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Objective: This study aimed to compare the approval of medicines for attention deficit/hyperactivity disorder (ADHD) for pediatric patients across five countries. Method: A document analysis was completed, using the drug labeling for ADHD medicines from five countries; United Kingdom, Australia, New Zealand, Canada and United States (US). Comparisons of available formulations and approval information for ADHD medicine use in pediatric patients were made. Results: The US had the highest number of approved medicines and medicine forms across the studied countries (29 medicine forms for 10 approved medicines). Approved age and dosage variations across countries and missing dosage information were identified in several drug labeling. Conclusions: The discrepancies in approval information in ADHD medicine drug labeling and differing availability of medicine formulations across countries suggest variations in the management of ADHD across countries. The update of drug labeling and further research into reasons for variability and impact on practice are needed.

Purpose: Many young children in need of early intervention are not identified in a timely manner. This preliminary study explored the emerging role of speech language pathologists (SLPs), providing training to improve the use of developmental screening in pediatric primary care. Method: A quantitative, descriptive methodology with a one-group pretest, posttest interventional design was utilized to assess the impact of an SLP-led educational intervention on the knowledge of 17 paraprofessional medical support personnel to administer a standardized developmental screening tool. Results: Data analysis revealed a significant increase on knowledge posttest scores from pretest scores. Conclusion: SLPs providing educational training in pediatric primary care is an important first step in identifying solutions to improving the early identification of children with developmental concerns.

Mobile health (mHealth) screening tools for autism are gaining in prevalence, and have benefits such as video content and direct resources linkage. However, it is unclear whether such tools will ameliorate autism inequities or will help only those already advantaged in autism care. To investigate this issue, we conducted semi-structured qualitative interviews with 18 primary care and Early Intervention/Early Childhood Special Education providers in six US states. Providers were given hypothetical scenarios in which a family presents to care with results from one of 9 mHealth autism screening tools. Providers discussed their clinical approach and assessed the tool's fit with their patient/client population. Each transcript was audio-recorded, transcribed, and coded; a phenomenological approach was used to develop key themes. 4 themes and 18 subthemes emerged. These included "Clinical and business factors" (e.g. scope of practice concerns and clinical efficiency), "Validity and trustworthiness" (e.g. familiarity, data privacy/security), "Family interaction quality" (e.g. supporting family advocacy, provision of information, affecting family anxiety, and emotional support), and "Accessibility" (e.g. English proficiency/language issues, cultural inclusivity, and literacy/educational level). Providers suggested modifications to enhance equity, such as portraying diverse families, reducing the reading level of text, and making tools shorter to better fit clinical context.

Children with developmental disabilities lack sufficient physical activity in their daily lives. The purpose of this study was to see if children with developmental disabilities who participated in stair-climbing exercises had better physical performance and health status than children with developmental disabilities who did not. This study adopted a pre-and-post-test experimental design, enrolling 30 subjects (experimental group, 15; control group, 15) with developmental disabilities aged 5-7 years from pediatric rehabilitation treatment departments of two regional teaching hospitals in Taiwan. The experimental group received stair-climbing exercises and physical therapy twice a week for eight consecutive weeks. The primary outcomes were health-related physical fitness assessment items, including body composition (body mass index: BMI), cardiorespiratory fitness (stair-climbing test), muscular fitness (knee-bend sit-ups), and flexibility (Chair Sit and Reach Test). The post-test measurements of BMI, cardiorespiratory fitness, sit-ups, and muscular flexibility of children in the experimental group were significantly better than the pre-test measurements. The stair-climbing exercise training results for cardiorespiratory fitness, muscular fitness, and muscular flexibility in the experimental group were significantly better than those in the control group. Stair-climbing exercise improves the physical fitness of children with developmental disabilities. The results of this study suggest that children with developmental disabilities should be encouraged to engage in this convenient and easy stair-climbing exercise to improve physical performance and health status.

Over the last three quarters of a century, international guidelines and regulations have undergone significant changes in how children are problematised as participants in biomedical research. While early guidelines enacted children as vulnerable subjects with diminished autonomy and in need of special protection, beginning in the early 2000s, international regulatory frameworks defined the paediatric population as vulnerable due to unaddressed public health needs. More recently, ethical recommendations have promoted the active engagement of minors as research partners. In this paper, I adopt a post-structuralist approach to policy analysis to examine deep-seated assumptions and presuppositions underlying the changes in the problematisation of children as biomedical research participants over time. While biomedical research ethics focuses on the autonomy and vulnerability of minors, ethical guidelines are situated in specific sociocultural contexts, shaped, among other things, by contingent public health needs and changing conceptions of the value of research and science for society. In the process, I demonstrate the challenge of moving away from an approach that in taking adults as the model overshadows the complexity of children's lived experiences as well as their personal, cultural, and social lives. The lack of acknowledgement of this complexity makes children vulnerable to epistemic injustice, which is particularly crucial to address in public involvement initiatives.

Background: Integrated primary care (IPC) can address prevalent behavioral health concerns identified in pediatric office visits, but research on IPC consultation patterns is limited. Objective: This study investigated variation in consultation rates across presenting problems, patient sociodemographic factors, and IPC treatment duration. Method: Retrospective electronic health record data were extracted for 970 patients seen in 12 pediatric primary care sites and for whom behavioral health consultation was requested between June 2018 and December 2019. Logistic regressions were used to examine associations between sociodemographic variables, consultation reasons, and IPC visit type. We used multiple linear regression to assess the association between consultation reason and treatment duration. Results: Anxiety (36.2%) and disruptive behavior (29.7%) were the most common consultation reasons. Consultation requests for internalizing (anxiety, mood) problems were more prevalent in school-aged children and adolescents, whereas consultations for disruptive behavior (tantrums) and health-related issues (toileting, sleep concerns) were common in early childhood. Girls were less likely to receive consultation requests for attention deficit/hyperactivity disorder (ADHD) and autism/developmental concerns compared to boys, but more likely to receive consultation for internalizing problems. Consultation requests varied by patient race, ethnicity, visit type, and insurance type. Treatment duration after consultation was longer among patients with consultation requests for ADHD and for depression/mood concerns. Conclusions: Age-related behavioral health consultation patterns in IPC conform with expected developmental trends; however, sociodemographic findings suggest opportunities for enhancing care. Additional research is needed on IPC consultation given its promise for early identification, prevention, and treatment of pediatric mental health concerns.

