Healthy Steps for Young Children: sustained results at 5.5 years

Pediatric Mental Health Prevention Programs in Primary Care

Children's mental health problems are pressing social, economic, and public health concerns in the U.S. While pediatric primary care offers important venues to integrate mental health services for children and their families, new challenges, including widening educational, economic, and health disparities in the context of structural racism and COVID-related social isolation, underscore the need for innovative approaches. The authors reviewed 6 innovative methods in pediatric care that have helped address these issues and amplify intervention efforts focused on children's mental health. Limitations and future directions for research and clinical practice in pediatric mental health services are also discussed.

A Brief Intervention in Primary Care to Improve Parents' Discipline Practices and Reach Other Caregivers

Parents (N = 599) of 6-month-old to 10-year-old children were given a handbook intervention that educates about healthy discipline in a pediatric clinic serving low-income families in Nashville, Tennessee. A research assistant spent approximately 1 minute introducing the intervention. A total of 440 parents (73.4%) responded to a follow-up survey 2 to 4 months later. Most parents (88%) who completed the follow-up survey had read at least part of the handbook. Of parents who received the handbook, 63% reported that the handbook helped them discipline their children. Half of parents reported specific changes they made because of the handbook. The most frequently reported changes were more talking/explaining/communicating (25%), more redirecting (7.8%), more patience/listening (6.0%), less anger/yelling (10.8%), and less spanking (7.5%). 42% of parents reported that they shared the handbook with other caregivers, friends, relatives, and children. A brief clinic intervention improves parents' discipline practices and reaches other caregivers.

Integrating community health workers in early childhood well-child care: a statement from the Pediatric Academic Societies Maternal Child Health: First 1,000 days Special Interest Group

This statement from the Pediatric Academic Societies Maternal Child Health: First 1,000 Days Special Interest Group provides an overview of the rationale, evidence, and key action steps needed to engage Community Health Workers (CHWs) into team-based well-child care (WCC) for families in low-income communities. CHWs have been defined as public health workers who have a trusted and valued connection to a community. Integrating CHWs into early childhood WCC can allow for greater cultural relevancy for families, reduce the burden on clinicians to provide the wide range of WCC services, many of which do not require the expertise of a high-level clinician, and improve preventive care services to families during the vulnerable but critical period of early childhood. There are evidence-based approaches to integrating CHWs into early childhood WCC, as well as payment models that can support them. Implementation and spread of these models will require collaboration and engagement across health systems, clinics, payors, and CHWs; flexibility for local adaptation of these models to meet the needs of clinics, practices, CHWs, and communities; publicly available training resources for CHW education; and research findings to guide effective implementation that incorporates parent and caregiver engagement as well as sustainable payment models.

Improving electronic health record documentation and use to promote evidence-based pediatric care

OBJECTIVE

Electronic health records (EHRs) often lack the necessary functionalities to support the full implementation of national clinical guidelines for pediatric care outlined in the American Academy of Pediatrics Bright Futures Guidelines. Using HealthySteps (HS), an evidence-based pediatric primary care program, as an exemplar, this study aimed to enhance pediatric EHRs, identify facilitators and barriers to EHR enhancements, and improve data quality for delivering clinical care as part of HS implementation and evidence building.

METHODS

Three HS sites-each differing in location, setting, number of children served, and mix of child insurance coverage-participated in the study. Sites received technical assistance to support data collection and EHR updates. A comprehensive evaluation, including a process evaluation and outcomes monitoring, was conducted to gauge progress toward implementing study data requirements over time. Data sources included administrative records, surveys, and interviews.

RESULTS

All sites enhanced their EHRs yet relied on supplemental data systems to track care coordination. Sites improved documentation of required data, demonstrating reductions in missing data and increases in extractable data between baseline and follow-up assessments. For example, the percentage of missing social-emotional screening results ranged from 0% to 8.0% at study conclusion. Facilitators and barriers to EHR enhancements included organizational supports, leadership, and capacity building.

CONCLUSIONS

With significant investment of time and resources, practices modified their EHRs to better capture services aligned with HS and Bright Futures. However, more scalable digital solutions are necessary to support EHR updates to help drive improvements in clinical care and outcomes for children and families.

Early Childhood Screening Practices and Barriers: A National Survey of Primary Care Pediatricians

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends screening during the first 3 years of life for developmental risk/delay, maternal depression, and social determinants of health (SDOH) using standardized tools. Adoption of these guidelines has been gradual, and barriers to screening are as varied as pediatric practices are themselves.

METHODS

We analyzed 2019 American Academy of Pediatrics Periodic Survey data. The survey included pediatricians' screening practices for developmental delay, maternal depression, and SDOH, and barriers to screening. We used Cochran's Q and McNemar's tests to compare barriers across topics, and χ2 tests and multivariable logistic regression to examine the relationship between barriers and screening practices.

RESULTS

The survey response rate was 46.9% (n = 688). Most pediatricians reported screening/surveilling for developmental delay (98.1%), maternal depression (83.2%), and SDOH (76.7%), but fewer used standardized instruments to do so (59.0%, 44.9%, 12.6%, respectively). Those not screening/only surveilling for maternal depression were more likely to report that screening is not an appropriate role for the pediatrician and difficulty prioritizing time. For SDOH, those not screening/only surveilling were more likely to report instruments not available in the electronic health record, lack of knowledge regarding referral options, and lack of treatment options for positive screens.

CONCLUSIONS

Rates of standardized screening, and barriers pediatricians encounter, have important implications for improving quality of early childhood preventive care. Opportunities include expanding the primary care team and integrating screening tools into the electronic health record. Programs to support social needs and maternal mental health could be strengthened to ensure robust referral options are available.

Widening Our Lane: How Child and Adolescent Psychiatrists Can Embrace the Full Spectrum of Mental Health

The majority of a psychiatrist's training and clinical attention is devoted to mental illness rather than mental health. This article suggests a broader understanding and application of mental well-being that can benefit both those already struggling with mental health challenges and those trying to stay well. Recommendations for being a well-being-oriented psychiatrist include increasing one's knowledge about well-being and health promotion and adjusting one's practice to incorporate these principles. Recommendations at the level of the field of psychiatry include revising the definition of a psychiatrist, increasing research on well-being and health promotion, improving financial incentives, expanding efforts in schools and community settings, and providing additional training.

A Two-Generation, Early Childhood Advanced Primary Care Model

It is well recognized that early experiences produce long-term impacts on health outcomes, yet many children are at risk of not achieving their full potential because of health and service disparities related largely to poverty and racism. Although many pediatric primary care (PPC) models address these needs, most are isolated, add-on efforts that struggle to be scalable and sustainable. We describe 3-2-1 IMPACT (Integrated Model for Parents and Children Together), an initiative to transform the model of PPC delivered within New York City Health + Hospitals, the largest public hospital system in the United States, to address the full range of child and family needs in early childhood. Taking advantage of the frequent contact with PPC in the early years and linking to prenatal services, the model assesses family mental, social, and physical health needs and offers evidence-based parenting supports and integrated mental health services. Launching and sustaining the model in our large health system has required coalition building and sustained advocacy at the state, city, and health system levels. Long-term sustainability of the IMPACT model will depend on the implementation of early childhood-focused advanced payment models, on which we have made substantial progress with our major contracted Medicaid managed care plans. By integrating multiple interventions into PPC and prenatal care across a large public-healthcare system, we hope to synergize evidence-based and evidence-informed interventions that individually have relatively small effect sizes, but combined, could substantially improve child and maternal health outcomes and positively impact health disparities.

Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences.

Objective

To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force.

Data Sources

PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023.

Study Selection

English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment.

Data Extraction and Synthesis

Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.

Main Outcomes and Measures

Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms.

Results

Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health.

Conclusion and Relevance

The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.

Integrating equifinality and multifinality into the of prevention programs in early childhood: The conceptual case for use of tiered models

Introduced in the context of developmental psychopathology by Cicchetti and Rogosh in the Journal, the current paper incorporates the principles of equifinality and multifinality to support the use of tiered models to prevent the development of emerging child psychopathology and promote school readiness in early childhood. We use the principles of equifinality and multifinality to describe the limitations of applying one intervention model to address all children presenting with different types of risk for early problem behavior. We then describe the potential benefits of applying a tiered model for having impacts at the population level and two initial applications of this approach during early childhood. The first of these tiered models, Smart Beginnings, integrates the use of two evidenced-based preventive interventions, Video Interaction Project, a universal parenting program, and Family Check-Up, a selective parenting program. Building on the strengths of Smart Beginnings, the second trial, The Pittsburgh Study includes Video Interaction Project and Family Check-Up, and other more and less-intensive programs to address the spectrum of challenges facing parents of young children. Findings from these two projects are discussed with their implications for developing tiered models to support children's early development and mental health.

Policy solutions to eliminate racial and ethnic child health disparities in the USA

Societal systems act individually and in combination to create and perpetuate structural racism through both policies and practices at the local, state, and federal levels, which, in turn, generate racial and ethnic health disparities. Both current and historical policy approaches across multiple sectors-including housing, employment, health insurance, immigration, and criminal legal-have the potential to affect child health equity. Such policies must be considered with a focus on structural racism to understand which have the potential to eliminate or at least attenuate disparities. Policy efforts that do not directly address structural racism will not achieve equity and instead worsen gaps and existing disparities in access and quality-thereby continuing to perpetuate a two-tier system dictated by racism. In Paper 2 of this Series, we build on Paper 1's summary of existing disparities in health-care delivery and highlight policies within multiple sectors that can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritised children.

Provider Perspectives on an Integrated Behavioral Health Prevention Approach in Pediatric Primary Care

The purpose of this study was to use qualitative interviews to ascertain the perspective of pediatric primary care providers on the implementation of Integrated Behavioral Health (IBH) as provided by psychologists within an expanded HealthySteps™ model, and with a particular focus on prevention of behavioral health symptoms in the first five years. A semi-structured interview guide was used to assess medical providers' perceptions of behavioral health integration into their primary care clinics. A conventional qualitative content analysis approach was utilized to identify patterns of meaning across qualitative interviews. Four themes were identified: (1) practice prior to IBH and initial concerns about integration, (2) psychologist's role and perceived added value, (3) what integration looks like in practice, and (4) perceived families' response to and experiences with IBH. Despite initial concerns about potential disruptions to clinic flow, providers indicated that adoption of IBH was seamless. The distinct roles of the psychologist were clear, and both treatment and prevention services provided by IBH were valued. Multidisciplinary collaboration and real-time response to family needs was seen as especially important and primary care providers reported that families were accepting of and highly valued IBH.

Parents' Preferences for Primary Care-Based Behavioral Services and the COVID-19 Pandemic: A Mixed Method Study

OBJECTIVE

This study examined how family factors impacted parents' attitudes toward integrated behavioral health (IBH) in pediatric primary care during the COVID-19 pandemic. We hypothesized that COVID-19 impact would predict family functioning challenges, and that pre-existing familial contextual factors would predict parents' interest in IBH modalities.

METHODS

Parents of children ages 1.5-5 years (N = 301) from five primary care clinics completed a survey with measures assessing familial contextual factors (income, race and ethnicity, and parents' childhood adversity), COVID-19 impact on family relationships and wellbeing, family functioning (child behavior, parenting self-efficacy, and parent psychological functioning), and parents' preferences for behavioral support in primary care. A subsample of parents (n = 23) completed qualitative interviews to provide deeper insights into quantitative relationships.

RESULTS

Higher COVID-19 impact was significantly associated with worse parent mental health and child behavior problems, as well as lower interest in IBH virtual support options. Overall, lower SES and racial and/or ethnic minority parents both indicated greater interest in IBH modalities compared to higher SES and White parents, respectively. Qualitative interviews identified how pandemic stressors led to increases in parents' desire for behavioral support from pediatricians, with parents sharing perspectives on the nature of support they desired, including proactive communication from providers and variety and flexibility in the behavioral supports offered.

CONCLUSIONS

Findings have important implications for the provision of behavioral supports for families in primary care, underlying the need to increase parents' access to IBH services by proactively providing evidence-based resources and continuing to offer telehealth support.

Early parenting interventions to prevent internalising problems in children and adolescents: a global systematic review and network meta-analysis

QUESTION

We compared the effectiveness of different types of parenting interventions based on an a priori taxonomy, and the impact of waitlists versus treatment as usual (TAU), in reducing child internalising problems.

STUDY SELECTION AND ANALYSIS

We conducted a systematic review and network meta-analysis of published and unpublished randomised controlled trials (RCTs) until 1 October 2022 that investigated parenting interventions with children younger than 4 years.

EXCLUSION CRITERIA

studies with children born preterm, with intellectual disabilities, or families receiving support for current abuse, neglect, and substance misuse. We assessed the certainty of evidence using the Confidence in Network Meta-Analysis framework. We used random-effects network meta-analysis to estimate standardised mean differences (SMDs) with 95% credible intervals (CrIs).

FINDINGS

Of 20 520 citations identified, 59 RCTs (18 349 participants) were eligible for the network meta-analysis. Parenting interventions focusing on the dyadic relationship (SMD: -0.26, 95% CrI: -0.43 to -0.08) and those with mixed focus (-0.09, -0.17 to -0.02) were more effective in reducing internalising problems than TAU at the first time point available. All interventions were more effective than waitlist, which increased the risk of internalising problems compared with TAU (0.36, 0.19 to 0.52). All effects attenuated at later follow-ups. Most studies were rated as with 'high risk' or 'some concerns' using the Risk of Bias Assessment Tool V.2. There was no strong evidence of effect modification by theoretically informed components or modifiers.

CONCLUSIONS

We found preliminary evidence that relationship-focused and mixed parenting interventions were effective in reducing child internalising problems, and the waitlist comparator increased internalising problems with implications for waiting times between referral and support. Considering the high risk of bias of most studies included, the findings from this meta-analysis should be interpreted with caution. PROSPERO registration number CRD42020172251.

