Decision-making in the delivery room: a survey of neonatologists.

OBJECTIVE: To examine influences on neonatologists' decision-making regarding resuscitation of extremely premature infants. STUDY DESIGN: A mailed survey of Illinois neonatologists evaluated influences on resuscitation. Personal and parentally opposed (that is, acting against parental wishes) gray zones of resuscitation were defined, with the lower limit (LL) the gestational age at or below which resuscitation would be consistently withheld and the upper limit (UL) above which resuscitation was mandatory. RESULT: Among the 85 respondents, LL and UL of the personal and parentally opposed gray zones were median 22 and 25 weeks, respectively. Neonatologists with an UL personal gray zone <25 completed weeks were significantly more fearful of litigation, more likely to have received didactic/continuing medical education teaching, and less likely to always consider parents' opinions in resuscitation decisions. Neonatologists with an UL parentally opposed gray zone <25 completed weeks were more fearful of litigation. CONCLUSION: Neonatologists perceive a 'gray zone' of resuscitative practices and should understand that external influences may affect their delivery room resuscitation practices.

Is there lead in the suburbs? Risk assessment in Chicago suburban pediatric practices. Pediatric Practice Research Group.

OBJECTIVE: This study was designed to determine: (1) the prevalence of elevated blood lead (BPb) levels (BPb > or = 10 micrograms/dL) in Chicago suburban children attending Pediatric Practice Research Group practices at 12 and 24 months of age, and (2) the efficacy of the Centers for Disease Control and Prevention (CDC) and Illinois lead exposure risk assessment questions. METHODS: Parents bringing their 1- and 2-year-old children for health supervision visits at pediatric practices completed questionnaires. BPb levels were drawn on children. Both questionnaire and an analyzable BPb level were obtained on 1393 subjects (79.2%). RESULTS: Only 2.1% of our sample had a venous BPb level > or = 10 micrograms/dL (0.48 mumol/L); no subjects had a level > or = 30 micrograms/dL (1.45 mumol/L). The CDC risk assessment questions had a sensitivity of .69 and specificity of .70. Due to the low prevalence of elevated BPb levels in this sample, CDC and Illinois screening strategies had high negative predictive values (.99) and low positive predictive values (.05 and .04, respectively). However, some of the subjects with BPb levels > or = 10 micrograms/dL were not at high risk by CDC and Illinois screening questions; 9 of 29 subjects with elevated lead levels (31%) did not respond affirmatively to any CDC risk assessment questions. The question best predicting an elevated BPb was the determination that the house the child lives in was built before 1960 (sensitivity = .83, specificity = .67). This question is not currently included in CDC or Illinois screening strategies. Screening based on the single question "Was your house built before 1960?" would have missed only five (17%) of the children with BPb levels > or = 10 micrograms/dL. Three of these five children were among the 17.1% of 1-year-olds and 26.3% of 2-year-olds in our sample who had moved. CONCLUSIONS: In this sample, children living in houses built before 1960 should be considered at high risk for high-dose lead exposure. Due to the high mobility of our sample, phrasing the question to include lifetime exposure (ie, Has your child ever lived in a house built before 1960?) should also be considered. Selective BPb testing of high-risk children in low-prevalence suburban areas using this question would miss few children with elevated BPb. Useful risk assessment questions in other areas and other populations may differ.

Family history evaluation as a predictive screen for childhood hypercholesterolemia. Pediatric Practice Research Group.

