Through the Webcam: Impact of Telehealth on Developmental and Behavioral Pediatric Fellowship Training.

OBJECTIVE: The purpose of this study was to examine how fellowship program directors (PDs) and their fellows perceived the impact of telehealth on fellowship education in developmental behavioral pediatrics (DBP) during the COVID-19 pandemic. METHODS: Two surveys were designed targeting DBP PDs and fellows and were distributed by e-mail from January to May 2021. Surveys consisted of closed-ended and open-ended questions about telehealth's impact on didactics, clinical teaching, and clinical experience. Analyses included descriptive statistics, Fisher's exact test, χ 2 test, and qualitative classical content analysis. RESULTS: A total of 31 PDs (82%) and 62 fellows (51%) responded. Before the pandemic, 0% of programs had fellows do telehealth visits at least weekly vs during the pandemic, and 85% of the programs had fellows conduct telehealth video visits at least once/week ( p < 0.001). PDs and fellows agreed on many advantages of learning through telehealth particularly preceptors giving "real-time" feedback by private text messages and being able to observe fellow-run encounters unobtrusively. Ninety-four percent of fellows and 100% of fellowship directors believe that telehealth should be a formal part of DBP fellowship training even if in-clinic visits are available. CONCLUSION: Prepandemic and pandemic learning experiences differed significantly. PDs and fellows shared similar perceptions on how telehealth affected fellow education, except how telehealth affected didactics. Institutions varied in how telehealth was used to teach fellows, but many reported they found benefit in giving real-time feedback using chat functions during telehealth appointments. DBP fellowship programs should consider providing specific guidance to effectively teach telehealth to fellows.

Secondary Analysis of Existing Data Sets for Developmental Behavioral Pediatrics.

ABSTRACT: Secondary analysis of existing large, national data sets is a powerful method to address many of the complex, key research questions in developmental behavioral pediatrics (DBP). Major advantages include decreasing the time needed to complete a study and reducing expenses associated with research by eliminating the need to collect primary data. It can also increase the generalizability of research and, with some data sets, provide national estimates that may form the basis for developing policy. However, few resources are available to direct researchers who seek to develop expertise in this area. This study aims to guide investigators with limited experience in this area who wish to improve their skills in performing secondary analysis of existing large data sets. This study provides direction on the steps to perform secondary analysis of existing data sets. It describes where and how data sets can be identified to answer questions of interest to DBP. Finally, it offers an overview of a number of data sets relevant to DBP.

Vaccine Hesitancy and Low Immunization Rates in Children with Down Syndrome.

OBJECTIVES: To determine the prevalence of vaccine hesitancy and refusal among parents of children with Down syndrome and to determine how well the Parent Attitudes about Childhood Vaccines Survey (PACV) is associated with vaccine receipt among children with Down syndrome. STUDY DESIGN: We mailed the PACV to parents of children with Down syndrome who attend the Down Syndrome Clinic at Akron Children's Hospital and examined associations between PACV scores and immunization status at 19 months of age. RESULTS: Of 120 surveys sent, 63 parents completed the PACV (52% response rate) of which 60 were linked to vaccination records. Of these 60 respondents, 55 children were ≥19 months old. PACV scores were significantly correlated with days of underimmunization at 19 months of age. All parents who refused all vaccines had PACV scores of ≥50. Only 58% of children were up to date for the combined 7 vaccine series at 19 months of age. CONCLUSIONS: The PACV may be a valuable tool to identify vaccine hesitancy among parents of young children with Down syndrome. Special emphasis is needed to increase adherence with on-time vaccine recommendations for children with Down syndrome to optimize their health and to potentially avoid hospitalizations.

Telemedicine for children with developmental disabilities: a more effective clinical process than office-based care.

BACKGROUND: The literature on the use of telemedicine for children with developmental disabilities (DD) is limited and mostly describes telemedicine being used to link patients with distant subspecialty multidisciplinary care. Parents generally have reported satisfaction with such care and have perceived it to be equally effective as in-person care. Here we report on the use of school-based asynchronous telemedicine to connect children with DD with primary care providers. MATERIALS AND METHODS: We developed Tele-Health-Kids, a school-based program using asynchronous telemedicine to connect children with DD with their primary care physician for the care of minor illnesses. We surveyed parents at enrollment and after the child's first telemedicine visit to assess satisfaction. We describe 4 cases that illustrate benefits, particularly for children with DD and challenging behaviors, suggesting that asynchronous telemedicine may actually be superior to traditional in-office visits in some circumstances. RESULTS: Most parents expressed a high level of satisfaction with the program. Benefits identified include decreased stress to the child and the parents as well as increasing the likelihood of a successful medical examination due to greater cooperation by the child. Visits using asynchronous or "store and forward" telemedicine technology may be superior in some situations by allowing the visit to be performed at a pace that can be adjusted to the needs of the child with DD. CONCLUSIONS: More research in the use of asynchronous telemedicine for children and youth with DD, particularly for children with DD and challenging behaviors, is needed.

Telehealth in developmental-behavioral pediatrics.

