Emerging evidence suggests that autism spectrum disorder (ASD) can be diagnosed by age 18 months and that early intensive behavioral intervention positively affects ASD core deficits. This pilot ...randomized controlled trial examined the feasibility of using an adapted form of patient navigation, Family Navigation (FN), to improve timely diagnosis of ASD in low-income families from racial-ethnic minority groups.
Forty children referred for an ASD diagnostic assessment were randomly allocated to receive FN or usual care. The primary outcome, time to diagnostic resolution, was assessed with survival analysis.
Nineteen of 20 FN children completed the diagnostic assessment, compared with 11 of 19 children receiving usual care (hazard ratio=3.21, 95% confidence interval=1.47-6.98, p<.01). In regard to engagement of participants, 17 of 20 families (85%) met with the navigator for the targeted three in-person visits (median=4, range 1-9).
FN may be a promising intervention to address barriers that impede timely ASD diagnosis.
American workers are currently engaged in an upsurge in collective actions aimed at achieving a stronger voice and representation at work; this desire for increased voice at work is also evident in ...survey data. However, union organizing drives in the United States typically meet with strong employer resistance, and such resistance reduces the likelihood that the organizing effort will be successful. In addition to unions, a broad array of other efforts has been initiated to strengthen worker voice and representation. The authors discuss these efforts, including worker centers, and observe that there is no “one size fits all” approach to contemporary worker organizing.
We sought to assess potential mechanisms of action of a patient navigation intervention in Head Start, designed to help depressed mothers engage with mental health care. We employed mixed methods, ...linking qualitative interviews (n = 21) to a randomized intervention pilot (n = 47). Early in follow‐up, navigated mothers had lower mean depressive symptom scores than non‐navigated mothers (9.61 vs. 12.95, p = 0.03). These differences attenuated but preceded a greater likelihood of engaging with care among navigated mothers. Navigated mothers reported greater self‐esteem (score 21.45 vs. 18.60, p = 0.05) and greater confidence in their ability to self‐manage depression (7.65 vs. 5.67, p = 0.01). In qualitative interviews, navigated mothers linked decreased symptom burden to feeling activated; they communicated optimism toward the future and a willingness to work toward symptom improvement by trying something new. Early symptom relief, behavioral activation, self‐esteem, self‐management, and optimism represent plausible navigation mechanisms of action. These constructs require formal testing.
It is advantageous for a clinician to understand how patients feel about their initial encounters, but it can be difficult to discern what is and what is not working. This qualitative, exploratory ...study is guided by the question, "What happens during an initial mental health encounter between a Black patient and a non-Black provider that leads the patient to describe it as a good or poor experience?" The findings are based on face-to-face, postintake interviews with 14 Black patients seen by 11 non-Black providers as part of the Patient-Provider Encounter Study. The objective is to explore the initial interpersonal interactions between Black patients and their non-Black mental health providers and to better understand how patients come to describe the encounter as good (favorable) or poor (unfavorable). A framework inclusive of 5 specific elements is introduced that maps the patient's conceptualization process about how judgments are made about the encounter. Owing to the naturalistic and exploratory nature of the study, a research hypothesis was not established. Instead, we observed how patients scanned the interaction with the provider, made assessments about their provider, and determined whether their experience was positive or negative. The implications of these findings will help to improve the interactions in mental health settings between minority patients and their providers.
Low-income and minority mothers experience a disproportionate incidence of depression and lack access to treatment services. Development of prevention strategies in accessible community-based venues ...is a potentially important public health strategy.
To determine the efficacy of a depression prevention strategy embedded in Head Start.
This randomized clinical trial was performed from February 15, 2011, through May 9, 2016, at 6 Head Start agencies serving families at or below the federal poverty level. Participants included mothers with depressed mood, anhedonia, or depression history but who were not in a current major depressive episode. Participants were followed up for 12 months with masked outcome assessments. Final follow-up was completed on May 9, 2016.
Participants were randomized to a problem-solving education (PSE) intervention (n = 111) or usual Head Start services (n = 119).
Primary outcomes were problem-solving skills and depressive symptoms. To capture the chronicity and intensity of symptoms, the Quick Inventory of Depressive Symptoms was administered bimonthly, and rates of clinically significant symptom elevations were compared across groups. Secondarily, the presence of a major depressive episode was assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders.
