Leveraging a Large Language Model to Assess Quality-of-Care: Monitoring ADHD Medication Side Effects.

Objective: To assess the accuracy of a large language model (LLM) in measuring clinician adherence to practice guidelines for monitoring side effects after prescribing medications for children with attention-deficit/hyperactivity disorder (ADHD). Methods: Retrospective population-based cohort study of electronic health records. Cohort included children aged 6-11 years with ADHD diagnosis and ≥2 ADHD medication encounters (stimulants or non-stimulants prescribed) between 2015-2022 in a community-based primary healthcare network (n=1247). To identify documentation of side effects inquiry, we trained, tested, and deployed an open-source LLM (LLaMA) on all clinical notes from ADHD-related encounters (ADHD diagnosis or ADHD medication prescription), including in-clinic/telehealth and telephone encounters (n=15,593 notes). Model performance was assessed using holdout and deployment test sets, compared to manual chart review. Results: The LLaMA model achieved excellent performance in classifying notes that contain side effects inquiry (sensitivity= 87.2%, specificity=86.3/90.3%, area under curve (AUC)=0.93/0.92 on holdout/deployment test sets). Analyses revealed no model bias in relation to patient age, sex, or insurance. Mean age (SD) at first prescription was 8.8 (1.6) years; patient characteristics were similar across patients with and without documented side effects inquiry. Rates of documented side effects inquiry were lower in telephone encounters than in-clinic/telehealth encounters (51.9% vs. 73.0%, p<0.01). Side effects inquiry was documented in 61% of encounters following stimulant prescriptions and 48% of encounters following non-stimulant prescriptions (p<0.01). Conclusions: Deploying an LLM on a variable set of clinical notes, including telephone notes, offered scalable measurement of quality-of-care and uncovered opportunities to improve psychopharmacological medication management in primary care.

Anxiety and Depression Treatment in Primary Care Pediatrics.

BACKGROUND AND OBJECTIVES: Primary care pediatricians (PCP) are often called on to manage child and adolescent anxiety and depression. The objective of this study was to describe PCP care practices around prescription of selective serotonin reuptake inhibitors (SSRI) for patients with anxiety and/or depression by using medical record review. METHODS: We identified 1685 patients who had at least 1 visit with a diagnosis of anxiety and/or depression in a large primary care network and were prescribed an SSRI by a network PCP. We randomly selected 110 for chart review. We reviewed the visit when the SSRI was first prescribed (medication visit), immediately previous visit, and immediately subsequent visit. We abstracted rationale for prescribing medication, subspecialist involvement, referral for psychotherapy, and medication monitoring practices. RESULTS: At the medication visit, in 82% (n = 90) of cases, PCPs documented reasons for starting an SSRI, most commonly clinical change (57%, n = 63). Thirty percent (n = 33) of patients had documented involvement of developmental-behavioral pediatrics or psychiatry subspecialists at 1 of the 3 visits reviewed. Thirty-three percent (n = 37) were referred to unspecified psychotherapy; 4% (n = 4) were referred specifically for cognitive behavioral therapy. Of 69 patients with a subsequent visit, 48% (n = 33) had documentation of monitoring for side effects. CONCLUSIONS: When prescribing SSRIs for children with anxiety and/or depression, PCPs in this network documented appropriate indications for starting medication and prescribed without subspecialist involvement. Continuing medical education for PCPs who care for children with these conditions should include information about evidence-based psychotherapy and strategies for monitoring potential side effects.

Detection of Speech-Language Delay in the Primary Care Setting: An Electronic Health Record Investigation.

OBJECTIVE: The purpose of this study is to determine the rate and age at first identification of speech-language delay in relation to child sociodemographic variables among a pediatric primary care network. METHODS: We analyzed a deidentified data set of electronic health records of children aged 1- to 5-years-old seen between 2015 and 2019 at 10 practices of a community-based pediatric primary health care network. Primary outcomes were numbers (proportions) of patients with relevant ICD-10 visit-diagnosis codes and patient age (months) at first documentation of speech-language delay. Regression models estimated associations between outcomes and patient characteristics, adjusting for practice affiliation. RESULTS: Of 14,559 included patients, 2063 (14.1%) had speech-language delay: 68.4% males, 74.4% with private insurance, and 96.1% with English as a primary household language. Most patients (60%) were first identified at the 18- or 24-month well-child visit. The mean age at first documentation was 25.4 months (SD = 9.3), which did not differ between practices reporting the use of standardized developmental screener and those using surveillance questionnaires. Regression models showed that males were more than twice as likely than females to be identified with speech-language delay (adjusted odds ratio [aOR] = 2.05, 95% CI: [1.86-2.25]); publicly insured were more likely than privately insured patients to be identified with speech-language delay (aOR = 1.48, 95% CI: [1.30-1.68]). Females were older than males at first identification (+1.2 months, 95% CI: [0.3-2.1]); privately insured were older than military insured patients (private +3.3 months, 95% CI: [2.2-4.4]). CONCLUSION: Pediatricians in this network identified speech-language delays at similar rates to national prevalence. Further investigation is needed to understand differences in speech-language delay detection across patient subgroups in practices that use developmental screening and/or surveillance.