Military HealthySteps Pilot Program Outcome Study

INTRODUCTION

Military families face many unique challenges, including frequent separations, demanding work hours, and relocations. The HealthySteps (HS) program may offset these challenges utilizing the expertise of a nonclinical child development specialist called a HS specialist who offers enhanced well-child visits (WCVs), support between visits, and connections to community resources. Our study sought to identify the impact of the military HS pilot program on the timeliness of WCVs, immunizations, routine behavioral and developmental screenings, and referrals to community resources within the first 15 months of life (MOL).

MATERIALS AND METHODS

We retrospectively reviewed charts of 26 HS-enrolled and 26 randomly selected age-matched non-HS-enrolled children from age 2 to 15 MOL. Demographic variables obtained include child's gender, child's birth order, mother's age, active duty parent's rank classification, and active duty parent's gender. We examined five outcomes measures aligning with the American Academy of Pediatrics health supervision, immunization, and screening recommendations and National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set measures: (1) completed six or more WCVs in the first 15 MOL, (2) completed developmental screening at the 9-month WCV, (3) up to date on vaccinations at 15 MOL, (4) completed three or more postpartum depression (PPD) screens in the first 6 MOL, and (5) the total number of documented referrals to community resources within the first 15 MOL. Chi-square analysis and independent t-tests were used to compare the groups.

RESULTS

There was no statistical significance (P > .05) between the HS-enrolled and control groups for all five demographic variables. A significantly higher percentage of children in the HS-enrolled group received PPD screening compared to the control group (96% vs. 73.1%, P = .021). The HS-enrolled group had a higher mean number of community resource referrals at 15 MOL of 2.46 (SD = 1.14) vs. the control group with a mean of 0.19 (SD = 0.49). None of the other outcomes showed a statistically significant difference between groups.

CONCLUSIONS

The results of this study indicate the positive impacts of the military HS program on referrals to community resources and PPD screening, reflecting the HS specialist focus on the family unit. Limitations of this study include the small population size and limited demographic information resulting from the retrospective nature of the study and pilot status of the HS program. Larger prospective studies are needed to clarify the true impact of the HS program in the military health system.

Addressing Structural Racism in Pediatric Clinical Practice

Structural racism is the inequitable allocation of various social determinants of health to different communities. Exposure to this and other discrimination levied from intersectional identities is the primary driver of disproportionately adverse health outcomes for minoritized children and their families. Pediatric clinicians must vigilantly identify and mitigate racism in health care systems and delivery, assess for any impact of patient and family exposure to racism and direct them to appropriate health resources, foster an environment of inclusion and respect, and ensure that all care is delivered through a race-conscious lens with the utmost cultural humility and shared decision-making.

Community Health Workers in Early Childhood Well-Child Care for Medicaid-Insured Children: A Randomized Clinical Trial

Importance

An intervention model (the Parent-focused Redesign for Encounters, Newborns to Toddlers; the PARENT intervention) for well-child care that integrates a community health worker into preventive care services may enhance early childhood well-child care.

Objective

To examine the effectiveness of the PARENT intervention vs usual care for parents with children younger than 2 years of age.

Design, Setting, and Participants

A cluster randomized clinical trial was conducted between March 2019 and July 2022. Of the 1283 parents with a child younger than 2 years of age presenting for a well-child visit at 1 of the 10 clinic sites (2 federally qualified health centers in California and Washington) approached for trial participation, 937 were enrolled.

Intervention

Five clinics implemented the PARENT intervention, which is a team-based approach to care that uses a community health worker in the role of a coach (ie, health educator) as part of the well-child care team to provide comprehensive preventive services, and 5 clinics provided usual care.

Main Outcomes and Measures

There were 2 primary outcomes: score for parent-reported receipt of recommended anticipatory guidance during well-child visits (score range, 0-100) and emergency department (ED) use (proportion with ≥2 ED visits). The secondary outcomes included psychosocial screening, developmental screening, health care use, and parent-reported experiences of care.

Results

Of the 937 parents who were enrolled, 914 remained eligible to participate (n = 438 in the intervention group and n = 476 in the usual care group; 95% were mothers, 73% reported Latino ethnicity, and 63% reported an annual income <$30 000). The majority (855/914; 94%) of the children (mean age, 4.4 months at parental enrollment) were insured by Medicaid. Of the 914 parents who remained eligible and enrolled, 785 (86%) completed the 12-month follow-up interview. Parents of children treated at the intervention clinics (n = 375) reported receiving more anticipatory guidance than the parents of children treated at the usual care clinics (n = 407) (mean score, 73.9 [SD, 23.4] vs 63.3 [SD, 27.8], respectively; adjusted absolute difference, 11.01 [95% CI, 6.44 to 15.59]). There was no difference in ED use (proportion with ≥2 ED visits) between the intervention group (n = 376) and the usual care group (n = 407) (37.2% vs 36.1%, respectively; adjusted absolute difference, 1.2% [95% CI, -5.5% to 8.0%]). The effects of the intervention on the secondary outcomes included a higher amount of psychosocial assessments performed, a greater number of parents who had developmental or behavioral concerns elicited and addressed, increased attendance at well-child visits, and greater parental experiences with the care received (helpfulness of care).

Conclusions and Relevance

The intervention resulted in improvements in the receipt of preventive care services vs usual care for children insured by Medicaid by incorporating community health workers in a team-based approach to early childhood well-child care.

Trial Registration

ClinicalTrials.gov Identifier: NCT03797898.

Using the Ages & Stages Questionnaire to assess later effects of an infant intervention promoting language in primary care

BACKGROUND

Positive relational experiences during infancy have a profound impact on child development and are critical for future health and school readiness. We have been evaluating a simple finger puppet intervention that takes one minute and costs $1USD to deliver in the primary care setting to promote caregiver-infant interactions. We explored using developmental trajectories to determine later outcomes of our early intervention program by comparing trajectories to age 36 months to assess optimal intervention timing when delivered in early versus late infancy.

METHODS

Three cohorts were enrolled and given a puppet at 2 months (early intervention) and 6 or 12 months (late intervention). Child development was assessed using the Ages & Stages Questionnaires (ASQ-3), which were independently collected during well visits. Scanned ASQ-3 forms from 2 to 36 months were obtained retrospectively through the electronic medical record. To compare longitudinal scores at different ages, all raw scores were first converted to z-scores. Longitudinal mixed effects models examined the trajectories of participant ASQ-3 scores over time by comparing the average intercepts and slopes.

RESULTS

Of 180 children enrolled, 172 (96%) completed 2 or more ASQ-3 questionnaires and were included in the analysis, with a mean of 4.9 and a total of 843 questionnaires. Most children (85%) were on government-sponsored insurance. There were no statistical differences comparing cohort intercepts, while early intervention had a significant difference in slope compared to late intervention for the Personal-Social domain (0.12, p=0.018), resulting in higher predicted scores at 36 months. Early compared to late intervention had a difference in slope approaching significance for Communication (0.14, p=0.056) and the combined non-motor score (0.33, p=0.052). There were no significant differences in slope for Problem Solving (0.05, p=0.48), Gross Motor (-0.009, p=0.84), Fine Motor (0.06, p=0.22), and total ASQ-3 (0.32, p=0.17) scores.

