Sandra H. Jee

Indices for Continuity of Care: A Systematic Review of the Literature

This article systematically reviews published literature on different continuity of care (COC) indices that assess the physician-patient relationship and the applicability of such indices to pediatric and chronic-disease patient populations. Frequency and visit type may vary for pediatric and chronically ill patients versus healthy adult patients. Two investigators independently examined 5,070 candidate articles and identified 246 articles related to COC. Forty-four articles were identified that include 32 different indices used to measure COC. Indices were classified into those that calculated COC primarily based on duration of provider relationship (n = 2), density of visits (n = 17), dispersion of providers (n = 8), sequence of providers (n = 1), or subjective estimates (n = 4). The diversity of COC indices reflect differences in how this measure is conceptualized. No index takes into account the visit type. A unique index that reflects continuity in the physicianpatient relationship for pediatric and chronic disease populations is needed.

Identification of social‐emotional problems among young children in foster care

BACKGROUND Little is known about how best to implement behavioral screening recommendations in practice, especially for children in foster care, who are at risk for having social-emotional problems. Two validated screening tools are recommended for use with young children: the Ages and Stages Questionnaire: Social Emotional (ASQ-SE) identifies emotional problems, and the Ages and Stages Questionnaire (ASQ) identifies general developmental delays in five domains, including personal-social problems. The current study examined: (1) whether systematic use of a social-emotional screening tool improves the detection rate of social-emotional problems, compared to reliance on clinical judgment; (2) the relative effectiveness of two validated instruments to screen for social-emotional problems; and (3) the patterns of social-emotional problems among children in foster care. METHODS We used retrospective chart review of children in foster care ages 6 months to 5.5 years: 192 children before and 159 after screening implementation, to measure detection rates for social-emotional problems among children. The ASQ-SE and the ASQ were used in multivariable logistic regression analyses to examine associations between children with social-emotional problems. RESULTS Use of the screening tool identified 24% of the children as having a social-emotional problem, while provider surveillance detected 4%. We identified significantly more children with social-emotional problems using the ASQ-SE than using the ASQ, and agreement between the instruments ranged from 56% to 75%, when data were stratified by age group. Multivariable modeling showed that preschool children were more likely to have a social-emotional problem than toddlers and infants (aOR = 3.4, 95% CI = 1.1-10.8). CONCLUSIONS Systematic screening using the ASQ-SE increased the detection rate for social-emotional problems among young children in foster care, compared to provider surveillance and the ASQ. A specific social-emotional screening tool appears to detect children with psychosocial concerns who would not be detected with a broader developmental screening tool.

Improved Detection of Developmental Delays Among Young Children in Foster Care

OBJECTIVE: Our goal was to determine if systematic use of a validated developmental screening instrument is feasible and improves the detection of developmental delay (DD) in a pediatric medical home for children in foster care. DESIGN AND METHODS: This study had a pre-post study design, following a practice intervention to screen all children in foster care for DD by using the Ages and Stages Questionnaire (ASQ). The baseline detection rate was determined by medical chart review for all children aged 4 to 61 months who were new to foster care (NFC) during a 2-year period. After implementation of systematic screening, caregivers of young children who were NFC or already in foster care (IFC) completed the ASQ at preventive health care visits. We assessed the feasibility of systematic screening (the percentage of ASQs completed among the NFC and IFC groups). We compared the detection of DD among the baseline NFC group and the screening-NFC group by using bivariate and multivariable logistic regression. RESULTS: Of 261 visits that occurred after initiation of screening, 251 (96%) visits had a completed ASQ form in the medical chart, demonstrating high feasibility. Among children who were NFC, the detection of DD was higher in the screening than baseline period for the entire population (58% vs 29%; P < .001), for each age group (infants: 37% vs 14%; toddlers: 89% vs 42%; preschool: 82% vs 44%; all P ≤ .01), and for all developmental domains. On adjusted analyses, the detection of potential DD in toddler and preschool children was higher among the NFC screening group than the NFC baseline group. CONCLUSION: Systematic screening for DD using the ASQ was feasible and seemed to double the detection of DDs.

Risk of recurrent seizures after a primary human herpesvirus 6-induced febrile seizure.

