The TREE Program: Promoting Positive Early Childhood Experiences During Well-Child Visits.

This feasibility study evaluated the developmental coaching TREE (Talk Read Engage Encourage) program for historically marginalized children ages 0 to 2 years, embedded within pediatric visits, examining if TREE could enhance caregiver-child interactions and increase pediatric resident report of competency and self-efficacy in coaching caregivers. Using a quasi-experimental design, a convenience sample (n = 167 families) was recruited (79 intervention; 88 control). Follow-up data were obtained from 45% of families (38 intervention; 38 control), impacted by COVID-19 attendance. Analyses demonstrated significant increases in self-reported Parent Verbal Responsivity (d = 0.68; 95% confidence interval [CI] = 0.17 to 1.18; P = .009) by intervention group caregivers. Intervention pediatric residents reported significant increases in promoting positive caregiver-child interactions and confidence in conveying child development (d = -.73; 95% CI = -1.21 to -0.22; P = .003). The TREE program is a promising practice that operationalizes promotion of relational health and positive early childhood experiences within pediatric primary care.

Initial Medical Assessment of Possible Child Sexual Abuse: History, History, History.

Primary care professionals (PCPs) can play a valuable role in the initial assessment of possible child sexual abuse (CSA), an all too prevalent problem. PCPs, however, are often reluctant to conduct these assessments. The goal of this paper is to help PCPs be more competent and comfortable playing a limited but key role. This is much needed as there may be no need for further assessment and also because of a relative paucity of medical experts in this area. While some children present with physical problems, the child's history is generally the critical information. This article therefore focuses on practical guidance regarding history-taking when CSA is suspected, incorporating evidence from research on forensic interviewing. We have been mindful of the practical constraints of a busy practice and the role of the public agencies in fully investigating possible CSA. The approach also enables PCPs to support children and their families.

Recovery in Young Children with Weight Faltering: Child and Household Risk Factors.

OBJECTIVE: To examine whether weight recovery among children with weight faltering varied by enrollment age and child and household risk factors. STUDY DESIGN: Observational, conducted in an interdisciplinary specialty practice with a skill-building mealtime behavior intervention, including coaching with video-recorded interactions. Eligibility included age 6-36 months with weight/age

The Effectiveness of Food Insecurity Screening in Pediatric Primary Care.

BACKGROUND: Food insecure children are at increased risk for medical and developmental problems. Effective screening and intervention are needed. METHODS: Our purpose was to (1) evaluate the validity and stability of a single item food insecurity (FI) screen. (2) Assess whether use may lead to decreased FI. Part of a larger cluster randomized controlled trial, pediatric residents were assigned to SEEK or control groups. A single FI question (part of a larger questionnaire) was used on SEEK days. SEEK residents learned to screen, assess, and address FI. A subset of SEEK and control clinic parents was recruited for the evaluation. Parents completed the USDA Food Security Scale ("gold standard"), upon recruitment and 6-months later. Validity, positive and negative predictive values (PPV, NPV) was calculated. The proportion of screened families with initial and subsequent FI was measured. Screening effectiveness was evaluated by comparing SEEK and control screening rates and receipt of Supplemental Nutrition Assistance Program (SNAP) benefits between initial and 6-month assessments. RESULTS: FI screen stability indicated substantial agreement (Cohen's kappa =0.69). Sensitivity and specificity was 59% and 87%, respectively. The PPV was 70%; NPV was 81%. SEEK families had a larger increase in screening rates than control families (24% vs. 4.1%, p<0.01). SEEK families were more likely to maintain SNAP enrollment (97% vs. 81%, p=0.05). FI rates remained stable at approximately 30% for both groups. CONCLUSIONS: A single question screen can identify many families with FI, and may help maintain food program enrollment. Screening may not be adequate to alleviate FI.

Training pediatric residents in a primary care clinic to help address psychosocial problems and prevent child maltreatment.

OBJECTIVE: The objectives of this study were to determine whether 1) residents trained in the SEEK (A Safe Environment for Every Kid) model would report improved attitudes, knowledge, comfort, competence, and practice regarding screening for psychosocial risk factors (parental depression, parental substance abuse, intimate partner violence, stress, corporal punishment, and food insecurity); 2) intervention residents would be more likely to screen for and assess those risk factors; and 3) families seen by intervention residents would report improved satisfaction with their child's doctor compared to families receiving standard care from control residents. METHODS: Pediatric residents in a university-based pediatrics continuity clinic were enrolled onto a randomized controlled trial of the SEEK model. The model included resident training about psychosocial risk factors, a Parent Screening Questionnaire, and a study social worker. Outcome measures included: 1) residents' baseline, 6-month, and 18-month posttraining surveys, 2) medical record review, and 3) parents' satisfaction regarding doctor-parent interaction. RESULTS: Ninety-five residents participated. In 4 of 6 risk areas, intervention residents scored higher on the self-assessment compared to control subjects, with sustained improvement at 18 months. Intervention residents were more likely than control subjects to screen and assess parents for targeted risk factors. Parents seen by intervention residents responded favorably regarding interactions with their doctor. CONCLUSIONS: The SEEK model helped residents become more comfortable and competent in screening for and addressing psychosocial risk factors. The benefits were sustained. Parents viewed the intervention doctors favorably. The model shows promise as a way of helping address major psychosocial problems in pediatric primary care.

