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This article presents long-term effects of a randomized trial evaluating 2 standardized, manual-based prevention strategies for families with parental mood disorder: informational lectures and a brief, clinician-based approach including child assessment and a family meeting. A sample of 105 families, in which at least 1 parent suffered from a mood disorder and at least 1 nondepressed child was within the 8- to 15-year age range, was recruited. Parents and children were assessed separately at baseline and every 9 to 12 months thereafter on behavioral functioning, psychopathology, and response to intervention. Both interventions produced sustained effects through the 6th assessment point, approximately 4.5 years after enrollment, with relatively small sample loss of families (

OBJECTIVE Young adults with type 1 diabetes transitioning from pediatric to adult care are at risk for adverse outcomes. Our objective was to describe experiences, resources, and barriers reported by a national sample of adult endocrinologists receiving and caring for young adults with type 1 diabetes. RESEARCH DESIGN AND METHODS We fielded an electronic survey to adult endocrinologists with a valid e-mail address identified through the American Medical Association Physician Masterfile. RESULTS We received responses from 536 of 4,214 endocrinologists (response rate 13%); 418 surveys met the eligibility criteria. Respondents (57% male, 79% Caucasian) represented 47 states; 64% had been practicing >10 years and 42% worked at an academic center. Only 36% of respondents reported often/always reviewing pediatric records and 11% reported receiving summaries for transitioning young adults with type 1 diabetes, although >70% felt that these activities were important for patient care. While most respondents reported easy access to diabetes educators (94%) and dietitians (95%), fewer (42%) reported access to mental health professionals, especially in nonacademic settings. Controlling for practice setting and experience, endocrinologists without easy access to mental health professionals were more likely to report barriers to diabetes management for young adults with depression (odds ratio [OR] 5.3; 95% CI 3.4, 8.2), substance abuse (OR 3.5; 95% CI 2.2, 5.6), and eating disorders (OR 2.5; 95% CI 1.6, 3.8). CONCLUSIONS Our findings underscore the need for enhanced information transfer between pediatric and adult providers and increased mental health referral access for young adults with diabetes post-transition.

We evaluated predictors and moderators of differential response to two family-based depression prevention programs for families with a depressed parent: a clinician-facilitated intervention and a lecture group intervention. Individual and family level variables were examined using regression analyses with generalized estimating equations. For the outcome of child understanding of depression, parental changes in child-related behaviors and attitudes predicted greater child understanding (p<0.001). For the parent outcome of behavior and attitude change, across intervention conditions, younger parent age (p<0.05), female parent gender (p<0.01), more chronic and severe parental depression history (p<0.05), lower SES (p<0.05), and single-parent status (p<0.05) were associated with better outcomes across conditions. Effect sizes were moderate, ranging from 0.4 to 0.7 SD. Family and marital functioning were not found to be predictors of any outcomes. When both parents were depressed at baseline, there was no difference in the clinician- versus lecture-based approach, and when only the father was depressed, families reported more changes with the clinician condition than with the lecture condition (p<0.05). Findings from this study can help identify intervention strategies that are appropriate for different types of at-risk individuals and families.

Objective: To assess the effectiveness of feedback of maternal blood markers in decreasing alcohol intake and improving neonatal outcomes. Method: Pregnant women were screened using a validated alcohol-screening questionnaire, the TWEAK, and blood markers of alcohol use (hemoglobin-associated aldehyde, mean red blood cell volume, carbohydrate deficient transferrin and gamma glutamyl transpeptidase). There were two independently recruited cohorts: 1) a reference group without feedback of the blood marker results, and 2) a subsequent feedback group with feedback of the blood results. Self-reported alcohol use, marker results over time, infant size and gestational age of the infant of the mothers with a positive alcohol screening questionnaire and at least one positive marker (Ns=53 and 38, respectively) were compared between the two cohorts. Results: Feedback of the blood marker results was an incentive to decrease alcohol intake in the majority of women with positive markers, as after the initial positive assay, there were fewer subsequent positive markers. More women in the feedback group had normalization of the markers compared to those in the reference group who did not have feedback (p=0.005). Furthermore the reported average daily absolute ounces of alcohol use before the feedback was 0.17 versus 0.01 ounces after feedback (p=0.004). In contrast the reported average daily absolute ounces of alcohol use in the reference cohort at the time of first blood draw was 0.042 compared to 0.031 at the time of the second blood draw (not statistically significant). There was no difference between groups in the birth size of the infants. Conclusion: These blood markers were useful as identifiers of at-risk women and motivational and monitoring tools in the care of alcohol abusing pregnant women. The women who received this intervention reported significantly reduced alcohol use and had fewer positive markers.

OBJECTIVE. Development of national biosurveillance systems to advance regional and national data exchange among sites of clinical care and public health authorities is a top federal priority, creating the opportunity to develop a unified national network for tracking and responding to cases of vaccine-preventable diseases. The purpose of this study was to assess the current practice and feasibility of developing a nationwide network of children's hospitals to conduct surveillance for vaccine preventable diseases. METHODS. In 2004–2005, Web-based surveys were sent to 506 key hospital personnel from 119 pediatric hospitals, identified by the National Association of Children's Hospitals and Related Institutions. Surveys measured attitudes toward public health initiatives, willingness to join a surveillance network of children's hospitals, knowledge of mandated reporting requirements, methods of disease detection and reporting, and data sources available for surveillance. RESULTS. A total of 395 (78%) respondents from 119 hospitals completed the survey. Surveillance at pediatric hospitals is largely passive and driven by unreimbursed efforts of infection control staff. It is vulnerable to missing cases that occur in the outpatient setting and are diagnosed clinically without laboratory confirmation or are never diagnosed by clinicians. Nearly 90% of hospital leaders are interested in participating in public health programs, and most are interested in a national network to conduct active surveillance for vaccine-preventable diseases, dependent on the provision of sufficient funding. Pediatric hospitals store records relevant to surveillance in an electronic fashion accessible to query, but CONCLUSIONS. There is both the will and capability to create a robust active pediatric hospital-based reporting system for vaccine preventable diseases. This effort would dovetail well with the national priority to bolster surveillance, as well as with the goal of reducing morbidity and mortality from vaccine-preventable diseases.

