencies framework for pediatric palliative care marks a third set of practice guidelines published. There is essential tension between specialist training in clinical child psychology (our “home” discipline) leading to further subspecialty training in pediatric psychology, the desired balance between the two, and impact on teaching, training, and patient care. A purpose of this invited commentary is to stimulate further awareness and subsequent discussion of the integration of more narrow practice skills in a growing and developing field, as the tendency toward greater specialization and siloed practice increases.

Objective:To examine the impact of early traumatic brain injury (TBI) on effortful control (EC) over time and the relationship of EC and executive functioning (EF) to long-term functional and social outcomes.Method:Parents of children (N = 206, ages 3–7) with moderate-to-severe TBI or orthopedic injuries (OIs) rated EC using the Child Behavior Questionnaire at 1 (pre-injury), 6, 12, and 18 months post-injury. Child functioning and social competence were assessed at 7 years post-injury. Mixed models examined the effects of injury, time since injury, and their interaction on EC. General linear models examined the associations of pre-injury EC and EC at 18 months with long-term functional and social outcomes. Models controlled for EF to assess the unique contribution of EC to outcomes.Results:Children with severe TBI had significantly lower EC than both the OI and moderate TBI groups at each post-injury time point. Both pre-injury and 18-month EC were associated with long-term outcomes. Among those with low EC at baseline, children with moderate and severe TBI had more functional impairment than those with OI; however, no group differences were noted at high levels of EC. EC had main effects on parent-reported social competence that did not vary by injury type.Conclusions:Findings suggest that EC is sensitive to TBI effects and is a unique predictor of functional outcomes, independent of EF. High EC could serve as a protective factor, and as such measures of EC could be used to identify children for more intensive intervention.

Purpose/Objective: Existing evidence suggests that the relationship between adolescent behavior problems following traumatic brain injury (TBI) and injury-related family burden may be bidirectional, with increased child behavior problems contributing to greater family burden over the first year postinjury and vice versa. We extended existing evidence by prospectively examining reciprocal influences between parent-adolescent interactions and adolescent behavior problems over the initial 2 years postinjury. Research Method/Design: Participants included 117 adolescents ages 12-17 with moderate-to-severe TBIs and their parents who participated in a randomized controlled trial. At baseline, adolescent-parent dyads completed a videotaped problem-solving task that yielded composites of negativity, effective communication, and warmth. Parents also completed a structured interview and problem checklists. Families repeated assessments at 6, 12, and 18 months postbaseline. Bidirectional associations between observed parenting behavior and adolescent behavior were examined with autoregressive cross-lagged panel analyses collapsed across the trial arms. Results: One cross-lagged model was significant, with higher observed effective communication predicting fewer externalizing behavior problems at subsequent time points, and fewer externalizing behavior problems predicting more effective communication. Other models indicated that effects were unidirectional, with observed parenting behaviors predicting externalizing behavior and everyday functioning. Conclusions/Implications: The bidirectional relationship between effective communication and adolescent externalizing behavior suggests a transactional model in pediatric TBI in which effective communication leads to reduced adolescent behavior problems and reduced behavior problems lead to improved communication over time. Findings yielded stronger evidence for parenting effects as compared to adolescent behavior effects, providing further support for clinical interventions targeting parent-adolescent interactions following TBI. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Childhood traumatic brain injury (TBI) affects over 600 000 children per year in the United States. Following TBI, children are vulnerable to deficits in psychosocial adjustment and neurocognition, including social cognition, which persist long-term. They are also susceptible to direct and secondary damage to related brain networks. In this study, we examine whether brain morphometry of the mentalizing network (MN) and theory of mind (ToM; one component of social cognition) mediates the effects of TBI on adjustment. Children with severe TBI (n = 15, Mage = 10.32), complicated mild/moderate TBI (n = 30, Mage = 10.81) and orthopedic injury (OI; n = 42, Mage = 10.65) completed measures of ToM and executive function and underwent MRI; parents rated children’s psychosocial adjustment. Children with severe TBI demonstrated reduced right-hemisphere MN volume, and poorer ToM, vs children with OI. Ordinary least-squares path analysis indicated that right-hemisphere MN volume and ToM mediated the association between severe TBI and adjustment. Parallel analyses substituting the central executive network and executive function were not significant, suggesting some model specificity. Children at greatest risk of poor adjustment after TBI could be identified based in part on neuroimaging of social brain networks and assessment of social cognition and thereby more effectively allocate limited intervention resources.

Objective To examine changes in depression and distress in parents of adolescents receiving family-problem-solving therapy (F-PST) following traumatic brain injury. Method Families of adolescents hospitalized for moderate to severe traumatic brain injury were randomized to face-to-face F-PST (34), therapist-guided online F-PST (56), or self-guided online F-PST (60). Outcomes were assessed pretreatment and 6 and 9 months later. Parents rated depression and distress on the Center for Epidemiological Studies Depression Scale and the Brief Symptom Inventory, respectively. Mixed modeling was used to examine changes over time and treatment moderators. Results The therapist-guided online group had significant reductions in parental depression over time. Analyses of slopes of recovery revealed differential improvement on the Center for Epidemiological Studies Depression Scale between the 2 online groups, with no significant change in depressive symptoms following self-guided F-PST. On the Brief Symptom Inventory Global Severity Index, the therapist-guided online group reported significant improvement from baseline to 6 months that was maintained at 9 months. The face-to-face and self-guided online groups reported significant reductions in distress between 6 and 9 months with corresponding large effect sizes. Differences on the Center for Epidemiological Studies Depression Scale between therapist-guided and self-guided online groups at the 9-month follow-up were more pronounced in families of lower socioeconomic status, t103 = -2.87; P = .005. Conclusions Findings provide further support for the utility of therapist-guided online F-PST in reducing parental depression and distress following pediatric traumatic brain injury and offer limited evidence of the efficacy of self-guided online treatment for these outcomes. Families of lower socioeconomic status may benefit more from therapist involvement.

