Developmental & Behavioral Pediatrics

Identification and Management of Adolescent Depression in a Large Pediatric Care Network ABSTRACT: Objective: Primary care has been promoted as a setting to identify and manage adolescent depression. This study examined primary care–based adolescent depression identification and follow-up care when elevated symptoms were identified. Methods: Data came from a large pediatric care network with an organizational recommendation to screen for depression at age 16 well-visits using an electronic health record (EHR)-integrated standardized measure. Analyses examined rates of screening and elevated symptoms, pediatricians' initial responses to elevated scores, and types of follow-up care received over 1 year using retrospective EHR data extraction and manual chart reviews. Results: Across program sites, 76.3% (n = 6981) of patients attending their age 16 well-visits were screened. About one-quarter had an elevated score (6.7% mild and 19.2% moderate-to-severe), many of whom received active follow-up on their well-visit date. Over 1 year, three-fourths of patients with scores in the moderate-to-severe range and 40.0% of patients with scores in the mild range received follow-up care (e.g., antidepressant prescriptions) as per EHR extraction. Follow-up rates were higher as per manual chart reviews. Conclusion: Routine adolescent depression screening is feasible across diverse primary care sites. Most patients with elevated scores were not already receiving behavioral health services, suggesting screening identified previously undetected concerns. In turn, many adolescents with elevated scores initiated treatment after screening, which indicates providing screen results at the point of care may facilitate pediatrician actions. Still, gaps in follow-up care demonstrate the need for greater investment in primary care–based behavioral health services to support high-quality treatment and ultimately decrease the burden of adolescent depression.

Experience with the Rapid Interactive Test for Autism in Toddlers in an Autism Spectrum Disorder Diagnostic Clinic ABSTRACT: Objective: To examine the psychometric properties of the Rapid Interactive Screening Test for Autism in Toddlers (RITA-T) in an autism spectrum disorder (ASD) clinic for children aged 18 to 36 months. Methods: The RITA-T (level 2 screening instrument) was integrated into an ASD screening and diagnostic process for evaluating children aged 18 to 36 months who were referred to a pediatric tertiary care center. Scoring of the RITA-T to differentiate ASD from non-ASD developmental concerns was evaluated. Screening instrument measurements included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR−). Results: From a total of 239 participants aged 18 to 36 months (males = 78% and females = 22%), 201 (84%) were diagnosed with ASD (4:1 male-to-female ratio). An ASD diagnosis was significantly associated with RITA-T scores, with ASD patients scoring higher than non-ASD patients [F (1,235) = 170, mean difference: males 9.21, mean difference: females 12.4, p < 0.001]. The RITA-T score was not statistically correlated with age or sex. The optimal cutoff score of ≥14 was determined from a receiver operator curve analysis (area under the curve = 0.953). In the study group, with a cutoff score of ≥14, the RITA-T showed a sensitivity of 0.97, specificity of 0.71, PPV of 0.95, NPV of 0.79, LR+ of 3.33, and LR− of 0.05. Conclusion: The RITA-T, as a level 2 screening instrument for ASD, exhibits discriminative psychometric properties similar to previously published results. When integrated into an ASD screening and diagnostic process for families for whom concerns about ASD have been raised with their children aged 18 to 36 months, the RITA-T helps to predict a best-estimate clinical diagnosis of ASD.

Profiles and Predictors of Infant Sleep Problems Across the First Year ABSTRACT: Objective: To identify profiles and predictors of maternal-reported infant sleep problems across the first postnatal year. Methods: Survey data examining maternal mental and physical health, intimate partner violence (IPV), and infant sleep problems and night waking were gathered from a cohort of 1,460 nulliparous women at 15 weeks' gestation and when their infants were 3, 6, 9, and 12 months old. Results: Latent class analysis revealed 5 profiles of infant sleep problems, including those who had few problems (24.7%), persistent moderate problems (27.3%), increased problems at 6 months (10.8%), increased problems at 9 months (17.8%), and persistent severe problems (19.4%). Persistent severe infant sleep problems were associated with prepartum and postpartum maternal depression (adjusted odds ratio [AOR] 2.13, 95% confidence interval [CI] 1.35–3.34, p < 0.01; AOR 2.52, 95% CI 1.64–3.87, p < 0.001, respectively), poorer prepartum and postpartum perception of health (adjusted mean difference [AMD] 23.48, 95% CI 24.9 to 22.1, p < 0.01; AMD 23.78, 95% CI 25.2 to 22.4, p < 0.001, respectively), increased postpartum anxiety (AOR 2.22, 95% CI 1.26–3.90, p < 0.01), and increased prevalence of IPV in the first year postpartum (AOR 1.86, 95% CI 1.20–2.87, p < 0.01). Conclusion: Poorer prepartum and postpartum maternal mental and physical health, and IPV, were associated with maternal report of persistent severe infant sleep problems. Women experiencing prenatal physical and mental health difficulties may benefit from advice on managing infant sleep and settling. Health professionals working with unsettled infants must be equipped to enquire about and respond appropriately to disclosures of IPV.

