Use of the Child Opportunity Index to Examine Racial Variations in Outpatient Antibiotic Prescribing to Children.

To examine further racial and ethnic variations in antibiotic prescribing to children, we used the Child Opportunity Index. Black children were less likely to be prescribed an antibiotic. Low- and moderate-opportunity areas were associated with greater rates of antibiotic prescribing, after adjusting for race and other factors.

High-level psychotropic polypharmacy: a retrospective comparison of children in foster care to their peers on Medicaid.

BACKGROUND: The use of antipsychotic medication and psychotropic polypharmacy has increased in the United States over the last two decades especially for children from low-income families and those in foster care. Although attention has been paid to providing greater insight, prescribing patterns remain concerning since there is a lack of evidence related to safety and efficacy. High-level psychotropic polypharmacy has not been described. We aim to compare the use of HLPP for children receiving Medicaid services and those in foster care and identify factors associated with the duration of use of high-level psychotropic polypharmacy. Additionally, we will examine the frequency of laboratory metabolic screening and emergency department, inpatient, and outpatient visits. METHODS: A cross-sectional, secondary analysis of statewide data describes trends in high-level psychotropic polypharmacy from 2012 to 2017 and the prevalence and predictors of high-level psychotropic polypharmacy duration and resource use in 2017 for all children on Medicaid and those in foster care. High-level psychotropic polypharmacy included concurrent use, at least four classes of medications including an antipsychotic, and at least 30 days duration. RESULTS: High-level psychotropic polypharmacy increased from 2012 to 2014 for both groups but stabilized in 2015-2016. Children in foster care showed a slight increase compared to their peers in 2017. There was no association between duration and demographic characteristics or foster care status. Diagnoses predicted duration. Neither group received metabolic monitoring at an acceptable rate. CONCLUSIONS: Concerning patterns of high-level psychotropic polypharmacy and metabolic monitoring were identified. Cautious use of high-level psychotropic polypharmacy and greater oversight to ensure that these children are receiving comprehensive services like behavioral health, primary care, and primary prevention.

Midlife Study of the Louisville Twins: Connecting Cognitive Development to Biological and Cognitive Aging.

The Louisville Twin Study (LTS) began in 1958 and became a premier longitudinal twin study of cognitive development. The LTS continuously collected data from twins through 2000 after which the study closed indefinitely due to lack of funding. Now that the majority of the sample is age 40 or older (61.36%, N = 1770), the LTS childhood data can be linked to midlife cognitive functioning, among other physical, biological, social, and psychiatric outcomes. We report results from two pilot studies in anticipation of beginning the midlife phase of the LTS. The first pilot study was a participant tracking study, in which we showed that approximately 90% of the Louisville families randomly sampled (N = 203) for the study could be found. The second pilot study consisted of 40 in-person interviews in which twins completed cognitive, memory, biometric, and functional ability measures. The main purpose of the second study was to correlate midlife measures of cognitive functioning to a measure of biological age, which is an alternative index to chronological age that quantifies age as a function of the breakdown of structural and functional physiological systems, and then to relate both of these measures to twins' cognitive developmental trajectories. Midlife IQ was uncorrelated with biological age (- .01) while better scores on episodic memory more strongly correlated with lower biological age (- .19 to - .31). As expected, midlife IQ positively correlated with IQ measures collected throughout childhood and adolescence. Additionally, positive linear rates of change in FSIQ scores in childhood significantly correlated with biological age (- .68), physical functioning (.71), and functional ability (- .55), suggesting that cognitive development predicts lower biological age, better physical functioning, and better functional ability. In sum, the Louisville twins can be relocated to investigate whether and how early and midlife cognitive and physical health factors contribute to cognitive aging.

Longitudinal Trends in the Diagnosis of Attention-Deficit/Hyperactivity Disorder and Stimulant Use in Preschool Children on Medicaid.

