Pediatrics

 

Recent data suggest the longer a patient with polyarticular forms of juvenile idiopathic arthritis stays on anti–tumor necrosis factor therapy to maintain a clinical inactive disease state, the higher the likelihood of experiencing disease flare after discontinuing anti-TNF therapy.

Daniel J. Lovell, MD, MPH, of the Cincinnati Children’s Hospital Medical Center, and his coauthors prospectively evaluated 137 patients with clinical inactive PF-JIA who were receiving anti-TNF therapy at 16 academic pediatric centers. Of these, 7 patients dropped from the study and 24 patients did not maintain clinical inactive disease (CID) for 6 months.

“CID was an unstable state and 18.5% of the patients were unable to maintain CID for 6 continuous months of observation, even while continuing to receive the anti-TNF agent and stable doses of all background medications,” Dr. Lovell and his colleagues wrote in their study, published in Arthritis & Rheumatology.

Among the 106 patients who continued anti-TNF therapy for 6 months and maintained CID, the investigators then stopped anti-TNF therapy and examined patients for disease flare at 1-month, 2-month, 3-month, 4-month, 6-month, and 8-month follow-up. A total of 42% of these patients were also taking background medication such as methotrexate. Investigators found 39 patients (37%) who showed signs of disease flare within 8 months of discontinuing anti-TNF therapy. A number of factors proved to be significantly associated with disease flare, including age at disease onset (hazard ratio, 0.92; 95% confidence interval, 0.85-0.99; P = .03), age at disease diagnosis (HR, 0.91; 95% CI, 0.84-0.99; P = .02), disease duration at enrollment (HR, 1.12; 95% CI, 1.04-1.21; P less than .01) and time from onset until first CID (HR, 1.10; 95% CI, 1.01-1.20; P = .04). Flare occurred at a mean 7.01 months (standard error of the mean, 0.32) and median 8.26 months (95% CI, 7.80-8.66).

“These data certainly do not support the existence of a protective effect of longer duration of CID before considering stopping anti-TNF therapy,” the authors wrote in their study. “In fact, the data suggest that CID, even in those who did demonstrate CID consistently for the first 6 months of the study, continued to be an unstable clinical state and prolonged observation of CID resulted in a significantly greater risk for flare.”

Dr. Lovell and his colleagues noted their results suggest a “window of opportunity” where treating JIA early with “aggressive therapy” to reach CID sooner will help improve outcomes and long-term control of the disease.

The study was sponsored by a grant from the National Institutes of Health.

SOURCE: Lovell D et al. Arthritis Rheumatol. 2018 Mar 31. doi: 10.1002/art.40509.

 

Recent data suggest the longer a patient with polyarticular forms of juvenile idiopathic arthritis stays on anti–tumor necrosis factor therapy to maintain a clinical inactive disease state, the higher the likelihood of experiencing disease flare after discontinuing anti-TNF therapy.

Daniel J. Lovell, MD, MPH, of the Cincinnati Children’s Hospital Medical Center, and his coauthors prospectively evaluated 137 patients with clinical inactive PF-JIA who were receiving anti-TNF therapy at 16 academic pediatric centers. Of these, 7 patients dropped from the study and 24 patients did not maintain clinical inactive disease (CID) for 6 months.

“CID was an unstable state and 18.5% of the patients were unable to maintain CID for 6 continuous months of observation, even while continuing to receive the anti-TNF agent and stable doses of all background medications,” Dr. Lovell and his colleagues wrote in their study, published in Arthritis & Rheumatology.

Among the 106 patients who continued anti-TNF therapy for 6 months and maintained CID, the investigators then stopped anti-TNF therapy and examined patients for disease flare at 1-month, 2-month, 3-month, 4-month, 6-month, and 8-month follow-up. A total of 42% of these patients were also taking background medication such as methotrexate. Investigators found 39 patients (37%) who showed signs of disease flare within 8 months of discontinuing anti-TNF therapy. A number of factors proved to be significantly associated with disease flare, including age at disease onset (hazard ratio, 0.92; 95% confidence interval, 0.85-0.99; P = .03), age at disease diagnosis (HR, 0.91; 95% CI, 0.84-0.99; P = .02), disease duration at enrollment (HR, 1.12; 95% CI, 1.04-1.21; P less than .01) and time from onset until first CID (HR, 1.10; 95% CI, 1.01-1.20; P = .04). Flare occurred at a mean 7.01 months (standard error of the mean, 0.32) and median 8.26 months (95% CI, 7.80-8.66).

“These data certainly do not support the existence of a protective effect of longer duration of CID before considering stopping anti-TNF therapy,” the authors wrote in their study. “In fact, the data suggest that CID, even in those who did demonstrate CID consistently for the first 6 months of the study, continued to be an unstable clinical state and prolonged observation of CID resulted in a significantly greater risk for flare.”

Dr. Lovell and his colleagues noted their results suggest a “window of opportunity” where treating JIA early with “aggressive therapy” to reach CID sooner will help improve outcomes and long-term control of the disease.

The study was sponsored by a grant from the National Institutes of Health.

SOURCE: Lovell D et al. Arthritis Rheumatol. 2018 Mar 31. doi: 10.1002/art.40509.

 

Recent data suggest the longer a patient with polyarticular forms of juvenile idiopathic arthritis stays on anti–tumor necrosis factor therapy to maintain a clinical inactive disease state, the higher the likelihood of experiencing disease flare after discontinuing anti-TNF therapy.

Daniel J. Lovell, MD, MPH, of the Cincinnati Children’s Hospital Medical Center, and his coauthors prospectively evaluated 137 patients with clinical inactive PF-JIA who were receiving anti-TNF therapy at 16 academic pediatric centers. Of these, 7 patients dropped from the study and 24 patients did not maintain clinical inactive disease (CID) for 6 months.

“CID was an unstable state and 18.5% of the patients were unable to maintain CID for 6 continuous months of observation, even while continuing to receive the anti-TNF agent and stable doses of all background medications,” Dr. Lovell and his colleagues wrote in their study, published in Arthritis & Rheumatology.

Among the 106 patients who continued anti-TNF therapy for 6 months and maintained CID, the investigators then stopped anti-TNF therapy and examined patients for disease flare at 1-month, 2-month, 3-month, 4-month, 6-month, and 8-month follow-up. A total of 42% of these patients were also taking background medication such as methotrexate. Investigators found 39 patients (37%) who showed signs of disease flare within 8 months of discontinuing anti-TNF therapy. A number of factors proved to be significantly associated with disease flare, including age at disease onset (hazard ratio, 0.92; 95% confidence interval, 0.85-0.99; P = .03), age at disease diagnosis (HR, 0.91; 95% CI, 0.84-0.99; P = .02), disease duration at enrollment (HR, 1.12; 95% CI, 1.04-1.21; P less than .01) and time from onset until first CID (HR, 1.10; 95% CI, 1.01-1.20; P = .04). Flare occurred at a mean 7.01 months (standard error of the mean, 0.32) and median 8.26 months (95% CI, 7.80-8.66).

“These data certainly do not support the existence of a protective effect of longer duration of CID before considering stopping anti-TNF therapy,” the authors wrote in their study. “In fact, the data suggest that CID, even in those who did demonstrate CID consistently for the first 6 months of the study, continued to be an unstable clinical state and prolonged observation of CID resulted in a significantly greater risk for flare.”

Dr. Lovell and his colleagues noted their results suggest a “window of opportunity” where treating JIA early with “aggressive therapy” to reach CID sooner will help improve outcomes and long-term control of the disease.

The study was sponsored by a grant from the National Institutes of Health.

SOURCE: Lovell D et al. Arthritis Rheumatol. 2018 Mar 31. doi: 10.1002/art.40509.

 

Caffeine for apnea of prematurity was neurobehaviorally safe and significantly improved fine motor coordination, visuomotor integration, visual perception, and visuospatial organization at 11-year follow-up, according to the results of a double-blind, randomized, controlled trial.

“There was little evidence for differences between the caffeine and placebo groups on tests of general intelligence, attention, executive function, and behavior. This highlights the long-term safety and efficacy of caffeine therapy for apnea of prematurity in very-low-birth-weight neonates,” wrote Ines M. Mürner-Lavanchy, PhD, of Monash University, Clayton, Australia, and her associates. The Caffeine for Apnea of Prematurity (CAP) trial, the first to assess long-term neurobehavioral outcomes of neonatal caffeine therapy, was published online April 11 in Pediatrics.

Herjua/Thinkstock

Apnea of prematurity affects more than half of preterm neonates. Respiratory stimulation with caffeine therapy is standard care, having been shown to improve disability-free survival and gross motor skills. In this randomized, multicenter, double-blind trial, very-low-birth-weight infants (500-1,250 g) received either normal saline placebo or caffeine citrate (20 mg/kg loading dose, followed by 5 mg/kg daily maintenance dose; could be increased to up to 10 mg/kg for refractory apnea). Patients started treatment at a median of 3 days and were weaned off by postmenstrual age 35 weeks.

Neonatal caffeine therapy significantly lowered the risk of death before 18 months, cerebral palsy, cognitive delay, severe hearing loss, and bilateral blindness, as has been reported (N Engl J Med. 2007;357:1893-902). By 5 years, caffeine no longer showed significant benefits, apart from improved motor performance, Dr. Mürner-Lavanchy and her associates noted.

 

At 11 years, available data from 870 patients showed generally similar neurobehavioral outcomes between groups, although the caffeine group scored higher on most scales. The most apparent benefits included visuomotor integration (mean difference from placebo, 1.8; 95% confidence interval, 0.0-3.7; P less than .05), visual perception (2.0; 95% CI, 0.3-3.8; P = .02), fine motor coordination (2.9; 95% CI, 0.7-5.1; P = .01), and Rey Complex Figure copy accuracy, a measure of visuospatial organization (1.2; 95% CI, 0.4-2.0; P = .003).

Eleven-year follow-up data were missing for 22% of patients, but their birth characteristics and childhood outcomes resembled those of patients with available data, the investigators said. “Therefore, we are confident that the outcomes of the whole cohort are reflected in the present results with sufficient accuracy.”

The Canadian Institutes of Health Research provided funding. The investigators reported having no relevant conflicts of interest.

SOURCE: Mürner-Lavanchy IM et al. Pediatrics. 2018 Apr 11. doi: 10.1542/peds.2017-4047.

 

Caffeine for apnea of prematurity was neurobehaviorally safe and significantly improved fine motor coordination, visuomotor integration, visual perception, and visuospatial organization at 11-year follow-up, according to the results of a double-blind, randomized, controlled trial.

“There was little evidence for differences between the caffeine and placebo groups on tests of general intelligence, attention, executive function, and behavior. This highlights the long-term safety and efficacy of caffeine therapy for apnea of prematurity in very-low-birth-weight neonates,” wrote Ines M. Mürner-Lavanchy, PhD, of Monash University, Clayton, Australia, and her associates. The Caffeine for Apnea of Prematurity (CAP) trial, the first to assess long-term neurobehavioral outcomes of neonatal caffeine therapy, was published online April 11 in Pediatrics.

Herjua/Thinkstock

Apnea of prematurity affects more than half of preterm neonates. Respiratory stimulation with caffeine therapy is standard care, having been shown to improve disability-free survival and gross motor skills. In this randomized, multicenter, double-blind trial, very-low-birth-weight infants (500-1,250 g) received either normal saline placebo or caffeine citrate (20 mg/kg loading dose, followed by 5 mg/kg daily maintenance dose; could be increased to up to 10 mg/kg for refractory apnea). Patients started treatment at a median of 3 days and were weaned off by postmenstrual age 35 weeks.

Neonatal caffeine therapy significantly lowered the risk of death before 18 months, cerebral palsy, cognitive delay, severe hearing loss, and bilateral blindness, as has been reported (N Engl J Med. 2007;357:1893-902). By 5 years, caffeine no longer showed significant benefits, apart from improved motor performance, Dr. Mürner-Lavanchy and her associates noted.

 

At 11 years, available data from 870 patients showed generally similar neurobehavioral outcomes between groups, although the caffeine group scored higher on most scales. The most apparent benefits included visuomotor integration (mean difference from placebo, 1.8; 95% confidence interval, 0.0-3.7; P less than .05), visual perception (2.0; 95% CI, 0.3-3.8; P = .02), fine motor coordination (2.9; 95% CI, 0.7-5.1; P = .01), and Rey Complex Figure copy accuracy, a measure of visuospatial organization (1.2; 95% CI, 0.4-2.0; P = .003).

Eleven-year follow-up data were missing for 22% of patients, but their birth characteristics and childhood outcomes resembled those of patients with available data, the investigators said. “Therefore, we are confident that the outcomes of the whole cohort are reflected in the present results with sufficient accuracy.”

The Canadian Institutes of Health Research provided funding. The investigators reported having no relevant conflicts of interest.

SOURCE: Mürner-Lavanchy IM et al. Pediatrics. 2018 Apr 11. doi: 10.1542/peds.2017-4047.

 

Caffeine for apnea of prematurity was neurobehaviorally safe and significantly improved fine motor coordination, visuomotor integration, visual perception, and visuospatial organization at 11-year follow-up, according to the results of a double-blind, randomized, controlled trial.

“There was little evidence for differences between the caffeine and placebo groups on tests of general intelligence, attention, executive function, and behavior. This highlights the long-term safety and efficacy of caffeine therapy for apnea of prematurity in very-low-birth-weight neonates,” wrote Ines M. Mürner-Lavanchy, PhD, of Monash University, Clayton, Australia, and her associates. The Caffeine for Apnea of Prematurity (CAP) trial, the first to assess long-term neurobehavioral outcomes of neonatal caffeine therapy, was published online April 11 in Pediatrics.

Herjua/Thinkstock

Apnea of prematurity affects more than half of preterm neonates. Respiratory stimulation with caffeine therapy is standard care, having been shown to improve disability-free survival and gross motor skills. In this randomized, multicenter, double-blind trial, very-low-birth-weight infants (500-1,250 g) received either normal saline placebo or caffeine citrate (20 mg/kg loading dose, followed by 5 mg/kg daily maintenance dose; could be increased to up to 10 mg/kg for refractory apnea). Patients started treatment at a median of 3 days and were weaned off by postmenstrual age 35 weeks.

Neonatal caffeine therapy significantly lowered the risk of death before 18 months, cerebral palsy, cognitive delay, severe hearing loss, and bilateral blindness, as has been reported (N Engl J Med. 2007;357:1893-902). By 5 years, caffeine no longer showed significant benefits, apart from improved motor performance, Dr. Mürner-Lavanchy and her associates noted.

 

At 11 years, available data from 870 patients showed generally similar neurobehavioral outcomes between groups, although the caffeine group scored higher on most scales. The most apparent benefits included visuomotor integration (mean difference from placebo, 1.8; 95% confidence interval, 0.0-3.7; P less than .05), visual perception (2.0; 95% CI, 0.3-3.8; P = .02), fine motor coordination (2.9; 95% CI, 0.7-5.1; P = .01), and Rey Complex Figure copy accuracy, a measure of visuospatial organization (1.2; 95% CI, 0.4-2.0; P = .003).

Eleven-year follow-up data were missing for 22% of patients, but their birth characteristics and childhood outcomes resembled those of patients with available data, the investigators said. “Therefore, we are confident that the outcomes of the whole cohort are reflected in the present results with sufficient accuracy.”

The Canadian Institutes of Health Research provided funding. The investigators reported having no relevant conflicts of interest.

SOURCE: Mürner-Lavanchy IM et al. Pediatrics. 2018 Apr 11. doi: 10.1542/peds.2017-4047.

 

A video-based intervention to promote parents reading aloud and playing with their child reduced hyperactivity at school entry and had sustained behavioral effects after the program was completed, according to results of a randomized clinical trial.

The Video Interaction Project (VIP), in which parents review and reflect upon recordings of themselves interacting with their children, is a low-cost, scalable intervention that has a “high potential” for enhancing social and emotional development by reducing disruptive behaviors, the study authors reported in Pediatrics.

Design Pics/Thinkstock

“With our findings, we support pediatric preventive intervention from birth to 5 years,” wrote Alan L. Mendelsohn, MD, of Bellevue Hospital Center, New York, and his coauthors.

The study included 675 parent-child dyads enrolled post partum at an urban public hospital serving low-income families. Of that group, 450 families were randomized to the VIP program from 0 to 3 years of age, a control group, or a third group that included a different intervention called Building Blocks that incorporates parenting education newsletters, learning materials, and parent questionnaires.

In the VIP intervention, parent-child dyads participated in up to 15 one-on-one sessions from 2 weeks of age to 3 years. In each 30-minute session, the parent and child were video recorded for 5 minutes of play or shared reading; immediately afterward, the parent would review the video with a bilingual facilitator to identify positive interactions and reflect on them.

As previously reported, the VIP intervention had enhanced children’s social and emotional development. Compared with controls, children in the VIP group had higher scores in imitation/play and attention at the end of the program and lower scores in separation distress, hyperactivity, and externalizing problems, according to investigators.

Now, investigators are reporting results that include a second phase of random assignment to VIP from 3-5 years or a control group. The second-phase VIP intervention included nine 30- to 45-minute sessions enhanced with new strategies designed to support the rapidly emerging developmental capacities of preschoolers, Dr. Mendelsohn and associates said. Ultimately, 252 families completed the 4.5 year assessment.

 

Those new strategies included building sessions around themes (such as birthday party), incorporation of writing into play (such as party invitations), focusing on story characters’ feelings, and video recording both reading and play, with the story serving as the basis for the play.

The initial VIP 0-3 year intervention and the VIP 3-5 year intervention were both independently associated with improved T-scores at 4.5 years on Behavior Assessment System for Children, Second Edition, rating scales, with Cohen’s d effect sizes ranging from approximately –0.25 to –0.30, according to investigators.

Participating in both VIP interventions was associated with a significant reduction in hyperactivity (effect size, –0.63; P = 0.001), Dr. Mendelsohn and his associates also reported.

Moreover, participation in the first VIP session was associated with a reduction in clinically significant hyperactivity (relative risk reduction, 69%; P = .03), they added.

 

The cost of the VIP program for 0-3 years is approximately $175-$200 per child per year, including staff, equipment, rent, and other expenses, according to the report, which notes that one interventionist can provide services for 400-500 families.

Taken together, these findings suggest the VIP intervention is a low-cost intervention that may prevent poverty-related disparities, investigators said.

“In this study, we provide strong support for the use of pediatric primary care to promote positive parenting activities such as reading aloud and play and the potential for such programs to promote social-emotional development as reflected through reductions in disruptive behaviors,” they wrote.

Dr. Mendelsohn and his coauthors reported no relevant financial disclosures. The study was supported by grants from the National Institutes of Health and the National Institute of Child Health and Human Development; the Tiger Foundation; the Marks Family Foundation; Children of Bellevue; KiDS of New York University Foundation; and Rhodebeck Charitable Trust. Several of the investigators were supported in part by awards or grants.

SOURCE: Mendelsohn AL et al. Pediatrics. 2018;141(5):e20173393.

 

A video-based intervention to promote parents reading aloud and playing with their child reduced hyperactivity at school entry and had sustained behavioral effects after the program was completed, according to results of a randomized clinical trial.

The Video Interaction Project (VIP), in which parents review and reflect upon recordings of themselves interacting with their children, is a low-cost, scalable intervention that has a “high potential” for enhancing social and emotional development by reducing disruptive behaviors, the study authors reported in Pediatrics.

Design Pics/Thinkstock

“With our findings, we support pediatric preventive intervention from birth to 5 years,” wrote Alan L. Mendelsohn, MD, of Bellevue Hospital Center, New York, and his coauthors.

The study included 675 parent-child dyads enrolled post partum at an urban public hospital serving low-income families. Of that group, 450 families were randomized to the VIP program from 0 to 3 years of age, a control group, or a third group that included a different intervention called Building Blocks that incorporates parenting education newsletters, learning materials, and parent questionnaires.