This study examines the existence and sources of variation in the management of pediatric splenic injuries among hospitals in the United States and the factors associated with splenectomy.Information on children 15 years of age and younger with a splenic injury diagnosis code was extracted from the Kids' Inpatient Database 2000, a pediatric inpatient database of 2,784 hospitals in 27 states covering 72% of the nation's population for the year 2000. Patient variables included age, sex, race, injury diagnoses, grade of splenic injury, splenic procedure code, and calculated Injury Severity Score. Hospital variables included pediatric status (free-standing, unit and adult), teaching status, annual pediatric splenic trauma volume, and national region. A multivariate logistic regression model was used to predict the factors associated with splenectomy based upon patient and hospital characteristics.In all, 2,191 children with splenic injuries were identified; 253 (12%) underwent splenectomy. The crude rate of splenectomy varied significantly among pediatric hospital types: 3% (11/339) at freestanding children's hospitals, 9% (45/525) at unit hospitals and 15% (197/1327) at adult hospitals (p0.001). Risk of splenectomy increased with the grade of splenic injury, patient age, and the presence of multiple injuries. Teaching hospitals and hospitals with higher patient volume were associated with lower risk for splenectomy. There was no relationship between splenectomy and gender, race, or national region. Despite adjustment for the above noted hospital and patient-specific variables, children treated at an adult hospital had 2.8 times the odds, and those treated at a unit pediatric hospital 2.6 times the odds, of undergoing splenectomy as those cared for at a free-standing pediatric hospital (p = 0.003 and 0.013, respectively).Nationally, children cared for at freestanding pediatric hospitals have a significantly lower risk of splenectomy than children treated at either adult hospitals or pediatric hospitals within an adult hospital. This may have implications for education, trauma triage and the establishment of practice guidelines.

Objectives: The goals of this project were 1) to develop and validate an objective instrument to measure surgical performance at tonsillectomy, 2) to assess its interobserver and interobservation reliability and construct validity, and 3) to select those items with best reliability and most independent information to design a simplified form suitable for routine use in otolaryngology surgical evaluation. Design: Prospective, observational data collection for an educational quality improvement project. Methods: The evaluation instrument was based on previous instruments developed in general surgery with input from attending otolaryngologic surgeons and experts in medical education. It was pilot tested and subjected to iterative improvements. After the instrument was finalized, a total of 55 tonsillectomies were observed and scored during academic year 2002 to 2003: 45 cases by residents at different points during their rotation, 5 by fellows, and 5 by faculty. Results were assessed for interobserver reliability, interobservation reliability, and construct validity. Factor analysis was used to identify items with independent information. Results: Interobserver and interobservation reliability was high. On technical items, faculty substantially outperformed fellows, who in turn outperformed residents (P < .0001 for both comparisons). On the “global” scale (overall assessment), residents improved an average of 1 full point (on a 5 point scale) during a 3 month rotation (P = .01). In the subscale of “patient care,” results were less clear cut: fellows outperformed residents, who in turn outperformed faculty, but only the fellows to faculty comparison was statistically significant (P = .04), and residents did not clearly improve over time (P = .36). Factor analysis demonstrated that technical items and patient care items factor separately and thus represent separate skill domains in surgery. Conclusions: It is possible to objectively measure surgical skill at tonsillectomy with high reliability and good construct validity. Factor analysis demonstrated that patient care is a distinct domain in surgical skill. Although the interobserver reliability for some patient care items reached statistical significance, it was not high enough for “high stakes testing” purposes. Using reliability and factor analysis results, we propose a simplified instrument for use in evaluating trainees in otolaryngologic surgery.

Background: Evaluation of sepsis accounts for one third of all nursery triage admissions. If umbilical cord blood could be accurately substituted for infant blood, it would spare infants the discomfort of an invasive procedure and save both time and resources. While awaiting 48-hour blood culture results, we decide on clinical management based on whether the white blood cell (WBC) immature to total (I:T) granulocyte ratio is ≧0.2. Objectives: Our goal was to assess the correlation of complete blood count (CBC), I:T ratio and blood culture results between umbilical cord and infant blood. Methods: We conducted a prospective cohort study comparing CBC/differential and blood culture results of paired samples of umbilical cord and infant blood from term newborns. Results: We sent 113 paired samples of cord and infant venous blood for CBC/differential and blood culture. All 113 umbilical cord and infant blood cultures were negative, yielding a false-positive blood culture rate of zero. For 92% of babies, both the cord and infant blood I:T ratio were Conclusion: We conclude that cord blood can be safely substituted for infant blood in routine sepsis evaluations of asymptomatic, term infants based on both the low false-positive cord blood culture rate and the significant association between high I:T ratios in cord and infant blood.

The double-deficit model has been examined primarily in relation to reading. We investigated whether children classified according to the double-deficit model would exhibit differences in other neuropsychological domains. Children referred for learning problems ( N = 188), ages 7 to 11, were classified by double-deficit subtype. Only three of the four groups predicted by the model could be identified. There were no group differences in IQ or attention problems. The three groups showed different neuropsychological profiles, involving functional domains other than reading and language. Differences also emerged in nonverbal low-level information processing. The double-deficit group was generally most severely affected. The double-deficit groupings identify children with different neuropsychological profiles and variation in the efficiency of basic online information processing, extending beyond the oral and written language domain.

Background: Nonoperative management of stable children with splenic injuries is the standard of care but has been variably applied in New England. The influence of surgeon training on this variation was analyzed. Methods: A region-wide administrative data set was queried for children with a splenic injury from 1990 through 1998. The influence of a range of patient- and hospital-specific variables, including surgeon pediatric training, on the risk of operation was analyzed. Results: The risk of operation increased with age, severity of splenic injury, and the presence of multiple injuries, but also trauma center status and the presence of a surgical training program. After allowance for these variables, the risk of operation was reduced by half when children with splenic injuries were cared for by a surgeon with pediatric specialty training. Conclusion: The risk of operation for pediatric splenic injury in New England is dependent on several variables, including the surgeon's training.

Based on recent safety and efficacy data, combined with the known pharmacokinetic parameters of aminoglycosides in the newborn, once-daily gentamicin should be preferable to the many other dosing regimens currently in use. Although there are growing data to support its use in term newborns, experience with preterm infants is more limited. In our Neonatal Intensive Care Unit, we experienced difficulties regarding complicated dosing regimens, actual dosing errors, and the tendency to check trough and peak levels around the third dose for infants receiving only a 48 hour course. Therefore, we conducted a quality improvement initiative in which we developed and tested a clinical practice guideline for the use of once-daily gentamicin for preterm and term infants that we hoped would yield trough and peak levels in our target range.We combined a review of the published English language literature with pharmacokinetic analysis of our own data prior to initiation of this new regimen to design the following dosing regimen:35 weeks gestation: 3 mg/kg q 24 hours,or =35 weeks gestation: 4 mg/kg q 24 hours. Our goal serum levels were a troughor =2 microg/ml and a peak between 6 and 12 microg/ml. We collected and analyzed trough and peak levels from all infants receiving this dosing regimen in the first week of life for at least 72 hours between 3/1/99 and 12/31/00.In total, 214 babies met our inclusion criteria, 75 of whom were35 weeks gestation. 100% of babies of all gestational ages had a nontoxic trough level. For infants35 weeks gestation, 79% had a therapeutic peak level, with a mean value of 6.8 microg/ml. For infants of at least 35 weeks gestation, 93% had a therapeutic peak level, with a mean value of 8.4 microg/ml. 92% of nontherapeutic peaks were too low.This study of once-daily gentamicin represents the largest sample size of pre-term infants published to date. The proposed regimen is simple and yields a high proportion of desirable levels. We recommend it for use in preterm and term newborns.

