OBJECTIVE:This study describes recruitment approaches and costs of engaging Spanish-speaking and Latino families and their young children with language delays in a randomized clinical trial of a naturalistic language intervention approach. METHOD:A total of 214 families were initially screened, and ultimately, 81 families were determined to be eligible and were enrolled in a randomized clinical trial. Families found out about the study via passive recruitment strategies (social media or word of mouth) and active recruitment strategies (referral by experts in early bilingual language development or referral by nonexperts in early bilingual language development). Differences in eligibility based on recruitment strategy type were examined, and a participant acquisition cost for each recruitment source was estimated. RESULTS:There were significant differences in eligibility based on how families were referred. Families who were referred to the study by experts were significantly more likely to qualify and enroll. Referrals from an early intervention provider were the most cost-effective way to recruit families. CONCLUSION:Active recruitment strategies were essential to recruiting Spanish-speaking and Latino families into a randomized clinical trial. Studies that use primarily or exclusively passive recruitment approaches may result in biased samples. Establishing relationships with community experts may be especially important for research targeting children with disabilities.
OBJECTIVE:The STAT-MD training program aims to address limited access to specialty autism evaluation services by teaching pediatric professionals to conduct autism assessments using the Screening Tool for Autism in Toddlers and Young Children (STAT). While previous research has demonstrated increased autism-focused assessment and diagnosis in community settings following STAT-MD training, implementation in real-world practice has been hindered by logistical barriers, limited follow-up support, and challenges with integration into community-based care. This study aimed to gather input from past STAT-MD training participants to better inform diagnostic training offerings for primary care clinicians and community providers. METHOD:We invited 1,190 eligible participants from past STAT-MD trainings (2004-2024) to complete an electronic survey. Survey respondents (n = 58) reported on the training's long-term impact on provider confidence, clinical use, and barriers to implementation. RESULTS:Results showed significant increases in provider confidence across 9 assessment-related domains (p < 0.001), but only 64% of respondents reported applying training content in practice or administering the STAT, and only 54% reported diagnosing autism following training. Reported barriers to implementation included time constraints, limited access to specialists, and inadequate reimbursement. Respondents highlighted the need for ongoing support, implementation guidance, and additional training on caregiver counseling and assessing a broader range of autism presentations. CONCLUSION:These findings underscore the need for training models that provide tailored resources and sustained support around integration within existing practice systems. Future efforts should refine diagnostic training based on provider feedback to increase their long-term impact and facilitate community-based autism assessment.
OBJECTIVE:To identify key barriers and facilitators to designing and implementing collaborative care (CC) for children with developmental disabilities (DD) in safety-net primary care. METHODS:This pre-implementation qualitative study involved semi-structured interviews with safety-net primary care leaders. Using purposive and respondent-driven sampling, interviews were conducted with 16 leaders across 9 safety-net organizations in Northern California between August 2024 and January 2025. Key Consolidated Framework for Implementation Research (CFIR) constructs guided data collection. Data were analyzed using the Rapid Assessment Process and validated through structured member checking. RESULTS:Leaders from 8 of 9 organizations reported existing integrated behavioral health programs staffed by mental health counselors and/or psychiatrists, but nearly all noted that these programs did not address the specific needs of children with DD. When asked about developing a CC intervention for this population, leaders identified implementation barriers and facilitators that mapped to CFIR inner and outer setting domains. Four themes were distilled: inner setting barriers (space and cost), inner setting facilitators (perceived clinical need among leadership), outer setting barriers (restrictive Medicaid reimbursement policies and limited performance measurement pressure), and outer setting facilitators (alternative financing mechanisms). CONCLUSION:Safety-net leaders indicate a clinical need for CC models specifically for children with DD, but implementation success will depend on addressing space, financing, and policy barriers through targeted implementation strategies.