OBJECTIVES: To describe trends in the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and prescribing of stimulants in preschool-age children receiving Medicaid and to identify factors associated with the receipt of psychosocial care. STUDY DESIGN: Data were extracted from 2012-2016 Kentucky Medicaid claims for children aged <6 years. ADHD was identified using International Classification of Diseases, Tenth Revision codes F90.0, F90.1, F90.2, F90.8, and F90.9. Psychosocial therapy was defined as having at least 1 relevant Current Procedural Terminology code in a claim within the year. A generalized linear model with a logit link and binomial distribution was used to assess factors associated with receipt of psychosocial treatment in 2016. RESULTS: More than 2500 (1.24%) preschool-aged children receiving Medicaid had a diagnosis of ADHD in 2016, with 988 (38.2%) of those receiving a stimulant medication. Children in foster care were diagnosed with and/or treated for ADHD 4 times more often than other Medicaid recipients. Of the 1091 preschoolers receiving stimulants, 99 (9%) did not have a diagnosis of ADHD. There were no significant differences in diagnoses by race/ethnicity, but children reported to be black, Hispanic, or other race/ethnicity received stimulants at a lower rate than white children. Positive predictors for receiving psychosocial therapy in 2016 included having the diagnosis but not receiving a stimulant, having at least 1 prescription written by a psychiatrist, having comorbidities, and age. The use of stimulants in children aged <6 years declined from 0.9% in 2012 to 0.5% in 2016. CONCLUSIONS: Promising trends demonstrate a decreasing use of stimulants in preschoolers; however, continued vigilance is needed to promote the optimal use of psychosocial interventions.

Efficacy of an Internet-based depression intervention to improve rates of treatment in adolescent mothers.

Approximately 400,000 adolescents give birth in the USA annually. Although one-half experience depressive symptoms, less than 25% comply with referrals for depression evaluation and treatment. The current study tested the effectiveness of an Internet-based depression intervention on seeking depression treatment. Based upon the theory of planned behavior (TPB), the intervention included vignettes, questions and answers, and resources. Before the intervention, immediately after the intervention, and 2 weeks later the adolescent mothers (n = 151) answered questions related to TPB variables and depression treatment. Data were compared to adolescent mothers (n = 138) in the control group. Data were collected in community organizations or home visits for the control group. Adolescent mothers in the intervention group answered questions and completed the intervention from a computer of their choice. The adolescents were primarily African American (89.2%), less than high school educated (51.7%), had given birth in last year (97.1%), with a mean age 18.2 years. The intervention led to significant changes in attitude, perceived control, intention to seek mental health treatment, and actually seeking depression treatment. Untreated postpartum depression dramatically impacts a mother's relationship with her child, her functioning at work and school, health care-seeking behaviors, mothering skills, and her development as well as the development of her child. An Internet-based depression intervention is an inexpensive method to increase rates of depression treatment.

Providers' Behaviors and Beliefs on Prescribing Antipsychotic Medication to Children: A Qualitative Study.

Fragmentation in behavioral and mental health care to children has resulted in suboptimal care and high rates of psychotropic medication use, especially antipsychotic medications (APM). A qualitative study, based on the Theory of Planned Behavior (TPB), aimed to better understand prescribing practices, barriers to optimal treatment, and potential interventions to safeguard the use of APM for children in Kentucky. The most common barrier to optimal care was access to mental health specialists. Social norms and pressure from families contribute to increased medication use. We identify promising interventions to safeguard the use of APM through the lens of the TPB.

Health Literacy and Preferences for Sources of Child Health Information of Mothers With Infants in the Neonatal Intensive Care Unit.