Although it is widely assumed that children with learning disabilities have “sequencing problems,” these have not been well specified. A non-verbal serial reaction time (SRT) paradigm was used to evaluate motor sequence learning in 422 children between ages 7 and 11 in relation to reading, cognitive ability level, and attention problems. The children demonstrated the response profile typically associated with motor sequence learning, but the component of the profile indicative of implicit sequence learning was not reliably associated with any of the predictors. Cognitive ability predicted overall response time; cognitive ability, reading, and attention problems each predicted overall accuracy. Explicit learning was predicted by cognitive ability, but not by reading or attention problems. Thus, we found no evidence that poor reading is preferentially associated with a domain general deficit in sequential learning.

Fourteen typically developing children from 7.9–11.3 years in age were studied with functional magnetic resonance imaging to identify the cerebral loci involved in performance of paced finger tapping by children. Each child performed two bimanual alternating paced finger-tapping tasks. In the first, paced finger tapping was conducted to external 3-Hz pacing provided by a metronome. In the second, the metronome was turned off and finger tapping continued while each child tried to maintain the 3-Hz rhythm by self pacing. Individual and group data were analyzed with statistical parametric mapping techniques that resulted in activation maps for the two tasks. Metronome tapping produced activation of the posterior regions of both superior temporal gyri, both primary sensorimotor cortices, anterodorsomedial cerebellum and supplementary motor area. Self-tapping resulted in recruitment of pre-supplementary motor area and cerebellum in addition to bilateral supplementary motor area and primary sensorimotor cortical activation. Bimanual alternating paced finger tapping performed by children activates a neural network involving primary motor cortex, supplementary motor area, and cerebellum. Posterior superior temporal gyrus may be important for encoding auditory information, and presupplementary motor area and midline cerebellum play an important role in self-paced finger tapping.

Children with learning difficulties have an increased prevalence of psychosocial adjustment problems. We hypothesized that within the context of a risk and resilience model contextual variables influence adjustment, over and above any effects of academic performance. The Behavior Assessment System for Children (BASC) was used to evaluate the relationship between psychosocial adjustment, changes in academic skills, and contextual factors longitudinally over a two–year period in 100 children (ages 7 to 11) referred for learning problems. Although there was little improvement in academic skills, contextual factors contributed to observed psychosocial outcome. Different factors were salient for parents, teachers, and children. Context–derived vulnerability and protective factors can be important determinants of adjustment in children with learning problems, even though the academic difficulties can remain chronic.

Background Biofeedback-assisted relaxation training (BART) can treat several common pediatric presentations, including chronic pain and anxiety. Its effectiveness, applicability to a variety of conditions, and equipment portability make it an ideal treatment approach for use in an inpatient pediatric consultation-liaison service. Objective Since there is a paucity of published research on the utility of BART in this setting, we studied pediatric patients (≥8y), medically-admitted to Boston Children's Hospital, and referred to the Psychiatry Consultation Service for assistance in managing pain, anxiety or both. Methods The patients received at least 1 session of BART. In addition to heart rate variability and skin temperature data collection, participants completed the Wong-Baker FACES Pain Rating Scale and a brief mood/affective state rating scale (Youth Feelings Scale) before and after the BART sessions. Results A total of 152 sessions were conducted with 66 patients across 11 referring services. BART was successfully used 61% of the time on the medical floor with common barriers involving patient unavailability or refusal. The patients completed an average of 1.57 sessions per admission. The post-BART session pain and mood ratings significantly improved over the presession ratings. Patients with both pain and anxiety reported the greatest changes across sessions in comparison with those with only pain or anxiety. Higher heart rate variability was observed in the "pain-only" group. Conclusions The use of BART in a consultation-liaison setting demonstrates promising utility in working with patients with pain, anxiety, or a combination of symptoms. BART was well-received by patients with subjective reports of benefit across sessions.

Children (7-11 years old) with standardized academic achievement test scores in the normal range referred for evaluation of learning problems were compared to low-achieving children matched for age, sex, and nonverbal cognitive ability, and to children with no known history of learning difficulty matched for age, sex, and reading (all N = 65) on a battery of computerized tasks of nonverbal information processing. The normally achieving referred children performed similarly to the low-achieving group but worse than reading-matched nonreferred counterparts. These findings suggest that children who struggle in school yet perform adequately on standardized achievement measures can have heightened neurodevelopmental vulnerability. Implications are discussed with respect to the underlying substrate of learning disabilities, as well as their diagnosis, classification, and remediation.

