Faculty Bibliography

OBJECTIVE: Since 1997 pediatric residencies have been required to provide a 4-week block rotation in developmental and behavioral pediatrics (DBP), but it is not known whether this has altered the care and management of children by practicing pediatricians. To compare the self-reported practice patterns of pediatricians who were trained with 4 or more weeks of DBP to the practice patterns of those who were trained for < 4 weeks. METHODS: We used self-reported practices from the American Academy of Pediatrics Periodic Survey #85. Pediatricians were asked whether they never, sometimes or usually inquired about and screened for, and whether they treated/managed/co-managed ADHD, depression, anxiety, behavior problems and learning problems. They were also asked about a series of barriers to care. Analyses were weighted to account for low response rates. RESULTS: Those with more DBP training were significantly more likely to treat/manage/co-manage depression, anxiety, behavior problems and learning problems, but were still doing so less than one third of the time. There were no differences in the care of patients with ADHD or in screening or inquiring about mental health conditions. Those with more training were more likely to perceive somewhat fewer barriers and to report more specific familiarity with some DSM criteria and some treatment modalities. CONCLUSION: Longer training is associated with more treatment, but significant deficits in self-reported practice remain, leaving much room for additional improvement in the training of clinicians in DBP.

OBJECTIVE: Cumulative adverse childhood experiences (ACE) can have profound and lasting effects on parenting. Parents with a history of multiple ACE have greater challenges modulating their own stress responses and helping their children adapt to life stressors. This paper examines pediatric practice in inquiring about parents' childhood adversities as of 2013. METHODS: Using data from the 85th Periodic Survey of the American Academy of Pediatrics (AAP), we restricted analyses to the 302 pediatricians exclusively practicing general pediatrics who answered questions regarding their beliefs about childhood stressors, their role in advising parents, and whether they asked about parents' ACE. Weighted descriptive and logistic regression analyses were conducted. RESULTS: Despite endorsing the influence of positive parenting on a child's life-course trajectory (96%), that their advice can impact parenting skills (79%), and that screening for social-emotional risks is within their scope of practice ((81%), most pediatricians (61%) did not inquire about parents' ACE. Pediatricians who believed that their advice influences positive parenting skills inquired about more parents' ACE CONCLUSION: As of 2013, few pediatricians inquired about parents' ACE despite recognizing their negative impact on parenting behaviors and child development.. Research is needed regarding the best approaches to the prevention and amelioration of ACE and the promotion of family and child resilience. Pediatricians need resources and education about the AAP's proposed dyadic approach to assessing family and child risk factors and strengths and to providing guidance and management.

OBJECTIVE: The objectives were to: assess the availability of on-site mental health professionals (MHP) in primary care; examine practice/pediatrician characteristics associated with on-site MHPs; and determine whether presence of on-site MHPs is related to pediatricians' co-managing or more frequently identifying, treat/managing or referring MH problems. METHODS: Analyses included AAP members who participated in an AAP Periodic Survey in 2013 and who practiced general pediatrics (N=321). Measures included socio-demographics, practice characteristics, questions on about on-site MHPs, co-management of MH problems and pediatricians' behaviors in response to 5 prevalent MH problems. Weighted univariate, bivariate and multivariable analyses were performed. RESULTS: Thirty-five percent reported on-site MHPs. Practice characteristics (medical schools/universities/HMOs, <100 visits/week, <80% of patients privately insured), and interactions of practice location (urban) with visits and patient insurance, were associated with on-site MHPs. There was no overall association between co-location and co-management or whether pediatricians usually identified, treat/managed or referred 5 common child MH problems. Among the subset of pediatricians who reported co-managing there was an association with co-management when the on-site MHP was a child psychiatrist, SA counselor, or social worker. CONCLUSIONS: On-site MHPs are more frequent in settings where low-income children are served and where pediatricians train. Pediatricians who co-manage MH problems are more likely to do so when the on-site MHP is a child psychiatrist, SA counselor, or social worker. Overall, on-site MHPs were not associated with co-management or increased likelihood of pediatricians identifying, treating/managing, or referring children with 5 common child MH problems.

