Developmental Milestone Attainment in US Children Before and During the COVID-19 Pandemic.

Importance: Restrictions related to the COVID-19 pandemic disrupted the lives of young children, but the association between the pandemic and any changes in early childhood developmental milestone achievement in the US remains unclear. Objectives: To determine the association between the COVID-19 pandemic and changes in developmental screening scores among US children aged 0 to 5 years and to investigate whether caregivers self-reported more worries about their children or concerns about children's behavior during the pandemic, regardless of milestone achievement. Design, Setting, and Participants: This was a cohort study using an interrupted time series analysis comparing prepandemic (March 1, 2018, to February 29, 2020), interruption (March 1 to May 31, 2020), and intrapandemic (June 1, 2020, to May 30, 2022) periods among 50 205 children (randomly sampled from a population of 502 052 children) aged 0 to 5 years whose parents or caregivers completed developmental screening at pediatric visits at US pediatric primary care practices participating in a web-based clinical process support system. Exposure: COVID-19 pandemic period. Main Outcomes and Measures: Age-standardized Ages and Stages Questionnaire, Third Edition (ASQ) domain scores (communication, personal-social, problem-solving, gross motor, fine motor), and rate of caregivers' concerns about the child's behavior or worries about the child as measured on the ASQ. Results: A total of 50 205 children (25 852 [51.5%] male; mean [SD] age, 18.6 [16.0] months) and 134 342 ASQ observations were included. In adjusted models, significant age-specific mean score decreases from prepandemic to intrapandemic were observed in communication (-0.029; 95% CI, -0.041 to -0.017), problem-solving (-0.018; 95% CI, -0.030 to -0.006), and personal-social (-0.016; 95% CI, -0.028 to -0.004) domains. There were no changes in fine or gross motor domains prepandemic to intrapandemic. For infants aged 0 to 12 months, similar effect sizes were observed but only for communication (-0.027; 95% CI, -0.044 to -0.011) and problem-solving (-0.018; 95% CI, -0.035 to -0.001). After accounting for age-standardized ASQ scores, caregiver worries about the child increased slightly in the intrapandemic period compared with the prepandemic period (rate ratio, 1.088; 95% CI, 1.036-1.143), but there were no changes in caregiver concerns about the child's behavior. While changes in developmental screening scores were modest (2%-3%), nationwide, this could translate to more than 1500 additional recommended developmental referrals over baseline each month. Conclusions and Relevance: Modest changes in developmental screening scores are reassuring in the short term but may tax an already overburdened developmental behavioral pediatrics infrastructure. Continued attention to developmental surveillance is critical since the long-term population- and individual-level implications of these changes are unclear.

Do Autism-Specific and General Developmental Screens Have Complementary Clinical Value?

Prior studies suggest autism-specific and general developmental screens are complementary for identifying both autism and developmental delay (DD). Parents completed autism and developmental screens before 18-month visits. Children with failed screens for autism (n = 167) and age, gender, and practice-matched children passing screens (n = 241) completed diagnostic evaluations for autism and developmental delay. When referral for autism and/or DD was considered, overall false positives from the autism screens were less frequent than for referral for autism alone. Presence of a failed communication subscale in the developmental screen was a red flag for autism and/or DD. An ordinally-scored autism screen had more favorable characteristics when considering autism and/or DD, yet none of the screens achieved recommended standards at 18 months, reinforcing the need for recurrent screening as autism emerges in early development.

Suicidal Ideation in Adolescents: Understanding Results from Screening with the PHQ-9M and the PSC-17P.