In the VIP intervention, parent-child dyads participated in up to 15 one-on-one sessions from 2 weeks of age to 3 years. In each 30-minute session, the parent and child were video recorded for 5 minutes of play or shared reading; immediately afterward, the parent would review the video with a bilingual facilitator to identify positive interactions and reflect on them.

As previously reported, the VIP intervention had enhanced children’s social and emotional development. Compared with controls, children in the VIP group had higher scores in imitation/play and attention at the end of the program and lower scores in separation distress, hyperactivity, and externalizing problems, according to investigators.

Now, investigators are reporting results that include a second phase of random assignment to VIP from 3-5 years or a control group. The second-phase VIP intervention included nine 30- to 45-minute sessions enhanced with new strategies designed to support the rapidly emerging developmental capacities of preschoolers, Dr. Mendelsohn and associates said. Ultimately, 252 families completed the 4.5 year assessment.

 

Those new strategies included building sessions around themes (such as birthday party), incorporation of writing into play (such as party invitations), focusing on story characters’ feelings, and video recording both reading and play, with the story serving as the basis for the play.

The initial VIP 0-3 year intervention and the VIP 3-5 year intervention were both independently associated with improved T-scores at 4.5 years on Behavior Assessment System for Children, Second Edition, rating scales, with Cohen’s d effect sizes ranging from approximately –0.25 to –0.30, according to investigators.

Participating in both VIP interventions was associated with a significant reduction in hyperactivity (effect size, –0.63; P = 0.001), Dr. Mendelsohn and his associates also reported.

Moreover, participation in the first VIP session was associated with a reduction in clinically significant hyperactivity (relative risk reduction, 69%; P = .03), they added.

 

The cost of the VIP program for 0-3 years is approximately $175-$200 per child per year, including staff, equipment, rent, and other expenses, according to the report, which notes that one interventionist can provide services for 400-500 families.

Taken together, these findings suggest the VIP intervention is a low-cost intervention that may prevent poverty-related disparities, investigators said.

“In this study, we provide strong support for the use of pediatric primary care to promote positive parenting activities such as reading aloud and play and the potential for such programs to promote social-emotional development as reflected through reductions in disruptive behaviors,” they wrote.

Dr. Mendelsohn and his coauthors reported no relevant financial disclosures. The study was supported by grants from the National Institutes of Health and the National Institute of Child Health and Human Development; the Tiger Foundation; the Marks Family Foundation; Children of Bellevue; KiDS of New York University Foundation; and Rhodebeck Charitable Trust. Several of the investigators were supported in part by awards or grants.

SOURCE: Mendelsohn AL et al. Pediatrics. 2018;141(5):e20173393.

 

A video-based intervention to promote parents reading aloud and playing with their child reduced hyperactivity at school entry and had sustained behavioral effects after the program was completed, according to results of a randomized clinical trial.

The Video Interaction Project (VIP), in which parents review and reflect upon recordings of themselves interacting with their children, is a low-cost, scalable intervention that has a “high potential” for enhancing social and emotional development by reducing disruptive behaviors, the study authors reported in Pediatrics.

Design Pics/Thinkstock

“With our findings, we support pediatric preventive intervention from birth to 5 years,” wrote Alan L. Mendelsohn, MD, of Bellevue Hospital Center, New York, and his coauthors.

The study included 675 parent-child dyads enrolled post partum at an urban public hospital serving low-income families. Of that group, 450 families were randomized to the VIP program from 0 to 3 years of age, a control group, or a third group that included a different intervention called Building Blocks that incorporates parenting education newsletters, learning materials, and parent questionnaires.

In the VIP intervention, parent-child dyads participated in up to 15 one-on-one sessions from 2 weeks of age to 3 years. In each 30-minute session, the parent and child were video recorded for 5 minutes of play or shared reading; immediately afterward, the parent would review the video with a bilingual facilitator to identify positive interactions and reflect on them.

As previously reported, the VIP intervention had enhanced children’s social and emotional development. Compared with controls, children in the VIP group had higher scores in imitation/play and attention at the end of the program and lower scores in separation distress, hyperactivity, and externalizing problems, according to investigators.

Now, investigators are reporting results that include a second phase of random assignment to VIP from 3-5 years or a control group. The second-phase VIP intervention included nine 30- to 45-minute sessions enhanced with new strategies designed to support the rapidly emerging developmental capacities of preschoolers, Dr. Mendelsohn and associates said. Ultimately, 252 families completed the 4.5 year assessment.

 

Those new strategies included building sessions around themes (such as birthday party), incorporation of writing into play (such as party invitations), focusing on story characters’ feelings, and video recording both reading and play, with the story serving as the basis for the play.

The initial VIP 0-3 year intervention and the VIP 3-5 year intervention were both independently associated with improved T-scores at 4.5 years on Behavior Assessment System for Children, Second Edition, rating scales, with Cohen’s d effect sizes ranging from approximately –0.25 to –0.30, according to investigators.

Participating in both VIP interventions was associated with a significant reduction in hyperactivity (effect size, –0.63; P = 0.001), Dr. Mendelsohn and his associates also reported.

Moreover, participation in the first VIP session was associated with a reduction in clinically significant hyperactivity (relative risk reduction, 69%; P = .03), they added.

 

The cost of the VIP program for 0-3 years is approximately $175-$200 per child per year, including staff, equipment, rent, and other expenses, according to the report, which notes that one interventionist can provide services for 400-500 families.

Taken together, these findings suggest the VIP intervention is a low-cost intervention that may prevent poverty-related disparities, investigators said.

“In this study, we provide strong support for the use of pediatric primary care to promote positive parenting activities such as reading aloud and play and the potential for such programs to promote social-emotional development as reflected through reductions in disruptive behaviors,” they wrote.

Dr. Mendelsohn and his coauthors reported no relevant financial disclosures. The study was supported by grants from the National Institutes of Health and the National Institute of Child Health and Human Development; the Tiger Foundation; the Marks Family Foundation; Children of Bellevue; KiDS of New York University Foundation; and Rhodebeck Charitable Trust. Several of the investigators were supported in part by awards or grants.

SOURCE: Mendelsohn AL et al. Pediatrics. 2018;141(5):e20173393.

 

WASHINGTON – Trauma-Informed Parenting Skills for Resource Parents, a new intervention program, might be an answer to addressing trauma symptoms in foster homes, according to a presentation at the annual conference of the Anxiety and Depression Association of America.

Rates of trauma exposure range from 80% to 93% in child welfare populations. In light of those statistics, foster parents are left to deal with the effects of traumatic stress symptoms without proper preparation or tools. Trauma-Informed Parenting Skills for Resource Parents targets different aspects of the way in which trauma can affect both the foster child and other members of the family.

“This is an intervention that occurs in the context of the caregiver-child relationship,” said presenters Jessica Eslinger, PhD, and Ginny Sprang, PhD, both of the University of Kentucky, Lexington. “The foster caregivers are the ones who are the recipients of the intervention in service of their child. Basically, what we are doing is teaching foster parents the skills they need to interact and intervene with their children in real time during the day-to-day interactions in their homes in ways that they can effect positive change.”

The program is structured over the course of 10 weekly, 60- to 90-minute sessions for parents with foster children or those who plan to begin fostering. It is designed for caregivers of children aged 0-17 years. In addition, the intervention uses four key components: trauma awareness, caregiver relationships as the context for healing, trauma-informed parenting strategies, and creating physical and psychological safety, according to the program’s website.

 

“Trauma awareness is a large part of this intervention [in order to] help resource parents understand what’s happening,” Dr. Eslinger said. “There is trauma 101, orientation to what happens in the body when a child is exposed to a traumatic event, and this is followed by learning how to use the caregiver relationship.”

The intervention also teaches caregivers how to help children develop healthy coping methods for traumatic stress, and then create a psychologically safe space for the child.

The 10 sessions were structured carefully, starting by addressing end goals, moving to education on the effects of early childhood trauma, transitioning to relaxation and coping skills, followed by teaching how to deal with challenging behaviors, and finishing with a final session where participants have a chance to bring it all together.

Caregivers also are instructed on using the cognitive triangle to understand their children’s feelings and build the framework to develop healthy reactions to behavior caused by traumatic stress.

“We work to help parents learn how to instill safety messages that the child needs to hear, creating a sense of safety in the home, and operating in the relationship in such a way to create psychological safety for their child,” Dr. Sprang said. “For many of [the parents], they’ve never understood that their disappointment and their hopelessness were a danger to the child – that children pick up on this.”

Neither Dr. Eslinger nor Dr. Sprang reported financial disclosures.

ezimmerman@mdedge.com

 

WASHINGTON – Trauma-Informed Parenting Skills for Resource Parents, a new intervention program, might be an answer to addressing trauma symptoms in foster homes, according to a presentation at the annual conference of the Anxiety and Depression Association of America.

Rates of trauma exposure range from 80% to 93% in child welfare populations. In light of those statistics, foster parents are left to deal with the effects of traumatic stress symptoms without proper preparation or tools. Trauma-Informed Parenting Skills for Resource Parents targets different aspects of the way in which trauma can affect both the foster child and other members of the family.

“This is an intervention that occurs in the context of the caregiver-child relationship,” said presenters Jessica Eslinger, PhD, and Ginny Sprang, PhD, both of the University of Kentucky, Lexington. “The foster caregivers are the ones who are the recipients of the intervention in service of their child. Basically, what we are doing is teaching foster parents the skills they need to interact and intervene with their children in real time during the day-to-day interactions in their homes in ways that they can effect positive change.”

The program is structured over the course of 10 weekly, 60- to 90-minute sessions for parents with foster children or those who plan to begin fostering. It is designed for caregivers of children aged 0-17 years. In addition, the intervention uses four key components: trauma awareness, caregiver relationships as the context for healing, trauma-informed parenting strategies, and creating physical and psychological safety, according to the program’s website.

 

“Trauma awareness is a large part of this intervention [in order to] help resource parents understand what’s happening,” Dr. Eslinger said. “There is trauma 101, orientation to what happens in the body when a child is exposed to a traumatic event, and this is followed by learning how to use the caregiver relationship.”

The intervention also teaches caregivers how to help children develop healthy coping methods for traumatic stress, and then create a psychologically safe space for the child.

The 10 sessions were structured carefully, starting by addressing end goals, moving to education on the effects of early childhood trauma, transitioning to relaxation and coping skills, followed by teaching how to deal with challenging behaviors, and finishing with a final session where participants have a chance to bring it all together.

Caregivers also are instructed on using the cognitive triangle to understand their children’s feelings and build the framework to develop healthy reactions to behavior caused by traumatic stress.

“We work to help parents learn how to instill safety messages that the child needs to hear, creating a sense of safety in the home, and operating in the relationship in such a way to create psychological safety for their child,” Dr. Sprang said. “For many of [the parents], they’ve never understood that their disappointment and their hopelessness were a danger to the child – that children pick up on this.”

Neither Dr. Eslinger nor Dr. Sprang reported financial disclosures.

ezimmerman@mdedge.com

 

WASHINGTON – Trauma-Informed Parenting Skills for Resource Parents, a new intervention program, might be an answer to addressing trauma symptoms in foster homes, according to a presentation at the annual conference of the Anxiety and Depression Association of America.

Rates of trauma exposure range from 80% to 93% in child welfare populations. In light of those statistics, foster parents are left to deal with the effects of traumatic stress symptoms without proper preparation or tools. Trauma-Informed Parenting Skills for Resource Parents targets different aspects of the way in which trauma can affect both the foster child and other members of the family.

“This is an intervention that occurs in the context of the caregiver-child relationship,” said presenters Jessica Eslinger, PhD, and Ginny Sprang, PhD, both of the University of Kentucky, Lexington. “The foster caregivers are the ones who are the recipients of the intervention in service of their child. Basically, what we are doing is teaching foster parents the skills they need to interact and intervene with their children in real time during the day-to-day interactions in their homes in ways that they can effect positive change.”

The program is structured over the course of 10 weekly, 60- to 90-minute sessions for parents with foster children or those who plan to begin fostering. It is designed for caregivers of children aged 0-17 years. In addition, the intervention uses four key components: trauma awareness, caregiver relationships as the context for healing, trauma-informed parenting strategies, and creating physical and psychological safety, according to the program’s website.

 

“Trauma awareness is a large part of this intervention [in order to] help resource parents understand what’s happening,” Dr. Eslinger said. “There is trauma 101, orientation to what happens in the body when a child is exposed to a traumatic event, and this is followed by learning how to use the caregiver relationship.”

The intervention also teaches caregivers how to help children develop healthy coping methods for traumatic stress, and then create a psychologically safe space for the child.

The 10 sessions were structured carefully, starting by addressing end goals, moving to education on the effects of early childhood trauma, transitioning to relaxation and coping skills, followed by teaching how to deal with challenging behaviors, and finishing with a final session where participants have a chance to bring it all together.

Caregivers also are instructed on using the cognitive triangle to understand their children’s feelings and build the framework to develop healthy reactions to behavior caused by traumatic stress.

“We work to help parents learn how to instill safety messages that the child needs to hear, creating a sense of safety in the home, and operating in the relationship in such a way to create psychological safety for their child,” Dr. Sprang said. “For many of [the parents], they’ve never understood that their disappointment and their hopelessness were a danger to the child – that children pick up on this.”

Neither Dr. Eslinger nor Dr. Sprang reported financial disclosures.

ezimmerman@mdedge.com

From the Jewish Family and Children’s Service, Phoenix, AZ (Dr. Henderson) and Consult-Stat, Macungie, PA (Ms. Wasser, Dr. Wasser).

 

Abstract

• Background: The reliability and validity of the Child and Adolescent Service Intensity Instrument (CASII) as a tool to help determine needed level of care for children with behavioral health needs has previously been established.
• Objective: To determine the utility of the CASII as an outcome measure.
• Methods: A sample consisting of all clients (n = 8465) admitted to service at an outpatient behavioral health facility from 2013 through 2016 were studied. CASII was administered at admission and discharge and ratings were compared with paired t-tests within demographic and diagnosis groups.
• Results: Mean CASII composite ratings decreased between admission and discharge in the entire cohort as well as within gender, age group, and multiple diagnosis groups tested.
• Conclusion: CASII was useful as an outcome measure in our relatively low to moderate acuity population.

Keywords: outcomes, evidence based practice, child psychology, outpatient research.

 

The primary goal of mental health services is to provide interventions that result in a reduction of problematic symptomatology [1]; therefore, evaluation of those interventions is important for both the client as well as the stakeholders of the organization providing them. Health care payment reforms require tracking quality measures, and such measures directly influence the development, administration, and monitoring of mental health programs as well as specific treatment modalities [2,3]. Organizations are more likely to benefit when outcomes measures are relayed quantitatively [4]. In addition, clients are becoming more informed regarding the quality of care, and outcomes assessments can inform clients that programs are delivering the most efficacious therapies based on current evidence-based practice standards.

Developing outcomes assessments in behavioral health is challenging [5–7]. There are numerous potential outcome domains that can be assessed as well as different ways of measuring them. Futher, evaluating treatment can be expensive, with components including developing a tool, training staff to administer the tool, ensuring the necessary technical support to store and process the data, interpretation of the data, compiling reports, and communicating results to clients and providers [5]. Being mindful of these components and their associated costs, our organization considered whether a tool we currently use to assess the appropriate intensity of service needed for an individual could also be used as an outcome measure.

Therapeutic methods for children in our organization consist of a “system of care” approach designed by a treatment team that incorporates varied methods depending on the needs of the child. The primary goal is to prevent children with traumatic-based disorders from developing continuing disorders associated with their experiences, such as substance use and chronic health and mental health disorders. Our organization currently uses the CASII (Child and Adolescent Service Intensity Instrument) to assess the appropriate level of intensity of service needed by the child. The CASII incorporates holistic information on the child, within the context of his/her family and social ecology, assessing across 6 dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services.

In order to comply with the call to consider outcomes measurement and evidence based practice as an integral component of children’s mental health services, this study was performed. It examines the use of the CASII as an outcomes measure based on the rationale that a decreased level of care upon discharge would correlate with a positive outcome by proxy.

Methods

CASII Instrument

The CASII is a decision support tool to help the service provider determine the intensity of services that a child should have to adequately address their behavioral health needs. The CASII has a strong evidence base supporting its reliability and validity [8], and has gained wide usage in a range of health care settings over the past 13 years [9–11].

As mentioned, the CASII assesses the client across 6 key dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services. Each dimension is scored along a 5-point rating scale, and a total or composite rating is calculated by adding the scores for each dimension. The composite rating corresponds with the level of service intensity needed. There are 7 levels of service intensity, ranging from Level 0 (corresponding with a composite rating of 9 or less) to Level 6 (corresponding with a composite rating of 28 or more) (Table 1).

Study Sample

The sample consisted of all clients (n = 8465) admitted to service from 2013 through 2016 to our facility. Our facility is an outpatient facility offering counseling, mental health assessment and treatment, early childhood trauma assessment, child crisis interventions and rehabilitation for domestic violence, child abuse and neglect, and substance abuse. All clients between the ages of 6 and 17 are assessed with the CASII on admission and then at 6-month intervals until discharge from the program. Being discharged from the program of care prompts the completion of the discharge CASII. If the client had been rated within the 30 days prior to discharge the most recent CASII is used as the discharge measure.

 

Data Analysis

Data for all admissions from 2013 and 2016 were extracted from the organization’s computer system into an Excel file. The data collected included gender, calendar year of admission to the program, age, and diagnosis group based on the discharge diagnosis given by the mental health team, and whether the client was a participant in the Youth in Transition (YIT) program (program for older clients that includes life skills training in addition to standard therapy). The CASII composite rating at baseline and discharge as well as ratings for each of the 6 dimensions assessed with the CASII were also collected.

We used SPSS (v25.01) software for statistical analysis. Analysis included paired (pre-post) t-tests that were applied to the entire cohort as well as within gender, age group, participation in the YIT program, and diagnosis groups. Diagnosis groups were included only if the frequency of cases within the group was large enough to meet the sample size requirements of central limit theorem (in general, n > 25), with 2 exceptions: schizophrenia spectrum was included because of the rarity of the diagnosis (n = 11) and neurodevelopmental disorders (also n = 11) was included because there was no violation of the equal variance assumption as well as interest to the investigators. In addition to the paired analysis, we used group t tests to determine if there were severity differences between groups at baseline. Lastly, we assessed change from admission to discharge for each of the 6 dimensions that make up the composite rating.

We designated the 7 levels of care defined by the CASII as continuous in nature, and therefore computations of means and standard deviations (SD) are appropriate for assessment. The interpretation of the CASII composite rating and the level of care as a continuous variable has also been reported in the literature [11,12].

The research and analysis was viewed as exploratory in nature and a P value less than 0.05 was considered statistically significant. There was no correction for multiple comparisons applied to the data in order to not mask any observed differences in the data. All analyses were 2-tailed. If any individual had a missing value for either an admission or discharge CASII assessment they were excluded from the statistical analysis.

Results

There were 8465 clients admitted from 2013 and 2016. The sample was predominantly male (54.5%), and the majority fell into the older 12–17 year old cohort (54.0%). Admissions were evenly distributed across the 4 years that we studied, with the lowest percentage in 2013 at 23.4% and the highest in 2014 at 26.0%. Discharge diagnosis was available for the majority of the cohort. The top 5 most frequent diagnosis groups were adjustment disorders (n = 807, 18.3%), ADHD (n = 798, 18.1%), child neglect (n = 775, 17.6%), mood disorders (n = 602, 13.6%), and impulse disorders (n = 262, 5.9%). There were 232 (2.7%) clients that participated in the YIT program. Table 2 

presents the demographic data for the cohort.

At admission, several groups had higher mean composite ratings. Males had higher ratings (in need of higher level of service intensity) than females (P < 0.001), 12–17 year olds had a significantly higher acuity level than 6–11 year olds (P < 0.001), and clients in the YIT program had a higher acuity level than those not in the YIT program (P = 0.001). Baseline acuity levels for primary discharge diagnosis for selected groups are shown in the Figure.

