Search

Information and techniques from evidence-based, trauma-informed mental health treatments, resilience and parenting literature and supporting evidence from neuroscience were adapted to provide pediatricians a practical approach and tools to promote resilience and respond to trauma symptoms.

Objective To examine how adverse childhood experiences (ACEs) relate to healthy weight behaviors in children. Methods We examined data from the 2016 National Survey of Children's Health. ACE scores were calculated from 6 measures of household dysfunction. Outcome measures included 5 healthy weight behaviors. Logistic regression models assessed associations between ACEs and healthy weight behaviors controlling for sociodemographic variables. Results Children 6 to 17 years of age (n = 32,528) with 0 ACEs had increased odds of: watching 2 hours or less of television daily (6–12 years: odds ratio [OR] 1.46; 95% confidence interval [CI], 1.20–1.80, 13–17 years: OR 1.64; 95% CI, 1.39–1.94), using electronics for 2 hours or less daily (6–12 years: OR 1.44; 95% CI, 1.15–1.80, 13–17 years: OR 1.86; 95% CI, 1.60–2.16), sharing 4 or more family meals per week (6–12 years: OR 1.39; 95% CI, 1.17–1.66, 13–17 years: OR 1.68; 95% CI, 1.44–1.95), and getting adequate age-specific sleep (6–12 years: OR 1.50; 95% CI, 1.26–1.79, 13–17 years: OR 1.31; 95% CI, 1.11–1.55) when compared to children with one or more ACEs. Children 13 to 17 years of age with 0 ACEs had increased odds of exercising for 60 minutes daily (OR 1.27; 95% CI, 1.02–1.58) when compared to children with one or more ACEs. There was an overall gradient dose pattern; the odds of engaging in a healthy weight behavior decreased as the number of ACEs increased, with mixed significance levels. Conclusions In children, ACE exposure is associated with decreased healthy weight behaviors and behavior counseling alone may be insufficient. Trauma-informed care to address intra-familial adversity may be necessary.

OBJECTIVE: The objective of this study is to examine parenting styles (observed parent-child interactions via the Two-Bag Task) associated with young children’s socio-emotional outcomes, comparing children from Mexican-American and African-American families to children from their white counterparts. METHODS: The Early Childhood Longitudinal Study-Birth Cohort (ECLS-B) data were used to examine six global parenting styles with socio-emotional outcomes at 48-months of age while controlling for both time-independent and time-depending socio-demographic, maternal mental health, and child characteristics. Data was stratified by race and ethnicity, and weighted longitudinal linear regressions models were estimated using STATA/Xtmixed. RESULTS: The six global parenting scores from the Two-Bag Task measures differed across White, African-American, and Mexican-American groups of parents. White parents on average scored higher on parenting styles related to sensitivity, positive regard, and cognitive stimulation, while Mexican-American and African-American parents scored lower. These parenting styles were associated with both approach to learning and social competence outcomes among White children, but were nearly non-existent for Mexican-American and African-American children, when adjusting for covariates. CONCLUSION: Our results highlight the need to critically evaluate measures of parenting behaviors used in research studies with racially and ethnically diverse families. Examining the comprehensive psychometric properties and cultural appropriateness of parenting measures for diverse families is important in order to optimally support child development for non-White children. Furthermore, a critical lens is important in order to mitigate the perpetuation of inaccurate research findings for Mexican-American and African-American children.

Most children will experience some type of trauma during childhood, and many children suffer from significant adversities. Research in genetics, neuroscience, and epidemiology all provide evidence that these experiences have effects at the molecular, cellular, and organ level, with consequences on physical, emotional, developmental, and behavioral health across the life span. Trauma-informed care translates that science to inform and improve pediatric care and outcomes. To practically address trauma and promote resilience, pediatric clinicians need tools to assess childhood trauma and adversity experiences as well as practical guidance, resources, and interventions. In this clinical report, we summarize current, practical advice for rendering trauma-informed care across varied medical settings.