OBJECTIVE: The objective of the study was to help pediatricians understand and respond to suicidal ideation (SI) in adolescents based on data from 2 widely used screening measures that assessed SI and other psychosocial vulnerabilities in a large, national sample. METHODS: Adolescents (ages 11-17 years) completed the Patient Health Questionnaire Modified for Teenagers (PHQ-9M) using the Comprehensive Health and Decision Information System software before their well-child visits. Question 9 asks about past 2-week SI. Their parents filled out the Pediatric Symptom Checklist (PSC-17P), which screens for a broad range of psychosocial problems. Chi-square analyses and one-way analysis of variances assessed the relationship between SI and psychosocial problems. RESULTS: Among 5411 adolescents, 266 (4.9%) reported SI at least several days in the past 2 weeks. Among adolescents with SI, 187 (70.3%) reported moderate to very severe depression on the PHQ-9M (≥10), 68.1% were at risk on at least 1 PSC-17P problem subscale, 59.7% on the PSC-17P internalizing scale, 42.9% on PSC-17P overall, 20.6% on PSC-17P externalizing, and 18.5% on PSC-17P attention. Within the subsample endorsing SI nearly all days, 35.7% had a former suicide attempt. CONCLUSION: The PHQ-9M identifies a clinically heterogeneous subset of approximately 5% of adolescents who report occasional to frequent SI. The PSC-17P corroborates their high degree of overall risk and offers additional information that can help pediatricians assess clinical severity and range of psychosocial problems. Given our limited knowledge of how to predict and prevent an individual adolescent's suicide, the focus of screening should be to identify and help the subset of patients with chronic psychosocial vulnerability of any type.

Autism screening at 18 months of age: a comparison of the Q-CHAT-10 and M-CHAT screeners.

BACKGROUND: Autism screening is recommended at 18- and 24-month pediatric well visits. The Modified Checklist for Autism in Toddlers-Revised (M-CHAT-R) authors recommend a follow-up interview (M-CHAT-R/F) when positive. M-CHAT-R/F may be less accurate for 18-month-olds than 24-month-olds and accuracy for identification prior to two years is not known in samples that include children screening negative. Since autism symptoms may emerge gradually, ordinally scoring items based on the full range of response options, such as in the 10-item version of the Quantitative Checklist for Autism in Toddlers (Q-CHAT-10), might better capture autism signs than the dichotomous (i.e., yes/no) items in M-CHAT-R or the pass/fail scoring of Q-CHAT-10 items. The aims of this study were to determine and compare the accuracy of the M-CHAT-R/F and the Q-CHAT-10 and to describe the accuracy of the ordinally scored Q-CHAT-10 (Q-CHAT-10-O) for predicting autism in a sample of children who were screened at 18 months. METHODS: This is a community pediatrics validation study with screen positive (n = 167) and age- and practice-matched screen negative children (n = 241) recruited for diagnostic evaluations completed prior to 2 years old. Clinical diagnosis of autism was based on results of in-person diagnostic autism evaluations by research reliable testers blind to screening results and using the Autism Diagnostic Observation Schedule-Second Edition (ADOS-2) Toddler Module and Mullen Scales of Early Learning (MSEL) per standard guidelines. RESULTS: While the M-CHAT-R/F had higher specificity and PPV compared to M-CHAT-R, Q-CHAT-10-O showed higher sensitivity than M-CHAT-R/F and Q-CHAT-10. LIMITATIONS: Many parents declined participation and the sample is over-represented by higher educated parents. Results cannot be extended to older ages. CONCLUSIONS: Limitations of the currently recommended two-stage M-CHAT-R/F at the 18-month visit include low sensitivity with minimal balancing benefit of improved PPV from the follow-up interview. Ordinal, rather than dichotomous, scoring of autism screening items appears to be beneficial at this age. The Q-CHAT-10-O with ordinal scoring shows advantages to M-CHAT-R/F with half the number of items, no requirement for a follow-up interview, and improved sensitivity. Yet, Q-CHAT-10-O sensitivity is less than M-CHAT-R (without follow-up) and specificity is less than the two-stage procedure. Such limitations are consistent with recognition that screening needs to recur beyond this age.

What Parents Want Doctors to Know: Responses to an Open-Ended Item on an Asthma Questionnaire.