When analyzing the entire cohort for which data were available (n = 6944), the mean CASII composite rating dropped from 13.23 (± 4.35 SD) to 12.04 (± 3.84 SD), P < 0.001. Excluding youth that participated in YIT, the mean CASII score dropped from 13.21 (± 4.33) at admission to 13.17 (± 4.52) at discharge. Mean composite rating for clients participating in the YIT program dropped from 14.31 (± 5.12) at admission to 13.17 (± 4.52) at discharge (P = 0.022). For diagnosis groups, statistically significant reduction in mean CASII composite rating was observed for all groups except neurodevelopmentall disorders (P = 0.166). The results for all groups and diagnosis cohorts can be found in Table 3.

As noted, the CASII assesses the client across 6 dimensions, each of which is scored along a 5-point rating scale, and the composite rating is calculated by adding the scores for each dimension. Table 4 shows the change in mean dimension scores from baseline to discharge for these dimensions. Mean scores improved significantly (all P < 0.001). 

Highest acuity on admission was for the Recovery Environment – Stress dimension (2.46 ± 0.757), which improved to 2.05 ± 0.796 on discharge. Table 5 shows the percentage of clients whose dimension scores decreased, increased, or stayed the same. The greatest decrease was for Recovery Environment – Stress, where 43.2% of clients had a lower score at discharge, followed by Functional Status (35.8%) and Resiliency/Response to Service at 30.7%. 

Level of care decreased for 28.7% of the cohort, increased for 21.7% , and stayed the same for 49.6% (P < 0.001).

 

Discussion

Organizations that provide mental health services are burdened with a complicated milieu of providing the best care possible in a complicated system of assessment, reimbursement, admissions/discharges, and a variety of other tasks. Using multiple measures complicates assessment and increases costs because of training staff, developing and interpreting the tool results, data storage and more comprehensive analysis and communication of results back to stakeholders and staff. Complicated measures are often times not understood by the staff and those responsible for care, nor are measures understood by the clients and their families. While a wide array of psychometric assessment tools exist, most are applicable to only specific diagnosis groups or illnesses.

Our study showed that the CASII may be used to monitor progress and reassess the level of service intensity needed, and therefore may be useful as an outcome measure. There are benefits in having a single score as an outcome measure. A single score for each client is quick and easy to understand by board members, staff of the organization as well as clients outside of the organization such as funders, client, press etc. Also the use of a single score is cost effective as costs for interpretation, training and communication within and outside of the organization are reduced.

A number of limitations must be mentioned. Although a change in score represents a change in client condition, this change in condition can have a wide variety of explanations. Change can be related to the therapy received, to changes in the client’s environment, support services, and many other factors. Our research did not allow us to discern what aspects of care may have reduced level of service intensity needed at discharge. In addition, our study involved clients of low and moderate acuity. The study does not address if CASII would be sensitive to change in upper acuity ranges. Therefore, our findings may not be generalizable in these settings.

Tolan and Dodge [10] called for the enhancement or an elevation in the assessment of psychology as a matter of public policy. An approach that involves all levels of scientific inquiry including economics, political science and other sciences is desperately needed. Assessment of the type presented in this article, even if instruments such as the CASII are not used, can help to shape that policy by providing unquestionably accurate assessment of a client’s condition which demonstrates the need for that support. Further research looking at specific attributes of therapy and the client’s condition and environment may be helpful in applying CASII composite ratings and dimension scores as outcome measures.

Corresponding author: Dr. Lorrie Henderson, Jewish Family and Children’s Service, 4747 North 7th St., Suite 100, Phoenix, AZ 850142.

Financial disclosures: None.

From the Jewish Family and Children’s Service, Phoenix, AZ (Dr. Henderson) and Consult-Stat, Macungie, PA (Ms. Wasser, Dr. Wasser).

 

Abstract

• Background: The reliability and validity of the Child and Adolescent Service Intensity Instrument (CASII) as a tool to help determine needed level of care for children with behavioral health needs has previously been established.
• Objective: To determine the utility of the CASII as an outcome measure.
• Methods: A sample consisting of all clients (n = 8465) admitted to service at an outpatient behavioral health facility from 2013 through 2016 were studied. CASII was administered at admission and discharge and ratings were compared with paired t-tests within demographic and diagnosis groups.
• Results: Mean CASII composite ratings decreased between admission and discharge in the entire cohort as well as within gender, age group, and multiple diagnosis groups tested.
• Conclusion: CASII was useful as an outcome measure in our relatively low to moderate acuity population.

Keywords: outcomes, evidence based practice, child psychology, outpatient research.

 

The primary goal of mental health services is to provide interventions that result in a reduction of problematic symptomatology [1]; therefore, evaluation of those interventions is important for both the client as well as the stakeholders of the organization providing them. Health care payment reforms require tracking quality measures, and such measures directly influence the development, administration, and monitoring of mental health programs as well as specific treatment modalities [2,3]. Organizations are more likely to benefit when outcomes measures are relayed quantitatively [4]. In addition, clients are becoming more informed regarding the quality of care, and outcomes assessments can inform clients that programs are delivering the most efficacious therapies based on current evidence-based practice standards.

Developing outcomes assessments in behavioral health is challenging [5–7]. There are numerous potential outcome domains that can be assessed as well as different ways of measuring them. Futher, evaluating treatment can be expensive, with components including developing a tool, training staff to administer the tool, ensuring the necessary technical support to store and process the data, interpretation of the data, compiling reports, and communicating results to clients and providers [5]. Being mindful of these components and their associated costs, our organization considered whether a tool we currently use to assess the appropriate intensity of service needed for an individual could also be used as an outcome measure.

Therapeutic methods for children in our organization consist of a “system of care” approach designed by a treatment team that incorporates varied methods depending on the needs of the child. The primary goal is to prevent children with traumatic-based disorders from developing continuing disorders associated with their experiences, such as substance use and chronic health and mental health disorders. Our organization currently uses the CASII (Child and Adolescent Service Intensity Instrument) to assess the appropriate level of intensity of service needed by the child. The CASII incorporates holistic information on the child, within the context of his/her family and social ecology, assessing across 6 dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services.

In order to comply with the call to consider outcomes measurement and evidence based practice as an integral component of children’s mental health services, this study was performed. It examines the use of the CASII as an outcomes measure based on the rationale that a decreased level of care upon discharge would correlate with a positive outcome by proxy.

Methods

CASII Instrument

The CASII is a decision support tool to help the service provider determine the intensity of services that a child should have to adequately address their behavioral health needs. The CASII has a strong evidence base supporting its reliability and validity [8], and has gained wide usage in a range of health care settings over the past 13 years [9–11].

As mentioned, the CASII assesses the client across 6 key dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services. Each dimension is scored along a 5-point rating scale, and a total or composite rating is calculated by adding the scores for each dimension. The composite rating corresponds with the level of service intensity needed. There are 7 levels of service intensity, ranging from Level 0 (corresponding with a composite rating of 9 or less) to Level 6 (corresponding with a composite rating of 28 or more) (Table 1).

Study Sample

The sample consisted of all clients (n = 8465) admitted to service from 2013 through 2016 to our facility. Our facility is an outpatient facility offering counseling, mental health assessment and treatment, early childhood trauma assessment, child crisis interventions and rehabilitation for domestic violence, child abuse and neglect, and substance abuse. All clients between the ages of 6 and 17 are assessed with the CASII on admission and then at 6-month intervals until discharge from the program. Being discharged from the program of care prompts the completion of the discharge CASII. If the client had been rated within the 30 days prior to discharge the most recent CASII is used as the discharge measure.

 

Data Analysis

Data for all admissions from 2013 and 2016 were extracted from the organization’s computer system into an Excel file. The data collected included gender, calendar year of admission to the program, age, and diagnosis group based on the discharge diagnosis given by the mental health team, and whether the client was a participant in the Youth in Transition (YIT) program (program for older clients that includes life skills training in addition to standard therapy). The CASII composite rating at baseline and discharge as well as ratings for each of the 6 dimensions assessed with the CASII were also collected.

We used SPSS (v25.01) software for statistical analysis. Analysis included paired (pre-post) t-tests that were applied to the entire cohort as well as within gender, age group, participation in the YIT program, and diagnosis groups. Diagnosis groups were included only if the frequency of cases within the group was large enough to meet the sample size requirements of central limit theorem (in general, n > 25), with 2 exceptions: schizophrenia spectrum was included because of the rarity of the diagnosis (n = 11) and neurodevelopmental disorders (also n = 11) was included because there was no violation of the equal variance assumption as well as interest to the investigators. In addition to the paired analysis, we used group t tests to determine if there were severity differences between groups at baseline. Lastly, we assessed change from admission to discharge for each of the 6 dimensions that make up the composite rating.

We designated the 7 levels of care defined by the CASII as continuous in nature, and therefore computations of means and standard deviations (SD) are appropriate for assessment. The interpretation of the CASII composite rating and the level of care as a continuous variable has also been reported in the literature [11,12].

The research and analysis was viewed as exploratory in nature and a P value less than 0.05 was considered statistically significant. There was no correction for multiple comparisons applied to the data in order to not mask any observed differences in the data. All analyses were 2-tailed. If any individual had a missing value for either an admission or discharge CASII assessment they were excluded from the statistical analysis.

Results

There were 8465 clients admitted from 2013 and 2016. The sample was predominantly male (54.5%), and the majority fell into the older 12–17 year old cohort (54.0%). Admissions were evenly distributed across the 4 years that we studied, with the lowest percentage in 2013 at 23.4% and the highest in 2014 at 26.0%. Discharge diagnosis was available for the majority of the cohort. The top 5 most frequent diagnosis groups were adjustment disorders (n = 807, 18.3%), ADHD (n = 798, 18.1%), child neglect (n = 775, 17.6%), mood disorders (n = 602, 13.6%), and impulse disorders (n = 262, 5.9%). There were 232 (2.7%) clients that participated in the YIT program. Table 2 

presents the demographic data for the cohort.

At admission, several groups had higher mean composite ratings. Males had higher ratings (in need of higher level of service intensity) than females (P < 0.001), 12–17 year olds had a significantly higher acuity level than 6–11 year olds (P < 0.001), and clients in the YIT program had a higher acuity level than those not in the YIT program (P = 0.001). Baseline acuity levels for primary discharge diagnosis for selected groups are shown in the Figure.

When analyzing the entire cohort for which data were available (n = 6944), the mean CASII composite rating dropped from 13.23 (± 4.35 SD) to 12.04 (± 3.84 SD), P < 0.001. Excluding youth that participated in YIT, the mean CASII score dropped from 13.21 (± 4.33) at admission to 13.17 (± 4.52) at discharge. Mean composite rating for clients participating in the YIT program dropped from 14.31 (± 5.12) at admission to 13.17 (± 4.52) at discharge (P = 0.022). For diagnosis groups, statistically significant reduction in mean CASII composite rating was observed for all groups except neurodevelopmentall disorders (P = 0.166). The results for all groups and diagnosis cohorts can be found in Table 3.

As noted, the CASII assesses the client across 6 dimensions, each of which is scored along a 5-point rating scale, and the composite rating is calculated by adding the scores for each dimension. Table 4 shows the change in mean dimension scores from baseline to discharge for these dimensions. Mean scores improved significantly (all P < 0.001). 

Highest acuity on admission was for the Recovery Environment – Stress dimension (2.46 ± 0.757), which improved to 2.05 ± 0.796 on discharge. Table 5 shows the percentage of clients whose dimension scores decreased, increased, or stayed the same. The greatest decrease was for Recovery Environment – Stress, where 43.2% of clients had a lower score at discharge, followed by Functional Status (35.8%) and Resiliency/Response to Service at 30.7%. 

Level of care decreased for 28.7% of the cohort, increased for 21.7% , and stayed the same for 49.6% (P < 0.001).

 

Discussion

Organizations that provide mental health services are burdened with a complicated milieu of providing the best care possible in a complicated system of assessment, reimbursement, admissions/discharges, and a variety of other tasks. Using multiple measures complicates assessment and increases costs because of training staff, developing and interpreting the tool results, data storage and more comprehensive analysis and communication of results back to stakeholders and staff. Complicated measures are often times not understood by the staff and those responsible for care, nor are measures understood by the clients and their families. While a wide array of psychometric assessment tools exist, most are applicable to only specific diagnosis groups or illnesses.

Our study showed that the CASII may be used to monitor progress and reassess the level of service intensity needed, and therefore may be useful as an outcome measure. There are benefits in having a single score as an outcome measure. A single score for each client is quick and easy to understand by board members, staff of the organization as well as clients outside of the organization such as funders, client, press etc. Also the use of a single score is cost effective as costs for interpretation, training and communication within and outside of the organization are reduced.

A number of limitations must be mentioned. Although a change in score represents a change in client condition, this change in condition can have a wide variety of explanations. Change can be related to the therapy received, to changes in the client’s environment, support services, and many other factors. Our research did not allow us to discern what aspects of care may have reduced level of service intensity needed at discharge. In addition, our study involved clients of low and moderate acuity. The study does not address if CASII would be sensitive to change in upper acuity ranges. Therefore, our findings may not be generalizable in these settings.

Tolan and Dodge [10] called for the enhancement or an elevation in the assessment of psychology as a matter of public policy. An approach that involves all levels of scientific inquiry including economics, political science and other sciences is desperately needed. Assessment of the type presented in this article, even if instruments such as the CASII are not used, can help to shape that policy by providing unquestionably accurate assessment of a client’s condition which demonstrates the need for that support. Further research looking at specific attributes of therapy and the client’s condition and environment may be helpful in applying CASII composite ratings and dimension scores as outcome measures.

Corresponding author: Dr. Lorrie Henderson, Jewish Family and Children’s Service, 4747 North 7th St., Suite 100, Phoenix, AZ 850142.

Financial disclosures: None.

From the Jewish Family and Children’s Service, Phoenix, AZ (Dr. Henderson) and Consult-Stat, Macungie, PA (Ms. Wasser, Dr. Wasser).

 

Abstract

• Background: The reliability and validity of the Child and Adolescent Service Intensity Instrument (CASII) as a tool to help determine needed level of care for children with behavioral health needs has previously been established.
• Objective: To determine the utility of the CASII as an outcome measure.
• Methods: A sample consisting of all clients (n = 8465) admitted to service at an outpatient behavioral health facility from 2013 through 2016 were studied. CASII was administered at admission and discharge and ratings were compared with paired t-tests within demographic and diagnosis groups.
• Results: Mean CASII composite ratings decreased between admission and discharge in the entire cohort as well as within gender, age group, and multiple diagnosis groups tested.
• Conclusion: CASII was useful as an outcome measure in our relatively low to moderate acuity population.

Keywords: outcomes, evidence based practice, child psychology, outpatient research.

 

The primary goal of mental health services is to provide interventions that result in a reduction of problematic symptomatology [1]; therefore, evaluation of those interventions is important for both the client as well as the stakeholders of the organization providing them. Health care payment reforms require tracking quality measures, and such measures directly influence the development, administration, and monitoring of mental health programs as well as specific treatment modalities [2,3]. Organizations are more likely to benefit when outcomes measures are relayed quantitatively [4]. In addition, clients are becoming more informed regarding the quality of care, and outcomes assessments can inform clients that programs are delivering the most efficacious therapies based on current evidence-based practice standards.

Developing outcomes assessments in behavioral health is challenging [5–7]. There are numerous potential outcome domains that can be assessed as well as different ways of measuring them. Futher, evaluating treatment can be expensive, with components including developing a tool, training staff to administer the tool, ensuring the necessary technical support to store and process the data, interpretation of the data, compiling reports, and communicating results to clients and providers [5]. Being mindful of these components and their associated costs, our organization considered whether a tool we currently use to assess the appropriate intensity of service needed for an individual could also be used as an outcome measure.

Therapeutic methods for children in our organization consist of a “system of care” approach designed by a treatment team that incorporates varied methods depending on the needs of the child. The primary goal is to prevent children with traumatic-based disorders from developing continuing disorders associated with their experiences, such as substance use and chronic health and mental health disorders. Our organization currently uses the CASII (Child and Adolescent Service Intensity Instrument) to assess the appropriate level of intensity of service needed by the child. The CASII incorporates holistic information on the child, within the context of his/her family and social ecology, assessing across 6 dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services.

In order to comply with the call to consider outcomes measurement and evidence based practice as an integral component of children’s mental health services, this study was performed. It examines the use of the CASII as an outcomes measure based on the rationale that a decreased level of care upon discharge would correlate with a positive outcome by proxy.

Methods

CASII Instrument

The CASII is a decision support tool to help the service provider determine the intensity of services that a child should have to adequately address their behavioral health needs. The CASII has a strong evidence base supporting its reliability and validity [8], and has gained wide usage in a range of health care settings over the past 13 years [9–11].

As mentioned, the CASII assesses the client across 6 key dimensions: risk of harm (including trauma issues), functional status, co-occurring conditions, recovery environment, resiliency/response to services, and involvement in services. Each dimension is scored along a 5-point rating scale, and a total or composite rating is calculated by adding the scores for each dimension. The composite rating corresponds with the level of service intensity needed. There are 7 levels of service intensity, ranging from Level 0 (corresponding with a composite rating of 9 or less) to Level 6 (corresponding with a composite rating of 28 or more) (Table 1).

Study Sample

The sample consisted of all clients (n = 8465) admitted to service from 2013 through 2016 to our facility. Our facility is an outpatient facility offering counseling, mental health assessment and treatment, early childhood trauma assessment, child crisis interventions and rehabilitation for domestic violence, child abuse and neglect, and substance abuse. All clients between the ages of 6 and 17 are assessed with the CASII on admission and then at 6-month intervals until discharge from the program. Being discharged from the program of care prompts the completion of the discharge CASII. If the client had been rated within the 30 days prior to discharge the most recent CASII is used as the discharge measure.

 

Data Analysis

Data for all admissions from 2013 and 2016 were extracted from the organization’s computer system into an Excel file. The data collected included gender, calendar year of admission to the program, age, and diagnosis group based on the discharge diagnosis given by the mental health team, and whether the client was a participant in the Youth in Transition (YIT) program (program for older clients that includes life skills training in addition to standard therapy). The CASII composite rating at baseline and discharge as well as ratings for each of the 6 dimensions assessed with the CASII were also collected.

We used SPSS (v25.01) software for statistical analysis. Analysis included paired (pre-post) t-tests that were applied to the entire cohort as well as within gender, age group, participation in the YIT program, and diagnosis groups. Diagnosis groups were included only if the frequency of cases within the group was large enough to meet the sample size requirements of central limit theorem (in general, n > 25), with 2 exceptions: schizophrenia spectrum was included because of the rarity of the diagnosis (n = 11) and neurodevelopmental disorders (also n = 11) was included because there was no violation of the equal variance assumption as well as interest to the investigators. In addition to the paired analysis, we used group t tests to determine if there were severity differences between groups at baseline. Lastly, we assessed change from admission to discharge for each of the 6 dimensions that make up the composite rating.

We designated the 7 levels of care defined by the CASII as continuous in nature, and therefore computations of means and standard deviations (SD) are appropriate for assessment. The interpretation of the CASII composite rating and the level of care as a continuous variable has also been reported in the literature [11,12].

The research and analysis was viewed as exploratory in nature and a P value less than 0.05 was considered statistically significant. There was no correction for multiple comparisons applied to the data in order to not mask any observed differences in the data. All analyses were 2-tailed. If any individual had a missing value for either an admission or discharge CASII assessment they were excluded from the statistical analysis.

Results

There were 8465 clients admitted from 2013 and 2016. The sample was predominantly male (54.5%), and the majority fell into the older 12–17 year old cohort (54.0%). Admissions were evenly distributed across the 4 years that we studied, with the lowest percentage in 2013 at 23.4% and the highest in 2014 at 26.0%. Discharge diagnosis was available for the majority of the cohort. The top 5 most frequent diagnosis groups were adjustment disorders (n = 807, 18.3%), ADHD (n = 798, 18.1%), child neglect (n = 775, 17.6%), mood disorders (n = 602, 13.6%), and impulse disorders (n = 262, 5.9%). There were 232 (2.7%) clients that participated in the YIT program. Table 2 

presents the demographic data for the cohort.

