Community Paediatric Services Research Articles

Opportunities for improving personnel situation assessment in community pediatric services: a retrospective analytical descriptive study

Background. The variety of current methods for assessing the healthcare personnel resources remains insufficient to completely evaluate the actual staffing and needs of certain medical institutions. Using a combination of different sources of data enables a more comprehensive picture of the healthcare personnel situation to be obtained. Objective. To identify the potential for improving approaches to assessment of the personnel situation in community pediatric services at the regional level. Methods. The present study involved data from Krasnodar Krai, Astrakhan and Volgograd Oblasts: Federal Statistical Monitoring form No. 30 “Information on Medical Organization” for 2007–2022, as well as depersonalized data from the regional registers of medical workers and assigned population of Krasnodar Krai as of 01.01.2023. The methodology involved statistical and analytical methods. The study estimated the following parameters: community pediatric staffing in relation to? the child population, the staffing level of pediatric full-time positions, the rate of part-time jobs, and the average number of children per pediatrician. Results. The study justified the possibility of using additional sources of data to evaluate the personnel situation in local, municipal or regional healthcare institutions. The authors suggested an interactive analytical board for graphical visualization of the current state of healthcare human resources. Conclusion. The introduction of additional sources of information and monitoring in the healthcare human resources policy encourages a systematic comprehensive approach to estimating the staffing requirements.

Obesity and Weight Concerns in Children with Special Needs in a Developing Country

Objective To investigate weight concerns in children with special needs. Methods Data from an established patient database on Microsoft Excel for a local community paediatric service was analysed for September 2015 to August 2016. Patient diagnoses were categorised as follows: Attention Deficit and Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), Learning Difficulty (LD), Cerebral Palsy (CP), Global Developmental Delay (GDD), Trisomy 21 (T 21) and Other syndromes. The proportions of these children being overweight/obese, underweight, having eating problems, requiring dietician services and having behavioural problems were recorded. Odds ratios were calculated comparing subgroups. Results One thousand and seventeen (1017) patients attended the clinics; Seven hundred and seventy one (771) were male. Fifteen point four percent (15.4%, 157) of patients had weight concerns, with 9.3% (95) being overweight or obese and 6.1% (62) underweight. Five point one percent (5.1%, 52) of children experienced eating problems. Seven point nine percent (7.9%,80) patients accessed the dietician services and behavioral concerns were noted in 8.8% (90) patients. Regarding ASD, the odds of being overweight or obese was lower compared to the rest of the group; 3.7% (15) were overweight or obese. For ADHD, 15% (13) were overweight or obese. Amongst children with Learning Difficulty, 17.5% (44) were overweight or obese. CP children had higher odds of being underweight compared to the rest of the group (14.9% of children with CP were underweight). For Trisomy 21 and other syndromes, 17% (5) were overweight or obese. Conclusion International data indicates that children with special needs have high rates of overweight and obesity. This study also shows that a significant proportion of children with special needs are overweight or obese and at risk of Non-Communicable Diseases (NCDs) like cardiovascular disease and diabetes. Strategies implemented locally to address NCDs must give emphasis to children with special needs. Keywords: Obesity, Special Needs, Children

Health status and health service use of urban Aboriginal children attending an Aboriginal community child health service in Sydney.

There is limited information on the health status of urban Australian Aboriginal children and young people attending community-based child health services. Such information is vital to plan appropriate services. The objective of the study is to describe the health status and service use of children and young people presenting to an urban Aboriginal Community Paediatric Service in Sydney, Australia. Cross-sectional analysis of routinely collected data extracted from electronic medical records and the Australian Immunisation Register for urban Aboriginal children and young people aged 0-18 years who visited the service between January 2013 and December 2017. A total of 273 Aboriginal children and young people had 609 occasions of service. Almost all (97.35%) were fully immunised. Forty-six percent of occasions of service noted >3 diagnoses; 55% of the consultations were for mental health and behavioural disorders. The most frequent diagnoses were speech and language delay, attention deficit hyperactivity disorder and school difficulty. Psychosocial concerns were noted in 61.2% of occasions of service, and 19.4% of children had a history of prematurity. Eighty-five percent of consultations had an onward referral to additional services. The most common referrals were for audiology, ear-nose and throat specialists and speech therapy. There were low numbers of referrals to mental health services relative to the high number of mental health diagnoses. It is essential that we address the mental, developmental and psychosocial needs of Aboriginal children and young people who attend urban Community Child Health services. Integrated service models should be developed in partnership with Aboriginal community to do this.

