Clinical Psychosocial Risk Factors for Sex Trafficking Involvement Among Adolescent Girls.

PURPOSE: This study assessed the characteristics that place adolescent girls at greatest risk for sex trafficking involvement. It was hypothesized that girls with a greater history of risk behaviors, unstable home environments, child maltreatment, and increased psychiatric complexity would be more likely to be involved in domestic minor sex trafficking (DMST). METHODS: Retrospective chart review of two cohorts of adolescent girls, one with known DMST history, and an age-matched cohort without DMST history, was conducted. Patients came from a Child Abuse clinic and primary care clinic within a single large urban children's hospital in the Northeast United States. Multivariate clustering analysis identified two groups of patients within the sample, one sharing "low risk" traits, and one with "high risk" traits. A variable for "psychiatric complexity" and its relationship to DMST risk was assessed. Hypothesis tests of mediation were conducted. RESULTS: 44 DMST patients and 181 Primary Care patients were included in the final sample, who were then grouped into two clusters based on conceptualized "risk" characteristics. Hypothesis testing supported evidence that patients in the "high risk" group tended toward higher psychiatric complexity (p = .0016) and greater likelihood of DMST involvement (p = .0328). Patients with increased psychiatric complexity also tended towards DMST involvement, regardless of "risk" cluster (p < .0001). DISCUSSION: This study demonstrates the relationship between social characteristics, psychiatric problems, and DMST involvement. We demonstrated that adolescents with increased psychiatric complexity tend towards greater risk of DMST. These findings demonstrate the important relationship between psychiatric complexity and sexual victimization.

Screening and Counseling Practices for Parental Combustible Versus Electronic Cigarette Use in Pediatric Primary Care: A Pilot Study.

OBJECTIVE: Tobacco exposure plays an important role in children's health. Little is known about pediatrician's experience with parental e-cigarette use. This pilot study aimed to assess pediatrician's knowledge, attitude, and behaviors regarding parental e-cigarette use. METHODS: This cross-sectional survey at an academic clinic assessed residents' and attendings' knowledge, attitudes, and behaviors regarding parental combustible and e-cigarette use and counseling and cessation barriers. RESULTS: Sixty of 69 care providers completed the survey. Participants reported asking about parental use (5% vs 58%, Δ = 53% [95% CI Δ = 40%-67%]), advising about harms (5% vs 52%, Δ = 47% [95% CI Δ = 33%-61%]), and assisting with quitting (2% vs 28%, Δ = 27% [95% CI Δ = 15%-39%]) significantly less for e-cigarettes than for combustible cigarettes. The most common barrier to discussing use was lack of time. Lack of knowledge, unsure of harm, and lack of training were reported significantly more for e-cigarettes than for combustible cigarettes. CONCLUSION: Parental screening and counseling rates are significantly lower for e-cigarettes than for combustible cigarettes in this pilot study. Increased training could help pediatricians better protect children from tobacco exposure.

Changes in Pediatricians' Child Passenger Safety Counseling With Initiation of a Booster Seat Program.

Booster seats reduce injury in motor vehicle crashes, yet they are used less frequently than car seats and seat belts. Primary care providers are well positioned to educate and encourage families to use booster seats. We aimed to assess how a booster seat distribution program affected the documentation of restraint usage and anticipatory guidance at well-child visits at a pediatric primary care practice. We performed a retrospective chart review of patients aged 4 to 12 years from June to December in 2019 and 2020, representing before and after a booster seat program. The most frequently documented restraints in 2019 and 2020 were seat belts (51% vs 30%), booster seats (25% vs 27%), and not documented/unclear (17% vs 25%) (P < .001). The program significantly increased referrals for booster seats (P < .001). Despite significant differences in the proportion of children in each restraint category, overall booster seat use was similar between years.

Give Me A Boost: A Child Passenger Safety Educational Intervention.

BACKGROUND: Motor vehicle crashes (MVCs) are a leading cause of morbidity and mortality among children, yet belt-positioning booster seats remain underutilized. This study analyzed the impact of a provider-oriented child passenger safety (CPS) educational intervention on pediatric resident confidence, knowledge, and counseling behavior in the primary care setting. METHODS: Pre- and post-educational intervention cross- sectional surveys were distributed to pediatric residents focusing on confidence, knowledge, barriers to, and frequency of CPS discussions. RESULTS: Pre-intervention, only 16% (95% CI: 6.2-32%) of respondents reported confidence in their knowledge of the American Academy of Pediatrics' (AAP) booster seat recommendations. Post-intervention frequency of CPS discussion, confidence and knowledge in all measured aspects increased. CONCLUSIONS: While pediatric residents are well positioned for CPS counseling, they lack adequate baseline knowledge of CPS recommendations, particularly for booster seats. Brief educational interventions can increase and maintain provider knowledge and confidence in counseling families on appropriate child car safety seats.