CONCLUSIONS

Finger puppets may provide a simple and scalable way to encourage responsive caregiver-infant interactions promoting language and social-emotional development, especially when provided in early versus late infancy. Our trajectory analysis also demonstrates a useful and potentially cost-effective approach to evaluating long-term developmental outcomes of an early intervention.

Time Spent at Well-Child Care Visits for English- and Spanish-Speaking Parents

OBJECTIVE

To measure duration of well-child care (WCC) visits at 2 federally qualified health centers (FQHCs), across 10 clinic sites, and determine if differences exist in visit duration for English- and Spanish-speaking parents.

METHODS

Upon arrival to their child's 2- to 24-month well visit, a research team member followed families throughout their visit noting start and end times for a series of 5 WCC visit tasks. The average time to complete each visit task for the entire sample was then calculated. Mann-Whitney U tests were run to determine if task completion time differed significantly between English- and Spanish-speaking parents.

RESULTS

The total sample included 199 parents of infants and children between 2 and 24 months old. Over one third of the sample spoke Spanish as their primary language (37%). The average visit time was 77 minutes (standard deviation [SD] = 48). Median time spent with the clinician was 14 minutes (SD = 5). Clinician visit time was significantly different U = 2608, P < .001, r = 0.38 between English- (median = 15 minutes) and Spanish (median = 11 minutes)-speaking parents. No other significant differences were identified.

DISCUSSION

Our findings align with previous studies showing the average time spent with a clinician during a WCC visit was 15 minutes. Further, the average time with a clinician was less for Spanish-speaking parents. With limited visit length to address child and family concerns, re-designing the structure and duration of WCC visits is critical to best meet the needs of families living in poverty, and may ensure that Spanish-speaking parents receive appropriate guidance and support without time limitations.

Role of Individual, Family, and Community Resilience in Moderating Effects of Adverse Childhood Experiences on Mental Health Among Children

OBJECTIVE

Mental health outcomes such as attention-deficit/hyperactivity disorder (ADHD), behavior disorders, anxiety, depression, and adverse childhood experiences (ACEs) are common disorders among children in the United States. Little is known on how potential resilient factors may moderate the relationship between exposure to ACEs and mental health outcomes. This study examines associations between ACEs and resilience on mental health outcomes using the 2018 National Survey of Children's Health (N = 26,572).

METHOD

Logistic regression and interactions examined the association between ACEs, resilience, and mental health outcomes. ACE exposure and low resiliency were associated with an increased likelihood of mental health outcomes.

RESULTS

There were significant interactions between exposure to ACEs and family resilience as well as significant interactions between ACE exposure and community resilience. On stratification, the presence of individual resilience and having all resilience measures decreased the odds of ADHD, behavioral disorders, anxiety, and depression and the presence of community resilience decreased the odds of depression among individuals who had experienced 4 or more ACEs.

CONCLUSION

These results illustrate the need to promote resilience measures for tackling mental health problems and reducing the negative effect of trauma in children.

In-the-moment ratings on the Early Relational Health Screen: A pilot study of application in home visiting and primary care

Early infant-parent interaction sets a critical foundation for young children's well-being, and evidence regarding the protective role of secure early relationships has led to increased interest in effective screening and promotion of early relational health in pediatric primary care and home visiting settings. We report findings from two pilot studies conducted in the United States that describe the reliability and validity of a relational health screening tool, the Early Relational Health Screen (ERHS), implemented in two different contexts: an innovative model of relational health promotion in pediatric primary care (Study 1) and an Infant Mental Health Home Visiting (IMH-HV) model (Study 2). Across both studies, a trained clinician rated the ERHS following real-time observation of interaction (i.e., "in-the-moment" ratings). Reliability was assessed by comparing "in-the-moment" ERHS ratings to subsequent coding of the same interaction from video by an independent evaluator. In addition, Study 2 data permitted evaluation of the validity of "in-the-moment" ERHS ratings. Results from both studies indicated reliability of "in-the-moment" ERHS ratings. In addition, Study 2 clinician "in-the-moment" ratings were associated with maternal depression and ratings of child-parent interaction derived from a separate observational task coded by independent evaluators using a different well-validated research-based measure. Discussion highlights the potential of the ERHS as a screening, promotion, and prevention tool that may be feasibly administered by providers across pediatric primary care and home visiting settings.

Focusing on Racial, Historical and Intergenerational Trauma, and Resilience: A Paradigm to Better Serving Children and Families

Research across populations demonstrates that intergenerational trauma can have lasting biological, psychological, and social consequences and affects groups of individuals in different ways. An appreciation of intergenerational trauma as experienced in diverse populations is important not only for understanding vulnerabilities and risk but also for cultivating opportunities for posttraumatic growth and healing. Understanding the contexts of trauma for children and families and the unveiling of structural inequities, both past and present, offers the opportunity to address these in using clinical and systems of care approaches in the public health spheres.

A Parent Coach-Led Model of Well-Child Care for Young Children in Low-Income Communities: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

The Parent-focused Redesign for Encounters, Newborns to Toddlers (PARENT) intervention was created as a team-based approach to well-child care (WCC) that relies on a health educator (Parent Coach) to provide the bulk of WCC services, address specific needs faced by families in low-income communities, and decrease reliance on the clinician as the primary provider of WCC services.

OBJECTIVE

This study aims to evaluate the impact of PARENT using a cluster randomized controlled trial.

METHODS

This study tested the effectiveness of PARENT at 10 clinical sites in 2 federally qualified health centers in Tacoma, Washington, and Los Angeles, California. We conducted a cluster randomized controlled trial that included 916 families with children aged ≤12 months at the time of the baseline survey. Parents will be followed up at 6 and 12 months after enrollment. The Parent Coach, the main element of PARENT, provides anticipatory guidance, psychosocial screening and referral, developmental and behavioral surveillance, screening, and guidance at each WCC visit. The coach is supported by parent-focused previsit screening and visit prioritization, a brief, problem-focused clinician encounter for a physical examination and any concerns that require a clinician's attention, and an automated text message parent reminder and education service for periodic, age-specific messages to reinforce key health-related information recommended by Bright Futures national guidelines. We will examine parent-reported quality of care (receipt of nationally recommended WCC services, family-centeredness of care, and parental experiences of care), and health care use (WCC, urgent care, emergency department, and hospitalizations), conduct a cost analysis, and conduct a separate time-motion study of clinician time allocation to assess efficiency. We will also collect data on exploratory measures of parent-and parenting-focused outcomes. Our primary outcomes were receipt of anticipatory guidance and emergency department use.

RESULTS

Participant recruitment began in March 2019. After recruitment, 6- and 12-month follow-up surveys will be completed. As of August 30, 2021, we enrolled a total of 916 participants.

CONCLUSIONS

This large pragmatic trial of PARENT in partnership with federally qualified health centers will assess its utility as an evidence-based and financially sustainable model for the delivery of preventive care services to children in low-income communities.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03797898; https://clinicaltrials.gov/ct2/show/NCT03797898.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/27054.

