Nerissa S. Bauer

Promoting Optimal Development: Screening for Behavioral and Emotional Problems

By current estimates, at any given time, approximately 11% to 20% of children in the United States have a behavioral or emotional disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Between 37% and 39% of children will have a behavioral or emotional disorder diagnosed by 16 years of age, regardless of geographic location in the United States. Behavioral and emotional problems and concerns in children and adolescents are not being reliably identified or treated in the US health system. This clinical report focuses on the need to increase behavioral screening and offers potential changes in practice and the health system, as well as the research needed to accomplish this. This report also (1) reviews the prevalence of behavioral and emotional disorders, (2) describes factors affecting the emergence of behavioral and emotional problems, (3) articulates the current state of detection of these problems in pediatric primary care, (4) describes barriers to screening and means to overcome those barriers, and (5) discusses potential changes at a practice and systems level that are needed to facilitate successful behavioral and emotional screening. Highlighted and discussed are the many factors at the level of the pediatric practice, health system, and society contributing to these behavioral and emotional problems.

Associations of Early Exposure to Intimate Partner Violence and Parental Depression With Subsequent Mental Health Outcomes

IMPORTANCE Children with known exposure to intimate partner violence (IPV) or maternal depression are at risk for negative mental health outcomes as early as preschool age. Active ongoing surveillance for these risk factors can lead to earlier mental health intervention for children. OBJECTIVE To examine the association between parent reports of IPV and depressive symptoms within the first 3 years of a childs life with subsequent mental health conditions and psychotropic drug treatment. DESIGN Prospective cohort study linking parental IPV and depression with subsequent billing and pharmacy data between November 1, 2004, and June 7, 2012. SETTING Four pediatric clinics. PARTICIPANTS A total of 2422 children receiving care from clinics that implemented the Child Health Improvement Through Computer Automation (CHICA) system. MAIN OUTCOME MEASURES Any report of IPV and/or parental depressive symptoms from birth to age 3 years, mental health diagnoses made with International Classification of Diseases, Ninth Revision criteria, and any psychotropic drug treatment between ages 3 and 6 years. RESULTS Fifty-eight caregivers (2.4%) reported both IPV and depressive symptoms before their children were aged 3 years, 69 (2.8%) reported IPV only, 704 (29.1%) reported depressive symptoms only, and 1591 (65.7%) reported neither exposure. Children of parents reporting both IPV and depressive symptoms were more likely to have a diagnosis of attention-deficit/hyperactivity disorder (adjusted odds ratio = 4.0; 95% CI, 1.5-10.9), even after adjusting for the childs sex, race/ethnicity, and insurance type. Children whose parents reported depressive symptoms were more likely to have been prescribed psychotropic medication (adjusted odds ratio = 1.9; 95%, CI 1.0-3.4). CONCLUSIONS AND RELEVANCE Exposure to both IPV and depression before age 3 years is associated with preschool-aged onset of attention-deficit/hyperactivity disorder; early exposure to parental depression is associated with being prescribed psychotropic medication. Pediatricians play a critical role in performing active, ongoing surveillance of families with these known social risk factors and providing early intervention to negate long-term sequelae.

Child exposure to parental violence and psychological distress associated with delayed milestones.

