A Quality Improvement Network for Interdisciplinary Training in Developmental Disabilities.

Children with developmental disabilities (DD), such as autism spectrum disorder (ASD), have complex health and developmental needs that require multiple service systems and interactions with various professionals across disciplines. The growing number of children and youth identified with ASD or DD, including anxiety and depression, has increased demand for services and need for highly qualified pediatric providers. Federally funded Leadership Education in Neurodevelopmental and related Disabilities (LEND) programs across the United States address today's health care shortages by providing comprehensive, interdisciplinary training to providers from multiple pediatric disciplines who screen, diagnose, and treat those with ASD and DD. Each LEND program develops training methods independently, including quality improvement efforts. In 2014, LEND programs began designing and validating common measures to evaluate LEND training. The LEND Program Quality Improvement (LPQI) Network was established in 2016. Participating LEND programs in the LPQI Network administer validated trainee self-report and faculty-observation measures that address skills in key competency domains of Interdisciplinary or Interprofessional Team Building, Family-Professional Partnerships, and Policy. This study reports data from faculty and trainees from 22 LEND programs that participated in the LPQI Network across the 5-year data collection period. The main outcome of this study was the change in trainee knowledge, skills, and attitudes scores in key competency domains across programs. Overall, trainees made significant knowledge, skills, and attitude gains based on both self-report and faculty observation scores for all 3 competency domains. Data demonstrate the value of LEND programs and feasibility of a national quality improvement approach to evaluate interdisciplinary training and systems-level improvement.

Evidence-Informed Milestones for Developmental Surveillance Tools.

The Centers for Disease Control and Prevention's (CDC) Learn the Signs. Act Early. program, funded the American Academy of Pediatrics (AAP) to convene an expert working group to revise its developmental surveillance checklists. The goals of the group were to identify evidence-informed milestones to include in CDC checklists, clarify when most children can be expected to reach a milestone (to discourage a wait-and-see approach), and support clinical judgment regarding screening between recommended ages. Subject matter experts identified by the AAP established 11 criteria for CDC milestone checklists, including using milestones most children (≥75%) would be expected to achieve by specific health supervision visit ages and those that are easily observed in natural settings. A database of normative data for individual milestones, common screening and evaluation tools, and published clinical opinion was created to inform revisions. Application of the criteria established by the AAP working group and adding milestones for the 15- and 30-month health supervision visits resulted in a 26.4% reduction and 40.9% replacement of previous CDC milestones. One third of the retained milestones were transferred to different ages; 67.7% of those transferred were moved to older ages. Approximately 80% of the final milestones had normative data from ≥1 sources. Social-emotional and cognitive milestones had the least normative data. These criteria and revised checklists can be used to support developmental surveillance, clinical judgment regarding additional developmental screening, and research in developmental surveillance processes. Gaps in developmental data were identified particularly for social-emotional and cognitive milestones.

Increasing Early Childhood Screening in Primary Care Through a Quality Improvement Collaborative.

OBJECTIVES: Multiple early childhood screenings are recommended, but gaps persist in implementation. Our aim for this project was to improve screening, discussion, referral, and follow-up of development, autism spectrum disorder (ASD), maternal depression, and social determinants of health (SDoH) to 90% by July 2018. METHODS: This 1-year national quality improvement collaborative involved 19 pediatric primary care practices. Supported by virtual and in-person learning opportunities, practice teams implemented changes to early childhood screening. Monthly chart reviews were used to assess screening, discussion, referral, and follow-up for development, ASD, maternal depression, and SDoH. Parent surveys were used to assess parent-reported screening and referral and/or resource provision. Practice self-ratings and team surveys were used to assess practice-level changes. RESULTS: Participating practices included independent, academic, hospital-affiliated, and multispecialty group practices and community health centers in 12 states. The collaborative met development and ASD screening goals of >90%. Largest increases in screening occurred for maternal depression (27% to 87%; +222%; P < .001) and SDoH (26% to 76%; +231%; P < .001). Statistically significant increases in discussion of results occurred for all screening areas. For referral, significant increases were seen for development (53% to 86%; P < .001) and maternal depression (23% to 100%; P = .008). Parents also reported increased screening and referral and/or resource provision. Practice-level changes included improved systems to support screening. CONCLUSIONS: Practices successfully implemented multiple screenings and demonstrated improvement in subsequent discussion, referral, and follow-up steps. Continued advocacy for adequate resources to support referral and follow-up is needed to translate increased screening into improved health outcomes.

