Promoting education, mentorship, and support for pediatric research.

Pediatricians have an important role to play in the advancement of child health research and should be encouraged and supported to pursue research activities. Education and training in child health research should be part of every level of pediatric training. Continuing education and access to research advisors should be available to practitioners and academic faculty. Recommendations to promote additional research education and support at all levels of pediatric training, from premedical to continuing medical education, as well as suggestions for means to increase support and mentorship for research activities, are outlined in this statement.

Pilot-testing a cancer education curriculum for grades K-6.

Risk behaviors established during childhood including tobacco use, sunning, and eating habits contribute to most adult cancers. This project pilot-tested a developmentally appropriate cancer prevention curriculum for grades K-6, using a treatment group only design with pretesting and posttesting using a standardized, semistructured interview and involving 67 students (77% of eligible students) attending mixed grade classes. A seven-unit curriculum based on cognitive development, social cognitive, and social influence theories was taught by classroom teachers. Students showed a significant (p < .0001) gain in conceptual understanding for causality and prevention of cancer; the gain for causality of cancer was comparable to the baseline difference between kindergarten and the highest (5-6) grade. Significant gains in factual knowledge and decreases in misconceptions about casual contact also were documented. A developmentally based elementary school cancer prevention curriculum can enhance young children's conceptual understanding and factual knowledge of common contributors to adult cancers.

Care to underserved children: Residents' attitudes and experiences.

OBJECTIVES: To examine: 1) the relationship between residents' responses toward caring for underserved children and families during residency and their perceptions of their continuity clinic experience; and 2) which characteristics are related to continuing to care for the underserved after completion of training. DESIGN: Cross-sectional descriptive study. METHODS: A 49-item questionnaire was mailed to 210 third-year pediatric residents at 12 urban training programs in the Northeast in May 1995. Information was collected about residents' emotional responses toward caring for underserved families, their assessments of clinic operations, their sense of effectiveness in caring for underserved patients in continuity clinic, preresidency experiences with the underserved, and their intent to care for the underserved after training. RESULTS: Of 210 surveys mailed, 71% were returned. Thirty-six percent of residents planned to pursue a career in primary care, 53% did not, and 11% did not answer or were planning a year as chief resident. Fifty-seven percent of all residents planned to devote a portion of their practice toward caring for the underserved after training. Residents whose emotional responses toward caring for the underserved included: 1) not worrying that they had become numb to children's psychosocial difficulties, 2) not feeling angry with how families cared for their children, and 3) feeling more empathy with the underserved had significantly higher mean scores on both their assessment of clinic operations and their sense of effectiveness. The only demographic characteristic associated with a greater sense of effectiveness was being black. To better characterize which residents planned to care for the underserved after training, we examined a subsample of 46 residents who recalled an interest in caring for the underserved during residency training and who were pursuing a career in primary care. Residents that did not recall an interest in caring for the underserved at the onset of residency training were unlikely to have plans to care for the underserved after the completion of training. Within this group residents who planned to care for the underserved after training differed significantly from residents who did not plan to continue this work by feeling a greater sense of effectiveness in clinic, feeling less worried about becoming numb, and having greater empathy for underserved families. CONCLUSIONS: There are a number of identifiable emotional responses residents develop toward caring for the underserved that relate to their perceptions of continuity clinic and whether a resident chooses to continue to care for the underserved after training.

Teaching young children about HIV and AIDS.

AIDS education initiatives need to begin early, within the elementary grades, to be effective. We should no longer underestimate the capacity of young children to understand and benefit from this instruction. In addition, we should not overestimate the impact of brief interventions, and should plan for continued AIDS prevention instruction throughout the school years, involving sequential, developmentally appropriate curricula that respond to the preadolescent's and adolescent's changing cognitive capabilities, social skills, and expanding exposure to sexual experiences. We should require that new approaches and methodologies for AIDS prevention education be developed and evaluated rigorously for efficacy with the same fervor required for the development and evaluation of new drugs to combat this illness on the biologic front. New modalities and approaches should be integrated with those that have already been shown to be effective, creating multimodal and comprehensive educational initiatives comparable to the multidrug treatment regimens. We should be skeptical of those who are satisfied with the implementation of one interesting and simplistic slogan for health promotion efforts for children (e.g., "Just say no"). Even if such efforts were effective in the short term, sole reliance on this approach is likely to result in the development of resistance. As the field of AIDS prevention looks for novel approaches and theoretic constructs, it should borrow ideas from other fields of study and foster interdisciplinary collaborations with professionals from complementary fields. In this manner, educational interventions can move beyond the individual context to begin to address the social influences on sexual behaviors. Sexual behavior is interpersonal and occurs in a social context. Programs must therefore address peer and social pressures to engage in sexual activity. Although attempts are being made to address the social network of children through such efforts as peer education, we cannot ignore the broader social context (e.g., poverty) within which these behaviors occur. For example, efforts to promote increased condom usage will be ineffective until we learn more about why significant numbers of adolescents practice unprotected sex. We are unlikely to affect behavioral change unless we understand fully the motivation for such behavior. We must also recognize that children are more than what they do and study outcomes other than behavior. There is a need for further research on the development of attitudes, fears, stigma, and coping in children, as well as means of promoting the development of healthy sexual relationships.

