Role of the medical home in family-centered early intervention services

Medical Home Care and Educational Services for Children and Youth on the Autism Spectrum: A Scoping Review

This scoping review examined current evidence on medical home care and its association with educational services for children and youth on the autism spectrum. We searched five databases and grey literature resulting in 328 publications. Publications meeting inclusion criteria were mapped to medical home care component(s) addressed, type(s) of educational services and their strength and type of association. The Andersen Behavioral Model of Health Services Use was used to summarize predisposing, enabling, and need factors considered. Eighteen publications were reviewed, including eight practice/policy reports and ten original research publications. Medical home care components most addressed included family-centered care (n = 10), referrals (n = 16), and effective care coordination (n = 13). Seven publications also addressed multiple educational service types. Two of the five publications that established a significant association between medical home care components and educational services had mixed results, with one publication reporting a negative association and the other publication reporting a positive association. Challenges to medical home care and educational services were most categorized as enabling factors. Results suggest three areas for further investigation: (1) limited evidence on the strength and type of association between medical home care components and educational services; (2) limited use of population data sources; and (3) the need to consider a broader range of factors when examining their association.

Using Telemedicine to Overcome Barriers to Neurodevelopmental Care from the Neonatal Intensive Care Unit to School Entry

Dedicated Neonatal Intensive Care Unit (NICU) follow-up programs are recommended for ongoing surveillance for infants at high-risk for future neurodevelopmental impairment (NDI). Systemic, socioeconomic, and psychosocial barriers remain for referrals and the continued neurodevelopmental follow-up of high-risk infants. Telemedicine can help overcome these barriers. Telemedicine allows standardization of evaluations, increased referral rates, and reduced time to follow-up as well as increased therapy engagement. Telemedicine can expand neurodevelopmental surveillance and support all NICU graduates, facilitating the early identification of NDI. However, with the recent expansion of telemedicine during the COVID-19 pandemic, new barriers related to access and technological support have arisen.

From zero to thrive: A model of cross-system and cross-sector relational health to promote early childhood development across the child-serving ecosystem

Early relational health between caregivers and children is foundational for child health and well-being. Children and caregivers are also embedded within multiple systems and sectors, or a "child-serving ecosystem", that shapes child development. Although the COVID-19 pandemic has made this embeddedness abundantly clear, systems remain siloed and lack coordination. Fostering relational health amongst layers of this ecosystem may be a way to systematically support young children and families who are facing adversity. We integrate theory, examples, and empirical findings to develop a conceptual model informed by infant mental health and public health frameworks that illustrates how relational health across the child-serving ecosystem may promote child health and well-being at a population level. Our model articulates what relational health looks like across levels of this ecosystem from primary caregiver-child relationships, to secondary relationships between caregivers and child-serving systems, to tertiary relationships among systems that shape child outcomes directly and indirectly. We posit that positive relational health across levels is critical for promoting child health and well-being broadly. We provide examples of evidence-based approaches that address primary, secondary, and tertiary relational health, and suggest ways to promote relational health through cross-sector training and psychoeducation in the science of early development. This model conceptualizes relational health across the child-serving ecosystem and can serve as a template for promoting child health and well-being in the context of adversity.

Early Intervention Referral Information, Transmission, and Sources-A Survey of State Part C Coordinators and Analysis of Referral Forms

OBJECTIVE

Early Intervention (EI) referral is a key connector between health care and early childhood systems serving children with developmental risks. This study aimed to describe the US network of EI referrals by answering the following: "What information is sent to EI?", "Who sends it?", and "How is it sent?"

METHOD

This study combined an analysis of national document-based and website-based referral forms with a survey of state Part C Coordinators (PCCs). Data on referral forms were systematically collected from state agency websites. PCCs from 52 jurisdictions were surveyed to assess current EI referral practices. Descriptive statistics were used for responses to multiple-choice items; free-text answers were condensed into key study themes.

RESULTS

EI referral forms came as e-documents (81%) or websites (35%), and 72% were in English alone. They emphasized family and referral source contact information and reason for the referral. The survey results indicated that health care (45%) sends the most referrals, followed by families (30%). EI agencies received referrals by phone (38%), electronically (23%), e-mail (17%), and fax (17%), and PCCs valued this diversity of methods. Few states received referral data directly from electronic health records (EHRs); however, PCCs hope to eventually receive referrals through websites, mobile devices, and EHRs.

CONCLUSION

EI referral data flow is complex, with opportunities for loss of children to follow-up. This study describes how EI referrals occur and provides examples of how communication and access to information may be improved.

Association of Positional Plagiocephaly and Developmental Delay Within a Primary Care Network

OBJECTIVE

Previous research has suggested an association between plagiocephaly and developmental delay. However, study samples drawn from children seen in subspecialty clinics increase the potential for selection and referral bias. Our study evaluates the association between plagiocephaly and developmental delay and the timing of these diagnoses in a primary care setting, where plagiocephaly is commonly diagnosed and managed.

METHODS

Our retrospective analysis used electronic medical record data from 45 primary care sites within a children's health system from 1999 to 2017, including children aged 0 to 5 years with diagnoses determined by physician diagnosis codes at primary care visits. Children were classified in the plagiocephaly group if diagnosis occurred by 12 months of age. Primary outcome was any developmental delay. Pearson χ2 test, Fisher exact test, and logistic regression analyses were conducted, with multivariable models adjusted for sex, race, ethnicity, insurance, prematurity status (22-36 weeks' gestation), primary care sites, birth year, and diagnoses of abnormal tone and torticollis.

