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.

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

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.

Lung deposition of aerosol--a comparison of different spacers.

AIMS: To investigate (1) aerosol lung deposition obtained from two small volume conventional spacers (Babyhaler and Aerochamber) and a home made spacer (modified 500 ml plastic cold drink bottle); (2) the effect of using a face mask or mouthpiece; and (3) the relation between age and pulmonary deposition. METHODS: Lung deposition of aerosolised technetium-99m DTPA inhaled via spacer was measured in 40 children aged 3-7 years with stable asthma. Each patient performed sequential randomly assigned inhalations using two spacers. Three studies were performed: Babyhaler compared to Aerochamber (with facemasks); Babyhaler with facemask compared to Babyhaler with mouthpiece; and Babyhaler with mouthpiece compared to a 500 ml bottle. RESULTS: Median lung aerosol deposition from a Babyhaler and Aerochamber with masks were similar (25% v 21%, p = 0.9). Aerosol lung deposition from a Babyhaler with mask compared to a Babyhaler with mouthpiece was equivalent (26% v 26%, p = 0.5). Lung deposition was higher from a 500 ml bottle compared to a Babyhaler in both young (25% v 12.5%, p = 0.005) and older children (42% v 22.5%, p = 0.003). A notable reduction in pulmonary deposition occurred at 50 months of age. CONCLUSION: A Babyhaler or Aerochamber produce equivalent lung deposition of aerosol. There is no difference in lung deposition when a mask or mouthpiece is used. A modified 500 ml plastic bottle produces greater pulmonary aerosol deposition than a conventional small volume spacer.

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.

Determination of spatial continuity of soil lead levels in an urban residential neighborhood.

This study uses geostatistical techniques to model and estimate soil lead levels in an urban, residential neighborhood. Sixty-two composite soil samples (median 1773 ppm; range 175 to 7953 ppm) in a four-block area of brick and stone homes were obtained. The spatial continuity of soil lead levels was modeled with a semi-variogram, which was then used to estimate lead levels at unsampled locations, a process called kriging. Because soil lead levels were spatially correlated, it is likely that a "nonrandom" process generated the lead distribution found. This finding signifies the existence of lead sources which were tentatively identified on historical maps of the area and from past traffic volume patterns. The distribution of kriged estimates of soil lead levels provides an explanatory tool for exploring and identifying potential sources and may be useful for targeting urban soil abatement efforts.

Rational service planning in pediatric primary care: continuity and change in psychopathology among children enrolled in pediatric practices.

OBJECTIVE: To examine the stability of the occurrence of psychiatric disorders in a nonpsychiatric sample of young children. METHOD: There were 510 children ages 2-5 years enrolled through pediatric practices, with 391 children participating in the second wave, and 344 in the third wave of data collection 42-48 months later. The assessment battery administered at each wave yielded best-estimate consensus DSM-III-R diagnoses and dimensional assessments of psychopathology. RESULTS: The prevalence of disruptive disorders (DDs) decreased, while emotional disorders (EDs), other disorders, and comorbid DD increased. The DDs were associated with lower family cohesion, more maternal negative affect, stressful life events, and male gender. Comorbid DDs were associated with increasing age and family cohesion. Older children, lower family cohesion, and maternal negative affect were associated with EDs. Time trends for the dimensional assessment of psychopathology was similar to DSM-III-R disorders, but correlates differed. CONCLUSIONS: We discuss implications for service planning in pediatric primary care.

Fast track and the pediatric emergency department: resource utilization and patients outcomes.

OBJECTIVE: To examine differences in the evaluation, management, and outcomes for patients seen in an on-site "fast track" (FT) vs the main ED. METHODS: Over a three-month period, patients presenting to an urban pediatric ED were prospectively assessed. Patients included were: triaged as "nonurgent"; aged 2 months to 10 years; not chronically ill; and had fever, or complaint of vomiting, diarrhea, or decreased oral intake. Evening and weekend care was provided in the FT; at all other times these low-acuity patients were seen in the ED. Seven days after the visit, families were interviewed by telephone. RESULTS: Four hundred seventy-nine and 557 patients were seen in the FT and ED, respectively. The patients in the two settings did not differ in age, clinical condition, race, or commercial insurance status. Patient mean test charges were $27 and $52 for the FT and ED, respectively (p < 0.01). Twenty-four percent of the FT patients vs 41% of the ED patients had tests performed (p < 0.01). Average length of stay was 28 minutes shorter in the FT (95% CI = 19 to 36, p < 0.01). Follow-up was completed for 480 of 755 families with telephones (64%). The FT and ED patients did not differ at follow-up: 90% vs 88% had improved conditions (p = 0.53), 18% vs 15% had received unscheduled follow-up care (p = 0.44), and 94% of the families in both groups were satisfied with the visit (p = 0.98). CONCLUSIONS: Compared with those in the main ED, the study patients seen in the FT had fewer tests ordered and had briefer lengths of stay. These findings were not explained by differences in patient ages, vital signs, or demographic characteristics. No difference in final outcomes or satisfaction was detected among the families contacted for follow-up.

Sleep and behavior problems among preschoolers.