Changes in Sick Visits at an Academic Pediatric Primary Care Practice due to the COVID-19 Pandemic.

BACKGROUND/OBJECTIVE: The COVID-19 pandemic decreased pediatric patient volumes; however, details regarding patterns of use within primary care sick visits are not well understood. METHODS: We performed a retrospective chart review of sick visits in an academic primary care clinic from March-August 2019 and 2020 and recorded demographics and visit diagnoses. Descriptive statistics, Chi-square, and Fisher's exact tests were used to compare the two time periods. RESULTS: Patient age, gender, and insurance type were similar across years. In 2020, there were 1,868 sick visits (247 telehealth, 4%-36% of monthly visits) compared to 4,007 (0 telehealth) in 2019. The proportion of infectious diagnoses decreased (35% vs 48%); non-infectious diagnoses increased, including dermatological (25% vs 19%) and genitourinary/reproductive (9% vs. 6%) diagnoses.  Conclusion: Similar to pediatric emergency departments, we found decreased primary care sick visits. Telehealth increased in 2020 and varied with COVID-19 community prevalence. Visits for contagious illnesses decreased in 2020, likely related to mitigation measures.

A Cyberbullying Media-Based Prevention Intervention for Adolescents on Instagram: Pilot Randomized Controlled Trial.

BACKGROUND: Between 15% and 70% of adolescents report experiencing cybervictimization. Cybervictimization is associated with multiple negative consequences, including depressed mood. Few validated, easily disseminated interventions exist to prevent cybervictimization and its consequences. With over 97% of adolescents using social media (such as YouTube, Facebook, Instagram, or Snapchat), recruiting and delivering a prevention intervention through social media and apps may improve accessibility of prevention tools for at-risk youth. OBJECTIVE: This study aims to evaluate the feasibility and acceptability of and obtain preliminary outcome data on IMPACT (Intervention Media to Prevent Adolescent Cyber-Conflict Through Technology), a brief, remote app-based intervention to prevent and reduce the effect of cyberbullying. METHODS: From January 30, 2020, to May 3, 2020, a national sample of 80 adolescents with a history of past-year cybervictimization was recruited through Instagram for a randomized control trial of IMPACT, a brief, remote research assistant-led intervention and a fully automated app-based program, versus enhanced web-based resources (control). Feasibility and acceptability were measured by consent, daily use, and validated surveys. Although not powered for efficacy, outcomes (victimization, bystander self-efficacy, and well-being) were measured using validated measures at 8 and 16 weeks and evaluated using a series of longitudinal mixed models. RESULTS: Regarding feasibility, 24.5% (121/494) of eligible participants provided contact information; of these, 69.4% (84/121) completed full enrollment procedures. Of the participants enrolled, 45% (36/80) were randomized into the IMPACT intervention and 55% (44/80) into the enhanced web-based resources groups. All participants randomized to the intervention condition completed the remote intervention session, and 89% (77/80) of the daily prompts were answered. The retention rate was 99% (79/80) at 8 weeks and 96% (77/80) at 16 weeks for all participants. Regarding acceptability, 100% (36/36) of the intervention participants were at least moderately satisfied with IMPACT overall, and 92% (33/36) of the participants were at least moderately satisfied with the app. At both 8 and 16 weeks, well-being was significantly higher (ß=1.17, SE 0.87, P=.02 at 8 weeks and ß=3.24, SE 0.95, P<.001 at 16 weeks) and psychological stress was lower (ß=-.66, SE 0.08, P=.04 at 8 weeks and ß=-.89, SE 0.09, P<.001 at 16 weeks) among IMPACT users than among control group users. Participants in the intervention group attempted significantly more bystander interventions than those in the control group at 8 weeks (ß=.82, SE 0.42; P=.02). CONCLUSIONS: This remote app-based intervention for victims of cyberbullying was feasible and acceptable, increased overall well-being and bystander interventions, and decreased psychological stress. Our findings are especially noteworthy given that the trial took place during the COVID-19 pandemic. The use of Instagram to recruit adolescents can be a successful strategy for identifying and intervening with those at the highest risk of cybervictimization. TRIAL REGISTRATION: ClinicalTrials.gov NCT04259216; http://clinicaltrials.gov/ct2/show/NCT04259216.

