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2.  Pediatric Response to Court-Mandated Medicaid Behavioral Screening in Massachusetts 
In 2007 in Massachusetts, a settlement of a class-action lawsuit on behalf of Medicaid beneficiaries mandated that primary care practices perform developmental, behavioral and mental health screening using formal tools. We aimed to assess perspectives from providers and practice staff about implementing developmental and mental health screening in response to the judicial ruling.
In this qualitative study, we conducted semi-structured interviews with eighteen physicians and staff from eleven pediatric and medicine-pediatric primary care practices in Eastern Massachusetts between April 2009–November 2010. Using an interview guide we asked about barriers and facilitators to implementing developmental and mental health screening, how practices selected tools and what processes or changes made screening routine. Clinicians were asked how screening changed the quality and/or content of well-child care visits. Interviews were transcribed and coded. Using thematic analysis, we generated overarching themes.
Participants were motivated to comply with the mandate, and most practices reported implementing routine screening for developmental and mental health problems over several months. While certain aspects of screening were endorsed, many perceived that screening added little to quality of care, primarily because tools lacked sensitivity and specialty resources were too scarce to address concerns adequately. Practices’ receptivity to change and physicians’ sense of duty to comply facilitated implementation. No practice developed processes specifically to track and follow up abnormal results.
Implementation of mandated developmental and mental health screening could be facilitated by providing assistance with practice change, improving the quality of screening tools, and assuring adequate referral resources.
PMCID: PMC3680882  PMID: 23751887
screening tools; developmental assessment; behavior disorders/problems; mental health; primary care
3.  Maternal Factors Predicting Cognitive and Behavioral Characteristics of Children with Fetal Alcohol Spectrum Disorders 
To provide an analysis of multiple predictors of cognitive and behavioral traits for children with fetal alcohol spectrum disorders (FASD).
Multivariate correlation techniques were employed with maternal and child data from epidemiologic studies in a community in South Africa. Data on 561 first grade children with fetal alcohol syndrome (FAS), partial FAS (PFAS), and not FASD and their mothers were analyzed by grouping 19 maternal variables into categories (physical, demographic, childbearing, and drinking) and employed in structural equation models (SEM) to assess correlates of child intelligence (verbal and non-verbal) and behavior.
A first SEM utilizing only seven maternal alcohol use variables to predict cognitive/behavioral traits was statistically significant (B = 3.10, p < .05), but explained only 17.3% of the variance. The second model incorporated multiple maternal variables and was statistically significant explaining 55.3% of the variance. Significantly correlated with low intelligence and problem behavior were demographic (B = 3.83, p < .05) (low maternal education, low socioeconomic status (SES), and rural residence) and maternal physical characteristics (B = 2.70, p < .05) (short stature, small head circumference, and low weight). Childbearing history and alcohol use composites were not statistically significant in the final complex model, and were overpowered by SES and maternal physical traits.
While other analytic techniques have amply demonstrated the negative effects of maternal drinking on intelligence and behavior, this highly-controlled analysis of multiple maternal influences reveals that maternal demographics and physical traits make a significant enabling or disabling contribution to child functioning in FASD.
PMCID: PMC3731773  PMID: 23751886
fetal alcohol spectrum disorders (FASD); fetal alcohol syndrome (FAS); partial fetal alcohol syndrome (PFAS); verbal intelligence; non-verbal intelligence; problem behaviors in children; maternal risk factors
4.  Parental Attributions for the Behavior Problems of Children and Adolescents With Autism Spectrum Disorders 
The authors examined parental attributions for child behavior problems in 63 married couples of children and adolescents (aged 3–20 years) with autism spectrum disorders (ASDs). Both child-referent attributions (i.e., beliefs about causes related to the child or adolescent) and parent-referent attributions (i.e., beliefs about causes related to the parent) were examined along the dimensions of locus, stability, and controllability. Parent and child/adolescent factors related to parental attributions were identified, and the associations between parental attributions and parenting burden were explored.
Mothers and fathers independently completed self-reported measures of parental attributions, parenting burden, and child behavior problems. Couples jointly reported on their son or daughter’s severity of autism symptoms, intellectual disability status, age, and gender.