OBJECTIVE: Unstructured parental comments could solicit important information about children's asthma, yet are rarely captured in clinical asthma questionnaires. This mixed-methods study describes parents' written responses to an open-ended question in a validated asthma questionnaire. METHODS: The Pediatric Asthma Control and Communication Instrument (PACCI) asthma questionnaire was administered to parents of children with asthma symptoms presenting to 48 pediatric primary care offices (PPCP), 1 pediatric pulmonology office, and 1 emergency department (ED). Responses to the question, "Please write down any concern or anything else you would like your doctor to know about your child's asthma" were analyzed using a phenomenological approach until thematic saturation was achieved for each site. Logistic regressions tested whether sociodemographic and clinical characteristics were associated with responding to the open-ended question. RESULTS: Of 7,988 parents who completed the PACCI, 954 (12%) responded to the open-ended question-2% in PPCP, 31% in the ED, and 50% in the pulmonary setting. More severe asthma was associated with higher odds of responding (odds ratio, 2.01; 95% confidence interval, 1.42-2.84). Based on responses provided, we identified 3 communication types: 1) clarifying symptoms, 2) asking questions, and 3) communicating distress. Responses also covered 5 asthma-related themes: 1) diagnostic uncertainty, 2) understanding asthma etiology and prognosis, 3) medication management, 4) impact on child function, and 5) personal asthma characteristics. CONCLUSION: Parents of children with severe asthma provided clarifying details, asked questions, and relayed health concerns and distress. None of these topics may be easily captured by closed-ended asthma questionnaires.

Recognizing Adolescent Depression with Parent- and Youth-Report Screens in Pediatric Primary Care.

OBJECTIVES: To compare the use of the parent-report Pediatric Symptom Checklist (PSC-17P) and youth-report Patient Health Questionnaire-9 Modified for Teens (PHQ-9M) in compliance with recent quality standards for adolescent depression screening. STUDY DESIGN: Parents of 5411 pediatric outpatients (11.0-17.9 years old) completed the PSC-17P, which contains scales that assign categorical risk for overall (PSC-17P-OVR), internalizing (PSC-17P-INT), externalizing (PSC-17P-EXT), and attention (PSC-17P-ATT) problems. Adolescents completed the PHQ-9M, which assesses depressive symptoms. Both forms were completed online within 24 hours of each other before pediatric well-child visits. RESULTS: A total of 9.9% of patients (n = 535) were at risk on the PSC-17P-OVR, 14.3% (n = 775) were at risk on the PSC-17P-INT, and 17.0% (n = 992) were at risk on either or both scales (PSC-17P-OVR and/or PSC-17P-INT). Using the PHQ-9M cut-off score of 10 (moderate-very severe depression), an additional 2.4% (n = 131) were classified as at risk, with 66.8% (n = 263) of all PHQ-9M positives (n = 394) also coded as at risk by the PSC-17P-OVR and/or PSC-17P-INT scales. Using a PHQ-9M cut-off score of 15 (severe-very severe depression), only 29 patients (21.8% of the PHQ-9M positives) not identified by the PSC-17P-OVR and/or PSC-17P-INT were classified as being at risk. CONCLUSIONS: The combined PSC-17P-OVR and/or PSC-17P-INT scales identified 17% of adolescents as at risk for depression, including about two-thirds to three-quarters of adolescents classified as at risk on the PHQ-9M. These findings support using the PSC-17P to meet quality standards for depression as well as overall screening in pediatrics. Primary care clinicians can add the PHQ-9M to identify additional adolescents who may self-report depressive symptoms.

Accurate Autism Screening at the 18-Month Well-Child Visit Requires Different Strategies than at 24 Months.

Accuracy of autism screening using M-CHAT plus the follow-up interview (M-CHAT/F) for children screened positive at 18-months was compared to screening at 24-months. Formal ASD testing was criterion for a community sample of M-CHAT positive children (n = 98), positive predictive value (PPV) was 0.40 for the M-CHAT and 0.58 for the M-CHAT/F. MCHAT/F PPV was 0.69 among children 20+ months compared to 0.36 for <20 months. Multivariate analyses incorporating data from the Ages and Stages Questionnaire, MacArthur-Bates Communicative Development Inventory, M-CHAT and M-CHAT/F results, and M-CHAT items suggest language variables carry greatest relative importance in contributing to an age-based algorithm with potential to improve PPV for toddlers <20 months to the same level as observed in older toddlers.

