Assessing child health is critical to a variety of child health, educational, and social programs, as well as to clinical research and practice. However, despite the apparent wealth of measures available in health, education, and legal and social welfare systems, little agreement exists as to what are the most important measures and for what domains of health. Development of improved measures may capitalize on advances in conceptualization of child health, including the dynamic nature of the interplay of child health and development over time. The need for enhanced measures can be illustrated by consideration of various aspects of pediatric care: well-child care, acute illness care, and the management of children with special health care needs. In particular, the strong theoretical perspectives on aspects of development such as cognition and behavioral development need to be informed by the experience of various states of health and their developmental implications. If generalist academicians are to further their research and educational mission, they must engage, and urgently, in the development and measurement of child health.
Objective.-To compare attendance at preventive medical and dental visits for children with special health care needs (CSHCN) and children without special health care needs, and associations between attending visits and unmet need.Methods.-We analyzed data on 102 353 children aged 0 to 17 years from the National Survey of Children's Health. We examined associations between attending preventive medical or dental visits and CSHCN status, and unmet need for medical or preventive dental care and attending preventive medical or dental visits.Results.-Medical care-CSHCN were more likely than other children to attend a well-child visit (odds ratio [95% confidence interval], 1.45 [1.12-1.93] for 0 to 5 years, 1.99 [1.74-2.28] for 6 to I I years, 1.84 [1.64-2.06] for 12 to 17 years). CSHCN aged 12 to 17 years attending a well-child visit had lower odds of unmet medical need (0.48 [0.27-0.85]) than CSHCN not attending visits; well-child visits and unmet need were not associated for Younger age groups. Dental care-CSHCN aged 3 to 5 years were more likely than other children of similar ages to attend a preventive dental visit (1.26 [1.04-1.52]). CSHCN attending a preventive dental visit had lower odds of unmet preventive dental needs than CSHCN not attending visits (0.52 [0.28-0.93] for 3 to 5 years, 0.18 [0.12-0.28] for 6 to 11 years, 0. 12 [0.08-0.17] for 12 to 17 years).Conclusions.-CSHCN attend preventive medical and dental visits at similar or higher rates than other children. CSHCN who attend visits are less likely to have unmet needs. Further research should examine differences in visit content for CSHCN and mechanisms whereby preventive care may reduce unmet need.
OBJECTIVE:To evaluate the acceptability to Latino parents of having their adolescent children vaccinated against sexually transmitted infections, and to identify potential demographic correlates of acceptability.METHODS:We applied established methodology to a sample of 119 Latino parents who accompanied their children (51% female, aged 12-17 years) to medical appointments. The parents used computer-based questionnaires to rate 9 hypothetical vaccine scenarios. The scenarios had 4 dimensions: mode of transmission (sexually transmitted or not sexually transmitted), severity of infection (curable, chronic, or fatal), vaccine efficacy (50%, 70%, or 90%), and availability of behavioral methods for prevention (available or not available). Willingness by parents to vaccinate their adolescents under each vaccine scenario was assessed on a scale (range, 0-100). Conjoint analysis was used to determine the relative contribution of each dimension to the ratings.RESULTS:The study sample consisted of predominantly Mexican immigrant parents, 94% of whom chose to complete the Spanish version of the computerized interview. The mean value of the parents' willingness to accept vaccination for their adolescent children was exceptionally high. For example, the mean score of the Latino parents for the 6 sexually transmitted infection (STI) vaccine scenarios (score 86.2; SD 21.1) was far higher than the mean score in previous studies (81.3, SD 21.1). Conjoint analysis revealed that the dimensions of vaccine efficacy and severity of infection were equal in terms of their influence on vaccine ratings for the Latino parents. The next most influential dimension on vaccine ratings was the availability of behavioral prevention, followed by the sexual transmissibility of the infection.CONCLUSIONS:Our sample of predominantly Mexican parents was accepting of the concept of STI vaccination for their adolescent children. Important issues for parents include vaccine efficacy and severity of infection, followed by vaccines for infections that had no method of behavioral prevention available. Overall, there is little difference in the relative preference of a STI versus non-STI vaccine for their adolescent children.
