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BACKGROUND. Depression in adolescents is underrecognized and undertreated despite its poor long-term outcomes, including risk for suicide. Primary care settings may be critical venues for the identification of depression, but there is little information about the usefulness of primary care interventions. OBJECTIVE. We sought to examine the evidence for the treatment of depression in primary care settings, focusing on evidence concerning psychosocial, educational, and/or supportive intervention strategies. METHODS. Available data on brief psychosocial treatments for adolescent depression in primary settings were reviewed. Given the paucity of direct studies, we also drew on related literature to summarize available evidence whether brief, psychosocial support from a member of the primary care team, with or without medication, might improve depression outcomes. RESULTS. We identified 37 studies relevant to treating adolescent depression in primary care settings. Only 4 studies directly examined the impact of primary care--delivered psychosocial interventions for adolescent depression, but they suggest that such interventions can be effective. Indirect evidence from other psychosocial/behavioral interventions, including anticipatory guidance and efforts to enhance treatment adherence, and adult depression studies also show benefits of primary care-delivered interventions as well as the impact of provider training to enhance psychosocial skills. CONCLUSIONS. There is potential for successful treatment of adolescent depression in primary care, in view of evidence that brief, psychosocial support, with or without medication, has been shown to improve a range of outcomes, including adolescent depression itself. Given the great public health problem posed by adolescent depression, the likelihood that most depressed adolescents will not receive specialty services, and new guidelines for managing adolescent depression in primary care, clinicians may usefully consider initiation of supportive interventions in their primary care practices. Key Words adolescent depression, primary care, treatment, psychosocial intervention Abbreviations PCC--primary care clinician IPT-A--interpersonal therapy modified for depressed adolescents CES-D--Center for Epidemiologic Studies-Depression Scale QI--quality improvement CBT--cognitive behavioral therapy SSRI--selective serotonin reuptake inhibitor ADHD--attention-deficit/hyperactivity disorder CST--coping skills training, ADOLESCENT DEPRESSION IS a serious public health problem. (1,2) Studies show that [less than or equal to] 9% of teenagers meet criteria for depression at any one time, with as [...]

OBJECTIVE. The goal was to examine whether moderately low birth weight children were at greater risk for health problems than normal birth weight children in a nationally representative sample of US children. METHODS. Data were analyzed for 7817 children, 0 to 12 years of age, from the sample child file of the 2002 National Health Interview Survey. Logistic regressions were estimated to examine whether morbidity rates were higher among moderately low birth weight children than among normal birth weight children and to control for covariates. Health was measured as having a special health care need, having a chronic condition, being hospitalized in the past year, having a learning disability, attention-deficit disorder/attention-deficit/hyperactivity disorder, or other behavioral disorders, having minor health conditions, and having acute illnesses. RESULTS. With control for other confounders, moderately low birth weight children were significantly more likely than normal birth weight children to be identified as having a special health care need, having a chronic condition, having a learning disability, and having attention-deficit disorder or attention-deficit/hyperactivity disorder. They were not more likely to have a hospitalization in the past year, other behavioral disorders, or minor health conditions or acute illnesses. CONCLUSIONS. This population-based study of rates of current morbidity shows that moderately low birth weight children born since 1990 are vulnerable to a wide range of health, learning, and behavioral problems, compared with normal birth weight children. This suggests the need for continued focus on ways to reduce morbidity rates for moderately low birth weight children. www.pediatrics.org/cgi/doi/10.1542/ peds.2005-2836 doi:10.1542/peds.2005-2836 Key Words moderately low birth weight, health status, chronic conditions, special health care needs, epidemiology Abbreviations MLBW--moderately low birth weight VLBW--very low birth weight LBW low birth weight NBW--normal birth weight ADD--attention-deficit disorder ADHD--attention-deficit/hyperactivity disorder CSHCN--children with special health care needs NHIS--National Health Interview Survey, IT IS WELL known that infants who are born prematurely or small for date are at increased risk for later physical and emotional health conditions and cognitive problems. (1-3) In [...]

CONTEXT. Disparities in child health are a major public health concern. However, it is unclear whether these are predominantly the result of low income, race, or other social risk factors that may contribute to their health disadvantage. Although others have examined the effects of the accumulation of risk factors, this methodology has not been applied to child health. OBJECTIVE. We tested 4 social risk factors (poverty, minority race/ethnicity, low parental education, and not living with both biological parents) to assess whether they have cumulative effects on child health and examined whether access to health care reduced health disparities. DESIGN. We analyzed data on 57 553 children <18 years from the 1994 and 1995 National Health Interview Survey Disability Supplement. Of the 4 risk factors, 3 (poverty, low parental education, and single-parent household) were consistently associated with child health. These were summed, generating the Social Disadvantage Index (range: 0-3). RESULTS. A total of 43.6% of children had no social disadvantages, 30.8% had 1, 15.6% had 2, and 10.0% had all 3. Compared with those with no social disadvantages, the odds ratios (ORs) of being in "good, fair, or poor health" (versus "excellent or very good") were 1.95 for 1 risk, 3.22 for 2 risks, and 4.06 for 3 risks. ORs of having a chronic condition increased from 1.25 (1 risk) to 1.60 (2 risks) to 2.11 (3 risks). ORs for activity limitation were 1.51 (1 risk) to 2.14 (2 risks) and 2.88 (3 risks). Controlling for health insurance did not affect these findings. CONCLUSIONS. The accumulation of social disadvantage among children was strongly associated with poorer child health and having insurance did not reduce the observed health disparities. Key Words child health status, ethnic disparity, racial disparity, poverty Abbreviations NHIS--National Health Interview Survey NHIS-D--NHIS Disability Supplement NCHS--National Center for Health Statistics QuICCC--Questionnaire for Identifying Children With Chronic Conditions, EVIDENCE IS INCONTROVERTIBLE that poverty is related to poor health, (1-5) and the vast majority of the literature indicates that the association is causal. (6) Poverty is associated with poor […]

ABSTRACT. Objective. To identify factors associated with depressive symptoms in inner-city mothers of young children. Design. A cross-sectional survey was administered to a convenience sample of English-speaking mothers attending a [...]

