Center researchers are involved in core investigations, new projects that have developed and address Center research goals, and Center-funded pilot projects. Our core divisions aim to better understand the common factors model as it applies in pediatric primary care. They will research its impact on children's mental health outcomes, its effect on family engagement in care, and other factors surrounding the model's implementation. Click on any project title for more details.
This page was last updated in January, 2014.
Original Center Grant Core Projects
- Research Methods Core 1: Common Factors and Children
- Research Methods Core 2: (Re)Designing Practice to Facilitate Planned Care: Measuring Provider and Practice Work in Pediatric Primary Care
- Research Methods Core 3: Improved Clinical Information Systems: Using Handheld Computers to Assess and Track Mental Health-Related Function in Pediatric Primary Care
- Principle Research Core 1: Common Factors: A Common Factors Treatment Program for Children with Anxiety
- Principle Research Core 2: Common Elements: PrimaryCare Anxiety Study
Active Projects and Collaborations
- Building Mental Wellness (BMW) Learning Collaborative
- Children of Maryland/Mental Health and Advocates Together (COMMHAT)
- Integrating Mental Health and HIV Care in Ethiopia
- Maryland Behavioral Health Integration in Pediatric Primary Care (B-HIPP)
- National Network of Child Psychiatry Access Programs (NNCPAP)
- Pediatric Integrated Care Collaborative (PICC)
- Project Training and Education for the Advancement of Children’s Health (TEACH) Evaluation
Original Center Grant Pilot Projects
- Engaging Youth and Their Families in Mental Health Services: School Nurses as the First Point of Contact
- Developing a Model for the Diffusion of the Common Factors/Treatment Elements-Chronic Care Model (CFTE-CCM)
- Mental Health Symptoms Presenting in Pediatric Primary Care
- Patient-Provider Communication Practices in an mhGAP Intervention for Children and Families in Nepal
- Does Long- Term Use of the Guidelines for Adolescent Preventive Services (GAPS) Lead to Earlier Mental Health or Substance Abuse Diagnosis?
- Mental Health Training for School-Based Mental Health Providers
- Supporting Parents with Depression in Pediatric Primary Care
- Behavior Health (BH) Problem Identification and Subsequent BH Utilization in Medicaid Children
- Investigating Prevalence of Pre-Psychotic Symptoms in a Primary Care Setting
- Emergency Medical Service (EMS) Use for Mental Health Issues Among Children: The Role of Primary Care Providers
- Parents’ Perspectives of the Primary Care Providers’ Role in Their Child’s Mental Health Care
- The Perception of Latino Mothers of Mental Health Problems among Children in their Community
Research Methods Core 1: Using Evidence-Based Care: Age Variation in Common Factors in Pediatric Primary Care
The goal of this project is to increase the evidence base for the use of common factors in pediatric primary care through study of provider and patient communication. African-American, Caucasian, and Latino parent-child pairs were recruited, and their sessions with their pediatricians were video recorded. Later, interviews with the children were conducted to understand their perspective on the visit.
We found that children anticipated positive interactions with their doctor, but at the same time were uncertain about the appropriateness of offering their own opinions or of providing information that the doctor appeared to be missing. They were also ambivalent about the presence of their parents, and, similar to adolescents, would have liked opportunities to speak alone with their doctor. Two manuscripts are currently in progress.
Research Methods Core 2: (Re)Designing Practice to Facilitate Planned Care: Measuring Provider and Practice Work in Pediatric Primary Care
The goal of this project is to understand and quantify providers’ perceptions of the amount of work involved in delivering mental health services in pediatric primary care.
Phase 1 of this project aimed to understand PCPs’ perceptions of work involved in the delivery of mental health services Interviews were conducted with 21 PCPs to assess their perceptions of the workload required for management of emotional, behavioral, and mental health (EBMH) problems in primary care. Most PCPs indicated that management of EBMH problems requires more time than that allotted for a routine visit. PCPs also reported that, in relation to required provider time and effort, EBMH problems are similar to complex chronic physical conditions such as asthma or diabetes. These results were used to inform the design of a survey about PCP workload perception for management of EBMH problems to be used in Phase 2.
