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1.  [No title available] 
PMCID: PMC3920306  PMID: 24509056
2.  [No title available] 
PMCID: PMC3928797  PMID: 24509055
3.  Utilization Patterns of Conventional and Complementary/Alternative Treatments in Children with Autism Spectrum Disorders and Developmental Disabilities in a Population-Based Study 
This study compared the utilization of conventional treatments to utilization of complementary and alternative medicine (CAM) in preschoolers with autism spectrum disorders (ASD) and other developmental disabilities (DD).
Participants were 578 children who were part of an ongoing population-based, case-control study of 2 to 5 year-olds with ASD, DD, and the general population. Parents completed an interview on past and current services.
Four hundred fifty-three children with ASD and 125 DD children were included. ASD families received more hours of conventional services compared to DD (17.8 vs. 11; p<0.001). The use of psychotropic medications was low in both groups (~3%). CAM use overall was not significantly different in ASD (39%) versus DD (30%). Hispanic families in both groups used CAM less often than non-Hispanics. Variables such as level of function, immunization status, and presence of an identified neurogenetic disorder were not predictive of CAM use. A higher level of parental education was associated with increased CAM use in ASD and DD. Families who utilized >20 hours per week of conventional services were more likely to use CAM, including potentially unsafe or disproven CAM. Under-immunized children were marginally more likely to use CAM, but not more likely to have received potentially unsafe or disproven CAM.
CAM use is common in families of young children with neurodevelopmental disorders and is predicted by higher parental education and non-Hispanic ethnicity but not developmental characteristics. Further research should address how healthcare providers can support families in making decisions about CAM use.
PMCID: PMC3896860  PMID: 24399100
autism; developmental delay; complementary and alternative medicine; gluten-free; casein-free diet; chelation; dietary supplements
4.  Primary Care Providers’ Initial Treatment Decisions and Antidepressant Prescribing for Adolescent Depression 
Adolescent depression is a serious and undertreated public health problem. Nonetheless, pediatric primary care providers (PCPs) may have low rates of antidepressant prescribing due to structural and training barriers. We examined the impact of symptom severity and provider characteristics on initial depression treatment decisions in a setting with fewer structural barriers, an integrated behavioral health network.
We administered a cross sectional survey to 58 PCPs within a large pediatric practice network. We compared PCP reports of initial treatment decisions in response to two vignettes describing depressed adolescents with either moderate or severe symptoms. We measured PCP depression knowledge, attitudes toward addressing psychosocial concerns, demographics, and practice characteristics.
Few PCPs (25% for moderate, 32% for severe) recommended an antidepressant. Compared with treatment recommendations for moderate depression, severe depression was associated with a greater likelihood of child psychiatry referral (OR 5.50[95% CI 2.47-12.2] p<.001). Depression severity did not affect the likelihood of antidepressant recommendation (OR 1.58[95% CI 0.80-3.11] p=.19). Antidepressants were more likely to be recommended by PCPs with greater depression knowledge (OR 1.72[95% CI 1.14-2.59] p=.009) and access to an on-site mental health provider (OR 5.13[95% CI 1.24-21.2] p=.02) and less likely to be recommended by PCPs who reported higher provider burden when addressing psychosocial concerns (OR 0.85[95% CI 0.75-0.98] p=.02).
PCPs infrequently recommended antidepressants for adolescents, regardless of depression severity. Continued PCP support through experiential training, accounting for provider burden when addressing psychosocial concerns, and co-management with mental health providers may increase PCPs’ antidepressant prescribing.
PMCID: PMC4105359  PMID: 24336091
primary health care; depressive disorder; adolescent; antidepressant agents; physician's practice patterns
5.  Family Adaptation 18 Months After Traumatic Brain Injury in Early Childhood 
The purpose of this study was to examine family adaptation to a traumatic brain injury (TBI) in young children during the first 18-month postinjury, when compared with children who had an orthopedic injury.
