Gregory S. Blaschke

Military Children, Families, and Communities: Supporting Those Who Serve

* Abbreviations: AAP — : American Academy of Pediatrics DoD — : Departent of Defense SOUS — : Section on Uniformed Services WWII — : World War II More than 2 million children in the United States live in military families and 90 000 infants are born to these families each year. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents , third edition,1 a publication of the American Academy of Pediatrics (AAP), outlines an approach to comprehensive care for the individual child in the context of his or her family, as well as the community. Understanding the unique concerns of military families, such as the stress of parental wartime separation, and the specific resources available to these families, can help prepare all pediatric providers to meet the needs of this population regardless of where a medical home is established. Although military pediatricians are subject matter experts on military children and family needs, military pediatricians are not the sole providers of care for military children. Up to 50% of children in military families obtain their primary care outside of a military medical facility.2 Some service members’ families leave military installations and return “home” during deployment and obtain local pediatric care. National Guard and Reserve members often use established local resources, rather than switch to active-duty services during their “activation.” The Department of Defense (DoD) direct health care system is not large enough to care for all military children. Therefore, all pediatricians should be familiar with the population of American children who live in military families. A review of the historical perspective and the current demographics of the US military family is helpful when framing the challenges faced by military children and those who care for them. Military and civilian pediatricians are better prepared to articulate the concerns of military children and support their needs if they understand the child within the context of his or her family and community. For most of its history, the … Address correspondence to Beth Ellen Davis MD MPH, Department of Pediatrics, Madigan Army Medical Center, Tacoma WA 98431. E-mail: bedavis{at}uw.edu

Competency in Community Pediatrics: Consensus Statement of the Dyson Initiative Curriculum Committee

During the past few years, the Accreditation Council of Graduate Medical Education has aimed to change the model of physician residency training to a competency-based system. The adoption of a competency-based training system is now required, and residency programs are expected to define and evaluate the achievement of competency. In an effort to facilitate this endeavor, the Anne E. Dyson Community Pediatrics Training Initiative Curriculum Committee developed competencies for physician training in community pediatrics. These competencies refer to 8 domains thought to be integral to the practice of community-based pediatrics: 1. Delivery of culturally effective care: Pediatricians must demonstrate interpersonal and communication skills that result in effective information exchange with children and families from all cultural backgrounds and diverse communities. 2. Child advocacy: Child advocacy pediatricians should advocate for the well-being of patients, families, and communities; must develop advocacy skills to address relevant individual, community, and population health issues; and understand the legislative process (local, state, and federal) to address community and child health issues. 3. Medical home: Pediatricians must be able to identify and/or provide a medical home for all children and families under their care. As defined by the American Academy of Pediatrics, the medical home is an approach to providing comprehensive primary health care services in partnership with families. Care received in the medical home is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. … Address correspondence to Beth Rezet, MD, Childrens Hospital of Philadelphia, Primary Care Center, 3819 Chestnut St, Suite 120, Philadelphia, PA 19104. E-mail: rezet{at}email.chop.edu

Racial, Ethnic, and Language Disparities in Early Childhood Developmental/Behavioral Evaluations A Narrative Review