A study was conducted to evaluate the efficacy of family history factors as screening criteria for childhood hypercholesterolemia. When they were seen for routine care at one of eight office practices, 1005 prepubertal children underwent random serum cholesterol determinations. Parental and grandparental histories of cardiovascular risk factors and atherosclerotic complications prior to 55 years of age were also obtained. Of the initial group, 274 children had total cholesterol levels greater than or equal to 175 mg/dL, and 175 of these children returned for retesting after an overnight fast. A total of 88 children were found to have low-density lipoprotein-cholesterol (LDL-C) values greater than or equal to 90th percentile for age and sex. Maternal and paternal histories of hypercholesterolemia were significantly associated with elevated LDL-C (odds ratio = 7.3 and 2.9, respectively), but had extremely low sensitivities (0.09, 0.15) despite modest positive predictive values (0.42, 0.22). Grandparental histories of sudden death, peripheral vascular disease, and gout were associated with elevated LDL-C, but sensitivities and positive predictive values for all of these factors were less than 0.22. Family history factors most commonly recommended as criteria for cholesterol screening in children did not identify half of all the children with elevated LDL-C and did not selectively identify the most severely affected children. Adding information concerning the presence of childhood obesity did not result in appreciable improvement in LDL-C detection beyond that achieved by family history factors alone. It was concluded that if thorough identification of young children with elevated LDL-C is desired, inclusive population screening rather than a family history-based strategy would be the most effective approach.

The effect of price information on test-ordering behavior and patient outcomes in a pediatric emergency department.

OBJECTIVE: We sought to determine whether information on hospital charges (prices) would affect test-ordering and quality of patient care in a pediatric emergency department (ED). DESIGN: Prospective, nonblind, controlled trial of price information. SETTING: Urban, university-affiliated pediatric ED. METHODS: We prospectively assessed patients 2 months to 10 years of age with a presenting temperature >/=38.5 degrees C or complaint of vomiting, diarrhea, or decreased oral intake. The assessments were done during three periods: September 1997 through December 1997 (control), January 1998 through March 1998 (intervention), and April 1998 (washout). In the control and washout periods, physicians noted tests ordered on a list attached to each chart. In the intervention period, physicians noted tests ordered on a similar list that included standard hospital charges for each test. Records of each visit were reviewed to determine clinical and demographic information as well as patient disposition. In the control and intervention periods, families of nonadmitted patients were interviewed by telephone 7 days after the visit. RESULTS: When controlled for triage level, vital signs, and admission rates, in a multivariate model, charges for tests in the intervention period were 27% less than charges in the control period. The greatest decrease was seen among low-acuity, nonadmitted patients (43%). In telephone follow-up, patients in the intervention period were slightly more likely to have made an unscheduled follow-up visit to a health care provider (24.4% vs 17.8%), but did not differ on improved condition (86.7% vs 83.4%) or family satisfaction (93.8% vs 93.0%). Adjusted charges in the washout period were 15% lower than in the control period and 15% higher than in the intervention period. CONCLUSION: Providing price information was associated with a significant reduction in charges for tests ordered on pediatric ED patients with acute illness not requiring admission. This decrease was associated with a slightly higher rate of unscheduled follow-up, but no difference in subjective outcomes or family satisfaction.

Foreign body ingestions in children: risk of complication varies with site of initial health care contact. Pediatric Practice Research Group.

Current recommendations for the management of pediatric foreign body ingestions are based on studies of patients cared for at tertiary care hospitals; they call for aggressive evaluation because of a high incidence of complications. Two hundred forty-four children with suspected foreign body ingestions were prospectively followed to analyze adverse outcomes, ie, procedures, complications, and hospitalizations. Patient enrollment into the study was from three sources: (1) patients who referred themselves to a tertiary pediatric emergency department, (2) patients referred to the same tertiary pediatric emergency department after an initial evaluation by another hospital or physician, and (3) patients who reported their foreign body ingestions to a private pediatric practitioner participating in the study. Most children were well toddlers in normal circumstances, under parent supervision at the time of ingestion. Coins were the most common item ingested (46%). Procedures were done in 53 (24%) of 221 patients and complications occurred in 48 (22%) of 221. Complications were higher in patients referred to the emergency department (63%) than in emergency department self-referred patients (13%) or private practice patients (7%) (chi 2, P < .01). These findings demonstrate the risk of drawing conclusions regarding a universal standard of care from studies involving only hospital-based patients.