Objective The need for behavioral health services, service utilization, and predictors of utilization was examined in children with moderate-to-severe traumatic brain injury (TBI) relative to a comparison group of children with orthopedic injury (OI) 6.8 years after injury. Methods A total of 130 children hospitalized for moderate-to-severe TBI (16 severe and 42 moderate) or OI (72) between the ages of 3 and 7 years, who were enrolled at the time of injury at 3 tertiary care children's hospital and one general hospital in Ohio, and completed a long-term follow-up 6.8 years after injury were included in analyses. Results Adolescents with TBI (moderate [38%] and severe [69%]) had significantly greater rates of need than those with OI (17%). Behavioral health services were utilized by 10% of the sample with no injury group differences (OI: 6%; moderate: 17%; severe: 13%). Early treatment and white race were associated with less service utilization; 77% had an unmet need, with no injury group differences (OI: 75%; moderate: 75%; severe: 82%). Rate of unmet need was greater among white than non-white children. Conclusion Children who sustain a TBI in early childhood experience persistent and clinically significant impairments even years after injury. Rates of unmet need were high for all injury groups. Findings underscore the importance of long-term monitoring to identify developing needs and prevent significant complications/deficits.

Background Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice’s degree of behavioral health integration. Methods Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered “Vanguard” (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice’s degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration. Discussion As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting. Trial registration ClinicalTrials.gov NCT02868983. Registered on August 16, 2016.

Although childhood traumatic brain injury (TBI) has been linked to heightened risk of impaired social skills and behavior, current evidence is weakened by small studies of variable methodological quality. To address these weaknesses, this international multi-cohort study involved synthesis of data from two large observational cohort studies of complicated mild-severe child TBI in Australia and North America. Both studies adopted a unified approach to data collection and coding procedures, providing the opportunity to merge datasets from multiple, well-characterized cohorts for which gold standard measures of social outcomes were collected during the chronic recovery phase. The study involved 218 children, including 33 children with severe TBI, 83 children with complicated mild-moderate TBI, 59 children with orthopedic injury, and 43 age- and sex-matched typically developing control children. All injured children were recruited from academic children's hospitals and underwent direct cognitive assessments including measures of theory of mind (ToM) at least 1-year post- injury. Parents rated their child's social adjustment using standardized measures of social skills, communication and behavior. Results showed a brain-injury specific effect on ToM abilities, such that children with both complicated mild to moderate and severe TBI displayed significantly poorer ToM than children without TBI. In mediator models, poorer ToM predicted poorer parent-rated self-direction and social skills, as well as more frequent behavioral symptoms. The ToM mediated the effect of severe TBI on parent ratings of communication and social skills, as well as on overall behavior symptoms. The findings suggest that deficits in ToM are evident across the spectrum of TBI severity and represent one mechanism linking severe child TBI to long-term social adjustment difficulties. The findings underscore the value of large-scale data harmonization projects to increase the quality of evidence regarding the outcomes of TBI. Clinical and scientific implications are discussed.

Objective: The COVID-19 pandemic has had a monumental impact on health care delivery The pediatric integrated primary care (IPC) program at MetroHealth Medical Center, 1 of the oldest such programs in the United States, has been profoundly changed by the COVID-19 pandemic of 2020 Method: This commentary provides a reflection on the early response of 1 established IPC program to the COVID-19 pandemic Results: Initial markers of successful adaptation to care delivery and training models include efforts that incorporate virtual consultation and telehealth practices Conclusions: The impact of the COVID-19 pandemic on pediatric psychology in IPC settings will largely depend on the flexibility and adaptability of workflows and training methods to meet the needs of the changing landscape (PsycInfo Database Record (c) 2021 APA, all rights reserved) Impact Statement Implications for Impact Statement-Pediatric integrated primary care (IPC) has been profoundly impacted by the COVID19 pandemic of 2020 The future success of IPC will depend on adapting models and training efforts that incorporate virtual and telehealth formats (PsycInfo Database Record (c) 2021 APA, all rights reserved)

White matter (WM) abnormalities, such as atrophy and hyperintensities (WMH), can be accessed via magnetic resonance imaging (MRI) after pediatric traumatic brain injury (TBI). Several methods are available to classify WM abnormalities (i.e., total WM volumes and WMHs), but automated and manual volumes and clinical ratings have yet to be compared in pediatric TBI. In addition, WM integrity has been associated reliably with processing speed. Consequently, methods of assessing WM integrity should relate to processing speed to have clinical application. This study had two goals: (1) to compare Scheltens rating scale, manual tracing, FreeSurfer, and NeuroQuant(®) methods of assessing WM abnormalities, and (2) to relate WM methods to processing speed scores. We report findings from the Social Outcomes of Brain Injury in Kids (SOBIK) study, a multi-center study of 60 children with chronic TBI (65% male) from ages 8–13. Scheltens WMH ratings had good to excellent agreement with WMH volumes for both NeuroQuant (ICC = 0.62; r = 0.29, p = 0.005) and manual tracing (ICC = 0.82; r = 0.50, p = 0.000). NeuroQuant WMH volumes did not correlate with manually traced WMH volumes (r = 0.12, p = 0.21) and had poor agreement (ICC = 0.24). NeuroQuant and FreeSurfer total WM volumes correlated (r = 0.38, p = 0.004) and had fair agreement (ICC = 0.52). The WMH assessment methods, both ratings and volumes, were associated with processing speed scores. In contrast, total WM volume was not related to processing speed. Measures of WMH may hold clinical utility for predicting cognitive functioning after pediatric TBI.

