Post-PICU sleep efficiency and quality of life in infants and toddlers with acquired brain injury.

STUDY OBJECTIVES: We aimed to investigate the use of sleep efficiency (SE) as a measure of sleep disturbance in infants and toddlers with acquired brain injury (ABI) and evaluate associations between SE and child health-related quality of life and family outcomes. METHODS: Retrospective cohort study of 101 children ages 3-36 months who survived critical care for ABI. SE was quantified from the Brief Infant Sleep Questionnaire as a ratio of nighttime sleep to total time in bed; poor SE was defined as < 80%. Outcome measures included the Pediatric Quality of Life Inventory Core Total Score (health-related quality of life) and Family Impact Module Total Score. Spearman's correlation quantified associations between SE and outcomes. Multivariable linear regression tested association between poor SE and health-related quality of life controlling for significant covariates (age, diagnosis, comorbidities, worsening Functional Status Scale). RESULTS: Following ABI, median SE was 91.7 (interquartile range = 83.3, 95.5). Nineteen (19%) children had poor SE (< 80%). SE correlated significantly with quality of life (Spearman's correlation = .307) and Family Impact Module (Spearman's correlation = .309; both P < .01). When controlling for covariates, poor SE significantly increased risk for lower health-related quality of life (ß-coefficient = -7.0; 95% confidence interval= -13.4, -0.6). CONCLUSIONS: One in five infants and young children with ABI have poor SE that is associated with poorer child and family health outcomes. Our study underscores the potential importance of sleep following ABI to optimize recovery and the need for additional investigation of SE in infants and young children. CITATION: Klapp JM, Hall TA, Riley AR, Janzen D, Williams CN. Post-PICU sleep efficiency and quality of life in infants and toddlers with acquired brain injury. J Clin Sleep Med. 2024;20(1):75-83.

Integrated behavioral health services in pediatric primary care and emergency department utilization for suicide risk.

Introduction: Universal screening for suicide risk in primary care settings is a promising avenue for preventing self-harm and improving health outcomes. Triaging youth to an appropriate level of care, including diverting lower-risk patients from the emergency department (ED) is a meaningful goal. Previous research indicates integrated behavioral health (IBH) may prevent unnecessary admission to the ED on the day of suicide risk screening. We hypothesized that youth who received an IBH consultation the same day as suicide risk screening would be less likely to be admitted to the ED, but more likely to contact IBH services and utilize primary care in the following month. Methods: We conducted a retrospective chart review of 3,649 youth aged 10-18 years who were screened with the Ask Suicide-Screening Questions (ASQ) in two pediatric primary care practices. We collected demographic data, ASQ and Patient Health Questionnaire-9 (PHQ-9) scores, as well as patient contacts with IBH, the ED, and medical primary care the day of screening and the following 31 days. We conducted a series of logistic regressions and chi-square analyses to determine whether contact with IBH on the same day as positive suicide risk screenings predicted same-day admission to the ED, IBH contact, and medical primary care utilization. Results: Among the 7,982 ASQ scores, 1,380 (18%) were non-acute and 87 ASQs (1%) screened acutely positive. Over 90% of positive screens were diverted from the ED regardless of IBH contact. None of the patients died from suicide. Same-day IBH was associated with higher likelihood of general ED visits for all positive screens (acute and non-acute together). None of the positive screens that received an IBH consultation on the same day as screening were admitted to the ED in the subsequent month. Contact with IBH the same day as screening positively predicted utilization of IBH and medical primary care services in the subsequent month, especially for youth with minority race and ethnicity identities. Discussion: In the context of clinics with IBH and systematic risk assessment processes, most youth who screen positive for suicide risk are diverted from the ED. However, contrary to our hypothesis, our study showed that youth who received same-day IBH consultations were more likely to be admitted to the ED compared to peers who did not receive IBH consultations. These findings suggest that systematic suicide screening combined with IBH consultations in pediatric primary care can effectively identify risk levels and triage patients to appropriate care.

