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ChiIdServ, a coordinated, region-wide system of early detection and intervention for at-risk children, was implemented Hartford, Conn, in 1998. In this article, we report our experience with the design and implementation of the of the program describe lessons learned and implications for subsequent program expansion. From 1998 to 2001, 124 child health providers referred 358 children with 516 different needs. One third of referred children had multiple needs. Developmental assessment, speech and language services, parenting classes, and counseling were frequently recommended. Only 43% of referred children ultimately received services, despite an average of 6.9 contacts with the family following initial referral. Boys, Hispanic children, and children with private insurance were more likely to receive services. We believe that ChildServ helps to address a critical gap in service delivery to children at risk for poor developmental and behavioral outcomes. A system of triage, referral, and care coordination appears to facilitate access to program and services. However, additional strategies are necessary to more successfully reach and engage families. In our experience, outreach capacity and such financial barriers as lack of private insurance should be included in the design and implementation of early detection and intervention programs. [ABSTRACT FROM AUTHOR]

Objective: To determine the amount of time primary care pediatricians devoted to anticipatory guidance duping well-child care, including the time spent on various issues, and to examine the influence of certain physician and patient factors on counseling time. Research design: Cross-sectional study of a random sample of Connecticut primary care pediatricians. Subjects and setting: Structured observations of health supervision visits were performed for one day in each of 19 pediatricians' offices. A total of 166 well-child visits were observed. Measurements: For each well-child visit, the child's age, total visit time, total time devoted to anticipatory guidance, and the time spent addressing specific issues were recorded. ANCOVAS examined the influence on counseling time of such factors as the child's age and the pediatrician's years since medical school graduation. Results: The mean time for health supervision visits was 17.8 minutes. Time devoted to anticipatory guidance was 2.4 minutes (12.4% of visit time). Counseling time varied by the child's age (p < 0.004) and by pediatrician (p < 0.001). Recently trained pediatricians performed more counseling (p < 0.004). Discussions of nutrition, immunizations, and development accounted for about 50% of counseling time, while 16.6% of counseling time was spent discussing safety. Conclusions: In comparison to past research. pediatricians may be spending more time providing anticipatory guidance during health supervision visits. Specific topics are consistent with contemporary patterns of childhood morbidity. [ABSTRACT FROM AUTHOR]

The Ready-to-Learn program, a school-based initiative begun in 1994 in three inner-city elementary schools in Hartford, Conn., provides medical input and medical-educational collaboration in the evaluation and treatment of children experiencing learning and behavior problems. The program is staffed by two specially trained nurse practitioners, with consultation provided by pediatricians and a child psychologist. During its first year of operation, pediatric assessment was performed on 57 students at all three schools. Data analysis indicates that children were referred to the program for a broad range of concerns, that assessments were completed in a timely fashion, and that a variety of diagnoses were identified. Feedback from school personnel and parents suggests that the program offers a unique and valued pediatric perspective to the evaluation of school failure. Future plans include a more formal evaluation of the program's cost and effectiveness. [ABSTRACT FROM AUTHOR]

