This study compared anxiety and physiological responses during the Trier Social Stress Test for Children (TSST-C) in adolescents. 38 subjects (26 females) were enrolled: 11 cyclic vomiting syndrome (CVS), 11 anxiety, and 16 controls. Salivary cortisol, α-amylase and heart rate variability (HRV) were assessed during the TSST-C. Anxiety was measured by the Screen for Childhood Anxiety and Related Emotional Disorders (SCARED), Anxiety Disorders Interview Schedule, and State-Trait Anxiety Inventory for Children (STAI-C). 11 anxiety and 7 CVS subjects had ≥1 anxiety disorder. 82% in the anxiety and CVS groups met criteria for an anxiety disorder on the SCARED. Combining groups, cortisol increased from baseline to recovery during the TSST-C (p = 0.0004) and the stressor to recovery (p = 0.005). α-amylase did not differ during the TSST-C for the total sample, but increased for anxiety compared to controls from baseline to recovery (p = 0.01). HRV decreased during the stressor (p = 0.0001) and increased at recovery (p = 0.004). No associations were found between biomarkers and trait anxiety. Associations were found between baseline HRV and pre-test state anxiety (r = −.406, p = .012) and between recovery HRV and post-test state anxiety (r = −.501, p = .002) for the total sample. Anxiety is prevalent in CVS warranting screening. HRV may serve as a biomarker for evaluating stress as a potential trigger for CVS episodes. State but not trait anxiety was associated with changes in HRV, suggesting acute anxiety may be more relevant in linking stress and CVS episodes.

Although care within a medical home increases parental satisfaction with health care services and improves health care utilization, significant racial/ethnic and language disparities persist in health care settings. Integrated, team-based approaches can decrease health disparities. The current study examines medical records of 2,353 youth who received a behavioral health consultation in an urban, residency training pediatric primary care clinic. A three-phase, mixed-method approach was used to examine whether differences in clinician-identified presenting concerns and recommendations were present across English-, Spanish-, and Other-language-speaking families. Findings reveal disparities among language groups in presenting concerns and referral to behavioral health services. Factors in medical record documentation also differed across language groups and by provider type. Recommendations for further research, identification, and assessment of psychosocial concerns for families with limited English proficiency (LEP) and development of evidence-based approaches for families with LEP in primary care are discussed.

The practice of early childhood behavioral health (ECBH) integration in primary care settings promotes optimal care for families with young children while simultaneously improving health care utilization and averting unnecessary health care expenditures. Implementing ECBH integration activities across four domainsscreening processes, prevention and health promotion, case-based consultation and intervention, and care coordination-has the potential to enhance the lifelong health and well-being of children and families. Unfortunately, billing and reimbursement for activities focused on prevention, early identification, and early childhood intervention in primary care settings presents challenges. The current article describes a financial analysis of a grant-funded project focused on ECBH activities delivered by pediatric psychologists and psychology fellows. A business case for HealthySteps (HS), an evidence-based intervention to enhance primary care in early childhood, was applied in a site serving a high risk pediatric population. Delivering HS in this pediatric primary care setting yielded significant cost aversion across both maternal and child level interventions. Estimated costs averted exceeded the program operating costs of HS implementation in this setting. In a changing health care landscape that is shifting away from volume-based, fee-for-service models to value-based, cost-control models, optimizing the potential of primary care for early childhood populations is necessary to improve health outcomes and reduce the total cost of care across the life span.

The purpose of this study was to (a) describe the development and implementation of Behavioral Health in Pediatric Populations:0 -5 (BHIPP:0 -5), an initiative designed to increase the capacity of primary care practices to deliver early childhood behavioral health (ECBH) integration activities; and (b) examine practice transformation changes in ECBH services for three types of primary care settings (federally qualified health care centers-FQHCs, private practices, nonprofit/community practices). Methods: BHIPP:0 -5 pediatric psychologists and interdisciplinary TA professionals provided monthly technical assistance sessions and quarterly cohort learning collaboratives to nine diverse primary care practices. Changes in ECBH activity implementation were examined across and within three practice type groupings. Results: All BHIPP:0 -5 practice types expanded their capacity to provide ECBH services from baseline to the end of Year 2. Prevention/health promotion activities evidenced the most growth (from 16% in baseline to 40% in Year 2). Practice types differed in implementation of ECBH services. FQHCs accounted for 75% of the total prevention/health promotion services, private practices provided the most case-based consultation/intervention (54%), and nonprofit/community practices accounted for 86% of the total care coordination/systems navigation services. Conclusions: Primary care settings are uniquely suited to address early childhood mental health in the context of routine care. The BHIPP:0 -5 initiative supports practice transformation in early childhood behavioral health integration while simultaneously advancing systems-level policies and practices that promote high quality care, increase efficiency, improve utilization of preventive services, and decrease overall costs in alignment with health care systems goals. Implications for Impact StatementThis study describes the development and implementation of a practice transformation initiative focused on early childhood behavioral health integration activities in a diverse group of primary care practices. The initiative was designed and delivered by pediatric psychologists in order to build the capacity of primary care settings to provide services aimed at addressing the complex needs of young children and their families. The data indicate that primary care practices successfully engaged in the initiative, benefitting from monthly technical assistance meetings and quarterly cohort learning collaboratives, and increased the amounts and types of early childhood services they provided to young children and their families.

This article describes how an innovative model of practice transformation, used by 4 integrated pediatric primary care practices over a 2 year grant period, promoted the practice of integrated primary care (IPC) behavioral health services. Practice transformation was possible through the implementation of an alternative billing strategy to enhance sustainability, effective utilization of clinical productivity to provide meaningful patient services, and the identification of strategies to further the practice of IPC. Specifically, we provide: (a) a description of the diversity of billing strategies typically used by pediatric practices utilizing integrated care and how those strategies are impacted by state health care policies; (b) a description of the grant, including the service delivery model, implementation phase, and data collection procedures; (c) results of implementation and billing/reimbursement data that were collected across the 4 practices; (d) an analysis of how billing strategies are critical in defining implementation strategies within pediatric integrated care; and (e) lessons learned about how billing strategies must be flexible and amenable to change over time to stay current with ever-changing health care policies and reimbursement models. Implications for Impact StatementThis article describes how an innovative model of practice transformation, used by 4 integrated pediatric primary care practices over a 2 year grant period, promoted the practice of integrated behavioral health services in primary care. We provide lessons learned about financing primary care using innovative billing strategies beyond the use mental health diagnoses and billing codes, which enable psychologists to focus more on preventative and health behavior change services.