John W. Harrington

Identifying the “Tipping Point” Age for Overweight Pediatric Patients

According to the National Health and Nutrition Examination Survey in 2007, nearly half of all American children are either overweight or obese. Retrospective chart review identified patients with the diagnostic codes for overweight, obese, and/or excessive weight gain. Inclusion criteria were current age between 2 and 20 years, a minimum of 5 visits with weight and height measurements, and a body mass index (BMI) at or above the 85th percentile. A total of 184 patients met inclusion criteria. More than half the children became overweight before age 2, and all patients were obese or overweight by age 10. The rate of gain is approximately 1 excess BMI unit/year, therefore causing most children to be overweight by age 2 (R 2 = .53). This study indicates that the critical period for preventing childhood obesity in this subset of identified patients is during the first 2 years of life and for many by 3 months of age.

The Clinician’s Guide to Autism

On the basis of the most recent epidemiologic research, Autism Spectrum Disorder (ASD) affects approximately 1% to 2% of all children. (1)(2) On the basis of some research evidence and consensus, the Modified Checklist for Autism in Toddlers isa helpful tool to screen for autism in children between ages 16 and 30 months. (11) The Diagnostic Statistical Manual of Mental Disorders, Fourth Edition, changes to a 2-symptom category from a 3-symptom category in the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition(DSM-5): deficits in social communication and social interaction are combined with repetitive and restrictive behaviors, and more criteria are required per category. The DSM-5 subsumes all the previous diagnoses of autism (classic autism, Asperger syndrome, and pervasive developmental disorder not otherwise specified) into just ASDs. On the basis of moderate to strong evidence, the use of applied behavioral analysis and intensive behavioral programs has a beneficial effect on language and the core deficits of children with autism. (16) Currently, minimal or no evidence is available to endorse most complementary and alternative medicine therapies used by parents, such as dietary changes (gluten free), vitamins, chelation, and hyperbaric oxygen. (16) On the basis of consensus and some studies, pediatric clinicians should improve their capacity to provide children with ASD a medical home that is accessible and provides family-centered, continuous, comprehensive and coordinated, compassionate, and culturally sensitive care. (20)

Screening Children for Autism in an Urban Clinic Using an Electronic M-CHAT

Background. The Modified Checklist for Autism in Toddlers (M-CHAT) is a screening tool for autism spectrum disorders in the clinic. However, the follow-up questions in the M-CHAT are difficult to implement on a paper format. Objective. To compare the effectiveness of the M-CHAT on an electronic format versus paper format in an outpatient clinic setting. Methods. A prospective study used electronic M-CHAT on the iPad. A retrospective review of paper M-CHATs 6 months prior to implementation was used as the comparison group. Results. A total of 176 participants completed the electronic M-CHAT format and 197 paper M-CHATs were retrospectively reviewed. The electronic format (3%) resulted in a significant difference in the frequency of children found to be at risk for autism compared with the paper version (11%); 99% of parents rated the experience as “good” or “excellent.” Conclusion. The electronic format lowered both false at-risk screens and false not-at-risk screens and had higher parental satisfaction.

Sexual Harassment in Middle and High School Children and Effects on Physical and Mental Health

Sexual harassment can be physical interaction and touching, as well as, psychological, environmental, or via Internet and text messaging. An online survey in an urban clinic asked children, aged 12 to 18 years the following: demographic data, height and weight, chronic medical conditions, healthcare use, questions concerning sexual harassment—witnessed and exposure, and finally questions from the Pediatric Symptom Checklist (PSC-35). Overall, 124 of 210 (59%) of the 12- to 18-year-olds surveyed had experienced sexual harassment, with the predominance being female 69% (80/116) versus 48% (49/92) male. Participants who had experienced sexual harassment were significantly more likely to score positive for psychological impairment than those who had not experienced sexual harassment (chi-square test P < .001; odds ratio: 4.7 (95% confidence interval, 1.9-11.8). There was a borderline significant association between elevated body mass index and having experienced sexual harassment (2-sample t test P = .08). Sexual harassment has a direct correlation to psychological impairment in adolescents, especially females.

SGA and VLBW Infants: Outcomes and Care

1. Kasey Jackson, MD* 2. John W. Harrington, MD*,† 1. *Eastern Virginia Medical School, Norfolk, VA 2. †Childrens Hospital of The Kings Daughters, Norfolk, VA Given the recent advances in medical care, babies are surviving at smaller birthweights. Categories have grown from normal birthweight (>2,500 g) to include low (<2,500 g), very low (VLBW, <1,500 g), extremely low (<1,000 g), and micro-premie (<750 g) birthweights. In addition, the categories of small and large for gestational age remain in place. Intrauterine growth retardation (IUGR) pertains to the fetal environment that can be affected by fetal, placental, or maternal factors, which is different than small for gestational age (SGA), which only defines a baby born at a weight more than 2 SD below the 50th percentile for their gestational age (ie, <10th percentile). Herein we discuss the complications, care, and outcomes for SGA (most likely caused by IUGR) and VLBW infants. The 2 categories share many of the same complications and concerns given that both infants are small but to varying degrees. However, infants who are VLBW are usually due to prematurity, whereas infants who are SGA may result from maternal complications due to pregnancy-induced or chronic hypertension, diabetes, collagen vascular disease of which systemic lupus is most prominent, asthma, chronic renal disease, receipt of anticonvulsant drugs, or use of substances such as tobacco, marijuana, and other drugs of abuse. Obviously, the complications worsen with smaller size and earlier gestational age at birth. Respiratory problems are a major concern. Asphyxia and/or meconium aspiration at birth requires immediate resuscitation and possible intubation. Decreased surfactant production …

