Gregory H. Gorman

Wartime Military Deployment and Increased Pediatric Mental and Behavioral Health Complaints

BACKGROUND: Children of military personnel face stress when a parent deploys. OBJECTIVE: Our goal was to determine the effect of parental military deployment on the relative rate of outpatient visits for mental and behavioral health disorders in children aged 3 to 8 years. METHODS: This was a retrospective cohort study. Records of children of active-duty personnel during fiscal years 2006 and 2007 were linked with their parents deployment records. Mental and behavioral health visits were identified by using International Classification of Diseases, Ninth Revision, codes. The incidence rate ratio (IRR) of visits per year according to parental deployment status was determined with random-effects negative binomial regression modeling with longitudinal data analysis. RESULTS: A total of 642 397 children aged 3 to 8 years and 442 722 military parents were included. Mean child age was 5.0 years (SD: 1.9 years); 50.6% were male, and 68.0% were white. Ninety percent of the parents were male, and 90.5% were married; 32.0% of the parents were deployed during the study. There were 1 049 081 person-years with 611 115 mental and behavioral health visits (0.6 visit per year). The IRR of mental and behavioral health visits for children with a deployed parent compared with when a parent was home was 1.11 (95% confidence interval [CI]: 1.07–1.14; P < .001). IRRs of pediatric anxiety, behavioral, and stress disorders when a parent deployed were 1.14 (95% CI: 0.98–1.32; P = .095), 1.19 (95% CI: 1.07–1.32; P < .001), and 1.18 (95% CI: 1.10–1.26; P < .001), respectively. Older children and children with military fathers and married parents had larger increases in rates of mental and behavioral health visits during parental deployments. In contrast, the overall outpatient rate and rates of visits for other diagnoses decreased when a parent was deployed. CONCLUSIONS: Mental and behavioral health visits increased by 11% in these children when a military parent deployed; behavioral disorders increased 19% and stress disorders increased 18%. Rates especially increased in older children and children of married and male military parents.

Association of Constipation and Fecal Incontinence With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE: Functional constipation and fecal incontinence are common childhood gastrointestinal conditions. Both conditions may be associated with behavioral problems. Attention-deficit/hyperactivity disorder (ADHD) is the most common behavioral disorder of childhood, characterized by shortened attention span and hyperactivity. We hypothesize that a diagnosis of ADHD increases the risk for functional constipation and fecal incontinence. METHODS: A retrospective cohort study of children was performed by using the military health system database. Children of active-duty military personnel, aged 4 to 12 years, from October 2005 to September 2007, were included. ADHD, constipation, and fecal incontinence were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Relative risks and adjusted incidence rate ratios (IRRs) were calculated. A subgroup analysis of subjects receiving medical therapy was performed. RESULTS: There were 742 939 children identified in the study, 32 773 (4.4%) of whom had ADHD. Children with ADHD had an increased prevalence of constipation (4.1% of children with ADHD vs 1.5% children without ADHD; P < .001) and fecal incontinence (0.9% of children with ADHD vs 0.15% of children without ADHD; P < .0001). Children with ADHD had more visits than those without ADHD for both constipation (IRR 3.39; 95% confidence interval 2.59–4.43) and fecal incontinence (IRR 7.74; 95% confidence interval 5.01–11.98). Children with ADHD receiving medicinal therapy did not differ significantly from children with ADHD not receiving medicinal therapy on rates of constipation visits (P = .57) or fecal incontinence visits (P = .32). CONCLUSIONS: Children with ADHD are significantly more likely to have constipation and fecal incontinence. Medical therapy for ADHD does not impact visit rates for defecation disorders.

Intimate partner violence increases adverse outcomes at birth and in early infancy.