Role of Sleep Duration in the Association Between Socioecological Protective Factors and Health Risk Behaviors in Adolescents Abstract: Objective: The purpose of this study was to examine the associations of sleep duration and socioecological protective factors with patterns of adolescent risk behaviors in Fairfax County, VA—one of the largest public school districts in the United States. Methods: A total of 21,360 and 20,330 students in 10th and 12th grades who completed the Youth Risk Behavior Survey were included in this cross-sectional analysis. Sleep duration was measured by self-report of the average number of hours of sleep on a school night. Ten socioecological protective factors included peer-individual, family, school, and community domains. Latent class analysis was used to classify 7 risk behaviors (alcohol use, cigarette use, illicit drug use, inappropriate prescription drug use, risky sexual behavior, deviant behavior, and academic failure) into 4 class memberships (low, some, moderate, and high). Multinomial regression models were adjusted for age, sex, and race. Results: Adolescents who reported sleeping the recommended 8 to 9 hours were significantly less likely to belong to the class memberships of greater risk behaviors compared with those who reported short and long sleep duration after controlling for age, sex, race, and survey year. There was a significant inverse relationship between the number of socioecological protective factors and risk behaviors for both 10th and 12th graders. Potential risks of age, sex, and race on risk behaviors were observed. No significant interaction between sleep duration and protective factors was found in either grade. Conclusion: This study highlights the significant associations between sleep duration and risk behaviors in adolescents with diverse socioecological protective factors. Prioritization of prevention-focused resources should consider sleep duration in addition to the socioecological protective factors commonly cited in the literature when addressing adolescent risk behaviors.

Is It Correct to Correct for Prematurity? Theoretic Analysis of the Bayley-4 Normative Data ABSTRACT: Objective: To determine whether correction for prematurity is appropriate for cognitive, language, and motor function at varying degrees of prematurity and at different baseline functional levels. Methods: The newly published Bayley-4 normative data on 1700 normal children were used. Raw scores for baseline levels of function (−2 SD, −1 SD, and M) were identified at 6, 12, 24, and 36 months for receptive communication, expressive communication, fine motor, and gross motor scaled scores and cognitive, language, and motor composite scores. Differences between the baseline and uncorrected scores at 4, 3, 2, and 1 months of prematurity were evaluated at each age. Results: Using a cutoff of 3 points (1/5 SD), correction is needed for cognitive composite scores at all gestational ages for the first 2 years and in those born 4 months premature at 3 years of age; language and motor composite scores should be corrected to 3 years at all degrees of prematurity. Conclusion: Not correcting for prematurity in cognitive, language, and motor function at 3 years and younger places preterm infants at a distinct disadvantage when compared to peers with few exceptions, suggesting that such correction should be routine.

Early Gross Motor Development Among Brazilian Children with Microcephaly Born Right After Zika Virus Infection Outbreak ABSTRACT: Objective: To assess the gross motor development of children with presumed congenital Zika virus (ZIKV) infection over the first 2 years of their lives. Methods: Seventy-seven children were assessed at the median ages of 11, 18, and 24 months, using the evaluative instrument Gross Motor Function Measure (GMFM-66). At the third assessment, the children with diagnoses of cerebral palsy (CP) were classified by severity through the Gross Motor Function Classification System (GMFCS) and stratified by topography indicating the predominantly affected limbs. With these instruments in combination and using the motor development curves as reference, the rate of development and functional ability were estimated. Results: At 2 years of age, all children had the diagnosis of CP. Seventy-four (96.1%) presented gross motor skills similar to those of children aged 4 months or younger, according to the World Health Organization's standard. The GMFM-66 median score among the 73 (94.8%) children with quadriplegia and GMFCS level V showed significant change between 11 and 18 months (p < 0.001) and between 11 and 24 months (p < 0.001). No significant difference (p = 0.076) was found between 18 and 24 months. Conclusion: Despite showing some gross motor progress during the initial 18 months of life, these children with presumed congenital ZIKV infection and CP experienced severe motor impairment by 2 years of age. According to the motor development curves, these children with quadriplegia have probably already reached about 90% of their motor development potential.

