Uninsured children with psychosocial problems: primary care management.

OBJECTIVE: Nearly 14% of children in the United States are uninsured. We compared the prevalence of psychosocial problems and mental health services received by insured and uninsured children in primary care practices. METHODS: The Child Behavior Study was a cohort study conducted by Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network. Four hundred one primary care clinicians enrolled an average sample of 55 consecutive children (4-15 years old) per clinician. RESULTS: Of the 13 401 visits to clinicians with 3 or more uninsured patients, 12 518 were by insured children (93.4%) and 883 were by uninsured children (6. 6%). A higher percentage of adolescents, Hispanic children, those with unmarried parents, and those with less educated parents were uninsured. According to clinicians, uninsured children and insured children had similar rates of psychosocial problems (19%) and severe psychosocial problems (2%). For children with a clinician-identified psychosocial problem, we found no differences in clinician-reported counseling, medication use, or referral to mental health professionals. CONCLUSIONS: Among children served in primary care practices, uninsured children have similar prevalence of clinician-identified psychosocial and mental health problems compared with insured children. Within their practices, clinicians managed uninsured children much the same way as insured children. psychosocial problems, uninsured children, pediatrics, family medicine, primary care.

Increasing identification of psychosocial problems: 1979-1996.

OBJECTIVE: To examine the changes in identification of pediatric psychosocial problems from 1979 to 1996. RESEARCH DESIGN: Comparison of clinician-identified psychosocial problems and related risk factors among large primary care pediatric cohorts from 1979 (Monroe County Study) and 1996 (Child Behavior Study). Data were collected from clinician visit questionnaires developed originally for the 1979 study. SETTING: Private practice offices of 425 community-based pediatricians and family practitioners across both studies. PATIENTS: We enrolled all children from 4 to 15 years of age who presented for nonemergent services in primary care offices. The 1979 study included 9612 children seen by 30 clinicians and the 1996 study included 21 065 children seen by 395 clinicians. SELECTION PROCEDURE: Each clinician enrolled consecutive eligible patients for both studies. MEASUREMENTS AND RESULTS: From 1979 to 1996, clinician-identified psychosocial problems increased from 6.8% to 18. 7% of all pediatric visits among 4- to 15-year-olds. We found increases in all categories of psychosocial problems, except for mental retardation. Attentional problems showed the greatest absolute increase (1.4%-9.2%) and emotional problems showed the greatest relative increase (.2%-3.6%). The use of psychotropic medications, counseling, and referral also increased substantially. In particular, the percentage of children with Attention deficit/hyperactivity problems receiving medications increased from 32% to 78%. These increases in psychosocial problems were associated with increases in the proportions of single-parent families and Medicaid enrollment from 1979 to 1996. Changes in clinician characteristics did not appear to be the source of increases in clinician diagnoses of psychosocial problems. CONCLUSIONS: Substantial increases in the identification of psychosocial problems in primary care paralleled demographic changes in children presenting to primary care offices and in the larger population.

Insurance status and recognition of psychosocial problems. A report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Networks.

OBJECTIVE: To examine the effect of insurance status on clinician recognition of psychosocial problems for pediatric primary care visits. DESIGN: A cohort study of 10,250 visits by children 4 to 15 years old for nonemergent care. SETTING: Two large primary care research networks reported data from 172 primary care clinicians in office-based practice. PATIENTS: Ten thousand two hundred and fifty unique children presenting consecutively to participating physicians for nonemergent services with a parent or caregiver. MAIN OUTCOME MEASURE: Children were classified as positive for psychosocial problems if their score on the parent-reported Pediatric Symptom Checklist exceeded the standard cutoff of 28. Clinician recognition was obtained by report as a dichotomous variable. Insurance status was categorized by payor and plan structure. RESULTS: Clinicians did not recognize psychosocial problems for a substantial number of children with scores suggestive of marked psychosocial dysfunction on the Pediatric Symptom Checklist. Insurance type was not associated with rates of recognition. However, provider familiarity with patients, provider discipline, and patient demographics were associated with increased recognition of psychosocial problems. CONCLUSIONS: Differences in treatment among various insurance groups documented in prior studies are not likely to be related to varying recognition rates, but rather to availability and choices of treatment by insurers, families, and clinicians. Continuity of care was the strongest predictor of clinician recognition.

The general pediatrician as care coordinator for children with chronic illness.

As the number of children with chronic illness increases due to advances in medical technology, general pediatricians are faced with the challenge of providing continuing care for such patients. These children and their families are most in need of a care coordinator to guide them through the complexities of obtaining optimal care in all aspects: medical, emotional, social, and developmental. The primary pediatrician is logically positioned to assumed the role of care coordinator. This undertaking requires a knowledge of the needs of such children and their families, an ability to interact with other professionals as member of a team, a sensitivity to the overall functional status of the child and family, and a commitment of a large amount of time and effort. Although these skills are rarely taught during residency training, they can be acquired through continuing education, thereby allowing the pediatrician to experience the satisfaction that derives from helping someone truly in need.