Background: The indications for treating children with immune thrombocytopenia (ITP) remain controversial. A valid and reliable bleeding assessment tool could assist in objectively quantifying bleeding and influence treatment decisions. Both the ITP Bleeding Score (IBLS) and the ITP-Bleeding Assessment Tool (BAT) have been developed to assess bleeding severity in ITP. The IBLS scores bleeding severity using an 11-item tool with grading from 0 to 2 and the 18-item BAT grades from 0 to 3 or 4. The BAT includes some types of bleeding not represented on the IBLS, such has intramuscular hematomas. To date, no data describe how these two measures compare when measuring bleeding associated with ITP. Objective: To describe and compare bleeding as assessed by both the IBLS and BAT and to correlate bleeding severity with platelet counts in a cohort of children with ITP. Methods: A longitudinal observational cohort of children ages >1 and < 18 years with ITP, were enrolled from 2013-2015 in the Pediatric ITP Consortium of North America ICON1 trial. All children were enrolled prior to starting a new second line monotherapy (not IVIG, steroids or anti-D). At enrollment, bleeding was assessed using the IBLS in all children. A subset of children also underwent a BAT assessment. Grades of bleeding were described and compared between tools and agreement in grading was assessed. Severity was correlated with platelet count using Spearman's correlation calculation. Results: 118 children were enrolled from 21 ICON centers. 54% had chronic ITP and the median age was 11.4y (range 1.2-17.8). The mean platelet count was 28 x 109/l (SD 57) and 88% had a baseline platelet count of Conclusion: The IBLS and BAT were similarly effective at identifying bleeding symptoms, although neither tool showed strong correlation with the platelet count. There were moderate correlations noted between skin bleeding scores and platelet counts for both tools. A major limitation of this comparison is the different definitions of bleeding severity between the two measures. For sites where the items were more detailed, agreement declined (i.e. adding specificity reduced generalizability). While no patients in our cohort exhibited significant grade 3 or 4 bleeding outside of skin findings, we conclude that in the setting of clinical trials, the ability to capture very severe bleeding might be an important distinction that supports using the more complicated BAT, but for clinical practice, a simplified assessment such as the IBLS may suffice. Disclosures Grace: Agios Pharmaceuticals: Other: Scientific Advisor, Research Funding. Neufeld:Novartis: Consultancy. Bussel:Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; UpToDate: Patents & Royalties; Protalex: Membership on an entity's Board of Directors or advisory committees, Research Funding; Genzyme: Research Funding; Ligand: Membership on an entity's Board of Directors or advisory committees, Research Funding; Symphogen: Membership on an entity's Board of Directors or advisory committees; Rigel Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Research Funding; Shionogi: Membership on an entity's Board of Directors or advisory committees; Sysmex: Research Funding; Momenta Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Immunomedics: Research Funding; Eisai: Membership on an entity's Board of Directors or advisory committees, Research Funding; Boehringer Ingelheim: Research Funding; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Cangene: Research Funding; Prophylix Pharma: Membership on an entity's Board of Directors or advisory committees, Research Funding; GSK: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Physicians Education Resource: Speakers Bureau; BiologicTx: Research Funding. Haley:CSL Behring: Honoraria; Baxalta: Membership on an entity's Board of Directors or advisory committees. Thompson:Celgene: Research Funding; ApoPharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Mast: Research Funding; Amgen: Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Research Funding; Amgen: Research Funding; Baxalta (now part of Shire): Research Funding; bluebird bio: Consultancy, Research Funding; Baxalta (now part of Shire): Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; bluebird bio: Consultancy, Research Funding; Mast: Research Funding; ApoPharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Eli Lily: Research Funding; Eli Lily: Research Funding.

Background: Decision-making in selecting second-line therapies for pediatric patients with immune thrombocytopenia (ITP) has not been studied. Using data collected from physicians experienced in treating ITP, we developed a conceptual model of factors that informed treatment choice. This study was a component of ICON1, a prospective, observational, longitudinal cohort study of second line treatments for childhood ITP performed by the Pediatric ITP Consortium of North America (ICON). Methods: Physicians who enrolled patients in ICON1 were asked to rank the top three reasons they chose a specific treatment so as to weight each factor. Those choices that were ranked 1, 2, or 3 were weighted to develop a propensity scored decisional model. In other questions, physicians were asked about all factors that may have influenced decisions to begin a particular second line therapy and this data was then used to examine additional factors that influenced therapy choices and to compare between therapies. Results: ICON1 enrolled 118 patients; 101 had primary ITP and 53 were receiving their first second line therapy. The majority of physicians in the study saw eleven or more patients per year, and the time since completion of fellowship ranged from 1 to 44 years (mean 12.5 (SD 11)). The most important factors guiding treatment decisions in propensity weighted modeling were "patient preference factors": patient/parental preference (40%), and treatment-related factors: possibility of remission (38%), side effect profile (36%), efficacy (27%), long-term toxicity (33%), and ease of administration (30%). Physician factors, such as experience and adhering to published guidelines, rarely influenced decision-making with only 2% of physicians giving published guidelines as a reason for choice of therapy, and there being no difference in choice based on years since fellowship or experience in treating ITP patients. However, 28% of physicians stated their comfort level with a treatment strongly influenced their choice. Additionally, 38% of physicians did not endorse any patient clinical factors (e.g. frequency of bleeding, expected compliance, response to other therapies, age, comorbidities) as key in their decision-making. Health system factors, such as insurance approval or distance from the closest medical center, rarely influenced treatment choice. Treatments could be categorized into five groups: oral immunosuppressive agents, rituximab, romiplostim, eltrombopag or splenectomy. A significant determinant of choosing splenectomy or rituximab was the "possibility of long-term remission" (p Conclusions: This first analysis of physician decision making regarding second line therapies shows that patient preference and physician perception of treatment characteristics (efficacy, side effects, possibility of long term remission) are primary drivers of physician choice in contrast to guidelines, clinical characteristics and health system factors. Future comparative effectiveness studies are necessary to better inform patient and physician choice. Disclosures Lambert: Novartis: Consultancy. Grace:Agios Pharmaceuticals: Other: Scientific Advisor, Research Funding. Bussel:Cangene: Research Funding; GSK: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Ligand: Membership on an entity's Board of Directors or advisory committees, Research Funding; Sysmex: Research Funding; Symphogen: Membership on an entity's Board of Directors or advisory committees; BiologicTx: Research Funding; Shionogi: Membership on an entity's Board of Directors or advisory committees; Physicians Education Resource: Speakers Bureau; Protalex: Membership on an entity's Board of Directors or advisory committees, Research Funding; Immunomedics: Research Funding; Rigel Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Research Funding; Boehringer Ingelheim: Research Funding; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; UpToDate: Patents & Royalties; Momenta Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Prophylix Pharma: Membership on an entity's Board of Directors or advisory committees, Research Funding; Genzyme: Research Funding; Eisai: Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Haley:Baxalta: Membership on an entity's Board of Directors or advisory committees; CSL Behring: Honoraria. Neufeld:Novartis: Consultancy.

Tallal hypothesized that reading disabled children have a domain-general deficit in processing rapidly occurring auditory stimuli that degrades speech perception, thereby limiting phonologic awareness and thus reading acquisition. She predicted they would be disproportionately affected by rapidly presented auditory stimuli. In this study, one hundred 7- to 11-year-old children with learning impairment (LI) and 243 non-learning impaired (NLI) children were evaluated on a two-tone auditory discrimination paradigm. LI committed more errors, but effects of timing were comparable. The same result was obtained for a subsample of good and poor readers. Task performance predicted reading, spelling, and calculation. Neural processes underlying perception of speech and other auditory stimuli may be less effective in poor readers; however, contrary to Tallal's hypothesis, rate may not be specifically affected.

