Faculty Bibliography

OBJECTIVE: Although low parent health literacy (HL) has been linked to poor child health outcomes, it is not known whether differences in perceptions related to access to care and provider-parent partnership in care are potential contributing factors. We sought to assess whether parent HL is associated with differences in perceived barriers to care and attitudes regarding participatory decision-making with the provider. METHODS: This was a cross-sectional analysis of data collected from parents presenting with their child to an urban public hospital pediatric clinic in New York City. Dependent variables were caregiver-reported barriers to care (ability to reach provider at night/on weekends, difficult travel to clinic) and attitudes towards participatory decision-making (feeling like a partner, relying on doctor's knowledge, leaving decisions up to the doctor, being given choices/asked opinion). The primary independent variable was caregiver HL (Short Test of Functional Health Literacy in Adults [S-TOHFLA]). RESULTS: A total of 823 parents were assessed; 1 in 4 (27.0%) categorized as having low HL. Parents with low HL were more likely to report barriers to care than those with adequate HL: trouble reaching provider nights/weekends, 64.9% vs. 49.6%, (p < 0.001, adjusted odds ratio [AOR] 1.7, 95% confidence interval [95% CI] 1.2-2.4); difficult travel, 15.3% vs. 8.0%, (p = 0.004, AOR 1.8, 95% CI 1.1-3.0). Low HL was also associated with not feeling like a partner (28.8% vs. 17.1%; AOR 2.0; 95% CI 1.4-3.0), preference for relying on the doctor's knowledge (68.9% vs. 52.2%; AOR 1.7; 95% CI 1.2-2.4), and preference for leaving decisions up to the doctor (57.7% vs. 33.3%; AOR 2.2; 95% CI 1.6-3.1). CONCLUSIONS: Addressing issues of parent HL may be helpful in ameliorating barriers to care and promoting provider-parent partnership in care.

OBJECTIVE: To assess the health literacy and numeracy skills of Spanish-speaking parents of young children and to validate a new Spanish language health literacy assessment for parents, the Spanish Parental Health Literacy Activities Test (PHLAT Spanish). METHODS: Cross-sectional study of Spanish-speaking caregivers of young children (<30 months) enrolled at primary care clinics in 4 academic medical centers. Caregivers were administered the 10-item PHLAT in addition to validated tests of health literacy (S-TOFHLA) and numeracy (WRAT-3 Arithmetic). Psychometric analysis was used to examine item characteristics of the PHLAT-10 Spanish, to assess its correlation with sociodemographics and performance on literacy/numeracy assessments, and to generate a shorter 8-item scale (PHLAT-8). RESULTS: Of 176 caregivers, 77% had adequate health literacy (S-TOFHLA), whereas only 0.6% had 9th grade or greater numeracy skills. Mean PHLAT-10 score was 41.6% (SD 21.1). Fewer than one-half (45.5%) were able to read a liquid antibiotic prescription label and demonstrate how much medication to administer within an oral syringe. Less than one-third (31.8%) were able to interpret a food label to determine whether it met WIC (Special supplemental nutrition program for Women, Infants, and Children) guidelines. Greater PHLAT-10 score was associated with greater years of education (r = 0.49), S-TOFHLA (r = 0.53), and WRAT-3 (r = 0.55) scores (P < .001). Internal reliability was good (Kuder-Richardson coefficient of reliability; KR-20 = 0.61). An 8-item scale was highly correlated with the full 10-item scale (r = 0.97, P < .001), with comparable internal reliability (KR-20 = 0.64). CONCLUSIONS: Many Spanish-speaking parents have difficulty performing health-related literacy and numeracy tasks. The Spanish PHLAT demonstrates good psychometric characteristics and may be useful for identifying parents who would benefit from receiving low-literacy child health information.

This study sought to determine the relationship between maternal controlling feeding styles and maternal perception of their infant's ability to regulate feeding and infant weight. A cross-sectional survey of 208 mothers with infants between 2 weeks and 6 months old was performed in a private pediatric office. The authors assessed the relationship between restrictive and pressuring feeding styles with (a) maternal perception of the infant's ability to regulate feeding and (b) infant weight (both actual and perceived). Restrictive feeding style was associated with the perception that infants could not recognize their own hunger or satiety and with concern that the infant would become overweight in the future. Pressuring feeding style was associated with the perception that the baby's appetite is less than other babies and with concern that the infant would become underweight in the future. Maternal perceptions of infant feeding and weight should be incorporated into early obesity prevention strategies.

