Using genograms to understand pediatric practices' readiness for change to prevent abuse and neglect

The genogram as a recruitment tool for identifying primary caregivers of youth living with sickle cell disease preparing for transition

AIMS

The purpose of this secondary analysis was to describe the impact of using genograms to identify family caregivers from an original research study which used family caregiver-adolescents/young adults (AYA) dyads.

BACKGROUND

Research to improve transition preparation for AYA with chronic disease is essential as 90% will survive into adulthood. Family-based transition research is specifically needed as a majority of transition preparation will occur in the home setting. Dyadic research on transition has not previously described strategies for recruiting appropriate family caregivers.

DESIGN

A descriptive, secondary analysis was conducted using genograms developed during the original study conducted between October 2019 and February 2020.

METHODS

For this secondary analysis conducted between July 2020 and August 2021, 50 genograms were analysed using descriptive statistics to describe family structures, relationships and responsibilities in families of AYAs living with sickle cell disease.

RESULTS

In 43 genograms, there was only one primary caregiver in the family. In seven genograms, there were multiple primary caregivers who met the inclusion criteria for primary caregiver in a single family. In five genograms, there were two appropriate primary caregivers in a single family, and in two genograms, there were three appropriate individuals in a single family who met study criteria as a primary caregiver.

CONCLUSIONS

Findings from the analysis of the genograms used in the original study demonstrated potential ability to improve on dyad recruitment by more specifically identifying the family member most involved in supporting the AYA's disease management.

IMPACT

Genograms are an established tool for gathering information on families and application with recruitment could improve research in the realm of transition and other family-based research.

NO PATIENT OR PUBLIC CONTRIBUTION

This was a secondary analysis that assessed already existing data.

Integrating childhood obesity resources into the patient-centered medical home: Provider perspectives in the United States

Pediatric primary care providers play a critical role in managing obesity yet often lack the resources and support systems to provide effective care to children with obesity. The objective of this study was to identify system-level barriers to managing obesity and resources desired to better managing obesity from the perspective of pediatric primary care providers. A 64-item survey was electronically administered to 159 primary care providers from 26 practices within a large pediatric primary care network. Bivariate analyses were performed to compare survey responses based on provider and practice characteristics. Also factor analysis was conducted to determine key constructs that effect pediatric interventions for obesity. Survey response rate was 69% ( n = 109), with the majority of respondents being female (77%), physicians (67%), and without prior training in obesity management (74%). Time constraints during well visits (86%) and lack of ancillary staff (82%) were the most frequently reported barriers to obesity management. Information on community resources (99%), an on-site dietitian (96%), and patient educational materials (94%) were most frequently identified as potentially helpful for management of obesity in the primary care setting. Providers who desired more ancillary staff were significantly more likely to practice in clinics with a higher percentage of obese, Medicaid, and Hispanic patients. Integrating ancillary lifestyle expert support into primary care practices and connecting primary care practices to community organizations may be a successful strategy for assisting primary care providers with managing childhood obesity, especially among vulnerable populations.

Child Abuse and Neglect Risk Assessment: Quality Improvement in a Primary Care Setting

OBJECTIVES

Practicing Safety is an American Academy of Pediatrics toolkit to help practices address child abuse and neglect (CAN) risk by increasing screening and providing resources. The objectives in an urban practice serving low-income children were to 1) standardize CAN risk assessment and developmental screening, and 2) improve resource provision.

METHODS

A quality improvement initiative to standardize CAN risk assessment, using materials adapted from Practicing Safety, was conducted through the use of SmartTools in an electronic health record. The Edinburgh Postnatal Depression Scale and Parents Evaluation of Developmental Status were used to assess maternal depression and child development, respectively. Charts were reviewed in waves-pre-, immediate post-, and early post-implementation (waves 1 to 3); monthly for 6 months (waves 4 to 9); and quarterly for 12 months (waves 10 to 13)-to assess screening and resource provision for 6 domains: infant crying, maternal depression, development, discipline, temper tantrums, and toilet training.

RESULTS

A total of 581 charts were reviewed (92, 95, and 94 for waves 1 to 3, respectively; 30 each for waves 4 to 13). Screening for infant crying, maternal depression, development, and discipline rose from 0% pre-implementation to over 50% post-implementation. Screening for temper tantrums and toilet training rose from 6% to 72% and from 36% to 82%, respectively. For all measures, resource provision improved over time, and all improvements were maintained for 1.5 years post-implementation.

