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A limited number of studies have estimated the prevalence of emotional-behavioral disorders among young children. None have assessed their co-occurrence with developmental delays using standardized assessment tools. Our objective was to estimate the prevalence of emotional-behavioral disorders and their co-occurrence with developmental delays among young children (2-5.5 years).Parents of young children (N=987) enrolled from pediatric waiting rooms completed developmental-behavioral screening questionnaires. Based on results, 585 families were invited to and 439 completed evaluations that included structured diagnostic interviews with parents to assess child psychopathology (Preschool Age Psychiatric Assessment (PAPA)), developmental testing with children (including the Bayley Scales of Infant and Toddler Development, 3According to PAPA algorithms, 23.0% of children met criteria for a DSM-IV disorder, while 9% qualified for a developmental delay. Presence of delay doubled the odds of having a DSM-IV disorder (OR=2.1; CI: 1.02-4.3), and presence of disorder doubled the odds of having a moderate-to-severe developmental delay (OR=2.0;CI: 1.10-3.50). Prevalence of DSM-IV disorders (48.8% (95% CI: 33.5-64.5%)) and developmental delays (57.5% (95% CI: 41.7-71.9%)) were both higher among children at risk for autism. While developmental delay did not vary by race/ethnicity, prevalence of DSM-IV disorders was lower among African-American/Black (10.6%; CI: 2.9-18.3) and Hispanic/Latino children (11.1%; CI: 4.3-17.9).Developmental delays and emotional-behavioral disorders among young children seen in pediatric settings are characterized by high prevalence and substantial co-occurrence.Few studies investigate the prevalence of emotional-behavioral disorders among young children in pediatrics, and none assess co-occurrence with developmental test results. Replicating prior studies, we confirm that emotional-behavioral-disorders are highly prevalent in pediatrics and document substantial co-occurrence with developmental delays.

Urine sodium and potassium are used as surrogate markers for dietary consumption in adults with hypertension, but their role in youth with hypertension and their association with components of the renin-angiotensin-aldosterone system (RAAS) are incompletely characterized. Some individuals with hypertension may have an abnormal RAAS response to dietary sodium and potassium intake, though this is incompletely described. Our objective was to investigate if plasma renin activity and serum aldosterone are associated with urine sodium and potassium in youth referred for hypertensive disorders.This pilot study was a cross-sectional analysis of baseline data from 44 youth evaluated for hypertensive disorders in a Hypertension Clinic. We recorded urine sodium and potassium concentrations normalized to urine creatinine, plasma renin activity, and serum aldosterone and calculated the sodium/potassium (UNaK) and aldosterone/renin ratios. We used multivariable generalized linear models to estimate the associations of renin and aldosterone with urine sodium and potassium.Our cohort was diverse (37% non-Hispanic Black, 14% Hispanic), 66% were male, and median age was 15.3 years; 77% had obesity and 9% had a secondary etiology. Aldosterone was associated inversely with urine sodium/creatinine (β: -0.34, 95% CI -0.62 to -0.06) and UNaK (β: -0.09, 95% CI -0.16 to -0.03), and adjusted for estimated glomerular filtration rate and serum potassium.Higher serum aldosterone levels, but not plasma renin activity, were associated with lower urine sodium/creatinine and UNaK at baseline in youth referred for hypertensive disorders. Further characterization of the RAAS could help define hypertension phenotypes and guide management. A higher resolution version of the Graphical abstract is available as supplementary information.

To assess changes in screening completion in a diverse, 7-clinic network after making annual screening for social/emotional/behavioral (SEB) problems the standard of care for all infant through late adolescent-aged patients and rolling out a fully automated screening system tied to the electronic medical record and patient portal.In 2017, the Massachusetts General Hospital made SEB screening using the age-appropriate version of the Pediatric Symptom Checklist the standard of care in its pediatric clinics for all patients aged 2.0 months to 17.9 years. Billing records identified all well-child visits between January 1, 2016 and December 31, 2019. For each visit, claims were searched for billing for an SEB screen and the electronic data warehouse was queried for an electronically administered screen. A random sample of charts was reviewed for other evidence of screening. Chi-square analyses and generalized estimating equations assessed differences in screening over time and across demographic groups.Screening completion (billing and/or electronic) significantly increased from 2016 (37.2%) through 2019 (2017 [46.2%] vs 2018 [66.8%] vs 2019 [70.9%]; χFollowing adoption of a best-practice policy and implementation of an electronic system, SEB screening increased in all age groups and clinics. Findings demonstrate that the AAP recommendation for routine psychosocial assessment is feasible and sustainable.

The Baby Pediatric Symptom Checklist (BPSC) is a screening tool developed for detecting behavioral or emotional concerns among parents of children younger than 18 months. Nationally representative survey data have not yet been used to assess the validity of the BPSC, nor to evaluate its appropriateness for use among children between 18 and 23 months old. The current study assesses the validity of the BPSC using data from the National Health Interview Survey (NHIS).Data from the 2019 NHIS were used to evaluate the 12-item BPSC screening tool among a nationally representative sample of children 2 to 23 months. Confirmatory factor analysis (CFA) and differential item functioning (DIF) were used to assess construct and predictive validity and test how response items differed by selected sociodemographics. Quantile regression was used to calculate 50th, 70th, and 90th percentiles for age-based normative curves of the previously established domains of irritability, inflexibility, and difficulty with routines.A 3-factor CFA produced comparable results to the original study. Tests of DIF did not reveal any significant effects for the child's sex, race and Hispanic origin, household urbanization level, number of children in family, or respondent type (mother, father, other). In addition, DIF was not found between children aged 2 to 17 months and 18 to 23 months. Age-based normative data were calculated for each subscale.The use of the BPSC in a nationally representative survey produced findings comparable to those of the original-validation study. The NHIS can be used to track BPSC scores over time at the population-level.

Background There is growing awareness and exposure in both the medical community and the lay media about the characteristics and complex needs of individuals who believe that their gender identity does not match their birth sex. Despite research and lay publications about teens with gender dysphoria and those who identify as transgender, little guidance is available regarding young (prepubertal) children with questions about their gender identity. Although many terms are used to describe these children, we have chosen to describe them as "gender nonconforming" (GNC). Objective Primary care and developmental-behavioral pediatric providers are often the first professionals with whom young gender nonconforming children and their families discuss their concerns about their emerging gender identity. It is important, therefore, that pediatric providers be knowledgeable about the dilemmas, conflicts, and choices that are typical of these children and their families to guide them appropriately. Overview In this special article, we present observations, informed by clinical experience, an emerging body of research, and a developmental-behavioral pediatric framework, of the complex needs of prepubertal gender nonconforming children and their families and an approach to their care. The article begins by outlining the cognitive and biological bases for gender identity development, as well as the natural history of gender nonconforming preferences and behaviors. It then sets the context for understanding the care of GNC children as an area in which developmentally sophisticated providers can play a crucial role in support of the complex developmental patterns and need for advocacy in multiple settings among these children.

