Does a one-day educational training session influence primary care pediatricians' mental health practice procedures in response to a community disaster? Results from the reaching children initiative (RCI).

Although many children and adolescents need assessment and treatment for psychological problems, few get such treatment from mental health specialists after a community disaster Research suggests that a very large proportion of children are seen in pediatric primary care settings and that pediatricians can provide appropriate care for many social and emotional problems in children. However few pediatricians have received training in providing this help. The focus of this study was to assess whether brief training to increase the capacity of primary care pediatricians (PCPs) to respond to the social or emotional problems of children after the World Trade Center terrorist attacks improved the quality of services to disaster-affected children. Pediatricians (N = 137) attended a one-day training workshop covering best practice treatments for mental health problems with an emphasis on trauma, bereavement, and medication use. We surveyed attendees prior to training, immediately post-intervention, and 1- and 6-months later. At 6-months post-intervention, 64% of the primary care clinicians reported instituting practice changes recommended during training. Reported use of formal mental health screening instruments increased, but greater use of medications was more limited. Although participants in the immediate post-intervention survey indicated strong agreement with the desirability to implement specific practice changes, the perceived desirability of such changes declined substantially at the 6-month follow-up. Changes in PCPs 'mental health related practice procedures can be facilitated by brief educational interventions, but continued training and support may be needed. We discuss these results relative to preparedness for community disasters.

Use of a psychosocial screen to detect children with symptoms of posttraumatic stress disorder: an exploratory study.

OBJECTIVE: The aim of this study was to evaluate the sensitivity and specificity of the parent and youth versions of the 17-item Pediatric Symptom Checklist (PSC-17) for identifying children with symptoms of posttraumatic stress disorder (PTSD). METHODS: Cross-sectional convenience samples of children aged 8 to 10 years treated at a primary care pediatrics practice in New York City were recruited. The PSC-17 and its 5-item internalizing subscale were used in both parent- and youth-completed formats. Posttraumatic stress disorder symptoms were identified with the University of California, Los Angeles posttraumatic stress reaction index (UCLA RI), used as a structured interview with the child. RESULTS: One hundred fifty-six children enrolled in the study. Twenty-two percent of children met the UCLA RI cutoff for likely PTSD. The youth version of the PSC-17 and its 5-item internalizing subscale identified these children with sensitivities of 78% and 75% and specificities of 77% and 77%, respectively, relative to the UCLA RI. The parent version of the PSC-17 and the internalizing subscale had poorer sensitivities of 44% and 25% and similar specificities of 79% and 92%, respectively. CONCLUSIONS: Symptoms of PTSD can be identified using the youth self-report version of the PSC-17. A 5-item subscale of the PSC-17 also performed well and can readily be used in primary care settings.

The prevalence and characteristics of childhood overweight in a multiethnic, school-based health setting.

OBJECTIVE: The prevalence and correlates of overweight and the risk of overweight in minority children attending urban school-based health centers remains poorly characterized. The purpose of our study was to examine the prevalence and characteristics of overweight and at risk for overweight in low socioeconomic status minority children enrolled in East Harlem school-based health centers in New York City. DESIGN: A retrospective cross-sectional study during the period of September 2002 to August 2003. SETTING: Four Pediatric School-based Health Centers in East Harlem. PARTICIPANTS: Children and adolescents, aged 5 to 18 years. MAIN OUTCOME MEASURES: We examined presence of overweight or the risk of overweight based on body mass index (BMI) percentile and other clinical characteristics. Bivariate and multivariate analyses were performed to assess the relationship between demographics and clinical characteristics with overweight and the risk of overweight. RESULTS: Of the 491 children enrolled, 45.8% were either overweight or at risk for overweight, with the highest risk observed in Hispanic/Latino children. This latter relation remained significant after adjusting for age, sex, and birthweight status. In addition, high screening office blood pressure was related to overweight status and higher BMI percentile. CONCLUSIONS: A large proportion of minorities, especially Hispanic/Latino children, attending school-based health centers in an urban community sample, are overweight or at risk for overweight. Elevated screening blood pressure was also a common co-morbidity. Further research should determine the predictors and correlates of overweight, and effective targeted school-based interventions should be tested in this high-risk population.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management.