Objective: Individuals with ADHD are often characterized as inconsistent across many contexts. ADHD is also associated with deficits in executive function. We examined the relationships between response time (RT) variability on five brief computer tasks to parents' ratings of ADHD-related features and executive function in a group of children with a broad range of ADHD symptoms from none to full diagnosis. Methods: We tested 98 children (mean age 9.9 +/- 1.4 years; 66 boys) from community clinics on short tasks of executive control (TEC) and the Eriksen Flanker task, while a parent completed the Conners' Parent Rating Scale and Behavior Rating Inventory of Executive Function. Results: Variability for two of the TEC tasks explained significant proportions of the variance of all five ADHD-related Conners' subscales and several executive function subscales. By contrast, variability on the flanker task or mean RTs for any task were not associated with any rating scale. Conclusion: The significant dimensional relationships observed between variability measures and parent ratings supported the utility of RT variability as an objective measure in ADHD and aspects of executive functioning that is superior to RT means or accuracy measures

OBJECTIVE: Medication dosing errors by parents are frequent. We sought to whether a pictographic dosing diagram could improve parent ability to dose infant acetaminophen, and to determine whether pictogram benefit varies by health literacy level. METHODS: We conducted an experimental study of parents presenting with their children to an urban public hospital pediatric clinic. Caregivers were randomized to dose infant acetaminophen with a standard dropper using text-only or text-plus-pictogram instructions (pictographic diagram of dose). The primary outcome variable was dosing accuracy (error defined as >20% deviation above/below dose; large overdosing error defined as >1.5 times recommended dose). Caregiver health literacy was assessed by means of the Newest Vital Sign measure. RESULTS: A total of 299 parents were assessed (144 text-only instructions; 155 text plus pictogram); 77.9% had limited health literacy (Newest Vital Sign score 0-3). Text-plus-pictogram recipients were less likely to make an error compared to text-only recipients (43.9% vs 59.0%, P = .01; absolute risk reduction, 15.2% [95% confidence interval, 3.8-26.0]; number needed to treat, 7 [4-26]). Of text-plus-pictogram recipients, 0.6% made a large overdosing error compared to 5.6% of text-only recipients (absolute risk reduction, 4.9% [0.9-10.0]; number needed to treat, 20 [10-108]). Pictogram benefit varied by health literacy, with a statistically significant difference in dosing error evident in the text-plus-pictogram group compared to the text-only group among parents with low health literacy (50.4% vs 66.4%; P = .02), but not for parents with adequate health literacy (P = .7). CONCLUSIONS: Inclusion of pictographic dosing diagrams as part of written medication instructions for infant acetaminophen may help parents provide doses of medication more accurately, especially those with low health literacy. High error rates, even among parents with adequate health literacy, suggest that additional study of strategies to optimize dosing is needed

OBJECTIVE: To determine the effects of pediatric primary care interventions on parent-child interactions in families with low socioeconomic status. DESIGN: In this randomized controlled trial, participants were randomized to 1 of 2 interventions (Video Interaction Project [VIP] or Building Blocks [BB]) or the control group. SETTING: Urban public hospital pediatric primary care clinic. PARTICIPANTS: Mother-newborn dyads enrolled post partum from November 1, 2005, through October 31, 2008. INTERVENTIONS: In the VIP group, mothers and newborns participated in 1-on-1 sessions with a child development specialist who facilitated interactions in play and shared reading by reviewing videos made of the parent and child on primary care visit days; learning materials and parenting pamphlets were also provided. In the BB group, parenting materials, including age-specific newsletters suggesting interactive activities, learning materials, and parent-completed developmental questionnaires, were mailed to the mothers. MAIN OUTCOME MEASURES: Parent-child interactions were assessed at 6 months with the StimQ-Infant and a 24-hour shared reading recall diary. RESULTS: A total of 410 families were assessed. The VIP group had a higher increased StimQ score (mean difference, 3.6 points; 95% confidence interval, 1.5 to 5.6 points; Cohen d, 0.51; 0.22 to 0.81) and more reading activities compared to the control group. The BB group also had an increased overall StimQ score compared with the control group (Cohen d, 0.31; 95% confidence interval, 0.03 to 0.60). The greatest effects for the VIP group were found for mothers with a ninth-grade or higher reading level (Cohen d, 0.68; 95% confidence interval, 0.33 to 1.03). CONCLUSIONS: The VIP and BB groups each led to increased parent-child interactions. Pediatric primary care represents a significant opportunity for enhancing developmental trajectories in at-risk children. Trial Registration clinicaltrials.gov Identifier: NCT00212576

