A Case-Based, Longitudinal Curriculum in Pediatric Behavioral and Mental Health.

Introduction: Pediatric behavioral and mental health (BMH) disorders are increasingly common, but most pediatricians feel inadequately trained to manage them. We implemented a case-based, longitudinal curriculum in BMH within a pediatric residency program to prepare trainees to diagnose and manage these conditions. Methods: The pediatric residency program at Wright State University/Wright-Patterson Medical Center implemented a new BMH curriculum in 2020-2021. The curriculum consisted of five simulated cases involving depression, anxiety, attention deficit disorder with hyperactivity (ADHD), developmental delays, behavioral concerns, and autism. To reflect follow-up within a continuity clinic, cases included initial encounters and multiple follow-up visits. Faculty facilitators led residents in monthly small-group meetings over the academic year, with each session consisting of two to three simulated patient encounters. Residents completed pre-post surveys regarding their confidence in diagnosing and managing BMH conditions and pre- and posttests to evaluate the impact of the curriculum on knowledge gains. Results: All 47 pediatric residents participated in the curriculum; 38 (81%) completed pre-post surveys. Upon completion of the curriculum, residents reported significantly increased confidence in managing ADHD, treating depression, creating safety plans for suicidality, recognizing autism, and counseling patients and families on special education services. Knowledge-based pre- and posttests completed by 25 residents (53%) also demonstrated significant improvement (M = 92.4, SD = 10.9, pre vs. M = 99.3, SD = 6.6, post, p = .009). Discussion: This case-based, longitudinal curriculum in pediatric BMH simulating patient continuity improved residents' confidence and knowledge in diagnosing and managing common BMH conditions.

Screening Tools for Autism Spectrum Disorder in Primary Care: A Systematic Evidence Review.

CONTEXT: Recommendations conflict regarding universal application of formal screening instruments in primary care (PC) and PC-like settings for autism spectrum disorder (ASD). OBJECTIVES: We systematically reviewed evidence for universal screening of children for ASD in PC. DATA SOURCES: We searched Medline, PsychInfo, Educational Resources Informational Clearinghouse, and Cumulative Index of Nursing and Allied Health Literature. STUDY SELECTION: We included studies in which researchers report psychometric properties of screening tools in unselected populations across PC and PC-like settings. DATA EXTRACTION: At least 2 authors reviewed each study, extracted data, checked accuracy, and assigned quality ratings using predefined criteria. RESULTS: We found evidence for moderate to high positive predictive values for ASD screening tools to identify children aged 16 to 40 months and 1 study for ≥48 months in PC and PC-like settings. Limited evidence evaluating sensitivity, specificity, and negative predictive value of instruments was available. No studies directly evaluated the impact of screening on treatment or harm. LIMITATIONS: Potential limitations include publication bias, selective reporting within studies, and a constrained search. CONCLUSIONS: ASD screening tools can be used to accurately identify percentages of unselected populations of young children for ASD in PC and PC-like settings. The scope of challenges associated with establishing direct linkage suggests that clinical and policy groups will likely continue to guide screening practices. ASD is a common neurodevelopmental disorder associated with significant life span costs.1,2 Growing evidence supports functional gains and improved outcomes for young children receiving intensive intervention, so early identification on a population level is a pressing public health challenge.3,4.

A Learning Collaborative Approach to Improve Mental Health Service Delivery in Pediatric Primary Care.

BACKGROUND: Pediatric primary care practitioners (PPCPs) report inadequate training in the care of children with common mental health conditions. Although additional training is needed, system changes are also necessary to support improvements in care. METHODS: We developed the Building Mental Wellness Learning Collaborative to assist PPCPs in delivering better mental health services in primary care by targeting 5 focus areas: mental health promotion; early identification and screening; practitioner skills; collaboration and community linkages; and medication management. Aims were developed for each area. RESULTS: Twenty-one practices and 50 practitioners completed the collaborative in 2 seven-month waves. For mental health promotion, ≥85% of charts showed documentation in 3 of 4 preselected areas. For early identification/screening, screening increased, but the ≥85% goal was not met. For practitioner skills, a ≥20% increase in the proportion of children/youth ≥1 visits for anxiety or depression was achieved, from 0.70% of children/youth in the 12 months preintervention to 1.09% children/youth in the 12 months after. For collaboration/linkages, mental health referral completion was unchanged and below the 60% goal. For medication use, a ≥15% increase in selective serotonin reuptake inhibitor prescribing by Building Mental Wellness (BMW) practitioners was achieved from 0.72% children/youth with office visits pre-BMW to 0.92% post. Prescribing did not decrease for atypical antipsychotic medication use or for psychotropic medication use in children younger than 6 years, although there was a trend toward more appropriate prescribing. CONCLUSIONS: The BMW Learning Collaborative was effective in helping PPCPs implement certain aspects of a comprehensive approach to the delivery of mental health services in primary care.