Learning to descend stairs requires motor and cognitive capacities on the part of infants and opportunities for practice and assurance of safety offered by caregivers. The American Academy of Pediatrics prescribes the age strategy to teach toddlers to safely descend stairs but without much consideration for individual differences in infants' skills or caregivers' techniques. The purpose of this study was to observe the natural ways in which caregivers teach infants to descend stairs at home and the extent to which infants abide. Of particular interest was to examine the dynamic nature of caregivers' teaching and infants' learning over the session with attention to individual differences. Dyads (N = 59) were videorecorded on Zoom for 10 min interacting on stairs at home in the United States, Brazil, Canada, Italy, and Spain. Infants (n = 30 girls, 29 boys; 13-month-olds ± 1 week) were novice walkers (M = 2.04 months walking experience). Caregivers used a variety of teaching strategies and focused on "backing" and "scooting." Infants were more likely to heed caregivers' guidance when caregivers provided hands-on support and verbal encouragement suggesting infants were engaged and responsive to caregivers' overtures. Infants' walking experience predicted change in descent strategy over the session. Although infants did not show evidence of learning over the session, consistent caregiver instruction suggested caregivers were persistent, if not effective, teachers. Teaching and learning motor skills in a potentially risky task creates a unique opportunity for interaction, allowing infants and caregivers to learn from one another.

To examine the association between psychologist and nurse practitioner scope-of-practice (SoP) regulations and pediatric mental health service access. A nationally representative sample of children with mental health needs was identified using 5 years of National Survey of Children's Health (2016-2020). Utilization was measured in two ways: (1) unmet mental health care needs and (2) receipt of mental health medication. Expanded SoP for psychologists and nurse practitioners was measured based on the child's state of residence and the year of the survey. The associations between both SoP expansion and both outcomes were assessed using logistic regression models adjusted for multiple covariates. The probability of having unmet mental health needs was 5.4 percentage points lower (95% CI - 0.102, - 0.006) for children living in a state with psychologist SoP expansion; however, there was no significant difference in unmet mental health needs between states with and without NP SoP expansion. The probability of receiving a mental health medication was 2.0 percentage points higher (95% CI 0.007, 0.034) for children living in a state with psychologist SoP expansion. Conversely, the probability of receiving a mental health medication was 1.5 percentage points lower (95% CI - 0.023, - 0.007) for children living in a state with NP SoP expansion. Expanded SoP for psychologists is associated with improved access to pediatric mental health care in terms of both unmet need and receiving medication. Expanded SoP for NPs, however, was not associated with unmet need and lower receipt of medication.

Background: Static and dynamic balance skills can be related to the activities of daily living (ADL) in children with non-syndromic intellectual disabilities, and the type of balance skills affecting ADL can differ depending on the domain of ADL (self-care, mobility, and social function). Methods: The ADL capabilities of 66 children with intellectual disabilities were assessed using the Pediatric Evaluation of Disability Inventory (PEDI) and were examined in relation to static and dynamic balance skills. Results: Significant positive correlations were found between the one-leg standing and PEDI (r = 0.841 for self-care, r = 0.700 for mobility, and r = 0.760 for social function). Our analysis showed that static balance skills affected self-care, dynamic balance skills affected mobility, and intelligence quotient affected social function. Conclusions: Improving balance skills is important for enhancing ADL capabilities, and the type of balance skills that need enhancement vary based on the domain of ADL.

The purpose of this research is to ascertain the effectiveness of using the e-learning method for a module in pediatric clerkship at the [redacted name] University Hospital, Karachi. The fourth-year undergraduate medical students, who rotates for eight weeks in Pediatric clerkship, participated in this study. It was a sequential (Quantitative-Qualitative) mixed-method study, which was conducted from May-August 2020. Students were divided according to their status of in-person rotation (Novice, Semi-expert, Expert). The quantitative component of the study consisted of pre and post-tests and pre-validated post-session feedback, while focused-group discussions were done to explore students' experiences. SPSS version 20.0 was used for quantitative data while qualitative data underwent content analysis. Fifty-nine participants (68.8%) were female. The intervention batch comprised of 102 students (41 Novice (40.2%), 21 Semi-expert (19.6%), and 40 Expert (39.2%)). Using paired t-test analysis between pre and post-test scores of each session, it was discerned that there was indeed a positive effect on knowledge acquisition during each session, depicted by the improvement in test scores. The Semi-expert and Expert groups were merged for analysis. The Novice group was found to be statistically significant for only the common newborn problem session. The qualitative component explored students' views, and three main themes emerged, i.e., the effectiveness of online learning, barriers and challenges to online learning, and future goals to enhance online learning. In conclusion, E-learning is an effective way of continuing the process of delivering medical education, especially in unprecedented times. Technological enhancements will help carry the impact forward as a blended-learning pedagogical approach in undergraduate medical education.

Current childhood obesity treatment programs do not address medically underserved populations or settings where all members of an interdisciplinary team may not exist - either within one organization or within the community. In this paper, we describe the use of a community-academic partnership to iteratively adapt Epstein's Traffic Light Diet (TLD), into Building Healthy Families (BHF), a community-placed evidence-based pediatric weight management intervention (PWMI) and evaluate its effectiveness in reducing BMI z scores. Nine cohorts of families completed BHF. Participants included children aged 6-12 years with obesity (M = 9.46, SD = 1.74). The Framework for Reporting Adaptations and Modifications-Expanded guided our classification of modifications across BHF cohorts. Using the FRAME reporting structure, the changes that were documented were (1) planned and occurred pre-implementation, (2) based on decisions from local stakeholders (e.g., school administrator, members of the implementation team), and (3) specific to changes in content and context - with a focus on implementation and potential for local scale-up. The nature of the adaptations included adding elements (whole of family approach), removing elements (calorie counting), and substituting elements (steps for minutes of physical activity). Across 9 cohorts, 84 families initiated the BHF program, 69 families successfully completed the 12-week program, and 45 families returned for 6-month follow-up assessments. Results indicated that the BMI z score in children was reduced by 0.31 ± 0.17 at 6 months across all cohorts. Reduction in BMI z score ranged from 0.41 in cohort 4 to 0.13 in cohort 5. Iterative adaptations to BHF were completed to improve the fit of BHF to the setting and participants and have contributed to a sustained community PWMI that adheres to the underlying principles and core elements of other evidence-based PWMIs. Monitoring adaptations and related changes to outcomes can play a role in long-term sustainability and effectiveness.