Vertical integration of a medical service such as pediatrics can improve continuity of care, primary care training, and involvement of senior clinicians as well as conserving resources significantly. Vertical integration means involving pediatricians, allied health professionals who range from inpatient to ambulatory, and setting up interdisciplinary teams all within a single management structure. It also improves the ability to unify pediatric patients and their families in the service structure., Background. The combined effects of recent changes in health care financing and training priorities have compelled academic medical centers to develop innovative structures to maintain service commitments yet conform to health care marketplace demands. In 1992, a municipal hospital in the Bronx, New York, affiliated with a major academic medical center reorganized its pediatric service into a vertically integrated system of four interdependent practice teams that provided comprehensive care in the ambulatory as well as inpatient settings. One of the goals of the new system was to conserve inpatient resources. Objective. To describe the development of a new vertically integrated pediatric service at an inner-city municipal hospital and to test whether its adoption was associated with the use of fewer inpatient resources. Design. A descriptive analysis of the rationale, goals, implementation strategies, and structure of the vertically integrated pediatric service combined with a before-and-after comparison of in-hospital resource consumption. Methods. A before-and-after comparison was conducted for two periods: the period before vertical integration, from January 1989 to December 1991, and the period after the adoption of vertical integration, from July 1992 to December 1994. Four measures of inpatient resource use were compared after adjustment for case mix index: mean certified length of stay per case, mean number of radiologic tests per case, mean number of ancillary tests per case, and mean number of laboratory tests per case. Difference-in-differences-in-differences estimators were used to control for institution-wide trends throughout the time period and regional trends in inpatient pediatric practice occurring across institutions. Results. In 1992, the Department of Pediatrics at the Albert Einstein College of Medicine reorganized the pediatric service at Jacobi Medical Center, one of its principal municipal hospital affiliates, into a vertically integrated pediatric service that combines ambulatory and inpatient activities into four interdependent practice teams composed of attending pediatricians, allied health professionals, house officers, and social workers. The new vertically integrated service was designed to improve continuity of care for patients, provide a model of practice for professional trainees, conserve scarce resources, and create a clinical research infrastructure. The vertically integrated pediatric service augmented the role of attending pediatricians, extended the use of allied health professionals from the ambulatory to the inpatient sites, established interdisciplinary practice teams that unified the care of pediatric patients and their families, and used less inpatient resources. Controlling for trends within the study institution and trends in the practice of pediatrics across institutions throughout the time period, the vertical integration was associated with a decline in 0.6 days per case, the use of 0.62 fewer radiologic tests per case, 0.21 fewer ancillary tests per case, and 2.68 fewer laboratory tests per case. Conclusions. We conclude that vertical integration of a pediatric service at an inner-city municipal hospital is achievable; conveys advantages of improved continuity of care, enhanced opportunities for primary care training, and increased participation of senior clinicians; and has the potential to conserve significant amounts of inpatient resources. Pediatrics 1998;102:91-97; vertical integration. ABBREVIATIONS. AECOM/MMC, Albert Einstein College of Medicine /Montefiore Medical Center; CMI, case mix index; JMC, Jacobi Medical Center; NP, nurse practitioner; PA, physician assistant., For decades the traditional mandates of academic medical centers have included both the training of future physicians and the provision of medical care to underserved populations. In recent years, however, [...]

Whether a child is classified as disabled depends on which definition of disability is used. Researchers used three different definitions of disability and the Questionnaire for Identifying Children with Chronic Conditions to assess 1,388 children. The definitions included functional limitations, dependence on compensatory mechanisms such as medication or a special diet, and the use of health services beyond the norm. Only 20% of the children were classified as disabled by all three definitions., Objective. To test how prevalence estimates and characteristics of children vary by the way that disability is defined. Specifically, to determine 1) the proportions of children identified as disabled by one particular operationalization of disability based on parental reports of three types of consequences (ie, functional limitations [FL]), dependence on compensatory mechanisms (CD), and service use or need beyond routine [SU/N]) and 2) whether children identified as disabled by these three types of consequences differ by type of disorder or condition, age, socioeconomic status, or race. Method. We analyzed a national dataset representing a random sample of 712 households with 1388 children. The Questionnaire for Identifying Children with Chronic Conditions (QuICCC) was used to identify children with disabling conditions. We divided the QuICCC items into three discrete sets, reflecting three definitional components of disability, and compared the proportions and characteristics of children fitting these components separately and in combination. Results. Using the QuICCC definition of disability, SUN identified the largest proportion of children (72%), followed by CD (55%) and FLs (49%). Forty-four percent of children were identified by only one component, 36% by two components in any combination, and 20% by all three components. The type of disorder or condition generally did not vary by the three definitional components, although the FL component may be more effective at identifying children with sensory impairments. Children identified by two or more components were more likely to have multiple conditions and had more pervasive disorders than those identified by only one component. The youngest children (0 to 3 years old) may be less likely to be identified as disabled than children of other ages, especially by FLs. FLs also were more likely to identify children from the poorest and least educated families. Conclusions. Although the specific findings reported here pertain to a single definitional approach (the QuICCC), the data highlight that who will be classified as disabled (and who will not) may be dependent on how disability is defined. The implications of using different definitions and definitional components on both the prevalence and the characteristics of children with disabilities need to be considered before data can be applied responsibly and appropriately. Pediatrics 1998;101:1025-1030; children, chronic illness, disability, functioning, definition, measurement., ABBREVIATIONS. ADA, Americans with Disabilities Act; QuICCC, Questionnaire for Identifying Children with Chronic Conditions; FL, functional limitations; CD, dependence on compensatory mechanisms; SU/N, service use or need beyond routine care. [...]

