Tele-assessment of young children referred for autism spectrum disorder evaluation during COVID-19: Associations among clinical characteristics and diagnostic outcome.

LAY ABSTRACT: The diagnosis of autism spectrum disorder (ASD) has traditionally been made through in-person evaluation. While the COVID-19 pandemic disrupted access to ASD services, there has been remarkable growth in research focused on novel ASD diagnostic practices, including the use of telemedicine. We implemented a standard ASD tele-assessment evaluation procedure, including use of a novel remote clinician-coached, caregiver-delivered ASD assessment tool (TELE-ASD-PEDS; TAP), with the goal of continuing to provide diagnostic services to young children and their families during the pandemic. We examined the relationship between child characteristics and diagnostic outcome for 335 children, ages 14-78 months, who received ASD tele-assessment conducted by psychologists and pediatricians in an outpatient clinic of a Midwestern academic medical center. We found that clinicians could make a determination about ASD diagnosis for most children (85%) evaluated using tele-assessment. Child clinical characteristics, including TAP scores and clinician ratings of ASD symptoms, were related to diagnostic outcome (i.e. diagnosis of ASD, no ASD, and Unsure about ASD). When all clinical characteristics were examined together, the presence of specific repetitive behaviors predicted ASD diagnosis. We also found that the TAP is effective for making an ASD diagnosis when used as part of comprehensive tele-assessment evaluation in children ⩾ 36 months of age with delayed language. Our study adds to an increasing body of research supporting use of tele-assessment for diagnosis of ASD. Although further research is needed, telemedicine may help families from different backgrounds and geographic locations to access high-quality diagnostic services.

Virtual Developmental Screening After Invasive Mechanical Ventilation in Children: A Prospective Cohort Pilot Study.

OBJECTIVES: With decreasing PICU mortality, survivor morbidity has increased. This study aims to evaluate feasibility of virtual PICU-led follow-up of patients at risk for pediatric postintensive care syndrome. DESIGN: Prospective cohort study. SETTING: Single-center, quaternary children's hospital. PATIENTS: Children less than or equal to 4 years without known preexisting neurodevelopmental deficits requiring greater than or equal to 12 hours mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age-appropriate Ages and Stages Questionnaires, Third Edition (ASQ-3) were administered via a web-based system at 3, 6, and 12 months following PICU discharge. Primary-care physicians were notified of results; at-risk patients were referred to early developmental intervention. Forty-eight patients enrolled with median age 11.5 months (interquartile range [IQR], 2-19.5 mo) and median mechanical ventilation duration 92.5 hours (IQR, 40.5-147 hr). Fifty-eight percent completed greater than or equal to 1 ASQ-3. Lower caregiver educational achievement, lower income, and single-caregiver status were associated with lower ASQ-3 completion rates. Of those completing any ASQ-3, 50% flagged as at-risk for developmental delay and referred to early developmental intervention. There was no association between patient characteristics and abnormal ASQ-3. CONCLUSIONS: Virtual caregiver-completed surveillance is a promising method to screen children for neurodevelopmental abnormalities following PICU hospitalization and facilitate early referral for developmental intervention, but special attention must be dedicated to families with limited resources for follow-up.

A Statewide Tiered System for Screening and Diagnosis of Autism Spectrum Disorder.

Although autism spectrum disorder (ASD) can be reliably detected in the second year of life, the average age of diagnosis is 4 to 5 years. Limitations in access to timely ASD diagnostic evaluations delay enrollment in interventions known to improve developmental outcomes. As such, developing and testing streamlined methods for ASD diagnosis is a public health and research priority. In this report, we describe the Early Autism Evaluation (EAE) Hub system, a statewide initiative for ASD screening and diagnosis in the primary care setting. Development of the EAE Hub system involved geographically targeted provision of developmental screening technical assistance to primary care, community outreach, and training primary care clinicians in ASD evaluation. At the EAE Hubs, a standard clinical pathway was implemented for evaluation of children, ages 18 to 48 months, at risk for ASD. From 2012 to 2018, 2076 children were evaluated (mean age: 30 months; median evaluation wait time: 62 days), and 33% of children received a diagnosis of ASD. Our findings suggest that developing a tiered system of developmental screening and early ASD evaluation is feasible in a geographic region facing health care access problems. Through targeted delivery of education, outreach, and intensive practice-based training, large numbers of young children at risk for ASD can be identified, referred, and evaluated in the local primary care setting. The EAE Hub model has potential for dissemination to other states facing similar neurodevelopmental health care system burdens. Implementation lessons learned and key system successes, challenges, and future directions are reviewed.

Fluoride in the diet of 2-years-old children.

