Developmental-Behavioral Pediatrics Research Articles

Developmental Milestone Attainment in US Children Before and During the COVID-19 Pandemic

Restrictions related to the COVID-19 pandemic disrupted the lives of young children, but the association between the pandemic and any changes in early childhood developmental milestone achievement in the US remains unclear. To determine the association between the COVID-19 pandemic and changes in developmental screening scores among US children aged 0 to 5 years and to investigate whether caregivers self-reported more worries about their children or concerns about children's behavior during the pandemic, regardless of milestone achievement. This was a cohort study using an interrupted time series analysis comparing prepandemic (March 1, 2018, to February 29, 2020), interruption (March 1 to May 31, 2020), and intrapandemic (June 1, 2020, to May 30, 2022) periods among 50 205 children (randomly sampled from a population of 502 052 children) aged 0 to 5 years whose parents or caregivers completed developmental screening at pediatric visits at US pediatric primary care practices participating in a web-based clinical process support system. COVID-19 pandemic period. Age-standardized Ages and Stages Questionnaire, Third Edition (ASQ) domain scores (communication, personal-social, problem-solving, gross motor, fine motor), and rate of caregivers' concerns about the child's behavior or worries about the child as measured on the ASQ. A total of 50 205 children (25 852 [51.5%] male; mean [SD] age, 18.6 [16.0] months) and 134 342 ASQ observations were included. In adjusted models, significant age-specific mean score decreases from prepandemic to intrapandemic were observed in communication (-0.029; 95% CI, -0.041 to -0.017), problem-solving (-0.018; 95% CI, -0.030 to -0.006), and personal-social (-0.016; 95% CI, -0.028 to -0.004) domains. There were no changes in fine or gross motor domains prepandemic to intrapandemic. For infants aged 0 to 12 months, similar effect sizes were observed but only for communication (-0.027; 95% CI, -0.044 to -0.011) and problem-solving (-0.018; 95% CI, -0.035 to -0.001). After accounting for age-standardized ASQ scores, caregiver worries about the child increased slightly in the intrapandemic period compared with the prepandemic period (rate ratio, 1.088; 95% CI, 1.036-1.143), but there were no changes in caregiver concerns about the child's behavior. While changes in developmental screening scores were modest (2%-3%), nationwide, this could translate to more than 1500 additional recommended developmental referrals over baseline each month. Modest changes in developmental screening scores are reassuring in the short term but may tax an already overburdened developmental behavioral pediatrics infrastructure. Continued attention to developmental surveillance is critical since the long-term population- and individual-level implications of these changes are unclear.

New-Onset Hallucinations and Developmental Regression in a Child with Autism Spectrum Disorder.

Nick is a 5-year-old boy who began displaying self-stimulating behaviors and decreased social interactions shortly before turning 3 years. At the age of 3.5 years, he was diagnosed with autism spectrum disorder by a local developmental-behavioral pediatrician. His parents recall that the physician described Nick to be "high functioning" and encouraged them to expect that he would attend college and live independently as an adult. Upon receiving the diagnosis, intervention was initiated using an applied behavioral analysis (ABA) approach. With this intervention, he demonstrated initial gains in the use of complex language and improved social interactions.Concerns regarding suspected psychosis emerged just before starting kindergarten when Nick began experiencing ego-dystonic visual and auditory hallucinations. Initially, Nick verbally responded to the hallucinations and vividly described what he was experiencing. Shortly after the onset of these hallucinations, Nick experienced a significant decrease in the frequency and complexity of his expressive language and became more withdrawn. Over time, his hallucinations intensified, and his parents became increasingly fearful for his safety. Various antipsychotic and mood-stabilizing medications, steroids, and immunotherapy have been trialed with limited improvement of his symptoms.An extensive medical evaluation yielded the following:1. Magnetic resonance imaging of the brain: dilated perivascular spaces.2. Urine organic acids: ketosis and increased lactic acid.3. Antinuclear antibody: minimally positive.4. Vitamin B12: elevated.All other studies, including lumbar puncture, electroencephalogram (awake and asleep), genetic studies (chromosomal microarray, fragile X testing, and whole exome sequencing), metabolic studies, inflammatory markers, and thyroid panel, were negative/normal.Nick is enrolled in a special education classroom within a school that utilizes an ABA-based approach for all students. As part of his educational programming, he receives 25 hours of ABA in a 1:1 setting, 2 hours of speech therapy, 3 hours of occupational therapy, 1 hour of physical therapy, and 30 minutes of music therapy weekly. Current concerns include significant head-banging and thrashing before falling asleep, hyperactivity, unsafe behaviors (e.g., banging on windows, climbing high to reach desired items), aggression toward caregivers, limited ability to complete self-care tasks (e.g., personal hygiene, toileting), significant decline in expressive language, and continued response to internal stimuli.Nick's parents now present to a multidisciplinary center seeking guidance regarding additional therapies/interventions to assist in management of his current developmental and behavioral challenges as well as information regarding his expected developmental trajectory as he reaches adulthood.