A short questionnaire given to parents may accurately assess children with chronic medical conditions. Researchers developed a 39-item questionnaire covering childhood medical conditions for use by parents of children under the age of 18. Parents were easily able to answer the questions within an average of seven to eight minutes for all children in a family. The questionnaire reliably identified children with chronic medical conditions without including children with non-chronic conditions. It may be used to compare rates of chronically ill children on national and state levels., Objective. To report on the development of the Questionnaire for Identifying Children with Chronic Conditions (QuICCC). This new instrument identifies children and adolescents who have chronic health conditions based on the noncategorical conceptual framework outlined in our earlier work. It uses the consequences of conditions as a method for identifying children with chronic health conditions and is completely independent of diagnosis. Method. Through a combination of techniques, we developed and piloted items and created 39 brief question sequences that were designed to be administered to a parent or guardian of children [is less than]18 years of age. The prototype was field tested extensively and refined using data from local hospital-based samples representing 318 households and 666 children. The instrument was then administered to two large representative samples (local: 657 households, 1275 children; national: 712 households, 1388 children) to establish validity and reliability. Results. Content, convergent, construct, and criterion validity each have been demonstrated. The QuICCC has good test-retest reliability. Parents find the questions easy to answer. It took 7 to 8 minutes on average to obtain information about all the children in a family. The QuICCC successfully identified children with a wide range of different conditions that are usually considered chronic, and excluded those with acute illnesses and those with conditions but no current consequences. Conclusions. The Questionnaire for Identifying Children with Chronic Conditions is a practical instrument that can be used for epidemiological purposes. It offers considerable flexibility and has many potential applications in health care delivery research. Pediatrics 1997;99: 513-521; children, chronic illness, epidemiology, disability, functioning, limitations., ABBREVIATIONS. QuICCC, Questionnaire for identifying Children with Chronic Conditions; FS-II(R), Functional Status-II(R); NHIS, National Health Interview Survey; RDD, random digit dialing. Condition lists are commonly used to identify children and [...]

Health maintenance organizations (HMOs) should be monitored and evaluated for their care of chronically ill children. Two types of data should be gathered: easily gathered general indicators such as surveys of enrollee satisfaction and more in depth studies such as comparing health outcomes in HMOs versus privately insured families. HMOs should be evaluated and monitored comprehensively and in detail, including such issues as access to care, use of services, quality of care, enrollee and caregiver satisfaction, cost of care, medical outcomes, and the impact of the child's care on the family., Objective. Children with chronic illnesses and disabilities are increasingly enrolling in managed care arrangements. Yet, the rapid expansion of managed care has unknown consequences for children with chronic conditions and disabilities. As managed care is likely to become the predominant mode of medical practice for children with chronic health problems, information gained from a thorough assessment of existing managed care models could be helpful in indicating adjustments and modifications that could result in improved outcomes for this population. The purpose of this article is to outline a new strategy for collecting needed information on the effects of managed care on children with chronic health problems. Methods. We reviewed the literature on the effects of managed care on children with chronic conditions and disabilities. We identified key domains relevant to monitoring and evaluating managed care for this population. Results. Two research approaches can provide helpful information for assessing the effects of managed care on children with chronic conditions. First, a monitoring strategy could be pursued in which enrollment trends in managed care, enrollee perceptions of access and satisfaction with care, and other general indicators of outcomes would be tracked over time using inexpensive and rapid turnaround data sources. Second, an evaluative strategy could be pursued using experimental or quasiexperimental designs, in which outcomes across a variety of domains for children with chronic conditions in managed care are compared with: (a) outcomes for the same children before enrollment in managed care; or (b) outcomes for similar children remaining in traditional fee-for-service settings. Evaluation and monitoring strategies should focus on outcomes in a number of domains including: (1) access to care; (2) utilization of services; (3) quality of care; (4) satisfaction with care; (5) expenditures for care; (6) health outcomes; and (7) family impact. Conclusion. Assessing outcomes that result from enrollment in managed care for children with chronic health problems presents a formidable challenge. The research strategy outlined in this article presents one approach to meeting that challenge. The monitoring and evaluation strategies described here would require commitment of additional resources on the part of government, private foundations, and/or health plans. Given the paucity of existing information and the stakes for children with chronic conditions and their families, investment of added resources in a comprehensive monitoring and evaluation strategy is essential. Pediatrics 1996;98:952-958; children, managed care, chronic illness, disability, HMO., ABBREVIATIONS. HMO, health maintenance organization; NHIS, National Health Interview Survey; HEDIS, Health Plan Employer Data and Information Set MEPS, Medical Expenditure Panel Survey; HCFA, Health Care Financing Administration. Children with [...]