The ability to connect key concepts of biochemistry with clinical presentations is essential for the development of clinical reasoning skills and adaptive expertise in medical trainees. To support the integration of foundational and clinical sciences in our undergraduate health science curricula, we developed a small group active learning exercise during which interprofessional groups of students use clinical cases to explore the biochemistry, diagnostic strategy, and evidence-based treatment options of inborn errors of metabolism (IEM). We designed multistage learning modules consisting of (1.) low-fidelity case simulations of pediatric patients presenting with IEMs, (2.) guided group discussions on clinical biochemistry, differential diagnoses, and diagnostic strategies, (3.) oral presentations of clinical reasoning strategies, and (4.) discussion of relevant evidence-based medicine topics related to the cases. These modules Scientific Knowledge Integrated in Patient Presentations (SKIPPs) were added to a first-semester foundational sciences course serving five health professions programs. The assessment of learning outcomes by students and faculty shows that SKIPPs sessions are well-received activities that significantly improve trainees' ability to integrate foundational science concepts into clinical scenarios, to practice interprofessional teamwork and to develop clinical reasoning skills.

We have observed that as the theoretical landscape in behavioral science continues to proliferate and diversify, it is not uncommon that distance between subspecialties emerge, artificially accentuating differences between camps. This may occur at the risk of losing sight of the common ground, and worsening communication between subspecialties. In this paper, we propose conceptual "crosswalking" as a means to preserve interdisciplinary communication within the behavioral sciences. This is illustrated using Bronfenbrenner's Person-Process-Context-Time (PPCT) Model, mapped onto therapeutic modalities with a focus on ecological systems. Recommendations for future crosswalking are made.

Background: Pediatric programs focused on treating chronic pain often do not include an educational liaison (EL) to coordinate services between the patient's medical home and school. As chronic pain in youth can have deleterious effects on school functioning, collaboration between the medical home and the school system are needed to assure these students receive appropriate accommodations. Contributions to Theory: This manuscript describes a model of coordinated care for students with chronic pain that includes a systemic strategy for collaborative care across settings. Specifically, the role of an EL is described in the context of advocating for the patient to receive appropriate educational accommodations. Conclusions: This paper provides a guide for caregivers and professionals to assure appropriate access to support services across settings. Recommendations are included for school accommodations and services to improve academic functioning and outcomes for students with chronic pain.

Fragile X syndrome (FXS) is characterized by variable neurobehavioral abnormalities, which leads to difficulties in developing and evaluating treatments and in determining accurate prognosis. We employed a pediatric cross-sectional sample (1,072 males, 338 females) from FORWARD, a clinic-based natural history study, to identify behavioral subtypes by latent class analysis. Input included co-occurring behavioral conditions, sleep and sensory problems, autistic behavior scales (SCQ, SRS-2), and the Aberrant Behavior Checklist revised for FXS (ABC[subscript FX]). A 5-class solution yielded the most clinically meaningful, pharmacotherapy independent behavioral groups with distinctive SCQ, SRS-2, and ABC[subscript FX] profiles, and adequate non-overlap ([greater than or equal to] 71%): "Mild" (31%), "Moderate without Social Impairment" (32%), "Moderate with Social Impairment" (7%), "Moderate with Disruptive Behavior" (20%), and "Severe" (9%). Our findings support FXS subtyping, for improving clinical management and therapeutic development. [Written with the FORWARD Consortium.]

To explore issues surrounding re-consenting youth in longitudinal studies as they reach legal adulthood interviews were conducted with 46 parents plus 13 autistic teens enrolled in the Simons Foundation Powering Autism Research for Knowledge (SPARK) study. Qualitative analysis focused on family sensitivities regarding guardianship decisions, transition concerns, and the re-consenting process. Questions regarding guardianship were difficult for parents unsure of a teen's future status. Mothers were key facilitators of re-consenting for soon-to-be-independent teens. As legal adulthood approached, parents were willing to assist teens with re-consenting but needed support, asking for multiple contacts, transition resources, and explanatory materials from the research team. Most teens were not cognizant of SPARK but willing to continue participation once made aware.

The hospital setting may be especially difficult for pediatric patients on the autism spectrum and their families compared to those not on the spectrum. Child life specialists are healthcare professionals specifically trained to support parents and their children and help prepare them for hospital procedures. Because of this specialized skill set, these professionals likely have a wealth of expertise to share relevant to caring for autistic patients. This study aimed to understand 21 child life specialists' experiences working with patients on the spectrum. Our findings highlighted the following themes: Parents are the Experts, Proactive and Individualized Care, Disclosure, and Hospital-Wide Suggestions to Improve Patient Care. We discuss the practice implications of these findings on the healthcare experiences of pediatric patients on the spectrum.

Identification procedures for autism spectrum disorders in paediatric settings include screening and routine clinical surveillance. Screening tools are perceived as challenging, and a preference for direct observation has been reported in Ecuadorian paediatric settings. Augmentative observational procedures could prompt the application of screening tools, increase professionals' sense of self-efficacy and support referral decision-making. Following the recommendations that identification procedures should be tested in a group of children without autism from local populations, we tested a set of observational tasks on 125 children from 12 to 59 months of age in various socio-economic settings, in semi-experimental conditions and on a group of 33 non-autistic children in a paediatric-setting condition. Results indicated that the social referencing task did not produce the expected response in most children in semi-experimental conditions. Responses to the elicitation of a gesture were significantly influenced by socio-economic status and geographic area. Three other tested tasks (response to name, eye contact, response to joint attention) produced the expected responses in semi-experimental and clinical conditions, suggesting that they could be used in daily routines if fidelity to training is ensured. We discuss the implication of those findings in clinical practice and professional education in an Ecuadorian context.