Language barriers and resource utilization in a pediatric emergency department.

BACKGROUND: Although an inability to speak English is recognized as an obstacle to health care in the United States, it is unclear how clinicians alter their diagnostic approach when confronted with a language barrier (LB). OBJECTIVE: To determine if a LB between families and their emergency department (ED) physician was associated with a difference in diagnostic testing and length of stay in the ED. DESIGN: Prospective cohort study. METHODS: This study prospectively assessed clinical status and care provided to patients who presented to a pediatric ED from September 1997 through December 1997. Patients included were 2 months to 10 years of age, not chronically ill, and had a presenting temperature >/=38.5 degrees C or complained of vomiting, diarrhea, or decreased oral intake. Examining physicians determined study eligibility and recorded the Yale Observation Score if the patient was <3 years old, and whether there was a LB between the physician and the family. Standard hospital charges were applied for each visit to any of the 22 commonly ordered tests. Comparisons of total charges were made among groups using Mann-Whitney U tests. Analysis of covariance was used to evaluate predictors of total charges and length of ED stay. RESULTS: Data were obtained about 2467 patients. A total of 286 families (12%) did not speak English, resulting in a LB for the physician in 209 cases (8.5%). LB patients were much more likely to be Hispanic (88% vs 49%), and less likely to be commercially insured (19% vs 30%). These patients were slightly younger (mean 31 months vs 36 months), but had similar acuity, triage vital signs, and Yale Observation Score (when applicable). In cases in which a LB existed, mean test charges were significantly higher: $145 versus $104, and ED stays were significantly longer: 165 minutes versus 137 minutes. In an analysis of covariance model including race/ethnicity, insurance status, physician training level, attending physician, urgent care setting, triage category, age, and vital signs, the presence of a LB accounted for a $38 increase in charges for testing and a 20 minute longer ED stay. CONCLUSION: Despite controlling for multiple factors, the presence of a physician-family LB was associated with a higher rate of resource utilization for diagnostic studies and increased ED visit times. Additional study is recommended to explore the reasons for these differences and ways to provide care more efficiently to non-English-speaking patients.

Practice-based research: opportunities and obstacles.

Renewed interest in practice-based research reflects growing realization of the limitations of research from a hospital perspective. Practice-based pediatric research promises to broaden the range and severity of conditions commonly studied, to enhance the study of the natural history of disease and of normal development, to provide normal controls and standards, and to facilitate recruitment of adequate sample sizes. Cohort, incidence, and health services research will be promoted by the development of patients registries. The Chicago area Pediatric Practice Research Group is a research consortium of 81 practitioners in 27 office practices. Formed in 1984, it receives logistic and financial support from Children's Memorial Hospital, with which it is affiliated. The Pediatric Practice Research Group has undertaken six studies, most with outside funding. During these studies, some unifying characteristics of practice-based research have emerged. These include the need to tailor study protocols to individual practice characteristics and routines and the critical role of office staff in the conduct of research. Features can be identified that make specific studies more or less intrusive into office functioning. It has proved feasible to obtain data of high quality and reproducibility despite geographically scattered data collection sites. This review of Pediatric Practice Research Group activities and experience is intended to open an exchange of ideas with others interested in practice-based research.

Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians' recognition. Pediatric Practice Research Group.