Elevated blood lead levels in children are associated with lower erythropoietin concentrations.

Eighty-six children (mean age, 34 months) were studied to determine whether elevated blood lead levels in children are associated with lower erythropoietin concentrations. The median erythropoietin concentration was 5.9 mIU/mL (range, 2.3 to 11.5 mIU/mL), and the median blood lead level was 0.87 micromol/L (18 microg/dL; range, 2 to 84 microg/dL). Blood lead concentration was inversely and independently related to erythropoietin concentration.

Elementary school-age children's developmental understanding of the causes of cancer.

This study examines children's conceptual understanding and factual knowledge of the causes of cancer. Using a standardized, developmentally based, semistructured interview (ASK [AIDS (acquired immunodeficiency syndrome) Survey for Kids]), 784 children (43% black, 38% white, and 18% Hispanic; 48% female) in kindergarten through sixth grade attending six public elementary/middle schools in New Haven, Connecticut, were asked open-ended questions about the causes of cancer and, for comparison, the causes of colds and AIDS. Responses were scored for level of conceptual understanding and coded for factual content and factual accuracy. The level of conceptual understanding for causality of cancer increased consistently as grade level increased. When comparisons were made among the illnesses, children's level of conceptual understanding was significantly lower for the causes of cancer than for the causes of colds (p < .0001), but not significantly different from that of AIDS. Although the single most frequent cause of cancer mentioned was cigarettes/smoking (24%), more than one in five students stated that casual contact or contagion was a cause of cancer. More children cited causal contact/contagion than cited the following factually accurate or logically contributory causes combined: poor diet, air/water pollution or overexposure to sun, alcohol, and old age. Slightly more than one half of students in kindergarten through sixth grade worried about getting cancer, and the vast majority (80%) knew that cancer could be fatal. Children have a less sophisticated conceptual understanding of cancer than of colds and a very limited factual knowledge base for cancer, and thus they have the capacity to increase both their understanding and knowledge. These results have implications for the creation of developmentally appropriate cancer prevention curricula for elementary school-age children.

Children's understanding of the symptoms of AIDS.

Symptoms are the outward manifestations that allow children to identify and recognize illness; children's understanding of the symptoms of an illness may be directly related to their understanding of its cause or means of transmission. This study is the first empirical investigation of children's conceptual understanding and factual knowledge of the symptoms of AIDS. Children (N = 361; grades K to 6; 57% black, 24% Hispanic, 19% white; 52% female) attending four public schools in New Haven, Connecticut, were interviewed using a standardized semistructured interview (ASK, AIDS Survey for Kids) that included open-ended questions about the symptoms of AIDS and, for comparison, cancer and colds. Responses were scored for level of conceptual understanding and coded for factual content. For each illness, grade level was the variable most strongly correlated with symptomatology concept score (R = .42-.48, p < .0001) and contributed significantly (p < .0001) to the variance observed in concept score even after controlling for race, gender, verbal fluency, and socioeconomic status. The mean concept score was lower (p < .01) for symptomatology of AIDS (2.8 of possible 5) than for cancer (3.1) or colds (3.9). In addition, far more symptoms were named for colds than for either cancer or AIDS. Children who believed that HIV is spread via each of five potential means of transmission by casual contact were more likely (p < 01) to cite cold symptoms as symptoms of AIDS. We conclude that there exists a developmental progression in children's understanding of the symptomatology of AIDS. Children have a less sophisticated conceptual understanding and narrower factual knowledge base for AIDS than for colds and therefore have the capability to increase their understanding and knowledge about AIDS. Furthermore, improving children's understanding of the symptoms of AIDS may diminish misconceptions about transmission of HIV via casual contact.

Talking with elementary school-age children about AIDS and death: principles and guidelines for school nurses.

Teaching school children about sensitive or controversial issues presents difficulties for classroom teachers as well as school nurses. At each developmental stage, there is appropriate information that can be absorbed by children that will help them in dealing with such things as death and AIDS. However, many children will have been involved at home with these events before they have come to understand them. Nurses and teachers have the task of imparting to young students what they know, while being sensitive to the probing and questioning that must precede a child's comprehension of unfortunate facts that still trouble adults.

Benefits and challenges of school-based crisis response teams.

