Inclusion of Children in Clinical Research: The Role of Advocacy and a Personal Journey.

Many groups have historically been excluded from clinical research. It has required vigorous, long-term advocacy efforts for better inclusion of women and children across racial and ethnic groups. To understand who is included in clinical research, data are required. A personal journey of advocacy requiring the National Institutes of Health to report inclusion in clinical studies by age was ultimately accomplished by federal legislation.

High-Deductible Health Plans for US Children: Trends, Health Service Use, and Financial Barriers to Care.

OBJECTIVE: Few studies have examined children's enrollment in high-deductible health plans (HDHPs) and associations with health service use. We examine trends, health service use, and financial barriers to care for US children with high-deductible private insurance. METHODS: Trend data on HDHP enrollment were available for 58,910 children ages 0 to 17 with private insurance from the 2007 to 2018 National Health Interview Survey. Health service indicators were examined in a cross-sectional sample of 23,959 children in the 2014-2018 datasets. High deductible was defined as a minimum of $2,700 for a family in 2018. Chi-square tests examined associations of HDHPs with health service indicators. Logistic regression models adjusted for sociodemographics and child health. RESULTS: The percent of privately insured children with HDHPs increased from 18.4% to 48.6% from 2007 to 2018. In adjusted regression, those with HDHPs fared worse than those with traditional plans on 7 of 10 measures and those with HDHPs and no health savings account (HSA) fared worse on eight. While small differences were found for various child-focused measures, the most consistent differences were found for family-focused measures. Parents with HDHPs were more likely than parents with traditional private insurance to report they had delayed or forgone their medical care (10.2% vs 5.7%), had problems paying medical bills (15.7% vs 10.3%), and had family medical debt (34.1% vs 25.8%). CONCLUSIONS: Privately insured families have seen substantial growth in high-deductible plans in the last decade. Families with HDHPs, especially those without HSAs, have more financial barriers to care.

Gender Differences in Earnings of Early- and Midcareer Pediatricians.

BACKGROUND: The US physician workforce includes an increasing number of women, with pediatrics having the highest percentage. In recent research on physicians, it is indicated that men earn more than women. It is unclear how this finding extends to pediatricians. METHODS: We examined cross-sectional 2016 data on earnings from the American Academy of Pediatrics Pediatrician Life and Career Experience Study, a longitudinal study of early- and midcareer pediatricians. To estimate adjusted differences in pediatrician earnings between men and women, we conducted 4 ordinary least squares regression models. Model 1 examined gender, unadjusted; model 2 controlled for labor force characteristics; model 3 controlled for both labor force and physician-specific job characteristics; and model 4 controlled for labor force, physician-specific job, and work-family characteristics. RESULTS: Sixty-seven percent of Pediatrician Life and Career Experience Study participants completed the 2016 surveys (1213 out of 1801). The analytic sample was restricted to participants who completed training and worked in general pediatrics, hospitalist care, or subspecialty care (n = 998). Overall pediatrician-reported mean annual income was $189 804. Before any adjustment, women earned ∼76% of what men earned, or ∼$51 000 less. Adjusting for common labor force characteristics such as demographics, work hours, and specialty, women earned ∼87% of what men earned, or ∼$26 000 less. Adjusting for a comprehensive set of labor force, physician-specific job, and work-family characteristics, women earned ∼94% of what men earned, or ∼$8000 less. CONCLUSIONS: Early- to midcareer female pediatricians earned less than male pediatricians. This difference persisted after adjustment for important labor force, physician-specific job, and work-family characteristics. In future work, researchers should use longitudinal analyses and further explore family obligations and choices.

Screening and Referral for Low-Income Families' Social Determinants of Health by US Pediatricians.