An Approach to Consolidating Pediatric Hospital Beds During the COVID-19 Surge.

On April 3, 2020, in response to the coronavirus disease 2019 pandemic, the Children’s Hospital Association of the United States issued guidance for coordinating pediatric hospital care and increasing general hospital surge capacity.1 Observing that ∼200 hospitals already care for 50% of all pediatric admissions, it called for immediate consolidation of pediatric care within experienced pediatric facilities and coordinated efforts between children’s and community hospitals to benefit both adult and pediatric patients. The goal was to expand adult capacity in community hospitals caring for older patients while, at the same time, providing care for pediatric patients in settings where customized pediatric resources are available. Because local conditions vary, flexibility and thoughtful coordination across hospital systems were advised. Here, we estimate hospital bed capacity under potential consolidation and the corresponding impact on patient travel distance.We used data from the 2018 American Hospital Association Annual Survey Database2 to quantify the availability of pediatric hospital beds within the continental United States. Ratios of beds per 1000 children (<18 years old) were calculated by using population data from the US Census.3 We excluded psychiatric, chemical-dependence, and neonatal beds. We report descriptive statistics and/or numbers for states, hospital service areas, and hospital referral regions.4 The distance from the centroid of counties to hospitals was estimated by using the Haversine formula.5 All analyses were conducted by using Jupyter notebooks and Python 3.7. Interactive visualizations were produced with Plotly (available at https://bit.ly/ped_beds_covid).From a universe of 6218 institutions, 3547 general hospitals with functioning emergency departments were identified. Of these, 3524 were located within the continental United States, and 1193 maintained a total of 30 798 pediatric beds. Only 52 institutions were characterized as exclusively pediatric (9904 beds, 32.2% of total US pediatric capacity), but 319 were sufficiently specialized to require PICUs. These were distributed more widely and housed 23 085 beds, or 74.9% of total US pediatric inpatient capacity.The distribution of all pediatric beds and of those in hospitals with PICUs is shown in Fig 1. The statewide fraction of pediatric beds contained in hospitals with PICUs ranged from 100% in Washington, District of Columbia, to 0% in Wyoming (median: 72.1%; interquartile range [IQR]: 61.0%–82.4%). The median distances from county centroids to the nearest pediatric bed increased from 24.4 miles (IQR: 13.7–37.2) under baseline conditions to 52.3 miles (IQR: 31.9–77.7 miles) with diversion to PICU hospitals.Populational distance estimates based on county census data are presented in Fig 2.Notably, 93.2% of hospital service areas and 39.8% of hospital referral regions did not contain a PICU. In the few regions with multiple PICUs (eg, Baltimore, Boston, Chicago, El Paso, Fort Lauderdale, Houston, Indianapolis, and Los Angeles), additional consolidation could be undertaken with little impact on travel distance.Decades of pediatric hospital care consolidation has left a system that is highly dependent on a subset of specialized centers.6,7 In a pandemic that preferentially spares children,8 this provides an opportunity for those centers to assume the entire burden of pediatric inpatient care. Here, we show that roughly three-quarters of all pediatric beds are currently maintained in centers with PICUs, so the remaining capacity could theoretically be accommodated if a corresponding volume of nonemergent caseload is deferred. Because, from previous estimates, it is suggested that at least 1 in 5 admissions to children’s hospitals can be considered elective and that admissions to general hospitals tend to have shorter lengths of stay,9 such accommodation may be achievable. However, as acknowledged by the Children’s Hospital Association,1 the degree to which this can be practically implemented will depend on many factors, including local practice characteristics, operating guidelines, transport systems, and the surge in patients with coronavirus disease 2019. Additionally, in our analysis we suggest that the immediate cost of such a strategy is, on average, a doubling of travel distances for families seeking urgent or emergent pediatric care. Additional costs from delayed care and financial dislocations will depend on the duration of the disruption and the extent to which elective pediatric medical and surgical care can be deferred. General pediatricians must be prepared to monitor and manage patients whose care has been delayed and to continue this through an extended period of backlog management. When the pandemic has passed, hospital administrators must be encouraged to reopen community pediatric services amid the related financial pressures.10

