Sara L. Toomey

Self-control as a Protective Factor Against Overweight Status in the Transition From Childhood to Adolescence

OBJECTIVE To determine whether more self-controlled children are protected from weight gain as they enter adolescence. DESIGN Prospective, longitudinal study. SETTING Ten sites across the United States from 1991 to 2007. PARTICIPANTS The 844 children in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development birth cohort who had height and weight information at 15 years of age in 2006. MAIN EXPOSURE A composite measure of self-control was created from mother, father, and teacher-reported ratings using items from the Social Skills Rating System. OUTCOME MEASURE Overweight status at 15 years of age. RESULTS Approximately one-third of the sample (n = 262) was overweight at 15 years of age. Compared with their nonoverweight peers, overweight adolescents aged 15 years were about a half standard deviation (SD) lower in self-control at 9 years of age (unstandardized difference, 0.15; pooled SD, 0.29; P < .001). Children rated higher by their parents and teachers in self-control at 9 years of age were less likely to be overweight at 15 years (relative risk, 0.74; 95% confidence interval, 0.56-0.98), controlling for overweight status at 10 years of age, pubertal development, age, intelligence quotient, sex, ethnicity, socioeconomic status, and maternal overweight status. CONCLUSION More self-controlled boys and girls are less likely to become overweight as they enter adolescence. The ability to control impulses and delay gratification enables children to maintain a healthy weight, even in todays obesogenic environment.

Disparities in Unmet Need for Care Coordination: The National Survey of Children’s Health

OBJECTIVE: To determine (1) the proportion of parents who report a need for and receipt of effective care coordination for their child, (2) whether unmet care coordination needs differ by children with special health care needs (CSHCN) status and sociodemographic characteristics, and (3) whether having a personal provider or family-centered care mitigates disparities. METHODS: This study was a cross-sectional analysis of the 2007 National Survey for Children’s Health, a nationally representative survey of 91 642 parents. Outcome measures were parent report of need for and lack of effective care coordination. We also examined the effect of parent report of having a personal provider and family-centered care. We conducted weighted bivariate and multivariate analyses. RESULTS: Forty-one percent of parents reported that their child needed care coordination. Among those who needed care coordination, 31% did not receive effective coordination. CSHCN (41%) were more likely than children without special health care needs (26%; P < .001) to have unmet care coordination needs. Latino (40%) and black (37%) children were more likely to have unmet needs than white (27%; P < .001) children. These patterns remained in multivariate analysis. Having a personal provider decreased the odds of having unmet need for care coordination but did not attenuate disparities. Receiving family-centered care mitigated disparities associated with race/ethnicity but not with health status or health insurance. CONCLUSIONS: A considerable proportion of parents reported their child needed more care coordination than they received. This was especially true for parents of CSHCN and parents of black and Latino children. Interventions that enhance family-centered care might particularly contribute to reducing racial/ethnic disparities.

Why Do Children With ADHD Discontinue Their Medication

Objective. To examine factors associated with parent-reported discontinuation of attention-deficit/hyperactivity disorder (ADHD) medication. Methods. The authors conducted a telephone survey of parents of children 6 to 18 years old who had recently initiated ADHD medication according to insurance claims. Results. A total of 127 parents of children with ADHD who had recently initiated ADHD medication completed the survey (43% response rate); 21% discontinued the ADHD medication. Parents of discontinuers were less likely to report having discussed the risks and benefits of ADHD medication with primary care providers (59% vs 82%, P = .03) and were more likely to report psychological side effects (58% vs 21%, P > .001). Multivariate analyses demonstrated that both psychological side effects and perceived inadequate medication effectiveness were associated with discontinuation. Conclusions. Many children discontinue ADHD medication within the first year, often because of psychological side effects or perceived inadequate medication effectiveness. Improved methods for psychological side effect management, setting realistic medication goals, and assessing therapeutic success are needed.

The Development of a Pediatric Inpatient Experience of Care Measure: Child HCAHPS®

The Centers for Medicare and Medicaid Services (CMS) uses Adult Hospital Consumer Assessment of Healthcare Providers and Systems (Adult HCAHPS®) scores for public reporting and pay-for-performance for most US hospitals, but no publicly available standardized survey of inpatient experience of care exists for pediatrics. To fill the gap, CMS and the Agency for Healthcare Research and Quality commissioned the development of a pediatric version (Child HCAHPS), a survey of parents/guardians of pediatric patients (<18 years old) who were recently hospitalized. This article describes the development of Child HCAHPS, which included an extensive review of the literature and quality measures, expert interviews, focus groups, cognitive testing, pilot testing of the draft survey, a national field test with 69 hospitals in 34 states, psychometric analysis, and end-user testing of the final survey. We conducted extensive validity and reliability testing to determine which items would be included in the final survey instrument and develop composite measures. We analyzed national field test data of 17 727 surveys collected in November 2012 to January 2014 from parents of recently hospitalized children. The final Child HCAHPS instrument has 62 items, including 39 patient experience items, 10 screeners, 12 demographic/descriptive items, and 1 open-ended item. The 39 experience items are categorized based on testing into 18 composite and single-item measures. Our composite and single-item measures demonstrated good to excellent hospital-level reliability at 300 responses per hospital. Child HCAHPS was developed to be a publicly available standardized survey of pediatric inpatient experience of care. It can be used to benchmark pediatric inpatient experience across hospitals and assist in efforts to improve the quality of inpatient care.