RESULTS

Of 77,108 patients seen by 12 months, 2315 (3.0%) were diagnosed with plagiocephaly, with an increase in diagnosis prevalence over the study time frame. Plagiocephaly was independently associated with an increased odds of any developmental delay diagnosis (adjusted odds ratio 1.50, 95% confidence interval 1.32-1.70). The diagnosis of plagiocephaly was recorded before the diagnosis of developmental delay in most cases when both diagnoses were present (374 of 404, 92.6%).

CONCLUSION

Data from a large primary care cohort demonstrate an association between plagiocephaly and developmental delay, affirming findings in previous subspecialty literature.

Identifying Caregiver Needs for Children With a Tracheostomy Living at Home

This study sought to understand caregiver needs of children with tracheostomies (CWT) living at home and inform development of standardized tracheostomy simulation training curricula. Long-term goals are decreasing hospital readmissions following tracheostomy placement and improving family experiences while implementing a medical home model. We recruited caregivers of CWT and conducted semistructured interviews, subsequently recorded, transcribed, and analyzed for emerging themes using NVivo. Demographic data were collected via quantitative surveys. Twenty-seven caregivers participated. Emerging themes included the following: (1) caregivers felt overwhelmed, sad, frightened when learning need for tracheostomy; (2) training described as adequate, but individualized training desired; (3) families felt prepared to go home, but transition was difficult; (4) home nursing care fraught with difficulty and yet essential for families of CWT. Families of CWT have specific needs related to discharge training, resources, support, and home nursing. Provider understanding of caregiver needs is essential for child well-being, patient-/family-centered care, and may improve health outcomes.

Value-Driven Care in Developmental-Behavioral Pediatrics, Part 2: Measuring Quality and Meeting the Challenge

The drive to improve quality and reduce cost of health care is leading to a value-driven transformation of the US health care landscape. This is the second of a 2-part series on value-driven care and its implications for developmental-behavioral pediatrics (DBP). Part 1 addressed costs of care and enhancing value of care, with a particular focus on the value proposition of the field of DBP. This study begins with a discussion of the Donabedian's model of quality, including structure, process, patient satisfaction, and outcomes. The challenges of measuring process and outcomes in DBP are discussed, with a focus on (1) children 0 to 3 years of age identified as having global developmental delay, (2) recent diagnosis of complex attention-deficit hyperactivity disorder (ADHD) (ADHD plus comorbid conditions), and (3) children with autism spectrum disorder (ASD) and disruptive behavior. The study concludes with some of the important next steps for DBP providers, researchers, health care systems, professional societies, and families. With a discussion of national trends and a local example of a DBP program's response to these trends, the series is intended to provoke discussion and action in the field, contribute to the demonstration of value of a DBP approach to care, and help to chart a course toward growth and sustainability of DBP in an era of value-based care.

Family quality of life among Taiwanese children with developmental delay before and after early intervention

BACKGROUND

Although early intervention (EI) practitioners emphasise the importance of individualised family-centred services for families of children with developmental delay (DD), few empirical studies have evaluated whether EI can improve family quality of life (FQOL). This study aimed to investigate the trajectory of FQOL and its predictors among families of children with DD during the first 12 months of EI.

METHODS

This study employed a prospective cohort design. Data were collected using structured questionnaires at the placement meeting before the commencement of EI, as well as 3, 6 and 12 months later. We recruited 142 primary caregivers of children with DD in northern Taiwan from March 2015 to August 2016. FQOL was measured using the Mandarin Chinese version of the Beach Centre FQOL Scale. Family resilience (FR) was measured using the Mandarin Chinese version of the FR Assessment Scale. Other independent variables included socio-demographics, type of DD and EI services. Generalised estimating equations were used to perform multivariate analysis.

RESULTS

Family quality of life exhibited a significant quadratic trend in the 12 months surrounding EI. The score was the lowest before EI started (89.85), then increased to peak (94.87) at 6 months and then decreased slightly to 92.34 at 12 months. FR followed a significantly increased linear trend during the period. There were significant and positive correlations between FQOL and FR across all time points. Multivariate analysis showed that employed caregivers, FR, sufficient caregiving manpower and satisfaction with marital quality were positively associated with FQOL. Receiving more types of EI services and having fathers who were not Taiwanese nationals were negatively associated with FQOL.

CONCLUSIONS

Family quality of life and FR increased significantly after receiving EI, revealing the latter's effectiveness. Unemployment, poor marital quality, father being an immigrant, low FR and insufficient family caregiving manpower were associated with lower FQOL, suggesting that these families require more assistance.

Systematic Review: United States Workforce for Autism-Related Child Healthcare Services

OBJECTIVE

A diversity of health professional disciplines provide services for children with autism spectrum disorder (ASD) in the United States. We conducted a systematic review examining the availability, distribution, and competencies of the US workforce for autism-related child health care services, and assess studies' strength of evidence.