Intrinsic inequity in assessment refers to sources of harmful discrimination inherent in the design of assessment tools and systems. This study seeks to understand intrinsic inequity in assessment systems by studying assessment policies and associated procedures in residency training, using general pediatrics as a discourse case study. Foucauldian discourse analysis (FDA) was conducted on assessment policy and procedure documents. Two authors independently prepared structured analytic notes using guiding questions. Documents and respective analytic notes were subsequently reviewed independently by all authors. Each author prepared further unstructured analytic notes on the documents' discourse. The authors then compared notes and constructed truth statements (i.e., interpretations of what the discourse establishes as true about the construct under study) and sub-strands (i.e., themes) that were repeated and legitimized across the documents via iterative discussion. Based on analysis, the authors constructed two truth statements. These truth statements, "good assessment is equitable assessment," and "everyone is responsible for inequity," conceptualized inequity in assessment as an isolated or individual-level aberration in an otherwise effective or neutral system. Closer examination of the truth statements and sub-strands in the discourse presented an alternative view, suggesting that inequity may in fact not be an aberration but rather an inherent feature of assessment systems.

Background: COVID-19 necessitated emergency telepractice for student-led speech-language therapy clinical practicals in training institutions, with limited preparation and evidence-based guidelines. Beyond the pandemic, practitioners and university training sites are likely to continue to offer telepractice necessitating thorough preparation for telepractice services underpinned by a comprehensive understanding of the complexities involved in online therapy. Aims: Adopting realist evaluation principles, our aim in this paper was to explore broadly what works and does not work in a set of student-led telepractice sessions in a diverse, resource-limited context. The broader goal of this project was to provide evidence-based support to enhance the efficiency and success of telepractice sessions in student clinical training contexts. Methods & Procedures: We used qualitative observational methods with reflexive thematic analysis to analyse 28 video recordings and 61 observation notes of student-led paediatric telepractice sessions from a South African university clinic as part of a pilot study. Outcomes & Results: We identified four overarching considerations for student-led telepractice: (1) additional, specific preparation is required, (2) with greater management of technology and adaptation of tasks, especially during times of poor connectivity; (3) telepractice relies heavily on caregiver input and collaboration; and (4) promoting engagement online, holding a client's attention, building rapport and offering reinforcement are critical skills that are complicated by the lack of face-to-face contact. Conclusions & Implications: Our findings indicate that telepractice pedagogy needs to be explicitly taught and students require practical assistance as they learn how to use this service delivery approach effectively. There are some aspects peculiar to telepractice that require unique consideration and planning, especially in contexts where service providers and users may be unfamiliar with this form of service provision. The findings of this pilot study can be used by clinical educators and student clinicians to enhance clinical training opportunities involving telepractice.

The Special Education Process (SEP) demands the collaboration of various professionals and personalities to create the Individualised Education Plan (IEP), beginning with the evaluation conducted by clinical psychologists, psychiatrists and in this study, developmental paediatricians. Assessments acts as a keystone document, serving as basis for determining placement levels, student support requirements and depth of academic training to be implemented. With inclusion gradually being implemented in the Philippines, the study sought to determine the translatability of the assessment report produced by developmental paediatricians into the IEP. The study used documentary analysis of 50 individualised education plans derived from the assessment reports of 10 different developmental paediatricians. The documents were analysed to determine the presence of components needed to refer to in making the IEP. The data shows that the assessment reports have four components, namely profile, present level of condition, report and recommendation. These components can be used as reference material in creating the IEP, and as a basis for a structured approach in creating the document. However, the study also shows how the report content and structure slightly differ for each other, making some of the reports easier to refer to compared to others.

The extent to which observed disparities in access to primary pediatric care are mirrored in student access to school nursing services is unknown. Using school employment records, we linked 1,346 nurses to school districts serving 1,141,495 students in Washington state. The percentage of students who are Black is negatively associated with the student-to-nurse ratio, while the percentage of students eligible for free-or-reduced-price lunch is positively associated, and relative to urban districts, rural districts have higher student-to-nurse ratios. Disparities in access to school nursing services mirror access gaps for pediatric care along socioeconomic status and geography. The increased number of nurses working in districts with more racial/ethnic minority students may play a protective role and ameliorate access gaps observed in pediatric primary care. States can likely use existing employment and licensing data to understand where school nurses work and therefore guide resource allocation decisions.

Pediatric cancer is the second leading cause of death among children ages 1-14 (Whitehead et al., 2016). Approximately 10,500 children ages 1-14 and 5090 adolescents ages 15-19 have been diagnosed with cancer in 2021 (American Cancer Society, 2021). An estimated 28% of childhood cases and 13% of adolescent patients will be diagnosed explicitly with Leukemia (American Cancer Society, 2021). Leukemia is a broad term that encompasses the malignant disease of bone marrow and other structures responsible for blood production (Olin et al., 2018). Children and adolescents experiencing pediatric leukemia often undergo treatment that produces biological, psychosocial, and cognitive impacts. Due to the occurrence of this disease in school-aged children and the wide-ranging consequences they face, school psychologists may be called upon to work with students and their families while they go through treatment during school-aged years. This article will discuss pediatric leukemia, treatment options, long-term impacts of treatment for patients, and considerations for working with children in the school system.

Background: Sleep plays an integral role in a child's physical and neuropsychological development. Children with sleep disorders are at risk of developing inattention, hyperactivity, and learning difficulties, challenges that impact them, their families, their classmates, and their communities. There is a paucity of pediatric sleep medicine providers equipped to partner with families in identifying and addressing sleep disorders. Additional barriers to accessing this specialized care include geographic proximity, parental ability to take time off from work, and hesitance for a child to miss valuable learning time at school. During the SARS-CoV-2 pandemic, our pediatric sleep department transitioned from largely in-person care to a predominantly virtual platform and collected data to monitor the impact of this transition. In this study, we share several key trends that emerged which may have broad implications on how pediatric sleep medicine providers can better support school-aged children with sleep challenges. Methods: We performed a chart review of all scheduled pediatric sleep medicine visits from June 2019 to June 2021, a time frame that included the pandemic-driven overnight transition from in-person to virtual clinic visits. The STEM framework was developed by pediatric telehealth experts to provide a unified approach to assessing the impact of telehealth programs. We applied this framework to the collected data to gauge the impact on the four major domains highlighted in STEM: health outcomes, healthcare delivery, individual experience (patient and provider), and program implementation. Results: The data demonstrated an increased proportion of completed visits and a decreased proportion of canceled/no-show visits when care was provided virtually. Patients accessing virtual care were doing so from greater distances than those who had in-person visits. The school-aged (5-12 years) cohort utilizing telehealth had notable differences in past medical history, with significantly more Attention Deficit-Hyperactivity Disorder. They also presented with significantly more insomnia and behavioral sleep difficulties. Discussion: Sleep disorders are common, and school-aged children have much to gain from sleep optimization. However, pediatric sleep care can be challenging to access. Geographic distance and time away from school and work preclude many families from formal sleep consultations. Telehealth allows high-quality pediatric sleep care to be offered in an easily accessible format to those near and far, resulting in clinics running more efficiently and school-aged children, who need it most, to receive the tools they need to sleep soundly. With a convenient click, families are better able to fit virtual sleep consultations into their day, without the stress of travel or the waiting room. They complete more scheduled visits, allowing pediatric sleep medicine departments to deliver care more efficiently. The low-pressure virtual platform also permits families to seek care for behavioral sleep issues. While our department's transition to predominantly virtual care occurred amidst a pandemic, with many confounding factors limiting the interpretation of the data we collected, the trends seen are very promising.

