Teaching pediatric residents about early intervention and special education

Post-graduate Medical Training in Intellectual and Developmental Disabilities: a Systematic Review

OBJECTIVE

Despite the increasing number of people with autism-spectrum disorder (ASD), intellectual disabilities (ID), and developmental disabilities (DDs), individuals with these conditions continue to have high levels of unmet physical and mental health needs. Robust training of health professionals can help bridge this gap. A systematic review was conducted to describe the features and educational outcomes of existing postgraduate medical education curricula to inform the development of future training to address the growing unmet care needs of people with intellectual and developmental disabilities (IDD) such as ASD and ID.

METHODS

Four major databases were searched for peer-reviewed, English-language research focusing on post-graduate training in IDD education. Educational curricula and outcomes were summarized including Best Evidence in Medical Education (BEME) Quality of Evidence and Kirkpatrick training evaluation model.

RESULTS

Sixteen studies were identified with a majority published after 2000 (69%). Pediatric departments were involved in 69%, Psychiatry 19%, Medicine-Pediatrics 19%, and Family Medicine 6.3%. Analysis of Kirkpatrick outcomes showed 31% were level 1 (satisfaction or comfort); 38% level 2 (change in objective knowledge or skills); 13% level 3 (change in behavior); and none at level 4. BEME analysis showed 19% of studies were grade 1 (no clear conclusions), 31% grade 2 (ambiguous results), and half (50%) grade 3 (conclusions can probably be based on findings), with none scoring four or higher.

CONCLUSIONS

There is a paucity of objectively evaluated research in the area. Studies reviewed show clear promise for specialized, interdisciplinary, competency-based education which may be foundational for future curriculum development.

The Role of Mentors in Early Intervention Referrals: Overlooked Views of Pediatric Residency Training Directors

Objectives There continues to be a pressing need to increase referrals to family-centered early intervention (EI) for more eligible infants and toddlers with inadequate consideration for the role of senior, mentoring professionals. Methods To address a dearth in our understanding, a subset of Pediatric Residency Training Directors shared views on EI, referral, and relevant training efforts. Results Participating directors primarily reported limited understanding of EI. Greater knowledge of family-focused EI correlated with its perceived helpfulness (r = .420; p = .021), which positively correlated with referring a child to EI. Despite 67% of the sample viewing pediatricians as 'most important' in screenings and EI referrals, residents were perceived as only somewhat aware of EI referral and services, and only somewhat aware of differences between clinic options and Part C EI. Although nearly all respondents noted minimal EI exposure during training, only 43% felt this amount was 'inadequate/insufficient'. The sample was fairly evenly divided in being 'extremely' or 'somewhat' interested in communicating with state EI leaders. Conclusions for Practice This preliminary analysis describes perceptions among senior medical professionals who may influence referrals via mentoring, training, and interdisciplinary collaboration. Findings inform next steps in terms of research, improving education for directors and residents, and collaborative information-sharing to bolster family-centered EI referrals to improve child and family outcomes.

Primary care physicians' knowledge of and confidence in their referrals for special education services in 3- to 5-year-old children

BACKGROUND

Children 3 to 5 years old with developmental delays are eligible for special education services.

OBJECTIVE

To assess primary care physicians' (PCPs) knowledge, attitudes, and practices regarding their referrals to the special education system on behalf of children 3 to 5 years old.

DESIGN/METHODS

Mail survey of 400 office-based general pediatricians and 414 family physicians in Michigan, fielded in fall 2012 and winter 2013, with a response rate of 44%. The 4-page survey included knowledge questions about special education eligibility, PCPs' role in accessing school-based services, and self-confidence in ability to help patients access these services.

RESULTS

PCPs neither fully understood requirements for special education services nor were they very confident in identifying 3- to 5-year-old children eligible for special education services.

CONCLUSIONS

PCPs recognize interacting with special education as a relative weakness, and they may be accepting of interventions to improve their knowledge and skills.

Approaches to enhancing the early detection of autism spectrum disorders: a systematic review of the literature

BACKGROUND

A reliable diagnosis of autism can be made as early as 24 months, yet in many children diagnoses are made much later. A delay in diagnosis translates into a missed opportunity to provide early intervention services and to improve outcomes. The aim of the current study was to review the literature on early detection approaches in primary care and other community settings in the United States.

METHODS

A search was conducted of the peer-reviewed and gray literature to identify studies published from January 1990 through January 2013 testing approaches to enhance the early detection of autism in community settings in the United States.

RESULTS

The search identified 40 studies describing 35 approaches, which were grouped into the following categories: awareness (n = 4), routine screening (n = 21), and practice improvement to enhance screening (n = 10). Awareness approaches were associated with positive changes in knowledge of autism-related topics. Routine screening yielded high or increased rates of screening and referrals; however, few studies assessed the effect of screening on age at diagnosis or services enrollment. Practice improvement approaches resulted in increased screening and referral rates and highlighted the importance of adopting a multipronged approach to enhance early detection.