Phase 2 involves surveying PCPs about the perceptions of work involved in mental health care. The survey includes 10 case vignettes, 1 of which serves as the reference case and is pre-assigned a work value of 10 Relative Value Units (RVUs). It asks PCPs to rate the work values of the nine other case vignettes relative to the reference case. After pilot testing the survey, a web version of the revised work survey was sent to the Maryland Chapter of the American Academy of Pediatrics.
We found that vignettes involving problems with depression were assigned greater overall workload on average as compared to vignettes involving ADHD. In addition, family psychosocial issues, psychiatric co-morbidity, and medical co-morbidity all increased workload, independent of mental health diagnosis. Published results accessible here.
Research Methods Core 3: Improved Clinical Information Systems: Using Handheld Computers to Assess and Track Mental Health-Related Function in Pediatric Primary Care
This project includes two studies on the use of an electronic screener--one with young children and the other with teens.
Study 1: The “child study” evaluated the acceptability of a pre-visit web-based screener designed to comprehensively assess child health, including mental health, using a mixed methods study design. Families were recruited from three sites (urban MD and rural NY and VT). One hundred and twenty English-speaking parents of children 4-10 years of age were recruited when they presented for a well child visit. Parents completed an electronic pre-visit screen, which included somatic concerns, health risks, four mental health tools, and exit questionnaires. A subset of these families participated in a follow-up phone interview. All PCPs were interviewed by phone following the completion of the study. Results showed that nearly 90% of parents agreed that the screener was easy to use, helped with recall, validated concerns, reframed issues they did not associate with primary care, and raised new questions. PCPs shared a positive view regarding the screener as it enabled them to normalize sensitive issues and permitted them to focus during the visit.
Academic Pediatrics published a paper from this project entitled, “Assessing the Impact of a Web-Based Comprehensive Somatic and Mental Health Screening Tool in Pediatric Primary Care (see publication here).”
Study 2: The “teen study” aims to better understand how PCPs use a comprehensive pre-visit electronic screen during health maintenance visits with adolescents and to examine the impact of using the screen on engagement of adolescents and parents in the assessment of problems and planning for care. Families with teenagers ages 15-19 were recruited at their annual well child visits at one urban site in Maryland and one rural site in New York. Sessions with PCPs were audio recorded, and PCP-patient communication in visits using the screen were compared to communication in visits not using the screen. Visit audio recordings were RIAS coded to reflect key visit tasks: information giving, information gathering, and discussion of adolescent health topics.
Teens completing the DartScreen offered more psychosocial information, and mental health was discussed more after the DartScreen. There was no difference in the discussion of somatic and substance abuse topics. http://www.ncbi.nlm.nih.gov/pubmed/25586231
Principle Research Core 1: Common Factors Pilot: A Common Factors Treatment Program for Children with Anxiety
The goal of this project is to examine the impact of providers’ training in and use of common factors techniques to enhance family involvement in “usual care” for anxiety problems. This project consists of three phases.
Phases 1 and 2 of this study are complete. In Phase 1, a common factors treatment program (CFTP) was developed and submitted to medical providers, experts in training issues, and caregivers of children with mental health challenges. They were asked for their opinions on reasons for PCP participation in training, the likelihood of PCPs putting it into practice, and the usefulness of different engagement and activation strategies during the process of screening and the development and implementation of a treatment plan. In Phase 2, the CFTP was administered to a small group of PCPs. Pre-post surveys obtained ratings from participants about the extent to which (1) they agree with beliefs about mental health treatment in primary care and (2) they believe strategies and skills for engaging and activating families addressed in the training are important. Positive change in ratings occurred in all but 2 of the 18 items. Participants also rated the format, quality, materials, and overall effectiveness of the trainers at the end of the 3-hour training on a 1-5 scale; average scores were above 4.75. For Phase 3, a pilot intervention is being implemented by randomly assigning PCPs to an intervention group receiving the CFTP or treatment as usual (TAU) group. PCPs have been recruited from clinics associated with the Departments of Pediatrics and Family Medicine of Georgetown University Hospital in DC and Virginia and the Children’s National Medical Center.