Screen Exposure During Daily Routines and a Young Child's Risk for Having Social-Emotional Delay.

This cross-sectional study assessed associations between social-emotional development in young children and their number of daily routines involving an electronic screen. We hypothesized children with poor social-emotional development have a significant portion of daily routines occurring with a screen. Two hundred and ten female caregivers of typically developing children 12 to 36 months old completed the Ages and Stages Questionnaire: Social-Emotional (ASQ: SE) and a media diary. Caregivers completed the diary for 1 day around 10 daily routines (Waking Up, Diapering/Toileting, Dressing, Breakfast, Lunch, Naptime, Playtime, Dinner, Bath, and Bedtime). Median number of daily routines occurring with a screen for children at risk and not at risk for social-emotional delay (as defined by the ASQ: SE) was 7 versus 5. Children at risk for social-emotional delay were 5.8 times more likely to have ≥5 routines occurring with a screen as compared to children not at risk for delay (χ12 = 9.28, N = 210, P = .002; 95% confidence interval = 1.66-20.39).

Perception of primary care pediatricians of effectiveness, acceptability, and availability of mental health services.

Approximately 20% of children in the United States meet the criteria for a psychosocial disorder; however, less than 25% of these children receive psychosocial services. A questionnaire assessed primary care pediatricians' (PCPs) perceptions of effectiveness, availability, and burden of treatment options for children's psychosocial difficulties and parents' acceptance and adherence with these treatments. Repeated measures analysis of variance found that PCPs are more likely to refer children with psychosocial problems to a mental health professional than to prescribe medication. PCPs prescribe medications more than counseling parents themselves or watchful waiting. PCPs reported children's behavior is more likely to improve with mental health services than with medication, though medication is the most available treatment. PCPs believe parent training programs are very effective for treating children's behavior problems, but believe parents are more accepting and compliant with other treatments. Findings indicate PCPs' perceptions of availability and acceptability of treatment options drive their treatment recommendations of psychosocial problems.

Partial deletion of ANKRD11 results in the KBG phenotype distinct from the 16q24.3 microdeletion syndrome.

KBG syndrome (OMIM 148050) is a very rare genetic disorder characterized by macrodontia, distinctive craniofacial abnormalities, short stature, intellectual disability, skeletal, and neurologic involvement. Approximately 60 patients have been reported since it was first described in 1975. Recently mutations in ANKRD11 have been documented in patients with KBG syndrome, and it has been proposed that haploinsufficiency of ANKRD11 is the cause of this syndrome. In addition, copy number variation in the 16q24.3 region that includes ANKRD11 results in a variable phenotype that overlaps with KBG syndrome and also includes autism spectrum disorders and other dysmorphic facial features. In this report we present a 2½-year-old African American male with features highly suggestive of KBG syndrome. Genomic microarray identified an intragenic 154 kb deletion at 16q24.3 within ANKRD11. This child's mother was mosaic for the same deletion (present in approximately 38% of cells) and exhibited a milder phenotype including macrodontia, short stature and brachydactyly. This family provides additional evidence that ANKRD11 causes KBG syndrome, and the mild phenotype in the mosaic form suggests that KBG phenotypes might be dose dependent, differentiating it from the more variable 16q24.3 microdeletion syndrome. This family has additional features that might expand the phenotype of KBG syndrome.

Pediatrician identification of child behavior problems: the roles of parenting factors and cross-practice differences.

While most primary care pediatricians acknowledge the importance of identifying child behavior problems, fewer than 2% of children with a diagnosable psychological disorder are referred for mental health care in any given year. The present study examined the potential role of parental characteristics (parental affect, parenting style, and parenting self-efficacy) in pediatrician identification of child behavior problems, and determined whether these relationships differed across practices. Parents of 831 children between 2 and 16 years completed questionnaires regarding demographic information, their child's behavior, their affect, their parenting style, and their parenting self-efficacy. Pediatricians completed a brief questionnaire following visits in four community-based primary care practices in the Midwest. Logistic regressions controlling for child behavior and demographic predictors of pediatrician identification found that an authoritarian parenting style, in which parents yell or strongly negatively react to problem behavior, was negatively associated with likelihood of identification in the overall sample. However, the variables that were predictive of pediatrician identification differed depending on the specific practice. Parental characteristics can aid in understanding which children are likely to be identified by their pediatrician as having behavioral problems. The finding that practices differed on which variables were associated with pediatrician identification suggests the need to potentially individualize interventions to certain physicians and practices to improve identification of child behavior problems in primary care.