Mothers appear to be more likely to spank young children when their misbehaviors are dangerous rather than annoying. A total of 204 mothers of children between one and four years old were interviewed about their beliefs about spanking. One hundred of the mothers were interviewed at a private pediatrician's office and 104 were interviewed in a teaching clinic. Mothers at the teaching clinic were more likely to be younger, less educated, have lower household incomes and be Hispanic or black when compared with the mothers at the private office. Most mothers agreed that spanking toddlers was warranted in some cases. Seventy-four percent of the mothers believed it was appropriate to spank a child who was between one and three years old. However, only 19% believed it was appropriate to spank a child younger than one year old. Mothers were more likely to believe it appropriate to spank a child if the child was older, if the child engaged in dangerous behavior, if the mother had been spanked as a child and if the child was being seen at the teaching clinic., Objective. To describe maternal beliefs and practices of spanking infants and toddlers and the relations between factors affecting these beliefs and practices. Design. Cross-sectional survey. Setting. Site 1 was an inner-city teaching hospital pediatric clinic. Site 2 was a private pediatrician&apos;s office in a nearby suburban neighborhood. Participants. Mothers of children less than 4 years old in the waiting area. Site 1: n = 104; site 2: n = 100. Selection. Systematic sample of convenience. Methods. Mothers were interviewed using a 20-minute structured questionnaire. Measures were constructed to assess beliefs (Cronbach&apos;s [alpha] = .90) and practices about spanking and approach to discipline ([alpha] > .71). Results. Belief in spanking correlated significantly (P < .001) with belief in negative approach (r = .52) and with the practice (r = .46) and severity (r = .34) of spanking. Nineteen percent of the mothers believed that there are times when it is appropriate to spank a child less than 1 year old, and 74% believed this about children 1 to 3 years old. Forty-two percent reported that they had spanked their own child in the past week. Mothers believed more strongly in spanking for dangerous misbehaviors than for annoying ones (P < .001). Belief in spanking and negative approach were stronger for older toddlers (P < .001). Belief in and frequency of spanking were more common at the inner-city site (P < .001). Conclusions. The belief in and practice of spanking are prevalent in disciplining very young children. The context of the spanking affects beliefs and practices. The finding that belief and practice of spanking are highly correlated suggests that belief rather than impulse largely explains spanking of children less than 4 years old. The high correlation between spanking and negative approach toward discipline raises questions about whether negative consequences of spanking are the result of spanking per se, the negative approach toward the child, or both. Pediatrics 1995;95:105-111; discipline, beliefs, child development, child rearing, punishment.

Children who live in inner-city areas may have higher rates of asthma than indicated by national survey data. Researchers surveyed 662 households with 1285 children younger than 18 years in Bronx County, NY. Results were compared to the 1988 National Health Interview Survey data. Slightly more than 14% of Bronx County children had asthma sometime during their lives. Almost 9% of the children had asthma within the last year compared to 4% of all U.S. children. Higher rates of asthma were found in Bronx children of all age groups and both genders than in their U.S. counterparts. White and Hispanic children and those from low-income families in the Bronx had higher asthma rates than white, Hispanic, or low-income children in other parts of the U.S. Slightly more than 4% of Bronx children who never had asthma experienced wheezing. Younger children, whites, and blacks were most likely to report this condition., Objective. To estimate the prevalence of asthma and wheezing unassociated with a diagnosis of asthma among inner-city children. Design. Cross-sectional survey of a sample of Bronx households. Methods. Random digit dialing telephone survey using parental report. Setting. Bronx County, NY. Participants. 662 self-designated heads-of-household who reported for all children 0 through 17 years of age living in their households. Measurements. Questions from the Child Health Supplement to the 1988 National Health Interview Survey and the International Union Against Tuberculosis and Lung Disease Bronchial Symptoms Questionnaire were used to estimate the prevalence of asthma and wheezing-related illness. Results. Information was gathered on 1285 children. Of this sample, 184 (14.3%) were reported to have ever had asthma (cumulative prevalence) and 111 (8.6%) were reported to have asthma in the last 12 months (period prevalence). The asthma period prevalence rate among Bronx children was twice the United States rate (4.3%) Among children 0 through 11 years of age, the prevalence rate was similar for boys and girls, although among children 12 through 17 years of age, asthma was significantly more prevalent among boys. Fifty-four children (4.2%) were reported to have had wheezing in the past 12 months unassociated with a diagnosis of asthma (wheeze only). The cumulative, but not the period, prevalence rate of asthma differed significantly by income and race/ethnicity. The cumulative prevalence was significantly higher among Hispanics and children from the lowest income families. The prevalence of wheeze only (no reported history of asthma) was higher among whites (6.4%) and blacks (5.8%) than Hispanics (2.9%) (P < .1) The reported number of wheezing attacks and the average number of nights per week that sleep was disturbed by wheezing during the past year were similar for those with asthma and those with wheeze only, although severe attacks (wheezing severe enough to limit speech) were significantly more likely among those reported to have asthma (P < .001). The total asthma prevalence (period prevalence of asthma plus wheeze only) was 12.8% and was quite consistent across subgroups. Conclusions. These data suggest that the prevalence of asthma among inner-city children may be substantially higher than the rates for this group estimated from national survey data. Some proportion of the wheeze only group may represent undiagnosed, and thereby undertreated, asthma. Public health efforts directed at reducing asthma morbidity and mortality need to address the possibility that asthma prevalence is higher within inner cities and that a large number of children with asthma may be inadequately diagnosed and treated. Pediatrics 1994;94:356-362; asthma, wheezing.