Improving Developmental Screening, Discussion, and Referral in Pediatric Practice.

Objective. Although pediatricians' use of standardized screening tools for identifying developmental delays has increased, only 63% of pediatricians report performing standardized screening as recommended. The purpose of the current quality improvement project was to improve developmental monitoring, screening, and referral for developmental concerns by pediatricians. Method. Twenty-eight pediatricians completed an in-person meeting, monthly webinars, and individualized feedback from an Expert Work Group on progress across a 3-month action period. Results. Statistically significant increases were observed in rates of autism screening, discussions of screening results with families, and referral following abnormal results. There was no statistically significant change in rates of general developmental screening. Comparing self-report with record review, pediatricians overestimated the extent to which they conducted discussion and referral. Conclusions. Universal screening for all children has yet to be achieved. The current project supports that practice-based improvements can be made and delineates some of the routes to success.

Socio-demographic, maternal, and child indicators of socioemotional problems in 2-year-old children: A cohort study.

Throughout infancy and early childhood, stable and secure relationships with caregivers are needed to promote optimal socioemotional (SE) and cognitive development.The objective is to examine socio-demographic, maternal, and child indicators of SE problems in 2-year-olds living in an urban-suburban community in the southern United States.Mother-infant pairs enrolled in a prospective pregnancy cohort study.Shelby County (Memphis), Tennessee.One thousand five hundred three women were recruited during their second trimester and followed with their children through the child's age of 2 years.Child SE development was measured by the Brief Infant-Toddler Social Emotional Assessment at 2 years of age. Mothers reported their own behavioral and mental health, temperament, parenting stress, and potential for child abuse during gestation and/or when their child was 1 year of age. Examiners measured maternal IQ during data collection at the child's age of 1 year. Child communication, cognitive development, and risk for autism spectrum disorder were assessed at 1 and 2 years of age. Multivariable regression models were developed to predict mother-reported SE problems.In bivariate analyses, multiple maternal behavioral and mental health indicators and child cognitive skills were associated with reported child SE problems at 2 years of age. Regression analyses, controlling for socio-demographic, maternal, and child variables, showed the following factors were independently associated with mother-reported child SE problems: maternal education of high school or less, lower maternal IQ, higher maternal cyclothymic temperament score, greater parenting stress, greater maternal psychological distress, lower child expressive communication score, and child risk for autism spectrum disorder. Socio-demographic variables accounted for the variance often attributed to race.Since mothers in the study were medically low-risk, generalizing these findings to medically high-risk mothers is unwarranted. In addition, these SE outcomes in 2-year-old children do not reflect the trajectory of SE development throughout early childhood.Attention to independent indicators of future SE problems in children may help identify individual children and families needing intervention and target public prevention/treatment programs in communities.

Maternal and Child Characteristics Associated With Mother-Child Interaction in One-Year-Olds.

Mothers' interactions with their young children have predicted later child development, behavior, and health, but evidence has been developed mainly in at-risk clinical samples. An economically and racially diverse sample of pregnant women who were not experiencing a high-risk pregnancy were recruited to participate in a community-based, longitudinal study of factors associated with child cognitive and social-emotional development during the first 3 years. The purpose of the present analysis was to identify associations between the characteristics of 1125 mothers and their 1-year-olds and the mothers' and children's scores on the Nursing Child Assessment Teaching Scale (NCATS). A multivariable approach was used to identify maternal and child characteristics associated with NCATS scores and to develop prediction models for NCATS total and subscale scores of mothers and children. Child expressive and receptive communication and maternal IQ, marital status, age, and insurance predicted NCATS Mother total score, accounting for 28% of the score variance. Child expressive communication and birth weight predicted the NCATS Child total score, accounting for 4% of variance. Child's expressive communication and mother's IQ and marital status predicted NCATS mother-child total scores. While these findings were similar to reports of NCATS scores in at-risk populations, no previous teams examined all of the mother and child characteristics included in this analysis. These findings support the utility of the NCATS for assessing mother-child interaction and predicting child outcomes in community-based, non-clinical populations. © 2017 Wiley Periodicals, Inc.