METHOD

We searched PubMed, PsychINFO, Embase, and Google Scholar from 2008 to 2018 for relevant US-based studies. Two investigators independently screened and evaluated studies against a set of prespecified inclusion criteria and evaluated strength of evidence (SOE) using a framework designed to integrate a mixed-methods research.

RESULTS

Of 754 records identified, 33 studies (24 quantitative, 6 qualitative, and 3 mixed-methods) were included. Strength of evidence associated was low-to-moderate, with only 8 studies (24%) satisfying criteria for strong SOE. Geographies and provider cadres varied considerably. The most common specialties studied were pediatricians (n = 13), occupational therapists (n = 12), speech therapists (n = 11), physical therapists (n = 10), and child psychiatrists (n = 8). Topical areas included the following: provider availability by service area and care delivery model; qualitative assessments of provider availability and competency; role of insurance mandates in increasing access to providers: and disparities in access. Across provider categories, we found that workforce availability for autism-related services was limited in terms of overall numbers, time available, and knowledgeability. The greatest unmet need was observed among minorities and in rural settings. Most studies were short term, were limited in scope, and used convenience samples.

CONCLUSION

There is limited evidence to characterize the availability and distribution of the US workforce for autism-related child health care services. Existing evidence to date indicates significantly restricted availability.

Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance

OBJECTIVES

To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU.

DESIGN

A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics.

METHODS

The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results.

RESULTS

The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written.

CONCLUSIONS

This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.

The Health and Well-Being of Caregivers of Technologically Dependent Children

Caregivers of technology-dependent children face considerable responsibilities. This study examined the association of 2 child-related stressors-functional status and use of mechanical ventilator-with 2 domains of family caregiver well-being-depressive symptoms (Center for Epidemiologic Studies Depression Scale [CES-D]) and health-related quality of life (HRQOL) and family function (PedsQL Family Impact Module). The secondary objective was to determine whether these associations were moderated by caregiver-perceived social support. Structured interviews were conducted with 88 primary family caregivers of technology-dependent children in Singapore. Hierarchical multiple regression was used to assess the primary and secondary objectives. A total of 44.3% of caregivers were at high risk of clinical depression. Moderately poor child functional status was associated with more caregiver depressive symptoms. Perceived social support moderated this association. Family caregivers of technology-dependent children have high levels of depressive symptoms and relatively poor HRQOL and family functioning. Enhancing caregivers' social support is important for their well-being.

Patient-Centered Medical Home and Receipt of Part C Early Intervention Among Young CSHCN and Developmental Disabilities Versus Delays: NS-CSHCN 2009-2010

Objective To determine, among a sample of young CSHCN with developmental conditions, (1) characteristics associated with receipt of both patient-centered medical home (PCMH) and Part C early intervention, (2) the association between each PCMH criterion and receipt of Part C generally, and (3) for CSHCN with disabilities versus delays. Methods Secondary data analysis of the 2009/10 National Survey of CSHCN. Sample included CSHCN (n = 755) birth to 3 years with a developmental disability or delay that affected their function. Adjusted ordinal regression analysis examined characteristics associated with receiving both PCMH and Part C. Stratified adjusted logistic regression examined the association between PCMH criteria and Part C, by disabilities versus delays. Results 19% of our sample received both PCMH and Part C. Black, non-Hispanic children had lower odds [OR 0.44, 95% CI (0.20, 0.97)] and CSHCN with more severe developmental conditions had higher odds [OR 2.13, 95% CI (1.22, 3.17)] of receiving both services. CSHCN with a PCMH were no more likely to be receiving Part C than those without a PCMH [OR 0.85, 95% CI (0.49, 1.49)]. Receiving any one of the PCMH criterion was not associated with receiving Part C, with one exception. Among CSHCN with delays, effective care coordination was associated with lower odds of Part C [OR 0.46, 95% CI (0.21, 0.97)]. Conclusion Concurrent PCMH and Part C access was low for young CSHCN with developmental conditions affecting their function. Given the overlapping mandates for PCMH and Part C, integrated efforts are warranted to identify if lack of concurrent services in fact reflects unmet service needs.

Ensuring Timely Connection to Early Intervention for Young Children With Developmental Delays

BACKGROUND AND OBJECTIVES

Timely provision of developmental services can improve outcomes for children 0 to 3 years old with developmental delays. Early Intervention (EI) provides free developmental services to children under age 3 years; however, data suggests that many children referred to EI never connect to the program. We sought to ensure that 70% of patients referred to EI from an academic primary care clinic serving a low-income population were evaluated within 120 days of referral.

METHODS

Recognizing that our baseline system of EI referrals had multiple routes to referral without an ability to track referral outcome, we implemented a multifaceted referral process with (1) a centralized electronic referral system used by providers, (2) patient navigators responsible for processing all EI referrals submitted by providers, and (3) a tracking system postreferral to facilitate identification of patients failing to connect with EI.

RESULTS

The percentage of patients evaluated by EI within 120 days increased from a baseline median of 50% to a median of 72% after implementation of the systems (N = 309). After implementation, the centralized referral system was used a median of 90% of the time. Tracking of referral outcomes revealed decreases in families refusing evaluations and improvements in exchange of information with EI.

CONCLUSIONS

Rates of connection to EI improved substantially when referrals were centralized in the clinic and patient navigators were responsible for tracking referral outcomes. Knowledge of EI intake processes and relationships between the practice and the EI site are essential to ensure successful connections.