At admission, several groups had higher mean composite ratings. Males had higher ratings (in need of higher level of service intensity) than females (P < 0.001), 12–17 year olds had a significantly higher acuity level than 6–11 year olds (P < 0.001), and clients in the YIT program had a higher acuity level than those not in the YIT program (P = 0.001). Baseline acuity levels for primary discharge diagnosis for selected groups are shown in the Figure.

When analyzing the entire cohort for which data were available (n = 6944), the mean CASII composite rating dropped from 13.23 (± 4.35 SD) to 12.04 (± 3.84 SD), P < 0.001. Excluding youth that participated in YIT, the mean CASII score dropped from 13.21 (± 4.33) at admission to 13.17 (± 4.52) at discharge. Mean composite rating for clients participating in the YIT program dropped from 14.31 (± 5.12) at admission to 13.17 (± 4.52) at discharge (P = 0.022). For diagnosis groups, statistically significant reduction in mean CASII composite rating was observed for all groups except neurodevelopmentall disorders (P = 0.166). The results for all groups and diagnosis cohorts can be found in Table 3.

As noted, the CASII assesses the client across 6 dimensions, each of which is scored along a 5-point rating scale, and the composite rating is calculated by adding the scores for each dimension. Table 4 shows the change in mean dimension scores from baseline to discharge for these dimensions. Mean scores improved significantly (all P < 0.001). 

Highest acuity on admission was for the Recovery Environment – Stress dimension (2.46 ± 0.757), which improved to 2.05 ± 0.796 on discharge. Table 5 shows the percentage of clients whose dimension scores decreased, increased, or stayed the same. The greatest decrease was for Recovery Environment – Stress, where 43.2% of clients had a lower score at discharge, followed by Functional Status (35.8%) and Resiliency/Response to Service at 30.7%. 

Level of care decreased for 28.7% of the cohort, increased for 21.7% , and stayed the same for 49.6% (P < 0.001).

 

Discussion

Organizations that provide mental health services are burdened with a complicated milieu of providing the best care possible in a complicated system of assessment, reimbursement, admissions/discharges, and a variety of other tasks. Using multiple measures complicates assessment and increases costs because of training staff, developing and interpreting the tool results, data storage and more comprehensive analysis and communication of results back to stakeholders and staff. Complicated measures are often times not understood by the staff and those responsible for care, nor are measures understood by the clients and their families. While a wide array of psychometric assessment tools exist, most are applicable to only specific diagnosis groups or illnesses.

Our study showed that the CASII may be used to monitor progress and reassess the level of service intensity needed, and therefore may be useful as an outcome measure. There are benefits in having a single score as an outcome measure. A single score for each client is quick and easy to understand by board members, staff of the organization as well as clients outside of the organization such as funders, client, press etc. Also the use of a single score is cost effective as costs for interpretation, training and communication within and outside of the organization are reduced.

A number of limitations must be mentioned. Although a change in score represents a change in client condition, this change in condition can have a wide variety of explanations. Change can be related to the therapy received, to changes in the client’s environment, support services, and many other factors. Our research did not allow us to discern what aspects of care may have reduced level of service intensity needed at discharge. In addition, our study involved clients of low and moderate acuity. The study does not address if CASII would be sensitive to change in upper acuity ranges. Therefore, our findings may not be generalizable in these settings.

Tolan and Dodge [10] called for the enhancement or an elevation in the assessment of psychology as a matter of public policy. An approach that involves all levels of scientific inquiry including economics, political science and other sciences is desperately needed. Assessment of the type presented in this article, even if instruments such as the CASII are not used, can help to shape that policy by providing unquestionably accurate assessment of a client’s condition which demonstrates the need for that support. Further research looking at specific attributes of therapy and the client’s condition and environment may be helpful in applying CASII composite ratings and dimension scores as outcome measures.

Corresponding author: Dr. Lorrie Henderson, Jewish Family and Children’s Service, 4747 North 7th St., Suite 100, Phoenix, AZ 850142.

Financial disclosures: None.

From the Children’s National Health System, Washington, DC (Dr. Manget, Dr. Kelley, Dr. White) and the Duke University School of Nursing, Durham, NC (Dr. Blood-Siegfried).

 

Abstract

• Background: Approximately 11% of children in the United States ages 4 to 17 have received the diagnosis of attention-deficit hyperactive disorder (ADHD). There are disproportionately higher rates of the diagnosis and fewer child psychiatrists available in underserved areas. The American Academy of Pediatrics (AAP) strongly encourages improved mental health competencies among primary care providers to combat this shortage.
• Objective: To improve primary care providers’ knowledge and confidence with the management of ADHD and institute an evidence-based process for assessing patients presenting with behavior concerns suggestive of ADHD.
• Methods: Three in-person educational sessions were conducted for primary care providers by a child psychiatrist to increase providers’ knowledge and confidence in the evaluation and management of ADHD. A Behavior Management Plan was also adopted for use in the clinic. Providers were encouraged to use the plan during patient visits for behavior concerns indicative of ADHD. Pre- and post-test surveys were given to providers to assess change in comfort level with managing ADHD. Patient charts were reviewed to determine how often the Behavior Management Plan was utilized.
• Results: We did not find significant changes in provider comfort in managing ADHD according to the survey results, although providers reported that the educational sessions and handouts were useful. Behavior Management Plans were utilized during 13 of 25 (52%) eligible visits.
• Conclusions: Behavior Management Plans were introduced in just over half of relevant visits. Further exploration about barriers to use of the plan and its utility to patients and families should be pursued in the future. Additionally, ongoing opportunities for continuing education and collaboration with psychiatry should continue to be sought.

Keywords: attention-deficit hyperactive disorder; ADHD; AAP clinical guidelines; underserved populations; disadvantaged communities.

 

The importance of the mental health of a child cannot be underestimated. Untreated symptoms of attention deficit/hyperactivity disorder (ADHD) can significantly interfere with school and social functioning [1]. Children with ADHD often have comorbid conditions such as anxiety, low self-esteem and learning disabilities. It is vital to screen and treat for ADHD and comorbidities early and comprehensively [2].

There are disproportionately higher rates of children diagnosed with ADHD living in underserved areas compared to other geographical regions [3]. The historically underserved Southeast region of Washington D.C. which encompasses Wards 7 and 8 is home to nearly 40% of the district’s children and has the highest rates of children with an ADHD diagnosis in D.C.; however, the majority of child psychiatrists are located in the Northwest regions [4]. In 2009, nearly 8% of children in Washington D.C. were reported to have a diagnosis of ADHD [1].

Due to the overwhelming demand and limited availability of child psychiatrists, it is important that primary care providers become better equipped to diagnose, treat, and manage non-complex cases of ADHD. Specific education about ADHD diagnosis and management along with implementation of standardized center-based processes may help primary care providers feel more comfortable caring for these patients and ensure that all patients presenting with behavior concerns are adequately assessed and treated.

The American Academy of Pediatrics (AAP) recommends that primary care providers expand their mental health competencies because pediatric primary care providers in the medical home will be the first point of access in most cases [5]. In 2011, the AAP Subcommittee on ADHD and Steering Committee on Quality Improvement and Management released clinical practice guidelines for diagnosis, evaluation, and treatment of ADHD [6]. These guidelines, which recommend that providers should initiate ADHD assessments for children ages 6 to 12 that present with behavioral and/or academic problems, have been incorporated into “Caring for Children with ADHD: A Resource Toolkit for Clinicians” by the AAP in partnership with the National Institute on Children’s Health Quality (NICHQ) and North Carolina’s Center for Child Health.

Our clinic has two on-site psychiatrists who provide evaluation and treatment of mental health problems in children identified by primary care providers for a combined total of 1.5 days each week. The current wait for psychiatric evaluation at our clinic is 2 to 3 months, which leaves the primary care providers to care for many children with behavior concerns who require more immediate intervention at the time of their presentation. Our clinic providers revealed that they felt there were deficits in the management of behavior concerns and initiating treatment for patients diagnosed with ADHD in the clinic. Providers expressed an interest in refreshing and enhancing their knowledge related to managing patients with ADHD.

To address this issue, we initiated a quality improvement project with several facets: provide ADHD education to primary care providers through use of educational sessions from our on-site psychiatrists, standardize the process of managing patients that present with behavior concerns to the primary care provider in the medical home, and develop a comprehensive and individualized patient management plan based on the “Caring for Children with ADHD” toolkit for clinicians.

Methods

Setting

This project took place in a federally qualified health center located in the Southeast quadrant of Washington, D.C. that serves patients up to 23 years of age. The clinic has 6 primary care medical providers (5 physicians and 1 nurse practitioner) employed in a part-time to full-time capacity. Additionally, 2 child psychiatrists provide services on-site during one full day and one half-day session on a weekly basis. Approximately 98% of patients at the clinic are classified as African American and close to 95% of patients are insured by Medicaid. Approximately 9% of patients in our clinic had a medical diagnosis of ADHD as of 2015.

Patients who presented to the clinic in April and May 2017 who had an existing diagnosis of ADHD and those with documentation of a new behavior concern in the assessment and treatment plan were studied. Eligible visit types were annual well-child checks, new consults for behavior, and follow-up appointments specifically for behavior.

This was a project undertaken as a quality improvement initiative at the hosting facility and did not constitute human subjects research. As such, it was not under the oversight of the institutional review board.

Intervention

Provider Education. Three in-person sessions were held at the clinic during April–May 2017 to provide education on the assessment and treatment of patients with ADHD and discuss challenges that have arisen when providing care for such patients. The sessions focused on diagnosing ADHD and teasing out comorbidities; initiating and titrating medications safely; educational rights; and strategies for managing behavior and community resources.

Current providers as well as medical residents and student trainees of the clinic were invited to attend the educational sessions. Each session followed a “lunch and learn” format where one of the clinic psychiatrists presented the information during the clinic lunch hour then related a discussion where participants asked questions. The information provided was derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) and the AAP/NICHQ Toolkit [5]. Educational handouts were disseminated during the provider sessions and emailed to all providers afterwards.

Behavior Management Plan. In March we introduced the providers to the Behavior Management Plan (Figure), 

 

which we adapted from the 2011 AAP/NICHQ Toolkit [5]. The Behavior Management Plan was intended for use during all clinic visits with a presenting complaint suggestive of ADHD. The plan, when completed with the family, helps ensure a comprehensive assessment has been performed and details specific individualized patient goals and the plans to reach them. It encourages families to complete Vanderbilt ADHD assessment scales and instructs them to have teachers complete and return them. Vanderbilt Assessment Scales were published by the AAP and NICHQ in 2002 as a tool to aid in the diagnosis of ADHD for children between the ages of 6 and 12 [7]. The Behavior Management Plan also encourages the providers to offer parents useful handouts, sample letters to the school and referrals to community agencies. Lastly, it advises families to return for subsequent clinic visits and gives the family a clear date and instructions for follow-up.

Providers were encouraged to initiate the Behavior Management Plan for patients that presented without an existing diagnosis for evaluation of their behavior concerns. The plan could also be used for patients that had previously been diagnosed with ADHD if changes were being made to their treatment plan or as a summary of their established treatment details. Instructions on the use of the plan were given to all clinic primary care providers through email communication as well as in the first in-person educational session. It was stressed to providers that formulating individual patient goals and the inclusion of a specific follow-up time were the most important aspects of the plan.

Assessment and Measurements

We assessed provider comfort in their ADHD evaluation and management skills before and after the intervention using a 5–point Likert scale questionnaire with 0 indicating “not comfortable at all” and 5 corresponding to “very comfortable.” The questionnaire was administered via a paper survey for the initial screening and an electronic survey at the conclusion of the intervention.

Patient charts were reviewed in July 2017 to determine how often the Behavior Management Plan was utilized. Provider documentation in the electronic medical record indicating that the Plan was given during the patient visit was considered utilization of the plan. We also examined documentation of dissemination/return of Vanderbilt ADHD assessment scales, referrals to psychiatry or counseling, and the initiation or refill of an ADHD medication during the encounter for all patients that were seen for behavior concerns. Patient data were obtained from manual chart review of the electronic medical record, eClinicalWorks.

 

Analysis

SPSS Statistics (Version 24) was used to conduct analyses. Independent sample t tests were employed to measure items related to the provider educational sessions. Mean provider responses for each item were reviewed from descriptive statistics. A chi-square cross tabulation was used to compare the percentage of patients receiving a Behavior Management Plan that adhered to follow-up visits versus a similar sample of patients that presented in 2016 before the introduction of the Behavior Management Plan. In addition, a chi-square cross tabulation was utilized to compare adherence to follow-up visits in those that received the Management Plan to that of eligible patients that presented during the same time period but did not receive the Plan. Additional chi-square tests were run to see if there was any difference in 2017 follow-up rates based on individual provider or visit type .

Results

Provider Questionnaire

Six providers responded to the pre-intervention questionnaire and five to the post-intervention questionnaire. The specific questions and their results are listed in Table 1.

Patient Management

Between April and May 2017, 61 eligible patients presented to the clinic. Details of the breakdown of patient visit type are displayed in Table 2. 

The majority of patients presented with concerns during their well-child visits. Over half of patients presenting for behavioral concerns (57%) already had a diagnosis of ADHD. Of those without a previous diagnosis, Behavior Management Plans were given during 52% (13 of 25) of visits. Two patients with an active diagnosis of ADHD were given Behavior Management Plans as changes to their medications or treatment plans were made.

Follow-up Rates

Notation of a specific time frame for follow-up by a primary care provider was found in 24 of 61 (39%) relevant patient charts (Table 3). 

Five patients were given follow-up times beyond the time frame of the study; therefore, calculations were based on the remaining 19 patients that were given specific instructions to follow-up in clinic before June of 2017. Seven (37%) returned for their follow-up visit within the time frame given by their provider during their initial visit and 12 patients (63%) failed to show during their advised follow-up period. A chi-square test confirmed that there was no significant difference in the follow-up rates between the intervention and prior year that was used for comparison (P = 0.99).

Further cross-tabulations were completed to assess if there were better follow-up rates for patients that received a Behavior Management Plan. The difference between the 2 groups was not significant (P = 0.99). There were no significant differences found in follow-up rates based on the provider for the visit (P = 0.51) or the type of patient visit (well child examination vs. behavior consult) (P = 0.65).

Discussion

This project aimed to improve provider confidence in the assessment and treatment of ADHD and improve ADHD management by providers at our clinic. We did not find significant changes in confidence according to the survey results. However, provider feedback indicated that, as a result of the educational sessions, they had a deeper appreciation for the presence of psychiatric comorbidities and the role they play in deciding appropriate treatment.  They also reported that they more fully understood the need to refer to child psychiatry for evaluation and management when comorbidities are present instead of attempting to independently provide ADHD medication.

We hoped to see the Behavior Management Plan used for patients with new behavior concerns during the evaluation for ADHD. During the intervention period, it was used in half of eligible clinic visits of patients without a prior diagnosis of ADHD. Future investigation should be directed at receiving specific input on the utility of the Behavior Management Plan from providers and families. The Management Plan contains important reminders and treatment information; however, if the plan is not perceived as effective or useful, taking the time needed to complete it may be seen as an additional cumbersome step in the already overloaded clinic visits.

The use of the Behavior Management Plan was not found to make a statistically significant difference in follow-up rates. Attendance at follow-up appointments for ADHD patients is not an area that has been greatly studied. In a recent analysis of ADHD treatment quality in Medicaid-enrolled children, African American families were less likely to have adequate follow-up compared to Caucasian counterparts during the initiation or  continuation and management phases of treatment. The review of specific follow-through rates showed that African Americans were 22% more likely to discontinue medication therapy and 13% more likely to disengage from treatment. The authors propose that future efforts focus on improving accessibility of behavioral therapy to combat the discontinuation rates and disparities in this area [8]. Another study that looked at a prospective cohort of ADHD patients found suboptimal attendance at appointments with a median of 1 visit every 6 months [9]. Further exploration of the challenges with attendance at follow-up appointments is warranted to help determine best practices for ADHD management in disadvantaged communities. More information is needed on the specific barriers to care in this subgroup at our clinic. However, data from this project related to adherence to follow-up appointments can be used to guide future studies.

Use of a Behavior Management Plan was not found to influence the return of completed teacher Vanderbilt scales by families. The rates of return of these assessment forms continue to be very low. Without input from teachers and schools, it is difficult to properly diagnose, treat and evaluate the treatment of patients. Feedback from all sources is essential for both medication management and construction of interventions for behavioral challenges at school. The development of partnerships with a child’s school may be useful in helping patients return for the treatment of behavior concerns at their initial stages. Before children are expelled multiple times due to their behavior, schools should strongly encourage parents to notify their healthcare provider of behavior concerns for evaluation.

In an ideal system, school-based nurses, guidance counselors or social workers could provide some case management and outreach to families of children with known behavior concerns to ensure they are attending appointments as recommended by their treatment plan and explore barriers to doing so. Social workers can provide direct mental health care services and make referrals to community agencies. However, the caseload for school-based providers is currently quite high and many children slip through the cracks until their behavior escalates to a dangerous and/or very disruptive level. School-based personnel in several districts are now required to split their time in multiple schools. Dang et al describe the piloting of a school-based framework for early identification and assessment of children suspected to have ADHD. The framework, called ADHD Identification and Management in Schools (AIMS), encourages school nurses to gather all parent and teacher assessment materials prior to the initial visit to their primary care providers thus reducing the number of visits needed and leading to faster diagnosis and treatment [10].

Clinic-based case managers solely dedicated to this population would also be useful. These case managers could provide management as described above and also potentially sit-in on clinic visits for behavior concerns so that they are fully aware of the instructions given by the provider. This would also give them the information needed so that they are able to complete forms such as the Behavior Management Plan, which would be helpful in relieving some provider time. Geltman et al trialed a workflow intervention with electronic Vanderbilt scales and an electronic registry managed by a care coordination team of a physician, nurse and medical assistant. This allowed patient calls to the families by the nurse or medical assistant to remind them of necessary follow-up and monthly meetings with the care coordination team. Those in the intervention group with the care coordination team were twice as likely to return the Vanderbilt questionnaires. During the intervention period, the rates of follow-up visits remained the same; however, when the intervention was further adopted and expanded to other sites, follow-up attendance improved to over 90% [11].

 

Limitations

Limitations of this project include the short time period in which it was conducted as well as the size of the study sample. Provider work schedules also caused some challenges with arranging the lunch and learn educational sessions and completing independent review of materials on the subject. This project focused on a primarily African American, predominately Medicaid population. Within urban and/or underserved populations, there may be other demographic distributions thus limiting the generalizability of these findings.

Summary

In summary, this project attempted to improve provider confidence in management of ADHD and standardize assessment practices of one urban pediatric clinic. At the project’s conclusion there were subjective improvements in provider confidence. Ongoing opportunities for continuing education on management of mental health diagnoses for primary care providers should persevere. This project also highlights the persistent problem of patient follow-up for behavior concerns. Further exploration of challenges with attendance at follow-up appointments including collaboration with community and academic resources is needed to help determine best practices for ADHD management in disadvantaged communities. 

Corresponding author: Jaytoya C. Manget, DNP, MSPH, FNP, jmanget@childrensnational.org.

Financial disclosures: None.

From the Children’s National Health System, Washington, DC (Dr. Manget, Dr. Kelley, Dr. White) and the Duke University School of Nursing, Durham, NC (Dr. Blood-Siegfried).