This study examined how well private-practice pediatricians can identify emotional/behavioral problems among preschool children. Children aged 2 through 5 (N = 3876) were screened during a visit to 1 of 68 pediatricians who rendered an opinion about the presence of emotional/behavioral problems. Subsequently, children who scored above the 90th percentile for behavioral problems on the Child Behavior Checklist, along with children matched on age, sex, and race who had screened low, were invited for an intensive second-stage evaluation. There were 495 mothers and children who participated in that evaluation, which included a behavioral questionnaire, maternal interview, play observation, and developmental testing. Two PhD-level clinical child psychologists rendered independent opinions about the presence of an emotional/behavioral disorder. The psychologists identified significantly higher rates of problems overall--13.0% when the criterion was independent agreement that the child had an emotional/behavioral problem and a regular psychiatric diagnosis was assigned, vs 8.7% based on pediatricians' ratings. Prevalence rates based on psychologists' independent ratings were significantly higher than pediatricians' for both sexes, 4- through 5-year-olds, and whites, but not for 2- through 3-year-olds, African-Americans, and all minorities. Prevalence rates based on psychologists' ratings were significantly higher than the pediatricians' for all subgroups when V-code diagnoses were included in the psychologists' ratings. Overall, pediatricians' sensitivity was 20.5%, and specificity was 92.7%. At least 51.7% of the children who had an emotional/behavioral problem based on the psychologist's independent agreement had not received counseling, medication, or a mental health referral from the pediatrician.(ABSTRACT TRUNCATED AT 250 WORDS)

What do parents know about lead poisoning? The Chicago Lead Knowledge Test. Pediatric Practice Research Group.

OBJECTIVES: To examine the extent of parental knowledge about lead poisoning and its prevention and to determine characteristics associated with accurate lead knowledge. SETTING: Twenty-three pediatric practices and 1 family practice in Chicago, Ill, and its suburbs. METHODS: A 24-question test regarding lead poisoning and its prevention (Chicago Lead Knowledge Test) was developed based on lead specialists' review and parental test-retest reliability. One point was assigned for each correct response. It was self-administered by a sample of 2225 parents of 0- to 6-year-old children visiting study practices. A 1-way analysis of variance (ANOVA) was used to determine the association of demographic descriptors with test scores. RESULTS: Respondents had a mean age of 33 years. Ninety percent were mothers, 49% were college graduates, and 80% were home owners. Fifteen percent lived in homes built before 1950, of which 36% were remodeled or renovated during the last 6 months. Respondents' youngest children were 80% white, 10% Hispanic, 5% African American, and 5% other. Ten percent received Medicaid and 86% had other medical insurance. Thirty-four percent recalled receipt of lead information from a health care provider, and 2.4% had had a child with a blood lead level of 0.48 micromol/L (10 microg/dL) or higher. The mean Chicago Lead Knowledge Test score was 12.2 (SD, 3.7). Questions related to lead exposure were more often answered correctly than those related to prevention and diet. In the ANOVA model, those who recalled receipt of lead information from a health care provider, college graduates, respondents aged 30 years or older, Hispanic respondents, and those living in homes built before 1950 had higher scores (all ANOVA P< or =.001). CONCLUSIONS: Parents do not have much knowledge of ways to prevent childhood lead poisoning. Information from a health care provider can aid parental knowledge. The Chicago Lead Knowledge Test is a new self-administered tool to help evaluate lead education programs.

Identification of adolescent tobacco users in a pediatric practice.

CONTEXT: Though prevention of adolescent tobacco use is a major public health goal, there is little information on the ability of pediatricians to identify adolescents experimenting with tobacco and regular tobacco users. OBJECTIVES: To pilot use of a short questionnaire and analysis of urinary cotinine level to identify adolescent smokers in a pediatric practice, and to determine characteristics of tobacco users. SETTING: Suburban pediatric practice. METHOD: Consecutive high school students completed a short questionnaire and urine cotinine assessment. Three groups were defined: smokers (urine cotinine level >100 ng/mL), experimenters (smoked within the last year; urine continine level

Strategies for managing group A streptococcal pharyngitis. A survey of board-certified pediatricians.