The Individuals With Disabilities Education Act (IDEA) for Children With Special Educational Needs

The pediatric health care provider has a critical role in supporting the health and well-being of children and adolescents in all settings, including early intervention (EI), preschool, and school environments. It is estimated that 15% of children in the United States have a disability. The Individuals with Disabilities Education Act entitles every affected child in the United States from infancy to young adulthood to a free appropriate public education through EI and special education services. These services bolster development and learning of children with various disabilities. This clinical report provides the pediatric health care provider with a summary of key components of the most recent version of this law. Guidance is also provided to ensure that every child in need receives the EI and special education services to which he or she is entitled.

Medically complex children and early intervention for comprehensive medical care at home

We present the case of a 4-year-old with multiple congenital anomalies. These included complete tracheal rings with agenesis of the right lung and missing right ribs. He was hospitalized from birth until he was age 3 years and 6 months. At age 4 years and 4 months he had yet to move to a family home or experience his first day of school because he was in a transitional care facility. The intensity of his care was initially high, slowly declined over time, and eventually entered the range where he would be potentially manageable in a home environment. Despite the countless medical teams treating him, he did not receive a referral either to the early intervention or educational services that he had a right to under the Individuals with Disabilities Education Act. While his case is extreme, there is a disconnect between the United States health care and educational systems, which negatively impacts both the health and development of children with chronic conditions who require frequent and prolonged hospitalizations.

Understanding Barriers to Early Intervention Services for Preterm Infants: Lessons From Two States

OBJECTIVE

To explore existing barriers and challenges to Early Intervention (EI) referral, enrollment, and service provision for very low birth weight (VLBW; <1500 g) infants.

METHODS

We conducted 10 focus groups with parents of VLBW children (n = 44) and 32 interviews with key informants from EI (n = 7), neonatal intensive care units (n = 17), and outpatient clinics (n = 8) at 6 sites in 2 states. We used grounded theory to identify themes about gaps in services.

RESULTS

Both parents and providers found EI helpful. However, they also identified gaps in the current EI system at the levels of eligibility, referral, family receptivity, and service provision and coordination with medical care. Inadequate funding and variable procedures for evaluation may affect children's eligibility. Referrals can be missed as a result of simple oversight or communication failure among hospitals, EI, and families; referral outcomes often are not formally tracked. Families may not be receptive to services as a result of wariness of home visits, social stressors, denial about potential developmental delays, or lack of understanding of the benefits of EI. Once a child is deemed eligible, services may be delayed or terminated early, and EI providers may have little specialized training. Communication and coordination with the child's medical care team is often limited.

CONCLUSIONS

Systemic barriers, including funding and staffing issues, state and federal regulations, and communication with families and medical providers, have led to gaps in the EI system. The chronic care model may serve as a framework for integrating community-based interventions like EI with medical care for VLBW children and other vulnerable populations.

Universal newborn screening for congenital CMV infection: what is the evidence of potential benefit?

Congenital CMV infection is a leading cause of childhood disability. Many children born with congenital CMV infection are asymptomatic or have nonspecific symptoms and therefore are typically not diagnosed. A strategy of newborn CMV screening could allow for early detection and intervention to improve clinical outcomes. Interventions might include antiviral drugs or nonpharmaceutical therapies such as speech-language therapy or cochlear implants. Using published data from developed countries, we analyzed existing evidence of potential benefit that could result from newborn CMV screening. We first estimated the numbers of children with the most important CMV-related disabilities (i.e. hearing loss, cognitive deficit, and vision impairment), including the age at which the disabilities occur. Then, for each of the disabilities, we examined the existing evidence for the effectiveness of various interventions. We concluded that there is good evidence of potential benefit from nonpharmaceutical interventions for children with delayed hearing loss that occurs by 9 months of age. Similarly, we concluded that there is fair evidence of potential benefit from antiviral therapy for children with hearing loss at birth and from nonpharmaceutical interventions for children with delayed hearing loss occurring between 9 and 24 months of age and for children with CMV-related cognitive deficits. We found poor evidence of potential benefit for children with delayed hearing loss occurring after 24 months of age and for children with vision impairment. Overall, we estimated that in the United States, several thousand children with congenital CMV could benefit each year from newborn CMV screening, early detection, and interventions.

Methodology for establishing a population-based birth cohort focusing on couple fertility and children's development, the Upstate KIDS Study

BACKGROUND

Critical data gaps remain regarding infertility treatment and child development. We assessed the utility of a birth certificate registry for developing a population cohort aimed at answering such questions.

METHODS

We utilised the Upstate New York livebirth registry (n = 201,063) to select births conceived with (n = 4024) infertility treatment or exposed infants, who were then frequency-matched by residence to a random sample of infants conceived without (n = 14,455) treatment or unexposed infants, 2008-10. Mothers were recruited at 2-4 months postpartum and queried about their reproductive histories, including infertility treatment for comparison with birth certificate data. Overall, 1297 (32%) mothers of exposed and 3692 of unexposed (26%) infants enrolled.