OBJECTIVES: To update clinical practice guidelines to assist primary care (PC) clinicians in the management of adolescent depression. This part of the updated guidelines is used to address practice preparation, identification, assessment, and initial management of adolescent depression in PC settings. METHODS: By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) draft revision and iteration among the steering committee, which included experts, clinicians, and youth and families with lived experience. RESULTS: Guidelines were updated for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in PC, including the identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The practice preparation, identification, assessment, and initial management section of the guidelines include recommendations for (1) the preparation of the PC practice for improved care of adolescents with depression; (2) annual universal screening of youth 12 and over at health maintenance visits; (3) the identification of depression in youth who are at high risk; (4) systematic assessment procedures by using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria; (5) patient and family psychoeducation; (6) the establishment of relevant links in the community, and (7) the establishment of a safety plan. CONCLUSIONS: This part of the guidelines is intended to assist PC clinicians in the identification and initial management of adolescents with depression in an era of great clinical need and shortage of mental health specialists, but they cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for depression management in adolescents. Additional research that addresses the identification and initial management of youth with depression in PC is needed, including empirical testing of these guidelines.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management.

OBJECTIVES: To update clinical practice guidelines to assist primary care (PC) in the screening and assessment of depression. In this second part of the updated guidelines, we address treatment and ongoing management of adolescent depression in the PC setting. METHODS: By using a combination of evidence- and consensus-based methodologies, the guidelines were updated in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) revision and iteration among the steering committee, including youth and families with lived experience. RESULTS: These updated guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in PC, including (1) active monitoring of mildly depressed youth, (2) treatment with evidence-based medication and psychotherapeutic approaches in cases of moderate and/or severe depression, (3) close monitoring of side effects, (4) consultation and comanagement of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and the grade of its evidence base are summarized. CONCLUSIONS: The Guidelines for Adolescent Depression in Primary Care cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist PC clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists. Additional research concerning the management of depressed youth in PC is needed, including the usability, feasibility, and sustainability of guidelines, and determination of the extent to which the guidelines actually improve outcomes of depressed youth.

The use of combination subtyping in the forensic evaluation of a three-year-old girl with gonorrhea.

The use of pulsed field gel electrophoresis and neisserial lipoprotein gene sequencing for subtyping Neisseria gonorrhoeae has not been reported in the evaluation of sexually abused children. We report the application and implications of combining pulsed field gel electrophoresis and lipoprotein subtyping in the evaluation of a 3-year-old girl with N. gonorrhoeae infection.

Pediatric organ transplant patients and long-term care: a review.

We review the role of the academic generalist in the care of the child or adolescent who has undergone an organ transplant. This care is seen within the context of the "medical home" and the special considerations for pediatric patients. These special considerations include growth and development, psychosocial adjustment, cardiac and renal complications, endocrine problems, medication management and regimen adherence, infectious complications, vaccination, post-transplant malignancies, post-transplant lymphoproliferative disorders, acute post-transplant complications, recurrence, contraception and pregnancy for adolescents, and transition to adulthood. Research needs in this complex area are highlighted.

Forensic child abuse evaluation: a review.

This review discusses the forensic medical and psychological assessments of children and adolescents suspected of being victims of sexual or physical abuse/neglect. Evaluation of the whole child and the need to minimize trauma during the investigative and assessment processes are stressed. The forensic medical examination is reviewed, including the specifics of the pediatric anogenital examination. The key components of the forensic medical examination in sexual assault cases are also reviewed, with particular attention to maintaining the integrity of the process. Special emphasis is placed on the forensic interview in child sexual abuse cases, the best evidence available and areas in need of further research.

Training needs of pediatricians facing the environmental health and bioterrorism consequences of September 11th.

OBJECTIVE: The September 11, 2001, terrorist attacks have been called "the worst environmental disaster in the history of New York City." As a result of the extensive nature of the destruction, our objective as pediatricians was to determine the experience and training needs of tri-state child health professionals in responding to the environmental health and bioterrorism-related demands placed on their practices. METHODOLOGY: American Academy of Pediatrics members in New York, Connecticut, and New Jersey were sent either a web-based or a paper survey requesting demographic data and data about post-9/11 practice experience and perceived knowledge with regard to environmental health and bioterrorism. RESULTS: Of the 1,396 respondents, 21% believed their practices to have been "very [much] affected" by the attacks. Eleven percent were often/very often asked by parents about air quality, 12.6% about environmental toxins, 4.3% about antibiotics for anthrax, and 4.2% about potassium iodide for nuclear events. Fifty-seven percent and 49.1% of respondents had patients present with environmental health and bioterrorism-related complaints, respectively. Most (86%) reported that their medical training had not sufficiently prepared them to meet these demands. Few considered themselves to be knowledgeable about bioterrorism (23.9%), local environmental issues (14%), air quality (11.4%), or environmental toxins (12.6%). Gender, race, practice setting, practice location, specialty, and level of training were associated with demands on practice. Location, age, years in practice, and gender were associated with level of preparedness. CONCLUSIONS: Our results indicate that nearly all child health professionals would benefit from post-disaster education, especially trainees. A role for the pediatric associations in the dissemination of this crucial information is implied.

