Defining Developmental-Behavioral Pediatrics.

There is an insufficient number of specialty developmental-behavioral pediatrics (DBP) physicians, despite nearly 25% of children and adolescents having a developmental, learning, behavioral, or emotional problem. In the nearly 20 years since becoming a board-certified subspecialty, the definition of DBP clinical practice remains somewhat unclear. This lack of clarity likely contributes to recruitment challenges and workforce issues, and limited visibility of DBP among parents, other professionals, payors, and administrators. Defining DBP is therefore an important step in the survival and growth of the field. In this paper, we describe the methodology used to develop this definition along with the origins of DBP, the persistent challenges to defining its scope, what training in DBP involves, and what distinguishes DBP from other overlapping fields of medicine. We propose the following definition of DBP: developmental-behavioral pediatrics (DBP) is a board-certified, medical subspecialty that cares for children with complex and severe DBP problems by recognizing the multifaceted influences on the development and behavior of children and addressing them through systems-based practice and a neurodevelopmental, strength-based approach that optimizes functioning. Developmental behavioral pediatricians care for children from birth through young adulthood along a continuum including those suspected of, at risk for, or known to have developmental and behavioral disorders.

International Interprofessional Collaborative Office Rounds (iiCOR): Addressing Children's Developmental, Behavioral, and Emotional Health Using Distance Technology.

Developmental, behavioral, and emotional issues are highly prevalent among children across the globe. Among children living in low- and middle-income countries, these conditions are leading contributors to the global burden of disease. A lack of skilled professionals limits developmental and mental health care services to affected children globally. Collaborative Office Rounds are interprofessional groups that meet regularly to discuss actual cases from the participants' practices using a non-hierarchical, peer-mentoring approach. In 2017, International Interprofessional Collaborative Office Rounds was launched with several goals: to improve the knowledge and skills of practicing child health professionals in high and low resourced settings regarding developmental and mental health care, to support trainees and clinicians in caring for these children, and to promote best practice in diagnosis and management of these conditions. Five nodes, each comprised of 3-4 different sites with an interprofessional team, from 8 countries in North America, Africa, Asia, and South America met monthly via videoconferencing. This report describes and evaluates the first 2 years' experience. Baseline surveys from participants (N = 141) found that 13 disciplines were represented. Qualitative analysis of 51 discussed cases, revealed that all cases were highly complex. More than half of the cases (N = 26) discussed children with autism or traits of autism and almost all (N = 49) had three or more themes discussed. Frequently occurring themes included social determinants of health (N = 31), psychiatric co-morbidity (N = 31), aggression and self-injury (N = 25), differences with the healthcare provider (N = 17), cultural variation in accepting diagnosis or treatment (N = 19), and guidance on gender and sexuality issues (N = 8). Participants generally sought recommendations on next steps in clinical care or management. A survey of participants after year 1 (N = 47) revealed that 87% (N = 41) had expectations that were completely or mostly met by the program. Our experience of regular meetings of interprofessional groups from different countries using distance-learning technology allowed participants to share on overlapping challenges, meet continuing educational needs while learning about different approaches in high- and low-resourced settings. International Interprofessional Collaborative Office Rounds may prove a useful strategy for increasing the work force capacity for addressing developmental, behavioral, and emotional conditions worldwide. More systematic studies are needed.

Helping Children and Families Deal With Divorce and Separation.

For the past several years in the United States, there have been more than 800 000 divorces and parent separations annually, with over 1 million children affected. Children and their parents can experience emotional trauma before, during, and after a separation or divorce. Pediatricians can be aware of their patients' behavior and parental attitudes and behaviors that may indicate family dysfunction and that can indicate need for intervention. Age-appropriate explanation and counseling for the child and advice and guidance for the parents, as well as recommendation of reading material, may help reduce the potential negative effects of divorce. Often, referral to professionals with expertise in the social, emotional, and legal aspects of the separation and its aftermath may be helpful for these families.

Need and unmet need for care coordination among children with mental health conditions.