RESULTS

Twins represented 22% of each infant group. The percentage of infants conceived with/without infertility treatment was similar whether derived from the birth registry or maternal report: 71% none, 16% drugs or intrauterine insemination, and 14% assisted reproductive technologies (ART). Concordant reporting between the two data sources was 93% for no treatment, 88% for ART, and 83% for fertility drugs, but differed by plurality. Exposed infants had slightly (P < 0.01) earlier gestations than unexposed infants (38.3 ± 2.8 and 38.7 ± 2.7 weeks, respectively) based upon birth certificates but not maternal report (38.7 ± 2.7 and 38.7 ± 2.9, respectively). Conversely, mean birthweight was comparable using birth certificates (3157 ± 704 and 3194 ± 679 g, respectively), but differed using maternal report (3167 ± 692 and 3224 ± 661, respectively P < 0.05).

CONCLUSIONS

The birth certificate registry is a suitable sampling framework as measured by concordance with maternally reported infertility treatment. Future efforts should address the impact of factors associated with discordant reporting on research findings.

Factors associated with early intervention referral and evaluation: a mixed methods analysis

OBJECTIVE

To identify parent, child, community, and health care provider characteristics associated with early intervention (EI) referral and multidisciplinary evaluation (MDE) by EI.

METHODS

We conducted a mixed methods secondary analysis of data from a randomized controlled trial of a developmental screening program in 4 urban primary care practices. Children <30 months of age not currently enrolled in EI and their parents were included. Using logistic regression, we tested whether parent, child, community, and health care provider characteristics were associated with EI referral and MDE completion. We also conducted qualitative interviews with 9 pediatricians. Interviews were recorded, transcribed, and coded. We identified themes using modified grounded theory.

RESULTS

Of 2083 participating children, 434 (21%) were identified with a developmental concern. A total of 253 children (58%) with a developmental concern were referred to EI. A total of 129 children (30%) received an MDE. Failure in 2 or more domains on developmental assessments was associated with EI referral (adjusted odds ratio [AOR] 3.15, 95% confidence interval [CI] 1.89-5.24) and completed MDE (AOR 2.16, 95% CI 1.19-3.93). Faxed referral to EI, as opposed to just giving families a phone number to call was associated with MDE completion (AOR 2.94, 95% CI 1.48-5.84). Pediatricians reported that office processes, family preference, and whether they thought parents understood the developmental screening tool influenced the EI referral process.

CONCLUSIONS

In an urban setting, one third of children with a developmental concern were not referred to EI, and two thirds of children with a developmental concern were not evaluated by EI. Our results suggest that practice-based strategies that more closely connect the medical home with EI such as electronic transmission of referrals (e.g., faxing referrals) may improve completion rates of EI evaluation.

Early intervention, IDEA Part C services, and the medical home: collaboration for best practice and best outcomes

The medical home and the Individuals With Disabilities Education Act Part C Early Intervention Program share many common purposes for infants and children ages 0 to 3 years, not the least of which is a family-centered focus. Professionals in pediatric medical home practices see substantial numbers of infants and toddlers with developmental delays and/or complex chronic conditions. Economic, health, and family-focused data each underscore the critical role of timely referral for relationship-based, individualized, accessible early intervention services and the need for collaborative partnerships in care. The medical home process and Individuals With Disabilities Education Act Part C policy both support nurturing relationships and family-centered care; both offer clear value in terms of economic and health outcomes. Best practice models for early intervention services incorporate learning in the natural environment and coaching models. Proactive medical homes provide strategies for effective developmental surveillance, family-centered resources, and tools to support high-risk groups, and comanagement of infants with special health care needs, including the monitoring of services provided and outcomes achieved.

Barriers to evaluation for early intervention services: parent and early intervention employee perspectives

OBJECTIVE

To explore barriers to early intervention (EI) evaluation among referred infants and toddlers.

METHODS

We conducted semistructured interviews with parents of children referred for EI services and with EI staff. We purposively sampled families according to whether they received an EI evaluation. Families were recruited from a randomized controlled trial testing implementation of developmental screening. Parents filled out demographic surveys. Interviews were recorded, transcribed, and coded. We identified themes within and across respondent groups using modified grounded theory.

RESULTS

We reached thematic saturation after interviewing 22 parents whose child was evaluated by EI, 22 not evaluated, and 14 EI employees. Mean child age at first referral was 16.7 months, and 80% were referred as the result of language concerns. We identified 5 primary themes: (1) Parents reported communication problems with their pediatrician, including misinterpreting reassurance and not understanding the referral process; (2) Many parents saw themselves as experts on their child's development and felt they should decide whether their child pursues EI services; (3) Some families preferred to wait for the developmental concern to resolve or work with their child on their own prior to seeking EI services; (4) For ambivalent parents, practical obstacles especially limited completion of evaluation, but highly motivated parents overcame obstacles; and (5) EI employees perceived that families avoid evaluation because they mistake EI for child protective services.

CONCLUSIONS

Communication between pediatricians and families that addresses practical logistics, families' perceptions of their child's development and EI, and motivation to address developmental concerns may improve the completion of EI referrals.

Risk and protective factors associated with stress in mothers whose children are enrolled in early intervention services

INTRODUCTION

Although considerable research has addressed children with special health care needs enrolled in early intervention (EI) services, little is known about families' needs. This study provides baseline data on factors informing health promotion and prevention interventions for mothers of children enrolled in EI services who are experiencing high levels of stress.

