Assisting primary care practices in using office systems to promote early childhood development.

OBJECTIVE: The aim of this study was to use family-centered measures to estimate the effect of a collaborative quality improvement program designed to help practices implement systems to promote early childhood development services. METHODS: A cohort study was conducted in pediatric and family practices in Vermont and North Carolina. Eighteen collaborative education practices and 17 comparison practices participated in a 12-month program to assist practices in implementing improved systems to provide anticipatory guidance and parental education. The main outcome measures were change over time in parent-reported measures of whether children received each of 4 aspects of recommended care, documentation of developmental and psychosocial screening, and practice-reported care delivery systems. RESULTS: The number of care delivery systems increased from a mean of 12.9 to 19.4 of 27 in collaborative practices and remained the same in comparison practices (P=.0002). The proportion of children with documented developmental and psychosocial screening among intervention practices increased from 78% to 88% (P<.001) and from 22% to 29% (P=.002), respectively. Compared with control practices, there was a trend toward improvement in the proportion of parents who reported receiving at least 3 of 4 areas of care. CONCLUSION: The learning collaborative was associated with an increase in the number of practice-based systems and tools designed to elicit and address parents' concerns about their child's behavior and development and a modest improvement in parent-reported measures of the quality of care.

The timing of maternal depressive symptoms and mothers' parenting practices with young children: implications for pediatric practice.

BACKGROUND: The prevalence of maternal depressive symptoms and its associated consequences on parental behaviors, child health, and development are well documented. Researchers have called for additional work to investigate the effects of the timing of maternal depressive symptoms at various stages in the development of the young child on the emergence of developmentally appropriate parenting practices. For clinicians, data are limited about when or how often to screen for maternal depressive symptoms or how to target anticipatory guidance to address parental needs. PURPOSE: We sought to determine whether concurrent maternal depressive symptoms have a greater effect than earlier depressive symptoms on the emergence of maternal parenting practices at 30 to 33 months in 3 important domains of child safety, development, and discipline. METHODOLOGY: Secondary analyses from the Healthy Steps National Evaluation were conducted for this study. Data sources included a self-administered enrollment questionnaire and computer-assisted telephone interviews with the mother when the Healthy Steps children were 2 to 4 and 30 to 33 months of age. The 30- to 33-month interview provided information about 4 safety practices (ie, always uses car seat, has electric outlet covers, has safety latches on cabinets, and lowered temperature on the water heater), 6 child development practices (ie, talks daily to child while working, plays daily with child, reads daily to child, limits child television and video watching to <2 hours a day, follows > or = 3 daily routines, and being more nurturing), and 3 discipline practices (ie, uses more reasoning, uses more harsh punishment, and ever slapped child on the face or spanked the child with an object). The parenting practices were selected based on evidence of their importance for child health and development, near complete data, and sample variability. The discipline practices were constructed from the Parental Response to Misbehavior Scale. Maternal depressive symptoms were assessed using a 14-item modified version of the Center for Epidemiologic Studies-Depression Scale. Multiple logistic regression models estimated the effect of depressive symptoms on parenting practices, adjusted for baseline demographic characteristics, Healthy Steps participation, and site. No significant interactions were found when testing analytic models with dummy variables for depressive symptoms at 2 to 4 months only, 30 to 33 months only, and at both times; reported models do not include interaction terms. We report main effects of depressive symptoms at 2 to 4 and 30 to 33 months when both are included in the model. RESULTS: Of 5565 families, 3412 mothers (61%) completed 2- to 4- and 30- to 33-month interviews and provided Center for Epidemiologic Studies-Depression Scale data at both times. Mothers with depressive symptoms at 2 to 4 months had reduced odds of using car seats, lowering the water heater temperature, and playing with the child at 30 to 33 months. Mothers with concurrent depressive symptoms had reduced odds of using electric outlet covers, using safety latches, talking with the child, limiting television or video watching, following daily routines, and being more nurturing. Mothers with concurrent depressive symptoms had increased odds of using harsh punishment and of slapping the child on the face or spanking with an object. CONCLUSIONS: The study findings suggest that concurrent maternal depressive symptoms have stronger relations than earlier depressive symptoms, with mothers not initiating recommended age-appropriate safety and child development practices and also using harsh discipline practices for toddlers. Our findings, however, also suggest that for parenting practices that are likely to be established early in the life of the child, it may be reasonable that mothers with early depressive symptoms may continue to affect use of those practices by mothers. The results of our study underscore the importance of clinicians screening for maternal depressive symptoms during the toddler period, as well as the early postpartum period, because these symptoms can appear later independent of earlier screening results. Providing periodic depressive symptom screening of the mothers of young patients has the potential to improve clinician capacity to provide timely and tailored anticipatory guidance about important parenting practices, as well as to make appropriate referrals.

Maternal depressive symptoms at 2 to 4 months post partum and early parenting practices.