* Abbreviations: DSM-5 — : Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition DTD — : developmental trauma disorder PMTS — : pediatric medical traumatic stress PTSD — : posttraumatic stress disorder PTSS — : posttraumatic stress symptoms SSNR — : safe, stable, nurturing relationship STS — : secondary traumatic stress TIC — : trauma-informed care Recent progress in understanding the lifelong effects of early childhood adversities has clarified the need for an organized strategy to identify and intervene with children, adolescents, and families who may be at risk for maladaptive responses. Trauma-informed care (TIC) in child health care operationalizes the biological evidence of toxic stress with the insights of attachment and resilience to enhance health care delivery to mitigate the effects of trauma. The resulting pediatric health care delivery strategy promotes and restores resilience in children and adolescents, partners with families to support relational health, and reduces secondary trauma among pediatric health care clinicians. This policy statement summarizes what policy makers, legislators, and health care organizations need to consider in terms of infrastructure, resources, and financial support to facilitate the integration of TIC principles into all pediatric points of care. The accompanying clinical report describes the elements of TIC in the direct care of children, adolescents, and families and covers the spectrum from prevention to treatment. The recommendations in this statement and the clinical report build on other American Academy of Pediatrics policies that address the needs of special populations (such as children and adolescents in foster or kinship care, in immigrant and refugee families, or in poor or homeless families) and are congruent with American Academy of Pediatrics policies and technical reports concerning the role of pediatric clinicians in the promotion of lifelong health. Over the past 2 decades, basic science has explained how cumulative adverse childhood experiences in the relative absence of safe, stable, nurturing relationships (SSNRs)1 alter neurohormonal stress responses, gene expression, telomere length, brain … Address correspondence to James Duffee, MD, MPH. E-mail: james.duffee{at}wright.edu

With this new practical guide, pediatricians and other child health professionals will learn to identify, evaluate, and treat children and families affected by trauma and adversity when they present at the office. Available for purchase at https://shop.aap.org/childhood-trauma-and-resilience-a-practical-guide-paperback/ (NOTE: This book features a full text reading experience. Click a chapter title to access content.)

* Abbreviations: AAP — : American Academy of Pediatrics COVID-19 — : coronavirus disease 2019 SARS-CoV-2 — : severe acute respiratory syndrome-coronavirus 2 It has been more than a year since Immediate Past President of the American Academy of Pediatrics (AAP), Sally Goza, MD, FAAP, warned against the threat severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) posed to children and families, including the harm coronavirus disease 2019 (COVID-19)–fueled racism and xenophobia could cause the Asian American community. Sadly, as the COVID-19 pandemic spread, racism and violent attacks on Asian Americans spread along with it. Since March 2020, increases in racist rhetoric have coincided with increases in racist abuse, bullying, and attacks. According to Human Rights Watch,1 an organization that investigates abuses happening throughout the world, reports of discrimination and violence against Asians and people of Asian descent have surged both in the United States and worldwide. A new study of police department statistics2 from 16 of America’s largest cities reveals that hate crimes against Asian Americans rose nearly 150% in 2020, despite overall hate crimes dropping by 7%. Stop AAPI Hate,3 a national coalition that tracks incidents of violence and harassment against Asian Americans and Pacific Islanders in the United States, reported nearly 3800 instances of discrimination against Asians between March 19, 2020, and February 28, 2021. Although these reports may represent only a fraction of the hate incidents that occur, it is an indication of how vulnerable Asian Americans have become to racial attacks and discrimination. Widespread media coverage of violence committed against elderly Asian Americans in cities across the country is stirring up fear and a sense of … Address correspondence to Lee Savio Beers, MD, FAAP. E-mail: president{at}aap.org

Objectives Calls for pediatricians to tend to children’s psychosocial concerns have existed for decades because they are known to negatively impact child health. Children with chronic illnesses frequently have child- and family-level psychosocial concerns that complicate the care provided by their pediatric subspecialists. This study compares pediatricians who exclusively practice general pediatrics with subspecialists regarding their inquiring/screening and referring for psychosocial concerns. Physician and practice characteristics associated with these behaviors were examined. Methods We conducted a cross-sectional study using the 2013 American Academy of Pediatrics Periodic Survey of Fellows. Respondents included 304 pediatricians who exclusively practice general pediatrics and 147 subspecialists. The primary analysis compared the current practices of generalists vs. subspecialists with regard to inquiring/screening and referring children with 10 different psychosocial concerns. Covariates included socio-demographics, practice characteristics, and training experiences. Weighted univariate, bivariate and multivariable analyses were performed. Results Less than half of all pediatricians in the sample reported routinely inquiring/screening for most psychosocial concerns, and 2/3 of subspecialists failed to routinely inquire/screen for most of these conditions. Pediatricians who practice general pediatrics exclusively were more likely to inquire/screen (incident rate ratio (IRR) 1.41, p

Background: Two decades ago, the medical literature reported an association between adverse childhood events (ACEs) and poor adult health outcomes. In 2012, the AAP issued a policy statement calling attention to toxic stress. Yet, a majority of pediatricians rated themselves as “not familiar” with childhood trauma in national surveys. Despite its importance, there is no standard structured curriculum for educating residents and medical students on these topics. A review of the medical education literature reveals a handful of medical schools and residency programs with independent lectures, but none with a cohesive curriculum. The AAP with the …