Screening for Anemia in Children with Down Syndrome ABSTRACT: Objective: As part of the 2011 American Academy of Pediatrics (AAP) health supervision guidelines for children with Down syndrome (DS), annual screening for iron deficiency anemia is recommended between the ages of 1 and 18 years, but the evidence supporting this recommendation is limited. This study aimed to assess the prevalence of anemia in patients with DS between the ages of 1 and 18 years to provide additional evidence for the AAP 2011 guideline recommendations for annual hemoglobin and ferritin screening in patients with DS. Methods: A retrospective cohort study was completed by obtaining data from the electronic health record (EHR) for patients meeting the following inclusion criterion: a diagnosis of DS in patients aged 1 to 18 years seen at our institution with hemoglobin drawn between July 2012 and 2016. Data were analyzed by the Fisher exact test and χ2 test. Results: A total of 200 patients were identified. 22.5% had anemia, defined as a hemoglobin concentration less than 2 SDs for normed age. The National Health and Nutrition Examination Survey (2007–2010) reported prevalence of anemia for children aged 1 to 5 years is 3.2% when compared with 18.7% in our sample. Of the 45 children with anemia, 5% had a microcytic, 67.5% a normocytic, and 27.5% a macrocytic anemia. Only 10 received a diagnosis of anemia in the EHR. Conclusion: The prevalence of anemia in this cohort of children with DS is significantly higher than that in the general population, supporting the AAP guidelines for an annual screening until the age of 18 years.

Camps for Children with Cancer and Their Families: A Systematic Review of Psychosocial and Physical Impacts ABSTRACT: Objective: Camps for children with cancer and their families aim to promote positive psychosocial and physical outcomes for attendees. However, evidence for this is inconsistent, and previous reviews have not delineated between camps for children (patient/survivors and siblings) and family camps (including parents/guardians). Such understanding is necessary to understand the evidence-based benefits of each type of camp. Our systematic review summarizes the findings and limitations of the recent literature for children's camps and family camps. Methods: We searched MEDLINE/PubMed, PsycINFO, Social Work Abstracts, and Google Scholar for relevant articles published between 2013 and 2018. Results: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, we included 19 articles (from 15 studies) in the review. Evidence for the impact of camps was mixed. All articles reported positive outcomes, yet 3 quantitative articles also reported nonsignificant changes. Camps for children (representing 2151 children with cancer/survivors) appeared to facilitate social skills, self-esteem, and physical activity. Family camps (representing 96 families) may provide families the opportunity to reconnect. Both types of camp provide attendees with social support and fun/respite. In 2 qualitative articles, some parents attending family camps reported tension between families of children on treatment and bereaved families. The literature is limited by small sample sizes and the lack of multisite, longitudinal, and controlled study designs. Conclusion: The recent literature provides evidence for some positive, short-term psychosocial and physical outcomes of camps. Future research should use rigorous quasiexperimental designs and should assess the long-term impact of camp attendance.

When to Raise Our White Flag—A Discussion of Scope of Practice in a Resource Scarce World CASE: Thomas is a 13-year-old boy with autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder, separation anxiety disorder, and major depressive disorder who presented for a follow-up to his developmental and behavioral pediatrician (DBP). His mother describes an increase in symptoms of anxiety and depression for the last 6 weeks, accompanied by suicidal ideation and thoughts of self-mutilation. Before this increase in symptoms, he had been doing well for the last several months with the exception of increasing weight gain, and Abilify was decreased from 5 mg to 2.5 mg at his last visit. Other medications at that time included Zoloft 100 mg twice daily, Focalin XR 40 mg every morning, and Focalin 5 mg every night. Without seeking the guidance of our developmental and behavioral pediatrics clinic, his mother increased his intake of Zoloft to 150 mg each morning and continued 100 mg each evening because of worsening anxiety and depression. Religion is very important to Thomas and his family. He acknowledges that he does not want to die and feels badly because “suicide is against our religion.” Helping Thomas receive appropriate care has been a challenge. He was diagnosed with ADHD and Asperger disorder at the age of 5. Thomas is homeschooled and is very attached to his mother. His parents have very different parenting styles, with his mother being more permissive and his father more authoritarian. At the time of initial diagnosis, the behavioral health services (BHS) in Thomas' community, which is about an hour away from the DBP, were limited to older children, and he was followed by a DBP for ADHD medication management. At the age of 11, he expressed passive suicidal ideation and described that he imagined his mother as “the devil with fire coming out of her eyes” when she corrected him. He was evaluated by BHS, diagnosed with anxiety disorder, and started on Lexapro. BHS linked to the DBP were out of network for his insurance. The family was unable to pay out of pocket, so care was subsequently transferred to a DBP clinic that was in network. Soon after, Thomas developed auditory hallucinations, and Abilify was added after consultation with BHS. Over the last few years, Thomas' symptoms have waxed and waned. He did well for a short time and then again developed auditory hallucinations, worsening symptoms of anxiety and depression, and increasing somatic symptoms including vomiting and penile pain. Medications were adjusted with input from BHS, and further attempts were made to link him to local BHS but were unsuccessful. With his current concerns of suicidal ideation and self-mutilation, what would be your next steps?

Journal Article Review No abstract available