Pediatric Practice Setting Research Articles

Towards practice change: a qualitative study examining the impact of a Child Psychiatric Access Program (Project TEACH) on Primary Care Provider practices in New York State during pandemic times

BackgroundThis study aims to explore the perceived impact of Project TEACH (Training and Education for the Advancement of Children’s Health), a New York State Office of Mental Health funded Child Psychiatric Access Program (CPAP), on pediatric Primary Care Providers (PCPs) and their practice. Practice change over time was assessed in the context of rising mental health needs and in the context of COVID19 pandemic.MethodsFocus groups utilizing a semi-structured format were conducted with pediatric PCPs who have been high utilizers of Project TEACH over the past 5–10 years and PCPs in similar regions who have been low or non-utilizers of the program. The semi-structured interview focused on practice change, asking about pediatric mental health, practice setting and flow, professional development, and changes over time in the context of COVID-19 pandemic and Project TEACH.ResultsThemes identified include increasing confidence of PCPs, particularly those who are high utilizers of the phone consultation line, increased routine use of screening and comfort bridging pediatric patients with mental health needs. Challenges include rising mental health needs, inadequate mental health services, difficulties with family follow through and high emotional burden on PCPs caring for these patients. In this context, participants noted that collaboration with Project TEACH provided needed emotional support.ConclusionsIntegrated care and CPAPs such as Project TEACH are vital to helping PCPs handle rising mental health needs particularly in current crisis times. Ongoing systemic challenges accessing care remain and contribute to emotional burden placed on pediatric PCPs.

Pediatric Rheumatology Care and Outcomes Improvement Network's Quality Measure Set to Improve Care of Children With Juvenile Idiopathic Arthritis.

To describe the selection, development, and implementation of quality measures (QMs) for juvenile idiopathic arthritis (JIA) by the Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN), a multihospital learning health network using quality improvement methods and leveraging QMs to drive improved outcomes across a JIA population since 2011. An American College of Rheumatology-endorsed multistakeholder process previously selected initial process QMs. Clinicians in PR-COIN and parents of children with JIA collaboratively selected outcome QMs. A committee of rheumatologists and data analysts developed operational definitions. QMs were programmed and validated using patient data. Measures are populated by registry data, and performance is displayed on automated statistical process control charts. PR-COIN centers use rapid-cycle quality improvement approaches to improve performance metrics. The QMs are revised for usefulness, to reflect best practices, and to support network initiatives. The initial QM set included 13 process measures concerning standardized measurement of disease activity, collection of patient-reported outcome assessments, and clinical performance measures. Initial outcome measures were clinical inactive disease, low pain score, and optimal physical functioning. The revised QM set has 20 measures and includes additional measures of disease activity, data quality, and a balancing measure. PR-COIN has developed and tested JIA QMs to assess clinical performance and patient outcomes. The implementation of robust QMs is important to improve quality of care. PR-COIN's set of JIA QMs is the first comprehensive set of QMs used at the point-of-care for a large cohort of JIA patients in a variety of pediatric rheumatology practice settings.

Pediatric Physical Therapists' Perceptions of Telehealth Continuation Post-pandemic: A Thematic Analysis of Open-Ended Survey Responses.

To explore pediatric physical therapists' (PTs) perceptions about continuing telehealth services post-pandemic. Two open-ended questions from a larger survey were analyzed using a pragmatic application of thematic analysis. Two hundred two pediatric PTs in the United States responded. Themes included Telehealth During COVID-19, Benefits, Drawbacks , and Recommendations . Telehealth During COVID-19 acknowledged adopting and providing telehealth during a global pandemic was likely different than at other times. Benefits described perceived positive aspects of telehealth for children, families, and PTs, which support continuation of telehealth post-pandemic. Drawbacks described perceived negative aspects of telehealth for children, families, and PTs, which may dissuade continuation. Recommendations described respondents' recommendations for the continuation of telehealth. Ultimately respondents recommended a hybrid model of telehealth and in-person services going forward. A hybrid model of telehealth and in-person services may have the benefits of increasing access, flexibility, efficiency, communication, and home programming across pediatric practice settings.