PURPOSE: Examine the impact of traumatic brain injury (TBI) on parenting behavior over time. METHOD: Included 206 children (3–7 years old) with moderate-severe TBI or orthopedic injury, using a prospective longitudinal cohort study design. Assessments completed at baseline, 6-months, 12-months, 18-months, 3.5 years, and 6.8 years after injury. Dependent variables included authoritative, permissive, and authoritarian parenting. RESULTS: Injury characteristics had limited impact on parenting behaviors over time. Levels of authoritative parenting remained stable over time; however, levels of warmth and involvement declined over time for those with TBI. Levels of permissive and authoritarian parenting declined for all participants by 3.5 years post injury. SES and stressors impacted parenting behaviors. CONCLUSIONS: While there was limited effect of TBI on parenting behavior over time, it remains unclear how individuals respond to these parenting behaviors years after injury. Clinicians should monitor family and parenting behaviors to foster an environment to promote positive recovery.

Introduction: The objective of this manuscript is to describe the methodology that will be used to test the comparative effectiveness, feasibility, and acceptability of three formats of family problem solving therapy (F-PST) for improving functional outcomes of complicated mild to severe adolescent TBI. Methods: Three-arm comparative effectiveness, randomized clinical trial (RCT) design. We describe the protocol of a three-arm RCT comparing the effectiveness of three modalities of F-PST to reduce executive dysfunction and behavior problems following TBI in adolescence. The RCT will compare the relative effectiveness among face-to-face; online and self-directed; and therapist-supported online modes of treatment. Ethics and dissemination: It is anticipated that findings from this work will inform future clinical care practices, with implications for treatment of other patient populations of youth with psychological symptoms arising from neurological conditions. Institutional review board approval will be obtained from all sites prior to commencement of the study. Clinical Trials Registration: NCT:02368366, Keywords: Pediatric traumatic brain injury, Telehealth, Problem solving, Behavior, Executive function

Objective The present study sought to examine adolescents’ perceptions of their interpersonal stressors and resources across parent, sibling, friend, and school relationships, and the longitudinal associations with self-reported adjustment after traumatic brain injury (TBI) over a 12-month period. Methods We examined the main effects of stressors and resources on internalizing and externalizing symptoms in 152 adolescents who had sustained complicated mild-to-severe TBI. We also investigated the conjoint effects of stressors and resources and the moderating effects of TBI severity with stressors and resources on outcomes. Results High stressors consistently predicted worse adjustment. High resources were generally only associated with fewer internalizing symptoms. Main effects were qualified by interactions between school stressors and resources in predicting externalizing symptoms and between friend stressors and resources in predicting internalizing and externalizing symptoms. For school stressors, the effects of resources on externalizing symptoms functioned as a buffer. In comparison, the buffering effects of friend resources on internalizing and externalizing symptoms disappeared at moderate-to-high levels of friend stress. Moderating effects of TBI severity were also observed, such that as family resources increased, only adolescents with complicated mild-to-moderate TBI, but not those with severe TBI, experienced decreases in internalizing and eternalizing symptoms. Conclusion Interpersonal stressors and social support have important implications for adolescent adjustment after TBI. Adolescents with low levels of school resources, with high levels of friend stress, and who sustain severe TBI are at greatest risk for difficulties with adjustment.

Growing numbers of transgender and gender-nonconforming (TGNC) youth are presenting for medical and mental health care, and increasingly, pediatric psychologists are being called upon to serve as critical members of interdisciplinary care teams. In this commentary, we present information on TGNC youth in three distinct developmental cohorts: prepubescent TGNC children, peripubertal TGNC youth, and pubertal TGNC adolescents. First, we describe the social, medical, and/or surgical treatments available to each cohort of youth. Next, we address the state of the science related to these treatments. Then, we highlight some of the ongoing controversies related to social, medical and/or surgical interventions that are most relevant to pediatric psychologists and the role they play in gender-affirming care. Finally, we conclude with a call for papers for an upcoming special issue of Clinical Practice in Pediatric Psychology focused on advancing the practice of pediatric psychology in transgender health care. Keywords: gender dysphoria; transgender; gender diversity; interdisciplinary care; gender affirmative care

Objective To examine the prevalence of academic need, academic service utilization, and unmet need as well as factors associated with academic service utilization 6.8 years after traumatic brain injury (TBI) in early childhood. Methods Fifty-eight (16 severe, 14 moderate, 28 complicated mild) children with TBI and 72 children with orthopedic injury (OI) completed the long-term follow-up 6.8 years after injury in early childhood (ages 3-7 years). Injury group differences in rates of need for academic services, academic service utilization, and unmet need as well as factors associated with service utilization and unmet need were examined. Results Students with moderate and severe TBI had significantly greater rates of need than those with OI. A greater proportion of the severe TBI sample was receiving academic services at long-term follow-up than the OI and complicated mild groups however, among those with an identified need, injury group did not affect academic service utilization. Below average IQ/achievement scores was the only area of need predictive of academic service utilization. Rates of unmet need were high and similar across injury groups (46.2%-63.6%). Conclusion The need for academic services among patients who sustained a TBI during early childhood remains high 6.8 years post injury. Findings underscore the importance of continued monitoring of behaviors and academic performance in students with a history of early childhood TBI. This may be especially true among children with less severe injuries who are at risk for being underserved.

