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Objective: We aimed to assess the degree to which the American Academy of Pediatrics’ (AAP) clinical guidelines were followed when treating attention deficit/hyperactivity disorder (ADHD) in preschoolers. Method: Using Medicaid claims for children 4 to 5 years of age receiving their first dose of stimulants/alpha-2 agonists in 2017 ( n = 836), we determined if BH was received prior to initiation of medication. We examined predictors after controlling for confounders. Results: More than half the sample did not receive first-line BH, which did not differ by demographics. Those receiving BH prior to medication had a higher rate of receiving an ADHD diagnosis. Only three diagnoses were significant in multivariate (OR 13.8, 95% CI [1.7–115.1]) analyses. Conclusion: More than half the sample did not, conservatively, meet the AAP clinical recommendations. Further research is needed to identify targets for intervention. Limitations are noted.

To evaluate the impact of the series 13Reasons Why on depression and suicidal behaviors in children and adolescents.Data from the 2016 to 2018 Nationwide Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS) of the Healthcare Cost and Utilization Project (HCUP) from 2016 to 2018 was used to determine the presentation in both settings for depression and suicidal thoughts and behavior. This was compared to predictive modeling for presentations in the same time frame.Following the release of 13 Reasons Why both hospital admissions and presentations to the Emergency Department (ED) increased for complaints of worsening depression or suicidal thoughts and behavior. This was more pronounced for youth aged 10-17 years, Black race, and female sex. There were no significant findings, overall, for females 6-9 years, but in-patient visits for depression increased in May 2017 for Black females 6-9 years. Males 6-9 years had higher rates of ED visits for depression and both ED and in-patient visits for suicidal behaviors.Secondary data analyses have known limitations including inability to track over time, inclusion of only visit-level data, and failure to collect variables of interest.The series 13 Reasons Why was likely associated with exacerbations of both depressive illnesses and suicidal behavior in youth, particularly for female and Black youth from 10 to 17 years. This study adds to known concerns regarding the role of media in influencing suicidal behavioral in vulnerable children and has important implications for youth monitoring and parent and youth education. More research is needed to identify specific targets for prevention.

OBJECTIVE Kentucky ranks among the highest in the nation for attention-deficit/hyperactivity disorder (ADHD) prevalence in children aged 4 to 17 years. In 2011, the American Academy of Pediatrics (AAP) released a clinical practice guideline based on the DSM-IV. A guideline revision based on the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) was released in October 2019. In this study, we assess and describe pediatric providers' ADHD practices using the 2011 guideline and DSM-5 diagnostic criteria. METHODS This was a cross-sectional, survey-based descriptive study. Kentucky Chapter of the AAP (KY AAP) members were anonymously surveyed. The results were examined for trends in routine practice. RESULTS Fifty-eight general pediatricians and pediatric residents responded to the survey, yielding a 38% (58/154) response rate. Among respondents performing routine diagnosis of ADHD (N = 51), 73% (37/51) used DSM-5 criteria. Most providers usually or always initially assessed for coexisting behavioral conditions (96%; 49/51), developmental conditions (78%; 39/51), and adverse childhood experiences (73%; 37/51). Among respondents performing routine management of ADHD (N = 55), only 11% (6/55) of respondents indicated that they titrated stimulant medications every 3 to 7 days. After initiation of medication, 78% of providers scheduled a follow-up visit within 2 to 4 weeks. During subsequent visits, only half indicated discussing behavioral interventions, screening for coexisting conditions, and reviewing follow-up teacher-rated ADHD scales. CONCLUSION Pediatricians in the KY AAP adhere to the DSM-5 criteria for diagnosing ADHD. Pediatric providers' practices would benefit from education in improvements in pharmacotherapy titration, surveillance of coexisting conditions associated with ADHD, discussion of psychosocial interventions, and school support strategies.

Objectives: The National Survey of Children's Health reported a concerning increase in children 2–5 years being diagnosed with attention-deficit/hyperactivity disorder (ADHD) in 2016. Concerns incl...

Objective : Rates of pediatric bipolar disorders have increased and some are concerned about diagnostic accuracy. Disruptive mood dysregulation disorder (DMDD) was added to the DSM-5 in 2013. The purpose of this study was to assess diagnostic trends of bipolar disorders and DMDD and to identify predictors of receiving the DMDD diagnosis since implementation of DSM-5. Method : Kentucky Medicaid claims from 2012–2017 for children under 18 years (N = 814,919; 2012 n = 473,389; 2013 n = 470,918; 2014 n = 499,094; 2015 n = 517,199; 2016 n = 529,048; 2017 n = 535,814) were used. Logistic regression was used to identify predictors of a diagnosis of DMDD in 2015–2017 for a sub-sample (n = 5,071). Results : The use of DMDD rose after 2013 and mood disorder NOS decreased steadily through 2017. This decrease was seen when there was a diagnosis of bipolar and oppositional defiant disorder (ODD) combined with mood disorder NOS. A diagnosis of only mood disorder NOS in 2012 did not predict DMDD in 2015–2017, but the same diagnosis in 2013 was predictive (OR 2.14, p = 0.049). The reverse is true for a diagnosis of only ADHD in 2013, which did not predict DMDD in later years, but its presence in 2012 was predictive (OR 1.36, p = 0.010). Conclusions : DMDD increased after 2013, and this was associated with a diagnosis of mood disorder NOS, ADHD, as well as with bipolar disorders comorbid with ODD. Given the complexity of comorbid diagnoses, DMDD may be more accurate in classifying some children. Administrative claims data have limitations, which are discussed; and the data represent only children living in Kentucky.