Principle Research Core 2: Common Elements Pilot: Stepped Use of Common Treatment Elements for Children with Anxiety Problems Seen in Pediatric Primary Care
The goal of this project is to test the feasibility of a common treatment elements intervention for childhood anxiety in primary care. The intervention is based on the principles of cognitive behavioral therapy.
Phase 1 has been completed. It focused on questions about current practices, PCP interest and motivation, feasibility, suggestions for training, and barriers to anxiety treatment in primary care. Responses revealed that there is interest in treating anxiety in pediatric care, but that providers are not confident, lack training, and confront barriers such as time and billing complications. Using these responses, a PCP-friendly intervention model was developed and called the “Anxiety Action Plan (AAP).” Phase 2 has been completed and culminated in an overall sample of 17 PCPs and 25 children.
Results indicated that PCPs were very satisfied with the training sessions and felt it was relevant and feasible to implement in their practices. PCPs’ level of confidence implementing the treatment significantly increased after the training and after completing the intervention with families. Parents reported that working with their PCP was the most helpful aspect of the intervention. In terms of child outcomes, overall, parents reported a general reduction of anxiety symptoms in their children from pre- to post-treatment. http://www.ncbi.nlm.nih.gov/pubmed/27403041
BMW is a statewide initiative in Ohio coordinated by the American Academy of Pediatrics (AAP). The initiative’s goal is to improve mental health service delivery and health outcomes for children and youth through a series of interventions customized for the state’s pediatric primary care practices. It aims to improve the delivery of children’s mental health services by enhancing knowledge and skills, office context, and integration of care and resources in participating practices.
The Center has completed its “train-the-trainer” sessions for local quality improvement coordinators responsible for conducting the on-site trainings in common factors and common elements. We have also completed the first of three rounds of in-depth qualitative interviews with a diverse cross-section of site visit participants. Findings are being combined in a mixed-methods study with outcomes data to explore the role of organizational context in pediatric primary care practice change and to illuminate practice typologies. Manuscripts are in preparation.
COMMHAT is a joint effort of the Maryland Chapters of the American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry, along with Parents’ Place of Maryland. In the spring of 2012, COMMHAT hosted a “Western Maryland Child Mental Health Summit Meeting” with the aim of developing primary care-mental health partnerships and encouraging more primary care practitioners to develop their mental health skills.
Currently, this project is on “standby” as another Center project, B-HIPP, gets underway. It is highly anticipated this project will reconvene as a way to coordinate training efforts. We've continued to collaborate with the Maryland AAP chapter via BHIPP.
The goal of this project is to work with Ethiopian mental health professionals and administrators to develop training and support for HIV care providers to detect and respond to common child and adult mental health problems.
Implementation began in May 2011. A training manual was developed and then pilot tested at four sites, and an informal evaluation was conducted. The project has provided Center investigators valuable experience in program implementation and evaluation.
We are currently analyzing evaluation data, which will help us understand which patients are being identified as having MH problems, the types of treatments being offered, and will provide limited but useful comparisons of screening instruments and between trained and untrained providers. Initial results suggest that trained providers increased their ability to detect adult mental health problems, especially anxiety among women. A copy of the training manual for HIV providers is available here. ***Larry will send it to Amelia
B-HIPP is conducted through a partnership among the University of Maryland School of Medicine/Department of Psychiatry, the Johns Hopkins University School of Public Health, and Salisbury University Social Work Department. The goal of this project is to support the efforts of primary care in assessing and managing mental health concerns in their patients from infancy through the transition to young-adulthood. B-HIPP offers this assistance through four main components: 1) Phone Consultation Service, 2) Continuing Education, 3) Referral & Resource Networking, and 4) Social Work Co-Location.
B-HIPP launched in January 2013 and has since then enrolled approximately 300 pediatric primary care providers enrolled and has fielded more than 1000 phone consultations. To better understand the challenges of providing behavioral health care to children and their families, and to learn about providers’ perceptions of the BHIPP program, interviews were conducted with key stakeholders and PCPs. 12-month follow-up questionnaires with enrolled providers are currently being collected. In the coming months, focus will be on further developing training initiatives and plans will move forward to conduct a pilot project offering telepsychiatry consultation services. More information about BHIPP is available at www.mdbhipp.org
The National Network of Child Psychiatry Access Programs continues to grow and now includes programs from more than 32 states. Representatives from these programs meet via regular teleconference calls to discuss topics including funding opportunities, generating enthusiasm for the programs among parents and primary care providers, and collecting baseline data for future program evaluation efforts. In 2012, NNCPAP funded the Center to develop a compendium of the tools used at individual programs to solicit consultations, monitor referrals, and evaluate the programs’ impact on factors such as primary care provider comfort with mental health care and parent satisfaction. The goal was to develop guidelines for best practices on program data collection.