The U.S. Department of Health and Human Services has proposed “Increasing the proportion of children with mental health problems who receive treatment” as one of its Healthy People 2020 Objectives.(1) With high rates (2) and increasing prevalence of childhood behavioral and developmental (DB) conditions,(3–6) promptly identifying and treating these disorders is important so that children’s functional outcomes can be maximized. In addition, since long-term treatment of childhood DB conditions is expensive,(7–9) intervention in early childhood has the potential to produce large cost savings.(10) However, as with other areas of child health,(11, 12) racial/ethnic and language disparities exist in the diagnosis and treatment of early childhood DB conditions. For instance, compared to other children, African-American and Latino children are less likely to be diagnosed with an autism spectrum disorder (ASD), and are more likely to be diagnosed at older ages and with more severe symptoms.(13–18) Likewise, African-American and Latino children are less likely to be diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), and are less likely to be treated with a stimulant medication once diagnosed.(19–22) Table 1 summarizes recent peer-reviewed studies of diagnostic disparities in ASD and ADHD, two common early childhood developmental conditions. Similar disparities exist in the areas of overall developmental risk,(23) depression and mental health disorders,(24–26) use of psychotropic medications,(27) and use of mental health services.(28) These racial and ethnic disparities deserve increased attention given recent demographic trends: Census estimates suggest that the U.S. population younger than age 5 is nearly 50% racial/ethnic minority,(29) and some states are now “majority minority” for young children (30) Table 1 Racial and Ethnic Differences in Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) Diagnosis Rates The medical evaluation and treatment of young children at risk for DB disorders is a complex process involving many steps. The process begins when families identify developmental concerns about their children and raise these concerns with health care providers (Figure 1). Alternatively, a medical or other community or educational professional may recognize a concern via direct observation, developmental/behavioral surveillance, or standardized developmental/behavioral or disease-specific screening. Once a concern is identified, the next step is diagnosis and treatment. Whereas some disorders (such as ADHD) can be diagnosed and treated in the primary care setting, in many cases, a child must be referred to a developmental or mental health specialist for diagnosis through further testing and clinical evaluation. In addition, the child may require additional therapeutic services (such as Early Intervention or disorder-specific therapy).(31, 32) Figure 1 Developmental evaluation and referral process In this review article, we examine the screening, referral, and evaluation process for early childhood DB conditions, assessing points in the process where which racial/ethnic and language disparities are known or likely to occur. In addition, this review article contributes to the current base of knowledge by exploring possible reasons for these disparities. First, we examine different parent beliefs about DB problems among minority children. We also address how minority children are cared for in primary and specialty care settings, looking at missed opportunities for identification of concerns and follow-up of abnormal findings. We investigate the performance of developmental and behavioral screening and diagnostic tests among minority children. Finally, we highlight areas for additional research and suggest possible improvements to reduce racial/ethnic and language disparities in DB care.

Evaluation of residency training in the delivery of culturally effective care

Objective  To augment resident training in the delivery of culturally effective care in order to improve clinician capacity to effectively care for patients from diverse backgrounds.

A multi-institutional medical educational collaborative: advocacy training in California pediatric residency programs.

Educational collaboratives offer a promising approach to disseminate educational resources and provide faculty development to advance residents’ training, especially in areas of novel curricular content; however, their impact has not been clearly described. Advocacy training is a recently mandated requirement of the Accreditation Council for Graduate Medical Education that many programs struggle to meet. The authors describe the formation (in 2007) and impact (from 2008 to 2010) of 13 California pediatric residency programs working in an educational collaboration (“the Collaborative”) to improve advocacy training. The Collaborative defined an overarching mission, assessed the needs of the programs, and mapped their strengths. The infrastructure required to build the collaboration among programs included a social networking site, frequent conference calls, and face-to-face semiannual meetings. An evaluation of the Collaborative’s activities showed that programs demonstrated increased uptake of curricular components and an increase in advocacy activities. The themes extracted from semistructured interviews of lead faculty at each program revealed that the Collaborative (1) reduced faculty isolation, increased motivation, and strengthened faculty academic development, (2) enhanced identification of curricular areas of weakness and provided curricular development from new resources, (3) helped to address barriers of limited resident time and program resources, and (4) sustained the Collaborative’s impact even after formal funding of the program had ceased through curricular enhancement, the need for further resources, and a shared desire to expand the collaborative network.