Objective Because children with medical complexity (CMC) display very different health trajectories, needs, and resource utilization than other children, it is unclear how well traditional conceptions of population health apply to CMC. We sought to identify key health outcome domains for CMC as a step toward determining core health metrics for this distinct population of children. Methods We conducted and analyzed interviews with 23 diverse national experts on CMC to better understand population health for CMC. Interviewees included child and family advocates, health and social service providers, and research, health systems, and policy leaders. We performed thematic content analyses to identify emergent themes regarding population health for CMC. Results Overall, interviewees conveyed that defining and measuring population health for CMC is an achievable, worthwhile goal. Qualitative themes from interviews included: 1) CMC share unifying characteristics that could serve as the basis for population health outcomes; 2) optimal health for CMC is child specific and dynamic; 3) health of CMC is intertwined with health of families; 4) social determinants of health are especially important for CMC; and 5) measuring population health for CMC faces serious conceptual and logistical challenges. Conclusions Experts have taken initial steps in defining the population health of CMC. Population health for CMC involves a dynamic concept of health that is attuned to individual, health-related goals for each child. We propose a framework that can guide the identification and development of population health metrics for CMC.

To assess the availability of on-site mental health professionals (MHPs) in primary care; to examine practice/pediatrician characteristics associated with on-site MHPs; and to determine whether the presence of on-site MHPs is related to pediatricians' comanaging or more frequently identifying, treating/managing, or referring mental health (MH) problems.Analyses included American Academy of Pediatrics (AAP) members who participated in an AAP Periodic Survey in 2013 and who practiced general pediatrics (n = 321). Measures included sociodemographics, practice characteristics, questions about on-site MHPs, comanagement of MH problems, and pediatricians' behaviors in response to 5 prevalent MH problems. Weighted univariate, bivariate, and multivariable analyses were performed.Thirty-five percent reported on-site MHPs. Practice characteristics (medical schools, universities, health maintenance organizations,100 visits per week,80% of patients privately insured) and interactions of practice location (urban) with visits and patient insurance were associated with on-site MHPs. There was no overall association between colocation and comanagement, or whether pediatricians usually identified, treated/managed, or referred 5 common child MH problems. Among the subset of pediatricians who reported comanaging, there was an association with comanagement when the on-site MHP was a child psychiatrist, substance abuse counselor, or social worker.On-site MHPs are more frequent in settings where low-income children are served and where pediatricians train. Pediatricians who comanage MH problems are more likely to do so when the on-site MHP is a child psychiatrist, substance abuse counselor, or social worker. Overall, on-site MHPs were not associated with comanagement or increased likelihood of pediatricians identifying, treating/managing, or referring children with 5 common child MH problems.

There has been increasing emphasis on the role of the pediatrician with respect to behavioral, learning, and mental health (MH) issues, and developmental behavioral rotations are now required in pediatric residency programs. We sought to examine whether this newer emphasis on MH is reflected in pediatricians' reports of their current practices.Data from 2 periodic surveys conducted in 2004 and 2013 by the American Academy of Pediatrics were examined to see whether there were differences in self-reported behaviors of usually inquiring/screening, treating/managing/comanaging, or referring patients for attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, behavioral problems, or learning problems. We examined patterns for all practicing members and for those who practiced general pediatrics exclusively.There were few changes over the decade in the percentage who inquired or screened among all clinicians; among those exclusively practicing general pediatrics, the percentage who inquired or screened increased about 10% for ADHD and depression. ADHD remained the only condition for which the majority of respondents treated/managed/comanaged (57%). While there was some increase in the percentages who treated other conditions, the other conditions were usually treated by30% of respondents. A similar pattern of results was observed in analyses adjusted for physician, practice, and patient characteristics.Despite the changing nature of pediatric practice and increased efforts to emphasize the importance of behavior, learning, and MH, the pediatric community appears to be making little progress toward providing for the long-term behavioral, learning, and MH needs of children and adolescents in its care.