Comparing Medical Homes for Children with ADHD and Asthma

OBJECTIVE The aims of our study were, among children with attention-deficit/hyperactivity disorder (ADHD) compared with children with asthma: 1) to assess characteristics associated with parent report of having a medical home for children with either of these 2 conditions; 2) to determine whether, controlling for these characteristics, the likelihood of having a medical home differs between children with ADHD and asthma; and 3) to identify the specific components of a medical home that are lacking for children with these 2 conditions. METHODS Cross-sectional analysis of the National Survey of Children with Special Health Care Needs, 2005-2006 (NS-CSHCN) was used. The outcome variable was parent report of their childs practice having specific attributes of the medical home. We used multivariate logistic regression to test whether the likelihood of having a medical home and its components differed for children with ADHD in comparison to children with asthma. RESULTS The NS-CSHCN interviewed parents of 11 674 children with ADHD and 13 517 children with asthma aged between 4 to 17 years. Significantly fewer children with ADHD compared with children with asthma have a medical home (OR [odds ratio] 0.68; P < .001). Specifically, parents reported differences in receiving family-centered (OR 0.79; P < .001) and coordinated care (OR 0.59; P < .001). CONCLUSION Parents of children with ADHD report worse performance across key dimensions of primary care compared with parents of children with asthma. For primary care to be optimally effective in addressing the needs of children with ADHD, efforts to significantly strengthen these key dimensions are needed.

Measuring Pediatric Hospital Readmission Rates to Drive Quality Improvement

The Pediatric Quality Measures Program is developing readmission measures for pediatric use. We sought to describe the importance of readmissions in children and the challenges of developing readmission quality measures. We consider findings and perspectives from research studies and commentaries in the pediatric and adult literature, characterizing arguments for and against using readmission rates as measures of pediatric quality and discussing available evidence and current knowledge gaps. The major topic of debate regarding readmission rates as pediatric quality measures is the relative influence of hospital quality versus other factors within and outside of health systems on readmission risk. The complex causation of readmissions leads to disagreement, particularly when rates are publicly reported or tied to payment, about whether readmissions can be prevented and how to achieve fair comparisons of readmission performance. Despite these controversies, the policy focus on readmissions has motivated widespread efforts by hospitals and outpatient providers to evaluate and reengineer care processes. Many adult studies demonstrate a link between successful initiatives to improve quality and reductions in readmissions. More research is needed on methods to enhance adjustment of readmission rates and on how to prevent pediatric readmissions.

The Patient-Centered Medical Home, Practice Patterns, and Functional Outcomes for Children with Attention Deficit/Hyperactivity Disorder

OBJECTIVE To determine whether children with attention deficit/hyperactivity disorder (ADHD) receive care in a patient-centered medical home (PCMH) and how that relates to their ADHD treatment and functional outcomes. METHODS Cross-sectional analysis of the 2007 National Survey for Childrens Health, a nationally representative survey of 91,642 parents. This analysis covers 5169 children with parent-reported ADHD ages 6-17. The independent variable is receiving care in a PCMH. Main outcome measures are receiving ADHD medication, mental health specialist involvement, and functional outcomes (difficulties with participation in activities, attending school, making friends; having problem behaviors; missed school days; and number of times parents contacted by school). RESULTS Only 44% of children with ADHD received care in a PCMH. Children with ADHD receiving care in a PCMH compared with those who did not were more likely to receive medication for ADHD (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1-1.9); less likely to have mental health specialist involvement (OR, 0.6; 95% CI, 0.4-0.7); less likely to have difficulties participating in activities (OR, 0.6; 95% CI 0.4-0.8), making friends (OR, 0.6; 95% CI, 0.5-0.9), and attending school (OR, 0.4; 95% CI, 0.3-06); less likely to have problem behaviors (OR 0.6; 95% CI 0.5-0.9); had fewer missed school days (β = -1.5, 95% CI -2.4 to -0.5); and parents were contacted by school less frequently (β = -0.2, 95% CI -0.3 to -0.1). CONCLUSIONS For children with ADHD, receiving care in a PCMH is associated with practice pattern change and better outcomes. The PCMH may represent a promising opportunity to improve quality of care and outcomes for children with ADHD.