Children with autism spectrum disorder (ASD) have more frequent use of healthcare services, including visits to the emergency department (ED). Medical care for children with ASD can be adversely affected by the highly stimulating environment of the ED. In this study, we gained insights from stakeholders with lived experience (parents of children with ASD, children with ASD, and ED healthcare providers) to create and implement a sensory equipment kit. The kit was evaluated and iteratively improved based on observations of children using the sensory equipment, satisfaction surveys from their parents, and interviews with healthcare providers in the ED. Findings from this study can be used to guide other EDs in creating their own ASD sensory kit.

Background: The association between early childhood psychosocial problems and poorer educational outcomes is well-documented, but the extent to which this association persists is less understood. The current study assessed the correlations between first-grade psychosocial functioning and educational outcomes through eighth grade in a large longitudinal sample of Chilean students. Methods: The Pediatric Symptom Checklist-Chilean (PSC-CL) and Teacher Observation of Classroom Adaptation Re-Revised (TOCA-RR) assessed psychosocial functioning for 9736 students who were screened four times from first through eighth grade through the Skills for Life program. Adjusted linear mixed effects models assessed the association between first grade PSC-CL and TOCA-RR risk and third, sixth, and eighth grade GPA and school attendance. Results: First-grade PSC-CL and TOCA-RR risk both significantly predicted lower third, sixth, and eighth grade GPAs; all p < 0.001. The relationships between first-grade psychosocial functioning and later school attendance rates were less consistent but still significant at certain time points. Conclusions: First-grade psychosocial risk was persistently associated with lower academic performance in a longitudinal sample of Chilean students followed through elementary and middle school. Implications for School Health Policy, Practice, and Equity: Early school-based psychosocial screening and follow-up interventions have the potential to improve students' long-term educational outcomes.

Background: School nurses are rarely integrated into primary care teams to their full potential. We aimed to characterize school nurses' perceptions related to current and optimal collaboration with primary care providers (PCPs) and identify actionable solutions to improve efficiency, quality, and coordination of pediatric care. Methods: We conducted and qualitatively analyzed interviews with school nurses to characterize structures, processes, and perceived benefits of optimized school nurse-PCP collaboration. Results: School nurse interviewees (n = 23) identified factors important to school nurse-PCP collaboration within 2 domains: information sharing and relationship building. Information sharing themes included health information sharing laws, data sharing systems, and technology-based communication systems. Relationship building themes included health care sector understanding of the school nurse role, PCP knowledge of school health requirements, shared professional development opportunities, and time and personnel. Perceived benefits of optimized PCP-school nurse collaboration were identified for children, PCPs, school nurses, and parents. Implications for School Health Policy, Practice, and Equity: Needs assessments and action plans guided by the domains of information sharing and relationship building can inform local improvements to optimize school nurse-PCP collaboration. Conclusions: School nurses highlighted cross-sector solutions to enhance school nurse-PCP collaboration including integrated information sharing systems and intentional relationship building.

Delays in autism spectrum disorder identification/services could impact developmental outcomes. Although trends are encouraging, children from historically underrepresented minority backgrounds are often identified later and have reduced engagement in care. It is unclear if disparities exist throughout the screen-evaluate-treat chain, or if early detection programs such as "Get SET Early" that standardize these steps are effective countermeasures. Pediatricians/primary care providers administered Communication and Symbolic Behavior Scales IT Checklist screens at 12-, 18-, and 24-month well-baby examinations, and parents designated race, ethnicity, and developmental concerns. Toddlers who scored in the range of concern, or whose pediatricians/primary care providers had concerns, were referred for evaluations. Rates of screening and evaluation engagement within ethnic/racial groups were compared to U.S. Census proportions. Age at screen, evaluation, and treatment and quantity was compared across groups. Regressions examined whether key factors were associated with ethnicity or race. No differences were found for mean age of screen, evaluation, initiation of behavioral therapy, or quantity received between racial and ethnic groups. Historically underrepresented minority children were more likely to fall into the range of concern, referred for evaluations, and have their parents express developmental concerns. Although there remain gaps within the pipeline, implementation of systemized programs can be effective in ensuring equitable access to resources across communities.

In this retrospective cohort study using data from an integrated primary care and subspecialty network, we examined medical records of children seen in primary care at eligible autism spectrum disorder (ASD) screening ages and followed through at least 4 years of age. We examined the prevalence of ASD; age of first documented ASD diagnosis; and whether the prevalence and age of documented diagnosis varied by race, ethnicity, socio-economic status (SES) and site of care (urban versus suburban/rural). The prevalence of ASD across the cohort was 3.2%, with a median age of diagnosis of 3.93 years. ASD prevalence was unexpectedly higher among Asian children, non-Hispanic Black children, children with higher Social Vulnerability Index scores (a neighborhood-level proxy of socio-economic risk), and children who received care in urban primary care sites. There were no statistically significant differences in age at which ASD diagnosis was documented across socio-demographic groups. Receiving primary care at an urban site accounted for most other socio-demographic differences in ASD prevalence rates, except among Asian children, who were found to have higher adjusted odds of ASD diagnosis compared to White children (aOR = 1.82, p < 0.001). Determining what clinical-, individual- or systems-level factors contribute to ASD diagnosis remains important to improve equity.

This is a retrospective case series of pediatric patients referred to the psychogenic nonepileptic events clinic (PNEE) who had comorbid diagnoses of autism spectrum disorder (ASD) or intellectual disability (ID). We describe 15 patients, nine with ASD and six with ID who had a telephone visit follow-up at 12 months. There were higher rates of male gender (40%) and comorbid epilepsy (53%) compared to the larger PNEE cohort. Eleven patients were available for follow-up and ten patients had improvement in events or were event-free. We report that patients with ASD or ID can develop PNEE and experience improvement from events.