OBJECTIVES: This study aimed to calculate the fluoride concentrations of commonly consumed foods and beverages for 2-years-old children utilizing market basket information for the US Midwest region. METHODS: Total Diet Study food lists were cross-referenced with National Health and Nutrition Examination Survey-What We Eat in America data to determine the foods and beverages to be included. Fluoride concentrations were determined using a modification of the hexamethyldisiloxane microdiffusion technique. Fluoride concentrations were summarized for each of the food categories. Daily dietary fluoride intake was estimated using a simulation analysis. RESULTS: Food and beverage fluoride concentrations varied widely, ranging from nondetectable for some oils and dairy products to more than 3.0 µgF/g food for some processed meats, fish and fruits. The estimated mean (±SD) daily dietary fluoride intake, excluding dentifrice and supplements, was 412±114 µgF/d. The estimated average ingestion for a 2-years-old weighing 12.24 kg was 0.034±0.009 mg/kg/d. A diet based on foods and beverages in the fifth percentile of fluoride intake distribution for an average child would result in 247 µgF/d or 0.020 mg/kg/d, while a diet with foods and beverages in the 95th percentile would result in a total intake of 622 µgF/d or 0.051 mg/kg/d. CONCLUSIONS: The fluoride concentrations of foods and beverages vary widely, and, if items in the 95th percentile of fluoride intake distribution are ingested, children could consume more fluoride than the recommended 0.05 mg/kg/d. Fluoride intake calculated in this study was higher than historically reported dietary levels.

REFLECTION IN HOME VISITING: THE WHAT, WHY, AND A BEGINNING STEP TOWARD HOW.

The work of home visitors in early childhood fields may include addressing many challenges to achieving curricular outcomes, including issues such as maintaining boundaries and managing one's own reactions to children, parents, and overall family situations. Increasingly, reflective supervision and consultation are recognized as a way for workers in home-visiting early intervention and early care fields to address these personal and professional challenges and build competence (Watson, Gatti, Cox, Harrison, & Hennes, ). The features of home visiting that make reflective supervision/consultation essential are discussed. Next, results of a pilot project in which a sample of Part C early intervention providers respond to a vignette portraying a challenging parent-child interaction are briefly presented and discussed. Despite often stating the importance of relationships, participants did not identify concrete methods of supporting relationship or demonstrate recognition of parallel process. In addition, providers seldom endorsed the use of reflective skills such as observing, listening, wondering, or reflecting (Weatherston, ), and no providers discussed a need for reflective supervision/consultation. We suggest that these findings illustrate some of the areas in which early intervention home visitors could benefit from participation in reflective supervision/consultation to move from identifying reflective skills as important to actually being able to use such skills in their work with families.

Behavior Assessment in Children Following Hospital-Based General Anesthesia versus Office-Based General Anesthesia.

The purpose of this study was to determine if differences in behavior exist following dental treatment under hospital-based general anesthesia (HBGA) or office-based general anesthesia (OBGA) in the percentage of patients exhibiting positive behavior and in the mean Frankl scores at recall visits. This retrospective study examined records of a pediatric dental office over a 4 year period. Patients presenting before 48 months of age for an initial exam who were diagnosed with early childhood caries were included in the study. Following an initial exam, patients were treated under HBGA or OBGA. Patients were followed to determine their behavior at 6-, 12- and 18-month recall appointments. Fifty-four patients received treatment under HBGA and 26 were treated under OBGA. OBGA patients were significantly more likely to exhibit positive behavior at the 6- and 12-month recall visits p = 0.038 & p = 0.029). Clinicians should consider future behavior when determining general anesthesia treatment modalities in children with early childhood caries presenting to their office.

Critical components of reflective supervision: responses from expert supervisors in the field.

This article offers a brief review of the history of supervision, defines reflective supervision, and reports the results of a Delphi study designed to identify critical components of reflective supervision. Academicians and master clinicians skilled in providing reflective supervision participated in a three-phase survey to elicit beliefs about best practice when engaging in reflective supervision. The process yielded consensus descriptions of optimal characteristics and behaviors of supervisors and supervisees when entering into supervisory relationships that encourage reflective practice. These results, although preliminary, suggest that it is possible to identify elements that are integral to effective reflective supervision. These initial findings may be used for future study of the reflective supervisory process.

Fluoride content of infant foods.

Excessive fluoride consumption during the first 2 years of life is associated with an increased risk of dental fluorosis. Estimates of fluoride intake from various sources may aid in determining a child's risk for developing fluorosis. This study sought to assess the fluoride content of commercially available foods for infants, and to guide dentists who are advising parents of young children about fluoride intake. Three samples each of 20 different foods (including fruits and vegetables, as well as chicken, turkey, beef/ham, and vegetarian dinners) from 3 manufacturers were analyzed (in duplicate) for their fluoride content. Among the 360 samples tested, fluoride concentration ranged from 0.007-4.13 µg fluoride/g food. All foods tested had detectable amounts of fluoride. Chicken products had the highest mean levels of fluoride, followed by turkey products. Consuming >1 serving per day of the high fluoride concentration products in this study would place children over the recommended daily fluoride intake. Fluoride from infant foods should be taken into account when determining total daily fluoride intake.