Association of Externalizing Behavior Disorder Symptoms and Injury Among Fifth Graders

OBJECTIVE Injury is the leading cause of death among American youth, killing more 11-year-olds than all other causes combined. Children with symptoms of externalizing behavior disorders such as attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) may have increased risk. Our aims were to determine: (1) whether increasing symptoms of ADHD and CD associate positively with injuries among a community sample of fifth graders; and (2) whether symptoms of ADHD and CD have a multiplicative rather than additive association with injuries among the sample. METHODS Data were collected from 4745 fifth graders and their primary caregivers participating in Healthy Passages, a multisite, community-based study of pediatric health risk behaviors and health outcomes. The primary outcome was injury frequency. Primary independent variables were ADHD and CD symptoms. Additional covariates included gender, race/ethnicity, and household income. Ordinal logistic regression examined correlates of injury frequency. The interaction between ADHD and CD symptoms also was examined. RESULTS In bivariate analyses, the odds of injury increased as ADHD symptoms (odds ratio [OR] 1.29; 95% confidence interval [95% CI] 1.18-1.41) and CD symptoms (OR 1.18; 95% CI 1.07-1.31) increased. However, in multivariate analysis, only ADHD symptoms were significantly associated with injury (OR 1.22; 95% CI 1.10-1.35). There was no statistically significant interaction between ADHD and CD symptoms. CONCLUSIONS ADHD symptoms are associated with increased odds of injury in fifth graders. Findings have implications for potential injury prevention strategies for mental health practitioners (for example, cognitive training with at-risk youth), pediatricians (ADHD screening), and parents (improved supervision).

Does Connection to Primary Care Matter for Children With Attention-Deficit/Hyperactivity Disorder?

OBJECTIVE. Whether high-quality primary care in the form of a medical home effectively meets the health care needs of children with attention-deficit/hyperactivity disorder is unknown. The objectives of this study were to (1) describe the percentage who report unmet health care need, (2) evaluate whether having a medical home is associated with lower risk for having unmet needs, and (3) compare the impact of having a medical home on unmet need for children with attention-deficit/hyperactivity disorder with those with asthma. METHODS. Cross-sectional analysis was conducted of the National Survey of Childrens Health, 2003, a nationally representative sample. The primary outcome variable was parent-reported unmet health care need. Multivariate logistic regression tested the impact of having a medical home on unmet needs for children with attention-deficit/hyperactivity disorder and asthma. RESULTS. The National Survey of Childrens Health interviewed parents of 6030 children who had attention-deficit/hyperactivity disorder and 6133 children who had asthma and were between the ages of 6 and 17 years. A total of 16.8% of children with attention-deficit/hyperactivity disorder had at least 1 unmet need compared with 6.7% of children with asthma. Although the proportion of children with a medical home was comparable, children with attention-deficit/hyperactivity disorder were 3.5 times more likely to have an unmet need than were children with asthma. Children with asthma who have a medical home have less than half the likelihood of reporting an unmet need in comparison with those without a medical home; however, among children with attention-deficit/hyperactivity disorder, having a medical home was not associated with decreased likelihood of reporting an unmet need. CONCLUSIONS. Having a medical home is not associated with fewer unmet needs for children with attention-deficit/hyperactivity disorder. Our results suggest that high-quality primary care may not be as successful at meeting the needs of children with behavioral health conditions compared with those with physical conditions.

Is obesity associated with reduced health-related quality of life in Latino, black and white children in the community?

Objective:Few studies have examined the impact of obesity on health-related quality of life (HRQOL) in non-clinical community samples of children, and methodological limitations have hindered drawing firm conclusions, especially whether the impact is similar across racial/ethnic groups. The present aims were to examine at what levels of non-normal weight, school-aged children experience lower HRQOL and whether this differs among racial/ethnic groups, when controlling for socioeconomic status (SES) differences.Design:Cross-sectional community cohort survey.Subjects and methods:Data are from the Healthy Passages, reporting on 4824 Latino, black and white 5th graders in a population-based survey conducted in three United States metropolitan areas. Children’s weight status was classified from measured weight and height into underweight (1%), normal weight (52%), overweight (19%), obese (13%) and extremely obese (14%). Children reported their own HRQOL using the Pediatric Quality of Life Inventory and additional scales addressing global self-worth, physical appearance and body satisfaction. Parents reported children’s overall health status.Results:Each increment in higher non-healthy weight class—overweight to obese to extremely obese—was associated with significantly lower scores in more domains of psychosocial HRQOL compared with that in normal weight. However, only extremely obese children reported significantly lower physical HRQOL. Differences among weight classes remained when adjusting for SES and were independent of race/ethnicity. Underweight children generally reported HRQOL that was not significantly different from normal weight children.Conclusions:Overweight, obese and extremely obese 5th graders on average experience worse HRQOL than normal weight children, especially in psychosocial domains including self-worth and peer relationships, regardless of race/ethnicity. If messages can be conveyed in a sensitive and supportive manner, the desire to improve HRQOL could provide additional motivation for children and their parents in addressing unhealthy weight.