Reducing Time to Diagnosis of Autism Spectrum Disorder Using an Integrated Community Specialty Care Model: A Retrospective Study

ObjectiveTo evaluate a fast-track triage model in an integrated community specialty clinic to reduce the age of diagnosis for patients with autism spectrum disorder (ASD). Study designA retrospective chart review was performed for patients seen in an integrated community specialty (ICS) pediatric practice using a fast-track screening and triage model. The percentage of ASD diagnoses, age at diagnosis, and time from referral to diagnosis were evaluated. The fast-track triage model was compared with national and statewide estimates of median age of first evaluation and diagnosis. ResultsFrom January 1, 2020, through December 31, 2021, 189 children with a mean (SD) age of 32.2 (12.4) months were screened in the ICS. Of these, 82 (43.4%) children were referred through the fast-track triage for further evaluation in the developmental and behavioral pediatrics (DBP) department, where 62 (75.6%) were given a primary diagnosis of ASD. Average wait time from referral to diagnosis using the fast-track triage model was 6 months. Mean (SD) age at diagnosis was 37.7 (13.5) months. The median age of diagnosis by the fast-track triage model was 33 months compared with the national and state median ages of diagnosis at 49 and 59 months respectively. ConclusionWith the known workforce shortage in fellowship-trained developmental behavioral pediatricians, the fast-track triage model is feasible and maintains quality of care while resulting in more timely diagnosis, and reducing burden on DBP by screening out cases who did not require further multidisciplinary DBP evaluation as they were appropriately managed by other areas.

Developmental Behavioral Pediatrics 5th Edition.

Developmental Behavioral Pediatrics 5th Edition.

Child Health Needs and the Developmental-Behavioral Pediatrics Workforce Supply: 2020-2040.

Developmental-behavioral pediatrics (DBP) subspecialists care for children with complex neurodevelopmental and behavioral health conditions; additional roles include education and training, advocacy, and research. In 2023, there were 1.0 DBP subspecialists per 100 000 US children aged 0 to 17 years (range 0.0-3.8), with wide variability in DBP subspecialist distribution. Given the prevalence of DB conditions, the current workforce is markedly inadequate to meet the needs of patients and families. The American Board of Pediatrics Foundation led a modeling project to forecast the US pediatric subspecialty workforce from 2020 to 2040 using current trends in each subspecialty. The model predicts workforce supply at baseline and across alternative scenarios and reports results in headcount (HC) and HC adjusted for percent time spent in clinical care, termed "clinical workforce equivalent." For DBP, the baseline model predicts HC growth nationally (+45%, from 669 to 958), but these extremely low numbers translate to minimal patient care impact. Adjusting for population growth over time, projected HC increases from 0.8 to 1.0 and clinical workforce equivalent from 0.5 to 0.6 DBP subspecialists per 100 000 children aged 0 to 18 years by 2040. Even in the best-case scenario (+12.5% in fellows by 2030 and +7% in time in clinical care), the overall numbers would be minimally affected. These current and forecasted trends should be used to shape much-needed solutions in education, training, practice, policy, and workforce research to increase the DBP workforce and improve overall child health.

Forecasting the Future Supply of Pediatric Subspecialists in the United States: 2020-2040.

