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Objective We developed a colocation "Rapid Developmental Evaluation" (RDE) model for Developmental-Behavioral Pediatrics (DBP) to evaluate young children for developmental concerns raised during routine developmental surveillance and screening in a pediatric primary care Federally Qualified Health Center (FQHC). In this low-income patient population, we anticipated that colocation would improve patient access to DBP and decrease time from referral to first developmental evaluation and therapeutic services. Methods Children were assessed at the FQHC by a DBP pediatrician, who made recommendations for therapeutic services and further diagnostic evaluations. A retrospective chart review over 27 months (N = 151) investigated dates of referral and visit, primary concern, diagnosis, and referral to tertiary DBP center and associated tertiary DBP center dates of service and diagnoses if appropriate. We surveyed primary care clinicians (PCCs) for satisfaction. Results The DBP pediatrician recommended that 51% of children be referred to the tertiary DBP center for further diagnostic evaluation or routine DBP follow-up. Average wait from referral to an RDE visit was 57 days compared with 137.3 days for the tertiary DBP center. Children referred from RDE to the tertiary DBP center completed visits at a higher rate (77%) than those referred from other sites (54%). RDE-recommended therapeutic services were initiated for 73% of children by the tertiary visit. Fidelity of diagnosis between RDE and the tertiary DBP center was high, as was PCC satisfaction. Conclusion Colocation of a DBP pediatrician in an FQHC primary care pediatrics program decreased time to first developmental assessment and referral for early intervention services for an at-risk, low-income patient population.

Clinical practice guidelines (CPGs) rely on a robust assessment of the quality of evidence supporting guideline recommendations. For the Society for Developmental and Behavioral Pediatrics (SDBP) CPG for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit Hyperactivity Disorder (ADHD), the nature of the evidence and resource constraints led the guideline panel to develop an innovative, yet rigorous, approach to evidence grading. This study will (1) describe the challenges of evidence grading for the SDBP Complex ADHD Guideline; (2) discuss the rationale, process, and tools developed to conduct evidence grading; and (3) report on the experiences and readiness of the volunteer reviewers with diverse background in research methodology to conduct evidence grading. This evidence review process may serve as an example of approaches that can be used by other groups tasked with evaluating the evidence in support of new CPGs.

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurodevelopmental disorder and is associated with an array of coexisting conditions that complicate diagnostic assessment and treatment. ADHD and its coexisting conditions may impact function across multiple settings (home, school, peers, community), placing the affected child or adolescent at risk for adverse health and psychosocial outcomes in adulthood. Current practice guidelines focus on the treatment of ADHD in the primary care setting. The Society for Developmental and Behavioral Pediatrics has developed this practice guideline to facilitate integrated, interprofessional assessment and treatment of children and adolescents with "complex ADHD" defined by age (4 years or presentation at age12 years), presence of coexisting conditions, moderate to severe functional impairment, diagnostic uncertainty, or inadequate response to treatment.

Behavior analysts have long recognized the potential of a partnership with pediatric medicine as an opportunity to expand the influence of behavior analysis and positively impact population health. Despite significant achievements in this domain, the impact of behavioral science on the daily practice of pediatrics has been limited. In this commentary, the authors argue that the current health care and research environments are ripe for a renewed focus on behavioral modification in pediatric primary care, with a particular emphasis on the study of high-frequency, low-intensity problems. They provide some analysis of why behavioral pediatrics has failed to gain traction in primary care, describe aspects of the current primary care practice and research landscapes that provide opportunities for an expanded portfolio of research, identify several exemplars from the behavior analytic literature that have influenced pediatric primary care or have the potential to do so, and make recommendations for producing influential data.

* Abbreviations: ASD — : autism spectrum disorder M-CHAT — : Modified Checklist for Autism in Toddlers PPV — : positive predictive value Despite efforts to reduce the age of diagnosis for autism spectrum disorder (ASD) and ameliorate disparities in the identification of children with ASD from diverse backgrounds, we have only recently begun to move the needle.1,2 We acknowledge the formidable task pediatricians face in recognizing ASD, a condition with relatively low prevalence and signs that may not be apparent during a brief clinical encounter.3 Despite its promise for aiding pediatricians and improving ASD identification, emerging research suggests that the Modified Checklist for Autism in Toddlers (M-CHAT) is less accurate in detecting ASD in clinical practice than previously thought. In this issue of Pediatrics , Carbone et al4 performed a retrospective study using electronic health record data to evaluate screening practices and ASD diagnostic outcomes for children aged 16 to 30 months seen between 2013 and 2016 in one large health system in Utah. This important work closely parallels a similar study published by our research group in Pediatrics in 2019.5 We applaud the editors for publishing 2 articles with such similar methods and findings, because replication is particularly critical … Address correspondence to Kate E. Wallis, MD, MPH, Division of Developmental and Behavioral Pediatrics, Children’s Hospital of Philadelphia, 3550 Market St, 3rd Floor, Philadelphia, PA 19104. E-mail: wallisk{at}email.chop.edu