OBJECTIVE: To examine the association between parental report of intimate partner violence (IPV) and parental psychological distress (PPD) with child attainment of developmental milestones. METHODS: By using data collected from a large cohort of primary care patients, this cross-sectional study examined the relationship between parental report of IPV and/or PPD and the attainment of developmental milestones within the first 72 months of a child’s life. Multivariate logistic regression analyses were used to adjust for parental report of child abuse concern and sociodemographic characteristics. RESULTS: Our study population included 16 595 subjects. Children of parents reporting both IPV and PPD (n = 88; 0.5%) were more likely to fail at least 1 milestone across the following developmental domains: language (adjusted odds ratio [aOR] 2.1; 95% confidence interval [CI] 1.3–3.3), personal-social (aOR 1.9; 95% CI 1.2–2.9), and gross motor (aOR 3.0; 95% CI 1.8–5.0). Significant associations for those reporting IPV-only (n = 331; 2.0%) were found for language (aOR 1.4; 95% CI 1.1–1.9), personal-social (aOR 1.7; 95% CI 1.4–2.2), and fine motor-adaptive (aOR 1.7; 95% CI 1.0–2.7). Significant associations for those reporting PPD-only (n = 1920; 11.6%) were found for: language (aOR 1.5; 95% CI 1.3–1.7), personal-social (aOR 1.6; 95% CI 1.5–1.8), gross motor (aOR 1.6; 95% CI 1.4–1.8), and fine-motor adaptive (aOR 1.6; 95% CI 1.3–2.0). CONCLUSIONS: Screening children for IPV and PPD helps identify those at risk for poor developmental outcomes who may benefit from early intervention.

Use of a Computerized Decision Aid for Developmental Surveillance and Screening: A Randomized Clinical Trial

IMPORTANCE Developmental delays and disabilities are common in children. Research has indicated that intervention during the early years of a childs life has a positive effect on cognitive development, social skills and behavior, and subsequent school performance. OBJECTIVE To determine whether a computerized clinical decision support system is an effective approach to improve standardized developmental surveillance and screening (DSS) within primary care practices. DESIGN, SETTING, AND PARTICIPANTS In this cluster randomized clinical trial performed in 4 pediatric clinics from June 1, 2010, through December 31, 2012, children younger than 66 months seen for primary care were studied. INTERVENTIONS We compared surveillance and screening practices after adding a DSS module to an existing computer decision support system. MAIN OUTCOMES AND MEASURES The rates at which children were screened for developmental delay. RESULTS Medical records were reviewed for 360 children (180 each in the intervention and control groups) to compare rates of developmental screening at the 9-, 18-, or 30-month well-child care visits. The DSS module led to a significant increase in the percentage of patients screened with a standardized screening tool (85.0% vs 24.4%, P < .001). An additional 120 records (60 each in the intervention and control groups) were reviewed to examine surveillance rates at visits outside the screening windows. The DSS module led to a significant increase in the percentage of patients whose parents were assessed for concerns about their childs development (71.7% vs 41.7%, P = .04). CONCLUSIONS AND RELEVANCE Using a computerized clinical decision support system to automate the screening of children for developmental delay significantly increased the numbers of children screened at 9, 18, and 30 months of age. It also significantly improved surveillance at other visits. Moreover, it increased the number of children who ultimately were diagnosed as having developmental delay and who were referred for timely services at an earlier age. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01351077.

Assessing Parenting Behaviors to Improve Child Outcomes

Parenting is increasingly recognized as an upstream, near-universal determinant of social, economic, and health outcomes. Pediatricians know that effective parenting can buffer many adverse childhood events, thereby decreasing toxic stress and improving health. Unlike many other determinants of health, parenting behaviors are modifiable.1 The upstream and modifiable nature of parenting combine to make it an effective, although underused, lever of pediatric outcomes.2 Increasing interest in supporting effective parenting behaviors as a means to improve pediatric health is being reflected in a growing array of professional and policy initiatives. Professionals in nursing, psychology, education, and social work have developed multiple interventions aimed at improving parenting behaviors and affecting child outcomes.3 Not to be outdone, physicians have worked to develop clinically relevant interventions, adapting other models and creating novel approaches.4,5 On the policy front, there is advocacy at the highest levels. For example, the Affordable Care Act of 2010, Section 2951, calls for and funds a home-visiting program, modeled after the Nurse-Family Partnership6; one of the metrics of success for this program is “improved parenting skills.” Supporting positive and effective parenting behaviors is vital, but there is one key caveat; the recommending, planning, and funding of parenting behavior interventions must occur with the guidance of assessment. Parenting behaviors are not currently assessed on either an individual or a population level, making it difficult to direct intervention. Although supporting positive and effective parenting behaviors should be a high priority for individual pediatricians, professional societies, and federal policymakers, instituting broad-based interventions without proper assessment is bad policy. Pediatricians are already invested in parenting behaviors. In the primary care setting, pediatricians are expected to … Address correspondence to Lauren K. O’Connell, Division of Child Behavioral Health, 1924 Taubman, University of Michigan Health System, 1501 E. Medical Center Dr, Ann Arbor, MI 48109. E-mail: lbeyero{at}med.umich.edu