Transitioning autistic youth from pediatric to adult healthcare requires coordination of multiple stakeholders, including youth, caregivers, and pediatric and adult care providers, whose interests at times overlap but often differ. To understand barriers and facilitators to inclusive transition experiences, we conducted thematic analysis of interviews with 39 stakeholders from the same large, integrated healthcare system. We identified three major themes: (1) Navigating the healthcare transition without guidance, (2) Health consequences of a passive healthcare transition, and (3) Strategies for inclusion and continuous engagement. Facilitators included gradual transition planning, a warm handoff between providers, and support of shared healthcare decision-making. Providers also sought clinical tools and logistical supports such as care coordinators and longer transition-specific visit types to enhance patient-centered care.

Background: Low adolescent HPV vaccination initiation due to parents declining vaccination remains a challenge for providers. In 2018, 65% of adolescent girls and 56% of adolescent boys in Texas initiated HPV vaccination. Gaps between HPV vaccination rates and those for Tdap (83%) and meningococcal vaccines (87%) among 13-17 year olds highlights missed opportunities to prevent HPV-related cancers. While leading medical organizations endorse a presumptive, bundled recommendation, in which the provider presents HPV vaccination the same way as other vaccines, bundled between Tdap and meningococcal at 11- or 12-year-old visits, provider recommendations vary. Methods: In 2015, we surveyed pediatricians in a large Texas pediatric clinic network to assess physician knowledge, beliefs, attitudes and behaviors regarding adolescent HPV vaccination. To ascertain HPV vaccination outcomes, survey data were merged with patient electronic health records. We examined the association of pediatrician HPV vaccination recommendation and vaccination using multivariable multilevel generalized linear models clustered by physicians. Adjusted odds ratios were calculated. Results: Among 226 physicians, 59.8% completed the emailed survey. Controlling for patient and physician demographics, odds of HPV vaccination initiation were significantly increased if physicians used a bundled approach to recommend the HPV vaccine: "Your child is due for three vaccines: Tdap, HPV, and meningococcal vaccine" versus "Your child is due for two vaccines, Tdap and meningococcal. There is also the HPV vaccine, which is optional" (OR: 1.59, 95% CI 1.30-1.96). Conclusion: This study links physician HPV vaccine recommendation wording and outcomes, showing the significant effect of bundling HPV vaccination for adolescent patients.

Statement of Purpose: Pediatric firearm access is a significant risk factor for unintentional injury and suicide. This study investigated parents' perspectives on an adapted firearm safety program, "S.A.F.E. Firearm," to ensure acceptability and optimize effectiveness prior to the launch of an upcoming hybrid effectiveness-implementation trial. Methods/Approach: We administered a cross-sectional survey with a convenience sample of U.S. parents to measure the acceptability of "S.A.F.E. Firearm" and other key variables (e.g., relationship with pediatrician) that may impact our implementation approach. The sample included 97 participants (52 firearm-owning and 45 non-owning) from across the country. We also conducted semi-structured interviews using a Think Aloud exercise with 11 survey participants that were analyzed with directed content analysis. Results: The mean acceptability score was 4.35 [SD 0.52] on a 1-5 Likert scale, indicating that participants viewed S.A.F.E. Firearm as highly acceptable. Most participants (84%) either agreed or completely agreed with recommending that a friend receive "S.A.F.E. Firearm." No significant differences in acceptability scores were found by firearm ownership status, gender, race and ethnicity, or region of residence. Parent-pediatrician depth of relationship was associated with acceptability (r= 0.21, p=0.038). Interviews indicated that a collaborative approach to decision-making, neutral messaging, and provision of tangible resources were key factors that contributed to the program's overall high acceptability scores. Conclusion & Significance: The present study served as the final check in our process of adapting an evidence-based safe firearm storage program to increase reach and effectiveness as a universal suicide prevention strategy in pediatric primary care. Convergent parent feedback confirms that "S.A.F.E. Firearm" is highly acceptable and ready for implementation. Moreover, our findings suggest that family-centeredness may be enhanced through explicit integration of parents' needs and preferences into program refinements. Use of qualitative Think Aloud exercises with end user groups can add value when actual implementation of firearm safety programs can only be approximated.

Securing clinical locations for Bachelor of Nursing Science (BSN) programs is always a complex challenge, particularly when clinical experiences are focused on vulnerable populations such as pediatric psychiatric patients. To provide students with a meaningful clinical experience during the first weeks of the COVID-19 pandemic, we developed a telehealth simulation centered on a pediatric psychiatric patient with unfolding adolescent depression and suicidal ideation. This case study uses qualitative data analysis of student debriefing sessions as well as a pre/posttest design to explore the effectiveness of the simulation. Results suggest that simulations can be useful for presenting unique patient scenarios focused on therapeutic communication in psychiatric assessment, particularly for vulnerable patient populations. Quantitative data analysis showed BSN students improved their understanding of communication needs of adolescents and retained their knowledge over time; qualitative comments showed that students felt the simulation was a valuable learning experience and achieved key learning outcomes.

The article is aimed at studying medical students' reflective strategies for learning the Pediatric Surgery course at medical university. We used a modified version of the Motivated Strategies for Learning questionnaire (Soemantri et al., 2018) which has four subscales: self-orientation, critical thinking, self-regulation, and feedback seeking. The self-orientation component deals with students' perceptions on their self-efficacy and internal motivation. The participants were fourty-six 5-th year medical students from the Bogomolets National Medical University, Kyiv, Ukraine. The survey was held in May 2021 when the students finished their spring semester in the online mode. We observed the prevalence of high and moderate levels in all the variables, but the indicators of Feedback seeking are lower which can be explained by the specificities of online learning. The authors propose methodological recommendations for educators how to create an environment for reflective learning to develop students' reflective skills and employ alternative assessment strategies in the classroom.