Developing a Clinic-Based, Vaccine-Promoting Intervention for African American Youth in Rural Alabama: Protocol for a Pilot Cluster-Randomized Controlled Implementation Science Trial.

BackgroundAfrican American youth in rural Alabama are clinically underserved and have limited knowledge about the human papillomavirus and the novel coronavirus 2019 (COVID-19) vaccines, including knowledge about the risk for developing cervical or oropharyngeal cancers or COVID-19.ObjectiveIn this 30-month study, we propose to develop an in-clinic, youth-tailored, vaccine-promoting intervention for vaccine hesitancy reduction that can be seamlessly integrated into the existing environments of pediatric and family practice settings in rural Alabama.MethodsThis exploratory, sequential mixed methods study will be conducted in 3 phases. In the first phase, we will assess stakeholders’ knowledge, sentiments, and beliefs related to vaccination in general, COVID-19 vaccination, and human papillomavirus vaccination. We will also assess stakeholders’ perceptions of barriers to vaccination that exist in rural Alabama. This will be followed by a second phase wherein we will use the data collected in the first phase to inform the development and finalization of a noninvasive, modular, synchronous counseling intervention that targets the behaviors of 15- to 26-year-old adolescents. In the third phase, we will conduct a pilot hybrid type 1 effectiveness-implementation cluster-randomized controlled trial to assess intervention acceptability and feasibility (clinics: N=4; African American youth: N=120) while assessing a “clinical signal” of effectiveness. We will document implementation contexts to provide real-world insight and support dissemination and scale-up.ResultsThe study was funded at the end of December 2020. Approval from the University of Alabama at Birmingham Institutional Review Board was obtained in May 2021, and the qualitative data collection process outlined in the first phase of this project concluded in November 2021. The entire study is expected to be complete at the end of December 2023.ConclusionsThe results of the trial will provide much needed information on vaccine hesitancy in rural Alabama, and if found efficacious, the intervention could notably increase rates of vaccinations in one of the most underserved parts of the United States. The results from the trial will provide information that is valuable to public health practitioners and providers in rural settings to inform their efforts in increasing vaccination rates among 15- to 26-year-old African American youth in rural southern United States.Trial RegistrationClinicalTrials.gov NCT04604743; https://clinicaltrials.gov/ct2/show/NCT04604743International Registered Report Identifier (IRRID)DERR1-10.2196/33982

Ikebana: An Ancient Tradition of Contemporary Healing and Artful Practice

Dr. Ricardo Carrásco, PhD, OTR/L, FAOTA, is an occupational therapy professor and ikebana artist. He provided the cover art for the Summer 2021 edition of The Open Journal of Occupational Therapy (OJOT). Ikebana is the ancient Japanese art of arranging flowers. “Kanta of the Wind, Sun and Moon” is an ikebana design made from blue and white Phalaenopsis orchids, chrysanthemum, bear grass, and heirloom driftwood. This gendaika, or freestyle design, is a haiku tribute to the wind, sun, and moon. Dr. Carrásco has been practicing occupational therapy and ikebana for more than 5 decades. As an occupational scientist and therapist, he has experience working in pediatric, academic, research, mental health, and wellness practice settings. Dr. Carrásco currently serves as headmaster of the Banmi Shofu Ryu school of ikebana. His story is shared from a sense of duty and obligation to preserve this ancient tradition of contemporary healing and artful practice.

How to Incorporate the Experiential Student Pharmacist Into the Pediatric Practice Setting.