Transforming Well-Child Care to Meet the Needs of Families at the Intersection of Racism and Poverty

Racism and poverty are intertwined throughout American society as a result of historic and current systemic oppression based on class and race. As the processes of pediatric preventive care, or well-child care, have evolved to better acknowledge and address health disparities due to racism and poverty, the structures of care have remained mostly stagnant. To cultivate long-term health and wellness of Black and Brown children, we must adopt an explicitly antiracist structure for well-child care. The pediatric medical home model is touted as the gold standard for addressing a host of health, developmental, and social needs for children and their families. However, the medical home model has not resulted in more equitable care for Black and Brown families living in poverty; there are ample data to demonstrate that these families often do not receive care that aligns with the principles of the medical home. This inequity may be most salient in the context of well-child care, as our preventive care services in pediatrics have the potential to impact population health. To appropriately address the vast array of preventive care needs of families living at the intersection of racism and poverty, a structural redesign of preventive care in the pediatric medical home is needed. In this paper, we propose a re-imagined framework for the structure of well-child care, with a focus on care for children in families living at the intersection of racism and poverty. This framework includes a team-based approach to care in which families build trusting primary care relationships with providers, as well as nonclinical members of a care team who have shared lived experiences with the community being served, and relies on primary care connections with community organizations that support the preventive health, social health, and emotional health needs of families of young children. Without a structural redesign of preventive care in the pediatric medical home, stand-alone revisions or expansions to processes of care cannot appropriately address the effects of racism and poverty on child preventive health outcomes.

Reducing Poverty-Related Disparities in Child Development and School Readiness: The Smart Beginnings Tiered Prevention Strategy that Combines Pediatric Primary Care with Home Visiting

This paper describes the Smart Beginnings Integrated Model, an innovative, tiered approach for addressing school readiness disparities in low-income children from birth to age 3 in the United States through universal engagement of low-income families and primary prevention in pediatric primary care integrated with secondary/tertiary prevention in the home. We build on both public health considerations, in which engagement, cost and scalability are paramount, and a developmental psychopathology framework (Cicchetti & Toth, Journal of Child Psychology and Psychiatry, and Allied Disciplines 50:16–25, 2009), in which the child is considered within the context of the proximal caregiving environment. Whereas existing early preventive models have shown promise in promoting children’s school readiness, the Smart Beginnings model addresses three important barriers that have limited impacts at the individual and/or population level: (1) identification and engagement of vulnerable families; (2) the challenges of scalability at low cost within existing service systems; and (3) tailoring interventions to address the heterogeneity of risk among low-income families. Smart Beginnings takes advantage of the existing platform of pediatric primary care to provide a universal primary prevention strategy for all families (Video Interaction Project) and a targeted secondary/tertiary prevention strategy (Family Check-Up) for families with additional contextual factors. We describe the theory underlying the Smart Beginnings model, some initial findings from its recent application in two cities, and implications for changing social policy to promote school readiness beginning during very early childhood.

Racial Disparities in Developmental Delay Diagnosis and Services Received in Early Childhood

BACKGROUND AND OBJECTIVE

Racial disparities in diagnosis and receipt of services for early childhood developmental delay (DD) are well known but studies have had difficulties distinguishing contributing patient, healthcare system, and physician factors from underlying prevalence. We examine rates of physician diagnoses of DD by preschool and kindergarten entry controlling for a child's objective development via scoring on validated developmental assessment along with other child characteristics.

METHODS

We used data from the preschool and kindergarten entry waves of the Early Childhood Longitudinal Study, Birth Cohort. Dependent variables included being diagnosed with DD by a medical provider and receipt of developmental services. Logistic regression models tested whether a child's race was associated with both outcomes during preschool and kindergarten while controlling for the developmental assessments, as well as other contextual factors.

RESULTS

Among 7950 children, 6.6% of preschoolers and 7.5% of kindergarteners were diagnosed with DD. Of preschool children with DD, 66.5% were receiving developmental services, while 69.1% of kindergarten children with DD were receiving services. Children who were Black, Asian, spoke a primary language other than English and had no health insurance were less likely to be diagnosed with DD despite accounting for cognitive ability. Black and Latinx children were less likely to receive services.

CONCLUSIONS

Racial minority children are less likely to be diagnosed by their pediatric provider with DD and less likely to receive services despite accounting for a child's objective developmental assessment. The pediatric primary care system is an important target for interventions to reduce these disparities.

Warm Connections: Integration of Infant Mental Health Services into WIC

Low-income women experience disproportionately high rates of adverse maternal mental health outcomes, such as pregnancy-related depression, and have less access to behavioral health support. Adverse maternal mental health affects children through compromising bonding, impeding early childhood development, and increasing risks of child maltreatment. Integrated behavioral health approaches can improve access to behavioral health services by locating services in community-based settings routinely accessed by low-income families. Warm Connections is an innovative integrated behavioral health program delivered in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and rooted in an infant and early childhood mental health (IECMH) framework. This exploratory study describes Warm Connections and provides evaluation results from its pilot implementation. Findings suggest Warm Connections may reduce distress and increase parenting efficacy among low-income mothers and support further research of this program's feasibility.

Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health

By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy. Driving this transformation are advances in developmental sciences as they inform a deeper understanding of how early life experiences, both nurturing and adverse, are biologically embedded and influence outcomes in health, education, and economic stability across the life span. This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. To translate this relational health framework into clinical practice, generative research, and public policy, the entire pediatric community needs to adopt a public health approach that builds relational health by partnering with families and communities. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner.

Resilience-promoting policies and contexts for children of color in the United States: Existing research and future priorities

The health status of children in the United States varies by racial and ethnic, shaped by an interrelated set of systems that disadvantage children of color in the United States. In this article, we argue for a broad view of resilience, in both research and policy, that views resilience not just as a property of individuals but also as a characteristic of social contexts and policies. Accordingly, we describe the empirical evidence for policies and contexts as factors that can improve health among children and families that are deprived of equal opportunities and resources due to structural racism. We discuss the evidence and opportunities for policies and interventions across a variety of societal systems, including programs to promote economic and food security, early education, health care, and the neighborhood and community context. Based on this evidence and other research on racism and resilience, we conclude by outlining some directions for future research.

Are Benefits From a Parenting Intervention Delivered Through the Health Services Sustainable? Follow-Up of a Randomized Evaluation in Jamaica

OBJECTIVE

An innovative low-cost parenting intervention, implemented through health services in Jamaica showed benefits to children's cognitive development at 18 months and parent's attitudes concerning childcare. We assessed the impact of the intervention on child and parent outcomes at 6 years of age.

METHODS

A cluster randomized trial of 2 parenting interventions was conducted through 20 health centers in Jamaica. Interventions were implemented from age 3 to 18 months and each intervention benefited cognitive development at 18 months (effect size 0.34-0.38 standard deviation). Children were reassessed at 6 years (n = 262, 80.1% of those assessed at 18 months) to determine any benefits to cognition, behavior, and parenting behavior. Loss to follow-up was not significantly different by treatment. Inverse probability weighting and Lee bounds were used to adjust for loss to follow-up, and multilevel regression analyses conducted with random effects at the health center level.

