Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-01

The purpose of this study was to examine the feasibility of a behavioral health referral protocol and barriers to behavioral health care in a pediatric epilepsy clinic. A sample of 93 youth with epilepsy ages 10–17 and caregivers completed behavioral health and seizure severity measures during a routine epilepsy clinic visit. Key findings are that 47 (50.5%) of the youth screened positive for a behavioral health referral, and 35 of these youth were referred for behavioral health services. However, only 20% made and presented for the behavioral health appointment. The most commonly cited barrier for accessing and utilizing behavioral health care was stigma related- a mental health label for the child. The significance of this study lies in the revelation that solely screening for and educating caregivers about behavioral health symptoms and providing behavioral health referral information is not an ideal model. Instead, stigma related barriers point to the necessity of continued integrated physical and behavioral health care within the pediatric epilepsy visit.

Cross-sectional studies suggest a prevalence of mental health problems from the age that children change to English secondary schools but there are few longitudinal appraisals of these issues and how enrolment policies influence psychological wellbeing. This research focuses on key factors linking competition for secondary schools and family responses to such challenges to determine enrolment policies that can sustain wellbeing longer-term. Integrated, model-based multimethodology was used in this urban, case-based study. Views were induced from multi-agency, expert practitioners to agree a system dynamics concept model. Parental decision-making behaviours were deduced by survey to understand key factors for model calibration. Dynamic system sensitivities were abduced from the simulation model before comparing long-term psychosocial impacts on children from expert, policy-support suggestions. Modelling demonstrates that two principal feedback loops influence family psychosocial systems when deciding secondary schools (parent-child wellbeing reinforcement plus knowledge of schools balancing parent concerns). Exogenous competition stressors on psychosocial systems can erode parent knowledge while testing student resolve. Competition guidance to remove risk-laden school options (league table comparison) before sequencing any remaining choices by profit (school visits), are not always used deciding urban secondary schools. Instead, families lacking experience can adopt decisive styles based on parent needs alone. Given autocratic leadership, child wellbeing rapidly deteriorates when student needs cannot be met by schools. Rather than ending student-selective entrance tests or raising knowledge of schools at visits, effective multi-agency support policy helps by increasing school choice debate frequency within families to address psychosocial system imbalances. The research makes a clear, three-way contribution to knowledge. Firstly, intrinsic case study theory is enhanced by data triangulation between induced, deduced and abduced research approaches. Secondly, the system dynamics discipline is strengthened by studying compulsory school enrolment. Finally, developing practice-based policy through multi-agency groups endorses cooperative rather than unilateral solutions, for helping change lives.

Integrated care is rapidly becoming the new paradigm of healthcare and with the transition into integrated practice, many providers from various disciplines must determine how best to work as a team to improve patient outcomes. One particular setting where the logistics of integrated practice must be scrutinized is pediatric primary care, specifically in rural areas, as many psychological problems are presented in pediatric primary care, and rural children are at greater risk for engaging in unhealthy behaviors, such as sedentary lifestyle, poorer nutrition, and greater substance use. All of these concerns can be ameliorated with successful referral to behavioral health consultants (BHC) who can assist in treating these various psychosocial issues. In order for the BHC to assist with patients with psychosocial concerns, other medical providers must be able to recognize and refer these patients to the BHC. The purpose of this study was to determine the prevalence of psychosocial concerns in pediatric primary care and how often the attending medical provider noticed these concerns and referred the patient for behavioral health services. The study also examined what types of psychosocial concerns were raised, and if the referral was not addressed during the same visit, the latency between the initial referral and the behavioral health service. Retrospective electronic health record data (N=300) was collected from the well visits of all 4 and 5 year old patients in 2014 from a rural Appalachian pediatric primary care clinic. Results indicated that when a psychosocial issue was raised, the majority of medical providers appropriately referred the patient to the BHC. Psychosocial concerns were raised in 21.3% (n=64) of visits. When psychosocial concerns were raised, 62.5% (n=40) were referred for behavioral health services with 87.5% (n=35) to the in house BHC. When patients were referred to the in-house BHC, 83.3% (n =30) received services immediately, while patients who were not seen immediately, 16.7% (n=5), waited for an average 21 days to be seen by the BHC. The most common psychosocial concerns raised were related to toilet training, temper tantrums, sleep hygiene, and hyperactivity. These findings highlight the high prevalence of psychosocial issues presented in rural pediatric primary care and the continued education of providers about recognizing these concerns so the appropriate referral can be made. These findings also highlight the need for more integrated practice as primary care is the often the primary source of healthcare in rural areas and by addressing all concerns about patient well-being in this setting via integrated care, patient physical and mental health outcomes can be greatly improved.