OBJECTIVE To understand developmental-behavioral pediatricians' (DBPs') use of clinic versus telephone encounters for preschool attention-deficit/hyperactivity disorder (ADHD) medication management. Understanding use of telephone encounters for pharmacologic management of ADHD in preschoolers may inform care for children with ADHD. METHODS DBP investigators within Developmental Behavioral Pediatrics Research Network abstracted data from medical records of 503 children aged younger than 72 months treated for ADHD with medication by a DBP clinician between January 1, 2013, and July 1, 2017, across 7 sites. We abstracted data about medication treatment episodes (defined as start and end/change of a specific type, dose, and frequency of ADHD medication) and encounter type (clinic vs telephone). We present descriptive statistics related to encounter types and χ2 analyses to compare frequencies across reasons for the end of treatment episode and across sites. RESULTS The study included 503 participants with a total of 1734 treatment episodes. The initial medication was started via a clinic encounter 85.9% of the time and via telephone encounters 14.1% of the time. When evaluating reasons for end of treatment episode, decreases in dose/frequency of medication were less common for clinic versus telephone encounters (27% vs 73%; p < 0.001) and adding an additional medication was more common at clinic versus telephone encounters (64% vs 36% p < 0.001). Sites varied significantly in frequency of telephone encounters, ranging from 16.9% to 68.9% (mean 45.7%). CONCLUSION Telephone encounters were used for pharmacologic management of ADHD in preschoolers to varying degrees across 7 DBP sites. These findings suggest that telephone management serves an important role in ADHD care.

Secondary analysis of existing large, national data sets is a powerful method to address many of the complex, key research questions in developmental behavioral pediatrics (DBP). Major advantages include decreasing the time needed to complete a study and reducing expenses associated with research by eliminating the need to collect primary data. It can also increase the generalizability of research and, with some data sets, provide national estimates that may form the basis for developing policy. However, few resources are available to direct researchers who seek to develop expertise in this area. This study aims to guide investigators with limited experience in this area who wish to improve their skills in performing secondary analysis of existing large data sets. This study provides direction on the steps to perform secondary analysis of existing data sets. It describes where and how data sets can be identified to answer questions of interest to DBP. Finally, it offers an overview of a number of data sets relevant to DBP.

Very little research has explored the complex relation between ACEs, poverty, and obesity in young children with neurodevelopmental delays. The purpose of this study was to examine whether ACEs predicted overweight/obesity in young children with neurodevelopmental delays after income was taken into account, and to examine the extent to which poverty moderated the relation between ACEs and overweight/obesity. Participants were 180 children between the ages of 2 and 7 who were referred for a developmental and behavioral pediatrics evaluation (mean age 4.5 years old; 76% male) in the northeast United States. Parents completed a survey about their child’s ACEs, and an electronic health record review was conducted. ACEs did not directly predict obesity after income was taken into account. However, poverty moderated the relation between ACEs and obesity, such that when children experienced no ACEs, there was no difference in the rates of obesity between children above and below the poverty threshold. Among children who did experience ACEs, children who also lived in poverty had higher rates of obesity than children who did not live in poverty. Children with neurodevelopmental delays are at greater risk for overweight/obesity if they experience both risk factors of being in poverty and of experiencing ACEs. When conducting screenings, providers should understand that the impact of ACEs may vary by contextual factors such as poverty. More research is needed to identify factors that can mitigate the impact of poverty and ACEs on children’s physical health.

Pediatric hypnosis emerged during 1960s and 1970s with pioneers Franz Baumann, Josephine Hilgard, Karen Olness, and Gail Gardner. Forty years later, it's matured as a separate, distinct field within hypnosis. Informed by childhood development, this treatment approach is child-centred, imaginatively focused, fundamentally optimistic, and inclusive of parent, family, and other systems in children's lives. Using hypnosis with younger children requires an active, flexible approach. Pediatric hypnosis values creative playful participation in which the clinician sometimes leads and at other times paces with the child's lead. Pediatric researchers and clinicians have added considerably to the body of hypnosis literature and training. Annual pediatric hypnosis workshops occurred through the Society for Developmental and Behavioral Pediatrics (1987-2009), which the National Pediatric Hypnosis Training Institute (established 2009) successfully continues. This article sketches the history and philosophical underpinnings of pediatric hypnosis, indicating how it adds therapeutic capacity for practitioners.