Normal pulmonary function measurements and airway reactivity in childhood after mild bronchiolitis.

Concern about the long-term sequelae of bronchiolitis has been raised through studies of children hospitalized for bronchiolitis, but the long-term sequelae of mild bronchiolitis have not been studied. We assessed the hypothesis that 25 children with mild bronchiolitis (index subjects) were at greater risk for abnormalities of pulmonary function or airway reactivity to cold air between the ages of 8 and 12 years than were randomly selected, matched controls. There were no consistent differences in pulmonary function or airway reactivity between index and control groups. Airway hyperreactivity was found in five control subjects and three index subjects, and all children with symptomatic asthma were identified by cold air challenge. Our data suggest that children with a history of mild bronchiolitis are not at increased risk between ages 8 and 12 years for airway hyperreactivity or for abnormalities in pulmonary function.

Mental health problems among children seen in pediatric practice: prevalence and management.

An ambulatory care survey involving 40% of all pediatricians in Monroe County, NY, was conducted between January and December 1979 to obtain an estimate of the prevalence of mental health problems among children seen by pediatricians. If a child with such a problem was identified, the pediatrician described the problem in detail, its impact on the family and the patient, and the action taken to handle the problem. The weighted 40% probability sample was representative of all pediatric practices in the county. During the 2 months for which each of the 30 pediatricians reported on all visits, there were 21,575 visits made by 18,351 children. There were 935 children detected at their first visit as having a problem, and another 48 children at a repeat visit during the reporting period. This is equivalent to a point prevalence at time of first visit of 5.09%. There was considerable variation between pediatricians: group practitioners reported a point prevalence of 4.06%, solo practitioners reported 5.06%, and health center pediatricians reported 7.33%. High rates were reported among children 7 to 14 years old (8.0%), boys (6.2%) compared with girls (3.9%), those on Medicaid (8.3%), and those whose presenting complaint was a chronic physical disorder (13.1%). The slightly higher rate among blacks than whites appeared to be related to the generally lower socioeconomic status among blacks. The rate among children in one-parent families was twice as high as in two-parent families. With regard to the mental health problem, most frequent diagnoses (primary or secondary) were adaptation reaction (31.5% of "problem" children), speech and language disorder (18.4%), other specific learning disorder (17.1%), hyperkinetic disorder (16.8%), and conduct disorder (14.7%). Functional impairment was moderate or severe in more than half the affected children; most frequent treatment provided by the pediatricians was supportive therapy or counseling (81.4%); drugs were prescribed for 11.3% of the affected children, amphetamines for 4.7%.

The changing pattern of primary pediatric care: update for one community.

The changing pattern of pediatric practice in the Rochester, New York, community between the late 1960s and the late 1970s is described, and some extrapolations for the next decade are discussed. The child population shrunk from 243,000 in 1970 to 192,000 in 1980 and is expected to decrease further to 160,000 in 1990, possibly stabilizing at 140,000 by 2000. The number of pediatric beds as well as occupancy rates declined, but the number of full-time equivalent practicing pediatricians increased slightly. One third of them are now practicing out of neighborhood health centers or health maintenance organizations. Problems of manpower shortage and inadequate access to care for the inner city residents have long since disappeared. Utilization rates by race and socioeconomic area are similar once the children enter the care system. For "well child" care, however, there may still be lower utilization for blacks, especially for older children. The high "market penetration" for child health services by pediatricians, and the high proportion of well child visits (40%) among all visits, may be atypical for the nation as a whole, but is probably indicative of what pediatric care elsewhere will be in the future. Fewer children, and less acute care per child, will allow pediatricians to focus increasingly on preventive, developmental, and psychosocial needs.

Comparative assessment of beta-adrenoceptor blocking agents as simple competitive antagonists in isolated heart muscle: similarity of inotropic and chronotropic blocking potencies against isoproterenol.

