Tumaini R. Coker

The Health and Health Care of Lesbian, Gay, and Bisexual Adolescents

Adolescents face a variety of challenges in their transition to adulthood; lesbian, gay, and bisexual adolescents face these typical challenges as well as additional challenges that are related to the social stigma of their sexual orientation. For some lesbian, gay, and bisexual adolescents, this stigma may induce psychosocial stress, leading to increased health risk behaviors and poorer health outcomes. In this article, we review data on the health and health care of LGB adolescents. We examine health indicators and health risks for LGB youth, including substance use, eating disorders, suicidality, risky sexual behaviors, violence exposure and victimization, and homelessness. We also examine health care provision and utilization for LGB youth. Lastly, we discuss ways in which researchers and clinicians can improve LGB adolescent health and health care.

Diagnosis, Microbial Epidemiology, and Antibiotic Treatment of Acute Otitis Media in Children: A Systematic Review

CONTEXT Acute otitis media (AOM) is the most common condition for which antibiotics are prescribed for US children; however, wide variation exists in diagnosis and treatment. OBJECTIVES To perform a systematic review on AOM diagnosis, treatment, and the association of heptavalent pneumococcal conjugate vaccine (PCV7) use with AOM microbiology. DATA SOURCES PubMed, Cochrane Databases, and Web of Science, searched to identify articles published from January 1999 through July 2010. STUDY SELECTION Diagnostic studies with a criterion standard, observational studies and randomized controlled trials comparing AOM microbiology with and without PCV7, and randomized controlled trials assessing antibiotic treatment. DATA EXTRACTION Independent article review and study quality assessment by 2 investigators with consensus resolution of discrepancies. RESULTS Of 8945 citations screened, 135 were included. Meta-analysis was performed for comparisons with 3 or more trials. Few studies examined diagnosis; otoscopic findings of tympanic membrane bulging (positive likelihood ratio, 51 [95% confidence interval {CI}, 36-73]) and redness (positive likelihood ratio, 8.4 [95% CI, 7-11]) were associated with accurate diagnosis. In the few available studies, prevalence of Streptococcus pneumoniae decreased (eg, 33%-48% vs 23%-31% of AOM isolates), while that of Haemophilus influenzae increased (41%-43% vs 56%-57%) pre- vs post-PCV7. Short-term clinical success was higher for immediate use of ampicillin or amoxicillin vs placebo (73% vs 60%; pooled rate difference, 12% [95% CI, 5%-18%]; number needed to treat, 9 [95% CI, 6-20]), while increasing the rate of rash or diarrhea by 3% to 5%. Two of 4 studies showed greater clinical success for immediate vs delayed antibiotics (95% vs 80%; rate difference, 15% [95% CI, 6%-24%] and 86% vs 70%; rate difference, 16% [95% CI, 6%-26%]). Data are absent on long-term effects on antimicrobial resistance. Meta-analyses in general showed no significant differences in antibiotic comparative effectiveness. CONCLUSIONS Otoscopic findings are critical to accurate AOM diagnosis. AOM microbiology has changed with use of PCV7. Antibiotics are modestly more effective than no treatment but cause adverse effects in 4% to 10% of children. Most antibiotics have comparable clinical success.

Perceived Racial/Ethnic Discrimination Among Fifth-Grade Students and Its Association With Mental Health

OBJECTIVES We sought to describe the prevalence, characteristics, and mental health problems of children who experience perceived racial/ethnic discrimination. METHODS We analyzed cross-sectional data from a study of 5147 fifth-grade students and their parents from public schools in 3 US metropolitan areas. We used multivariate logistic regression (overall and stratified by race/ethnicity) to examine the associations of sociodemographic factors and mental health problems with perceived racial/ethnic discrimination. RESULTS Fifteen percent of children reported perceived racial/ethnic discrimination, with 80% reporting that discrimination occurred at school. A greater percentage of Black (20%), Hispanic (15%), and other (16%) children reported perceived racial/ethnic discrimination compared with White (7%) children. Children who reported perceived racial/ethnic discrimination were more likely to have symptoms of each of the 4 mental health conditions included in the analysis: depression, attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder. An association between perceived racial/ethnic discrimination and depressive symptoms was found for Black, Hispanic, and other children but not for White children. CONCLUSIONS Perceived racial/ethnic discrimination is not an uncommon experience among fifth-grade students and may be associated with a variety of mental health disorders.

Family-Centered Care for US Children With Special Health Care Needs: Who Gets It and Why?