Background Dating fractures is critical in cases of suspected infant abuse. There are little scientific data to guide radiologists, and dating is generally based on personal experience and conventional wisdom. Objective Since birth-related clavicular fractures are not immobilized and their age is known, we propose that an assessment of these injuries may serve as a guide for dating inflicted fractures in young infants, acknowledging that patterns observed in the clavicle may not be entirely generalizable to other bones injured in the setting of abuse. Materials and methods One hundred thirty-one radiographs of presumed birth-related clavicular fractures in infants between 0 and 3 months of age were reviewed by two pediatric radiologists with 30 and 15 years' experience. Readers were asked to evaluate images based on several parameters of fracture healing, with a focus on subperiosteal new bone formation (SPNBF) and callus formation. SPNBF and callus were each evaluated with regard to presence, thickness and character. Responses were correlated with known fracture ages. Results SPNBF was rarely seen in fractures less than 7 days old and was most often present by 10 days. Callus formation was rarely seen in fractures less than 9 days old and was most often present by 15 days. SPNBF thickness increased with fracture age and the character of SPNBF evolved from single-layered to solid/multilayered. Callus thickness decreased with fracture age and callus matrix evolved from soft to intermediate to hard in character. Conclusion There is an evolution in clavicular fracture healing in young infants that follows a predictable pattern. These findings afford the prospect that predictable patterns of infant clavicular fracture healing can provide an evidence base that may be applicable in cases of suspected infant abuse.

Background: Hospital emergency departments (ED) are con- fronted with triaging and managing dental emergencies of both trau- matic and non-traumatic origin. However, the literature suggests that there exists inadequate knowledge of the management of traumatic dental injuries (TDI) among medical professionals who must be knowl- edgeable and have the appropriate resources needed to triage or treat patients presenting with TDI. Aim: The aims of this study were to (i) evaluate the resources of Massachusetts emergency departments (MEDs) for TDI, (ii) determine the knowledge of management of TDI among MED physicians, and (iii) investigate potential factors that affect their knowledge. Materials and methods: Surveys were mailed to MED directors and their physicians. The director survey contained questions regarding institutional information for each emergency department (ED). The physician survey contained questions about physician characteristics and tested their knowledge of managing dental trauma. Results: A total of 72 surveys (16 MED directors and 56 physicians) were returned and included in the analysis. Only 50% of the MEDs had on-site dental coverage, 43.8% had 24-h off-site dental coverage, and none had a for- mal written dental trauma protocol. MED physician's knowledge of the appropriate management of luxations and avulsions was generally good, but poor for dental fractures. The MED physician's knowledge for the emergent nature of the various injuries was generally good with that of avulsions being the best. Physicians were more likely to have a better knowledge of managing dental trauma if they were specialists in pediat- ric emergency medicine (P = 0.001) or their hospitals had an academic affiliation (P = 0.05). Conclusions: Based on the findings from this study, educational campaigns must be undertaken to improve both the resources available to the ED, and the knowledge of physicians regarding emergency management of TDI. In addition, efforts should be made by local dental organizations to provide ED with lists of dentists who are knowledgeable and willing to be available 24 h day 1 to consult with and, if necessary, treat TDI. These efforts would enhance the long-term outcomes for patients sus- taining dental trauma who present to hospital ED.

This study examined the association between family functioning and the development of posttraumatic stress symptoms (PTSS) in youth and parents following an unintentional traumatic injury of a child. Fifty-one parent-child dyads completed questionnaires and a structured interview assessing PTSS and family functioning. Multiple regression analyses were applied to evaluate the contribution of family functioning to the development of PTSS after controlling for demographic characteristics and known predictors. Family functioning had both direct and moderating influences on the development of PTSS in parents. We were unable to demonstrate a systematic impact of family functioning on the development of PTSS in children from the same families.

Evidence-based practice, the rigorous conduct of clinical analysis and intervention, includes practice-based evidence. Here, practice data were the source of three “clinical portraits” used for exploratory analysis of an array of cognitive and social problems in 30 children whose neurobehavioral profiles fulfilled psychometric criteria for a nonverbal learning disability (NLD). Qualitative analysis of the children's academic and adjustment difficulties revealed patterns of dissociable deficits. These findings argue for at least three groups within the NLD construct. Identifying such subgroups is of practical importance: More precise characterization of neuropsychological competencies leads to improved interventions and better outcomes.

Objective The authors examined the validity of documentation produced during paediatric emergency care to determine if a patient-driven health information technology called ParentLink produced higher-quality data than documentation completed by nurses and physicians. Design The authors analysed the quality of information across elements of allergies to medications and the history of present illness (HPI) collected during a quasiexperimental intervention study where control periods with usual care alternated with intervention periods when ParentLink was operational. Documentation by emergency department (ED) providers was abstracted and compared with information generated through ParentLink. The criterion standard for the history of allergies to medications was a structured telephone interview with parents after the ED visit. A valid report for a medication allergy was one that was both accurate and complete. Completeness of the HPI for acute head trauma was evaluated across seven elements relevant to an evidence-based risk assessment. Results Of 1410 enrolled parents, 1111/1410 (79%) completed the criterion standard interview. Parents’ valid reports of allergies to medications were higher than those of nurses (parents 94%, nurses 88%, p

Objective To identify and quantify errors and adverse events on an inpatient academic tertiary-care pediatric otolaryngology service, a trigger tool was developed and validated as part of a quality improvement initiative. Study Design Retrospective record review. Setting Children's Hospital Boston quality improvement initiative. Subjects and Methods Fifty inpatient admissions were reviewed. The gold standard for errors and adverse events identification was a detailed chart review by two board-certified otolaryngologists blinded to trigger tool findings. Results Trigger tool interrater reliability ranged from poor to high for admission triggers (kappa = 0.35, 95% confidence interval [95% CI] −0.07 to 0.76), discharge triggers (kappa = 0.63, 95% CI 0.27-0.99), medical records triggers (kappa = 0.61, 95% CI 0.11-1.00), and medication triggers (kappa = 0.90, 95% CI 0.71-1.00). Errors and adverse events were found in all admissions: three percent were potentially harmful, and 93 percent were documentation-related. Conclusion The trigger tool was successful in identifying clerical and administrative errors and adverse events but failed to identify complex errors and adverse events. A hybrid approach for chart review may be cost-effective in pediatric otolaryngology.

Objective The goal of this study was to pilot a randomized controlled trial of OROS methylphenidate (OROS-MPH) to treat attention deficit hyperactivity disorder (ADHD) plus epilepsy. Methods Thirty-three patients, 6–18 years of age, taking antiepileptic drugs and with a last seizure 1–60 months prior were assigned to a maximum daily dose of 18, 36, or 54 mg of OROS-MPH in a double-blind placebo-controlled crossover trial. Results There were no serious adverse events and no carryover effects in the crossover trial. OROS-MPH reduced ADHD symptoms more than did placebo treatment. There were too few seizures during the active (5) and placebo arms (3) to confidently assess seizure risk; however, considering exposure time, we observed an increased daily risk of seizures with increasing dose of OROS-MPH, suggesting that potential safety concerns require further study. Conclusion A larger study to assess the effect of OROS-MPH on seizure risk is needed. A crossover design including subjects with frequent seizures could maximize power and address high patient heterogeneity and recruitment difficulties.