The current analysis investigates genetic and environmental influences on the bidirectional relationships between temperament and general cognitive ability (GCA). Measures of GCA and three temperament factors (persistence, approach, and reactivity) were collected from 486 children ages 4-9 years (80% white, 50% female) from the Louisville Twin Study from 1976 to 1998. The results indicated a bidirectional dynamic model of temperament influencing subsequent GCA and GCA influencing subsequent temperament. The dynamic relationship between temperament and GCA arose primarily from shared genetic variance, particularly in families with higher socioeconomic status, where input from temperament contributed on average 20% to genetic variance in GCA versus 0% in lower SES families.

The Louisville Twin Study (LTS) began in 1958 and became a premier longitudinal twin study of cognitive development. The LTS continuously collected data from twins through 2000 after which the study closed indefinitely due to lack of funding. Now that the majority of the sample is age 40 or older (61.36%, N = 1770), the LTS childhood data can be linked to midlife cognitive functioning, among other physical, biological, social, and psychiatric outcomes. We report results from two pilot studies in anticipation of beginning the midlife phase of the LTS. The first pilot study was a participant tracking study, in which we showed that approximately 90% of the Louisville families randomly sampled (N = 203) for the study could be found. The second pilot study consisted of 40 in-person interviews in which twins completed cognitive, memory, biometric, and functional ability measures. The main purpose of the second study was to correlate midlife measures of cognitive functioning to a measure of biological age, which is an alternative index to chronological age that quantifies age as a function of the breakdown of structural and functional physiological systems, and then to relate both of these measures to twins' cognitive developmental trajectories. Midlife IQ was uncorrelated with biological age (- .01) while better scores on episodic memory more strongly correlated with lower biological age (- .19 to - .31). As expected, midlife IQ positively correlated with IQ measures collected throughout childhood and adolescence. Additionally, positive linear rates of change in FSIQ scores in childhood significantly correlated with biological age (- .68), physical functioning (.71), and functional ability (- .55), suggesting that cognitive development predicts lower biological age, better physical functioning, and better functional ability. In sum, the Louisville twins can be relocated to investigate whether and how early and midlife cognitive and physical health factors contribute to cognitive aging.

Background The use of antipsychotic medication and psychotropic polypharmacy has increased in the United States over the last two decades especially for children from low-income families and those in foster care. Although attention has been paid to providing greater insight, prescribing patterns remain concerning since there is a lack of evidence related to safety and efficacy. High-level psychotropic polypharmacy has not been described. We aim to compare the use of HLPP for children receiving Medicaid services and those in foster care and identify factors associated with the duration of use of high-level psychotropic polypharmacy. Additionally, we will examine the frequency of laboratory metabolic screening and emergency department, inpatient, and outpatient visits. Methods A cross-sectional, secondary analysis of statewide data describes trends in high-level psychotropic polypharmacy from 2012 to 2017 and the prevalence and predictors of high-level psychotropic polypharmacy duration and resource use in 2017 for all children on Medicaid and those in foster care. High-level psychotropic polypharmacy included concurrent use, at least four classes of medications including an antipsychotic, and at least 30 days duration. Results High-level psychotropic polypharmacy increased from 2012 to 2014 for both groups but stabilized in 2015–2016. Children in foster care showed a slight increase compared to their peers in 2017. There was no association between duration and demographic characteristics or foster care status. Diagnoses predicted duration. Neither group received metabolic monitoring at an acceptable rate. Conclusions Concerning patterns of high-level psychotropic polypharmacy and metabolic monitoring were identified. Cautious use of high-level psychotropic polypharmacy and greater oversight to ensure that these children are receiving comprehensive services like behavioral health, primary care, and primary prevention.

Background: Kentucky has among the highest rate of attention deficit/hyperactivity disorder (ADHD) and stimulant use in the United States. Little is known about this use by race/ethnicity and geography. This article describes patterns of diagnosis of ADHD and receipt of stimulants and psychosocial interventions for children aged 6-17 years receiving Kentucky Medicaid in 2017 and identifies factors associated with diagnosis and treatment. Methods: Using Medicaid claims, children with and without ADHD (ICD-10 codes F90.0, F90.1, F90.2, F90.8, and F90.9) were compared and predictors of diag­nosis and treatment type were examined. Psychosocial interventions were defined as having at least one relevant CPT code. Chi-squared tests and logistic regression models were used for univariate and multivariable analysis, respectively. Results: The rates of ADHD, stimulant use, and psychosocial interventions in our study population exceeded the national aver­age (14% vs 9%; 75% vs 65.5%; and 51% vs 46.5%, respectively). The distributions varied by sex, race/ethnicity, sex among race/ethnicities, and population density. In general, race/ethnicity predicted ADHD diagnosis, stimulant use, and receipt of psy­chosocial interventions with non-Hispanic White children being more likely to receive diagnosis and medication, but less likely to receive psychosocial therapy than other children. Differences were also shown for rural compared with urban residence, sex, and sex within racial/ethnic groups. Conclusions: Diagnosis and treatment modalities differed for children by race/ ethnicity, population density, and sex. More data are needed to better understand whether differences are due to provider bias, child characteristics, or cultural varia­tions impacting the utilization of different treatment options. Ethn Dis. 2021;31(1):67- 76; doi:10.18865/ed.31.1.67

Purpose The primary purpose of this study was to evaluate acceptability by new mothers of postpartum depression (PPD) screening and education about community resources by hospital-based perinatal nurses. A secondary purpose was to determine further screening for PPD that women received by community providers in the first few weeks after birth. Methods The study design was descriptive. As per standard practice on the unit, all new mothers were screened for depression the night before hospital discharge using the Edinburgh Postnatal Depression Scale (EPDS). New mothers identified as high risk for depression by EPDS scores greater than or equal to 10 (n = 75) and a comparison group of mothers at low risk for depression with EPDS scores less than 10 (n = 26) were recruited from an academic health sciences center. Participants were contacted by telephone 2 to 4 weeks later and asked about the acceptability of screening for depression and education about community resources by hospital-based perinatal nurses, as well as if they had received further screening for depression by community providers. Descriptive and correlational statistics were used to analyze data. Results The majority of new mothers found it acceptable to be screened for depression and educated about community resources by hospital-based perinatal nurses. Many new mothers were not asked about depressive symptoms by community providers. There was no significant correlation between demographics and depression risk. Clinical implications New mothers viewed depression screening and receiving information on community resources as a positive part of their care. Communication between inpatient and community caregivers should be improved so that new mothers can benefit from seamless depression assessment, evaluation, and treatment.