A program that provides comprehensive services to families of chronically ill children may satisfy previously unmet needs, especially in the areas of psychological and social concerns. Chronic illness in children includes a wide variety of conditions such as asthma, diabetes, sickle cell anemia, leukemia and juvenile rheumatoid arthritis. Of 209 chronically ill children up to 12 years old, half were assigned to Pediatric Home Care (PHC), a comprehensive care program, and half received standard care. PHC included care in the home or other convenient location, coordination with specialists as needed, patient and family education and counseling, and liaison with social services or other outside agencies. The mothers were interviewed before the study and six months and one year later. The most significantly improved area of service with PHC was having someone listen to concerns about caring for a sick child. Coordination with other agencies was also better under the PHC plan., Objectives. To test whether a program of outreach and comprehensive health care for children with chronic disorders provides more complete care and reduces unmet health needs compared with traditional care. Design. A pretest-posttest randomized control trial. Setting. An inner-city municipal teaching hospital. Sample. Two hundred nineteen systematically enrolled mothers of children with diverse chronic physical health conditions. Interventions. A comprehensive outreach program, Pediatric Home Care (PHC), contrasted with Standard Care. Measurements and Results. Nine elements of comprehensive care established in the literature as components of a basic package of care for those with chronic conditions. The PHC intervention addressed gaps in services and improved both the acquisition and maintenance of elements of comprehensive care. Conclusions. These data suggest mechanisms through which comprehensive care programs may contribute to the improvement in psychological and social outcomes previously reported for those in the PHC intervention. Pediatrics 1994;93:602-607; unmet health needs, chronic illness, comprehensive care, home care, intervention, randomized trial.

A new approach needs to be developed for the definition and classification of chronic health conditions in children and adolescents. The number of children and adolescents with chronic health conditions is increasing. The old method for identifying children with chronic conditions is a condition-specific or categorical approach. It is based on the presence of an individual condition that is expected to be or is of long duration. These conditions include diabetes, asthma and cerebral palsy. A generic or non-categorical approach may be more practical. This approach would focus more on the impact of a condition on the child and less on the condition itself. It would also take into consideration the variations that can occur among children with the same condition., The need for a widely applicable definition of chronic conditions for research, policy, and program development has led to an extensive review of the development of such definitions, the considerations involved in their use, and some recommendations for a new approach. This paper examines some of the methodologic and conceptual issues related to defining and classifying chronic conditions and describes some consequences resulting from decisions made about these issues. While most examples are taken from child health applications, the basic concepts apply to all age groups. The dominant method for identifying and classifying children as having a chronic condition has relied on the presence of an individual health condition of lengthy duration. This condition-specific or "categorical" approach has increasingly seemed neither pragmatically nor conceptually sound. Thus, the development of a "generic" approach, which focuses on elements that are shared by many conditions, children, and families, is recommended. Such a definition might reflect the child&apos;s functional status or ongoing use of medical services over a specified time period. In addition, it is suggested that conditions be classified based on the experience of individual children, thus emphasizing the tremendous variability in expression of seemingly similar conditions. Pediatrics 1993, 91:787-793; chronic illness, chronic condition, special health care needs.

In the case of Sullivan vs. Zebley, the Supreme Court struck down the criteria used to determine the eligibility of disabled children for Supplemental Security Income (SSI). This 1990 decision held that existing regulations discriminated against children because they were required to meet a stricter standard than did adults; a liberalized access for children to SSI has been mandated by the court. The SSI program was primarily designed to improve the financial standing of aged, blind, or disabled people. It also infers automatic eligibility for Medicaid in many states, thus providing access to otherwise unavailable essential health services. The intent of SSI for adults was to partially replace income lost as a result of inability to work, while the intent for children was less clear. Congress stipulated that the standards for eligibility of children be comparable to that for adults, but was not specific. Of about 290,000 children currently receiving SSI, 42 percent are mentally retarded. Others have nervous system diseases, congenital anomalies, mental disorders, cancers, or other problems. Rules governing family income and resources are complex. Criteria for diagnostic listings are very specific; often require a child to have very great delays in development or other areas; are poorly updated to meet current understanding; and do not deal with the frequent coexistence of multiple conditions. These very technical rules were not in step with the reality of disabling childhood conditions, which was recognized by the court. Unlike adults, children were ineligible for further assessment of residual functional capacity, which does not deal with specific diseases or disorders. The plaintiff in this class action decision was denied SSI benefits despite being developmentally delayed, having cerebral palsy, and speech and hearing problems. Improvements in assessing disabled children have been made, but policy, fiscal, and legal issues still need to be addressed. Establishing linkages between the Social Security Administration and other governmental and private agencies that deal with disabled children may provide major cost savings as well as enhancing collaboration. (Consumer Summary produced by Reliance Medical Information, Inc.)

