Adolescent offenders with mental disorders

Thomas Grisso points out that youth with mental disorders make up a significant subgroup of youth who appear in U.S. juvenile courts. And he notes that juvenile justice systems today are struggling to determine how best to respond to those youths' needs, both to safeguard their own welfare and to reduce re-offending and its consequences for the community. In this article, Grisso examines research and clinical evidence that may help in shaping a public policy that addresses that question. Clinical science, says Grisso, offers a perspective that explains why the symptoms of mental disorders in adolescence can increase the risk of impulsive and aggressive behaviors. Research on delinquent populations suggests that youth with mental disorders are, indeed, at increased risk for engaging in behaviors that bring them to the attention of the juvenile justice system. Nevertheless, evidence indicates that most youth arrested for delinquencies do not have serious mental disorders. Grisso explains that a number of social phenomena of the past decade, such as changes in juvenile law and deficiencies in the child mental health system, appear to have been responsible for bringing far more youth with mental disorders into the juvenile justice system. Research shows that almost two-thirds of youth in juvenile justice detention centers and correctional facilities today meet criteria for one or more mental disorders. Calls for a greater emphasis on mental health treatment services in juvenile justice, however, may not be the best answer. Increasing such services in juvenile justice could simply mean that youth would need to be arrested in order to get mental health services. Moreover, many of the most effective treatment methods work best when applied in the community, while youth are with their families rather than removed from them. A more promising approach, argues Grisso, could be to develop community systems of care that create a network of services cutting across public child welfare agency boundaries. This would allow the juvenile justice system to play a more focused and limited treatment role. This role would include emergency mental health services for youth in its custody and more substantial mental health care only for the smaller share of youth who cannot be treated safely in the community. www.futureofchildren.org     

American Academy of Pediatrics: Health care for children and adolescents in the juvenile correctional care system

Over the past decade, there has been a dramatic increase in the population of juvenile offenders in the United States. Juveniles detained or confined in correctional care facilities have been shown to have numerous health problems. Such conditions may have existed before incarceration; may be closely associated with legal problems; may have resulted from parental neglect, mental health disorders, or physical, drug, or sexual abuse; or may develop within the institutional environment. Delinquent youths are often disenfranchised from traditional health care services in the community. For these adolescents, health care provided through correctional services may be their major source of health services. Pediatricians and correctional health care systems have an opportunity and responsibility to help improve the health of this underserved and vulnerable group of adolescents.     

A call for action: Recommendations to improve transition to adult care for youth with complex health care needs

Youth with complex health care needs, defined as those requiring specialized health care and services for physical, developmental, and/or mental health conditions, are often cared for by paediatricians and paediatric specialists. In Canada, the age at which provincial/territorial funders mandate the transfer of paediatric care to adult services varies, ranging between 16 and 19 years. The current configuration of distinct paediatric and adult care service boundaries is fragmentary, raising barriers to continuity of care during an already vulnerable developmental period. For youth, the lack of care integration across sectors can negatively impact health engagement and jeopardize health outcomes into adulthood. To address these barriers and improve transition outcomes, paediatric and adult care providers, as well as family physicians and other community partners, must collaborate in meaningful ways to develop system-based strategies that streamline and safeguard care for youth transitioning to adult services across tertiary, community, and primary care settings. Flexible age cut-offs for transfer to adult care are recommended, along with considering each youth’s developmental stage and capacity as well as patient and family needs and circumstances. Specialized training and education in transitional care issues are needed to build capacity and ensure that health care providers across diverse disciplines and settings are better equipped to accept and care for young people with complex health care needs.     

