Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales.

Carter G, Milner A, McGill K, Pirkis J, Kapur N, Spittal MJ.

Prediction of suicidal behaviour is an aspirational goal for clinicians and policy makers; with patients classified as 'high risk' to be preferentially allocated treatment. Clinical usefulness requires an adequate positive predictive value (PPV). AimsTo identify studies of predictive instruments and to calculate PPV estimates for suicidal behaviours.
A systematic review identified studies of predictive instruments. A series of meta-analyses produced pooled estimates of PPV for suicidal behaviours.
For all scales combined, the pooled PPVs were: suicide 5.5% (95% CI 3.9-7.9%), self-harm 26.3% (95% CI 21.8-31.3%) and self-harm plus suicide 35.9% (95% CI 25.8-47.4%). Subanalyses on  self-harm found pooled PPVs of 16.1% (95% CI 11.3-22.3%) for high-quality studies, 32.5% (95% CI 26.1-39.6%) for hospital-treated self-harm and 26.8% (95%  CI 19.5-35.6%) for psychiatric in-patients.
No 'high-risk' classification was clinically useful. Prevalence imposes a ceiling on PPV. Treatment should reduce exposure to modifiable risk factors and offer effective interventions for selected subpopulations and unselected clinical populations.


Self-Reported Mental Health Problems Among Adults Born Preterm: A Meta-analysis

Pyhälä R, Wolford E, Kautiainen H, Andersson S, Bartmann P, Baumann N, Brubakk AM, Evensen KA, Hovi P, Kajantie E, Lahti M, Van Lieshout RJ, Saigal S, Schmidt LA, Indredavik MS, Wolke D, Räikkönen K.

CONTEXT: Preterm birth increases the risk for mental disorders in adulthood, yet findings on abstract self-reported or subclinical mental health problems are mixed.
OBJECTIVE: To study self-reported mental health problems among adults born preterm at very low birth weight (VLBW; ≤1500 g) compared with term controls in an individual participant data meta-analysis.
DATA SOURCES: Adults Born Preterm International Collaboration.
STUDY SELECTION: Studies that compared self-reported mental health problems using the Achenbach Young Adult Self Report or Adult Self Report between adults born preterm at VLBW (n = 747) and at term (n = 1512).
DATA EXTRACTION: We obtained individual participant data from 6 study cohorts and compared preterm and control groups by mixed random coefficient linear and Tobit regression.
RESULTS: Adults born preterm reported more internalizing (pooled β = .06; 95% confidence interval .01 to .11) and avoidant personality problems (.11; .05 to .17), and less externalizing (–.10; –.15 to –.06), rule breaking (–.10; –.15 to –.05), intrusive behavior (–.14; –.19 to –.09), and antisocial personality problems (–.09; –.14 to –.04) than controls. Group differences did not systematically vary by sex, intrauterine growth pattern, neurosensory impairments, or study cohort.
LIMITATIONS: Exclusively self-reported data are not confirmed by alternative data sources.
CONCLUSIONS: Self-reports of adults born preterm at VLBW reveal a heightened risk for internalizing problems and socially avoidant personality traits together with a lowered risk for externalizing problem types. Our findings support the view that preterm birth constitutes an early vulnerability factor with long-term consequences on the individual into adulthood.


Priority setting in paediatric preventive care research.

Lavigne M, Birken CS, Maguire JL, Straus S, Laupacis A.

OBJECTIVES: To identify the unanswered research questions in paediatric preventive care that are most important to parents and clinicians, and to explore how questions from parents and clinicians may differ.
DESIGN: Iterative mixed methods research priority setting process.
SETTING: Toronto, Ontario, Canada.
PARTICIPANTS: Parents of children aged 0-5 years enrolled in a research network in Toronto, and clinicians practising in Toronto, Ontario, Canada.
INTERVENTIONS: Informed by the James Lind Alliance's methodology, an online questionnaire collected unanswered research questions in paediatric preventive care from study participants. Similar submissions were combined and ranked. A consensus workshop attended by 28 parents and clinicians considered the most highly ranked submissions and used the nominal group technique to select the 10 most important unanswered research questions.
RESULTS: Forty-two clinicians and 115 parents submitted 255 and 791 research questions, respectively, which were combined into 79 indicative questions. Most submissions were about nutrition, illness prevention, parenting and behavior management. Parents were more likely to ask questions about screen time (49 parents vs 8 clinicians, p<0.05) and environmental toxins (18 parents vs 0 clinicians, p<0.05). The top 10 unanswered questions identified at the workshop related to mental health, parental stress, physical activity, obesity, childhood development, behaviour management and screen time.
CONCLUSION: The top 10 most important unanswered research questions in paediatric preventive care from the perspective of parents and clinicians were identified. These research priorities may be important in advancing preventive healthcare for children.


Provider Perspectives on Adding Biomarker Screening for Tobacco Smoke Exposure to Lead Screening at Well-Child Visits.

Ghidei W, Brottman G, Lenne E, Quan T, Joseph A.

INTRODUCTION: Measurement of cotinine, a biomarker of tobacco smoke exposure, can accurately identify children at risk of health consequences from secondhand smoke. This study reports perspectives from pediatric health care providers on incorporating routine cotinine screening into well-child visits.
METHODS: Key informant interviews (N = 28) were conducted with pediatric primary  care providers: physicians, nurse practitioners, and registered nurses.
RESULTS: Themes identified in the interviews included the following: (a) Cotinine screening would assess children's exposure to tobacco smoke more reliably tan parental report; (b) Addressing positive cotinine screening results might require additional resources; (c) Wheezing and a history of emergency department visits increased the salience of cotinine screening; and (d) A better understanding of the significance of specific cotinine test values would improve utility.
DISCUSSION: Pediatric providers see advantages of biomarker screening for tobacco smoke exposure at well-child visits, especially for children with wheezing, but have concerns about limited capacity for follow-up with parents.