METHODS

A non-experimental descriptive-correlational study measured the following risk and protective factors in mothers of children enrolled in EI services: parent stress, severity of child's behavior, stressful life events, family functioning, appraisal of the situation, resources, and social support.

RESULTS

More than one third of mothers had stress and family-functioning scores necessitating referral. Services for cognitive or social-emotional delays, unhealthy family functioning, and many co-existing stress events were significantly associated with increased stress. Mothers did not find caring for a child with a disability stressful and were satisfied with their social support. Higher incomes and levels of education were significantly associated with less stress; however, this sample was highly educated with middle-class incomes.

DISCUSSION

Many mothers with children enrolled in EI services could be helped by specific primary, secondary, and tertiary interventions by pediatric nurse practitioners and primary health care providers.

Missed opportunities in the referral of high-risk infants to early intervention

OBJECTIVE

Using a statewide population-based data source, we describe current neonatal follow-up referral practices for high-risk infants with developmental delays throughout California.

METHODS

From a cohort analysis of quality improvement data from 66 neonatal follow-up programs in the California Children's Services and California Perinatal Quality Care Collaborative High-Risk Infant Follow-Up Quality of Care Initiative, 5129 high-risk infants were evaluated at the first visit between 4 and 8 months of age in neonatal follow-up. A total of 1737 high-risk infants were evaluated at the second visit between 12 and 16 months of age. We calculated referral rates in relation to developmental status (high versus low concern) based on standardized developmental testing or screening.

RESULTS

Among infants with low concerns (standard score >70 or passed screen) at the first visit, 6% were referred to early intervention; among infants with high concerns, 28% of infants were referred to early intervention. Even after including referrals to other (private) therapies, 34% infants with high concerns did not receive any referrals. These rates were similar for the second visit.

CONCLUSIONS

In spite of the specialization of neonatal follow-up programs to identify high-risk infants with developmental delays, a large proportion of potentially eligible infants were not referred to early intervention.

Home care of children and youth with complex health care needs and technology dependencies

Children and youth with complex medical issues, especially those with technology dependencies, experience frequent and often lengthy hospitalizations. Hospital discharges for these children can be a complicated process that requires a deliberate, multistep approach. In addition to successful discharges to home, it is essential that pediatric providers develop and implement an interdisciplinary and coordinated plan of care that addresses the child's ongoing health care needs. The goal is to ensure that each child remains healthy, thrives, and obtains optimal medical home and developmental supports that promote ongoing care at home and minimize recurrent hospitalizations. This clinical report presents an approach to discharging the child with complex medical needs with technology dependencies from hospital to home and then continually addressing the needs of the child and family in the home environment.

Patient- and family-centered care and the pediatrician's role

Drawing on several decades of work with families, pediatricians, other health care professionals, and policy makers, the American Academy of Pediatrics provides a definition of patient- and family-centered care. In pediatrics, patient- and family-centered care is based on the understanding that the family is the child's primary source of strength and support. Further, this approach to care recognizes that the perspectives and information provided by families, children, and young adults are essential components of high-quality clinical decision-making, and that patients and family are integral partners with the health care team. This policy statement outlines the core principles of patient- and family-centered care, summarizes some of the recent literature linking patient- and family-centered care to improved health outcomes, and lists various other benefits to be expected when engaging in patient- and family-centered pediatric practice. The statement concludes with specific recommendations for how pediatricians can integrate patient- and family-centered care in hospitals, clinics, and community settings, and in broader systems of care, as well.

Concurrent validity of the Bayley-III and the Peabody Developmental Motor Scale-2

PURPOSE

To determine concurrent validity of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) and the Peabody Developmental Motor Scales, Second Edition (PDMS-2).

METHOD

Tests were administered to 48 children with corrected age ranging from 29 days to 26 months. Concurrent validity between age-equivalent (AE) scores and standard scores was assessed for 4 age groups.

RESULTS

Moderate to very high correlation for all groups was found between the Bayley-III composite scores and the PDMS-2 Total Motor quotient scores. High correlations were found between the Bayley-III composite scores and the PDMS-2 Gross and Fine Motor quotients (12-26 months); high correlations were found between the Bayley-III and the PDMS-2 Gross Motor quotient (6-12 months) and moderate correlations were found for younger age groups. High concurrent validity for AE scores was found only above 18 months.

CONCLUSIONS

The study supports the substitution of the Bayley-III for the PDMS-2 for standard scores or AE scores for children aged 19 to 26 months and for standard scores for children birth to 18 months.

Parent-provider-community partnerships: optimizing outcomes for children with disabilities

Children with disabilities and their families have multifaceted medical, developmental, educational, and habilitative needs that are best addressed through strong partnerships among parents, providers, and communities. However, traditional health care systems are designed to address acute rather than chronic conditions. Children with disabilities require high-quality medical homes that provide care coordination and transitional care, and their families require social and financial supports. Integrated community systems of care that promote participation of all children are needed. The purpose of this clinical report is to explore the challenges of developing effective community-based systems of care and to offer suggestions to pediatricians and policy-makers regarding the development of partnerships among children with disabilities, their families, and health care and other providers to maximize health and well-being of these children and their families.