Parents tended to attribute the behavior problems of their child/adolescent with an ASD to characteristics that were not only internal to and stable in the child/adolescent but also controllable by the child/adolescent. Mothers were more likely to attribute their son or daughter’s behavior problems to characteristics that were less internal to and less stable in the child/adolescent with an ASD than were fathers. In addition, parents with a higher level of symptoms of the broader autism phenotype, parents of younger children, and parents of children/adolescents with intellectual disability, a higher severity of autism symptoms, and a higher severity of overall behavior problems were more likely to attribute their son or daughter’s behavior problems to characteristics that were more internal to and stable in the child/adolescent and factors that were less controllable by the child/adolescent. Parental attributions were related to parents’ level of parenting burden.
Findings have implications for designing appropriate interventions and services for families of children and adolescents with ASDs.
PMCID: PMC4029333  PMID: 24217029
autism; behavior problems; attribution; parents; parenting stress
6.  Development of an Expressive Language Sampling Procedure in Fragile X Syndrome: A Pilot Study 
There is a great need for valid outcome measures of functional improvement for impending clinical trials of targeted interventions for Fragile X syndrome (FXS). Families often report conversational language improvement during clinical treatment, but no validated measures exist to quantify this outcome. This small-scale study sought to determine the feasibility, reproducibility, and clinical validity of highly structured expressive language sampling as an outcome measure reflecting language ability.
Narrative and conversation tasks were administered to 36 verbal participants (25 males, 11 females) with FXS (age 5–36, mean 18±7). Alternate versions were used with randomized task order, at 2–3 week (mean 19.6±6.4 days) intervals. Audio recordings of sessions were transcribed and analyzed. Dependent measures reflected talkativeness (total number of utterances), utterance planning (proportion of communication (C) units with mazes), articulation (proportion of unintelligible/partly unintelligible C-units), vocabulary (number of different word roots) and syntactic ability (mean length of utterance (MLU) in words). Reproducibility of measures was evaluated with intra-class correlation coefficients (ICC).
All participants could complete the tasks. Coded data were highly reproducible with Pearson correlations p<0.01 for all measures, and ICC values of 0.911–0.966 (conversation) and 0.728–0.940 (narration). Some measures including MLU and different word roots were correlated with expressive language subscale scores from the Vineland Adaptive Behavior Scale (VABS).
These expressive language sampling tasks appear to be feasible, reproducible, and clinically valid and should be further validated in a larger cohort, as a promising means of assessing functional expressive language outcomes during clinical trials in FXS.
PMCID: PMC3654391  PMID: 23669871
fragile X syndrome; FMR1; expressive language; outcome measure; autistic disorder
7.  Health-Related Quality of Life in Children and Adolescents with Cystic Fibrosis: Convergent Validity with Parent Reports and Objective Measures of Pulmonary Health 
This study examined the convergent validity of health-related quality of life (HRQOL) reported by patients with cystic fibrosis compared with their parents’ reports and objective pulmonary measures across three time points.
Ninety-two children (8–13 years) and adolescents (14–18 years) with CF and their parents completed Cystic Fibrosis Questionnaires to examine concordance with Wisconsin Chest X-Ray (WCXR) scores and pulmonary function tests, e.g., forced expiratory volume at one second (FEV1), and parent-child/adolescent concordance across multiple HRQOL domains. Concordance was analyzed relative to patient age and gender.
Parent reports were closely aligned with WCXR scores, while patient reports were more closely aligned with FEV1. Adolescents and parents of both age groups had more HRQOL domains concordant with pulmonary health measures than did child self-reports. Parent-child concordance was inversely related to child age, particularly with male adolescents. Children generally reported better HRQOL than parents. Male adolescents and their parents were more likely to have significantly discordant HRQOL scores than female adolescents and their parents. Male and female adolescents reported higher HRQOL than their parents reported for all but Vitality and Health Perception domains. Younger male children showed concordance with their parents on five of seven domains.
Parent-child/adolescent discordance on HRQOL was consistent with normative child development expectations. Findings underscore the value of enlisting perspectives from parents as well as children regarding HRQOL.
PMCID: PMC3775595  PMID: 23669872
8.  A Year-Long Caregiver Training Program to Improve Neurocognition in Preschool Ugandan HIV-Exposed Children 
Mediational intervention for sensitizing caregivers (MISC) is a structured program enabling caregivers to enhance their child’s cognitive and emotional development through daily interactions. The principal aim was to evaluate if a year-long MISC caregiver training program produced greater improvement in child cognitive and emotional development compared with a control program.