Objective To review the candidacy criteria used to counsel parents of profoundly deaf children, to determine if these criteria have changed over time, and to evaluate eventual communication outcomes for these patients. Design Retrospective review of 483 pediatric cochlear implant candidates from September 1995 to December 2006 seen at a tertiary care pediatric hospital. Results Out of 483 implant candidates, 191 patients were initially felt not to be favorable candidates based on CI team evaluation. Of this group, 3 had insufficient records to review and were excluded. The remaining 188 patients underwent a detailed analysis of specific possible contraindications to implantation. This included audiologic, medical and psychosocial parameters. The data was divided into two time periods: Group 1 included 44 patients from 1995 to 2000, and Group 2 included 144 patients from 2001 to 2006. In Group 1, there was a higher percentage of children with language deprivation and developmental concerns and patients not ready, compared to Group 2 which had a higher percentage of families not ready and inadequate support systems. Group 1 had a higher percentage of patients who ultimately underwent cochlear implant, but otherwise the two groups were largely similar. Conclusion Analysis of our data showed that the degree of concern that the cochlear implant team has in relationship to specific candidacy criteria has changed over time. Recommendations against a cochlear implant were often revisited after initial concerns were addressed. The use of a team approach, in conjunction with a validation tool, is important for establishing criteria for successful cochlear implantation in children to support appropriate counseling of patients and families and to plan post-implant management.

Article-at-a-Glance Background A quasi-experimental intervention study composed of control and intervention periods was conducted to determine if a parent-driven health information technology influenced completeness of documentation and adherence to evidence-based emergency care for children. Methods Structured chart abstraction was used to assess documentation and correctness of clinical actions at test ordering, medication prescribed for disease, and medication ordered for pain in a tertiary care pediatric emergency department and a suburban general emergency department. During the intervention periods, parents of children who presented with complaints related to otitis media, urinary tract infection, head trauma, or asthma entered data into a health information technology (ParentLink), which produced treatment plans in the context of evidence-based guidelines. Results Of 1,410 subjects analyzed, 1,072 (76%) were assigned to one of four disease categories: urinary tract infection (22%), otitis media (20%), asthma (11%) and head trauma (47%). During ParentLink use, documentation of pain significantly improved (28% incomplete [control] versus 15% [intervention], p = .003). Incorrect actions for pain treatment decreased, but not significantly (33% [control] versus 24% [intervention], p = .13). ParentLink did not influence actions for test ordering or prescribing for disease. Discussion Parent-driven health information technology intended to translate parents' knowledge into clinical practice and to support evidence-based care suggested a trend toward modest impact on pain management but did not demonstrate broad effects across diseases or care processes. The emergence and proliferation of personally controlled health records (PCHRs) presents opportunities for patients and parents to control their medical profiles. Although ParentLink is not a comprehensive PCHR, it represents a step in incorporating parent-derived information into medical decision making.

Variability of metabolic control in phenylketonuria (PKU) potentially affects cognitive outcome in early and continuously treated children with this condition. The possibility that homeostasis is more important than the absolute level of exposure to phenylalanine (phe) has not previously been examined. A meta-analysis of 40 studies showed that in children with phenylketonuria (PKU), mean lifetime blood phe levels were significantly correlated with Full Scale IQ (FSIQ) (r=-0.34). A similar correlation (r=-0.35) was found between FSIQ and mean exposure during 0-12 years of age. Most of the studies in the meta-analysis, however, included children who had discontinued the phe restricted diet. None examined the impact of fluctuations in metabolic control in continuously treated children. This is important because new therapies may increase stability in blood phe levels. The question has arisen whether these therapies are beneficial in children whose blood phe levels are generally within the recommended range of 120-360 micromol/L. In this study, we describe the relationship between FSIQ and two parameters of metabolic control: (1) mean blood phe level of all reported specimens for each subject, and (2) variability of the blood phe level as indicated by the standard deviation of blood phe levels for each subject. Analyses were performed using lifetime phe levels and levels during three periods (0-6 years, 0-10 years, and >10 years of age). The most recent FSIQ for each child was used in the correlation analyses. Data were collected from medical records on all 46 children born between 1999 and 2006 with early and continuously treated PKU followed at the Metabolism Program at Children's Hospital Boston. The mean age of the children at the time of their most recent FSIQ test was 7.5+3.3 (2.9-15.5) and their mean FSIQ was 104+15 (68-143). The mean lifetime blood phe level in these children was 312+132 micromol/L (125-852). The standard deviation of blood phe levels was 182+72 micromol/L (96-336). The correlation between lifetime blood phe levels and most recent FSIQ was -.17 (p=0.38) and the correlation between standard deviation of blood phe levels and most recent FSIQ was -.36 (p=.058), not reaching significance, but indicating a trend. These results indicate that stability of blood phe levels may be more important to cognitive functioning than overall exposure to phe in early and continuously treated PKU. In treating PKU, attention should be given to variability in blood phe levels as well as maintenance of phe levels within the recommended range.

Objectives To describe hospital volumes for common pediatric specialty operations, to evaluate hospital and patient characteristics associated with operations performed at a low-volume hospital, and to evaluate outcomes with hospital volume. Design Retrospective cohort using the Kids' Inpatient Database 2003. Setting Discharges from 3438 hospitals in 36 states from 2003. Participants Children aged 0 to 18 years undergoing ventriculoseptal defect surgery (n = 2301), tracheotomy (n = 2674), ventriculoperitoneal shunt placement (n = 3378), and posterior spinal fusion (n = 4002). Main Exposure Hospital volume. Main Outcome Measures In-hospital mortality and postoperative complications. Results For tracheotomy and posterior spinal fusion, at least one fourth of the hospitals performed only 1 operation for children aged 0 to 18 years in 2003. For these same operations, at least half of hospitals treated 4 or fewer cases per year. For all operations, discharges from low-volume hospitals were less likely to be from children's or teaching hospitals compared with discharges from higher-volume hospitals. For tracheotomy, children were less likely to experience postoperative complications in high-volume hospitals compared with low-volume hospitals (odds ratio, 0.48; 95% confidence interval, 0.21-1.09). Conclusions Many children undergoing common pediatric specialty operations had these procedures performed in low-volume hospitals. Low-volume hospitals were less likely to be children's or teaching hospitals. Children undergoing tracheotomy experienced higher rates of complications in low-volume hospitals. Further research is needed to identify the reasons why so many children have these operations performed in low-volume hospitals.