Enhancing the algorithm for developmental-behavioral surveillance and screening in children 0 to 5 years

OBJECTIVE

To determine if the 2006 American Academy of Pediatrics developmental surveillance and screening algorithm is adequate or if revisions are needed.

METHODS

A comprehensive literature search was conducted to investigate a clinician's ability to perform developmental-behavioral surveillance in children 0 to 5 years.

RESULTS

Even when a broad-band developmental screen is typical, pediatricians should refer when they confidently suspect a delay but be far more suspicious about children who seem asymptomatic. Periodic screening enhances surveillance by improving early detection and early intervention (EI) eligibility rates. Nevertheless, children with concerning screens are not consistently referred and interlinked to EI. Once referred, approximately half are deemed EI-ineligible, even though they typically perform well below average and have numerous, predictive academic and psychosocial risk factors. Meanwhile, clinicians struggle with tracking at-risk children.

CONCLUSION

Revisions are needed to optimize early detection, prevention, and monitoring. Greater emphasis is needed on developmental-behavioral promotion and referral care coordination.

Enhancing developmentally oriented primary care: an Illinois initiative to increase developmental screening in medical homes

In 2005, the Enhancing Developmentally Oriented Primary Care (EDOPC) project of the Illinois chapter of the American Academy of Pediatrics and the Illinois Department of Healthcare and Family Services began a project to improve the delivery and financing of preventive health and developmental services for children in Illinois. The leaders of this initiative sought to increase primary care providers' use of validated tools for developmental, social/emotional, maternal depression, and domestic violence screening and to increase early awareness of autism symptoms during pediatric well-child visits in children aged 0 to 3 years. These screenings facilitate identification of children at risk and those who need referral for further evaluation. Primary barriers to such screenings include lack of practitioner confidence in using validated screening tools. In this article we describe the accomplishments of the EDOPC project, which created training programs to address these barriers. This training is delivered by EDOPC staff and peer educators (physicians and nurse practitioners) in medical practices. The EDOPC project enhanced confidence and intent to screen among a large group of Illinois primary health care providers. Among a sample of primary care sites at which chart reviews were conducted, the EDOPC project increased developmental screening rates to the target of 85% of patients at most sites and increased social/emotional screening rates to the same target rate in nearly half of the participating practices.

Accelerating evidence into practice for the benefit of children with early hearing loss

Over the years, multiple groups have issued recommendations for newborn hearing screening, diagnosis, and intervention. In January 2008, the US Department of Health and Human Services held an invitational workshop at which more than 50 national experts met for 2 days to consider ways to accelerate the movement of evidence-based recommendations into practice. Participants set priorities among existing recommendations, identified areas with the most promise and created a national blueprint to accelerate evidence into practice. Workshop participants adopted the "3T's Roadmap to Transform US Health Care" as the conceptual model for this work and used a modified Delphi process to identify high-priority recommendations in 5 areas (diagnosis, treatment, parental and public awareness, continuous quality improvement, and stewardship). A matrix of responsibility was developed to specify entities that could take action to implement these recommendations. Participants placed a high priority on measurement and recommended improved data-tracking of newborns after screening and creation of a limited set of national indicators to monitor progress toward evidence-based system goals. They also identified a greater role for parents and families in contributing to system transformation and a need for more culturally and linguistically appropriate resources. Targeting infants in the NICU for early testing and creating guidelines and resources for early intervention were additional priorities. Finally, the work group noted the need to create a stewardship function to monitor the progress of the entire system of care, disseminate reports, consider future research directions, and continue to develop critical cross-agency and public-private coordination of activities.

Policy statement--health equity and children's rights

Many children in the United States fail to reach their full health and developmental potential. Disparities in their health and well-being result from the complex interplay of multiple social and environmental determinants that are not adequately addressed by current standards of pediatric practice or public policy. Integrating the principles and practice of child health equity-children's rights, social justice, human capital investment, and health equity ethics-into pediatrics will address the root causes of child health disparities. Promoting the principles and practice of equity-based clinical care, child advocacy, and child- and family-centered public policy will help to ensure that social and environmental determinants contribute positively to the health and well-being of children. The American Academy of Pediatrics and pediatricians can move the national focus from documenting child health disparities to advancing the principles and practice of child health equity and, in so doing, influence the worldwide practice of pediatrics and child health. All pediatricians, including primary care practitioners and medical and surgical subspecialists, can incorporate these principles into their practice of pediatrics and child health. Integration of these principles into competency-based training and board certification will secure their assimilation into all levels of pediatric practice.

Health care professionals' views of sharing information with families who have a child with a genetic condition

The purpose of this study was to examine health care professionals' views and strategies for individualizing information sharing in families who have a child with a genetic condition. The sample consisted of 37 health professionals from three clinical sites in the greater metropolitan area of a large Midwestern city. Qualitative content thematic analysis was used to analyze data from the health professionals' semi-structured interviews. Four themes captured how health care professionals work with families around information management: Sharing Information with Parents, Taking into Account Parental Preferences, Understanding of the Condition, and Helping Parents Inform Others. These findings contribute to understanding the processes that health professionals use in sharing information with parents who have children with a genetic condition, and they provide guidance for clinical practice, professional training, and future research.