Purpose/objective To describe the Teen Online Problem Solving-Teen Only (TOPS-TO) intervention relative to the original Teen Online Problem Solving-Family (TOPS-F) intervention, to describe a randomized controlled trial to assess intervention efficacy, and to report feasibility and acceptability of the TOPS-TO intervention. Research method and design: This is a multisite randomized controlled trial, including 152 teens (49 TOPS-F, 51 TOPS-TO, 52 IRC) between the ages of 11-18 who were hospitalized for a moderate to severe traumatic brain injury in the previous 18 months. Assessments were completed at baseline, 6-months post baseline, and 12-months post baseline. Data discussed include adherence and satisfaction data collected at the 6-month assessment (treatment completion) for TOPS-F and TOPS-TO. Results Adherence measures (sessions completed, dropout rates, duration of treatment engagement, and rates of program completion) were similar across treatment groups. Overall, teen and parent reported satisfaction was high and similar across groups. Teens spent a similar amount of time on the TOPS website across groups, and parents in the TOPS-F spent more time on the TOPS website than those in the TOPS-TO group (p = .002). Parents in the TOPS-F group rated the TOPS website as more helpful than those in the TOPS-TO group (p = .05). Conclusions/implications TOPS-TO intervention is a feasible and acceptable intervention approach. Parents may perceive greater benefit from the family based intervention. Further examination is required to understand the comparative efficacy in improving child and family outcomes, and who is likely to benefit from each approach. (PsycINFO Database Record

Objectives:This study examined the relationship of the home environment to long-term executive functioning (EF) following early childhood traumatic brain injury (TBI).Methods:Participants (N=134) were drawn from a larger parent study of 3- to 6-year-old children hospitalized for severe TBI (n=16), complicated mild/moderate TBI (n=44), or orthopedic injury (OI;n=74), recruited prospectively at four tertiary care hospitals in the United States and followed for an average of 6.8 years post-injury. Quality of the home environment, caregiver psychological distress, and general family functioning were assessed shortly after injury (i.e., early home) and again at follow-up (i.e., late home). Participants completed several performance-based measures of EF at follow-up. Hierarchical regression analyses examined the early and late home environment measures as predictors of EF, both as main effects and as moderators of group differences.Results:The early and late home environment were inconsistent predictors of long-term EF across groups. Group differences in EF were significant for only the TEA-Ch Walk/Don’t Walk subtest, with poorer performance in the severe TBI group. However, several significant interactions suggested that the home environment moderated group differences in EF, particularly after complicated mild/moderate TBI.Conclusions:The home environment is not a consistent predictor of long-term EF in children with early TBI and OI, but may moderate the effects of TBI on EF. The findings suggest that interventions designed to improve the quality of stimulation in children’s home environments might reduce the long-term effects of early childhood TBI on EF. (JINS, 2018,24, 11–21)

OBJECTIVE: This study examined how the family environment predicts long-term academic and behavioral functioning in school following traumatic brain injury (TBI) in early childhood. METHOD: Using a concurrent cohort, prospective design, 15 children with severe TBI, 39 with moderate TBI, and 70 with orthopedic injury (OI) who were injured when they were 3-7 years of age were compared on tests of academic achievement and parent and teacher ratings of school performance and behavior on average 6.83 years postinjury. Soon after injury and at the longer term follow-up, families completed measures of parental psychological distress, family functioning, and quality of the home environment. Hierarchical linear regression analyses examined group differences in academic outcomes and their associations with measures of the early and later family environment. RESULTS: The severe TBI group, but not the moderate TBI group, performed worse than did the OI group on all achievement tests, parent ratings of academic performance, and teacher ratings of internalizing problems. Higher quality early and late home environments predicted stronger academic skills and better classroom behavior for children with both TBI and OI. The early family environment more consistently predicted academic achievement, whereas the later family environment more consistently predicted classroom functioning. The quality of the home environment predicted academic outcomes more strongly than did parental psychological distress or family functioning. CONCLUSION: TBI in early childhood has long-term consequences for academic achievement and school performance and behavior. Higher quality early and later home environments predict better school outcomes for both children with TBI and children with OI. (PsycINFO Database Record(c) 2017 APA, all rights reserved). Language: en

OBJECTIVE: To identify latent trajectories of executive functioning (EF) recovery overtime after childhood traumatic brain injury (TBI) and examine the predictive value of known risk factors within and across recovery trajectories using latent class growth modeling (LCGM). METHOD: A total of 206 children between the ages of 3 and 7 years with a moderate to severe TBI or orthopedic injury (OI) were included. LCGM was applied to identify longitudinal trajectories of postinjury EF as assessed by the Behavior Rating Inventory of Executive Functioning General Executive Composite (GEC). Separate models were estimated for the TBI and OI groups. RESULTS: Two TBI trajectories-normal limits (70.8%) and clinically elevated (29.2%)-and 3 OI trajectories-normal limits (20.9%), subclinical (49.0%), and clinically elevated (30.17%)-were identified. Baseline GEC was the only predictor of class membership for all models. Both TBI trajectories demonstrated an increase in GEC over time, whereas only 1 of the 3 OI classes demonstrated this pattern. Family variables were associated with GEC across trajectories. CONCLUSION: The lack of association of injury characteristics with trajectory class membership highlights the heterogeneity in recovery after pediatric TBI. Associations of EF trajectories with family factors underscore the importance of involving the family in interventions for children with traumatic injuries. Language: en