Mirtazapine is indicated for major depression and used for anxiety in adults; however, little is known about its application in pediatric populations. This is an 8-week open-label pilot study of mirtazapine in children with social phobia age 8-17 years. Primary outcomes were symptom improvement based on clinician rating and self-report, as well as tolerability based on rates of discontinuation due to adverse effects. Fifty-six percent (10/18) responded to treatment, 17% (3/18) achieved full remission. Social phobia symptoms improved significantly during the first 2 weeks of treatment, as did comorbid symptoms of depression and anxiety. Eleven patients (61%) did not complete all 8 weeks of treatment; four patients (22%) discontinued due to adverse effects including fatigue and irritability. The others discontinued due to study burden (28%), insufficient response (6%), or to pursue herbal treatment (6%). Significant weight gain was observed. Larger controlled trials are needed to further evaluate efficacy and safety.

The National Institutes of Health (NIH) Magnetic Resonance Imaging (MRI) Study of Normal Brain Development is a landmark study in which structural and metabolic brain development and behavior are followed longitudinally from birth to young adulthood in a population-based sample of healthy children. The neuropsychological assessment protocol for children aged 6 to 18 years is described and normative data are presented for participants in that age range (N = 385). For many measures, raw score performance improved steeply from 6 to 10 years, decelerating during adolescence. Sex differences were documented for Block Design (male advantage), CVLT, Pegboard and Coding (female advantage). Household income predicted IQ and achievement, as well as externalizing problems and social competence, but not the other cognitive or behavioral measures. Performance of this healthy sample was generally better than published norms. This linked imaging-clinical/behavioral database will be an invaluable public resource for researchers for many years to come.

High-stakes achievement testing is a centerpiece of education reform. Children from socially disadvantaged backgrounds typically perform more poorly than their more advantaged peers. The authors evaluated 91 fifth-grade children from low-income urban schools using clinical neuropsychological tests and behavioral questionnaires and obtained fourth-grade scores on state mandated standards-based testing. Goals were to determine whether executive functions are selectively diminished in children from poor urban environments and to evaluate to what extent integrity of executive functions is associated with test scores. Neuropsychological variables (particularly executive functions) accounted for 40% of the variance in English scores and 30% in mathematics. Efforts to improve children's academic achievement should consider developmental factors as well as curricular content.

OBJECTIVE. Communication barriers between parents of children with asthma and clinical emergency department (ED) providers and subsequent underrecognition of chronicity and severity impede improvements in disease management for patients with asthma in the ED setting. The asthma kiosk, a novel patient-driven decision-support tool, provides ED clinicians with tailored recommendations for guideline-based treatment. We evaluated the impact of the asthma kiosk on measures of quality during ED care, specifically, parent-reported satisfaction with dimensions of care related to communication and providers' adoption of guideline-endorsed processes of care. METHODS. A clinical trial composed of a baseline and an intervention period was conducted at a single tertiary care pediatric ED. Eligible participants were English- or Spanish-speaking parents of children who were 1 to 12 years of age and had a respiratory complaint and history of asthma. Parents used the kiosk to report children's symptoms, current medications, and unmet needs. During a 2-month baseline, no output from the kiosk was shared, and usual care proceeded. During a 3-month intervention that followed a 1-week run-in period, the output was shared with ED clinicians. All parents completed a telephone follow-up interview 1 week after discharge. Primary outcomes were (1) prescription of controller medication to patients who had persistent asthma symptoms and were not on controllers and (2) mean problem scores for 2 specific dimensions of care: information-sharing and partnership. RESULTS. Over 5 months, 1090 parent-child dyads were screened and 430 were eligible. A total of 286 (66.5%) of 430 parents enrolled in the trial. The kiosk generated severity classifications for 264 (92.3%) of 286 children. A total of 131 parents enrolled during baseline, 13 during a 1-week test phase, and 142 during intervention. Baseline participants were older (mean age: 5.3 years) compared with intervention (4.4 years) but did not differ on chronic severity, current use of controllers, or race. The total number of prescribed inhaled corticosteroids did not vary significantly between intervention and baseline (9 of 50 vs 4 of 43). Providers did prescribe inhaled fluticasone to eligible patients more often during intervention than baseline (9 of 50 vs 2 of 43). The number of reported information problems was unchanged between the baseline and intervention periods. The mean number of partnership problems increased from a mean of 1.5 (SD: 1.9) at baseline to a mean of 1.9 (SD: 1.4) during the intervention. This difference was marginally significant after adjustment for child gender, age, and severity category. When ED providers acted on kiosk data, reports of information problems were fewer (0.6 ± 0.8) than when no action was taken (1.1 ± 1.1). CONCLUSIONS. The asthma kiosk demonstrated small and variable impact on quality. Physicians' nonuse of kiosk-generated recommendations may explain the limited impact of the intervention.

The effect of fluid balance on respiratory outcomes for critically ill children has not been evaluated. The only indicator of fluid balance routinely recorded across our intensive care units was estimated fluid intake and output. We sought to determine whether cumulative intake minus output (I-O) at the start of weaning predicted weaning duration and whether cumulative I-O at extubation predicted extubation failure.Prospective observational study.Ten pediatric intensive care units.Cumulative I-O was recorded daily for 301 mechanically ventilated children (18 yrs of age) from November 1999 through April 2001.Cumulative I-O was recorded during a study of weaning strategies and extubation failure in which mechanical ventilation of the majority of patients during weaning and extubation was managed according to a protocol that did not include fluid balance indicators. Outcomes were the time to successful removal of ventilatory support and the rate of initial extubation failure.Relationships between cumulative I-O and outcomes were assessed by means of proportional hazards and logistic regression. The mean cumulative I-O per kilogram of ideal body weight at the start of weaning was 101 mL (sd, 180). Cumulative I-O at the time weaning was initiated did not predict duration of mechanical ventilator weaning. The mean cumulative I-O per kilogram of ideal body weight at extubation was 136 mL (sd, 237). Cumulative I-O at extubation did not predict extubation outcome. There was an association between cumulative I-O at extubation and the duration of weaning in cases not managed by a protocol.Although routinely recorded, cumulative fluid I-O does not appear to have clinical utility in cases managed according to a mechanical ventilator protocol in which tidal volume and oxygenation on minimal levels of ventilator support are systematically tested.