Cyberbullying Prevention for Adolescents: Iterative Qualitative Methods for Mobile Intervention Design.

BACKGROUND: Cybervictimization among adolescents is associated with multiple negative mental health consequences. Although pediatricians often screen for cyberbullying, validated and acceptable programs to reduce the frequency and impact of adolescent cybervictimization are lacking. OBJECTIVE: This study uses agile qualitative methods to refine and evaluate the acceptability of a mixed-modality intervention, initiated within the context of usual pediatric care, for adolescents with a history of cyberharassment and cyberbullying victimization. METHODS: Three groups of adolescents were successively recruited from an urban primary care clinic to participate in three consecutive iterations (1, 2, and 3) of the program, which consisted of a brief in-clinic intervention followed by 8 weeks of daily, automated SMS text messaging. After 2 weeks of messaging, iteration 1 (I1) participants completed semistructured interviews regarding intervention experiences. Participant feedback was evaluated via framework matrix analysis to guide changes to the program for iteration 2 (I2). Feedback from 2-week interviews of I2 participants was similarly used to improve the program before initiating iteration 3 (I3). Participants in all 3 iterations completed the interviews after completing the program (8 weeks). Daily response rates assessed participant engagement, and satisfaction questionnaires assessed acceptability. RESULTS: A total of 19 adolescents (aged 13-17 years) reporting past-year cybervictimization were enrolled: 7 in I1, 4 in I2, and 8 in I3. Demographic variables included the following: a mean age of 15 (SD 1.5) years; 58% (11/19) female, 42% (8/19) male, 63% (12/19) Hispanic, 37% (7/19) non-Hispanic, 79% (15/19) people of color, and 21% (4/19) White. A total of 73% (14/19) self-identified as having a low socioeconomic status, and 37% (7/19) self-identified as lesbian, gay, or bisexual. The average past 12-month cybervictimization score at baseline was 8.2 (SD 6.58; range 2-26). Participant feedback was used to iteratively refine intervention content and design. For example, participants in I1 recommended that the scope of the intervention be expanded to include web-based conflicts and drama, rather than narrowly focusing on cyberbullying prevention. On the basis of this feedback, the I2 content was shifted toward more general de-escalation skills and bystander empowerment. Overall, 88.34% (940/1064) of the daily queries sent to participants across all 3 iterations received a reply. Participant satisfaction improved considerably with each iteration; 0% (0/7) of I1 participants rated the overall quality of Intervention to Prevent Adolescent Cybervictimization with Text message as excellent, compared to 50% (2/4) of I2 participants and 86% (6/7) of I3 participants. Engagement also improved between the first and third iterations, with participants replying to 59.9% (235/392) of messages in I1, compared to 79.9% (358/488) of messages in I3. CONCLUSIONS: This study shows the value of structured participant feedback gathered in an agile intervention refinement methodology for the development of a technology-based intervention targeting adolescents.

Visits for Possible COVID-19 in a Pediatric Primary Care Practice Early in the Pandemic.

BACKGROUND: Children with COVID-19 usually present with mild symptoms. We characterize visits with respect to symptoms and testing in the outpatient setting. METHODS: A retrospective chart review of sick visits in a pediatric academic primary care clinic April-August 2020. We included possible COVID-19 cases, or "persons under investigation" (PUIs), recording symptoms, positive contacts, and COVID-19 testing. Descriptive statistics and Chi-square or Fisher's exact tests for comparisons were used. RESULTS: 32% (476/1,474) of sick visits were PUIs; 20% were telehealth. Symptoms most commonly reported were fever, congestion/rhinorrhea and cough. 76% of PUIs were tested for COVID-19. Only presence of COVID-19 contacts and loss of taste/smell were significantly associated with positive tests (p<0.001). CONCLUSION: Nearly a third of sick visits in an academic pediatric practice were seen for possible COVID-19 symptoms and most were tested. The majority with and without COVID-19 had fever, congestion and/or cough. Our findings suggest low thresholds for testing in children.

Feasibility and Cost of Using Instagram to Recruit Adolescents to a Remote Intervention.