Feeding problems are associated with the consumption of a limited amount or restricted variety of foods and often occur in children with gastrointestinal diseases. The majority of studies to date do not use valid and reliable measurements to detect feeding problems. The aim of this cross-sectional study was to assess behavioral and skill-based feeding problems in young children with gastrointestinal diseases by using a well-established parent-reported feeding measure and identify demographic, anthropometric, and environmental factors associated with maladaptive feeding behaviors in this pediatric population. Parents completed the Greek version of the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and self-reported questionnaires assessing mealtime environment and parental feeding practices. It was found that 18.6% of the sample had abnormal Total Frequency Score (TFS) (frequency of problematic feeding behaviors) and 39.5% had abnormal Total Problem Score (TPS) (number of behaviors perceived as problematic by parents). Younger children, with lower body mass index, lower birth weight, and only children were more likely to have feeding problems. The study showed that parent-reported feeding problems are increased in young children with gastrointestinal diseases and are associated with specific aspects of mealtime environment and parental feeding practices.

As many as 20% of children are need in of mental health services but only a small percentage receive them. Primary care pediatricians are often the first providers to see these children so it is critical to understand how they manage their care. Therefore, we developed a vignette-based survey to obtain data about pediatricians’ mental health-related diagnostic accuracy, confidence and comfort level in diagnosis and management, and decisions related to care. Pediatricians (N = 106) responded to one of two vignettes, one describing a child with symptoms consistent with ADHD, inattentive type, and the other with symptoms of a depressive disorder. Overall diagnostic accuracy was ~60%, although pediatricians who received the ADHD vignette indicated greater confidence in their diagnosis and greater likelihood of providing treatment themselves. Those who received the ADHD vignette were also more likely to conduct a next level assessment and not to refer to a specialist. Participant characteristics, other than level of interest in mental health, were generally not associated with accuracy, confidence, comfort level, and decisions. Neither years in practice nor completion of a residency rotation in developmental and behavioral pediatrics yielded significant differences in or correlations with diagnosis and management. Consistent with previous reports, pediatric primary care providers vary in their responses to mental health concerns, depending upon the symptom presentation. Primary care providers in our study also appear to value consultation with mental health specialists, supporting the importance of interprofessional collaboration in caring for children with mental health related concerns.

Junior physicians describe mentoring relationships as integral to their career development and success. Current evidence suggests that mentoring is under-utilized despite interest from trainees. The purpose of this study is to describe the mentoring practices in developmental-behavioral pediatric (DBP) fellowship programs and identify mentoring needs of DBP fellows and recent graduates.DBP fellows and recent graduates less than 5 years out of training from US-based DBP fellowship programs were contacted to complete a survey on their mentoring experiences in fellowship and early career.A total of 90 respondents completed the entire survey including 47 current DBP fellows and 43 recent graduates. Only 52% of respondents reported having a formal faculty mentor during their fellowship. Only 45% of recent graduates reported that they currently have a mentor, of those without a current mentor 83% said they would like to have a mentor. Adequate mentoring during fellowship was lowest for career development and research (34% and 27%). Satisfaction with mentoring was associated with having a formal mentor (p.001) and receiving mentoring in multiple areas (p.001). Qualitative responses suggested that effective mentoring addresses the mentee's career goals, provides insight into being a developmental-behavioral pediatrician, assists in navigating academics, and involves a personal relationship.Results suggest opportunities for improved mentoring in DBP fellowship programs, particularly in the areas of career development and research and that there is a significant need for mentorship among recent graduates. Findings from this study can inform program improvement in mentoring for DBP fellows and recent graduates.

Objective. Although pediatricians’ use of standardized screening tools for identifying developmental delays has increased, only 63% of pediatricians report performing standardized screening as recommended. The purpose of the current quality improvement project was to improve developmental monitoring, screening, and referral for developmental concerns by pediatricians. Method. Twenty-eight pediatricians completed an in-person meeting, monthly webinars, and individualized feedback from an Expert Work Group on progress across a 3-month action period. Results. Statistically significant increases were observed in rates of autism screening, discussions of screening results with families, and referral following abnormal results. There was no statistically significant change in rates of general developmental screening. Comparing self-report with record review, pediatricians overestimated the extent to which they conducted discussion and referral. Conclusions. Universal screening for all children has yet to be achieved. The current project supports that practice-based improvements can be made and delineates some of the routes to success.

