Families, Systems, & Health

Addressing mental health, earlier in pediatric primary care: Introduction to the special section.
Leading national health organizations have declared pediatric mental health an urgent public health issue. Pediatric primary care is an ideal setting to improve mental health in young children; however, various existing barriers limit the effective identification of social–emotional risk among toddlers. This special section of Families, Systems, & Health includes four articles that identify multilevel barriers and facilitators to population-level early childhood mental health screening, identification, and referral and describe implementation strategies that may be used to improve pediatric mental health. In the first article, authors describe clinicians’ concerns regarding the social–emotional screening of young children. In the second article, authors highlight the potential for a transdiagnostic screening tool for assessing toddler irritability that may support clinical decision making. In the third article, authors use information gathered from clinicians to generate a logic model that can guide the implementation of screening and referral for toddlers with elevated social–emotional risk. In the fourth article, authors explore caregivers’ perceptions of other factors, such as effectiveness, demand, and cost, of the proposed intervention, that may impact their service engagement. Together, these articles outline a plan for facilitating early childhood mental health screening, identification, and referral that has the potential for reducing the prevalence of pediatric mental health diagnoses. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
A vision for implementing equitable early mental health and resilience support in pediatric primary care: A transdiagnostic, developmental approach.
Introduction: Primary care is at the forefront of addressing the pediatric mental health (MH) crisis due to its broad reach to young children and prevention and health promotion orientation. However, the promise of the delivery system for population impact remains unrealized due to several barriers, including pragmatic screening, decisional uncertainty, and limited access to evidence-based services. Method: This article lays the conceptual foundations for the articles in this Special Section on Mental Health, Earlier in Pediatric Primary Care, which all apply a translational mindset to proposed strategies and solutions to overcome the barriers that have limited the potential of pediatric primary care for improving the MH and wellbeing of all children. Results: Valid, pragmatic, transdiagnostic, developmentally-based screening measures to identify children at heightened risk are needed. Risk screening for MH problems should assess and empirically weight socioecological risk and protective factors, as well as the child’s own assets for resilience to determine probabilistic risk. Pediatric clinicians require clear clinical cutoffs and guidelines for action when risk for MH problems is identified. Discussion: These strategies—a developmentally-based screener with associated risk calculator that offers clear guidance to pediatric clinicians—address decisional uncertainty regarding when to worry and when to act. The communication of probabilistic risk requires additional client-centered communication skills to overcome different types of biases (e.g., implicit, benevolent, and cognitive) that contribute to MH inequities and decisional uncertainty in acting on identified risk. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Possible unintended consequences of pediatric clinician strategies for communicating about social-emotional and developmental concerns in diverse young children.
Introduction: Screening to promote social-emotional well-being in toddlers has positive effects on long-term health and functioning. Communication about social-emotional well-being can be challenging for primary care clinicians for various reasons including lack of time, training and expertise, resource constraints, and cognitive burden. Therefore, we explored clinicians’ perspectives on identifying and communicating with caregivers about social-emotional risk in toddlers. Method: In 2021, semistructured interviews were conducted with pediatric clinicians (N = 20) practicing in Federally Qualified Health Centers in a single metropolitan area. Most participants identified as female (n = 15; 75%), white non-Hispanic/Latino (n = 14; 70%), and were Doctors of Medicine or Osteopathic Medicine (n = 14; 70%). Thematic analysis was conducted on audio-recorded interview transcripts. Results: Clinicians used various approaches to identify social-emotional concerns which were sometimes difficult to distinguish from other developmental concerns. The clinician–caregiver relationship guided identification and communication practices and cut-across themes. Themes include: starting with caregivers’ concerns, communicating concerns with data and sensitivity, navigating labels, culture, and stigma, and limiting communication based on family capacity and interest. Discussion: Prioritizing the clinician–caregiver relationship is consistent with best practice and family-centered care. Yet, the dearth of standardized decision support may undermine clinician confidence and impede timely conversations about social-emotional concerns. An evidence-based approach with developmentally based culturally informed quantitative tools and standardized decision supports could help ensure equitable management and decision making about young children’s social and emotional well-being and development. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Making it “EASI” for pediatricians to determine when toddler tantrums are “more than the terrible twos”: Proof-of-concept for primary care screening with the Multidimensional Assessment Profiles–Early Assessment Screener for Irritability (MAPS-EASI).