119 uninfected HIV-exposed preschool children and their caregivers were randomly assigned to one of two treatment arms: biweekly MISC training alternating between home and clinic for one year or a health and nutrition curriculum. All children were evaluated at baseline, 6 months, and 1 year with the Mullen Early Learning Scales, Color-Object Association Test (COAT) for memory, and Achenbach Child Behavior Checklist (CBCL) for psychiatric symptoms. Caregivers were evaluated on the same schedule with the Hopkins Symptoms Checklist (HSCL-25) for depression and anxiety.
The treatment arms were compared using repeated-measures ANCOVA with child age, gender, weight, SES, caregiving quality, caregiver anxiety, and caregiver education as covariates. The MISC children had significantly greater gains compared to controls on the Mullen Receptive and Expressive Language development, and on the Mullen composite score of cognitive ability. COAT total memory for MISC children was marginally better than controls. No CBCL differences between the groups were noted. Caldwell HOME scores and observed mediational interaction scores from videotapes measuring caregiving quality also improved significantly more for the MISC group.
MISC enhanced cognitive performance, especially in language development. These benefits were possibly mediated by improved caregiving and positive emotional benefit to the caregiver.
PMCID: PMC3655140  PMID: 23535340
child development; HIV; caregiver; training; Uganda; language; cognition; nutrition
9.  Parenting stress in pediatric IBD: Relations with child psychopathology, family functioning, and disease severity 
Parenting stress in pediatric IBD has been under-examined. Data validating use of The Pediatric Inventory for Parents (PIP), a measure of parenting stress associated with caring for a chronically-ill child, in chronic diseases with intermittent, unpredictable disease courses, such as Inflammatory Bowel Disease, are needed. This study presents validity data in support of the PIP in pediatric IBD and examines relations between parenting stress and important psychosocial and medical outcomes.
Adolescents (N = 130) with IBD and their caregivers across three sites completed measures of parenting stress, family functioning, and emotional/behavioral functioning. Disease severity was also assessed for each participant.
The PIP demonstrates excellent internal consistency. Parenting stress was significantly higher among those with unhealthy general family functioning and those with children with Borderline or Clinically-elevated internalizing symptoms. Caregiving stress was greater among parents of youth with more active Crohn's disease.
Results supported the reliability and validity of the PIP for assessing caregiving stress in pediatric IBD. Routine assessment of parenting stress is recommended, particularly among parents reporting unhealthy family functioning and parents of youth with Borderline or Clinically-elevated internalizing symptoms and more active disease.
PMCID: PMC3678249  PMID: 23669870
IBD; parenting stress; adolescent; assessment; internalizing
10.  Importance of Stability of Early Living Arrangements on Behavior Outcomes of Children With and Without Prenatal Drug Exposure 
We evaluated whether living arrangements of children with or without prenatal drug exposure would be associated with their behavior outcomes and adaptive functioning.
1388 children with or without prenatal cocaine or opiate exposure were enrolled in a longitudinal cohort study at one month of age, were seen at intervals, tracked over time for their living situation, and evaluated for behavior problems and adaptive functioning at three years of age. Child Behavior Check List and Vineland Adaptive Behavior Scales (VABS) were administered. Using multiple regression models, we determined the factors that would predict behavior problems and adaptive functioning.
1,092 children were evaluated. Total and externalizing behavior problems T scores of children in relative care were lower (better) than those in parental; externalizing behavior scores were lower than those in non-relative care (p<0.05). Total behavior problem scores increased 2.3 and 1.3 points respectively with each move/year and each year of Child Protective Services’ involvement. Compared to children in non-relative care, those in parental or relative care had higher (better) scores in the VABS total composite (p<0.023), communication (p<0.045), and daily living (p<0.001). Each caretaker change was associated with a decrease of 2.65 and 2.19 points respectively in communication and daily living scores.
Children’s living arrangements were significantly associated with childhood behavior problems and adaptive functioning. The instability of living situation was also a significant predictor of these outcomes. While family preservation continues to be the goal of the child welfare system, expediting decision toward permanency remains paramount once children are placed in foster care.
PMCID: PMC3984541  PMID: 18349707
Prenatal cocaine; prenatal opiate; out-of-home-care; child behavior
11.  Patterns of Self-Management in Pediatric Type 1 Diabetes Predict Level of Glycemic Control Two Years Later 
To determine if three distinct self-management patterns (i.e., maladaptive, moderate/mixed, and adaptive) observed at baseline, one, and two years in a sample of youth with type 1 diabetes and their caregivers predicted mean differences in adolescent’s subsequent glycemic control.