Factors influencing behavior guidance: a survey of practicing pediatric dentists.

PURPOSE: The purpose of this study was to identify factors influencing behavior guidance technique utilization among practicing pediatric dentists and explore potential barriers to the incorporation of previously unused techniques. METHODS: The data for this study were obtained from a web-based survey containing 15 multiple choice questions concerning the practitioners' past, current, and anticipated future behavior guidance technique utilization. RESULTS: Most respondents received hands-on training in 10 of the American Academy of Pediatric Dentistry behavior guidance techniques. The type of training was associated with the practitioners' level of comfort using a given technique upon graduation and with the current frequency of technique utilization. Residency type impacted hands-on behavior guidance training, with 39 percent of respondents reporting no intravenous sedation training. The type of practice was associated with the frequency of behavior guidance technique utilization, as was graduation decade. Currently practicing dentists cited legal concerns, parental acceptance to change, and limited resources as perceived obstacles in the incorporation of new techniques. CONCLUSIONS: Behavior guidance technique selection and utilization among practicing pediatric dentists was influenced by multiple factors, including advanced education training, residency type, graduation decade, and practice type. Obstacles to the incorporation of previously unused techniques appear to be multifactorial.

Demand in pediatric dentistry for sedation and general anesthesia by dentist anesthesiologists: a survey of directors of dentist anesthesiologist and pediatric dentistry residencies.

This study describes what training programs in pediatric dentistry and dental anesthesiology are doing to meet future needs for deep sedation/general anesthesia services required for pediatric dentistry. Residency directors from 10 dental anesthesiology training programs in North America and 79 directors from pediatric dentistry training programs in North America were asked to answer an 18-item and 22-item online survey, respectively, through an online survey tool. The response rate for the 10 anesthesiology training program directors was 9 of 10 or 90%. The response rate for the 79 pediatric dentistry training program directors was 46 of 79 or 58%. Thirty-seven percent of pediatric dentistry programs use clinic-based deep sedation/general anesthesia for dental treatment in addition to hospital-based deep sedation/general anesthesia. Eighty-eight percent of those programs use dentist anesthesiologists for administration of deep sedation/general anesthesia in a clinic-based setting. Pediatric dentistry residency directors perceive a future change in the need for deep sedation/general anesthesia services provided by dentist anesthesiologists to pediatric dentists: 64% anticipate an increase in need for dentist anesthesiologist services, while 36% anticipate no change. Dental anesthesiology directors compared to 2, 5, and 10 years ago have seen an increase in the requests for dentist anesthesiologist services by pediatric dentists reported by 56% of respondents (past 2 years), 63% of respondents (past 5 years), and 88% of respondents (past 10 years), respectively. Predicting the future need of dentist anesthesiologists is an uncertain task, but these results show pediatric dentistry directors and dental anesthesiology directors are considering the need, and they recognize a trend of increased need for dentist anesthesiologist services over the past decade.

The use of office-based sedation and general anesthesia by board certified pediatric dentists practicing in the United States.

The purpose of this study is to explore the use of office-based sedation by board-certified pediatric dentists practicing in the United States. Pediatric dentists have traditionally relied upon self-administered sedation techniques to provide office-based sedation. The use of dentist anesthesiologists to provide office-based sedation is an emerging trend. This study examines and compares these two models of office-based sedations. A survey evaluating office-based sedation of diplomates of the American Board of Pediatric Dentistry (ABPD) based on gender, age, years in practice, practice types, regions, and years as a diplomate of the ABPD was completed by 494 active members. The results were summarized using frequencies and percentages. Relationships of dentist age, gender, and number of years in practice with the use of intravenous (IV) sedation was completed using two-way contingency tables and Mantel-Haenszel tests for ordered categorical data. Relationships of office-based sedation use and the type of one's practice were examined using Pearson chi-square tests. Of the 1917 surveys e-mailed, 494 completed the survey for a response rate of 26%. Over 70% of board-certified US pediatric dentists use some form of sedation in their offices. Less than 20% administer IV sedation, 20 to 40% use a dentist anesthesiologist, and 60 to 70% would use dentist anesthesiologists if one were available.

Fracture resistance of 3 types of primary esthetic stainless steel crowns.