OBJECTIVE: To determine prevalence and correlates of need and unmet need for care coordination in a national sample of children with mental health conditions. METHODS: Using data from the 2007 National Survey of Children's Health, we identified children aged 2 to 17 years with ≥1 mental health condition (attention-deficit/hyperactivity disorder, anxiety disorder, conduct disorder, or depression) who had received ≥2 types of preventive or subspecialty health services in the past year. We defined 2 outcome measures of interest: (1) prevalence of need for care coordination; and (2) prevalence of unmet need for care coordination in those with a need. Logistic regression models were used to estimate associations of clinical, sociodemographic, parent psychosocial, and health care characteristics with the outcome measures. RESULTS: In our sample (N = 7501, representing an estimated 5,750,000 children), the prevalence of having any need for care coordination was 43.2%. Among parents reporting a need for care coordination, the prevalence of unmet need was 41.2%. Higher risk of unmet need for care coordination was associated with child anxiety disorder, parenting stress, lower income, and public or no insurance. Parents reporting social support and receipt of family-centered care had a lower risk of unmet need for care coordination. CONCLUSIONS: Approximately 40% of parents of children with mental health conditions who reported a need for care coordination also reported that their need was unmet. Delivery of family-centered care and enhancing family supports may help to reduce unmet need for care coordination in this vulnerable population.

Autism training in pediatric residency: evaluation of a case-based curriculum.

Despite recent studies indicating the high prevalence of autism spectrum disorders (ASDs), there has been little focus on improving ASD education during pediatric residency training. The objective of this study was to evaluate a new curriculum developed in partnership with the Centers for Disease Control and Prevention and the Maternal and Child Health Bureau about ASDs. "Autism Case Training (ACT): A Developmental-Behavioral Pediatrics Curriculum" consists of 7 case-based teaching modules. Modules were facilitated by faculty at 26 pediatric residency programs and data were obtained on 114 residents. Pre- and post-test data revealed significant short-term improvements in residents' knowledge and self-assessed competence regarding ASDs. Findings suggest that the ACT curriculum is effective in enhancing training about ASDs in pediatric residency programs.

Markers of maternal depressive symptoms in an urban pediatric clinic.

OBJECTIVE: To identify markers of maternal depressive symptoms in medical records of children aged 1-6 years. STUDY DESIGN: Using a case-control methodology, mothers who were screened for depressive symptoms with the Quick Inventory of Depressive Symptomatology Self-Rated Questionnaire (QIDS-SR) at well-child visits between June 2006 and June 2008 in an inner-city pediatric clinic were grouped into cases with depressive symptoms (QIDS-SR score ≥ 11) and controls with no symptoms (QIDS-SR score ≤ 5). Potential markers for maternal depressive symptoms were collected from the children's medical record and grouped into 3 domains: (1) child health and development (eg, maternal concerns/negative attributions regarding the child's behavior); (2) child health care utilization (eg, missed appointments); and (3) maternal psychosocial factors (eg, single parent). The association between maternal depressive symptoms and each factor was determined using multiple logistic regression to calculate aORs. RESULTS: Maternal depressive symptoms were significantly associated with reports of concerns/negative attributions about the child's behavior (aOR, 2.35; P = .01) and concerns about speech (aOR, 2.40; P = .04) and sleep (aOR, 7.75; P < .001); these were identified at the visit when the depression screening was done. Other associations included history of maternal depression (aOR, 4.94; P = .001) and a previous social work referral (aOR, 1.98; P = .01). CONCLUSION: Information readily available to pediatricians was associated with maternal depressive symptoms and can serve as clinical markers to help identify at-risk mothers during well-child visits.

When clinicians and a parent disagree on the extent of medical care.