Transactional relations between caregiving stress, executive functioning, and problem behavior from early childhood to early adolescence.

Developmental psychopathologists face the difficult task of identifying the environmental conditions that may contribute to early childhood behavior problems. Highly stressed caregivers can exacerbate behavior problems, while children with behavior problems may make parenting more difficult and increase caregiver stress. Unknown is: (a) how these transactions originate, (b) whether they persist over time to contribute to the development of problem behavior and (c) what role resilience factors, such as child executive functioning, may play in mitigating the development of problem behavior. In the present study, transactional relations between caregiving stress, executive functioning, and behavior problems were examined in a sample of 1,388 children with prenatal drug exposures at three developmental time points: early childhood (birth to age 5), middle childhood (ages 6 to 9), and early adolescence (ages 10 to 13). Transactional relations differed between caregiving stress and internalizing versus externalizing behavior. Targeting executive functioning in evidence-based interventions for children with prenatal substance exposure who present with internalizing problems and treating caregiving psychopathology, depression, and parenting stress in early childhood may be particularly important for children presenting with internalizing behavior.

Cortisol reactivity to social stress as a mediator of early adversity on risk and adaptive outcomes.

Children chronically exposed to stress early in life are at increased risk for maladaptive outcomes, though the physiological mechanisms driving these effects are unknown. Cortisol reactivity was tested as a mediator of the relation between prenatal substance exposure and/or early adversity on adaptive and maladaptive outcomes. Data were drawn from a prospective longitudinal study of prenatal substance exposure (N = 860). Cortisol reactivity was assessed at age 11. Among African Americans, prenatal substance exposure exerted an indirect effect through early adversity and cortisol reactivity to predict externalizing behavior, delinquency, and a positive student-teacher relationship at age 11. Decreased cortisol reactivity was related to maladaptive outcomes, and increased cortisol reactivity predicted better executive functioning and a more positive student-teacher relationship.

Physiological correlates of neurobehavioral disinhibition that relate to drug use and risky sexual behavior in adolescents with prenatal substance exposure.

Physiological correlates of behavioral and emotional problems, substance use onset and initiation of risky sexual behavior have not been studied in adolescents with prenatal drug exposure. We studied the concordance between baseline respiratory sinus arrhythmia (RSA) at age 3 and baseline cortisol levels at age 11. We hypothesized that children who showed concordance between RSA and cortisol would have lower neurobehavioral disinhibition scores which would in turn predict age of substance use onset and first sexual intercourse. The sample included 860 children aged 16 years participating in the Maternal Lifestyle Study, a multisite longitudinal study of children with prenatal exposure to cocaine and other substances. Structural equation modeling was used to test pathways between prenatal substance exposure, early adversity, baseline RSA, baseline cortisol, neurobehavioral disinhibition, drug use, and sexual behavior outcomes. Concordance was studied by examining separate male and female models in which there were statistically significant interactions between baseline RSA and cortisol. Prenatal substance exposure was operationalized as the number of substances to which the child was exposed. An adversity score was computed based on caregiver postnatal substance use, depression and psychological distress, number of caregiver changes, socioeconomic and poverty status, quality of the home environment, and child history of protective service involvement, abuse and neglect. RSA and cortisol were measured during a baseline period prior to the beginning of a task. Neurobehavioral disinhibition, based on composite scores of behavioral dysregulation and executive dysfunction, substance use and sexual behavior were derived from questionnaires and cognitive tests administered to the child. Findings were sex specific. In females, those with discordance between RSA and cortisol (high RSA and low cortisol or low RSA and high cortisol) had the most executive dysfunction which, in turn, predicted earlier initiation of alcohol by age 16. Among boys, there also existed a significant baseline RSA by baseline cortisol interaction. Boys with low baseline RSA and high baseline cortisol had the highest levels of behavioral dysregulation. This increase in behavioral dysregulation was in turn related to initiation of alcohol use by age 16 and lower age of first sexual intercourse. We found sex-specific pathways to the initiation of alcohol use and risky sexual behavior through the combined activity of parasympathetic and neuroendocrine functioning. The study of multiple physiological systems may suggest new pathways to the study of age of onset of substance use and engagement in risky sexual behavior in adolescents.