A Feasibility Study of Autism Behavioral Markers in Spontaneous Facial, Visual, and Hand Movement Response Data

Autism spectrum disorder (ASD) is a neurodevelopmental disability with atypical traits in behavioral and physiological responses. These atypical traits in individuals with ASD may be too subtle and subjective to measure visually using tedious methods of scoring. Alternatively, the use of intrusive sensors in the measurement of psychophysical responses in individuals with ASD may likely cause inhibition and bias. This paper proposes a novel experimental protocol for non-intrusive sensing and analysis of facial expression, visual scanning, and eye-hand coordination to investigate behavioral markers for ASD. An institutional review board approved pilot study is conducted to collect the response data from two groups of subjects (ASD and control) while they engage in the tasks of visualization, recognition, and manipulation. For the first time in the ASD literature, the facial action coding system is used to classify spontaneous facial responses. Statistical analyses reveal significantly (p <0.01) higher prevalence of smile expression for the group with ASD with the eye-gaze significantly averted (p<0.05) from viewing the face in the visual stimuli. This uncontrolled manifestation of smile without proper visual engagement suggests impairment in reciprocal social communication, e.g., social smile. The group with ASD also reveals poor correlation in eye-gaze and hand movement data suggesting deficits in motor coordination while performing a dynamic manipulation task. The simultaneous sensing and analysis of multimodal response data may provide useful quantitative insights into ASD to facilitate early detection of symptoms for effective intervention planning.

Nutritional Assessment of Snacks and Beverages in Southeastern Virginia Daycare Centers

This study sought to determine the nutritional quality of snacks and beverages provided at licensed daycare centers of variable sizes in Southeastern Virginia. This cross-sectional study employed self-report surveys about snack offerings administered at each daycare site that agreed to participate. In addition, researchers completed an observation survey on the day of visit to observe and document the food and beverages actually served at snack time. Although many daycare directors reported serving fresh fruit and vegetables for snacks, there was a poor correlation on the offering of these healthy snacks between researchers and directors (P < .05). Researchers observed salty, caloric dense foods for snack time more frequently than fresh fruits and vegetables. These findings demonstrate the importance of improving and perhaps regulating the quality and diversity of snacks and beverages offered in childcare, as dietary amendments may prevent the development of childhood obesity.

Parental Self-Assessment of Behavioral Effectiveness in Young Children and Views on Corporal Punishment in an Academic Pediatric Practice:

This article assesses parental confidence and current behavioral techniques used by mostly African American caregivers of young children in an urban Southeastern setting, including their use and attitudes toward corporal punishment (CP). Two hundred and fifty parental participants of children aged 18 months to 5 years completed a survey on factors affecting their behavioral management and views on CP. Statistical analysis included χ2 test and logistic regression with confidence interval significance determined at P <.05. Significant associations of CP usage were found in parents who were themselves exposed to CP and parental level of frustration with child disobedience. A total of 40.2% of respondents answered that they had not received any discipline strategies from pediatricians and 47.6% were interested in receiving more behavioral strategies. Clear opportunities exist for pediatricians to provide information on evidence-based disciplinary techniques, and these discussions may be facilitated through the creation of a No Hit Zone program in the pediatric practice.

Parental Perception and Participation in Genetic Testing Among Children With Autism Spectrum Disorders

The purpose of this study was to determine the factors associated with genetic testing in children with autism spectrum disorders (ASDs) and understand parental involvement in the decision to test using survey data of parents of children with ASD. Evaluation by a geneticist was associated with genetic testing by more than 39 times compared to evaluation by a nongeneticist (95% CI = 9.15-168.81). Those offered testing by the physicians were more than 6 times more likely to be tested than those not offered testing (95% CI = 1.66-24.61). Financial concerns, not being offered testing, and lack of awareness were the most consistent reasons for not testing given by participants. A physician’s recommendation for testing and an evaluation by a geneticist were the most important factors associated with genetic testing in children with ASD. Educating primary care physicians and nongenetic specialists can potentially improve genetic testing among children with ASD.

Analysis of facial muscle activation in children with autism using 3D imaging

Autism Spectrum Disorder (ASD) impairs an individuals non-verbal skills including natural and contextual facial expressions. Such impairments may manifest as odd facial expressions (facial oddity) based on subjective evaluations of facial images. A few studies conducted on individuals with ASD have focused on the physiology of facial muscle usage by employing eletrophysiological sensors in response to visual stimuli. The sensors are placed directly on the face and may inhibit or limit the spontaneous facial response which may be too subtle for subjective human evaluations. This study uses a non-intrusive 3D facial imaging sensor that captures detailed geometric information of the face to facilitate quantification and detection of subtle changes in facial expression based on the physiology of facial muscle. A novel computer vision and data mining approach is developed from curve-based geometric feature of 3D facial data to discern the changes in the facial muscle actions. A pilot study is conducted with sixteen subjects (8 subjects with ASD and 8 typically-developing controls) where 3D facial images have been captured in response to visual stimuli involving 3D facial expressions. Statistical analyses reveal a significantly asymmetric facial muscle action in subjects with ASD compared to the typically-developing controls. This study demonstrates feasibility of using non-intrusive facial imaging sensor data in evaluating possible physiology-based impairments.