Screening for harsh punishment in a pediatric primary care clinic.

OBJECTIVES: To determine: (1) the prevalence of harsh punishment among parents in a pediatric clinic, and (2) the sensitivity, specificity, predictive values, and stability of a brief screening measure. METHODS: A subset of families involved in a study of child maltreatment prevention were recruited for this study. Two items in a parent screening questionnaire (PSQ) were related to child punishment. Comparisons were made between parents' responses on the PSQ and on the Parent-Child Conflict Tactic Scale (CTSPC). RESULTS: On the PSQ, 7% of parents of infants and 32% of parents of toddlers/preschoolers reported that their child was difficult to take care of or needed to be hit or spanked. On the CTSPC, 14% of the infants had experienced physical assault and 21% psychological aggression. For older children, subscales were modified to exclude common discipline measures, resulting in 20% experiencing physical assault and 19% psychological aggression. Sensitivities for the PSQ were relatively poor for infants, but moderate for older children. Specificities were good. Stability was adequate. CONCLUSIONS: Harsh punishment experienced by older children was similar to that in published studies. Punishment of infants is concerning. The PSQ can be used to screen out parents who are not using harsh discipline measures. PRACTICE IMPLICATIONS: The PSQ has variable utility in determining which families are using harsh punishment. Until the measure can be further refined, universal counseling is needed.

Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) Model.

CONTEXT: Effective strategies for preventing child maltreatment are needed. Few primary care-based programs have been developed, and most have not been well evaluated. OBJECTIVE: Our goal was to evaluate the efficacy of the Safe Environment for Every Kid model of pediatric primary care in reducing the occurrence of child maltreatment. METHODS: A randomized trial was conducted from June 2002 to November 2005 in a university-based resident continuity clinic in Baltimore, Maryland. The study population consisted of English-speaking parents of children (0-5 years) brought in for child health supervision. Of the 1118 participants approached, 729 agreed to participate, and 558 of them completed the study protocol. Resident continuity clinics were cluster randomized by day of the week to the model (intervention) or standard care (control) groups. Model care consisted of (1) residents who received special training, (2) the Parent Screening Questionnaire, and (3) a social worker. Risk factors for child maltreatment were identified and addressed by the resident physician and/or social worker. Standard care involved routine pediatric primary care. A subset of the clinic population was sampled for the evaluation. Child maltreatment was measured in 3 ways: (1) child protective services reports using state agency data; (2) medical chart documentation of possible abuse or neglect; and (3) parental report of harsh punishment via the Parent-Child Conflict Tactics scale. RESULTS: Model care resulted in significantly lower rates of child maltreatment in all the outcome measures: fewer child protective services reports, fewer instances of possible medical neglect documented as treatment nonadherence, fewer children with delayed immunizations, and less harsh punishment reported by parents. One-tailed testing was conducted in accordance with the study hypothesis. CONCLUSIONS: The Safe Environment for Every Kid (SEEK) model of pediatric primary care seems promising as a practical strategy for helping prevent child maltreatment. Replication and additional evaluation of the model are recommended.

Screening for intimate partner violence in a pediatric primary care clinic.

OBJECTIVES: To estimate the prevalence of intimate partner violence among parents at a pediatric primary care clinic and to evaluate the stability, sensitivity, specificity, positive and negative predictive values, and likelihood ratios of a very brief screen for intimate partner violence. METHODS: A total of 200 parents (mostly mothers) bringing in children less than 6 years of age for child health supervision completed the Parent Screening Questionnaire in a primary care clinic. The Parent Screening Questionnaire, a brief screen for psychosocial problems developed for the study, includes 3 questions on intimate partner violence. Mothers then completed the computerized study protocol within 2 months. This included the Parent Screening Questionnaire as well as the Revised Conflict Tactics Scale. Different combinations of the intimate partner violence questions were evaluated against the Revised Conflict Tactics Scale. RESULTS: A total of 12.0% of the mothers answered "yes" to at least one of the screening questions. On the standardized Revised Conflict Tactics Scale, responses ranged from 9% reporting a physical injury in the past year to 76% reporting psychological aggression. There was moderate stability of the screening questions. A single question, "Have you ever been in a relationship in which you were physically hurt or threatened by a partner?" in relation to the "physically injured" Revised Conflict Tactics Scale subscale was most effective. Sensitivity was 29%, specificity was 92%, positive predictive value was 41%, and negative predictive value was 88%. The positive likelihood ratio was 3.8, and the negative likelihood ratio was 0.77. CONCLUSIONS: Intimate partner violence is a prevalent problem. A very brief screen can reasonably identify some mothers who could benefit from additional evaluation and possible services. Additional research is needed to find a more sensitive screen and to examine whether identifying intimate partner violence leads to interventions that benefit mothers, families, and children.