Continuity of Care in Primary Care for Young Children With Chronic Conditions.

OBJECTIVES: 1) To assess continuity of care (CoC) within primary-care practices for children with asthma and autism spectrum disorder (ASD) compared to children without chronic conditions, and 2) to determine patient and clinical-care factors associated with CoC. METHODS: Retrospective cohort study of electronic health records from office visits of children <9 years, seen ≥4 times between 2015 and 2019 in 10 practices of a community-based primary health care network in California. Three cohorts were constructed: 1) Asthma: ≥2 visits with asthma visit diagnoses; 2) ASD: same method; 3) Controls: no chronic conditions. CoC, using Usual Provider of Care measure (range > 0-1), was calculated for 1) all visits (overall) and 2) well-care visits. Fractional regression models examined CoC adjusting for patient age, medical insurance, practice affiliation, and number of visits. RESULTS: Of 30,678 children, 1875 (6.1%) were classified with Asthma, 294 (1.0%) with ASD, and 15,465 (50.4%) as Controls. Overall CoC was lower for Asthma (Mean = 0.58, SD 0.21) and ASD (M = 0.57, SD = 0.20) than Controls (M = 0.66, SD = 0.21); differences in well-care CoC were minimal. In regression models, lower overall CoC was found for Asthma (aOR = 0.90, 95% CI, 0.85-0.94). Lower overall and well-care CoC were associated with public insurance (aOR = 0.77, CI, 0.74-0.81; aOR = 0.64, CI, 0.59-0.69). CONCLUSION: After accounting for patient and clinical-care factors, children with asthma, but not with ASD, in this primary-care network had significantly lower CoC compared to children without chronic conditions. Public insurance was the most prominent patient factor associated with low CoC, emphasizing the need to address disparities in CoC.

Medical genetics education for pediatrics residents: A brief report.

PURPOSE: Genetic testing is ubiquitous in the field of medicine and is often ordered or requested by primary care providers, nongenetics subspecialists, and patients themselves. Other studies have shown that providers are often not comfortable ordering genetic testing. There have been initiatives to teach these concepts via continuing medical education; however, there is not a standardized training program for teaching resident physicians about genetic testing. METHODS: During September to October 2020, we recruited all the pediatrics residents at our institution via email (N = 102). Residents were invited to complete a Qualtrics electronic survey that addressed self-perceived level of knowledge about core concepts of genetic testing, as well as self-perceived confidence discussing these concepts with families. RESULTS: Response rate was 46 to 102 (45%). Proportions of respondents reporting they felt insufficiently knowledgeable ranged from 28% (basic concepts of genetics) to 80% (Genetic Information Nondiscrimination Act). Most pediatrics residents agreed that a curriculum teaching basics of genetic testing would be helpful to them. Desired curricular topics included indications and limitations of genetic testing, testing procedures, and counseling families. CONCLUSION: Despite its expanding importance across medicine, genetics education is lacking in pediatrics residency programs and residents would benefit from a curriculum teaching basic concepts of genetic testing.

Primary Care Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in School-Age Children: Trends and Disparities During the COVID-19 Pandemic.