Computer decision support to improve autism screening and care in community pediatric clinics

An autism module was added to an existing computer decision support system (CDSS) to facilitate adherence to recommended guidelines for screening for autism spectrum disorders in primary care pediatric clinics. User satisfaction was assessed by survey and informal feedback at monthly meetings between clinical staff and the software team. To assess outcomes, such as changes in identification and referrals, we reviewed data captured from the CDSS. Between November 15, 2010 and July 26, 2012, 857 patients were eligible for screening. Of these, 66% (567/857) were screened as determined by the number of forms scanned into the system, of which 30% (171/567) had concerning Modified Checklist for Autism in Toddlers. However, pediatricians failed to respond to alerts for 73 children. Of the remaining 98 children, pediatricians felt 50 (68%) did not have an Autism spectrum disorder, 23 (32%) were referred for autism evaluation, eight (11%) were suspected but not referred and two (3%) were referred for audiology. Seventy percent of all users agreed that automation of the screening process helped them to adhere to recommended guidelines. Automating autism care into a CDSS resulted in moderate adherence to guidelines. Health information technology can facilitate the implementation of autism guidelines in busy pediatric clinics.

Do state factors moderate the relationship between depressive symptoms and morning cortisol

To fully capitalize on the utility of morning cortisol in biosocial studies of health and well-being researchers must carefully control for potential confounds. Recent reports have highlighted wake time, workday, and anticipatory negative emotions as regulators of intra-individual variation, with the potential to obscure cortisol-trait associations if not properly controlled. The purpose of this analysis is to examine the potential for trait-factors (i.e., depressive symptoms) to interact with state fluctuations in the prediction of morning cortisol. Saliva samples were collected from 56 working women at awakening and 30 min post awakening. Samples were collected on four consecutive days-two non-workdays followed by two workdays. Confirming prior research, morning cortisol levels were higher on work days and when individuals had early wake times. However, this relationship was strongest for women with fewer depressive symptoms. Similarly, only in women with fewer depressive symptoms was workday related to higher cortisol levels, and the anticipation of high negative affect related to steeper CARs and higher cortisol levels. Findings raise the possibility that certain populations may not be as physiologically sensitive to external regulatory cues, thus affecting intra-individual differences in HPA axis activity. Implications for future biobehavioral studies of depression and studies involving non-clinical samples are discussed.

Prevalence of infant television viewing and maternal depression symptoms.

Background: Early television (TV) viewing has been linked with maternal depression and has adverse health effects in children. However, it is not known how early TV viewing occurs. This study evaluated the prevalence at which parents report TV viewing for their children if asked in the first 2 years of life and whether TV viewing is associated with maternal depression symptoms. Methods: Using a cross-sectional design, TV viewing was evaluated in children 0 to 2 years of age in 4 pediatric clinics in Indianapolis, IN, between January 2011 and April 2012. Families were screened for any parental report of depression symptoms (0–15 months) and for parental report of TV viewing (before 2 years of age) using a computerized clinical decision support system linked to the patients electronic health record. Results: There were 3254 children in the study. By parent report, 50% of children view TV by 2 months of age, 75% by 4 months of age, and 90% by 2 years of age. Complete data for both TV viewing and maternal depression symptoms were available for 2397 (74%) of children. In regression models, the odds of parental report of TV viewing increased by 27% for each additional month of childs age (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.25–1.30; p < .001). The odds of TV viewing increased by almost half with parental report of depression symptoms (OR, 1.47; CI, 1.07–2.00, p = .016). Publicly insured children had 3 times the odds of TV viewing compared to children with private insurance (OR, 3.00; CI, 1.60–5.63; p = .001). Black children had almost 4 times the odds (OR, 3.75; CI, 2.70–5.21; p < .001), and white children had one-and-a-half times the odds (OR, 1.55; CI, 1.04–2.30; p = .032) of TV viewing when compared to Latino children. Conclusions: By parental report, TV viewing occurs at a very young age in infancy, usually between 0 and 3 months and varies by insurance and race/ethnicity. Children whose parents report depression symptoms are especially at risk for early TV viewing. Like maternal depression, TV viewing poses added risks for reduced interpersonal interactions to stimulate infant development. This work suggests the need to develop early targeted developmental interventions. Children as young as 0 to 3 months are viewing TV on most days. In the study sample of 0 to 2 year olds, the odds of TV viewing increased by more than a quarter for each additional month of childs age and by as much as half when the mother screened positive for depression symptoms.