Screening for parental substance abuse in pediatric primary care.

OBJECTIVE: Parental alcohol and drug abuse may have significant deleterious effects on children. Although screening in the pediatric office is recommended, few screening measures have been evaluated for use in this setting. We sought to validate a 2-question screening tool for parental substance abuse. METHODS: A total of 216 caregivers bringing children to a primary care clinic completed a brief screening for psychosocial problems that contained 2 substance abuse questions. To assess reliability and validity of the questionnaire, recruited caregivers returned within 2 months to complete a computerized study protocol that contained the brief screening questions and the substance abuse sections of the Composite International Diagnostic Inventory (CIDI). RESULTS: Sixteen percent of caregivers acknowledged a problem with drugs or alcohol on the CIDI. A "yes" response to either screening question had a sensitivity of 29%, specificity of 95%, positive predictive value of 17%, and negative predictive value of 98% for drug abuse. Values were 13%, 96%, 33%, and 87%, respectively for predicting alcohol abuse. CONCLUSIONS: Brief screening in pediatric primary care can identify many, but not all, parents who may need intervention for problems with drugs and/or alcohol. Children should benefit from such screening if it enables parents to acknowledge and receive treatment for substance abuse. Further research is needed to assess whether sensitivity of screening can be improved without sacrificing brevity.

Screening for depression in an urban pediatric primary care clinic.

OBJECTIVES: The goals were to estimate the prevalence of parental depressive symptoms among parents at a pediatric primary care clinic and to evaluate the stability, sensitivity, specificity, and positive and negative predictive values of a very brief screen for parental depression. METHODS: A total of 216 mothers (because 96% of caregivers were mothers, we use this term) bringing in children <6 years of age for child health supervision completed a parent screening questionnaire in a primary care clinic. The parent screening questionnaire, a brief screen for psychosocial problems developed for the study, includes 2 questions on depressive symptoms. Mothers then completed the computerized study protocol within 2 months. This included the parent screening questionnaire as well as the Beck Depression Inventory II. Different combinations of the depression questions were evaluated against Beck Depression Inventory II clinical cutoff values. RESULTS: Twelve percent of the mothers met the Beck Depression Inventory II clinical cutoff value for at least moderate depressive symptoms. There was moderate stability of the screening questions. When a positive response to either or both of the 2 questions was considered, the sensitivity was 74%, the specificity was 80%, the positive predictive value was 36%, and the negative predictive value was 95%. CONCLUSIONS: Maternal depressive symptoms are prevalent. A very brief screen can identify reasonably those who could benefit from additional evaluation and possible treatment. This should benefit mothers, families, and children.

A double-blind, placebo-controlled, pilot study of bovine lactoferrin supplementation in bottle-fed infants.

BACKGROUND: Lactoferrin has an array of biological activities that include growth, immune modulation, and antimicrobial effects. The aim of this randomized, placebo-controlled, double-blind study was to examine the impact of bovine lactoferrin supplementation in infants. PATIENTS AND METHODS: Healthy, formula-fed infants, > or =34 weeks' gestation and < or =4 weeks of age, enrolled in a pediatric clinic. Infants received either formula supplemented with lactoferrin (850 mg/L) or commercial cow milk-based formula (102 mg/L) for 12 months. Growth parameters and information on gastrointestinal, respiratory, and colic illnesses were collected for the infants' first year. Antibodies to immunizations and hematologic parameters were measured at 9 and 12 months. RESULTS: The lactoferrin-enhanced formula was well tolerated. There were significantly fewer lower respiratory tract illnesses, primarily wheezing, in the 26 lactoferrin-fed (0.15 episodes/y) compared with the 26 regular formula-fed (0.5 episodes/y) infants (P < 0.05). Significantly higher hematocrit levels at 9 months (37.1% vs 35.4%; P < 0.05) occurred in the lactoferrin-supplemented group compared with the control formula group. CONCLUSIONS: Lactoferrin supplementation was associated with potentially beneficial outcomes such as significantly fewer lower respiratory tract illnesses and higher hematocrits. Larger, more focused studies in infants are warranted.

Changes in pediatric residents' perceptions of their continuity experience during their training: a national study.

