Jeanne Van Cleave

Dynamics of Obesity and Chronic Health Conditions Among Children and Youth

CONTEXT Rates of obesity and other childhood chronic conditions have increased over recent decades. Patterns of how conditions change over time have not been widely examined. OBJECTIVE To evaluate change in prevalence of obesity and other chronic conditions in US children, including incidence, remission, and prevalence. DESIGN, SETTING, AND PARTICIPANTS Prospective study using the National Longitudinal Survey of Youth-Child Cohort (1988-2006) of 3 nationally representative cohorts of children. Children were aged 2 through 8 years at the beginning of each study period, and cohorts were followed up for 6 years, from 1988 to 1994 (cohort 1, n = 2337), 1994 to 2000 (cohort 2, n = 1759), and 2000 to 2006 (n = 905). MAIN OUTCOME MEASURES Parent report of a child having a health condition that limited activities or schooling or required medicine, special equipment, or specialized health services and that lasted at least 12 months. Obesity was defined as a body mass index at or above the 95th percentile for age. Chronic conditions were grouped into 4 categories: obesity, asthma, other physical conditions, and behavior/learning problems. RESULTS The end-study prevalence of any chronic health condition was 12.8% (95% confidence interval [CI], 11.2%-14.5%) for cohort 1 in 1994, 25.1% (95% CI, 22.7%-27.6%) for cohort 2 in 2000, and 26.6% (95% CI, 23.5%-29.9%) for cohort 3 in 2006. There was substantial turnover in chronic conditions: 7.4% (95% CI, 6.5%-8.3%) of participants in all cohorts had a chronic condition at the beginning of the study that persisted to the end, 9.3% (95% CI, 8.3%-10.3%) reported conditions at the beginning that resolved within 6 years, and 13.4% (95% CI, 12.3%-14.6%) had new conditions that arose during the 6-year study period. The prevalence of having a chronic condition during any part of the 6-year study period was highest for cohort 3 (51.5%; 95% CI, 47.3%-55.0%), and there were higher rates among male (adjusted odds ratio [AOR], 1.24; 95% CI, 1.07-1.42), Hispanic (AOR, 1.36; 95% CI, 1.11-1.67), and black (AOR, 1.60; 95% CI, 1.35-1.90) youth. CONCLUSIONS Prevalence of chronic conditions among children and youth increased from 1988 to 2006. However, presence of these conditions was dynamic over each 6-year cohort.

Bullying and Peer Victimization Among Children With Special Health Care Needs

BACKGROUND. Dr Van Cleave’s current address is Department of Pediatrics, Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, 50 Staniford St, Room 901, Boston, MA 02114. The association between bullying, being bullied, or being a bully/victim and having a special health care need has not been well described in a national sample of children with a broad variety of special needs. OBJECTIVE. We aimed to determine the prevalence of bullying, being bullied, or being a bully/victim in children with special health care needs and associations of behaviors with particular types of special needs. DESIGN. We performed a secondary data analysis using the National Survey of Childrens Health, a nationally representative telephone survey conducted by the National Center for Health Statistics of >102000 US households. METHODS. We measured associations between having a special health care need and being a victim of bullying, bullying other children, and being a bully/victim in children and adolescents aged 6 to 17 years. Multiple logistic-regression models were used to examine the association of children with special health care needs overall, and of particular special needs, with the bullying measures. RESULTS. Overall, children with special health care needs were 21% of the population. In multivariate models adjusting for sociodemographic factors, being a child with special health care needs was associated with being bullied but not with bullying or being a bully/victim. Having a chronic behavioral, emotional, or developmental problem was associated with bullying others and with being a bully/victim. CONCLUSIONS. Having a special health care need generally is associated with being bullied, and having a behavioral, emotional, or developmental problem is associated with bullying others and being a bully/victim. These findings may help pediatricians, mental health providers, and schools use targeted screening and interventions to address bullying for children with special health care needs.

Understanding Factors Associated With Work Loss for Families Caring for CSHCN

OBJECTIVE: Parents of children with special health care needs (CSHCN) are at risk for work loss as a result of the complex health needs of their children. Our objective was to determine how child- and family-level factors and the medical home are associated with work loss for these families. METHODS: We performed secondary data analyses of the National Survey of Children With Special Health Care Needs (NS-CSHCN) 2005–2006. This is a nationally representative sample of CSHCN in the United States. The primary outcome measure was having any family member report work loss to care for a CSHCN. We calculated survey-weighted unadjusted and adjusted odds ratios by using independent variables that included child demographic factors, functional limitation, condition stability, insurance status/type, family income, and criteria of the medical home. RESULTS: Overall, 23.7% of the parents of CSHCN reported work loss as a result of their childs health care needs. Greater functional limitation and condition instability were associated with increased odds of family work loss. The presence of a medical home in the multivariate model was associated with a 50% reduction in the odds of reported family work loss. CONCLUSIONS: Approximately 24% of families with CSHCN have experienced work loss to meet the medical needs of their child. Availability of a system of care support, such as the medical home, is associated with lower work loss reported by families. Therefore, improved systems of care for CSHCN may have the potential to optimize work productivity for families.