BACKGROUND: Parents of infants hospitalized in the neonatal intensive care unit (NICU) frequently need guidance to prepare them for the care and health promotion of their child after hospital discharge. The health literacy of the parents should be considered so that education can be tailored to meet their needs. It is also important to understand the parents' preferences for how, and from whom, they receive education. PURPOSE: The purpose of this study was to identify health literacy levels of parents of infants in an NICU and preferences for who they want to provide them with education. METHODS: An exploratory, descriptive design was used to assess participant health literacy and preferences for obtaining child health information. Only mothers (no fathers) with babies in the NICU were available to complete the survey. Mean participant age was 26.4 years (SD = 6.7). RESULTS: Participants had a mean Rapid Estimate of Adult Literacy in Medicine, Revised, score of 5.64 (SD = 2.4), indicating a low level of health literacy. Questions regarding when to administer medication were correctly answered by 69% of participants. Proper medication dosage was understood by 92% of participants; however, only 30% were able to correctly convert measurements. One-on-one discussions with a physician were the preferred source of health information for 80% of participants. IMPLICATIONS FOR PRACTICE/RESEARCH: The current exploratory study provides new information that will help inform the development of future studies and increase awareness of nurses regarding health literacy and the specific types of skills for which parents need the most help.

Senior Medical Student Mock Interview Program in Pediatrics.

OBJECTIVES: Residency interviews play an integral part in medical residency placement. We aimed to develop and evaluate a mock interview program for fourth-year medical students interested in a pediatric specialty. METHODS: A mock interview program for fourth-year medical students interested in pediatrics was developed and implemented. Preinterview quantitative data and postinterview qualitative data were collected. Fifty-nine students completed the program across three consecutive academic years. Preinterview surveys were completed regarding comfort and confidence levels specific to aspects of the interview process. Descriptive analyses were used. In addition, a focus group was held with nine of the participating students to obtain qualitative data via a paper blog process. Themes in student responses were identified through constant comparative analysis. RESULTS: Before the mock interview, students were most uncomfortable with introductory and closing remarks and their confidence levels varied by topic. A thematic analysis of focus group data identified five themes (preparation, stress reduction, interview process familiarity, confidence of skills, and receiving feedback) for which the mock interviews were most helpful. CONCLUSIONS: Implementation of a mock interview program was feasible and acceptable for senior medical students and may improve comfort and confidence levels in the residency interview process. Further longitudinal research is needed.

Development and Initial Testing of the Parent Beliefs about Early Childhood Social-Emotional Development Instrument.

BACKGROUND: No instrument exists to measure parent beliefs about early social-emotional development, which is foundational for child outcomes. We developed and tested an instrument to measure parent beliefs. METHODS: Positive parenting was defined from the literature and 84 items were developed based on the theory of planned behavior (TPB). The instrument was tested with mothers (N=200) from the United States. RESULTS: Data support our initial supposition of five factors based upon the TPB, which accounted for 65.5% of the total variance. CONCLUSION: The instrument demonstrates strong initial psychometric properties and is ready for further testing.

Genetic and Environmental Contributions to Behavioral Stability and Change in Children 6-36 months of Age Using Louisville Twin Study Data.

The Infant Behavior Record (IBR) from the Bayley Scales of Infant Development has been used to study behavioral development since the 1960s. Matheny (1983) examined behavioral development at 6, 12, 18, and 24 months from the Louisville Twin Study (LTS). The extracted temperament scales included Task Orientation, Affect-Extraversion, and Activity. He concluded that monozygotic twins were more similar than same-sex dizygotic twins on these dimensions. Since this seminal work was published, a larger LTS sample and more advanced analytical methods are available. In the current analyses, Choleksy decomposition was applied to behavioral data (n = 1231) from twins 6-36 months. Different patterns of genetic continuity vs genetic innovations were identified for each IBR scale. Single common genetic and shared environmental factors explained cross-age twin similarity in the Activity scale. Multiple shared environmental factors and a single genetic factor coming on line at age 18 months contributed to Affect-Extraversion. A single shared environmental factor and multiple genetic factors explained cross-age twin similarity in Task Orientation.

Applying Biometric Growth Curve Models to Developmental Synchronies in Cognitive Development: The Louisville Twin Study.