The contributions of early adverse experiences and trajectories of respiratory sinus arrhythmia on the development of neurobehavioral disinhibition among children with prenatal substance exposure.

Neurobehavioral disinhibition (ND) is a complex condition reflecting a wide range of problems involving difficulties with emotion regulation and behavior control. Respiratory sinus arrhythmia (RSA) is a physiological correlate of emotion regulation that has been studied in a variety of at-risk populations; however, there are no studies of RSA in children with ND. Data were drawn from a prospective longitudinal study of prenatal substance exposure that included 1,073 participants. Baseline RSA and RSA reactivity to an attention-demanding task were assessed at 3, 4, 5, and 6 years. ND was assessed at ages 8/9, 11, and 13/14 years via behavioral dysregulation and executive dysfunction composite measures. Greater exposure to early adversity was related to less RSA reactivity at 3 years, increases in RSA reactivity from ages 3 to 6 years, and increased behavioral dysregulation from ages 8/9 to 13/14. RSA reactivity was examined as a moderator of the association between early adversity and changes in ND. A significant Early Adversity × RSA Reactivity quadratic interaction revealed that children with decelerations in RSA reactivity exhibited increases in behavioral dysregulation, regardless of their exposure to early adversity. However, greater exposure to early adversity was related to greater increases in behavioral dysregulation, but only if children exhibited accelerations in RSA reactivity from ages 3 to 6 years. The results contribute to our understanding of how interactions across multiple levels of analysis contribute to the development of ND.

Risk-taking behavior among adolescents with prenatal drug exposure and extrauterine environmental adversity.

OBJECTIVE: High-risk environments characterized by familial substance use, poverty, inadequate parental monitoring, and violence exposure are associated with an increased propensity for adolescents to engage in risk-taking behaviors (e.g., substance use, sexual behavior, and delinquency). However, additional factors such as drug exposure in utero and deficits in inhibitory control among drug-exposed youth may further influence the likelihood that adolescents in high-risk environments will engage in risk-taking behavior. This study examined the influence of prenatal substance exposure, inhibitory control, and sociodemographic/environmental risk factors on risk-taking behaviors in a large cohort of adolescents with and without prenatal cocaine exposure (PCE). METHOD: Risk-taking behavior (delinquency, substance use, and sexual activity) was assessed in 963 adolescents (433 cocaine-exposed, 530 nonexposed) at 15 years of age. RESULTS: Prenatal cocaine exposure predicted later arrests and early onset of sexual behavior in controlled analyses. Associations were partially mediated, however, by adolescent inhibitory control problems. PCE was not associated with substance use at this age. In addition, male gender, low parental involvement, and violence exposure were associated with greater odds of engaging in risk-taking behavior across the observed domains. CONCLUSIONS: Study findings substantiate concern regarding the association between prenatal substance exposure and related risk factors and the long-term outcomes of exposed youth. Access to the appropriate social, educational, and medical services is essential in preventing and intervening with risk-taking behaviors and the potential consequences (e.g., adverse health outcomes and incarceration), especially among high-risk adolescent youth and their families.

Prenatal substance exposure: neurobiologic organization at 1 month.

OBJECTIVE: To examine the autonomic nervous system and neurobehavioral response to a sustained visual attention challenge in 1-month-old infants with prenatal substance exposure. STUDY DESIGN: We measured heart rate, respiratory sinus arrhythmia, and neurobehavior during sustained visual orientation tasks included in the Neonatal Intensive Care Unit Network Neurobehavioral Scale in 1129 1-month-old infants with prenatal substance exposure. Four groups were compared: infants with prenatal cocaine and opiate exposure, infants with cocaine exposure, infants with opiate exposure, and infants with exposure to other substances (ie, alcohol, marijuana, and tobacco). RESULTS: The infants with prenatal exposure to both cocaine and opiates had the highest heart rates and lowest levels of respiratory sinus arrhythmia during a sustained visual attention challenge compared with the other 3 groups. Infants with prenatal cocaine and opiate exposure had poorer quality of movement and more hypertonicity during the Neonatal Intensive Care Unit Network Neurobehavioral Scale examination. They also had more nonoptimal reflexes and stress/abstinence signs compared with infants with prenatal exposure to cocaine only and those with prenatal exposure to alcohol, tobacco, and marijuana. CONCLUSION: Problems with arousal regulation were identified in infants with prenatal substance exposure. Autonomic dysregulation has been implicated as a mechanism by which these difficulties occur. Our results suggest that infants with prenatal exposure to both cocaine and opiates have the greatest autonomic response to the challenge of a sustained visual attention task, possibly putting these infants at risk for problems associated with physiologic and behavioral regulation, a necessary prerequisite for early learning.