Experiential education conducted in the pediatric practice setting provides student pharmacists the opportunity to learn about a unique patient population. For many students, experiential rotations may be the only form of pediatric education they receive in pharmacy school. Providing quality pediatric experiences is essential to stimulate students' interest in this practice area and train those with goals to become pediatric pharmacists. It is also important to ensure graduating pharmacists have exposure to fundamental pediatric pharmacy concepts. Although pediatric practice areas and institutions differ in patient populations and services, a well-rounded rotation experience should be provided for the pharmacy student. Preceptors must decide what concepts to teach and what activities students should be incorporated into during this experiential period. This article provides goals and activities for student pharmacists that can be included in newly designed introductory pharmacy practice experiences and advanced pharmacy practice experiences within various pediatric settings.

Understanding Gaps in Developmental Screening and Referral.

* Abbreviations: AAP — : American Academy of Pediatrics EI — : early intervention In this issue of Pediatrics , Lipkin et al1 describe trends in pediatrician-reported developmental screening and referral practices between 2002 and 2016. The authors compare data across serial American Academy of Pediatrics (AAP) Periodic Surveys conducted in 2002, 2009, and 2016. They demonstrate that pediatricians’ self-reported use of formal developmental screening tools increased from 21% in 2002 to 63% in 2016 and that referral of patients identified as at risk for developmental delay to early intervention (EI) services increased concomitantly from 41% to 59%. Their data, however, also suggest that in 2016, more pediatricians considered lack of available treatment options to be a barrier to screening than did so in 2002 (21% vs 9%). Although developmental screening, surveillance, and referral to services has long been an important aspect of pediatric primary care, the AAP issued its first policy statement calling for universal developmental screening in 2001.2 The unique sampling frames queried with each Periodic Survey included in the current study preclude a true longitudinal analysis of individual-level practice changes; however, the current study represents an important barometer of screening and referral practices over the nearly 20 years since the AAP’s initial policy … Address correspondence to Mei Elansary, MD, MPhil, Division of General Pediatrics, School of Medicine, Boston University, 801 Albany St, Boston, MA 02118. E-mail: mei.elansary{at}bmc.org

Age-Specific Differences in Foreign Bodies Ingested by Children: A Cohort Study of 252 Japanese Cases.

Background and Objectives: When children accidentally ingest foreign bodies, they may be unable to communicate adequately; it is often difficult to identify the causative foreign body unless someone is watching over them. In such instances, to identify the causative foreign body during clinical practice, we aimed to determine if it varies according to age. Materials and Methods: From April 2013 to June 2018, 252 records of pediatric patients with a confirmed diagnosis of foreign-body ingestion were retrospectively examined in a Japanese university hospital. Comparisons among multiple age groups, according to type of ingested foreign body, were analyzed using Kruskal‒Wallis tests. The differences between the individual data were tested using the Steel‒Dwass test. Results: The median age of the patients was 15 months, and of the total patients, 140 were boys (55.5%). The types of foreign bodies ingested were as follows, in order of frequency: cigarettes (n = 44, 17%, median age: 12 months), plastics (n = 43, 17%, median age: 11 months), chemicals (n = 27, 11%, median age: 13 months), internal medicines (n = 26, 10%, median age: 33 months), and metals (n = 26, 10%, median age: 35 months). The median age was significantly different among the types of causative foreign bodies (p < 0.01). The patient age for the ingestion of cigarettes was significantly younger than that for ingesting metals or coins. The age for ingesting internal medicines was significantly older than that for ingesting plastics, cigarettes, paper, or chemicals (p < 0.01). Conclusions: The causative foreign body ingested differed according to age. This will be valuable information for physicians that encounter pediatric patients who may have ingested an unknown foreign body in Japanese pediatric emergency or general practice settings.

Development and Validation of the Adolescent Insomnia Questionnaire.

