Telehealth May Reduce Rural-Urban Disparities in Accessing Pediatric Psychiatry Services: A Case Study of Trends in Central Ohio from 2020 to 2021 (Preprint)

BACKGROUND The rural-urban disparities in access to child behavioral health services are well known and are further exacerbated by the COVID-19 pandemic related restrictions on travel and in person visits. Fortunately, regulatory flexibilities allowed rapid transition of telehealth to reduce contagion while maintaining continuity of care. However, there has been contradicting evidence on whether telehealth narrows the rural-urban gap. OBJECTIVE To examine the telehealth utilization trends and no-show rates between urban vs rural areas for pediatric psychiatry visits after the public health emergency was declared. METHODS Using 2020-2021 electronic health records (EHR) data from the psychiatry department at a large urban academic pediatric hospital, we calculated the telemedicine utilization rates by patient’s residence area (urban vs rural). We used two proportions z-tests to examine whether the observed differences in no-show rates among 4 types of visit (urban office visit, urban telemedicine visit, rural office visit, and rural telemedicine visit) were statistically significant. RESULTS Telemedicine utilization rates (~80%) are comparable in urban and rural areas. The average no-show rates for telemedicine visits were around 17% for both urban and rural patients, while the average no-show rates for office visits were around 20% for urban patients and fluctuated between 15% and 36% for rural patients. Two proportions z-tests indicated that, for rural patients, telemedicine visits had significantly lower no-show rates than office visits between Sept 2020 and Feb 2021, but such difference turned insignificant after March 2021. CONCLUSIONS Telehealth improved access to child psychiatric services for rural families when primary delivery of services was telehealth-based. Returning to in-person only options and limiting telehealth access would be detrimental to behavioral health outcomes of rural children that have been traditionally underserved. CLINICALTRIAL N/A

Validity of the patient health questionnaire 9-item in autistic youths: a pilot study

Background Autistic adolescents have greater predisposition to depression and suicidality than neurotypical adolescents. Early detection is essential for timely treatment. The Patient Health Questionnaire 9-item (PHQ-9) is a brief screen for depression. The study examines the validity of the PHQ-9 for detecting major depressive disorder (MDD) in autistic youths. Methods English speaking youths aged 10–18 years, with DSM-IV/DSM-5/ICD-10 diagnosis of Autism Spectrum Disorder (ASD), and their parents presenting to a child psychiatric service were invited to participate between May 2018 to August 2020. Participants completed the respective self- and parent-rated PHQ-9 independently. MDD was verified using the MINI-Kid (Mini-International Neuropsychiatric Interview, Kid version). Results One hundred one youth, mean (SD) age 14.6 (2.3), were enrolled. 27 (27%) met criteria for current MDD. Mean total PHQ-9 scores, percentage ratings for severity of symptoms of depression, functional impairment, dysthymia and suicidality were compared. Areas under the ROC curve and statistically optimal cutoffs were determined. Parents rated depressive symptoms severity lower than their children. The PHQ-9 displayed low sensitivity with high false negative rates at conventional, adjusted and proposed cutoffs. Conclusions Future studies should improve on the validity and reliability of existing depression screening tools, or develop more appropriate screening methods of depression, for autistic youths.

Paternal Feelings and Child’s Anxiety: The Mediating Role of Father–Child Insecure Attachment and Child’s Emotional Regulation

The study introduces a path model that links between paternal feelings and child’s anxiety symptoms, aiming to test the mediational role of father–child insecure attachment and the child’s difficulties in emotional regulation in the occurrence of anxiety disorders among a sample of 148 fathers and their children (65 boys and 83 girls aged 8–18) attending the child psychiatric center of a public hospital. Participants completed a battery of diagnostical and research questionnaires, including the Parental Feelings Inventory (PFI), the Difficulties in Emotion Regulation Scale (DERS), the Screen for Child Anxiety–Related Emotional Disorders (SCARED), and the Experiences in Close Relationships Scale–Revised Child version (ECR-RC). Using structural equation modeling, we found father’s anger to be associated with father–child anxiety attachment, while the latter simultaneously mediated the link to the child’s anxiety both directly and indirectly (through emotion regulation [ER]). Consistent with previous evidence, we found insecure attachment and emotional regulation to be uniquely associated with the child’s anxiety. The current findings are among the first to demonstrate the interrelations between these variables in the context of father–child relations, suggesting that the child’s exposure to paternal anger might contribute to developing difficulties in ER and elevated anxiety due to a father–child insecure-anxious attachment relationship. The theoretical and practical implications of the findings are discussed in light of parental gender.