This study is a descriptive, multisite, prospective study that examined a sample of youth diagnosed with type 1 diabetes (ages 9–11 years at baseline). Youth and their maternal and paternal caregivers provided information about the youth’s self-management patterns at baseline, one, and two years using the Diabetes Self-Management Profile (DSMP) structured interview. Glycemic control (Hemoglobin A1c: HbA1c) was examined at baseline, six, 12, 18, and 24 months.
Three distinct self-management patterns were observed at one and two years that were conceptually consistent with previously reported baseline self-management patterns. Youth identified by their maternal caregivers as having adaptive self-management patterns at baseline had better glycemic control across two years compared to those in the maladaptive and mixed self-management groups. Similarly, maternal reports suggested that youth with less adaptive self-management patterns generally had worse glycemic control over time as well as HbA1c values above the American Diabetes Association recommendations. Youth and paternal caregiver reports yielded more variable findings.
Findings underscore the stability of self-management patterns in pediatric type 1 diabetes and the need for preventive interventions that are tailored to specific patterns of self-management associated with risk for problematic glycemic control.
PMCID: PMC3652245  PMID: 23572169
12.  A Randomized Double-Blind, Placebo-Controlled Trial of Minocycline in Children and Adolescents with Fragile X Syndrome 
Minocycline rescued synaptic abnormalities and improved behavior in the fragile X mouse model. Prior open-label human studies demonstrated benefits in individuals with fragile X syndrome (FXS); however, its efficacy in patients with FXS has not been assessed in a controlled trial.
Randomized, double-blind, placebo-controlled, crossover trial in individuals with FXS, ages 3.5-16 years (n=55, mean age 9.2 (SD 3.6 years)). Participants were randomized to minocycline or placebo for three months, then switched to the other treatment.
Sixty-nine subjects were screened and 66 were randomized. Fifty-five subjects (83.3%) completed at least the first period and 48 (72.7%) completed the full trial. Intention-to-treat analysis demonstrated significantly greater improvements in one primary outcome, Clinical Global Impression Scale-Improvement after minocycline compared to placebo (2.49 ±0.13, 2.97 ±0.13, respectively, p 0.0173) and greater improvement in ad hoc analysis of anxiety and mood-related behaviors on the Visual Analoge Scale (minocycline 5.26 cm ±0.46 cm, placebo 4.05 cm±0.46cm; p 0.0488). Side effects were not significantly different during the minocycline and placebo treatments. No serious adverse events occurred on minocycline. Results may be potentially biased by study design weaknesses, including unblinding of subjects when they completed the study, drug-related side effects unblinding and preliminary efficacy analysis results known to investigators.
Minocycline treatment for three months in children with FXS resulted in greater global improvement than placebo. Treatment for three months appears safe; however, longer trials are indicated to further assess benefits, side effects, and factors associated with a clinical response to minocycline.
PMCID: PMC3706260  PMID: 23572165
Fragile X Syndrome; Intellectual Disability; Minocycline; Matrix Metalloproteinase 9
13.  Attention and Internalizing Behaviors in Relation to White Matter in Children Born Preterm 
Diffusion Tensor Imaging (DTI) is a magnetic resonance imaging technique that provides quantitative characterization of white matter tracts in the brain. This study used DTI to examine the degree of association between parent-rated scores of attention, internalizing behaviors including anxiety symptoms, and externalizing behaviors and white matter fractional anisotropy (FA) in children born preterm.
Participants were 9 to 16 years of age; 25 were born at less than 36 weeks gestation (mean = 28.6 weeks, birth weight = 1191 grams) and 20 were full term. We analyzed the results using Tract-Based Spatial Statistics, a technique that generates a skeleton representing the core of white matter tracts throughout the brain. We examined correlations between behavior scores and FA of (1) the whole skeleton and (2) specific regions of interest.
In preterm children, scores on attention and internalizing behavior scales were each associated with whole skeleton FA and several regions of interest; unfavorable scores were consistently associated with lower FA. Externalizing behaviors were not associated with whole skeleton FA, but significant associations were found within a few regions of interest. The network of significant regions for attention and internalizing symptoms was widely distributed and overlapping. In full term children no associations of FA and behavior were significant.