Homeless adolescents: common clinical concerns

Homeless youth are at alarmingly high risk for a myriad of physical and psychological problems as a result of both the circumstances that prededed their homelessness, and as a direct consequence of life on the streets. Sexually transmitted infections (STIs), pregnancy, trauma, tuberculosis, uncontrolled asthma, and dermatologic infestations are a few of the health problems with which these youth commonly present. These somatic problems are compounded by high rates of drug and alcohol abuse as well as depression and suicide. Despite the obvious need for medical services, homeless youth often do not receive appropriate medical care due to numerous individual and systems barriers impeding health care access by this population. In addition to the barriers experienced by the adult homeless population, homeless adolescents confront further hurdles stemming from their age and developmental stage. Some of these impediments include a lack of knowledge of clinic sites, fear of not being taken seriously, concerns about confidentiality, and fears of police or social services involvement. Improved access to appropriate health care is necessary if we are to better support and care for this population of young people. To effectively manage and treat homeless youth, individual providers must be aware of the diagnoses associated with homelessness, as well as the community resources available to these youth. Finally, providers need to be the voices advocating for improved services for this disadvantaged and silent population.     

Children with medical complexity in Canada

The burden of chronic disease is placing pressure on the Canadian health care system. A small but important chronic disease population is children with medical complexity, defined as individuals with: high family-identified needs; complex chronic disease necessitating specialized care; functional disability; and high health care utilization. These patients present a challenge to community providers who are expected to provide holistic care and manage complex issues, often with a paucity of services and supports. Alternative models of care may address the complex needs of this population. In addition, strategies can be implemented in community practices that may assist with the care of children with medical complexity such as collaborative care, engagement of key workers, focus on goal-directed care and use of care plans. The paediatric community should engage in health care reform discussions focused on chronic disease to ensure that the complex needs of these children are met.     

Child welfare caseworkers as service brokers for youth in foster care: findings from project focus

Youth in the foster care system have substantially higher rates of mental health needs compared to the general population, yet they rarely receive targeted, evidence-based practices (EBPs). Increasingly emerging in the literature on mental health services is the importance of "brokers" or "gateway providers" of services. For youth in foster care, child welfare caseworkers often play this role. This study examines caseworker-level outcomes of Project Focus, a caseworker training and consultation model designed to improve emotional and behavioral outcomes for youth in foster care through increased linkages with EBPs. Project Focus was tested through a small, randomized trial involving four child welfare offices. Caseworkers in the Project Focus intervention group demonstrated an increased awareness of EBPs and a trend toward increased ability to identify appropriate EBP referrals for particular mental health problems but did not have significantly different rates of actual referral to EBPs. Dose of consultation was associated with general awareness of EBPs. Implications for practice and outcomes for youth are discussed.     

Children and youth with special healthcare needs: there is no place like (a medical) home

PURPOSE OF REVIEW: This review highlights the importance, components, and outcomes of the medical home for children and youth with special healthcare needs. Relevant work supporting the medical home concept for this vulnerable group is highlighted for healthcare providers. RECENT FINDINGS: Developing a medical home model is garnering support from many national organizations and agencies. Having a medical home for children and youth with special healthcare needs is associated with favorable impacts on healthcare utilization and family-centered care. Achieving family-centered care is associated with increases in satisfaction and linkages to specialists, decreases in school absences and unmet medical needs. Consistent insurance coverage is important for children and youth with special healthcare needs to thrive. Further, lack of access to informational resources minimizes families' knowledge of available public programs. SUMMARY: Children and youth with special healthcare needs constitute a vulnerable population in need of comprehensive and accessible care. Provision of care via a medical home can be efficient and effective in this population of children and their families. Due to the relatively high cost of providing fragmented care to these children and youth, advances in coordinating access to services will have a cost-effective outcome.     

Health care transition for youth living with HIV/AIDS

There are ~1 million people in the United States living with HIV/AIDS, and >50,000 new infections occur each year. With an estimated 13% of all new infections occurring among young people aged 13 to 24 years and an increasing number of perinatally infected youth surviving to adulthood, there is now an increasing need to transition both perinatally and behaviorally infected youth to the adult health care setting. Recently, pediatric providers and professional societies have prioritized the development of transition programs for adolescents with chronic disease to address the many challenges these youth face in the process. Although multiple position papers have called for continuous, coordinated, culturally appropriate, compassionate, family-centered transition programs for youth with special health care needs and have recognized the need for evidence-based models, few data exist on what strategies are most effective. To date, published data on health care transition for HIV-positive youth are limited and include only 2 studies, which considered behaviorally infected youth. In this state-of-the-art review, we discuss the unique transition challenges to consider for this population, including socioeconomic and health insurance status, the special role of the pediatric or adolescent provider as family, stigma and disclosure issues, cognitive development and mental health issues, medication adherence, and sexual, reproductive, and gender health concerns. Future research will need to include the experiences of transition in low-resource settings and examine clinical outcomes and factors that may predict success or failure of the transition process.     