OBJECTIVE: To measure the frequency US pediatricians report screening and referring for social needs and identify pediatrician and practice-level predictors for screening and referral. METHODS: Data were from the American Academy of Pediatrics Periodic Survey for October 2014 to March 2015 with a response rate of 46.6% (732/1570). Respondents reported on: 1) routine screening of low-income families for social needs, 2) attitudes toward screening, and 3) referral of low-income families for community resources. Results were analyzed by pediatrician and practice characteristics. RESULTS: Although most pediatricians (61.6%) thought that screening is important, fewer (39.9%) reported that screening is feasible or felt prepared addressing families' social needs (20.2%). The topics that pediatricians reported routinely asking low-income families about at visits (defined as ≥50% visits) were need for childcare (41.5%) and transportation barriers (28.4%). Pediatricians were less likely to report asking about housing (18.7%), food (18.6%), and utilities/heating (14.0%) insecurity. In multivariable analyses, pediatricians were more likely to report both that they screen and refer when they reported having more patients in financial hardship and having someone in the practice with the responsibility to connect low-income families to community services. Pediatricians who endorsed the importance of screening and who reported being prepared were also more likely to screen/refer. CONCLUSIONS: A minority of pediatricians report routinely screening for social needs. Pediatricians were more likely to report that they screen and refer if they had positive attitudes toward the importance of screening, felt prepared, and had support staff to assist families in need.

United States Pediatricians' Attitudes Regarding Public Policies for Low-Income Children and Their Profession's Advocacy Priorities.

OBJECTIVE: To examine pediatricians' attitudes toward public policies for low-income children and the advocacy efforts for the American Academy of Pediatrics (AAP). METHODS: Data from the AAP Periodic Survey in October 2014 to March 2015 were used. Respondents ranked 1) attitudes toward government programs, and 2) attitudes toward AAP policies on: income support, housing, education, job training, food, and health care. Results were analyzed according to age, gender, practice location, practice region, type of practice setting, and percent of patients with economic hardship. RESULTS: Response rate was 47% (n = 650). Most respondents reported that for children, the government should guarantee health insurance (88.9%), and food and shelter (90.0%). Most also reported that the government should guarantee health insurance (68.9%) and food and shelter (63.9%) for every citizen and to take care of people who cannot take care of themselves. There was variation among the level of support on the basis of practice setting. In multivariable analyses related to supporting the role of government for children and citizens, not being from the Northeast was associated with lower odds of support of children as well as citizens; primary care practices in rural areas were less supportive of government involvement related to all citizens but similar for children; and those younger than 40 and 50 to 59 years of age were more supportive of government guaranteeing enough to eat and a place to sleep for children. More than 55% supported the AAP advocating for income support, housing, education, and access to health care. CONCLUSIONS: Pediatricians strongly support government policies that affect child poverty and the provision of basic needs to families. This support should be used to inform professional organizations, advocates, and policy-makers focused on children and families.

Trends in Access to Health Care Services for US Children: 2000-2014.

BACKGROUND AND OBJECTIVE: Recent years have witnessed substantial gains in health insurance coverage for children, but few studies have examined trends across a diverse set of access indicators. We examine US children's access to health services and whether trends vary by race/ethnicity and income. METHODS: Analysis of 178 038 children ages 0 to 17 from the 2000 to 2014 National Health Interview Survey. Trends are examined for health insurance and 5 access indicators: no well-child visit in the year, no doctor office visit, no dental visit, no usual source of care, and unmet health needs. Logistic regression models add controls for sociodemographics and child health status. Statistical interactions test whether trends vary by race/ethnicity and income. RESULTS: Among all children, uninsured rates declined from 12.1% in 2000 to 5.3% in 2014, with improvement across all 5 access indicators. Along with steep declines in the uninsured rate, Hispanic children had sizeable improvement for no doctor office (19.8% to 11.9%), no dental visit (43.2% to 21.8%), and no usual source of care (13.9% to 6.3%). Black children and those in poor and near-poor families also had large gains. Results from adjusted statistical interaction models showed more improvement for black and Hispanic children versus whites for 3 of 5 access indicators and for children in poor and near-poor families for 4 of 5 access indicators. CONCLUSIONS: Children's access to health services has improved since 2000 with greater gains in vulnerable population groups. Findings support a need for continued support of health insurance for all children.

Pediatricians Working Part-Time Has Plateaued.