Validating the Developmental and Well-Being Assessment (DAWBA) in a clinical population with high-functioning autism

Background: With increasing numbers of referrals to health services for assessment of Autism Spectrum Disorder (ASD), the Developmental and Well-Being Assessment (DAWBA) has been suggested as a useful screening instrument to assist in prioritising patients for review. It is an online interview for parents that has been previously validated for ASD in a non-clinical community sample of twins. Our study aimed to evaluate its predictive validity in a complex clinically-referred sample of children with suspected high-functioning autism. Methods: The sample comprised 136 children (females = 53; males = 83) who were referred for ASD assessment at the Social Communication Disorder Clinic (SCDC) at Great Ormond Street Hospital. Parents completed the DAWBA online prior to undergoing a multi-disciplinary team (MDT) assessment. This included completing the Developmental, Dimensional and Diagnostic Interview (3di) and the Autism Diagnostic Observation Schedule (ADOS). Two clinicians independently rated the DAWBA using DSM-5 diagnostic criteria and compared results to the MDT outcome, which was considered gold standard. Results: Compared with an MDT assessment, the DAWBA interview demonstrated good sensitivity (0.91) but poor specificity (0.12). Overall, 64% of cases were accurately assigned as case/non-case. Estimates of positive (0.66) and negative (0.43) predictive validity were influenced by the relatively high prevalence of ASD in the study sample (65%). Conclusion: The DAWBA online interview has excellent sensitivity in a clinical population of complex neurodevelopmental disorders, containing a high prevalence of ASD, but specificity was poor. As the SCDC offers tertiary opinions on disputed cases of suspected ASD, the population cohort limits the generalisability of these results. Further evaluation is required in community child mental health or paediatric services.

Hypermobility, developmental coordination disorder and physical activity in an Irish paediatric population.

The primary aim of the study was to explore the prevalence of generalized joint hypermobility (GJH) and generalized hypermobility spectrum disorder (gHSD) using the new classification system in a community paediatric physiotherapy service in Ireland. The second aim was to explore the relationship between GJH, gHSD and physical activity level, while considering the association of probable developmental coordination disorder (pDCD). A case-controlled cross-sectional study of children aged 6-12 years, recruited from the community paediatric physiotherapy department (n = 32) and a local school (n = 41), was carried out. A Beighton score of ≥6/9 distinguished GJH. The new framework for hypermobility spectrum disorder (HSD) was used. Self-reported physical activity level was measured using the Physical Activity Questionnaire-Older Children. A parent-reported validated questionnaire screened for pDCD. The prevalence of GJH was 21.9% of children attending physiotherapy. One child in the physiotherapy group was identified as having gHSD, with a prevalence of 3.1%. There was no significant difference in physical activity level between children with and without GJH attending physiotherapy (independent samples t-test, p = 0.28). Probable developmental coordination disorder (pDCD) was observed in 71.9% of children attending physiotherapy. There was no significant difference in the number of children with pDCD in those with and without GJH (Fisher's exact test, p = 0.370). This study was the first to explore the prevalence of GJH and gHSD in the paediatric physiotherapy population in Ireland. The presence of GJH did not affect self-reported physical activity level or motor coordination in children attending physiotherapy.

The Strengths and Difficulties Questionnaire Self-Report: A Valid Instrument for the Identification of Emotional and Behavioral Problems