The rates of mental health diagnoses in children have increased. Children in poverty have the highest rates. The use of psychotropic medication for children has been increasing, which is concerning because of the unknown long-term effects and the increased burden on the health care system. The state of Kentucky ranks among the highest in the United States for children with mental health problems, children living in poverty, and children receiving psychotropic medication.To examine recent trends and determinants of interclass psychotropic polypharmacy (PP) use for children and youth receiving Medicaid to inform intervention development.A retrospective cohort study was conducted using 2012-2015 Kentucky Medicaid claims for children aged 0-17 years, with continuous enrollment for ≥ 90 days with at least 1 behavioral health diagnosis (N = 237,393). Interclass PP was defined as the presence of at least 2 psychotropic medication prescription fills for at least 2 different classes of medication that, if taken as directed, would be used concurrently for at least 90 consecutive days (allowing for a single 15-day lag). The outcome variables were the presence of any interclass PP and the number of months a child received interclass PP. We conducted a descriptive analysis and developed 2 separate generalized linear regression models to test for associations between individual characteristics of children treated with psychotropic medication for ≥ 90 days (n = 75,639) and each outcome of interest.For the sample of children with at least 90 days of psychotropic medication treatment, 38% had at least 3 covered months of PP over the 4 years studied. Children in foster care received alpha agonists (116 vs. 69 per 1,000 children) or antidepressants (225 vs. 176 per 1,000) at a higher rate than other children receiving Medicaid but received stimulants at a lower rate (403 vs. 638 per 1,000). The primary 2-drug class combinations were stimulants with either alpha agonists or antidepressants. Children in foster care (OR = 1.7, 95% CI = 1.58, 1.84, P0.001), with a bipolar disorder (OR = 2.24, 95% CI = 2.10, 2.38, P0.001), mood disorder not otherwise specified (OR = 1.11, 95% CI = 1.04, 1.17, P0.001), or autism spectrum disorders (OR = 1.17, 95% CI = 1.08, 1.26, P0.001) had increased the odds of ever receiving PP. Black children had lower odds (OR = 0.72, 95% CI = 0.67, 0.77, P0.001) of ever receiving PP. Children aged 6-11 years (beta = 3.08, 95% CI = 2.87, 3.29) and 12-17 years (beta = 1.61, 95% CI = 1.38, 1.83) had more covered months with PP compared with those aged 0-5 years. Black children had fewer covered months of PP compared with white children (beta = -1.36, 95% CI = -1.61, -1.11]. Children in foster care (beta = 1.83, 95% CI = 1.53, 2.13) had more covered months with PP. Children residing in nonurban areas had fewer months with PP (beta = -0.4, 95% CI = -0.54, -0.26) compared with those residing in urban areas, as did those children with depression (beta = -3.32, 95% CI = -3.55, -3.1), impulse control disorder (beta = -2.07, 95% CI = -2.28, -1.85), and conduct disorder (beta = -1.34, 95% CI = -1.64, -1.05). Children with bipolar disorder (beta = 3.62, 95% CI = 3.38, 3.86) and autism (beta = 2.04, 95% CI = 1.75, 2.33) had more covered months with PP. As comorbidity increased, the duration of PP treatment increased (beta = 2.49, 95% CI = 2.36, 2.62).The rates of PP are concerning, especially for children in foster care and children aged 6-11 years. Efforts to safeguard medication use are needed, as well as future exploration of racial differences in PP.This project was supported by the Kentucky Cabinet for Health and Family Services, Department for Medicaid; Norton Healthcare; and the School of Medicine, Department of Pediatrics; School of Public Health and Information Sciences; and Kent School of Social Work at the University of Louisville. Kentucky Medicaid approved the use of the data and granted permission to publish but played no role in the interpretation of data. Lui is employed by Kentucky Medicaid. The other authors report no potential conflicts of interest. An earlier version of this study was presented at the Pediatric Academic Societies' Annual Meeting in Baltimore, MD, on April 30-May 3, 2016. A poster presentation was given at the Society for Developmental and Behavioral Pediatrics in Cleveland, OH, on October 14-16, 2017.

Purpose The purpose of this study was to describe new mothers' knowledge related to maternal mortality. Study design and methods Using a cross-sectional design, new mothers were recruited from a postpartum unit of an academic health sciences center where the population was predominately low-income women. Before hospital discharge, they answered questions on their knowledge of potential postpartum complications that could lead to maternal mortality. Questions were based on recommendations from an expert nursing panel. Descriptive statistics were used for data analysis. Results One hundred twenty new mothers participated. Results indicated that most new mothers knew that they should watch for heavy bleeding, a severe headache, and swelling after hospital discharge. However, fewer participants knew that a new mother could experience feelings that she could harm herself or her baby, have blood clots larger than a baby's hand, a temperature of 100.4 °F or higher, and odor with vaginal discharge. Courses of action new mothers would take if experiencing any of the warning signs included 18% of mothers would take no action, 76.7% would tell their boyfriend/husband/partner, 72.5% would inform their mother. Only 60% who would call the labor and delivery unit. Only 38% of the sample knew that pregnancy-related complications can occur for up to 1 year after birth, and 13% of mothers reported not knowing that complications can occur for up to 6 weeks postpartum. Clinical implications Our findings provide a foundation to enhance postpartum education for new mothers and their families and to potentially decrease rates of maternal mortality in the United States.