Objectives: A children's hospital explored the feasibility and utility of social network analysis as a tool for system building in community child health, to identify gaps and opportunities in community partnerships, and to assess its role as a contributor to collective impact., Methods: We employed social network analysis with the PARTNER survey to assess relationships among community-based organizations and a children's hospital's community-oriented programs. We utilized a two-stage, snowball sampling strategy to identify community partners. We analyzed social capital, network density, degree centralization, perceived trust, and perceived value. Network mapping depicted the hospital programs' relationships with community partners., Results: Of the 153 contacted potential respondents, 76 responded for a response rate of 50%. Respondents reported a total of 1116 ties, ranging in strength from awareness and cooperation to coordination and integration. Approximately 60% of network members could reach 100 or more members in 2 steps or less. The overall network trust score was 74%. Network mapping indicated that hospital programs enhance bonding relationships within sectors, bridge gaps between partners from different sectors, and provide linkages to resources such as funders. Deficits in bonding, bridging, and access to funding are evident when the hospital's programs are omitted from network maps., Conclusions: Findings support the feasibility and utility of social network analysis as a tool for system building in community child health. The study demonstrates the potential of a children's hospital's programs to provide social capital in the form of bonding, bridging, and linking relationships., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objectives: To identify the diverse services required by families of children with special health care needs (CSHCN) and identify the specific care coordination (CC) efforts associated with the most common types of observed diagnoses. Requested services were categorized into specific sectors, and CC efforts were quantified by observed diagnoses and defined sectors., Methods: CC service data were extracted and analyzed from patient encounters over 4 years (2009-2013) in a department database. This included descriptive information about referrals and linkages to medical, dental, and behavioral health providers and to state, private, and community agencies. Diagnostic classifications and CC sectors were defined to enable categorization., Results: A total of 2682 CSHCN records were reviewed. The majority (59%) required services/resources in 1 to 2 sectors, 24% required services/resources in 3 to 5 sectors, and 17% required services/resources in 6 or more sectors. Including informational service, the most frequently required sectors across the study population were education, financial, medical/dental, social connections, and advocacy. Children diagnosed with autism spectrum disorder had the highest needs across all sectors., Conclusion: Most CSHCN and their families use a substantial amount of CC time and effort to secure services from diverse sectors. High-quality and efficient CC requires an understanding of the specific needs of these CSHCN and their families and how to link them to a diverse array of services and resources.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Dworkin is founding director of the Help Me Grow National Center; Dr Garg is lead researcher of the WE CARE project.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Research suggests that many disparities in overall health and well-being are rooted in early childhood (1,2). Stressors in early childhood can disrupt neurologic, metabolic, and immunologic systems, leading to poorer developmental outcomes (1). However, consistent, responsive caregiving relationships and supportive community and health care environments promote an optimal trajectory (3,4). The first 8 years of a child's life build a foundation for future health and life success (5-7). Thus, the cumulative and lifelong impact of early experiences, both positive and negative, on a child's development can be profound. Although the health, social service, and education systems that serve young children and their families and communities provide opportunities to support responsive relationships and environments, efforts by these systems are often fragmented because of restrictions that limit the age groups they can serve and types of services they can provide. Integrating relationship-based prevention and intervention services for children early in life, when the brain is developing most rapidly, can optimize developmental trajectories (4,7). By promoting collaboration and data-driven intervention activities, public health can play a critical role in both the identification of at-risk children and the integration of systems that can support healthy development. These efforts can address disparities by reducing barriers that might prevent children from reaching their full potential.

Objective: We aimed to identify characteristics of parents who do not voice developmental concerns when prompted by their children's nurse and/or primary care provider (PCP), despite reporting concerns on parent-completed questionnaires., Methods: We reviewed 376 medical records of children seen for a 9-month well-child visit in an urban pediatric clinic between September 2011 and December 2012 for sociodemographic variables hypothesized to affect parents' sharing of developmental concerns: the child's birth order and gender; parents' education level, employment, relationship status, and primary language; and family size and racial/ethnic background. The target population was parents who reported concerns on the Parents' Evaluation of Developmental Status (PEDS), a routinely administered, parent-completed screening questionnaire. We subdivided parents who reported concerns on the PEDS (N = 86) based on whether they voiced developmental concerns when prompted by their children's nurse and/or PCP. Two-sided Fisher's exact tests and logistic regression evaluated the relationship between sociodemographic variables and parents' voicing of developmental concerns., Results: Only parent education approached significance, as parents with less than a high school education (

What if the goal of child health services was not "merely" treating, or even preventing, childhood diseases and disorders, but was expanded to that of promoting children's optimal healthy development? Pediatrics has evolved from an exclusive focus on the treatment of illness to the opportunity to promote children's healthy development. This evolution has profound implications for the content of child health services and programs, for system transformation, and for public policy. Enhanced understanding of the impact of social determinants on children's health and developmental outcomes underscores the importance of an evolving framework for system transformation with key policy implications., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Within the medical home, understanding the family and community context in which children live is critical to optimally promoting children's health and development. How to best identify psychosocial issues likely to have an impact on children's development is uncertain. Professional guidelines encourage pediatricians to incorporate family psychosocial screening within the context of primary care, yet few providers routinely screen for these issues. The authors propose applying the core principles of surveillance and screening, as applied to children's development and behavior, to also address family psychosocial issues during health supervision services. Integrating psychosocial surveillance and screening into the medical home requires changes in professional training, provider practice, and public policy. The potential of family psychosocial surveillance and screening to promote children's optimal development justifies such changes.