OBJECTIVE:The long-term relationship between breakfast habits in early childhood and academic performance remains unclear. Therefore, this study aimed to investigate the association between breakfast habits at age 3 years and academic performance in the first grade of elementary school. METHODS:We conducted a retrospective analysis of a population-based cohort in Amagasaki City that followed children from birth until entry into elementary school. Academic outcomes included performance in the national language and math, as well as subdomains within each subject. RESULTS:Among 7847 children, regular breakfast consumption at age 3 years was associated with higher academic performance. Children who ate breakfast daily had higher mean scores in national language (73.12 ± 19.19 vs 66.16 ± 22.33) and math (81.09 ± 19.19 vs 73.31 ± 24.71). In multivariable regression analyses, daily breakfast consumption at age 3 years was modestly associated with higher first-grade academic performance, specifically with overall math scores (β = 2.46, 95% confidence interval [CI]: 0.07-4.85), calculation-related skills (β = 1.94, 95% CI: 0.29-3.59), and language-related skills (β = 1.74, 95% CI: 0.02-3.46). Associations with other domains were not significant. These associations remained significant after adjusting for economic status, suggesting an independent association between early childhood breakfast habits and academic performance. Children who did not eat breakfast daily were more likely to have financial difficulties and irregular lifestyles. CONCLUSION:Regular breakfast consumption during early childhood was associated with higher subsequent academic achievement. However, the observed association may reflect underlying social and environmental factors.
OBJECTIVES:Extension for community health care outcomes (ECHO) Autism is a successful tele-education program that improves primary care clinicians' knowledge, skills, and self-efficacy in providing medical care to children with autism spectrum disorder (ASD). However, less is known about the effectiveness of the ECHO Autism model for allied health professionals (AHPs). The study objective was to determine if ECHO Autism participation has long-lasting effects (>6 months postparticipation) on AHPs' care practices. METHODS:Participants from 3 cohorts of the ECHO Autism for AHPs (EAA) program were invited to participate in qualitative interviews to provide perspectives on barriers to treating children with ASD, reflections on their learnings from EAA, and suggestions for program improvement. Interview recordings were transcribed, and thematic analysis was conducted. RESULTS:Participants included 9 AHPs (4 occupational therapists, 4 speech language pathologists, and 1 physical therapist). AHPs reported that EAA participation reinforced and updated their existing knowledge when treating patients with ASD, affirmed their clinical practice, improved patient and family rapport, advanced professional development, and built interdisciplinary learning. The EAA's free virtual format was convenient; however, participation barriers included time away from clinical visits and inexperience with giving case presentations. Barriers to providing care to children with ASD included limited resources and managing challenging behaviors. CONCLUSION:EAA provided a flexible format for AHPs to increase their ASD-related knowledge, build interdisciplinary learning, and gain confidence in working with children with ASD. Study findings have the potential to improve the EAA program experience and enhance the autism-related clinical care practices of AHPs.
OBJECTIVE:This study examines associations between sleep problems, screen time, physical activity, and deficient emotional self-regulation (DESR) in children with and without attention-deficit hyperactivity disorder (ADHD). METHODS:A total of 74 children aged 6 to 10 years participated in this cross-sectional study, including 43 inpatients diagnosed with ADHD and 31 control participants. DESR was assessed using a composite derived from Child Behavior Checklist subscales. Parents provided information on children's sleep, screen time, and physical activity using questionnaire measures. Hierarchical regression and group comparisons were conducted to examine associations between lifestyle factors and DESR. RESULTS:Children with ADHD exhibited more sleep problems and higher screen time than controls. Sleep problems were strongly associated with DESR after adjusting for ADHD diagnosis. Screen time was positively correlated with DESR but was not independently associated with DESR in multivariate models. Physical activity was not associated with DESR, and no group differences in physical activity were observed. CONCLUSION:In this inpatient sample, sleep problems showed the most robust association with DESR, particularly among children with ADHD. These findings highlight sleep as a potentially important clinical target. Future studies should use longitudinal designs and objective measures to clarify directionality and mechanisms.
OBJECTIVE:Evaluate the outcomes of individuals with intellectual and developmental disabilities (IDD) admitted to an intensive behavior treatment program to reduce severe externalizing behavior (e.g., aggression; self-injury). METHODS:The authors conducted a retrospective electronic health record review of 40 consecutive patients aged 6 to 19 years with severe externalizing behavior causing imminent risk of harm to self or others over a 4-year period (January 2020 to December 2023). The intensive outpatient model involved daily intervention (Monday-Friday; 5 hours per day across an approximate 5-month period) that was structured and individualized based on the tenants of applied behavior analysis. Systematic data extraction included participant characteristics, outcomes of behavioral assessments, components of the behavioral intervention, percent reduction of externalizing behavior, and percent of caregiver-directed goals met. RESULTS:All participants had a diagnosis of autism and 80% had a co-occurring intellectual disability. Participants presented with 3 primary types of externalizing behavior-aggression (87.5%), disruption (82.5%), and self-injury (67.5%). At discharge, participants had a 90.74% reduction in externalizing behavior and 82.5% of participants met their primary caregiver-directed goal. CONCLUSION:Findings provide provisional evidence regarding the benefits of intensive behavioral treatment for children with IDD and severe externalizing behavior.