OBJECTIVE To determine the effect of intimate partner violence (IPV) on birth outcomes and infant hospitalization. STUDY DESIGN Hospitalization records for the first 4 months of life for infants born in the Military Health System in 2006-2007 were linked to Family Advocacy Program-substantiated cases of IPV among military parents. Adverse outcomes were identified using International Classification of Diseases, Ninth Revision codes. Logistic regression modeling calculated the OR of children exposed to IPV experiencing adverse outcomes. RESULTS A total of 204,546 infants were born during the study period. Among these, 173,026 infants (85%) were linked to active duty military parents. 31,603 infants (18%) experienced adverse outcomes, and 3059 infants (1.8%) were born into families with IPV. The infants exposed to IPV had a 31% increased odds of experiencing adverse outcomes compared with infants without known IPV exposure. IPV exposure increased the odds of the following outcomes: prematurity (OR, 1.45; 95% CI, 1.29-1.62), low birth weight (OR, 1.57; 95% CI, 1.25-1.97), respiratory problems (OR, 1.17; 95% CI, 1.04-1.32), neonatal hospitalization (OR, 1.39; 95% CI, 1.20-1.61), and postneonatal hospitalization (OR, 1.52; 95% CI, 1.29-1.81). After controlling for prematurity and demographic variables, IPV exposure was associated with low birth weight (OR, 1.52; 95% CI, 1.16-1.99), neonatal hospitalization (OR, 1.24; 95% CI, 1.02-1.49), and postneonatal hospitalization (OR, 1.27; 95% CI, 1.03-1.56). CONCLUSION Infants exposed to IPV are more likely to experience adverse birth outcomes and infant hospitalization. Routinely addressing IPV during prenatal and early pediatric visits may potentially prevent these adverse outcomes.

Association Between Use of Acid-Suppressive Medications and Antibiotics During Infancy and Allergic Diseases in Early Childhood

Importance Allergic diseases are prevalent in childhood. Early exposure to medications that can alter the microbiome, including acid-suppressive medications and antibiotics, may influence the likelihood of allergy. Objective To determine whether there is an association between the use of acid-suppressive medications or antibiotics in the first 6 months of infancy and development of allergic diseases in early childhood. Design, Setting, and Participants A retrospective cohort study was conducted in 792 130 children who were Department of Defense TRICARE beneficiaries with a birth medical record in the Military Health System database between October 1, 2001, and September 30, 2013, with continued enrollment from within 35 days of birth until at least age 1 year. Children who had an initial birth stay of greater than 7 days or were diagnosed with any of the outcome allergic conditions within the first 6 months of life were excluded from the study. Data analysis was performed from April 15, 2015, to January 4, 2018. Exposures Exposures were defined as having any dispensed prescription for a histamine-2 receptor antagonist (H2RA), proton pump inhibitor (PPI), or antibiotic. Main Outcomes and Measures The main outcome was allergic disease, defined as the presence of food allergy, anaphylaxis, asthma, atopic dermatitis, allergic rhinitis, allergic conjunctivitis, urticaria, contact dermatitis, medication allergy, or other allergy. Results Of 792 130 children (395 215 [49.9%] girls) included for analysis, 60 209 (7.6%) were prescribed an H2RA, 13 687 (1.7%) were prescribed a PPI, and 131 708 (16.6%) were prescribed an antibiotic during the first 6 months of life. Data for each child were available for a median of 4.6 years. Adjusted hazard ratios (aHRs) in children prescribed H2RAs and PPIs, respectively, were 2.18 (95% CI, 2.04-2.33) and 2.59 (95% CI, 2.25-3.00) for food allergy, 1.70 (95% CI, 1.60-1.80) and 1.84 (95% CI, 1.56-2.17) for medication allergy, 1.51 (95% CI, 1.38-1.66) and 1.45 (95% CI, 1.22-1.73) for anaphylaxis, 1.50 (95% CI, 1.46-1.54) and 1.44 (95% CI, 1.36-1.52) for allergic rhinitis, and 1.25 (95% CI, 1.21-1.29) and 1.41 (95% CI, 1.31-1.52) for asthma. The aHRs after antibiotic prescription in the first 6 months of life were 2.09 (95% CI, 2.05-2.13) for asthma, 1.75 (95% CI, 1.72-1.78) for allergic rhinitis, 1.51 (95% CI, 1.38-1.66) for anaphylaxis, and 1.42 (95% CI, 1.34-1.50) for allergic conjunctivitis. Conclusions and Relevance This study found associations between the use of acid-suppressive medications and antibiotics during the first 6 months of infancy and subsequent development of allergic disease. Acid-suppressive medications and antibiotics should be used during infancy only in situations of clear clinical benefit.