Biometric latent growth curve models were applied to data from the LTS in order to replicate and extend Wilson's (Child Dev 54:298-316, 1983) findings. Assessments of cognitive development were available from 8 measurement occasions covering the period 4-15 years for 1032 individuals. Latent growth curve models were fit to percent correct for 7 subscales: information, similarities, arithmetic, vocabulary, comprehension, picture completion, and block design. Models were fit separately to WPPSI (ages 4-6 years) and WISC-R (ages 7-15). Results indicated the expected increases in heritability in younger childhood, and plateaus in heritability as children reached age 10 years. Heritability of change, per se (slope estimates), varied dramatically across domains. Significant genetic influences on slope parameters that were independent of initial levels of performance were found for only information and picture completion subscales. Thus evidence for both genetic continuity and genetic innovation in the development of cognitive abilities in childhood were found.

Twin Differentiation of Cognitive Ability Through Phenotype to Environment Transmission: The Louisville Twin Study.

The Louisville Twin Study is one of the most intensive twin studies of cognitive ability. The repeated measurements of the twins are ideal for testing developmental twin models that allow for the accumulation of gene-environment correlation via a (P⇒E) transmission process to explain twins' divergence in mean ability level over time. Using full-scale IQ scores from 566 pairs of twins (MZ = 278; DZ = 288), we tested whether a P⇒E transmission model provided better representation of actual developmental processes than a genetic simplex model. We also addressed whether the induced gene-environment correlation alters the meaning of the latent nonshared environmental factors with a simple numerical method for interpreting nonshared environmental factors in the context of P⇒E transmission. The results suggest that a P⇒E model provided better fit to twins' FSIQ data than a genetic simplex model and the meaning of the nonshared environment was preserved in the context of P⇒E.

The Role of Stigma in Parental Help-Seeking for Perceived Child Behavior Problems in Urban, Low-Income African American Parents.

Significant numbers of children have diagnosable mental health problems, but only a small proportion of them receive appropriate services. Stigma has been associated with help-seeking for adult mental health problems and for Caucasian parents. The current study aims to understand factors, including stigma, associated with African American parents' help-seeking behavior related to perceived child behavior problems. Participants were a community sample of African American parents and/or legal guardians of children ages 3-8 years recruited from an urban primary care setting (N = 101). Variables included child behavior, stigma (self, friends/family, and public), object of stigma (parent or child), obstacles for engagement, intention to attend parenting classes, and demographics. Self-stigma was the strongest predictor of help-seeking among African American parents. The impact of self-stigma on parents' ratings of the likelihood of attending parenting classes increased when parents considered a situation in which their child's behavior was concerning to them. Findings support the need to consider parent stigma in the design of care models to ensure that children receive needed preventative and treatment services for behavioral/mental health problems in African American families.

Variation in classification of live birth with newborn period death versus fetal death at the local level may impact reported infant mortality rate.

BACKGROUND: To better understand factors that may impact infant mortality rates (IMR), we evaluated the consistency across birth hospitals in the classification of a birth event as either a fetal death or an early neonatal (infant) death using natality data from North Carolina for the years 1995-2000. METHODS: A database consisting of fetal deaths and infant deaths occurring within the first 24 hours after birth was constructed. Bivariate, followed by multivariable regression, analyses were used to control for relevant maternal and infant factors. Based upon hospital variances, adjustments were made to evaluate the impact of the classification on statewide infant mortality rate. RESULTS: After controlling for multiple maternal and infant factors, birth hospital remained a factor related to the classification of early neonatal versus fetal death. Reporting of early neonatal deaths versus fetal deaths consistent with the lowest or highest hospital strata would have resulted in an adjusted IMR varying from 7.5 to 10.64 compared with the actual rate of 8.95. CONCLUSIONS: Valid comparisons of IMR among geographic regions within and between countries require consistent classification of perinatal deaths. This study demonstrates that local variation in categorization of death events as fetal death versus neonatal death within the first 24 hours after delivery may impact a state-level IMR in a meaningful magnitude. The potential impact of this issue on IMRs should be examined in other state and national populations.