The goals of this cross-sectional study were to (a) describe the prevalence of 5 basic social needs in a cohort of parents attending an urban teaching hospital-based pediatric clinic, (b) assess parental attitudes toward seeking assistance from their child's provider, and (c) examine resident providers' attitudes and behaviors toward addressing these needs. Parents (n = 100) reported a median of 2 basic needs at the pediatric visit. The most common was employment (52%), followed by education (34%), child care (19%), food (16%), and housing (10%). Most parents (67%) had positive attitudes toward requesting assistance from their child's pediatrician. The majority of resident providers (91%) believed in the importance of addressing social needs; however, few reported routinely screening for these needs (range, 11% to 18%). There is great potential for assisting low-income parents within the medical home. Further practice-based interventions are needed to enhance providers' self-efficacy to screen and address low-income families' needs at pediatric visits.

Objective: Our goal was to evaluate the feasibility and impact of an intervention on the management of family psychosocial topics at well-child care visits at a medical home for low-income children., Patients and Methods: A randomized, controlled trial of a 10-item self-report psychosocial screening instrument was conducted at an urban hospital-based pediatric clinic. Pediatric residents and parents were randomly assigned to either the intervention or control group. During a 12-week period, parents of children aged 2 months to 10 years presenting for a well-child care visit were enrolled. The intervention components included provider training, administration of the family psychosocial screening tool to parents before the visit, and provider access to a resource book that contained community resources. Parent outcomes were obtained from postvisit and 1-month interviews, and from medical chart review. Provider outcomes were obtained from a self-administered questionnaire collected after the study., Results: Two hundred parents and 45 residents were enrolled. Compared with the control group, parents in the intervention group discussed a significantly greater number of family psychosocial topics (2.9 vs 1.8) with their resident provider and had fewer unmet desires for discussion (0.46 vs 1.41). More parents in the intervention group received at least 1 referral (51.0% vs 11.6%), most often for employment (21.9%), graduate equivalent degree programs (15.3%), and smoking-cessation classes (14.6%). After controlling for child age, Medicaid status, race, educational status, and food stamps, intervention parents at 1 month had greater odds of having contacted a community resource. The majority of residents in the intervention group reported that the survey instrument did not slow the visit; 54% reported that it added <2 minutes to the visit., Conclusions: Brief family psychosocial screening is feasible in pediatric practice. Screening and provider training may lead to greater discussion of topics and contact of community family support resources by parents.

Purpose: Pediatricians are encouraged by the American Academy of Pediatrics and Bright Futures guidelines to use well-child care as an opportunity to promote learning and development, encourage positive parenting practices, help children acquire behavioral self-control, and enhance the well-being of children and their families. Such counseling can consume considerable provider time. In an era of dwindling resources for health care, there is pressure to deliver services as efficiently and effectively as possible. Thus, the purpose of this article is to view methods for patient and parent education that are not only effective but also brief., Design: Review of 114 articles on issues relevant to patient education., Results and Conclusions: Parents appear to respond best to information that focuses on their specific area of concern. Media, such as advertising campaigns or office posters, can be helpful for broadening parents' range of interests. In response, verbal suggestions are effective for conveying brief, concrete information when parents are not stressed. Written information should be added for addressing more complex issues. Modeling and role-playing appear especially useful when confronted with problematic parenting or child behavior. These approaches, if selected wisely and applied well, offer families needed assistance that has proven effectiveness in improving children's and families' health and well-being.

Objective: To determine whether expectations about normal infant and child development are different among mothers from 4 ethnocultural groups., Participants: Two hundred fifty-five mothers (90 Puerto Rican, 59 African American, 69 European American, 37 West Indian-Caribbean) whose children received health care at hospital-based pediatric clinics and private pediatricians' and family practitioners' offices., Design: Verbally administered questionnaire that included 25 questions in which mothers were asked to give their opinions about the age at which a normal child should begin to accomplish standard developmental milestones., Analysis: Responses (mean ages at which mothers expected children to attain the milestones) from each group were compared after controlling for age of mother, number of children, level of education, and socioeconomic status., Results: Significant differences among ethnic groups' responses were seen for 9 of 25 developmental milestones. Differences were mainly seen among personal and social milestones, and Puerto Rican mothers tended to expect children to attain these milestones at a later age than did other mothers. No differences in responses were seen between Spanish- and English-speaking Puerto Rican mothers. European-American mothers expected children to take first steps and become toilet trained at a later age., Conclusions: Developmental expectations differ among mothers from different ethnocultural groups. Many of these differences can be explained by underlying cultural beliefs and values and specific child-rearing practices. Clinicians should ask about maternal expectations during child health visits to interpret mothers' concerns and opinions about their children's development.