In pursuit of meaningful use of learning goals in residency: A qualitative study of pediatric residents

Purpose Medical education aims to equip physicians for lifelong learning, an objective supported by the conceptual framework of self-regulated learning (SRL). Learning goals have been used to develop SRL skills in learners across the medical education continuum. This study’s purpose was to elicit residents’ perspectives on learning goal use and to develop explanations suggesting how aspects of the learning environment may facilitate or hinder the meaningful use of learning goals in residency. Method Resident focus groups and program director interviews were conducted in 2012–2013, audio-recorded, and transcribed. Programs were selected to maximize diversity of size, geographic location, type of program, and current use of learning goals. Data were analyzed using the constant comparative method associated with grounded theory. Further analysis compared themes frequently occurring together to strengthen the understanding of relationships between the themes. Through iterative discussions, investigators built a grounded theory. Results Ninety-five third-year residents and 12 program directors at 12 pediatric residency programs participated. The analysis identified 21 subthemes grouped into 5 themes: program support, faculty roles, goal characteristics and purposes, resident attributes, and accountability and goal follow-through. Review of relationships between the themes revealed a pyramid of support with program support as the foundation that facilitates the layers above it, leading to goal follow-through. Conclusions Program support facilitates each step of the SRL process that leads to meaningful use of learning goals in residency. A strong foundation of program support should include attention to aspects of the implicit curriculum as well as the explicit curriculum.

Autism Spectrum Disorders and Metabolic Complications of Obesity

OBJECTIVES To assess for an increased risk of obesity, type 2 diabetes mellitus, hypertension, hyperlipidemia, and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis in children with autism spectrum disorders (ASD). Additionally, to determine the rates of prescribed treatment for obesity-related metabolic disorders and to determine whether treatment with psychotropic medications is associated with the development of obesity for children with ASD. STUDY DESIGN A retrospective 1:5 case-control study was performed by use of the Military Health System database from October 2000 to September 2013. For children with ASD and matched controls, International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes for obesity, type 2 diabetes mellitus, hypertension, hyperlipidemia, nonalcoholic fatty liver disease/nonalcoholic steatohepatitis, and prescriptions were obtained. Conditional logistic regression determined ORs and 95% CIs. RESULTS A total of 48 762 individuals with ASD and 243 810 matched controls were identified. Children with ASD had significantly greater odds of having obesity (OR 1.85; 95% CI 1.78-1.92), having obesity-related disorders, and being prescribed a medication when they had these diseases. In children with ASD, mood stabilizers, antipsychotics, antiepileptic drugs, and selective serotonin reuptake inhibitors were associated with obesity. CONCLUSIONS Children with ASD have an increased risk of obesity and obesity-related metabolic disorders. They are more likely to be prescribed medications to treat these complications, suggesting they may have more severe disease. There is a significant association between the use of some psychotropic categories and a diagnosis of obesity, suggesting that obesity in children with ASD may be partially iatrogenic.

Prevalence of Diagnosed Sleep Disorders and Related Diagnostic and Surgical Procedures in Children with Autism Spectrum Disorders.

Objective: Sleep disorders are common and important comorbid conditions in children with autism spectrum disorder (ASD) and can contribute to cognitive and behavioral problems. Sleep-disordered breathing (SDB) is a diagnosable and treatable cause of behavioral problems in children. We aimed to quantify the relative risk for children with ASD versus controls of being diagnosed with sleep disorders including SDB and undergoing related diagnostic and surgical procedures. Method: This retrospective case-cohort study included 48,762 children with ASD aged 2 to 18 years enrolled in the military health system (MHS) from 2000 to 2013. Children with ASD were matched 1:5 by birthdate, sex, and enrollment time to children without an ASD diagnosis. The MHS database was queried for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for sleep disorders or ICD-9-CM and Current Procedural Terminology codes for diagnostic and surgical procedures. Relative risks (RR) and 95% confidence intervals (CI) were determined with binary Poisson regression conditional on the match and adjusting for confounders. Results: Children with ASD were at higher risk of receiving any sleep disorder diagnosis (RR: 1.97 [95% CI, 1.91–2.02]) including SDB (RR: 1.96 [95% CI, 1.88–2.05]). Children with ASD also were at increased risk of undergoing polysomnography (RR: 3.74 [95% CI, 3.56–3.93]) and sleep disorder-related surgery (RR: 1.50 [95% CI, 1.46–1.54]). Conclusion: Children with ASD are more likely to be given a sleep disorder diagnosis including SDB and are more likely to undergo related diagnostic and surgical procedures compared with controls without ASD.