OBJECTIVE To test the hypothesis that children experiencing first febrile seizures caused by human herpesvirus 6 (HHV-6) have an increased risk for recurrent seizures when compared with children experiencing first febrile seizures attributed to other illnesses. DESIGN AND PARTICIPANTS Descriptive prospective study of 36 HHV-6 culture-positive children and a matched subgroup of 86 HHV-6 culture-negative children, all of whom had their first febrile seizures evaluated in a tertiary care emergency department and were followed for at least 12 months, with an average follow-up of 35.7 months. PRIMARY OUTCOME MEASURE The recurrence of seizures among HHV-6 culture-positive and HHV-6 culture-negative children with no known previous neurologic deficits. RESULTS A decreased incidence of recurrent seizures occurred in children whose first febrile seizures were caused by HHV-6. Twenty percent of HHV-6 culture-positive children and 40% of HHV-6 culture-negative children (P < 0.038) experienced a recurrent seizure within 1 year of their first febrile seizure. The mean time to recurrence within 12 months was 8.6 months for children with HHV-6 infection and 3.8 months (P < 0.001) for children without HHV-6 infection. Most recurrent seizures occurred within 12 months of a first febrile seizure for both HHV-6-positive and HHV-6-negative children (88 and 91%). CONCLUSIONS Children who had their first febrile seizures caused by primary HHV-6 infection did not demonstrate an increased risk for recurrent seizures when compared with children whose first febrile seizures were from other etiologies.

Validating office-based screening for psychosocial strengths and difficulties among youths in foster care.

OBJECTIVES: To assess the effectiveness of social-emotional screening in the primary care setting for youths in foster care. METHODS: The setting was a primary care practice for all youth in home-based foster care in 1 county. Subjects were youths, aged 11 to 17 years, and their foster parents; both completed a Strengths and Difficulties Questionnaire at well-child visits. The Strengths and Difficulties Questionnaire is a previously validated 25-item tool that has 5 domains: emotional symptoms; conduct problems; hyperactivity/inattention; peer problems; and prosocial behaviors and an overall total difficulties score. We first compared youth versus parent Strengths and Difficulties Questionnaire scores and then assessed the accuracy of these Strengths and Difficulties Questionnaire scores by comparing them in a subsample of youths (n = 50) with results of home-based structured clinical interviews using the Childrens Interview for Psychiatric Syndromes. RESULTS: Of 138 subjects with both youth and parent reports, 78% had prosocial behaviors (strengths), and 70% had 1 or more social-emotional problems. Parents reported significantly more conduct problems (38% vs 16%; P < .0001) and total difficulties (30% vs 16%; P = .002) than did youth. The Strengths and Difficulties Questionnaire had better agreement with the Childrens Interview for Psychiatric Syndromes (n = 50) for any Strengths and Difficulties Questionnaire–identified problem for combined youth and foster-parent reports (93%), compared with youth report alone (54%) or parent report alone (71%). CONCLUSIONS: Although most youths in foster care have social-emotional problems, most have strengths as well. Youth and foster-parent perspectives on these problems differ. Systematic social-emotional screening in primary care that includes both youth and parent reports can identify youths who may benefit from services.

Use of a Brief Standardized Screening Instrument in a Primary Care Setting to Enhance Detection of Social-Emotional Problems Among Youth in Foster Care

OBJECTIVE To determine whether systematic use of a validated social-emotional screening instrument in a primary care setting is feasible and improves detection of social-emotional problems among youth in foster care. METHODS Before-and-after study design, following a practice intervention to screen all youth in foster care for psychosocial problems using the Strengths and Difficulties Questionnaire (SDQ), a validated instrument with 5 subdomains. After implementation of systematic screening, youth aged 11 to 17 years and their foster parents completed the SDQ at routine health maintenance visits. We assessed feasibility of screening by measuring the completion rates of SDQ by youth and foster parents. We compared the detection of psychosocial problems during a 2-year period before systematic screening to the detection after implementation of systematic screening with the SDQ. We used chart reviews to assess detection at baseline and after implementing systematic screening. RESULTS Altogether, 92% of 212 youth with routine visits that occurred after initiation of screening had a completed SDQ in the medical record, demonstrating high feasibility of systematic screening. Detection of a potential mental health problem was higher in the screening period than baseline period for the entire population (54% vs 27%, P < .001). More than one-fourth of youth had 2 or more significant social-emotional problem domains on the SDQ. CONCLUSIONS Systematic screening for potential social-emotional problems among youth in foster care was feasible within a primary care setting and doubled the detection rate of potential psychosocial problems.