IMPORTANCE: Universal developmental screening is widely recommended, yet studies of the accuracy of commonly used questionnaires reveal mixed results, and previous comparisons of these questionnaires are hampered by important methodological differences across studies. OBJECTIVE: To compare the accuracy of 3 developmental screening instruments as standardized tests of developmental status. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional diagnostic accuracy study recruited consecutive parents in waiting rooms at 10 pediatric primary care offices in eastern Massachusetts between October 1, 2013, and January 31, 2017. Parents were included if they were sufficiently literate in the English or Spanish language to complete a packet of screening questionnaires and if their child was of eligible age. Parents completed all questionnaires in counterbalanced order. Participants who screened positive on any questionnaire plus 10% of those who screened negative on all questionnaires (chosen at random) were invited to complete developmental testing. Analyses were weighted for sampling and nonresponse and were conducted from October 1, 2013, to January 31, 2017. EXPOSURES: The 3 screening instruments used were the Ages & Stages Questionnaire, Third Edition (ASQ-3); Parents’ Evaluation of Developmental Status (PEDS); and Survey of Well-being of Young Children (SWYC): Milestones. MAIN OUTCOMES AND MEASURES: Reference tests administered were Bayley Scales of Infant and Toddler Development, Third Edition, for children aged 0 to 42 months, and Differential Ability Scales, Second Edition, for older children. Age-standardized scores were used as indicators of mild (80-89), moderate (70-79), or severe (

The inadequacy of mental health and developmental services for children is a widely recognized and growing problem. Although a variety of solutions have been proposed, none has been generally successful or feasible. This research describes models of colocation that have evolved in primary care settings in Massachusetts and reports on pediatricians’ and their colocated colleagues’ impressions of their benefits and challenges. Pediatricians in 18 practices that included a colocated mental health/developmental specialist (MH/DS) were identified through a survey administered through the state American Academy of Pediatrics Chapter, and interviewed. Practices varied widely in the professional expertise/training and roles of the MH/DSs, communication among providers, and financial arrangements. The majority of pediatricians and MH/DSs reported being pleased with their colocated arrangements, despite the costs rarely being supported by billing revenues. This study suggests that further development of such systems hold promise to meet the growing need for accessible pediatric mental and developmental health care.

Anxiety disorders are the most common psychiatric disorder of childhood, and are associated with high risk for development of future psychopathology. Yet, pediatric anxiety disorders continue to be...

BACKGROUND AND OBJECTIVES:Pediatric surveillance of young children depends on providers’ assessment of developmental milestones, yet normative data are sparse. Our objectives were to develop new norms for common milestones to aid in clinical interpretation of milestone attainment.METHODS:We analyzed responses to the developmental screening form of the Survey of Well-being of Young Children from 41 465 screens across 3 states. Associations between developmental status and a range of child characteristics were analyzed, and norms for individual questions were compared to guidelines regarding attainment of critical milestones from the Centers for Disease Control and Prevention (CDC).RESULTS:A contemporary resource of normative data for developmental milestone attainment was established. Lower developmental status was associated with child age in the presence of positive behavioral screening scores (P < .01), social determinants of health (P < .01), Medicaid (P < .01), male sex (P < .01), and child race (P < .01). Comparisons between Survey of Well-being of Young Children developmental questions and CDC guidelines reveal that a high percentage of children are reported to pass milestones by the age at which the CDC states that “most children pass” and that an even higher percentage of children are reported to pass milestones by the age at which the CDC states that parents should “act early.” An interactive data visualization tool that can assist clinicians in real-time developmental screening and surveillance interpretation is also provided.CONCLUSIONS:Detailed normative data on individual developmental milestones can help clinicians guide caregivers’ expectations for milestone attainment, thereby offering greater specificity to CDC guidelines.

Pediatric anxiety disorders are highly prevalent, but tend to go undetected as pediatricians often lack relevant training. We developed a brief, video-based training program for pediatric residents aimed at improving early identification of child anxiety disorders. The novel training was completed in a group-based format or via an online, asynchronous training program. Pediatric residents from 2 residency programs (n = 63) participated and completed pre- and posttraining surveys evaluating attitudes about previous training, knowledge about child anxiety, perceived evaluation skills, and responses to clinical vignettes. Most residents (81%) reported they did not receive enough prior training in the presentation of anxiety disorders in young children. Residents’ knowledge and perceived evaluation skills increased posttraining. On the vignette-based assessment, residents demonstrated increased sensitivity with regard to interference, diagnosis, and referral urgency. Despite some challenges with participation, results provide preliminary evidence that brief training programs could be an effective way to improve resident education.

BACKGROUND: Gay men have become fathers in the context of a heterosexual relationship, by adoption, by donating sperm to 1 or 2 lesbian women and subsequently sharing parenting responsibilities, and/or by engaging the services of a surrogate pregnancy carrier. Despite legal, medical, and social advances, gay fathers and their children continue to experience stigma and avoid situations because of fear of stigma. Increasing evidence reveals that stigma is associated with reduced well-being of children and adults, including psychiatric symptoms and suicidality. METHODS: Men throughout the United States who identified as gay and fathers completed an online survey. Dissemination of the survey was enhanced via a “snowball” method, yielding 732 complete responses from 47 states. The survey asked how the respondent had become a father, whether he had encountered barriers, and whether he and his child(ren) had experienced stigma in various social contexts. RESULTS: Gay men are increasingly becoming fathers via adoption and with assistance of an unrelated pregnancy carrier. Their pathways to fatherhood vary with socioeconomic class and the extent of legal protections in their state. Respondents reported barriers to becoming a father and stigma associated with fatherhood in multiple social contexts, most often in religious institutions. Fewer barriers and less stigma were experienced by fathers living in states with more legal protections. CONCLUSIONS: Despite growing acceptance of parenting by same-gender adults, barriers and stigma persist. States’ legal and social protections for lesbian and gay individuals and families appear to be effective in reducing experiences of stigma for gay fathers.