A qualitative study was conducted to better understand the factors that contribute to psychotropic medication (PM) overuse among children in the child welfare system in Kentucky, including barriers...

The Louisville Twin Study (LTS) is nationally recognized as one of the largest and most comprehensive studies of child development related to multiple birth status. The LTS is unique because of the extensive longitudinal face-to-face assessments, the frequency of data collection, the inclusion of data on additional family members (i.e., parents, siblings, grandparents; and later, twins’ own spouses and children), and the variety of data collection methods used. Data preservation efforts began in 2008 and are largely complete, although efforts are ongoing to obtain funding to convert the electronic data to a newer format. A pilot study was completed in the summer of 2018 to bring the twins, who are now middle-aged, back for testing. A grant is currently under review to extend the pilot study to include all former participants who are now ≥40 years of age. Opportunities for collaboration are welcome.

Background Parental depression has been associated with adverse child outcomes. However, the specific parenting behaviors that may result in such child outcomes and the effect of family-centered care (FCC) on positive parenting behavior of depressed parents has not previously been examined. Methods Data from the National Survey of Early Childhood Health was used ( n = 2,068). Groups were stratified by the presence of parental depression and compared with regard to demographics and the mean number of specific positive parenting behaviors. Generalized linear models were developed based on testing whether individuals performed more or less than the median number of positive behaviors. Lastly, we tested whether depression independently predicted each outcome after adjustment for FCC, coping, social support, and ethnicity to evaluate if depression independently predicted each outcome after adjustment. Results No difference was found in demographic variables between parents who were depressed and not depressed. Parents who were not depressed performed significantly more routines ( p = .036); reported coping better with parenting ( p p = .022); and needed/had less social support ( p = .002) compared with parents who were depressed. Individual items and scale scores were associated in the expected directions. FCC was independently associated with study variables but did not moderate the effect of depression. Conclusions These data identify specific parenting behaviors that differ between parents who report depressive symptoms compared with parents who do not have depressive symptoms. More targeted interventions coordinated through a medical home are needed for parents with depressive symptoms to reduce the child health disparities often associated with parental depression.

OBJECTIVES Residency interviews play an integral part in medical residency placement. We aimed to develop and evaluate a mock interview program for fourth-year medical students interested in a pediatric specialty. METHODS A mock interview program for fourth-year medical students interested in pediatrics was developed and implemented. Preinterview quantitative data and postinterview qualitative data were collected. Fifty-nine students completed the program across three consecutive academic years. Preinterview surveys were completed regarding comfort and confidence levels specific to aspects of the interview process. Descriptive analyses were used. In addition, a focus group was held with nine of the participating students to obtain qualitative data via a paper blog process. Themes in student responses were identified through constant comparative analysis. RESULTS Before the mock interview, students were most uncomfortable with introductory and closing remarks and their confidence levels varied by topic. A thematic analysis of focus group data identified five themes (preparation, stress reduction, interview process familiarity, confidence of skills, and receiving feedback) for which the mock interviews were most helpful. CONCLUSIONS Implementation of a mock interview program was feasible and acceptable for senior medical students and may improve comfort and confidence levels in the residency interview process. Further longitudinal research is needed.

The Louisville Twin Study is one of the most intensive twin studies of cognitive ability. The repeated measurements of the twins are ideal for testing developmental twin models that allow for the accumulation of gene-environment correlation via a phenotype to environment (P=>E) transmission process to explain twins’ divergence in mean ability level over time. Using full-scale IQ scores from 566 pairs of twins (MZ=278; DZ=288), we tested whether a P=>E transmission model provided better representation of actual developmental processes than a genetic simplex model. We also addressed whether the induced gene-environment correlation alters the meaning of the latent nonshared environmental factors with a simple numerical method for interpreting nonshared environmental factors in the context of P=>E transmission. The results suggest that a P=>E model provided better fit to twins’ FSIQ data than a genetic simplex model and the meaning of the nonshared environment was preserved in the context of P=>E.