Background: The annual number of childhood injury admissions to New England hospitals decreased by more than half from 1991 through 2000. This study was undertaken to determine whether this decrease was caused by decreased injury incidence or changes in the diagnosis and/or management of childhood injury. Methods: Patients younger than 16 years of age with an injury diagnosis code were extracted from the New England Pediatric Trauma Database and an Injury Severity Score and hospital-specific variables were assigned. U.S. Census Bureau age-specific population estimates were used to generate population-based data. Admission rates were analyzed by organ system injured and injury severity category. Acute care length of stay and hospital charges were analyzed. Femur fracture admission rate was used to determine the baseline rate of childhood injury admission, and rates of admission for other injuries were divided by the rate of femur fracture admissions to produce a femur-standardized rate. Variation in this standardized rate was felt to be secondary to changes in the diagnosis and/or management of the injury. Results: The population-based pediatric trauma hospital admission rates decreased 56% during the 10-year study period, from 464 to 208 per 100,000 children per year. Femur fracture admission rates decreased 26% over the same time period. Admission rates for minor injuries decreased by 61% and, when standardized by the rate of injury incidence, as determined by the femur fracture rate, still decreased by 47%. Standardized admission rates for moderate and severe injuries were unchanged. Injury admission rates decreased for most organ systems, except for thoracic and abdominal injuries, which increased 20%. Admission rates for unspecified intracranial, skull, and spine injuries decreased 60%, whereas the admission rate for specified brain injuries was unchanged. The mean, median, and 75th percentile length of stay decreased significantly for moderate and severe injuries. Despite this, median per-patient hospital charges increased each year. Conclusion: Fewer New England children were hospitalized for injury each year during the past decade. Although the overall rate of childhood injury hospitalization declined by half, the majority of the decrease was secondary to changes in the diagnosis and/or management of pediatric injury. Evaluation of the true effectiveness of injury prevention efforts should take this changing diagnosis and management pattern into account.

We evaluated community general education (CGE; n = 178), community special education (CSE; n = 30) and hospital-referred (HR, n = 145) children (ages 7-6 to 11-11) prospectively over a 2-year period. During this period, 17 CGE children were referred for evaluation (community referred; CR). Prior to referral, CR children performed more poorly than community-nonreferred (CNR) children on cognitive ability, academic achievement, attention problems, and information processing. CR group performance was equivalent to that of CSE and HR groups, but HR children showed poorer academic achievement. Referred children performed more poorly on all measures than nonreferred, whether they met formal diagnostic criteria for a learning disorder or not. Learning disorders may be better conceptualized as a context-dependent problem of functional adaptation than as a disability analogous to physical disabilities, raising questions about the validity of using psychometric test scores as the criterion for identification.

Objectives.—Major gaps exist between usual clinical practice and evidence-based recommendations for care. Many interventions to improve care are costly and time intensive. This study sought to determine whether a clinician's self-assessment of their practice performance for the diagnosis and management of children with attention deficit hyperactivity disorder (ADHD) followed by attendance at a 2-day conference focused on system change would result in improvement in care. Methods.—Design: Quasi-experimental—before and after with external controls. Participants: Clinician attendees compared with convenience sample of nonattendees. Outcomes: Consistency with 10 specific recommendations from the American Academy of Pediatrics Guidelines concerning ADHD. Analysis: Logistic regression, with use of generalized estimating equations to account for clustering of subjects within clinician practices. Results.—Widespread deficiencies in care were present prior to the intervention. Practice improved significantly more among conference attendees in 2 of the 10 performance measures (evaluation for coexisting conditions and offering treatment options), with positive trends in most of the other indicators. Conclusions.—Practice assessment and system-based training may be a cost-effective strategy to improve practice performance.

This study contrasted the development of processing speed in children with and without learning disabilities. We examined whether the same global mechanism presumed to be responsible for the normal developmental improvement in processing speed might also be associated with the processing speed deficiencies observed in children with learning impairments. One hundred and twenty-two children with learning disabilities in reading and/or math and 206 non-disabled community controls participated. There were no differences in relation of age to the development of processing speed for children with and without learning disabilities. We interpreted these results as suggesting that the underlying etiologies for the normal developmental change in processing speed and for the relative deficiencies in processing speed seen among children with learning disabilities were different.

Designing robust clinical trials in critically ill, mechanically ventilated children requires an understanding of the epidemiology and course of pediatric respiratory failure. As part of a clinical trial, we screened all mechanically ventilated children in nine large pediatric intensive care units (ICUs) across North America for 6 consecutive months. Of 6,403 total ICU admissions, 1,096 (17.1%) required mechanical ventilator support for a minimum of 24 hours. Of these, 701 (64%) met one or more exclusion criteria for trial enrollment. Common reasons for exclusion were upper airway obstruction (13.5%) and cyanotic congenital heart disease (11.5%). Life support interventions were restricted for 9.7% of patients, and 5.5% were chronically ventilator dependent. In the patients who were eligible for respiratory failure studies, 62.4% had an acute primary diagnosis of pulmonary disease, 14.2% neurologic disease, and 8.9% cardiac disease. Chronic underlying conditions were present in 43.2% of the patients. The most common acute diagnosis was bronchiolitis in infants (43.6%) and pneumonia in children 1 year old and older (24.5%). Mortality was rare (1.6%), and the median duration of ventilation was 7 days. The design of clinical trials in critically ill children is feasible but must account for the diverse population, infrequent mortality, and short duration of mechanical ventilation.

Because the Rapid Automatized Naming (RAN) test reliably predicts reading skill, it is typically viewed as a diagnostic indicator of risk for reading disability (RD). Since most of the work on naming speed has been undertaken within the framework of reading research, however, the extent to which poor RAN is specifically associated with RD or with learning impairment (LI) in general is uncertain. We tested the hypothesis that slow naming speed is specific to RD. Participants were 188 children (ages 7 to 11) referred for evaluation of learning problems. Receiver operating characteristic (ROC) analysis was used to evaluate the utility of the RAN task for classifying children in diagnostic groups. RAN was an excellent tool for detecting risk for learning problems in general, but it was much less effective at distinguishing LI children with and without RD from each other.

A dynamic assessment approach was used to examine the source of poor performance on the Rey-Osterrieth Complex Figure Test (ROCF) among 202 school-age children referred for learning difficulties. The ROCF was administered in the standard format and then in a structured format that highlighted the design's organizational framework. Manipulating encoding in this way improved recall to at least age-level for the majority of children. Those children who did not benefit from the structured format had relatively poor visual organizational skills. For most children with learning problems, poor ROCF performance stems from metacognitive difficulties; for a minority, the source appears to be more perceptual. A dynamic assessment procedure can enhance the diagnostic utility of the ROCF for children.

Disabled readers exhibit motor timing control (MTC) deficits in bimanual coordination relative to average readers. This article evaluates to what extent poor MTC is specific to reading or if it is related to learning problems in general. Children (7 to 11 years of age) referred for learning impairment (LI; n = 100) and same-age children nonlearning impaired (NLI; n = 243) performed a paced finger-tapping task. Greater variability of interresponse intervals was associated with poorer reading, spelling, and arithmetic achievement. The LI group performed more poorly than the NLI group, a difference that persisted even after adjusting for reading skill. Poor MTC is associated with poor reading but may also be a characteristic of children referred for learning problems, possibly signaling increased vulnerability of underlying neural integrative processes relevant to the child's adaptation to academic demands, including reading.