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1.  A 7-year-old boy experiencing difficulty at school 
PMCID: PMC3796598  PMID: 24003102
2.  Parental Preferences and Goals Regarding ADHD Treatment 
Pediatrics  2013;132(4):692-702.
To describe the association between parents’ attention-deficit/hyperactivity disorder (ADHD) treatment preferences and goals and treatment initiation.
Parents/guardians of children aged 6 to 12 years diagnosed with ADHD in the past 18 months and not currently receiving combined treatment (both medication and behavior therapy [BT]) were recruited from 8 primary care sites and an ADHD treatment center. Parents completed the ADHD Preference and Goal Instrument, a validated measure, and reported treatment receipt at 6 months. Logistic regression was used to analyze the association of baseline preferences and goals with treatment initiation. Using linear regression, we compared the change in preferences and goals over 6 months for children who initiated treatment versus others.
The study included 148 parents/guardians. Baseline medication and BT preference were associated with treatment initiation (odds ratio [OR]: 2.6 [95% confidence interval (CI):1.2–5.5] and 2.2 [95% CI: 1.0–5.1], respectively). The goal of academic achievement was associated with medication initiation (OR: 2.1 [95% CI: 1.3–3.4]) and the goal of behavioral compliance with initiation of BT (OR: 1.6 [95% CI: 1.1–2.4]). At 6 months, parents whose children initiated medication or BT compared with others had decreased academic and behavioral goals, suggesting their goals were attained. However, only those initiating BT had diminished interpersonal relationship goals.
Parental treatment preferences were associated with treatment initiation, and those with distinct goals selected different treatments. Results support the formal measurement of preferences and goals in practice as prioritized in recent national guidelines for ADHD management.
PMCID: PMC3784291  PMID: 23999959
ADHD; shared decision-making
3.  Parental Depressive Symptoms and Children’s School Attendance and Emergency Department Use: A Nationally Representative Study 
Maternal and child health journal  2013;17(6):1130-1137.
We sought to assess the association between parental depressive symptoms and school attendance and emergency department (ED) use among children with and without chronic health conditions.
Secondary analysis of the 1997–2004 National Health Interview Survey, a nationally representative survey. Parental depressive symptoms were measured by three questions assessing sadness, hopelessness, or worthlessness in the past month. Children with and without asthma or attention-deficit/hyperactivity disorder (ADHD) were identified, and their school attendance and ED visits were reported by adult household respondents. Children with information on parental depressive symptoms, health conditions, and services use were eligible. We incorporated weights available in the survey for each eligible child to reflect the complex sampling design.
104,930 eligible children were identified. The point prevalence of parental depressive symptoms was low (1.8%, 95% CI 1.7–2.0), but greater among children with asthma (2.7%, 95% CI 2.4–3.0) and ADHD (3.8%, 95% CI 3.2–4.4) than among other children (1.6%, 95% CI 1.5–1.7). After adjustment for potential confounders, children whose parents reported depressive symptoms most or all of the time were more likely to report an ED visit (adjusted Incident Rate Ratio [IRR] 1.18, 95% CI 1.06–1.32) or school absence (adjusted IRR 1.36, 95% CI 1.14–1.63) than children whose parents did not. The effect of parental depressive symptoms was not modified by child health conditions.
Parental depressive symptoms were adversely associated with school attendance and ED use in children. These results suggest the importance of measuring depressive symptoms among adult caregivers of children.
PMCID: PMC3538089  PMID: 22903306
Depression; Child of Impaired Parents; asthma; attention deficit disorder with hyperactivity; health services; schools
4.  Challenges to implementation of developmental screening in urban primary care: a mixed methods study 
BMC Pediatrics  2014;14:16.
Research is needed to identify challenges to developmental screening and strategies for screening in an urban pediatric setting.
Parents of young children and clinicians at four urban pediatric practices participated in focus groups prior to implementation of screening. Participants were queried regarding attitudes, social norms, and barriers to developmental screening. Using information from the focus groups, workflow strategies were developed for implementing screening. Referral rates and satisfaction with screening were gathered at the conclusion.
Six focus groups of parents and clinicians were conducted. Major themes identified included 1) parents desired greater input on child development and increased time with physicians, 2) physicians did not fully trust parental input, 3) physicians preferred clinical acumen over screening tools, and 4) physicians lacked time and training to conduct screening. For the intervention, developmental screening was implemented at the 9-, 18-, 24-, and 30-month well visits using the Ages & Stages Questionnaire-II and the Modified Checklist for Toddlers. 1397 (98% of eligible) children under 36 months old were enrolled, and 1184 (84%) were screened at least once. 1002 parents (85%) completed a survey at the conclusion of the screening trial. Most parents reported no difficulty completing the screens (99%), felt the screens covered important areas of child development (98%), and felt they learned about their child’s strengths and limitations (88%).
Developmental screening in urban low-income practices is feasible and acceptable, but requires strategies to capture parental input, provide training, facilitate referrals, and develop workflow procedures and electronic decision support.
PMCID: PMC3899611  PMID: 24447411
Child development; Primary care; Screening; Hospitals; Urban; Developmental assessment
5.  Coordinating Mental Health Care Across Primary Care and Schools: ADHD as a Case Example 
Although primary care practices and schools are major venues for the delivery of mental health services to children, these systems are disconnected, contributing to fragmentation in service delivery. This paper describes barriers to collaboration across the primary care and school systems, including administrative and fiscal pressures, conceptual and linguistic differences between healthcare and educational professionals, role restrictions among professionals, and privacy laws. Strategies for overcoming these barriers that can be applied in both primary care and school settings are described. The paper has a primary focus on children with ADHD, but the principles and strategies described are applicable to children with a range of mental health and health conditions.