Attention and internalizing behaviors in preterm children were associated with FA in a widely distributed, overlapping network of white matter tracts, suggesting common underlying neurobiology. DTI contributes to understanding individual differences in attention and behavior characteristics in children born preterm.
PMCID: PMC3737250  PMID: 23572166
prematurity; preterm; diffusion tensor imaging; white matter; behavior; attention; internalizing; anxiety
14.  Developmental Regression, Depression, and Psychosocial Stress in an Adolescent with Down Syndrome 
Journal of developmental and behavioral pediatrics : JDBP  2013;34(3):10.1097/DBP.0b013e31828b2b42.
CASE: Kristen is a 13-year-old girl with Down syndrome (DS) who was seen urgently with concerns of cognitive and developmental regression including loss of language, social, and toileting skills. The evaluation in the DS clinic focused on potential medical diagnoses including atlantoaxial joint instability, vitamin deficiency, obstructive sleep apnea (OSA), and seizures. A comprehensive medical evaluation yielded only a finding of moderate OSA. A reactive depression was considered in association with several psychosocial factors including moving homes, entering puberty/onset of menses, and classroom change from an integrated setting to a self-contained classroom comprising unfamiliar peers with behavior challenges.
Urgent referrals for psychological and psychiatric evaluations were initiated. Neuropsychological testing did not suggest true regression in cognitive, language, and academic skills, although decreases in motivation and performance were noted with a reaction to stress and multiple environmental changes as a potential causative factor. Psychiatry consultation supported this finding in that psychosocial stress temporally correlated with Kristen’s regression in skills.
Working collaboratively, the team determined that Kristen’s presentation was consistent with a reactive form of depression (DSM-IV-TR: depressive disorder, not otherwise specified). Kristen’s presentation was exacerbated by salient environmental stress and sleep apnea, rather than a cognitive regression associated with a medical cause. Treatment consisted of an antidepressant medication, continuous positive airway pressure for OSA, and increased psychosocial supports. Her school initiated a change in classroom placement. With this multimodal approach to evaluation and intervention, Kristen steadily improved and she returned to her baseline function.
PMCID: PMC3884753  PMID: 23572173
Down syndrome; developmental regression; depression; obstructive sleep apnea
15.  Neurodevelopmental Manifestations of Mitochondrial Disease 
Mitochondrial disease is an increasingly recognized but widely heterogeneous group of multi-systemic disorders that commonly involve severe neurodevelopmental manifestations in childhood. This article will review the presentation, genetic basis, and diagnostic evaluation of primary mitochondrial disease. Emphasis will be placed on neurodevelopmental findings that may be encountered by a Developmental Pediatrician that should provoke consideration of a mitochondrial disorder. The inheritance patterns and mechanisms by which mutations in genes located in either the nuclear or mitochondrial genomes can cause mitochondrial diseases will be discussed. A general overview of the current diagnostic evaluation that can be readily initiated by the Developmental Pediatrician will be provided, along with a summary of currently available treatment options.
PMCID: PMC3923321  PMID: 20814259
16.  A Systematic Review of Sleep in Pediatric Pain Populations 
The primary aim of this systematic review was to examine the evidence for a pain-sleep relationship in children with persistent pain by reviewing studies using single and mixed pediatric persistent pain samples.
Electronic searches of Medline, PubMed, the Cochrane Database of Systematic Reviews, and PsycINFO were conducted to identify all relevant empirical studies. Studies were included in the review if the majority of participants were between 0-17 years and from one of the following pediatric pain populations: juvenile idiopathic arthritis, sickle cell disease, migraine/headache, functional abdominal pain, juvenile fibromyalgia syndrome, chronic musculoskeletal pain, or mixed populations including the aforementioned conditions.
Research from single and mixed sample studies support the hypothesis that children and adolescents with persistent pain suffer from sleep impairment. Literature addressing factors that may influence or mediate the pain-sleep relationship and the functional outcomes of the pain-sleep relationship was reviewed, and a model of the interrelationships with pain and sleep developed.
Findings from this review highlight the need to assess and treat sleep problems in children presenting with persistent pain. Healthcare providers should consider conducting routine sleep screenings, including a comprehensive description of sleep patterns and behaviors obtained through clinical interview, sleep diaries, and/or the use of standardized measures of sleep. Future research focusing on investigating the mechanisms associating sleep and pediatric persistent pain and on functional outcomes of poor sleep in pediatric pain populations is needed.