A pilot study using children's books to understand caregiver perceptions of parenting practices.

Objective: To conduct a pilot study to test the feasibility and acceptability of using childrens books to understand caregiver perceptions of parenting practices around common behavior challenges. Methods: A prospective 1-month pilot study was conducted in 3 community-based pediatric clinics serving lower income families living in central Indianapolis. One hundred caregivers of 4- to 7-year-old children presenting for a well-child visit chose 1 of 3 available childrens books that dealt with a behavioral concern the caregiver reported having with the child. The book was read aloud to the child in the caregivers presence by a trained research assistant and given to the families to take home. Outcomes measured were caregiver intent to change their interaction with their child after the book reading, as well as caregiver reports of changes in caregiver-child interactions at 1 month. Results: Reading the book took an average of 3 minutes. Most (71%) caregivers reported intent to change after the book reading; two-thirds (47/71) were able to identify a specific technique or example illustrated in the story. One month later, all caregivers remembered receiving the book, and 91% reported reading the book to their child and/or sharing it with someone else. Three-fourths of caregivers (60/80) reported a change in caregiver-child interactions. Conclusions: The distribution of childrens books with positive parenting content is a feasible and promising tool, and further study is warranted to see whether these books can serve as an effective brief intervention in pediatric primary care practice.

Parent Health Literacy, Depression, and Risk for Pediatric Injury

BACKGROUND: Population-wide research on the impact of parent health literacy to children’s health outcomes is limited. We assessed the relationship of low parent health literacy to a range of pediatric health risks within a large cohort of primary care patients. METHODS: Data were from 17 845 English- and Spanish-speaking parents of children aged ≤7 years presenting for well-child care. We used a 3-item screener to measure health literacy. Outcomes included secondhand smoke exposure, asthma treatment nonadherence, parent depression, child-rearing practices, injury prevention, and parent first-aid knowledge. We summarized study variables with descriptive statistics and then performed multivariable logistic regression to identify associations between low parent literacy and our dependent measures. RESULTS: Mean child age was 4.8 years (SD 3.7); 36.5% of parent respondents had low health literacy. In models adjusted for child gender, race/ethnicity, insurance, age, and parent language preference, low parent health literacy was related to a range of pediatric health risks, including parent depression (adjusted odds ratio [AOR] 1.32; 95% confidence interval 1.18–1.48), firearm access (AOR 1.68; 1.49–1.89), not having a working smoke detector (AOR 3.54; 2.74–4.58), and lack of first-aid knowledge about choking (AOR 1.67; 1.44–1.93) and burns (AOR 1.45; 1.29–1.63). Children of parents with low health literacy were also more likely to watch >2 hours of television per day (AOR 1.27; 1.17–1.36). CONCLUSIONS: Low parent health literacy is independently and significantly related to parent depression, child television viewing, and at-risk family behaviors associated with child injury. Use of low-literacy approaches to health-behavior interventions may be essential to address common child morbidities.