OBJECTIVE:To investigate whether positive parenting is associated with higher self-report resilience in children with attention-deficit hyperactivity disorder (ADHD) after controlling for other possible related factors. METHOD:After providing informed consent, children with ADHD aged 7 to 11 years completed the Resilience Scale for Children (RS10), and adolescents aged 12 to 18 years completed the 14-item Resilience Scale (RS14). Higher resilience was defined as a resilience score above the mean score minus 1 SD (> mean - 1SD) for comparable age groups provided in the manuals. Children with scores under this cut-point were defined as having lower resilience. Parents completed the Parenting Styles and Dimensions Questionnaire and the Vanderbilt ADHD Rating Scale. Factors associated with higher resilience were analyzed using univariable and multivariable logistic regression analyses. RESULTS:A total of 181 children participated in the study. The mean participant age was 11.15 (SD: 2.46) years. Of the participants, 79% were boys. A total of 118 children (65.19%) comprised the higher resilience group. Multivariable logistic regression analyses showed that higher positive parenting behavior score (adjusted odds ratio [aOR]: 1.40, 95% confidence interval [CI]: 1.08-1.83) and peer acceptance (aOR: 4.14, CI: 1.83‒9.37) were associated with higher resilience. Older age and having a diagnosis of borderline intelligence were associated with lower resilience: aORs: 0.84 (95% CI: 0.73-0.97) and 0.08 (95% CI: 0.01-0.75), respectively. CONCLUSION:Positive parenting and peer acceptance were associated with higher self-perceived resilience. Health care providers should promote positive parenting and social skills to nurture resilience in children with ADHD.
OBJECTIVE:Current clinical practice guidelines recommend that pediatricians screen all youth for overweight/obesity and provide or refer to treatment those with elevated weight status. Despite pediatricians' intentions to provide high-quality care, weight stigma and bias impede health care delivery. A shift in training is needed to optimize the experiences of adolescents with high weight status (body mass index ≥85 th percentile) during primary care visits. The present study sought adolescent, caregiver, and pediatrician perspectives on current practice, gaps in care, and needs for training to address health behaviors in youth at high weight status. METHODS:Individual qualitative interviews were conducted with adolescents with high weight status (ages 13-17), their caregivers, and pediatricians. Recruitment occurred primarily through a hospital-based primary care practice in the Northeastern United States. Interviews were audio recorded, transcribed, and analyzed using an applied thematic analysis approach. RESULTS:A total of 13 adolescents, 13 caregivers, and 11 pediatricians participated in the study. Themes from adolescents and caregivers included preferences for weight-specific communication, the importance of patient centered care, and specific guidance for pediatricians delivering care. Themes from pediatricians included philosophy of addressing high weight status, gaps in training, and preferred components of a future training. CONCLUSION:Multiple perspectives, including patients and pediatricians, emphasize the need to develop further training for pediatricians to improve care for adolescents at high weight status to meet current clinical practice guidelines. Findings provide specific guidance for development of pediatrician-focused training to navigating health behavior and weight-related conversations using a patient-centered approach.
OBJECTIVE:The present study examined the diagnostic sequencing of co-occurring autism spectrum disorder (ASD) and mental health diagnoses in youth and the impact of demographic factors on diagnostic patterns. METHODS:Data were extracted from the electronic health record of youth (n = 3357) under age 18 years in a pediatric health care system in the midwestern United States. Patients with co-occurring ASD and mental health disorders were categorized based on the order in which they were diagnosed: ASD first, mental health disorder first, or concurrent diagnoses. T -tests and linear and multinomial regressions were used to examine whether age at ASD diagnosis differed based on the presence of a mental health disorder and to examine demographic variables as predictors of diagnostic patterning. RESULTS:ASD was diagnosed 3 years later in youth with a mental health disorder, t(13,464) = 34.26, p < 0.001. Youth were most often diagnosed with a mental health disorder before ASD. Girls were 0.65 times less likely than boys to receive an ASD diagnosis first compared with a mental health diagnosis first ( p = 0.006) and were diagnosed with ASD later than boys (B = 0.97, p = 0.006). Black and multiracial Hispanic children were more likely than White children to receive an ASD diagnosis first compared with a mental health diagnosis (odds ratios 1.37-1.93) and were diagnosed with ASD earlier. Minoritized children were more likely to receive externalizing diagnoses. CONCLUSION:Findings highlight issues of diagnostic overshadowing in the diagnosis of ASD and co-occurring mental health conditions, and elucidate demographic groups who may be at risk for late diagnosis of ASD.