Key wordsAdolescent, depression, research recruitmentAbstractPurpose: Adolescent mothers have high rates of depressive symptoms and inadequate rates of depression evaluation and treatment. The purpose of this qualitative study was to identify characteristics of effective recruitment ads for an Internet-based depression intervention for pregnant and parenting adolescents.Methods: Using focus group methods, participants (N = 35) were recruited and enrolled at a teen parent program, part of the public school system. Focus group sessions were analyzed for participant preferences, rationale for choices, key words, and the frequency of words within the videotapes and audiotapes.Results: Findings indicated that adolescent mothers preferred pictures in which everyone looked happy, narrative that clearly indicated cost and eligibility, and words that they would use in conversation.Clinical Relevance: The study filled an important gap in the literature by soliciting from pregnant and parenting adolescents their preferences regarding visual appeal, content adequacy, and message clarity of advertisements that would motivate them to visit an Internet intervention for depression. Results could be extrapolated to education of pregnant and parenting adolescents in clinical settings.National experts agree that adolescent mothers have high rates of depressive symptoms and inadequate rates of depression evaluation and treatment (Substance Abuse and Mental Health Services Administration, 2005; Williams, O'Connor, Eder, & Whitlock, 2009; Yozwiak, 2010). Internet-based interventions for depression have been successful in overcoming barriers to treatment in adolescents (Christiansen, Griffiths, & Jorm, 2004; O'Kearney, Kang, Christensen, & Griffiths, 2009). However, the best ways to recruit adolescent mothers for an Internet-based intervention for depression are not known. The purpose of this study was to identify characteristics of effective recruitment ads from the perspective of adolescents for an Internet-based depression intervention for adolescent mothers.BackgroundSuccessful and cost-effective recruitment is one of the greatest challenges for researchers, particularly in underserved and minority populations (Logsdon & Gohmann, 2008; Pinto-Foltz, Logsdon, & Derrick, 2011). Difficulty with recruitment is often cited as the reason for failure to reach an estimated sample size, resulting in underpowered studies and serving as a barrier to using research in practice. Strategies to improve research recruitment have been disseminated by the Cochrane Library (Treweek et al., 2010) as well as by noted researchers (Nguyen et al., 2012), but challenges remain.Recently, researchers have begun to use the Internet for research recruitment and interventions (Fenner et al., 2012; Morgan, Jorm, & McKinnon, 2013; Smith, Wilde, & Brasch, 2012). In a recent systematic review, Park and Calamaro (2013) noted the potential of social media for research study recruitment with adolescents and young adults. For example, Facebook has been successfully used to recruit young adults for studies of young adult smokers (Ramo & Prochaska, 2012) and Google ads have been successfully employed to recruit adults to health research websites (Gross, Liv, Contreras, Munoz, & Leykin, 2014). However, the effective characteristics and qualities of the recruitment ads were not discussed, leading to the need for this study.MethodsSampleParticipants were recruited and enrolled at two locations of a teen parent program, which is part of the public school system. The study was approved by the institutional review boards of the university and the site. Eligibility criteria included (a) currently pregnant or adolescent mother who is 13 to 18 years of age; and (b) child lives with adolescent mother. Three groups of adolescent mothers (total N = 35) participated in the study. …

PURPOSE Educational materials used by healthcare agencies frequently do not follow national health guidelines for plain talk. Adolescent mothers are a vulnerable population in need of accurate and accessible health information to promote their own health and that of their baby. The aims of our study were to: Determine acceptability of simple, written educational pamphlets to adolescent mothers; Determine efficacy of simple, written educational pamphlets in improving an adolescent mother's knowledge related to breastfeeding, infant care, postpartum depression, and mother-infant relationship; Determine if higher knowledge scores are maintained after a 2-week period; and Determine general parenting health literacy of adolescent mothers. STUDY DESIGN AND METHODS Using a prospective, experimental design, students enrolled in a teen parent program (n = 123) completed a pretest and The Parent Health Literacy Activities Test (PHLAT), read the health educational materials, and completed an immediate posttest of knowledge and acceptability. Two weeks later, the same participants completed a second posttest of knowledge. RESULTS Adolescent mothers found the intervention (simple, written educational materials) to be acceptable. The intervention was initially effective in improving knowledge scores in all four content areas. However, knowledge was not retained and scores were not significantly different from baseline at the 2-week assessment. The mean health literacy of the adolescent mothers was poor. CLINICAL IMPLICATIONS A booster session may be necessary for knowledge retention. Other methods of education should be studied to evaluate efficacy for adolescent mothers' knowledge retention of important health information.

OBJECTIVE/BACKGROUND: Approximately 400,000 adolescents give birth in the US annually. Although one-half experience depressive symptoms, less than 25% comply with referrals for depression evaluation and treatment. The current study tested the effectiveness of an internet based depression intervention on seeking depression treatment. METHODS: Based upon the Theory of Planned Behavior (TPB), the intervention included vignettes, questions and answers, and resources. Before the intervention, immediately after the intervention, and two-weeks later the adolescent mothers (n=151) answered questions related to TPB variables and depression treatment. Data were compared to adolescent mothers (n=138) in the control group. Data were collected in community organizations or home visits for the control group. Adolescent mothers in the intervention group answered questions and completed the intervention from a computer of their choice. RESULTS: The adolescents were primarily African American (89.2%); less than high school educated (51.7%); had given birth in last year (97.1%); with a mean age 18.2 years. The intervention led to significant changes in attitude, perceived control, intention to seek mental health treatment, and actually seeking depression treatment. CONCLUSIONS/DISCUSSION: Untreated postpartum depression dramatically impacts a mother’s relationships with her child, her functioning at work and school, health care seeking behaviors, mothering skills, and her development as well as the development of her child. An Internet based depression intervention is an inexpensive method to increase rates of depression treatment.

The purpose was to critique existing parenting apps using established criteria and health literacy guidelines.Descriptive methodology was used.The Apple App Store was searched using the terms parenting, child health, and infant health. To be included, the apps had to have relevant content (parenting, child health, or infant health), be in English, and contain parent education. After eliminating apps that failed to meet inclusion criteria from the original 203 apps, 46 apps were reviewed. The Patient Education Materials Assessment Tool was used to evaluate the health literacy subscales called Understandability and Actionability. Content analysis included Authority, Objectivity, Accuracy, Timeliness, and Usability.The majority of the apps (70%) were in English only. The price ranged from free to $4.99. The purpose, target audience, and topics varied. Although all included apps were for parents, some were for more targeted groups of parents. The source of the information was not presented in 26% of the apps. Most apps took the user to a Web site or an article to read. Functionality of the apps was limited, with none of them providing a customized experience.Much development and research is needed before mobile health (mHealth) solutions can be recommended by nurses caring for new parents. It is critical that consumers and interdisciplinary professionals be involved in the early design phase of the product to ensure that the end product is acceptable and usable and that it will lead to healthy behaviors.