Background: Up to 20% of youth have impairing mental health problems as early as age 3. Early identification and intervention of mental health risks in pediatric primary care could mitigate this crisis via prevention prior to disease onset. The purpose of this study was to establish the feasibility and acceptability of implementing a brief transdiagnostic screening instrument in pediatric primary care for irritability and corollary impairment. Method: Five pediatric clinicians in a Midwest clinic implemented the Multidimensional Assessment Profiles–Early Assessment Screener of Irritability (MAPS-EASI) for toddlers (24–30 months) and their families. MAPS-EASI (psychometrically derived from the well-validated MAPS-Scales) includes six items (scored 0–5) about symptoms (e.g., tantrums, grumpy mood), context, and frequency and two items (scored 0–3) assessed impairment. Positive screens (MAPS-EASI ≥ 5 plus impairment ≥ 2) were referred to an evidence-based parenting intervention. We assessed reach and outcomes of MAPS-EASI screening. Follow-up interviews with clinicians assessed perspectives on irritability screening and MAPS-EASI implementation. Results: Of 201 eligible families, 100 (49.8%) completed the screener for a 24- or 30-month well-child visit. Mean MAPS-EASI scores were 5.8 (SD = 3.2), mean impairment scores were 0.9 (SD = 0.9), and 24 (24.0%) screened positive. Clinicians indicated that irritability screening for toddlers was aligned with their prevention-oriented, developmentally based practice. MAPS-EASI had face validity and increased clinician decision-making confidence. Finally, clinicians identified barriers and facilitators to large-scale implementation. Conclusions: MAPS-EASI proved to be feasible and acceptable in pediatric primary care. Further tailoring will be needed as the MAPS-EASI processes are scaled out to new contexts and populations. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Engaging primary care clinicians in the selection of implementation strategies for toddler social-emotional health promotion in community health centers.
Background: Social-emotional risk for subsequent behavioral health problems can be identified at toddler age, a period where prevention has a heightened impact. This study aimed to meaningfully engage pediatric clinicians, given the emphasis on health promotion and broad reach of primary care, to prepare an Implementation Research Logic Model to guide the implementation of a screening and referral process for toddlers with elevated social-emotional risk. Method: Using an adaptation of a previously published community partner engagement method, six pediatricians from community health centers (CHCs) comprised a Clinical Partner Work Group. The group was engaged in identifying determinants (barriers/facilitators), selecting and specifying strategies, strategy-determinant matching, a modified Delphi approach for strategy prioritization, and user-centered design methods. The data gathered from individual interviews, two group sessions, and a follow-up survey resulted in a completed Implementation Research Logic Model. Results: The Clinical Partner Work Group identified 16 determinants, including barriers (e.g., patient access to electronic devices) and facilitators (e.g., clinician buy-in). They then selected and specified 14 strategies, which were prioritized based on ratings of feasibility, effectiveness, and priority. The highest-rated strategies (e.g., integration of the screener into the electronic health record) provided coverage of all identified barriers and comprised the primary implementation strategy “package” to be used and tested. Conclusions: Clinical partners provided important context and insights for implementation strategy selection and specification to support the implementation of social-emotional risk screening and referral in pediatric primary care. The methodology described herein can improve partner engagement in implementation efforts and increase the likelihood of success. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Potential parental determinants of the pace of evidence-based practice change in children’s mental health care.
Background: Strength of evidence is key to advancing children’s mental health care but may be inadequate for driving practice change. The Designing for Accelerated Translation (DART) framework proposes a multifaceted approach: pace of implementation as a function of evidence of effectiveness, demand for the intervention, sum of risks, and costs. To inform empirical applications of DART, we solicited caregiver preferences on key elements. Method: In March–April 2022, we fielded a population-representative online survey in Illinois households (caregivers N = 1,326) with ≥1 child
Pediatric psychosocial preventative health model: Achieving equitable psychosocial care for children and families.