Parents' Preferences for Primary Care-Based Behavioral Services and the COVID-19 Pandemic: A Mixed Method Study.

OBJECTIVE: This study examined how family factors impacted parents' attitudes toward integrated behavioral health (IBH) in pediatric primary care during the COVID-19 pandemic. We hypothesized that COVID-19 impact would predict family functioning challenges, and that pre-existing familial contextual factors would predict parents' interest in IBH modalities. METHODS: Parents of children ages 1.5-5 years (N = 301) from five primary care clinics completed a survey with measures assessing familial contextual factors (income, race and ethnicity, and parents' childhood adversity), COVID-19 impact on family relationships and wellbeing, family functioning (child behavior, parenting self-efficacy, and parent psychological functioning), and parents' preferences for behavioral support in primary care. A subsample of parents (n = 23) completed qualitative interviews to provide deeper insights into quantitative relationships. RESULTS: Higher COVID-19 impact was significantly associated with worse parent mental health and child behavior problems, as well as lower interest in IBH virtual support options. Overall, lower SES and racial and/or ethnic minority parents both indicated greater interest in IBH modalities compared to higher SES and White parents, respectively. Qualitative interviews identified how pandemic stressors led to increases in parents' desire for behavioral support from pediatricians, with parents sharing perspectives on the nature of support they desired, including proactive communication from providers and variety and flexibility in the behavioral supports offered. CONCLUSIONS: Findings have important implications for the provision of behavioral supports for families in primary care, underlying the need to increase parents' access to IBH services by proactively providing evidence-based resources and continuing to offer telehealth support.

Is Pediatric Intensive Care Trauma-Informed? A Review of Principles and Evidence.

Pediatric critical illness and injury, along with the experience of recovering from critical illness are among the most potentially traumatic experiences for children and their families. Additionally, children often come to the Pediatric Intensive Care Unit (PICU) with pre-existing trauma that may sensitize them to PICU-related distress. Trauma-informed care (TIC) in the PICU, while under-examined, has the potential to enhance quality of care, mitigate trauma-related symptoms, encourage positive coping, and provide anticipatory guidance for the recovery process. This narrative review paper first describes the need for TIC in the PICU and then introduces the principles of TIC as outlined by the American Academy of Pediatrics: awareness, readiness, detection and assessment, management, and integration. Current clinical practices within PICU settings are reviewed according to each TIC principle. Discussion about opportunities for further development of TIC programs to improve patient care and advance knowledge is also included.

Parental Cannabis Use, Negative Parenting, and Behavior Problems of Young Children.

Introduction: Cannabis use in the United States is increasingly accepted and legal. Rise in use among childbearing aged adults is potentially concerning, as the impacts of parental cannabis use on children are largely unknown, especially for young children. This study examined whether cannabis use is associated with increased risk for negative parenting and child emotional and behavioral problems among the parents of young children. Methods: We conducted a cross-sectional survey of parents and child behavior, recruited through five primary care practices in three states. Parents of children aged 1.5-5 years reported on family demographics, last 6-months cannabis use, negative parenting, parent mental health, parents' adverse childhood experiences (ACEs), and child emotional/behavioral problems. We conducted hierarchical regressions to determine if parental cannabis use predicts negative parenting and/or child emotional/behavioral problems when controlling for other risk factors. Results: Of 266 responding parents, 34 (13%) reported cannabis use in the last 6 months. Parents who endorsed cannabis use reported significantly more negative parenting, ACEs, anxiety, depression, and child emotional/behavioral problems. Adjusting for the effects of other risk factors, cannabis use significantly predicted more negative parenting, but was not uniquely and significantly associated with child emotional/behavioral problems. Conclusion: Parental cannabis predicted negative parenting, which in turn predicted early childhood emotional/behavioral problems; however, parental cannabis use did not predict child emotional/behavioral problems when other risk factors were considered. Further research is needed to elucidate the nature and direction of relationships between parent cannabis use, negative parenting, child psychological outcomes, and other risk factors.