OBJECTIVES: To examine elevated neonatal inflammatory and neurotrophic proteins from children born extremely preterm in relation to later childhood brain Magnetic Resonance Imaging volumes and cognition. STUDY DESIGN: We measured circulating inflammation-related proteins and neurotrophic proteins on postnatal days 1, 7, and 14 in 166 children at 10 years of age (73 males; 93 females). Top quartile levels on ≥2 days for ≥3 inflammation-related proteins and for ≥4 neurotrophic proteins defined exposure. We examined associations among protein levels, brain Magnetic Resonance Imaging volumes, and cognition with multiple linear and logistic regressions. RESULTS: Analyses were adjusted for gestational age at birth and sex. Children with ≥3 elevated inflammation-related proteins had smaller grey matter, brain stem/cerebellar, and total brain volumes than those without elevated inflammation-related proteins, adjusted for neurotrophic proteins. When adjusted for inflammation-related proteins, children with ≥4 neurotrophic proteins, compared with children with no neurotrophic proteins, had larger grey matter and total brain volumes. Higher grey matter, white matter, and cerebellum and brainstem volumes were significantly correlated with higher IQ. Grey and white matter volumes were correlated with each other (r = −0.18; P = .021), and cerebellum and brainstem was highly correlated with grey matter (r = 0.55; P < .001) and white matter (r = 0.29; P < .001). Adjusting for other brain compartments, cerebellum and brainstem was associated with IQ (P = .016), but the association with white matter was marginally significant (P = .051). Grey matter was not associated with IQ. After adjusting for brain volumes, elevated inflammation-related proteins remained significantly associated with a lower IQ, and elevated neurotrophic proteins remained associated with a higher IQ. CONCLUSIONS: Newborn inflammatory and neurotrophin protein levels are associated with later brain volumes and cognition, but their effects on cognition are not entirely explained by altered brain volumes.

Background. Integration of autism screening into primary care practice in Saudi Arabia is not well established. Objectives. To evaluate the feasibility and effectiveness of implementing the Arabic Modified Checklist for Autism in Toddlers (M-CHAT) in a primary care practice at John Hopkins Aramco Healthcare Center in Saudi Arabia. Method. The Arabic version of M-CHAT was distributed to caregivers of 1207 toddlers (16-32 months) from January to December 2014. Feasibility was assessed by measuring the proportion of visits with M-CHAT completed, and reports of workflow challenges and provider satisfaction. The effectiveness of screening was evaluated based on the number of referrals for autism evaluation and autism identification rates. Results. Total M-CHAT completion rate was 89% (1078 out of 1207 child-specific visits). Those identified as low risk (n = 951; 88%) were reassured and followed routinely. Those screening positive (n = 127; 12%) were referred for diagnostic assessment. Twelve (1% of toddlers screened) were diagnosed with autism at a mean age of 24 months. In addition, positive M-CHAT detected speech delay and social anxiety. Providers acknowledged their satisfaction with the M-CHAT implementation process; the main challenge was communicating to families the importance of screening. Referrals for diagnostic evaluations increased from 23 to 43 cases in the first year, and 35 in the second year. Conclusion. Implementation of the autism screening using the Arabic M-CHAT is feasible and effective in a primary care setting in Saudi Arabia. Sustaining the implementation of developmental screening in practice requires staff engagement and systematic monitoring of the impact of change.

Objective Autism screening is recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention at ages 18 and 24 months. Popular screening tests have been validated for the age range of 16 to 30 months. However, only a minority of children with autism spectrum disorder (ASD) are identified by age 3 years, and many are not identified until after they enter school. Thus, we aimed to measure the sensitivity and specificity of 2 available screening tests for ASDs in children older than 30 months. Methods We assessed the sensitivity and specificity of 2 ASD screening tools administered to parents of children who were referred to a developmental clinic between the ages of 16 and 48 months: the Modified Checklist for Autism in Toddlers (M-CHAT) and the Parent's Observations of Social Interactions (POSI), which is a component of a comprehensive screening instrument called, the Survey of Well-being of Young Children. Results Both the M-CHAT and the POSI had acceptable sensitivity (≥75%) among children across the age range studied. Their specificity was limited by the fact that the study was conducted in a developmental referral clinic. Conclusion Two readily available screening tools, the POSI and the M-CHAT, have acceptable sensitivity in evaluating risk for autism in children at least to age 48 months. Further research should investigate their sensitivity and specificity when used in primary care settings.

Objective Children whose parents do not speak English experience significant disparities in the identification of developmental delays and disorders; however, little is known about the availability and validity of translations of developmental screeners. The goal was to create a map of the scientific evidence regarding translations of the 9 Academy of Pediatrics-recommended screening instruments into languages other than English. Methods The authors conducted a systematic search of Medline and PsycINFO, references of identified articles, publishers' Web sites, and official manuals. Through evidence mapping, a new methodology supported by AHRQ and the Cochrane Collaboration, the authors documented the extent and distribution of published evidence supporting translations of developmental screeners. Data extraction focused on 3 steps of the translation and validation process: (1) translation methods used, (2) collection of normative data in the target language, and (3) evidence for reliability and validity. Results The authors identified 63 distinct translations among the 9 screeners, of which 44 had supporting evidence published in peer-reviewed sources. Of the 63 translations, 35 had at least some published evidence regarding translation methods used, 28 involving normative data, and 32 regarding reliability and/or construct validity. One-third of the translations found were of the Denver Developmental Screening Test. Specific methods used varied greatly across screeners, as did the level of detail with which results were reported. Conclusion Few developmental screeners have been translated into many languages. Evidence map of the authors demonstrates considerable variation in both the amount and the comprehensiveness of information available about translated instruments. Informal guidelines exist for conducting translation of psychometric instruments but not for documentation of this process. The authors propose that uniform guidelines be established for reporting translation research in peer-reviewed journals, similar to those for clinical trials and studies of diagnostic accuracy.

SummaryBackground Decreased sleep duration and altered sleep quality are risk factors for obesity in youth. Structured exercise training has been shown to increase sleep duration and improve sleep quality. Objectives This study aimed at evaluating the impact of exercise training for improving sleep duration, sleep quality and physical activity in obese adolescents (OB). Methods Twenty OB (age: 14.5 ± 1.5 years; body mass index: 34.0 ± 4.7 kg m−2) and 20 healthy-weight adolescents (HW) completed an overnight polysomnography and wore an accelerometer (SenseWear Bodymedia) for 7 days. OB participated in a 12-week supervised exercise-training programme consisting of 180 min of exercise weekly. Exercise training was a combination of aerobic exercise and resistance training. Results Sleep duration was greater in HW compared with OB (P

The association of hand preference (left, mixed, and right) with cognitive, academic, motor, and behavioral function was evaluated in 864 extremely preterm children at 10 years of age. Left-handed and right-handed children performed similarly but mixed-handed children had greater odds of functional deficits across domains than right-handed children.

An 8-year 8-month-old biological female who self-identifies as a boy, Ricardo is brought by his mother for a well-child check to his new pediatrician. Ricardo and his mother report that he is doing well, but have concerns about the upcoming changes associated with puberty. Ricardo states that he is particularly afraid of developing breasts. His mother asks about obtaining a referral to a specialist who can provide "hormone therapy" to delay puberty.Ricardo was adopted from Costa Rica at the age of 2 as a healthy girl named "Angela." From the age of 3, he displayed clear preference for male gender-associated clothes, toys, and games. At age 5, his mother sought care for hyperactivity and sleep problems. He was diagnosed with attention-deficit hyperactivity disorder and sleep onset disorder at age 6, and his symptoms have been well controlled with Adderall and melatonin.Ricardo lives with his parents who are accepting and supportive of his gender preference. He sees a therapist who has experience with gender dysphoria. For the past years, he has attended school as male, with the confidential support of administrators at his elementary school.

