A simple provider-based educational intervention to boost infant immunization rates: a controlled trial.

We sought to determine if a simple educational intervention initiated at the first well-child care visit, with reinforcement at subsequent visits, can improve inner-city infant immunization rates. We conducted a controlled trial involving 315 newborn infants and their primary caregivers in 3 inner-city primary care centers. Child health care providers gave caregivers in the intervention group an interactive graphic card with verbal reinforcement. At later visits, stickers were applied to the card when immunizations were given. Routine information was given to controls. After the trial, age-appropriate immunization rates at 7 months were 58% in each group. Intervention infants had 50% fewer missed opportunities to immunize (p=0.01) but cancelled 77% more appointments (p=0.04) than controls. We conclude that a brief educational intervention at the first well-child care visit did not boost 7-month immunization rates, although it was associated with fewer missed opportunities to immunize.

Brief approaches to educating patients and parents in primary care.

PURPOSE: Pediatricians are encouraged by the American Academy of Pediatrics and Bright Futures guidelines to use well-child care as an opportunity to promote learning and development, encourage positive parenting practices, help children acquire behavioral self-control, and enhance the well-being of children and their families. Such counseling can consume considerable provider time. In an era of dwindling resources for health care, there is pressure to deliver services as efficiently and effectively as possible. Thus, the purpose of this article is to view methods for patient and parent education that are not only effective but also brief. DESIGN: Review of 114 articles on issues relevant to patient education. RESULTS AND CONCLUSIONS: Parents appear to respond best to information that focuses on their specific area of concern. Media, such as advertising campaigns or office posters, can be helpful for broadening parents' range of interests. In response, verbal suggestions are effective for conveying brief, concrete information when parents are not stressed. Written information should be added for addressing more complex issues. Modeling and role-playing appear especially useful when confronted with problematic parenting or child behavior. These approaches, if selected wisely and applied well, offer families needed assistance that has proven effectiveness in improving children's and families' health and well-being.

Maternal expectations about normal child development in 4 cultural groups.

OBJECTIVE: To determine whether expectations about normal infant and child development are different among mothers from 4 ethnocultural groups. PARTICIPANTS: Two hundred fifty-five mothers (90 Puerto Rican, 59 African American, 69 European American, 37 West Indian-Caribbean) whose children received health care at hospital-based pediatric clinics and private pediatricians' and family practitioners' offices. DESIGN: Verbally administered questionnaire that included 25 questions in which mothers were asked to give their opinions about the age at which a normal child should begin to accomplish standard developmental milestones. ANALYSIS: Responses (mean ages at which mothers expected children to attain the milestones) from each group were compared after controlling for age of mother, number of children, level of education, and socioeconomic status. RESULTS: Significant differences among ethnic groups' responses were seen for 9 of 25 developmental milestones. Differences were mainly seen among personal and social milestones, and Puerto Rican mothers tended to expect children to attain these milestones at a later age than did other mothers. No differences in responses were seen between Spanish- and English-speaking Puerto Rican mothers. European-American mothers expected children to take first steps and become toilet trained at a later age. CONCLUSIONS: Developmental expectations differ among mothers from different ethnocultural groups. Many of these differences can be explained by underlying cultural beliefs and values and specific child-rearing practices. Clinicians should ask about maternal expectations during child health visits to interpret mothers' concerns and opinions about their children's development.

Toddler development.

The toddler years are ones of exciting and challenging changes in cognitive, affective, and physical growth. Physical growth is particularly remarkable for the child's increasing skills and ability to navigate the environment. Affective development is marked by the push for autonomy and independence and the highly visible nature of the child's temperament or behavioral style. The toddler also enters the wonderful years of imagination and pretend play. Perhaps most noteworthy is the child's dramatic increase in ability to communicate with others through speech and language, as evidence of the progression to symbolic thinking. The dynamic changes in children's development during the toddler years have important implications for child health supervision. Familiarity with toddler development will enable the pediatrician to monitor children's development effectively and to address common, stage-related behaviors with families during anticipatory guidance.

The Ready-to-Learn program: a school-based model of nurse practitioner participation in evaluating school failure.

The Ready-to-Learn program, a school-based initiative begun in 1994 in three inner-city elementary schools in Hartford, Conn., provides medical input and medical-educational collaboration in the evaluation and treatment of children experiencing learning and behavior problems. The program is staffed by two specially trained nurse practitioners, with consultation provided by pediatricians and a child psychologist. During its first year of operation, pediatric assessment was performed on 57 students at all three schools. Data analysis indicates that children were referred to the program for a broad range of concerns, that assessments were completed in a timely fashion, and that a variety of diagnoses were identified. Feedback from school personnel and parents suggests that the program offers a unique and valued pediatric perspective to the evaluation of school failure. Future plans include a more formal evaluation of the program's cost and effectiveness.

The role of parents in the detection of developmental and behavioral problems.