BACKGROUND AND OBJECTIVE: Demand is increasing for esthetic restorations in pediatric dentistry. When full coverage is indicated, one option is to use esthetic stainless steel crowns (SSCs). However, this type of crown is prone to fracture. The purpose of this study was to evaluate the fracture resistance of 3 types of esthetic SSCs. MATERIALS AND METHODS: Esthetic SSCs for first primary mandibular molars were cemented to idealized epoxy dies with glass ionomer cement. The die-crown units were fractured on a universal testing machine. The force was delivered by a stainless steel ball fixture, set in a uniaxial lever to replicate a cusp contact, with a crosshead speed of 1 mm/min. The differences among the 3 types of crown, in terms of force required to fracture, were compared statistically by 1-way analysis of variance. Pairwise comparisons were performed with Fisher's protected least significant difference test, at an overall significance level of 5%. RESULTS: The force required to fracture, expressed as average ± standard error, did not differ significantly among the 3 brands of esthetic SSCs: 1730 N ± 50 N, 1826 N ± 62 N and 1671 N ± 68 N, respectively (p = 0.19), well below the maximum bite force of pediatric patients determined in a previous study. CONCLUSION: Esthetic SSCs should be able to resist occlusal forces over short clinical periods. However, long-term occlusal loading and fatigue failures should be taken into account when evaluating the success of this type of crown.

Fluoride content of water used to reconstitute infant formula.

OBJECTIVE: To assess the fluoride content of water used to reconstitute infant formula by a Latino population living in the Indianapolis, Indiana, area. BACKGROUND: Negligible as well as excessive fluoride can be detrimental to oral health. Estimates of fluoride intake and exposure for individuals may aid in the determination of their risk for developing dental fluorosis or caries. METHODS: Interviews were conducted to determine brands of bottled water used to reconstitute infant formula. Identified brands were analyzed for fluoride concentration. RESULTS: Of the 458 samples tested (from 20 brands), fluoride concentration ranged from 0.006 to 0.740 µg/mL. All brands but one had fluoride concentration less than 0.7 µg/mL, with 16 brands having less than 0.22 µg/mL. Most bottled waters analyzed in the study comply with the American Dental Association recommendation to prevent fluorosis. Comparisons made demonstrated that only waters targeted for infants and that are fluoridated do not comply with recent American Dental Association recommendations.

Pediatrician's role in children's oral health: an Indiana survey.

OBJECTIVES: To evaluate Indiana pediatricians' current practices related to oral health, knowledge of oral health prevention, and opinions on anticipatory guidance integration into their practices. BACKGROUND: The American Academy of Pediatrics (AAP) May 2003 policy statement on oral health risk assessment timing and establishment of a dental home has provided pediatricians with guidelines to assess patients' oral health and caries risk status. METHODS: A survey of 31 questions was distributed via mail to all active Indiana pediatricians (300) registered in the Indiana State Medical Association to evaluate current practices relating to oral health prevention and guidance. RESULTS: Of the 300 distributed surveys, 138 were returned (46%). The authors found that 15% of pediatricians recognize the AAP-recommended age for a dental home as 12 months and practice this recommendation. Among the respondents, 7% believe application of fluoride should be part of a well-child visit. The majority (89%) of respondents reported interest in obtaining further knowledge on oral health.

Observe, listen, wonder, and respond: A preliminary exploration of reflective function skills in early care providers.

Parents' behaviors demonstrating reflective capacity towards their children, parental reflective functioning, have been identified as central to both the formation of a secure attachment and therapeutic efforts to remediate attachment problems (Fonagy & Target, 2005; Sadler, Slade, & Mayes, 2006). We hypothesize that reflective skills in providers may be key elements in effecting change through the parent-professional relationship. As a first step, the present study examined early care and intervention providers' self-report of the importance of reflective practice skills in their work with families of young children. We further examined whether provider characteristics such as professional affiliation and experience related to importance ratings. Lastly, we examined, in a preliminary fashion, whether provider valuing of reflective functioning skills is associated with reported practice using hypothetical vignettes drawn from common home-visiting scenarios.

Effect on behavior of dental treatment rendered under conscious sedation and general anesthesia in pediatric patients.

PURPOSE: The purpose of this study was to determine if there were differences in the amount of time it took to exhibit positive behavior following dental treatment under general anesthesia (GA) vs conscious sedation (CS). METHODS: This retrospective study examined charts of a pediatric dental office between 1999 to 2003. Patients presenting before 36 months old for an initial exam who were diagnosed with early childhood caries were included in the study. Following the initial exam, the patients were treated under GA or CS. These patients were followed to determine their behavior at the 6-, 12-, and 18-month recoil appointments. RESULTS: Thirty-nine patients who received treatment under GA were identified and 41 were treated under CS. The former were 3.9 times (P < .01) (P = .0057) more likely to exhibit positive behavior at the 6-month recall appointment. Although not statistically significant, a trend toward positive behavior was exhibited at the 12- and 18-month appointments. CONCLUSION: Clinicians should consider future behavior, in addition to caries, when determining treatment modalities for children presenting to their office with dental caries.