BACKGROUND AND OBJECTIVES: Defining and measuring health for children with medical complexity (CMC) is poorly understood. We engaged a diverse national sample of stakeholder experts to generate and then synthesize a comprehensive list of health outcomes for CMC. METHODS: With national snowball sampling of CMC caregiver, advocate, provider, researcher, and policy or health systems experts, we identified 182 invitees for group concept mapping (GCM), a rigorous mixed-methods approach. Respondents (n = 125) first completed Internet-based idea generation by providing unlimited short, free-text responses to the focus prompt, “A healthy life for a child or youth with medical complexity includes: ___.” The resulting 707 statements were reduced to 77 unique ideas. Participants sorted the ideas into clusters based on conceptual similarity and rated items on perceived importance and measurement feasibility. Responses were analyzed and mapped via GCM software. RESULTS: The cluster map best fitting the data had 10 outcome domains: (1) basic needs, (2) inclusive education, (3) child social integration, (4) current child health-related quality of life, (5) long-term child and family self-sufficiency, (6) family social integration, (7) community system supports, (8) health care system supports, (9) a high-quality patient-centered medical home, and (10) family-centered care. Seventeen outcomes representing 8 of the 10 domains were rated as both important and feasible to measure (“go zone”). CONCLUSIONS: GCM identified a rich set of CMC outcome domains. Go-zone items provide an opportunity to test and implement measures that align with a broad view of health for CMC and potentially all children.

Background Adverse childhood experiences (ACEs) negatively impact health throughout the life course. For children exposed to ACEs, resilience may be particularly important. However, the literature regarding resilience, particularly the self-regulation aspect of resilience, is not often described in children with ACEs. Additionally, family and community factors that might help promote resilience in childhood may be further elucidated. We aimed to describe the relationship between ACEs and parent-perceived resilience in children and examine the child, family, and community-level factors associated with child resilience. Methods Using the US-based, 2011–2012 National Survey of Children’s Health, we examined adverse childhood experiences (NSCH-ACEs) as the main exposure. Affirmative answers to adverse experiences generated a total parent-reported NSCH-ACE score. Bivariate and multivariable logistic regression models were constructed for parent-perceived child resilience and its association with ACEs, controlling for child, family, and neighborhood-level factors. Results Among 62,200 US children 6–17 years old, 47% had 0 ACEs, 26% had 1 ACE, 19% had 2–3 ACEs, and 8% had 4 or more ACEs. Child resilience was associated with ACEs in a dose-dependent relationship: as ACEs increased, the probability of resilience decreased. This relationship persisted after controlling for child, family, and community factors. Specific community factors, such as neighborhood safety (p

* Abbreviation: OHC — : out-of-home care In an intriguing article by Liu et al,1 “Out-of-Home Care and Subsequent Preterm Delivery: An Intergenerational Cohort Study,” in the current issue of Pediatrics , the authors report on the elevated rates of preterm delivery among women with a history of out-of-home care (OHC) before and after the age of 10 years. The authors framed their study using the science of toxic stress and its known impact on health outcomes as the theoretical construct and using OHC as a proxy for early life adversity. Based in Sweden, this study reinforces the value of large national birth cohort databases and linked data sets using unique identifiers in evaluating the impact of population-level health risk factors on outcomes. This approach enabled the authors to study a variety of maternal psychosocial, health, mental health, and perinatal risk factors and arrive at the conclusion that maternal childhood adversity made a moderate contribution to the risk for preterm delivery over and above those other factors. The complex ways in which childhood adversity negatively impacts long-term health and well-being are still being unraveled but are important to understand in terms of opportunities for prevention and intervention. In the initial Adverse Childhood … Address correspondence to Moira Szilagyi, MD, PhD, Division of General Pediatrics, Department of Pediatrics, University of California at Los Angeles, 300 Medical Plaza, Room 3-334, Los Angeles, CA 90095. E-mail: mszilagyi{at}mednet.ucla.edu

Learning collaboratives (LC) are an important method of implementing quality improvement by serving as laboratories to translate research into practice and sharing knowledge. We created a Foster Care Learning Collaborative (FCLC) of 11 foster care health sites to share best practices on providing health services for children in foster care. Using a collaborative approach involving monthly conference calls, we invited each health site to present specific health care delivery issues for the purpose of developing collaborative quality improvement projects regarding the delivery of healthcare to children placed into foster care. For health sites providing primary care (n = 8 of 11 sites), we examined adherence to two American Academy of Pediatrics (AAP) guidelines for children entering foster care: a) the initial health screen, and b) the comprehensive medical evaluations. At least four distinct types of health care models that provide either direct primary care or administrative oversight for children in foster care were identified: 1) medical home sites (n = 3); 2) foster care evaluation/intake sites (n = 2); 3) specialized primary care sites (n = 1); and, 4) state administrative programs (n = 2). Data from the six direct primary care sites (n = 586 children) and two state administrative models (n = 3855 children) was collected. The time-frame for the initial health screen was adjusted to 7 days after entry and adherence (31%) was comparable among primary care sites. Adherence to AAP guidelines regarding completion of a comprehensive medical evaluation within 30 days of intake varied among medical homes (30%–86%), intake models (23%–33%), specialized primary care site (43%), and state models (43%–73%). No site was fully compliant with the AAP guideline for universal comprehensive medical evaluation within 30 days, and there is variation within and among care models. A foster care learning collaborative identified significant variability in adherence to a commonly accepted guideline for timely access to healthcare for children placed into foster care. The LC c model offers the opportunity to evaluate best practices, identify barriers to care, and provide objective feedback for improvement.

