Researchers presented new findings on mental health, equity and the impact of the COVID-19 pandemic during an AAP-sponsored plenary at the Pediatric Academic Societies meeting May 2-6 in Toronto.
“We are really delighted to be able to select this exceptional group of abstracts, this exceptional group of researchers to share their scholarship,” said AAP Past President
Lee Savio Beers, M.D., FAAP (2021), medical director for community health and advocacy at Children's National Hospital in Washington, D.C. Dr. Beers led the panel with Maria E. Trent, M.D., M.P.H., FSAHM, FAAP, director of the Division of Adolescent/Young Adult Medicine at Johns Hopkins University in Baltimore.
SSRI prescribing by primary care pediatricians
A study from Massachusetts showed an effective model for integrating selective serotonin reuptake inhibitor (SSRI) prescribing into primary care.
SSRIs are a common treatment for anxiety and depression, but many pediatricians have received inadequate training on prescribing them, according to presenting author Louis Vernacchio, M.D., M.Sc., FAAP, director of research for the Pediatric Physicians' Organization at Boston Children’s Hospital.
In 2013, his organization launched a behavioral health program within its statewide network. The program included extensive education for clinicians in identifying and treating behavioral health disorders, support for integrating behavioral health specialists into practices and on-demand consultation with child psychiatrists.
To look at SSRI prescribing since that time, researchers analyzed claims data from a large commercial insurer in Massachusetts from 2013-2022. They found that the number of SSRI prescriptions written by primary care providers increased eight-fold, while specialist-written prescriptions also increased. Primary care pediatricians also went from being responsible for 19% of SSRI prescriptions to 54%.
“This suggests there was really a large unmet need for treatment,” Dr. Vernacchio said.
An analysis of 16,000 SSRI prescriptions written by primary care clinicians found the vast majority did well with using a preferred SSRI and appropriate starting dose, while there was room for improvement in using a validated symptom rating scale and recommended follow-ups with patients.
Patient-centered medical home and equity
A team of researchers looking at the impact of the patient-centered medical home (PCMH) model of care found that it improves overall care, but there still are disparities by race and income level.
Researchers looked at data on about 43,000 children from the 2020 National Survey of Children’s Health and compared care for those with and without a PCMH. Data showed children with a PCMH had increased rates of preventative care compared to those without.
“While the percentages were pretty small, for things like preventative medical care which had a 4% difference, putting this in perspective of the general population this is actually related to 3 million children so … we think PCMH overall is benefiting access to these preventative services,” said presenting author Olivia O. Familusi, M.D., M.S.H.P., FAAP, resident physician at Children's Hospital of Philadelphia.
However, among children with a PCMH, those below the federal poverty level had decreased rates of preventative visits compared to other income groups. Black and Asian children with a PCMH had significantly lower adjusted rates of mental health care compared to white children. Black children with a PCMH also had lower rates of developmental screening.
“What we saw was that having a PCMH increased access to a lot of primary care services and thus increased the quality of pediatric primary care,” Dr. Familusi said.
“That being said, significant health disparities were sustained in the PCMH model and so as we continue to use this model of primary care, it is really important that we think about equity-focused interventions that work to eliminate these disparities.”
Pandemic housing policies and youth homelessness
Pandemic-era policies providing emergency rental assistance and/or a moratorium on evictions made a significant impact on preventing youth homelessness, researchers found.
Data showed each additional 10% of the year with an eviction moratorium was associated with a 1.3% smaller increase in a state’s rate of youth homelessness.
Providing an additional 10% of low-income renters with emergency rental assistance was associated with a 5.3% smaller increase in state rate of homelessness, according to presenting author Kathryn M. Leifheit, Ph.D., M.S.P.H., assistant professor of pediatrics at UCLA David Geffen School of Medicine in Los Angeles.
“We found that jointly, state eviction moratoria and emergency rental assistance from 2020-2022 prevented an estimated 16,000 youth from becoming homeless,” Dr. Leifheit said. “So, it’s not only statistically significant, but significant in terms of children’s lives.”
She noted there was a resurgence of homelessness in 2023 and called for “ongoing supports to prevent further youth homelessness.”
Prolonged mental health hospitalization
Another study looked at characteristics of prolonged mental health hospitalizations.
Hospitalizations for mental health conditions at medical hospitals are increasing and now account for 20% of pediatric hospitalizations, according to presenting author Adrienne G. DePorre, M.D., FAAP, hospitalist at Children's Mercy Hospitals and Clinics, Children’s Mercy Kansas City.
Her team analyzed data from 46 children’s hospitals, which included more than 42,000 youths ages 5-20 years old hospitalized with a primary mental health diagnosis in 2021 and 2022. About 5% had a prolonged stay of 14 days or more.
The data showed higher odds of prolonged mental health hospitalization for children who were identified as Black, Asian or other races/ethnicities compared to white children.
“We speculate our results might reflect both pre-hospital and hospital level care,” Dr. DePorre said. “We know that unconscious bias exists in mental health evaluations and treatment plans, and unconscious bias may have contributed to our findings.”
Patients with more mental health diagnostic categories and those with a greater number of complex chronic conditions had higher odds of prolonged stay than those with fewer such diagnoses.
In addition, feeding/eating disorders, schizophrenia/psychotic disorders, autism and disruptive/conduct disorders had the highest risk of prolonged length of stay, and all were higher than anxiety disorders, which were used as a reference.
Long COVID
In the Researching COVID to Enhance Recovery initiative, investigators found that some long COVID symptoms vary by age group.
The team studied more than 7,000 children, adolescents and young adults, looking at symptoms that lasted four weeks or more and started or worsened during the COVID pandemic. They compared these symptoms in infected versus uninfected young people.
Results showed that in early childhood, infected children had greater odds of general systems issues like trouble sleeping and decreased appetite as well as respiratory symptoms, according to presenting author Rachel Gross, M.D., M.S., associate professor of pediatrics and population health at NYU Grossman School of Medicine in New York City.
As children got older, more systems became involved in the infected group, which had greater odds of general, musculoskeletal, gastrointestinal, dermatological and neurocognitive symptoms and behavioral/emotional symptoms compared to uninfected peers.
Adolescents with long COVID had similar organ system involvement as younger children but also a loss of or change in smell and taste similar to what is seen in adults. Young adults had a wide range of symptoms across the same organ symptoms, including the loss/change of smell and taste. In addition, this group had cardiopulmonary symptoms like chest pain and palpitations.
“What we did find was that symptom patterns were similar but distinguishable across age groups,” Dr. Gross said.
The group’s next steps are to evaluate clusters of symptoms, risk factors for long COVID and underlying mechanisms.
“Having better understanding of how these different age groups are affected by the long-term effects of COVID will ultimately help clinicians to appropriately diagnose and treat long COVID,” Dr. Gross said.
Additional PAS meeting coverage