Objective: Children from low-income families are often not well-prepared for kindergarten entry, especially in mathematical skills. Caregivers may lack the knowledge and confidence to teach early mathematical skills. The purpose of this study was to develop a parent–child activities-based mathematics learning programme and test its acceptability and initial efficacy. Method: The evidence-based Reach Out and Read (ROR) programme was adapted to incorporate mathematics content. ROR plus Mathematics (ROR+M) was developed and introduced during well-child visits. Descriptive and repeated-measures analysis of variance analyses were used to evaluate pre- and three weekly post-intervention assessments. Results: Parents self-reported acceptability and initial efficacy of the ROR+M programme was demonstrated. No change was reported in non-mathematical reading behaviour. Discussion: ROR+M was developed and implemented in a primary care paediatric setting serving primarily low-income families. Acceptability and initia...

Purpose Millions of adults lack adequate reading skills and many written patient education materials do not reflect national guidelines for readability and suitability of materials, resulting in barriers to patients being partners in their own health care. The purpose of this study was to evaluate commonly used printed health materials for readability and suitability for patients with limited general or health literacy skills, while providing easy recommendations to health care providers for how to improve the materials. Methods Materials (N = 97) from three clinical areas that represented excellence in nursing care in our organization (stroke, cancer, and maternal-child) were reviewed for a composite reading grade level and a Suitability Assessment of Materials (SAM) score. Results Twenty-eight percent of the materials were at a 9th grade or higher reading level, and only 23% were 5th grade or below. The SAM ratings for not suitable, adequate, and superior were 11%, 58%, and 31%, respectively. Few materials were superior on both scales. The SAM scale was easy to use and required little training of reviewers to achieve interrater reliability. Conclusions Improving outcomes and reducing health disparities are increasingly important, and patients must be partners in their care for this to occur. One step to increasing patient understanding of written instructions is improving the quality of the materials in the instruction for all patients and their families, especially those with limited literacy skills. Clinical Relevance Using materials that are written in a manner that facilitates the uptake and use of patient education content has great potential to improve the ability of patients and families to be partners in care and to improve outcomes, especially for those patients and families with limited general literacy or health literacy skills.

Numerous studies have found interactions between socioeconomic status (SES) and the heritability of cognitive ability in samples from the United States, with individuals from lower SES backgrounds showing decreased heritability compared to those reared in higher SES environments. However, nearly all published studies of the Scarr-Rowe interaction have been univariate and cross-sectional. In this study, we sought to maximize statistical power by fitting multivariate models of gene (G) x SES interaction, including longitudinal models. Cognitive ability data collected at up to five time points between ages 7 and 15 years were available for 566 twin pairs from the Louisville Twin Study. We used multilevel and latent factor models to pool intelligence subtest scores cross-sectionally. To examine interactions longitudinally, we fit latent growth curve models to IQ scores. Power analysis results indicated that the multivariate approach substantially boosted power to detect G x SES interaction. The predicted interaction effect was observed at most ages in cross-sectional multivariate analyses. In longitudinal analyses, we found significant G x SES interactions on mean-level (intercept) full scale IQ and performance IQ (ps

Health literacy has been shown to predict health behaviors and outcomes above the effects of education or socioeconomic status. Much remains unknown about the health literacy of parents and the role it plays in children’s health outcomes or in health disparities. The current study explored the health communication needs and health literacy indicators in a diverse sample of parents (n = 75) to identify potential areas for future interventions. The sample consisted of parents of children 18 to 36 months old who were visiting 3 different pediatric medical offices, 2 of which served low-income families and 1 located in an affluent suburb. When comparisons were made between 2 educational attainment groups, there were variations in indicators of health literacy and health communication needs. These data can be used to guide the development of interventions by primary care providers to improve parent education.

Child sexual abuse poses a serious threat to public health and is often unreported, unrecognized, and untreated. Prevention, early recognition, and treatment are critically important to reduce long-term effects. Little data are available on effective methods of preventing child sexual abuse. The current research demonstrates a unique approach to promoting awareness and stimulating discussion about child sexual abuse. Qualitative methods have rarely been used to study child sexual abuse prevention. Qualitative inductive analyses of interviews from 20 key informants identified both positive and negative assessments with six emergent themes. The themes revealed inherent tensions in using narrative accounts to represent the complex cultural context within which child sexual abuse occurs. More research is needed, but the program shows potential as a methodology to raise awareness of child sexual abuse.

Early childhood is an important period for development. Parents play an important role in structuring children’s physical and psychosocial environments. Much remains unknown about the best methods for engaging parents in health promotion programs. It is critical that programs meet the needs of the families while encouraging the use of positive parenting strategies. The article describes how one pediatrician used the American Academy of Pediatrics’ Community Access to Child Health grant program to develop and implement The Arts of Parenting program with input from predominantly low-income families. A community mapping and needs assessment was conducted as well as stakeholder interviews and parent focus groups to determine the needs of the families with preschoolers. Family programs that are centered in play and the arts provide families with a supportive environment in which to engage their children and learn about their child’s socioemotional development, and build a network with neighborhood peers.

Fragmentation in behavioral and mental health care to children has resulted in suboptimal care and high rates of psychotropic medication use, especially antipsychotic medications (APM). A qualitative study, based on the Theory of Planned Behavior (TPB), aimed to better understand prescribing practices, barriers to optimal treatment, and potential interventions to safeguard the use of APM for children in Kentucky. The most common barrier to optimal care was access to mental health specialists. Social norms and pressure from families contribute to increased medication use. We identify promising interventions to safeguard the use of APM through the lens of the TPB.