Sexual and Gender Minority Adolescents: Meeting the Needs of Our LGBTQ Patients and Their Families

Adolescent patients comprise up to 16% of all emergency department (ED) visits in the United States. Although an exact prevalence is difficult to determine, an estimated 4-17% of youth identify as lesbian, gay, bisexual, transgender, and questioning. Health care providers need to understand gender identity and sexual orientation to provide competent medical care within a clinical setting that is safe for minority youth. Despite the ED presence of lesbian, gay, bisexual, transgender, and questioning teens, many ED providers report a lack of comfort with understanding the health care needs of this patient population. In this article, we aim to review the topics of gender identity, gender presentation, sexual orientation, and pronoun use, and provide practical guidelines for eliciting important information in the care of sexual and gender minority youth.     

Redefining primary pediatric care for children with special health care needs: the primary care medical home

PURPOSE OF REVIEW: As considerations of the quality of health care have matured, the role of pediatric primary care providers and models for the delivery of primary care have received growing attention. Particularly for children with chronic conditions, the need for proactive, planned, and coordinated care delivered in partnership with consumers has become more apparent. The primary care medical home has emerged as a model favored by national organizations representing pediatricians and family physicians as well as national public health policy makers, yet implementation of this model remains limited and the evidence base for its value is not yet highly developed. RECENT FINDINGS: Most studies of primary care outcomes involve individual elements of the medical home such as care coordination and continuity of care. Limited data that are emerging from studies of the medical home model as a whole in practice settings suggest improvements in patient satisfaction and in some areas of utilization. No data are available that examine specific functional or physical health outcomes associated with primary care models like the medical home. SUMMARY: The pediatric primary care medical home provides a care model for both well children and those with special health care needs that expands primary care services beyond those provided in the examination room by individual providers to include systemic services such as patient registries, explicit care planning and care coordination, planned co-management with specialists, patient advocacy, and patient education. There is an immediate need for large-scale, practice-based studies of the outcomes for children and youth, providers, and the health care system when such improvements in primary care are implemented.     

HIV and AIDS in adolescents

HIV infection in adolescents continues to challenge health care providers, policy makers, and advocates for youth. Primary care providers working with parents of adolescents and at-risk youth are in a unique position to identify or help develop HIV prevention and care programs that address many needs. Effective interventions are those that move beyond moralism to realism and a willingness to engage youth and their families. Youth at high risk for HIV should be identified and engaged in primary care as soon as possible. HIV-infected youth need intensive individual and group interventions to keep themselves healthy and reduce transmission to others. Incumbent on all providers is to make adolescents' services visible, flexible, affordable, confidential, culturally appropriate, and available for all youth.     

<Emphasis Type="Italic">Priority Mental Health Disorders</Emphasis> of Children and Adolescents in Primary-care Pediatric Setting in India 1: Developing a Child and Adolescent Mental Health Policy,Program, and Service Model

India has a huge child and adolescent population. Psychiatric disorders are widely prevalent and the mental health needs of these children are well recognized. Nonetheless, there are no country-centric and child specific mental health policies, plans or programs. There is also a significant lack of human resources for child and adolescent mental health in India. This combination of factors makes the primary care a critical setting for the early identification, treatment, consultation and referral of children and adolescents with mental health and developmental needs. Even though the importance of primary care as a system for addressing the mental health care has been recognized for decades, its potential requires further development in India as the Child and Adolescent Mental Health Services (CAMHS) emerge and evolve. A country and child specific mental health policy, plan and program needs to be formulated as well an integrated, multi-tier CAMHS with a focus on the primary-care physicians as care providers for this population has to be developed.     

