Barry Zuckerman

Primary Care Pediatricians' Roles and Perceived Responsibilities in the Identification and Management of Depression in Children and Adolescents

OBJECTIVEnTo describe primary care pediatricians 1) approach to the identification and management of childhood and adolescent depression and 2) perception of their skills, responsibilities, and barriers in recognizing and managing depression in children and adolescents.nnnDESIGN AND METHODSnNational cross-sectional survey of randomly selected primary care pediatricians that assessed the management of recalled last case of child or adolescent depression, attitudes, limitations to care from barriers and skills, and willingness to implement new educational or intervention strategies to improve care.nnnRESULTSnThere were 280 completed surveys about child and adolescent depression (63% response rate). Pediatricians overwhelmingly reported it was their responsibility to recognize depression in both children and adolescents (90%) but were unlikely to feel responsible for treating children or adolescents (26%-27%). Those with most of their practice in capitated managed care were less likely to feel responsible for recognizing depression in either children or adolescents. Forty-six percent of pediatricians lacked confidence in their skills to recognize depression in children, and few of them (10%-14%) had confidence in their skills in different aspects of treatment with children or adolescents. Diagnostic, assessment, and management details for their last recalled case of depression in a child or adolescent were provided by 248 of these pediatricians. In addition to referring 78%-79% of the cases to mental health care professionals, 77% of pediatricians provided a wide range of brief interventions. Only 19%-20% prescribed medication. Major factors cited that limited their diagnosis or management were time (56%-68%) and training or knowledge of issues (38%-56%). Fewer pediatricians noted limitations due to insurer or financial issues (8%-39%) or patient issues (19%-31%). The 35% of pediatricians who were motivated to change their recognition and management of suspected depression were significantly more interested in implementing in the future a variety of new strategies to improve care.nnnCONCLUSIONnPrimary care pediatricians felt responsible for recognizing but not for treating child and adolescent depression. Although the lack of confidence and lack of knowledge and/or skills and time issues are major barriers that limit pediatricians in their treatment of childhood and adolescent depression, pediatricians varied in their readiness to change, with some being more willing to implement new strategies to care for depression. Educational and practice interventions need to focus on how to assist all pediatricians in diagnosis and to prepare these motivated pediatricians to manage depression in primary care settings.

Mobile and Interactive Media Use by Young Children: The Good, the Bad, and the Unknown

The use of interactive screen media such as smartphones and tablets by young children is increasing rapidly. However, research regarding the impact of this portable and instantly accessible source of screen time on learning, behavior, and family dynamics has lagged considerably behind its rate of adoption. Pediatric guidelines specifically regarding mobile device use by young children have not yet been formulated, other than recent suggestions that a limited amount of educational interactive media use may be acceptable for children aged <2 years.1 New guidance is needed because mobile media differs from television in its multiple modalities (eg, videos, games, educational apps), interactive capabilities, and near ubiquity in children’s lives. Recommendations for use by infants, toddlers, and preschool-aged children are especially crucial, because effects of screen time are potentially more pronounced in this group. The aim of this commentary is to review the existing literature, discuss future research directions, and suggest preliminary guidance for families.nn### Educational ValuennAlthough well-researched television programs such as Sesame Street or Blue’s Clues can promote early academic skills in preschool-aged children, children <30 months cannot learn from television and videos as they do from real-life interactions.2 Interactive media, on the other hand, allow for contingent responses to children’s actions and thus may facilitate more retention of taught material. For example, socially contingent media (ie, with appropriate content, timing, and intensity) such as videophone apps are just as effective as real-life encounters in teaching language to 24 month olds,3 but otherwise, published research on whether infants and toddlers can learn from interactive screens is scant.nnPromising research suggests that interactive media such as learn-to-read apps and electronic books (e-books) may increase early literacy … nnAddress correspondence to Jenny S. Radesky, Boston Medical Center, Vose 4, 88 E Newton St, Boston, MA 02118. E-mail: jenny.radesky{at}bmc.org

The Association of Maternal Obesity and Diabetes With Autism and Other Developmental Disabilities.

BACKGROUND: Obesity and diabetes are highly prevalent among pregnant women in the United States. No study has examined the independent and combined effects of maternal prepregnancy obesity and maternal diabetes on the risk of autism spectrum disorder (ASD) in parallel with other developmental disorders (DDs). METHODS: This study is based on 2734 children (including 102 ASD cases), a subset of the Boston Birth Cohort who completed at least 1 postnatal study visit at Boston Medical Center between 1998 and 2014. Child ASD and other DDs were based on physician diagnoses as documented in electronic medical records. Risks of ASD and other DDs were compared among 6 groups defined by maternal prepregnancy obesity and diabetes status by using Cox proportional hazard regression controlling for potential confounders. RESULTS: When examined individually, maternal prepregnancy obesity and pregestational diabetes (PGDM) were each associated with risk of ASD. When examined in combination, only mothers with obesity and PGDM (hazard ratio 3.91, 95% confidence interval 1.76–8.68) and those with obesity and gestational diabetes (hazard ratio 3.04, 95% confidence interval 1.21–7.63) had a significantly increased risk of offspring ASD. Intellectual disabilities (IDs), but not other DDs, showed a similar pattern of increased risk associated with combined obesity and PGDM. This pattern of risk was mostly accounted for by cases with co-occurring ASD and ID. CONCLUSIONS: Maternal prepregnancy obesity and maternal diabetes in combination were associated with increased risk for ASD and ID. ASD with ID may be etiologically distinct from ASD without ID.

