Faculty Bibliography

OBJECTIVE:Childhood poverty is unacceptably common in the US and threatens the health, development, and lifelong well-being of millions of children. Health care providers should be prepared through medical curricula to directly address the health harms of poverty. In this article, authors from The Child Poverty Education Subcommittee (CPES) of the Academic Pediatric Association Task Force on Child Poverty describe the development of the first such child poverty curriculum for teachers and learners across the medical education continuum. METHODS:Educators, physicians, trainees, and public health professionals from 25 institutions across the United States and Canada were convened over a 2-year period and addressed 3 goals: 1) define the core competencies of child poverty education, 2) delineate the scope and aims of a child poverty curriculum, and 3) create a child poverty curriculum ready to implement in undergraduate and graduate medical education settings. RESULTS:The CPES identified 4 core domains for the curriculum including the epidemiology of child poverty, poverty-related social determinants of health, pathophysiology of the health effects of poverty, and leadership and action to reduce and prevent poverty's health effects. Workgroups, focused on each domain, developed learning goals and objectives, built interactive learning modules to meet them, and created evaluation and faculty development materials to supplement the core curriculum. An editorial team with representatives from each workgroup coordinated activities and are preparing the final curriculum for national implementation. CONCLUSIONS:This comprehensive, standardized child poverty curriculum developed by an international group of educators in pediatrics and experts in the health effects of poverty should prepare medical trainees to address child poverty and improve the health of poor children.

We sought to determine impacts of a pediatric primary care intervention, the Video Interaction Project, on 3-year trajectories of parenting stress related to parent-child interactions in low socioeconomic status (SES) families. A randomized controlled trial (RCT) was conducted, with random assignment to one of two interventions (Video Interaction Project [VIP]; Building Blocks [BB]) or control (C). As part of VIP, dyads attended one-on-one sessions with an interventionist who facilitated interactions in play and shared reading through review of videotaped parent-child interactions made on primary care visit days; learning materials and parenting pamphlets were also provided to facilitate parent-child interactions at home. Parenting stress related to parent-child interactions was assessed for VIP and Control groups at 6, 14, 24, and 36 months using the Parent-Child Dysfunctional Interaction subscale of the Parenting Stress Index- Short Form, with 378 dyads (84%) assessed at least once. Group differences emerged at 6 months with VIP associated with lower parenting stress at 3 of 4 ages considered cross-sectionally and an 17.7% reduction in parenting stress overall during the study period based on multi-level modeling. No age by group interaction was observed, indicating persistence of early VIP impacts. Results indicated that VIP, a preventive intervention targeting parent-child interactions, is associated with decreased parenting stress. Results therefore support the expansion of pediatric interventions such as VIP as part of a broad public health strategy to address poverty-related disparities in school-readiness.

OBJECTIVE: The goal of this study was to determine what effects pediatric primary care interventions, focused on promotion of positive parenting through reading aloud and play, have on the socioemotional development of toddlers from low-income, primarily immigrant households. METHODS: This randomized controlled trial included random assignment to 1 of 2 interventions (Video Interaction Project [VIP] or Building Blocks [BB]) or to a control group. Mother-newborn dyads were enrolled postpartum in an urban public hospital. In VIP, dyads met with an interventionist on days of well-child visits; the interventionist facilitated interactions in play and shared reading through provision of learning materials and review of videotaped parent-child interactions. In BB, parents were mailed parenting pamphlets and learning materials. This article analyzes socioemotional outcomes from 14 to 36 months for children in VIP and BB versus control. RESULTS: A total of 463 dyads (69%) contributed data. Children in VIP scored higher than control on imitation/play and attention, and lower on separation distress, hyperactivity, and externalizing problems, with effect sizes approximately 0.25 SD for the sample as a whole and approximately 0.50 SD for families with additional psychosocial risks . Children in BB made greater gains in imitation/play compared with control. CONCLUSIONS: These findings support the efficacy of VIP, a preventive intervention targeting parent-child interactions, for enhancing socioemotional outcomes in low-income toddlers. Given the low cost and potential for scalability of primary care interventions, findings support expansion of pediatric-based parenting programs such as VIP for the primary prevention of socioemotional problems before school entry.