The work of Stein and colleagues 1 based on an analysis of the 59th American Academy of Pediatrics (AAP) Periodic Survey suggests that approximately 90% of pediatricians accept the professional responsibility of identifying children with 7 conditions: attention-deficit/ hyperactivity disorder (ADHD), eating disorders, child and adolescent depression, substance abuse, behavior problems, anxiety, and learning disabilities. The demographic mix of the sample of physicians answering the survey seemed reasonable, with possibly an over-representation of those who had some additional specialized mental health training experiences. Although 70% felt they should treat/ manage ADHD, only approximately 25% felt they should treat/manage any of the other quite common diagnoses, instead indicating they would choose to refer. These results suggest 3 key questions: 1. If 90% believe they should identify and refer, why is the rate of identification within pediatric primary care approximately 20%? 2–6 Part of the answer is that pediatricians have not adopted an approach to psychosocial screening that parallels the measurement methods applied to height, weight, and other office screening procedures. A number of screening questionnaires exist—from the brief Pediatric Symptom Checklist 7,8 to the longer, more thorough Child Behavior Checklist. 9 For young children, there are also well-validated screening tests for autism, 10 and for adolescents, tests to recognize depression 11 and substance abuse. 12 In most primary care settings, pediatricians recognize psychosocial issues based on observation, 1 or 2 questions, or parental complaint. The result is a level of recognition that is low, unsystematic, and often delayed. The 2 major obstacles to a system of screening are a lack of reimbursement and concern about finding places to refer for services. We pay for what we value, and some would say that if the marketplace does not bid on an item (a house) or pay for a service (a pediatrician’s professional time), it is de facto worthless. Further, the mental health services that would follow positive screening, including pediatric management, are poorly reimbursed, if at all. We would not accept the current identification and referral rate for any other ‘‘real’’ illness. Imagine if the same results reported by Stein and colleagues 1 applied to children with diabetes or asthma: low recognition, reluctance to treat, and a 1 in 5 recognition rate. Rather than complacency, we would launch an urgent national effort based on quality and safety. 2. If approximately 80% of pediatricians said they should refer identified children, why is the referral rate from
OBJECTIVE:When gathering sensitive information about personal experiences such as child abuse, drug and alcohol use, and intimate partner violence (IPV), it is especially important for both research and clinical purposes to use optimal methods to limit socially desirable responses. The purpose of this paper is to determine which of the following 3 methods is optimal for gathering data: 1) face-to-face interviews, 2) self-administered paper and pencil questionnaires, or 3) audio computer-assisted self-interviews (ACASI). METHODS:The sample consisted of 514 parents bringing their preschoolers (0-5 years) to a pediatric primary care clinic for a checkup. The parent screening questionnaire (PSQ) addressing psychosocial problems was completed by participants themselves. Participants completed the PSQ in 1 of 3 ways: paper and pencil, face-to-face interview, or directly onto a computer (ACASI). RESULTS:In general, ACASI yielded the highest rates for sensitive problems such as social isolation and parental stress, with face-to-face interviews occupying an intermediate position. The differences between ACASI and self-administered paper and pencil questionnaires were significant for many items. The differences between ACASI and face-to-face interviews, however, were modest. There were no significant group differences among the 3 methods in the prevalence rates of the neutral, less sensitive items. CONCLUSION:ACASI resulted in greater disclosure of sensitive information than did a paper and pencil approach. No significant differences were observed between the computer-assisted interview and the face-to-face interview, both done in a research setting. The 3 methods appeared similar when gathering less sensitive data.