Objective The Ohio Head Injury Outcomes study was a 12-year longitudinal study of early childhood traumatic brain injury (TBI). This article reviewed the findings pertaining to caregiver and family functioning and child cognition, behavior, social competence, emotional functioning, and academics. We further considered individual and social-environmental influences on recovery and interventions. Setting Recruitment was completed at 3 children's hospitals and 1 general hospital. Participants Children aged 3 to 7 years at the time of injury with complicated mild to moderate and severe TBI or orthopedic injury requiring hospitalization were included. Design A concurrent cohort/prospective research design was used. A baseline assessment was completed shortly after the injury. Follow-up assessments were completed at 6, 12, and 18 months and at an average of 38 and 82 months postinjury. Main measures At baseline, parents/guardians completed retrospective ratings of their child's behavioral, emotional, and social functioning preinjury. At the subsequent assessments, ratings reflected current functioning. Information about current family and caregiver functioning was collected at each time point and cognitive testing was completed at selected time points. Results and conclusions Recovery after TBI is complex, varies over time, and involves injury-related and premorbid influences, cognition, genetics, and caregiver and family functioning. A sizable number of children with TBI have persisting unmet clinical needs.

OBJECTIVE: To examine the comparative effectiveness of three modes of family problem-solving therapy (F-PST): therapist-guided online, self-guided online, and face-to-face. SETTING: Four children’s hospitals and a general hospital with pediatric commitment. PARTICIPANTS: 150 adolescents aged 14 to 18 years, previously hospitalized with traumatic brain injury (TBI), and evidence of behavior problems at enrollment. DESIGN: Multicenter, randomized clinical trial (RCT). MAIN MEASURES: Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC), Behavior Regulation Index (BRI), and Metacognitive Index (MI) and Strengths and Difficulties Questionnaire total (SDQ) at baseline and 6 and 9 months later. RESULTS: Mixed model intention-to-treat analyses of comparative effectiveness failed to reveal statistically significant differences among treatment groups. At six months, parent BRIEF-GEC improved for the therapist-guided and self-guided, online groups. Effects remained significant and increased in magnitude at 9 months for the self-guided online group. Scores for the Self-guided online group significantly improved from baseline to 9 months on the SDQ Total. CONCLUSIONS: This comparative effectiveness study supports the utility of both self- and therapist-guided online F-PST in improving executive function behaviors in adolescents following TBI. Further work regarding clinical implementation and how best to integrate telehealth with ongoing rehabilitation care is warranted.

Pediatric psychologists have a long and rich history in a variety of medical settings, including pediatric primary care. Pediatric primary care settings provide the opportunity to extend beyond traditional inpatient-based models and provide impactful consultation, assessment, and intervention strategies to a cross section of children, families, and integrated clinical team members. Consider this: at least half of mental health problems present initial symptoms by the age of 14 (Kessler et al., 2007), yet there are many barriers that can impede effective screening, assessment, and intervention in pediatric primary care settings. Children and families who are offered on-site behavioral health care are twice as likely to initiate treatment than those who are referred elsewhere for treatment (Kolko et al., Pediatrics 133:e981–e992, 2014).

OBJECTIVE To examine changes in quality of life (QoL) in adolescents receiving family problem-solving therapy (F-PST) following traumatic brain injury (TBI). METHOD Adolescents hospitalized for moderate-to-severe TBI were randomized to 1 of 3 ten-session, 6-month long treatments: face-to-face F-PST (n = 34), therapist-guided online F-PST (n = 56), and self-guided online F-PST (n = 60). Participants included 96 boys and 54 girls, of whom 124 were White and 6 were Hispanic. Outcomes were assessed pretreatment and 6 and 9 months later. Adolescents and parents rated adolescent QoL and TBI-related symptoms on the PedsQL and Health and Behavior Inventory (HBI), respectively. We used mixed modeling to examine changes over time and moderators of treatment efficacy. RESULTS Therapist- and self-guided online groups demonstrated improvements in parent-proxy QoL from baseline to 9 months, Cohen's d = 0.75; p = .004 and Cohen's d = 1.30; p < .001, respectively. The face-to-face group had poorer parent-proxy QoL at 6 months (M = 62, SE = 3.4) than either the therapist- (M = 70.9, SE = 2.8) or self-guided online group (M = 71.1, SE = 2.6). There were no changes or group differences in self-reported QoL over time. Similar findings were observed on the HBI. Differential treatment effects on parent-proxy outcomes were found in boys versus girls and in those from single versus 2-parent households. Improvements in parent-proxy HBI ratings mediated QoL improvements. CONCLUSIONS Both online treatments, but not face-to-face F-PST, were associated with clinical improvements, raising questions about our current delivery paradigm. Individual and family moderators of treatment efficacy underscore the potential of personalized treatment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Autism spectrum disorder (ASD) screening completion rates are often low despite their validity and influence on earlier intervention and positive treatment outcomes. This study sought to examine the use of one ASD screening tool, the Modified Checklist for Autism in Toddlers-Revised (MCHAT-R), in a racially and ethnically diverse urban pediatric clinic to review potential disparities within screening rates and referral practices.A retrospective chart review was conducted for children (N = 999) within the ages of 17 to 34 months seen for a well-child appointment at one of 3 pediatric clinics: a general pediatric clinic, resident pediatric clinic, and Hispanic pediatric clinic.MCHAT-R screening completion rates were low for all clinics. There were no significant differences in MCHAT-R screening completion based on ethnicity; however, the percentage of children screening positive on the MCHAT-R was significantly higher for Hispanic versus non-Hispanic children. Referral practices were highly variable across positive screenings, and few children received the appropriate combination of referrals.Ethnic disparities in ASD positive screening rates and inconsistent referrals represent a critical issue in current pediatric practice. There is a great need for the development of more culturally sensitive ASD screening instruments. Additionally, to help increase ASD screening rate and accuracy, as well as consistency in referrals, greater emphasis is needed on professional training, parental education, and technology use within pediatric clinics.