OBJECTIVE: The aim of this study was to assess rates of primary care provider (PCP) diagnosis and treatment of school-age children with attention-deficit/hyperactivity disorder (ADHD) during the COVID-19 pandemic compared with prepandemic years and to investigate disparities in care. METHOD: We retrospectively analyzed electronic health records from all primary care visits (in-person and telehealth) of children aged 6 to 17 years seen between January 2016 and March 2021 in a community-based primary health care network (n = 77,298 patients). Study outcomes are as follows: (1) number of primary care visits, (2) number of visits with ADHD diagnosis (ADHD-related visits), (3) number of PCP prescriptions for ADHD medications, (4) number of patients with first ADHD diagnoses, and (5) number of first PCP prescriptions of ADHD medications. Interrupted time series analysis evaluated changes in rates of study outcomes during 4 quarters of the pandemic year (March 15, 2020-March 15, 2021) compared with prepandemic years (January 1, 2016-March 14, 2020). Patient demographic characteristics during prepandemic and pandemic years were compared. RESULTS: ADHD-related visits dropped in the first quarter of the pandemic year by 33% (95% confidence interval, 22.2%-43.6%), returning to prepandemic rates in subsequent quarters. ADHD medication prescription rates remained stable throughout the pandemic year. Conversely, rates of first ADHD diagnoses and first medication prescriptions remained significantly lower than prepandemic rates. The proportion of ADHD-related visits for patients living in low-income neighborhoods was lower in the pandemic year compared with prepandemic years. CONCLUSION: Ongoing treatment for school-age children with ADHD was maintained during the pandemic, especially in high-income families. Socioeconomic differences in ADHD-related care emphasize the need to improve access to care for all children with ADHD in the ongoing pandemic and beyond.

Medication Management of Anxiety and Depression by Primary Care Pediatrics Providers: A Retrospective Electronic Health Record Study.

Objectives: To describe medication management of children diagnosed with anxiety and/or depression by primary care providers within a primary care network. Study Design/Methods: We performed a retrospective cross-sectional analysis of electronic health record (EHR) structured data from all children seen at least twice in a 4-year observation period within a network of primary care clinics in Northern California. For children who had visit diagnoses of anxiety, depression, anxiety+depression or symptoms characteristic of these conditions, we analyzed the rates and types of medications prescribed. A logistic regression model considered patient variables for the combined sample. Results: Of all patients 6-18 years old (N = 59,484), 4.4% (n = 2,635) had a diagnosis of anxiety only, 2.4% (n = 1,433) depression only, and 1.2% (n = 737) both anxiety and depression (anxiety + depression); 18% of children with anxiety and/or depression had comorbid ADHD. A total of 15.0% with anxiety only (n = 357), 20.5% with depression only (n = 285), and 47.4% with anxiety+depression (n=343) were prescribed a psychoactive non-stimulant medication. For anxiety and depression only, the top three medications prescribed were sertraline, fluoxetine, and citalopram. For anxiety + depression, the top three medications prescribed were citalopram, sertraline, and escitalopram. Frequently prescribed medications also included benzodiazepines. Logistic regression modeling showed that the depression only and anxety + depression categories had increased likelihood of medication prescription. Older age and mental health comorbidities were independently associated with increased likelihood of medication prescription. Conclusions: In this network, ~8% of children carried a diagnosis of anxiety and/or depression. Medication choices generally aligned with current recommendations with the exception of use of benzodiazepines.

Academic Half-Day Education Experience in Post-graduate Medical Training: A Scoping Review of Characteristics and Learner Outcomes.

Background: The academic half-day (AHD) has grown in popularity for medical education because it intends to provide learners with uninterrupted, immersive learning time that may promote participant attendance, engagement, and knowledge. Little is known about the extent of use, forms, or effectiveness of AHD in Post-graduate medical education. This scoping review summarizes existing literature and describes the learning outcomes, according to the Kirkpatrick model of learning evaluation, of AHD experiences on Post-graduate medical trainees. Methods: Authors used Arksey and O'Malley's methodological framework, searching electronic scientific literature databases from the years of 1977-2019 with relevant key terms and identifying 735 papers. Two independent raters completed title/abstract screening and then extracted pertinent data from papers meeting specified criteria. Results: Authors identified 38 relevant papers published in English, originating from programs in US (n = 19) and Canada (n = 19), spanning 4 disciplines: Medicine (n = 17, 45%), Pediatrics (n = 10, 26%), Critical Care/Surgery (n = 9, 24%), Radiology (n = 2, 5%). A majority (n = 33, 87%) described specific educational experiences; most focused on residents only (n = 27). The educational experiences included various teaching strategies; few were didactics only (n = 4) and most were multi-modal including simulation, case-based learning, problem-based learning, and/or self-directed online study. AHD size ranged from 5 to 364 participants (median 39). AHD length was 1.5-6 h (median 3). Required resources were inconsistently described. When evaluations of the specific educational experience were reported (n = 35 studies), the majority of studies used weak research designs (e.g., one group, pre/post-test, n = 19); few studies used strong research designs (e.g., randomized controlled trial, n = 2). Positive effects of AHD ranged across Kirkpatrick levels 1-3 learner outcomes. Conclusions: The composition and content of AHD in Post-graduate medical education vary. Few studies of AHD use stringent research designs, and none include learner outcome measures at the highest Kirkpatrick level (i.e., level 4 results/patient outcomes). A consensus definition and further high-quality research on AHD in Post-graduate medical education is needed.