BACKGROUND Exercise training has been shown to improve cardiometabolic health in obese adolescents. OBJECTIVES Evaluate the impact of a 12-week exercise-training programme (without caloric restriction) on obese adolescents' cardiometabolic and vascular risk profiles. METHODS We measured systemic markers of oxidation, inflammation, metabolic variables and endothelial function in 20 obese adolescents (OB) (age: 14.5 ± 1.5 years; body mass index: 34.0 ± 4.7 kg m(-2) ) and 20 age- and gender-matched normal-weight adolescents (NW). Body composition was assessed by magnetic resonance imagery. Peak aerobic capacity and maximal fat oxidation were evaluated during specific incremental exercise tests. OB participated in a 12-week exercise-training programme. RESULTS OB presented lower peak aerobic capacity (24.2 ± 5.9 vs. 39.8 ± 8.3 mL kg(-1) min(-1) , P

OBJECTIVE: To evaluate sustained improvements 6 months after a 40-session, in-school computer attention training intervention using neurofeedback or cognitive training (CT) administered to 7- to 11-year-olds with attention-deficit/hyperactivity disorder (ADHD). METHODS: One hundred four children were randomly assigned to receive neurofeedback, CT, or a control condition and were evaluated 6 months postintervention. A 3-point growth model assessed change over time across the conditions on the Conners 3–Parent Assessment Report (Conners 3-P), the Behavior Rating Inventory of Executive Function Parent Form (BRIEF), and a systematic double-blinded classroom observation (Behavioral Observation of Students in Schools). Analysis of variance assessed community-initiated changes in stimulant medication. RESULTS: Parent response rates were 90% at the 6-month follow-up. Six months postintervention, neurofeedback participants maintained significant gains on Conners 3-P (Inattention effect size [ES] = 0.34, Executive Functioning ES = 0.25, Hyperactivity/Impulsivity ES = 0.23) and BRIEF subscales including the Global Executive Composite (ES = 0.31), which remained significantly greater than gains found among children in CT and control conditions. Children in the CT condition showed delayed improvement over immediate postintervention ratings only on Conners 3-P Executive Functioning (ES = 0.18) and 2 BRIEF subscales. At the 6-month follow-up, neurofeedback participants maintained the same stimulant medication dosage, whereas participants in both CT and control conditions showed statistically and clinically significant increases (9 mg [P = .002] and 13 mg [P < .001], respectively). CONCLUSIONS: Neurofeedback participants made more prompt and greater improvements in ADHD symptoms, which were sustained at the 6-month follow-up, than did CT participants or those in the control group. This finding suggests that neurofeedback is a promising attention training treatment for children with ADHD.

To evaluate the efficacy of 2 computer attention training systems administered in school for children with attention-deficit hyperactivity disorder (ADHD).Children in second and fourth grade with a diagnosis of ADHD (n = 104) were randomly assigned to neurofeedback (NF) (n = 34), cognitive training (CT) (n = 34), or control (n = 36) conditions. A 2-point growth model assessed change from pre-post intervention on parent reports (Conners 3-Parent [Conners 3-P]; Behavior Rating Inventory of Executive Function [BRIEF] rating scale), teacher reports (Swanson, Kotkin, Agler, M-Flynn and Pelham scale [SKAMP]; Conners 3-Teacher [Conners 3-T]), and systematic classroom observations (Behavioral Observation of Students in Schools [BOSS]). Paired t tests and an analysis of covariance assessed change in medication.Children who received NF showed significant improvement compared with those in the control condition on the Conners 3-P Attention, Executive Functioning and Global Index, on all BRIEF summary indices, and on BOSS motor/verbal off-task behavior. Children who received CT showed no improvement compared to the control condition. Children in the NF condition showed significant improvements compared to those in the CT condition on Conners 3-P Executive Functioning, all BRIEF summary indices, SKAMP Attention, and Conners 3-T Inattention subscales. Stimulant medication dosage in methylphenidate equivalencies significantly increased for children in the CT (8.54 mg) and control (7.05 mg) conditions but not for those in the NF condition (0.29 mg).Neurofeedback made greater improvements in ADHD symptoms compared to both the control and CT conditions. Thus, NF is a promising attention training treatment intervention for children with ADHD.

Extensive data available from more than 30 years of research reveal that children raised by gay and lesbian parents have demonstrated resilience with regard to social, psychological, and sexual health despite economic and legal disparities and social stigma. Many studies have demonstrated that children's well-being is affected much more by their relationships with their parents, their parents' sense of competence and security, and the presence of social and economic support for the family than by the gender or the sexual orientation of their parents. Lack of opportunity for same-gender couples to marry adds to families’ stress, which affects the health and welfare of all household members. Because marriage strengthens families and, in so doing, benefits children’s development, children should not be deprived of the opportunity for their parents to be married. Paths to parenthood that include assisted reproductive techniques, adoption, and foster parenting should focus on competency of the parents rather than their sexual orientation.

Objective To develop and validate the Baby Pediatric Symptom Checklist (BPSC), a brief social/emotional screening instrument for children less than 18 months. The BPSC is modeled after the Pediatric Symptom Checklist (PSC) and is part of the Survey of Wellbeing of Young Children, a comprehensive, freely available screening instrument designed for use in pediatric primary care. Method BPSC items were developed by a team of experts who reviewed existing assessment instruments and relevant research literature. Scale construction and initial validation were conducted with 205 families from pediatric primary care sites and 54 families from referral clinics. A replication sample of 146 additional families were enrolled from an independent set of primary care practices. Results Exploratory factor analysis revealed 3 dimensions of the BPSC: irritability, inflexibility, and difficulty with routines. Factor structure was confirmed in the replication sample. Retest reliability and internal reliability were adequate (intraclass correlation coefficient >0.70) across subscales, with the exception of the "irritability" subscale's internal reliability in the replication sample. Construct validity of the "irritability" and the "difficulty with routines" subscales is supported by correlations with the Parenting Stress Index and the Ages & Stages Questionnaire: Social/Emotional, but the "inflexibility" subscale seems to be distinct from performance on these instruments. Tests of differential item functioning revealed no significant effects for race/ethnicity, child gender, parent education, or family income. Age-based normative data were calculated for each subscale. Conclusion The BPSC assesses 3 domains of behavior for very young children and shows promise as a social/emotional screening instrument for pediatric primary care.