A concurrent cohort/prospective research design was used with repeated assessments of children aged 3 to 6 years with TBI or orthopedic injury requiring hospitalization and their families. Shortly after injury and at 6-, 12-, and 18-month postinjury, parents of 99 children with TBI (20 severe, 64 moderate, 15 mild) and 117 with orthopedic injury completed standardized assessments of family functioning, parental distress and coping, injury-related burden, and noninjury-related parent stressors and resources. Mixed models analyses examined group differences in parental burden and distress adjusted for race and social demographic factors.
Both moderate and severe TBI were associated with higher levels of injury-related stress than orthopedic injury, with stress levels diminishing over time in all groups. Severe TBI was also associated with greater psychological distress on the Brief Symptom Inventory but not with more depressive symptoms. Family functioning and social resources moderated the relationship of TBI severity to injury-related burden and caregiver distress, respectively. Lower child adaptive skills were associated with poorer family outcome but group differences remained even when controlling for this effect.
Severe TBI in young children has adverse consequences for parents and families during the first 18-month postinjury. The consequences lessen over time for many families and vary as a function of social resources.
PMCID: PMC4278359  PMID: 20431399
traumatic brain injury; family impact; parent coping; early childhood
6.  Diffusion Tensor Imaging: A Review for Pediatric Researchers and Clinicians 
Diffusion tensor imaging (DTI) is a magnetic resonance imaging technique that allows for the visualization and characterization of the white matter tracts of the brain in vivo. DTI does not assess white matter directly. Rather, it capitalizes on the fact that diffusion is isotropic (equal in all directions) in cerebral spinal fluid and cell bodies but anisotropic (greater in one direction than the other directions) in axons that comprise white matter. It provides quantitative information about the degree and direction of water diffusion within individual units of volume within the magnetic resonance image, and by inference, about the integrity of white matter. Measures from DTI can be applied throughout the brain or to regions of interest. Fiber tract reconstruction, or tractography, creates continuous 3-dimensional tracts by sequentially piecing together estimates of fiber orientation from the direction of diffusion within individual volume units. DTI has increased our understanding of white matter structure and function. DTI shows nonlinear growth of white matter tracts from childhood to adulthood. Delayed maturation of the white matter in the frontal lobes may explain the continued growth of cognitive control into adulthood. Relative to good readers, adults and children who are poor readers have evidence of white matter differences in a specific region of the temporo-parietal lobe, implicating differences in connections among brain regions as a factor in reading disorder. Measures from DTI changed in poor readers who improved their reading skills after intense remediation. DTI documents injury to white matter tracts after prematurity. Measures indicative of white matter injury are associated with motor and cognitive impairment in children born prematurely. Further research on DTI is necessary before it can become a routine clinical procedure.
PMCID: PMC4245082  PMID: 20453582
diffusion tensor imaging; magnetic resonance imaging; tractography; children; white matter development; white matter associations with reading disorder; white matter injury in prematurity
7.  Health-Related Quality of Life in Children with Hemifacial Microsomia: Parent and Child Perspectives 
To compare health-related quality of life (HRQOL) among children with and without hemifacial microsomia (HFM) as assessed by parents and the children themselves during the elementary school years.
One hundred thirty-six children with HFM (49 females, mean age = 6 years, 11.9 months, SD = 1.004) were compared with 568 matched controls (285 females, mean age = 6 years, 10.2 months, SD = 0.998) for parent and child responses on the PedsQL Version 4.0.
After adjustment for sociodemographic factors, parent-reported summary scores were worse for affected children than control group children for physical (effect sizes [ES] = 0.26, p = .004), social (ES = 0.34, p = .001), and school (ES = 0.32, p = .001) functioning. There were no significant mean differences in summary scores based on children’s self-reported functioning.
Case-control mean differences in HRQOL were more apparent based on parent report, but not child self-report. Summary score findings suggest that case parents have concerns about their child’s HRQOL, particularly with respect to their child’s physical, social, and school functioning. Additionally, our findings highlight the potential differences between child and parent perspectives and the importance of collecting data from multiple reporters.