Protective factors can mitigate behavior problems after prenatal cocaine and other drug exposures.

BACKGROUND: We determined the role of risk and protective factors on the trajectories of behavior problems associated with high prenatal cocaine exposure (PCE)/polydrug exposure. METHODS: The Maternal Lifestyle Study enrolled 1388 children with or without PCE, assessed through age 15 years. Because most women using cocaine during pregnancy also used other substances, we analyzed for the effects of 4 categories of prenatal drug exposure: high PCE/other drugs (OD), some PCE/OD, OD/no PCE, and no PCE/no OD. Risks and protective factors at individual, family, and community levels that may be associated with behavior outcomes were entered stepwise into latent growth curve models, then replaced by cumulative risk and protective indexes, and finally by a combination of levels of risk and protective indexes. Main outcome measures were the trajectories of externalizing, internalizing, total behavior, and attention problems scores from the Child Behavior Checklist (parent). RESULTS: A total of 1022 (73.6%) children had known outcomes. High PCE/OD significantly predicted externalizing, total, and attention problems when considering the balance between risk and protective indexes. Some PCE/OD predicted externalizing and attention problems. OD/no PCE also predicted behavior outcomes except for internalizing behavior. High level of protective factors was associated with declining trajectories of problem behavior scores over time, independent of drug exposure and risk index scores. CONCLUSIONS: High PCE/OD is a significant risk for behavior problems in adolescence; protective factors may attenuate its detrimental effects. Clinical practice and public health policies should consider enhancing protective factors while minimizing risks to improve outcomes of drug-exposed children.

Neurobehavioral disinhibition predicts initiation of substance use in children with prenatal cocaine exposure.

BACKGROUND: In previous work we (Fisher et al., 2011) examined the emergence of neurobehavioral disinhibition (ND) in adolescents with prenatal substance exposure. We computed ND factor scores at three age points (8/9, 11 and 13/14 years) and found that both prenatal substance exposure and early adversity predicted ND. The purpose of the current study was to determine the association between these ND scores and initiation of substance use between ages 8 and 16 in this cohort as early initiation of substance use has been related to later substance use disorders. Our hypothesis was that prenatal cocaine exposure predisposes the child to ND, which, in turn, is associated with initiation of substance use by age 16. METHODS: We studied 386 cocaine exposed and 517 unexposed children followed since birth in a longitudinal study. Five dichotomous variables were computed based on the subject's report of substance use: alcohol only; tobacco only; marijuana only; illicit substances and any substance. RESULTS: Cox proportional hazard regression showed that the 8/9 year ND score was related to initiation of alcohol, tobacco, illicit and any substance use but not marijuana use. The trajectory of ND across the three age periods was related to substance use initiation in all five substance use categories. Prenatal cocaine exposure, although initially related to tobacco, marijuana and illicit substance initiation, was no longer significant with ND scores in the models. CONCLUSION: Prenatal drug exposure appears to be a risk pathway to ND, which by 8/9 years portends substance use initiation.

Psychopathology and special education enrollment in children with prenatal cocaine exposure.

OBJECTIVE: This study evaluated how enrollment in special education services in 11-year-old children relates to prenatal cocaine exposure (PCE), psychopathology, and other risk factors. METHODS: Participants were 498 children enrolled in The Maternal Lifestyle Study, a prospective, longitudinal, multisite study examining outcomes of children with PCE. Logistic regression was used to examine the effect of PCE and psychopathology on enrollment in an individualized education plan (IEP; a designation specific to children with special education needs), with environmental, maternal, and infant medical variables as covariates. RESULTS: PCE, an interaction of PCE and oppositional defiant disorder, child attention-deficit hyperactivity disorder, parent-reported internalizing behaviors, and teacher-reported externalizing behaviors, predicted enrollment in an IEP. Other statistically significant variables in the model were male gender, low birth weight, being small for gestational age, white race, caregiver change, low socioeconomic status, low child intelligence quotient, caregiver depression, and prenatal marijuana exposure. CONCLUSIONS: PCE increased the likelihood of receiving an IEP with adjustment for covariates. Psychopathology also predicted this special education outcome, in combination with and independent of prenatal cocaine exposure.

