Young child socioemotional/behavioral problems and cumulative psychosocial risk.

Limited information is available about the rates and risk correlates of socioemotional/behavioral problems in young children in pediatric primary care settings serving low-income families. Our objective was to determine rates of clinically significant socioemotional/behavior problems in 12- to 48-month-olds from low-income families and identify associations between problems and individual and cumulative demographic and psychosocial risks. In this study, 378 Spanish- and English-speaking mothers attending a pediatric primary care practice serving low-income families were surveyed before well-child visits to assess socioemotional/behavioral problems (Brief Infant-Toddler Social-Emotional Assessment; M.J. Briggs-Gowan & A.S. Carter, ) and psychosocial and demographic risks (e.g., unemployment, low social support) (Parent Risk Questionnaire; D.I. Lowell, A.S. Carter, L. Godoy, B. Paulicin, & M.J. Briggs-Gowan, ). We found that 19.8% of children had clinically significant problems, and 53.2% experienced one or more psychosocial risks. Clinically significant socioemotional/behavioral problems were modestly to strongly associated with individual psychosocial risks, with the strongest associations with parental medical problems, parent depression/anxiety, and extreme parental distress, Adjusted Relative Risk (ARR) = 4.8-6.6, p < .0001. Cumulative demographic and psychosocial risk were uniquely associated with clinically significant problems, particularly among children experiencing three to four psychosocial risks, ARR = 3.0-11.6, p < .05. Psychosocial risks affect the majority of low-income families with young children, with a steep increase in likelihood of clinically significant socioemotional/behavioral problems as risks accumulate, underscoring the need to address both socioemotional/behavioral issues and psychosocial risk in young children.

Evaluating the use of a computerized clinical decision support system for asthma by pediatric pulmonologists.

PURPOSE: To investigate use of a new guideline-based, computerized clinical decision support (CCDS) system for asthma in a pediatric pulmonology clinic of a large academic medical center. METHODS: We conducted a qualitative evaluation including review of electronic data, direct observation, and interviews with all nine pediatric pulmonologists in the clinic. Outcome measures included patterns of computer use in relation to patient care, and themes surrounding the relationship between asthma care and computer use. RESULTS: The pediatric pulmonologists entered enough data to trigger the decision support system in 397/445 (89.2%) of all asthma visits from January 2009 to May 2009. However, interviews and direct observations revealed use of the decision support system was limited to documentation activities after clinic sessions ended. Reasons for delayed use reflected barriers common to general medical care and barriers specific to subspecialty care. Subspecialist-specific barriers included the perceived high complexity of patients, the impact of subject matter expertise on the types of decision support needed, and unique workflow concerns such as the need to create letters to referring physicians. CONCLUSIONS: Pediatric pulmonologists demonstrated low use of a computerized decision support system for asthma care because of a combination of general and subspecialist-specific factors. Subspecialist-specific factors should not be underestimated when designing guideline-based, computerized decision support systems for the subspecialty setting.

The association between parent worry and young children's social-emotional functioning.

OBJECTIVE: : Behavioral health problems are reported to affect as many as 24% of children younger than 4 years. Screening within primary care settings remains low. Brief, inexpensive methods to identify children are needed. The objective of this study was to determine the extent to which parent worry about their children's behavior and development is associated with social-emotional problems. METHODS: : In this cross-sectional study, 378 Spanish and English speaking mothers of 12- to 48-month-old, underserved children were surveyed before a well-child visit with the Brief Infant-Toddler Social-Emotional Assessment. This is a parent-report measure that was scored to identify clinically significant (CS) social-emotional problems (≥85th percentile) and at-risk (AR) problems (75th-84th percentile). Parents rated their worry about their children's behavior and social-emotional development on 3 questions. RESULTS: : A total of 42.1% of children had AR or CS problems or low social competence, with 19.8% of these children having CS problems. Overall, 30.4% of parents expressed worry about social-emotional/behavioral issues. A total of 19.9% of parents expressed worry despite having rated their child's behavior in the normal range on the Brief Infant-Toddler Social-Emotional Assessment. Worry was significantly associated with having either AR or CS problems. However, worry significantly distinguished the CS group, but not the AR group, from the normal group. Parent worry regarding behavior and social-emotional development approached adequate sensitivity (66.7%) to identify children CS problems with specificity being 78.6%. Parent worry, however, was not adequately sensitive in detecting AR problems. Ethnic differences indicated that the sensitivity and specificity of worry to detect CS behavior and social-emotional problems were excellent in Hispanic families, but sensitivity was poor in African-American ones. Among parents with low educational attainment, sensitivity to detect CS behavior and social-emotional problems was excellent. CONCLUSIONS: : Parent worry regarding social-emotional/behavioral issues may be a useful adjunct to developmental surveillance, as it identifies children with the most significant behavioral and social-emotional problems. However, as a screening method to identify all young children with social-emotional problems, parent worry does not currently achieve acceptable classification.