PMCID: PMC4218728  PMID: 24213374
health; well-being; subjective; parent-report; child-report; craniofacial
8.  Feeding Interactions in Infants with Very Low Birth Weight and Bronchopulmonary Dysplasia 
Infants with very low birth weight (VLBW) are at increased risk for feeding disorders that can affect growth and development. One hundred and forty one mother-infant pairs were compared [55 with infants with high medical risk due to infant VLBW and bronchopulmonary dysplasia (BPD), 34 VLBW without BPD, and 52 term infants] on operationally defined measures of feeding behaviors and maternal self-report of depression and anxiety. Mothers of VLBW infants with and without BPD spent more time prompting their infants to feed when their infants engaged in nonfeeding behavior. Despite increased maternal efforts, infants with BPD took in less formula, spent less time sucking, and spent a greater proportion of time nonfeeding. VLBW infants without BPD were equivalent to term infants in percentage of time sucking and in volume of formula ingested and were more likely to take in higher calories than infants with BPD. Mothers of VLBW infants with and without BPD were also more likely to report clinically significant symptoms of depression and anxiety than mothers of term infants. Because mothers of VLBW infants who were more depressed or anxious were less likely to verbally prompt their infants to eat, maternal psychological symptoms should be considered in assessing interactions of VLBW mother-infant dyads.
PMCID: PMC4192536  PMID: 8727839
bronchopulmonary dysplasia; very low birth weight infant; feeding; maternal depression; prematurity
9.  Provider Communication Behaviors that Predict Motivation to Change in Black Adolescents with Obesity 
The goal of this research was to identify communication behaviors used by weight loss counselors that mostly strongly predicted Black adolescents’ motivational statements. Three types of motivational statements were of interest: change talk (CT; statements describing their own desires, abilities, reasons, and need for adhering to weight loss recommendations), commitment language (CML; statements about their intentions or plans for adhering), and counter change talk (CCT; amotivational statements against change and commitment).
Thirty-seven Black adolescents with obesity received a single Motivational Interviewing session targeting weight-related behaviors. The video-recorded, transcribed sessions were coded using the MY-SCOPE generating a sequential chain of communication. Data were then subjected to sequential analysis to determine causal relationships between counselor and adolescent communication.
Asking open-ended questions to elicit adolescent CT and emphasizing adolescents’ autonomy most often led to CT. Open-ended questions to elicit CML, reflecting adolescent CML, and emphasizing autonomy most often led to CML. In contrast, open-ended questions to elicit CCT, reflecting CCT, reflecting ambivalence, and neutral open-ended questions about the target behavior led to CCT.
This study provides clinicians with insight into the most effective way to communicate with Black adolescents with obesity about weight loss. Specifically, reflective statements and open questions focusing on their own desires, abilities, reasons, need and commitment to weight loss recommendations are more likely to increase motivational statements whereas other types of reflections and questions may be counterproductive. Finally, because adolescents have a strong need for autonomous decision-making, emphasizing their autonomy may be particularly effective in evoking motivational statements.
PMCID: PMC4184411  PMID: 24131883
Patient-Provider Communication; Adolescents; Obesity
11.  ADHD is a risk factor for overweight and obesity in children 
Journal of developmental and behavioral pediatrics : JDBP  2013;34(8):10.1097/DBP.0b013e3182a50a67.
Although hyperactivity would seem to increase energy expenditure, attention deficit/hyperactivity disorder (ADHD) appears to increase the risk for being overweight. The present study examined the Body Mass Index (BMI) in children with ADHD and its relationship with age, gender, ADHD and comorbid symptom severity, inhibitory control, developmental coordination disorder (DCD), sleep duration and methylphenidate use.
Participants were 372 Dutch children with ADHD combined type aged 5–17 years participating in the International Multicenter ADHD Genetics (IMAGE) study. We categorized BMI according to international age- and gender-specific reference values and calculated BMI-standard deviation scores (BMI-SDS). The control population was matched for age, gender and ethnicity and originated from the same birth cohort as the ADHD group. Inhibitory control was measured by the computerized Stop-signal task. Prevalence differences of underweight, overweight and obesity between groups were expressed in odds ratio’s. We used linear regression analyses with gender, age, parent- and teacher-rated ADHD and comorbid scores, inhibitory control, sleep duration, motor coordination and methylphenidate use to predict BMI-SDS.