OBJECTIVE:To explore sleep health knowledge, perspectives, and experiences in diverse caregivers of school-aged children receiving care from community health care centers to inform clinical practice. METHOD:Mixed-methods study including surveys and semistructured interviews with caregivers of school-aged children were conducted to provide understanding of their sleep beliefs, child sleep disturbances, and home sleep environment. Survey data (n = 19) were summarized descriptively and examined using Fisher exact tests. Qualitative data (n = 21) were analyzed using constant comparative analysis. RESULTS:Survey data indicated a few caregiver misconceptions about sleep health, such as "Most school-aged children need about 8 hours of sleep per night," reported by 95% of caregivers and the belief that "If a child has trouble falling asleep, you should move their bedtime earlier," reported by 84% of caregivers. Four major qualitative themes were identified for caregivers: (1) perceptions of their child's sleep; (2) experiences in the primary care setting regarding their child's sleep health; (3) experiences searching for information about sleep; (4) needed information and resources to help support their child's sleep. CONCLUSION:Findings emphasize the need for (1) health care providers to integrate sleep health education into routine care and (2) the development of sleep health education for diverse caregivers of school-aged children.
OBJECTIVES:Mitral valve prolapse (MVP) is generally benign in youth but is often accompanied by somatic sensations that resemble anxiety symptoms. This study examined the prevalence and severity of separation anxiety disorder in children and adolescents with MVP and explored associations with parental attitudes and anxiety sensitivity (AS). METHODS:Sixty-five youth with MVP (ages 7-18 years) and 60 age-matched healthy controls underwent structured cardiologic and mental health evaluation. Diagnoses were established using the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version. Validated scales assessed separation anxiety symptoms, parental attitudes, and AS. RESULTS:Separation anxiety disorder prevalence and symptom severity were significantly higher in the MVP group than in controls ( p < 0.001). Parents of children with MVP reported higher levels of overprotection. AS did not differ significantly between groups. Mitral regurgitation jet length correlated positively with physical AS ( p = 0.043) and negatively with perceived maternal emotional warmth ( p = 0.026). In a parsimonious multivariable model, only physical AS independently predicted separation anxiety severity. CONCLUSION:Youth with MVP exhibit elevated separation anxiety, suggesting that somatic cues linked to benign cardiac findings may interface with family context to increase separation-related vulnerability. Integrating mental health assessment into routine pediatric cardiology care may facilitate early identification and intervention.
OBJECTIVES:Chat Generative Pretrained Transformer (ChatGPT) is a widely adopted tool that can provide immediate parenting guidance. The aim of this study was to examine the quality of ChatGPT parenting advice. METHODS:Clinically relevant ChatGPT queries (n = 100) were created by investigators from a national poll on parents' most pressing concerns (screen media, mental health, feeding, school violence, smoking/vaping, and cost of health care/health insurance). ChatGPT 4o was queried for responses to these questions (June-July 2024). A coding scheme on parenting advice quality was adapted from previous literature with 15 items (presence or absence) and independently coded by an interdisciplinary team. Disagreements were resolved by majority consensus. Seven of these codes were summed, creating an overall quality variable (range 0-7, 7 = high). ANOVA with post hoc Tukey-Kramer analyses compared the overall quality of advice across topics (except cost of health care/health insurance). Analyses were conducted in SAS 9.4. RESULTS:ChatGPT frequently shared accurate information about the benefits of parenting approaches and infrequently shared information about risks or psychosocial nuances such as developmental information, race/ethnic diversity, neurodiversity, and social drivers of health. There were differences in response quality between categories (F-value 4.29, p = 0.003). Post hoc analyses found that screen media advice (mean = 3.7, SD = 1.0) was of lower quality versus mental health (mean = 4.6, SD = 1.5, p = 0.03) and smoking/vaping (mean = 5.0, SD = 1.3, p = 0.03). Feeding mean was 3.7 (SD = 1.3); school violence mean was 4.8 (SD = 1.2); cost of health care/health insurance mean was 2.8 (SD = 0.6). CONCLUSION:ChatGPT's information was overall accurate; however, the quality of advice varied by parenting topic. ChatGPT quality may be lower for topics such as screen media, which may have more nuanced or variable approaches.