OBJECTIVE: To examine trends in pediatricians working part-time and residents seeking part-time work and to examine associated characteristics. STUDY DESIGN: The American Academy of Pediatrics (AAP) Periodic Survey of Fellows and the AAP Annual Survey of Graduating Residents were used to examine part-time employment. Fourteen periodic surveys were combined with an overall response rate of 57%. Part-time percentages were compared for surveys conducted from 2006-2009 and 2010-2013. The AAP Annual Surveys of Graduating Residents (combined response rate = 60%) from 2006-2009 were compared with 2010-2013 surveys for residents seeking and obtaining part-time positions following training. Multivariable logistic regression models identified characteristics associated with part-time work. RESULTS: Comparable percentages of pediatricians worked part-time in 2006-2009 (23%) and 2010-2013 (23%). There was similarly no statistically significant difference in residents seeking part-time work (30%-28%), and there was a slight decline in residents accepting part-time work (16%-13%, aOR .75, 95% CI .56-.96). Increases in working part-time were not found for any subgroups examined. Women consistently were more likely than men to work part-time (35% vs 9%), but they showed different patterns of part-time work across age. Women in their 40s (40%) were more likely than other women (33%) and men in their 60s (20%) were more likely than other men (5%) to work part-time. CONCLUSIONS: There has been a levelling off in the number of pediatricians working part-time and residents seeking part-time work. Overall, women remain more likely to work part-time, although 1 in 5 men over 60 work part-time.

Location of Usual Source of Care among Children and Adolescents in the United States, 1997-2013.

OBJECTIVES: To examine national trends in the percentage of children whose usual source of care is at a clinic, health center, or hospital outpatient department (hereafter "clinics") and whether trends differ by sociodemographic subpopulations. STUDY DESIGN: Analysis of serial, cross-sectional, nationally representative in-person household surveys, the 1997-2013 National Health Interview Surveys, was conducted to identify children with a usual source of care (n = 190,571), and the percentage receiving that care in a clinic. We used joinpoint regression to identify changes in linear trends, and logistic regression with predictive margins to obtain per-year changes in percentages, both unadjusted and adjusted for sociodemographic factors. Interaction terms in logistic regressions were used to assess whether trends varied by sociodemographic subgroups. RESULTS: Of all children with a usual source of care, the percentage receiving that care in a clinic declined 0.44 percentage points per year (P < .001) from 22.97% in 1997 to 19.31% in 2002. Thereafter, it increased approximately 0.57 percentage points per year (P < .001), reaching 26.1% in 2013. Trends for some sociodemographic subgroups varied from these overall trends. No changes were observed between 2003 and 2013 for non-Hispanic black and Medicaid/State Children's Health Insurance Program insured children. CONCLUSIONS: This study shows that, although the percentage of children with a usual source of care in a clinic declined between 1997 and 2002, it has steadily increased since that time.

A Longitudinal Study of Pediatricians Early in Their Careers: PLACES.

The American Academy of Pediatrics (AAP) launched the Pediatrician Life and Career Experience Study (PLACES), a longitudinal study that tracks the personal and professional experiences of early career pediatricians, in 2012. We used a multipronged approach to develop the study methodology and survey domains and items, including review of existing literature and qualitative research with the target population. We chose to include 2 cohorts of US pediatricians on the basis of residency graduation dates, including 1 group who were several years out of residency (2002-2004 Residency Graduates Cohort) and a second group who recently graduated from residency at study launch (2009-2011 Residency Graduates Cohort). Recruitment into PLACES was a 2-stage process: (1) random sample recruitment from the target population and completion of an initial intake survey and (2) completion of the first Annual Survey by pediatricians who responded positively to stage 1. Overall, 41.2% of pediatricians randomly selected to participate in PLACES indicated positive interest in the study by completing intake surveys; of this group, 1804 (93.7%) completed the first Annual Survey and were considered enrolled in PLACES. Participants were more likely to be female, AAP members, and graduates of US medical schools compared with the target sample; weights were calculated to adjust for these differences. We will survey PLACES pediatricians 2 times per year. PLACES data will allow the AAP to examine career and life choices and transitions experienced by early-career pediatricians.

Cognitive ability at kindergarten entry and socioeconomic status.