Background Parents of infants hospitalized in the neonatal intensive care unit (NICU) frequently need guidance to prepare them for the care and health promotion of their child after hospital discharge. The health literacy of the parents should be considered so that education can be tailored to meet their needs. It is also important to understand the parents' preferences for how, and from whom, they receive education. Purpose The purpose of this study was to identify health literacy levels of parents of infants in an NICU and preferences for who they want to provide them with education. Methods An exploratory, descriptive design was used to assess participant health literacy and preferences for obtaining child health information. Only mothers (no fathers) with babies in the NICU were available to complete the survey. Mean participant age was 26.4 years (SD = 6.7). Results Participants had a mean Rapid Estimate of Adult Literacy in Medicine, Revised, score of 5.64 (SD = 2.4), indicating a low level of health literacy. Questions regarding when to administer medication were correctly answered by 69% of participants. Proper medication dosage was understood by 92% of participants; however, only 30% were able to correctly convert measurements. One-on-one discussions with a physician were the preferred source of health information for 80% of participants. Implications for practice/research The current exploratory study provides new information that will help inform the development of future studies and increase awareness of nurses regarding health literacy and the specific types of skills for which parents need the most help.

This study describes the experiences of and barriers for pediatricians in Kentucky in providing behavioral/mental health (B-MH) services in primary care settings. These data will serve as a foundation for improving service delivery. An online survey was completed by 70 pediatricians. Descriptive data are presented. More than 90% of the respondents said that they saw at least one patient a month with 1 of 10 specific B-MH diagnoses. Physicians' comfort with diagnosing and treating disorders varied widely by diagnosis, age-group, and drug classification. Major barriers to providing optimal care were inaccessibility of mental health professionals for consultation and referral, lack of communication, and lack of knowledge. Respondents were more likely to favor consultation and co-location models over an integration model of care delivery. Overall, the authors found that pediatricians are dealing with patients with B-MH problems for which they may not have been adequately trained. Communication and collaboration needs were identified.

This study reviewed Kentucky Medicaid claims data for children with autism spectrum disorders to determine psychotropic drug (PTD) use in this population. Children with autism spectrum disorders (ICD-9 code 299.XX) in 3 different age-groups from 2005 to 2008 were identified; PTD use was defined as at least 1 prescription per year. PTD use in all age ranges was higher than in previously reported studies. High PTD use in children between 1 and 5 years is particularly of concern and may reflect perceived inadequacies of comprehensive educational/behavioral services for these children.

Changes in nutritional strategies over the past decade have been shown to improve postnatal growth in extremely low birth weight (ELBW) infants. We showed 10 years ago that the majority of these ELBW infants with bronchopulmonary dysplasia (BPD) suffer postnatal growth failure. We theorized that recent changes in nutritional support strategies would positively affect growth outcomes in ELBW infants with BPD.A retrospective study of 88 ELBW infants with BPD. Nutritional data, postnatal growth and BPD severity were compared across three cohorts: (1) weight gain ≤14 g kg(-1) per day, (2) 14.1 to 16 g kg(-1) per day and (3) ≥16 g kg(-1) per day from return to birth weight through discharge. We also compared these to a historical cohort.In all, 73% of current subjects grew at or above fetal rates. There was less extrauterine growth restriction (EUGR) by weight and head circumference for those ELBW infants with BPD receiving higher amounts of protein. Aggressive early TPN and receipt of caloric-dense milk seemed to be the 'new' nutritional strategies improving growth for current ELBW infants with BPD compared with those 10 years ago.Despite a diagnosis of BPD, improved nutritional strategies have enhanced postnatal growth in infants at high risk for EUGR.

The diagnosis of attention deficit/hyperactivity disorder (ADHD) in children has been steadily increasing over the past 10 years. ADHD is associated with numerous health, behavioral, social, and academic outcomes. The use of medication is common for the treatment of ADHD. However, the evidence base for pharmacological and non-pharmacological treatments for children younger than 6 years of age is limited. Both short-term and long-term studies of efficacy and safety of all interventions are needed in this population, especially the use of psychotropic medications. Understanding the long-term effects of psychotropic medication on the developing brains of preschoolers has important implications for outcomes into adulthood. Nonpharmacologic evidence-based interventions are available and should serve as the first line of treatment in this population. Future research needs include further evidence regarding specific curricula, dose, duration, delivery methods, and staff training to ensure optimal intervention outcomes.

Even in the absence of major disabilities, children born prematurely are at high risk for academic delays and deficits. Research suggests that some differences in outcomes may relate to problems with self‐regulation, especially attention regulation. Previous research has demonstrated that individual differences in attention regulation is associated with both child and parent factors. This study examines the role of child temperament and parental sensitivity for attention regulation in preschool‐age children (n = 95) born with very low birth weights (VLBW) by using both questionnaire and observational data. Regression analyses demonstrate differential effects of specific child temperament characteristics and specific aspects of parental sensitivity on attention regulation. Early assessment of temperament and individualised parent sensitivity training may be important for improving outcomes for VLBW children.

The ecological model is used as a framework for applying social justice concepts to the care of childbearing women and families. In this model, the environment of childbearing women has 3 distinct levels: macrosystem, mesosystem, and microsystem. Two scenarios are described and examples of nursing actions to promote social justice at each level are provided. This article demonstrates how maternal/infant nursing practice can be expanded to promote health equities, social justice, and support.