Concerns persist about whether the United States has an adequate supply of pediatric subspecialists and whether they are appropriately distributed across the nation to meet children's health needs. This article describes the data and methods used to develop a workforce projection model that estimates the future supply of 14 pediatric subspecialities certified by the American Board of Pediatrics at the national and US census region and division levels from 2020 to 2040. The 14 subspecialties include adolescent medicine, pediatric cardiology, child abuse pediatrics, pediatric critical care medicine, developmental-behavioral pediatrics, pediatric emergency medicine, pediatric endocrinology, pediatric gastroenterology, pediatric hematology-oncology, pediatric infectious diseases, neonatal-perinatal medicine, pediatric nephrology, pediatric pulmonology, and pediatric rheumatology. Hospital medicine was excluded because of the lack of historical data needed for the model. This study addresses the limitations of prior models that grouped adult and pediatric physician subspecialty workforces together and aggregated pediatric subspecialties. The model projects supply at national and subnational levels while accounting for geographic moves that pediatric subspecialists make after training and during their career. Ten "what if" scenarios included in the model simulate the effect of changes in the number of fellows entering training, the rate at which subspecialists leave the workforce, and changes in hours worked in direct and indirect clinical care. All model projections and scenarios are available on a public, interactive Web site. The model's projections can also be examined with other data to provide insight into the possible future of the pediatric subspecialty workforce and offer data to inform decision-making.

Rapid Online Assessment of Reading (ROAR): Evaluation of an Online Tool for Screening Reading Skills in a Developmental-Behavioral Pediatrics Clinic.

Reading difficulties are highly prevalent and frequently co-occur with other neurodevelopmental/behavioral conditions. It is difficult to assess reading routinely in pediatric clinical practice because of time and resource constraints. Rapid Online Assessment of Reading (ROAR) is an objective, gamified assessment that children take in a web browser without adult supervision. This study's purpose was to evaluate ROAR as a screening tool for reading difficulties in a clinical setting. A convenience sample of 6- to 14-year-old children, attending an in-person or telehealth visit in a developmental-behavioral pediatrics (DBP) clinic participated. Children took ROAR and completed the Woodcock-Johnson IV Letter-Word Identification (LWID) and Word Attack (WA). Basic Reading Skills (BRS), a standardized aggregate score of LWID and WA, was used as the gold-standard assessment. The strength of association between standard scores on ROAR and BRS was calculated. BRS scores < 90 (bottom quartile) were classified as poor readers. Receiver operating characteristic (ROC) curve analysis was used to assess the quality of ROAR as a screening test. A sample of 41 children, 78% boys, mean age 9.5 years (SD 2.0 years), completed the study. The correlation of ROAR standard score with BRS was r = 0.66, p < 0.001. ROC curve analysis with ROAR scores accurately classified poor readers with an area under the curve (AUC) of 0.90. ROAR is a useful objective screening tool to identify children at high risk for reading difficulties. Assessment of the tool during a busy clinic was challenging, and a larger replication is warranted.

Performance of a Tic Screening Tool (MOVeIT) in Comparison to Expert Clinician Assessment in a Developmental-Behavioral Pediatrics Clinic Sample

ABSTRACT Youth with intellectual and developmental disabilities typically have higher rates of tics and stereotypies compared to children with otherwise typical development. Differentiating between these two pediatric movement disorders can be challenging due to overlapping clinical features, but is relevant due to distinct treatment modalities. The current study evaluated sensitivity and specificity of a tic screening measure, the Motor or Vocal Inventory of Tics (MOVeIT) in a pediatric sample enriched for stereotypy and tics. Children (n = 199, age 2–15 years old) receiving care in a developmental-behavioral pediatrics clinic underwent a gold-standard diagnostic assessment by a tic expert; these evaluations were compared to the MOVeIT. The MOVeIT demonstrated good sensitivity (89.8%) and relatively lower specificity (57.1%) compared to tic expert for detecting tics in the overall sample. Specificity of the MOVeIT to identify tics improved to 75% when excluding children with co-occurring stereotypy. For children with tics and co-occurring stereotypy, sensitivity remained high (91.9%) but specificity was low (39.1%). The area under the curve (AUC) value to detect tics on the MOVeIT compared to the tic expert gold standard was significantly higher for children without stereotypy (AUC = 85.7%) than those with stereotypy (AUC = 64.3%, p < .01). Overall, the ability to detect tics was better in those without co-occurring stereotypy symptoms. Further work is needed to establish the utility of the MOVeIT in populations where there is a high likelihood of co-occurring tics and stereotypy and in general population settings. Accurate distinction between tics and stereotypy will guide choices for intervention and anticipatory guidance for families.