The Network is on schedule to become a formal 501c3 by fall of 2014 and has organized an initial group of volunteer board members to guide the group in the interim. NNCPAP will be holding a meeting at the Annual Meeting for the American Academy of Child and Adolescent Psychiatry on October 23rd.
Funded by the Substance Abuse Mental Health Services Administration (SAMHSA), the goal of this project, which is part of the National Child Traumatic Stress Network, is to raise the standard of care and improve access to services for traumatized and chronically stressed children, their families, and communities. The Center will support three levels of collaborative activity: 1) a Breakthrough Series, 2) a Learning Collaborative, and 3) an Integrated Care Collaborative Group of participants from SAMHSA-NCTSN– funded sites and Network Affiliates.
Look for more information and a link to the PICC integrated care toolkit here (***link to projects tab)
Funded by the New York State’s Office of Mental Health, the goal of this project is to improve the treatment of mild and moderate child MH disorders in primary care, promote appropriate psychotropic medication prescribing practices, increase access to child adolescent psychiatrists consultation support, and increase linkages within the health care system. This evaluation project assessed whether the TEACH training model is achieving its goals. The information learned was used to plan what additional training or program support may be necessary.
This program evaluation was completed and subsequently published in General Hospital Psychiatry http://www.ncbi.nlm.nih.gov/pubmed/24973125. Analysis of NYS Medicaid claims showed that there were changes in PCP prescribing practices without change in ER, outpatient, and hospitalization utilization by children seeing those PCP.
The goal of this project is to enhance pediatricians’ capacity to prescribe and manage psychotropic medications. At the AAP’s request, this project developed a way to select basic psychotropic medications for use in primary care.
In 2012, selected modules via webinars and live presentations were piloted aiming towards the ultimate goal of disseminating knowledge for the safe and effective management of psychotropic medications in pediatric primary care. An article describing the conceptual framework is available here http://www.ncbi.nlm.nih.gov/pubmed/24298753. A more detailed version was published by the American Academy of Pediatrics: Riddle MA. Pediatric psychopharmacology for primary care, 2016.
Engaging Youth and Their Families in Mental Health Services: School Nurses as the First Point of Contact
Kimberly Becker, PhD, (Assistant Professor, University of Maryland School of Medicine) received pilot funds to 1) examine the feasibility, acceptability, and preliminary efficacy of an engagement protocol (EP) delivered by six school nurses, 2) validate and test a new caregiver-report measure of practitioners’ use of evidence-based engagement practices, and 3) test whether a caregiver report of treatment expectancy is affected by practitioners’ use of evidence-based engagement practices.
Data on school nurses’ use of evidence-based engagement practices from 6-10 families was collected before any training occurs. Then, 6-10 families were recruited to gather post-training data on school nurses’ utilization of evidence-based engagement practices, treatment expectations, and engagement in mental health services. A focus group with the school nurses regarding feasibility/acceptability of the EP was conducted. Six school nurses were recruited from the Los Angeles Unified School District. The publication describing the results is available here. http://www.ncbi.nlm.nih.gov/pubmed/26251671
Developing a Model for the Diffusion of the Common Factors/Treatment Elements-Chronic Care Model (CFTE-CCM)
Matthew Biel, MD, MSc, (Assistant Professor, Georgetown University Medical Center Clinical Psychiatry; Director, Georgetown University Medical Center Clinical Psychiatry Child and Adolescent Psychiatry) received pilot funding to obtain key information to create effective strategies to integrate capacity-building concepts and strategies into primary care sites.
Key informant interviews were conducted with physicians and nursing staff, including trainees, and administrative staff. Qualitative analytic procedures were used to understand current perceived needs, perceived obstacles, and goals held by pediatric primary care clinicians around the identification of mental health problems. Information was also gathered on the provision of care for these problems within the primary care setting as well as the key attributes of CFTE-CCM, which will help devise effective methods to create positive attitudes toward this approach and to enhance the likelihood of adoption.