 

Abstract

• Background: Approximately 11% of children in the United States ages 4 to 17 have received the diagnosis of attention-deficit hyperactive disorder (ADHD). There are disproportionately higher rates of the diagnosis and fewer child psychiatrists available in underserved areas. The American Academy of Pediatrics (AAP) strongly encourages improved mental health competencies among primary care providers to combat this shortage.
• Objective: To improve primary care providers’ knowledge and confidence with the management of ADHD and institute an evidence-based process for assessing patients presenting with behavior concerns suggestive of ADHD.
• Methods: Three in-person educational sessions were conducted for primary care providers by a child psychiatrist to increase providers’ knowledge and confidence in the evaluation and management of ADHD. A Behavior Management Plan was also adopted for use in the clinic. Providers were encouraged to use the plan during patient visits for behavior concerns indicative of ADHD. Pre- and post-test surveys were given to providers to assess change in comfort level with managing ADHD. Patient charts were reviewed to determine how often the Behavior Management Plan was utilized.
• Results: We did not find significant changes in provider comfort in managing ADHD according to the survey results, although providers reported that the educational sessions and handouts were useful. Behavior Management Plans were utilized during 13 of 25 (52%) eligible visits.
• Conclusions: Behavior Management Plans were introduced in just over half of relevant visits. Further exploration about barriers to use of the plan and its utility to patients and families should be pursued in the future. Additionally, ongoing opportunities for continuing education and collaboration with psychiatry should continue to be sought.

Keywords: attention-deficit hyperactive disorder; ADHD; AAP clinical guidelines; underserved populations; disadvantaged communities.

 

The importance of the mental health of a child cannot be underestimated. Untreated symptoms of attention deficit/hyperactivity disorder (ADHD) can significantly interfere with school and social functioning [1]. Children with ADHD often have comorbid conditions such as anxiety, low self-esteem and learning disabilities. It is vital to screen and treat for ADHD and comorbidities early and comprehensively [2].

There are disproportionately higher rates of children diagnosed with ADHD living in underserved areas compared to other geographical regions [3]. The historically underserved Southeast region of Washington D.C. which encompasses Wards 7 and 8 is home to nearly 40% of the district’s children and has the highest rates of children with an ADHD diagnosis in D.C.; however, the majority of child psychiatrists are located in the Northwest regions [4]. In 2009, nearly 8% of children in Washington D.C. were reported to have a diagnosis of ADHD [1].

Due to the overwhelming demand and limited availability of child psychiatrists, it is important that primary care providers become better equipped to diagnose, treat, and manage non-complex cases of ADHD. Specific education about ADHD diagnosis and management along with implementation of standardized center-based processes may help primary care providers feel more comfortable caring for these patients and ensure that all patients presenting with behavior concerns are adequately assessed and treated.

The American Academy of Pediatrics (AAP) recommends that primary care providers expand their mental health competencies because pediatric primary care providers in the medical home will be the first point of access in most cases [5]. In 2011, the AAP Subcommittee on ADHD and Steering Committee on Quality Improvement and Management released clinical practice guidelines for diagnosis, evaluation, and treatment of ADHD [6]. These guidelines, which recommend that providers should initiate ADHD assessments for children ages 6 to 12 that present with behavioral and/or academic problems, have been incorporated into “Caring for Children with ADHD: A Resource Toolkit for Clinicians” by the AAP in partnership with the National Institute on Children’s Health Quality (NICHQ) and North Carolina’s Center for Child Health.

Our clinic has two on-site psychiatrists who provide evaluation and treatment of mental health problems in children identified by primary care providers for a combined total of 1.5 days each week. The current wait for psychiatric evaluation at our clinic is 2 to 3 months, which leaves the primary care providers to care for many children with behavior concerns who require more immediate intervention at the time of their presentation. Our clinic providers revealed that they felt there were deficits in the management of behavior concerns and initiating treatment for patients diagnosed with ADHD in the clinic. Providers expressed an interest in refreshing and enhancing their knowledge related to managing patients with ADHD.

To address this issue, we initiated a quality improvement project with several facets: provide ADHD education to primary care providers through use of educational sessions from our on-site psychiatrists, standardize the process of managing patients that present with behavior concerns to the primary care provider in the medical home, and develop a comprehensive and individualized patient management plan based on the “Caring for Children with ADHD” toolkit for clinicians.

Methods

Setting

This project took place in a federally qualified health center located in the Southeast quadrant of Washington, D.C. that serves patients up to 23 years of age. The clinic has 6 primary care medical providers (5 physicians and 1 nurse practitioner) employed in a part-time to full-time capacity. Additionally, 2 child psychiatrists provide services on-site during one full day and one half-day session on a weekly basis. Approximately 98% of patients at the clinic are classified as African American and close to 95% of patients are insured by Medicaid. Approximately 9% of patients in our clinic had a medical diagnosis of ADHD as of 2015.

Patients who presented to the clinic in April and May 2017 who had an existing diagnosis of ADHD and those with documentation of a new behavior concern in the assessment and treatment plan were studied. Eligible visit types were annual well-child checks, new consults for behavior, and follow-up appointments specifically for behavior.

This was a project undertaken as a quality improvement initiative at the hosting facility and did not constitute human subjects research. As such, it was not under the oversight of the institutional review board.

Intervention

Provider Education. Three in-person sessions were held at the clinic during April–May 2017 to provide education on the assessment and treatment of patients with ADHD and discuss challenges that have arisen when providing care for such patients. The sessions focused on diagnosing ADHD and teasing out comorbidities; initiating and titrating medications safely; educational rights; and strategies for managing behavior and community resources.

Current providers as well as medical residents and student trainees of the clinic were invited to attend the educational sessions. Each session followed a “lunch and learn” format where one of the clinic psychiatrists presented the information during the clinic lunch hour then related a discussion where participants asked questions. The information provided was derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) and the AAP/NICHQ Toolkit [5]. Educational handouts were disseminated during the provider sessions and emailed to all providers afterwards.

Behavior Management Plan. In March we introduced the providers to the Behavior Management Plan (Figure), 

 

which we adapted from the 2011 AAP/NICHQ Toolkit [5]. The Behavior Management Plan was intended for use during all clinic visits with a presenting complaint suggestive of ADHD. The plan, when completed with the family, helps ensure a comprehensive assessment has been performed and details specific individualized patient goals and the plans to reach them. It encourages families to complete Vanderbilt ADHD assessment scales and instructs them to have teachers complete and return them. Vanderbilt Assessment Scales were published by the AAP and NICHQ in 2002 as a tool to aid in the diagnosis of ADHD for children between the ages of 6 and 12 [7]. The Behavior Management Plan also encourages the providers to offer parents useful handouts, sample letters to the school and referrals to community agencies. Lastly, it advises families to return for subsequent clinic visits and gives the family a clear date and instructions for follow-up.

Providers were encouraged to initiate the Behavior Management Plan for patients that presented without an existing diagnosis for evaluation of their behavior concerns. The plan could also be used for patients that had previously been diagnosed with ADHD if changes were being made to their treatment plan or as a summary of their established treatment details. Instructions on the use of the plan were given to all clinic primary care providers through email communication as well as in the first in-person educational session. It was stressed to providers that formulating individual patient goals and the inclusion of a specific follow-up time were the most important aspects of the plan.

Assessment and Measurements

We assessed provider comfort in their ADHD evaluation and management skills before and after the intervention using a 5–point Likert scale questionnaire with 0 indicating “not comfortable at all” and 5 corresponding to “very comfortable.” The questionnaire was administered via a paper survey for the initial screening and an electronic survey at the conclusion of the intervention.

Patient charts were reviewed in July 2017 to determine how often the Behavior Management Plan was utilized. Provider documentation in the electronic medical record indicating that the Plan was given during the patient visit was considered utilization of the plan. We also examined documentation of dissemination/return of Vanderbilt ADHD assessment scales, referrals to psychiatry or counseling, and the initiation or refill of an ADHD medication during the encounter for all patients that were seen for behavior concerns. Patient data were obtained from manual chart review of the electronic medical record, eClinicalWorks.

 

Analysis

SPSS Statistics (Version 24) was used to conduct analyses. Independent sample t tests were employed to measure items related to the provider educational sessions. Mean provider responses for each item were reviewed from descriptive statistics. A chi-square cross tabulation was used to compare the percentage of patients receiving a Behavior Management Plan that adhered to follow-up visits versus a similar sample of patients that presented in 2016 before the introduction of the Behavior Management Plan. In addition, a chi-square cross tabulation was utilized to compare adherence to follow-up visits in those that received the Management Plan to that of eligible patients that presented during the same time period but did not receive the Plan. Additional chi-square tests were run to see if there was any difference in 2017 follow-up rates based on individual provider or visit type .

Results

Provider Questionnaire

Six providers responded to the pre-intervention questionnaire and five to the post-intervention questionnaire. The specific questions and their results are listed in Table 1.

Patient Management

Between April and May 2017, 61 eligible patients presented to the clinic. Details of the breakdown of patient visit type are displayed in Table 2. 

The majority of patients presented with concerns during their well-child visits. Over half of patients presenting for behavioral concerns (57%) already had a diagnosis of ADHD. Of those without a previous diagnosis, Behavior Management Plans were given during 52% (13 of 25) of visits. Two patients with an active diagnosis of ADHD were given Behavior Management Plans as changes to their medications or treatment plans were made.

Follow-up Rates

Notation of a specific time frame for follow-up by a primary care provider was found in 24 of 61 (39%) relevant patient charts (Table 3). 

Five patients were given follow-up times beyond the time frame of the study; therefore, calculations were based on the remaining 19 patients that were given specific instructions to follow-up in clinic before June of 2017. Seven (37%) returned for their follow-up visit within the time frame given by their provider during their initial visit and 12 patients (63%) failed to show during their advised follow-up period. A chi-square test confirmed that there was no significant difference in the follow-up rates between the intervention and prior year that was used for comparison (P = 0.99).

Further cross-tabulations were completed to assess if there were better follow-up rates for patients that received a Behavior Management Plan. The difference between the 2 groups was not significant (P = 0.99). There were no significant differences found in follow-up rates based on the provider for the visit (P = 0.51) or the type of patient visit (well child examination vs. behavior consult) (P = 0.65).

Discussion

This project aimed to improve provider confidence in the assessment and treatment of ADHD and improve ADHD management by providers at our clinic. We did not find significant changes in confidence according to the survey results. However, provider feedback indicated that, as a result of the educational sessions, they had a deeper appreciation for the presence of psychiatric comorbidities and the role they play in deciding appropriate treatment.  They also reported that they more fully understood the need to refer to child psychiatry for evaluation and management when comorbidities are present instead of attempting to independently provide ADHD medication.

We hoped to see the Behavior Management Plan used for patients with new behavior concerns during the evaluation for ADHD. During the intervention period, it was used in half of eligible clinic visits of patients without a prior diagnosis of ADHD. Future investigation should be directed at receiving specific input on the utility of the Behavior Management Plan from providers and families. The Management Plan contains important reminders and treatment information; however, if the plan is not perceived as effective or useful, taking the time needed to complete it may be seen as an additional cumbersome step in the already overloaded clinic visits.

The use of the Behavior Management Plan was not found to make a statistically significant difference in follow-up rates. Attendance at follow-up appointments for ADHD patients is not an area that has been greatly studied. In a recent analysis of ADHD treatment quality in Medicaid-enrolled children, African American families were less likely to have adequate follow-up compared to Caucasian counterparts during the initiation or  continuation and management phases of treatment. The review of specific follow-through rates showed that African Americans were 22% more likely to discontinue medication therapy and 13% more likely to disengage from treatment. The authors propose that future efforts focus on improving accessibility of behavioral therapy to combat the discontinuation rates and disparities in this area [8]. Another study that looked at a prospective cohort of ADHD patients found suboptimal attendance at appointments with a median of 1 visit every 6 months [9]. Further exploration of the challenges with attendance at follow-up appointments is warranted to help determine best practices for ADHD management in disadvantaged communities. More information is needed on the specific barriers to care in this subgroup at our clinic. However, data from this project related to adherence to follow-up appointments can be used to guide future studies.

Use of a Behavior Management Plan was not found to influence the return of completed teacher Vanderbilt scales by families. The rates of return of these assessment forms continue to be very low. Without input from teachers and schools, it is difficult to properly diagnose, treat and evaluate the treatment of patients. Feedback from all sources is essential for both medication management and construction of interventions for behavioral challenges at school. The development of partnerships with a child’s school may be useful in helping patients return for the treatment of behavior concerns at their initial stages. Before children are expelled multiple times due to their behavior, schools should strongly encourage parents to notify their healthcare provider of behavior concerns for evaluation.

In an ideal system, school-based nurses, guidance counselors or social workers could provide some case management and outreach to families of children with known behavior concerns to ensure they are attending appointments as recommended by their treatment plan and explore barriers to doing so. Social workers can provide direct mental health care services and make referrals to community agencies. However, the caseload for school-based providers is currently quite high and many children slip through the cracks until their behavior escalates to a dangerous and/or very disruptive level. School-based personnel in several districts are now required to split their time in multiple schools. Dang et al describe the piloting of a school-based framework for early identification and assessment of children suspected to have ADHD. The framework, called ADHD Identification and Management in Schools (AIMS), encourages school nurses to gather all parent and teacher assessment materials prior to the initial visit to their primary care providers thus reducing the number of visits needed and leading to faster diagnosis and treatment [10].

Clinic-based case managers solely dedicated to this population would also be useful. These case managers could provide management as described above and also potentially sit-in on clinic visits for behavior concerns so that they are fully aware of the instructions given by the provider. This would also give them the information needed so that they are able to complete forms such as the Behavior Management Plan, which would be helpful in relieving some provider time. Geltman et al trialed a workflow intervention with electronic Vanderbilt scales and an electronic registry managed by a care coordination team of a physician, nurse and medical assistant. This allowed patient calls to the families by the nurse or medical assistant to remind them of necessary follow-up and monthly meetings with the care coordination team. Those in the intervention group with the care coordination team were twice as likely to return the Vanderbilt questionnaires. During the intervention period, the rates of follow-up visits remained the same; however, when the intervention was further adopted and expanded to other sites, follow-up attendance improved to over 90% [11].

 

Limitations

Limitations of this project include the short time period in which it was conducted as well as the size of the study sample. Provider work schedules also caused some challenges with arranging the lunch and learn educational sessions and completing independent review of materials on the subject. This project focused on a primarily African American, predominately Medicaid population. Within urban and/or underserved populations, there may be other demographic distributions thus limiting the generalizability of these findings.

Summary

In summary, this project attempted to improve provider confidence in management of ADHD and standardize assessment practices of one urban pediatric clinic. At the project’s conclusion there were subjective improvements in provider confidence. Ongoing opportunities for continuing education on management of mental health diagnoses for primary care providers should persevere. This project also highlights the persistent problem of patient follow-up for behavior concerns. Further exploration of challenges with attendance at follow-up appointments including collaboration with community and academic resources is needed to help determine best practices for ADHD management in disadvantaged communities. 

Corresponding author: Jaytoya C. Manget, DNP, MSPH, FNP, jmanget@childrensnational.org.

Financial disclosures: None.

From the Children’s National Health System, Washington, DC (Dr. Manget, Dr. Kelley, Dr. White) and the Duke University School of Nursing, Durham, NC (Dr. Blood-Siegfried).

 

Abstract

• Background: Approximately 11% of children in the United States ages 4 to 17 have received the diagnosis of attention-deficit hyperactive disorder (ADHD). There are disproportionately higher rates of the diagnosis and fewer child psychiatrists available in underserved areas. The American Academy of Pediatrics (AAP) strongly encourages improved mental health competencies among primary care providers to combat this shortage.
• Objective: To improve primary care providers’ knowledge and confidence with the management of ADHD and institute an evidence-based process for assessing patients presenting with behavior concerns suggestive of ADHD.
• Methods: Three in-person educational sessions were conducted for primary care providers by a child psychiatrist to increase providers’ knowledge and confidence in the evaluation and management of ADHD. A Behavior Management Plan was also adopted for use in the clinic. Providers were encouraged to use the plan during patient visits for behavior concerns indicative of ADHD. Pre- and post-test surveys were given to providers to assess change in comfort level with managing ADHD. Patient charts were reviewed to determine how often the Behavior Management Plan was utilized.
• Results: We did not find significant changes in provider comfort in managing ADHD according to the survey results, although providers reported that the educational sessions and handouts were useful. Behavior Management Plans were utilized during 13 of 25 (52%) eligible visits.
• Conclusions: Behavior Management Plans were introduced in just over half of relevant visits. Further exploration about barriers to use of the plan and its utility to patients and families should be pursued in the future. Additionally, ongoing opportunities for continuing education and collaboration with psychiatry should continue to be sought.

Keywords: attention-deficit hyperactive disorder; ADHD; AAP clinical guidelines; underserved populations; disadvantaged communities.

 

The importance of the mental health of a child cannot be underestimated. Untreated symptoms of attention deficit/hyperactivity disorder (ADHD) can significantly interfere with school and social functioning [1]. Children with ADHD often have comorbid conditions such as anxiety, low self-esteem and learning disabilities. It is vital to screen and treat for ADHD and comorbidities early and comprehensively [2].

There are disproportionately higher rates of children diagnosed with ADHD living in underserved areas compared to other geographical regions [3]. The historically underserved Southeast region of Washington D.C. which encompasses Wards 7 and 8 is home to nearly 40% of the district’s children and has the highest rates of children with an ADHD diagnosis in D.C.; however, the majority of child psychiatrists are located in the Northwest regions [4]. In 2009, nearly 8% of children in Washington D.C. were reported to have a diagnosis of ADHD [1].

Due to the overwhelming demand and limited availability of child psychiatrists, it is important that primary care providers become better equipped to diagnose, treat, and manage non-complex cases of ADHD. Specific education about ADHD diagnosis and management along with implementation of standardized center-based processes may help primary care providers feel more comfortable caring for these patients and ensure that all patients presenting with behavior concerns are adequately assessed and treated.

The American Academy of Pediatrics (AAP) recommends that primary care providers expand their mental health competencies because pediatric primary care providers in the medical home will be the first point of access in most cases [5]. In 2011, the AAP Subcommittee on ADHD and Steering Committee on Quality Improvement and Management released clinical practice guidelines for diagnosis, evaluation, and treatment of ADHD [6]. These guidelines, which recommend that providers should initiate ADHD assessments for children ages 6 to 12 that present with behavioral and/or academic problems, have been incorporated into “Caring for Children with ADHD: A Resource Toolkit for Clinicians” by the AAP in partnership with the National Institute on Children’s Health Quality (NICHQ) and North Carolina’s Center for Child Health.

Our clinic has two on-site psychiatrists who provide evaluation and treatment of mental health problems in children identified by primary care providers for a combined total of 1.5 days each week. The current wait for psychiatric evaluation at our clinic is 2 to 3 months, which leaves the primary care providers to care for many children with behavior concerns who require more immediate intervention at the time of their presentation. Our clinic providers revealed that they felt there were deficits in the management of behavior concerns and initiating treatment for patients diagnosed with ADHD in the clinic. Providers expressed an interest in refreshing and enhancing their knowledge related to managing patients with ADHD.

To address this issue, we initiated a quality improvement project with several facets: provide ADHD education to primary care providers through use of educational sessions from our on-site psychiatrists, standardize the process of managing patients that present with behavior concerns to the primary care provider in the medical home, and develop a comprehensive and individualized patient management plan based on the “Caring for Children with ADHD” toolkit for clinicians.

Methods

Setting

This project took place in a federally qualified health center located in the Southeast quadrant of Washington, D.C. that serves patients up to 23 years of age. The clinic has 6 primary care medical providers (5 physicians and 1 nurse practitioner) employed in a part-time to full-time capacity. Additionally, 2 child psychiatrists provide services on-site during one full day and one half-day session on a weekly basis. Approximately 98% of patients at the clinic are classified as African American and close to 95% of patients are insured by Medicaid. Approximately 9% of patients in our clinic had a medical diagnosis of ADHD as of 2015.

Patients who presented to the clinic in April and May 2017 who had an existing diagnosis of ADHD and those with documentation of a new behavior concern in the assessment and treatment plan were studied. Eligible visit types were annual well-child checks, new consults for behavior, and follow-up appointments specifically for behavior.

This was a project undertaken as a quality improvement initiative at the hosting facility and did not constitute human subjects research. As such, it was not under the oversight of the institutional review board.