PURPOSE: The purpose of this study was to describe the feasibility, cost-effectiveness, and generalizability of a strategy for recruiting adolescents into research studies through social media. METHODS: We designed and tested six Instagram advertisements (ads) with a combination of Instagram campaign objectives (Traffic vs. Reach) and types of placement (Story vs. Feed). The goal was to obtain remote assent and screen for a larger remote behavioral intervention study. The eligibility criteria for screening were being aged 13-17 years, residing in the United States, and English-speaking. The eligibility for the larger study was past year cybervictimization and smartphone ownership. A target sample was 80 participants, randomly assigned to a control or intervention group and followed up for 16 weeks. Recruitment rates and cost-per-enrolled participant with different advertising strategies, demographics, and retention were examined using descriptive statistics. RESULTS: The six ads were run over 907.5 hours, generating 1,069,747 impressions, 2,051 click-throughs, and 663 completed screening surveys. Of 493 eligible participants, 24.4% assented to participate, 69.4% completed enrollment, and 4.8% dropped/withdrew after randomization. Average advertising costs were $52/participant; the lowest-cost strategy (Traffic campaign + Feed ad placement) was $19/enrolled participant. The study sample was largely white (81.3%), non-Hispanic (87.5%), and female (77.5%) with an average age of 15.33 years. Nearly half of the participants were identified as lesbian, gay, or bisexual. More than 96% of participants were retained at the 16-week follow-up. CONCLUSIONS: Instagram can be a feasible and cost-effective way to recruit adolescents for a remote study. This method may be ideal for recruiting hard-to-reach audiences.

What Counts?: A Qualitative Study of Adolescents' Lived Experience With Online Victimization and Cyberbullying.

OBJECTIVE: To inform development of cyberbullying interventions that are both accurate and meaningful to all adolescents, this qualitative analysis examines experiences of online peer victimization among a sample of predominately minority and low-income youth. METHODS: Adolescents ages 13 to 17 years who reported past-year cyberbullying on a previously validated survey were recruited from an urban pediatric clinic to complete semistructured interviews. Interview topics included definitions of cyberbullying, prior cyberbullying experiences, and strategies to reduce cyberbullying and its consequences. Interviews were audio-recorded and transcribed verbatim. Using thematic analysis, study team members applied both structural and emergent codes to transcripts. RESULTS: Saturation was reached after 23 interviews (mean age 14.8 years; 65% female, 47.8% Hispanic, 35% Black, 74% low socioeconomic status). Four main themes emerged: 1) Teens avoided the term "cyberbullying," due to its association with suicidality and severe depression; they preferentially described experiences (even those meeting criteria for repetition, power differential, etc.) as "online conflict". 2) In-person bullying categories (bully, victim, bully victim, bystander) apply to online conflict. Few identify purely as victims. 3) Cyberbullying is part of a larger continuum of peer violence, including physical fights and in-person bullying. 4) Teens want to help victims of cyberbullying; they desire more guidance in so doing. CONCLUSIONS: These youth rarely acknowledge presence of cyberbullying; instead, they describe online conflict as part of a larger spectrum of peer violence. Clinicians may consider prevention of a range of conflict-related behaviors (rather than focusing exclusively on cyberbullying), and may consider engaging adolescent bystanders in prevention of online conflict.

An Electronic Sexual Health Module for Hospitalized Adolescent Girls.

OBJECTIVES: To evaluate the acceptability and feasibility of an electronic sexual health module for inpatient adolescent girls and assess the preliminary effect on uptake of sexual health services. METHODS: We recruited girls 14 to 18 years old admitted to the hospitalist service of 1 academic children's hospital from January 2016 to October 2016. Participants completed an electronic sexual health module that included a sexual health assessment, tailored feedback (randomized for half of the participants only), and a questionnaire to request sexual health services. Participation and completion rates, along with effects of tailored feedback, risk perception, age group, and sexual activity on uptake of services, were examined. RESULTS: Seventy-seven percent of eligible participants who were approached enrolled in the study (n = 66 of 86). The completion rate was 100%. Fifty-three percent (n = 35) requested some form of sexual health service; of these, 83% (n = 29) requested to watch a contraception video. There was no statistically significant difference in the frequency of requests for those who received tailored feedback and for those who did not (57% vs 48%; P = .48). Younger teens and those without sexual experience made requests similar to older and sexually experienced girls except regarding sexually transmitted infection testing, which was significantly higher in the latter populations. CONCLUSIONS: This pilot study demonstrated reasonable feasibility and acceptability of a standardized sexual health module for adolescent girls admitted to the general pediatric wards. Videos focused on adolescent health were of particular interest to this population. Further study should examine the impact of such a module on long-term sexual health behaviors.

Documentation of Tobacco, Alcohol, and Drug Screening in Hospitalized Adolescents.

