Addressing Early Education and Child Care Expulsion.

An important goal of early childhood education is teaching emotional self-regulation within the context of a safe, stable, nurturing environment. Expulsion of young children ignores underlying emotional and behavioral concerns, disproportionately affects children of color (Black or Hispanic), males, children with disabilities, and socioeconomically disadvantaged populations, and has long-term consequences on educational and life success. Addressing implicit bias and providing child mental health consultation (psychologists, social workers, developmental behavioral pediatricians, child psychiatrists, and child neurologists) to child care providers can prevent expulsion. Pediatricians and other providers within the medical home play an important part in preventing expulsion. However, pediatricians need more training in early childhood mental health and in understanding how systemic racism and implicit bias lead to preschool expulsion in children of color. By identifying children at risk for expulsion because of poverty, racial discrimination, toxic stress, insecure attachment, or history of trauma, the pediatrician can connect families with community resources that may ameliorate these effects. Pediatricians can provide information on social-emotional development in early childhood, promote positive parent-child relationships, and model and discuss age-appropriate and developmentally appropriate behavior management. Pediatricians can also guide parents toward high-quality child care programs that use mental health consultation and developmentally appropriate activities, both of which lessen the chance of child expulsion. Furthermore, behavioral health providers integrated into the medical home can provide consultation to child care providers on managing patients. These recommendations are consistent with our knowledge of early child brain development and support the current tenets of the American Academy of Pediatrics regarding the pediatrician's role in building resilience and buffering toxic stress to promote optimal child development.

Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health.

By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy. Driving this transformation are advances in developmental sciences as they inform a deeper understanding of how early life experiences, both nurturing and adverse, are biologically embedded and influence outcomes in health, education, and economic stability across the life span. This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. To translate this relational health framework into clinical practice, generative research, and public policy, the entire pediatric community needs to adopt a public health approach that builds relational health by partnering with families and communities. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner.

Integrated Behavioral Health for Preschool Children in Pediatric Primary Care.

Behavioral problems in preschool children have led to increased rates of expulsion and suspension from preschool. This case report describes the management of children aged 0-5 with behavioral concerns in a pediatric practice. Identified children were referred to an integrated behavioral health provider who provided accessible evaluation and treatment to parents and children, as well as consultation to childcare providers. The report describes case examples of how these services prevented adverse outcomes at the preschool age for three children.

Postpartum Depressive Symptoms and Screening Opportunities at Health Care Encounters.

Background: The American College of Obstetricians and Gynecologists recommends that providers screen women for depression at the postpartum checkup. If this checkup is the only screening opportunity, women who do not attend or whose depressive episode occurs at a different time may not be identified. We evaluated women's encounters with postpartum health care to identify screening opportunities for postpartum depressive symptoms (PDS). Materials and Methods: Pregnancy Risk Assessment Monitoring System (PRAMS) data for 2012-2015 from eight jurisdictions (n = 23,990, representing 1,939,865 women) were used to calculate percentage of women reporting attendance at postpartum checkups, well-child visits, or postpartum home visitation, by presence of PDS. PDS were assessed using a modified two-item Patient Health Questionnaire. Using Modified Poisson regression, adjusted prevalence ratios (aPR) and confidence intervals (95% CI) were calculated to compare health services by PDS, adjusted for sociodemographic characteristics. Results: Almost all women with or without PDS attended a postpartum checkup (85.1% and 91.4%; aPR: 0.96; 95% CI: 0.93-0.99) and their infants attended a well-child visit (97.3% and 98.9%; aPR: 0.99; 95% CI: 0.98-1.00); 13.7% and 10.9% received home visitation (aPR: 1.18; 95% CI: 1.02-1.35). Of women with PDS who missed their postpartum checkup, 13.5% reported infant attendance at well-child visits, and 2.0% received home visitation. Of women with PDS, 98.8%, 86.1%, and 11.2% attended 1, 2, or 3 health services. Conclusion: A large percentage of women with PDS may attend well-child visits or receive home visitation, representing opportunities for depression screening and referral for care.

Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice.

Perinatal depression is the most common obstetric complication in the United States, with prevalence rates of 15% to 20% among new mothers. Untreated, it can adversly affect the well-being of children and families throught increasing the risk for costly complications during birth and lead to deterioration of core supports, including partner relationships and social networks. Perinatal depression contributes to long-lasting, and even permanent, consequences for the physical and mental health of parents and children, including poor family functioning, increased risk of child abuse and neglect, delayed infant development, perinatal obstetric complications, challenges with breastfeeding, and costly increases in health care use. Perinatal depression can interfere with early parent-infant interaction and attachment, leading to potentially long-term disturbances in the child's physical, emotional, cognitive, and social development. Fortunately, perinatal depression is identifiable and treatable. The US Preventive Services Task Force, Centers for Medicare and Medicaid Services, and many professional organizations recommend routine universal screening for perinatal depression in women to facilitate early evidence-based treatment and referrals, if necessary. Despite significant gains in screening rates from 2004 to 2013, a minority of pediatricians routinely screen for postpartum depression, and many mothers are still not identified or treated. Pediatric primary care clinicians, with a core mission of promoting child and family health, are in an ideal position to implement routine postpartum depression screens at several well-child visits throughout infancy and to provide mental health support through referrals and/or the interdisciplinary services of a pediatric patient-centered medical home model.

Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice.

Perinatal depression (PND) is the most common obstetric complication in the United States. Even when screening results are positive, mothers often do not receive further evaluation, and even when PND is diagnosed, mothers do not receive evidence-based treatments. Studies reveal that postpartum depression (PPD), a subset of PND, leads to increased costs of medical care, inappropriate medical treatment of the infant, discontinuation of breastfeeding, family dysfunction, and an increased risk of abuse and neglect. PPD, specifically, adversely affects this critical early period of infant brain development. PND is an example of an adverse childhood experience that has potential long-term adverse health complications for the mother, her partner, the infant, and the mother-infant dyad. However, PND can be treated effectively, and the stress on the infant can be buffered. Pediatric medical homes should coordinate care more effectively with prenatal providers for women with prenatally diagnosed maternal depression; establish a system to implement PPD screening at the 1-, 2-, 4-, and 6-month well-child visits; use community resources for the treatment and referral of the mother with depression; and provide support for the maternal-child (dyad) relationship, including breastfeeding support. State chapters of the American Academy of Pediatrics, working with state departments of public health, public and private payers, and maternal and child health programs, should advocate for payment and for increased training for PND screening and treatment. American Academy of Pediatrics recommends advocacy for workforce development for mental health professionals who care for young children and mother-infant dyads, and for promotion of evidence-based interventions focused on healthy attachment and parent-child relationships.

The Power of Play: A Pediatric Role in Enhancing Development in Young Children.

Children need to develop a variety of skill sets to optimize their development and manage toxic stress. Research demonstrates that developmentally appropriate play with parents and peers is a singular opportunity to promote the social-emotional, cognitive, language, and self-regulation skills that build executive function and a prosocial brain. Furthermore, play supports the formation of the safe, stable, and nurturing relationships with all caregivers that children need to thrive.Play is not frivolous: it enhances brain structure and function and promotes executive function (ie, the process of learning, rather than the content), which allow us to pursue goals and ignore distractions.When play and safe, stable, nurturing relationships are missing in a child's life, toxic stress can disrupt the development of executive function and the learning of prosocial behavior; in the presence of childhood adversity, play becomes even more important. The mutual joy and shared communication and attunement (harmonious serve and return interactions) that parents and children can experience during play regulate the body's stress response. This clinical report provides pediatric providers with the information they need to promote the benefits of play and and to write a prescription for play at well visits to complement reach out and read. At a time when early childhood programs are pressured to add more didactic components and less playful learning, pediatricians can play an important role in emphasizing the role of a balanced curriculum that includes the importance of playful learning for the promotion of healthy child development.

The Prenatal Visit.

A pediatric prenatal visit during the third trimester is recommended for all expectant families as an important first step in establishing a child's medical home, as recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition As advocates for children and their families, pediatricians can support and guide expectant parents in the prenatal period. Prenatal visits allow general pediatricians to establish a supportive and trusting relationship with both parents, gather basic information from expectant parents, offer information and advice regarding the infant, and may identify psychosocial risks early and high-risk conditions that may require special care. There are several possible formats for this first visit. The one used depends on the experience and preference of the parents, the style of the pediatrician's practice, and pragmatic issues of payment.

Integrated Behavioral Health Care in Pediatric Primary Care: A Quality Improvement Project.

The top 5 reasons for pediatric office visits in the United States today are behavioral health concerns. This article describes a colocated behavioral health and care coordination integration model in a pediatric primary care office to reduce barriers to behavioral health care.

Addressing Early Childhood Emotional and Behavioral Problems.

More than 10% of young children experience clinically significant mental health problems, with rates of impairment and persistence comparable to those seen in older children. For many of these clinical disorders, effective treatments supported by rigorous data are available. On the other hand, rigorous support for psychopharmacologic interventions is limited to 2 large randomized controlled trials. Access to psychotherapeutic interventions is limited. The pediatrician has a critical role as the leader of the medical home to promote well-being that includes emotional, behavioral, and relationship health. To be effective in this role, pediatricians promote the use of safe and effective treatments and recognize the limitations of psychopharmacologic interventions. This technical report reviews the data supporting treatments for young children with emotional, behavioral, and relationship problems and supports the policy statement of the same name.

Fathers' Roles in the Care and Development of Their Children: The Role of Pediatricians.

Fathers' involvement in and influence on the health and development of their children have increased in a myriad of ways in the past 10 years and have been widely studied. The role of pediatricians in working with fathers has correspondingly increased in importance. This report reviews new studies of the epidemiology of father involvement, including nonresidential as well as residential fathers. The effects of father involvement on child outcomes are discussed within each phase of a child's development. Particular emphasis is placed on (1) fathers' involvement across childhood ages and (2) the influence of fathers' physical and mental health on their children. Implications and advice for all child health providers to encourage and support father involvement are outlined.