Objective: The Pediatric Psychosocial Preventative Health Model (PPPHM) is a three-tier model of family psychosocial risk used to guide intervention approaches in pediatric healthcare settings. Screening all families to determine levels of risk supports equitable care. We review evidence from papers using the Psychosocial Assessment Tool (PAT), a brief caregiver-report measure of family psychosocial risk with scores that map to the PPPHM, to characterize the distribution of risk. We predict that across study samples the distribution of risk on the PPPHM will be approximately 60% universal (low), 30% targeted (moderate), and 10% clinical (high). Method: We conducted a scoping review searching PubMed, MEDLINE, Emcare, and PsycInfo for articles that reported PPPHM data using the PAT. Results: Forty-seven samples from 43 papers were included, reporting on patients with 17 conditions. PPPHM scores were highly consistent with median percentages of 55% universal, 34% targeted, and 11% clinical. There is evidence of higher levels of risk for samples using the Spanish version of the PAT, from weight management programs and with families who have children with autism spectrum disorder. Conclusions: The data demonstrate consistent patterns of psychosocial risk distributions on the PPPHM and support implementation of universal family psychosocial risk screening, followed by delivery of personalized care based on level of risk. Screening all families promotes health equity in pediatric health care settings by normalizing the importance of understanding psychosocial risk and resiliencies and assuring family input in the delivery of integrated psychosocial care. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Health and care utilization among youth with a history of parental incarceration and homelessness.
Introduction: Despite widespread recognition of the health and social risks posed by parental incarceration (PI) and homelessness, these challenges are rarely considered in unison. We sought to (a) assess the experiences of homelessness among youth with and without a history of PI and (b) compare the health and healthcare utilization among youth with a combined history of PI and homelessness. Method: Examining data from eighth-, ninth-, and 11th-grade public school participants in the 2019 Minnesota Student Survey (N = 110,904), we calculated univariate and multivariate analyses to characterize the health status and care utilization of youth who have experienced PI, past-year homelessness, or both. Results: We observed higher prevalence of homelessness among youth with a history of PI compared to those without. The group with dual PI-homelessness experience had a higher proportion of youth that were younger, male, and non-White; and living in poverty or urban areas compared to youth with PI history only. Even after accounting for demographic factors, the dual PI-homelessness group evidenced higher expected odds for several physical health conditions (e.g., asthma, diabetes), and differences in care utilization indicators relative to individual PI and homelessness groups. Discussion: Findings suggest that PI may be overrepresented among recently homeless youth and that youth with such dual experience possess distinct, and often elevated, health service needs. Health, education, housing, and other systems may need intersectoral strategies to better identify and support this at-risk subset of youth through clinical and policy approaches. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Suicide prevention programming across ecological levels: Recommendations from Latinx immigrant origin youth and their parents.
Introduction: Latinx immigrant-origin youth (IOY) have unique risks for suicidal thoughts and behaviors. It has been suggested that these risks should be addressed from an ecological perspective, addressing cultural and family context as well as structural and systemic barriers to prevention. This study sought to explore perspectives of immigrant-origin Latinx adolescents and their caregivers on suicide and its prevention, including the potential impact of stressors specific to immigrant status. Method: Focus groups were conducted in 2018–2019 with Latinx immigrant-origin caregivers (N = 41, 97.5% female) and adolescents (ages = 14–19, N = 56, 50% female). Participants were recruited from community-based organizations in two different cities. A codebook approach to thematic analysis was used to identify themes, which were subsequently mapped onto levels of the Center for Disease Control’s Social-Ecological Framework for Violence Prevention. Results: Participants identified both contributors to suicidal behavior and potential components of prevention programming across ecological levels. Specific recommendations for suicide prevention included engaging in recreation, parenting education and support, enhancing academic supports for adolescents, and enhancing school–family communication. Structural barriers (e.g., caregiver work schedules) to implementing recommendations were described. Discussion: Our results highlight the potential role of access to school and community-based supports as public health-oriented suicide prevention strategies and suggest a need to address barriers faced by immigrant families in accessing these supports alongside addressing barriers to mental health treatment. Policies impacting immigrant families’ financial stability and increasing the availability of recreational and academic opportunities may promote mental health and prevent suicidal thoughts and behavior among IOY. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Benefits of expanding behavioral health screening in a pediatric diabetes clinic to include anxiety and caregiver reports in youth 12 years and younger.