OBJECTIVES: To determine whether pediatric primary care-based programs to enhance parenting and early child development reduce media exposure and whether enhanced parenting mediates the effects. DESIGN: Randomized controlled trial. SETTING: Urban public hospital pediatric primary care clinic. PARTICIPANTS: A total of 410 mother-newborn dyads enrolled after childbirth. INTERVENTIONS: Patients were randomly assigned to 1 of 2 interventions, the Video Interaction Project (VIP) and Building Blocks (BB) interventions, or to a control group. The VIP intervention comprised 1-on-1 sessions with a child development specialist who facilitated interactions in play and shared reading through review of videotapes made of the parent and child on primary care visit days; learning materials and parenting pamphlets were also provided. The BB intervention mailed parenting materials, including age-specific newsletters suggesting activities to facilitate interactions, learning materials, and parent-completed developmental questionnaires (Ages and Stages questionnaires). OUTCOME MEASURES: Electronic media exposure in the home using a 24-hour recall diary. RESULTS: The mean (SD) exposure at 6 months was 146.5 (125.0) min/d. Exposure to VIP was associated with reduced total duration of media exposure compared with the BB and control groups (mean [SD] min/d for VIP, 131.6 [118.7]; BB, 151.2 [116.7]; control, 155.4 [138.7]; P = .009). Enhanced parent-child interactions were found to partially mediate relations between VIP and media exposure for families with a ninth grade or higher literacy level (Sobel statistic = 2.49; P = .01). CONCLUSION: Pediatric primary care may represent an important venue for addressing the public health problem of media exposure in young children at a population level. Trial Registration clinicaltrials.gov Identifier: NCT00212576

OBJECTIVE: To determine whether duration and content of media exposure in 6-month-old infants are associated with development at age 14 months. DESIGN: Longitudinal analysis of 259 mother-infant dyads participating in a long-term study related to early child development, from November 23, 2005, through January 14, 2008. SETTING: An urban public hospital. PARTICIPANTS: Mothers with low socioeconomic status and their infants. Main Exposure Duration and content of media exposure at age 6 months. MAIN OUTCOME MEASURES: Cognitive and language development at age 14 months. RESULTS: Of 259 infants, 249 (96.1%) were exposed to media at age 6 months, with mean (SD) total exposure of 152.7 (124.5) min/d. In unadjusted and adjusted analyses, duration of media exposure at age 6 months was associated with lower cognitive development at age 14 months (unadjusted: r = -0.17, P < .01; adjusted: beta = -0.15, P = .02) and lower language development (r = -0.16, P < .01; beta = -0.16, P < .01). Of 3 types of content assessed, only 1 (older child/adult-oriented) was associated with lower cognitive and language development at age 14 months. No significant associations were seen with exposure to young child-oriented educational or noneducational content. CONCLUSIONS: This study is the first, to our knowledge, to have longitudinally assessed associations between media exposure in infancy and subsequent developmental outcomes in children from families with low socioeconomic status in the United States. Findings provide strong evidence in support of the American Academy of Pediatrics recommendations of no media exposure prior to age 2 years, although further research is needed

OBJECTIVE:: To determine whether screening children in an urban pediatric emergency department (PED) would lead to identification of previously undiagnosed developmental delay. METHODS:: This was a cross-sectional study of families presenting to an urban public hospital PED with children 6 to 36 months and no history of developmental delay. Children were screened for possible developmental delay using the Ages and Stages Questionnaire; parents completed an instrument that assesses 5 domains: communication, gross motor, fine motor, problem solving, and personal-social. Sociodemographic data were also obtained. RESULTS:: One hundred thirty-eight children were enrolled, all accompanied by their mothers. Mean age of the children was 18.9 months; 51.5% were female; 56.8% of the mothers were high-school graduates; 59.9% were immigrants; 75.4% were Latino. Twenty-one percent did not have a regular source of primary care; 26.8% (95% confidence interval, 20.1%-34.8%) screened positive in at least 1 domain, with a trend toward the highest percentage of positive screens on the communication domain (z = 1.89, P = 0.059). In a simultaneous multiple logistic regression model including all predictor variables, child age of 12 to 30 months was associated with increased adjusted odds of positive screen (adjusted odds ratio, 8.4; 95% confidence interval, 1.4-48.9). Having a primary caregiver born in the United States was statistically significant for screening positive in at least 1 Ages and Stages Questionnaire domain (P = 0.03). CONCLUSIONS:: Almost 30% of 6- to 36-month-old children presenting to an urban PED without prior developmental concerns screened positive for possible delay, suggesting the utility of performing routine developmental screening in the PED. Pediatric emergency department use alone may be an indication for screening. Further study is needed for feasibility of screening for delay in the PED