Pediatricians report many barriers to caring for children with mental health (MH) problems. The American Academy of Pediatrics (AAP) has focused attention on MH problems, but the impact on perceived barriers is unknown. We examined whether perceived barriers and their correlates changed from 2004 to 2013.In 2004, 832 (52%) of 1600 and in 2013, 594 (36.7%) of 1617 of randomly selected AAP members surveyed responded to periodic surveys, answering questions about sociodemographics, practice characteristics, and 7 barriers to identifying, treating/managing, and referring child/adolescent MH problems. To reduce nonresponse bias, weighted descriptive and logistic regression analyses were conducted.Lack of training in treatment of child MH problems (∼66%) and lack of confidence treating children with counseling (∼60%) did not differ across surveys. Five barriers (lack of training in identifying MH problems, lack of confidence diagnosing, lack of confidence treating with medications, inadequate reimbursement, and lack of time) were less frequently endorsed in 2013 (all P .01), although lack of time was still endorsed by 70% in 2013. In 2004, 34% of pediatricians endorsed 6 or 7 barriers compared to 26% in 2013 (P .005). Practicing general pediatrics exclusively was associated with endorsing 6 or 7 barriers in both years (P .001).Although fewer barriers were endorsed in 2013, most pediatricians believe that they have inadequate training in treating child MH problems, a lack of confidence to counsel children, and limited time for these problems. These findings suggest significant barriers still exist, highlighting the need for improved developmental and behavioral pediatrics training.

Background Child welfare has increasingly focused on alternatives to out-of-home (OOH) placement. In-home services, such as parent training, have increased and more maltreated children remain in-home. Yet, little is known about the effect on mental health of maintaining vulnerable children in-home vs placement in stable OOH care. Objective To evaluate and compare difference in mental health among children investigated by child welfare and who remained in-home vs. those who were placed in stable OOH care. Design/methods We examined a cohort of children (aged 1.5–18 years) from a nationally representative sample of children investigated by child welfare using the National Survey of Child and Adolescent Well-Being II (NSCAW II). We compared changes in mental health functioning over 18 months for children who remained in-home with parent training versus those placed in stable OOH care. Results Among the 749 children in our sample, baseline characteristics of children who remained in-home with parent training and those placed in stable OOH care were similar. Among school-aged children placed in stable OOH care, mental health problems decreased from 26% to 13% (p = .003). This differed significantly from school-aged children who remained in home, for whom mental health problems increased (50% decrease stable OOH care vs. 23% increase in home; p = .007). Among pre-school aged children, mental health problems increased in both settings, particularly stable out-of-home care (p = .008). Conclusions For school aged children with a history of maltreatment, mental health outcomes improve following stable OOH placement, yet worsen when remaining in-home with parents. Pediatricians should be watchful for mental health problems among children who remain home after maltreatment and should advocate for high-quality stable OOH care when it is necessary. Child welfare may need to monitor the outcomes of children remaining at home more closely and provide more intensive preventive and treatment services to families.

Demystifying child development is a defining element of pediatric care, and pediatricians have long appreciated the profound influences that families and communities have on both child development and life course trajectories. Dramatic advances in the basic sciences of development are beginning to reveal the biologic mechanisms underlying well-established associations between a spectrum of childhood adversities and less than optimal outcomes in health, education and economic productivity. Pediatricians are well positioned to translate this new knowledge into both practice and policy, but doing so will require unprecedented levels of collaboration with educators, social service providers, and policy makers. Pediatricians might recognize the negative impact of family-level adversities on child development, but developing an effective response will likely require the engagement of community partners. By developing collaborative, innovative ways to promote the safe, stable, and nurturing relationships that are biologic prerequisites for health, academic success, and economic productivity, family-centered pediatric medical homes will remain relevant in an era that increasingly values wellness and population health.