BACKGROUND AND OBJECTIVES: The use of written asthma action plans (WAAPs) has been associated with reduced asthma-related morbidity, but there are concerns about their complexity. We developed a health literacy-informed, pictogram- and photograph-based WAAP and examined whether providers who used it, with no training, would have better asthma counseling quality compared with those who used a standard plan. METHODS: Physicians at 2 academic centers randomized to use a low-literacy or standard action plan (American Academy of Allergy, Asthma and Immunology) to counsel the hypothetical parent of child with moderate persistent asthma (regimen: Flovent 110 mug 2 puffs twice daily, Singulair 5 mg daily, Albuterol 2 puffs every 4 hours as needed). Two blinded raters independently reviewed counseling transcriptions. PRIMARY OUTCOME MEASURES: medication instructions presented with times of day (eg, morning and night vs number of times per day) and inhaler color; spacer use recommended; need for everyday medications, even when sick, addressed; and explicit symptoms used. RESULTS: 119 providers were randomly assigned (61 low literacy, 58 standard). Providers who used the low-literacy plan were more likely to use times of day (eg, Flovent morning and night, 96.7% vs 51.7%, P < .001; odds ratio [OR] = 27.5; 95% confidence interval [CI], 6.1-123.4), recommend spacer use (eg, Albuterol, 83.6% vs 43.1%, P < .001; OR = 6.7; 95% CI, 2.9-15.8), address need for daily medications when sick (93.4% vs 34.5%, P < .001; OR = 27.1; 95% CI, 8.6-85.4), use explicit symptoms (eg, "ribs show when breathing," 54.1% vs 3.4%, P < .001; OR = 33.0; 95% CI, 7.4-147.5). Few mentioned inhaler color. Mean (SD) counseling time was similar (3.9 [2.5] vs 3.8 [2.6] minutes, P = .8). CONCLUSIONS: Use of a low-literacy WAAP improves the quality of asthma counseling by helping providers target key issues by using recommended clear communication principles.

Poor children are at greater risk for worse health, less productivity, and harms to well-being that extend into adulthood and subsequent generations. Timing and duration of poverty matter and influence life course outcomes, especially for education, health, and lifetime productivity. This article focuses on interventions by policy advocacy and the pediatric health system, and protection of the health and well-being of families in economic hardship from disadvantages and trauma wrought by poverty. A framework is presented for child poverty prevention and its consequences for lifelong health and success on a national scale.

OBJECTIVES: As part of a large randomized controlled trial, the authors assessed the impact of 2 early primary care parenting interventions-the Video Interaction Project (VIP) and Building Blocks (BB)-on the use of physical punishment among low-income parents of toddlers. They also determined whether the impact was mediated through increases in responsive parenting and decreases in maternal psychosocial risk. METHODS: Four hundred thirty-eight mother-child dyads (161 VIP, 113 BB, 164 Control) were assessed when the children were 14 and/or 24 months old. Mothers were asked about their use of physical punishment and their responsive parenting behaviors, depressive symptoms, and parenting stress. RESULTS: The VIP was associated with lower physical punishment scores at 24 months, as compared to BB and controls. In addition, fewer VIP parents reported ever using physical punishment as a disciplinary strategy. Significant indirect effects were found for both responsive parenting and maternal psychosocial risk, indicating that the VIP affects these behaviors and risk factors, and that this is an important pathway through which the VIP affects the parents' use of physical punishment. CONCLUSION: The results support the efficacy of the VIP and the role of pediatric primary care, in reducing the use of physical punishment among low-income families by enhancing parent-child relationships. In this way, the findings support the potential of the VIP to improve developmental outcomes for at-risk children.