Intervention

Provider Education. Three in-person sessions were held at the clinic during April–May 2017 to provide education on the assessment and treatment of patients with ADHD and discuss challenges that have arisen when providing care for such patients. The sessions focused on diagnosing ADHD and teasing out comorbidities; initiating and titrating medications safely; educational rights; and strategies for managing behavior and community resources.

Current providers as well as medical residents and student trainees of the clinic were invited to attend the educational sessions. Each session followed a “lunch and learn” format where one of the clinic psychiatrists presented the information during the clinic lunch hour then related a discussion where participants asked questions. The information provided was derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) and the AAP/NICHQ Toolkit [5]. Educational handouts were disseminated during the provider sessions and emailed to all providers afterwards.

Behavior Management Plan. In March we introduced the providers to the Behavior Management Plan (Figure), 

 

which we adapted from the 2011 AAP/NICHQ Toolkit [5]. The Behavior Management Plan was intended for use during all clinic visits with a presenting complaint suggestive of ADHD. The plan, when completed with the family, helps ensure a comprehensive assessment has been performed and details specific individualized patient goals and the plans to reach them. It encourages families to complete Vanderbilt ADHD assessment scales and instructs them to have teachers complete and return them. Vanderbilt Assessment Scales were published by the AAP and NICHQ in 2002 as a tool to aid in the diagnosis of ADHD for children between the ages of 6 and 12 [7]. The Behavior Management Plan also encourages the providers to offer parents useful handouts, sample letters to the school and referrals to community agencies. Lastly, it advises families to return for subsequent clinic visits and gives the family a clear date and instructions for follow-up.

Providers were encouraged to initiate the Behavior Management Plan for patients that presented without an existing diagnosis for evaluation of their behavior concerns. The plan could also be used for patients that had previously been diagnosed with ADHD if changes were being made to their treatment plan or as a summary of their established treatment details. Instructions on the use of the plan were given to all clinic primary care providers through email communication as well as in the first in-person educational session. It was stressed to providers that formulating individual patient goals and the inclusion of a specific follow-up time were the most important aspects of the plan.

Assessment and Measurements

We assessed provider comfort in their ADHD evaluation and management skills before and after the intervention using a 5–point Likert scale questionnaire with 0 indicating “not comfortable at all” and 5 corresponding to “very comfortable.” The questionnaire was administered via a paper survey for the initial screening and an electronic survey at the conclusion of the intervention.

Patient charts were reviewed in July 2017 to determine how often the Behavior Management Plan was utilized. Provider documentation in the electronic medical record indicating that the Plan was given during the patient visit was considered utilization of the plan. We also examined documentation of dissemination/return of Vanderbilt ADHD assessment scales, referrals to psychiatry or counseling, and the initiation or refill of an ADHD medication during the encounter for all patients that were seen for behavior concerns. Patient data were obtained from manual chart review of the electronic medical record, eClinicalWorks.

 

Analysis

SPSS Statistics (Version 24) was used to conduct analyses. Independent sample t tests were employed to measure items related to the provider educational sessions. Mean provider responses for each item were reviewed from descriptive statistics. A chi-square cross tabulation was used to compare the percentage of patients receiving a Behavior Management Plan that adhered to follow-up visits versus a similar sample of patients that presented in 2016 before the introduction of the Behavior Management Plan. In addition, a chi-square cross tabulation was utilized to compare adherence to follow-up visits in those that received the Management Plan to that of eligible patients that presented during the same time period but did not receive the Plan. Additional chi-square tests were run to see if there was any difference in 2017 follow-up rates based on individual provider or visit type .

Results

Provider Questionnaire

Six providers responded to the pre-intervention questionnaire and five to the post-intervention questionnaire. The specific questions and their results are listed in Table 1.

Patient Management

Between April and May 2017, 61 eligible patients presented to the clinic. Details of the breakdown of patient visit type are displayed in Table 2. 

The majority of patients presented with concerns during their well-child visits. Over half of patients presenting for behavioral concerns (57%) already had a diagnosis of ADHD. Of those without a previous diagnosis, Behavior Management Plans were given during 52% (13 of 25) of visits. Two patients with an active diagnosis of ADHD were given Behavior Management Plans as changes to their medications or treatment plans were made.

Follow-up Rates

Notation of a specific time frame for follow-up by a primary care provider was found in 24 of 61 (39%) relevant patient charts (Table 3). 

Five patients were given follow-up times beyond the time frame of the study; therefore, calculations were based on the remaining 19 patients that were given specific instructions to follow-up in clinic before June of 2017. Seven (37%) returned for their follow-up visit within the time frame given by their provider during their initial visit and 12 patients (63%) failed to show during their advised follow-up period. A chi-square test confirmed that there was no significant difference in the follow-up rates between the intervention and prior year that was used for comparison (P = 0.99).

Further cross-tabulations were completed to assess if there were better follow-up rates for patients that received a Behavior Management Plan. The difference between the 2 groups was not significant (P = 0.99). There were no significant differences found in follow-up rates based on the provider for the visit (P = 0.51) or the type of patient visit (well child examination vs. behavior consult) (P = 0.65).

Discussion

This project aimed to improve provider confidence in the assessment and treatment of ADHD and improve ADHD management by providers at our clinic. We did not find significant changes in confidence according to the survey results. However, provider feedback indicated that, as a result of the educational sessions, they had a deeper appreciation for the presence of psychiatric comorbidities and the role they play in deciding appropriate treatment.  They also reported that they more fully understood the need to refer to child psychiatry for evaluation and management when comorbidities are present instead of attempting to independently provide ADHD medication.

We hoped to see the Behavior Management Plan used for patients with new behavior concerns during the evaluation for ADHD. During the intervention period, it was used in half of eligible clinic visits of patients without a prior diagnosis of ADHD. Future investigation should be directed at receiving specific input on the utility of the Behavior Management Plan from providers and families. The Management Plan contains important reminders and treatment information; however, if the plan is not perceived as effective or useful, taking the time needed to complete it may be seen as an additional cumbersome step in the already overloaded clinic visits.

The use of the Behavior Management Plan was not found to make a statistically significant difference in follow-up rates. Attendance at follow-up appointments for ADHD patients is not an area that has been greatly studied. In a recent analysis of ADHD treatment quality in Medicaid-enrolled children, African American families were less likely to have adequate follow-up compared to Caucasian counterparts during the initiation or  continuation and management phases of treatment. The review of specific follow-through rates showed that African Americans were 22% more likely to discontinue medication therapy and 13% more likely to disengage from treatment. The authors propose that future efforts focus on improving accessibility of behavioral therapy to combat the discontinuation rates and disparities in this area [8]. Another study that looked at a prospective cohort of ADHD patients found suboptimal attendance at appointments with a median of 1 visit every 6 months [9]. Further exploration of the challenges with attendance at follow-up appointments is warranted to help determine best practices for ADHD management in disadvantaged communities. More information is needed on the specific barriers to care in this subgroup at our clinic. However, data from this project related to adherence to follow-up appointments can be used to guide future studies.

Use of a Behavior Management Plan was not found to influence the return of completed teacher Vanderbilt scales by families. The rates of return of these assessment forms continue to be very low. Without input from teachers and schools, it is difficult to properly diagnose, treat and evaluate the treatment of patients. Feedback from all sources is essential for both medication management and construction of interventions for behavioral challenges at school. The development of partnerships with a child’s school may be useful in helping patients return for the treatment of behavior concerns at their initial stages. Before children are expelled multiple times due to their behavior, schools should strongly encourage parents to notify their healthcare provider of behavior concerns for evaluation.

In an ideal system, school-based nurses, guidance counselors or social workers could provide some case management and outreach to families of children with known behavior concerns to ensure they are attending appointments as recommended by their treatment plan and explore barriers to doing so. Social workers can provide direct mental health care services and make referrals to community agencies. However, the caseload for school-based providers is currently quite high and many children slip through the cracks until their behavior escalates to a dangerous and/or very disruptive level. School-based personnel in several districts are now required to split their time in multiple schools. Dang et al describe the piloting of a school-based framework for early identification and assessment of children suspected to have ADHD. The framework, called ADHD Identification and Management in Schools (AIMS), encourages school nurses to gather all parent and teacher assessment materials prior to the initial visit to their primary care providers thus reducing the number of visits needed and leading to faster diagnosis and treatment [10].

Clinic-based case managers solely dedicated to this population would also be useful. These case managers could provide management as described above and also potentially sit-in on clinic visits for behavior concerns so that they are fully aware of the instructions given by the provider. This would also give them the information needed so that they are able to complete forms such as the Behavior Management Plan, which would be helpful in relieving some provider time. Geltman et al trialed a workflow intervention with electronic Vanderbilt scales and an electronic registry managed by a care coordination team of a physician, nurse and medical assistant. This allowed patient calls to the families by the nurse or medical assistant to remind them of necessary follow-up and monthly meetings with the care coordination team. Those in the intervention group with the care coordination team were twice as likely to return the Vanderbilt questionnaires. During the intervention period, the rates of follow-up visits remained the same; however, when the intervention was further adopted and expanded to other sites, follow-up attendance improved to over 90% [11].

 

Limitations

Limitations of this project include the short time period in which it was conducted as well as the size of the study sample. Provider work schedules also caused some challenges with arranging the lunch and learn educational sessions and completing independent review of materials on the subject. This project focused on a primarily African American, predominately Medicaid population. Within urban and/or underserved populations, there may be other demographic distributions thus limiting the generalizability of these findings.

Summary

In summary, this project attempted to improve provider confidence in management of ADHD and standardize assessment practices of one urban pediatric clinic. At the project’s conclusion there were subjective improvements in provider confidence. Ongoing opportunities for continuing education on management of mental health diagnoses for primary care providers should persevere. This project also highlights the persistent problem of patient follow-up for behavior concerns. Further exploration of challenges with attendance at follow-up appointments including collaboration with community and academic resources is needed to help determine best practices for ADHD management in disadvantaged communities. 

Corresponding author: Jaytoya C. Manget, DNP, MSPH, FNP, jmanget@childrensnational.org.

Financial disclosures: None.

A fussy 6-month-old infant is brought to the emergency department (ED) with a rectal temperature of 101.5°F. She is consolable, breathing normally, and appears well hydrated. You find no clear etiology for her fever and suspect that a urinary tract infection (UTI) may be the source of her illness. How do you proceed with obtaining a urine sample?

A  febrile infant in a family practice office or ED is a familiar clinical situation that may require an invasive diagnostic workup. Up to 7% of infants ages 2 to 24 months with fever of unknown origin may have a UTI.² Collecting a urine sample from pre–toilet-trained children can be time consuming. In fact, in one RCT, obtaining a clean-catch urine sample in this age group took more than an hour, on average.³ But more convenient methods of urine collection, such as placing a cotton ball in the diaper or using a perineal collection bag, have contamination rates of up to 63%.⁴

In its guidelines for evaluating possible UTI in a febrile child younger than age 2, the American Academy of Pediatrics (AAP) recommends obtaining a sample for urinalysis “through the most convenient means.”⁵ If urinalysis is positive, only urine obtained by catheterization or suprapubic aspiration should be cultured. Guidelines from the National Institute for Health and Care Excellence in the United Kingdom are similar, but allow for culture of clean-catch urine samples.⁶

A recent prospective cohort study examined a noninvasive alternating lumbar-bladder tapping method to stimulate voiding in infants ages 6 months or younger.⁷ Within five minutes, 49% of the infants provided a clean-catch sample, with contamination rates similar to those of samples obtained using invasive methods.⁷ Younger infants were more likely to void within the time allotted. Another trial of bladder tapping conducted in hospitalized infants younger than 30 days old showed similar results.⁸ There are, however, no previously reported randomized trials demonstrating the efficacy of a noninvasive urine collection technique in the outpatient setting.

Use of invasive collection methods requires skilled personnel and may cause significant discomfort for patients (and parents). Noninvasive methods, such as bag urine collection, have unacceptable contamination rates. In addition, waiting to catch a potentially cleaner urine sample is time consuming, so better strategies to collect urine from infants are needed. This RCT is the first to examine the efficacy of a unique stimulation technique to obtain a clean-catch urine sample from infants ages 1 to 12 months.

STUDY SUMMARY

Noninvasive stimulation triggers faster samples

A nonblinded, single-center RCT conducted in Australia compared two methods for obtaining a clean-catch urine sample within five minutes: the Quick-Wee method (suprapubic stimulation with gauze soaked in cold fluid) or usual care (waiting for spontaneous voiding with no stimulation).¹ A total of 354 infants (ages 1-12 mo) who required urine sample collection were randomized in a 1:1 ratio; allocation was concealed. Infants with anatomic or neurologic abnormalities and those needing immediate antibiotic therapy were excluded.

The most common reasons for obtaining the urine sample were fever of unknown origin and “unsettled baby,” followed by poor feeding and suspected UTI. The primary outcome was voiding within five minutes; secondary outcomes included time to void, whether urine was successfully caught, contamination rate, and parent/clinician satisfaction.

Study personnel removed the diaper, then cleaned the genitals of all patients with room temperature sterile water. A caregiver or clinician was ready and waiting to catch urine when the patient voided. In the Quick-Wee group, a clinician rubbed the patient’s suprapubic area in a circular fashion with gauze soaked in refrigerated saline (2.8°C). At five minutes, clinicians recorded the voiding status and decided how to proceed.

Using intention-to-treat analysis, 31% of the patients in the Quick-Wee group voided within five minutes, compared with 12% of the usual-care patients. Similarly, 30% of patients in the Quick-Wee group provided a successful clean-catch sample within five minutes, compared with 9% in the usual-care group (number needed to treat, 4.7).

Contamination rates were no different between the Quick-Wee and usual-care samples. Both parents and clinicians were more satisfied with the Quick-Wee method than with usual care (median score of 2 vs 3 on a 5-point Likert scale, in which 1 is “most satisfied”). There was no difference when results were adjusted for age or sex. No adverse events occurred.

Continue to: WHAT'S NEW

 

 

WHAT’S NEW

Method could reduce need for invasive sampling

A simple suprapubic stimulation technique increased the number of infants who provided a clean-catch voided urine sample within five minutes—a clinically relevant and satisfying outcome. In appropriate patients, use of the Quick-Wee method to obtain a clean-catch voided sample for initial urinalysis, rather than attempting methods with known high contamination rates, may potentially reduce the need for invasive sampling using catheterization or suprapubic aspiration.

Credit: Shutterstock/Atstock Productions

CAVEATS

Complete age range & ideal storage temperature are unknown

Neonates and precontinent children older than 12 months were not included in this trial, so these conclusions do not apply to those groups. The intervention period lasted only five minutes, but other published studies suggest that this amount of time is adequate for voiding to occur.^6,7 Although this study used soaking fluid stored at 2.8°C, the ideal storage temperature is unknown.

CHALLENGES TO IMPLEMENTATION

AAP doesn’t endorse clean-catch urine samples

The Quick-Wee method is simple and easy to implement, and requires no specialized training or equipment. AAP guidelines do not endorse the use of clean-catch voided urine for culture, which may be a barrier to changing urine collection practices in some settings.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Copyright © 2018. The Family Physicians Inquiries Network. All rights reserved.

Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice (2018;67[3]: 166, 168-169).

A fussy 6-month-old infant is brought to the emergency department (ED) with a rectal temperature of 101.5°F. She is consolable, breathing normally, and appears well hydrated. You find no clear etiology for her fever and suspect that a urinary tract infection (UTI) may be the source of her illness. How do you proceed with obtaining a urine sample?

A  febrile infant in a family practice office or ED is a familiar clinical situation that may require an invasive diagnostic workup. Up to 7% of infants ages 2 to 24 months with fever of unknown origin may have a UTI.² Collecting a urine sample from pre–toilet-trained children can be time consuming. In fact, in one RCT, obtaining a clean-catch urine sample in this age group took more than an hour, on average.³ But more convenient methods of urine collection, such as placing a cotton ball in the diaper or using a perineal collection bag, have contamination rates of up to 63%.⁴

In its guidelines for evaluating possible UTI in a febrile child younger than age 2, the American Academy of Pediatrics (AAP) recommends obtaining a sample for urinalysis “through the most convenient means.”⁵ If urinalysis is positive, only urine obtained by catheterization or suprapubic aspiration should be cultured. Guidelines from the National Institute for Health and Care Excellence in the United Kingdom are similar, but allow for culture of clean-catch urine samples.⁶

A recent prospective cohort study examined a noninvasive alternating lumbar-bladder tapping method to stimulate voiding in infants ages 6 months or younger.⁷ Within five minutes, 49% of the infants provided a clean-catch sample, with contamination rates similar to those of samples obtained using invasive methods.⁷ Younger infants were more likely to void within the time allotted. Another trial of bladder tapping conducted in hospitalized infants younger than 30 days old showed similar results.⁸ There are, however, no previously reported randomized trials demonstrating the efficacy of a noninvasive urine collection technique in the outpatient setting.

Use of invasive collection methods requires skilled personnel and may cause significant discomfort for patients (and parents). Noninvasive methods, such as bag urine collection, have unacceptable contamination rates. In addition, waiting to catch a potentially cleaner urine sample is time consuming, so better strategies to collect urine from infants are needed. This RCT is the first to examine the efficacy of a unique stimulation technique to obtain a clean-catch urine sample from infants ages 1 to 12 months.

STUDY SUMMARY

Noninvasive stimulation triggers faster samples

A nonblinded, single-center RCT conducted in Australia compared two methods for obtaining a clean-catch urine sample within five minutes: the Quick-Wee method (suprapubic stimulation with gauze soaked in cold fluid) or usual care (waiting for spontaneous voiding with no stimulation).¹ A total of 354 infants (ages 1-12 mo) who required urine sample collection were randomized in a 1:1 ratio; allocation was concealed. Infants with anatomic or neurologic abnormalities and those needing immediate antibiotic therapy were excluded.

The most common reasons for obtaining the urine sample were fever of unknown origin and “unsettled baby,” followed by poor feeding and suspected UTI. The primary outcome was voiding within five minutes; secondary outcomes included time to void, whether urine was successfully caught, contamination rate, and parent/clinician satisfaction.

Study personnel removed the diaper, then cleaned the genitals of all patients with room temperature sterile water. A caregiver or clinician was ready and waiting to catch urine when the patient voided. In the Quick-Wee group, a clinician rubbed the patient’s suprapubic area in a circular fashion with gauze soaked in refrigerated saline (2.8°C). At five minutes, clinicians recorded the voiding status and decided how to proceed.

Using intention-to-treat analysis, 31% of the patients in the Quick-Wee group voided within five minutes, compared with 12% of the usual-care patients. Similarly, 30% of patients in the Quick-Wee group provided a successful clean-catch sample within five minutes, compared with 9% in the usual-care group (number needed to treat, 4.7).

Contamination rates were no different between the Quick-Wee and usual-care samples. Both parents and clinicians were more satisfied with the Quick-Wee method than with usual care (median score of 2 vs 3 on a 5-point Likert scale, in which 1 is “most satisfied”). There was no difference when results were adjusted for age or sex. No adverse events occurred.

Continue to: WHAT'S NEW

 

 

WHAT’S NEW

Method could reduce need for invasive sampling

A simple suprapubic stimulation technique increased the number of infants who provided a clean-catch voided urine sample within five minutes—a clinically relevant and satisfying outcome. In appropriate patients, use of the Quick-Wee method to obtain a clean-catch voided sample for initial urinalysis, rather than attempting methods with known high contamination rates, may potentially reduce the need for invasive sampling using catheterization or suprapubic aspiration.

Credit: Shutterstock/Atstock Productions

CAVEATS

Complete age range & ideal storage temperature are unknown

Neonates and precontinent children older than 12 months were not included in this trial, so these conclusions do not apply to those groups. The intervention period lasted only five minutes, but other published studies suggest that this amount of time is adequate for voiding to occur.^6,7 Although this study used soaking fluid stored at 2.8°C, the ideal storage temperature is unknown.