Objective: Traumatic brain injury (TBI) sustained in childhood is associated with poor social outcomes. This study investigated the role of theory of mind (ToM) as a mediator of the relation between TBI and peer rejection/victimization and reciprocated friendships, as well as the moderating effect of parental nurturance on those relationships. Method: Participants were children of 8–13 years old (M = 10.45, SD = 1.47), including 13 with severe TBI, 39 with complicated mild/moderate TBI, and 32 children with orthopedic injuries. Data on peer rejection/victimization and friendship were collected in school classrooms using the Extended Class Play and friendship nominations. Parents rated parental nurturance using the Child-Rearing Practices Report. Finally, ToM was measured based on children’s average performance across three tasks measuring different aspects of ToM. Results: Severe TBI was associated with poorer ToM, greater peer rejection/victimization, and fewer reciprocated friendships. ToM mediated the relation between severe TBI and peer rejection/victimization (i.e., severe TBI predicted poorer ToM, which in turn predicted greater rejection/victimization). Parental nurturance significantly moderated this relation, such that the mediating effect of ToM was significant only at low and average levels of parental nurturance, for both severe and complicated mild/moderate TBI groups. Neither the mediating effect of ToM nor the moderating effect of parental nurturance was significant for reciprocated friendships. Conclusion: High parental nurturance may mitigate the negative effects of ToM deficits on risk of peer rejection/victimization among children with TBI. Interventions designed to increase parental nurturance or ToM may promote better social outcomes among children with TBI.

OBJECTIVE: This study sought to determine whether parenting styles predict long-term psychosocial outcomes after traumatic brain injury in young children. METHODS: The study involved a concurrent cohort, prospective design, with longitudinal assessments up to early adolescence. Participants included 126 children with moderate to severe traumatic brain injury or orthopaedic injury, ages 3 to 6 years 11 months, recruited between 2003 and 2006. Parents rated children’s pre-injury behavioral adjustment, social competence, and executive functioning shortly after injury, and again 6.8 years post injury. Parents also rated their parenting styles (permissive, authoritarian, authoritative) at both occasions. RESULTS: After controlling for pre-injury functioning, the groups differed significantly on all three outcomes (ΔR(2) .07 to .13). Later but not early parenting styles predicted outcomes in all groups (ΔR(2) .06 to .17): more permissive parenting predicted worse outcomes in all domains (β = −0.18, 0.20, 0.27); and more authoritative parenting predicted better social competence and executive functioning (β = −0.17, 0.46). Severe traumatic brain injury interacted with parenting style for several outcomes, with ineffective parenting exacerbating the negative sequelae. CONCLUSIONS: Parenting style predicts children’s long-term psychosocial functioning after early childhood injury, and may moderate the effects of early traumatic brain injury.

PURPOSE/OBJECTIVE: Traumatic brain injury (TBI) in adolescence has well documented effects on social competence. Few studies have examined the effects of behavioral interventions on social competence or identified factors associated with changes in social competence after injury. Research Method/Design: Adolescents with moderate to severe TBI ages 12-17 years were randomized within 6 months of injury to either a problem solving and communication (CAPS) group that received online counseling (n = 65) or an Internet resources comparison (IRC) group (n = 67) for a comparative effectiveness trial. Parent-report measures of social competence (Child Behavior Checklist, CBCL; Home and Community Social Behavior Scales, HCSBS; Behavioral and Emotional Rating Scale, BERS-2) were administered at baseline (preintervention) and approximately 6 months later. Analyses examined these measures in relation to treatment group, TBI severity, and age. Regression analyses were also conducted to examine baseline measures of cognition as predictors of social competence after TBI. RESULTS: CAPS had a more positive effect than the comparison condition on the HCSBS and BERS-2 for younger teens with moderate TBI and older teens with severe TBI. More parent-rated executive dysfunction at baseline was related to both lower concurrent levels of social competence and less positive gains in competence over time, whereas higher baseline IQ predicted greater gains in competence. CONCLUSIONS/IMPLICATIONS: CAPS may be effective for improving social competence for teens after TBI, with benefits dependent on the teen's age and injury severity. Parent-rated executive dysfunction, moreover, has utility in predicting both lower concurrent levels of social competence and subsequent postinjury gains in competence. (PsycINFO Database Record(c) 2016 APA, all rights reserved). Language: en

OBJECTIVE: Pediatric traumatic brain injury (TBI) may affect children's ability to perform everyday tasks (i.e., adaptive functioning). Guided by the American Association for Intellectual and Developmental Disabilities (AAIDD) model, we explored the association between TBI and adaptive functioning at increasing levels of specificity (global, AAIDD domains, and subscales). We also examined the contributions of executive function and processing speed as mediators of TBI's effects on adaptive functioning. METHOD: Children (ages 8-13) with severe TBI (STBI; n = 19), mild-moderate TBI (MTBI; n = 50), or orthopedic injury (OI; n = 60) completed measures of executive function (TEA-Ch) and processing speed (WISC-IV) an average of 2.7 years postinjury (SD = 1.2; range: 1-5.3). Parents rated children's adaptive functioning (ABAS-II, BASC-2, CASP). RESULTS: STBI had lower global adaptive functioning (η2 =.04-.08) than the MTBI and OI groups, which typically did not differ. Deficits in the STBI group were particularly evident in the social domain, with specific deficits in social participation, leisure, and social adjustment (η2 =.06-.09). Jointly, executive function and processing speed were mediators of STBI's effects on global adaptive functioning and in conceptual and social domains. In the STBI group, executive function mediated social functioning, and processing speed mediated social participation. CONCLUSIONS: Children with STBI experience deficits in adaptive functioning, particularly in social adjustment, with less pronounced deficits in conceptual and practical skills. Executive function and processing speed may mediate the effects of STBI on adaptive functioning. Targeting adaptive functioning and associated cognitive deficits for intervention may enhance quality of life for pediatric TBI survivors. (PsycINFO Database Record(c) 2016 APA, all rights reserved). Language: en