OBJECTIVE: To examine how gradients in socioeconomic status (SES) impact US children's reading and math ability at kindergarten entry and determine the contributions of family background, health, home learning, parenting, and early education factors to those gradients. METHODS: Analysis of 6600 children with cognitive assessments at kindergarten entry from the US Early Childhood Longitudinal Birth Cohort Study. A composite SES measure based on parent's occupation, education, and income was divided into quintiles. Wald F tests assessed bivariate associations between SES and child's cognitive ability and candidate explanatory variables. A decomposition methodology examined mediators of early cognitive gradients. RESULTS: Average reading percentile rankings increased from 34 to 67 across SES quintiles and math from 33 to 70. Children in lower SES quintiles had younger mothers, less frequent parent reading, less home computer use (27%-84%), and fewer books at home (26-114). Parent's supportive interactions, expectations for their child to earn a college degree (57%-96%), and child's preschool attendance (64%-89%) increased across quintiles. Candidate explanatory factors explained just over half the gradients, with family background factors explaining 8% to 13%, health factors 4% to 6%, home learning environment 18%, parenting style/beliefs 14% to 15%, and early education 6% to 7% of the gaps between the lowest versus highest quintiles in reading and math. CONCLUSIONS: Steep social gradients in cognitive outcomes at kindergarten are due to many factors. Findings suggest policies targeting levels of socioeconomic inequality and a range of early childhood interventions are needed to address these disparities.

Changing trends of childhood disability, 2001-2011.

BACKGROUND: Over the past half century the prevalence of childhood disability increased dramatically, coupled with notable increases in the prevalence of mental health and neurodevelopmental conditions. This study provides a detailed assessment of recent trends in childhood disability in relation to health conditions and sociodemographic factors. METHODS: Secondary data analysis of National Health Interview Survey (NHIS) datasets 2001-2002, 2004-2005, 2007-2008, and 2010-2011 (N = 198888) was conducted to calculate the prevalence, rate of change, severity, and sociodemographic disparities of parent-reported childhood disability. RESULTS: The prevalence of childhood disability has continued to increase, growing by 15.6% between 2001-2002 and 2010-2011. Nearly 6 million children were considered disabled in 2010-2011. Children living in poverty experienced the highest rates of disability, 102.6 cases per 1000 population in 2010-2011, but unexpectedly, children living in households with incomes ≥ 400% above the federal poverty level experienced the largest increase (28.4%) over this 10-year period. The percentage of disability cases related to any physical health condition declined 11.8% during the decade, whereas cases related to any neurodevelopmental or mental health condition increased by 20.9%. CONCLUSIONS: Over the past decade, parent-reported childhood disability steadily increased. As childhood disability due to physical conditions declined, there was a large increase in disabilities due to neurodevelopmental or mental health problems. For the first time since the NHIS began tracking childhood disability in 1957, the rise in reported prevalence is disproportionately occurring among socially advantaged families. This unexpected finding highlights the need to better understand the social, medical, and environmental factors influencing parent reports of childhood disability.

An exploration of adolescent nonsuicidal self-injury and religious coping.

Many adolescents who engage in nonsuicidal self-injury (NSSI) self-identify as religious, but the role of religion in their NSSI is not known. This exploratory study examined the relationship between religious coping and religiousness among adolescents who self-injure and the function of their NSSI. Thirty adolescents aged 12-19 years who had engaged in NSSI participated in an interview and completed questionnaires. Multiple regressions were used to examine the relationship between religious coping and NSSI, and Pearson correlations were used to assess the relationship between religiousness and function of NSSI. Greater use of positive religious coping was associated with lower likelihood of engaging in NSSI to rid oneself of unwanted emotions, whereas greater use of negative religious coping was associated with greater likelihood of engaging in NSSI for this reason as well as to avoid punishment or unwanted responsibility. Higher religiousness was associated with greater use of NSSI to communicate with or gain attention from others, whereas lower religiousness was associated with greater use of NSSI to relieve unwanted emotions. Having a greater understanding of how religious constructs are related to the various functions served by NSSI may inform treatment of this population, particularly among religious youth who self-injure.

Media education in pediatric residencies: a national survey.

BACKGROUND: Little is known about the current state of residency education with respect to counseling parents about media usage and whether trainees consider it to be adequate. METHODS: A national survey of graduating pediatric residents was conducted in the United States to determine the amount of training they receive on traditional and new media, their perceptions of its quality, and their self-reported practices regarding talking to families about media usage. RESULTS: A 58% response rate was achieved with no evidence of response bias based on age or gender. Only 38% rated their residency program as "very good" or "excellent" in preparing them to provide anticipatory guidance on the effects of media on children and adolescents. In logistic regression analyses, controlling for demographic characteristics, more training on media issues was a significant predictor for usually/always advising families on traditional, passive media (adjusted odds ratio = 3.29; 95% confidence interval 2.26-4.81) and usually/always advising families on new, interactive media use (adjusted odds ratio = 3.96; 95% confidence interval 2.61-6.00) during well-child visits. CONCLUSIONS: The majority of residents believe their training on children in media is inadequate. Enhanced training on media is needed in US pediatric residencies.