OBJECTIVE:To investigate changes in volume and characteristics of new patients referred when a private pediatric neurology practice (PP) opened in 2004 in an area served primarily by an academic medical center's (AMC) pediatric neurology practice. METHODS:Retrospective analysis of medical and billing records to examine changes in volume, diagnosis, and sociodemographic factors of new patients at the AMC from July 2004 to June 2005; the PP during the same period; and the AMC during the year before. RESULTS:One year after the PP opened, 40% more new pediatric neurology patients were seen in this area than the year before. Compared with the AMC, PP saw a greater proportion of seizures (34% vs 26%, P < .05) and headaches (32% vs 17%, P < .001), and a lesser proportion of developmental delay/musculoskeletal disorders (12% vs 19%, P < .001) and congenital/metabolic disorders (<1% vs 2%, P < .001). Fewer PP patients lived >20 miles from the practice (32% vs 64%, P < .001), and fewer had public insurance (4% vs 33%, P < .001). CONCLUSIONS:The establishment of the PP dramatically increased the volume of new pediatric neurology patients in this area. After the PP opened, the AMC continued to care for most patients with rare diseases and fewer financial resources. Future research should examine whether the increase in volume reflects relief of pent-up demand or increased referral rates due to eased access, and should elucidate how differences in patient populations at academic and private subspecialty practices relate to access to subspecialty care and financial well-being of academic practices.
Objective.-Because caregiver knowledge deficiencies are associated with the development of dehydration and nonurgent emergency department visits, we sought to develop and describe the characteristics of a Caregiver Gastroenteritis Knowledge Questionnaire.Methods.-We conducted a cross-sectional, associational analysis with a questionnaire consisting of 38 true/false questions covering signs of dehydration, indications to see a physician, oral rehydration therapy, solid intake and refeeding, medication use, and disease transmission. After completing initial validation procedures, 80 caregivers of children with gastroenteritis, 25 nurses, and 22 pediatric emergency medicine physicians completed the questionnaire.Results.-Con tent validity was confirmed qualitatively. Construct validity was demonstrated by incremental increases (P < .001) in mean total scores from caregivers to nurses to physicians. Multiple regression analysis revealed the reported number of prior visits for gastroenteritis was inversely associated with overall caregiver score (beta coefficient, -0.26; 95% confidence interval, -3.04, -0.28; P=.02). Internal consistency was demonstrated with a Cronbach's alpha of 0.67 at time 0.Conclusions.-The Caregiver Gastroemeritis Knowledge Questionnaire may have application in identifying knowledge gaps in gastroenteritis management and measuring improvement following educational interventions. Future uses may focus oil individual knowledge deficits or serve to document larger community educational needs.
Objective.-Nonurgent conditions account for 58% to 82% of pediatric emergency department (ED) visits, but only 1 preliminary qualitative study has examined reasons why parents bring children to the ED for nonurgent care. The aim of this study was to identify parents' reasons for choosing the ED over their primary care provider (PCP) for nonurgent pediatric care.Methods.-Audiotaped ethnographic interviews in English and Spanish were conducted of parents of children presenting for nonurgent care on weekdays from 8 AM to 4 PM at a children's hospital ED over a 4-week period.Results.-For the 31 families interviewed, the mean parental age was 28 years, and mean child age, 3 years. Reasons cited by care-givers for choosing the ED over their child's PCP were long appointment waits, dissatisfaction with the PCP. communication problems (accents and unhelpful staff at PCP), health care provider referral, efficiency, ED resources, convenience, quality of care, and ED expertise with children. Some parents said they would like education on the urgency of pediatric problems.Conclusions.-Parents bring their children to the ED for nonuraent care because of problems with their PCP, PCP referral, and perceived advantages to ED care. Although parents report that education on the urgency of pediatric conditions would be helpful, substantial reduction of pediatric nonurgent ED use may require improvements in families' PCP office access, efficiency, experiences, and appointment scheduling.