Introduction: Depression and anxiety among youth with Type 1 diabetes (T1D) are associated with poor diabetes management. Further guidance regarding psychosocial screening measures would benefit pediatric integrated care clinics. The purpose of this exploratory study was to examine whether screening for anxiety, assessing caregiver reports, and screening children 12 years old and younger could identify a larger percentage of youth who may benefit from behavioral health support compared to the standard approach of only screening youth 13 and older for depression. Method: Sixty-five youth 8–17 years old with T1D (N = 65; M = 13.2 years; 55.4% females) and their caregivers (75% mothers) completed validated self-report and proxy-report depression and anxiety screeners during routine clinic visits between 2019 and 2021. Twenty-seven youth aged 13–17 also completed a measure of diabetes-related distress. Results: The standard approach of screening youth aged 13–17 for depression via self-report identified 25.6% of participants, whereas screening youth ages 8–17 for depression and anxiety via self- and proxy-reports identified 47.7%. Screening for depression/anxiety identified unique portions of youth independent of diabetes distress. Discussion: Utilizing anxiety and proxy-report measures may identify youth likely to benefit from behavioral health support who are not identified when only a self-report depression measure is used in screening. Research should evaluate whether utilizing multiple measures and screening children under 13 years old improve detection and connection to care for youth experiencing difficulty managing diabetes. Early identification and intervention could subsequently mitigate the negative impacts of social–emotional difficulties on diabetes management. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Examining differences in long-term weight loss outcomes after bariatric surgery: The role of romantic relationship status.
Introduction: This study tested for differences based on relationship status at the time of surgery in baseline body mass index (BMI), weight loss outcomes (change in BMI [ΔBMI], percent total weight loss [%TWL], percent excess weight loss [%EWL]), and rates of successful weight loss (defined as ≥ 50%EWL) up to 4-year postbariatric surgery. Method: Data came from a secondary analysis of patients (N = 492) who were up to 4-year postsurgery and completed a presurgical psychological evaluation and postsurgical survey. Results: Sixty-nine percent of participants were patients in committed relationships and 31% were single/divorced/widowed patients. Single patients had higher presurgical BMIs than those who were partnered (t = 2.28, p = .02). There were no differences between those who were partnered and singles regarding ΔBMI and %TWL, although singles had smaller %EWL (t = −2.08, p = .04), which became nonsignificant after controlling for covariates. Most participants had successful weight loss (76.8%); however, this was not related to romantic relationship status. Discussion: The results suggest those who were partnered undergo surgery at better-starting weights than singles and maintain this advantage in the long term. Providers working with patients considering bariatric surgery could inquire about how their romantic and social relationships play a part in their decision-making process. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
It’s time to stop using “stepchild” as a pejorative term in science.
Despite their ubiquity, stepfamilies generally hold a stigmatized status. The scientific community at large has not been immune to the influence of stepfamily stigmatization. Misusing the term “stepchild” in science is unnecessary on several fronts. “Stepchild” is often intended to denote neglect, oversight, or mistreatment. Scholars should consider using more direct and precise language, especially considering that scientific writing benefits from clarity, parsimony, and precision. In any case, it’s time to stop using “stepchild” as a pejorative term. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Review of Handbook of Positive Youth Development: Advancing Research, Policy, and Practice in Global Contexts.
Reviews the book, Handbook of Positive Youth Development: Advancing Research, Policy, and Practice in Global Contexts edited by Radosveta Dimitrova and Nora Wiium (2021). This volume deals with both the applications and interventions of positive youth development (PYD) in the context of families and other systems in global contexts. Additionally, it advances empirical and theoretical knowledge in PYD, refinement of methodological issues, and measurement and integration of PYD-related knowledge with policy, research, and practice. This book will interest a broad spectrum of readers, including social scientists, students, professionals, policymakers, and practitioners from various disciplines. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
“Deeper cuts”: A 55-word story.