CHALLENGES TO IMPLEMENTATION

AAP doesn’t endorse clean-catch urine samples

The Quick-Wee method is simple and easy to implement, and requires no specialized training or equipment. AAP guidelines do not endorse the use of clean-catch voided urine for culture, which may be a barrier to changing urine collection practices in some settings.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Copyright © 2018. The Family Physicians Inquiries Network. All rights reserved.

Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice (2018;67[3]: 166, 168-169).

A fussy 6-month-old infant is brought to the emergency department (ED) with a rectal temperature of 101.5°F. She is consolable, breathing normally, and appears well hydrated. You find no clear etiology for her fever and suspect that a urinary tract infection (UTI) may be the source of her illness. How do you proceed with obtaining a urine sample?

A  febrile infant in a family practice office or ED is a familiar clinical situation that may require an invasive diagnostic workup. Up to 7% of infants ages 2 to 24 months with fever of unknown origin may have a UTI.² Collecting a urine sample from pre–toilet-trained children can be time consuming. In fact, in one RCT, obtaining a clean-catch urine sample in this age group took more than an hour, on average.³ But more convenient methods of urine collection, such as placing a cotton ball in the diaper or using a perineal collection bag, have contamination rates of up to 63%.⁴

In its guidelines for evaluating possible UTI in a febrile child younger than age 2, the American Academy of Pediatrics (AAP) recommends obtaining a sample for urinalysis “through the most convenient means.”⁵ If urinalysis is positive, only urine obtained by catheterization or suprapubic aspiration should be cultured. Guidelines from the National Institute for Health and Care Excellence in the United Kingdom are similar, but allow for culture of clean-catch urine samples.⁶

A recent prospective cohort study examined a noninvasive alternating lumbar-bladder tapping method to stimulate voiding in infants ages 6 months or younger.⁷ Within five minutes, 49% of the infants provided a clean-catch sample, with contamination rates similar to those of samples obtained using invasive methods.⁷ Younger infants were more likely to void within the time allotted. Another trial of bladder tapping conducted in hospitalized infants younger than 30 days old showed similar results.⁸ There are, however, no previously reported randomized trials demonstrating the efficacy of a noninvasive urine collection technique in the outpatient setting.

Use of invasive collection methods requires skilled personnel and may cause significant discomfort for patients (and parents). Noninvasive methods, such as bag urine collection, have unacceptable contamination rates. In addition, waiting to catch a potentially cleaner urine sample is time consuming, so better strategies to collect urine from infants are needed. This RCT is the first to examine the efficacy of a unique stimulation technique to obtain a clean-catch urine sample from infants ages 1 to 12 months.

STUDY SUMMARY

Noninvasive stimulation triggers faster samples

A nonblinded, single-center RCT conducted in Australia compared two methods for obtaining a clean-catch urine sample within five minutes: the Quick-Wee method (suprapubic stimulation with gauze soaked in cold fluid) or usual care (waiting for spontaneous voiding with no stimulation).¹ A total of 354 infants (ages 1-12 mo) who required urine sample collection were randomized in a 1:1 ratio; allocation was concealed. Infants with anatomic or neurologic abnormalities and those needing immediate antibiotic therapy were excluded.

The most common reasons for obtaining the urine sample were fever of unknown origin and “unsettled baby,” followed by poor feeding and suspected UTI. The primary outcome was voiding within five minutes; secondary outcomes included time to void, whether urine was successfully caught, contamination rate, and parent/clinician satisfaction.

Study personnel removed the diaper, then cleaned the genitals of all patients with room temperature sterile water. A caregiver or clinician was ready and waiting to catch urine when the patient voided. In the Quick-Wee group, a clinician rubbed the patient’s suprapubic area in a circular fashion with gauze soaked in refrigerated saline (2.8°C). At five minutes, clinicians recorded the voiding status and decided how to proceed.

Using intention-to-treat analysis, 31% of the patients in the Quick-Wee group voided within five minutes, compared with 12% of the usual-care patients. Similarly, 30% of patients in the Quick-Wee group provided a successful clean-catch sample within five minutes, compared with 9% in the usual-care group (number needed to treat, 4.7).

Contamination rates were no different between the Quick-Wee and usual-care samples. Both parents and clinicians were more satisfied with the Quick-Wee method than with usual care (median score of 2 vs 3 on a 5-point Likert scale, in which 1 is “most satisfied”). There was no difference when results were adjusted for age or sex. No adverse events occurred.

Continue to: WHAT'S NEW

 

 

WHAT’S NEW

Method could reduce need for invasive sampling

A simple suprapubic stimulation technique increased the number of infants who provided a clean-catch voided urine sample within five minutes—a clinically relevant and satisfying outcome. In appropriate patients, use of the Quick-Wee method to obtain a clean-catch voided sample for initial urinalysis, rather than attempting methods with known high contamination rates, may potentially reduce the need for invasive sampling using catheterization or suprapubic aspiration.

Credit: Shutterstock/Atstock Productions

CAVEATS

Complete age range & ideal storage temperature are unknown

Neonates and precontinent children older than 12 months were not included in this trial, so these conclusions do not apply to those groups. The intervention period lasted only five minutes, but other published studies suggest that this amount of time is adequate for voiding to occur.^6,7 Although this study used soaking fluid stored at 2.8°C, the ideal storage temperature is unknown.

CHALLENGES TO IMPLEMENTATION

AAP doesn’t endorse clean-catch urine samples

The Quick-Wee method is simple and easy to implement, and requires no specialized training or equipment. AAP guidelines do not endorse the use of clean-catch voided urine for culture, which may be a barrier to changing urine collection practices in some settings.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Copyright © 2018. The Family Physicians Inquiries Network. All rights reserved.

Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice (2018;67[3]: 166, 168-169).

Special consideration should be given to female-to-male transgender patients because of the dermatologic effects of testosterone, and possibly accompanying depression, according to the results of a case series.

“Acne is a foreseeable adverse effect of testosterone treatment in transgender adolescents, and it may be advisable that, once such treatment has begun, they be monitored for the appearance of acne,” Lucia Campos-Munoz, MD, of the Hospital Clinico San Carlos in Madrid wrote in Pediatric Dermatology. “Even if only mild, treatment should be provided.”

Dr. Campos-Munoz and her colleagues examined five female-to-male transgender patients who were admitted to their clinic from 2016-2017. All five patients presented with testosterone-associated acne. Two patients with severe acne were treated with 20 mg/day of isotretinoin. While one patient tolerated this well and discontinued treatment after 4 months, another patient stopped treatment because of a bout of depression at 3 months. The remaining patients received other treatments, including doxycycline, 0.05 topical tretinoin, and 3% benzoyl peroxide.

This case study highlights the unique role that dermatologists and primary care providers play in treating acne in female-to-male transgender patients. Using the proper pronouns and recognizing that physical examinations of the chest and thorax may be especially embarrassing for these patients are important considerations, according to Dr. Campos-Munoz and her colleagues. Also, neither antiandrogenic agents nor contraceptives can be given because “this would conflict with the masculinization sought.”

Apart from being aware of the patients’ feelings, there are real medical concerns associated with dermatologic treatment of acne in female-to-male transgender patients. One of these risks is depression, which several studies have shown to be associated with severe acne. This is compounded by higher rates of depression and suicidal ideation in transgender adolescents, they said.

 

An additional concern is the teratogenic effects of isotretinoin in patients with natal female internal genitalia. While these patients may not think they can get pregnant because of testosterone-associated amenorrhea, the potential is still present and pregnancy should be avoided, Dr. Campos-Munoz and her colleagues warned.

No funding or conflicts of interest were disclosed.

ilacy@mdedge.com

SOURCE: Campos-Munoz L et al. Pediatr Dermatol. 2018 Mar 25. doi: 10.1111/pde.13448.

Special consideration should be given to female-to-male transgender patients because of the dermatologic effects of testosterone, and possibly accompanying depression, according to the results of a case series.

“Acne is a foreseeable adverse effect of testosterone treatment in transgender adolescents, and it may be advisable that, once such treatment has begun, they be monitored for the appearance of acne,” Lucia Campos-Munoz, MD, of the Hospital Clinico San Carlos in Madrid wrote in Pediatric Dermatology. “Even if only mild, treatment should be provided.”

Dr. Campos-Munoz and her colleagues examined five female-to-male transgender patients who were admitted to their clinic from 2016-2017. All five patients presented with testosterone-associated acne. Two patients with severe acne were treated with 20 mg/day of isotretinoin. While one patient tolerated this well and discontinued treatment after 4 months, another patient stopped treatment because of a bout of depression at 3 months. The remaining patients received other treatments, including doxycycline, 0.05 topical tretinoin, and 3% benzoyl peroxide.

This case study highlights the unique role that dermatologists and primary care providers play in treating acne in female-to-male transgender patients. Using the proper pronouns and recognizing that physical examinations of the chest and thorax may be especially embarrassing for these patients are important considerations, according to Dr. Campos-Munoz and her colleagues. Also, neither antiandrogenic agents nor contraceptives can be given because “this would conflict with the masculinization sought.”

Apart from being aware of the patients’ feelings, there are real medical concerns associated with dermatologic treatment of acne in female-to-male transgender patients. One of these risks is depression, which several studies have shown to be associated with severe acne. This is compounded by higher rates of depression and suicidal ideation in transgender adolescents, they said.

 

An additional concern is the teratogenic effects of isotretinoin in patients with natal female internal genitalia. While these patients may not think they can get pregnant because of testosterone-associated amenorrhea, the potential is still present and pregnancy should be avoided, Dr. Campos-Munoz and her colleagues warned.

No funding or conflicts of interest were disclosed.

ilacy@mdedge.com

SOURCE: Campos-Munoz L et al. Pediatr Dermatol. 2018 Mar 25. doi: 10.1111/pde.13448.

Special consideration should be given to female-to-male transgender patients because of the dermatologic effects of testosterone, and possibly accompanying depression, according to the results of a case series.

“Acne is a foreseeable adverse effect of testosterone treatment in transgender adolescents, and it may be advisable that, once such treatment has begun, they be monitored for the appearance of acne,” Lucia Campos-Munoz, MD, of the Hospital Clinico San Carlos in Madrid wrote in Pediatric Dermatology. “Even if only mild, treatment should be provided.”

Dr. Campos-Munoz and her colleagues examined five female-to-male transgender patients who were admitted to their clinic from 2016-2017. All five patients presented with testosterone-associated acne. Two patients with severe acne were treated with 20 mg/day of isotretinoin. While one patient tolerated this well and discontinued treatment after 4 months, another patient stopped treatment because of a bout of depression at 3 months. The remaining patients received other treatments, including doxycycline, 0.05 topical tretinoin, and 3% benzoyl peroxide.

This case study highlights the unique role that dermatologists and primary care providers play in treating acne in female-to-male transgender patients. Using the proper pronouns and recognizing that physical examinations of the chest and thorax may be especially embarrassing for these patients are important considerations, according to Dr. Campos-Munoz and her colleagues. Also, neither antiandrogenic agents nor contraceptives can be given because “this would conflict with the masculinization sought.”

Apart from being aware of the patients’ feelings, there are real medical concerns associated with dermatologic treatment of acne in female-to-male transgender patients. One of these risks is depression, which several studies have shown to be associated with severe acne. This is compounded by higher rates of depression and suicidal ideation in transgender adolescents, they said.

 

An additional concern is the teratogenic effects of isotretinoin in patients with natal female internal genitalia. While these patients may not think they can get pregnant because of testosterone-associated amenorrhea, the potential is still present and pregnancy should be avoided, Dr. Campos-Munoz and her colleagues warned.

No funding or conflicts of interest were disclosed.

ilacy@mdedge.com

SOURCE: Campos-Munoz L et al. Pediatr Dermatol. 2018 Mar 25. doi: 10.1111/pde.13448.

 

Chikungunya infections in young children resemble skin symptoms characteristic of Stevens-Johnson syndrome and toxic epidermal necrolysis, (SJS-TEN), according to data from a case series of 21 children seen during a chikungunya outbreak in India in August and September 2016.

CDC/Cynthia Goldsmith

“Cutaneous involvement in chikungunya is seen in 40%-75% of patients,” having varied presentations, wrote Taru Garg, MD, and colleagues at the Lady Hardinge Medical College and Associated Hospitals, New Delhi, India. Chikungunya mimicking SJS-TEN is rare: 96 cases have been reported in the literature, to the investigators’ knowledge.

The researchers described their observations of 13 boys and eight girls aged 1-36 months in Pediatric Dermatology. All 21 children presented with vesiculobullous and necrotic lesions and mild to moderate fever; 16 children (76%) had large erosions, purpuric macules, and necrosis. Most of the lesions occurred on the extremities.

The time from the onset of illness to presentation ranged from 1 to 9 days, and the skin lesions resolved in 5-7 days. The lesions resolved with no sequelae in 11 patients, with hyperpigmentation in seven (33%) , and with hypopigmentation in three patients (14%).

In addition, three patients (14%) developed minor oral erosions, and four (19%) developed palmoplantar erythema, which also may be associated with SJS-TEN. However, none of the patients experienced the severe mucositis and ocular and genital involvement common to SJS-TEN, Dr. Garg and associates noted. A total of seven children tested positive for chikungunya based on enzyme-linked immunosorbent assay results.

Severity of illness can be helpful to distinguish chikungunya from SJS-TEN, the researchers said. Based on the Nelson severity index, 11 children in this series met the criteria for “not sick,” nine were “moderately sick,” and one was “very sick.”

 

It is key “to be aware of SJS-TEN–like presentation of chikungunya and not to misinterpret it as true SJS-TEN, which will lead to unnecessary intervention and management,” Dr. Garg and associates said.

The researchers had no financial conflicts to disclose.

SOURCE: Garg T et al. Pediatr Dermatol. 2018 Mar 24. doi: 10.1111/pde.13450.

 

Chikungunya infections in young children resemble skin symptoms characteristic of Stevens-Johnson syndrome and toxic epidermal necrolysis, (SJS-TEN), according to data from a case series of 21 children seen during a chikungunya outbreak in India in August and September 2016.

CDC/Cynthia Goldsmith

“Cutaneous involvement in chikungunya is seen in 40%-75% of patients,” having varied presentations, wrote Taru Garg, MD, and colleagues at the Lady Hardinge Medical College and Associated Hospitals, New Delhi, India. Chikungunya mimicking SJS-TEN is rare: 96 cases have been reported in the literature, to the investigators’ knowledge.

The researchers described their observations of 13 boys and eight girls aged 1-36 months in Pediatric Dermatology. All 21 children presented with vesiculobullous and necrotic lesions and mild to moderate fever; 16 children (76%) had large erosions, purpuric macules, and necrosis. Most of the lesions occurred on the extremities.

The time from the onset of illness to presentation ranged from 1 to 9 days, and the skin lesions resolved in 5-7 days. The lesions resolved with no sequelae in 11 patients, with hyperpigmentation in seven (33%) , and with hypopigmentation in three patients (14%).

In addition, three patients (14%) developed minor oral erosions, and four (19%) developed palmoplantar erythema, which also may be associated with SJS-TEN. However, none of the patients experienced the severe mucositis and ocular and genital involvement common to SJS-TEN, Dr. Garg and associates noted. A total of seven children tested positive for chikungunya based on enzyme-linked immunosorbent assay results.

Severity of illness can be helpful to distinguish chikungunya from SJS-TEN, the researchers said. Based on the Nelson severity index, 11 children in this series met the criteria for “not sick,” nine were “moderately sick,” and one was “very sick.”

 

It is key “to be aware of SJS-TEN–like presentation of chikungunya and not to misinterpret it as true SJS-TEN, which will lead to unnecessary intervention and management,” Dr. Garg and associates said.

The researchers had no financial conflicts to disclose.

SOURCE: Garg T et al. Pediatr Dermatol. 2018 Mar 24. doi: 10.1111/pde.13450.

 

Chikungunya infections in young children resemble skin symptoms characteristic of Stevens-Johnson syndrome and toxic epidermal necrolysis, (SJS-TEN), according to data from a case series of 21 children seen during a chikungunya outbreak in India in August and September 2016.

CDC/Cynthia Goldsmith

“Cutaneous involvement in chikungunya is seen in 40%-75% of patients,” having varied presentations, wrote Taru Garg, MD, and colleagues at the Lady Hardinge Medical College and Associated Hospitals, New Delhi, India. Chikungunya mimicking SJS-TEN is rare: 96 cases have been reported in the literature, to the investigators’ knowledge.

The researchers described their observations of 13 boys and eight girls aged 1-36 months in Pediatric Dermatology. All 21 children presented with vesiculobullous and necrotic lesions and mild to moderate fever; 16 children (76%) had large erosions, purpuric macules, and necrosis. Most of the lesions occurred on the extremities.

The time from the onset of illness to presentation ranged from 1 to 9 days, and the skin lesions resolved in 5-7 days. The lesions resolved with no sequelae in 11 patients, with hyperpigmentation in seven (33%) , and with hypopigmentation in three patients (14%).

In addition, three patients (14%) developed minor oral erosions, and four (19%) developed palmoplantar erythema, which also may be associated with SJS-TEN. However, none of the patients experienced the severe mucositis and ocular and genital involvement common to SJS-TEN, Dr. Garg and associates noted. A total of seven children tested positive for chikungunya based on enzyme-linked immunosorbent assay results.

Severity of illness can be helpful to distinguish chikungunya from SJS-TEN, the researchers said. Based on the Nelson severity index, 11 children in this series met the criteria for “not sick,” nine were “moderately sick,” and one was “very sick.”

 

It is key “to be aware of SJS-TEN–like presentation of chikungunya and not to misinterpret it as true SJS-TEN, which will lead to unnecessary intervention and management,” Dr. Garg and associates said.

The researchers had no financial conflicts to disclose.

SOURCE: Garg T et al. Pediatr Dermatol. 2018 Mar 24. doi: 10.1111/pde.13450.

 

KAUAI, HAWAII – Every child diagnosed with medulloblastoma deserves a careful dermatologic evaluation for possible comorbid basal cell nevus syndrome, according to Jennifer Huang, MD, a pediatric dermatologist at Boston Children’s Hospital and Harvard Medical School.

“Medulloblastoma occurs in 10%-20% of patients with basal cell nevus syndrome and can be the presenting sign. So if a patient with basal cell nevus syndrome gets medulloblastoma, it usually occurs within the first year of life – and it can be the first thing you see,” she said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Dr. Huang presented a series of pediatric dermatology clinical pearls focused not only on basal cell nevus syndrome (BCNS) and medulloblastoma, but also on the implications of skin-limited Langerhans cell histiocytosis, how to recognize and treat drug-induced follicular eruptions in pediatric patients on targeted anticancer therapies, and when to suspect Demodex folliculitis in immunosuppressed patients.
 

Skin-limited Langerhans cell histiocytosis

Around 10%-20% of patients with Langerhans cell histiocytosis (LCH) have the skin-limited form of the malignancy. These are patients who, after a thorough workup, have a normal CBC, skeletal survey, and liver function tests; essentially, no evidence of multisystem disease.

Bruce Jancin/MDedge News

A pair of studies published several years ago provide guidance on how to best manage such patients. In one study of 26 patients with LCH with skin involvement, 16 had skin-limited LCH which was present at birth and 10 had multisystem disease. During a mean 19.5 months of follow-up only 1 of the 16 with skin-limited LCH went on to multisystem involvement; the other 15 experienced complete resolution of their skin disease by age 7 months (J Pediatr Hematol Oncol. 2014 Nov;36(8):613-6). The other study included 71 patients with skin-involved LCH; none of the 21 patients with the skin-limited variety progressed to multisystem LCH during 3 years of follow-up (J Pediatr. 2014 Nov;165[5]:990-6).

“It’s very rare for patients who present with skin-limited LCH alone to develop multisystem disease and to require chemotherapy or other more aggressive treatment,” Dr. Huang said. “I think that skin-limited LCH is probably a separate entity with its own natural history distinct from multisystem disease. We can see that with current genomic testing: in multisystem LCH, BRAF mutations are identified in at least half of patients, but very few with skin-limited disease express those mutations.