A retrospective observational cohort study: Epidemiology and outcomes of pediatric unintentional falls in US emergency departments.

INTRODUCTION: The objective is to determine how outcomes from unintentional falls differ for children with and without developmental disabilities, with a sensitivity analysis specifically examining those with ADHD. MATERIALS AND METHODS: This is a retrospective observational cohort study of 2010-2015 data from the Nationwide Emergency Department Sample (NEDS). The NEDS is a sampling of ED visits across 953 hospitals in 36 states. Unintentional falls for children with and without developmental disabilities were compared, adjusting for age, sex, payment source, income, mechanism, injury severity score (ISS). A sensitivity analysis was then performed for children with ADHD (n=139,642) and those without any developmental disabilities. A priori chosen outcomes included hospital admission, length of stay, intubation, and surgery. Logistic regression analysis estimated adjusted odds ratios for outcomes. RESULTS: Among children who presented to the ED with unintentional falls (n=13,217,237), there were 223,445 (1.7%) with developmental disabilities. The majority of those with developmental disabilities were male, ages 10-14 years. Compared to children without developmental disabilities, those with developmental disabilities were more likely to have an inpatient admission (aOR=2.27, 95% CI=2.10-2.44), length of stay more than 2 days (aOR=1.73, 95% CI=1.51-1.98), intubation (aOR=4.77, 95% CI=3.62-6.27) and surgery (aOR=2.11, 95% CI=1.93-2.32). A sensitivity analysis showed that 139,642 (1%) of children ages 5-17 years had ADHD. Of those with ADHD, the majority was also male, ages 10-14 years. Compared to children without ADHD, those with ADHD had a higher odds of inpatient admission (aOR=1.74, 95% CI=1.58-1.91), length of stay greater than 2 days (aOR=1.59, 95% CI=1.37-1.85), intubation (aOR=3.96, 95% CI=2.73-5.73), and surgery (aOR=1.82, 95% CI=1.60-2.06). CONCLUSIONS: Children with developmental disabilities, in particular those with ADHD, who experience falls are often older and male. They had greater odds of poor outcomes. These children need additional anticipatory guidance and attention to adequate treatment to prevent injuries from unintentional falls.

Autism-Focused Online Training in Shared Decision-Making: A Randomized Controlled Trial.

OBJECTIVE: This medical education quasi-randomized controlled trial (quasi-RCT), involving 97 developmental-behavioral pediatrics fellows across the United States, examined differential effects of 2 autism-focused, online, interactive case-based trainings on shared decision-making (SDM). METHODS: An intervention case provided direct teaching about SDM, addressing autism treatment options. A comparison case focused on evidence-based practice (EBP) related to medication use in autism with no specific SDM teaching. Measured outcomes included self-reported SDM and attitudes toward concordance in medication-prescribing. RESULTS: After the intervention, both groups showed significantly increased SDM, but not medication-prescribing concordance (controlling for trainee level, autism patient numbers, and past SDM training). CONCLUSION: This quasi-RCT presents evidence that knowledge of SDM in care of children with autism can be enhanced by online case-based training focused either indirectly on evidence-based practice or directly on SDM. Consistent online SDM training can be provided to all trainees, irrespective of the location.

Attention-Deficit/Hyperactivity Disorder in 2- to 5-Year-Olds: A Primary Care Network Experience.