Background.-The Accreditation Council for Graduate Medical Education recommends using patient surveys for assessing resident competency in interpersonal and communication skills. Despite the existence of several validated patient surveys for communication assessment, no system has been developed for their sustained use in resident assessment.Methods.-We developed and pilot tested a system to collect surveys from parents of hospitalized children on the day of discharge. We used a 28-item, tablet computer-based survey that measures individual provider and team communication. The computer displays resident photographs to ensure accurate identification and offers the survey in multiple languages. We assessed parental acceptance of the system by analyzing response rate, as well as reasons for response and nonresponse.Results.-Of the 98 eligible parents that were approached, 62 (63%) completed the survey. Only 2 (2%) of the eligible families refused to participate, and only 5 (5%) refused participation because of the survey not being available in a language they were familiar with.Conclusions.-Use of a tablet computer parent survey for resident assessment is feasible, with response rates comparable to those of mailed surveys. The low rate of parental refusal indicates our system could be used to attain sufficient numbers of survey responses to help validly measure resident communication skills.
Objective.-To describe the development and assess the validity and reliability of the Collaborative Care for Attention-Deficit Disorders Scale (CCADDS), a measure of collaborative care processes for children with attention-deficit/hyperactivity disorder who attend primary care practices.Methods.-Collaborative care was conceptualized as a multidimensional construct. The 41-item CCADDS was developed from an existing instrument, review of the literature, focus groups, and an expert panel. The CCADDS was field tested in a national mail survey of 600 stratified and randomly selected practicing general pediatricians. Psychometric analysis included assessments of factor structure, construct validity, and internal consistency.Results.-The overall response rate was 51%. Most respondents were male (56%), 46 years old or older (59%), and white (69%). Common factor analysis identified 3 subscales: beliefs, collaborative activities, and connectedness. Internal consistency reliability (coefficient alpha) for the overall scale was .91, and subscale scores ranged from .80 to .89. The CCADDS correlated with a validated measure of provider psychosocial orientation (r = -.36, P < .001) and with self-reported frequency of mental health referrals or consultations (r = -.24 to -.42, P < .001). CCADDS scores were similar among physicians by race/ethnicity, gender, age group, and practice location.Conclusions.-Scores on the CCADDS were reliable for measuring collaborative care processes in this sample of primary care clinicians who provide treatment for children with attention-deficit/hyperactivity disorder. Evidence for validity of scores was limited. Future research is needed to confirm its psychometric properties and factor structure and provide guidance on score interpretation.
Objective.-Studies of antibiotic overuse often rely on physicians' reports of diagnoses, which can overestimate bacterial illness. To assess potential overdiagnosis, we determine bacterial upper respiratory infection diagnoses by direct observation of visit videotapes.Design.-From an observational study of videotaped visits for upper respiratory symptoms (N = 66), coders assessed diagnostic criteria (symptoms, physician description of physical examination findings, and diagnostic tests), physician diagnosis, and prescribing. Survey data included patient demographics and health care utilization as well as physician/practice characteristics (n = 15).Outcomes.-Criteria-based diagnoses were determined from coded diagnostic criteria. Interrater reliabilities were determined for 33% (n = 22) of visits. Chi-square tests assessed concordance between the physician's diagnosis and the criteria-based diagnosis and compared rates of antibiotic overuse as determined from physician and criteria-based diagnoses.Results.-The criteria-based diagnosis agreed with 100% of physicians' diagnoses of streptococcal pharyngitis and 73% of physicians' acute otitis media diagnoses but with only 17% of physicians' sinusitis diagnoses. Antibiotic overuse occurred in 11% of visits based on physicians' diagnoses but in 32% of visits when criteria-based diagnoses were considered, a difference of 21% (95% confidence interval, 2%-38%; P < 0.05).Conclusions.-Criteria-based diagnoses revealed that antibiotic overuse occurred 3 times more frequently than suggested by physician diagnoses. Concordance between physician and criteria-based diagnoses was lowest for sinusitis. Future studies should consider the contribution of overdiagnosis to antibiotic overuse and target this practice to further reduce overuse.