ObjectiveValidated questionnaires help community pediatric services to identify emotional and behavioral problems (EBPs). This study assesses the psychometric properties of the self-report version of the Strengths and Difficulties Questionnaire (SDQ) for the identification of EBPs in adolescents (13 to 14years old) and the added value of the SDQ parent-form version. MethodsWe obtained data on 500 adolescents (mean age 13.5 years) from community well-child services and schools. Adolescents completed the SDQ self-report and the Youth Self-Report (YSR). Parents completed the SDQ parent-form and the Child Behavior Checklist (CBCL) for their children. We assessed the internal consistency and validity using the YSR and CBCL as the criteria, and the degree to which the SDQ parent-form provides additional information by comparison with the self-report. ResultsThe internal consistency of the SDQ total score was good (Cronbach's alpha, 0.75). Sensitivity and specificity using the YSR as the criterion were 0.75 and 0.91, respectively. When the CBCL was adopted as the criterion, these validity indices were lower. The SDQ parent-form does not provide additional information by comparison with self-reporting only when the YSR score is used as the criterion (odds ratio, 0.48; 95% confidence interval, 0.14–1.65); however, it does do so when the CBCL is the criterion (odds ratio, 10.9; 95% confidence interval, 4.23–27.9). ConclusionsThe SDQ self-report is valid for the detection of EBPs in adolescents, and the SDQ parent-form provides additional information by comparison with the self-report. This indicates that it is useful to involve adolescents and their parents as informants for the identification of EBPs in adolescents.

Online referral and immediate appointment selection system empowers families and improves access to public community paediatric clinics.

We aimed to introduce a low-cost combined online referral and immediate appointment selection system (CORIAS) to empower referrers and parents by allowing them to schedule an appointment at a time and location of their choosing in conjunction with the referrer at the time of referral. This was because an unacceptably high rate of reported lost referrals, combined with a high rate of failure to attend initial appointments (FTAs), was noted at a six-site community paediatric clinic service. We aimed to analyse the impact of CORIAS on important outcomes including timely appointment scheduling, attendance, loss of referrals, user acceptance, overall cost and administrative burden. For 3-month periods before and after the implementation of CORIAS, data were collected regarding all new referrals received and initial appointments scheduled, as well as reports of lost referrals. The number of attended initial appointments, FTAs, failures in successfully scheduling appointments, referrer background, CORIAS cost and qualitative feedback received from relevant parties was collated and analysed. The proportion of referrals reported lost was 6% following the implementation of the combined online system in comparison to 17% pre-implementation. The FTA rate for scheduled initial appointments pre-implementation was 16%; post-implementation, the FTA rate was 9%. Qualitative benefits included a decrease in the administrative burden associated with appointment scheduling and increased service access for culturally and linguistically diverse families. Appropriately designed and implemented novel online systems may improve timely and equitable access to health care by providing secure, reliable pathways for referrers and by empowering and improving communication with patients and families.

A randomized controlled trial to compare two methods of constraint-induced movement therapy to improve functional ability in the affected upper limb in pre-school children with hemiplegic cerebral palsy: CATCH TRIAL

Objective: To determine the feasibility and short-term efficacy of caregiver-directed constraint-induced movement therapy to improve upper limb function in young children with hemiplegic cerebral palsy. Design: Randomized controlled trial with masked assessment. Setting: Community paediatric therapy services. Subjects: Pre-school children with hemiplegic cerebral palsy. Interventions: Caregiver-directed constraint-induced movement therapy administered using either 24-hour short-arm restraint device (prolonged) or intermittent holding restraint during therapy (manual). Main measures: Primary measures include Assisting Hand Assessment (AHA) at 10 weeks. Secondary measures include adverse events, Quality of Upper Extremity Skills Test and Pediatric Quality of Life Inventory. Feasibility measures include recruitment, retention, data completeness and adherence. Results: About 62/81 (72%) of eligible patients in 16 centres were randomized (prolonged restraint n = 30; manual restraint n = 32) with 97% retention at 10 weeks. The mean change at 10 weeks on the AHA logit-based 0–100 unit was 9.0 (95% confidence interval (CI): 5.7, 12.4; P < 0.001) for prolonged restraint and 5.3 (95% CI: 1.3, 9.4; P = 0.01) for manual restraint with a mean group difference of 3.7 (95% CI: −1.5, 8.8; P = 0.156) (AHA smallest detectable difference = 5 units). No serious related adverse events were reported. There were no differences in secondary outcomes. More daily therapy was delivered with prolonged restraint (60 vs 30 minutes; P < 0.001). AHA data were complete at baseline and 10 weeks. Conclusion: Caregiver-directed constraint-induced movement therapy is feasible and associated with improvement in upper limb function at 10 weeks. More therapy was delivered with prolonged than with manual restraint, warranting further testing of this intervention in a longer term trial.