Assessment of the quality of routine ambulatory healthcare for common disorders in children and adolescents in Germany: study protocol for a retrospective medical record review (QualiPäd)

IntroductionThe quality of healthcare in childhood and adolescence is of key importance, in order to foster a healthy development and to avoid chronic health problems. Yet, data for Germany regarding the quality of healthcare for this patient group are lacking. The QualiPäd research project aims to estimate the quality of outpatient healthcare for children and adolescents in Germany, focusing on common psychiatric and physical disorders.Methods and analysisQuality indicators for seven common physical and mental childhood and adolescent clinical conditions (attention deficit/hyperactivity disorder, asthma, atopic dermatitis, depression, otitis media, conduct disorder/oppositional defiant disorder, tonsillitis) will be developed and ratified by experts, using the RAND/UCLA Appropriateness Method.Initially, 1400 medical records of children and adolescents with one of the aforementioned clinical conditions will then be randomly drawn from 40 outpatient practices in the German federal state of Hessen. The records will then be assessed regarding their adherence to the respective quality indicators. Based on this, the percentage of appropriate and inappropriate (eg, wasteful) healthcare of all clinical conditions (primary endpoint) will be estimated. Additionally, possible factors influencing the quality of care (eg, patient characteristics, type of condition, type of practice) will be identified using generalised estimation equation models.Ethics and disseminationThis study will show for which of the studied clinical conditions and/or patients improvement of quality of care is necessary within the German health system. Also, the quality indicators designed for the study can afterwards be implemented in regular care and thus enable regular reporting of the outpatient care of this target group. The authors plan to disseminate their findings through international, peer-reviewed scientific publications, and through presentations at national and international paediatric and child psychiatric conferences.Trial registration numberDRKS00022408.

The 25-Item Ontario Child Health Study Emotional Behavioural Scales-Brief Version (OCHS-EBS-B): Test-Retest Reliability and Construct Validity When Used as Categorical Measures

Objective Child and youth mental health problems are often assessed by parent self-completed checklists that produce dimensional scale scores. When converted to binary ratings of disorder, little is known about their psychometric properties in relation to classifications based on lay-administered structured diagnostic interviews. In addition to estimating agreement, our objective is to test for statistical equivalence in the test-retest reliability and construct validity of two instruments used to classify child emotional, behavioural, and attentional disorders: the 25-item, parent completed Ontario Child Health Study Emotional Behavioural Scales-Brief Version (OCHS-EBS-B) and the Mini International Neuropsychiatric Interview for Children and Adolescents-parent version (MINI-KID-P). Methods This study draws on independent samples ( n = 452) and uses the confidence interval approach to test for statistical equivalence. Reliability is based on kappa (κ). Construct validity is based on standardized beta coefficients (β) estimated in structural equation models. Results The average differences between the MINI-KID-P and OCHS-EBS-B in κ and β were −0.022 and −0.020, respectively. However, in both instances, criteria for statistical equivalence were met in only 5 of 12 comparisons. Based on κ, between-instrument agreement on the classifications of disorder went from 0.481 (attentional disorder) to 0.721 (emotional disorder) but were substantially higher (0.731 to 0.895, respectively) when corrected for attenuation due to measurement error. Conclusions Although falling short of equivalence, the results suggest on balance that the reliability and validity of the two instruments for classifying child psychiatric disorder assessed by parents are highly comparable. This conclusion is supported by the high levels of agreement between the instruments after correcting for attenuation due to measurement error.