OBJECTIVE: To assess the management strategies and knowledge of board-certified pediatricians regarding group A beta-hemolytic streptococcal (GABHS) pharyngitis. DESIGN: Survey of 1000 US pediatricians in 1991, chosen randomly from the membership of the American Academy of Pediatrics. The survey included questions related to 2 clinical scenarios, respondent demographics, and knowledge of streptococcal pharyngitis. SUBJECTS: Pediatricians who treated patients with pharyngitis. Of the 690 surveys that were returned, 510 pediatricians treated patients with pharyngitis and were included in the data analysis. DATA ANALYSIS: Data were analyzed using Chi 2 statistics for categorical data and the Student t test for continuous variables. RESULTS: Antigen detection tests (ADTs) were used by 64% of the pediatricians; 85% used throat cultures. Strategies for diagnosing streptococcal pharyngitis were throat culture alone (38%), consider positive ADTs definitive and use throat culture when ADTs are negative (42%), ADT alone (13%), ADT and throat culture for all patients with pharyngitis (5%), and no tests for GABHS performed (2%). Thirty-one percent usually or always treated with antibiotics before test results were available. Only 29% of these "early treaters" always discontinued antibiotics when tests did not confirm the presence of group A streptococci. The drug of choice for treatment was penicillin (73%); another 26% preferred a derivative of penicillin, particularly amoxicillin. Many pediatricians altered their management when a patient had recurrent streptococcal pharyngitis. Nearly half of the respondents would use a different antibiotic than they used for routine acute streptococcal pharyngitis. They most often changed to erythromycin (25%), cefadroxil (23%), or amoxicillin-clavulanate (20%). Follow-up throat culture was obtained by 51% of pediatricians after treatment of recurrent streptococcal pharyngitis. A patient with chronic carriage of GABHS and symptoms of pharyngitis would be treated with an antibiotic by 84%; most (62%) would use a penicillin. Other choices were cephalosporins (19%), erythromycin (12%), clindamycin (3%), or rifampin plus penicillin (3%). Tonsillectomy was recommended for symptomatic carriers by 31% of respondents. Carriers without symptoms were less likely to be treated with antibiotics (23%) or referred for tonsillectomy (21%). CONCLUSIONS: Most surveyed board-certified pediatricians managed acute GABHS pharyngitis appropriately, but 15% to 20% used diagnostic or treatment strategies that are not recommended. There was lack of a consensus about the management of recurrent GABHS pharyngitis and chronic carriage of GABHS.

The physicians' office laboratory: 1988 and 1996 survey of Illinois pediatricians. Pediatric Practice Research Group.

OBJECTIVES: To contrast practices of physicians' office laboratories in the years 1988 and 1996 and ascertain physicians' perception of the effect of the Clinical Laboratory Improvement Amendments of 1988 (CLIA). DESIGN: Mailed surveys to members of the Illinois chapter of the American Academy of Pediatrics in 1988 and 1996. SUBJECTS: There were 525 and 980 respondents in 1988 and 1996, respectively; analyses included 282 and 374 surveys representing offices where direct patient care was provided in a nonhospital setting. A paired analysis was also conducted on 101 offices that responded to both surveys. RESULTS: There was a decline from 1988 to 1996 in the percentage of offices doing in-office laboratory testing (93% to 84%, respectively; chi2 test; P<.01) and median number of types of tests (6 tests vs 4 tests; Mann-Whitney U test; P<.001). Decreases (chi2 test; P<.01) were seen in the proportion of offices offering throat culture for group A streptococci (63% to 33%), urinalysis (54% to 33%), urine culture (53% to 22%), rapid hemagglutination slide test for mononucleosis (42% to 17%), theophylline level (27% to 4%), and total cholesterol (22% to 13%). The proportion of offices offering urine dipstick, hematocrit or hemoglobin, complete blood cell count, and stool occult blood tests remained stable. For solo practitioner offices only, streptococcal antigen detection testing decreased (66% to 39%; chi2 test; P<.001). Findings in the paired analyses were similar. In 1996, more offices participated in a formal proficiency testing program (60% vs 11%; chi2 test; P<.001). The CLIA guidelines were deemed responsible for increased documentation (58%), discontinuing 1 or more tests (56%), increased frequency of quality control (50%), joining a proficiency program (40%), and increased cost to patients (32%). CONCLUSIONS: These surveys provide large-scale data concerning change in office-based laboratories of physicians serving children during an 8-year period. Office laboratories reduced their menu of tests and enhanced documentation and quality control for the tests that were done. Data like these in multiple specialties over time contribute to a comprehensive picture of the effects of CLIA on office laboratory practices.