Protocol investigating the clinical utility of an objective measure of attention, impulsivity and activity (QbTest) for optimising medication management in children and young people with ADHD ‘QbTest Utility for Optimising Treatment in ADHD’ (QUOTA): a feasibility randomised controlled trial

IntroductionAttention-deficit hyperactivity disorder (ADHD) is characterised by symptoms of inattention, hyperactivity and impulsivity. To improve outcomes, the National Institute for Health and Care Excellence ADHD guidelines recommend regular monitoring of...

P191 Establishing an integrated level 2 sexual health service for people with learning difficuties

Background/introduction A local needs assessment by Public Health in 2013 identified an unmet need for sexual health services for young people (13–25 years) with learning difficulties. Public Health identified funding and developed a service specification for a local level 2 sexual service that was tendered for a pilot period of 15months. We were successful in bidding for the service. Aim(s)/objectives We describe our journey in establishing a bespoke sexual health service for people with learning difficulties as part of our level 3 Sexual Health and HIV service. We outline the difficulties we encountered, how we overcame them and highlight learning points for other providers wishing to establish similar services. Methods A descriptive analysis of the clinic history, service provision, staff training, clinic activity and STI and contraception diagnoses. The complexity of individual cases is captured by brief case histories. Results The service delivery model is multidisciplinary and was developed in collaboration with all key stakeholders including the users themselves. An initial survey identified a community site co-located with the community paediatric service for disability and a Friday afternoon after school as the preferred options. We advertised the service widely including all schools for children with special education needs, social services and carers and GPs. The service opened in March 2014 as a monthly service (Friday 2–6 pm) and was provided by an experienced dual trained speciality doctor, band 6 nurse and band 2 technician together with the community nurse specialist for children with learning difficulties. The service provided STI/HIV screening and management, a full range of contraception choices and sexual health advice. New patient appointments were 1hr and involved time with both the Dr and nurse in order to meet the complex needs of the patients. After 14 months we relocated the service to our level 3 Sexual Health centre located on the main hospital site due to practical difficulties with providing a remote service to a complex group of patients. We changed the clinic session to a regular weekly session on a Wednesday afternoon (3–6 pm). From March 2014 to Dec 2015 there have been 60 attendances by 18 patients (13F, 5M; 17 heterosexual, 1 MSM; 90% white British). 50% patients were under 25 years with a range from 16 to 40 years. Number of STI screens: GC, chlamydia and HIV = 15; GC and chlamydia only = 10; HIV only = 3. STIs diagnosed: chlamydia = 3, TV = 1, PID = 2, 1st episode HSV = 1. Contraception services provided: implant 3, IUS 1, depo 2, COCP 2, EMC 2, PT 6. Historic child sexual abuse was disclosed by three patients. Discussion/conclusion We successfully established a dedicated sexual health service for people with learning difficulties. Although numbers of attendances are small the patients present with complex needs and require long appointment times. 38% of our patients were diagnosed with an STI. The service team benefited from additional training in learning difficulties and capacity assessments and support from senior staff in the level 3 clinic.

G283 Epilepsy12 – united kingdom collaborative clinical audit of health care for children and young people with suspected epileptic seizures

Objective To assess changes between 2012 and 2014 in the quality of paediatric clinical and nursing care for UK children and young people affected with seizures and epilepsies. Methods Epilepsy12, a UK wide audit, commenced in 2009 with the aim of evaluating epilepsy care against NICE and SIGN guidelines. All NHS hospital and community paediatric services managing children with epilepsy were invited to participate. National key recommendations and local action plans were made after Round 1. Round 2 was undertaken between 2013 and 2014 to assess changes since Round 1 and results are reported here. Children referred for first EEG were used to find a new cohort of eligible children aged 1 month to 16 years receiving a first paediatric assessment between January and April 2013 for afebrile paroxysmal episodes. Retrospective case-note analysis was undertaken using a specifically designed web-based platform and audit pack. Service descriptor data were collected from secondary services on census day, 1 January 2014. Patient reported experience measure (PREM) questionnaires were collected from sequential children with epilepsy and their carers/parents attending clinics between February and March 2014. Results 192/196 paediatric services enrolled. 186 units provided service descriptor data, 174 clinical audit data and 145 PREM data. The clinical cohort consisted of 3449 patients; median age 5.2 years; male: female 55:45%. Anonymised PREM data were received from 2335 parents, carers, children and young people. 45% of first assessments occurred within an acute presentation. 35% of children had epilepsy diagnosed by 12 months. 22.6% of children had a documented neurodisability. 68% of paediatric services now have at least one Epilepsy Specialist Nurse (ESN). There has been a significant increase in percentage of children having ESN input; access to a paediatrician with expertise in epilepsies; appropriate assessment, classification and investigations in 2014 compared to 2012. PREM data showed 88% (1897/2148) overall satisfaction with services; 20% thought that staff are not good at working together. Conclusion There is evidence of significant improvements in the provision of medical and nursing epilepsy care. However, many children still do not receive recommended practice and access fully resourced paediatric epilepsy services.

