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Research has shown that parents of children with special health care needs experience more parenting stress than parents of typically developing children, but the relation between the type of disability and parenting stress is far from clear (Stein 1988; Tew and Lawrence 1975; Breslau et al. 1982; Miller et al. 1992). To explore the relation between the type of disability and parenting stress, parenting stress data on the Parenting Stress Index (PSI) (Abidin 1995) and demographic information were collected from convenience samples of parents of four cohorts of children: children with ADHD, children with developmental disabilities, children with HIV infection and children with asthma, and typically developing children. Parents of children with attention deficit hyperactivity disorder (ADHD) and parents of children with developmental disabilities (DD) reported higher total stress than parents of HIV-infected, asthmatic, and typically developing children. Ethnicity did not explain any of the group differences, but caregiver’s language, education, employment status, and overall life stresses explained some of the group differences in parent-related domains. Level of stress in parents of children with special needs is determined by overall nature of the disorder, with the parents of children with ADHD and developmental disorders reporting higher levels of parenting stress than children with HIV infection, asthma, and healthy controls.

Objective. To examine the frequency with which pediatricians provide care coordination services to children, particularly those with special health care needs, in their practices and the barriers to providing these services.Methods. An 8-page questionnaire was mailed to 1632 randomly selected US members of the American Academy of Pediatrics.Results. The response rate was 56.7%. Most pediatricians (71.2%) reported that they or someone in their practice serves as the primary care coordinator for their children with special needs, but fewer than one fourth (23.3%) always contact the school about the child’s health and educational needs as part of care coordination, only 18.7% always schedule time with the child’s family to discuss the findings of a specialist, and only 23.2% meet with the discharge planning team to facilitate transition from hospital to home. The respondents identified the 2 top barriers that impede this activity: limited time and lack of medical staff in their offices.Conclusions. Although most pediatricians believe that they are providing care coordination services, when asked about specific care coordination activities, such as contacting the school or scheduling time with the family to discuss the findings of a specialist, many do not provide these services.

The parents of 151 children, ages 4-16 years, attending the pediatric outpatient clinic of an urban hospital were surveyed to determine if aggressive behavior among children of low literacy and low-income parents is related to excessive television viewing or to sociological variables such as ethnicity/race, education, occupation, and parents' marital status. The survey consisted of 22 questions about the ethnicity, marital status, education, and occupation of the parent, the television viewing behavior of the child, and the externalizing behavior scale of the Child Behavior Checklist of Achenbach (CBC). The television viewing habits of children in this study were not significantly different from viewing habits reported in national surveys of the US population. T scores in the aggression scale of CBC were unrelated to the hours of television watched by children and the control of viewing by the parent but were significantly associated with the employment and marital status of the mother. Children of unemployed and single mothers had higher externalizing-behavior scores, suggesting that family ecological variables may have more influence on children's behavior than the duration of television viewing.

CASE Marcus is a handsome, sweet, 7½-year-old boy with a significant history of delayed development, specifically in speech and language skills, as well as difficulties with social interactions that have led other specialists to be concerned about a diagnosis of an autism spectrum disorder.He has been seen in our primary care practice since birth. He was born full-term after vaginal delivery weighing 6 pounds, 6 ounces. There were no pregnancy or delivery complications noted. Genetic testing revealed normal chromosomes, fragile X, and microarray testing. Marcus was a picky eater and good sleeper and had delays in toilet training.There is no family history of attention-deficit hyperactivity disorder (ADHD), autism, or substance abuse. Maternal grandmother and mother have a history of learning difficulties, and his father and a paternal uncle have a history of depression and anxiety. Marcus lives in a supportive environment with his mother, father, and sister.Marcus was noted to have significantly delayed language, stuttering, and immediate echolalia as a toddler. Gross and fine motor milestones were met on time, but he did not talk or follow directions until 4 to 5 years old. As a younger child, he would pretend to talk on the phone or mow the grass with a pretend lawn mower, but other household activities were not of interest to Marcus.Currently, he enjoys puzzles, reading, and board games. He likes to play with other children and can interact with familiar adults. Marcus is reported to initiate social interactions, although he has difficulty in understanding personal space. Imaginative play is preferred over other types. He seeks out adult attention and will bring objects over to an adult especially to share his perceived accomplishment. Marcus has difficulty in playing cooperatively with his sister.He is independent with activities of daily living. Marcus is noted to have auditory defensiveness including covering his ears to loud noises and becoming distressed. Parents feel he is immature and inattentive for his age. Marcus responds well when a routine is followed.Previous testing about 2 years ago revealed significant language deficits on the Clinical Evaluation of Language Functioning with average scores on the Woodcock Johnson Achievement Testing and Test of Nonverbal Intelligence Version 3. Marcus was not referred for early intervention and he did not attend preschool. In a regular education Kindergarten, he received speech and occupational therapy along with reading and math support.Comments from teachers or evaluator include the following: Marcus looked to his peers for clues about what he should be doing. Marcus has great difficulty in understanding requests but seems to be interested in pleasing his teacher and others. Marcus' language difficulty makes socialization with his peers problematic; however, he is interested in interacting with them and they seem to accept him willingly. Marcus has intent to communicate with others but relies on visual support to decipher social situations. Marcus has difficulty in attending to details and moves from activity to activity quickly. His short attention span is likely impacting not only learning but also his ability to socially interact with peers.On the day you see him for his 7-year-old checkup, he brought many toys over to show his father and interrupted your conversation to get your attention intermittently throughout the examination. He immediately pointed out a lit ceiling tile with Nemo illuminated to show his father. Marcus does not have any notable or significant repetitive motor mannerisms or stereotypies reported or observed. Marcus' gesture use was appropriate for age and included both symbolic (directing eye gaze and pointing) and concrete (hands up to be picked up and touching an item rather than pointing to it) gestures. Play observed today, although immature for age, was novel, imaginative, and functional. Answers to questions did not always match the question posed. He had a difficult time waiting for his turn before interrupting a conversation. Visual cues were helpful in understanding what was expected of him and what was going on socially.Marcus' speech is notable for persistent stuttering and difficulty in turn-taking in conversation. He gets frustrated easily and has a hard time being understood. He continues to confuse pronouns and makes some grammatical errors. He is able to follow simple directions but has a hard time following complex or multistep directions with accuracy. Nonverbal communication includes pointing to objects of interest in order to share the experience ("Look mom!"). He will point to identify an object and can follow a point across the room. He is able to use his eye contact to direct yours to moderate social interactions.Marcus has a special interest in Thomas the Tank Engine Train and Disney movies but is able to move away from those topics to engage in other play interests. Repetitive behaviors are not noted. Toe walking, hand flapping, or spinning, or unusual hand motions or observation of objects were not observed.Difficulties noted today include delays in his receptive and expressive language, poor intelligibility, dysfluency, and impaired motor planning. He recently underwent an audiogram which was normal. You decide to refer to a specialist for further evaluation.