Insomnia is a highly prevalent sleep disorder that is particularly common among adolescents with health conditions. We aimed to develop and validate a brief screening measure of insomnia in adolescents that can be used across clinical and community samples. We hypothesized that we would identify evidence supporting reliability, convergent/discriminant validity, and that we would determine preliminary clinical cutoff scores. A team of experts in behavioral sleep medicine developed a 13-item brief screening measure of insomnia in adolescents (Adolescent Insomnia Questionnaire [AIQ]). We evaluated the psychometric properties of the AIQ in a sample of 315 youth (11-18 years old, Mean = 14.90, SD = 2.02; 64% female) who had chronic pain (n = 37), headache (n = 170), insomnia diagnosed by a sleep specialist (n = 22), or were otherwise healthy (n = 86). Using Exploratory and Confirmatory Factor Analysis, we identified three subscales consistent with major diagnostic criteria of insomnia. As expected, the measure showed strong reliability through high internal consistency (α =.91). We also found strong convergent validity through expected positive relationships between the AIQ and self-report measures of sleep disturbance, and divergent validity via weak relationships with parent-report of snoring. Results of receiver operating characteristic (ROC) identified a clinical cutoff score that may assist in clinical decision making. We found that the AIQ has sound psychometric properties in a large heterogeneous sample of treatment-seeking youth and youth from the community. The AIQ can quickly screen adolescent insomnia and could address an important clinical need in identifying youth in need of insomnia treatment in pediatric practice settings.

The Speech-Language Pathologists' Role in Mild Traumatic Brain Injury for Early Childhood-, Preschool-, and Elementary School-Age Children: Viewpoints on Guidelines From the Centers for Disease Control and Prevention.

Purpose Traumatic brain injury (TBI) impacts millions of children each year, with those between birth and 4 years of age being 1 of the highest incidence groups. To address gaps in service provision specifically for children with mild TBI (mTBI), the Centers for Disease Control and Prevention (CDC) recently released guidelines for providers. Method The goal of this commentary is to deliver viewpoints on the application of the CDC guidelines directly to speech-language pathology clinical practice, with special attention paid to assessment, symptom monitoring, and intervention using a family-centered approach to care for infants, toddlers, preschoolers, and early elementary students with mTBI. Results In all pediatric practice settings, speech-language pathologists (SLPs) are a critical component of the care team for children who experience mTBI and should participate in symptom monitoring, assessment, intervention, education, and advocacy for this population. Conclusions SLPs can use the CDC guidelines to advocate for their role in the care of young children with mTBI. In addition, SLPs can use the guidelines to create a framework for clinical care provision when working with young children with mTBI. Much work is needed to advance evidence-based practices for this population, and dissemination of current clinical practices could help to close this gap.

Doing More About Health Care Disparities: Moving Past Description to Action.

In this issue of Pediatrics , Goyal et al1 report race- and ethnicity-based differences in the receipt of antibiotics for acute respiratory viral illnesses over a 1-year period from sites participating in the Pediatric Emergency Care Applied Research Network. In their report, Goyal et al1 demonstrate that, regardless of race, non-Hispanic white children were given or prescribed antibiotics at a higher rate than non-Hispanic black patients or Hispanic children. Unfortunately, the findings in this study do not come as a surprise. Not only have researchers in other studies found differences in prescribing antibiotics in various pediatric practice settings but differences in all aspects of care, such as use of diagnostic testing, pain management, and even hospitalization rates.2–5 One of the challenges in assessing racial and ethnic disparities is in understanding the degree to which they are attributable to confounding factors such as socioeconomic status and access to care. In their study, Goyal et al1 control for insurance status but no other measures of socioeconomic status. Nonetheless the overall weight of scientific evidence supports that significant disparities exist on the basis of race and ethnicity. There was a time when results like this would have shocked us. That time is gone. We must recognize that we are biased in our treatment of patients. This does not mean we accept this fact. We should strive to provide care in our clinics and emergency departments that is of high … Address correspondence to Marvin B. Harper, MD, Division of Emergency Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: marvin.harper{at}childrens.harvard.edu

Characteristics of Pediatric Clinical Interventions Documented by a School of Pharmacy.