71 Profiles of Parent Ratings on the Behavior Assessment System for Children-Third Edition in Children with Autism Spectrum Disorder who are Deaf and Hard of Hearing

Objective:Standardized assessment measures can provide data to inform a diagnosis of Autism Spectrum Disorder (ASD). Most measures assessing ASD characteristics rely on some degree of behavioral response to sound (e.g., responding to name, demonstrating listening response), and are often not appropriate for use with children who are Deaf and Hard of Hearing (DHH), especially with individuals who use signed languages. Few studies have reported on the Behavioral Assessment System for Children, Third Edition (BASC-3) for DHH children, and we aim to describe BASC-3 profiles in children with ASD who are DHH.Participants and Methods:Participants include eight DHH patients diagnosed with ASD through interdisciplinary team evaluations by developmental-behavioral pediatricians, speech-language pathologists, and neuropsychologists with expertise in DHH child development. Demographics include a mean age of 6.17 years, and 62.5% were Male. Self-reported racial distribution was 75% White, 12.5% Black and 12.5% declined to answer. Average Area Deprivation Index (marker of socioeconomic status) was 32.13%tile. As a part of the evaluation, parents rated their children using the BASC-3. Languages include spoken English (75%) and American Sign Language (25%). Relevant co-occurringneurodevelopmental/psychological diagnoses include Global Developmental Delay (n=1), Moderate Intellectual Disability (n=1), and Depression (n=1). Types of hearing loss include sensorineural (75%), conductive (12.5%), and mixed (12.5%). Three participants had different degrees of bilateral hearing loss in each ear: mild sloping-severe, moderate rising-mild (n=1), profound, moderate rising-normal level (n=1), and profound, moderate (n=1). Four participants had the same level of hearing loss in both ears: moderate-moderately severe (n=1), moderately severe-severe (n=1), severe-profound (n=1), and profound (n=1). One child had a unilateral moderate hearing loss. Technology utilized: unilateral hearing aid (n=2), bilateral hearing aids (n=2), unilateral cochlear implant (n=1), bilateral cochlear implants (n=2), and bimodal technology (n=1). BASC-3 scales of interest in this study were the developmental social disorders scale (DSD), Autism probability index (AUI), clinical scales, and adaptive scales. BASC-3 scores were standardized using General Combined norms and means were plotted.Results:BASC-3 mean scores on clinical scales were elevated (T&gt;60) on Atypicality (M=71), Hyperactivity (M=63), Withdrawal (M=63), and Attention Problems (M=65) in children with ASD who are DHH in this sample. BASC-3 mean scores on adaptive scales were below threshold (T&lt;40) on Social Skills (M=37), Functional Communication (M=39), and overall Adaptive Skills (M=39). DSD scores were in the at-risk (T&gt;60&lt;70) range for 2 out of 8 cases and clinically significant (T&gt;70) for 5 out of 8 cases.The AUI was clinically significant for 2 out of the 3 cases within the age range for reporting AUI data.Conclusions:In this preliminary sample of DHH children with a confirmed diagnosis of ASD by comprehensive specialized interdisciplinary clinical evaluations, parent ratings on the BASC-3 were consistent with what is known about BASC-3 profiles in hearing children diagnosed with ASD. Our findings suggest it may be helpful to review the DSD, AUI, clinical scales, and adaptive skills scales profiles when assessing DHH children at risk for ASD. Further research, including a larger sample size and assessment of language differences among participants, is necessary.

Addressing Early Education and Child Care Expulsion.