Background: Many children with intellectual developmental disorders are insufficiently physically active and do not reach recommendations for physical activity. Pediatric healthcare providers play a key role in addressing these children's needs, including promoting interventions for physical activity. Aim: To explore pediatric healthcare providers' perceived needs, barriers, and facilitators for promoting physical activity for children with intellectual developmental disorders. Methods: Semi-structured focus groups, analyzed using qualitative content analysis. Sixteen healthcare providers participated. Results: Main findings are the importance of parental support and engagement, need for structure, and stakeholder collaboration to bridge the gap between pediatric organizations and external stakeholders. Conclusion: The study highlights the need for developing and implementing strategies to promote physical activity for children with intellectual developmental disorders in pediatric health care, and for producing guidelines regarding physical activity interventions for this vulnerable group.

Objective: To evaluate cardiopulmonary resuscitation (CPR) skills performance and retention in schoolchildren aged 8 to 12 years following instruction by their teachers and with the guidance of a school nurse using paediatric manikins. Design: Descriptive simulation trial. Method: A school nurse provided support to six schoolteachers as they taught a modified 40-minute CPR course. Pupils were shown an out-of-hospital cardiac-arrest recognition video followed by a CPR simulation using paediatric manikins. 117 schoolchildren aged 8 to 12 years received the training. Both the schoolchildren and teachers completed a survey before and afterwards. Children completed an out-of-hospital cardiac-arrest recognition test and a 1-minute CPR test 1 week later. Results: After training, schoolchildren increased their self-efficacy as rescuers (8 ± 2 vs 10 ± 2; p < 0.001). Irrespective of age differences, 74% of schoolchildren performed the entire out-of-hospital cardiac-arrest recognition sequence correctly. Children aged 11 to 12 years and 10 to 11 years performed higher quality CPR (49% and 47%, respectively) compared to 8 to 9 year olds (14%, p = 0.008 and p = 0.014). Children aged 11 to 12 years outperformed younger children aged 8 to 9 years with respect to compression depth (48 ± 6 mm vs 43 ± 5 mm, p = 0.008) Conclusion: Schoolchildren's teachers, who were guided by a nurse using paediatric manikins, taught children aged 10 to 12 years to perform high-quality CPR. We suggest integrating paediatric manikins as part of children's CPR training as feedback from successful CPR performance increases motivation and confidence to act as a rescuer as well as improves skills retention.

We conducted an open-trial proof of concept study to determine the safety, acceptability, and feasibility of Mindful Self-Care for Caregivers (MSCC) for parents of children with Autism Spectrum Disorders (ASD) (N = 13). The intervention was offered as a co-located care model in a pediatric specialty center where the participants' children received care. Results demonstrated that the intervention was: highly acceptable to all stakeholders (i.e., participants, the group facilitator, and center administration) and could be conducted safely by a masters-level practitioner with minimal resources. Further, secondary measures support a hypothesized interventional model of MSCC, demonstrating gains in mindfulness skills and sense of competency in the parenting role reduced perceived stress and depression in parents of children with ASD.

The purpose of this study was to examine the frequency and quality of primary care physician (PCP) recommendations to investigate the management of young children with delays and self-injury (SIB; e.g., head banging) from the time of initial SIB concern to specialty referral as recommended by the American Academy of Pediatrics (AAP). Via a structured electronic health record review, PCP referrals and recommendations were examined for a cohort of 250 children (10-59 months old) with delays and SIB. Only a small portion of cohort charts reviewed (8.0%) received AAP recommended intervention via referral to subspecialty providers by their PCP. Further, only 37.5% received SIB-specific care recommendations. Findings suggest that future targeted education is needed to improve primary care access to AAP recommended intervention for young children with delays and early SIB.

Background: The Montreal Children's Hospital Feeding Scale (MCH-FS) allows paediatricians and other health care professionals to identify feeding difficulties among children. Aim: To translate and adapt the MCH-FS into Italian, and to evaluate the validity and reliability of this Italian version of the Montreal Children's Hospital Feeding Scale (I-MCH-FS). Methods & Procedures: A total of 150 children with special healthcare needs were admitted to the Rare Disease Unit of the Paediatrics Department at the Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy, between March 2021 and March 2022 (74 males; mean age = 3.85 ± 1.96 years; median age = 4 years; age range = 6 months-6 years and 11 months) and 150 healthy participants (83 males; mean age = 3.5 ± 1.98 years; median age = 3 years; age range = 6 months-6 years and 11 months) were included in the study, which was approved by the local ethics committee. The original version of the MCH-FS was translated and cross-cultural adapted through five stages: (1) initial translation, (2) synthesis of the translations, (3) back translation, (4) expert committee and (5) test of the prefinal version. Test-retest reliability and internal consistency were assessed using Pearson r, Spearman r and Cronbach's alpha, respectively. Construct validity was established by comparing data obtained from patients with those of healthy participants using the Mann-Whitney U-test. Outcomes & Results: A Pearson "r" of 0.98, a Spearman "r" of 0.95 and Cronbach's alpha value of 0.86 were obtained. In the clinical group, 40.6% children were classified as having feeding disorders (n = 61), while in the normative group 4.7% were diagnosed with feeding problems (n = 7). Mean total score of the clinical group was significatively different from the normative's. Conclusions & Implications: The I-MCH-FS is a valid and reliable one-page, quick screening tool used to identify feeding disorders among children with special needs in outpatient paediatric setting.

Background: Poor complementary feeding practices can expose young children to increased burdens of undernutrition, morbidity, and poor health outcomes in adulthood. Parents and caregivers, who feed the children, are shaped by socio-cultural beliefs and pervasive socioeconomic realities. Also, parental values are influenced by their perceptions and childhood feeding experiences among others. This study, therefore, explored the role of parental childhood feeding experiences and changing socioeconomic realities on complementary feeding practices in urban households of Aba, Nigeria. Method: Twenty-eight in-depth interviews and eight focus group discussions were held with parents of young children aged 6-23 months attending postnatal care clinics in selected healthcare facilities in Aba city, Nigeria. Aba city is one of the sprawling urban centers in South-East Nigeria. Data were thematically analyzed using Atlas.ti software. Results: Complementary feeding practices in the Aba urban households of South-East Nigeria did not meet the recommended feeding guidelines on timely complementary feeding and dietary diversity. Consumption of processed foods and sweetened beverages was prevalent. Data suggest this feeding pattern was affected by two factors: parental feeding experiences in early life and changing socioeconomic realities. Parents who lacked satisfactory feeding experiences in their childhood but achieved some socioeconomic success in later life exhibited poor complementary feeding practices. Also, certain food types were associated with affluence notwithstanding their nutritional values. Poor complementary feeding was also linked to the parental desire to not reliving their poor childhood feeding experiences. Conclusion: The parental perceived poor childhood feeding experience has led many to adopt the consumption of processed foods and sweetened beverages. This may expose children to risks of undernutrition, obesity, and overall poor health outcomes in later adulthood. More effort should be made to educate parents on healthful eating patterns and the dangers of poor complementary feeding practices in children's overall health well-being in later life.