Prevalence of overweight and obesity in a large clinical sample of children with autism.

BACKGROUND Overweight and obesity are major pediatric public health problems in the United States; however, limited data exist on the prevalence and correlates of overnutrition in children with autism. METHODS Through a large integrated health care systems patient database, we identified 6672 children ages 2 to 20 years with an assigned ICD-9 code of autism (299.0), Asperger syndrome (299.8), and control subjects from 2008 to 2011 who had at least 1 weight and height recorded in the same visit. We calculated age-adjusted, sex-adjusted body mass index and classified children as overweight (body mass index 85th to 95th percentile) or obese (≥ 95th percentile). We used multinomial logistic regression to compare the odds of overweight and obesity between groups. We then used logistic regression to evaluate factors associated with overweight and obesity in children with autism, including demographic and clinical characteristics. RESULTS Compared to control subjects, children with autism and Asperger syndrome had significantly higher odds of overweight (odds ratio, 95% confidence interval: autism 2.24, 1.74-2.88; Asperger syndrome 1.49, 1.12-1.97) and obesity (autism 4.83, 3.85-6.06; Asperger syndrome 5.69, 4.50-7.21). Among children with autism, we found a higher odds of obesity in older children (aged 12-15 years 1.87, 1.33-2.63; aged 16-20 years 1.94, 1.39-2.71) compared to children aged 6 to 11 years. We also found higher odds of overweight and obesity in those with public insurance (overweight 1.54, 1.25-1.89; obese 1.16, 1.02-1.40) and with co-occurring sleep disorder (obese 1.23, 1.00-1.53). CONCLUSIONS Children with autism and Asperger syndrome had significantly higher odds of overweight and obesity than control subjects. Older age, public insurance, and co-occurring sleep disorder were associated with overweight or obesity in this population.

Preventive Care Utilization Among Children With and Without Special Health Care Needs: Associations With Unmet Need

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 Childrens 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 11 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.

Electronic Health Record Decision Support and Quality of Care for Children With ADHD

OBJECTIVES: The objective of this study was to assess the effect of electronic health record (EHR) decision support on physician management and documentation of care for children with attention-deficit/hyperactivity disorder (ADHD). METHODS: This study involved 79 general pediatricians in 12 pediatric primary care practices that use the same EHR who were caring for 412 children who were aged 5 to 18 years and had a previous diagnosis of ADHD. We conducted a cluster randomized trial of EHR-based decision support that included (1) clinician reminders to assess ADHD symptoms every 3 to 6 months and (2) an ADHD note template with structured fields for symptoms, treatment effectiveness, and adverse effects. The main outcome measures were (1) proportion of children with visits during the 6-month study period in which ADHD was assessed and (2) quality of documentation of ADHD assessment. Generalized estimating equations were used to control for the clustering by providers. RESULTS: Children at intervention sites were more likely to have had a visit during the study period in which their ADHD was assessed. The ADHD template was used at 32% of visits at which patients were scheduled specifically for ADHD assessment, and its use was associated with improved documentation of symptoms, treatment effectiveness, and treatment adverse effects. CONCLUSIONS: EHR-based decision support improved the likelihood that children with ADHD had visits for as well as care related to managing this condition. Better understanding of how to optimize provider use of the decision support and templates could promote additional improvements in care.

Outpatient Visits and Medication Prescribing for US Children With Mental Health Conditions

OBJECTIVE: To compare the mental health care US children receive from primary care providers (PCPs) and other mental health care providers. METHODS: Using nationally representative data from the Medical Expenditure Panel Survey (MEPS) from 2008 to 2011, we determined whether children and youth aged 2 to 21 years with outpatient visits for mental health problems in the past year saw PCPs, psychiatrists, and/or psychologists/social workers for these conditions. We compared the proportion of children prescribed psychotropic medications by provider type. Using logistic regression, we examined associations of provider type seen and medication prescribing with race/ethnicity, household income, insurance status, geographical area, and language at home. RESULTS: One-third (34.8%) of children receiving outpatient care for mental health conditions saw PCPs only, 26.2% saw psychiatrists only, and 15.2% saw psychologists/social workers only. Nearly a quarter (23.8%) of children saw multiple providers. A greater proportion of children with attention-deficit/hyperactivity disorder (ADHD) versus children with anxiety/mood disorders saw a PCP only (41.8% vs 17.2%). PCPs prescribed medications to a higher percentage of children than did psychiatrists. Children seeing a PCP for ADHD were more likely to receive stimulants or α-agonists than children with ADHD seeing psychiatrists (73.7% vs 61.4%). We found only limited associations of sociodemographic characteristics with provider type or medication use. CONCLUSIONS: PCPs appear to be sole physician managers for care of 4 in 10 US children with ADHD, and one-third with mental health conditions overall. Efforts supporting mental health in primary care will reach a substantial portion of children receiving mental health services.