This study described the relationship between amount of sleep and behavior problems among preschoolers. Participants were 510 children aged 2 to 5 years who were enrolled through 68 private pediatric practices. Parents reported on the amount of sleep their child obtained at night and in 24-hour periods. With demographic variables controlled, regression models were used to determine whether sleep was associated with behavior problems. The relationship between less sleep at night and the presence of a DSM-III-R psychiatric diagnosis was significant (odds ratio = 1.23, p = .026). Less night sleep (p < .0001) and less sleep in a 24-hour period (p < .004) were associated with increased total behavior problems on the Child Behavior Checklist; less night sleep (p < .0002) and less 24-hour sleep (p < .004) were also associated with more externalizing problems on that measure. Further research is needed to ascertain whether sleep is playing a causal role in the increase of behavior problems.

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.

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.

Adrenal suppression in children with the human immunodeficiency virus treated with megestrol acetate.

Symptoms and laboratory evidence of adrenal suppression developed in 2 children with the human immunodeficiency virus after megestrol acetate (MA) therapy was discontinued; both required transient glucocorticoid replacement therapy. High-dose corticotropin stimulation testing performed on children with the human immunodeficiency virus treated or not treated with MA showed that baseline and post-corticotropin cortisol levels were extremely low in 7 of 10 treated patients and normal in 10 of 10 members of a control group (P <.01). MA may suppress adrenal function, and replacement glucocorticoids may prevent or relieve associated symptoms at times of severe stress or on discontinuation of MA therapy.

Evaluation of risk assessment questions used to target blood lead screening in Illinois.

OBJECTIVE: Beginning in 1995, Illinois law permitted targeted-as opposed to universal-blood lead screening in low-risk areas, which were defined by ZIP code characteristics. State guidelines recommended specific lead risk assessment questions to use when targeting screening. This study was designed to evaluate the sensitivity and specificity of Illinois lead risk assessment questions. DESIGN: Parents bringing their 9- or 10- or 12-month and 24-month-old children for health supervision visits at 13 pediatric practices and parents of children (aged 6 through 25 months and who needed a blood lead test) receiving care at 5 local health departments completed a lead risk assessment questionnaire concerning their child. Children had venous or capillary blood lead testing. Venous confirmation results of children with a capillary level >/=10 micrograms/dL were used in analyses. CHILDREN: There were 460 children with both blood and questionnaire data recruited at the pediatric practices (58% of eligible) and 285 children (51% of eligible) recruited at local health departments. Of the 745 children studied, 738 provided a ZIP code that allowed their residence to be categorized as in a low-risk (n = 456) or high-risk (n = 282) area. RESULTS: Sixteen children (3.5%) living in low-risk areas versus 34 children (12.1%) living in high-risk areas had a venous blood lead level (BLL) >/=10 micrograms/dL; 1.8% and 5.3%, respectively, had a venous BLL >/=15 micrograms/dL. For children living in low-risk areas, Illinois mandated risk assessment questions (concerning ever resided in home built before 1960, exposure to renovation, and exposure to adult with a job or hobby involving lead) had a combined sensitivity of.75 for levels >/=10 micrograms/dL and.88 for levels >/=15 micrograms/dL; specificity was.39 and.39, respectively. The sensitivity of these questions was similar among children from high-risk areas; specificity decreased to.27 and.28, for BLLs >/=10 micrograms/dL and >/=15 micrograms/dL, respectively. The combination of items requiring respondents to list house age (built before 1950 considered high risk) and indicate exposure to renovation had a sensitivity among children from low-risk areas of.62 for BLLs >/=10 micrograms/dL with specificity of.57; sensitivity and specificity among high-risk area children were.82 and.36, respectively. For this strategy, similar sensitivities and specificities for low and high-risk areas were found for BLLs >/=15 micrograms/dL. CONCLUSIONS: The Illinois lead risk assessment questions identified most children with an elevated BLL. Using these questions, the majority of Illinois children in low-risk areas will continue to need a blood lead test. This first example of a statewide screening strategy using ZIP code risk designation and risk assessment questions will need further refinement to limit numbers of children tested. In the interim, this strategy is a logical next step after universal screening.

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.

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.

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.

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.

Psychopathology and health care use among preschool children: a retrospective analysis.

OBJECTIVE: To examine the relationship between psychopathology and health care utilization beginning in the preschool (ages 2 to 5) years. METHOD: Five hundred ten preschool children were enrolled through 68 primary care physicians. The test battery used for diagnoses included the Child Behavior Checklist, a developmental evaluation, the Rochester Adaptive Behavior Inventory, and a videotaped play session. Consensus DSM-III-R diagnoses were assigned using best-estimate procedures. Frequency of primary care visits was established through 1-year retrospective record review; mothers estimated total visits and emergency department (ED) use. RESULTS: Logistic regression models showed that a DSM-III-R diagnosis was related to increased ED use but not primary care or total visits. Greater functional impairment was associated with fewer primary care visits and more ED visits. Total, internalizing, and externalizing behavior problem scores were associated with increased primary care and total visits; ED visits were associated with increased total and internalizing problems. Child's health status consistently correlated with utilization. CONCLUSION: There is a consistent relationship between health care use and child psychopathology beginning in the preschool years.