Sleep disturbances in infants and young children following an acquired brain injury.

STUDY OBJECTIVES: Sleep disturbances impact over half of older children and teens with acquired brain injury (ABI) following critical care hospitalization but are underevaluated in infants and young children. Given the importance of sleep in brain development and healing after injury, we hypothesized sleep disturbances would be associated with worse neurodevelopmental outcomes in infants with ABI. METHODS: We performed a retrospective cohort study of 68 children aged 2-32 months following critical care hospitalization for ABI. The Brief Infant Sleep Questionnaire assessed sleep disturbances. Bayley Scales of Infant and Toddler Development, third edition and Adaptive Behavior Assessment System, third edition assessed developmental and adaptive functioning outcomes, respectively. t tests compared sleep characteristics in infants with ABI to historical healthy controls. Spearman's correlation evaluated relationships among sleep and outcomes. Multiple linear regression investigated relationships controlling for demographic and ABI characteristics. RESULTS: Compared to healthy controls, children with ABI had shorter nighttime sleep duration (P = .01), longer daytime sleep duration (P < .001), and longer duration of nighttime awakenings (P < .001). Duration of night awakenings negatively correlated with Bayley Cognitive scores (Spearman's correlation = -.40). Night awakenings negatively correlated with worse Adaptive Behavior Assessment System, third edition General Adaptive Composite scores (Spearman's correlation = -.42). When controlling for demographic and ABI characteristics, ≥ 3 awakenings was significantly associated with worse Adaptive Behavior Assessment System, third edition General Adaptive Composite (ß = -11.3; 95% confidence interval = -19.2, -3.5). CONCLUSIONS: Sleep disturbances are associated with poorer outcomes in infants and toddlers after ABI. Sleep is vital to recovery and a potentially modifiable target to improve outcomes. CITATION: Klapp JM, Hall TA, Riley AR, Williams CN. Sleep disturbances in infants and young children following an acquired brain injury. J Clin Sleep Med. 2022;18(10):2387-2395.

Parents' Preferences for Behavioral Services in Primary Care During the COVID-19 Pandemic.

OBJECTIVE: Pediatric primary care is an ideal setting to provide behavioral health services to young children and their families during the COVID-19 pandemic. However, it is unclear how the pandemic altered parents' priorities and preferences to obtain behavioral services in this setting. METHOD: Between July 2020 and January 2021, 301 parents of young children in 5 pediatric sites across the United States completed survey measures on their preferences for behavioral topics and service delivery methods in primary care. The current sample was compared with a previous sample of parents (n = 396) who completed the same measures in 2018. RESULTS: Child self-calming was the only behavioral topic that was rated as significantly more important in the pandemic cohort in comparison with the prepandemic cohort. The pandemic cohort also reported significantly more interest in using certain media resources (e.g., mobile apps and videos) as a delivery method and less interest in group classes/seminars. After controlling for demographic differences between the samples, there was an increased preference for multimedia resources overall in the pandemic cohort, as well as a decreased preference for usual care. CONCLUSION: Parents generally endorse similar priorities for behavioral topics in primary care during the pandemic as they did before the pandemic. However, there is a clear preference for more remote and media-based services during the pandemic. Pediatric practices may consider augmenting behavioral health services with multimedia resources during and after the COVID-19 pandemic to meet parents' needs.

A Mixed-Method Investigation of Parent Perspectives on Early Childhood Behavioral Services in Primary Care.