PMCID: PMC3562475  PMID: 23369958
adolescent; child; persistent pain; sleep
17.  Adiposity and Physical Activity Are Not Related to Academic Achievement in School-Aged Children 
To investigate the hypotheses that in elementary school students: 1) adiposity and academic achievement are negatively correlated and 2) physical activity and academic achievement are positively correlated.
Participants were 1963 children in fourth through sixth grades. Adiposity was assessed by calculating body mass index (BMI) percentile and percent body fat and academic achievement with statewide standardized tests in four content areas. Socioeconomic status and age were control variables. A subset of participants (n = 261) wore an accelerometer for three days to provide objective measurement of physical activity. Additionally, the association between weight status and academic achievement was examined by comparing children who could be classified as “extremely obese” and the rest of the sample, as well as comparing children who could be classified as normal weight, overweight, or obese. Extreme obesity was defined as >= 1.2 times the 95th percentile.
Results indicated that there were no significant associations between adiposity or physical activity and achievement in students. No academic achievement differences were found between children with BMI percentiles within the extreme obesity range and those who did not fall within the extreme obesity classification. Additionally, no academic achievement differences were found for children with BMI percentiles within the normal weight, overweight, or obese ranges.
These results do not support the hypotheses that increased adiposity is associated with decreased academic achievement or that greater physical activity is related to improved achievement. However, these results are limited by methodological weaknesses, especially the use of cross-sectional data.
PMCID: PMC3897206  PMID: 22617499
childhood; academic achievement; adiposity; physical activity
18.  Early Speech-Language Impairment and Risk for Written Language Disorder: A Population-Based Study 
Compare risk of written-language disorder (WLD) in children with and without speech-language impairment (S/LI) from a population-based cohort.
Subjects included all children born 1976–1982 in Rochester, Minnesota, who remained in the community after age 5 years (n = 5718). Records from public and private schools, medical agencies, and tutoring services were abstracted. S/LI was determined based on eligibility criteria for an individualized education plan. Incident cases of WLD were identified by research criteria using regression-based discrepancy, non-regression-based discrepancy, and low achievement formulas applied to cognitive and academic achievement tests. Incidence of WLD (with or without Reading Disorder [RD]) was compared between children with and without S/LI. Associations were summarized using hazard ratios.
Cumulative incidence of WLD by age 19 years was significantly higher in children with S/LI than without S/LI. The magnitude of association between S/LI and WLD with RD was significantly higher for girls than boys. This was not true for the association between S/LI and WLD without RD.
Risk for WLD is significantly increased among children with S/LI compared to children without S/LI based on this population-based cohort. Early identification and intervention for children at risk for WLD could potentially influence academic outcomes.
PMCID: PMC3546529  PMID: 23275057
19.  Caregiver Concern in Adolescents with Persistent Obesity: The Importance of Quality of Life Assessment 
To examine female caregiver and adolescent dyad characteristics that predict the female caregiver’s concern about their adolescent’s weight, and the degree to which caregiver concern predicts desire for physician intervention.
Fifty three caregivers of adolescents with persistent obesity were asked to report on their adolescent’s QOL, weight status, concern about their adolescent’s weight, and desire for physician intervention.
Results indicated that only caregiver-reported QOL was a meaningful predictor of caregiver concern for African American adolescents with persistent obesity accounting for 51% of the variance, and that caregiver concern predicted desire for physician intervention accounting for 46% of the variance.
Based on these findings it is recommended that practitioners assess caregiver perception of obesity-specific QOL in their adolescent patients with persistent obesity particularly those who are African American.
PMCID: PMC3593190  PMID: 23275053
Obesity; quality of life; adolescents; caregiver concern; assessment
20.  The Effect of Prenatal Methamphetamine Exposure on Attention as Assessed by Continuous Performance Tests: Results from the Infant Development, Environment, and Lifestyle (IDEAL) Study 
The purpose of this study is to assess for increased risk of attention deficit hyperactivity problem in young children with prenatal methamphetamine exposure from the multicenter, longitudinal Infant Development, Environment, and Lifestyle (IDEAL) study.