Children with chronic physical illness are more likely to develop psychological and social problems, which sometimes persist into adulthood. It is not clear whether interventions or treatment programs can improve these complications of chronic physical illness in childhood. The Pediatric Home Care program, also referred to as the Pediatric Outreach Program, was designed to provide medical and psychosocial care and community-based services to chronically ill children. The program was implemented in 1970 and staffed by pediatricians, pediatric nurses, and a social worker, who provide care in the home, office, hospital, school, or community. The program provides the child and family with information about the chronic condition and with training in self-care skills, and consists of both hospital-based and outpatient services. The long-term effects of this pediatric home care program were assessed four and a half to five years after the initiation of the program. Sixty-eight percent of the patients who started with the program were available for follow-up. The program was previously shown to reduce psychological problems among chronically ill children at six months and one year after the start of the program. These short-term benefits persisted and were more pronounced at follow-up. These findings show that a family-oriented program which combines medical and psychosocial care can provide long-term benefits for the mental health of children with chronic physical illness. (Consumer Summary produced by Reliance Medical Information, Inc.)

The Pediatric Home Care (PHC) program is a treatment program that provides medical and psychosocial care and community-based services to chronically ill children. The program was started in 1970 and is staffed by pediatricians, pediatric nurses, and a social worker, who can provide care in the home, office, hospital, school, or community. The program supplies the child and family with information about the chronic condition and with training in self-care skills, and coordinates health services and social and community resources. The mental health benefits of the PHC program were evaluated at six months and one year after its implementation. The results were compared with those of a standard care program, which consisted of services provided by a university-affiliated hospital, its clinic system, and related community services. The PHC program resulted in greater improvement in the child's psychological adjustment, and in the mother's psychiatric symptoms and satisfaction with care as compared with the standard care program. However, the effects of chronic illness on the family and child's functional condition were similar for all patients. The differences in benefit gained from the PHC program were assessed in various subgroups of patients. The patients who benefited most from the PHC program were those with mild chronic illness, but with low coping resources, such as social, educational, financial, and personal support. In cases where the chronic illness was mild and coping resources were ample, the patient benefited more from standard care than from PHC. Results varied among patients with more severe chronic illness. These findings suggest that patients with immense needs may not derive the greatest benefit from intervention programs. Medical and social factors should be taken into consideration when planning the distribution of resources. (Consumer Summary produced by Reliance Medical Information, Inc.)

Background/Objective. Treatment of dehydrating gastroenteritis, a major cause of morbidity in children, remains controversial. Practice parameters issued by the American Academy of Pediatrics (AAP) recommend oral rehydration therapy (ORT) as the preferred treatment for losses from both mild and moderate dehydration. The objective of this study was to test the hypothesis that awareness of the AAP practice parameters would be associated with a higher rate of use of ORT among emergency physicians. Methods. A national random survey of emergency physicians selected from the mailing list of the AAP Section on Emergency Medicine was conducted. Respondents were asked about level of awareness of AAP guidelines and preferred route of rehydration for scenarios representing mild ([less than or equal to] 5%), moderate (6%-9%), and severe ([greater than or equal to] 10%) dehydration. Respondents who were very familiar with the AAP practice parameters were designated as the familiar group; those who were less familiar were designated as the unfamiliar group. Differences in proportions of dichotomous variables were tested by [chi square] or Fisher exact test as appropriate. Univariate logistic regression modeling was used to determine the independent influence of awareness of AAP guidelines on the use of ORT. Results. A total of 176 physicians responded (73% response rate). Most were board certified in 1 or more specialties: pediatrics (89%), pediatric emergency medicine (84%), and adult emergency medicine (63%). Median duration of practice was 16 years. Thirty-seven percent of respondents were very familiar with the AAP practice parameters. In contrast to the unfamiliar group, the familiar group was more likely to use ORT in scenarios of mild dehydration (81% vs 66%) and moderate dehydration (25% vs 10%). Logistic regression analysis confirmed that this familiar group overall was nearly 3 times more likely to use ORT (odds ratio: 2.85; 95% confidence interval: 2.46-3.24). Conclusions. This is the first national study to establish a relationship between awareness of the AAP practice parameters and physician practices in the treatment of dehydration. Emergency medicine physicians who were very familiar with the AAP parameters were significantly more likely to use ORT. These findings may have important implications for future efforts directed at increasing the rate of ORT use and for the evaluation of practice parameters in general. Pediatrics 2002;109:259-261; oral rehydration, emergency physicians, policy., ABBREVIATIONS. ORT, oral rehydration therapy; AAP, American Academy of Pediatrics; ED, emergency department; OR, odds ratio; CI, confidence interval. Dehydrating gastroenteritis is a major cause of morbidity in children. Each [...]

CONTEXT. Child psychosocial issues and maternal depression are underidentified and undertreated, but we know surprisingly little about the barriers to identification and treatment of these problems by primary care pediatricians. [...]