Matthew Biel, MD, MSc, (Assistant Professor, Georgetown University Medical Center Clinical Psychiatry; Director, Georgetown University Medical Center Clinical Psychiatry Child and Adolescent Psychiatry) received pilot funding to learn more about how mental health concerns present in pediatric primary care and physicians’ beliefs regarding the provision of mental health care in this setting.
A “Presenting Problems” paper has been submitted. Using a data set with pediatric caregivers’ responses to the Strengths and Difficulties Questionnaire, this paper describes the most prevalent concerns at different developmental stages and think about which issues might be the best targets for screening or other clinical intervention.*** http://www.ncbi.nlm.nih.gov/pubmed/25922333 In addition, researchers are planning a second paper, which describes their experiences training pediatricians in evidenced-based developmental screening.
Patient-Provider Communication Practices in an mhGAP Intervention for Children and Families in Nepal
Matthew Burkey, MD, (Child Psychiatry Fellow and PhD student, Johns Hopkins School of Medicine) was funded to assess expectations and beliefs of non-specialist providers, children, and families around communication and therapeutic strategies as part of an mhGAP program in Nepal. The project is being conducted in partnership with Transcultural Psychosocial Organization (TPO)-Nepal, a research-oriented NGO working to improve mental health services in Nepal.
Specifically, the aims are to 1) assess parent expectations of child mental health visits and experienced providers’ beliefs about effective communication and therapeutic strategies in child mental health visits, 2) assess current utilization of communication and therapeutic strategies identified by parents, local providers, and an existing patient-provider communication assessment (RIAS) in child mental health visits, and 3) evaluate the relationship between utilization of communication strategies and parent satisfaction, adherence indicators, and disorder-specific outcomes.
Initial work involved stakeholder meetings in the target community with teachers, healthcare workers, law enforcement, community health volunteers, NGOs working on issues related to child labor and street children, and parents to discuss perceived needs and review the study protocol. The stakeholders uniformly agreed that behavior-related problems are a concern in the classroom, in families, and in the community as a whole. Teachers and health workers discussed their attempts to address individual cases, and all reported the virtual absence of treatment options currently available for child mental health problems—especially among those in rural areas.
Dr. Burkey and his collaborators published an analysis developing descriptions of ethnopsychological models of disruptive behavior problems. ***http://www.ncbi.nlm.nih.gov/pubmed/27173743 As a next step, we will assess the prevalence of behavior problems and validate an assessment tool for disruptive behavior problems in the target population. These initial steps will inform the adaptation process and provide valid assessment tools for the planned intervention.
Does Long- Term Use of the Guidelines for Adolescent Preventive Services (GAPS) Lead to Earlier Mental Health or Substance Abuse Diagnosis?
Anne Gadomski, MD, MPH, (Attending Pediatrician and Research Scientist, Bassett Medical Center) was awarded pilot funds to compare the frequency of mental health or substance abuse diagnoses pre-and post -introduction of GAPS, a pre-visit screener, to the clinical routine at one rural, primary care clinic. The primary aims were to 1) determine whether long-term use of the comprehensive GAPS screen led to increased detection and/or earlier diagnosis of mental health/substance abuse disorders among teens at their annual visits, and 2) determine the sensitivity, specificity of the GAPS relative to mental health or substance abuse diagnoses and time to subsequent mental health or substance abuse diagnoses among 297 adolescents ages 11-18 included in our prior GAPS implementation study. Results showed that even though GAPS related to past or eventual mental health/substance abuse diagnosis, it did not change the rate of or time to diagnosis these disorders. The paper describing the results can be accessed here: http://www.ncbi.nlm.nih.gov/pubmed/24488253
Jill Haak Bohnenkamp, PhD, (Postdoctoral Fellow, University of Maryland School of Medicine) was awarded pilot funding to test the conceptual models of the Mental Health Training Intervention for Health Providers in Schools (MH-TIPS) professional development content and process to refine materials for use in a pilot study.