To evaluate the difference in 10-year neurocognitive outcomes between extremely low gestational age newborns without bacteremia and those with suspected or confirmed late-onset bacteremia.Neurocognitive function was evaluated at 10 years of age in 889 children born at28 weeks of gestation and followed from birth. Definite (culture-positive) late-onset bacteremia during postnatal weeks 2-4 was identified in 223 children, and 129 children had suspected bacteremia.Infants with the lowest gestational age and birth weight z-score had the highest prevalence of definite and suspected late-onset bacteremia. Compared with peers with no or suspected bacteremia, infants with definite bacteremia performed worse on tests of general cognitive ability, language, academic achievement, and executive function, even after adjustment for potential confounders. Adjustment for low IQ attenuated the associations between bacteremia and all dysfunctions at age 10 years. Children with suspected bacteremia did not differ appreciably from those with no evidence of bacteremia. The motor domain was unaffected.Extremely low gestational age newborns who had definite late bacteremia during postnatal weeks 2-4 are at heightened risk of neurocognitive limitations at age 10 years.

OBJECTIVE: To assess the association between maternal prepregnancy body mass index and adequacy of pregnancy weight gain in relation to neurocognitive function in school-aged children born extremely preterm.STUDY DESIGN: Study participants were 535 ten-year-old children enrolled previously in the prospective multicenter Extremely Low Gestational Age Newborns cohort study who were products of singleton pregnancies. Soon after delivery, mothers provided information about prepregnancy weight. Prepregnancy body mass index and adequacy of weight gain were characterized based on this information. Children underwent a neurocognitive evaluation at 10 years of age.RESULTS: Maternal prepregnancy obesity was associated with increased odds of a lower score for Differential Ability Scales-II Verbal IQ, for Developmental Neuropsychological Assessment-II measures of processing speed and visual fine motor control, and for Wechsler Individual Achievement Test-III Spelling. Children born to mothers who gained an excessive amount of weight were at increased odds of a low score on the Oral and Written Language Scales Oral Expression assessment. Conversely, children whose mother did not gain an adequate amount of weight were at increased odds of a lower score on the Oral and Written Language Scales Oral Expression and Wechsler Individual Achievement Test-III Word Reading assessments.CONCLUSION: In this cohort of infants born extremely preterm, maternal obesity was associated with poorer performance on some assessments of neurocognitive function. Our findings are consistent with the observational and experimental literature and suggest that opportunities may exist to mitigate risk through education and behavioral intervention before pregnancy.

An online survey was distributed via snowball sampling and resulted in responses from 61 gay fathers raising children in 2 states. Fathers reported on the barriers they experienced and the pathways they took to becoming parents. They reported also on experiences of stigma directed at them and their children, especially from family members, friends, and people in religious institutions. Despite these difficulties they reported that they engaged actively in parenting activities and that their child(ren)'s well-being was consistent with national samples.

The reliability and validity of the Parent's Observations of Social Interactions (POSI), a new, seven-item screening instrument for autism spectrum disorders (ASD), is examined in two substudies. In Study 1, parents of 217 children (18–48 months) evaluated at a developmental clinic completed intake questionnaires that included the POSI and the Modified Checklist for Autism in Toddlers (M-CHAT) checklist. POSI and M-CHAT scores were compared to clinical evaluation results to assess reliability and validity. In Study 2, parents of 232 children (16–36 months) from both primary care and subspecialty settings completed the POSI, the M-CHAT, and a report of their child's diagnoses. POSI and M-CHAT scores were compared to reported diagnoses to assess reliability and validity. In both studies, the POSI demonstrated adequate internal reliability (Cronbach α = 0.83 and 0.86, respectively). In Study 1, POSI sensitivity (89%) was higher than that for the M-CHAT (71%; p < .05); specificities were not significantly different (POSI: 54%, M-CHAT: 62%). In Study 2, sensitivity (83%) compared favorably to that for the M-CHAT (50%), although specificity was lower (75 vs. 84%). Despite its brevity, the POSI demonstrated good internal reliability and comparable sensitivity/specificity to the M-CHAT checklist in two independent populations. If results are reproduced in larger, more diverse samples, the POSI may provide an efficient method for ASD screening in young children.

To describe responses to the questions "Do you have concerns about your child's behavior? Development? Learning?" among parents seeking pediatric care, and to analyze their correspondence to formal screening questionnaires.Of 465 parents of children aged 3 to 65 months recruited at pediatric primary care practices in Greater Boston, 451 provided complete data for analysis. After completing a questionnaire that asked whether they had any or all of these concerns, parents filled out a developmental screener (Ages and Stages Questionnaire-3) and a behavioral screener (Ages and Stages Questionnaire: Social-Emotional).One hundred eight parents (24%) reported having at least 1 concern about their child. Greater child age, male gender, and lower family income were associated with more concerns about development, behavior, and learning. Moderate agreement was found between parents' concerns and their responses on screening instruments, but among parents who identified no concerns, 18% were identified as at risk on one or both screening tests. Compared with children who were not identified on either screener, parents of children identified only on the behavioral screener were more likely to have concerns about behavior and parents of children identified on both screeners were more likely to have noted concerns about both behavior and development. No type of concern was associated with identification on the developmental screener alone.Parents' self-report of concerns showed moderate agreement with the results of developmental and behavioral screening instruments. Agreement was higher for behavioral concerns than for developmental concerns.

Objective: To compare the quality of life (QoL), a measure of psychological well-being, of adoles- cents reared in lesbian-mother families with that of a matched comparison group of adolescents with heterosexual parents. The adolescents in the comparison group were derived from a representative sample of adolescents in Washington state. The second aim of the study was to assess among teens with lesbian mothers whether donor status, maternal relationship continuity, and self-reported stigmatization are associ- ated with QoL. Methods: In 1986, prospective lesbian mothers were recruited in Boston, Washington, DC, and San Francisco. Currently, 93% of the National Longitudinal Lesbian Family Study (NLLFS) families are still participating in the study. This report is based on an online questionnaire completed by 78 NLLFS adolescent offspring—39 girls and 39 boys. Six items of the Youth Quality of Life Instrument were used to assess QoL. Also, the NLLFS adolescents were asked whether they had experienced stigmatization, and if so, to describe these experiences (e.g., teasing and ridicule). Mothers were queried about donor status and maternal relationship continuity. Results: The results revealed that the NLLFS adolescents rated their QoL comparably to their counterparts in heterosexual-parent families. Donor status, maternal relationship continuity, and experienced stigmatization were not related to QoL. Conclusion: Adolescent offspring in planned lesbian families do not show differences in QoL when compared with a matched group of adolescents reared in heterosexual families. By investigating QoL, this study provides insight into positive aspects of mental health of adolescents with lesbian mothers. (J Dev Behav Pediatr 33:000-000, 2012) Index terms: adolescents, lesbian families, quality of life, stigmatization.