Polymorphism in Maternal LRP8 Gene Is Associated with Fetal Growth

Fetal growth restriction (FGR) affects >200,000 pregnancies in the United States annually and is associated with increased perinatal mortality and morbidity, as well as poorer long-term health for infants with FGR compared with infants without FGR. FGR appears to be a complex trait, but the role of genetic factors in the development of FGR is largely unknown. We conducted a candidate-gene association study of birth weight and FGR in two independent study samples obtained at the Boston Medical Center. We first investigated the association between maternal genotypes of 68 single-nucleotide polymorphisms (SNPs) from 41 candidate genes and fetal growth in a sample of 204 black women selected for a previous study of preeclampsia, 92 of whom had preeclampsia (characterized by high blood pressure and the presence of protein in the urine). We found significant association between SNP rs2297660 in the LRP8 gene and birth weight. Subsequently, we replicated the association in a larger independent sample of 1,094 black women; similar association between LRP8 and FGR was observed in this sample. The A allele at rs2297660 was associated with a higher standardized birth weight and a lower risk of FGR. Under the additive genetic model, each additional copy of the A allele reduced the risk of FGR by 33% (P<.05). In conclusion, results from the two independent samples of black women provide consistent evidence that SNP rs2297660 in LRP8 is associated with fetal growth.

Inconsolable Infant Crying and Maternal Postpartum Depressive Symptoms

OBJECTIVE: To quantify the extent to which maternal report of inconsolable infant crying, rather than colic (defined by Wessel’s criteria of daily duration of fussing and crying >3 hours), is associated with maternal postpartum depressive symptoms. METHODS: Participants were 587 mothers who were recruited shortly before or after delivery and followed longitudinally. At 5 to 6 weeks postpartum, mothers recorded the duration and mode (fussing, crying, or inconsolable crying) of their infant’s distress by using the Baby’s Day Diary. The Edinburgh Postnatal Depression Scale (EPDS) was administered at enrollment and at 8 weeks postpartum. Using regression models that included baseline EPDS scores and multiple confounders, we examined associations of colic and inconsolable crying with later maternal EPDS scores at 8 weeks postpartum. RESULTS: Sixty mothers (10%) met the EPDS threshold for “possible depression” (score ≥9) at 8 weeks postpartum. For mothers reporting >20 minutes of inconsolable crying per day, the adjusted odds ratio for an EPDS score ≥9 was 4.0 (95% confidence interval: 2.0–8.1), whereas the adjusted odds ratio for possible depression in mothers whose infants had colic was 2.0 (95% confidence interval: 1.1–3.7). These associations persisted after adjusting for baseline depression symptoms. CONCLUSIONS: Maternal report of inconsolable infant crying may have a stronger association with postpartum depressive symptoms than infant colic. Asking a mother about her ability to soothe her infant may be more relevant for potential intervention than questions about crying and fussing duration alone.

Infant Self-Regulation and Early Childhood Media Exposure

OBJECTIVES: Examine prospective associations between parent-reported early childhood self-regulation problems and media exposure (television and video viewing) at 2 years. We hypothesized that children with poor self-regulation would consume more media, possibly as a parent coping strategy. METHODS: We used data from 7450 children in the Early Childhood Longitudinal Study–Birth Cohort. When children were 9 months and 2 years old, parents completed the Infant Toddler Symptom Checklist (ITSC), a validated scale of self-regulation. With daily media use at 2 years as our outcome, we conducted weighted multivariable regression analyses, controlling for child, maternal, and household characteristics. RESULTS: Children watched an average of 2.3 hours per day (SD 1.9) of media at age 2 years. Infants with poor self-regulation (9-month ITSC score ≥3) viewed 0.23 hour per day (95% confidence interval [CI] 0.12–0.35) more media at 2 years compared with those with 9-month ITSC score of 0 to 2; this remained significant in adjusted models (0.15 hour per day [95% CI 0.02–0.28]). Children rated as having persistent self-regulation problems (ITSC ≥3 at both 9 months and 2 years) were even more likely to consume media at age 2 (adjusted β 0.21 hour per day [95% CI 0.03–0.39]; adjusted odds ratio for >2 hours per day 1.40 [95% CI 1.14–1.71]). These associations were slightly stronger in low socioeconomic status and English-speaking households. CONCLUSIONS: Early childhood self-regulation problems are associated with mildly increased media exposure, even after controlling for important confounding variables. Understanding this relationship may provide insight into helping parents reduce their children’s screen time.