Children's bicycle helmet attitudes and use. Association with parental rules. The Pediatric Practice Research Group.

BACKGROUND: Previous studies have assessed the attitudes of parents and children toward bicycle helmet ownership and use in various settings, but they have not addressed the role of parental rules in promoting bicycle helmet use by children. OBJECTIVES: To further explore the attitudes of parents and children at pediatric practices toward bicycle helmet ownership and use by children and to assess the role of parental rules in promoting bicycle helmet use by children. DESIGN: One hundred sixty-nine 5- to 14-year-old children who owned bicycles and their parents were surveyed during well-child visits at 5 general pediatric practices in the Chicago, Ill, area. One hundred twenty-nine families were represented. Of the children, 60% were aged 5 to 9 years, and 50% were girls. RESULTS: Forty-eight children (28%) reported helmet ownership. Of the helmet owners, 21 (45%) reported helmet use; thus, the overall percentage of helmet use was 12%. Helmet ownership by children was significantly (P < .05) related to parental characteristics: educational level, race, perceived effectiveness of bicycle helmets, seat belt use, and parental helmet ownership. The most common reasons parents gave for lack of helmet ownership by children were "never thought about purchasing" a helmet (35%), "never got around to purchasing" a helmet (29%), "child wouldn't wear it anyway" (26%), and the bicycle helmet was "too expensive" (16%). Only 33% of the parents reported hearing about helmets from their children's pediatrician, but 40% of these parents regarded pediatricians as their most important information source. Of the children who did not own helmets, 64% said they would wear a bicycle helmet if they had one, a more frequent comment for 5- to 9-year-old children than 10- to 14-year-old children (76% vs 49%, P < .01). The most common reasons for not wearing a helmet among owners were as follows: forgot or lost it and not needed. The most common reasons for not wearing a helmet among nonowners were as follows: uncomfortable and appearance or perception of others. Children who owned helmets and whose parents had a strict rule about wearing helmets were more likely to always wear their helmets than helmet owners whose parents had a partial rule or no rule (88% vs 19%, P < .001). CONCLUSIONS: Parental rules are associated with bicycle helmet use by children. Pediatricians may increase helmet use rates by promoting strict parental helmet rules as part of their anticipatory guidance regarding bicycle safety. More research about the effectiveness of this strategy is needed.

Growth of Chicago-area infants, 1985 through 1987. Not what the reference curves predict. Pediatric Practice Research Group.

OBJECTIVE: To determine if the National Center for Health Statistics (NCHS) growth curves (including 867 white infants, born between 1929 and 1975, in the Yellow Springs, Ohio, area) reflect contemporary infant growth in pediatric practices. DESIGN: Observational cohort study of healthy term infants. Office personnel obtained standardized measurements at health maintenance visits. SETTING: Ten pediatric community practices that were members of the Chicago, III, area Pediatric Practice Research Group (PPRG). METHODS: Measurements of 1574 PPRG infants, seen on at least 5 occasions between 2 and 54 weeks of age, generated sex-specific growth curves using a 3-parameter mathematical model fitted to the serial data for each infant. Values from the computed curves were compared with NCHS growth references at 1, 3, 6, 9, and 12 months. The birth weights of PPRG and NCHS cohorts were compared. RESULTS: Mean birth weight of PPRG infants was significantly greater than a similar NCHS measure. Compared with the NCHS reference curve, PPRG infants were heavier at 1, 3, and 6 months, longer on all comparisons, and had greater head circumferences, particularly in the early months of age. CONCLUSIONS: The NCHS growth curves do not accurately reflect infant growth in this cohort. Nationally representative data are needed to revise the NCHS growth curves.