Pediatric resident debt and career intentions.

OBJECTIVE: To examine current levels of educational debt among pediatric residents and the relationship between educational debt and career intentions. METHODS: Annual national random samples of 1000 graduating pediatric residents from 2006 through 2010 were surveyed. Responses were combined. We used t tests and 1-way analysis of variance to compare debt, linear regression to examine factors associated with educational debt, and logistic regression to assess the influence of debt on clinical practice goal. Response rate was 61%. RESULTS: Three in 4 residents reported having educational debt. The mean debt (in 2010 dollars) among all residents, which included spouse's debt if married, increased 34% from $104 000 in 2006 to $139 000 in 2010. Among the subgroup who reported having any debt, the mean debt increased 24% from $146 000 in 2006 to $181 000 in 2010. Residents had varied clinical practice goals; 43% had goals that required fellowship training (subspecialty and combined primary-subspecialty) and 57% had goals not typically requiring fellowship training (primary care and hospitalist). In multivariate analyses, debt level (low, medium, high) remained an independent predictor of practice goal. Residents with medium debt (adjusted odds ratio: 1.46, 95% confidence interval: 1.16-1.84) and high debt (adjusted odds ratio: 1.51; 95% confidence interval: 1.20-1.90) had higher odds than residents with low debt of having a practice goal that does not typically require fellowship training. Other factors also had an independent association with career choice. CONCLUSIONS: Multiple factors shape decisions about careers. Higher educational debt is one factor that may push residents toward primary care or hospitalist practice, rather than pursuing fellowship training.

The role of forgiveness in adolescents who engage in nonsuicidal self-injury.

The present study is an exploratory investigation assessing the role of forgiveness of self and forgiveness of others in adolescent nonsuicidal self-injury (NSSI). Participants included a diverse sample of self-injuring adolescents (N = 30). Results indicated that lack of self-forgiveness was associated with engaging in NSSI for specific reasons related to the regulation of emotions and social functioning, namely to get rid of unwanted emotions, to feel something due to feeling numb or empty, and to communicate with others. Lack of self-forgiveness was also associated with greater lifetime frequency of NSSI. No relationship was found between forgiveness of others and NSSI. The implications of these findings are discussed in relation to Dialectical Behavior Therapy for NSSI, traditional forgiveness interventions, and treatment of youth who engage in NSSI.

Mediators of asthma outcomes.

BACKGROUND: Patient adherence, the level of asthma self-management skills, exposure to stress, and depression can have considerable influence on a wide range of asthma outcomes and thus are considered asthma outcome mediators. OBJECTIVE: National Institutes of Health institutes and other federal agencies convened an expert group to recommend standardized measures for 7 domains of asthma clinical research outcomes measures. Although the review of mediators of these outcomes was not within the scope of any specific outcome topic, a brief summary is presented so that researchers might consider potential mediators. METHODS: We prepared a summary of key mediators of asthma outcomes based on expertise and knowledge of the literature. RESULTS: The rationale for including measures of adherence, self-management skills, and exposures to stress in asthma clinical research is presented, along with a brief review of instruments for collecting this information from clinical research participants. CONCLUSIONS: Appropriate measurement of adherence, self-management skills, and exposures to stress will enhance characterization of study participants and provide information about the potential impact these factors can have on mediating the effects of treatment interventions.

Asthma outcomes: quality of life.