Given the increasing prevalence of schoolchildren's experience with crises and resulting loss through sudden or violent death, adoption of a school-based crisis prevention and response plan becomes crucial. This article reviews a model of regional, district, and school-based levels of response designed collaboratively by four school districts and consultants from Yale University. The team approach on which the model is based is examined through benefits it affords students, staff, parents, and the community. Obstacles that can impede full implementation of the model are identified, and strategies for overcoming logistical and systemic resistances are offered. This proactive design helps promote individual and organizational resiliency to traumatic events by promoting communication, collaboration, and service provision in an efficient and comprehensive manner.

A randomized, controlled trial of a school-based, multi-faceted AIDS education program in the elementary grades: the impact on comprehension, knowledge and fears.

OBJECTIVE: Several educational theorists have suggested that young children are unlikely to benefit from detailed instruction regarding AIDS prevention because of inherent developmental cognitive limitations. This study aims to determine whether AIDS education in the elementary grades can advance young children's understanding of this illness. METHODS: A randomized, controlled trial was used to measure the impact of a 3-week, multifaceted AIDS education program on conceptual understanding, factual knowledge, and fears about AIDS in 189 students in grades kindergarten through 6th. The ASK (AIDS Survey for Kids), a standardized, semistructured interview that measures conceptual understanding, factual information, and fears about AIDS, was administered before and after the intervention. RESULTS: Children in the intervention group, as compared to those in the control group, showed significant (P < .0001) gains in their level of understanding of the concepts of causality and prevention of AIDS. These results were unaffected by controlling for grade, gender, race, socioeconomic status, and verbal fluency. The gains in children's understanding of causality of AIDS represented at least 2 years' growth in the level of conceptual sophistication and persisted at a follow-up evaluation several months later. After the intervention, more children (P < .001) in the intervention group than in the control group accurately identified causes of AIDS in response to open-ended questions: germ/germ theory (41% vs 13%), mother-to-infant transmission (54% vs 15%), blood transmission (83% vs 40%), and sexual transmission (56% vs 30%). Fewer than half as many children in the intervention group responded incorrectly to each of five direct questions about transmission of HIV through casual contact. The intervention did not increase children's fears about the illness. CONCLUSIONS: A short, developmentally based, multifaceted AIDS education program in the elementary grades can advance children's conceptual understanding and factual knowledge about AIDS and decrease their misconceptions about casual contact as a means of acquiring the illness, without increasing their fears. Significant advances in conceptual understanding about AIDS can be achieved through direct educational interventions.

Screening for lead poisoning by fingerstick in suburban pediatric practices.

OBJECTIVE: To assess the false-positive rate of blood lead determinations on samples obtained by fingerstick from children screened in private suburban and rural practices. METHODS: Screening capillary lead samples were obtained by fingerstick; children with capillary lead levels of 0.7 mumol/L (15 micrograms/dL) or greater were recalled for a confirmatory venous lead test that served as the criterion standard. Parents completed a five-question risk assessment questionnaire at the time of initial screening. SETTING: Four private suburban to rural practices that serve predominantly white, middle-class populations. PARTICIPANTS: Children seen for routine care between August 1992 and February 1993 (N = 1085; 98% between 6 months and 6 years of age). RESULTS: Capillary lead level was 0.7 mumol/L (15 micrograms/dL) or greater in 35 children (3% of total sample); venous lead samples were obtained in 30 patients. Nine of the elevated capillary lead results were true-positives (venous lead = 0.7, 0.8, 0.8, 0.9, 0.9, 0.9, 1.1, 1.1, and 1.7 mumol/L [15, 17, 17, 18, 18, 18, 22, 22, and 35 micrograms/dL]); parents of only two of these children answered yes to any question on the risk assessment questionnaire. Although the false-positive rate of the capillary lead screening test was 70% (21/30) in this setting, only 2% of the total sample had a false-positive screening test (an average of fewer than one false-positive per month per practice). Screening by fingerstick allowed phlebotomy to be avoided for 97% of the children. CONCLUSION: Fingerstick screening for lead poisoning is a reasonable alternative to direct venous testing within private suburban and rural practices, provided that care is taken to avoid specimen contamination, that appropriate caution is used in the interpretation of screening test results, and that medical and environmental interventions are based on the results of confirmatory venous testing.

The accuracy of children's reports with anatomically correct dolls.

The accuracy of children's reports of alleged sexual abuse during interviews with anatomically correct dolls is the focus of considerable controversy. This study used an analog experience to measure empirically the accuracy of reports in a relevant, but controlled setting: the forensic medical examination for suspected sexual abuse. Twenty-one 3- to 7-year-old children were interviewed about what occurred during previous examinations with open-ended questions, open-ended questions with anatomically correct dolls, and direct questions with the dolls. Children provided significantly more accurate reports and fewer omissions with direct questions using the dolls compared with either of the two open-ended sections, but there was no significant difference in the number of false reports across the three sections of the interview. These results suggest that anatomically correct dolls may bolster the recall of children's memory in the setting of direct questions without prompting false reports.