Health care providers' experience reporting child abuse in the primary care setting. Pediatric Practice Research Group.

OBJECTIVES: To describe (1) primary care providers' experiences identifying and reporting suspected child abuse to child protective services (CPS) and (2) variables affecting providers' reporting behavior. DESIGN AND METHODS: Health care providers (76 physicians, 8 nurse practitioners, and 1 physician assistant) in a regional practice-based network completed written surveys that collected information about the demographic characteristics of each provider and practice; the provider's career experience with child abuse; and the provider's previous year's experience identifying and reporting suspected child abuse, including experience with CPS. RESULTS: All providers (N = 85) in 17 participating practices completed the survey. In the preceding 1 year, 48 respondents (56%) indicated that they had treated a child they suspected was abused, for an estimated total of 152 abused children. Seven (8%) of 85 providers did not report a total of 7 children with suspected abuse (5% of all suspected cases). A majority of providers (63%; n = 29) believed that children who were reported had not benefited from CPS intervention, and 21 (49%) indicated that their experience with CPS made them less willing to report future cases of suspected abuse. Providers who had some formal education in child abuse after residency were 10 times more likely to report all abuse than were providers who had none. CONCLUSIONS: Primary care providers report most, but not all, cases of suspected child abuse that they identify. Past negative experience with CPS and perceived lack of benefit to the child were common reasons given by providers for not reporting. Education increases the probability that providers will report suspected abuse.

Oppositional defiant disorder with onset in preschool years: longitudinal stability and pathways to other disorders.

OBJECTIVE: To examine the stability and change in oppositional defiant disorder (ODD) with onset among preschool children in a pediatric sample. METHOD: A total of 510 children aged 2-5 years were enrolled initially in 1989-1990 (mean age 3.42 years); 280 participated in five waves of data collection over a period of 48 to 72 months (mean wave 5 age, 8.35 years). Test batteries varied by age, but they included the Child Behavior Checklist, developmental evaluation, Rochester Adaptive Behavior Inventory, and a play session (before age 7 years) and a structured interview (Diagnostic Interview for Children and Adolescents, parent and child versions) at ages 7+ years. Consensus diagnoses were assigned by using best-estimate procedures. RESULTS: Wave 1 single-diagnosis ODD showed a significant relationship with both single-diagnosis ODD and single-diagnosis attention-deficit hyperactivity disorder (ADHD) at subsequent waves, but not with single-diagnosis anxiety or mood disorders. Single-diagnosis ODD at wave 1 was associated with later comorbidity of ODD/ADHD, ODD/anxiety, and ODD/mood disorders. Stability across waves 2 through 5 was moderate to high for comorbid ODD/anxiety and ODD/ADHD; low to moderate stability for single-diagnosis ODD and single-diagnosis mood disorder; and low for mood disorder, single-diagnosis ADHD, and single-diagnosis anxiety disorder. CONCLUSIONS: Preschool children with ODD are likely to continue to exhibit disorder, with increasing comorbidity with ADHD, anxiety, or mood disorders.

Psychiatric disorders with onset in the preschool years: I. Stability of diagnoses.

OBJECTIVE: To examine the stability of psychiatric disorders with onset in preschool years. METHOD: Five hundred ten children aged 2 through 5 years enrolled initially, with 344 participating in a third wave of data collection 42 through 48 months later. The test batteries used for diagnoses varied by child's age, but they included the Child Behavior Checklist, developmental evaluation, Rochester Adaptive Behavior Inventory and a play session (under age 7 years), and a structured interview (Diagnostic Interview for Children and Adolescents, for parent and child) (ages 7 and older). Consensus DSM-III-R diagnoses were assigned using best-estimate procedures. RESULTS: Intraclass correlations were 0.497 for emotional disorders, 0.718 for disruptive disorders, 0.457 for other diagnoses, and 0.544 for disruptive disorders comorbid with another disorder, indicating moderate stability for all groups of disorders. More than 50% of the children who were aged 2 through 3 years at wave 1 continued to have some psychiatric disorder at wave 2 or 3. Rates were higher for children aged 4 through 5 initially; approximately two thirds were cases subsequently. Odds ratios indicate that having an emotional or disruptive disorder is a strong risk factor for later diagnoses. CONCLUSIONS: While some preschool children in primary care "grow out of" their disorder, an equally large number do not; this finding supports the need for early detection and intervention.