Disparities in complementary and alternative medical therapy recommendations for children in two different socioeconomic communities.

OBJECTIVE: To compare the content, quality, and cost of recommendations for children made by complementary and alternative medicine (CAM) retailers within 2 New York City neighborhoods of divergent socioeconomic status (SES). METHODS: Posing as consumers, researchers sought recommendations from CAM retailers for 2 clinical scenarios: 1) a febrile 6-week-old and 2) a 4-year-old with an upper respiratory infection (URI). All retailers selling CAM therapies outside the direction of a licensed provider within East Harlem (EH) and the Upper East Side (UES) were eligible and mapped. The febrile infant scenario was posed at sites in business in March (n = 23) and the URI scenario at sites that remained in business in April (n = 20) of 2004. RESULTS: In response to the febrile infant scenario, 33% of UES retailers referred to a MD, 0% to the emergency department, and 47% made other recommendations-of which 43% were not indicated. In EH, 50% referred to a MD, 5% to the emergency department, and 37% made other recommendations. The mean price of UES recommendations was Dollars 9.66, whereas EH was Dollars 2.33 (P = .04). In response to the URI scenario, 93% of UES and 83% of EH retailers made recommendations. The mean price of UES recommendations was Dollars 10.55 while EH was Dollars 4.26 (P = .002). CONCLUSIONS: Complementary and alternative medicine retailers made numerous recommendations for children, including some that were contraindicated for age. East Harlem retailers tended to refer an infant with a potentially serious condition to the emergency department or to an MD and made less expensive recommendations than their UES counterparts.

Relationships of US youth homicide victims and their offenders, 1976-1999.

BACKGROUND: Homicide is the second leading cause of death in children aged 0 to 19 years. Tailoring violence prevention programs to high-risk individuals requires understanding victim-offender relationships. OBJECTIVE: To elucidate differences in the relationships between homicide victims aged 0 to 19 years and their offenders. DESIGN: Cross-sectional study using the Uniform Crime Reports: Supplemental Homicide Reports, 1976-1999. SETTING AND PARTICIPANTS: The Supplemental Homicide Reports contain incident-level information about criminal homicides, including location and victim and offender characteristics. National coverage is approximately 92%; 70 258 victims were studied. MAIN OUTCOME MEASURES: Differences in the relationships of homicide victims and offenders based on sex, age, population of homicide location, and weapon. RESULTS: Odds ratios and 95% confidence intervals (CIs) are reported. Using strangers as the referent group, murdered girls were 3.6 (95% CI, 3.4-3.9) times more likely to have been killed by family members and 21.3 (95% CI, 18.5-24.4) times more likely to have been killed by intimate partners than murdered boys. Victims younger than 10 years were 33 (95% CI, 30.4-36.1) times more likely than victims older than 10 years to have been killed by a family member and 2.4 (95% CI, 2.2-2.6) times more likely to have been killed by someone else known to them. Stranger homicides occurred in areas with approximately 145 000 more residents (P<.01). Handguns were more likely to be used during homicides committed by strangers (P<.01). These associations remained after adjusting for potential confounders. CONCLUSIONS: Future violence prevention programs may have more effect when targeted to specific sex and age groups. Elucidation of the origins of sex differences, focus on evidence-based child abuse prevention efforts, and enforcement of current gun control laws may help reduce the number of homicides among children.

Complexities in HIV consent in adolescents.

A large proportion of people infected with the human immunodeficiency virus (HIV) are adolescents. Unfortunately, there is no uniform policy on minors' rights to consent to HIV testing and treatment. The process of obtaining consent is complex and depends on several factors, including individual state HIV laws and laws relating to a minor's capacity to consent to general health care. These issues are particularly relevant given the growth of HIV in this population. In this review, the complex laws of informed consent and confidentiality surrounding HIV disease in adolescents are reviewed. Familiarity with these laws by the clinician is essential to halting the HIV epidemic in adolescents and will be underscored.

Children neglected: Where cumulative risk theory fails.

Neglected children, by far the majority of children maltreated, experience an environment most deficient in cognitive stimulation and language exchange. When physical abuse co-occurs with neglect, there is more stimulation through negative parent-child interaction, which may lead to better cognitive outcomes, contrary to Cumulative Risk Theory. The purpose of the current study was to assess whether children only neglected perform worse on cognitive tasks than children neglected and physically abused. Utilizing LONGSCAN archived data, 271 children only neglected and 101 children neglected and physically abused in the first four years of life were compared. The two groups were assessed at age 6 on the WPPSI-R vocabulary and block design subtests, correlates of cognitive intelligence. Regression analyses were performed, controlling for additional predictors of poor cognitive outcome, including socioeconomic variables and caregiver depression. Children only neglected scored significantly worse than children neglected and abused on the WPPSI-R vocabulary subtest (p=0.03). The groups did not differ on the block design subtest (p=0.4). This study shows that for neglected children, additional abuse may not additively accumulate risk when considering intelligence outcomes. Children experiencing only neglect may need to be referred for services that address cognitive development, with emphasis on the linguistic environment, in order to best support the developmental challenges of neglected children.