Whether to address behavioral health issues in pediatric primary care is no longer debated; instead, we are challenged to determine "how" and who can best deliver services in an effective and sustainable manner. This commentary explores how pediatric psychology can contribute to this discussion by developing and evaluating innovative clinical models (such as a hybrid Collaborative Care/Primary Care Behavioral Health model) and expanding workforce and teaching initiatives.

In a sample of children with traumatic brain injury, this magnetic resonance imaging (MRI)–based investigation examined whether presence of a focal lesion uniquely influenced cortical thickness in any brain region. Specifically, the study explored the relation of cortical thickness to injury severity as measured by Glasgow Coma Scale score and length of stay, along with presence of encephalomalacia, focal white matter lesions or presence of hemosiderin deposition as a marker of shear injury. For comparison, a group of children without head injury but with orthopedic injury of similar age and sex were also examined. Both traumatic brain injury and orthopedic injury children had normally reduced cortical thickness with age, assumed to reflect neuronal pruning. However, the reductions observed within the traumatic brain injury sample were similar to those in the orthopedic injury group, suggesting that in this sample traumatic brain injury, per se, did not uniquely alter cortical thickness in any brain region at the group level. Injury severity in terms of Glasgow Coma Scale or longer length of stay was associated with greater reductions in frontal and occipitoparietal cortical thickness. However, presence of focal lesions were not related to unique changes in cortical thickness despite having a prominent distribution of lesions within frontotemporal regions among children with traumatic brain injury. Because focal lesions were highly heterogeneous, their association with cortical thickness and development appeared to be idiosyncratic, and not associated with group level effects.

Objective To examine the effectiveness of a web-based parenting intervention (Internet-Based Interacting Together Everyday: Recovery After Childhood TBI [I-InTERACT]) and an abbreviated version (Express) in reducing executive dysfunction and internalizing problems among young children following traumatic brain injury (TBI). Method Parents of 113 children (ages 3-9 years) who had sustained a TBI were randomized to 1 of 3 treatment groups: I-InTERACT, Express, or an Internet Resource Comparison (IRC) group. Parents who participated in either I-InTERACT or Express completed self-guided web sessions and received live coaching of their parenting skills via videoconferencing with a therapist. I-InTERACT included additional psychoeducation, stress management, and family communication skills (eg, marriage, grief, pain, and sleep). Analyses of covariance were utilized to compare the groups on parent-reported executive function behaviors (ie, Behavior Rating Inventory of Executive Function) and internalizing symptoms (ie, Child Behavior Checklist) at baseline and 6 months. Results Parents who participated in Express reported significantly lower levels of executive dysfunction than those in I-InTERACT, β = -0.49; t(2, 73) = -2.47, P = .048, and significantly lower levels of withdrawal than those in the IRC group, β = -0.44; t(2, 74) = -2.22, P = .03. The Express group did not significantly differ from the IRC group on executive function behaviors or the I-InTERACT group on internalizing problems, all P > .05. Children with more problems at baseline, families with lower education levels, and parents with more symptoms of depression benefited most. Conclusion A brief, online parent training intervention may be efficacious in improving executive dysfunction and internalizing problems following early TBI, particularly among children of lower socioeconomic status or with existing behavioral concerns.

Objective To examine parent and family outcomes of a randomized controlled trial (RCT) comparing Teen Online Problem-Solving with Family (TOPS-F), Teen Online Problem-Solving-Teen Only (TOPS-TO), or access to Internet resources alone (Internet resource comparison [IRC]). Design Three-arm RCT. Setting Four children’s hospitals and 1 general medical center in Ohio and Colorado. Participants Children and adolescents (N=152), 11-18 years old, hospitalized for complicated mild to severe traumatic brain injury in the previous 18 months. Interventions Intervention groups: TOPS-F, TOPS-TO, and IRC. Main Outcome Measure Parental depression (CES-D), parental psychological distress (SCL-90-GSI), family functioning (FAD-GF), cohesiveness (PARQ), and conflict (IBQ) were assessed pre- and post-treatment. Treatment effects and the moderating effect of the number of parents in the home (single vs 2-parent families). Results Number of parents moderated treatment effects with effects ranging from trending to statistically significant for depression, family functioning, cohesion, and conflict. Among single parents, TOPS-TO reported better family functioning than TOPS-F and greater cohesion and less conflict than IRC. Among 2-parent families, TOPS-F reported less depression than IRC and less depression and greater cohesion than TOPS-TO. The effect of family composition was also noted within TOPS-TO and TOPS-F. In TOPS-F, 2-parent families reported less depression than single-parent families. In TOPS-TO single parents reported greater cohesion and better family functioning than 2-parent families. Conclusions Findings support the TOPS intervention improves family outcomes, with differential effects noted for single vs 2-parent households. The TOPS-TO format appeared more beneficial for single-parent households, while TOPS-F was more beneficial for 2-parent households, highlighting the importance of considering family composition when determining the best treatment modality.