RESULTS

There were no significant benefits to any child outcomes at age 6 years or to parenting behavior. Results are robust using the wild cluster bootstrap procedure and using Lee bounds for attrition. The initial trial benefits were reproduced with the current sample and methods.

CONCLUSION

Lack of sustained benefits may be related to the initial effect size and low intensity of the intervention that ended very young at age 18 months. It may also be related to lack of initial impact on home environment and fade-out of effects in a country with near universal preschool. The findings have implications for intervention design and targeting.

Social Capital as a Positive Social Determinant of Health: A Narrative Review

Social determinants of health influence child health behavior, development, and outcomes. This paper frames social capital, or the benefits that a child receives from social relationships, as a positive social determinant of health that helps children exposed to adversity achieve healthy outcomes across the life course. Children are uniquely dependent on their relationships with surrounding adults for material and nonmaterial resources. We identify and define three relevant aspects of social capital: 1) social support, which is embedded in a 2) social network, which is a structure through which 3) social cohesion can be observed. Social support is direct assistance available through social relationships and can be received indirectly through a caregiver or directly by a child. A child's social network describes the people in a child's life and the relationships between them. Social cohesion represents the strength of a group to which a child belongs (eg, family, community). Pediatric primary care practices play an important role in fostering social relationships between families, the health care system, and the community. Further research is needed to develop definitional and measurement rigor for social capital, to evaluate interventions (eg, peer health educators) that may improve health outcomes through social capital, and to broaden our understanding of how social relationships influence health outcomes.

Pediatric Primary Care and Partnerships Across Sectors to Promote Early Child Development

Poverty remains a critical predictor of children's school readiness, health and longer term outcomes. Early relational health (ERH) (ie, parenting practices and relationship quality) mediates the impact of poverty on child development, and thus has been the focus of many parenting interventions. Despite the documented efficacy of parenting interventions at reducing poverty-related disparities in child health and development, several key barriers prevent achieving population-level reach to families with young children. In the current paper we highlight several of these barriers including gaining population-level access to young children and families, reaching families only through single points of access, addressing the significant heterogeneity of risk that exists among families living in poverty, as well as addressing each of these barriers in combination. We suggest that understanding and confronting these barriers will allow family-centered interventions to more effectively address issues related to ERH at a population level, which in turn will reduce poverty-related disparities in child development.

Parenting Interventions in Pediatric Primary Care: A Systematic Review

CONTEXT

More than 4 decades of research indicate that parenting interventions are effective at preventing and treating mental, emotional, and behavioral disorders in children and adolescents. Pediatric primary care is a viable setting for delivery of these interventions.

OBJECTIVE

Previous meta-analyses have shown that behavioral interventions in primary care can improve clinical outcomes, but few reviews have been focused specifically on the implementation of parenting interventions in primary care. We aimed to fill this gap.

DATA SOURCES

We reviewed 6532 unique peer-reviewed articles published in PubMed, the Cumulative Index to Nursing and Allied Health Literature, and PsycInfo.

STUDY SELECTION

Articles were included if at least part of the intervention was delivered in or through primary care; parenting was targeted; and child-specific mental, emotional, and behavioral health outcomes were reported.

DATA EXTRACTION

Articles were reviewed in Covidence by 2 trained coders, with a third coder arbitrating discrepancies.

RESULTS

In our review of 40 studies, most studies were coded as a primary. Few researchers collected implementation outcomes, particularly those at the service delivery system level.

LIMITATIONS

Including only published articles could have resulted in underrepresentation of implementation-related data.

CONCLUSIONS

Parenting interventions delivered and implemented with fidelity in pediatric primary care could result in positive and equitable impacts on mental, emotional, and behavioral health outcomes for both parents and their children. Future research on the implementation strategies that can support adoption and sustained delivery of parenting interventions in primary care is needed if the field is to achieve population-level impact.

Population-Based Approaches to Mental Health: History, Strategies, and Evidence

There is growing recognition in the fields of public health and mental health services research that the provision of clinical services to individuals is not a viable approach to meeting the mental health needs of a population. Despite enthusiasm for the notion of population-based approaches to mental health, concrete guidance about what such approaches entail is lacking, and evidence of their effectiveness has not been integrated. Drawing from research and scholarship across multiple disciplines, this review provides a concrete definition of population-based approaches to mental health, situates these approaches within their historical context in the United States, and summarizes the nature of these approaches and their evidence. These approaches span three domains: (a) social, economic, and environmental policy interventions that can be implemented by legislators and public agency directors, (b) public health practice interventions that can be implemented by public health department officials, and (c) health care system interventions that can be implemented by hospital and health care system leaders.

Evolving Roles for Health Care in Supporting Healthy Child Development

Health care reaches more children under age three in the United States than any other family-facing system and represents the most common entry point for developmental assessment of and services for children. In this article, Adam Schickedanz and Neal Halfon examine how well the child health care system promotes healthy child development early in life. They also review children's access to health care through insurance coverage, the health care system's evolution in response to scientific and technical advances, and the shifting epidemiology of health and developmental risk. The authors find that the health care system is significantly underperforming because it is constrained by antiquated conventions, insufficient resources, and outmoded incentive structures inherent in the traditional medical model that still dominates pediatric care. These structural barriers, organization challenges, and financial constraints limit the system's ability to adequately recognize, respond to, and, most importantly, prevent adverse developmental outcomes at the population level. To achieve population-level progress in healthy child development, Schickedanz and Halfon argue that pediatric care will need to transform itself and go beyond simply instituting incremental clinical process improvement. This will require taking advantage of opportunities to deliver coordinated services that bridge sectors and focusing not only on reducing developmental risk and responding to established developmental disability but also on optimizing healthy child development before developmental vulnerabilities arise. New imperatives for improved population health, along with the growing recognition among policy makers and practitioners of the social and developmental determinants of health, have driven recent innovations in care models, service coordination, and coverage designs. Yet the available resources and infrastructure are static or shrinking, crowded out by rising overall health care costs and other policy priorities. The authors conclude that child health systems are at a crossroads of conflicting priorities and incentives, and they explore how the health system might successfully respond to this impasse.

School Readiness

School readiness includes the readiness of the individual child, the school's readiness for children, and the ability of the family and community to support optimal early child development. It is the responsibility of schools to meet the needs of all children at all levels of readiness. Children's readiness for kindergarten should become an outcome measure for a coordinated system of community-based programs and supports for the healthy development of young children. Our rapidly expanding insights into early brain and child development have revealed that modifiable factors in a child's early experience can greatly affect that child's health and learning trajectories. Many children in the United States enter kindergarten with limitations in their social, emotional, cognitive, and physical development that might have been significantly diminished or eliminated through early identification and attention to child and family needs. A strong correlation between social-emotional development and school and life success, combined with alarming rates of preschool expulsion, point toward the urgency of leveraging opportunities to support social-emotional development and address behavioral concerns early. Pediatric primary care providers have access to the youngest children and their families. Pediatricians can promote and use community supports, such as home visiting programs, quality early care and education programs, family support programs and resources, early intervention services, children's museums, and libraries, which are important for addressing school readiness and are too often underused by populations who can benefit most from them. When these are not available, pediatricians can support the development of such resources. The American Academy of Pediatrics affords pediatricians many opportunities to improve the physical, social-emotional, and educational health of young children, in conjunction with other advocacy groups. This technical report provides an updated version of the previous iteration from the American Academy of Pediatrics published in 2008.