OBJECTIVE: To determine whether maternal depressive symptoms, reported when infants are 2 to 4 months old, are associated with mothers' early parenting practices. DESIGN: Secondary data analyses collected from the National Evaluation of Healthy Steps for Young Children. Data sources included newborn enrollment questionnaires and parent interviews when infants were 2 to 4 months old. Maternal depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale. SETTING: Twenty-four pediatric practices across the United States. PARTICIPANTS: A total of 5565 families enrolled in Healthy Steps; 4874 mothers (88%) completed 2- to 4-month interviews and provided Center for Epidemiologic Studies Depression Scale data; 17.8% of mothers reported having depressive symptoms. MAIN OUTCOME MEASURES: Ten parenting practices assessed in 3 domains: safety (sleep position and lowering water temperature), feeding (cereal, water, or juice; continuing breastfeeding), and practices to promote child development (showing books, playing with infant, talking to infant, and following 2 or more routines). RESULTS: Mothers with and without depressive symptoms reported similar uses of safety and feeding practices. Mothers with depressive symptoms had reduced odds of continuing breastfeeding (adjusted odds ratio [AOR], 0.73; 95% confidence interval [CI], 0.61-0.88), showing books (AOR, 0.81; 95% CI, 0.68-0.97), playing with the infant (AOR, 0.70; 95% CI, 0.54-0.90), talking to the infant (AOR, 0.74; 95% CI, 0.63-0.86), and following routines (AOR, 0.61; 95% CI, 0.52-0.72). CONCLUSION: Maternal depressive symptoms are common in early infancy and contribute to unfavorable parenting practices.

Developmental services in primary care for low-income children: clinicians' perceptions of the Healthy Steps for Young Children program.

Difficulties with providing quality primary health care for low-income Americans have been well documented. Few studies have addressed the challenges faced by pediatric clinicians serving low-income families or whether practice-based interventions improve clinicians' ability to provide quality preventive health services. We investigated if, over time, the Healthy Steps for Young Children program affected the practices and perceptions of clinicians in pediatric primary care practices serving low-income families compared to practices serving more affluent families. Self-administered questionnaires were completed at baseline (N = 104) and at 30 months (N = 91) by clinicians at 20 pediatric practices participating in the Healthy Steps program. Practices were divided into three groups: those serving families with low, middle, and high incomes. Barriers to providing care, provision of preventive developmental services, and perceptions of care were assessed at baseline and at 30 months after introducing the program. Across all income groups and over time, clinicians were more likely to report the provision of preventive developmental health services. Clinicians in low-income practices reported increased problems with both reimbursement and time barriers; clinicians in high-income practices reported increased problems with reimbursement. At 30 months, clinicians serving low-income families reported the greatest positive changes in their perceptions about the quality of care provided by their practices. They also were more likely to strongly agree that they gave support to families and to be very satisfied with the ability of their clinical staff to meet the developmental needs of children. We found that Healthy Steps was successful in universally increasing developmental services despite the reported practice barriers for both low- and high-income practices. The Healthy Steps program enabled low-income practices to achieve similar levels of clinician satisfaction as middle- and high-income practices despite having reported lower levels at the beginning months of the program.

A practice-based intervention to enhance quality of care in the first 3 years of life: the Healthy Steps for Young Children Program.

CONTEXT: There is growing concern regarding the quality of health care available in the United States for young children, and specific limitations have been noted in developmental and behavioral services provided for children in the first 3 years of life. OBJECTIVE: To determine the impact of the Healthy Steps for Young Children Program on quality of early childhood health care and parenting practices. DESIGN, SETTING, AND PARTICIPANTS: Prospective controlled clinical trial enrolling participants between September 1996 and November 1998 at 6 randomization and 9 quasi-experimental sites across the United States. Participants were 5565 children enrolled at birth and followed up through age 3 years. INTERVENTION: Incorporation of developmental specialists and enhanced developmental services into pediatric care in participants' first 3 years of life. MAIN OUTCOME MEASURES: Quality of care was operationalized across 4 domains: effectiveness (eg, families received > or =4 Healthy Steps-related services or discussed >6 anticipatory guidance topics), patient-centeredness (eg, families were satisfied with care provided), timeliness (eg, children received timely well-child visits and vaccinations), and efficiency (eg, families remained at the practice for > or =20 months). Parenting outcomes included response to child misbehavior (eg, use of severe discipline) and practices to promote child development and safety (eg, mothers at risk for depression discussed their sadness with someone at the practice). RESULTS: Of the 5565 enrolled families, 3737 (67.2%) responded to an interview at 30 to 33 months (usual care, 1716 families; Healthy Steps, 2021 families). Families who participated in the Healthy Steps Program had greater odds of receiving 4 or more Healthy Steps-related services (for randomization and quasi-experimental sites, respectively: odds ratio [OR], 16.90 [95% confidence interval [CI], 12.78 to 22.34] and OR, 23.05 [95% CI, 17.38 to 30.58]), of discussing more than 6 anticipatory guidance topics (OR, 8.56 [95% CI, 6.47 to 11.32] and OR, 12.31 [95% CI, 9.35 to 16.19]), of being highly satisfied with care provided (eg, someone in the practice went out of the way for them) (OR, 2.06 [95% CI, 1.64 to 2.58] and OR, 2.11 [95% CI, 1.72 to 2.59]), of receiving timely well-child visits and vaccinations (eg, age-appropriate 1-month visit) (OR, 1.98 [95% CI, 1.08 to 3.62] and OR, 2.11 [95% CI, 1.16 to 3.85]), and of remaining at the practice for 20 months or longer (OR, 2.02 [95% CI, 1.61 to 2.55] and OR, 1.75 [95% CI, 1.43 to 2.15]). They also had reduced odds of using severe discipline (eg, slapping in face or spanking with object) (OR, 0.82 [95% CI, 0.54 to 1.26] and OR, 0.67 [95% CI, 0.46 to 0.97]). Among mothers considered at risk for depression, those who participated in the Healthy Steps Program had greater odds of discussing their sadness with someone at the practice (OR, 0.95 [95% CI, 0.56 to 1.63] and OR, 2.82 [95% CI, 1.57 to 5.08]). CONCLUSION: Universal, practice-based interventions can enhance quality of care for families of young children and can improve selected parenting practices.