BACKGROUND AND OBJECTIVES: Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship.METHODS: Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site.RESULTS: Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2-4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03-3.5) dose; associations greater for parents with low health literacy and non-English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon-associated measurement errors.CONCLUSIONS: Findings support a milliliter-only standard to reduce medication errors.

We studied associations between 2 pediatric primary care interventions promoting parental responsiveness and maternal depressive symptoms among low-income mothers. This randomized controlled trial included 2 interventions (Video Interaction Project [VIP], Building Blocks [BB]) and a control group. VIP is a relationship-based intervention, using video-recordings of mother-child dyads to reinforce interactional strengths. BB communicates with parents via parenting newsletters, learning materials, and questionnaires. At mean (SD) child age 6.9 (1.2) months, depressive symptoms were assessed with the Patient Health Questionnaire-9 (PHQ-9), parental responsiveness was assessed with StimQ-I. A total of 407 dyads were assessed. Rates of mild depressive symptoms were lower for VIP (20.6%) and BB (21.1%) than Controls (32.1%, P = .04). Moderate depressive symptoms were lower for VIP (4.0%) compared to Controls (9.7%, P = .031). Mean PHQ-9 scores differed across 3 groups (F = 3.8, P = .02): VIP mothers scored lower than controls (P = .02 by Tukey HSD). Parent-child interactions partially mediated VIP-associated reductions in depressive symptoms (indirect effect -.17, 95% confidence interval -.36, -.03).

OBJECTIVE: To examine the degree to which recommended provider counseling strategies, including advanced communication techniques and dosing instrument provision, are associated with reductions in parent liquid medication dosing errors. METHODS: Cross-sectional analysis of baseline data on provider communication and dosing instrument provision from a study of a health literacy intervention to reduce medication errors. Parents whose children (<9 years) were seen in 2 urban public hospital pediatric emergency departments (EDs) and were prescribed daily dose liquid medications self-reported whether they received counseling about their child's medication, including advanced strategies (teachback, drawings/pictures, demonstration, showback) and receipt of a dosing instrument. The primary dependent variable was observed dosing error (>20% deviation from prescribed). Multivariate logistic regression analyses were performed, controlling for parent age, language, country, ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease status; and site. RESULTS: Of 287 parents, 41.1% made dosing errors. Advanced counseling and instrument provision in the ED were reported by 33.1% and 19.2%, respectively; 15.0% reported both. Advanced counseling and instrument provision in the ED were associated with decreased errors (30.5 vs 46.4%, P = .01; 21.8 vs 45.7%, P = .001). In adjusted analyses, ED advanced counseling in combination with instrument provision was associated with a decreased odds of error compared to receiving neither (adjusted odds ratio 0.3; 95% confidence interval 0.1-0.7); advanced counseling alone and instrument alone were not significantly associated with odds of error. CONCLUSIONS: Provider use of advanced counseling strategies and dosing instrument provision may be especially effective in reducing errors when used together.

AIM: To establish whether young children watched foreground electronic media or background media that was not aimed at them or was inappropriate for their age. METHODS: We performed a longitudinal analysis of mother-infant dyads participating in a larger parenting study. The primary dependent variable was maternal reports of watching habits from media diaries at 6, 14, 24 and 36 months. Independent variables were child age, programme content and whether the programme was turned on specifically for the child. RESULTS: We analysed 3570 programme exposures in 527 children, mostly from television. Children were significantly more likely to actually watch programmes if they were older, if the content was coded as 'educational young child' or if the parent tuned on the programme specifically so the child could watch it. Children under the age of two were more likely than older children to watch background media that featured age-inappropriate content or had not been turned on for them to watch [30% versus 16% of programmes; AOR = 2.19 (95%CI 1.82-2.65)]. CONCLUSION: Young children under the age of two frequently watch background media that has age-inappropriate content or has not been turned on for them to watch.