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Objective To evaluate the impact of TEAM UP-an initiative that fully integrates behavioral health services into pediatric primary care in three Boston-area Community Health Centers (CHCs)-on health care utilization and costs. Data sources 2014-2017 claims data on continuously enrolled children from a Massachusetts Medicaid managed care plan. Study design We used a difference-in-difference approach with inverse probability of treatment weights to compare outcomes in children receiving primary care at TEAM UP CHCs versus comparison site CHCs, in the pre (2014-2016q2)- versus post (2016q3-2017)-intervention periods. Utilization outcomes included emergency department visits, inpatient admissions, primary care visits, and outpatient/professional visits (all cause and those with mental health (MH) diagnoses). Cost outcomes included total cost of care (inpatient, outpatient, professional, pharmacy). We further assessed differential effects by baseline MH diagnosis. Principal findings After 1.5 years, TEAM UP was associated with a relative increase in the rate of primary care visits (IRR = 1.15, 95% CI 1.04-1.27, or 115 additional visits/1000 patients/quarter), driven by children with a MH diagnosis at baseline. There was no significant change in avoidable health care utilization or cost. Conclusions Expanding the TEAM UP behavioral health integration model to other sites has the potential to improve primary care engagement in low-income children with MH needs.

Pediatric behavioral health integration (BHI) represents a promising approach to address unmet child mental health need but little research exists to guide BHI implementation. Through in-depth interviews with 38 professionals involved in a comprehensive pediatric BHI initiative at 3 community health centers, we explored perceptions of the impact of BHI on clinical practice, and facilitators and barriers to BHI implementation. Professionals identified 2 overarching themes about the impact of BHI on clinical practice (greater interdisciplinary collaboration/communication and enhanced provider wellness); 5 themes about facilitators of BHI (staff buy-in for BHI, leadership support, staff belonging to the same team culturally and/or structurally, co-location with close physical proximity, and data-driven quality improvement); and 5 themes about barriers to BHI (inadequate clinician staffing, insufficient space, limited provider time, billing/reimbursement issues, and care coordination challenges). Future pediatric BHI efforts may consider these findings to develop strategies to promote facilitators and reduce barriers during implementation.

Background: Understanding is an important goal of the informed consent process in research. We sought to assess the interrater reliability (IRR) and concurrent validity of two measures of understanding in child and young adult subjects and their parents. Methods: We conducted a cross-sectional survey and interview-based study of children and young adults participating in a clinical trial for cancer, along with one parent per child or young adult subject. We estimated the IRR of the Semi-Structured Comprehension Interview (SSCI) and the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR). We also estimated concordance between the SSCI, the MacCAT-CR, and the Quality of Informed Consent (QuIC). Results: For our sample of 32 subjects (16 parent–child pairs), IRR estimates were high for total score on the SSCI (intraclass correlation coefficient [ICC] = 0.88, 95% confidence interval [CI] = 0.76–0.94), as well as on the understanding (ICC = 0.93, 95% CI = 0.86–0.97) and reasoning (ICC = 0.97...

Whether and how to return individual genetic results to study participants is among the most contentious policy issues in contemporary genomic research.We surveyed corresponding authors of genome-wide association studies, identified through the National Human Genome Research Institute's Catalog of Published Genome-Wide Association Studies, to describe the experiences and attitudes of these stakeholders.Of 357 corresponding authors, 200 (56%) responded. One hundred twenty-six (63%) had been responsible for primary data and sample collection, whereas 74 (37%) had performed secondary analyses. Only 7 (4%) had returned individual results within their index genome-wide association studies. Most (69%) believed that return of results to individual participants was warranted under at least some circumstances. Most respondents identified a desire to benefit participants' health (63%) and respect for participants' desire for information (57%) as major motivations for returning results. Most also identified uncertain clinical utility (76%), the possibility that participants will misunderstand results (74%), the potential for emotional harm (61%), the need to ensure access to trained clinicians (59%), and the potential for loss of confidentiality (51%) as major barriers to return of results.Investigators have limited experience returning individual results from genome-scale research, yet most are motivated to do so in at least some circumstances.

Aim: The return of individual genetic research results has been identified as one of the most pressing ethical challenges warranting immediate policy attention. We explored the practices and perspectives of genome-wide association studies (GWAS) investigators on this topic. Materials & methods: Corresponding authors of published GWAS were invited to participate in a semistructured interview. Interviews (n = 35) were transcribed and analyzed using conventional content analysis. Results: Most investigators had not returned GWAS results. Several had experience returning results in the context of linkage/family studies, and many felt that it will become a larger issue in whole-genome/-exome sequencing. Conclusions: Research context and nature of the study are important considerations in the decision to return results. More nuanced ethical guidelines should take these contextual factors into account.

ObjectiveTo evaluate the relationship between recently trained paediatricians' ethics knowledge and exposure to a formal ethics or professionalism curriculum during residency.MethodsWe conducted a cross-sectional survey of recently trained paediatricians which included a validated 23-item instrument called the Test of Residents' Ethics Knowledge for Pediatrics. The sample included paediatricians who completed medical school in 2006–2008, whose primary specialty was paediatrics or a paediatric subspecialty, and who completed paediatric residency training in 2010–2011. This sample was stratified based on residency programme variables: presence of a formal curriculum in ethics or professionalism, programme size and American Board of Pediatrics certifying exam passage rate. Paediatricians were randomly selected from each stratum for survey participation.ResultsAmong the 370 responding paediatricians (55%), the mean knowledge score was 17.3 (SD 2.2) out of a possible 23. Presence of a formal curriculum in ethics and/or professionalism was not significantly associated with knowledge. Knowledge was lowest on items about parental requests for a child to undergo genetic testing (2 items, 44% and 85% incorrect), preserving patient confidentiality over email (55% incorrect), decision-making regarding life-sustaining technologies (61% incorrect), and decision-making principles such as assent and parental permission (2 items, 47% and 49% incorrect).ConclusionsThis study highlights several areas in which paediatricians' knowledge may be low and that are amenable to targeted educational interventions. These findings should prompt discussion and research among ethicists and educators about how ethics and professionalism curricula can more consistently influence paediatricians' knowledge.