Documentation of interventions by pharmacists has become a standard of practice in clinical practice sites. Pharmacists' interventions in pediatric practice settings for short periods of time have been reported in the literature. A single study has described faculty and student interventions in the pediatric setting. The objective of this study was to characterize 4 years of interventions by faculty and students of a school of pharmacy that occurred at various pediatric practice sites throughout a state. Pharmacy practice faculty and fourth year student pharmacists are required to document clinical interventions during advanced pharmacy practice experiences. Interventions are documented in a single, commercially available, Web-based system. Reports of interventions with cost avoidance at pediatric inpatient and outpatient practice sites throughout a state from 2011 to 2014 were collected and analyzed. Data were sorted based on year, practice site, type, and number of activities and interventions, and estimated cost avoidance. Two full-time faculty members practiced in pediatrics and, on average, 25 students entered interventions at pediatric sites each year. A total of 12,784 interventions were documented by faculty and students over the 4-year period, with students entering 81.8% of the interventions and 69% occurring in the inpatient setting. Total cost avoidance for all 4 years was $1,684,609. The most frequent interventions were patient medication history, patient counseling, allergy information clarified, drug therapy adjusted, and drug information. Pharmacy faculty and students documented various types of clinical interventions in the inpatient and outpatient pediatric settings and demonstrated a positive impact at pediatric practice sites throughout a state, as well as cost avoidance in the associated healthcare systems.

Effectiveness of anti-TNFα for Crohn disease: research in a pediatric learning health system.

ImproveCareNow (ICN) is the largest pediatric learning health system in the nation and started as a quality improvement collaborative. To test the feasibility and validity of using ICN data for clinical research, we evaluated the effectiveness of anti-tumor necrosis factor-α (anti-TNFα) agents in the management of pediatric Crohn disease (CD). Data were collected in 35 pediatric gastroenterology practices (April 2007 to March 2012) and analyzed as a sequence of nonrandomized trials. Patients who had moderate to severe CD were classified as initiators or non-initiators of anti-TNFα therapy. Among 4130 patients who had pediatric CD, 603 were new users and 1211 were receiving anti-TNFα therapy on entry into ICN. During a 26-week follow-up period, rate ratios obtained from Cox proportional hazards models, adjusting for patient and disease characteristics and concurrent medications, were 1.53 (95% confidence interval [CI], 1.20-1.96) for clinical remission and 1.74 (95% CI, 1.33-2.29) for corticosteroid-free remission. The rate ratio for corticosteroid-free remission was comparable to the estimate produced by the adult SONIC study, which was a randomized controlled trial on the efficacy of anti-TNFα therapy. The number needed to treat was 5.2 (95% CI, 3.4-11.1) for clinical remission and 5.0 (95% CI, 3.4-10.0) for corticosteroid-free remission. In routine pediatric gastroenterology practice settings, anti-TNFα therapy was effective at achieving clinical and corticosteroid-free remission for patients who had Crohn disease. Using data from the ICN learning health system for the purpose of observational research is feasible and produces valuable new knowledge.

Children’s Reaction to Depictions of Healthy Foods in Fast-Food Television Advertisements

Since 2009, quick-service restaurant chains, or fast-food companies, have agreed to depict healthy foods in their advertising targeted at children. To determine how children interpreted depictions of milk and apples in television advertisements for children's meals by McDonald's and Burger King (BK) restaurants. Descriptive qualitative study in a rural pediatric practice setting in Northern New England. A convenience sample of 99 children (age range, 3-7 years) was shown depictions of healthy foods in fast-food advertisements that aired from July 1, 2010, through June 30, 2011. The images from McDonald's and BK showed milk and apples. Children were asked what they saw and not prompted to respond specifically to any aspect of the images. Two still images drawn from advertisements for healthy meals at McDonald's and BK. Children's responses were independently content coded to food category by 2 researchers. Among the 99 children participating, only 51 (52%) and 69 (70%) correctly identified milk from the McDonald's and BK images, respectively, with a significantly greater percentage correct (P = .02 for both) among older children. The children's recall of apples was significantly different by restaurant, with 79 (80%) mentioning apples when describing the McDonald's image and only 10 (10%) for the BK image (P < .001). The percentage correct was not associated with age in either case. Conversely, although french fries were not featured in either image, 80 children (81%) recalled french fries after viewing the BK advertisement. Of the 4 healthy food images, only depiction of apples by McDonald's was communicated adequately to the target audience. Representations of milk were inadequately communicated to preliterate children. Televised depictions of apple slices by BK misled the children in this study, although no action was taken by government or self-regulatory bodies.