IDEAL enrolled 412 mother-infant pairs at four sites (Tulsa, OK; Des Moines, IA; Los Angeles, CA; and Honolulu, HI). Methamphetamine exposed subjects (n=204) were identified by self-report and/or gas chromatography/mass spectrometry confirmation of amphetamine and metabolites in infant meconium. Matched subjects (n=208) denied methamphetamine use and had a negative meconium screen. This analysis includes a subsample of 301 subjects that were administered the Conners’ Kiddie Continuous Performance Test (K-CPT) at age 5.5 years (153 exposed, 148 comparison). Hierarchical linear models adjusted for covariates tested exposure effects on K-CPT measures. Using the same covariates, logistic regression was used to determine the effect of exposure on the incidence of a positive ADHD confidence index score, defined as greater than 50%.
There were no differences between the groups in omission or commission errors or reaction time for correct trials. However, methamphetamine exposure was associated with subtle differences in other outcomes predictive of ADHD, including increased slope of reaction time across blocks (p<0.001), increased variability in reaction time with longer interstimulus intervals (p<0.01), and increased likelihood of greater than 50% on the ADHD confidence index (OR 3.1, 95% CI 1.2–7.8; p=0.02).
Prenatal methamphetamine exposure was associated with subtle differences in K-CPT scores at age 5.5 years. Even at this relatively young age, these children exhibit indicators of risk for ADHD and warrant monitoring.
PMCID: PMC3800474  PMID: 23275056
21.  Truancy is associated with sexual risk among early adolescents 
While previous studies have identified relationships between school truancy and adolescent substance use risk, sexual risk remains unaddressed. Urban early adolescents (mean age 13.14 years) with mental health symptoms completed audio computer-assisted self-interviews regarding risk behaviors. Teens who reported a history of skipping school (n=25), compared to those who did not (n=113), indicated greater frequency of having ever engaged in oral, vaginal, and anal sex, as well as non-intercourse sexual behaviors. They also reported less value in remaining abstinent but did not demonstrate differences in HIV knowledge or school connectedness. Truancy may serve as an important marker for the early identification of youth at risk for unintended pregnancy or sexually transmitted diseases.
PMCID: PMC3488264  PMID: 23117598
truancy; sexual risk; adolescents
22.  Associations Between Temperament at Age 1.5 Years and Obesogenic Diet at Ages 3 and 7 Years 
To investigate whether temperament in 1.5-year-olds predicts their consumption of potentially obesogenic foods and drinks at ages 3 and 7 years.
Participants were 6 997 mothers and infants from the Norwegian Mother and Child Cohort Study. Questionnaires were collected during pregnancy, at birth, and at child ages 6 months and 1.5, 3, and 7 years. Predictor variables: children’s temperament at age 1.5 (internalizing, externalizing, surgent) and mothers’ negative affectivity. Outcome variables: children’s consumption of sweet foods, sweet drinks, and fruits/vegetables at ages 3 and 7 (dichotomized at the 85th percentile).
Controlling for covariates, internalizing 1.5-year-olds (anxious, dependent) were 77% and 63% more likely to consume sweet drinks daily at ages 3 and 7, respectively; they were 55% and 43% more likely to consume sweet foods daily at ages 3 and 7, respectively. Externalizing 1.5-year-olds (hyperactive, aggressive) were 34% more likely to consume sweet drinks daily at age 7, 39% and 44% more likely to consume sweet foods daily at ages 3 and 7, respectively, and they were 47% and 33% less likely to consume fruits/vegetables daily at ages 3 and 7, respectively. Surgent 1.5-year-olds (active, sociable) were 197% and 78% more likely to consume two portions of fruits/vegetables daily at ages 3 and 7, respectively. The association of maternal negative affectivity was limited to the child’s consumption of sweet foods at 3 and 7 years.
Early child temperament is a risk factor for obesogenic diet in later childhood. Mechanisms explaining this association need to be explored.
PMCID: PMC3492946  PMID: 23117597
child; temperament; obesity; diet; eating
23.  An examination of the relationship of anxiety and intelligence to adaptive functioning in children with chromosome 22q11.2 deletion syndrome 
This study investigates the relationship between anxiety symptoms and adaptive function in children with Chromosome 22q11.2 Deletion Syndrome (22q11.2DS).
Seventy-eight children ages 7-14 years with 22q11.2DS and 36 typically developing (TD) children without known genetic syndromes participated in a larger study of neurocognition. Parents completed questionnaires about their child’s anxiety symptoms (Behavior Assessment System for Children, 2nd ed.: BASC-2 and Spence Children’s Anxiety Scale: SCAS) and adaptive functioning (BASC-2 and Adaptive Behavior Assessment System, 2nd ed.: ABAS-II). Within the 22q11.2DS group, different DSM-IV anxiety domains were also analyzed using SCAS subscales.