Children in foster care suffer from an extremely high prevalence of mental health problems, yet, it remains unclear if they consistently use mental health treatments, such as therapy. To determine whether these children receive treatment more often when they have specific types of mental health problems, we examined the prevalence and associations between mental health problems, as identified by standardized screening, and mental health treatment utilization. Using descriptive statistics, multivariate models, and moderation and exploratory mediation analysis, we analyzed data for 237 children in foster care, aged 5–17 years. We found 71 % were identified with a mental health problem in at least one of the sub-domains examined (emotional, conduct, inattention/hyperactivity, peer, and prosocial), and 61 % of children received mental health treatment (p = .001). Yet, the only sub-domains predictive of treatment utilization were peer problems (p = .004) and low prosocial behaviors (p = .030). Moderation analysis revealed that the relation between peer problems and treatment utilization was strongest among white children (p = .012). Exploratory mediation analysis suggested that peer problems may increase the likelihood of treatment for children with emotional (95 % CI 0.05, 0.53) and conduct problems (95 % CI 0.05, 0.58). It remains unknown whether this occurs because peer problems are associated with overt symptoms, or because peers problems can exacerbate existing social–emotional problems. Routine screening for mental health problems among children in foster care can facilitate timely treatment, and potentially improve the present and future quality of life for this high risk population.

* Abbreviation: AAP — : American Academy of Pediatrics The article by Greiner et al1 entitled “Laboratory Screening for Children Entering Foster Care” in the current issue is the first study in which researchers explore the application of the American Academy of Pediatrics (AAP) recommended laboratory screening guidelines for children entering foster care. Those guidelines, “Fostering Health: Health Care for Children and Adolescents in Foster Care,”2 were first developed in the state of New York by a 20-person expert panel and were later endorsed by the AAP’s Task Force on Foster Care in 20053 and reiterated in the latest AAP Policy Statement.4 Expert consensus was the only approach available in the absence of evidence about what constitutes quality health care for this population of underserved children with special health care needs. Given the absence of evidence to the contrary, the guidelines remain the standard today. The “Fostering Health” guidelines were developed on the heels of the crack cocaine epidemic for those at high risk for vertically and horizontally transmitted infections but who mostly lack health records.2 Children of all ages were considered to be at risk given the rates of disclosed and/or suspected sexual abuse, the high prevalence of … Address correspondence to Moira Szilagyi, MD, PhD, Department of Pediatrics, University of California, Los Angeles, 300 UCLA Medical Plaza, Los Angeles, CA 90095. E-mail: mszilagyi{at}mednet.ucla.edu

Objective Efforts to promote early brain and child development (EBCD) include initiatives to support healthy parent–child relationships, tools to identify family social-emotional risk factors, and referrals to community programs to address family risk factors. We sought to examine if pediatricians perceive barriers to implementing these activities, and if they utilize resources to address those barriers. Methods Data were analyzed from 304 nontrainee pediatricians who practice general pediatrics and completed a 2013 American Academy of Pediatrics Periodic Survey. Sample weights were used to decrease nonresponse bias. Bivariate comparisons and multivariable regression analyses were conducted. Results At least half of the pediatricians agreed that barriers to promoting EBCD include: a lack of tools to promote healthy parent–child relationships, a lack of tools to assess the family environment for social-emotional risk factors, and a lack of local resources to address family risks. Endorsing a lack of tools to assess the family environment as a barrier was associated with using fewer screening tools and community resources. Endorsing a lack of local resources as a barrier was associated with using fewer community resources and fewer initiatives to promote parent–child relationships. Interest in pediatric mental health was associated with using more initiatives to promote healthy parent–child relationships, screening tools, and community resources. Conclusions Although the majority of pediatricians perceive barriers to promoting EBCD, few are routinely using available resources to address these barriers. Addressing pediatricians' perceived barriers and encouraging interest in pediatric mental health may increase resource utilization and enhance efforts to promote EBCD.

Objective Cumulative adverse childhood experiences (ACE) can have profound and lasting effects on parenting. Parents with a history of multiple ACE have greater challenges modulating their own stress responses and helping their children adapt to life stressors. We examined pediatric practice in inquiring about parents' childhood adversities as of 2013. Methods Using data from the 85th Periodic Survey of the American Academy of Pediatrics (AAP), we restricted analyses to the 302 pediatricians exclusively practicing general pediatrics who answered questions regarding their beliefs about childhood stressors, their role in advising parents, and whether they asked about parents' ACEs. Weighted descriptive and logistic regression analyses were conducted. Results Despite endorsing the influence of positive parenting on a child's life-course trajectory (96%), that their advice can impact parenting skills (79%), and that screening for social-emotional risks is within their scope of practice (81%), most pediatricians (61%) did not inquire about parents' ACE. Pediatricians who believed that their advice influences positive parenting skills inquired about more parents' ACE. Conclusions As of 2013, few pediatricians inquired about parents' ACEs despite recognizing their negative impact on parenting behaviors and child development. Research is needed regarding the best approaches to the prevention and amelioration of ACEs and the promotion of family and child resilience. Pediatricians need resources and education about the AAP's proposed dyadic approach to assessing family and child risk factors and strengths and to providing guidance and management.