Lead poisoning in children.

There is no safe lead level in children. Primary prevention is the most effective way to bring about the complete removal of lead from the environment and eliminate lead poisoning as a public health concern. The National Lead Information Center can be reached via the Internet at www.epa.gov/lead and www.hud.gov/lead, or via phone at 1-800-424-LEAD (5323).

Maternal posttraumatic stress disorder and depression in pediatric primary care: association with child maltreatment and frequency of child exposure to traumatic events.

IMPORTANCE: Maternal posttraumatic stress disorder (PTSD) may be associated with increased risk for child maltreatment and child exposure to traumatic events. Exposure to multiple traumatic events is associated with a wide range of adverse health and social outcomes in children. OBJECTIVE: To examine the association of probable maternal depression, PTSD, and comorbid PTSD and depression with the risk for child maltreatment and parenting stress and with the number of traumatic events to which preschool children are exposed. DESIGN: Cross-sectional observational design. We used analysis of variance to determine whether probable maternal psychopathology groups differed on child maltreatment, parenting stress, and children's exposure to traumatic events. Hierarchical regression analyses were used to examine the unique and interactive effects of depression and PTSD severity scores on these outcomes. SETTING: Urban pediatric primary care outpatient clinic. PARTICIPANTS: Ninety-seven mothers of children aged 3 to 5 years. EXPOSURE: Pediatric primary care visit. MAIN OUTCOMES AND MEASURES: Probable maternal depression and/or PTSD, parenting stress, child exposure to traumatic events, and child maltreatment. RESULTS: Mothers with probable comorbid PTSD and depression reported greater child-directed psychological aggression and physical assault and greater parenting stress. The children of mothers with PTSD (mean number of events the child was exposed to, 5.0) or with comorbid PTSD and depression (3.5 events) experienced more traumatic events than those of mothers with depression (1.2 events) or neither disorder (1.4 events). Severity of depressive symptoms uniquely predicted physical assault and neglect. Symptom scores for PTSD and depression interacted to predict psychological aggression and child exposure to traumatic events. When PTSD symptom severity scores were high, psychological aggression and the number of traumatic events children experienced rose. Depressive symptom severity scores predicted the risk for psychological aggression and exposure to traumatic events only when PTSD symptom severity scores were low. CONCLUSIONS AND RELEVANCE: Children of mothers with PTSD are exposed to more traumatic events. Posttraumatic stress disorder is associated with an increased risk for child maltreatment beyond that associated with depression. Screening and intervention for maternal PTSD, in addition to maternal depression, may increase our ability to reduce children's exposure to traumatic stress and maltreatment.

Resident cross-cultural training, satisfaction, and preparedness.

OBJECTIVE: To describe the diversity of pediatric residents and examine relationships of cross-cultural training experiences with training satisfaction, perceived preparedness for providing culturally effective care, and attitudes surrounding care for underserved populations. METHODS: A cross-sectional survey was conducted of a national random sample of graduating pediatric residents and an additional sample of minority residents. Using weighted analysis, we used multivariate regression to test for differences in satisfaction, preparedness, and attitudes between residents with more and less cross-cultural experiences during residency, controlling for residents' characteristics and experiences before training. RESULTS: The survey response rate was 57%. Eleven percent were Hispanic, 61% white, 21% Asian, 9% African American, 9% other racial/ethnic groups; 34% grew up in a bi- or multilingual family. Ninety-three percent of residents were satisfied with their residency training, 81% with the instruction they received on health and health care disparities, and 54% on global health issues. Ninety-six percent of residents felt they were prepared to care for patients from diverse backgrounds, but fewer felt prepared to care for families with beliefs at odds with Western medicine (49%) and families who receive alternative or complementary care (37%). Residents with more cross-cultural experiences during residency reported being better prepared than those with less experience to care for families with limited English proficiency (adjusted odds ratio [aOR] 2.11; 95% confidence interval [CI] 1.40-3.17), new immigrants (aOR 1.91; 95% CI 1.32-2.75), and with religious beliefs that might affect clinical care (aOR 1.62; 95% CI 1.13-2.32). CONCLUSIONS: Pediatric residents begin their training with diverse cross-cultural backgrounds and experiences. Residency experiences in cross-cultural care contribute to feelings of preparedness to care for diverse US children.