The toddler years are ones of exciting and challenging changes in cognitive, affective, and physical growth. Physical growth is particularly remarkable for the child's increasing skills and ability to navigate the environment. Affective development is marked by the push for autonomy and independence and the highly visible nature of the child's temperament or behavioral style. The toddler also enters the wonderful years of imagination and pretend play. Perhaps most noteworthy is the child's dramatic increase in ability to communicate with others through speech and language, as evidence of the progression to symbolic thinking. The dynamic changes in children's development during the toddler years have important implications for child health supervision. Familiarity with toddler development will enable the pediatrician to monitor children's development effectively and to address common, stage-related behaviors with families during anticipatory guidance.

Objective: The success of early identification of children with developmental and behavioral problems is influenced by the manner in which pediatricians elicit, recognize, and select clinical information and derive appropriate impressions. Parents are ready sources of clinical information, and they can be asked to provide two broad types of data: appraisals, including concerns, estimations, and predictions; and descriptions, including recall and report. The purpose of this article is to help pediatricians make optimal use of clinical information from parents to increase the accuracy of clinical judgment in detecting children with developmental and behavioral problems., Design: Review of 78 research articles and tests relying on parent information from pediatric, psychological, and education literature., Results and Conclusion: There are several formats for eliciting parental information that are superior in terms of accuracy and ease of evocation. Specifically, parents' concerns and good-quality standardized parent report measures such as the Child Development Inventories capitalize best on parents' observations and insights into their children. In combination, these two types of parental information offer an effective method for the early detection of behavioral and developmental problems in primary-care settings.

Objective: To define outcomes of pediatric patients with chronic fatigue., Design: Cohort study with a mean follow-up of 3.8 years., Setting: Outpatient pediatrics department at a university health center., Patients: Patients 21 years old and younger referred by their private physicians for evaluation of unexplained fatigue lasting at least 3 months., Intervention: Patients were seen from January 1986 through April 1990 and were telephoned in April 1992 to determine outcome., Results: Of the 55 patients who were evaluated from 1986 to 1990, an organic cause of the fatigue, sinusitis, was found for one. Of the 54 patients with unexplained fatigue, 48 were contacted in 1992. The mean age of these 48 patients was 15 years; 73% were female. Fatigue was present a mean of 7 months before evaluation, and in 78% an acute illness preceded the fatigue. Most patients believed their fatigue had an organic cause. In general, laboratory studies were not helpful. All patients were encouraged to resume normal functioning despite their symptoms. At follow-up, 65% reported resolution of symptoms, 29% reported improvement, and 6% were unchanged., Conclusions: In pediatric patients with chronic fatigue, diagnostic and therapeutic interventions should be based on positive findings; with simple encouragement, the prognosis is excellent. Based on this experience, we suggest a structured approach to the management of pediatric patients with chronic fatigue.

Parents' concerns for their children's behavior were investigated to predict a diagnosis of attention-deficit hyperactivity disorder (ADHD) in this retrospective comparative study of 245 children, aged 4 through 15 years (mean = 8.1 years), consecutively referred for comprehensive pediatric evaluation of school problems between 1981 and 1992. Concerns identified by parents were categorized (inattention, impulsivity, overactivity) and compared to children's final diagnoses of ADHD to measure their sensitivity, specificity, and predictive value. For 92% of subjects, significant school-related problems were diagnosed and 38% received a diagnosis of ADHD. Parental concern for one or more major symptoms of ADHD identified almost all of the children with a diagnosis of ADHD (sensitivity = .87), but also identified many children without such a diagnosis (specificity = .41). Concerns with impulsivity and overactivity were specific (.82, .87) but not sensitive (.38, .29). Concerns with attention had modest sensitivity (.57) and specificity (.57). Positive predictive value was modest for all categories of concerns (.45 to .57). Findings support the importance of eliciting parents' concerns for their children's school performance and of performing comprehensive assessment to identify the underlying causes of problems with attention.

Whether recent advances in developmental pediatrics have influenced pediatric practice is uncertain. We interviewed, in their offices, 41 randomly selected, board-certified, primary care pediatricians in Connecticut to explore their attitudes and clinical approaches to developmental problems. Responses were compared with those from a similar survey of 97 New England pediatricians performed 15 years ago. Important changes in certain clinical approaches were found. For example, pediatricians are currently less likely to rely on history and physical examination alone to confirm a suspicion of mental retardation (p < .01) and are more likely to refer such a child for further assessment (p < .01); they are more likely to perform hearing screening in evaluating a child with delayed speech (p < .05); they are more likely to contact the school in evaluating a failing child (p < .01), and are more likely to refer such a child for further assessment (p < .01). Results indicate favorable changes in pediatricians' approaches to developmental problems and support the greater emphasis on developmental issues in pediatric education.