An important goal of early childhood education is teaching emotional self-regulation within the context of a safe, stable, nurturing environment. Expulsion of young children ignores underlying emotional and behavioral concerns, disproportionately affects children of color (Black or Hispanic), males, children with disabilities, and socioeconomically disadvantaged populations, and has long-term consequences on educational and life success. Addressing implicit bias and providing child mental health consultation (psychologists, social workers, developmental behavioral pediatricians, child psychiatrists, and child neurologists) to child care providers can prevent expulsion. Pediatricians and other providers within the medical home play an important part in preventing expulsion. However, pediatricians need more training in early childhood mental health and in understanding how systemic racism and implicit bias lead to preschool expulsion in children of color. By identifying children at risk for expulsion because of poverty, racial discrimination, toxic stress, insecure attachment, or history of trauma, the pediatrician can connect families with community resources that may ameliorate these effects. Pediatricians can provide information on social-emotional development in early childhood, promote positive parent-child relationships, and model and discuss age-appropriate and developmentally appropriate behavior management. Pediatricians can also guide parents toward high-quality child care programs that use mental health consultation and developmentally appropriate activities, both of which lessen the chance of child expulsion. Furthermore, behavioral health providers integrated into the medical home can provide consultation to child care providers on managing patients. These recommendations are consistent with our knowledge of early child brain development and support the current tenets of the American Academy of Pediatrics regarding the pediatrician's role in building resilience and buffering toxic stress to promote optimal child development.

Receipt of Behavioral Therapy in Preschool-Age Children with ADHD and Coexisting Conditions: A DBPNet Study.

Practice guidelines from the American Academy of Pediatrics and Society for Developmental and Behavioral Pediatrics recommend evidence-based behavioral therapy (BT) as first-line treatment for preschool-age children with ADHD, prior to medication initiation. Thus, this study's objective is to present the frequency of physician-documented receipt of BT in preschool-age children with ADHD prior to medication initiation and to determine factors associated with receipt BT receipt. This retrospective medical record review was conducted across 7 Developmental Behavioral Pediatrics Research Network (DBPNet) sites. Data were abstracted for children <72 months old seen by a DBP clinician and initiated on ADHD medication between 1/1/2013-7/1/2017. From narrative text of the medical records, BT receipt was coded as: parent training in behavior management (PTBM), Applied Behavior Analysis (ABA), other, or did not receive. Of the 497 children in this study; 225 children (45%) had reported receipt of any BT prior to ADHD medication initiation, with 15.9% (n = 79) receiving PTBM. Children with co-existing diagnoses of ASD or disruptive behavior disorder were more likely to receive BT than children without co-existing conditions (59.3% vs 69.0% vs 30.6%). There was significant site variability in reported receipt of BT, ranging from 22.4% to 74.1%, and sex and insurance were not associated with BT rates. The percentage of children with documented receipt of any BT, and particularly PTBM, was low across all sites and co-existing conditions. These findings highlight the universal need to increase receipt of evidence-based BT for all young children with ADHD.

Ending Developmental-Behavioral Pediatrics Faculty Requirement for Pediatric Residency Programs—Desperate Times Do Not Justify Desperate Actions

This Viewpoint discusses the issues at stake and potential adverse consequences of the Accreditation Council for Graduate Medial Education’s proposal to remove the requirement for pediatric training programs to have board-certified developmental-behavioral pediatrician faculty members.

The Association of Pediatric Emergency Medicine Physicians' Self-Identified Skills in Suicide Risk Assessment and Management With Training in Mental Health.

Because changes to pediatric emergency medicine (PEM) education may help address barriers to youth suicide risk screening programs, this study aimed to understand the impact of formal training in areas that likely include suicide-related practices, developmental-behavioral pediatrics (DBP) and adolescent medicine (AM), on PEM physician-perceived level of training, attitudes, and confidence assessing and managing youth suicide risk. Twenty-seven PEM attendings and trainees completed an online survey and were divided into 2 groups: those who had completed DBP and AM rotations (DBP/AM+; n = 20) and those who had not completed either rotation (DBP/AM-; n = 7). We compared perceived level of training, attitudes, and confidence in assessing and managing suicide risk across groups. We also examined the relationship between perceived level of training and confidence. Finally, we conducted exploratory analyses to evaluate the effect of an additional formal rotation in child psychiatry. The DBP/AM+ and DBP/AM- groups did not differ on perceived level of training or on attitudes and confidence in suicide risk assessment or management. Perceived level of training in assessment and management predicted confidence in both assessing and managing suicide risk. Additional training in child psychiatry was not associated with increased perceived level of training or confidence. The DBP and AM rotations were not associated with higher perceived levels of suicide risk training or greater confidence; however, perceived level of training predicted physician confidence, suggesting continued efforts to enhance formal PEM education in mental health would be beneficial.