Boys with ADHD 10–17 and girls 10–12 years of age were more likely to be overweight than children in the general Dutch population. Younger girls and female teenagers, however, seemed to be at lower risk for being overweight. Higher oppositional behavior and social communication problems related to higher BMI-SDS scores, whereas more stereotyped behaviors related to lower BMI-SDS scores. We found no effects of the other examined associated risk factors on BMI-SDS.
ADHD in boys is a risk factor for overweight. In girls with ADHD, the prevalence of overweight is age-dependent and most pronounced in girls 10–12 years of age. They have a fourfold risk of being obese. Higher oppositional and social communication problems pose an increased risk for overweight, whereas sleep duration, motor coordination problems and methylphenidate use do not.
PMCID: PMC3859965  PMID: 24131879
ADHD; BMI; DCD; sleep; methylphenidate
12.  Social and behavioral risk factors for obesity in early childhood 
While multiple social and behavioral risk factors associated with obesity co-occur among young children, most studies have examined them separately. The purpose of this study is to examine the relationship between social risk factors, behavioral problems, health behaviors and obesity among preschool children in the Fragile Families and Child Wellbeing Study (N=1589).
A cumulative social risk score was created by summing maternal reports of intimate partner violence, food insecurity, housing insecurity, maternal depressive symptoms, maternal substance use, and father's incarceration, obtained when the child was 3 years old. Mothers reported on the child's internalizing and externalizing behaviors with the Child Behavior Checklist (CBCL) at age 5. Mothers also reported on hours the child spent watching TV and sleeping as well as servings of soda or juice drinks the child consumed per day. Child height and weight were measured at age 5. Obesity was defined as Body Mass Index (BMI) >=95th percentile.
In regression analyses adjusted for health behaviors, behavioral problems and socio-demographic factors, cumulative social risk was associated with obesity among girls. Externalizing behavioral problems, were associated with obesity among girls (PR 1.5 95%CI 1.2, 1.7) and boys (PR 1.3 95%CI 1.1, 1.6). Short sleep duration was also associated with obesity among girls (PR 1.2 95% CI 1.0, 1.4) and boys (PR 1.3 95%CI 1.1, 1.5) even after adjusting for behavioral problems and social risk factors. Watching more than 2 hours of television per day was associated with obesity among boys (PR 1.5, 95%CI 1.2, 1.9) but not girls.
Co-occurring social and behavioral risk factors are associated with obesity among five-year old children.
PMCID: PMC3960979  PMID: 24131877
13.  Obesity-Related Behaviors of US and Non-US Born Parents and Children in Low-income Households 
To examine differences in obesity-related behaviors by parental US born status among low-income, minority families participating in Healthy Habits, Happy Homes, an intervention trial to improve household routines for childhood obesity prevention. Evidence suggests lower obesity risk among adult immigrants, but research is inconclusive regarding the influence of having a non-US born parent on childhood obesity.
We sampled 57 US born and 64 non-US born families of children ages 2–5.9 years living in the Boston area. At baseline, parents reported their own screen time, physical activity, diet, and sleep as well as their children’s behaviors. We used linear and logistic regression to examine the association of parental US born status with obesity-related behaviors.
Mean (SD) BMI z-score was 0.94 (1.16) and did not differ between groups. After adjusting for parental education and child race/ethnicity, children of non-US (v. US) born parents had later bedtimes (0.81 hours later; 95% CI: 0.37, 1.25) and wake-up times (0.56 hours later; 95% CI: 0.16, 0.95) and engaged in less active play (0.15 fewer hours/day; 95% CI: −0.28, −0.01). Non-US (v. US) born parents had less screen exposure.
In this cross-section of low-income, urban families, having a parent born outside the US was associated with a profile of risk and protective behavior; adjustment for education and race/ethnicity removed protective associations of parental nativity with child behavior. Obesity-related differences in behaviors and home environments should be considered when designing interventions targeting low-income communities with a high proportion of non-US born participants.