CASE: TG is a 32-month-old girl with a rare lysosomal storage disease. The diagnosis was confirmed at 8 months of age; she underwent bone marrow transplant at 14 months. TG's father remained at home with her siblings whereas her mother lived at the transplant hospital with TG for 1 year. Significant respiratory infections led to dependency on a tracheotomy and ventilator. She was transferred to the current hospital 10 months ago for respiratory rehabilitation, which has been complicated by pulmonary hemorrhages. On examination, TG was in a wheelchair with truncal support and leg splints. She is a small child with coarse facial features, generalized hypotonia, and significant joint restriction. She exhibited intermittent repetitive arm movements. A tracheotomy was in place, and she did not vocalize. Variable levels of alertness were observed although she rarely signaled to others for social engagement or to express her needs. Eye contact was limited and she responded inconsistently to her name. TG's mother states that her daughter interacts well with her and uses a number of signs for communication. The rehabilitation staff reported limited progress and recommends withdrawal of services. TG's mother expressed frustration with her daughter's poor developmental improvement and believes she needs more intensive therapy, not less. Staff members are now frustrated with TG's mother's level of involvement with her daughter's care. Although TG's mother spends full weekdays at her daughter's bedside, she is often working on her computer managing her business. TG's father works full time and visits on the weekends, when her mother returns home. TG's mother has expressed frustration with her daughter's level of improvement; she believes TG needs more intensive therapy that the hospital is not providing. She informed the staff that other children with this type of storage disease may have delays, but are often higher functioning. TG's mother made the point to the staff that the family's reason for pursuing a bone marrow transplant was to attempt to correct the enzyme deficiency and improve her daughter's outcome.

When clinicians and a parent disagree on the extent of medical care.

CASE: TG is a 32-month-old girl with a rare lysosomal storage disease. The diagnosis was confirmed at 8 months of age; she underwent bone marrow transplant at 14 months. TG's father remained at home with her siblings whereas her mother lived at the transplant hospital with TG for 1 year. Significant respiratory infections led to dependency on a tracheotomy and ventilator. She was transferred to the current hospital 10 months ago for respiratory rehabilitation, which has been complicated by pulmonary hemorrhages. On examination, TG was in a wheelchair with truncal support and leg splints. She is a small child with coarse facial features, generalized hypotonia, and significant joint restriction. She exhibited intermittent repetitive arm movements. A tracheotomy was in place, and she did not vocalize. Variable levels of alertness were observed although she rarely signaled to others for social engagement or to express her needs. Eye contact was limited and she responded inconsistently to her name. TG's mother states that her daughter interacts well with her and uses a number of signs for communication. The rehabilitation staff reported limited progress and recommends withdrawal of services. TG's mother expressed frustration with her daughter's poor developmental improvement and believes she needs more intensive therapy, not less. Staff members are now frustrated with TG's mother's level of involvement with her daughter's care. Although TG's mother spends full weekdays at her daughter's bedside, she is often working on her computer managing her business. TG's father works full time and visits on the weekends, when her mother returns home. TG's mother has expressed frustration with her daughter's level of improvement; she believes TG needs more intensive therapy that the hospital is not providing. She informed the staff that other children with this type of storage disease may have delays, but are often higher functioning. TG's mother made the point to the staff that the family's reason for pursuing a bone marrow transplant was to attempt to correct the enzyme deficiency and improve her daughter's outcome.

Screening for behavioral health problems in primary care.

PURPOSE OF REVIEW: The epidemiology of behavioral health disorders in children and the current literature on the identification of these problems within primary care are reviewed. Suggestions are offered on how to implement screening within primary care settings. RECENT FINDINGS: The prevalence of behavioral health problems in children is approximately 12-27% yet the detection of these problems within the primary care setting is much lower. Although identification may be improving, underidentification and limited referral for services remain a significant problem. Few physicians use standardized instruments or DSM-IV criteria to identify children. Families, in addition, often do not disclose behavioral health concerns about their child to their physician. Multiple barriers exist for successful screening, including lack of training, limited time and poor reimbursement. Recent evidence suggests that a number of well validated instruments are now available for behavioral health screening within primary care. SUMMARY: Pediatric settings hold the potential to be an optimal environment to address behavioral health concerns due to the frequent contact and trusted relationship many families have with their pediatrician. There is new evidence that screening can be thoughtfully implemented and that system change around the detection of behavioral health problems is possible.