OBJECTIVE: The success of early identification of children with developmental and behavioral problems is influenced by the manner in which pediatricians elicit, recognize, and select clinical information and derive appropriate impressions. Parents are ready sources of clinical information, and they can be asked to provide two broad types of data: appraisals, including concerns, estimations, and predictions; and descriptions, including recall and report. The purpose of this article is to help pediatricians make optimal use of clinical information from parents to increase the accuracy of clinical judgment in detecting children with developmental and behavioral problems. DESIGN: Review of 78 research articles and tests relying on parent information from pediatric, psychological, and education literature. RESULTS AND CONCLUSION: There are several formats for eliciting parental information that are superior in terms of accuracy and ease of evocation. Specifically, parents' concerns and good-quality standardized parent report measures such as the Child Development Inventories capitalize best on parents' observations and insights into their children. In combination, these two types of parental information offer an effective method for the early detection of behavioral and developmental problems in primary-care settings.

Outcome of 48 pediatric patients with chronic fatigue. A clinical experience.

OBJECTIVE: To define outcomes of pediatric patients with chronic fatigue. DESIGN: Cohort study with a mean follow-up of 3.8 years. SETTING: Outpatient pediatrics department at a university health center. PATIENTS: Patients 21 years old and younger referred by their private physicians for evaluation of unexplained fatigue lasting at least 3 months. INTERVENTION: Patients were seen from January 1986 through April 1990 and were telephoned in April 1992 to determine outcome. RESULTS: Of the 55 patients who were evaluated from 1986 to 1990, an organic cause of the fatigue, sinusitis, was found for one. Of the 54 patients with unexplained fatigue, 48 were contacted in 1992. The mean age of these 48 patients was 15 years; 73% were female. Fatigue was present a mean of 7 months before evaluation, and in 78% an acute illness preceded the fatigue. Most patients believed their fatigue had an organic cause. In general, laboratory studies were not helpful. All patients were encouraged to resume normal functioning despite their symptoms. At follow-up, 65% reported resolution of symptoms, 29% reported improvement, and 6% were unchanged. CONCLUSIONS: In pediatric patients with chronic fatigue, diagnostic and therapeutic interventions should be based on positive findings; with simple encouragement, the prognosis is excellent. Based on this experience, we suggest a structured approach to the management of pediatric patients with chronic fatigue.

Do parental concerns predict a diagnosis of attention-deficit hyperactivity disorder?

Parents' concerns for their children's behavior were investigated to predict a diagnosis of attention-deficit hyperactivity disorder (ADHD) in this retrospective comparative study of 245 children, aged 4 through 15 years (mean = 8.1 years), consecutively referred for comprehensive pediatric evaluation of school problems between 1981 and 1992. Concerns identified by parents were categorized (inattention, impulsivity, overactivity) and compared to children's final diagnoses of ADHD to measure their sensitivity, specificity, and predictive value. For 92% of subjects, significant school-related problems were diagnosed and 38% received a diagnosis of ADHD. Parental concern for one or more major symptoms of ADHD identified almost all of the children with a diagnosis of ADHD (sensitivity = .87), but also identified many children without such a diagnosis (specificity = .41). Concerns with impulsivity and overactivity were specific (.82, .87) but not sensitive (.38, .29). Concerns with attention had modest sensitivity (.57) and specificity (.57). Positive predictive value was modest for all categories of concerns (.45 to .57). Findings support the importance of eliciting parents' concerns for their children's school performance and of performing comprehensive assessment to identify the underlying causes of problems with attention.

Pediatricians' approaches to developmental problems: has the gap been narrowed?

Whether recent advances in developmental pediatrics have influenced pediatric practice is uncertain. We interviewed, in their offices, 41 randomly selected, board-certified, primary care pediatricians in Connecticut to explore their attitudes and clinical approaches to developmental problems. Responses were compared with those from a similar survey of 97 New England pediatricians performed 15 years ago. Important changes in certain clinical approaches were found. For example, pediatricians are currently less likely to rely on history and physical examination alone to confirm a suspicion of mental retardation (p < .01) and are more likely to refer such a child for further assessment (p < .01); they are more likely to perform hearing screening in evaluating a child with delayed speech (p < .05); they are more likely to contact the school in evaluating a failing child (p < .01), and are more likely to refer such a child for further assessment (p < .01). Results indicate favorable changes in pediatricians' approaches to developmental problems and support the greater emphasis on developmental issues in pediatric education.

Detection of behavioral, developmental, and psychosocial problems in pediatric primary care practice.

By virtue of their ongoing relationship with families and young children, pediatric primary care providers are well positioned to participate in the early detection of children's behavioral, developmental, and psychosocial problems. Yet research suggests that many such problems elude early detection. Awareness of the prevalence of such problems should encourage pediatric providers to carefully elicit parents' opinions and concerns, obtain a relevant behavioral and developmental history, skillfully observe parent and child behaviors, and obtain, when indicated, the opinions of such other relevant professionals as preschool teachers. Possible strategies to improve early detection include the use of parent questionnaires, parent record-keeping of children's behavior, and a developmental screening tool as an aid to surveillance. The development of a classification system for such problems designed for primary care, rather than psychiatry, should also facilitate early detection.