This commentary argues that a standardized tool such as Autism Diagnostic Observation Schedule (ADOS) is not always required to make the diagnosis of autism, which can be made by obtaining a thorough history and performing an astute clinical examination as William Osler, founder of John Hopkins School of Medicine, taught or Dr. Leo Kanner practiced.

Healthcare seeking behavior is a dynamic process that evolves through the stages of self evaluation of symptoms, self treatment, seeking professional advice and acting on professional advice. (Weaver, 1970) This article explores the influence of culture at each of these stages in the context of Asian Indian culture. Although Asian-Indians constitute only 1.5% of the US population they are among the fastest growing minorities in the United States. Through the example of Asian Indian culture this article informs the clinicians that at the initial visit they should explore what the symptoms mean to the patient and what modalities including complementary and alternative (CAM) were used by the patient to address them and at subsequent visits they should explore how their advise was filtered through the prism of the patient's culture and what was adhered to and what was not. In the case of disability and death the clinicians should explore religious beliefs such as karma that help the patient in coping.

CASE: An 11-year old Asian-Indian boy was recently discovered to have acute myelogenous leukemia. The pediatric hematologist-oncologist arranged a meeting to inform the parents about the diagnosis, prognosis and treatment. The physician planned to include the child in this process. However, the child's father, a computer programmer, made a request that his son should not be informed about the diagnosis of leukemia. The father asked that his son should be told that he has a severe infection and will require intensive treatment. The oncologist then informed the father that, as a physician, she has the responsibility to truthfully disclose the diagnosis to a patient, and she insisted on informing the child about the leukemia in an open and truthful manner.

The American Academy of Pediatrics (AAP) policy statement “Identifying Infants and Young Children With Developmental Disorders: An Algorithm for Developmental Surveillance and Screening” (published in the July issue of Pediatrics ) highlights the importance of ongoing developmental surveillance of all children during preventive care visits.1 Early identification of and intervention for developmental problems improves developmental outcomes and allays parental anxiety.2,3 This is particularly critical in children with autism spectrum disorders (ASDs), who may demonstrate significant developmental gains with early intervention.4,5 Although the average age of diagnosis of ASDs has decreased,6 many children still do not receive a definitive diagnosis of autism until the age of 3½ to 4 years or later.7,8 The policy statement recommends surveillance for developmental problems at all well-child preventive care visits and routine screening with a general screening tool at the 9-, 18-, and 30-month visits, plus screening with an autism-specific tool at the age of 18 months. Although we commend the statement for … Address correspondence to Vidya Bhushan Gupta, MD, 32 Sunset Rd, Demarest, NJ 07627. E-mail: bhushan07627{at}yahoo.com