Primary care is a key setting for the delivery of parent-focused behavioral interventions. Various methods of intervention show promising efficacy but fail to engage adequate parental participation. This study used a sequential-explanatory mixed-method design to understand factors underlying parents' attitudes toward the content, sources, and delivery methods of behavioral guidance in primary care. Fifteen parents who previously participated in a larger survey study participated in interviews about their experiences and attitudes toward integrated primary care. Qualitative data were analyzed and sorted by quantitative data of interest to identify demographic, child, and parental factors that shape attitudes toward integrated care. Parents emphasized a need for tailored behavioral guidance, and multiple interconnected factors (e.g., trust of providers, perceived convenience of delivery modalities, stigma associated with behavioral health services) drove parents' attitudes toward behavioral primary care. These attitudes varied based on socioeconomic status, child behavior symptoms, and reported use of corporal punishment.

COVID-19 distress, negative parenting, and child behavioral problems: The moderating role of parent adverse childhood experiences.

BACKGROUND: Heightened familial stress and distress during the COVID-19 pandemic may lead to increased negative parenting practices, particularly for parents with substantial adverse childhood experiences (ACES). OBJECTIVE: To determine whether families' COVID-19-related distress is associated with young children's emotional/behavioral functioning via negative parenting, and whether these relationships vary based on parents' ACEs. PARTICIPANTS AND SETTING: Participants were 267 parents of children ages 1.5-5 years recruited from five primary care sites across the United States. METHODS: Participants completed internet questionnaires including measures of demographics, parent ACES, negative parenting, parent mental health, and COVID-19 distress. We used regression analyses to test a moderated mediation model in which the relationship between COVID-19 distress and child emotional/behavioral problems is mediated by negative parenting, and both the direct and indirect effects of COVID-19 distress on child emotional/behavioral problems is moderated by parents' ACEs. RESULTS: Negative parenting significantly mediated the relationship between COVID-19 distress and child emotional/behavioral problems (indirect effect ß = 0.07). Parents' ACEs moderated the associations between COVID-19 distress and both negative parenting and child emotional/behavioral problems, such that each relationship was stronger in the context of higher parental ACEs. The model accounted for 42% of the variance in child emotional/behavioral problems. CONCLUSIONS: Findings have implications for managing risk and promoting well-being in young children during periods of significant stress and routine disruption. This study advances understanding of factors influencing negative outcomes in children during the pandemic's acute phase and may have implications for the development of targeted interventions to improve families' adjustment in the future.

Parental Posttraumatic Stress Symptoms in the Context of Pediatric Post Intensive Care Syndrome: Impact on the Family and Opportunities for Intervention.

OBJECTIVE: Pediatric intensive care unit (PICU) survivors and their families experience ongoing impacts on physical, cognitive, and psychosocial functioning, described as Post-Intensive Care Syndrome (PICS). The objective of this study was to determine whether the posttraumatic stress symptoms (PTSS) of parents predict the impact of critical illness on families following PICU admission beyond other factors (e.g., sex, race/ethnicity, age, insurance status, illness severity, family involvement or death). METHOD: We conducted a retrospective analysis of data from 88 children aged 1 month to 18 years who were hospitalized with critical illness and acquired brain injury in the PICU and their families. Patients and their families participated in a 1-3 month post-discharge follow-up assessment, during which data on demographics, medical diagnoses, parent self-report of PTSS, and family impact of critical illness (via the Pediatric Quality of Life Family Impact Module) were collected. We used a hierarchical linear regression to determine whether parent PTSS predicted family impact above and beyond demographic and injury/illness factors. RESULTS: One-third of parents reported elevated PTSS. Among those with complete available data (n = 56), PTSS were the only significant predictor of family impact (ß = -.52, t = -3.58, p = .001), with the overall model accounting for 41% of variance. CONCLUSION: In addition to the direct effects on parents of children who survive the PICU, PTSS may negatively impact families and interfere with rehabilitative progress. We provide a rationale and conceptual model for integrating interventions designed to address parent PTSS into post-PICU care.

A Systematic Review of External Validity in Pediatric Integrated Primary Care Trials.