OBJECTIVE: To assess 1) rates of primary care provider (PCP) diagnosis of attention-deficit/hyperactivity disorder (ADHD) in young children, 2) documented PCP adherence to ADHD clinical practice guidelines, and 3) patient factors influencing PCP variation in diagnosis and management. METHODS: Retrospective cohort study of electronic health records from all office visits of children aged 2 to 5 years, seen ≥2 times between 2015 and 2019, in 10 practices of a community-based primary health care network. Outcomes included ADHD diagnosis (symptom or disorder), and adherence to guidelines in 1) comorbidity documentation at or after ADHD diagnosis, 2) ADHD medication choice, and 3) follow-up of medicated patients. Logistic regressions assessed associations between outcomes and patient characteristics. RESULTS: Of 29,408 eligible children, 195 (0.7%) had ADHD diagnoses. Of those, 56% had solely symptom-level diagnoses (eg, hyperactivity); 54% had documented comorbidities. ADHD medications were prescribed only to 4- to 5-year olds (40 of 195 [21%]); 85% received stimulants as first-line medication; 48% had follow-up visits within 2 months. Likelihood of ADHD diagnosis was higher for children with public or military insurance (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.40-2.66; OR 3.17; 95% CI 1.93-4.96). Likelihood of comorbidity documentation was lower for older ADHD patients (OR 0.48; 95% CI 0.32-0.71) and higher for those with military insurance (OR 3.11; 95% CI 1.13-9.58). CONCLUSION: PCPs in this network frequently used symptom-level ADHD diagnoses in 2- to 5-year olds; ADHD diagnosis rates were below estimated population prevalence, with evidence for sociodemographic disparities. PCP comorbidity documentation and choice of stimulant medications were consistent with guidelines. Rates of timely follow-up were low.

Development and Evaluation of a School Readiness Curriculum for Pediatrics Residents.

Introduction: The American Academy of Pediatrics (AAP) recommends that pediatricians promote school readiness with children and families. To our knowledge, no published resident-focused curricula addressing school readiness are currently available. We sought to fill this gap by developing and evaluating a school readiness curriculum for pediatrics residents. Methods: We conducted a literature review and targeted needs assessment of pediatrics residents. We then developed a school readiness curriculum and piloted it over several months, adjusting it iteratively each month. The final curriculum was delivered to 34 primarily first-year pediatrics residents over 11 months and included three self-guided observations at local preschools using a templated observation guide, followed by a 1.5-hour in-person facilitated workshop with three components: a PowerPoint presentation, a discussion about preschool observations, and a case study with hands-on developmental questionnaire practice. The curriculum was evaluated with preintervention, immediate postintervention, and 2-months delayed postintervention surveys. Results: Our curriculum successfully increased pediatrics residents' knowledge regarding the correct definition of school readiness and appropriate management plan for school readiness concerns, confidence discussing school readiness and addressing families' school readiness concerns, and behavior raising the topic of school readiness with families during well child checks. Discussion: A school readiness curriculum had a beneficial effect of increasing pediatrics residents' knowledge, confidence, and behavior addressing school readiness in clinical encounters, meeting a priority of the AAP.

A Clinic-Based School Readiness Coaching Intervention for Low-Income Latino Children: An Intervention Study.

This intervention study assessed school readiness (SR)-related parent behaviors and perceived barriers for Latino parent-child pairs (N = 149, Mage = 4.5) after a clinic-based SR intervention (n = 74) or standard well-child care (n = 75). Intervention was a 1-hour visit with a community health worker (CHW) to assess child SR, model SR interactions, and provide SR tools and resources. Primary outcomes were parent behaviors and barriers collected by phone questionnaire. Regression analyses revealed that parents in the intervention were more likely to tell their child a story and visit the library in the last week and less likely to report barriers of limited SR knowledge. A brief, SR coaching intervention with a CHW increased SR-related parent behaviors and reduced barriers to SR. Evaluation with school entry data is underway.

Brain Development in School-Age and Adolescent Girls: Effects of Turner Syndrome, Estrogen Therapy, and Genomic Imprinting.

BACKGROUND: The study of Turner syndrome (TS) offers a unique window of opportunity for advancing scientific knowledge of how X chromosome gene imprinting, epigenetic factors, hormonal milieu, and chronologic age affect brain development in females. METHODS: We described brain growth trajectories in 55 girls with TS and 53 typically developing girls (258 magnetic resonance imaging datasets) spanning 5 years. Using novel nonparametric and mixed effects analytic approaches, we evaluated influences of X chromosome genomic imprinting and hormone replacement therapy on brain development. RESULTS: Parieto-occipital gray and white matter regions showed slower growth during typical pubertal timing in girls with TS relative to typically developing girls. In contrast, some basal ganglia, cerebellar, and limited cortical areas showed enhanced volume growth with peaks around 10 years of age. CONCLUSIONS: The parieto-occipital finding suggests that girls with TS may be particularly vulnerable to altered brain development during adolescence. Basal ganglia regions may be relatively preserved in TS owing to their maturational growth before or early in typical pubertal years. Taken together, our findings indicate that particular brain regions are more vulnerable to TS genetic and hormonal effects during puberty. These specific alterations in neurodevelopment may be more likely to affect long-term cognitive behavioral outcomes in young girls with this common genetic condition.