CONTEXT: Recent mandates and recommendations for formal screening programs are based on the claim that pediatric care providers underidentify children with developmental-behavioral disorders, yet the research to support this claim has not been systematically reviewed. OBJECTIVE: To review research literature for studies regarding pediatric primary care providers' identification of developmental-behavioral problems in children. METHODS: On the basis of a Medline search conducted on September 22, 2010, using relevant key words, we identified 539 articles for review. We included studies that (1) were conducted in the United States, (2) were published in peer-reviewed journals, (3) included data that addressed pediatric care providers' identification of developmental-behavioral problems in individual patients, (4) included an independent assessment of patients' developmental-behavioral problems, such as diagnostic interviews or validated screening instruments, and (5) reported data sufficient to calculate sensitivity and specificity. Studies were not limited by sample size. Eleven articles met these criteria. We used Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria to evaluate study quality. Although the studies were similar in many ways, heterogeneous methodology precluded a meta-analysis. RESULTS: Sensitivities for pediatric care providers ranged from 14% to 54%, and specificities ranged from 69% to 100%. The authors of 1 outlier study reported a sensitivity of 85% and a specificity of 61%. CONCLUSIONS: Pediatricians are often the first point of entry into developmental and mental health systems. Knowing their accuracy in identifying children with developmental-behavioral disabilities is essential for implementing optimal evaluation programs and achieving timely identification. Moreover, these statistics are important to consider when planning large-scale screening programs.

Objective. This study examined the efficacy of 2 computer-based training systems to teach children with attention deficit/hyperactivity disorder (ADHD) to attend more effectively. Design/methods. A total of 41 children with ADHD from 2 middle schools were randomly assigned to receive 2 sessions a week at school of either neurofeedback (NF) or attention training through a standard computer format (SCF), either immediately or after a 6-month wait (waitlist control group). Parents, children, and teachers completed questionnaires pre- and postintervention. Results. Primary parents in the NF condition reported significant ( P < .05) change on Conners’s Rating Scales—Revised (CRS-R) and Behavior Assessment Scales for Children (BASC) subscales; and in the SCF condition, they reported significant ( P < .05) change on the CRS-R Inattention scale and ADHD index, the BASC Attention Problems Scale, and on the Behavioral Rating Inventory of Executive Functioning (BRIEF). Conclusion. This randomized control trial provides preliminary evidence of the effectiveness of computer-based interventions for ADHD and supports the feasibility of offering them in a school setting.

Background This study provides preliminary data about a parenting intervention for families of preschoolers with early attention deficit hyperactivity disorder/oppositional defiant disorder symptoms carried out in two diverse primary care pediatric offices. Method Parents of toddlers completed behavioral screening questionnaires at well-child visits. Eligible parents participated in a 10-week parenting education group using the Incredible Years program. Mothers completed several outcome measures at three time points: before participating in the group, immediately after the group ended, and 6 months thereafter. These measures assessed changes in parenting practices, parenting stress, and child symptoms. Parent and provider satisfaction also were assessed. Results Mothers reported improvements in parenting skills and a decrease in stress. They also reported a decrease in child aggression and an increase in compliance. Mothers and providers reported high levels of satisfaction. Conclusions Results support the benefits and feasibility of providing parenting education groups to parents of toddlers in pediatric practice settings.

Resume La survenue d’une acidose lactique dans l’asthme aigu grave (AAG) est classique chez l’adulte mais peu decrite chez l’enfant. Sa reconnaissance peut avoir des consequences sur la prise en charge therapeutique de la crise d’asthme. Une petite fille de 2 ans a ete hospitalisee en reanimation pediatrique pour un AAG, traite par oxygenotherapie a haut debit, methylprednisolone et salbutamol par voie intraveineuse. Elle a presente une acidose metabolique (pH = 7,29) avec hypocapnie (26 mmHg), chute des bicarbonates (12 mmol/L), trou anionique (20 mmol/L) et augmentation des lactates (8 mmol/L). La recherche d’une maladie metabolique sous-jacente a ete negative. L’evolution a ete favorable avec amelioration spontanee de l’acidose lactique permettant la sortie de l’unite de reanimation apres 72 heures. L’origine d’une acidose lactique au cours de l’AAG est multifactorielle. Bien que sa resolution soit spontanee, il est essentiel de la reconnaitre car elle peut modifier la symptomatologie respiratoire et conduire a une escalade therapeutique inappropriee.

Objectives To test the hypothesis that higher blood levels of neurotrophic proteins (proteins that support neuronal survival and function) in the first 2 weeks of life are associated with a lower risk of cognitive impairment at 10 years. Study design We evaluated 812 10-year-old children with neonatal blood specimens enrolled in the multicenter prospective Extremely Low Gestational Age Newborn Study, assessing 22 blood proteins collected on 3 days over the first 2 weeks of life. Using latent profile analysis, we derived a cognitive function level based on standardized cognitive and executive function tests. We defined high exposure as the top quartile neurotrophic protein blood level on ≥2 days either for ≥4 proteins or for a specific cluster of neurotrophic proteins (defined by latent class analysis). Multinomial logistic regression analyzed associations between high exposures and cognitive impairment. Results Controlling for the effects of inflammatory proteins, persistently elevated blood levels of ≥4 neurotrophic proteins were associated with reduced risk of moderate (OR, 0.35; 95% CI, 0.18-0.67) and severe cognitive impairment (OR, 0.22; 95% CI, 0.09-0.53). Children with a cluster of elevated proteins including angiopoietin 1, brain-derived neurotrophic factor, and regulated upon activation, normal T-cell expressed, and secreted had a reduced risk of adverse cognitive outcomes (OR range, 0.31-0.6). The risk for moderate to severe cognitive impairment was least with 0-1 inflammatory and >4 neurotrophic proteins. Conclusions Persisting elevations of circulating neurotrophic proteins during the first 2 weeks of life are associated with lowered risk of impaired cognition at 10 years of age, controlling for increases in inflammatory proteins.

Objective: Little has been published about the professional activities of developmental-behavioral (DB) pediatricians. To better understand the settings in which DB pediatricians work, allocation of their professional time, and how financial considerations impact their practice, the Society for Developmental and Behavioral Pediatrics surveyed its membership. Method: An extensive on-line three-part survey was conducted in 2006-2007 assessing sociodemographic characteristics, practice descriptors, coding and billing practices, productivity goals and perceived pressures among Society for Developmental and Behavioral Pediatric's 438 physician members. Results: Of the pediatricians responding, representing all regions of the United States, 93% were DB pediatrics subspecialty board certified or eligible. The majority was practicing DB pediatrics full-time (73%); and 67% were exclusively in academic settings. All reported seeing patients, 84% reported teaching, 76% reported having administrative responsibilities, and 46% reported conducting research. Despite having non-clinical responsibilities, full-time equivalent positions included an average of 25 hours per week in direct patient care and 14.5 hours per week (37% of clinical time) in indirect patient care. Only 42% reported working with multidisciplinary teams. Salaries varied widely within and across regions. Deficits in billing/coding practices, awareness of personal clinical productivity, and familiarity with national productivity benchmarks were identified. Conclusions: DB pediatricians work in diverse settings nationwide. They provide considerable time in indirect patient care, which is poorly reimbursed in general and relative to direct patient care. The results of this survey offer opportunities for provider, institutional and payer education.