CONCLUSIONS

Incorporating an adapted version of Practicing Safety into an electronic health record is a practical and effective approach to improving CAN risk assessment and resource provision. This quality improvement initiative is an example of a practice-wide improvement that resulted in clinical practice change.

Practicing safety: a quality improvement intervention to test tools to enhance pediatric psychosocial care for children 0-3 years

BACKGROUND

Child maltreatment is a significant public health issue in the United States. Yet, fewer than half of pediatricians discuss behavioral, developmental, or parenting issues with parents.

OBJECTIVE

This paper describes the testing of bundles of tools and processes, part of a larger intervention, Practicing Safety, targeted at changing physician and staff behavior to identify families at risk for child maltreatment, provide anticipatory guidance, refer to community resources, and follow-up and track at-risk families. The intervention was implemented with 14 pediatric primary care practices throughout the United States; the study was completed in 2011.

METHODS

A within-subjects repeated measures pre-post follow-up design was used to evaluate the intervention. Baseline and repeated measurements of pediatric practices' processes were collected using qualitative and quantitative methods. In total, 14 core improvement teams from across the country tested three bundles of tools (maternal, infant, toddler) within a quality improvement framework over seven months.

RESULTS

Quantitative results showed statistically significant adoption of tools and processes and enhancement of practice behaviors and office environmental supports. The increase in tool use was immediate and was sustained for six months after implementation. Qualitative data provided insight as to how meaningful the intervention was to the core improvement teams, especially with more complicated behaviors (eg, engaging social workers or community agencies for referrals). Barriers included lack of community resources. Findings showed unanticipated outcomes such as helping practices to become medical homes.

CONCLUSION

Lessons learned included that practices appreciate and can adopt brief interventions that have meaningful and useful tools and process to enhance psychosocial care for children 0-3 and that do not place a burden on pediatric practice. An innovative, quality improvement strategy, intuitive to pediatricians, with a brief intervention may help prevent child maltreatment.

DEGRADATION OF PARENTAL BONDING AND VIOLENCE AGAINST CHILDREN: THE USE OF FAMILY GENOGRAM IN THE PEDIATRIC CLINIC

Objective:

To demonstrate the importance of using the family genogram in pediatric consultation, as an analysis tool to evaluate the degradation of parental bonding and also violence against children.

Methods:

A qualitative study was conducted in 2011 wherein 63 children, aged between 2 and 6 years, enrolled in a slum nursery, was studied. In order to construct the genogram, data were collected in four stages: pediatric evaluation at nursery; interview with caregivers; interview with teachers; and interview with the nursery coordinator. The data about the families were used to construct the genograms with the aid of GenoPro^®-2016 software. In order to evaluate the quality of bonding, the following items were included in the genograms: violence against children, drug addiction, neglect, mental disorder, type of relationship among family members.

Results:

The evaluated children and their families generated 55 genograms. In 38 of them, functional family arrangements, and close or very close emotional ties were observed. In 17 cases, situations involving physical, emotional, or sexual violence against children were perceived. Among these, four represented extreme cases, with fraying parental bonding, and dysfunctional family arrangements. In these families, chemical addiction was prevalent among multiple members, as well as severe mental disorder, persistent physical and verbal abuse, and sexual abuse.

Conclusions:

The use of the genogram helps to identify at an early stage the degradation of parental bonding and violence against children, and when it is incorporated into the pediatric practice routine, it may contribute to the promotion of the comprehensive health care of the child, regardless of the presence of social vulnerability.

Pediatrician preferences, local resources, and economic factors influence referral to a subspecialty access clinic

BACKGROUND

Pediatric patients seek timely access to subspecialty care within a complex delivery system while facing barriers: distance, economics, and clinician shortages. Aim We examined stakeholder perceptions about solutions to the access challenge. We engaged over 300 referring primary care pediatricians in the evaluation of Access Clinics at an academic children's hospital.

METHODS

Using an anonymous online survey, we asked pediatricians about their and their patients' experiences and analyzed factors that may influence referrals. Findings Referring pediatricians reported satisfaction; they provided feedback about their patients' experiences, physician communication, and referral influences. Distance from the Access Clinic does not correlate with differences in referral volume; living in areas with higher child populations and higher median income is associated with more referrals. Referring pediatricians have strong opinions about referrals, are attuned to patient experiences, and desire bi-directional communication. Multiple factors influence referral to and acceptance of Access Clinics, but external influences have less impact than expected.