Variation in Rate of Attention-Deficit/Hyperactivity Disorder Management by Primary Care Providers.

OBJECTIVE: To describe variation in rates of attention-deficit/hyperactivity disorder (ADHD) management by pediatrics primary care providers (PCPs) and to assess influence of clinician characteristics on variation. METHODS: Retrospective cohort study of electronic health records from all office visits of patients aged 4 to 17 years seen at least twice between 2015 and 2017 by 73 clinicians in 9 pediatrics practices of a community-based primary health care network in California. Outcomes per clinician: 1) percent patients seen for ADHD management; (2) percent ADHD patients with diagnosed comorbid conditions. Logistic random-effects regression models examined practice- and clinician-level variation. RESULTS: Of 40,323 patients in the cohort, 2039 (5.1%) carried an ADHD diagnosis, of which 1142 (56%) received ADHD medication. Percent of patients seen for ADHD management varied by clinician from 0.0% to 8.3% (median 3.0%). After accounting for practice-level variation and patient characteristics (ie, sex, age, insurance), clinician characteristics explained 28% of clinician variation in ADHD management. ADHD management rate was associated with high-percent full-time equivalent (odds ratio 1.17; 95% confidence interval 1.07-1.27). Percent of ADHD patients with diagnoses of comorbidities varied by clinician from 0.0% to 100% (median 35%). Association between ADHD management rate and comorbidity diagnosis was minimal (R = 0.10). CONCLUSIONS: Objective electronic health records measures showed that PCPs in this network varied widely in their involvement in ADHD management. For most PCPs, percent of patients with ADHD and diagnosis of comorbidities was lower than estimated prevalence rates. Exploration of modifiable factors associated with PCP variation is needed to inform strategies for implementation of evidence-based practices.

Cluster Randomized Controlled Trial of Disability Education Module During Clinical Clerkship.

The effect of a randomized disability education program on medical student knowledge and attitudes concerning disability was performed. Intervention group received bedside teaching of physical examination/interview skills and case-based discussion. Twenty-three participants completed the study (control group n = 11; intervention group n = 12). Pre-clerkship, 39% of all participants reported no personal experience and 43% reported no professional experience with people with disabilities. Post-clerkship knowledge was higher for both groups; the test of group-by-time interaction was not significant. Qualitative analysis of post-clerkship attitude responses demonstrated that intervention group gave more detailed answers. Intervention group used terms representing functional aspects of disability twice as frequently as control group. Intervention group responses described long-term experience of a disability within community and family; control group responses focused on acute medical management. Participation in disability education resulted in changed attitude toward disability and better understanding of aspects of disability.

Sleep Problem Detection and Documentation in Children With Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder by Developmental-Behavioral Pediatricians: A DBPNet Study.

OBJECTIVE: To determine the percentage of children with autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and combined ASD + ADHD who had sleep problems documented by developmental-behavioral pediatricians at diagnostic and follow-up visits at 12 US academic medical centers comprising the Developmental-Behavioral Pediatrics Research Network (DBPNet) and to identify the predictors of sleep problem documentation. METHODS: Developmental-behavioral pediatricians completed encounter forms that covered sociodemographic, medical, clinician, and visit factors. There was 1 dependent variable, sleep problem documentation, for which 4 definitions were developed (Model 1 = Sleep Disorder coded; Model 2 = Sleep Disorder or polysomnogram coded; Model 3 = Sleep Disorder, polysomnogram, or sleep medication coded; and Model 4 = Sleep Disorder, polysomnogram, sleep medication, or clonidine coded). RESULTS: Sleep problem documentation was 14.1% for Model 1, 15.2% for Model 2, 17.3% for Model 3, and 19.7% for Model 4. All values were lower (p < 0.001) than the reported prevalence of sleep problems in these conditions. For Model 4, predictors of sleep problem documentation were age group, ethnicity, medical insurance type, and DBPNet site. CONCLUSION: Developmental-behavioral pediatricians in DBPNet under-reported sleep problems in children with ASD and ADHD. Variation among sites was substantial. Care plans for children with ASD and ADHD should specify which treating clinician(s) monitors sleep issues.