Background. In 2001, the American Academy of Pediatrics (AAP) adopted a policy that all infants and young children should be screened for developmental delays at regular intervals. The policy statement promoted the use of valid reliable instruments. It is unknown, however, what proportion of pediatricians follow this recommendation and whether such a practice is associated with improved identification of children with developmental difficulties.Objectives. To describe the use of developmental screening tests among board-certified pediatricians practicing general pediatrics and to determine the association between standardized screening and the self-reported identification of children with developmental difficulties.Methods. We mailed a survey to a random sample of AAP members. We used multivariate logistic/linearregression analyses to determine the association between standardized screening and the self-reported identification of children with developmental disabilities.Results. Of the 1617 surveys mailed, 894 were returned, for a response rate of 55%. Of the respondents, 646 practiced general pediatrics and were included in the analysis. Seventy-one percent of those pediatricians indicated that they almost always used clinical assessment without an accompanying screening instrument to identify children with developmental delays. Only 23% indicated that they used a standardized screening instrument. The most commonly used instrument was the Denver II. Logistic regression modeling demonstrated odds ratios between 1.71 and 1.90 for a >10% rate of identification of developmental problems among patients of pediatricians reporting standardized screening. Each adjusted odds ratio bordered on statistical significance. Linear-regression models estimating the difference in mean proportions of children identified with developmental problems across screening groups failed to show a statistically or clinically significant difference in physician-reported identification rates.Conclusions. Our findings indicate that, despite the AAP policy and national efforts to improve developmental screening in the primary care setting, few pediatricians use effective means to screen their patients for developmental problems. It is uncertain whether standardized screening, as it is practiced currently, is associated with an increase in the self-reported identification of children with developmental disabilities.

Objective Early intervention (EI) programs provide services to children with developmental conditions, regardless of whether such children have an underlying medical diagnosis. We aim to (1) Determine the proportion of general pediatricians who believe an established diagnosis is important when considering EI referral; and (2) Determine whether this perception is associated with lower reported likelihood of referral. Methods Mailed survey to random sample of pediatricians. We used multivariable logistic regression to study the association between the perception that a medical diagnosis is important when referring to EI, and the reported likelihood of EI referral for children with common developmental conditions. Results Response rate was 55% (894 of 1617). A total of 64% of respondents considered an established diagnosis important for EI referral. Likelihood of referral for delayed speech was lower among those who considered a diagnosis important than among those who did not (77% vs 87%; P = .02). Similar patterns held for global delay (91% vs 97%; P = .02), loss of developmental milestones (80% vs 88%; P = .03), and parental concern for inappropriate development (45% vs 60%; P = .002). In multivariable models, perception of the importance of an established diagnosis was associated with lower likelihood of referral for children with delayed speech (adjusted odds ratio [aOR] 0.48; 95% confidence interval [CI] 0.26–0.87) and for parental concern for inappropriate development (aOR 0.46; 95% CI 0.30–0.72). Conclusions A majority of general pediatricians believe that an established diagnosis is important when considering EI referral. This perception is associated with decreased reported referral for children with speech delay and those whose parents express concern for inappropriate development.

History, Definition, and Classification of Pervasive Developmental Disorders Vidya B. Gupta The Epidemiology of Autism and Autism Spectrum Disorders Tanya Karapurkar, Nora Lee, Laura Kresch Curran, Craig Newschaffer, and Marshalyn Yeargin-Allsopp Etiology of Autism Vidya B. Gupta Neurological Basis of Autism (Pathophysiology of Autism) Vidya B. Gupta Early Clinical Characteristics of Children with Autism Chris Plauche Johnson Screening and Diagnosis for Autistic Spectrum Disorders Pasquale Accardo Informing, Educating, and Supporting the Family Alfred L. Scherzer Behavioral and Educational Interventions for Young Children with Autism John M. Suozzi Communication Disorders in Children with Autism: Characteristics, Assessment, Treatment Elaine Dolgin Schneider Sensory Integration and Occupational Therapy Intervention for Autistic Spectrum Disorders Pat Stevens, Sallie Tidman, and Kari Glasgow

All the issues raised by Dr Pivalizza are pertinent to developmental surveillance and screening for autism. We agree that access to health care is pivotal to any public health effort. The American Academy of Pediatrics (AAP) is committed to every child's access to a medical home, including children with autism and other developmental disorders.1 The medical home should be linked to an array of specialty services with which children who screen positive for autism can be evaluated to confirm the diagnosis. The child should also be referred to a local early intervention program, coincident with such evaluation.2,3 In the United States, early …

The non-linear visco-elastic behavior of various thermoplastic materials has long ago been established. A vast field, however, remains unexplored, firstly, in finding out workable theories for actual engineering applications with their limits of applicability specified, and secondly, in understanding the physical mechanisms which control the manifestation of non-linear visco elastic behavior in these polymeric materials. An attempt to understand these phenomena has been made by performing 6 hrs isothermal creep tests on unreinforced and glass-fibre reinforced polypropylene samples under uniaxial tension. In the case of the homopolymer, experiments were performed under different stress levels and at various temperatures up to 60 °C. Stress levels were chosen in such a way that maximum strain level always remained below 3%. This was done in order to achieve complete recovery druing the successive recovery cycle. Validity of an equation of the form ε = εo + ε+tn has been tested. It is found that ε o in the above equation is approximately a linear function of stress and is weakly dependent on temperature, whereas ε+ is a non-linear function of stress and is strongly temperature-dependent. The exponent n, however, is a constant independent of both stress and temperature. With incorporation of glass fibers appreciable increase in the modulus and slowing down of time dependent deformation were achieved.