Based on parent report, 19% of children with 22q11.2DS had a prior diagnosis of an anxiety disorder vs. 58% with at least one elevated anxiety score (BASC-2 and/or SCAS). Mean BASC-2 anxiety scores were significantly higher in 22q11.2DS (55.6+12.5) than TD (48.3+10; p=0.003) and a greater percentage of children with 22q11.DS (37%) had elevated BASC-2 anxiety scores compared with TD (14%; p=0.01). Higher anxiety scores were related to lower adaptive function (r=−0.27, p=0.015) but there was no relationship between WISC-IV FSIQ and BASC-2 adaptive skills (r=−0.06, p=0.6) in the 22q11.2DS group. For the individual SCAS anxiety subscales, panic-agoraphobia (r=−0.38, p=0.03), physical injury (r=−0.34, p=0.05), and obsessive compulsive disorder (r=−0.47, p=0.005) were significantly negatively related to adaptive function in 22q11.2DS.
Despite known risk, anxiety is under-identified in children with 22q11.2DS. The presence of anxiety symptoms, but not intelligence levels, in children with 22q11.2DS is negatively correlated with adaptive function and impacts everyday living skills.
PMCID: PMC3523689  PMID: 23117596
24.  Ethnic Differences in Caregiver Quality of Life in Pediatric Asthma 
The aim of this study was to determine ethnic and site differences in quality of life (QOL) in a sample of Latino (Puerto Rican and Dominican) and non-Latino White (NLW) caregivers of children with asthma in mainland US and Island PR. We also investigated ethnic and site differences in associations between caregiver QOL and indicators of asthma morbidity.
Seven-hundred and eighty-seven children with asthma (7–16 years of age) and their primary caregivers participated. Primary caregivers completed a measure of QOL, child asthma control, and emergency department utilization, among other measures.
Ethnic and site differences were found on total QOL scores (ΔF(1, 783) = 29.46, p < .001). Island PR caregivers reported worse QOL scores than RI Latino and NLW caregivers; RI Latino caregivers reported significantly worse QOL scores than NLW caregivers. In RI Latino and Island PR children, worse caregiver QOL was associated with asthma that was not in control and with 1 or more ED visits.
Latino caregivers may be experiencing a greater level of burden related to their child’s asthma than NLW caregivers. Caregiver QOL in pediatric asthma may be a reflection of broader, contextual stress that some Latino caregivers experience on a daily basis (e.g., cultural beliefs, acculturation). Future research should continue to investigate mechanisms that explain the burden associated with pediatric asthma in Latino families, as well as whether QOL assessments should consider the impact of everyday stressors on caregiver QOL in pediatric asthma.
PMCID: PMC3463809  PMID: 23027132
pediatric asthma; quality of life; caregivers; disparities; ethnicity
25.  Screening for Autism Spectrum Disorders in Extremely Preterm Infants 
Extremely preterm (EP) infants screen positive for Autism Spectrum Disorders (ASD) at high rates. However it is not clear whether this is due to high rates of ASD in EPs or to high rates of false positive screens for ASD in children with a high rate of underlying neurodevelopmental impairments. Combining a parent questionnaire designed to distinguish developmental delay from ASD with direct observation of infant behavior may more accurately screen for ASD in EPs.
To determine rates of positive screen for ASD at 18–22months(m) in EPs using three screens; to determine factors associated with a positive screen.
554 infants born <27 weeks were screened at 18–22m using the Pervasive Developmental Disorders Screening Test, 2nd edition, Stage 2 (PDDST-II) and the response to name and response to joint attention items from the Autism Diagnostic Observation Schedule. Infants with severe cerebral palsy, deafness and blindness were excluded. Associations between positive screen and neonatal/infant characteristics were determined.
113/554 (20 %) had ≥1 positive screen. 10% had a positive PDDST-II, 6% response to name, 9% response to joint attention; in only 1% were all 3 screens positive. Positive screen was associated with male gender, more hospital days, white race, lower maternal education, abnormal behavioral scores, and cognitive/language delay.
The use of three screens for ASD in EPs results in higher screen positive rates than use of one screen alone. Diagnostic confirmation is needed before true rates of ASD in EPs are known.
PMCID: PMC3434239  PMID: 22926660
Autism; Prematurity; Screening

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