“The clinical pearl here is if you have a patient with skin-limited LCH it very rarely progresses to multisystem involvement. It’s associated with a good prognosis. That doesn’t mean you shouldn’t monitor them, but I think it can be reassuring information for the family,” she said.

 

Basal cell nevus syndrome and medulloblastoma

“Half of cases of medulloblastoma are associated with mutations in the sonic hedgehog pathway – and a subset of that group has basal cell nevus syndrome,” Dr. Huang said.

BCNS is not a diagnosis frequently made by oncologists, who typically dismiss the multitude of lesions as skin tags, which they often mimic in both appearance and location, particularly on the neck and intertriginous areas. So it’s useful for dermatologists to establish a good referral relationship with their local oncologists.

“As dermatologists it’s really important to recognize not only the major features of basal cell nevus syndrome, but also the associated findings because we can really help in making this diagnosis early,” Dr. Huang stressed.

Early diagnosis of BCNS is a high priority for two reasons: to start treatment aimed at reducing development of basal cell carcinomas, and because radiation therapy for their medulloblastoma is contraindicated in patients with BCNS because it boosts their skin cancer burden.

 

BCNS is caused by mutations in the PTCH (Patched) gene found on chromosome arm 9q. The major features of BCNS include odontogenic keratocysts, palmoplantar pits, ectopic calcification, and, of course, basal cell carcinomas. The associated findings in BCNS, in addition to medulloblastoma, include macrocephaly and dysmorphic features such as cleft lip or palate, frontal bossing, and hypertelorism.

Children with BCNS can develop hundreds of initially tiny skin tumors. Session chair Lawrence F. Eichenfield, MD, observed that treatment can be tricky. Hedgehog pathway inhibitors such as vismodegib (Erivedge) are contraindicated in children. He shared a tip he learned from a colleague: treat these numerous microbasal cells using a stacked pulse dye laser without cooling.

“I’ve treated a hundred at a time. It’s incredibly successful. It’s locally destructive. It leaves a little bit of hypopigmentation but no scar, which the CO₂ laser will do in this instance. It’s actually a pretty cool modality,” said Dr. Eichenfield, professor of dermatology and pediatrics at Rady Children’s Hospital and the University of California, San Diego.

Follicular eruptions in cancer patients on MAPK inhibitors

Cutaneous reactions to anticancer drugs aimed at inhibiting the key MAPK (mitogen-activated protein kinase) pathway in children are common and diverse. Dr. Huang focused on the most common one: follicular eruptions, which occur in up to 80% of pediatric cancer patients on targeted therapy. These eruptions can express themselves in a variety of ways and are easily mistaken for comedonal acne, varicella zoster infection, herpes simplex, or bacterial folliculitis.

 

The key clues are highly suggestive that a follicular eruption in a child on targeted anticancer therapy is caused by the drug and not something else are the eruption’s symmetric distribution, that it’s truly follicular upon close inspection, and the timing: The eruption typically begins 2-3 weeks after initiation of therapy or within a week after a dose escalation.

Anti-inflammatory agents are the treatment mainstay. Treatment of the cutaneous eruption often is successful without need to discontinue the patient’s MAPK inhibitor.

“Even though some of these eruptions look comedonal, they’re not. It’s not a follicular plugging disorder, it’s an inflammatory condition. Topical steroids, oral tetracyclines, and dilute bleach baths all work pretty well. I haven’t had good experiences with keratolytics like tretinoin cream and benzoyl peroxide; they’re less effective. Dose reduction is the last resort for these patients. Often they are very sick. They need the drug and I think the last thing we want to do is take them off it,” Dr. Huang said.

She has observed that prepubertal children are more likely to have an eczematous reaction to their targeted anticancer therapy than a follicular eruption.

 

D. folliculitis in immunocompromised patients

“The clinical pearl here is to strongly consider the diagnosis of Demodex folliculitis in an immunosuppresed patient with an itchy acneiform eruption,” Dr. Huang said.

Demodex is a human mite which is part of the normal skin flora. She called it “a great mimicker”: It can cause dermatoses mistaken for rosacea, acne, seborrheic dermatitis, perioral facial dermatitis, blepharitis, and acute graft-versus-host disease.

In the setting of a young, immunosuppressed patient who develops an acneiform eruption, the differential diagnosis is lengthy and includes steroid-induced acne, a cutaneous reaction to targeted anticancer therapy, gram-negative folliculitis secondary to long-term antibiotic therapy, and Pityrosporum folliculitis, as well as D. folliculitis.

Demodex and P. folliculitis are the two acneiform dermatoses where itch figures prominently. A couple of clues are helpful in differentiating the two conditions: P. folliculitis often involves the chest and back, while D. folliculitis generally spares the trunk and is focused on the face and neck. And D. folliculitis typically arises when immunosuppression is weaned. Overgrowth of the mites occurs during immunosuppression, then as the immunosuppression is lifted a prominent inflammatory response with an acne-like appearance occurs.

 

Dr. Huang usually sticks with topical therapies for D. folliculitis. These include topical sulfur 5%, permethrin 5%, metronidazole, and/or ivermectin. If a young patient is unresponsive to this panoply of topical agents, she resorts to a single dose of oral ivermectin at 0.2 mg/kg, usually with good effect.

Dr. Huang reported having no financial conflicts of interest regarding her presentation.

The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com

 

KAUAI, HAWAII – Every child diagnosed with medulloblastoma deserves a careful dermatologic evaluation for possible comorbid basal cell nevus syndrome, according to Jennifer Huang, MD, a pediatric dermatologist at Boston Children’s Hospital and Harvard Medical School.

“Medulloblastoma occurs in 10%-20% of patients with basal cell nevus syndrome and can be the presenting sign. So if a patient with basal cell nevus syndrome gets medulloblastoma, it usually occurs within the first year of life – and it can be the first thing you see,” she said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Dr. Huang presented a series of pediatric dermatology clinical pearls focused not only on basal cell nevus syndrome (BCNS) and medulloblastoma, but also on the implications of skin-limited Langerhans cell histiocytosis, how to recognize and treat drug-induced follicular eruptions in pediatric patients on targeted anticancer therapies, and when to suspect Demodex folliculitis in immunosuppressed patients.
 

Skin-limited Langerhans cell histiocytosis

Around 10%-20% of patients with Langerhans cell histiocytosis (LCH) have the skin-limited form of the malignancy. These are patients who, after a thorough workup, have a normal CBC, skeletal survey, and liver function tests; essentially, no evidence of multisystem disease.

Bruce Jancin/MDedge News

A pair of studies published several years ago provide guidance on how to best manage such patients. In one study of 26 patients with LCH with skin involvement, 16 had skin-limited LCH which was present at birth and 10 had multisystem disease. During a mean 19.5 months of follow-up only 1 of the 16 with skin-limited LCH went on to multisystem involvement; the other 15 experienced complete resolution of their skin disease by age 7 months (J Pediatr Hematol Oncol. 2014 Nov;36(8):613-6). The other study included 71 patients with skin-involved LCH; none of the 21 patients with the skin-limited variety progressed to multisystem LCH during 3 years of follow-up (J Pediatr. 2014 Nov;165[5]:990-6).

“It’s very rare for patients who present with skin-limited LCH alone to develop multisystem disease and to require chemotherapy or other more aggressive treatment,” Dr. Huang said. “I think that skin-limited LCH is probably a separate entity with its own natural history distinct from multisystem disease. We can see that with current genomic testing: in multisystem LCH, BRAF mutations are identified in at least half of patients, but very few with skin-limited disease express those mutations.

“The clinical pearl here is if you have a patient with skin-limited LCH it very rarely progresses to multisystem involvement. It’s associated with a good prognosis. That doesn’t mean you shouldn’t monitor them, but I think it can be reassuring information for the family,” she said.

 

Basal cell nevus syndrome and medulloblastoma

“Half of cases of medulloblastoma are associated with mutations in the sonic hedgehog pathway – and a subset of that group has basal cell nevus syndrome,” Dr. Huang said.

BCNS is not a diagnosis frequently made by oncologists, who typically dismiss the multitude of lesions as skin tags, which they often mimic in both appearance and location, particularly on the neck and intertriginous areas. So it’s useful for dermatologists to establish a good referral relationship with their local oncologists.

“As dermatologists it’s really important to recognize not only the major features of basal cell nevus syndrome, but also the associated findings because we can really help in making this diagnosis early,” Dr. Huang stressed.

Early diagnosis of BCNS is a high priority for two reasons: to start treatment aimed at reducing development of basal cell carcinomas, and because radiation therapy for their medulloblastoma is contraindicated in patients with BCNS because it boosts their skin cancer burden.

 

BCNS is caused by mutations in the PTCH (Patched) gene found on chromosome arm 9q. The major features of BCNS include odontogenic keratocysts, palmoplantar pits, ectopic calcification, and, of course, basal cell carcinomas. The associated findings in BCNS, in addition to medulloblastoma, include macrocephaly and dysmorphic features such as cleft lip or palate, frontal bossing, and hypertelorism.

Children with BCNS can develop hundreds of initially tiny skin tumors. Session chair Lawrence F. Eichenfield, MD, observed that treatment can be tricky. Hedgehog pathway inhibitors such as vismodegib (Erivedge) are contraindicated in children. He shared a tip he learned from a colleague: treat these numerous microbasal cells using a stacked pulse dye laser without cooling.

“I’ve treated a hundred at a time. It’s incredibly successful. It’s locally destructive. It leaves a little bit of hypopigmentation but no scar, which the CO₂ laser will do in this instance. It’s actually a pretty cool modality,” said Dr. Eichenfield, professor of dermatology and pediatrics at Rady Children’s Hospital and the University of California, San Diego.

Follicular eruptions in cancer patients on MAPK inhibitors

Cutaneous reactions to anticancer drugs aimed at inhibiting the key MAPK (mitogen-activated protein kinase) pathway in children are common and diverse. Dr. Huang focused on the most common one: follicular eruptions, which occur in up to 80% of pediatric cancer patients on targeted therapy. These eruptions can express themselves in a variety of ways and are easily mistaken for comedonal acne, varicella zoster infection, herpes simplex, or bacterial folliculitis.

 

The key clues are highly suggestive that a follicular eruption in a child on targeted anticancer therapy is caused by the drug and not something else are the eruption’s symmetric distribution, that it’s truly follicular upon close inspection, and the timing: The eruption typically begins 2-3 weeks after initiation of therapy or within a week after a dose escalation.

Anti-inflammatory agents are the treatment mainstay. Treatment of the cutaneous eruption often is successful without need to discontinue the patient’s MAPK inhibitor.

“Even though some of these eruptions look comedonal, they’re not. It’s not a follicular plugging disorder, it’s an inflammatory condition. Topical steroids, oral tetracyclines, and dilute bleach baths all work pretty well. I haven’t had good experiences with keratolytics like tretinoin cream and benzoyl peroxide; they’re less effective. Dose reduction is the last resort for these patients. Often they are very sick. They need the drug and I think the last thing we want to do is take them off it,” Dr. Huang said.

She has observed that prepubertal children are more likely to have an eczematous reaction to their targeted anticancer therapy than a follicular eruption.

 

D. folliculitis in immunocompromised patients

“The clinical pearl here is to strongly consider the diagnosis of Demodex folliculitis in an immunosuppresed patient with an itchy acneiform eruption,” Dr. Huang said.

Demodex is a human mite which is part of the normal skin flora. She called it “a great mimicker”: It can cause dermatoses mistaken for rosacea, acne, seborrheic dermatitis, perioral facial dermatitis, blepharitis, and acute graft-versus-host disease.

In the setting of a young, immunosuppressed patient who develops an acneiform eruption, the differential diagnosis is lengthy and includes steroid-induced acne, a cutaneous reaction to targeted anticancer therapy, gram-negative folliculitis secondary to long-term antibiotic therapy, and Pityrosporum folliculitis, as well as D. folliculitis.

Demodex and P. folliculitis are the two acneiform dermatoses where itch figures prominently. A couple of clues are helpful in differentiating the two conditions: P. folliculitis often involves the chest and back, while D. folliculitis generally spares the trunk and is focused on the face and neck. And D. folliculitis typically arises when immunosuppression is weaned. Overgrowth of the mites occurs during immunosuppression, then as the immunosuppression is lifted a prominent inflammatory response with an acne-like appearance occurs.

 

Dr. Huang usually sticks with topical therapies for D. folliculitis. These include topical sulfur 5%, permethrin 5%, metronidazole, and/or ivermectin. If a young patient is unresponsive to this panoply of topical agents, she resorts to a single dose of oral ivermectin at 0.2 mg/kg, usually with good effect.

Dr. Huang reported having no financial conflicts of interest regarding her presentation.

The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com

 

KAUAI, HAWAII – Every child diagnosed with medulloblastoma deserves a careful dermatologic evaluation for possible comorbid basal cell nevus syndrome, according to Jennifer Huang, MD, a pediatric dermatologist at Boston Children’s Hospital and Harvard Medical School.

“Medulloblastoma occurs in 10%-20% of patients with basal cell nevus syndrome and can be the presenting sign. So if a patient with basal cell nevus syndrome gets medulloblastoma, it usually occurs within the first year of life – and it can be the first thing you see,” she said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Dr. Huang presented a series of pediatric dermatology clinical pearls focused not only on basal cell nevus syndrome (BCNS) and medulloblastoma, but also on the implications of skin-limited Langerhans cell histiocytosis, how to recognize and treat drug-induced follicular eruptions in pediatric patients on targeted anticancer therapies, and when to suspect Demodex folliculitis in immunosuppressed patients.
 

Skin-limited Langerhans cell histiocytosis

Around 10%-20% of patients with Langerhans cell histiocytosis (LCH) have the skin-limited form of the malignancy. These are patients who, after a thorough workup, have a normal CBC, skeletal survey, and liver function tests; essentially, no evidence of multisystem disease.

Bruce Jancin/MDedge News

A pair of studies published several years ago provide guidance on how to best manage such patients. In one study of 26 patients with LCH with skin involvement, 16 had skin-limited LCH which was present at birth and 10 had multisystem disease. During a mean 19.5 months of follow-up only 1 of the 16 with skin-limited LCH went on to multisystem involvement; the other 15 experienced complete resolution of their skin disease by age 7 months (J Pediatr Hematol Oncol. 2014 Nov;36(8):613-6). The other study included 71 patients with skin-involved LCH; none of the 21 patients with the skin-limited variety progressed to multisystem LCH during 3 years of follow-up (J Pediatr. 2014 Nov;165[5]:990-6).

“It’s very rare for patients who present with skin-limited LCH alone to develop multisystem disease and to require chemotherapy or other more aggressive treatment,” Dr. Huang said. “I think that skin-limited LCH is probably a separate entity with its own natural history distinct from multisystem disease. We can see that with current genomic testing: in multisystem LCH, BRAF mutations are identified in at least half of patients, but very few with skin-limited disease express those mutations.

“The clinical pearl here is if you have a patient with skin-limited LCH it very rarely progresses to multisystem involvement. It’s associated with a good prognosis. That doesn’t mean you shouldn’t monitor them, but I think it can be reassuring information for the family,” she said.

 

Basal cell nevus syndrome and medulloblastoma

“Half of cases of medulloblastoma are associated with mutations in the sonic hedgehog pathway – and a subset of that group has basal cell nevus syndrome,” Dr. Huang said.

BCNS is not a diagnosis frequently made by oncologists, who typically dismiss the multitude of lesions as skin tags, which they often mimic in both appearance and location, particularly on the neck and intertriginous areas. So it’s useful for dermatologists to establish a good referral relationship with their local oncologists.

“As dermatologists it’s really important to recognize not only the major features of basal cell nevus syndrome, but also the associated findings because we can really help in making this diagnosis early,” Dr. Huang stressed.

Early diagnosis of BCNS is a high priority for two reasons: to start treatment aimed at reducing development of basal cell carcinomas, and because radiation therapy for their medulloblastoma is contraindicated in patients with BCNS because it boosts their skin cancer burden.

 

BCNS is caused by mutations in the PTCH (Patched) gene found on chromosome arm 9q. The major features of BCNS include odontogenic keratocysts, palmoplantar pits, ectopic calcification, and, of course, basal cell carcinomas. The associated findings in BCNS, in addition to medulloblastoma, include macrocephaly and dysmorphic features such as cleft lip or palate, frontal bossing, and hypertelorism.

Children with BCNS can develop hundreds of initially tiny skin tumors. Session chair Lawrence F. Eichenfield, MD, observed that treatment can be tricky. Hedgehog pathway inhibitors such as vismodegib (Erivedge) are contraindicated in children. He shared a tip he learned from a colleague: treat these numerous microbasal cells using a stacked pulse dye laser without cooling.

“I’ve treated a hundred at a time. It’s incredibly successful. It’s locally destructive. It leaves a little bit of hypopigmentation but no scar, which the CO₂ laser will do in this instance. It’s actually a pretty cool modality,” said Dr. Eichenfield, professor of dermatology and pediatrics at Rady Children’s Hospital and the University of California, San Diego.

Follicular eruptions in cancer patients on MAPK inhibitors

Cutaneous reactions to anticancer drugs aimed at inhibiting the key MAPK (mitogen-activated protein kinase) pathway in children are common and diverse. Dr. Huang focused on the most common one: follicular eruptions, which occur in up to 80% of pediatric cancer patients on targeted therapy. These eruptions can express themselves in a variety of ways and are easily mistaken for comedonal acne, varicella zoster infection, herpes simplex, or bacterial folliculitis.

 

The key clues are highly suggestive that a follicular eruption in a child on targeted anticancer therapy is caused by the drug and not something else are the eruption’s symmetric distribution, that it’s truly follicular upon close inspection, and the timing: The eruption typically begins 2-3 weeks after initiation of therapy or within a week after a dose escalation.

Anti-inflammatory agents are the treatment mainstay. Treatment of the cutaneous eruption often is successful without need to discontinue the patient’s MAPK inhibitor.

“Even though some of these eruptions look comedonal, they’re not. It’s not a follicular plugging disorder, it’s an inflammatory condition. Topical steroids, oral tetracyclines, and dilute bleach baths all work pretty well. I haven’t had good experiences with keratolytics like tretinoin cream and benzoyl peroxide; they’re less effective. Dose reduction is the last resort for these patients. Often they are very sick. They need the drug and I think the last thing we want to do is take them off it,” Dr. Huang said.

She has observed that prepubertal children are more likely to have an eczematous reaction to their targeted anticancer therapy than a follicular eruption.

 

D. folliculitis in immunocompromised patients

“The clinical pearl here is to strongly consider the diagnosis of Demodex folliculitis in an immunosuppresed patient with an itchy acneiform eruption,” Dr. Huang said.

Demodex is a human mite which is part of the normal skin flora. She called it “a great mimicker”: It can cause dermatoses mistaken for rosacea, acne, seborrheic dermatitis, perioral facial dermatitis, blepharitis, and acute graft-versus-host disease.

In the setting of a young, immunosuppressed patient who develops an acneiform eruption, the differential diagnosis is lengthy and includes steroid-induced acne, a cutaneous reaction to targeted anticancer therapy, gram-negative folliculitis secondary to long-term antibiotic therapy, and Pityrosporum folliculitis, as well as D. folliculitis.

Demodex and P. folliculitis are the two acneiform dermatoses where itch figures prominently. A couple of clues are helpful in differentiating the two conditions: P. folliculitis often involves the chest and back, while D. folliculitis generally spares the trunk and is focused on the face and neck. And D. folliculitis typically arises when immunosuppression is weaned. Overgrowth of the mites occurs during immunosuppression, then as the immunosuppression is lifted a prominent inflammatory response with an acne-like appearance occurs.

 

Dr. Huang usually sticks with topical therapies for D. folliculitis. These include topical sulfur 5%, permethrin 5%, metronidazole, and/or ivermectin. If a young patient is unresponsive to this panoply of topical agents, she resorts to a single dose of oral ivermectin at 0.2 mg/kg, usually with good effect.

Dr. Huang reported having no financial conflicts of interest regarding her presentation.

The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

bjancin@mdedge.com