PMCID: PMC4159704  PMID: 24131876
14.  Outcome Measures for Clinical Trials in Fragile X Syndrome 
Progress in basic neuroscience has led to identification of molecular targets for treatment in fragile X syndrome (FXS) and other neurodevelopmental disorders, however, there is a gap in translation to targeted therapies in humans. One major obstacle to the demonstration of efficacy in human trials has been the lack of generally accepted endpoints to assess improvement in function in individuals with FXS. To address this problem, the NIH convened a meeting of leading scientists and clinicians with the goal of identifying and standardizing outcome measures for use as potential endpoints in clinical trials in FXS.
Participants in the meeting included FXS experts, experts in the design and implementation of clinical trials and measure development, and representatives from advocacy groups, industry, and federal agencies.
The group generated recommendations for optimal outcome measures in cognitive, behavioral, and biomarker/medical domains, including additional testing and validation of existing measures, and development of new measures in areas of need. Although no one endpoint or set of endpoints could be identified that met all criteria as an optimal measure, recommendations are presented in this report.
The report is expected to guide the selection of measures in clinical trials and lead to the use of a more consistent battery of measures across trials. Further, this will help to direct research toward gaps in the development of validated FXS-specific outcome measures, and to assist with interpretation of clinical trial data by creating templates for measurement of treatment efficacy.
PMCID: PMC3784007  PMID: 24042082
fragile X syndrome; clinical trials; outcome measures; intellectual disability
15.  Dietary Adequacy of Children with Autism Compared to Controls and the Impact of Restricted Diet 
Journal of developmental and behavioral pediatrics : JDBP  2013;34(7):10.1097/DBP.0b013e3182a00d17.
Children with autism may consume a restricted diet relative to typical peers, whether due to therapeutic measures or sensory sensitivities. Our objective was to compare children with autism to both typically developing and developmentally delayed children on nutrient and food group intake and overall diet quality and to evaluate the impact of diet restriction.
Three-day food records and interview information were analyzed from 69 children with autism, 14 children with developmental delay, and 37 typically developing children, drawn from a larger longitudinal study.
Children with autism did not differ significantly from children with other developmental delays on any dietary measures. Although there were differences in average intake of some nutrients between autism and typical controls, only calcium and dairy were also less likely to be consumed in adequate amounts by the autism group. Intentional diet restriction accounted for most of the differences between autism and typical controls. On average, all groups had inadequate fiber, vitamin D, and vegetable intake. Inadequate intake of folate, grains, and dairy was noted for the autism subgroup with intentional diet restrictions. Children in the autism group not following a restricted diet received significantly worse Healthy Eating Index-2005 scores than those following a restricted diet and typical controls. These differences were not nutritionally significant.
When evaluating nutritional adequacy of children with autism, special consideration should be given to calcium, folate, dairy, and grains. Diets of all children with autism should be evaluated for idiosyncratic deficiencies due to unique dietary patterns.
PMCID: PMC3819433  PMID: 24042076
16.  Usefulness of child development assessments for low-resource settings in francophone Africa 
Journal of developmental and behavioral pediatrics : JDBP  2013;34(7):10.1097/DBP.0b013e31829d211c.
Few tools are available to screen or assess infant’s cognitive development, especially in French-speaking Africa. This study evaluated the use of the French translation of the Mullen Scales of Early Learning (MSEL), and the ‘Ten Questions’ questionnaire (TQ) in 1-year-old children in Benin, a francophone country.
A cross-sectional study was conducted in three health centers serving a semi-rural area in Benin. Three hundred fifty-seven children aged 12 months and their mothers were enrolled in 2011. Infant development was assessed at local health centers followed by a home visit to collect information on socioeconomic status, maternal Raven score, maternal depressive symptoms, and mother–child interactions (HOME Inventory) and to administer the TQ.