Developmental-behavioral pediatrics (DBP) is recognized as one of the fields with the greatest shortages of pediatric subspecialists. Families who access care often must travel great distances to tertiary academic medical centers or endure long waiting lists. While the shortages are likely to persist due to limited provider availability and an increasing number of children with developmental and behavioral disorders being identified, our field must look to innovative ways to reduce the barriers to access. One such way is telehealth, the use of videoconferencing to deliver DBP services to underserved populations. We aim to describe the practical uses of telehealth for the delivery of diagnostic and management clinical services in a variety of settings and for the additional educational and research benefits of the modality. We will highlight the obstacles to setting up a successful DBP telehealth practice and direct readers to resources to address these in their communities. Most of all, we will demonstrate the benefit to families and children, practitioners, and health care systems of supplementing traditional in-person DBP services with telehealth modalities to enhance outreach and engagement with communities.

Impact of location and availability of behavioral health services for children.

Literature suggests advantages for co-locating behavioral health care in primary care. We compared the impact of location of services on attendance at behavioral health appointments when access to care was assured for externalizing behavior problems with referral as usual. Two primary care pediatric practices had an evidence-based parenting program co-located in the practice for parents of children aged 2-12 years and two practices had the program available using an enhanced-referral procedure for locations external to the practices. The program was available at the regional children's hospital (referral as usual). During an 8-month period, the rate of attendance at first appointments was significantly higher in the co-located than the enhanced referral condition (.38 and .12 % of patient visits, respectively; χ(2) = 13.32; p < .0003; OR = 3.10; 95 % CI: 1.63, 5.89). These outcomes, while low, were better than the near 0 rate of attendance to referral as usual. Availability of behavioral health services in both conditions increased rates of attended appointments. However, the low rates of attendance indicate increasing availability of services, alone, is not sufficient to decrease the unmet need of children with behavioral problems. Factors other than availability must be addressed in order to improve outcomes for children.

Supervision to prevent childhood unintentional injury: developmental knowledge and self-efficacy count.

Caregiver developmental knowledge was tested as a moderator of the association between caregiver-perceived self-efficacy and perceived supervision to prevent childhood unintentional injury. Caregivers (N = 123; 95 mothers and 28 fathers) of children (M = 3.5 ± 1.2 years, 49.6% female, 80.8% Caucasian) were recruited from pediatric primary care offices and local message boards. All caregivers completed self-report questionnaires on perceived self-efficacy, developmental knowledge, and perceived supervision to prevent injury. Separate hierarchical linear regression models were conducted to test moderation for mothers and fathers. The interaction effect of perceived self-efficacy and developmental knowledge significantly predicted maternal-perceived supervision, R (2) change = .06, F(1, 86) = 6.76, p < .01. No significant findings were detected for fathers. Models of studying injury prevention that consider complex cognitive-behavioral interactions and their potential modifiable role in the development of injury-prevention practices may elucidate upon the attitude-practice gap currently identified in the literature.

Underimmunization in Ohio's Amish: parental fears are a greater obstacle than access to care.

OBJECTIVE: Holmes County, Ohio, one of the largest Amish communities in the world, has persistently low immunization rates. Studies of other Amish communities have revealed that parents do not immunize their children because of lack of access to immunizations. Our study explored reasons that Amish parents in the previously uninvestigated Holmes County population exempt themselves from immunizations. METHODS: In January 2007, questionnaires for assessing attitudes regarding immunizations were mailed to a random sampling of 1000 Amish parents in Holmes County. RESULTS: Thirty-seven percent of the parents responded. Among the 359 respondents, 68% stated that all of their children had received at least 1 immunization, and 17% reported that some of their children had received at least 1 immunization. Only 14% of the parents reported that none of their children had received immunizations. Eighty-six percent of the parents who completely exempted their children from vaccines stated that the main reason they do not vaccinate their children is concern over adverse effects. Many parents indicated that they allow their children to receive only some vaccines because of concern about the way certain vaccines are produced. CONCLUSIONS: The reasons that Amish parents resist immunizations mirror reasons that non-Amish parents resist immunizations. Even in America's closed religious communities, the major barrier to vaccination is concern over adverse effects of vaccinations. If 85% of Amish parents surveyed accept some immunizations, they are a dynamic group that may be influenced to accept preventative care. Underimmunization in the Amish population must be approached with emphasis on changing parental perceptions of vaccines in addition to ensuring access to vaccines.

Techniques for handling missing data in secondary analyses of large surveys.

OBJECTIVE: Using an appropriate method to handle cases with missing data when performing secondary analyses of survey data is important to reduce bias and to reach valid conclusions for the target population. Many published secondary analyses using child health data sets do not discuss the technique employed to treat missing data or simply delete cases with missing data. Missing data may threaten statistical power by reducing sample size or, in more extreme situations, estimates derived by deleting cases with missing values may be biased, particularly if the cases with missing values are systematically different from those with complete data. The aim of this study was to determine which of 4 techniques for handling missing data most closely estimates the true model coefficient when varying proportions of cases are missing data. METHODS: We performed a simulation study to compare model coefficients when all cases had complete data and when 4 techniques for handling missing data were employed with 10%, 20%, 30%, or 40% of the cases missing data. RESULTS: When >10% of the cases had missing data, the reweight and multiple imputation techniques were superior to dropping cases with missing scores or hot deck imputation. CONCLUSIONS: These findings suggest that child health researchers should use caution when analyzing survey data if a large percentage of cases have missing values. In most situations, the technique of dropping cases with missing data should be discouraged. Investigators should consider reweighting or multiple imputation if a large percentage of cases are missing data.