When Do Clinicians Decide to Screen Children for Mental Health-Behavioral-Developmental Delays/Disorders: Is it Time to Reconsider Policy Recommendations?

OBJECTIVES

To determine at which ages providers choose to screen for mental, behavioral, and developmental disorder/delay (MBDD), and what they find; and which, if any, public and professional guidelines are most effective at identification.

STUDY DESIGN

Naturalistic retrospective cohort study of 215 general pediatric and family practice clinics within 24 US states involving 160 634 encounters during which MBDD screening tests were administered.

RESULTS

Almost all clinicians (96%) administered screens at ages targeted by the American Academy of Pediatrics (AAP), that is, 9, 18, 24, and/or 30 months of age, but also at younger and older ages: 57% opted to screen at ≥5 years of age. Of the 8% of children at risk for probable MBDD, 27% were detected at American Academy of Pediatrics-targeted ages-71% across the birth to 5-year age range and an additional 29% at ≥5 years of age. Children >30 months of age were 3 times more likely to have probable MBDD than were younger children, and those >5 years of age were almost 4 times more likely to have probable MBDD. Older children were more likely to have psychosocial risk factors, but age itself was the most powerful predictor.

CONCLUSIONS

Most clinicians preferred to screen across the birth to 8-year age range and their findings revealed that most MBDDs cannot be detected in the earliest years of life. Policies regarding the timing of screening should be expanded to include all well visits and between visits if needed.

What's known about implementing co-located paediatric integrated care: a scoping review

Several studies have demonstrated clinical benefits of integrated care for a range of child and adolescent mental health outcomes. However, there is a significant gap between the evidence for efficacy of integrated care interventions vs their implementation in practice. While several studies have examined large-scale implementation of co-located integrated care for adults, much less is known for children. The goal of this scoping review was to understand how co-located mental health interventions targeting children and adolescents have been implemented and sustained. The literature was systematically searched for interventions targeting child and adolescent mental health that involved a mental health specialist co-located in a primary care setting. Studies reporting on the following implementation outcomes were included: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. This search identified 34 unique studies, including randomized controlled trials, observational studies, and survey/mixed method approaches. Components facilitating implementation of on-site integrated behavioural healthcare included interprofessional communication and collaboration at all stages of implementation; clear protocols to facilitate intervention delivery; and co-employment of integrated care providers by specialty clinics. Some studies found differences in service use by demographic factors, and others reported funding challenges affecting sustainability, warranting further study.

Primary Care Interventions to Prevent Child Maltreatment: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Child maltreatment, also referred to as child abuse and neglect, can result in lifelong negative consequences.

OBJECTIVE

To update the evidence on interventions provided in or referable from primary care to prevent child maltreatment for the US Preventive Services Task Force.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, and trial registries through December 18, 2017; references; experts; literature surveillance through July 17, 2018.

STUDY SELECTION

English-language fair- and good-quality randomized clinical trials that (1) included children with no known exposure to maltreatment and no signs or symptoms of current or past maltreatment, (2) evaluated interventions feasible in a primary care setting or that could result from a referral from primary care, and (3) reported abuse or neglect outcomes or proxies for abuse or neglect (eg, injury with a specificity for abuse, visits to the emergency department, hospitalization).

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently assessed titles/abstracts, full-text articles, and study quality; a third resolved conflicts when needed. When at least 3 similar trials were available, random-effects meta-analyses were conducted.

MAIN OUTCOMES AND MEASURES

Direct measures (including reports to child protective services and removal of the child from the home) or proxy measures of abuse or neglect; behavioral, emotional, mental, or physical well-being; and harms.

RESULTS

Twenty-two trials (33 publications) were included (N = 11 132). No significant association was found between interventions and reports to child protective services within 1 year of intervention completion (10.6% vs 11.9%; pooled odds ratio [OR], 0.94 [95% CI, 0.72-1.23]; 10 trials [n = 2444]) or removal of the child from the home within 1 to 3 years of follow-up (3.5% vs 3.7%; pooled OR, 1.09 [95% CI, 0.16-7.28]; 4 trials [n = 609]). No statistically significant associations were observed between interventions and outcomes for emergency department visits in the short term (<2 years), hospitalizations, child development, school performance, and prevention of death. Nonsignificant results from single trials led to a conclusion of insufficient evidence for injuries, failure to thrive, failure to immunize, school attendance, and other measures of abuse or neglect. Inconsistent results led to a conclusion of insufficient evidence for long-term (≥2 years) outcomes for reports to child protective services (ORs range from 0.48 to 1.13; 3 trials [n = 1690]), emergency department visits (1 of 2 trials reported significant differences) and internalizing and externalizing behavior symptoms (3 of 6 trials reported reductions in behavior difficulties). No eligible trials on harms of interventions were identified.

CONCLUSIONS AND RELEVANCE

Interventions provided in or referable from primary care did not consistently prevent child maltreatment. No evidence on harms is available.

Interventions to Prevent Child Maltreatment: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

In 2016, approximately 676 000 children in the United States experienced maltreatment (abuse, neglect, or both), with 75% of these children experiencing neglect, 18% experiencing physical abuse, and 8% experiencing sexual abuse. Approximately 14% of abused children experienced multiple forms of maltreatment, and more than 1700 children died as a result of maltreatment.

OBJECTIVE

To update the US Preventive Services Task Force (USPSTF) 2013 recommendation on primary care interventions to prevent child maltreatment.

EVIDENCE REVIEW

The USPSTF commissioned a review of the evidence on primary care interventions to prevent maltreatment in children and adolescents without signs or symptoms of maltreatment.

FINDINGS

The USPSTF found limited and inconsistent evidence on the benefits of primary care interventions, including home visitation programs, to prevent child maltreatment and found no evidence related to the harms of such interventions. The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. The level of certainty of the magnitude of the benefits and harms of these interventions is low.

CONCLUSIONS AND RECOMMENDATION

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. (I statement).

Six Questions for Well-Child Care Redesign

In the United States, well-child care has the goal of providing comprehensive care to children by addressing developmental, behavioral, psychosocial, and health issues through visits at recommended intervals. The preventive care needs of families can outpace the capacity of clinics and practices to provide it, necessitating a redesign of our well-child care system that aligns the structure of preventive care delivery with the needs of families. Here we focus on 6 questions (the what, when, who, why, how, and where) for well-child care redesign for infants and young children. By addressing these key questions and providing recommendations for advancing well-child care redesign in the clinical and research arenas, we hope to accelerate the process of well-child care redesign. In the current political and socioeconomic environment, continuing with well-child care "as usual" will mean that many families will find that their well-child care visits do not fully address the most pressing needs impacting children's health and well-being. It is time to implement and sustain real change in our system for preventive care.