School nurse expert advisors participated in semi-structured interviews organized around validation of the MH-TIPS process and content. A focus group of school nurse practitioners provided feedback on the MH-TIPS process and content using a nominal group decision-making process. In addition, all participants completed a quantitative survey. One version of the material is available here.
Karen Hacker, MD, MPH, (Director, Allegheny County Health Department; Associate Professor, Harvard Medical School and Harvard School of Public Health) received a pilot grant to learn about the nature of children (ages 0-18) who were identified as having a BH need through receipt of the MassHealth mandated BH screening and the course of those children’s service utilization in the subsequent two years.
The FY08 – FY11 data from the Massachusetts Medicaid Program was used to look at differences among children who had a BH need identified, who were determined not to have BH need, and those with undetermined screening results. This project assessed differences between the children who received positive results for a BH need who received BH care within 90 days of identification and those who did not receive BH care within those 90 days. Results showed that children with a positive BH screen in FY09 were more likely to have had a BH history than those who did not have a positive BH screen. In addition, the strongest predictor of treatment was having a BH history. Having a positive screen, being in foster care, and being male were all predictors of getting treatment, while being Asian reduced changes of getting treatment.
Results were presented at the 2013 meeting of Academy Health. Pediatrics published the project’s first paper, “New behavioral health issues identified by screening in children enrolled in Massachusetts Medicaid.” (see publication here).
Emergency Medical Service (EMS) Use for Mental Health Issues Among Children: The Role of Primary Care Providers
Amy Knowlton, ScD, (Associate Professor, Johns Hopkins Bloomberg School of Public Health), was funded to 1) examine demographic, mental health, and other health issues associated with any and repeat use of Baltimore EMS among children and youth; 2) explore barriers to care and other factors promoting EMS use among youths with mental or behavioral health problems, and the potential role of PCPs and other gatekeepers in facilitating their access to care.
Researchers conducted quantitative analysis of EMS data from 2008-10 and presented findings to fire department officials. Results indicated that repeat users accounted for 15.9% of pediatric users and 20.8% of pediatric incidents. Compared to non-repeat users and to the population distribution, repeat users were more likely to be older adolescents and female. In patient level analysis, greater proportions of repeat compared to one-time EMS users had evidence of asthma, behavioral health (mental and substance use) problems, seizures, and diabetes. Of repeat users, 41.2% had evidence of asthma and 18.3% of mental health problems.
The findings indicate the major role of chronic somatic conditions and behavioral health issues in repeat pediatric use of this EMS system. The results demonstrate the utility of EMS records in identifying pediatric populations for public health intervention. Targeted intervention is needed to promote repeat users’ engagement in primary care with integrated behavioral health services.
The paper “Patient demographic and health factors associated with frequent use of emergency medical services in a mid-sized city” was recently submitted to Academic Emergency Medicine (see publication here). http://www.ncbi.nlm.nih.gov/pubmed/27142996
Parents’ Perspectives of the Primary Care Providers’ Role in Their Child’s Mental Health Care
Justine Larson, MD, MPH, (Assistant Professor, Johns Hopkins Child and Adolescent Psychiatry; Director, Johns Hopkins Consultation and Liaison for Child and Adolescent Psychiatry) was funded to 1) explore the factors that influence parents’ perspectives of the PCP’s role in their child’s mental health care, and 2) examine correlations between these conceptualizations and where and how parents engage in mental health care for their child.
The study uses data previously collected on 37 parents or guardians of children referred from the Harriet Lane Clinic (HLC) at Johns Hopkins Hospital, for mental health services at the Children’s Mental Health Center (CMHC). Semi-structured, qualitative interviews were conducted to explore parents’ beliefs about mental health treatment, relationship with their child’s PCP, and any perceived barriers in obtaining mental health care. Interesting themes emerged, including the fact that families expect ongoing involvement in behavioral health issues; even after a behavioral health referral has been made. The findings support the concept of the "health home" for physical and behavioral health.
Two papers from this project were published: 1) “Are Pediatricians Doing More Family ‘Therapy’ Than They Realize? Changing Families Through Single Encounters” in Clinical Pediatrics, and 2) “Barriers to mental health care for urban lower income families referred from pediatric primary care” in Administration and Policy in Mental Health (see publication here).