Objective To estimate additional payments associated with co-existing mental health or substance use disorders (MH/SUDs) among commercially insured children and youth with chronic medical conditions (CMCs) and to determine whether children's MH/SUDs have similar associations with parental health care payments. Methods Cross-sectional analysis of a national database of paid commercial insurance claims for 2012–2013. Participants were children and youth ages 0 to 26 years covered as dependents on parents’ health insurance and categorized by the presence or absence of any of 11 chronic medical conditions and MH/SUDs. We determined the numbers of children and youth with CMCs and paid health care claims categorized as hospital, professional, and pharmacy services and as medical or behavioral. We compared paid claims for children and youth with CMCs with and without co-occurring MH/SUDs and for their parents. Results The sample included almost 6.6 million children and youth and 5.8 million parents. Compared to children without CMCs, children with CMCs had higher costs, even higher for children with CMCs who also had MH/SUDs. Children with CMCs and co-occurring MH/SUDs had 2.4 times the annual payments of those with chronic conditions alone, especially for medical expenses. Estimated additional annual payments associated with MH/SUDs in children with CMCs were $8.8 billion. Parents of children with CMCs and associated MH/SUDs had payments 59% higher than those for parents of children with CMCs alone. Conclusions MH/SUDs in children and youth with CMCs are associated with higher total health care payments for both patients and their parents, suggesting potential benefits from preventing or reducing the impact of MH/SUDs among children and youth with CMCs.

Objective To characterize treatment preferences for delivery of family problem-solving treatment (F-PST) to adolescents with behavioral challenges following traumatic brain injury (TBI) and to examine associations with attrition, adherence, satisfaction, and efficacy. Method Adolescents who had been hospitalized for moderate to severe TBI were randomized to face-to-face F-PST (n = 34), therapist-guided online F-PST (n = 56), and self-guided online F-PST (n = 60). Adolescents and parents rated treatment convenience and anticipated benefit before group assignment. Sessions completed served as an index of adherence. Satisfaction was rated posttreatment. The Behavior Rating Inventory of Executive Function and Strengths and Difficulties Questionnaire were used to assess parent-reported behavioral concerns. Results Both parents and adolescents were more likely to agree or strongly agree that they anticipated self-guided online F-PST to be the most convenient relative to either of the therapist-involved approaches. Parents were also less likely to anticipate face-to-face treatment as most beneficial, relative to the two online treatments. Adolescent preferences were significantly related to attrition with 27% versus 13% dropout rates for those assigned to nonpreferred and preferred treatments, respectively. Parent and adolescent preferences before treatment were unrelated to post-intervention satisfaction, adherence, or improvements in parent-reported child behavior problems. Conclusions Online treatments are perceived favorably among adolescents with TBI and their parents. For adolescents, these pretreatment preferences influenced treatment completion. Poor correspondence between initial preferences and posttreatment satisfaction and benefit suggests that therapeutic experience more strongly influences ultimate satisfaction.

Recent health care legislation and shifting health care financing strategies are transforming health and behavioral health (a broad term referring to mental health, substance use, and health behavior) care in the United States. Advances in knowledge regarding effective treatment and services coupled with incentives for innovation in health and behavioral health care delivery systems make this a unique time for mobilizing our science to enhance the success of health and behavioral health care redesign. To optimize the potential of our current health care environment, a team was formed composed of leaders from the Societies of Clinical Child & Adolescent Psychology, Pediatric Psychology, and Child and Family Policy and Practice (Divisions 53, 54, and 37 of the American Psychological Association). This team was charged with reviewing the scientific and policy literature with a focus on five major issues: (a) improving access to care and reducing health disparities, (b) integrating behavioral health care within primary care, (c) preventive services, (d) enhancing quality and outcomes of care, and (e) training and workforce development. The products of that work are summarized here, including recommendations for future research, clinical, training, and policy directions. We conclude that the current emphasis on accountable care and evaluation of the outcomes of care offer numerous opportunities for psychologists to integrate science and practice for the benefit of our children, families, and nation. The dramatic changes that are occurring in psychological and behavioral health care services and payment systems also require evolution in our practice and training models.

Little is known regarding the predictors of social deficits that occur following childhood traumatic brain injury (TBI). The current study sought to investigate social problem solving (SPS) and its relationship to social adjustment after TBI.Participants included 8-13 year old children, 25 with severe TBI, 57 with complicated mild-to-moderate TBI and 61 with orthopaedic injuries (OI). Children responded to scenarios involving negative social situations by selecting from a fixed set of choices their causal attribution for the event, their emotional reaction to the event and how they would behave in response. Parent ratings of social behaviours and classmate friendship nominations and sociometric ratings were obtained for a sub-set of all participants.Children with severe TBI were less likely than children with OI to indicate they would attribute external blame or respond by avoiding the antagonist; they were more likely to indicate they would feel sad and request adult intervention. Although several SPS variables had indirect effects on the relationship between TBI and social adjustment, clinical significance was limited.The findings suggest that, while children with TBI display atypical SPS skills, SPS cannot be used in isolation to accurately predict social adjustment.

Objective The goal of the current study was to test a proposed model of social competence for children who have suffered a traumatic brain injury (TBI). We hypothesized that both peer and teacher reports of social behavior would mediate the relation between intraindividual characteristics (e.g., executive function) and peer acceptance. Methods Participants were 52 children with TBI (M age = 10.29; M time after injury: 2.46 years). Severity of TBI ranged from complicated mild to severe. Classroom and laboratory measures were used to assess executive function, social behavior, and peer acceptance. Results Analyses revealed that peer reports of social behavior were a better mediator than teacher reports of the associations between executive function, social behaviors, and peer acceptance. Discussion The results underscore the importance of including peer reports of social behavior when developing interventions designed to improve the social, emotional, and behavioral outcomes of children with TBI.