Priority mental health disorders of children and adolescents in primary-care pediatric setting in India 1: developing a child and adolescent mental health policy, program, and service model

India has a huge child and adolescent population. Psychiatric disorders are widely prevalent and the mental health needs of these children are well recognized. Nonetheless, there are no country-centric and child specific mental health policies, plans or programs. There is also a significant lack of human resources for child and adolescent mental health in India. This combination of factors makes the primary care a critical setting for the early identification, treatment, consultation and referral of children and adolescents with mental health and developmental needs. Even though the importance of primary care as a system for addressing the mental health care has been recognized for decades, its potential requires further development in India as the Child and Adolescent Mental Health Services (CAMHS) emerge and evolve. A country and child specific mental health policy, plan and program needs to be formulated as well an integrated, multi-tier CAMHS with a focus on the primary-care physicians as care providers for this population has to be developed.     

Transition Care: Future Directions in Education,Health Policy,and Outcomes Research

All youth must transition from pediatric to adult-centered medical care. This process is especially difficult for youth with special health care needs. Many youth do not receive the age-appropriate medical care they need and are at risk during this vulnerable time. Previous research has identified barriers that may prevent effective transition, and protocols have been developed to improve the process. Health outcomes related to successful transition have yet to be fully defined.Health care transition can also be influenced by education of providers, but there are gaps in medical education at the undergraduate, graduate, and postgraduate levels. Current changes in federal health policy allow improved health care coverage, provide some new financial incentives, and test new structures for transitional care, including the evolution of accountable care organizations (ACO). Future work must test how these systems changes will affect quality of care. Finally, transition protocols exist in various medical subspecialties; however, national survey results show no improvement in transition readiness, and there are no consistent measures of what constitutes transition success.In order to advance the field of transition, research must be done to integrate transition curricula at the undergraduate, graduate, and postgraduate levels; to provide advance financial incentives and pilot the ACO model in centers providing care to youth during transition; to define outcome measures of importance to transition; and to study the effectiveness of current transition tools on improving these outcomes.     

School-based health centers and pediatric practice

School-based health centers (SBHCs) have become an important method of health care delivery for the youth of our nation. Although they only represent 1 aspect of a coordinated school health program approach, SBHCs have provided access to health care services for youth confronted with age, financial, cultural, and geographic barriers. A fundamental principle of SBHCs is to create an environment of service coordination and collaboration that addresses the health needs and well-being of youth with health disparities or poor access to health care services. Some pediatricians have concerns that these centers are in conflict with the primary care provider's medical home. This policy provides an overview of SBHCs and some of their documented benefits, addresses the issue of potential conflict with the medical home, and provides recommendations that support the integration and coordination of SBHCs and the pediatric medical home practice.     

Bacterial sexually transmitted infections in gay, lesbian, and bisexual adolescents: medical and public health perspectives

Gay, lesbian, and bisexual adolescents, like all adolescents who engage in high-risk sexual behaviors, are at elevated risk for acquiring sexually transmitted infections (STIs). Personal sexual risk factors and issues related to access to care complicate the lives of youth who engage in same-gender sexual activity and who may or may not self-identify as gay, lesbian, or bisexual. Whereas epidemiologic rates of gonorrhea, chlamydia, and syphilis generally have trended downward in adolescents as a whole during the past 15 years, rates for these common reportable bacterial STIs have increased overall during recent years among men who have sex with men. This article focuses on bacterial STIs in youth with same-gender sexual activity. An understanding of trends among gay, lesbian, and bisexual youth remains incomplete, given the absence of consistent and uniform mechanisms for collecting data on sexual behaviors in adolescents and difficulties in associating these behaviors with reportable STIs. Special attention should be given to the screening, diagnosis, and treatment of bacterial STIs in those who engage in same-sex behavior, as new recommendations from the Centers for Disease Control and Prevention have been made available. It is critical that healthcare providers who work with adolescents be aware of the assortment of specific healthcare needs of gay, lesbian, and bisexual youth and address them appropriately in the clinical setting. Medical providers may be one of few true advocates for this often-marginalized adolescent population and have the power to have a positive influence on health promotion and education efforts.     