OBJECTIVE: The goal was to examine racial/ethnic and language disparities in family-centered care (FCC) and in FCC components for children with special health care needs (CSHCN). METHODS: Bivariate and multivariate logistic regression analyses of data from the 2005–2006 National Survey of CSHCN were performed. RESULTS: A total of 66% of CSHCN with a health visit in the past year received FCC. In adjusted analyses, we found lower odds of FCC for Latino (odds ratio: 0.53 [95% confidence interval: 0.45–0.63]), African-American (odds ratio: 0.60 [95% confidence interval: 0.52–0.69]), and other (odds ratio: 0.58 [95% confidence interval: 0.43–0.78]) children, compared with white children, and for children in households with a non-English primary language (odds ratio: 0.48 [95% confidence interval: 0.36–0.64]), compared with those in households with English as the primary language. These disparities persisted after adjustment for child health (condition severity and emotional, behavioral, and developmental needs), socioeconomic (poverty level, parental education, household composition, and residing in a metropolitan statistical area), and access (insurance type, usual source of care, and having a personal physician) factors. Of these factors, only condition severity was significantly associated with the racial/ethnic disparities; none was significantly associated with the language disparities. Disparities were found for Latino and African-American children and children in households with a non-English primary language for the FCC components of time spent with the provider and sensitivity to the familys values and customs. CONCLUSIONS: Robust FCC racial/ethnic and language disparities exist for CSHCN; initial efforts to address these disparities should focus on increasing provider time and cultural sensitivity.

Common and Costly Hospitalizations for Pediatric Mental Health Disorders

BACKGROUND AND OBJECTIVES: Inpatient pediatric mental health is a priority topic for national quality measurement and improvement, but nationally representative data on the patients admitted or their diagnoses are lacking. Our objectives were: to describe pediatric mental health hospitalizations at general medical facilities admitting children nationally; to assess which pediatric mental health diagnoses are frequent and costly at these hospitals; and to examine whether the most frequent diagnoses are similar to those at free-standing children’s hospitals. METHODS: We examined all discharges in 2009 for patients aged 3 to 20 years in the nationally representative Kids’ Inpatient Database (KID) and in the Pediatric Health Information System (free-standing children’s hospitals). Main outcomes were frequency of International Classification of Diseases, Ninth Revision, Clinical Modification–defined mental health diagnostic groupings (primary and nonprimary diagnosis) and, using KID, resource utilization (defined by diagnostic grouping aggregate annual charges). RESULTS: Nearly 10% of pediatric hospitalizations nationally were for a primary mental health diagnosis, compared with 3% of hospitalizations at free-standing children’s hospitals. Predictors of hospitalizations for a primary mental health problem were older age, male gender, white race, and insurance type. Nationally, the most frequent and costly primary mental health diagnoses were depression (44.1% of all mental health admissions;

Low-Income Parents' Views on the Redesign of Well-Child Care

1.33 billion), bipolar disorder (18.1%;

Prevalence, Characteristics, and Associated Health and Health Care of Family Homelessness Among Fifth-Grade Students

702 million), and psychosis (12.1%;

A Parent Coach Model for Well-Child Care Among Low-Income Children: A Randomized Controlled Trial

540 million). CONCLUSIONS: We identified the child mental health inpatient diagnoses with the highest frequency and highest costs as depression, bipolar disorder, and psychosis, with substance abuse an important comorbid diagnosis. These diagnoses can be used as priority conditions for pediatric mental health inpatient quality measurement.

Redesigning Health Care Practices to Address Childhood Poverty

OBJECTIVE: To examine the perspectives of low-income parents on redesigning well-child care (WCC) for children aged 0 to 3 years, focusing on possible changes in 3 major domains: providers, locations, and formats. METHODS: Eight focus groups (4 English and 4 Spanish) were conducted with 56 parents of children aged 6 months to 5 years, recruited through a federally qualified health center. Discussions were recorded, transcribed, and analyzed by using the constant comparative method of qualitative analysis. RESULTS: Parents were mostly mothers (91%), nonwhite (64% Latino, 16% black), and <30 years of age (66%) and had an annual household income of <

Well-Child Care Clinical Practice Redesign for Young Children: A Systematic Review of Strategies and Tools

35000 (96%). Parents reported substantial problems with WCC, focusing largely on limited provider access (especially with respect to scheduling and transportation) and inadequate behavioral/developmental services. Most parents endorsed nonphysician providers and alternative locations and formats as desirable adjuncts to usual physician-provided, clinic-based WCC. Nonphysician providers were viewed as potentially more expert in behavioral/developmental issues than physicians and more attentive to parent-provider relationships. Some alternative locations for care (especially home and day care visits) were viewed as creating essential context for providers and dramatically improving family convenience. Alternative locations whose sole advantage was convenience (eg, retail-based clinics), however, were viewed more skeptically. Among alternative formats, group visits in particular were seen as empowering, turning parents into informal providers through mutual sharing of behavioral/developmental advice and experiences. CONCLUSIONS: Low-income parents of young children identified major inadequacies in their WCC experiences. To address these problems, they endorsed a number of innovative reforms that merit additional investigation for feasibility and effectiveness.