This study examines the relation of maternal scaffolding and children's attention regulation abilities in preschool children from low-income families within the context of a parent–child interaction task and in a child-alone task. Maternal scaffolding behaviors differed for mothers of children with different attention regulation skills. Mothers whose children demonstrated poor attention regulation skills in the parent–child interaction were more likely to verbally engage their children, including more strategic questions, verbal hints, and verbal prompts. Children's level of attention regulation skills interacted with mother's amount of scaffolding to predict performance in the child-alone task. Attention regulation skills were related to independent performance only in the context of high maternal scaffolding. Findings contribute new information important for parent interventions to promote attention regulation skills in children who are at risk for poor academic achievement outcomes.

PROBLEM: Children born prematurely have been shown to have a range of problems that often result in delayed academic achievement. METHODS: The current study assessed both attention problem scores (Child Behavior Checklist) and actual performance on tasks tapping three attention networks in a sample of children (n = 94) born with very low birth weights (VLBW; ≤ 1500 grams). FINDINGS: Attention problem scores were extremely low and did not predict children's actual attention performance. CONCLUSIONS: A body of research is developing that suggests VLBW children may have specific, yet subtle, attention problems that may differ from those of other children.

We examine updated Wechsler IQ data in 7-year old twins from the Louisville Twin Study for evidence of an interaction between the heritability of IQ and socioeconomic status. Data records that had never been entered were recovered, allowing us to increase previously reported sample sizes by more than 20%. Twin families were assigned socioeconomic status scores using a Hollingshead index based on parental education and occupation. A structural equation model in which genetic and environmental variances were modeled as squared linear functions of SES provided ambiguous replication of earlier findings from the National Collaborative Perinatal Project: relations between SES and heritability for performance and full scale IQ were in the same direction as the previous report, but at p < 0.07. As was the case in Turkheimer et al. (Psychol Sci 14(6):623-628, 2003), no interaction was found for VIQ. These results cannot yet be taken as a definitive replication of Turkheimer et al. (Psychol Sci 14(6):623-628, 2003). Many more measurement occasions, subtests and environmental moderators remain to be analyzed.

The Infant Behavior Record (IBR) from the Bayley Scales of Infant Development has been used to study behavioral development since the 1960s. Matheny (1983) examined behavioral development at 6, 12, 18, and 24 months from the Louisville Twin Study (LTS). The extracted temperament scales included Task Orientation, Affect-Extraversion, and Activity. He concluded that monozygotic twins were more similar than same-sex dizygotic twins on these dimensions. Since this seminal work was published, a larger LTS sample and more advanced analytical methods are available. In the current analyses, Choleksy decomposition was applied to behavioral data (n = 1231) from twins 6 - 36 months. Different patterns of genetic continuity vs genetic innovations were identified for each IBR scale. Single common genetic and shared environmental factors explained cross-age twin similarity in the Activity scale. Multiple shared environmental factors and a single genetic factor coming on line at age 18 months contributed to Affect-Extraversion. A single shared environmental factor and multiple genetic factors explained cross-age twin similarity in Task Orientation.

Biometric latent growth curve models were applied to data from the LTS in order to replicate and extend Wilson's (Child Dev 54:298-316, 1983) findings. Assessments of cognitive development were available from 8 measurement occasions covering the period 4-15 years for 1032 individuals. Latent growth curve models were fit to percent correct for 7 subscales: information, similarities, arithmetic, vocabulary, comprehension, picture completion, and block design. Models were fit separately to WPPSI (ages 4-6 years) and WISC-R (ages 7-15). Results indicated the expected increases in heritability in younger childhood, and plateaus in heritability as children reached age 10 years. Heritability of change, per se (slope estimates), varied dramatically across domains. Significant genetic influences on slope parameters that were independent of initial levels of performance were found for only information and picture completion subscales. Thus evidence for both genetic continuity and genetic innovation in the development of cognitive abilities in childhood were found.

Significant numbers of children have diagnosable mental health problems, but only a small proportion of them receive appropriate services. Stigma has been associated with help-seeking for adult mental health problems and for Caucasian parents. The current study aims to understand factors, including stigma, associated with African American parents’ help-seeking behavior related to perceived child behavior problems. Participants were a community sample of African American parents and/or legal guardians of children ages 3–8 years recruited from an urban primary care setting (N = 101). Variables included child behavior, stigma (self, friends/family, and public), object of stigma (parent or child), obstacles for engagement, intention to attend parenting classes, and demographics. Self-stigma was the strongest predictor of help-seeking among African American parents. The impact of self-stigma on parents’ ratings of the likelihood of attending parenting classes increased when parents considered a situation in which their child’s behavior was concerning to them. Findings support the need to consider parent stigma in the design of care models to ensure that children receive needed preventative and treatment services for behavioral/mental health problems in African American families.

Background No instrument exists to measure parent beliefs about early social–emotional development, which is foundational for child outcomes. We developed and tested an instrument to measure parent beliefs. Methods Positive parenting was defined from the literature and 84 items were developed based on the theory of planned behavior (TPB). The instrument was tested with mothers ( N =200) from the United States. Results Data support our initial supposition of five factors based upon the TPB, which accounted for 65.5% of the total variance. Conclusion The instrument demonstrates strong initial psychometric properties and is ready for further testing.

Introduction The aim of this study is to understand low-income parents' preferences for and barriers to receiving child health promotion information. Methods A mixed-methods approach was used. Data were collected in an urban pediatric primary care setting serving predominantly low-income African American families. Parents ( n = 190) of 3- to 8-year-old children completed a survey; a randomly selected subset participated in focus groups. Results The quantitative and qualitative samples differed with regard to whether they would like to get parenting information from their doctors. The most commonly cited obstacles to attending parenting classes were time (50.6%), work schedule (40.6%), transportation (37.7%), and own health (22.4%). Discussion New and creative methods are needed to promote child health and development that do not increase the burden associated with raising children in the context of limited resources.