BACKGROUND: "Asthma-related quality of life" (QOL) refers to the perceived impact that asthma has on the patient's QOL. OBJECTIVE: National Institutes of Health institutes and other federal agencies convened an expert group to recommend standardized measures of the impact of asthma on QOL for use in future asthma clinical research. METHODS: We reviewed published documentation regarding the development and psychometric evaluation; clinical research use since 2000; and extent to which the content of each existing QOL instrument provides a unique, reliable, and valid assessment of the intended construct. We classified instruments as core (required in future studies), supplemental (used according to the study's aims and standardized), or emerging (requiring validation and standardization). This work was discussed at an National Institutes of Health-organized workshop convened in March 2010 and finalized in September 2011. RESULTS: Eleven instruments for adults and 6 for children were identified for review. None qualified as core instruments because they predominantly measured indicators of asthma control (symptoms and/or functional status); failed to provide a distinct, reliable score measuring all key dimensions of the intended construct; and/or lacked adequate psychometric data. CONCLUSIONS: In the absence of existing instruments that meet the stated criteria, currently available instruments are classified as either supplemental or emerging. Research is strongly recommended to develop and evaluate instruments that provide a distinct, reliable measure of the patient's perception of the impact of asthma on all of the key dimensions of QOL, an important outcome that is not captured in other outcome measures.

Duration of a well-child visit: association with content, family-centeredness, and satisfaction.

BACKGROUND: Studies of pediatric primary care suggest that time is an important limitation to the delivery of recommended preventive services. Given the increasingly frenetic pace of pediatric practice, there is an increased need to monitor the length of pediatric visits and the association of visit length with content, family-centered care, and parent satisfaction with care. OBJECTIVE: To examine the length of well-child visits and the associations of visit length with content, family-centered care, and parent satisfaction among a national sample of children. METHODS: We conducted a cross-sectional telephone survey of parents of children aged 4 to 35 months from the 2000 National Survey of Early Childhood Health (n = 2068). RESULTS: One-third (33.6%) of parents reported spending ≤ 10 minutes with the clinician at their last well-child visit, nearly half (47.1%) spent 11 to 20 minutes, and 20.3% spent >20 minutes. Longer visits were associated with more anticipatory guidance, more psychosocial risk assessment, and higher family-centered care ratings. A visit of >20 minutes was associated with 2.4 (confidence interval [CI]: 1.5-3.7) higher odds of receiving a developmental assessment, 3.2 (CI: 1.7-6.1) higher odds of recommending the clinician, and 9.7 (CI: 3.5-26.5) higher odds of having enough time to ask questions. CONCLUSIONS: Many well-child visits are of short duration, and shorter visits are associated with reductions in content and quality of care and parent satisfaction with care. Efforts to improve preventive services will require strategies that address the time devoted to well-child care. The results of this study should be interpreted in light of changes in practice standards, reimbursement, and outcome measurement that have taken place since 2000 and the limitations of the measurement of utilization solely on the basis of parent report.

Trends in the use of standardized tools for developmental screening in early childhood: 2002-2009.

BACKGROUND: Early identification of developmental delays is essential for optimal early intervention. An American Academy of Pediatrics (AAP) 2002 Periodic Survey of Fellows found <25% of respondents consistently used appropriate screening tools. Over the past 5 years, new research and education programs promoted screening implementation. In 2006, the AAP issued a revised policy statement with a detailed algorithm. Since the 2002 Periodic Survey, no national surveys have examined the effectiveness of policy, programmatic, and educational enhancements. OBJECTIVE: The goal of this study was to compare pediatricians' use of standardized screening tools from 2002 to 2009. METHODS: A national, random sample of nonretired US AAP members were mailed Periodic Surveys (2002: N=1617, response rate: 55%; 2009: N=1620, response rate: 57%). χ(2) analyses were used to examine responses across survey years; a multivariate logistic regression model was developed to compare differences in using ≥1 formal screening tools across survey years while controlling for various individual and practice characteristics. RESULTS: Pediatricians' use of standardized screening tools increased significantly between 2002 and 2009. The percentage of those who self-reported always/almost always using ≥1 screening tools increased over time (23.0%-47.7%), as did use of specific instruments (eg, Ages & Stages Questionnaire, Parents' Evaluation of Developmental Status). No differences were noted on the basis of physician or practice characteristics. CONCLUSIONS: The percentage of pediatricians who reported using ≥1 formal screening tools more than doubled between 2002 and 2009. Despite greater attention to consistent use of appropriate tools, the percentage remains less than half of respondents providing care to patients younger than 36 months. Given the critical importance of developmental screening in early identification, evaluation, and intervention, additional research is needed to identify barriers to greater use of standardized tools in practice.