Given the prevalence of mental health (MH) conditions (MHC) in children, pediatricians should initiate treatment alone or in collaboration with a specialist for children with MHC. However, the majority of pediatricians do not manage or comanage common MHC even with an on-site MH provider. We examined which physician, practice, and training characteristics are associated with pediatricians' comanaging at least half of their patients with MHC.We analyzed responses of general pediatricians (n = 305) from the American Academy of Pediatrics 2013 Periodic Survey. Practice characteristics include presence of an on-site MH provider and perceived access to services. Independent variables included sociodemographics, training experiences, and interest in further training. The outcome was comanagement of ≥50% of patients with MHC. Weighted univariate, bivariate, and multivariable analyses were performed.Of the pediatricians who reported comanaging ≥50% of their patients with MHC, logistic regression analysis showed that pediatricians who completed ≥4 weeks of developmental behavioral pediatrics training had 1.8 increased odds (95% confidence interval 1.06, 3.08, P = .03) of comanagement, those very interested in further education in managing/treating MHC had 2.75 increased odds (95% confidence interval 1.63, 3.08, P .001), and those with more training in MH treatment with medications had 1.4 increased odds (95% confidence interval 1.12, 1.75, P = .004) of comanaging children with MHC.Specific educational experiences and interest in further education in managing or treating MHC were significantly associated with comanaging ≥50% of patients, suggesting that enhanced MH training among pediatricians could increase the comanagement of children with MHC.

Objective Since 1997 pediatric residencies have been required to provide a 4-week block rotation in developmental and behavioral pediatrics (DBP), but it is not known whether this has altered the care and management of children by practicing pediatricians. The objective of this study was to compare the self-reported practice patterns of pediatricians who were trained with 4 or more weeks of DBP with the practice patterns of those who were trained for Methods We used self-reported practices from the American Academy of Pediatrics Periodic Survey 85. Pediatricians were asked whether they never, sometimes, or usually inquired about and screened for, and whether they treated/managed/comanaged attention deficit hyperactivity disorder, depression, anxiety, behavior problems and learning problems. They were also asked about a series of barriers to care. Analyses were weighted to account for low response rates. Results Those with more DBP training were significantly more likely to treat/manage/co-manage depression, anxiety, behavior problems and learning problems, but were still doing so less than one third of the time. There were no differences in the care of patients with attention deficit hyperactivity disorder or in screening or inquiring about mental health conditions. Those with more training were more likely to perceive somewhat fewer barriers and to report more specific familiarity with some Diagnostic and Statistical Manual of Mental Disorders criteria and some treatment modalities. Conclusions Longer length of training is associated with more treatment, but significant deficits in self-reported practice remain, leaving much room for additional improvement in the training of clinicians in DBP.

OBJECTIVE Maternal depression affects 10% to 40% of mothers with young children and has negative consequences for children's health and development. The American Academy of Pediatrics (AAP) recommends that pediatricians identify women with maternal depression. The authors examined trends in inquiring about (asking informal questions) or screening for (using a standardized instrument) maternal depression by pediatricians in 2004 and 2013 and identified correlates of usually inquiring/screening to identify maternal depression. METHODS Data were ascertained from 778 nontrainee pediatricians exclusively practicing general pediatrics who completed the 2004 (n = 457) and 2013 (n = 321) AAP Periodic Surveys. Pediatricians answered questions about physician and practice characteristics, training, attitudes, and inquiring/screening to identify maternal depression. Sample weights were used to reduce nonresponse bias. Weighted descriptive and logistic regression analyses were conducted. RESULTS The prevalence of usually inquiring/screening to identify maternal depression increased from 33% to 44% (p < .01). In both years, pediatricians who usually inquired about child/adolescent depression had increased odds of usually inquiring/screening to identify maternal depression. Patient race/ethnicity and training in adult Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria for depression were associated with inquiring/screening in 2004, and believing that family screening is within the scope of the pediatrician was associated with inquiring/screening in 2013. CONCLUSION Although inquiring/screening about maternal depression has increased since 2004, less than half of pediatricians usually screen or inquire about maternal depression, representing a missed opportunity to identify depression and manage or refer women for treatment. Further training on the importance of mental and family health to children's health may increase identification of maternal depression in pediatric primary care.