Feasibility of Implementing Group Well Baby/Well Woman Dyad Care at Federally Qualified Health Centers

OBJECTIVE

Group care has been shown to be effective for delivery of infant well child care. Centering Parenting (CP) is a model of group dyad care for mothers and infants. CP might improve quality and efficiency of preventive care, particularly for low-income families. Federally qualified health centers (FQHCs) might be optimal sites for implementation, however, facilitators and barriers might be unique. The aim of this qualitative study was to assess stakeholder perspectives on the feasibility of implementing CP in FQHCs in Baltimore.

METHODS

Semistructured interviews were conducted with mothers, clinicians, staff, and administrators recruited from 2 FQHCs using purposive sampling. Interviews were recorded, transcribed verbatim, and uploaded to Atlas.ti version 7.0 (Atlas.ti Scientific Software Development, GmbH Berlin, Germany) for analysis. Using an inductive thematic analysis approach, 2 investigators coded the transcripts. Matrices of key codes were developed to identify themes and patterns across stakeholder groups.

RESULTS

Interviews were completed with 26 mothers and 16 clinicians, staff, and administrators. Most participants considered CP desirable. Facilitators included: peer support and education, emphasis on maternal wellness, and increased patient and clinician satisfaction. Barriers included: exposure to "others," scheduling and coordination of care, productivity, training requirements, and cost. Parenting experience did not appear to affect perspectives on CP.

CONCLUSIONS

Perceptions regarding facilitators and barriers to CP implementation in FQHCs are similar to existing group well-child care literature. The benefit of emphasis on maternal wellness is a unique finding. Maternal wellness integration might make CP a particularly desirable model for implementation at FQHCs, but potential systems barriers must be addressed.

Identifying Effective Components of Child Maltreatment Interventions: A Meta-analysis

There is a lack of knowledge about specific components that make interventions effective in preventing or reducing child maltreatment. The aim of the present meta-analysis was to increase this knowledge by summarizing findings on effects of interventions for child maltreatment and by examining potential moderators of this effect, such as intervention components and study characteristics. Identifying effective components is essential for developing or improving child maltreatment interventions. A literature search yielded 121 independent studies (N = 39,044) examining the effects of interventions for preventing or reducing child maltreatment. From these studies, 352 effect sizes were extracted. The overall effect size was significant and small in magnitude for both preventive interventions (d = 0.26, p < .001) and curative interventions (d = 0.36, p < .001). Cognitive behavioral therapy, home visitation, parent training, family-based/multisystemic, substance abuse, and combined interventions were effective in preventing and/or reducing child maltreatment. For preventive interventions, larger effect sizes were found for short-term interventions (0-6 months), interventions focusing on increasing self-confidence of parents, and interventions delivered by professionals only. Further, effect sizes of preventive interventions increased as follow-up duration increased, which may indicate a sleeper effect of preventive interventions. For curative interventions, larger effect sizes were found for interventions focusing on improving parenting skills and interventions providing social and/or emotional support. Interventions can be effective in preventing or reducing child maltreatment. Theoretical and practical implications are discussed.

Reading Aloud, Play, and Social-Emotional Development

OBJECTIVES

To determine impacts on social-emotional development at school entry of a pediatric primary care intervention (Video Interaction Project [VIP]) promoting positive parenting through reading aloud and play, delivered in 2 phases: infant through toddler (VIP birth to 3 years [VIP 0-3]) and preschool-age (VIP 3 to 5 years [VIP 3-5]).

METHODS

Factorial randomized controlled trial with postpartum enrollment and random assignment to VIP 0-3, control 0 to 3 years, and a third group without school entry follow-up (Building Blocks) and 3-year second random assignment of VIP 0-3 and control 0 to 3 years to VIP 3-5 or control 3 to 5 years. In the VIP, a bilingual facilitator video recorded the parent and child reading and/or playing using provided learning materials and reviewed videos to reinforce positive interactions. Social-emotional development at 4.5 years was assessed by parent-report Behavior Assessment System for Children, Second Edition (Social Skills, Attention Problems, Hyperactivity, Aggression, Externalizing Problems).

RESULTS

VIP 0-3 and VIP 3-5 were independently associated with improved 4.5-year Behavior Assessment System for Children, Second Edition T-scores, with effect sizes (Cohen's d) ∼-0.25 to -0.30. Receipt of combined VIP 0-3 and VIP 3-5 was associated with d = -0.63 reduction in Hyperactivity (P = .001). VIP 0-3 resulted in reduced "Clinically Significant" Hyperactivity (relative risk reduction for overall sample: 69.2%; P = .03; relative risk reduction for increased psychosocial risk: 100%; P = .006). Multilevel models revealed significant VIP 0-3 linear effects and age × VIP 3-5 interactions.

CONCLUSIONS

Phase VIP 0-3 resulted in sustained impacts on behavior problems 1.5 years after program completion. VIP 3-5 had additional, independent impacts. With our findings, we support the use of pediatric primary care to promote reading aloud and play from birth to 5 years, and the potential for such programs to enhance social-emotional development.

Preventive Behavioral Health Programs in Primary Care: A Systematic Review

CONTEXT

Early childhood is a critical period for socioemotional development. Primary care is a promising setting for behavioral health programs.

OBJECTIVES

To identify gaps in the literature on effectiveness and readiness for scale-up of behavioral health programs in primary care.

DATA SOURCES

PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Embase, Evidence-Based Medicine Reviews, and Scopus databases were searched for articles published in English in the past 15 years. Search terms included terms to describe intervention content, setting, target population, and names of specific programs known to fit inclusion criteria.

STUDY SELECTION

Inclusion criteria were: (1) enrolled children 0 to 5 years old, (2) primary care setting, (3) measured parenting or child behavior outcomes, and (4) clinical trial, quasi-experimental trial, pilot study, or pre-post design.

DATA EXTRACTION

Data were abstracted from 44 studies. The rigor of individual studies and evidence base as a whole were compared with the Society of Prevention Research's standards for efficacy, effectiveness, and scale-up research.

RESULTS

Gaps in the literature include: study findings do not always support hypotheses about interventions' mechanisms, trust in primary care as a mediator has not been sufficiently studied, it is unclear to which target populations study findings can be applied, parent participation remains an important challenge, and the long-term impact requires further evaluation.

LIMITATIONS

Potential limitations include publication bias, selective reporting within studies, and an incomplete search.

CONCLUSIONS

Targeting gaps in the literature could enhance understanding of the efficacy, effectiveness, and readiness for scale-up of these programs.

How to Convince Parents to Stop Spanking Their Children

English- and Spanish-speaking parents of 1- to 5-year-old children were invited to view 5-10 minutes of parent training program, "Play Nicely," as part of the well-child checkup. Key measures were parents' plans to change how they discipline and, if they planned to use less spanking, how the program worked in their situation. Of 197 parents who participated, 128 (65.0%) planned to change how they discipline. Nineteen parents (9.6%) reported that they planned to spank less. The most common reasons for parents to plan to spank less were that the program taught other discipline options (12/19, 63.2%) and that the program taught that spanking was not recommended as a form of discipline (6/19, 31.6%). The majority of parents report that the program works because it offers alternatives to spanking. This study has implications for the development of parent training programs and the primary prevention of child abuse, violence, and other health problems.