OBJECTIVE:The aim of this study was to evaluate a culturally effective health care (CEHC) curriculum integrated into the real-time clinical experience of a third-year medical student pediatric clerkship.METHODS:The intervention group (n = 22) and the nonintervention group (n = 69) consisted of students who were assigned to one of two sites for their clerkship. Students did not volunteer for the curriculum. A curriculum in 2002 was developed based upon a local needs assessment of students and parents, key CEHC concepts and experts' input. Learning strategies included incorporation of CEHC issues into clinic precepting, attending rounds, and written histories. Evaluation methods were preintervention and postintervention knowledge tests and Likert-type attitudinal surveys, and a final objective structured clinical exam (OSCE; nonintervention group, n = 22, intervention group, n = 22).RESULTS:Pretest knowledge scores were similar in both groups. The post-test scores were significantly different. The intervention group demonstrated higher gain in the knowledge scores (42% vs 5%; P < .001). The intervention group demonstrated significantly higher gains in observed role modeling (85% vs 31%; P = .01), self-perceived skill (82% vs 19%; P < .001), and attitude (21% vs 0%; P = .02), but not in self-perceived knowledge domains (65% vs 15%; P = .14) on the attitudinal survey. The intervention group performed significantly better in the folk (83% vs 70%; P = .02) and language (75% vs 63%; P = .01) OSCE stations and had a significantly higher total OSCE score (79% vs 68%; P = .01).CONCLUSION:A CEHC curriculum, stressing clinical relevance, was successfully incorporated into the real-time experience of a third-year medical student pediatric clerkship. Students demonstrated significant gains in knowledge, attitudinal domains, and clinical skills.
OBJECTIVE:To assess the relationship between underimmunization and child maltreatment among children referred to a child advocacy center for a child maltreatment evaluation.METHODS:We conducted a secondary data analysis of 399 children aged 3 to 48 months who were referred to a child advocacy center at an academic medical center. The primary independent variable was age-appropriate immunization status. The dependent variable was maltreatment (confirmed, suspected, or ruled out). Multivariate models were used to control for insurance, race/ethnicity, and maternal education.RESULTS:At 3 and 7 months of age, underimmunized children were significantly more likely to have confirmed maltreatment than children whose immunizations were up to date (at 3 months, 32.0% vs 17.6%, P < .05; at 7 months, 23.7% vs 8.6%, P < .01). At 19 months, rates were not significantly different (16.1% vs 24.1%, P = .33). In multivariate analyses, children underimmunized at 3 or 7 months of age were 4 times more likely to have confirmed maltreatment compared with children whose immunizations were up to date (at 3 months, adjusted odds ratio [AOR], 3.97, 95% confidence interval [95% CI], 1.67-9.49; at 7 months, AOR, 4.79, 95% CI, 1.47-15.66). This relationship was statistically significant for children evaluated for physical abuse (AOR, 4.34, 95% CI, 1.18-16.02), but not for sexual abuse.CONCLUSIONS:Underimmunization at 3 and 7 months of age was associated with confirmed maltreatment, specifically physical abuse, in children evaluated for child maltreatment. The association between underimmunization and child abuse in the general population deserves further study.
OBJECTIVE:The aim of this study was to examine the prevalence of regressive autism and associated demographic, medical, and developmental factors by using 2 different definitions of regression based on the Autism Diagnostic Interview, Revised.METHODS:Subjects were aged 2 to 5 years, with autism (AU) or autism spectrum disorder (ASD) confirmed by standardized measures. Children with regression, defined as a) loss of both language and social skills or b) loss of either language or social skills, were compared with each other and to children with AU or ASD with no reported loss of skills on developmental and adaptive functioning. Parents reported on seizure, gastrointestinal, and sleep concerns.RESULTS:Fifteen percent (50/333) of the combined AU-ASD group lost both language and social skills; 41% (138/333) lost either language or social skills. No differences were found between the 2 samples of children with regression. Few developmental, demographic, or medical differences were found between the combined regression group and children without loss of skills, in both the larger AU-ASD sample and the more homogeneous AU-only sample. Children with regression had significantly lower communication scores than children without regression.CONCLUSIONS:The prevalence of regression in a large sample of young children with AU and ASD varies depending on the definition used; requiring loss of language significantly underestimates the frequency of developmental regression. Children with regression performed significantly less well than those without regression on 2 measures of communication, but the clinical meaningfulness of these differences is uncertain because of the small effect sizes.