Choosing the Bright Futures Guidelines: Lessons from leaders and early adopters

Gregory S. Blaschke, MD, MPH, FAAP, is Associate Professor of Pediatrics at Uniformed Services University, Bethesda, MD; practices at Naval Medical Center, San Diego, CA; and is a Captain in the Medical Corps of the United States Navy. Joseph O. Lopreiato, MD, MPH, FAAP, is Associate Professor of Pediatrics at Uniformed Services University, Bethesda, MD; practices at Naval Medical Center, San Diego, CA; and is a Captain in the Medical Corps of the United States Navy. Bruce Bedingfi eld, DO, FAAP, FACOP, is a private practitioner in Hoffman Estates, IL. Francis C. Rash, MD, FAAP, is Clinical Professor of Pediatrics at Uniformed Services University, Bethesda, MD; practices at Naval Medical Center, San Diego; and is a Captain (retired) in the Medical Corps of the United States Navy. Ann E. Burke, MD, FAAP, is Program Director of Pediatrics and practices inpatient and outpatient general pediatrics at Dayton Children’s Hospital, Wright State University, Dayton, OH. Rick Goldstein, MD, FAAP, is Assistant Professor of Pediatrics at Boston University School of Medicine; Associate Program Director of the Boston Combined Residency Program; and practices in a group practice in Cambridge, MA, and Boston Medical Center. Timothy R. Shope, MD, MPH, FAAP, is Associate Professor of Pediatrics at Uniformed Services University, Bethesda, MD; practices at Naval Medical Center, Portsmouth, VA; and is a Captain in the Medical Corps of the United States Navy. Christine Johnson, MD, FAAP, is Assistant Professor of Pediatrics at Uniformed Services University, Bethesda, MD; practices at Naval Medical Center, San Diego, CA; and is a Commander in the Medical Corps of the United States Navy. Frances E. Biagioli is an Associate Professor of Family Medicine at Oregon Health & Science University; sees patients and serves as the Medical Director at the OHSU Gabriel Park Family Health Center and is the Family Medicine Associate Residency Director. Nathaniel S. Beers, MD, MPA, FAAP, is Assistant Professor of Pediatrics at George Washington University, Washington, DC, and practices at Children’s National Medical Center. Joseph F. Hagan, Jr., MD, FAAP, is Clinical Professor of Pediatrics at University of Vermont College of Medicine, Burlington, VT; co-editor of Bright Futures, third edition; and primary care pediatrician in Burlington, VT. The views expressed in this article are those of the authors and do not necessarily refl ect the offi cial policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government. The Bright Futures Text is published by the American Academy of Pediatrics. Since its inception in 1990, the ongoing development of this guideline has been funded by the U.S. Department of Health and Human Services, the Health Resources and Services Administration, the Maternal Child Health Bureau. Editors, authors, contributors and reviewers of Bright Futures, third edition do not benefi t from the sale or dissemination of the guidelines. Most invited authors have had varying involvement in formulating, leading, informing, writing, reviewing, researching, disseminating and/or implementing Bright Futures; none has any fi nancial benefi t to this specifi c guideline’s incorporation into health supervision practice. Address correspondence to: Gregory S. Blaschke, MD, MPH, FAAP, Captain, Medical Corps, United States Navy, Naval Medical Center, Pediatrics, San Diego, CA, 92134-2100; fax 619-532-9902; e-mail Gregory.Blaschke@med.navy.mil. Dr. Blaschke, Dr. Lopreiato, Dr. Bedingfi eld, Dr. Rash, Dr. Burke, Dr. Goldstein, Dr. Shope, Dr. Johnson, Dr. Biagioli, Dr. Beers, and Dr. Hagan have disclosed no relevant fi nancial relationships. Gregory S. Blaschke, MD, MPH, FAAP; Joseph O. Lopreiato, MD, MPH, FAAP; Bruce Bedingfi eld, DO, FAAP, FACOP; Francis C. Rash, MD, FAAP; Ann E. Burke, MD, FAAP; Rick Goldstein, MD, FAAP; Timothy R. Shope, MD, MPH, FAAP; Christine Johnson, MD, FAAP; Frances E. Biagioli, MD; Nathaniel S. Beers, MD, MPA, FAAP; and Joseph F. Hagan, Jr., MD, FAAP

Screening for food insecurity in pediatric primary care: A clinic’s positive implementation experiences

Summary:Our project’s purpose was to assess the acceptability of a screening and intervention program to address food insecurity (FI) in pediatric primary care. We implemented systematic FI screening during routine health supervision visits. Our positive results can help to inform implementation of routine FI screening in clinical practice.