OBJECTIVE: We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to conduct a systematic review of external validity reporting in integrated primary care (IPC) interventions for mental health concerns. METHODS: We searched Medline, CINAHL, PsycINFO, the Cochrane Center Register of Controlled Trials, and relevant literature to identify publications from 1998 to 2018 reporting on open, randomized, or quasi-randomized trials of IPC interventions that targeted child (ages 0-18 years) psychological symptoms. For each publication, we extracted the information reported in each RE-AIM domain and calculated the proportion of the total studies reviewed. RESULTS: Thirty-nine publications describing 25 studies were included in the review. Publications rarely reported some indicators of external validity, including the representativeness of participants (12%), rate of adoption clinics or providers (16%), cost of implementation (8%), or evidence of maintenance (16%). Few studies reported on key pragmatic factors such as cost or organizational change processes related to implementation and maintenance. Strengths of some studies included comparisons of multiple active treatments, use of tailorable interventions, and implementation in "real world" settings. CONCLUSIONS: Although IPC interventions appear efficacious under research conditions, there are significant knowledge gaps regarding the degree to which they reach and engage target recipients, what factors impact adoption and implementation of IPC interventions by clinicians, how fidelity can be maintained over time, and cost-effectiveness. Pediatric IPC researchers should embrace dissemination and implementation science methods to balance internal and external validity concerns moving forward.

Development and initial validation of a measure of parents' preferences for behavioral counseling in primary care.

INTRODUCTION: There is a significant need to understand the factors that contribute to parents' consumer preferences for behavioral health services in pediatric primary care; however, no validated measure of such preferences exists. We developed the BIPS (Behavioral Information Preferences Scale), a measure of parents' preferences for delivery of behavioral guidance in pediatric primary care and assessed its psychometric properties. METHOD: An initial item pool consisted of 3 sections: Behavior topics, intervention approach, and delivery methods. In addition to the BIPS, parents of young children (N = 396) completed measures of child behavior problems and parenting self-efficacy. We conducted principle component analyses and examined correlations of the resulting factors. RESULTS: The behavior topics section resulted in a two-factor solution (conduct/emotions and healthy habits), as did the intervention approach section (behavior change and psychoeducation), whereas the delivery methods yielded three factors (usual care, auxiliary care, and media resources). Patterns of association with parent reported child behavior problems and parenting self-efficacy were indicative of construct validity for the behavior topics and media resources sections. DISCUSSION: The BIPS holds potential for informing the design and dissemination of primary care parenting interventions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Small Interventions for Big Change: Brief Strategies for Distress and Self-Management Amongst Youth with Type 1 Diabetes.

PURPOSE OF REVIEW: Diabetes self-management and diabetes distress are complex processes implicated in glycemic control and other health outcomes for youth with type 1 diabetes. Growing integration of medical and behavioral care provides opportunities for brief psychosocial interventions during routine diabetes care. This review focuses on interventions for self-management and diabetes distress that can be delivered alongside usual medical care or via a single-patient encounter. RECENT FINDINGS: Recent research underscores the potential of brief interventions delivered by both medical providers and integrated behavioral health professionals, but little is known regarding the comparative effectiveness of different interventions or the factors that impact dissemination and implementation. This article asserts that brevity is critical to maximizing the reach, scalability, and impact of psychosocial interventions for youth with type 1 diabetes. The authors review existing evidence for brief interventions, describe several untested clinical strategies, and make recommendations for accelerating the translational study of brief interventions.

More than Mental Health: Parent Physical Health and Early Childhood Behavior Problems.