BACKGROUND: Children referred to child welfare (CW) due to suspected maltreatment are vulnerable and need many services, particularly minority children. OBJECTIVE: To assess whether service use has improved over the past decade and whether racial-ethnic disparities in service use have decreased. METHODS: We used two national data sets (the National Survey of Child and Adolescent Well-Being I and II) collected a decade apart to assess changes over time in health, education, mental health (MH), dental services and overall service use. RESULTS: In NSCAW II, more children were young, had lower child behavior checklist (CBCL) scores, and were Hispanic. We found significant increases in dental services, a decrease in special education services and a decrease in MH services on the bivariate level (all p<.01). A large proportion of the change in MH services occurred in school settings, but the pattern continued when examining only those services delivered outside of school. The greatest decrease occurred for children with CBCL scores <64. However, in multivariate analyses, older children, white non-Hispanic children and children placed out of the home were significantly more likely to receive MH services. Rates of MH services controlling for CBCL scores showed no improvement over the decade, nor was there a decrease in racial and ethnic disparities CONCLUSION: These data show no change in MH services over time for children referred for CW evaluation, but improvement in dental services. Racial and ethnic disparities persist. MH services decrease occurred predominantly among children whose MH symptoms are below the clinical range.

BACKGROUND: Postpartum depression is prevalent among women who have had a baby within the last 12 months. Depression can compromise parenting practices, child development, and family stability. Effective treatments are available, but access to mental healthcare is challenging. Routine infant healthcare visits represent the most regular contact mothers have with the healthcare system, making pediatric primary care (PPC) an ideal venue for managing postpartum depression. METHODS: We conducted a review of the published literature on postpartum depression programs. This was augmented with a Google search of major organizations' websites to identify relevant programs. Programs were included if they focused on clinical care practices, for at-risk or depressed women during the first year postpartum, which were delivered within the primary care setting. RESULTS: We found that 18 programs focused on depression care for mothers of infants; 12 were developed for PPC. All programs used a screening tool. Psychosocial risk assessments were commonly used to guide care strategies, which included brief counseling, motivating help seeking, engaging social supports, and facilitating referrals. Available outcome data suggest the importance of addressing postpartum depression within primary care and providing staff training and support. The evidence is strongest in family practices and community-based health settings. More outcome data are needed in pediatric practices. CONCLUSION: Postpartum depression can be managed within PPC. Psychosocial strategies can be integrated as part of anticipatory guidance. Critical supports for primary care clinicians, especially in pediatric practices, are needed to improve access to timely nonstigmatizing care.

BACKGROUND AND OBJECTIVE: There has been increasing emphasis on the role of the pediatrician with respect to behavioral, learning, and mental health (MH) issues, and developmental behavioral rotations are now required in pediatric residency programs. We sought to examine whether this newer emphasis on MH is reflected in pediatricians' reports of their current practices. METHODS: Data from 2 periodic surveys conducted in 2004 and 2013 by the American Academy of Pediatrics were examined to see whether there were differences in self-reported behaviors of usually inquiring/screening, treating/managing/comanaging, or referring patients for attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, behavioral problems, or learning problems. We examined patterns for all practicing members and for those who practiced general pediatrics exclusively. RESULTS: There were few changes over the decade in the percentage who inquired or screened among all clinicians; among those exclusively practicing general pediatrics, the percentage who inquired or screened increased about 10% for ADHD and depression. ADHD remained the only condition for which the majority of respondents treated/managed/comanaged (57%). While there was some increase in the percentages who treated other conditions, the other conditions were usually treated by <30% of respondents. A similar pattern of results was observed in analyses adjusted for physician, practice, and patient characteristics. CONCLUSIONS: Despite the changing nature of pediatric practice and increased efforts to emphasize the importance of behavior, learning, and MH, the pediatric community appears to be making little progress toward providing for the long-term behavioral, learning, and MH needs of children and adolescents in its care.

OBJECTIVE: The stress associated with adverse childhood experiences (ACEs) has immediate and long-lasting effects. The objectives of this study were to examine 1) how often pediatricians ask patients' families about ACEs, 2) how familiar pediatricians are with the original ACE study, and 3) physician/practice characteristics, physicians' mental health training, and physicians' attitudes/beliefs that are associated with asking about ACEs. METHODS: Data were collected from 302 nontrainee pediatricians exclusively practicing general pediatrics who completed the 2013 American Academy of Pediatrics Periodic Survey. Pediatricians indicated whether they usually, sometimes, or never inquired about or screened for 7 ACEs. Sample weights were used to reduce nonresponse bias. Weighted descriptive and logistic regression analyses were conducted. RESULTS: Only 4% of pediatricians usually asked about all 7 ACEs; 32% did not usually ask about any. Less than 11% of pediatricians reported being very or somewhat familiar with the ACE study. Pediatricians who screened/inquired about ACEs usually asked about maternal depression (46%) and parental separation/divorce (42%). Multivariable analyses showed that pediatricians had more than twice the odds of usually asking about ACEs if they disagreed that they have little effect on influencing positive parenting skills, disagreed that screening for social emotional risk factors within the family is beyond the scope of pediatricians, or were very interested in receiving further education on managing/treating mental health problems in children and adolescents. CONCLUSIONS: Few pediatricians ask about all ACEs. Pediatric training that emphasizes the importance of social/emotional risk factors may increase the identification of ACEs in pediatric primary care.