Background. Capitation rates for the State Children&apos;s Health Insurance Program (SCHIP) funded under Title XXI of the Social Security Act were based on assumptions about the health care needs of children enrolled in this program. It has been suggested that parents are selective in enrolling children who are, in their opinion, most likely to need care, and that families who do not view their children as needing such care are more likely to ignore opportunities to seek or to maintain enrollment in SCHIP insurance. Thus, there have been concerns that enrollees might have more health conditions than a general population of children. Objective. The purpose of this study was to test the hypothesis that children in Title XXI have more ongoing health conditions than expected by comparing health status data from enrollees in 1 state SCHIP program to a nationally representative sample of children in the United States. Methods. This study used statewide data obtained in a survey of Florida SCHIP program enrollees and national data obtained on a subset of the children who were assessed in the 1994 National Health Interview Survey (NHIS). We examined health and demographic data collected by means of a structured telephone survey from parents for a random sample of 2432 children 2 to 18 years old who participated in the Florida Healthy Kids Program during the time period of October 1, 1997 through September 30, 1998. We compared these data to information on a national sample of all 26 845 children in the same age range whose health was assessed by the 1994 NHIS, and to a subset of the 6460 children in the NHIS sample whose family income met the eligibility criteria for SCHIP. To do this, we eliminated those children who were receiving Medicaid and those children whose household income levels were known to be above the eligibility level for SCHIP. We also excluded children whose household income was not reported. Thus, effectively this subsample contained non-Medicaid children, whose family incomes were below 185% of the Federal Poverty Level. In Florida, a parent interview conducted by telephone included the Questionnaire for Identifying Children with Chronic Conditions (QuICCC), and their responses were used to determine if the child had any chronic health conditions. The QuICCC is a validated questionnaire containing 39-item sequences that ask about consequences of health conditions in children. It not only provides an overall classification of whether the child has a chronic condition, but also yields information about the consequences affecting the child within 3 condition-related domains: 1) functional limitations; 2) dependency on compensatory mechanisms or assistance; and 3) service need or use above and beyond routine care for age. The 1994 NHIS Core Interview and Disability Supplement contained a series of questions about children&apos;s functioning and service use that simulated the QuICCC, and we applied a previously published algorithm for determining the presence of a chronic condition using these items. Both data sets included comparable information on parental ratings of children&apos;s health status (excellent, very good, good, fair, poor), and on school absences, bed days, and restricted activity days in the previous 2 weeks. Results. Children in the Florida SCHIP program were more than twice as likely to have chronic health conditions than similarly aged children in the general population or children in the income restricted national subsample (31% vs 15.9% and 14.6%, respectively) and there also were more SCHIP children with school absences (29% vs 18% and 16.7%, respectively). In contrast, the rating of overall health of SCHIP children was not poorer according to their parents, and they did not have more activity restrictions. Children in Florida SCHIP who had conditions were more likely to experience related consequences within each of 3 domains, and they were nearly 3 times as likely to have all 3 types of consequences (7% in Florida SCHIP sample vs 2.8% and 1.7% in the full national sample and in the income-matched subsample). However, the Florida SCHIP enrollees differed from the age and income-matched national sample in terms of the proportion of Hispanics. Thus, to verify these findings, we weighted the SCHIP sample to match the racial and ethnic proportions found in the national sample and repeated the analyses. The findings were robust, and there was no change in the percentage of children with special health care needs after such weighting. Conclusions. Overall, the results of these analyses support the notion of adverse selection and retention in the SCHIP program. This is unlikely to be the result of aggressive marketing in enrollment sites that serve children with more medical problems, as Florida health care providers rank third as a source of information about the Title XXI program after family and friends and the schools. In addition, Florida has active outreach and single-page application process for Medicaid and an aggressive program to move children to Title V, which also should minimize the numbers of children with special health care needs enrolled in SCHIP. Nevertheless, these findings suggest that the children being enrolled in Florida&apos;s SCHIP program are not the largely healthy population that was envisioned. If replicated in other SCHIP programs, these findings raise questions about the basic underlying assumptions concerning the health of potential enrollees and could have implications for the long-term fiscal viability of the program. URL: http://www.pediatrics.org/cgi/ content/full/112/2/e119; children with special health care needs, chronic conditions, health status, insurance, State Children&apos;s Health Insurance Program.

OBJECTIVE. The proliferation of policy statements from the American Academy of Pediatrics presents pediatricians with an increasing amount of health advice to deliver, yet no quantitative estimates of pediatric health advice expectations exist in the literature. The objective of this study was to quantify and characterize verbal health advice that pediatricians are expected to deliver to patients/guardians. METHODS. The authors read and coded the 344 American Academy of Pediatrics policy statements that are contained in the American Academy of Pediatrics&apos; Pediatric Clinical Practice Guidelines and Policies, Third Edition, and identified 57 policies that contained health advice directives that are broadly relevant to pediatric practice. We extracted the individual advice text to a database in which we also coded its date of issue, its theme, and whether (1) it was duplicated in another policy, (2) a screening question was required to identify a target population for the advice, (3) handouts or other aids to delivering the advice were referenced in the policy itself, or (4) the text of the statement referred to evidence of the effectiveness of office-based delivery of the advice. RESULTS. These 57 policies were found to contain 192 discrete health advice directives that pediatricians are expected to deliver to patients/guardians. Seven (4%) of these directives originated before 1993, and 185 (96%) were created from 1993 to 2002. After removal of the 30 (16%) duplicates, safety advice composed 67%, media use composed 12%, substance abuse composed 5%, environmental health hazards composed 4%, development/emotional health composed 4%, sexuality and pregnancy composed 3%, nutrition composed 2%, and miscellaneous composed 3%. In 41% of the directives, a screening question was required to identify the target population for the advice. Aids to delivering advice were referenced in 20% of the policies. In no policy statements did the text refer to evidence that office-based counseling was an effective method to achieve the desired health or behavioral outcome. CONCLUSIONS. We examined the American Academy of Pediatrics policy statements and found 162 different verbal health advice directives on which pediatricians should counsel parents and patients throughout childhood. The expectation that delivery of all of this advice can be achieved is unrealistic. Moreover, none of the reviewed statements were found to include an evidence-based discussion of the efficacy of the suggested advice. In light of these findings, we suggest that committees should consider both the feasibility and the evidence of efficacy of office-based health advice when generating future policy statements. KEY WORDS. anticipatory guidance, health supervision. URL: www.pediatrics.org/cgi/doi/10.1542/peds.2006-0652