OBJECTIVE: Caring for young children is a physically demanding task, and some evidence suggests parental physical limitations may impact the parent-child relationship and child behavioral development, but research examining this dynamic is nascent. METHODS: This study aims to explicate the role of general parent physical health problems in child disruptive behavior outcomes. A model that included physical and mental health, parenting style and self-efficacy, and child behavior symptom ratings was derived. The tenability of the model was assessed using Pearson's correlations, followed by structural equation modeling using data from 375 parents with a child between 18 months and 5 years. RESULTS: After several modifications to the initial model, findings revealed that higher levels of parent self-reported physical and mental health concerns indirectly influence child behavior symptoms through different pathways. Impaired parent physical health was associated with poorer parental self-efficacy and more disruptive child behavior, whereas increased parent mental health concerns were associated with a more negative parenting style and lower self-efficacy, which was related to more child behavior symptoms. CONCLUSION: Findings elucidate the need for increased awareness and screening of parent physical health limitations in pediatric primary care. Furthermore, appropriate interventions among parents with physical health problems may target different aspects of parenting than routinely discussed.

Parents' Consumer Preferences for Early Childhood Behavioral Intervention in Primary Care.

OBJECTIVE: Early childhood parenting interventions are increasingly delivered in primary care, but parental engagement with those interventions is often suboptimal. We sought to better understand parents' preferences for the content and delivery method of behavioral health guidance in pediatric primary care and to determine the relationship of those preferences with demographic characteristics, child behavior problems, and parenting style. METHODS: Participants were 396 parents of young children recruited from primary care offices. We collected measures of parental preferences (including behavioral topics, intervention strategies, and methods of delivery) for behavioral intervention in primary care, child behavior symptoms, parenting style, and demographic characteristics. Descriptive statistics were used to identify parents' most preferred behavioral topics and intervention delivery methods. We used a hierarchical regression approach to determine whether parenting style predicted parents' preferences beyond demographic and child-level factors. RESULTS: Nearly all parents (96%) endorsed a behavioral topic (e.g., aggression) as important. Most preferred to receive intervention during routine medical appointments. Child behavior problems correlated with parents' overall interest in behavioral guidance, but clinically significant symptoms did not differentiate interest in any single topic. Socioeconomic factors and negative parenting practices predicted some parental preferences. Notably, lax parenting generally predicted higher interest in behavioral intervention, whereas hostile and physically controlling parenting predicted lower interest. CONCLUSION: Most parents are interested in behavioral guidance as part of primary care, but their preferences for the content and delivery of that guidance vary by known socioeconomic, child, and parenting risk factors. Tailoring intervention to parents' preferences may increase engagement with available interventions.

Impacting Pediatric Primary Care: Opportunities and Challenges for Behavioral Research in a Shifting Healthcare Landscape.

Behavior analysts have long recognized the potential of a partnership with pediatric medicine as an opportunity to expand the influence of behavior analysis and positively impact population health. Despite significant achievements in this domain, the impact of behavioral science on the daily practice of pediatrics has been limited. In this commentary, the authors argue that the current health care and research environments are ripe for a renewed focus on behavioral modification in pediatric primary care, with a particular emphasis on the study of high-frequency, low-intensity problems. They provide some analysis of why behavioral pediatrics has failed to gain traction in primary care, describe aspects of the current primary care practice and research landscapes that provide opportunities for an expanded portfolio of research, identify several exemplars from the behavior analytic literature that have influenced pediatric primary care or have the potential to do so, and make recommendations for producing influential data.

The impact of behavioral health consultations on medical encounter duration in pediatric primary care: A retrospective match-controlled study.

INTRODUCTION: The disproportionate time required to effectively manage psychosocial concerns is a key barrier to advancing delivery of behavioral care by primary care providers. Improved time efficiency is one potential benefit of the integration of behavioral health consultants (BHCs) into pediatric care, but few studies have systematically studied this outcome. We examined the impact of embedded BHCs on duration of medical encounters in a pediatric primary care clinic. METHOD: We conducted a retrospective matched-pairs analysis of encounters involving behavioral consultations versus encounters for similar patients that did not include a consultation (N = 114) using electronic health record timestamp data. We examined both medical duration (i.e., medical provider services) and total duration (i.e., medical services + behavioral consultation). RESULTS: Patient encounters involving behavioral consultation had a significantly longer (+11.23 min) total duration than matched controls, but significantly shorter (-11.67 min) medical duration. DISCUSSION: The results indicate BHCs may improve primary care provider efficiency for patients with behavioral concerns, a notable finding given the impact of clinical time-constraints on important health care outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Pediatric primary care psychologists' reported level of integration, billing practices, and reimbursement frequency.