The infant’s gender (female), the HOME and maternal education were associated with a higher Early Learning Composite score in multivariate analyses (P=.02, P=.004, P=.007, respectively). The HOME and family wealth were also associated with the gross motor scale (P=.03 and P=.03, respectively). Mothers were more likely to report difficulties on the TQ when the child presented lower score on the MSEL. When considering the gross motor scale as the gold standard to define moderate delays, the two combined motor-related questions on the TQ showed good sensitivity and specificity (76.5 and 75.7).
In a low-resource rural setting in Africa, the TQ effectively identified three-quarters of 1-year-old infants with delayed development. After this screening, the MSEL may be useful for further assessment as it showed good feasibility and sensitivity to known risk factors for poor child development.
PMCID: PMC3821168  PMID: 23899660
Child development; Mullen Scales of Early Learning; Ten Questions Questionnaire; HOME scale; Africa
17.  The Relationship between ADHD Symptom Dimensions, Clinical Correlates and Functional Impairments 
To better understand how heterogeneity in ADHD symptoms relates to heterogeneity in functional impairment domains in children with ADHD after accounting for demographic variables and comorbidities, in particular oppositionality and internalizing symptoms.
Parents and teachers (n=5,663) rated child/adolescent impairments across impairment domains in the International Classification of Functioning, Disability and Health as well as symptoms of ADHD and comorbidities. Hierarchical regressions were conducted to assess the relationship between parent- and teacher-ratings of ADHD symptom domains and functional impairments after accounting for personal factors and comorbid disorders.
Symptoms of inattention were the strongest predictor of ratings of academic (math, writing, etc.) functioning, while hyperactivity/impulsivity symptoms were the strongest predictor of classroom disruption even after accounting for the presence of learning disorders and oppositional symptoms. Symptoms of ADHD accounted for minimal variance in interpersonal functioning or participation in organized activities after controlling oppositional symptoms.
The ADHD symptom domains demonstrate domain-specific relations with various ADHD-related functional impairments. In addition, the results highlight the role of oppositionality in interpersonal relationship difficulties and participation in organized activities.
PMCID: PMC4014057  PMID: 24042078
inattention; hyperactivity/impulsivity; comorbidities; ICF
18.  Risk-Taking Behavior among Adolescents with Prenatal Drug Exposure and Extrauterine Environmental Adversity 
High-risk environments characterized by familial substance use, poverty, inadequate parental monitoring, and violence exposure are associated with an increased propensity for adolescents to engage in risk-taking behaviors (e.g., substance use, sexual behavior, and delinquency). However, additional factors such as drug exposure in utero and deficits in inhibitory control among drug-exposed youth may further influence the likelihood that adolescents in high-risk environments will engage in risk-taking behavior. This study examined the influence of prenatal substance exposure, inhibitory control, and sociodemographic/environmental risk factors on risk-taking behaviors in a large cohort of adolescents with and without prenatal cocaine exposure (PCE).
Risk-taking behavior (delinquency, substance use, and sexual activity) was assessed in 963 adolescents (433 cocaine-exposed, 530 nonexposed) at 15 years of age.
PCE predicted later arrests and early onset of sexual behavior in controlled analyses. Associations were partially mediated, however, by adolescent inhibitory control problems. PCE was not associated with substance use at this age. In addition, male gender, low parental involvement, and violence exposure were associated with greater odds of engaging in risk-taking behavior across the observed domains.
Study findings substantiate concern regarding the association between prenatal substance exposure and related risk factors and the long-term outcomes of exposed youth. Access to the appropriate social, educational, and medical services are essential in preventing and intervening with risk-taking behaviors and the potential consequences (e.g., adverse health outcomes, incarceration), especially among high-risk adolescent youth and their families.
PMCID: PMC4139145  PMID: 24220515
prenatal drug exposure; cocaine; adolescence; risk-taking behavior
19.  Behavior, Brain, and Genome in Genomic Disorders: Finding the Correspondences 
Within the last decade or so, there has been an acceleration of research attempting to connect specific genetic lesions to patterns of brain structure and activation. This article comments on observations that have been made based on these recent data and discusses their importance for the field of investigations into developmental disorders.
In making these observations, we focus on one specific genomic lesion, the well-studied, yet still incompletely understood, 22q11.2 deletion syndrome (22q11.2DS).