Obstacles to effective developmental surveillance: errors in clinical reasoning.

Recent research and legislation support the importance of early identification and intervention for children with developmental and behavioral or emotional problems. Detecting these children often depends on medical professionals, especially pediatricians. However, few pediatricians use developmental screening tests to help them identify children. Rather, physicians usually rely on their clinical impressions to discriminate children with and without difficulties. Research on the accuracy of clinical impressions, although sparse, suggests that only half the children in need are identified. The most obvious reasons, such as severity of the problem or the type of clinical information physicians select (e.g., parents' concerns, observations of the child, history, etc.), do not fully explain why some children are identified and others are not. More complete explanations are found in research on clinical impression formation that suggests physician's selection from the array of clinical data is mediated by their unique experiences, beliefs, and attitudes. These qualities provide a set of judgment heuristics for sorting seemingly relevant from irrelevant information. Judgment heuristics, depending on their content, may lead to accurate or inaccurate impressions. This article suggests a model of ideal impression formation that may help physicians learn to more accurately identify children with developmental and behavioral or emotional problems.

Ready to learn: a mandate for pediatrics.

As the professional concerned with monitoring children's growth and development, the pediatric provider is well positioned to contribute to the early detection of children unready for school. Successful early detection requires cooperation and an interchange of information among parents and health and educational personnel. The process of developmental surveillance acknowledges the limitations of screening tests and may be most effective in predicting children's school readiness. Child health supervision services are useful in the promotion of children's optimal school readiness. Research findings support a continued emphasis on developmentally oriented anticipatory guidance while individualizing content to respond to families' needs and encouraging parent-led agendas. Innovations in context worthy of consideration include home visiting, group well-child care, and parent-held child health records. The broad-based societal efforts necessary to promote school readiness and to diminish school failure demand firm and effective pediatric advocacy.

Infancy problem behaviors.

The goal of pediatric health supervision is to promote the optimal growth and development of children. Parent-infant interaction and parental attitudes toward their infant are important determinants of child development. Anticipatory guidance during child health supervision enables the pediatric provider to discuss developmental stages and demystify common stage-related behaviors, such as fussing, night-waking, repetitive movements, and clinging. Anticipating the emergence of such behaviors and issues may lessen parental anxiety and concern. When behavioral problems such as colic or sleep difficulties do arise, a consideration of developmental stage is helpful in suggesting specific management strategies. The successful implementation of developmentally-oriented approaches has benefits for the family and pediatric provider, including increased parental self-confidence, enhanced family functioning, and increased parental confidence in the pediatrician. Furthermore, by encouraging developmentally-oriented approaches, parents will be less inclined to adopt inappropriate or ineffectual behavioral management strategies.

British and American recommendations for developmental monitoring: the role of surveillance.

Major British and American pediatric organizations have recently issued recommendations for developmental monitoring during preventive child health care. After initial inspection, similarities between the British and American recommendations are not apparent. For example, the Committee on Practice and Ambulatory Medicine of the American Academy of Pediatrics emphasizes the importance of assessing development during all child health supervision visits, whereas the British Joint Working Party on Child Health Surveillance discourages routine, repeated developmental examinations. Further analysis reveals, however, that such recommendations are compatible. Neither committee recommends the routine administration of developmental screening tests. Such recommendations are consistent with the lack of evidence to justify routine screening of all children for developmental problems. Instead, both committees suggest that developmental monitoring be performed by the process of surveillance. With developmental surveillance, the importance of eliciting parents' opinions and concerns, obtaining a relevant developmental history, and performing skilled, longitudinal observations of children is emphasized. The success of surveillance depends on the extent to which its implementation is enhanced through clinical practice, professional training, and research.

School failure.

Numerous factors may contribute to a child's failure to learn. Certain causes of school failure, such as specific learning disabilities, mental retardation, sensory impairment, and chronic illness may be regarded as intrinsic characteristics of the child. Other causes, such as family dysfunction, social problems, and ineffective schooling, are characteristics of the child's environment. Still other influences on school performance, such as temperamental dysfunction, attention deficits, and emotional illness, may be viewed as the consequence of the interaction between the child and his or her environment. The reasons for a child's school failure must not be considered in isolation but rather within the context of social and environmental circumstances. Evaluation must consider the myriad of reasons for a child's school failure and attempt to identify "clusters" of adverse influences on school performance. Detailed information must be sought from the student, parents, and school system through the history and physical examination. Questionnaires are useful in data gathering. Ancillary methods of assessment that may be of value include neurodevelopmental screening and laboratory studies. Further investigations and referrals, particularly psychoeducational evaluation, are of major importance. Traditional roles of the pediatrician in school failure include the treatment of underlying medical conditions, counseling, the coordination of further investigations and referrals, and the facilitation of communication with community services and resources. Participation with other disciplines in the development of a child's educational plan is feasible and useful.