Background There is concern about the effect of the COVID-19 pandemic on psychosocial functioning among school-age children, who have faced unusual stressors during this time. Our goal was to assess mental health symptoms and social risks during COVID-19, compared to before the pandemic, for urban, racial and ethnic minority school-age children, and investigate the relationship between mental health and social risks. Methods We conducted a cohort study from September 2019 until January 2021 of children age 5–11 years old recruited from an urban safety net hospital-based pediatric primary care practice. We measured emotional and behavioral symptoms (including attention, internalizing, and externalizing symptoms) before and during the pandemic with the Pediatric Symptom Checklist (PSC-17). We measured social risks (including food and housing insecurity) before and during the pandemic with the THRIVE screener. We measured additional mid-pandemic COVID-related stressors with items on school participation, screens/media use, illness exposure, and caregiver mental health. We compared pre- and mid-pandemic PSC-17 symptom scores across 4 domains (total, attention, internalizing, and externalizing) and used path analysis to examine the relationship between mental health and social risks pre- and mid-pandemic. Results Caregivers of 168 children (54% non-Hispanic Black, 29% Hispanic, and 22% non-English speaking) completed the study. Children had significantly higher levels of emotional and behavioral symptoms midpandemic- vs. pre-pandemic in all domains. Significantly more children had a positive PSC-17 total score (18% vs. 8%, p < 0.01) and internalizing (depression and anxiety) score (18% vs. 5%, p < 0.001) during the pandemic vs. before, indicating clinical concerns in these areas. Caregivers reported significantly more social risks during vs. before the pandemic (p < 0.001). Mental health symptoms significantly correlated with number of social risks before the pandemic, but not during the pandemic. Less school assignment completion, increased screen time, and caregiver depression were all significantly associated with worse mid-pandemic mental health in children. Conclusion The COVID-19 pandemic has led to a dramatic increase in depression/anxiety problems and social risks among urban, racial and ethnic minority school-age children compared to before the pandemic. More research is needed to understand if these changes will persist.

Over 50% of young adults (defined as individuals aged 18-25 years) with substance use disorders (SUDs) have at least 1 co-occurring psychiatric disorder, and the presence of cooccurring disorders worsens SUD outcomes. Treatment of both co-occurring psychiatric disorders and SUDs in young adults is imperative for optimal treatment, yet many barriers exist to achieving this goal. We present a series of evidence-informed principles of care for young adults with co-occurring psychiatric disorders derived by a workgroup of experts convened by Boston Medical Center's Grayken Center for Addiction. The 3 principles are as follows:(1) young adults should receive integrated mental health and addiction care across treatment settings; (2) care should be responsive to the needs of young adults exposed to trauma and other adverse childhood experiences; and (3) treatment programs should regularly assess and respond to the evolving mental health needs, motivations, and treatment goals of young adults with co-occurring disorders. Our guidance for each principle is followed by a review of the evidence supporting that principle, as well as practice considerations for implementation. More research among young adults is critical to identify effective treatments and service systems for those with co-occurring disorders.

BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental condition in children. Although ADHD is treatable, barriers remain to engagement in treatment, especially among socioeconomically disadvantaged and racial and ethnic minority families. Our goal was to examine the process by which families engage in ADHD treatment and to identify targets for an intervention to improve engagement in care. METHODS We conducted in-depth semistructured qualitative interviews with 41 parents of diverse youth aged 3 to 17 years old in treatment of ADHD at an urban safety net hospital. Parents were asked about their journey through diagnosis and treatment, community attitudes about ADHD, and other factors influencing treatment access and decision-making. Transcripts were analyzed by using thematic analysis. RESULTS Of children with ADHD, 69.2% were male, 57.7% were Black or African American, and 38.5% were of Hispanic, Latino, or Spanish origin. Parents were 92.7% female, were 75.6% English speaking, and had a median income of $20 000. Parents described 6 stages to the process of engaging in care for their child’s ADHD, which unfolded like a developmental process: (1) normalization and hesitation, (2) fear and stigmatization, (3) action and advocacy, (4) communication and navigation, (5) care and validation, and (6) preparation and transition. Barriers often occurred at points of stage mismatch between parents and providers and/or systems. Difficulty resolving an earlier stage interfered with the progression through subsequent stages. CONCLUSIONS The 6 stages framework could be used to develop new strategies to measure engagement and to design family-centered interventions to facilitate engagement in ADHD treatment.

Background As an alternative to co-located integrated care, off-site integration (partnerships between primary care and non-embedded specialty mental health providers) can address the growing need for pediatric mental health services. Our goal is to review the existing literature on implementing off-site pediatric integrated care. Methods We systematically searched the literature for peer-reviewed publications on off-site pediatric integrated care interventions. We included studies that involved systematic data collection and analysis, both qualitative and quantitative, of implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability). Results We found 39 original articles from 24 off-site programs with a variety of study designs, most with secondary implementation outcomes. Models of off-site integration varied primarily along two dimensions: direct vs. indirect, and in-person vs. remote. Overall, off-site models were acceptable to providers, particularly when the following were present: strong interdisciplinary communication, timely availability and reliability of services, additional support beyond one-time consultation, and standardized care algorithms. Adoption and penetration were facilitated by enhanced program visibility, including on-site champions. Certain clinical populations (e.g., school-age, less complicated ADHD) seemed more amenable to off-site integrated models than others (e.g., preschool-age, conduct disorders). Lack of funding and inadequate reimbursement limited sustainability in all models. Conclusions Off-site interventions are feasible, acceptable, and often adopted widely with adequate planning, administrative support, and interprofessional communication. Studies that focus primarily on implementation and that consider the perspectives of specialty providers and patients are needed.