Comparison of Autism Screening in Younger and Older Toddlers.

This study examined the effect of age at completion of an autism screening test on item failure rates contrasting older (>20 months) with younger (<20 months) toddlers in a community primary care sample of 73,564 children. Items related to social development were categorized into one of three age sets per criteria from Inada et al. (Research in Autism Spectrum Disorders 4(4):605-611, 2010). Younger toddlers produced higher rates of item failure than older toddlers and items in both of the later acquired item sets had higher probability rates for failure than the earliest acquired item set (prior to 8 months). Use of the same items and the same scoring throughout the target age range for autism screening may not be the best strategy for identifying the youngest toddlers at risk for autism.

Use of an Online Clinical Process Support System as an Aid to Identification and Management of Developmental and Mental Health Problems.

PURPOSE OF REVIEW: To describe benefits and problems with screening and addressing developmental and behavioral problems in primary care and using an online clinical process support system as a solution. RECENT FINDINGS: Screening has been found to have various implementation barriers including time costs, accuracy, workflow and knowledge of tools. In addition, training of clinicians in dealing with identified issues is lacking. Patients disclose more to and prefer computerized screening. An online clinical process support system (CHADIS) shows promise in addressing these issues. SUMMARY: Use of a comprehensive panel of online pre-visit screens; linked decision support to provide moment-of-care training; and post-visit activities and resources for patient-specific education, monitoring and care coordination is an efficient way to make the entire process of screening and follow up care feasible in primary care. CHADIS fulfills these requirements and provides Maintenance of Certification credit to physicians as well as added income for screening efforts.

School-based Screening to Identify Children At Risk for Attention-Deficit/Hyperactivity Disorder: Barriers and Implications.

This report describes a school-based screening project to improve early identification of children at risk for attention-deficit/hyperactivity disorder (ADHD) and communicate these concerns to parents, recommending that they contact their child's primary care provider (PCP). Of 17,440 eligible children in first through fifth grades in five school districts, 47.0% of parents provided required written consent, and teachers completed 70.4% of the online screeners (using the Vanderbilt AD/HD Diagnostic Teacher Rating Scale). Of 5,772 screeners completed, 18.1% of children (n = 1,044) were identified as at risk. Parents of at-risk children were contacted to explain risk status and recommended to visit their child's PCP for further evaluation. It was not possible to contact 39.1% of parents of at-risk children. Of the 636 parents of at-risk children who could be contacted, 53.1% (n = 338) verbally accepted the recommendation to follow-up with their PCP, which was not related to ADHD symptom severity. Parents of children with IEPs or related services were more likely to accept the recommendation to visit the PCP. Our exploration of the potential for school-based screening for ADHD identified a number of barriers to successful execution, but the data also indicated that this is an important problem to address.

Autism Screening With Online Decision Support by Primary Care Pediatricians Aided by M-CHAT/F.

BACKGROUND AND OBJECTIVE: Autism spectrum disorders (ASDs) often go undetected in toddlers. The Modified Checklist for Autism in Toddlers (M-CHAT) With Follow-up Interview (M-CHAT/F) has been shown to improve detection and reduce over-referral. However, there is little evidence supporting the administration of the interview by a primary care pediatrician (PCP) during typical checkups. The goal of this study was to evaluate the feasibility, validity, and reliability of the M-CHAT/F by PCPs with online prompts at the time of a positive M-CHAT screen. DESIGN: Forty-seven PCPs from 22 clinics completed 197 M-CHAT/Fs triggered by positive M-CHAT screens via the same secure Web-based platform that parents used to complete M-CHATs before an 18- or 24-month well-child visit. A second M-CHAT/F was administered live or by telephone by trained research assistants (RAs) at the Kennedy Krieger Institute Center for Autism and Related Disorders. The Autism Diagnostic Observation Schedule, Second Edition, and the Mullen Scales of Early Learning were administered as criterion measures. Measures of agreement between PCPs and RAs were calculated, and measures of test performance compared. RESULTS: There was 86.6% agreement between PCPs and RAs, with a Cohen's κ of 0.72. Comparison of sensitivity, specificity, positive predictive value (PPV), and overall accuracy for M-CHAT/F between PCPs and RAs showed significant equivalence for all measures. Use of the M-CHAT/F by PCPs resulted in significant improvement in PPV compared with the M-CHAT alone. CONCLUSIONS: Minimally trained PCPs can administer the M-CHAT/F reliably and efficiently during regular well-child visits, increasing PPV without compromising detection.