Learning Difficulties Among Children Separated From a Parent

OBJECTIVE To study the relationship between experiencing separation from parents and having learning difficulties among children in a community-based sample. METHODS In 2003, parents of children entering kindergarten in the city of Rochester completed a survey assessing the childs social background, medical history, and behavioral profile. Children separated from parents for >1 month were compared with those who had never been away for >1 month on 4 validated developmental measures (range, 1-4): a learning scale, an expressive language scale, a preliteracy scale, and a speech scale. Bivariate analyses and multivariate logistic regression analyses were used to determine associations between separation from parents and learning difficulties. RESULTS Among the 1619 children, 18% had been separated from a parent for >1 month at least once (11% once, 7% > or =2 times). Separated children scored worse compared with those without separations on learning (3.14 vs 3.28, P = .001) and preliteracy (2.21 vs 2.35, P = .03). Higher rates of learning difficulties (26.7% vs 16.7%, P < .001) and preliteracy problems (25.9% vs 18.7%, P = .01) were noted among those who had been separated versus those who had not. In multivariable modeling, separation was associated with learning problems (adjusted odds ratio, 1.71; 95% confidence interval, 1.18-2.49) and preliteracy problems (adjusted odds ratio, 1.46; 95% confidence interval, 1.04-2.05) when adjusted for demographic, medical, and social factors. CONCLUSIONS Urban children who have experienced separation from a parent may have more learning difficulties at entrance to kindergarten. Screening and intervention practices to remedy these challenges may better equip such young children to succeed when they enter school.

Foster care issues in general pediatrics.

Purpose of review This study highlights recent publications on foster care, focusing on concerns for the general pediatrician, including risk factors for foster care placement, outcomes of foster care, healthcare and screening standards, and developmental and mental health problems. Recent findings Many children and youth in foster care have been exposed to complex trauma prior to foster care placement. As clinicians gain a greater understanding of the life experiences of children in foster care, more preventive and supportive efforts can be implemented in the clinical setting, specifically around health and mental health issues. Enhanced awareness of the issues would enable healthcare professionals to advocate effectively for the needs of children in the child welfare system. To address the complex health and socio-emotional needs of children in foster care, several healthcare models and innovative programs for the care of children in foster care have been developed. This literature review for the past year suggests a lack in program evaluation of these efforts. Summary Pediatricians have the opportunity to address physical and mental health issues for children in foster care, and can provide anticipatory guidance to foster and biological parents who bring their children for evaluation.

Mental Health Treatment Experiences and Expectations in Foster Care: A Qualitative Investigation

This study explores perspectives on mental health treatment experiences and expectations for youth in foster care and their foster parents. In-depth interviews were conducted and identified for major themes: (1) the dual stigma of foster care and mental health care; (2) the lack of engagement in mental health therapy; (3) trust issues with the therapist and other individuals; and (4) the desire to integrate mental health services with primary care services. These results have implications for mental health service delivery and suggest opportunities to improve mental health treatment through an integrated care approach.

A pilot randomized trial teaching mindfulness-based stress reduction to traumatized youth in foster care

This article presents a pilot project implementing a mindfulness-based stress reduction program among traumatized youth in foster and kinship care over 10 weeks. Forty-two youth participated in this randomized controlled trial that used a mixed-methods (quantitative, qualitative, and physiologic) evaluation. Youth self-report measuring mental health problems, mindfulness, and stress were lower than anticipated, and the relatively short time-frame to teach these skills to traumatized youth may not have been sufficient to capture significant changes in stress as measured by electrocardiograms. Main themes from qualitative data included expressed competence in managing ongoing stress, enhanced self-awareness, and new strategies to manage stress. We share our experiences and recommendations for future research and practice, including focusing efforts on younger youth, and using community-based participatory research principles to promote engagement and co-learning. CLINICALTRIALS.GOV: Protocol Registration System ID NCT01708291.