CONCLUSIONS

Although studies that tested screening approaches in community settings found positive results, the effectiveness of such efforts on reducing time to diagnosis and services enrollment remains largely untested. The fact that few studies reported outcomes beyond rates of referral indicates the need for enhanced methodological rigor, particularly with respect to length of follow-up and quality of measures used.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

Comparison of methods for teaching developmental milestones to pediatric residents

BACKGROUND

Interactive media are effective tools in teaching and allow for self-directed study, which develops skills for life-long learning among health professionals. With this type of study, the learner can review material at his/her own pace and target areas that require emphasis. Pediatric residents require an accurate understanding of developmental milestones in children of various ages and their normal variations. The best representation of developmental milestones requires video recordings of children demonstrating appropriate skills. However, such recordings are not always available, so printed materials are most often used. In this realm, a computer-based interactive learning tool using animated cartoons gives flexibility for presentation using drawings. We compared pediatric residents' knowledge of developmental milestones in neonates to 5-year-olds before and after study with either an interactive DVD or paper-based materials.

METHODS

A team of physicians and educational specialists in Texas Tech University Health Sciences Center produced an interactive DVD containing animated cartoons and questions. Residents were divided into an intervention group that used the DVD and a control group that used traditional paper-based materials. Each group's improvement [or increase] in knowledge was measured.

RESULTS

Compared with the 17 residents in the control group, the 37 in the intervention group tended to acquire more knowledge about developmental milestones. The mean scores at T1, T2, and T3 doubled from the initial scores in the intervention group, while no difference was observed in the control group.

CONCLUSION

An interactive educational DVD can be an effective supplement to improve residents' knowledge of developmental milestones.

Improving developmental screening in pediatric resident education

OBJECTIVE

Given that pediatricians cite low competency in developmental screening, this study aims to effectively teach screening to residents.

DESIGN

Using a quasi-experimental design, residents received an educational module and one-on-one teaching of 3 validated developmental screeners (Denver II, ASQ [Ages and Stages Questionnaire], and PEDS [Parents' Evaluation of Developmental Status]), with subsequent independent use with all 3 screeners with their own continuity patients. Outcome measures included changes in knowledge, skills, and preferences.

RESULTS

All residents achieved significantly increased skills with all screeners. They strongly preferred the ASQ (70%), citing that this taught them normal (30.2%) and pathological (27.9%) development while negatively noting time (72.1%), scheduling issues (30.2%), and difficulties with child cooperation (20.9%). Knowledge specifics did not significantly increase.

CONCLUSIONS

In-depth developmental screening education revealed marked improvement in skills and preferences. These evaluations led to full adoption of the ASQ in resident clinics. Future research must test if effective development teaching in residency leads to increased routine screenings in practice.

A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations

BACKGROUND

There is growing interest in the use of cognitive, behavioural, and organisational theories in implementation research. However, the extent of use of theory in implementation research is uncertain.

METHODS

We conducted a systematic review of use of theory in 235 rigorous evaluations of guideline dissemination and implementation studies published between 1966 and 1998. Use of theory was classified according to type of use (explicitly theory based, some conceptual basis, and theoretical construct used) and stage of use (choice/design of intervention, process/mediators/moderators, and post hoc/explanation).

RESULTS

Fifty-three of 235 studies (22.5%) were judged to have employed theories, including 14 studies that explicitly used theory. The majority of studies (n = 42) used only one theory; the maximum number of theories employed by any study was three. Twenty-five different theories were used. A small number of theories accounted for the majority of theory use including PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation), diffusion of innovations, information overload and social marketing (academic detailing).

CONCLUSIONS

There was poor justification of choice of intervention and use of theory in implementation research in the identified studies until at least 1998. Future research should explicitly identify the justification for the interventions. Greater use of explicit theory to understand barriers, design interventions, and explore mediating pathways and moderators is needed to advance the science of implementation research.

Resident training in developmental/behavioral pediatrics: where do we stand?

Approximately 25% to 30% of all complaints to a general pediatrician are developmental or behavioral in origin. Despite this, residency education in developmental/behavioral pediatrics has consistently been rated poorly. Changes were set forth in 1997 to include a mandatory 1-month block rotation in developmental/behavioral pediatrics. This study was a nationwide, cross-sectional, self-administered, mailed survey of pediatricians who completed residency either before or after these changes went into effect. Overall, pediatricians' comfort level in developmental/behavioral pediatrics was unchanged in the 2 groups. Certain areas (behavior problems, learning disabilities, sleep, and depression/anxiety) of developmental/behavioral pediatrics had lower comfort scores. Our data provide direction for the ongoing refinement of pediatric education that is based on feedback from currently practicing pediatricians.

Use of an electronic record audit to enhance mental health training for pediatric residents

BACKGROUND

Increased emphasis has been placed in pediatric residency programs on the identification and treatment of child mental health disorders.