The PSC-17: Subscale Scores, Reliability, and Factor Structure in a New National Sample.

BACKGROUND: The Pediatric Symptom Checklist-17 (PSC-17) is a widely used, briefer version of the PSC-35, a parent-completed measure of children's psychosocial functioning. Despite the extensive use of the PSC-17 over the past 15 years there has not been a large-scale replication of the original derivation study. OBJECTIVE: To examine the prevalence of positive screens, reliability, and factor structure of PSC-17 scores in a new national sample and compare them with the derivation sample. METHODS: Data were collected on 80 680 pediatric outpatients, ages 4 to 15 years, whose parents filled out the PSC-17 from 2006 to 2015 via the Child Health and Development Interactive System, an electronic system that presents and scores clinical measures. RESULTS: The rates of positive screening on the overall PSC-17 (11.6%) and on the internalizing (10.4%) and attention (9.1%) subscales were comparable to rates found in the original sample, although the rate of externalizing problems (10.2%) was lower than in the derivation study. Reliability was high (internal consistency 0.89; test-retest 0.85), and a confirmatory factor analysis provided support for the original 3-factor model. CONCLUSIONS: Fifteen years after the PSC-17 was derived in a large nationally representative outpatient pediatric sample, a new and larger national sample found rates of positive screening, reliability, and factor structure that were comparable. Findings from this study support the continued use of the PSC-17 clinically as a screening tool in pediatric settings and in research.

Parents' goals for ADHD care in a clinical pediatric sample.

OBJECTIVE: This report describes goals parents have for their children with attention deficit/hyperactivity disorder (ADHD) when coming for a pediatric visit. METHOD: Data were collected from 441 parents of children presenting to either a primary care pediatric practice or a developmental behavioral pediatric practice. Parents were asked to report their top 1 or 2 goals for improvement for their children, and responses were coded into 17 categories. These categories were further grouped into 7 goal composites and examined in relation to demographic characteristics of the families, office type, and symptomology. RESULTS: Goals related to reducing symptoms of inattention were most common, but goals were heterogeneous in nature. Goals were meaningfully, but modestly, related to symptomology. In several instances, symptoms of comorbid conditions interacted with symptoms of ADHD in relation to specific goals being reported. CONCLUSIONS: Parents' goals extended beyond ADHD symptoms. Pediatricians need an array of resources to address parents' goals.

No technological innovation is a panacea: a case series in quality improvement for primary care mental health services.

Evaluations of quality improvement efforts targeted at mental health services in primary care pediatrics are rare. We evaluated a short-targeted educational session, a Web-based system, the Child Health and Development Interactive System, and a local area mental health services resource guide. Most physicians believed the information in the educational session was at least somewhat likely to change their practice. However, only 9.2% of the families invited to complete the Web-based system did so. Physicians found access to the Web-based system time consuming and, because the billing code for the screening activity was carved out of most of Ohio's privately-insured contract, physicians received no reimbursement for the screenings. Physicians were unenthusiastic about the local resource guide because the resources were not rated for quality. This quality improvement effort demonstrates that there are not easy solutions to practice change and highlights the need for implementation support when introducing new technology.

A proposed adaptation of DC: 0-3R for primary care, developmental research, and prevention of mental disorders.

The development of the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-3; Zero to Three: National Center for Clinical Infant Programs, 1994) has been an important step in the field of infant mental health. In this paper, we propose some additions to the existing classification system. These additions include the development of criteria for infant, toddler, and family strengths, and the development of criteria for symptomatology that represents risk for disorder, but not fully manifest disorder. These additions will give DC: 0-3R greater potential for use in the primary health care of children, thereby increasing the system's utility in diagnosing and preventing infant mental health problems.