Evaluation of printed health education materials for use by low-education families.

PURPOSE: Millions of adults lack adequate reading skills and many written patient education materials do not reflect national guidelines for readability and suitability of materials, resulting in barriers to patients being partners in their own health care. The purpose of this study was to evaluate commonly used printed health materials for readability and suitability for patients with limited general or health literacy skills, while providing easy recommendations to health care providers for how to improve the materials. METHODS: Materials (N = 97) from three clinical areas that represented excellence in nursing care in our organization (stroke, cancer, and maternal-child) were reviewed for a composite reading grade level and a Suitability Assessment of Materials (SAM) score. RESULTS: Twenty-eight percent of the materials were at a 9th grade or higher reading level, and only 23% were 5th grade or below. The SAM ratings for not suitable, adequate, and superior were 11%, 58%, and 31%, respectively. Few materials were superior on both scales. The SAM scale was easy to use and required little training of reviewers to achieve interrater reliability. CONCLUSIONS: Improving outcomes and reducing health disparities are increasingly important, and patients must be partners in their care for this to occur. One step to increasing patient understanding of written instructions is improving the quality of the materials in the instruction for all patients and their families, especially those with limited literacy skills. CLINICAL RELEVANCE: Using materials that are written in a manner that facilitates the uptake and use of patient education content has great potential to improve the ability of patients and families to be partners in care and to improve outcomes, especially for those patients and families with limited general literacy or health literacy skills.

Evaluation of an innovative tool for child sexual abuse education.

Child sexual abuse poses a serious threat to public health and is often unreported, unrecognized, and untreated. Prevention, early recognition, and treatment are critically important to reduce long-term effects. Little data are available on effective methods of preventing child sexual abuse. The current research demonstrates a unique approach to promoting awareness and stimulating discussion about child sexual abuse. Qualitative methods have rarely been used to study child sexual abuse prevention. Qualitative inductive analyses of interviews from 20 key informants identified both positive and negative assessments with six emergent themes. The themes revealed inherent tensions in using narrative accounts to represent the complex cultural context within which child sexual abuse occurs. More research is needed, but the program shows potential as a methodology to raise awareness of child sexual abuse.

First-line Behavioral Health Treatment Prior to Stimulant or Alpha-2 Agonist Use for Preschoolers on Kentucky Medicaid in 2017.

OBJECTIVE: We aimed to assess the degree to which the American Academy of Pediatrics' (AAP) clinical guidelines were followed when treating attention deficit/hyperactivity disorder (ADHD) in preschoolers. METHOD: Using Medicaid claims for children 4 to 5 years of age receiving their first dose of stimulants/alpha-2 agonists in 2017 (n = 836), we determined if BH was received prior to initiation of medication. We examined predictors after controlling for confounders. RESULTS: More than half the sample did not receive first-line BH, which did not differ by demographics. Those receiving BH prior to medication had a higher rate of receiving an ADHD diagnosis. Only three diagnoses were significant in multivariate (OR 13.8, 95% CI [1.7-115.1]) analyses. CONCLUSION: More than half the sample did not, conservatively, meet the AAP clinical recommendations. Further research is needed to identify targets for intervention. Limitations are noted.

Genetic and environmental correlates of the nonlinear recovery of cognitive ability in Twins.