INTRODUCTION: Integration of psychological services into pediatric primary care is increasingly common, but models of integration vary with regard to their level of coordination, colocation, and integration. High-integration models may provide some distinct advantages, such as preventative care and brief consultation for subclinical behavior concerns; however, psychologists face barriers to seeking reimbursement for these services. Alternatives to traditional psychotherapy and psychological testing codes, specifically Health & Behavior (H&B) codes, have been proposed as 1 method for supporting integrated care. The aim of this study was to investigate the relationships between psychologists' reported billing practices, reimbursement rates, and model of integration in pediatric primary care. METHOD: As part of a larger survey study, 55 psychologists working in pediatric primary care reported on characteristics of their practice's model of integration, billing practices, and frequency of reimbursement for consultative services. RESULTS: Compared with those who categorized their integrated care model as colocated, psychologists who endorsed working in integrated models reported a significantly higher usage of H&B codes and more frequent reimbursement for consultations. Overall, use of H&B codes was associated with higher reported levels of coordination and integration. DISCUSSION: Survey results showed a clear pattern of higher integration being associated with greater utilization of H&B codes and better reimbursement for consultation activities. These results underscore the importance of establishing and maintaining billing and reimbursement systems that adequately support integrated care. (PsycINFO Database Record

A Survey of Parents' Perceptions and Use of Time-out Compared to Empirical Evidence.

OBJECTIVE: To assess parents' perceptions and use of time-out (TO) in contrast to empirical indications and examine the relationship between reported implementation procedures and perceived effectiveness. METHODS: We surveyed parents of preschool and school-age children (n = 401, aged 15 months to 10 years) at well-child visits with regard to their awareness, perception, and usage of TO. Parents were specifically surveyed regarding TO components that have been empirically evaluated or pertain directly to its underlying behavioral principles. Descriptive analyses, group comparisons, and correlational analyses were used to characterize responses and evaluate the relationship between TO administration variation and perceived effectiveness. RESULTS: Most parents (76.8%) reported using TO in response to misbehavior, but a large majority of these parents (84.9%) reported implementing TO in a manner counter to empirical evidence. Parents who endorsed TO as effective varied significantly from those who did not on key implementation components (eg, use of a single warning). Further, several reported implementation practices were correlated with perceived effectiveness and challenging child behavior. For example, requiring a child to be calm before ending TO was positively correlated with perceived effectiveness. CONCLUSIONS: These results cement TO as a widely disseminated practice but cast doubt on the fidelity with which it is typically implemented. Better methods of educating parents on evidence-based discipline are needed.

Dissemination of Evidence-Based Behavioral Advice via Video in Pediatric Primary Care: An Acceptance and Utilization Study.

BACKGROUND: Research suggests that multimedia-based interventions possess advantages for disseminating safe and effective methods of behavior management to parents in pediatric primary care; however, little is known about their utilization in real-life settings. In order to maximize the impact of multimedia resources, more knowledge regarding dissemination and implementation is needed. OBJECTIVE: To examine provider and parental perception and utilization of videos designed to communicate evidence-based parenting strategies for disruptive behavior. Videos were available in clinic and online. RESULTS: Both provider and parent perceptions of the videos were largely positive. However, of 240 parents surveyed, only 33% were aware of the availability of videos subsequent to a well-child visit. Parents were unlikely to view the videos if they did not do so as part of their child's health care visit. CONCLUSION: Multimedia interventions for behavior management are likely to be well received, but systematic methods of implementation are needed. Further study of dissemination of multimedia interventions is merited.