Addressing the inverse care law: the role of community paediatric services

Children's health suffers disproportionately from the effects of poverty. The inverse care law states that those who need care the most are the least likely to receive it. Community paediatricians are well placed to address health inequalities in children. To explore, using routinely collected data, whether we address health inequalities and the inverse care law, particularly for certain conditions targeted by our specialty. Five years of data were analysed, during which health equity audits have led to service changes in order to tackle inequities. The data include postcodes, allowing each child to be assigned to a deprivation quintile, and a range of diagnoses, including five sentinel conditions: attention deficit hyperactivity disorder (ADHD) on medication, autistic spectrum disorder (ASD), epilepsy, cerebral palsy and Down's syndrome. This allowed analysis of the caseload by deprivation index for these conditions, comparison with the background population and exploration of time trends. The number of children on the caseload and their distribution across the quintiles remained stable. The proportion of deprived children (i.e. in the lowest two quintiles) on the caseload over the last five years taken together is 56%, compared to 44% in the background population. The numbers of children with ADHD on medication has almost quadrupled in deprived quintiles and doubled in the least deprived quintile, while the numbers of children with this diagnosis in the most deprived is four times that in the least deprived. Numbers of children with ASD have also increased in each quintile. In contrast, the number of children with epilepsy and cerebral palsy did not show much variation, but those from deprived quintiles made up a greater proportion of the caseload. Routine data collection demonstrates that inequalities are addressed using all four quality domains of service provision and sentinel conditions more likely to affect deprived children are targeted. We believe it is possible for all services to collect and analyse data thus with minimal effort, thereby providing a foundation from which to address the inverse care law.

Effectiveness of Primary Care Triple P on child psychosocial problems in preventive child healthcare: a randomized controlled trial

BackgroundPsychosocial problems in children have adverse effects on the children, their families, and society, thus early intervention is important. Community pediatric services offer an ideal setting to detect problem behaviour in children and provide support to parents. The objective of this study was to assess the effectiveness of a Primary Care Triple P (PCTP) program compared with care as usual (UC) for parents of children with mild psychosocial problems after an initial, evidence-based screening in routine community pediatric care.MethodsWe conducted a multicenter, randomized, controlled trial in community pediatric services in the Netherlands, enrolling parents of children with mild psychosocial problems. The population was identified by screening using the Strengths and Difficulties Questionnaire (SDQ) with a cut-off point of 11 or higher (that is, a subclinical score). We compared PCTP with UC, and measured the effects immediately after treatment and after 6 and 12 months. PCTP comprised four individual counseling sessions with the parent of 20 to 30 minutes each. The primary outcome measures were the child psychosocial problems as measured by the SDQ and the Eyberg Child Behaviour Inventory (ECBI).ResultsIn total, 81 families were recruited and randomized, and 67 provided post-intervention data. Both treatment groups improved after treatment, with the PCTP group improving only slightly more than the UC group on most measures. The maximum difference on the SDQ was 1.94 (95% CI = −0.30 to 4.19, P = 0.09) and 5.81 (95% CI = −3.37 to 14.99, P = 0.21) on the ECBI (n = 67). None of the differences between PCTP and UC was significant. In the subsidiary analyses, only one of the twenty outcomes (that is, SDQ conduct problems) was significant.ConclusionsPCTP did produce a reduction in psychosocial problems in children but had no statistically significant advantage over UC. In general, a few outcomes improved in both groups. Based on this admittedly underpowered study, we cannot conclude that PCTP is more effective than UC in preventive child healthcare.Trial registrationNederlands Trial Register (Dutch Trial Register): NTR1338.