VIEWS OF PEDITRICIANS ON SPEECH AND LANGUAGE DEVELOPMENT

Pediatricians that, in addition to treating children’s diseases, deal with early growth and development, have a special responsibility in the early detection and diagnosis of speech and language difficulties. Aim of this research was to examine pediatricians’ and pediatric specialists’ familiarity with speech-language development, developmental-behavioral pediatrics, opinions on acquired knowledge at the specialist study on early growth and development and to examine the importance of multidisciplinary approach and cooperation between pediatricians and speech therapists, educators and rehabilitators and psychologists.The sample was comprised of 14 specialists pediatricians and 1 pediatrics resident, who were employed in primary and secondary health care and private practice, from different cities of the Federation of B&amp;H and Republika Srpska. Results of this research have shown that surveyed pediatricians are working with children with difficulties in speech-language development on a daily basis. Respondents have mostly correctly answered all questions related to speech-language development which indicates that they have solid knowledge in this area. Results have shown that most of the respondents is not satisfied with the knowledge obtained from specialist study on early growth and development and that they are not completely familiar with developmental-behavioral pediatrics, but all of the pediatricians have agreed that this field of sub-specialty should be included as a part of our higher education program. When it comes to a multidisciplinary approach and cooperation with speech therapists, educators-rehabilitators and psychologists, respondents support and practice a multidisciplinary approach in the detection and diagnosis of speech and language difficulties.Keywords:opinions of pediatricians, speech-language development, developmental-behavioral pediatrics.

Provider and Caregiver Perspectives on Telehealth Assessments for Autism Spectrum Disorder in Young Children: A Multimethod DBPNet Study Exploring Equity.

Telehealth uptake increased dramatically during the COVID-19 pandemic, including for autism spectrum disorder (ASD) assessment by developmental-behavioral pediatric (DBP) clinicians. However, little is known about the acceptability of telehealth or its impact on equity in DBP care. Engage providers and caregivers to glean their perspectives on the use of telehealth for ASD assessment in young children, exploring acceptability, benefits, concerns, and its potential role in ameliorating or exacerbating disparities in access to and quality of DBP care. This multimethod study used surveys and semistructured interviews to describe provider and family perspectives around the use of telehealth in DBP evaluation of children younger than 5 years with possible ASD between 3/2020 and 12/2021. Surveys were completed by 13 DBP clinicians and 22 caregivers. Semistructured interviews with 12 DBP clinicians and 14 caregivers were conducted, transcribed, coded, and analyzed thematically. Acceptance of and satisfaction with telehealth for ASD assessments in DBP were high for clinicians and most caregivers. Pros and cons concerning assessment quality and access to care were noted. Providers raised concerns about equity of telehealth access, particularly for families with a preferred language other than English. This study's results can inform the adoption of telehealth in DBP in an equitable manner beyond the pandemic. DBP providers and families desire the ability to choose telehealth care for different assessment components. Unique factors related to performing observational assessments of young children with developmental and behavioral concerns make telehealth particularly well-suited for DBP care.

Developmentally-Trained Primary Care Clinicians: A Pipeline to Improved Access?

The purpose of this study is to decrease wait time and improve access to developmental-behavioral pediatric (DBP) evaluation in children 4 years of age and younger as part of a quality improvement (QI) initiative in an urban safety-net hospital. A primary care pediatrician received DBP minifellowship training 6 hours per week for 1 year to become a developmentally-trained primary care clinician (DT-PCC). DT-PCCs then conducted developmental evaluations that consisted of using a Childhood Autism Rating Scale and Brief Observation of Symptoms of Autism to evaluate children 4 years and younger referred within the practice. Baseline standard practice involved a 3-visit model: DBP advanced practice clinician (DBP-APC) intake visit, neurodevelopmental evaluation by a developmental-behavioral pediatrician (DBP), and feedback by a developmental-behavioral pediatrician. Two QI cycles were completed to streamline the referral and evaluation process. Seventy patients with a mean age of 29.5 months were seen. The average days to initial developmental assessment decreased from 135.3 days to 67.9 days with a streamlined referral to the DT-PCC. Of the 43 patients who required further evaluation by a DBP, the average days to developmental assessment reduced from 290.1 to 120.4 days. Developmentally-trained primary care clinicians allowed for earlier access to developmental evaluations. Further research should explore how DT-PCCs can improve access to care and treatment for children with developmental delays.