DESCRIPTION

An electronic record audit was developed to assess residents' behavioral health skills and optimize behavioral health training. Information from the electronic audit was used to provide feedback to preceptors, modify the training curriculum, and increase access to mental health referrals.

EVALUATION

The audit determined the frequency of detected mental health problems, types of disorders identified, use of screening instruments, and behavioral health interventions and/or referrals by pediatric residents over a 2-year period. However, measurement of the effectiveness of curriculum and training interventions was undetermined due to the evolving implementation of changes based on continuous audit findings.

CONCLUSIONS

Recommendations for future use of this technique include establishing baseline skills and targeting specific areas for training and evaluation, providing feedback to residents, and tracking specific patients over time.

Effectiveness of an Educational Intervention in Oral Health for Pediatric Residents

OBJECTIVE

To evaluate the effectiveness of an oral health educational intervention designed to increase proficiency of pediatric residents in oral health.

METHODS

Pediatric residents at the University of North Carolina at Chapel Hill (UNC) participated in oral health education that included didactic sessions, hands-on instruction by pediatric dentists and residents, preventive dentistry prompts, and change strategies to introduce oral health into practice. Pediatric residents at East Carolina University (ECU), who had a short practicum in oral health, and Wake Forest University (WFU), who had no specific oral health instruction, served as comparison groups. All residents completed questionnaires before and 12 months after instruction began at UNC. Effects were tested for each school separately by repeated-measure analysis of variance.

RESULTS

The mean percentage of UNC residents who answered 18 knowledge questions correctly and reported frequently performing 10 preventive dental practices increased by 17.7% and 65.1%, respectively, from baseline levels. Residents' confidence in performing 10 counseling and oral health screening activities improved by 17.9%. Opinions about including oral health in their clinical care improved only slightly. Changes at ECU and WFU were small, but low response rates in those schools preclude substantive conclusions from between schools comparisons.

CONCLUSIONS

Multifaceted instruction in oral health was effective in improving pediatric residents' knowledge about oral health, their confidence in providing oral health services, and the delivery of these services in their ambulatory care practices. Residents also adopted the use of fluoride varnish, an innovation in pediatrics. More studies are needed to define the most efficient and effective residency-based instruction.

Improving the early detection of children with subtle developmental problems

This article briefly reviews the recent literature identifying the possible reasons why children with subtle developmental problems are passing through health care systems undetected. It offers some explanations as to why consequently, in many Western societies, a large number of these children are not identified by health professionals until they reach school age. Early identification is one of the challenges facing health visitors or child health nurses, and it is suggested that if they can utilize the knowledge and experience of parents, the opportunities for early identification and intervention would be dramatically improved.

An innovative curriculum for primary care neonatology

This article describes the design of an innovative curriculum for pediatric residency newborn nursery rotation. In 1989, the Accreditation Committee for Graduate Medical Education added the requirement of newborn care to pediatric residency training; in 1996, the Accreditation Committee for Graduate Medical Education expanded that requirement. Specifically, certification required 4 weeks of newborn care, separate from any neonatal intensive care experience, and with at least 2 weeks in a newborn nursery. In response, we designed a structured newborn nursery curriculum for our pediatric residency training program. Three areas of focus were identified, from which the content and the strategies for teaching were derived. The areas of focus were (1). primary care, (2). confluence of levels of care that arise in newborn care, and (3). limitations and advantages of the structure and the environment of the rotation. The curriculum was implemented on a pediatric level 1 (PL-1) rotation entitled "primary care neonatology."

Assessing quality and costs of education in the ambulatory setting: a review of the literature

PURPOSE

Time-pressured interactions with little direct observation or feedback characterize teaching in ambulatory settings. The authors report findings from the literature on teaching and learning in the ambulatory setting and propose opportunities for further research that addresses these barriers.

METHOD

The authors searched 1995-1999 databases for all empirical studies that focused on research conducted in ambulatory settings. Publications were reviewed for evidence of inclusion criteria. Findings were sorted into categories previously described for defining and evaluating quality of ambulatory care educational programs.

RESULTS

Most studies were conducted in departments of internal medicine (40%), focused on medical students (43%), and took place in a single program (77%), making generalizations difficult. Students and residents are learning in ambulatory environments, and the types of patients they encounter are likely to prepare them for practice. Patient care outcomes have emerged as a measure of learning. Teachers may be the single most important factor, yet they lack self-confidence as teachers. Community-based preceptors teach because of enjoyment of teaching and the opportunity to stay current. However, none of the studies addressed the impact of the Medicare documentation requirements on satisfaction with teaching. Teaching settings cost about one third more than non-teaching settings to operate.

CONCLUSION

This review identifies many gaps in our knowledge of effective clinical teaching practices, and of learning environments in which that teaching takes place. The predominance of single-institution studies limits generalizability of current findings. A prioritized research agenda should be established and funded, focusing on improving the efficiency and effectiveness of teaching and learning in ambulatory settings.