Teaching the Essentials of “Well-Child Care”: Inspiring Proficiency and Passion

Before the pediatric clerkship, most medical students learn to take a patient history starting with the “chief complaint.” Upon encountering their first pediatric patients, students quickly recognize that they are not prepared to ask the appropriate follow-up questions when the chief complaint is “well-child visit.” In this article, we present a practical method for teaching medical students how to approach pediatric health supervision visits that build upon their existing clinical skills. Primary care pediatricians address the health care needs of each child in the context of their family and community. They acknowledge the important ways in which social and psychological determinants of health impact wellness. Clinical teachers of pediatrics can inspire future physicians to use patient-centered communication skills to address the needs and priorities of families by making explicit the different aspects of a pediatric health supervision visit that include the following: 1. Identifying patient and family concerns by practicing a structured communication strategy. 2. Using reliable resources to identify the established priorities for each age and access most up-to-date anticipatory guidance recommendations. 3. Delivering prioritized anticipatory guidance that is specific to each patient within his or her community. A useful strategy for approaching the conversation with parents and children is for students to: “Elicit and ask…then assess, prioritize, and advise.”1 Clinical preceptors should explain the importance of eliciting patient and family concerns by asking open-ended questions. Then, with feedback on their ability to assess the most important issues, preceptors ask students to prioritize which topics to address and then together, advise the family accordingly. Eliciting concerns through open-ended questions creates the essential foundation for the health supervision visit.2 Recent studies have demonstrated that using a patient-centered communication style with open-ended questions is not only time-effective but allows for greater adherence to the current standards for well-child … Address correspondence to Erin K. Balog, MD, CDR, MC, USN, Department of Pediatrics, Uniformed Services University of the Health Sciences. E-mail: erin.balog{at}usuhs.edu

Disparities in Family Health-Related Internet and Email Use in the General Pediatrics Setting

Consumer-centered health information is increasingly accessible through the internet1. Many electronic health records (EHRs) offer internet portals for patient/provider communication2. Likewise, many websites address parents’ concerns about child health. However, parents may not have equal access to online technology, since using these technologies requires both financial resources and computer literacy3. Prior research has demonstrated disparities in use of health information technology (HIT) along racial/ethnic and socioeconomic lines2: Studies have found that minority patients and patients with limited English proficiency enroll in and use patient portals less than English speaking, non-Hispanic whites4,5. However, few studies assess disparities in use of HIT to communicate with health care providers, and none have assessed disparities in a pediatric setting. Understanding how families use online technology, and which families are more likely to use it, may allow for better provider/family communication. Additionally, access to online communication with providers is a key quality metric for Meaningful Use of EHRs, a federal incentive program requiring providers and health care facilities to adopt, implement, or upgrade EHR technologies. To meet Stage 2 Meaningful Use criteria, providers are required to “Use secure electronic messaging to communicate with patients on relevant health information.”6 Thus, access to these technologies in underserved populations may also be of financial interest to pediatric providers. The goal of this study was to understand which patient, family, and technology use characteristics were associated with overall internet use for health information, as well as internet use to communicate with a health care provider, with a particular focus on underserved families who might have less access to HIT.

Pediatric and Adolescent LGBT Health

Lesbian, gay, bisexual, and transgender (LGBT) youth face multiple challenges during their adolescence. This chapter addresses the developmental, psychosocial, medical, and mental health needs of LGBT youth and their families. This chapter explores literature on LGBT youth health disparities and introduces a framework for providing LGBT youth clinically and culturally competent care. Best practices and clinical resources for those caring for LGBT youth are reviewed in this chapter.