As a popular tenant underpinning paediatric health service provision, the ability of health professionals to achieve Family-Centred Care (FCC) is often questioned. A major factor has been the judgmental attitudes and behaviour of health professionals. According to expectancy-value theory, individuals' behavioural decisions are based on their attitudes and beliefs. In this sense, this study assessed the hypothesis: when necessity beliefs (beliefs and attitudes) rise, the actual implementation of FCC components (behavioural decisions) will improve. Using a correlation design, the study measured staff perceived self-reported implementation of FCC in their practice and their necessity beliefs of its core components using a modified questionnaire. Outcomes of 65 questionnaires revealed an overall mean of self reported implementation of 2.37/5.0 (SD = 0.57) and an overall mean of necessity beliefs of 3.06/5.0 (SD = 1.04). A significant moderate correlation (Spearman's rho (64) = -0.4, p < 0.001) indicated that professionals better practiced FCC components they favourably perceived necessary. It is recommended that policymakers should focus on changing attitudes of professionals towards FCC elements. The outcomes suggest that education that positively influences the attitudes and beliefs of health professionals may facilitate the involvement of families, and subsequently, better health outcomes for children.

A survey was distributed to Part C early intervention (EI) service coordination (SC) stakeholders in one state in order to gain a deeper understanding of service coordinator knowledge, skills, and motivators for professional growth and recognition. Survey participants (N = 107), including dedicated service coordinators, program managers, social emotional consultants, parent liaisons, local interagency council coordinators, and developmental pediatric consultants, identified knowledge and skills required for the role of service coordinators. Key motivators for professional growth within the SC role were also identified, including monetary, award/acknowledgment, and varied levels of responsibility. Data collected were analyzed, reviewed with Part C administrators, system point of entry leadership, and shared with EI stakeholders. Findings are being used to guide systems planning and decision-making to ensure service coordinators have opportunities for professional growth and are well prepared with the knowledge, skills, and supports necessary to partner with families and other professionals in EI. Information gained may also inform other state Part C programs and professional development entities as they (1) create and assess systems to support SC personnel; (2) build service coordinators' capacity to implement evidence-informed practices; (3) recognize service coordinators' critical role and expertise; and (4) foster the retention of well-trained, well-supported service coordinators.

Background: Play is an essential component of children's development. Children with intellectual disability tend to have poor socioemotional abilities and impaired play. This study examined the effects of a medical/therapeutic clowning play intervention on the playfulness of children with intellectual disability. Method: Two medical clowns facilitated a play intervention in a preschool classroom setting with a total of 52 children with intellectual disability. We compared before and after two groups that received the intervention: group 1 met the medical clowns once a week for 6 months (long-intervention group) and group 2 for 3 months (short intervention group). Children's functioning was assessed using the Vineland Adaptive Behaviour Scales. Children's playfulness was scored using the Test of Playfulness observational assessment. A teachers' focus-group was used to gather additional information on the clowns' work. Results: Children's playfulness increased significantly at the end of the intervention, whereas the improvement in the playfulness scores of group 1 was significantly larger than those of group 2 (t[subscript 50] = -4.82, p < 0.001). The teachers' focus group revealed additional benefits of the medical clowns' work. Conclusion: The results shed light on the play and playfulness of children with intellectual disability and the possible contribution of a clowning play intervention to their development.

Background: The aim of this study was to investigate the demographic, clinical characteristics, and service systems of patients with autism spectrum disorder (ASD) and/or intellectual disability presenting to a large paediatric hospital emergency department (ED) with behaviours of concern (BOC) over a two-year period. Method: Retrospective audit of ED presentations with BOC in patients with ASD and/or intellectual disability from 1 January 2019 to 31 December 2020, at the Royal Children's Hospital, Melbourne, Australia. Results: There were 124 presentations (84 patients) in 2019 and 129 presentations (82 patients) in 2020. The mean age was 11.7 years. 55% arrived by ambulance, 24% required physical restraint, and 26% required sedation. Re-presentation was predicted by single-parent household, child protection involvement, and requirement of an interpreter. Conclusions: Children and adolescents with ASD and/or intellectual disability regularly present to ED with BOC. New models of care are required to better support this highly vulnerable patient group.

Despite documented healthcare disparities among Latino autistic children, little is known about how their families experience the autism "diagnostic odyssey." Pediatricians have a critical role in the "diagnostic odyssey," but when it becomes arduous, parents may also use complementary health approaches, particularly when conventional care does not adequately address their concerns. Shared decision-making is important in healthcare for autistic children, especially when parents also choose complementary health approaches; but little is known about shared decision-making among Latino parents of autistic children. We conducted a 12-month ethnography with 12 bicultural/bilingual Latino families of autistic children to understand their healthcare experiences (conventional and complementary health approaches) for their children, focusing on shared decision-making. Thematic analysis revealed: (1) most pediatricians were involved early in the "diagnostic odyssey" but were largely uninvolved thereafter; (2) conventional healthcare was satisfactory to the parents for physical health, but not developmental issues; and (3) parents who used complementary health approaches were more frustrated about a lack of autism information from pediatricians than those who did not. Finally, (4) we describe two exemplars of successful shared decision-making between Latino parents and pediatricians. Increasing pediatricians' autism knowledge and ability to discuss complementary health approaches may facilitate shared decision-making and reduce healthcare disparities for Latino autistic children.

Research ethics committees (RECs) have a crucial role in protecting children in research. However, studies on REC members' perspectives on paediatric research are scarce. We conducted a qualitative study to explore Swedish scientific REC members' perspectives on ethical aspects in applications involving children with severe health conditions. The REC members considered promoting participation, protecting children and regulatory adherence to be central aspects. The results underscored the importance of not neglecting ill children's rights to adapted information and participation. REC members supported a contextual and holistic approach to vulnerability and risk, which considers the child's and parents' psychological wellbeing and the child's integrity, both short and long term. The ethical complexity of paediatric research requires continuous ethical competence development within RECs.