The pattern of antagonism between isoproterenol and various beta-adrenoceptor blocking agents was explored in spontaneously beating right atria and in driven left atrial strips from kittens and guinea pigs. The onset of beta-adrenoceptor blockade is usually very slow in such preparations; incubation periods of up to an hour may be required for equilibrium conditions. The speed of onset of the blocking action is directly related to the concentration of the antagonist, and therefore, for a given degree of blockade, inversely related to its potency. beta-Adrenoceptor blocking agents were found to interact with isoproterenol in a manner consistent with a simple competitive antagonism provided that (1) the antagonist had little intrinsic stimulant action on the preparation under study, (2) the concentrations of antagonist used had no direct depressant action on the preparation, (3) precautions were taken to assure that the pattern of antagonism was not distorted by loss of agonist into tissue sinks, and (4) dose-response curves were normalized for changes in the baseline frequency or force in successive curves. Corrections for desensitization were necessary only in inotropic dose-response curves. Estimates of the equilibrium dissociation constants (KB) derived from the antagonism of the chronotropic and inotropic effects of isoproterenol were determined for fifteen beta-adrenoceptor blocking agents of widely differing potency. In no case was there a substantial difference between the inotropic and chronotropic values. Published estimates of binding constants for beta-blockers determined on cardiac membrane particles are more variable than those determined on intact tissues, and tend to be slightly (adenylyl cyclase measurements) or considerably (radioligand binding studies) lower than the values obtained in intact tissues. These differences raise the possibility that the properties of the beta-adrenoceptor may sometimes be altered during the isolation and partial purification of membrane fragments.

Collaborative research between a Department of Pediatrics and its clinical faculty.

Collaborative research involving members of the full-time and clinical faculties of a Department of Pediatrics increases our knowledge of problems encountered in primary care practice by bringing the practitioner's perspective on the nature of such problems and the population of patients he serves to the investigative arena. For the practitioner, active involvement in collaborative research is rewarding because he or she formulates the questions to be addressed and takes part in planning and implementing the research and reporting results. Through such collaboration, the academician gains immeasurably by being able to study common clinical problems in primary care settings, where they are encountered most often. To be successful, collaborative research must be a joint effort with ongoing communication and sharing of responsibilities between academicians and practitioners.

The role of the pediatrician in the delivery of mental health services to children.

Nine pediatricians reported on all patients seen during a four-week period in January and February 1976 in Monroe County, N.Y., to determine the prevalence and nature of mental health problems seen in their practices, the characteristics of the affected children, and the treatment provided to them. Of the 3,742 patients seen, 187, or 5.0%,were reported to have an emotional, behavioral, or school problem. The prevalence rate ranged from 1.4% to 7.8% by pediatrician, with five reporting rates within +/- 1.2% of the mean. High rates were associated with children in the 7 to 14 year age group (9.9%), those on Medicaid (8.6%), those who were not living with a father (10.9%), those whose presenting complaint was a chronic physical condition (11.7%), and children with a disease of the digestive system (16.7%) or with ""symptoms, signs and ill-defined conditions'' (14.3%). Functional impairment was reported to be moderate or severe in 40% of the 187 children with mental health problems. The most frequently reported problems (primary or otherwise) were adaptation reaction (22.5%), specific learning disorder (19.3%), hyperkinetic disorder (19.3%), psychosomatic disorder (12.8%), and conduct disorder (12.8%). The most frequent form of treatment provided was supportive therapy or counseling (85.6%) and suggestions regarding environmental changes (43.3%). Drugs were prescribed for 16.0% of the affected children, with 6.4% receiving methylphenidate or amphetamines. Referral for psychological care or consultation was made for 36.9%. The frequency of mental health problems observed by the pediatricians was about five times the annual rate of Monroe County children contacting a psychiatric inpatient or outpatient setting.

Prevention and therapy of serous otitis media by oral decongestant: a double-blind study in pediatric practice.

We studied the efficacy of (1) preventing the development of serous otitis media (SOM) by using an oral decongestant in children with acute otitis media and (2) treating SOM with an oral decongestant. In a randomized double-blind study, 190 children were treated for acute otitis media with antibiotics and either pseudoephedrine hydrochloride (Sudafed) or placebo. They were evaluated two weeks later by tympanometry and (independently) by clinical evaluation and pneumotoscopy. There were no significant differences between the two groups, except that males developed SOM significantly more often than did females. Use of decongestant and placebo was continued in 78 patients with SOM for up to four more weeks. Again, there were no siginificant differences between the treatment groups except that patients with an allergic history did significantly worse using a decongestant. Overall there was no benefit from pseudoephedrine in either the prevention or treatment of SOM.

Primary pediatric care in one community.

Primary pediatric practice in one community was studied by using a household interview survey, a pediatrician mail questionnaire, and an ambulatory care survey of nine practices reporting on all visits over a four-week period. The results for the study year 1975 are compared with those for 1971 and 1967. Pediatricians provided an ever-increasing proportion of ambulatory care. Of all the children who had a regular physician in 1967, only 47% had a pediatrician; by 1975, this proportion had increased to 74%. Well-child care continues to be the largest diagnostic category (30%), followed by treatment for upper respiratory tract infections (24%), otitis media (14%), and lower respiratory tract infections (6%). Variations by practice and patient characteristics are examined. If the observed changes indicate a nationwide trend, a larger number of pediatricians will be needed to cover their growing share in primary care for children. Working in multiple settings and delegating part of the work load to nurse practioners have helped to meet the growing demand.