Hospital emergency departments (EDs) serve a critical role in its non-discriminatory evaluation and stabilization of all individuals who present for care, regardless of ability to pay. However, EDs are not adequately prepared or capable of caring for children and adolescents who are in behavioral health crisis and require acute treatment. The frequency and duration of pediatric ED visits have also increased over time, leading to crowded EDs, suboptimal delivery of behavioral health care, and strain on hospital resources. In response, hospital systems, states, and the federal government developed a variety of policies to support EDs in the delivery of high-quality care and improve pediatric behavioral health outcomes. Numerous drivers involving the low supply of pediatric behavioral health care professionals, high demand for emergency behavioral health evaluation and treatment, and fragmentation of the behavioral health care system interact to continue to drive patients to EDs despite the implemented policies. Further investigations are needed to exactly determine patients’ unmet needs and identify root causes of pediatric behavioral health ED visits. Last, pediatric behavioral health care policy must not only expand on individual policy successes but also take innovative, value-based approaches to effectively address the worsening pediatric behavioral health crisis.

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Objective: Social support for physical activity (PA) has been shown to enhance PA levels in adolescents. Although social support has been examined extensively in the literature, less is known about the role of social support for PA for high school adolescents in rural southern Appalachia. PA is important because adolescent obesity is greater in Appalachia than in the rest of the United States. Methods: This was a qualitative secondary analysis of focus groups conducted in 2013-2014 among parents, teachers, and high school students (N = 77) in 6 counties across rural southern Appalachia. Beets' typology of social support was used to categorize themes. Results: Participants discussed instrumental supports, including providing transportation and paying fees, enrolling child in recreation/sports, and providing PA equipment at home. Performing PA with adolescents and modeling, watching/supervising, and prioritizing PA were identified as conditional supports. Several motivational supports were identified: encouragement, force, and the admiration of people who are active. Participants also identified key informational supports, including discussing the importance/health benefits of PA, how to be physically active, and general advice/information. Barriers to PA engagement (eg, body image issues, bullying, competitive nature of PA opportunities) and the role of referent groups (eg, family, peers, teachers) emerged as important concepts in the discussion. Conclusion This study identifies opportunities and practical ways for families and schools to provide, build, and strengthen supports for PA among adolescents in rural Appalachia.

Twitter may be useful for learning about indoor tanning behavior and attitudes. The objective of this study was to analyze the content of tweets about indoor tanning to determine the extent to which tweets are posted by people who tan, and to characterize the topics of tweets. We extracted 4,691 unique tweets from Twitter using the terms “tanning bed” or “tanning salon” over 7 days in March 2016. We content analyzed a random selection of 1,000 tweets, double-coding 20% of tweets (κ = 0.74, 81% agreement). Most tweets (71%) were by tanners (n = 699 individuals) and included tweets expressing positive sentiment about tanning (57%), and reports of a negative tanning experience (17%), burning (15%), or sleeping in a tanning bed (9%). Four percent of tweets were by tanning salon employees. Tweets posted by people unlikely to be tanners (15%) included tweets mocking tanners (71%) and health warnings (29%). The term “tanning bed” had higher precision for identifying individuals who engage in indoor tanning than “tanning salon”; 77% versus 45% of tweets captured by these search terms were by individuals who engaged in indoor tanning, respectively. Extrapolating to the full data set of 4,691 tweets, findings suggest that an average of 468 individuals who engage in indoor tanning can be identified by their tweets per day. The majority of tweets were from tanners and included reports of especially risky habits (e.g., burning, falling asleep). Twitter provides opportunity to identify indoor tanners and examine conversations about indoor tanning.

Substance use disorders among the baby boomer generation are steadily increasing, but knowledge and training satisfaction regarding older adult substance use disorders among behavioral health providers (BHPs) has not been explored. Using the Kirkpatrick evaluation model, this quantitative study involved an examination of the knowledge and training satisfaction of four behavioral provider groups: addiction counselors, licensed professional counselors, marriage and family therapists/social workers, and psychologists. Each participant (N = 154) completed a demographic questionnaire, satisfaction questionnaire, and the Alcohol and Older Adult Questionnaire to measure knowledge level on older adult substance use disorders. The results showed that licensed professional counselors held significantly higher levels of knowledge than any other BHP group. There were no significant differences between BHPs regarding satisfaction with training on older adult substance use disorders. No relationship was found between BHP satisfaction and BHP knowledge scores, even when considering the number of years, a BHP was licensed. Therefore, the findings of this study may encourage more training for BHPs aside from licenses professional counselors as well as future research on BHPs treating older adult substance use disorders.