Meta-analytic structural equation modeling of the influences of family-centered care on parent and child psychological health

Background. Family-centered care is now practiced throughout the world by physicians, nurses, and allied health care professionals. The call for adoption of family-centered care is based on the contention that the physical and psychological health of a child is influenced by parents' psychological health where family-centered care enhances parent well-being which in turn influences child well-being. We empirically assessed whether these relationships are supported by available evidence. Method. Meta-analytic structural equation modeling was used to test the direct and indirect influences of family-centered care and self-efficacy beliefs on parent and child psychological health. Data from more than 2900 parents and other caregivers in 15 studies were used for the analyses. Results. Family-centered care had indirect effects on parent and child psychological health mediated by self-efficacy beliefs. Conclusion. The relationships posited in the literature about family-centered care were supported by the study results.

Immunization programs for infants, children, adolescents, and adults: clinical practice guidelines by the Infectious Diseases Society of America

Evidence-based guidelines for immunization of infants, children, adolescents, and adults have been prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). These updated guidelines replace the previous immunization guidelines published in 2002. These guidelines are prepared for health care professionals who care for either immunocompetent or immunocompromised people of all ages. Since 2002, the capacity to prevent more infectious diseases has increased markedly for several reasons: new vaccines have been licensed (human papillomavirus vaccine; live, attenuated influenza vaccine; meningococcal conjugate vaccine; rotavirus vaccine; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis [Tdap] vaccine; and zoster vaccine), new combination vaccines have become available (measles, mumps, rubella and varicella vaccine; tetanus, diphtheria, and pertussis and inactivated polio vaccine; and tetanus, diphtheria, and pertussis and inactivated polio/Haemophilus influenzae type b vaccine), hepatitis A vaccines are now recommended universally for young children, influenza vaccines are recommended annually for all children aged 6 months through 18 years and for adults aged > or = 50 years, and a second dose of varicella vaccine has been added to the routine childhood and adolescent immunization schedule. Many of these changes have resulted in expansion of the adolescent and adult immunization schedules. In addition, increased emphasis has been placed on removing barriers to immunization, eliminating racial/ethnic disparities, addressing vaccine safety issues, financing recommended vaccines, and immunizing specific groups, including health care providers, immunocompromised people, pregnant women, international travelers, and internationally adopted children. This document includes 46 standards that, if followed, should lead to optimal disease prevention through vaccination in multiple population groups while maintaining high levels of safety.

Addressing early childhood development in primary health care: experience from a middle-income country

OBJECTIVE

This study aimed to evaluate the efficacy of a national training program in Turkey in improving primary health providers' knowledge and perceived competence about the promotion of early childhood development and prevention, early identification and management of developmental problems; and barriers to implementation and sustainability of skills gained.

METHODS

A pre-post intervention design was used. Tools measuring perceived competence and knowledge about childhood development were administered to primary health providers before and after training. Immediate skills were observed, and implementation and sustainability of skills were determined using individual surveys and focus group discussions 1 year after training.

RESULTS

The training was provided in 5 provinces. Of the 148 primary health providers trained, 90% had >5 years experience in providing primary care. Median knowledge test scores were 13 pretraining and increased to 22 posttraining (p < 0.001). Median perceived competence scores increased from 159 to 222 (p < 0.001). A year after the training, the program and materials were reported to be valued and remembered but used limitedly. Patient load, insufficient time allocated to primary care, lack of reimbursement, and ineffective referrals to pediatricians who had knowledge gaps regarding child development were identified as important barriers to implementation and sustainability of skills gained.

CONCLUSIONS

In Turkey and potentially other countries with similar health systems, short-term inservice training on child development can improve primary health providers' knowledge, perceived competence and skills related to child development. To decrease the disparities between high- and low- and middle-income countries in addressing child development, significant barriers within health systems need to be identified and addressed.

Factors influencing the enrollment of eligible extremely-low-birth-weight children in the part C early intervention program

OBJECTIVE

To determine whether eligible extremely-low-birth-weight children (<1000 g) were enrolled in the federally enacted, state-coordinated Early Intervention (EI) program intended to help children with developmental delay or disability regardless of parental income, and the factors associated with enrollment.

METHODS

Retrospective analysis of 884 EI-eligible ELBW children born in South Carolina with birth weight 401 to 999 g, gestation > or =24 weeks, and survival for the first 120 days of life. We created a linked data set with data from Early Intervention (1996-2001), Vital Records (1996-1998), death certificates, and Medicaid. Each child was followed from birth to 3 years old, the program eligibility period.

RESULTS

A total of 54% of ELBW children were enrolled in EI at any time from birth to 36 months. Even among children ever enrolled in Medicaid (83% of all ELBW children), only 63% were enrolled in EI. Being born in a multiple gestational birth, having heavier birth weight (750 to 999 g), and having ever enrolled in Medicaid were positively associated with EI enrollment. Among Medicaid patients for whom perinatal data were available, additional risk adjustment showed that EI enrollment was more likely with birth in level 3 hospitals, birth weight 750 to 999 g, Neonatal Medical Index severity level V (most severe), and longer initial length of hospital stay.

CONCLUSIONS

Only about half of eligible ELBW children in South Carolina were enrolled-much lower than reported elsewhere. Efforts are needed to understand why eligible infants are not being enrolled and to develop strategies to remedy the situation.