Objective The stress associated with adverse childhood experiences (ACEs) has immediate and long-lasting effects. The objectives of this study were to examine 1) how often pediatricians ask patients' families about ACEs, 2) how familiar pediatricians are with the original ACE study, and 3) physician/practice characteristics, physicians' mental health training, and physicians' attitudes/beliefs that are associated with asking about ACEs. Methods Data were collected from 302 nontrainee pediatricians exclusively practicing general pediatrics who completed the 2013 American Academy of Pediatrics Periodic Survey. Pediatricians indicated whether they usually, sometimes, or never inquired about or screened for 7 ACEs. Sample weights were used to reduce nonresponse bias. Weighted descriptive and logistic regression analyses were conducted. Results Only 4% of pediatricians usually asked about all 7 ACEs; 32% did not usually ask about any. Less than 11% of pediatricians reported being very or somewhat familiar with the ACE study. Pediatricians who screened/inquired about ACEs usually asked about maternal depression (46%) and parental separation/divorce (42%). Multivariable analyses showed that pediatricians had more than twice the odds of usually asking about ACEs if they disagreed that they have little effect on influencing positive parenting skills, disagreed that screening for social emotional risk factors within the family is beyond the scope of pediatricians, or were very interested in receiving further education on managing/treating mental health problems in children and adolescents. Conclusions Few pediatricians ask about all ACEs. Pediatric training that emphasizes the importance of social/emotional risk factors may increase the identification of ACEs in pediatric primary care.

lems have their origins early in life. 1 The timing, intensity, and cumulative burden of adversities, especially in the relative absence of protective factors, can affect gene expression, the conditioning of stress responses, and the development of immune system function. Individuals affected by a high burden of adverse experiences may adopt compensatory high-risk behaviors that can further erode their health and mental health. Not all adversity occurs in childhood(eg,military combat),but a highburden of cumulative intrafamilial (child maltreatment, domestic violence, impaired caregiving) and other adversities (income and food insecurity) in childhood can have profound lifelong effects unless mitigated by protective factors within the family or the community, or through specific interventions. Two of the articles in this issue indicate that the impact of intrafamilial adverse childhood experiences (ACEs) on health and mental health begin to manifest in childhood. Kerker et al 2 used the nationally representative longitudinal National Survey of Child and Adolescent Well-Being study toassessthe ACEscoresofchildrenunder theageof6years who remained at home after child protective investigation and found they were similar to those of children who were removed and placed in foster/kinship care. The authors also reported that higher ACE scores in this population were associated with more mental health (Child Behavior Checklist score >64) and chronic medical problems, and, for preschool children, lower social scores. Earlier studies of children informally placed with kinship caregivers after child welfare investigation showed a high prevalence of health problems, although fewer mental health problems, compared to children in nonrelative foster care, indicating that almost all children involved with child welfare are at high risk for poor outcomes that may be rooted in cumulative childhood trauma. 3 In a second article in this issue, Thompson et al 4 used LONGSCAN longitudinal data to

Objective.— To examine emergency department (ED) utilization of children in foster care using nationally representative data. Methods.— Cross-sectional analysis of the National Survey of Child and Adolescent Well-Being, Wave 1, which provided data for children ages 1 to 14 years in foster care for 1 year between October 1999 and December 2000. We identified children as having used the ED based upon foster parent responses to the question, "In the last 12 months, has your child gone to an emergency room or urgent care center (UCC) for an illness or injury?" We examined child and family demographic variables that were associated with having used the ED. Results.— The sample included 559 children in foster care. Thirty-one percent (95% confidence interval=26%, 36%) of foster children had visited the ED or UCC in the past 12 months. Multivariate logistic regression analysis revealed that out of all children in foster care, children who had a chronic condition, children of younger age, and children with younger foster caregivers were significantly more likely to have used the ED. Conclusion.— A sizeable proportion of children in foster care use the ED, and subgroups of these children have particularly high rates of ED use. An important component of providing a medical home for children in foster care should involve coordination of care around ED visits for this vulnerable group of children.

It is unclear why the school-aged children of adolescent mothers have more cognitive and behavioral problems than those of adult mothers. To clarify why these children have problems and when during their lives they develop, the relationship between adolescent maternal age and the nature of the behavioral interaction between mothers and their children was studied in the laboratory. Thirty lower socioeconomic status mothers who were 15.5 years to 20 years of age and their 9- to 12-month-old children were videotaped for 20 minutes. Rating scales were developed to score the videotapes. There were significant correlations indicating that younger mothers tended to show less acceptance (r = .63; P < .001), less cooperation (r = .57; P < .001), less accessibility (r = .51; P < .003), less sensitivity (r = .46; P < .006), and more negative verbal communication (r = .32; P < .047) than older adolescent mothers. Younger maternal age was also associated with more overall negative interaction between mother and child (r = .35; P < .032) and with less child-initiated social contact with the mother (r = .32; P < .050). We conclude that over the relatively narrow age range younger adolescent maternal age is related to less favorable mothering behaviors in the laboratory when the children are 9 to 12 months of age.