Pilot Interprofessional Education Program for OT Student Pediatric Practice Readiness

This mixed methods pilot study investigated the impact of an interprofessional education program on OT student readiness for collaboration with SLP students in a pediatric teaching-clinic practice setting. OT students were randomly assigned to either the treatment group, which received the interprofessional education experience, or the control group, which received the typical educational experience. Students completed pre and post surveys and journaled about the experience. Results pointed to a ceiling effect in the measurement scales in both the treatment and control groups due to positive attitudes at baseline. This positivity was also reflected in journal entries for the treatment group students. Several insights were gained through data analysis about the feasibility of this type of program, the usefulness of available measuring tools for detecting change in small samples, and the developmental progression of interprofessional skills attainment. Comments Declaration on interest This project was funded by a doctoral student research grant from the Blue Cross Blue Shield Foundation of Michigan.

Perceptions among Adolescent Girls and Their Mothers Regarding Tampon Use

Study ObjectiveTo explore the perceptions of perimenarchal females and their mothers regarding tampons and tampon use. DesignDescriptive study; convenience sample survey. SettingDiverse pediatric practice setting. Participants139 females 11-18 years of age and 129 of their mothers/female guardians. InterventionSurvey. Main Outcome MeasuresFrequencies, chi-square tests, t-tests. ResultsMost adolescents (38%-55%) respond “don't know” to various attitude and knowledge items pertaining to tampon use. Adolescent-mother pairs report similar perceptions about tampon use for adolescents. Mothers and adolescents who have “ever tried” tampons (including 68% and 56% of respondents, respectively) have more favorable attitudes about tampons than those who have not tried tampons. Adolescent females list their mothers as the primary source of tampon information; 70% of adolescents and 66% of mothers report that no doctor has spoken to them about tampon use for the daughter. ConclusionsThere is a vast educational deficit among both adolescent females and their mothers regarding the use of tampons among youth. Adolescents and their mothers note that few providers have educated 11- to 18-year-old females or their parents about tampons. Providers have the opportunity to influence adolescent health choices and quality of life associated with tampon use.

The Use of Standardized Assessments in Occupational Therapy in the United States

ABSTRACTThe purpose of this study was to investigate the use of standardized assessments in occupational therapy practice. Five-thousand surveys were mailed to recipients of ADVANCE for OT who indicated their primary role to be a “clinician.” With a response rate of 16%, 794 responses were analyzed. Results include occupational therapists in a pediatric practice setting reporting using standardized assessments more frequently to determine eligibility of services than do adult setting practitioners. Respondents also perceived they have the highest knowledge or skill level in their ability to communicate the results of standardized assessments to their clients and other health professionals, but lacked knowledge or skill level in knowing the difference between criterion and norm-referenced measures. Implications for practice, research, as well as academic and continuing professional education are discussed.

Accuracy and Precision of the Axis-Shield Afinion Hemoglobin A1c Measurement Device