Accuracy of a computerized clinical decision-support system for asthma assessment and management.

OBJECTIVE: To evaluate the accuracy of a computerized clinical decision-support system (CDSS) designed to support assessment and management of pediatric asthma in a subspecialty clinic. DESIGN: Cohort study of all asthma visits to pediatric pulmonology from January to December, 2009. MEASUREMENTS: CDSS and physician assessments of asthma severity, control, and treatment step. RESULTS: Both the clinician and the computerized CDSS generated assessments of asthma control in 767/1032 (74.3%) return patients, assessments of asthma severity in 100/167 (59.9%) new patients, and recommendations for treatment step in 66/167 (39.5%) new patients. Clinicians agreed with the CDSS in 543/767 (70.8%) of control assessments, 37/100 (37%) of severity assessments, and 19/66 (29%) of step recommendations. External review classified 72% of control disagreements (21% of all control assessments), 56% of severity disagreements (37% of all severity assessments), and 76% of step disagreements (54% of all step recommendations) as CDSS errors. The remaining disagreements resulted from pulmonologist error or ambiguous guidelines. Many CDSS flaws, such as attributing all 'cough' to asthma, were easily remediable. Pediatric pulmonologists failed to follow guidelines in 8% of return visits and 18% of new visits. LIMITATIONS: The authors relied on chart notes to determine clinical reasoning. Physicians may have changed their assessments after seeing CDSS recommendations. CONCLUSIONS: A computerized CDSS performed relatively accurately compared to clinicians for assessment of asthma control but was inaccurate for treatment. Pediatric pulmonologists failed to follow guideline-based care in a small proportion of patients.

Secure web messaging in a pediatric chronic care clinic: a slow takeoff of "kids' airmail".

BACKGROUND: Although e-mail may be an efficient clinician-patient communication tool, standard e-mail is not adequately secure to meet Health Insurance Portability and Accountability Act (HIPAA) guidelines. For this reason, firewall-secured electronic messaging systems have been developed for use in health care. Impact and usability of these secure systems have not been broadly assessed. OBJECTIVE: To evaluate the impact of a secure electronic messaging system implemented for a pediatric subspecialty clinic. METHODS: This study was performed in an outpatient, academic pediatric respiratory clinic in spring 2009 in New Haven, Connecticut. Patients were surveyed prior to implementation regarding internet usage. The Kryptiq messaging system was implemented and messages were monitored continuously and tracked. Open-ended qualitative interviews with 28 users and nonusers were conducted, and we described the process of implementation. RESULTS: All of the 127 patients/families surveyed expressed interest in using the Internet to contact their clinic providers, and they all reported having the ability to access the Internet. In the 8 months after implementation, only 5 messages were initiated by patients in contrast to 2363 phone calls. Themes emerged from the open-ended interviews that indicated promoters, barriers, and potential uses. Prominent barriers included the lack of convenience and personal touch and being technically difficult to use. CONCLUSIONS: Although these patients/families expressed strong interest in e-mailing, secure Web messaging was less convenient than using the phone, too technically cumbersome, lacked a personal touch, and was used only by a handful of patients.