We demonstrate the degree of variability in the phenotype that occurs at both the brain and behavioral levels of genomic disorders, and describe how this variability is, upon close inspection, represented at the genomic level.
We emphasize the importance of combining genetic/genomic analyses and neuroimaging for research and for future clinical diagnostic purposes, and for the purposes of developing individualized, patient-tailored treatment and remediation approaches.
PMCID: PMC4124614  PMID: 20814258
20.  Population Differences in Dysmorphic Features Among Children With Fetal Alcohol Spectrum Disorders 
To examine the variation in significant dysmorphic features in children from 3 different populations with the most dysmorphic forms of fetal alcohol spectrum disorders, fetal alcohol syndrome (FAS), and partial fetal alcohol syndrome (PFAS).
Advanced multiple regression techniques are used to determine the discriminating physical features in the diagnosis of FAS and PFAS among children from Northern Plains Indian communities, South Africa, and Italy.
Within the range of physical features used to identify children with fetal alcohol spectrum disorders, specifically FAS and PFAS, there is some significant variation in salient diagnostic features from one population to the next. Intraclass correlations in diagnostic features between these 3 populations is 0.20, indicating that about 20% of the variability in dysmorphology core features is associated with location and, therefore, specific racial/ethnic population. The highly significant diagnostic indicators present in each population are identified for the full samples of FAS, PFAS, and normals and also among children with FAS only. A multilevel model for these populations combined indicates that these variables predict dysmorphology unambiguously: small palpebral fissures, narrow vermillion, smooth philtrum, flat nasal bridge, and fifth finger clinodactyly. Long philtrum varies substantially as a predictor in the 3 populations. Predictors not significantly related to fetal alcohol spectrum disorders dysmorphology across the 3 populations are centile of height (except in Italy) strabismus, interpupilary distance, intercanthal distance, and heart murmurs.
The dysmorphology associated with FAS and PFAS vary across populations, yet a particular array of common features occurs in each population, which permits a consistent diagnosis across populations.
PMCID: PMC4113014  PMID: 20431397
fetal alcohol spectrum disorders (FASD); fetal alcohol syndrome (FAS); partial fetal alcohol syndrome (PFAS); dysmorphology; human malformations
21.  Examining Depressive Symptoms and Use of Counseling in the Past Year Among Filipino and Non-Hispanic White Adolescents in California 
We compared measures of depressive symptoms and use of counseling in the past year for Filipino versus non-Hispanic white adolescents in California.
This cross-sectional study used data from 4421 adolescents who completed the 2003 and 2005 California Health Interview Survey. Bivariate analyses, linear regression, and logistic regression were performed.
Compared to non-Hispanic white adolescents, Filipino adolescents had higher mean 8-item version of Center for Epidemiologic Studies Depression Scale scores (5.43 vs 3.94) and were more likely to report a clinically significant level of depressive symptoms (defined as 8-item version of Center for Epidemiologic Studies Depression Scale score >7) (29.0 vs 17.9%). Filipino adolescents are just as likely as their non-Hispanic white counterparts to report low use of counseling in the past year (17.6 vs 28.4%). Multivariate analyses indicate that depressive symptoms were positively associated with Filipino ethnicity, female gender, living in a single parent household, lower parental education, and poverty. The effect that ethnicity had on use of counseling in the past year varied by gender, income level, and parental education level. Filipino male adolescents with family incomes >300% federal poverty level and parents with more than a college degree were significantly less likely than their non-Hispanic white counterparts to report use of counseling in the past year (odds ratio, 0.01; confidence interval, 0.0004 – 0.44). Filipino female adolescents with family incomes <300% federal poverty level and parental education less than a college degree were significantly more likely to report use of counseling than their non-Hispanic white counterparts (odds ratio, 3.99; confidence interval, 1.00 –15.89).
Further studies and interventions are needed to effectively screen for and treat depression among Filipino adolescents.
PMCID: PMC4104158  PMID: 20431400
Asian American; Filipino; mental health; adolescent
23.  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
24.  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
25.  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

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