OBJECTIVES: To examine the frequency of documented screening for tobacco, alcohol, and drug use in hospitalized adolescents on the pediatric hospitalist service. PATIENTS AND METHODS: This was a retrospective chart review of adolescents aged 14 to 17 years hospitalized at a large urban academic children's hospital in the Northeast from 2013 to 2015. Only patients admitted directly to the hospitalist service and only the first admission (if multiple occurred) were included. Patients presenting for psychiatric illness, ingestions, or impaired neurologic functioning were excluded. Admission history and physical (H&P) notes were reviewed to identify documented screening for tobacco, alcohol, and drug use. χ2 tests and 95% confidence intervals (CIs) were used to compare screenings for each substance and assess for associations of patient and encounter characteristics. RESULTS: A total of 443 charts met criteria for inclusion. The majority of adolescents were girls (n = 286; 64.6%), and mean age was 15.6 years (SD: 1.1). The H&P notes included notation of screening for tobacco use in 75.4% (95% CI: 71.1%-79.3%), alcohol use in 56.4% (95% CI: 51.7%-61.1%), and drug use in 37.9% (95% CI: 33.4%-42.6%) of charts. Girls were 1.4 times more likely to have of documented screening for alcohol use than boys. The admission diagnosis category was significantly associated with documentation of alcohol screening. Tobacco and drug screening frequency did not differ on the basis of sex, age, or diagnosis category. CONCLUSIONS: Documentation of substance use screening was not universal in admission H&P notes. These discrepancies suggest a need for improvements in screening protocols and documentation methods.

Documentation of Sexual History in Hospitalized Adolescents on the General Pediatrics Service.

OBJECTIVES: To determine the frequency of sexual history taking and the associated characteristics of hospitalized adolescents in the pediatric hospitalist service. METHODS: A retrospective chart review of adolescents 14 to 18 years old who were admitted to the pediatric hospitalist service at an urban, academic children's hospital in the Northeast from 2013 to 2015 was conducted. Repeat admissions, admissions to specialty services, and charts that noted impairment because of psychosis, cognitive delay, or illness severity were excluded. For charts that met the criteria, the admission history and physical was carefully reviewed for a notation of sexual history. For those with documentation, sexual activity status and a risk level assessment were recorded. Patient demographics and admission characteristics were extracted. χ2 tests and logistic regression were used to examine differences between those with sexual history and those without. RESULTS: A total of 752 charts met the criteria for inclusion. The majority of adolescents were girls (n = 506; 67.3%); the mean age was 15.7 years (SD = 1.2). Girls had 2.99 (95% confidence interval [CI] 2.18-4.11) higher odds of documentation than boys, and older adolescents had 1.41 (95% CI 1.03-1.91) higher odds than younger adolescents. Documentation did not differ significantly on the basis of admission type (medical or psychiatric), admission time, patient race and/or ethnicity, or provider gender. Among those with a documented sexual history, risk-level details were often omitted. CONCLUSIONS: Sexual history taking does not occur universally for hospitalized adolescents. Girls were screened more often than boys despite similar rates of sexual activity. The inpatient admission may be a missed opportunity for harm-reduction counseling and adherence to sexually transmitted infection testing guidelines.

Clinical Outcomes of Bronchiolitis After Implementation of a General Ward High Flow Nasal Cannula Guideline.

OBJECTIVE: The goal of this study was to assess the association of the introduction of a ward's high-flow nasal cannula (HFNC) guideline with clinical outcomes of infants with bronchiolitis. METHODS: We conducted a retrospective, pre-post intervention study with an interrupted time series analysis of infants admitted with bronchiolitis between 2010 and 2014 at an urban, tertiary care children's hospital. Patients admitted in the 24 months before and after initiation of a guideline for HFNC use on the general wards were compared. The primary outcome was length of hospital stay. Secondary outcomes were PICU transfer rate and length of stay, intubation rate, and 30-day readmission, adjusted for season. RESULTS: A total of 1937 patients met inclusion criteria; 936 were admitted before and 1001 admitted after the introduction of HFNC use on the general wards. Comparing the 2 groups, the hospital-wide rate of HFNC use in bronchiolitis treatment increased after HFNC became available on the wards (23.9% vs 35.2%; P < .001). The ward's HFNC guideline was not associated with a change in preintervention trajectory of total hospital length of stay (P = .48), PICU length of stay (P = .06), or rate of PICU transfer (P = .97). There was also no difference in intubation rate or 30-day readmission between the 2 groups. CONCLUSIONS: Initiating a guideline for HFNC use on the general pediatric wards was associated with an increase in the use of the intervention with no significant change in total hospital length of stay, PICU length of stay and transfer rate, intubation rate, or 30-day readmission for patients with bronchiolitis.