The home management of asthma in inner-city children does not fully incorporate the guidelines of the National Heart, Lung, and Blood Institute (NHLBI). Researchers interviewed 220 caretakers of asthmatic children and found that only 51% had been given written home-care guidelines and only 30% had peak-flow meters for monitoring asthma symptoms. Antiinflammatory medications were only given to 39% of eligible children, despite guidelines recommending the wider use of these asthma treatment drugs. Most of the families had not taken steps to reduce the levels of asthma-inducing allergens in their home, like encasing mattresses and pillows in mite-proof covers., Objectives. 1) To describe the asthma morbidity, primary care practices, and asthma home management of inner-city children with asthma; 2) to determine the responses of parental caretakers to asthma exacerbations in their child; and 3) to compare these responses to the recommendations of the National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines for home management of acute exacerbations of asthma. Design and Methods. A 64-item telephone survey was administered between July 1996 and June 1997 to 220 parental caretakers of 2- to 12-year-old children who had been hospitalized with asthma at an inner-city medical center from January, 1995 to February, 1996. Sociodemographics, primary care practices, asthma morbidity, and asthma home management were assessed. Parents were asked what they would do if their child "began wheezing and breathing faster than usual." Results. Morbidity measures indicated that there were an average of 2.5 [+ or -] 4.5 emergency department visits for asthma in the last 6 months, 1.6 [+ or -] 2.2 hospitalizations for asthma in the last 12 months, and 18.1 [+ or -] 17.9 asthma-related school absences in the previous school year. Most, but not all, of the families had primary care providers and most had phone access to them. Half of the families (51%) reported having been given a written asthma action plan. Only 30% of families with children age 5 years and older had peak flow meters. In contrast, almost all families (97%) had equipment for inhalation of [Beta]-agonists. Only 39% of the 181 children with persistent symptoms were receiving daily antiinflammatory agents as recommended in the guidelines of the NHLBI. In response to the scenario of an acute exacerbation of asthma, no one mentioned that they would refer to a written plan, only 1 caretaker would measure peak flow and 36% would give [Beta]-agonists. Two percent would give oral steroids initially, and 1 additional person would do so if wheezing continued 40 minutes later. Only 4% responded that they would contact their clinician. Reports of actual practice differed from the scenario responses in that more people began [Beta]-agonists and oral steroids in response to an exacerbation in the past 6 months than said they would in response to the scenario. Conclusion. In this population of previously hospitalized inner-city children with asthma, the NHLBI guidelines for the home management of asthma exacerbations are not being followed. Interventions are needed to affect both clinician and caretaker practices. Pediatrics 1999;103:422-427; asthma, children, morbidity, inner city, management, guidelines, standard of care, scenario, peak flow, oral steroids, [Beta]-agonist, access to care, symptoms, antiinflammatory agents., ABBREVIATIONS. NHLBI, National Heart, Lung, and Blood Institute; HMO, health maintenance organization; ED, emergency department. Asthma is a major cause of childhood morbidity, affecting 4.8 million children in the United [...]

Abstract. The ongoing care needed by children with chronic physical illness is a topic of national concern. The Pediatric Ambulatory Care Treatment Study (PACTS) is a classic pretest-posttest randomized experiment designed to evaluate a Pediatric Home Care (PHC) program in which an interdisciplinary team provides comprehensive primary health care, support, coordination, patient advocacy, and education to chronically ill children and their families. Home interviews were conducted by an independent research team with the 219 families at enrollment, 6 months, and i year; 80% completed all three interviews. Analyses indicate that pediatric home care is effective in improving the satisfaction of the family with care, in improving the child's psychological adjustment, and in lessening the psychiatric symptoms of the mother. The functional status of the children was equally well maintained in both groups, and there was no significant difference in the impact of the illness on the family between the two groups. There are indications that there may be a dose-related effect with respect to the child's psychological adjustment with those in the program for the longest period of time showing the greatest benefit. Such a home care program can be an effective intervention for minimizing the social and psychological consequences of chronic illness. [ABSTRACT FROM AUTHOR]

The extent to which children's psychological adjustment is affected by the presence of chronic physical illness is a subject of controversy. Data obtained at entry to a study of children with chronic illness show that among the 81 children is greater than or equal to 5 years of age there is little relationship between psychological adjustment and traditional morbidity measures such as days he)spiral[zed and days in bed, There is, however, a moderate but significant relationship between psychological adjustment and both the number of days absent from school and the child's functional status: children who have more absences and those with poor function. a[ status have poorer psychological adjustment. The data a}so suggest that these relationships may differ in size within demographic subgroups of the population, something that may explain current controversies over the relationship between the child's chromic condition and psychological adjustment. [ABSTRACT FROM AUTHOR]