OBJECTIVE: To determine how pediatric residents' perceptions of continuity clinic experiences vary by level of training, after controlling for the effect of continuity setting. METHOD: Cross-sectional survey of pediatric and combined pediatric trainees in US residency programs. RESULTS: Survey responses were received from 1355 residents in 36 training programs. Residents' continuity experiences were in hospital-based and community settings. Numbers of patients seen increased between PGY-1 and PGY-3 years, but not in the PGY-4 and PGY-5 years. Compared to PGY-1 residents, PGY-2 and PGY-3 residents were more likely to report more encounters with established patients, but were not more likely to feel like the primary care provider. There were no significant differences by training level in terms of involvement in panel patients' laboratory results, hospitalizations, or telephone calls, although nursery involvement decreased with increasing training level. Autonomy was directly related to training level. The perception of having the appropriate amount of exposure to practice management issues was low for all respondents. CONCLUSIONS: Residents perceived that they had greater autonomy and continuity with patients as they become more senior, yet they were not more likely to feel like the primary care provider. Lack of increased involvement in key patient care and office responsibilities across training years may reflect a need for changes in resident education. These data may be helpful in formulating recommendations to program directors with regard to determining which Accreditation Council for Graduate Medical Education competencies should be emphasized and evaluated in the continuity experience.

Factors associated with resident satisfaction with their continuity experience.

OBJECTIVE: To identify factors associated with resident satisfaction concerning residents' continuity experience. DESIGN AND METHODS: Continuity directors distributed questionnaires to residents at their respective institutions. Resident satisfaction was defined as satisfied or very satisfied on a Likert scale. The independent variables included 60 characteristics of the continuity experience from 7 domains: 1) patient attributes, 2) continuity and longitudinal issues, 3) responsibility as primary care provider, 4) preceptor characteristics, 5) educational opportunities, 6) exposure to practice management, and 7) interaction with other clinic and practice staff. A stepwise logistic regression model and the Generalized Estimating Equations approach were used. RESULTS: Thirty-six programs participated. Of 1155 residents (71%) who provided complete data, 67% (n = 775) stated satisfaction with their continuity experience. The following characteristics (adjusted odds ratio [OR] and 95% confidence interval [CI]) were found to be most significant: preceptor as good role model, OR = 7.28 ( CI = 4.2, 12.5); appropriate amount of teaching, OR = 3.25 (CI = 2.1, 5.1); involvement during hospitalization, OR = 2.61 (CI = 1.3, 5.2); exposure to practice management, OR = 2.39 (CI = 1.5, 3.8); good balance of general pediatric patients, OR = 2.34 (CI = 1.5, 3.6); resident as patient advocate, OR = 1.74 (CI = 1.2, 2.4); and appropriate amount of nursing support, OR = 1.65 (CI = 1.1, 2.6). Future career choice, type of continuity site, and level of training were not found to be statistically significant. CONCLUSIONS: Pediatric resident satisfaction was significantly associated with 7 variables, the most important of which were the ability of the preceptor to serve as a role model and teacher. The type of continuity site was not significant. Residency programs may use these data to develop interventions to enhance resident satisfaction, which may lead to enhanced work performance and patient satisfaction.

The relationship among violence victimization, witnessing violence, and youth distress.

PURPOSE: To explore whether violence victimization and witness experiences of predominantly African-American, low-income, urban adolescents were associated with distress and whether psychosocial factors contributed to symptomatology. METHODS: Data for this study were obtained from a cross-sectional survey of 349 youth between the ages of 9 and 15 years who resided in any of 10 low-income public housing communities in an East Coast city. Survey instruments assessed exposure to violence, distress symptomatology, youth psychosocial functioning, and family dynamics. Data were analyzed by computing Pearson correlation coefficients and a series of multiple linear regression models. RESULTS: Witnessing violence was related to youth reports of intrusive thoughts and feelings, difficulties with concentration, and vigilant or avoidant behavior. Violence victimization was correlated with feelings of despondency about having either a happy or long life, as well as feelings of being unloved, uncared for, and afraid. Younger youth, boys, and active problem solvers were more likely to report intrusive thoughts. Problematic family communication was related to intrusive thoughts, distraction, feeling a lack of belonging, and expressions of emotional numbing. CONCLUSIONS: The act of witnessing violence may be associated with a set of distinct symptoms. Youth who witness violence also need to be identified so they may be aided in dealing with their distress. Family communication, particularly problematic family communication, and problem solving also contribute to symptomatology.

Unprotected sex among African-American adolescents: a three-year study.

This study examined the cumulative change of unprotected sex over a period of three years among 383 African American youth ages 9 to 15 at baseline who participated in a trial of a Human Immunodeficiency Virus (HIV) risk reduction intervention. Cumulative scores of sexual intercourse and failure to use condoms were compared between intervention and control groups. The results indicate that cumulatively over the three-year period, intervention youth reported significantly lower rates of failure to use a condom. The findings indicate that face-to-face interventions may offer significant cumulative protection from unprotected sex over the long-term.