Psychiatric disorders with onset in the preschool years: II. Correlates and predictors of stable case status.

OBJECTIVE: To examine the correlates and predictors of stability and change in psychiatric disorder occurring among preschool children in a nonpsychiatric, primary care pediatric sample. METHOD: Five hundred ten children aged 2 through 5 years were enrolled; 344 participated in a third wave of data collection 42 through 48 months later. Consensus diagnoses were assigned using best-estimate procedures; variables of maternal psychopathology, family climate, and life stresses were the correlates/predictors studied. RESULTS: For children who were cases initially, family cohesion predicted diagnostic stability. Among initial noncases, those remaining noncases experienced increased family cohesion; for those who later became cases, family cohesion declined. Negative life events declined when children were consistently noncases. Children who were initially noncases but were cases at the two subsequent waves had the highest levels of maternal negative affect. Predictors at wave 1 for wave 2 cases status included lower socioeconomic status, less family cohesiveness, and greater family inhibition/control. Wave 2 correlates of wave 2 status included older children and negative life events. Wave 2 predictors of wave 3 status included being older, while wave 3 correlates of wave 3 case status included older children and higher maternal negative affect. CONCLUSIONS: Family context contributes to the maintenance and onset of problems beginning in the preschool years.

Prevalence rates and correlates of psychiatric disorders among preschool children.

OBJECTIVE: To determine the prevalence and correlates of psychiatric disorders among preschool children in a primary care pediatric sample. METHOD: In a two-stage design, 3,860 preschool children were screened; 510 received fuller evaluations. RESULTS: For quantitative assessment of disorder (> or = 90th percentile), prevalence of behavior problems was 8.3%. "Probable" occurrence of an Axis I DSM-III-R disorder was 21.4% (9.1%, severe). Logistic regression analyses indicated significant demographic correlates for quantitative outcomes (older age, minority status, male sex, low socio-economic status, father absence, small family size) but not for DSM-III-R diagnoses. Maternal and family characteristics were generally not significant. Child correlates included activity level, timidity, persistence, and IQ. CONCLUSIONS: Overall prevalence of disorder was consistent with rates for older children; correlates varied by approach used for classification.

Mental health service use among young children receiving pediatric primary care.

OBJECTIVE: To investigate the factors associated with mental health service use among young children. METHOD: Five hundred ten preschool children aged 2 through 5 years were enrolled through 68 primary care physicians, with 388 (76% of the original sample) participating in a second wave of data collection, 12 to 40 months later. Consensus DSM-III-R diagnoses were assigned using best-estimate procedures. The test battery included the Child Behavior Checklist, a developmental evaluation, the Rochester Adaptive Behavior Inventory, and a videotaped play session (preschool children) or structured interviews (older children). At wave 2, mothers completed a survey of mental health services their child had received. RESULTS: In logistic regression models, older children, children with a wave 1 DSM-III-R diagnosis, children with more total behavior problems and family conflict, and children receiving a pediatric referral were more likely to receive mental health services. Among children with a DSM-III-R diagnosis, more mental health services were received by children who were older, white, more impaired, experiencing more family conflict, and referred by a pediatrician. CONCLUSIONS: Young children with more impairment and family conflict are more likely to enter into treatment. Services among young children of different races with diagnoses are not equally distributed. Pediatric referral is an important predictor of service use.