The Rise In Chronic Conditions Among Infants, Children, And Youth Can Be Met With Continued Health System Innovations

Since the early twentieth century, medical and public health innovations have led to dramatic changes in the epidemiology of health conditions among infants, children, and youth. Infectious diseases have substantially diminished, and survival rates for children with cancer, congenital heart disease, leukemia, and other conditions have greatly improved. However, over the past fifty years chronic health conditions and disabilities among children and youth have steadily risen, primarily from four classes of common conditions: asthma, obesity, mental health conditions, and neurodevelopmental disorders. In this article we describe the epidemiological shift among infants, children, and youth and examine sociodemographic and other factors contributing to it. We describe how health systems are responding by reorganizing and innovating. For children with rare complex conditions, concentrating subspecialty care at regional centers has been effective. For the much larger numbers of children with common chronic conditions, primary care providers have expanded diagnosis, treatment, and management options in promising ways.

Interventions to improve screening and follow-up in primary care: a systematic review of the evidence.

BACKGROUND The American Academy of Pediatrics and other organizations recommend several screening tests as part of preventive care. The proportion of children who are appropriately screened and who receive follow-up care is low. OBJECTIVE To conduct a systematic review of the evidence for practice-based interventions to increase the proportion of patients receiving recommended screening and follow-up services in pediatric primary care. DATA SOURCE Medline database of journal citations. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS We developed a strategy to search MEDLINE to identify relevant articles. We selected search terms to capture categories of conditions (eg, developmental disabilities, obesity), screening tests, specific interventions (eg, quality improvement initiatives, electronic records enhancements), and primary care. We searched references of selected articles and reviewed articles suggested by experts. We included all studies with a distinct, primary care-based intervention and post-intervention screening data, and studies that focused on children and young adults (≤21 years of age). We excluded studies of newborn screening. STUDY APPRAISAL AND SYNTHESIS METHODS Abstracts were screened by 2 reviewers and articles with relevant abstracts received full text review and were evaluated for inclusion criteria. A structured tool was used to abstract data from selected articles. Because of heterogeneous interventions and outcomes, we did not attempt a meta-analysis. RESULTS From 2547 returned titles and abstracts, 23 articles were reviewed. Nine were pre-post comparisons, 5 were randomized trials, 3 were postintervention comparisons with a control group, 3 were postintervention cross-sectional analyses only, and 3 reported time series data. Of 14 articles with preintervention or control group data and significance testing, 12 reported increases in the proportion of patients appropriately screened. Interventions were heterogeneous and often multifaceted, and several types of interventions, such as provider/staff training, electronic medical record templates/prompts, and learning collaboratives, appeared effective in improving screening quality. Few articles described interventions to track screening results or referral completion for those with abnormal tests. Data were often limited by single-site, nonrandomized design. CONCLUSIONS Several feasible, practice- and provider-level interventions appear to increase the quality of screening in pediatric primary care. Evidence for interventions to improve follow-up of screening tests is scant. Future research should focus on which specific interventions are most effective, whether effects are sustained over time, and what interventions improve follow-up of abnormal screening tests.

Medical Home Transformation in Pediatric Primary Care—What Drives Change?

PURPOSE The aim of this study was to characterize essential factors to the medical home transformation of high-performing pediatric primary care practices 6 to 7 years after their participation in a national medical home learning collaborative. METHODS We evaluated the 12 primary care practice teams having the highest Medical Home Index (MHI) scores after participation in a national medical home learning collaborative with current MHI scores, a clinician staff questionnaire (assessing adaptive reserve), and semistructured interviews. We reviewed factors that emerged from interviews and analyzed domains and subdomains for their agreement with MHI and adaptive reserve domains and subthemes using a process of triangulation. RESULTS At 6 to 7 years after learning collaborative participation, 4 essential medical home attributes emerged as drivers of transformation: (1) a culture of quality improvement, (2) family-centered care with parents as improvement partners, (3) team-based care, and (4) care coordination. These high-performing practices developed comprehensive, family-centered, planned care processes including flexible access options, population approaches, and shared care plans. Eleven practices evolved to employ care coordinators. Family satisfaction appeared to stem from better access, care, and safety, and having a strong relationship with their health care team. Physician and staff satisfaction was high even while leadership activities strained personal time. CONCLUSIONS Participation in a medical home learning collaborative stimulated, but did not complete, medical home changes in 12 pediatric practices. Medical home transformation required continuous development, ongoing quality improvement, family partnership skills, an attitude of teamwork, and strong care coordination functions.