The Afinion HbA1c (Axis-Shield) is a newer point-of-care device for measurement of hemoglobin A1c (A1C) using a boronate affinity method unlike the more commonly used DCA immunoassay method (Siemens Medical Solutions Diagnostics). The Afinion's accuracy and precision, when compared with high-performance liquid chromatography (HPLC) and DCA methods, have not been established in pediatric practice settings. Capillary blood was collected from 700 subjects with diabetes mellitus at seven Pediatric Diabetes Consortium sites. Each subject's A1C was measured locally using Afinion and DCA devices, and by a central laboratory (University of Minnesota) using a Tosoh HPLC method. In addition, repeated measurements on six whole blood samples provided by the National Glycohemoglobin Standardization Program (NGSP) were taken at three clinical centers using the Afinion and DCA methods and centrally using the Tosoh HPLC method to assess the precision of each device. The coefficient of variation for measurements of whole blood samples for precision analysis was 2% for Afinion, 3% for DCA, and 1% for HPLC. In the patient samples measured at the seven clinic sites, the Afinion generated higher A1C results than the HPLC (mean difference = +0.15; p < 0.001), while the DCA produced lower values (mean difference = -0.19; p < 0.001). The absolute differences with HPLC were similar for the Afinion and DCA (median 0.2%) with a slight advantage for the Afinion when compared with DCA (p < 0.001 by rank test). The DCA tended to read lower than HPLC, particularly at high A1C levels (p < 0.001), while the Afinion's accuracy did not vary by A1C. When compared to the central laboratory HPLC method, the differences between the results of the Afinion and DCA devices are clinically insignificant, and the Afinion and DCA have similar accuracy and precision when used in pediatric practice settings.

Passport to Health: An Innovative Tool to Enhance Healthy Lifestyle Choices

Obesity in children and adolescents has become an epidemic in the United States. The ramifications of obesity at a young age are longstanding and affect physical health, emotional health, and the economics of the health care industry. The Strong Pediatric Practice at Golisano Children's Hospital is a large inner-city practice serving more than 14,000 urban children and adolescents, the majority living below the poverty level. The Obesity Task Force, which comprises four nurse practitioners, two nurses, a nutritionist, and one physician, developed and implemented the “Passport to Health” tool in an attempt to encourage providers to assess and work with families around the issues of weight and activity, a need that was identified through chart audits. The Passport to Health supports the policy statements on prevention of overweight and obesity by the Centers for Disease Control and Prevention, National Association of Pediatric Nurse Practitioners, and American Academy of Pediatrics. Quality assurance standards for managed care that mandate body mass index (BMI) assessment and nutrition counseling in all children and adolescents also is supported by this tool. The Passport to Health also provides the same message as a current community initiative in the Rochester area that has received widespread media coverage. This tool includes a visual color-coded indicator of the child's BMI status and a synopsis of specific healthy eating and activity goals, and it permits an individualized goal to be established. The Passport to Health translates information that the provider knows about the BMI status into information that the family and child can embrace and understand. Chart audits as well as exit interviews have demonstrated that use of the Passport to Health has increased the assessment, identification, and counseling by providers in relation to healthy eating and activity. Chart audits found that nurse practitioners embraced this practice change more readily than did other providers. We also found that the use of the Passport to Health has increased the involvement of the child and adolescent in discussions about weight and activity status. Recommendations to encourage future practice changes have been established and will be implemented. The changes include intensive education with providers who were less likely to utilize the Passport to Health tool. The Passport to Health could be implemented easily in any pediatric practice setting.

Early Intervention in Pediatrics Offices for Emerging Disruptive Behavior in Toddlers

Background This study provides preliminary data about a parenting intervention for families of preschoolers with early attention deficit hyperactivity disorder/oppositional defiant disorder symptoms carried out in two diverse primary care pediatric offices. Method Parents of toddlers completed behavioral screening questionnaires at well-child visits. Eligible parents participated in a 10-week parenting education group using the Incredible Years program. Mothers completed several outcome measures at three time points: before participating in the group, immediately after the group ended, and 6 months thereafter. These measures assessed changes in parenting practices, parenting stress, and child symptoms. Parent and provider satisfaction also were assessed. Results Mothers reported improvements in parenting skills and a decrease in stress. They also reported a decrease in child aggression and an increase in compliance. Mothers and providers reported high levels of satisfaction. Conclusions Results support the benefits and feasibility of providing parenting education groups to parents of toddlers in pediatric practice settings.