Otitis Media and Related Complications among Children with Autism Spectrum Disorders.

Acute otitis media (AOM) symptoms can be masked by communication deficits, common to children with autism spectrum disorders (ASD). We sought to evaluate the association between ASD and otitis media. Using ICD-9-CM diagnostic codes, we performed a retrospective case-cohort study comparing AOM, and otitis-related diagnoses among children with and without ASD. Children with ASD had a significantly increased rate of AOM, otitis media with effusion, otorrhea, and PE tube placement. Children with ASD were more than twice as likely to develop mastoiditis, and to undergo mastoidectomy and tympanoplasty. Children with ASD are more likely to have middle ear infections and otitis-related complications, highlighting the importance of routine middle ear examinations and close attention to hearing impairment in this population.

Feeding Disorders in Children With Autism Spectrum Disorders Are Associated With Eosinophilic Esophagitis

Objectives: Eosinophilic esophagitis (EoE) can present as food selectivity or feeding disorders in children. Children with autism spectrum disorders (ASDs) commonly demonstrate behavioral food selectivity in type and texture, which often leads to the diagnosis of feeding disorder. We sought to evaluate the association of ASD with EoE. Methods: A retrospective matched case-cohort study was performed using the Military Health System database from October 2008 to September 2013. We performed a 1:5 case-control match by age, sex, and enrollment timeframe. Feeding disorders, EoE, and atopic disorders were defined using diagnostic and procedure codes. Results: There were 45,286 children with ASD and 226,430 matched controls. EoE was more common in children with ASD (0.4%) compared with controls (0.1%). Feeding disorders were associated with EoE in both children with ASD and controls. Feeding disorders also had a higher odds ratio for EoE compared with other atopic conditions, among both children with ASD (7.17, 95% confidence interval [CI] 4.87–10.5) and controls (11.5, 95% CI 7.57–17.5). Compared with controls with a feeding disorder, children with ASD and a feeding disorder had no difference in the rate of diagnosed EoE (0.85, 0.95% CI 0.39–1.88). Conclusions: Children with ASD are more likely to be diagnosed with EoE compared with controls; however, among children with feeding disorders, there is no difference in the odds of EoE. A diagnosis of feeding disorder was strongly associated with EoE. Feeding disorders in children with ASD should not be assumed to be solely behavioral and an esophagogastroduodenoscopy should be performed to evaluate for EoE.

Attention Deficit Hyperactivity Disorder and Medication Use by Children During Parental Military Deployments

OBJECTIVE Parental deployment is associated with childrens increased mental health needs. Attention Deficit Hyperactivity Disorder (ADHD) is the most common pediatric mental health diagnosis. We hypothesize children with ADHD will have increased mental health and medication needs during parental deployment. METHODS Retrospective cohort study of children with ADHD aged 4-8 years in the Military Health System. RESULTS Of 413,665 children aged 4-8 years, 34,205 (8.3%) had ADHD and 19,123 (55.9%) of these were prescribed ADHD medications. During parental deployments, children with ADHD had a 13% increased rate of mental and behavioral health care visits (IRR 1.13 [95% CI 1.12-1.14; p < 0.00001]) and a decreased rate of medication changes (IRR 0.94 [95% CI 0.91-0.96; p < 0.00001]) compared to when parents were at home. Medication changes related to deployment varied by age; school-aged children had decreased medication events (IRR 0.88 [95% CI 0.86-0.91; p < 0.00001]) and preschool-aged children had increased medication events (IRR 1.05 [95% CI 1.02-1.10; p = .006]) during parental deployment. CONCLUSIONS During parental deployment, children with ADHD aged 4-8 years have increased mental health visits and decreased ADHD medication changes. Younger children have increased medication changes, whereas older children have decreased changes during a parents deployment.