Objectives: Whether medical services received by children and youth with behavioral health conditions are consistent with a Medical Home has not been systematically studied. The objectives of this study were to examine the variation among four behavioral health conditions in regard to services related to the Medical Home. Methods: Cross-sectional analyses of the 2003 National Survey of Children's Health were conducted. Multiple logistic regression analyses tested the impact of behavioral health conditions on medical needs, on Medical Home components, and on likelihood of having a Medical Home overall. Results: Autism, Depression/Anxiety, and Behavior/Conduct problems were associated with reduced likelihood of having a Medical Home, whereas Attention-Deficit Hyperactivity Disorder was associated with increased likelihood. All health conditions predicted increased access to a primary care physician (PCP) and a preventive visit in the past year. However, all were also associated with higher needs for specialty care and all behavioral health conditions except Attention-Deficit Hyperactivity Disorder were associated with difficulties accessing this care. Conclusions: A detailed examination of the receipt of services among children and youth with behavioral health conditions reveals two primary reasons why such care is less likely to be consistent with a Medical Home model: (1) parents are more likely to report needing specialty care; and (2) these needs are less likely to be met. These data suggest that the reason why services received by children and youth with behavioral health conditions are not consistent with the Medical Home has more to do with difficulty accessing specialty care than with problems accessing quality primary care.

CASE: Alexandra is 5 ½ years old, the youngest of four girls, and lives with her parents. She is described by her teachers as a thoughtful, imaginative girl with a good sense of humor, and strong literacy and math skills. Parents describe her typical mood as happy and easy going. She has many friends and engages in a variety of play activities. At 18 months, Alexandra insisted on wearing boys' underwear before she would complete toilet training. At 3 years, she told her parents that she "should have been a boy," and insisted on wearing boys' clothes. Alexandra now refuses to wear dresses and wears a coat and tie to formal occasions, which has led to conflicts with her grandparents. During make-believe play, Alexandra always chooses to play the male roles. She keeps her hair short and her dress and mannerisms are so masculine that people who do not know her assume that she is a boy. Alexandra makes frequent statements about being or wishing she were a boy. When asked directly she says "I'm a girl, but I'm a boy inside." Her parents have recently become alarmed because Alexandra has begun saying "I hate myself," and once said that when her breasts grow she will "slice them off." She has recently asked her parents to call her "Alex." There is no apparent bullying or teasing from other children. Alex's parents are understanding and supportive of her quandary, though they have questions and concems about the long-term implications of these behaviors and choices. Chris is a 9-year-old boy, referred because of his preference for traditionally feminine clothing, toys, and activities. Chris's parents are divorced; he lives with his father and paternal grandparents, visiting his mother once a week. Chris met developmental milestones on time and always seemed "smart" and eager to learn. By 2 years of age, his family noticed that he was attracted to pretty and shiny things like dresses, sequins, and glitter, although he has always worn boys' clothing without complaint. During the next few years, he asked for Barbie dolls for his birthday and seemed fascinated by long blond hair. When coloring, he preferred pink and purple crayons and usually drew female characters, very decorated and with long hair. In comparison, his drawings of himself were small and plain. He occasionally said "I know I'm a boy, but I'm a girl in my head." His pediatrician advised the family to throw out the dolls and "girlish" toys, emphasize "male" activities, and insist that he draw boys as well as girls. Chris was so distraught by this that he was allowed to keep one Barbie doll, as long as he only played with it indoors and did not talk about the doll with friends. In kindergarten and first grade, Chris played mostly with girls and was not interested in sports or rough-and-tumble play. He was teased by other children and had few friends, mostly girls. He started to have sudden outbursts at home and at school that seemed beyond his control, sometimes kicking walls and punching himself in the head. At the beginning of third grade, Chris agreed to join the soccer team as his father wanted. His family no longer sees him playing with Barbies and he has agreed to a few play dates with new boys in his class. Chris is quieter than he used to be, with fewer outbursts. For his birthday, he privately asked his father's fiance for a blond long-haired wig, but when his father confronted him, he denied it. His father reports that "the phase" has finally passed.

This study examined how 7 to 8-year-old and 11 to 12-year-old children with and without attention-deficit hyperactivity disorder (ADHD) interpreted the causes and treatment of ADHD and colds. We also examined the complexity of children's explanations of medications for ADHD and colds.A semi-structured interview was used to assess children's understanding of ADHD and colds. Interviews were coded separately for each of 3 categories: principles (e.g., biological or psychological) used to explain cause and treatment; ideas about the intentionality of symptoms; and articulation of mechanisms underlying the action of medications.Younger children without ADHD demonstrated a belief that children with ADHD have control over and choose to exhibit their symptoms. Younger children with ADHD used nonintentional psychology (e.g., learning or early childhood experiences) or biological principles in their responses whereas older children with ADHD combined both of these categories in their accounts of ADHD. Older children without ADHD favored purely biological explanations of ADHD. Both age and experience were related to the complexity of children's responses to questions about the action of medications for ADHD and colds.Findings highlight the need for educational interventions to rework the notion that children with ADHD intentionally display their symptoms. Educational interventions should clearly be tailored to children's developmental level as well as their experience with a condition.

A small pilot program of 9 youth 13 to 18 years old with high-functioning autism spectrum disorder (ASD) or Asperger’s syndrome assessed the feasibility, acceptability, and potential efficacy of an individualized mentoring program. Youth met weekly for 6 months with trained young adult mentors at a local boys and girls club. Participants reported improvements in self-esteem, social anxiety, and quality of life. Participants, parents, mentors, and staff reported that the program improved participants’ social connectedness. Although the pilot study was small, it provides preliminary data that mentoring for youth with ASD has promise for increasing self-esteem, social skills, and quality of life.