Delinquent adolescents: health problems and health care guidelines for juvenile correctional facilities

The aim of this article was to provide an update that would serve to increase knowledge of health problems among juvenile delinquents before and during incarceration in juvenile correctional centers. Recommendations are made for the care of mental and physical health and for the health education of these teenagers that could be useful for health professionals providing health care to these teenagers while in custody as well as for those seeing them in the ambulatory setting. From the literature consulted, 63 % of studies have been performed in the United States, 24 % in Western Europe (Spain, United Kingdom, Holland, Belgium, Sweden, Finland), 8 % in Australia and 5 % in Canada. These studies show no appreciable qualitative differences in the health problems most frequently presented by these teenagers and there is agreement that the areas that should be prioritized are the provision of preventive and/or therapeutic dental care, as well as programs for psychiatric care, immunization, infectious diseases and health education. Failure to identify the health requirements of these teenagers and to provide early interventions can not only adversely effect their quality of life and their future physical, emotional and intellectual development but can also make their rehabilitation and reintegration into society more difficult.     

Medical neglect: Working with children,youth, and families

All children have a basic right to health care. When a child’s health care needs are not met, for any reason, health care providers (HCPs) must consider the barriers involved and the processes required to resolve the situation. Social, economic, or other barriers can prevent parents from accessing care for their child. Sometimes differing opinions, priorities, or values, between a child’s HCPs and parents come to impede the child receiving needed medical care. In some cases, caregiver failure to ensure needed care may be considered medical neglect. Specific skills and knowledge can help HCPs to prevent such situations from arising, and to work effectively with the family if they do. This statement offers an approach that HCPs can use to promote the best interests, well-being, and safety of children or youth at risk for medical neglect.     

School-based health centers in an era of health care reform: building on history

School-based health centers (SBHCs) provide a variety of health care services to youth in a convenient and accessible environment. Over the past 40 years, the growth of SBHCs evolved from various public health needs to the development of a specific collaborative model of care that is sensitive to the unique needs of children and youth, as well as to vulnerable populations facing significant barriers to access. The SBHC model of health care comprises of on-school site health care delivery by an interdisciplinary team of health professionals, which can include primary care and mental health clinicians. Research has demonstrated the SBHCs' impacts on delivering preventive care, such as immunizations; managing chronic illnesses, such as asthma, obesity, and mental health conditions; providing reproductive health services for adolescents; and even improving youths' academic performance. Although evaluation of the SBHC model of care has been complicated, results have thus far demonstrated increased access to care, improved health and education outcomes, and high levels of satisfaction. Despite their proven success, SBHCs have consistently faced challenges in securing adequate funding for operations and developing effective financial systems for billing and reimbursement. Implementation of health care reform (The Patient Protection and Affordable Care Act [P.L. 111-148]) will profoundly affect the health care access and outcomes of children and youth, particularly vulnerable populations. The inclusion of funding for SBHCs in this legislation is momentous, as there continues to be increased demand and limited funding for affordable services. To better understand how this model of care has and could further help promote the health of our nation's youth, a review is presented of the history and growth of SBHCs and the literature demonstrating their impacts. It may not be feasible for SBHCs to be established in every school campus in the country. However, the lessons learned from the synergy of the health and school settings have major implications for the delivery of care for all providers concerned with improving the health and well-being of children and adolescents.     

Health care issues of gay and lesbian youth.

Gay and lesbian youth are adolescents who, in many ways, are no different from their peers. What distinguishes homosexual youth from other adolescent populations is the emotional, psychological and physical trauma resulting from the homophobia they experience in their daily lives. Although suicide, HIV infection, substance use, and violence appear to disproportionately affect this population, most homosexual youth grow up healthy and happy. Frequently lost in discussions of risk and risk behaviors is an appreciation of the strengths very much present in these young people. Health care providers must remain aware of the unique issues and health risks of homosexual youth but must also remember to address each patient as an individual within the context of general adolescent development. By doing so, pediatricians can play a vital role in preserving and enhancing the health of this "at-risk" population.