Among the 230 participants, 152 (66.1%) were Hispanic, with a mean (SD) age of 31.4 (7.3) years. An intention-to-treat analysis among 223 participants contributing follow-up data found no differences in problem-solving skills across groups. The mean (SD) number of depressive symptom elevations among the PSE participants was 0.84 (1.39) compared with 1.12 (1.47) among the usual service participants (adjusted incident rate ratio aIRR, 0.60; 95% CI, 0.41-0.90). In analyses stratified according to baseline depressive symptoms, PSE exerted a preventive effect among those with lower-level baseline symptoms, with a mean (SD) of 0.39 (0.84) elevations among PSE participants compared with 0.88 (1.37) among usual service participants (aIRR, 0.39; 95% CI, 0.21-0.75). However, no difference was observed among those with higher-level baseline symptoms (mean SD elevations, 2.06 1.92 for PSE and 2.00 1.91 for usual service; aIRR, 1.10; 95% CI, 0.67-1.80). Analysis of symptom scores followed the same pattern, with an adjusted mean reduction of 1.33 (95% CI, 0.36-2.29) among participants with lower-level baseline symptoms.
The PSE intervention is efficacious in preventing depressive symptom episodes and performs optimally among those with initial low-level symptoms. Additional effectiveness studies in Head Start are necessary to develop meaningful public health programs.
clinicaltrials.gov Identifier: NCT01298804.
Introduction: Given recent advances in medical care for children with Sickle Cell Disease (SCD), families are now seeing their children survive into adulthood. This presents new challenges around ...transition from pediatric to adult medical care, with responsibility for self-management shifting from parent to child. Interventions to improve self-management skills, such as problem solving education (PSE), have been used to increase self-efficacy and medication adherence in youth with other chronic diseases. The present study sought to explore common barriers and facilitators of disease management during the transition period and the acceptability of adapting PSE to improve transition readiness in adolescents with SCD.
Methods: We purposively sampled adolescents with SCD ages 13 to 18 who received care at either Boston Medical Center (BMC) or Boston Children's Hospital and their primary caregiver to participate in focus groups. Each focus group was audio recorded and transcribed. Data were analyzed through use of grounded theory and coded with NVivo, a qualitative analysis software. Transcripts were double-coded until thematic saturation was achieved.
Results: A total of 17 adolescents and 15 adult caregivers participated in five focus groups. Groups initially met together to discuss barriers and facilitators of self-management and then split into separate groups of teens and parents to discuss PSE. Teens and parents identified common methods of disease management includingtaking medication, staying warm and dressing appropriately, maintaining hydration and a healthy diet, and staying rested. Teens identified having a daily routine and sharing responsibility with a caregiver as facilitators of self-management. Caregivers commonly mentioned using a set of reminder techniques to help teens manage their health. Barriers to increasing teens' self-management included wanting to fit in with peers and lacking appropriate knowledge. Parents found it challenging to allow teens more responsibility.
Parents and teens unanimously approved the adaption of PSE to SCD management and transition. Though a small number of parents stated low interest in participating either for social reasons or lack of perceived need, many identified the potential benefits of the intervention for both parents and teens. Parents felt that educational support would be most beneficial to them, while teens prioritized the benefits of emotional support during the transition period. Most participants would prefer that parents and teens meet separately in a group setting at the hospital or a comfortable environment outside of the home, then join together for a final session. Groups would be held on a weekly basis for a minimum of two months. However, some participants felt the support was imperative and thus could be effective for a year. Participants favored a mentor-style structure where a knowledgeable, college-aged individual with sickle cell disease would serve as the interventionist. This appeared to be a common preference for both parents and teens as they felt it was important to work with an individual that excelled independently and academically, despite any challenges with SCD.
Parents and teens willingly identified specific scenarios where they felt PSE would be most valuable. Common PSE scenarios for teens were related to disclosing the diagnosis to peers, enhancing methods of management, and addressing identified barriers to transitioning. PSE scenarios for parents involved working with healthcare and school systems on select adaption issues and learning to “let go” of their teen.
Conclusion: Though parents and teens have adapted management techniques to facilitate their transition from pediatric to adult medical care, barriers still exist across medical, personal and educational environments. Applying PSE as an intervention for both parents and teens of a sickle cell population could improve self-management and transition readiness in this vulnerable population.
No relevant conflicts of interest to declare.
Early identification of autism spectrum disorder (ASD) is associated with improved cognitive and behavioral outcomes. Targeted strategies are needed to support equitable access to diagnostic services ...to ensure that children from low-income and racial/ethnic minority families receive the benefits of early ASD identification and treatment.