Use of Mobile Technology to Calm Upset Children: Associations With Social-Emotional Development

Use of Mobile Technology to Calm Upset Children: Associations With Social-Emotional Development Although it is known that parents of infants and toddlers with difficult behavior disproportionately use television and videos as calming tools,1 there are no published data regarding to what degree mobile technologies (such as cell phones and tablets) are used for this purpose. Previous qualitative work with parents has suggested that parental perceived control, defined as feelings of control over children’s behavior and development, may determine how parents set limits around screen media use2 and respond to difficult child behavior.3 We therefore sought to further explore this observation by examining associations between the social-emotional development of toddlers and mobile media use in a sample of parenttoddler dyads, and to determine whether potential associations are modified by parental perceived control.

Role of African Ancestry and Gene-Environment Interactions in Predicting Preterm Birth

OBJECTIVE: To estimate whether African ancestry, specific gene polymorphisms, and gene–environment interactions could account for some of the unexplained preterm birth variance within African American women. METHODS: We genotyped 1,509 African ancestry–informative markers, cytochrome P450 1A1 (CYP1A1), and glutathione S-transferases Theta 1 (GSTT1) variants in 1,030 self-reported African American mothers. We estimated the African ancestral proportion using the ancestry-informative markers for all 1,030 self-reported African American mothers. We examined the effect of African ancestry and CYP1A1– and GSTT1–smoking interactions on preterm birth cases as a whole and within its subgroups: very preterm birth (gestational age less than 34 weeks); and late preterm birth (gestational age greater than 34 and less than 37 weeks). We applied logistic regression and receiver operating characteristic curve analysis, separately, to evaluate whether African ancestry and CYP1A1– and GSTT1–smoking interactions could make additional contributions to preterm birth beyond epidemiologic factors. RESULTS: We found significant associations of African ancestry with preterm birth (22% compared with 31%, odds ratio [OR] 1.11, 95% confidence interval [CI] 1.02–1.20) and very preterm birth (23% compared with 33%, OR 1.17, 95% CI 1.03–1.33), but not with late preterm birth (22% compared with 29%, OR 1.06, 95% CI 0.97–1.16). In addition, the receiver operating characteristic curve analysis suggested that African ancestry and CYP1A1– and GSTT1–smoking interactions made substantial contributions to very preterm birth beyond epidemiologic factors. CONCLUSION: Our data underscore the importance of simultaneously considering epidemiologic factors, African ancestry, specific gene polymorphisms, and gene–environment interactions to better understand preterm birth racial disparity and to improve our ability to predict preterm birth, especially very preterm birth. LEVEL OF EVIDENCE: II

From principle to practice: moving from human rights to legal rights to ensure child health

Perspective on the paper by Waterston and Goldenhagen ( see 176 )nnWe applaud Waterston and Goldenhagen’s1 call to arms to healthcare professionals to consider the poor health of the world’s children (the United Nation’s Convention on the Rights of the Child providing the framework to direct such efforts). We also agree that it is essential to deal with the pervasive structural barriers that lead to inequality, poor health and suffering.2 But, as we continue to push for rights-based laws around the world, we also encourage an active strategy of promoting the enforcement of existing laws that protect children—especially those laws that ensure access to children’s basic needs, such as food, housing, safety, healthcare and education. Waterston and Goldenhagen themselves lay the groundwork by noting that one triumph of recent human rights campaigns has not only been to identify rights violations but also to establish rights-based laws in 50 countries. Indeed, a strategy focusing on the enforcement of existing laws would go a long way in dealing with a number of the injustices cited by the authors, such as non-compliance with Jordanian child labour laws and Kenyan laws regarding child well-being.nnOver the past several decades, the confluence of human rights work, increased humanitarian infrastructure and new progressive governments has, in many countries, laid a foundation of legal rights accruing to children. Ensuring adherence to the laws delineating those rights is the next step. When evaluating and treating sick children, healthcare professionals frequently identify how inadequate food, housing, safety, access to basic medications such as vaccines or other unmet basic needs contribute solely or partly to …

A Perspective on 360-Degree Evaluations

From the Department of Pediatrics, Boston University School of Medicine (R.G.), the Department of Pediatrics at Boston University Medical Center (B.Z.), and the A decade after the introduction of the Accreditation Council for Graduate Medical Education (ACGME) Outcomes Project, a mystique continues to surround 360-degree evaluations. The ACGME requires residency training programs to provide objective assessments of resident performance and improvement in the 6 general competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. It further requires that these assessments involve the use of ‘‘multiple evaluators’’ (eg, faculty, peers, patients, self, and other professional staff), essentially mandating the use of 360-degree evaluations. In the Boston Combined Residency Program at Boston Medical Center and Children’s Hospital Boston, we have developed and completed piloting of a 360-degree evaluation for use on the general pediatrics ward at Boston Medical Center. With support from the Arthur Vining Davis Foundation to encourage caring attitudes in our trainees, we have challenged ourselves to devise a process that has evaluative and educational integrity with an obvious and meaningful impact on how our residents understand the work they do. Our 360-degree evaluation emphasizes interpersonal and communication skills, and professionalism. In various presentations, we have found that others have many of the questions we had as we began, and so we share what we have learned in the spirit of furthering the goals of the Outcomes Project. We especially want to comment on limitations to claims about the reliability and validity of evaluation tools in the context of medical training, and on the hidden opportunity to help residents develop important leadership skills.