Long-term impact of maternal substance use during pregnancy and extrauterine environmental adversity: stress hormone levels of preadolescent children.

Prenatal cocaine exposure (PCE) is associated with blunted stress responsivity within the extrauterine environment. This study investigated the association between PCE and diurnal salivary cortisol levels in preadolescent children characterized by high biological and/or social risk (n = 725). Saliva samples were collected at their home. Analyses revealed no group differences in basal evening or morning cortisol levels; however, children with higher degrees of PCE exhibited blunted overnight increases in cortisol, controlling for additional risk factors. Race and caregiver depression were also associated with diurnal cortisol patterns. Although repeated PCE may contribute to alterations in the normal or expected stress response later in life, sociodemographic and environmental factors are likewise important in understanding hormone physiology, especially as more time elapses from the PCE. Anticipating the potential long-term medical, developmental, or behavioral effects of an altered ability to mount a normal protective cortisol stress response is essential in optimizing the outcomes of children with PCE.

Serial pediatric symptom checklist screening in children with prenatal drug exposure.

OBJECTIVE: To examine screening results obtained by serial annual behavioral assessment of children with prenatal drug exposure. METHOD: The Maternal Lifestyle Study enrolled children with prenatal cocaine exposure (PCE) at birth for longitudinal assessments of developmental, behavioral, and health outcomes. At 8, 9, 10, 11, and 12 years of age, caregivers rated participants on the Pediatric Symptom Checklist (PSC). Serial PSC results were compared with an established broad-based behavioral measure at 9, 11, and 13 years. PSC results were analyzed for 1081 children who had at least 2 annual screens during the 5-year time span. Most subjects (87%) had 4 or more annual screens rated by the same caregiver (80%). PSC scores (and Positive screens) over time were compared at different time points for those with and without PCE. Covariates, including demographic factors and exposures to certain other substances, were controlled. RESULTS: Children with PCE had significantly higher scores overall, with more Positive screens for behavior problems than children without PCE. Children with PCE had more externalizing behavior problems. Children exposed to tobacco prenatally and postnatally also showed higher PSC scores. Over time, PSC scores differed slightly from the 8-year scores, without clear directional trend. Earlier PSC results predicted later behavioral outcomes. CONCLUSION: Findings of increased total PSC scores and Positive PSC screens for behavioral concerns in this group of children with prenatal substance exposure support the growing body of evidence that additional attention to identification of mental health problems may be warranted in this high-risk group.

Prevalence of developmental and behavioral disorders in a pediatric hospital.

OBJECTIVE: The objective of this study was to estimate the prevalence of developmental and behavioral disorders in a convenience sample of children in an acute care pediatric hospital setting. We hypothesized that hospitalized children would have a higher prevalence of developmental and behavioral disorders than the general population. METHODS: Data for this cross-sectional study were collected during interviews with primary caregivers of 325 children from infancy throughout childhood who were admitted to a general pediatric service. Screening tests included the Child Development Inventory (3 months to 6 years), Parents' Evaluation of Developmental Status (0-8 years), Pediatric Symptom Checklist (4-18 years), and Vanderbilt Attention-Deficit/Hyperactivity Disorder Parent Rating Scale (6-18 years). Children were classified as having a known developmental and behavioral disorder, a suspected developmental and behavioral disorder, or no developmental and behavioral disorder. RESULTS: The prevalence of developmental and behavioral disorders among the hospitalized children 6 months to 17 years of age was 33.5%. A total of 72 children (22.1%) had known developmental and behavioral disorders and 37 (11.4%) had suspected developmental and behavioral disorders. This high prevalence of developmental and behavioral disorders included high rates of cerebral palsy (6.1%) and mental retardation or developmental delay (8.6%). CONCLUSION: Hospitalization for treatment of acute conditions provides another opportunity for developmental surveillance. This higher prevalence of developmental and behavioral disorders in hospitalized children emphasizes the need to screen for developmental disabilities at every opportunity. Strategies to implement systematic screening of hospitalized children should be examined.