By virtue of their ongoing relationship with families and young children, pediatric primary care providers are well positioned to participate in the early detection of children's behavioral, developmental, and psychosocial problems. Yet research suggests that many such problems elude early detection. Awareness of the prevalence of such problems should encourage pediatric providers to carefully elicit parents' opinions and concerns, obtain a relevant behavioral and developmental history, skillfully observe parent and child behaviors, and obtain, when indicated, the opinions of such other relevant professionals as preschool teachers. Possible strategies to improve early detection include the use of parent questionnaires, parent record-keeping of children's behavior, and a developmental screening tool as an aid to surveillance. The development of a classification system for such problems designed for primary care, rather than psychiatry, should also facilitate early detection.

Recent research and legislation support the importance of early identification and intervention for children with developmental and behavioral or emotional problems. Detecting these children often depends on medical professionals, especially pediatricians. However, few pediatricians use developmental screening tests to help them identify children. Rather, physicians usually rely on their clinical impressions to discriminate children with and without difficulties. Research on the accuracy of clinical impressions, although sparse, suggests that only half the children in need are identified. The most obvious reasons, such as severity of the problem or the type of clinical information physicians select (e.g., parents' concerns, observations of the child, history, etc.), do not fully explain why some children are identified and others are not. More complete explanations are found in research on clinical impression formation that suggests physician's selection from the array of clinical data is mediated by their unique experiences, beliefs, and attitudes. These qualities provide a set of judgment heuristics for sorting seemingly relevant from irrelevant information. Judgment heuristics, depending on their content, may lead to accurate or inaccurate impressions. This article suggests a model of ideal impression formation that may help physicians learn to more accurately identify children with developmental and behavioral or emotional problems.

As the professional concerned with monitoring children's growth and development, the pediatric provider is well positioned to contribute to the early detection of children unready for school. Successful early detection requires cooperation and an interchange of information among parents and health and educational personnel. The process of developmental surveillance acknowledges the limitations of screening tests and may be most effective in predicting children's school readiness. Child health supervision services are useful in the promotion of children's optimal school readiness. Research findings support a continued emphasis on developmentally oriented anticipatory guidance while individualizing content to respond to families' needs and encouraging parent-led agendas. Innovations in context worthy of consideration include home visiting, group well-child care, and parent-held child health records. The broad-based societal efforts necessary to promote school readiness and to diminish school failure demand firm and effective pediatric advocacy.

The goal of pediatric health supervision is to promote the optimal growth and development of children. Parent-infant interaction and parental attitudes toward their infant are important determinants of child development. Anticipatory guidance during child health supervision enables the pediatric provider to discuss developmental stages and demystify common stage-related behaviors, such as fussing, night-waking, repetitive movements, and clinging. Anticipating the emergence of such behaviors and issues may lessen parental anxiety and concern. When behavioral problems such as colic or sleep difficulties do arise, a consideration of developmental stage is helpful in suggesting specific management strategies. The successful implementation of developmentally-oriented approaches has benefits for the family and pediatric provider, including increased parental self-confidence, enhanced family functioning, and increased parental confidence in the pediatrician. Furthermore, by encouraging developmentally-oriented approaches, parents will be less inclined to adopt inappropriate or ineffectual behavioral management strategies.

Numerous factors may contribute to a child's failure to learn. Certain causes of school failure, such as specific learning disabilities, mental retardation, sensory impairment, and chronic illness may be regarded as intrinsic characteristics of the child. Other causes, such as family dysfunction, social problems, and ineffective schooling, are characteristics of the child's environment. Still other influences on school performance, such as temperamental dysfunction, attention deficits, and emotional illness, may be viewed as the consequence of the interaction between the child and his or her environment. The reasons for a child's school failure must not be considered in isolation but rather within the context of social and environmental circumstances. Evaluation must consider the myriad of reasons for a child's school failure and attempt to identify "clusters" of adverse influences on school performance. Detailed information must be sought from the student, parents, and school system through the history and physical examination. Questionnaires are useful in data gathering. Ancillary methods of assessment that may be of value include neurodevelopmental screening and laboratory studies. Further investigations and referrals, particularly psychoeducational evaluation, are of major importance. Traditional roles of the pediatrician in school failure include the treatment of underlying medical conditions, counseling, the coordination of further investigations and referrals, and the facilitation of communication with community services and resources. Participation with other disciplines in the development of a child's educational plan is feasible and useful.