Paul H. Dworkin

Improving the management of family psychosocial problems at low-income children's well-child care visits: the WE CARE Project.

OBJECTIVE. Our goal was to evaluate the feasibility and impact of an intervention on the management of family psychosocial topics at well-child care visits at a medical home for low-income children. PATIENTS AND METHODS. A randomized, controlled trial of a 10-item self-report psychosocial screening instrument was conducted at an urban hospital-based pediatric clinic. Pediatric residents and parents were randomly assigned to either the intervention or control group. During a 12-week period, parents of children aged 2 months to 10 years presenting for a well-child care visit were enrolled. The intervention components included provider training, administration of the family psychosocial screening tool to parents before the visit, and provider access to a resource book that contained community resources. Parent outcomes were obtained from postvisit and 1-month interviews, and from medical chart review. Provider outcomes were obtained from a self-administered questionnaire collected after the study. RESULTS. Two hundred parents and 45 residents were enrolled. Compared with the control group, parents in the intervention group discussed a significantly greater number of family psychosocial topics (2.9 vs 1.8) with their resident provider and had fewer unmet desires for discussion (0.46 vs 1.41). More parents in the intervention group received at least 1 referral (51.0% vs 11.6%), most often for employment (21.9%), graduate equivalent degree programs (15.3%), and smoking-cessation classes (14.6%). After controlling for child age, Medicaid status, race, educational status, and food stamps, intervention parents at 1 month had greater odds of having contacted a community resource. The majority of residents in the intervention group reported that the survey instrument did not slow the visit; 54% reported that it added <2 minutes to the visit. CONCLUSIONS. Brief family psychosocial screening is feasible in pediatric practice. Screening and provider training may lead to greater discussion of topics and contact of community family support resources by parents.

Avoiding the Unintended Consequences of Screening for Social Determinants of Health

Screening for social determinants of health, which are the health-related social circumstances (eg, food insecurity and inadequate or unstable housing) in which people live and work, has gained momentum as evidenced by the recent Centers for Medicare & Medicaid Services innovation initiative of

From Medical Home to Health Neighborhood: Transforming the Medical Home into a Community-Based Health Neighborhood

157 million toward creation of accountable health communities.1 Funding will allow grantees to test a novel model of health care that includes identifying and addressing social determinants of health for Centers for Medicare & Medicaid Services beneficiaries. The initiative promotes collaboration between the clinical realm and the community through screening of beneficiaries to (1) identify unmet health-related social needs and (2) assist high-risk beneficiaries (ie, >2 emergency department visits and a health-related social need) with accessing available community services. Some health policy makers have embraced screening of social determinants as the next hope for achieving the triple aim of better health, improved health care delivery, and reduced costs because social and environmental factors are thought to contribute half

Selecting developmental surveillance and screening tools.

From the Department of Pediatrics, Boston University School of Medicine, Boston Medical Center, Boston, MA; Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT; and Connecticut Children’s Medical Center, Hartford, CT; and Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH Social Determinants and the Medical Home

Role of Pediatric Health Care Professionals in the Provision of Parenting Advice: A Qualitative Study With Mothers From 4 Minority Ethnocultural Groups

1. Dennis Drotar, PhD* 2. Terry Stancin, PhD† 3. Paul H. Dworkin, MD‡ 4. Laura Sices, MD§ 5. Susan Wood** 1. *Professor of Pediatrics, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio 2. †Professor of Pediatrics, Psychiatry and Psychology, Case Western Reserve University and Metro Health Medical Center, Cleveland, Ohio 3. ‡Professor of Pediatrics, University of Connecticut School of Medicine, Farmington, Conn 4. §Assistant Professor of Pediatrics, Boston University School of Medicine, Boston, Mass 5. **Coordinator, Division of Behavioral and Developmental Pediatrics, Rainbow Babies & Childrens Hospital, Cleveland, Ohio The importance of surveillance and screening for developmental problems in primary care has been well recognized in scholarly reviews and practice guidelines. (1) The need for early detection of developmental problems in infants and young children in primary pediatric care settings stems from the high prevalence of such problems and the potential for early intervention for the child and family. Frequent longitudinal contact with young children and their families at critical times in their early development provides pediatricians and other practitioners with important opportunities to conduct developmental surveillance and screening to detect clinically significant developmental problems and institute early intervention. (1)(2)(3)(4) Early identification and referral to early intervention programs can ameliorate the negative consequences of developmental problems on children, families, and society. (3) However, studies have indicated consistently that many infants and young children who have clinically significant developmental delays are not detected in pediatric primary care. (1)(3)(4) As a consequence, critical opportunities for early intervention for young children who are at risk for developmental problems may be lost. (2)(5)(6)(7) To address this need, the American Academy of Pediatrics (AAP) developed a policy statement for identifying infants and young children who have developmental delays and disorders. (8) This statement is a significant advance in the clinical application of developmental screening in several respects. One is the recommendation to address parental concerns about development as one of several health topics in routine pediatric preventive care visits throughout the first 5 years after birth. Developmental surveillance, defined as a flexible, longitudinal, continuous, and cumulative process, is recommended for inclusion at every pediatric visit. The five components of developmental surveillance described in the AAP statement include: 1) eliciting and attending to the parents concerns about his …

Applying Surveillance and Screening to Family Psychosocial Issues: Implications for the Medical Home

