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To describe the evolution, accomplishments, and limitations of a research consortium after 25 years of existence. A narrative historical account supplemented by data documenting citations to all group papers. In 1980 the Research Consortium on Children with Chronic Conditions was established. Since then, we have met 2-3 times a year to discuss issues related to research and policies for children with special health care needs. We describe the origin of the Consortium, its operation, and some of its accomplishments, as well as the difficulties it encountered. Our interactions helped promote and sustain research on an emerging topic and did so in an interdisciplinary manner. We include a citation analysis suggesting that group papers published by Consortium members are reasonably well cited by others. We believe our work has been of value in developing influencing research, clinical practice, and policy. This paper is intended to serve as a guide for others who believe that this type of interaction can do much to promote an emerging field. However, it also highlights some of the difficulties in forging and maintaining a productive, research-focused relationship over an extended period of time. The most important lesson learned is that a small group of committed individuals able to meet on a regular basis can accelerate movement in a new field. However, unless stable funding can be secured, maintaining a consortium is truly challenging. Keywords Interdisciplinary * Research consortium * Translational research * Knowledge transfer * Socio-emotional impacts * Special health care needs * Chronic conditions, Introduction In 1980, a group of investigators, now known as the Research Consortium on Children with Chronic Conditions (RCCCC), were brought together by the Center for Study of Families and [...]

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

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

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

As of April, 2001, the federal government is only funding 21 research studies on the behavioral and emotional problems of children and teenagers. This represents 0.05% of the 45,022 research proposals listed in the Computer Retrieval of Information on Scientific Projects (CRISP) database of the US Department of Health and Human Services. This is despite the fact that in 1999, the US Surgeon General recommended increased attention to this issue.

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

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

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

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

We compared the item content of three commonly used scales of psychiatric symptoms [the broad-band Psychiatric Symptom Index (Ilfeld) and two narrow-band scales, the Center for Epidemiologic Studies-Depression Scale (Radloff) and the State-Trait Anxiety Inventory (Spielberger)], with diagnostic criteria and criterion-based symptoms for Major Depressive Episode and Generalized Anxiety Disorder as they appeared in DSM-IV. The Psychiatric Symptom Index and the Center for Epidemiologic Studies-Depression Scale each measured 7 of 9 criterion-based symptoms of Major Depressive Episode. The Psychiatric Symptom Index and State-Trait Anxiety Inventory each measured 5 of 8 domains for Generalized Anxiety Disorder. The Psychiatric Symptom Index had comparable content validity to the narrow-band measures. All met a majority of DSM-IV criteria for depression and anxiety, supporting their applicability for current research.

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

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

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