Repetitive mild traumatic brain injuries in children of abuse

Repetitive mild traumatic brain injuries in children of abuse

Descriptive Analysis of Documentation Time for the National Developmental-Behavioral Pediatric Physician Workforce Using a Commercial Electronic Health Record System.

The national developmental-behavioral pediatric (DBP) workforce struggles to meet current service demands because of several factors. Lengthy and inefficient documentation processes are likely to contribute to service demand challenges, but DBP documentation patterns have not been sufficiently studied. Identifying clinical practice patterns may inform strategies to address documentation burden in DBP practice. Nearly 500 DBP physicians in the United States use a single commercial electronic health record (EHR) system (EpicCare Ambulatory, Epic Systems Corporation, Verona WI). We evaluated descriptive statistics using the US Epic DBP provider data set. We then compared DBP documentation metrics against those of pediatric primary care and selected pediatric subspecialty providers who provide similar types of care. One-way analyses of variance (ANOVAs) were conducted to determine whether outcomes differed among provider specialties. We identified 4 groups for analysis from November 2019 through February 2020: DBP (n = 483), primary care (n = 76,423), pediatric psychiatry (n = 783), and child neurology (n = 8589). Post hoc pairwise comparisons revealed statistically significant differences between multiple outcome-specialty combinations. Time in notes per appointment and progress note length demonstrated the strongest evidence of an increased burden on DBP providers compared with other similar provider groups. DBP providers spend a significant amount of time documenting progress notes both during and outside of normal clinic hours. This preliminary analysis highlights the utility of using EHR user activity data to quantitatively measure documentation burden.

Evaluating the Efficiency and Equity of Autism Diagnoses via Telehealth During COVID-19

Given existing barriers to a timely autism diagnosis, this study compares the efficiency and equity of diagnoses conducted in-person vs. telehealth in a developmental behavioral pediatrics setting. The transition to telehealth was prompted by the COVID-19 pandemic. Eleven months of clinic data in electronic medical records were retrospectively analyzed for children diagnosed with autism in-person (N=71) vs. telehealth (N=45). Time to autism diagnosis, patient demographics, and deferred diagnoses did not significantly differ across visit types. However, privately insured patients and families living farther from the clinic had a longer time to diagnosis via telehealth vs. in-person. Results of this exploratory study highlight the feasibility of telehealth evaluations for autism and which families may benefit from additional support to ensure a timely diagnosis.

Through the Webcam: Impact of Telehealth on Developmental and Behavioral Pediatric Fellowship Training.

The purpose of this study was to examine how fellowship program directors (PDs) and their fellows perceived the impact of telehealth on fellowship education in developmental behavioral pediatrics (DBP) during the COVID-19 pandemic. Two surveys were designed targeting DBP PDs and fellows and were distributed by e-mail from January to May 2021. Surveys consisted of closed-ended and open-ended questions about telehealth's impact on didactics, clinical teaching, and clinical experience. Analyses included descriptive statistics, Fisher's exact test, χ 2 test, and qualitative classical content analysis. A total of 31 PDs (82%) and 62 fellows (51%) responded. Before the pandemic, 0% of programs had fellows do telehealth visits at least weekly vs during the pandemic, and 85% of the programs had fellows conduct telehealth video visits at least once/week ( p < 0.001). PDs and fellows agreed on many advantages of learning through telehealth particularly preceptors giving "real-time" feedback by private text messages and being able to observe fellow-run encounters unobtrusively. Ninety-four percent of fellows and 100% of fellowship directors believe that telehealth should be a formal part of DBP fellowship training even if in-clinic visits are available. Prepandemic and pandemic learning experiences differed significantly. PDs and fellows shared similar perceptions on how telehealth affected fellow education, except how telehealth affected didactics. Institutions varied in how telehealth was used to teach fellows, but many reported they found benefit in giving real-time feedback using chat functions during telehealth appointments. DBP fellowship programs should consider providing specific guidance to effectively teach telehealth to fellows.