Frankie is an 8-year-old boy seen in consultation because of school difficulties in 2nd grade and “odd behavior.” His family has been concerned about him for the past 2 years, and he has had psychological testing at school. His parents are seeking another evaluation now because they are concerned that his school performance is declining and his self-confidence is decreasing. Frankie was born at term weighing 7 lb, 3 oz. Delivery was complicated by the “cord around the neck,” but Apgar scores were 8 and 9, and he had no difficulties in the neonatal period. He went home with his mother. As an infant he was easily soothed and liked to be held. He sat at 6 months, crawled at 8 months, and walked alone at 14 months. He spoke 3 intelligible words at 1 year and was speaking in sentences by 2 years. He was fully toilet-trained by 2 years, 9 months. He had no significant medical illnesses. His parents began to be concerned about Frankie when his preschool teacher noted a concern about his fine motor skills. She remarked also that, although he had no problems socially, he seemed happy to play alone. From a very early age, he liked ropes and often carried around a length of rope as some children carry a blanket. He was never a difficult child or disruptive at home or in his preschool. The only problem his parents have had is that he tends to get extremely involved in a particular activity (watching television, building with LEGO blocks), and it is very difficult to turn his attention away from that activity to a family task. At the same time, he is also noted to be easily distracted from tasks in which he has less investment. Frankie’s father is said to have attention-deficit/hyperactivity …

Objectives.— Consistent with the "medical home" model, the GAPS program was developed to provide expanded care for children with a range of chronic health conditions within the context of primary care pediatric offices. Parents, pediatricians, and representatives from local Title V agencies participated to assess the child's and family's needs and to identify ways of addressing them. Methods.— Eleven pediatricians in 5 pediatric practices participated in the 4 main activities of the GAPS project: a) needs assessment; b) planning meeting among parents and pediatricians; c) practice-based advisory group; and d) Department of Public Health consultation. A telephone interview of parents and 2 needs assessment questionnaires completed by families were the 2 evaluation methods used. Results.— Parents were able to meet desires for "information" and "specific help." Moderate amounts of success were reported for meeting "contact" and "counseling" needs. Parents' explanations of unmet needs included lack of follow-through in obtaining services, unavailability of services, change of mind regarding needs, and pragmatic barriers. Socioeconomic status, the diagnosis and severity of the child's condition, and maternal psychological status were not significant predictors of success in families' ability to get their needs met. Conclusions.— Active collaboration among parents, pediatricians, and Department of Public Health staff helps to ensure comprehensive coordinated care for families of children with chronic health conditions. Considerable challenges remain in implementing effective medical homes.

1. Ellen Perrin, MD, MA* 2. Terry Stancin, PhD† 1. *Professor of Pediatrics, The Floating Hospital for Children, Tufts-New England Medical Center, Boston, MA 2. †Associate Professor of Pediatrics, MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH After completing this article, readers should be able to: 1. Describe the prevalence of child behavior problems in primary care settings. 2. List possible reasons that child behavior problems are underidentified by pediatricians. 3. Describe formal and informal procedures for identifying behavioral problems in children. 4. Delineate the advantages of and concerns about formal and informal methods for screening and assessing behavioral problems in children. 5. Decide whether and how to incorporate screening methods into practice. 6. Describe options for improving mental health services for children, including development of collaborative care practices. Pediatricians are accustomed to the use of screening in the course of primary care for children and adolescents. Screening for some problems, such as lead poisoning or anemia, involves relatively simple procedures compared with the more daunting task of screening for possible behavioral or developmental concerns. To merit population screening, a condition must be important, reasonably common, identifiable by screening before becoming evident clinically, have an effective treatment that is enhanced if provided early, and have an acceptable screening test available. Screening tests must be inexpensive to administer and score, be acceptable to patients, produce reliable results, and have adequate validity. It has been established that substantial variations and delays in children’s motor and cognitive development meet these criteria. (1) However, behavioral variations and problems are harder to define and to classify, and the boundaries of pediatricians’ responsibility are less clearly delineated. Clearly, behavioral and emotional difficulties are important in terms of both personal suffering and social consequences. High rates of depression, school failure, and violence are some indicators of late consequences. These problems are common, with up to 50% of parents expressing concern about their child’s behavior and many surveys documenting an identifiable emotional difficulty in 25% of school-age children. Limited but improving evidence documents the effectiveness of treatment for various mental health …

A growing body of scientific literature demonstrates that children who grow up with 1 or 2 gay and/or lesbian parents fare as well in emotional, cognitive, social, and sexual functioning as do children whose parents are heterosexual. Children’s optimal development seems to be influenced more by the nature of the relationships and interactions within the family unit than by the particular structural form it takes.

1. Ellen C. Perrin, MD* 2. Susan Starr, MEd* 1. 2. *Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA. Books about common pediatric concerns read to or by children can serve several purposes: 1) provide accurate information, 2) normalize feelings and experiences, 3) facilitate conversations between parents and children about difficult topics, 4) help children develop strategies to cope with complex situations, and 5) develop understanding and empathy for children coping with a variety of circumstances. Our recommended list of books is based on how regularly we have received requests for book suggestions from parents, children, students, residents, and clinicians. There is a virtual explosion of books for children, and it is impossible to be inclusive either of all possible topics or of particular books within each topic. In some topic areas few books are available (eg, smoking); in others the vast array makes it very difficult and sometimes overwhelming to make a reasoned choice (eg, death or illness). An informal survey of community pediatricians yielded specific direction for the choice of topic areas. We have included books that address new babies, adoption, sibling rivalry/sibling love, puberty and sexuality, divorce, eating problems, learning disabilities, attention deficit hyperactivity disorder, substance abuse, depression and mental illness, illness and disabilities, family violence, and death. Other topics deserve similar lists, such as descriptions of doctor and dentist visits and the process of physical examination, anatomy and physiology, child development, and specific parenting practices. We have not included videotapes or books in languages other than English. We have assembled a list of books that we think are among the best in each content area, although not necessarily the only excellent examples. We have included books appropriate for children of all ages and for the adults who care for them. Many of these books go out of print very quickly and may be accessed best through libraries. For the most current information, we suggest that …

Resume La cheilite granulomateuse est caracterisee par un œdeme labial evoluant par poussees intermittentes et pouvant devenir permanent. Elle est parfois associee a une maladie de Crohn ou a une sarcoidose. Elle survient habituellement chez l'adulte jeune. Nous rapportons un cas de cheilite granulomateuse survenant chez une enfant, amelioree par la minocycline. Observation Une enfant de huit ans avait une cheilite œdemateuse, fissuraire et crouteuse avec perleche, debord inflammatoire sur la joue et aspect en « museau de tapir . La langue, les gencives et les autres muqueuses etaient normales. Il n'y avait pas de paralysie faciale associee. Un traitement antibiotique oral et l'application de dermocorticoides n'avaient qu'une efficacite partielle et transitoire. La biopsie labiale montrait la presence de trois granulomes epithelioides et gigantocellulaires sans tropisme vasculaire, ni necrose caseeuse, ni corps etranger, associes a un infiltrat lymphoide. Il n'y avait pas de signes cliniques evocateurs de la maladie de Crohn ou de sarcoidose associee. Un traitement par hydroxychloroquine puis metronidazole etait inefficace. Un traitement par minocycline (100 mg/j) entrainait une tres nette amelioration. Conclusion Le diagnostic de cheilite granulomateuse doit aussi etre envisage chez l'enfant, sa meconnaissance pouvant faire evoquer une cheilite infectieuse, allergique ou factice. Ce diagnostic est d'autant plus important que la cheilite granulomateuse peut s'associer a ou preceder de plusieurs mois ou annees une maladie de Crohn ou une sarcoidose. De plus, la mise en route d'un traitement peut limiter, s'il est efficace, la constitution d'un œdeme permanent inesthetique.