A Clinical Care Algorithmic Toolkit for Promoting Screening and Next-Level Assessment of Pediatric Depression and Anxiety in Primary Care.

Honigfeld L, Macary SJ, Grasso DJ.
With a documented shortage in youth mental health services, pediatric primary care (PPC) providers face increased pressure to enhance their capacity to identify and manage common mental health problems among youth, such as anxiety and depression. Because 90% of U.S. youth regularly see a PPC provider, the primary care setting is well positioned to serve as a key access point for early identification, service provision, and connection to mental health services. In to assist PPC providers in overcoming barriers to practice-wide mental health the context of task shifting, we evaluated a quality improvement project designed screening through implementing paper and computer-assisted clinical care family mental health histories, next-level actions, and referral options. Task algorithms. PPC providers were fairly successful at changing practice to better address mental health concerns when equipped with screening tools that included when guided by computer-assisted algorithms. shifting is a promising strategy to enhance mental health services, particularly when guided by computer-assisted algorithms.


Lifestyle Interventions in Preschool Children: A Meta-analysis of Effectiveness.

Ling J, Robbins LB, Wen F, Zhang N.

CONTEXT: With healthy behaviors becoming established in the preschool years, intervening with preschool children to assist them in establishing a healthy lifestyle and maintaining a long-term healthy weight is critical. To optimize future intervention designs, this meta-analysis aimed to estimate the effects of  lifestyle interventions on BMI among preschool children and explore potential
intervention moderators.
EVIDENCE ACQUISITION: In October 2015, a search of PubMed, CINAHL, EMBASE, PsycINFO, ERIC, and Cochrane library databases yielded 52 eligible articles with  42 randomized intervention-control comparisons (31 prevention and 11 treatment).  In 2016, weighted standardized mean differences for BMI were calculated using random-effects models to estimate effect sizes.
EVIDENCE SYNTHESIS: The effect sizes were -0.19 (95% CI= -0.28, -0.09) and -0.28  (95% CI= -0.48, -0.09) kg/m(2) for prevention and treatment interventions, with sustained effect sizes of -0.21 (95% CI= -0.35, -0.08) and -0.23 (95% CI= -0.43,  -0.04) kg/m(2), respectively. Child mean age, percentage Hispanic, and parental intervention sessions were common significant moderators. School-based or prevention interventions with active parental involvement did not yield better outcomes. Interventions targeting parents with parenting skill training and behavioral change strategies, and children with general health and nutrition education, resulted in greater effects.
CONCLUSIONS: Although publication bias limits the validity of the study findings, the meta-analysis results highlight the promising intervention approaches of parenting skill training and behavioral change strategies to target parents.
However, for children, general health and nutrition education should be employed.


The Identification of Psychosocial Risk Factors Associated With Child Neglect Using the WE-CARE Screening Tool in a High-Risk Population.

Zielinski, S., Paradis, H. A., Herendeen, P., & Barbel, P. 

Neglect accounts for over 70% of child maltreatment and carries significant sequelae. Identification of psychosocial determinants of health may allow pediatric providers to ameliorate precursors of child neglect.
Data were collected 1 month before and after implementation of the Well-Child Care Visit, Evaluation, Community Resources, Advocacy, Referral, Education (i.e., WE-CARE) screen at all well-child visits. Social workers recorded number and types of referrals, and providers completed surveys.
Analysis of 602 completed screens (75% capture rate) showed 377 families (63%) with at least one need and 198 (33% overall, 53% of those with positive results) indicating a desire to discuss. Of families requesting assistance, 122 (62%) connected with a social worker, and total referrals increased after implementation. Provider surveys supported an increased frequency of and comfort with assessing families for certain risk factors, and screening was not perceived to interrupt clinic flow.
Standardized screening identifies families at risk for neglect, improves provider comfort, and minimally affects flow. Identification of psychosocial needs should be part of routine preventive care.


Multilevel Correlates of Healthy BMI Maintenance and Return to a Healthy BMI among Children in Massachusetts.

Fiechtner L, Cheng ER, Lopez G, Sharifi M, Taveras EM. 

To examine predictors of healthy BMI maintenance (HBM) or return to a healthy BMI (RHB) among children.
We studied 33,272 children in Massachusetts between 2008 and 2012. We used multinomial logistic regression to examine associations of individual- and neighborhood-level factors with the odds of: (1) HBM: maintenance of a healthy BMI ≥5th to <85th percentile and (2) RHB: transition to a healthy BMI range from  an initial BMI ≥85th percentile between two clinic visits spanning an average of 
3.5 years.
Racial/ethnic minorities had lower odds of HBM and RHB than non-Hispanic white children. Higher neighborhood educational attainment was associated with an increased odds of HBM and RHB. Higher neighborhood median household income, proximity to a supermarket, and access to more open recreational space were associated with a higher odds of HBM. Children of ages 2-5 years at baseline had  higher odds of RHB and HBM than children 13 years and older.
Early childhood interventions and efforts to create health-promoting neighborhoods including improving access to supermarkets and open recreational space could have important effects on obesity prevention and management.