Peering into the future: pediatrics in a changing world.

Over the last decade, health care has experienced continuous, capricious, and ever-accelerating change. In response, the American Academy of Pediatrics convened the Vision of Pediatrics (VOP) 2020 Task Force in 2008. This task force was charged with identifying forces that affect child and adolescent health and the implications for the field of pediatrics. It determined that shifts in demographics, socioeconomics, health status, health care delivery, and scientific advances mandate creative responses to these current trends. Eight megatrends were identified as foci for the profession to address over the coming decade. Given the unpredictable speed and direction of change, the VOP 2020 Task Force concluded that our profession needs to adopt an ongoing process to prepare for and lead change. The task force proposed that pediatric clinicians, practices, organizations, and interest groups embark on a continual process of preparing, envisioning, engaging, and reshaping (PEER) change. This PEER cycle involves (1) preparing our capacity to actively participate in change efforts, (2) envisioning possible futures and potential strategies through ongoing conversations, (3) engaging change strategies to lead any prioritized changes, and (4) reshaping our futures on the basis of results of any change strategies and novel trends in the field. By illustrating this process as a cycle of inquiry and action, we deliberately capture the continuous aspects of successful change processes that attempt to peer into a multiplicity of futures to anticipate and lead change.

Pediatrics in the year 2020 and beyond: preparing for plausible futures.

Although the future of pediatrics is uncertain, the organizations that lead pediatrics, and the professionals who practice within it, have embraced the notion that the pediatric community must anticipate and lead change to ultimately improve the health of children and adolescents. In an attempt to proactively prepare for a variety of conceivable futures, the board of directors of the American Academy of Pediatrics established the Vision of Pediatrics 2020 Task Force in 2008. This group was charged to think broadly about the future of pediatrics, to gather input on key trends that are influencing the future, to create likely scenarios of the future, and to recommend strategies to best prepare pediatric clinicians and pediatric organizations for a range of potential futures. The work of this task force led to the development of 8 "megatrends" that were identified as highly likely to have a profound influence on the future of pediatrics. A separate list of "wild-card" scenarios was created of trends with the potential to have a substantial influence but are less likely to occur. The process of scenario-planning was used to consider the effects of the 8 megatrends on pediatrics in the year 2020 and beyond. Consideration of these possible scenarios affords the opportunity to determine potential future pediatric needs, to identify potential solutions to address those needs, and, ultimately, to proactively prepare the profession to thrive if these or other future scenarios become realities.

Role of the medical home in family-centered early intervention services.

There is growing evidence that early intervention services have a positive influence on the developmental outcome of children with established disabilities as well as those who are considered to be "at risk" of disabilities. Various federal and state laws now mandate the establishment of community-based, coordinated, multidisciplinary, family-centered programs that are accessible to children and families. The medical home, in close collaboration with the family and the early intervention team, can play a critical role in ensuring that at-risk children receive appropriate clinical and developmental early intervention services. The purpose of this statement is to assist the pediatric health care professional in assuming a proactive role with the interdisciplinary team that provides early intervention services.

Multisite controlled study of OROS methylphenidate in the treatment of adolescents with attention-deficit/hyperactivity disorder.

BACKGROUND: Despite the persistence of attention-deficit/hyperactivity disorder (ADHD) into adolescence, little is known about the efficacy and tolerability of stimulant medications in this age group. OBJECTIVE: To report the results of a multisite controlled study among adolescents with ADHD evaluating the efficacy and tolerability of osmotic-release oral system (OROS) methylphenidate. DESIGN: Adolescents (N = 220) having a confirmed Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of ADHD underwent dose titration to identify dosages of OROS methylphenidate that improved symptoms to predefined criteria. Subjects successfully completing the dose titration phase (n = 177) (ie, tolerated and responded to treatment and adhered to the protocol) were randomized to receive 2 weeks' treatment with their individualized dosage of OROS methylphenidate (18, 36, 54, or 72 mg once daily) or placebo. Treatment effectiveness was measured using investigator, parent, and adolescent assessments of ADHD. RESULTS: A significant reduction from baseline in the investigator-rated ADHD Rating Scale, the primary efficacy measure, was found with OROS methylphenidate treatment compared with placebo. Similar findings were noted with parent- and adolescent-report measures. Based on a Clinical Global Impression improvement subscale score of much or very much improved, 52% of subjects in the OROS methylphenidate group improved compared with 31% receiving placebo. Thirty-seven percent of subjects required the maximum dosage of 72 mg/d. The incidence of drug-related adverse events was similar between the 2 study groups. CONCLUSION: In adolescents, once-daily OROS methylphenidate significantly reduced ADHD symptoms and was well tolerated using dosages up to 72 mg/d.