Three Questionnaires to Detect Psychosocial Problems in Toddlers: A Comparison of the BITSEA, ASQ:SE, and KIPPPI

ObjectiveValidated questionnaires can improve the identification of psychosocial problems in community pediatric services. Our aim was to assess which of 3 short questionnaires—the Brief Infant-Toddler Social and Emotional Assessment (BITSEA), the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE), and the KIPPPI (Brief Instrument Psychological and Pedagogical Problem Inventory)—was most suitable as a routine screening tool for identification among toddlers. MethodsWe included 2106 parents (response rate 81%) of children aged 6, 14, or 24 months at routine well-child visits in 18 services across the Netherlands. Child health care professionals interviewed and examined children and parents. Parents were randomized to complete either the BITSEA or the KIPPPI; all filled out the ASQ:SE and the Child Behavior Checklist. For each questionnaire, we assessed the internal consistency, validity with Child Behavior Checklist–Total Problems Score (CBCL-TPS) as a criterion, and added value to identification compared to clinical assessment alone. ResultsCronbach's alphas of the total scales varied between 0.46 to 0.91. At the ages of 6 and 14 months, none of the instruments studied had adequate validity. At the age of 24 months, only the BITSEA discriminated sufficiently between children with and without problems (sensitivity = 0.84 at specificity = 0.90), but not the other 2 questionnaires (with sensitivity indices varying between 0.53 and 0.60 at similar specificity). The BITSEA at this age offered slightly higher added value to the identification of psychosocial problems by child health care professionals. ConclusionsFor toddlers aged 6 and 14 months, no questionnaire is sufficiently valid to support the identification of psychosocial problems. The BITSEA is the best short tool for the early detection of psychosocial problems in 2-year-old children.

Tackling child health inequalities due to deprivation: using health equity audit to improve and monitor access to a community paediatric service

Deprived children constitute a large population with high levels of ill health, and difficulty with access to healthcare contributes to their poor health outcomes. There is debate on how best to engage deprived families and the literature on differential access to paediatric care based on deprivation is limited. To demonstrate that community paediatrics can contribute to reduction of health inequalities by providing services that are accessible to and preferentially used by children whose health is likely to be affected by deprivation. To provide a template for others to improve and monitor equity in their services. Long-term service reconfiguration and health equity audit. We used routinely collected activity data and the Indices of Multiple Deprivation to construct equity profiles of the children using our service, and compared these with the profile of the population aged 0-16 years in the geographical area covered by the service. The new patient contact rate for the most deprived children in the population was more than three times that of the least deprived [odds ratio (OR) 3.29, 95% confidence interval (CI) 2.76-3.93]. Deprived children were more than twice as likely to require multi-agency meetings as part of their medical care (OR 2.28, 95% CI 1.94-2.69). Seventy per cent (3693/5312) of our total contacts were with children in the two most deprived quintiles. There was a marked socio-economic gradient in all types of contact. The model of care used by our community paediatric service successfully engages deprived families, thereby reducing health inequalities due to poor access. Key features are multi-agency working, removing barriers to access, raising staff awareness and use of health equity audit. Our findings provide support for tackling health inequalities via health services that are available to all, but capable of responding proportionately according to level of need, a model recently described as proportionate universalism.

Gulamabbas Juma (Zef) Ebrahim

Transformed maternal and paediatric care in Tanzania By the time he left Tanzania in 1970, Gulamabbas Juma (Zef) Ebrahim had created the first department of paediatrics in the country, at...