The purposes of this chapter are to: (a) describe examples of integrated care designed to improve children’s educational functioning through the use of pharmacological and psychosocial treatments, (b) describe models of integrated behavioral health involving collaboration between school professionals and primary care providers to implement pharmacological and psychosocial interventions, and (c) describe strategies for coordinating treatment services between schools and health professionals in specialty practices, such as child psychiatry, developmental and behavioral pediatrics, and pediatric neurology. Additionally, the chapter addresses the role of school psychologists in IBH contexts, including implications for training. The main focus of this chapter is on models of integrated behavioral health in primary care that foster connections with school professionals. Limitations of current models of integrated care, future directions for research, and implications for training and practice are discussed. A set of references and web-based materials are provided to readers for additional information.

AIM: Define relationships of early feeding performance with feeding outcomes in childhood, while assessing the predictive validity of the Neonatal Eating Outcome Assessment. STUDY DESIGN: Ninety-one infants (44 preterm infants born ≤ 32 weeks at term-equivalent age and 47 full-term infants within 4 days of life) had feeding evaluated using the Neonatal Eating Outcome Assessment and the Neonatal Oral Motor Assessment Scale (NOMAS). At 4 years of age, 39 of these infants (22 preterm infants and 17 full-term infants; 43% follow-up rate) had parent-report measures of feeding conducted using the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) and Pediatric Eating Assessment Tool (PediEAT). RESULTS: Lower Neonatal Eating Outcome Assessment scores were related to higher PediEAT scores (p = 0.01; r = −0.44), but were not related to BPFAS scores (p = 0.17; r = −0.23). Relationships were not detected between the NOMAS and BPFAS (p = 0.35; r = 0.17), and relationships between the NOMAS and PediEAT failed to reach significance (p = 0.06; r = 0.34). There was a relationship between the BPFAS and PediEAT scores at 4 years (p < 0.001; r = 0.66). Preterm infants performed poorer than full-term infants on the Neonatal Eating Outcome Assessment (p < 0.001) and NOMAS (p

Pediatric primary care providers (PCPs) play a critical role in caring for children with mental health concerns. Some states have introduced programs to support PCPs in managing these patients more independently. The Massachusetts Child Psychiatry Access Project consultation program is one example. This study compared responses from PCPs in Massachusetts (n = 73) with PCPs in Indiana (n = 33), a state without a consultation program, to vignettes about children with possible attention-deficit/hyperactivity disorder or depression. Participants from MA indicated a stronger interest in behavioral health issues and were more likely to screen patients. PCPs from IN were more likely to have completed a rotation in developmental and behavioral pediatrics during residency. IN respondents were also more likely to choose the correct diagnosis for vignettes and less likely to refer to a psychiatric provider for psychotropic medication. Results suggest greater independence for PCPs in IN.

Because of the widening access gap between need for individual and pediatric psychology services and child specialist availability, secure videoconferencing options are more needed than ever to address access challenges across underserved settings.The authors summarize real-time videoconferencing evidence to date across individual therapy with children and pediatric psychology interventions using videoconferencing. The authors summarize emerging guidelines that inform best practices for individual child therapy over videoconferencing.The authors present three case examples to illustrate best practices. The first behavioral pediatrics case summarizes evidence-based approaches in treating a rural young adolescent with attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and hearing impairment. The second pediatric psychology case describes similarities and difference between on-site and videoconferencing services in treating a rural child with toileting concerns. The third adolescent case describes treatment of an urban honors student with depression.Videoconferencing is an effective approach to improving access to individual and pediatric psychology interventions for children and adolescents. Videoconferencing approaches are well accepted by families and show promise for disseminating evidence-based treatments to underserved communities.

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

* Abbreviations: ABP — : American Board of Pediatrics ABPN — : American Board of Psychiatry and Neurology DB — : developmental-behavioral DBP — : developmental-behavioral pediatrics NDD — : neurodevelopmental disabilities In their article entitled “2015 Developmental Behavioral Pediatrics Workforce Survey,” Bridgemohan et al1 argue that the current system for managing US children with complex developmental-behavioral (DB) conditions is not viable. Despite high demand for services as measured by the increasing prevalence and complexity of childhood DB conditions, the provider supply remains limited. Results from their survey with general and subspecialty physicians and nurse practitioners, who self-identified as assessing and treating children with DB needs, suggest inadequate overall numbers of providers and overworked physicians; in addition, one-third of physician respondents reported planned retirement in 3 to 5 years.1 Two critical questions arise: (1) given a 48% response rate across a convenience sample from 3 membership organizations, are the results generalizable to the larger DB workforce, and (2) if yes, what are the implications for the health care workforce caring for children with DB conditions? Although it is difficult to determine the study’s generalizability by using publicly available information, additional data shed light on supply constraints. Certification data suggest the survey captured 261 of 775 (33.7%) of … Address correspondence to Laurel K. Leslie, MD, MPH, American Board of Pediatrics, 111 Silver Cedar Court, Chapel Hill, NC 27514. E-mail: lleslie{at}abpeds.org