Research is lacking on the efficacy of aggression management training programs based on clinical outcomes. This study examined the efficacy of an aggression management training on managing aggression and violent behavior at East Mississippi State Hospital (EMSH), an inpatient behavioral health program. This training, The Mandt System, replaced a previous training, Techniques for the Management of Aggressive Behavior (TMAB), which was considered to be non-replicable outside state facilities in Mississippi. This study should not be seen as a comparative study between The Mandt System and TMAB, but rather as an investigation into the effects of implementing The Mandt System as a new training at EMSH. The efficacy of The Mandt System was examined through 4 key variables: patient to patient incidents, patient to staff incidents, seclusion episodes and restraint episodes. Over a 6 year period, incidents of aggression and violence were identified by extracting archival data from incident reports. Archival data were examined 3 years prior to the implementation of The Mandt System and 3 years after the implementation of the training. The researcher found that the rate of patient to patient incidents decreased as well as the rate of seclusions and restraint episodes following implementation of The Mandt System training. The rate of the patient to staff incidents did not decrease. Effective training on the management of aggression is essential in decreasing aggressive and violent behavior. Nevertheless, these findings are difficult to validate due to a scarcity of research that is supported by evidence from randomized controlled studies. A review of the literature revealed that researchers do not give precedence to the study of aggression management training when dealing with aggressive behavior in inpatient behavior health settings. This is possibly due to the findings of Hage, Van Meijel, Fluttert, and Berden (2009) that research on the effectiveness of intervention strategies requires a more complicated study design and involves many methodological and logistical challenges. Although the results of this study suggest that this training can have a positive effect on aggression and violence, much more needs to be done to evaluate the effectiveness of aggression management training programs.

This study examined pediatric residents’ responsiveness and experiences in the context of a new pilot program, building an on-site Behavioral Health Consultant (BHC) into their primary care training site. Fifteen pediatric residents were divided so that 9 had access to an on-site BHC and 6 did not. Over the first year of the program, research assistants observed 322 patient visits to record concerns raised, residents’ responses, and visit length. Data regarding BHC activity and residents’ subjective impressions of the program were also collected. Results showed that at least one BH concern was raised in 24% of observed visits. Residents with access to the BHC initiated 89 on-the-spot referrals, resulting in 127 BHC-to-patient interactions. On average, residents spent 10 additional min/visit when BH concerns were raised but those with access to the BHC saved 8 min/visit when BH concerns were raised. Overall, residents utilized the service, particularly first and second year residents. Those with BHC access managed BH concerns in less time than those in the control group. Residents who utilized the BHC were very satisfied, perceived a better quality of care and patient outcomes, and desired future BHC collaboration. Implications for training residents in the area of pediatric behavioral health by using an on-site provider are discussed.

Background: Environmental exposures acting through different mechanisms have been linked with a number of cancers. Perfluoroalkyl chemicals (PFCs) are endocrine disrupting chemicals affecting estrogen homeostasis. Objectives: We examined the association between PFCs and a group of estrogen related cancers and explored if increased non-occupational exposure was associated with increased odds of developing these cancers. We also explored which of these chemical exposures was more correlated with each cancer. Methods: Using data from the National Health and Nutrition Examination Survey (NHANES), we selected participants ≥ 20 years of age. Our outcome variable was presence or absence of breast, prostate, ovarian and uterine cancer (yes/no); our exposure variables were serum PFCs. Logistic regression models were used in investigating the association between PFCs and cancer types and between quartiles of PFCs exposure concentrations and presence or absence of cancer while adjusting for covariates. Discriminant analysis was used to assess the correlation between individual PFCs compounds and individual cancer types. Results: PFCs were associated with increased odds of ovarian cancer; PFOA: 1.02(1.01, 1.02), PFOS: 1.01 (1.012, 1.013), PFHS 1.031 (1.030, 1.033), PFDE: 1.29(1.27, 1.30) and increased odds of breast cancer; PFOA: 1.089(1.089, 1.09), PFOS: 1.011(1.011, 1.011), PFNA: 1.031(1.030, 1.033), PFHS: 1.02 (1.02, 1.02), PFDE: 1.19(1.18, 1.19). PFCs were not associated with increased odds of prostate or uterine cancers. Comparing the odds in quartile 4 to quartile 1 for ovarian cancer, PFOA: 1.77(1.75,1.79), PFOS: 2.25(2.22, 2.28), PFHS: 1.86(1.84, 1.88), PFDE: 2.11(2.09, 2.14). For breast cancer, PFOA: 2.30(2.28, 2.31), PFOS: 1.47(1.46, 1.48), PFNA: 1.04(1.03, 1.05), PFHS:7.07(6.97,7.17), PFDE: 1.38(1.37, 1.39). PFOA was more correlated with breast cancer (0.7) and PFHS was more correlated with ovarian cancer (0.9). Discussion: PFCs were associated with increased odds of ovarian and breast cancers with a positive dose-response relationship. PFOA was more correlated with breast cancer and PFHS more with ovarian cancer.

Entrepreneurs in integrated care face some of the same challenges in empirically demonstrating impact, regardless of the model of care they espouse. In this editorial, 2 leading model developers reflect on the state of the science in primary care integration, including research gaps and promising research underway. We asked these leaders to discuss conceptual areas of shared concern, and we present those with reference to the metaphor of the translational research bridge. Their insights resonate with one another and suggest a role for collaboration to advance empirical support for the implementation of integrated care.

Toxic stress in childhood starts the trajectory toward complex health and social health needs in adulthood. In this breakout, a long-standing team (social work, behavioral health, and medicine) describe their efforts to systematically address toxic stress in pediatric primary care.