What do minority elementary students understand about the causes of acquired immunodeficiency syndrome, colds, and obesity?

Elementary school-age children's conceptual understanding and factual knowledge about the causes of acquired immunodeficiency syndrome (AIDS), colds, and obesity are poorly understood, particularly among black children living in low-income, urban neighborhoods. We examined minority children's conceptual understanding about the causes of these illnesses. In addition, children's knowledge and misconceptions about the causal agents of AIDS, colds, and obesity were investigated. A developmentally based, semistructured interview was developed to measure children's level of understanding about the causes of each condition. Interviews were conducted with 239, predominately black, first, third, and fifth grade students attending two public elementary schools in a low income city in northern California. Interviews were verbally administered and tape recorded for later verbatim transcription. Children's responses to questions about causality first were scored based on their level of conceptual sophistication. Responses then were assigned to thematic categories reflecting the children's factual knowledge about the causes of AIDS, colds, and obesity. Increases in grade level were associated with higher scores for causality of AIDS (p < .0001), colds (p < .0001), and obesity (p < .01). In all three conditions, causality scores increased between first and fifth grades, but did not significantly vary between third and fifth grades. Gender, socioeconomic status, and number of adults living in the household were not significantly associated with causality scores. Within each grade, the finding of lower causality scores for AIDS, as compared to colds and obesity, points out the need for developmentally appropriate explanations to children about the causes of AIDS.(ABSTRACT TRUNCATED AT 250 WORDS)

Screening for lead poisoning in an urban pediatric clinic using samples obtained by fingerstick.

OBJECTIVE: To assess the false positive rate of blood lead (BPb) determinations on samples obtained by fingerstick from children screened in an urban clinic. METHOD: From a single fingerstick (N = 1573), blood was collected in a capillary tube for determining lead concentration (CPb) by graphite furnace and an additional sample was absorbed onto a filter paper for determining lead concentration (FPb) by atomic absorption spectrophotometry with Delves cup. Zinc protoporphyrin (ZPP) was measured immediately and a confirmatory venous lead (VPb) specimen was obtained at the same visit if the ZPP was > or = 35 micrograms/dL (0.6 mumol/L); children with either a CPb or FPb > or = 15 micrograms/dL (0.7 mumol/L) were later recalled for determining VPb. RESULTS: For the 172 children who had a VPb on the same day as the screening tests, the false positive rates (95% confidence intervals) at a lead threshold of 15 micrograms/dL (0.7 mumol/L) were: CPb, 13.5% (6.7-20.3); FPb, 19.1% (11.8-26.4). Analyses using all 679 screens with a paired venous specimen (mean delay between screen and venous testing = 30 days) yielded much higher false positive rates (CPb, 31.3%; FPb, 46.0%). CONCLUSIONS: Screening for lead poisoning is feasible within an urban pediatric clinic by direct measurement of lead concentration in blood samples obtained by fingerstick. The false positive rate that can be obtained is acceptable given the precision of measuring BPb concentration. Practitioners using a staged screening protocol may incorrectly attribute a higher false positive rate to the screening tests, when much of the error may be due to the temporal variability of BPb resulting from both biologic variability in BPb concentration and intermittent exposures.

School-based crisis intervention: a role for pediatricians.

We have presented an overview of issues to consider in school-based crisis intervention using an organizational model for crisis response within the school. A wide range of ways exist in which pediatricians and other pediatric primary care providers can assist in the development, implementation, and functioning of school-based crisis intervention services for children. Those pediatricians with an interest in this area will find such activities personally and professionally rewarding and will come to appreciate the impact that such services can have on the lives of the students within the school, within their pediatric practices, and within their community.

Talking with children about death.

Nurses are often asked to respond to children's questions about death and to advise parents and teachers on how to discuss this topic with children. This article reviews the concepts that children must learn to understand and cope with a death. Cognitive limitations of young children that may result in guilt and misinterpretations are reviewed. Advice is provided on how nurses can assist infants, young children, and adolescents in dealing with deaths of significant others or their own impending death. The importance of identifying and addressing the personal needs of the helper are underscored.

New developments in pediatric lead poisoning.

In October 1991, the Centers for Disease Control and Prevention issued new lead guidelines, dramatically lowering the intervention level from 25 micrograms/dL of lead in blood to only 10 micrograms/dL and calling for universal screening. This review summarizes recent research findings on the effects of lead exposure on cognitive abilities and presents current information on sources of exposure to lead, methods of screening for lead poisoning, and options for treatment.