OBJECTIVE:To examine demographic and child/family factors predictive of autism spectrum disorder (ASD) in children with diagnostic uncertainty after initial assessment by experienced Developmental Behavioral Pediatric (DBP) clinicians. METHODS:A retrospective cohort of 87 consecutive children was seen for Interdisciplinary Autism Diagnostic Team (IADT) assessment between January 2022 and March 2023 because of initial DBP clinician diagnostic uncertainty. Sociodemographic and child/family characteristics including IADT results were analyzed using Mann-Whitney U tests, χ 2 tests, and logistic regression to determine predictors of ASD diagnosis. RESULTS:Mean age of referred children was 6.9 (SD 3.02) years, 74% were male, and 78% did not exhibit cognitive delays. Demographic factors did not significantly differ between ASD and non-ASD diagnostic groups. The ASD group had lower rates of prenatal substance exposure ( p < 0.001), physical aggression ( p = 0.033), family history of non-ASD mental health conditions ( p = 0.002), and adverse childhood events ( p = 0.016). Autism spectrum disorder diagnostic testing best predicted an ASD diagnosis. The ASD group had significantly higher Autism Diagnostic Observation Schedule (ADOS) Total ( p < 0.001) and Comparison scores ( p < 0.001) than the non-ASD group. CONCLUSION:Children with ASD diagnostic uncertainty often share similar demographic and clinical features. This study found that family history of non-ASD conditions and child experiences of early adversity are significant factors in differentiating ASD and non-ASD. Child and family factors at point-of-referral may help discern need for an ASD team evaluation including structured observational tools (e.g., ADOS-2) and improve efficiency of assessment planning.
OBJECTIVES:Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder with multilevel risk and prognostic factors. Family resilience (FR) has a positive impact on youth ADHD prognosis. Research suggests health care interventions can enhance FR. Family-centered care (FCC), a component of the Medical Home Model often missed in families of youth with ADHD, is 1 possible health care intervention. This secondary analysis examined the relationship between FCC and FR in families of youth with ADHD in the United States. METHODS:The 2018 National Survey of Children's Health data on families of 6- to 17-year-olds with ADHD were analyzed. A cumulative logistic regression analysis was conducted to model the relationship between FCC and FR as defined by the Family Resilience and Connection Index (FRCI) in families of 6- to 17-year-olds with ADHD. RESULTS:There is a significant association between FCC and FRCI. Although only 13.31% of families of 6- to 17 year-olds with ADHD had an FRCI of 6, the highest measure of FR in this study, families who reported receiving FCC were more likely to have an FRCI 6 when compared with similar families that did not report receiving FCC. CONCLUSION:Results suggest a positive association between FCC and FRCI in families of youth with ADHD in the United States, supporting FCC as an important health care factor in youth ADHD prognosis and management. Future research may consider measuring the impact of FCC on FRCI in families of youth with ADHD and/or implementation of FCC within youth ADHD health care management.
Objectives:Much research has documented disruptions to parent well-being and family functioning because of the COVID-19 pandemic in the United States, but little is known about how parents' provision of cognitive stimulation to young children has been affected. This question is of added importance for families with low incomes, who were disproportionately disadvantaged by the pandemic. The current study examined whether and how provision of cognitive stimulation at home, as measured by the parent-reported StimQ2, changed for parents with low incomes after onset of the COVID-19 pandemic. We examined scores on a total scale and subscales tapping multiple aspects of verbal responsivity and reading.Design:Data from 7 cohorts of families with low incomes across 3 US cities were de-identified and combined into a single analytic sample for secondary analysis. Cohorts ranged in timing relative to the onset of the pandemic (i.e., as early as 2015 and as late as April 2023). Each study contributed data from families assessed at multiple timepoints between birth and age 4 years.Results:Total scores on the StimQ2 increased after the onset of the COVID-19 pandemic. Subscales reflecting reading stayed the same (quantity) or declined (quality), whereas subscales reflecting verbal responsivity increased.Conclusion:Relative to prepandemic levels, low-income parents' child-directed speech and responsivity increased postpandemic, but the quantity of parent-child reading was unchanged and its quality declined. Findings suggest the possibility of stability or improvement among parents with low incomes during the pandemic and opportunities for intervention.