OBJECTIVE. This studys aim was to elicit the perspectives of minority parents on their expectations of pediatric health care providers as a source of advice on “raising their child” and whether they would seek advice from these providers. A secondary aim was to demonstrate the value of qualitative methods for assessing parental attitudes in pediatric research. METHODS. Mothers with children between 3 and 12 years of age who identified themselves as African American, Jamaican, Haitian, or Puerto Rican were recruited from community sites. Audiotaped focus groups were conducted by trained moderators using an interview guide, to obtain the perspectives of the participants regarding the role of pediatric providers in the provision of parenting advice. RESULTS. Ninety-one mothers participated in a total of 20 focus groups, with 4 to 6 discussions per ethnocultural group. The focus groups revealed that, in general, parents do not look to child health care providers for advice on raising their children. The identified themes emphasized the importance of the relationship between providers and families. A few parents had the type of relationship within which the pediatrician already functioned as a provider of parenting advice. Physicians were considered skilled in the maintenance of physical health. The parents expressed a desire to receive more anticipatory guidance on developmental and behavioral stages and milestones. Pediatricians also served specific administrative functions valued by parents. CONCLUSIONS. Minority parents of preschool-aged and school-aged children do not view the primary care providers role as including the provision of parenting advice. Expectations must be modified to enable health care professionals to function effectively in the role of advisor regarding parenting issues.

Families matter: Even for kids in child care

Within the medical home, understanding the family and community context in which children live is critical to optimally promoting childrens health and development. How to best identify psychosocial issues likely to have an impact on childrens development is uncertain. Professional guidelines encourage pediatricians to incorporate family psychosocial screening within the context of primary care, yet few providers routinely screen for these issues. The authors propose applying the core principles of surveillance and screening, as applied to childrens development and behavior, to also address family psychosocial issues during health supervision services. Integrating psychosocial surveillance and screening into the medical home requires changes in professional training, provider practice, and public policy. The potential of family psychosocial surveillance and screening to promote childrens optimal development justifies such changes.

ChildServ: Lessons Learned From the Design and Implementation of a Community-based Developmental Surveillance Program

Editor’s Note. A commentary by Jay Belsky on the impact of the amount of child care on children’s socioemotional development appeared in the June 2002 issue of the Journal. Belsky, a member of the National Institute of Child Health and Human Development (NICHD) Early Child Care Research Network, based his argument that a lot of time in child care has worrisome negative effects on children’s socioemotional development partly on his interpretation of findings from the NICHD Study of Early Child Care and Youth Development. We promised more discussion on the impact of child care on children’s development. We are pleased to now publish this Commentary from the NICHD Early Child Care Research Network. The authors emphasize the important influence of families on children with extensive child care experience. We are hopeful that these commentaries will continue to advance discourse on this important topic. We welcome further thoughts from our readers.

2003 C. Anderson Aldrich Award Lecture: Enhancing Developmental Services in Child Health Supervision—An Idea Whose Time Has Truly Arrived

ChildServ, a coordinated, region-wide system of early detection and intervention for at-risk children, was implemented in Hartford, Conn, in 1998. In this article, we report our experience with the design and implementation of the program and describe lessons learned and implications for subsequent program expansion. From 1998 to 2001, 124 child health providers referred 358 children with 516 different needs. One third of referred children had multiple needs. Developmental assessment, speech and language services, parenting classes, and counseling were frequently recommended. Only 43% of referred children ultimately received services, despite an average of 6.9 contacts with the family following initial referral. Boys, Hispanic children, and children with private insurance were more likely to receive services. We believe that ChildServ helps to address a critical gap in service delivery to children at risk for poor developmental and behavioral outcomes. A system of triage, referral, and care coordination appears to facilitate access to program and services. However, additional strategies are necessary to more successfully reach and engage families. In our experience, outreach capacity and such financial barriers as lack of private insurance should be included in the design and implementation of early detection and intervention programs.

A Simple Provider-Based Educational Intervention to Boost Infant Immunization Rates: A Controlled Trial

In 1938, in his famous Babies Are Human Beings , C. Anderson Aldrich was cautious in describing the feasibility of enhancing childrens developmental potential: “Every human being, as he grows into childhood, must inevitably be hampered and opposed by the restrictions of his environment, and the best we can hope for is to modify somewhat the urgency of this conflict. The degree to which we are considerate of our babys early needs, however, may be the measure of his later ability to feel secure in a world of change and to adapt himself to the necessities of circumstance.”1(p xi) Aldrichs contributions occurred at a crucial transitional period for child health. In the early 20th century, child health services were almost exclusively focused on the treatment of the sick child, with the modest exception of cursory examinations to detect signs of contagion, milk stations for feeding and weighing, and urban child health conferences for examining and later immunizing children. Subsequent control of infection through improved sanitation, public health measures, the introduction of antibiotic agents, and effective immunization profoundly influenced the scope of child health care, with the founding of the American Academy of Pediatrics in 1930 heralding a shift of emphasis to include health promotion and disease prevention.2 In 1944, Aldrich helped to pioneer this shift through the founding of the Rochester (Minnesota) Child Health Institute, devoted to research on the development of normal infants and children and to a program of delivering child health care to an entire community. Contemporary efforts to enhance the effectiveness of developmental services similarly occur within the context of a profound transition in childrens health services. In the mid-1970s, the recognition of developmental, behavioral, and psychosocial problems as the “new morbidity” of pediatric practice by Haggerty et al3 reinforced an emphasis … Reprint requests to (P.H.D.) Connecticut Childrens Medical Center, 282 Washington St, Hartford, CT 06106. E-mail: pdworki{at}ccmckids.org