Health professionals spend their careers in the expert care of patients experiencing difficult and chronic illnesses. However, there is no equivalent in professional training for personal, lived experiences as patients or loved ones of patients, both of which can serve as unforgettably humanizing teachers for building empathy, compassion, and perspective-taking skills. This 55-word story is a reflection on a memorable moment in one such experience. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
E pluribus unum: I am we.
E Pluribus Unum, out of many, one. This is intended to signify unification and inclusion for the people of the United States. I, a cis-gendered, gay man, have come to appreciate the meaning in a different way. The following poem is a critical reflection of how I came to understand me, as a member of an interconnected society. This piece reflects my lived experiences as an out of the mainstream masculine male, despite my white privilege. In the poem, I include a powerful derogatory word often used by others to destructively affect queer people like me. I have altered the appearance of the word to lessen any additional hurt it might produce. I hope this poem encourages a recognizing, understanding, and respecting of the uniqueness and differences among us. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
The “in between”.
When the authors were 12 and 14 years old, their worlds shifted suddenly without warning or consent, and bifurcated our lives into “a before” and “an after.” They were both diagnosed with inflammatory bowel disease (IBD) and found themselves in an “in between” space—young but not healthy, sick but not dying, treatments but not cures, intestines swollen and bleeding but appearing fine on the outside, in every sense the definition: an invisible illness. Their own chronic illness experiences helped to shape our pursuit of careers in healthcare, with one of them choosing pediatric IBD psychology (Jennie David) and the other choosing pediatric gastroenterology (Samantha R. Paglinco). Being patients and healthcare professionals (HCPs) created a new “in between” space to occupy and explore. They continue on in these “in between” spaces and choose to bring all of themselves—as patients and HCPs—as theiy work with pediatric IBD patients in their endless pursuit of caring for young people as full, wonderful, complex, flawed, and worthy humans (PsycInfo Database Record (c) 2024 APA, all rights reserved)
You belong.
The author describes how she has earnestly struggled to find her fit in providing mental health services to Hispanic/Latino clients and the Latino communities that she belongs to. She wonders, if no one belongs, then who stands up for historically marginalized Latino communities? Personal and systemic biases and arbitrary criteria for being enough to serve Latino patients hurt providers and clients alike. Her work reminds her of the need to charge against stereotyping and racism to meet patients’ needs regardless of skin color or linguistic abilities. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Who won?
This poem describes the ugly face of misinformation and lies-spewing bile as COVID shook us and humanity came undone. Vaccines were rejected and lockdowns were broken. We barely withstood. Who won? No one. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Don Bloch nomination letter.
In this letter to the Collaborative Family Healthcare Association (CFHA) Board and Community, the author nominates Mountainview Consulting Group, specifically Patricia Robinson, PhD (Patti) and Kirk Strosahl, PhD, for the 2023 Don Bloch Award. When he thinks of the qualities Don Bloch is remembered for—Intellectual, Behavioral, and Relational qualities—there simply is no entity or person more qualified for this award than Patti and Kirk. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Acta non verba.
It is with a great deal of gratitude that Kirk D. Strosahl and Patricia J. Robinson accept the Don Bloch Award. Thirty-five years ago, when they embarked on their mission to improve healthcare, they never imagined that this recognition would come their way. Now that it has, they want to take about 1,000 words to share their views on health and their understanding of important barriers to improving healthcare services, and offer four practical strategies to consider as we do your part. (PsycInfo Database Record (c) 2024 APA, all rights reserved)
Contemplating on the end of integrated care—part II: Living the questions to foster adaptability.
This article extends the use of the ecocycle planning framework to describe challenges ahead for the integrated care and Collaborative Family Healthcare Association (CFHA). The authors make the case that to remain agile and adaptable, there are contextual, ecological, and moral challenges that integrated care and CFHA should keep in the forefront as they navigate the future of an inequitable health care system that is morphing at a rapid pace. These influences include but are not limited to challenges of social determinants of health, artificial intelligence, generational differences in technology among older and younger populations, the moral issue of poverty, challenges to retain an integrated care workforce, and rethinking development of evidence-based supported treatments for integrated care. (PsycInfo Database Record (c) 2024 APA, all rights reserved)

Families, Systems, & Health - Vol 42, Iss 1