To test the efficacy of family navigation (FN), an individually tailored, culturally informed care management strategy, to increase the likelihood of achieving diagnostic ascertainment among young children at risk for ASD.
This randomized clinical trial of 249 families of children aged 15 to 27 months who had positive screening results for possible ASD was conducted in 11 urban primary care sites in 3 cities. Data collection occurred from February 24, 2015, through November 5, 2018. Statistical analysis was performed on an intent-to-treat basis from November 5, 2018, to July 27, 2020.
Families were randomized to FN or conventional care management (CCM). Families receiving FN were assigned a navigator who conducted community-based outreach to families to address structural barriers to care and support engagement in recommended services. Families receiving CCM were assigned to a care manager, who did limited telephone outreach. Families received FN or CCM after positive initial screening results and for 100 days after diagnostic ascertainment.
The primary outcome, diagnostic ascertainment, was measured as the number of days from randomization to completion of the child's clinical developmental evaluation, when a diagnosis of ASD or other developmental disorder was determined.
Among 250 families randomized, 249 were included in the primary analysis (174 boys 69.9%; mean SD age, 22.0 3.5 months; 205 82.3% publicly insured; 233 93.6% non-White). Children who received FN had a greater likelihood of reaching diagnostic ascertainment over the course of 1 year (FN, 108 of 126 85.7%; CCM, 94 of 123 76.4%; unadjusted hazard ratio HR, 1.39 95% CI, 1.05-1.84). Site (Boston, New Haven, and Philadelphia) and ethnicity (Hispanic vs non-Hispanic) moderated the effect of FN (treatment × site interaction; P = .03; Boston: HR, 2.07 95% CI, 1.31-3.26; New Haven: HR, 1.91 95% CI, 0.94-3.89; and Philadelphia: HR, 0.91 95% CI, 0.60-1.37) (treatment × ethnicity interaction; P < .001; Hispanic families: HR, 2.81 95% CI, 2.23-3.54 vs non-Hispanic families: HR, 1.49 95% CI, 1.45-1.53). The magnitude of FN's effect was significantly greater among Hispanic families than among non-Hispanic families (diagnostic ascertainment among Hispanic families: FN, 90.9% 30 of 33, and CCM, 53.3% 16 of 30; vs non-Hispanic families: FN, 89.7% 35 of 39, and CCM, 77.5% 31 of 40).
Family navigation improved the likelihood of diagnostic ascertainment among children from racial/ethnic minority, low-income families who were detected as at risk for ASD in primary care. Results suggest differential effects of FN by site and ethnicity.
ClinicalTrials.gov Identifier: NCT02359084.
Although depression is common among patients receiving maintenance hemodialysis, data on their acceptance of treatment and on the comparative efficacy of various therapies are limited.
To determine ...the effect of an engagement interview on treatment acceptance (phase 1) and to compare the efficacy of cognitive behavioral therapy (CBT) versus sertraline (phase 2) for treating depression in patients receiving hemodialysis.
Multicenter, parallel-group, open-label, randomized controlled trial. (ClinicalTrials.gov: NCT02358343).
41 dialysis facilities in 3 U.S. metropolitan areas.
Patients who had been receiving hemodialysis for at least 3 months and had a Beck Depression Inventory-II score of 15 or greater; 184 patients participated in phase 1, and 120 subsequently participated in phase 2.
Engagement interview versus control visit (phase 1) and 12 weeks of CBT delivered in the dialysis facility versus sertraline treatment (phase 2).
The primary outcome for phase 1 was the proportion of participants who started depression treatment within 28 days. For phase 2, the primary outcome was depressive symptoms measured by the Quick Inventory of Depressive Symptoms-Clinician-Rated (QIDS-C) at 12 weeks.
The proportion of participants who initiated treatment after the engagement or control visit did not differ (66% vs. 64%, respectively; P = 0.77; estimated risk difference, 2.1 95% CI, -12.1 to 16.4). Compared with CBT, sertraline treatment resulted in lower QIDS-C depression scores at 12 weeks (effect estimate, -1.84 CI, -3.54 to -0.13; P = 0.035). Adverse events were more frequent in the sertraline than the CBT group.
No randomized comparison was made with no treatment, and persistence of treatment effect was not assessed.
An engagement interview with patients receiving maintenance hemodialysis had no effect on their acceptance of treatment for depression. After 12 weeks of treatment, depression scores were modestly better with sertraline treatment than with CBT.
Patient-Centered Outcomes Research Institute, Dialysis Clinic, Kidney Research Institute, and National Institute of Diabetes and Digestive and Kidney Diseases.
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