OBJECTIVE: Maternal depression affects 10% to 40% of mothers with young children and has negative consequences for children's health and development. The American Academy of Pediatrics (AAP) recommends that pediatricians identify women with maternal depression. The authors examined trends in inquiring about (asking informal questions) or screening for (using a standardized instrument) maternal depression by pediatricians in 2004 and 2013 and identified correlates of usually inquiring/screening to identify maternal depression. METHODS: Data were ascertained from 778 nontrainee pediatricians exclusively practicing general pediatrics who completed the 2004 (n = 457) and 2013 (n = 321) AAP Periodic Surveys. Pediatricians answered questions about physician and practice characteristics, training, attitudes, and inquiring/screening to identify maternal depression. Sample weights were used to reduce nonresponse bias. Weighted descriptive and logistic regression analyses were conducted. RESULTS: The prevalence of usually inquiring/screening to identify maternal depression increased from 33% to 44% (p < .01). In both years, pediatricians who usually inquired about child/adolescent depression had increased odds of usually inquiring/screening to identify maternal depression. Patient race/ethnicity and training in adult Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria for depression were associated with inquiring/screening in 2004, and believing that family screening is within the scope of the pediatrician was associated with inquiring/screening in 2013. CONCLUSION: Although inquiring/screening about maternal depression has increased since 2004, less than half of pediatricians usually screen or inquire about maternal depression, representing a missed opportunity to identify depression and manage or refer women for treatment. Further training on the importance of mental and family health to children's health may increase identification of maternal depression in pediatric primary care.

OBJECTIVE: Pediatricians report many barriers to caring for children with mental health (MH) problems. The American Academy of Pediatrics (AAP) has focused attention on MH problems, but the impact on perceived barriers is unknown. We examined whether perceived barriers and their correlates changed from 2004 to 2013. METHODS: In 2004, 832 (52%) of 1600 and in 2013, 594 (36.7%) of 1617 of randomly selected AAP members surveyed responded to periodic surveys, answering questions about sociodemographics, practice characteristics, and 7 barriers to identifying, treating/managing, and referring child/adolescent MH problems. To reduce nonresponse bias, weighted descriptive and logistic regression analyses were conducted. RESULTS: Lack of training in treatment of child MH problems ( approximately 66%) and lack of confidence treating children with counseling ( approximately 60%) did not differ across surveys. Five barriers (lack of training in identifying MH problems, lack of confidence diagnosing, lack of confidence treating with medications, inadequate reimbursement, and lack of time) were less frequently endorsed in 2013 (all P < .01), although lack of time was still endorsed by 70% in 2013. In 2004, 34% of pediatricians endorsed 6 or 7 barriers compared to 26% in 2013 (P < .005). Practicing general pediatrics exclusively was associated with endorsing 6 or 7 barriers in both years (P < .001). CONCLUSIONS: Although fewer barriers were endorsed in 2013, most pediatricians believe that they have inadequate training in treating child MH problems, a lack of confidence to counsel children, and limited time for these problems. These findings suggest significant barriers still exist, highlighting the need for improved developmental and behavioral pediatrics training.

OBJECTIVE: To determine the relationships between adverse childhood experiences (ACEs) and mental health, chronic medical conditions, and social development among young children in the child welfare system. METHODS: This cross-sectional study used a nationally representative sample of children investigated by child welfare (National Survey of Child and Adolescent Well-Being II) from 2008 to 2009. Our analysis included caregiver interviews and caseworker reports about children aged 18 to 71 months who were not in out-of-home care (n = 912). We examined the associations between ACEs and mental health (measured by the Child Behavior Checklist [CBCL]), reported chronic medical conditions, and social development (measured by the Vineland Socialization Scale) in bivariate and multivariate analyses. RESULTS: Nearly all children (98.1%) were reported to have had an ACE in their lifetime; the average number of ACEs was 3.6. For every additional reported ACE, there was a 32% increased odds of having a problem score on the CBCL (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.14, 1.53) and a 21% increased odds of having a chronic medical condition (OR 1.21, 95% CI 1.05, 1.40). Among children aged 36 to 71 months, for every additional reported ACE, there was a 77% increased odds of a low Vineland Socialization score (OR 1.77, 95% CI 1.12, 2.78). CONCLUSIONS: ACEs were associated with poor early childhood mental health and chronic medical conditions, and, among children aged 3 to 5, social development. Efforts are needed to examine whether providing early intervention to families with multiple stressors mitigates the impact of ACEs on children's outcomes.