Twins regularly score nearly a standard deviation below the population mean on standardized measures of cognitive development in infancy but recover to the population mean by early childhood, making rapid gains through the toddler years. To date, only polynomial growth models have been fit to model cognitive recovery across childhood, limiting the applicability of the growth parameters to later developmental periods. We fit a nonlinear asymptotic Gompertz growth model to prospective cognitive scores from 1,153 individual twins from 578 families (47.9% male, 91.5% White, 61.6% monozygotic) measured at 16 time points between 3 months and 15 years. Twins displayed a lower asymptote of 86.47 (.90 SD below the population mean) and gained on average 17.01 points, achieving an upper asymptote of 103.48. Growth was observed to be most rapid at 3.26 years, highlighting the importance of the toddler years in cognitive development. Biometric analyses revealed that shared environmental factors accounted for the majority of the variance in initial cognitive ability as well as asymptotic growth in cognitive ability. Gestational age and family socioeconomic status (SES) were robust predictors of cognitive growth. Results from the present study provide insight into the growth processes underlying the recovery of cognitive ability to the population mean for children evincing slight delays in their initial cognitive ability. In particular, findings highlight prenatal factors and family economic resources as important aspects of the environment in the recovery of cognitive ability. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Examination of U.S. national rates of emergency department visits and hospitalizations for depression and suicidal behaviors after the release of the 13 Reasons Why Netflix series by demographic characteristics.

BACKGROUND: To evaluate the impact of the series 13Reasons Why on depression and suicidal behaviors in children and adolescents. METHODS: Data from the 2016 to 2018 Nationwide Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS) of the Healthcare Cost and Utilization Project (HCUP) from 2016 to 2018 was used to determine the presentation in both settings for depression and suicidal thoughts and behavior. This was compared to predictive modeling for presentations in the same time frame. RESULTS: Following the release of 13 Reasons Why both hospital admissions and presentations to the Emergency Department (ED) increased for complaints of worsening depression or suicidal thoughts and behavior. This was more pronounced for youth aged 10-17 years, Black race, and female sex. There were no significant findings, overall, for females 6-9 years, but in-patient visits for depression increased in May 2017 for Black females 6-9 years. Males 6-9 years had higher rates of ED visits for depression and both ED and in-patient visits for suicidal behaviors. LIMITATIONS: Secondary data analyses have known limitations including inability to track over time, inclusion of only visit-level data, and failure to collect variables of interest. CONCLUSIONS: The series 13 Reasons Why was likely associated with exacerbations of both depressive illnesses and suicidal behavior in youth, particularly for female and Black youth from 10 to 17 years. This study adds to known concerns regarding the role of media in influencing suicidal behavioral in vulnerable children and has important implications for youth monitoring and parent and youth education. More research is needed to identify specific targets for prevention.

Antipsychotic Medications for Low-Income Preschoolers: Long Duration and Psychotropic Medication Polypharmacy.

OBJECTIVE: This study aimed to evaluate prescribing patterns of antipsychotic medication and factors that predict duration of use among low-income, preschool-age children. METHODS: State Medicaid claims from 2012 to 2017 were used to identify antipsychotic medication use for children <6 years old. ICD-9 and ICD-10 codes were used to describe child diagnoses. Descriptive and multivariable analyses were used to determine patterns of antipsychotic medication use and factors that predicted duration of use. RESULTS: In 2012, 316 children <6 years of age started an antipsychotic medication in a southeastern state. Most were non-Hispanic White (N=202, 64%) and boys (N=231, 73%). Diagnoses included attention-deficit hyperactivity disorder (N=288, 91%), neurodevelopmental disorders (N=208, 66%), anxiety and trauma-related diagnoses (N=202, 64%), and autism spectrum disorders (ASDs) (N=137, 43%). The mean±SD duration of exposure to antipsychotic medication for children in the cohort was 2.6±1.7 years, but 86 children (27%) had >4 years of exposure. Almost one-third (N=97, 31%) received polypharmacy of four or more medication classes, and 42% (N=131) received metabolic screening. Being male, being in foster care, and having a diagnosis of ASD or disruptive mood dysregulation disorder were significantly associated with duration of use of antipsychotic medications; race-ethnicity was not significantly associated with duration of use. Emergency department visits (N=277, 88%) and inpatient hospitalizations (N=107, 34%) were observed during the study period. CONCLUSIONS: Many preschoolers received antipsychotic medications for substantial periods. Further research is needed to identify evidence-based practices to reduce medication use and improve outcomes.