Early Childhood Assessments of Community Pediatric Professionals Predict Autism Spectrum and Attention Deficit Hyperactivity Problems

For clinically referred children with Autism Spectrum Disorder (ASD) or Attention Deficit/Hyperactivity Disorder (ADHD) several early indicators have been described. However, knowledge is lacking on early markers of less severe variants of ASD and ADHD from the general population. The aim of the present study is to identify early indicators of high risk groups for ASD and ADHD problems based on routine data from community pediatric services between infancy and age four. Data are from 1,816 participants who take part in Tracking Adolescents’ Individual Lives Survey (TRAILS), a longitudinal study. Information on early developmental factors was extracted from charts of routine Preventive Child Healthcare (PCH) visits. To assess ASD and ADHD problems, respectively, we used the Children’s Social Behavior Questionnaire (CSBQ) and the Child Behavior Checklist (CBCL), filled out by parents three times between the ages of 11 and 17. Note that these are parent ratings and not diagnostic instruments performed by trained clinicians. Male gender, low birth weight, low level of education of the mother, social, behavioral, language, psychomotor and eating problems significantly predicted ASD problems (odds ratios (OR) between 1.34 and 2.41). ADHD problems were also predicted by male gender and low level of education of the mother and by maternal smoking during pregnancy, good gross motor skills in first year, early attention and hyperactivity problems, and absence of parent-reported positive behavior (ORs between 1.36 and 1.74). Routine data on early childhood from PCH services are predictive for ASD and ADHD problems in adolescents in the general population. The PCH services are a useful setting to identify high risk groups, and to monitor them subsequently.

An audit of transitional care for adolescents with ADHD in a North West England district

Aim ADHD is now considered to be a chronic neuro-developmental disorder that persists from childhood into adolescence and adulthood. We aimed to analyse the transition of adolescents diagnosed with ADHD in childhood into adult specialist ADHD services in a local district. Methods Patients were diagnosed with ADHD using the standard DSM-IV criteria. Adolescents who were eligible for transitional to adult ADHD services were identified from a community paediatric service database. Patients who reached the age of 16 years over a period of two years consecutively (June 2010 to May 2011) were studied by a retrospective analysis of the clinical records. Results From a total of 495 patients on the specialist ADHD database, 104 adolescents were eligible for transitional to adult services over the study period. 68 adolescents (65%) were discharged from the paediatric services, often due to voluntary discontinuation of medications and self-discharge due to non-attendance at follow-up clinics (including 2 patients who moved out of the area). 19 patients (18%) were referred to CAMHS (5 of them already discharged). Only 16 patients (15%) were successfully referred to the specialist adult ADHD services (3 of them already discharged). Only one patient still remains under the community paediatric services. Conclusion There is a high rate of discontinuation of medications, loss to follow-up and a remarkably low rate of successful transition to locally commissioned adult ADHD services among adolescents diagnosed with ADHD in childhood. A total of 73% of eligible patients were either discharged or lost to follow-up. Establishing a formal transitional process early from the age of 13 years among patients with childhood ADHD may help minimise this high rate of attrition. There must be some flexibility in the referral pathway to the adult ADHD services so that the adolescents who were previously lost to follow-up can be re-referred by other primary or secondary care healthcare professionals if the need arises in the future.

How does socio-economic deprivation affect the prevalence of ADHD in North West of England?

<h3>Aim</h3> This study investigated the relationship between socioeconomic deprivation and the prevalence of ADHD from cross-sectional study of 3 socio-economically distinct regions in North West of England. <h3>Method</h3> Patients diagnosed with ADHD using standard clinical procedures based on DSM-IV criteria by the community paediatric services in Liverpool, St Helens/Knowsley and Warrington districts were studied in relation to the census derived social deprivation data (Index of Multiple Deprivation scores 2007). <h3>Results</h3> Warrington is a relatively affluent area while the other 2 districts are among the most deprived areas of England (table 1). The prevalence of ADHD was significantly associated with the degree of deprivation in a linear fashion in both Warrington and Liverpool districts, while showing a bimodal distribution in St Helens/Knowsley with a higher peak in the most affluent Quintiles of the community (figure 1). <h3>Conclusion</h3> Socioeconomic deprivation appears to be significantly associated with the prevalence of ADHD in children and adolescents living in the North West of England, as demonstrated by very high coefficients of correlation (up to 1.0). A bimodal distribution of prevalence was found only in the district with the lowest rate of ADHD prevalence. This suggests that the more affluent parents are more likely to seek for medical help and diagnosis first in the presence of limited service delivery/coverage. As the rate of diagnosis and pick-up rate improves, progressively more patients from the deprived areas of the society are diagnosed, and their overall numbers eventually surpass those of children from the more affluent backgrounds.