To determine whether health literacy was associated with parental self-efficacy in a diverse sample of parents of newborns. We hypothesized that parents with lower health literacy would have lower parental self-efficacy.We conducted a cross-sectional analysis of baseline surveys from 253 English and Spanish speaking parents18 years old with newborns28 days old enrolled in a trial testing a multisite primary care-based parenting intervention. Surveys assessed parental, child, and environmental characteristics, and used validated instruments to measure health literacy and parental self-efficacy (total and 4 subtypes). Bivariate analyses identified parental, child, and environmental characteristics associated with parental self-efficacy. Multivariable linear regression models examined the associations between health literacy and parental self-efficacy, adjusting for covariates.Parents (median age, 29 years) were 92.1% female, 54.5% black/African American, and 29.6% Hispanic/Latino. More than one-half (58.9%) had completed some college education or more, 49.0% spoke mostly English, and 16.2% had low health literacy. In bivariate analyses, parental self-efficacy was significantly lower in parents with fewer household residents. In multivariable analyses, parents with low compared with high health literacy had significantly lower parental self-efficacy scores (total and 4 subtypes including caretaking procedures, evoking behaviors, reading behaviors and signaling, and situational beliefs).Lower health literacy was associated with lower parental self-efficacy in parents of newborns. To maximize impact on positive parenting behaviors and child outcomes, interventions assisting parents with low parental self-efficacy should consider strategies to address low health literacy.

Heart rate and skin conductance were measured for 83 college students (20 male nail biters, 19 male non-nail biters, 22 female nail biters, and 22 female non-nail biters) during baseline, task, and 3 stressors. Psychodiagnostic measures included the Beck Depression Inventory and the State-Trait Anxiety Inventory. A significant nail-biting status x sex interaction was found in skin conductance reactivity (task minus baseline) for all tasks. Male nail biters were significantly more reactive than the other 3 groups. There was no significant difference in heart rate reactivity in any of the tasks. None of the psychodiagnostic measures differentiated among any of the subgroups. Nail biting, for males, is associated with psychophysiological changes during stress, although the implication of this relationship remains to be clarified.

Objective: To determine the clinical effectiveness of a standardised behavioural medicine group intervention when implemented by different group leaders in 7 geographically diverse healthcare organisations (HCOs). Design: This study used longitudinal data collected for quality assurance purposes. Patients were asked to complete questionnaires measuring presenting problems (Initial Health Status questionnaire), health and functional status [Short Form-36 Health Survey (SF-36)], and physical [Medical Symptom Check List (MSCL)] and psychological distress [Brief Symptom Inventory (BSI)]. Intervention: The Personal Health Improvement Program™ (PHIP) designed to treat somatising high utilisers of general medical services. Participants: Patients enrolled in PHIP courses at 7 different HCOs. Complete data were collected from 1194 patients before the course, 787 immediately after the course and 467 at a 6-month follow-up. 39% of patients who finished the course completed questionnaires at all 3 time-points (times 1, 2 and 3, respectively). Of the 467 patients who provided data at all points, complete information was obtained for 356 patients (the study sample). Main outcome measures and results: Patients’ symptoms of anxiety, depression, hostility and somatisation, as well as overall psychological distress improved (p ≤ 0.001) after the course and at follow-up as determined by repeated measures by group analysis of variance (ANOVA). Results were similar for health status (SF-36), with significant improvements in all of the functional health measures between time 1 and time 3. The majority of participants completing the PHIP reported long term reductions in patterns of distress commonly associated with high levels of medical utilisation. Participants also reported improvements in functional status. In addition, the value of the programme was highly rated by participants. Conclusions: Despite the lack of a control group, the consistency of these findings across the sites are likely to be due to the clinical effectiveness of the course content. The PHIP is an effective and standardised programme, which can be taught to leaders in a short period of time and implemented across very different sites to different populations.

This is one of a series of studies on the long-term effects of early childhood malnutrition in Barbadian school children. This is the first report of the relationship between early malnutrition and later performance on a national examination administered to all 11-y-old children in Barbados to assign high school seats. We compared scores achieved on the 11-plus examination by 103 boys and girls with histories of marasmus or kwashiorkor with those obtained by 63 healthy comparison children and also with scores obtained by the total island population of children during the same years. We report that children with histories of either type of malnutrition confined to infancy had significantly lower scores on the national high school examination than healthy comparison children. Reduced 11-plus scores were closely associated with teacher reports of attention deficits in the classroom documented when the children were as young as 5 to 8 y of age and also with IQ and academic performance. Early malnutrition had independent effects on performance on the 11-plus examination even when home environmental conditions were controlled for. These findings have important implications for future opportunities available to children with histories of infantile malnutrition.

•Educational research has shown that children become literate more easily if their parents read to them. A clinic-based program was designed to encourage early book use among parents of children at risk. It included (1 ) waiting room readers, (2) guidance about literacy development, and (3) provision of children's books at each visit. Seventy-nine parents of children aged 6 to 60 months were interviewed. Parents who had previously received a book were more likely to report looking at books with their children or that looking at books was a favorite activity (adjusted odds ratio, 4.05). This association was strongest among parents receiving Aid to Families With Dependent Children (odds ratio, 7.8). This preliminary study suggests that pediatricians can play a role in enriching children's early literacy environments, especially for children at high risk of school failure. ( AJDC . 1991;145:881-884)