PMCID: PMC3582374  PMID: 23459527
Primary Care; Schools; Mental Health; ADHD; Service Coordination
6.  Disparities in the Reporting and Treatment of Health Conditions in Children: An Analysis of the Medical Expenditure Panel Survey 
Health Services Research  2006;41(2):532-549.
To determine whether racial and ethnic disparities in health care use differ for physical and behavioral health conditions.
Data Sources
Secondary analysis of the 1996–1997 Medical Expenditure Panel Survey.
Study Design
Retrospective cohort study of children aged 2–18 years old who were members of participating households. Children were categorized as Hispanic, black, or white. Differences in caregiver-reported behavioral and physical health conditions and services use were compared, and estimates were weighted to reflect the complex sampling scheme.
Principal Findings
Of eligible children weighted to represent over 44 million in each year, 13–15 percent were Hispanic, 14 percent black, and 68–70 percent white. After adjusting for potential confounding, Hispanic and black children were less likely to report externalizing behavioral conditions than white children. Black but not Hispanic children were more likely than white children to report asthma. In addition, Hispanic and black children were less likely to report ambulatory visits, and black children were less likely to report receiving a prescription medication than white children. There were no differences in reported emergency room visits or hospitalizations. Interactions between race and various health conditions, health status, insurance, and income were not significant.
In this nationally representative sample, we identified racial and ethnic disparities in the reporting of health conditions and the use of discretionary health services. Disparities differed between those with behavioral conditions and those with physical conditions. These disparities were not explained by traditional measures including the presence of health conditions, health status, insurance, and family income, and suggest that national surveys such as Medical Expenditure Panel Survey may benefit from the inclusion of additional explanatory measures.
PMCID: PMC1702509  PMID: 16584463
Disparities; mental health disorders; health care services; children
7.  Development of an Instrument to Measure Parents’ Preferences and Goals for the Treatment of Attention Deficit-Hyperactivity Disorder 
Academic pediatrics  2012;12(5):445-455.
To describe the development and validation of an instrument to measure parents' attention deficit-hyperactivity disorder (ADHD) treatment preferences and goals.
Parents of children 6–12 years diagnosed with ADHD in the past 18 months were recruited from 8 primary care sites and an ADHD treatment center (autism excluded). A 16-item medication and 15-item behavior therapy preference scale and a 23-item goal scale, developed following literature review, 90 parent and clinician semi-structured interviews, and input from parent advocates and professional experts, were administered to parents. Parent cognitive interviews confirmed item readability, clarity, content, and response range. We conducted an exploratory factor analysis, assessed internal consistency and test-retest reliability, and construct and concurrent validity.
We recruited 237 parents (mean child age 8.1 years, 51% Black, 59% from primary care, 61% of children medication naive). Factor analyses identified 4 medication preference subscales (treatment acceptability, feasibility, stigma, and adverse effects, Cronbach's α 0.74 to 0.87); three behavior therapy subscales (treatment acceptability, feasibility, and adverse effects, α 0.76 to 0.83); and three goal subscales (academic achievement, behavioral compliance, and interpersonal relationships, α 0.83 to 0.86). The most strongly endorsed goal was academic achievement. The scales demonstrated construct validity, concurrent validity (r= 0.3–0.6) compared to the Treatment Acceptability Questionnaire and Impairment Rating Scale and moderate to excellent test-retest reliability (ICC= 0.7–0.9).
We developed a valid and reliable instrument for measuring preferences and goals for ADHD treatment, which may help clinicians more easily adhere to new national treatment guidelines for ADHD that emphasize shared decision making.
PMCID: PMC3456970  PMID: 22748759
ADHD; Shared Decision Making; Patient Preference; Practice-Based Research
8.  Amphetamines, Atomoxetine and the Risk of Serious Cardiovascular Events in Adults 
PLoS ONE  2013;8(1):e52991.
Main Objective
To compare the incidence rates of serious cardiovascular events in adult initiators of amphetamines or atomoxetine to rates in non-users.
This was a retrospective cohort study of new amphetamines (n = 38,586) or atomoxetine (n = 20,995) users. Each medication user was matched to up to four non-users on age, gender, data source, and state (n = 238,183). The following events were primary outcomes of interest 1) sudden death or ventricular arrhythmia, 2) stroke, 3) myocardial infarction, 4) a composite endpoint of stroke or myocardial infarction. Cox proportional hazard regression was used to calculate propensity-adjusted hazard ratios for amphetamines versus matched non-users and atomoxetine versus matched non-users, with intracluster dependence within matched sets accounted for using a robust sandwich estimator.
The propensity-score adjusted hazard ratio for amphetamines use versus non-use was 1.18 (95% CI: 0.55–2.54) for sudden death/ventricular arrhythmia, 0.80 (95% CI: 0.44–1.47) for stroke, 0.75 (95% CI: 0.42–1.35) for myocardial infarction, and 0.78 (95% CI: 0.51–1.19) for stroke/myocardial infarction. The propensity-score adjusted hazard ratio for atomoxetine use versus non-use was 0.41 (95% CI: 0.10–1.75) for sudden death/ventricular arrhythmia, 1.30 (95% CI: 0.52–3.29) for stroke, 0.56 (95% CI: 0.16–2.00) for myocardial infarction, and 0.92 (95% CI: 0.44–1.92) for stroke/myocardial infarction.
Initiation of amphetamines or atomoxetine was not associated with an elevated risk of serious cardiovascular events. However, some of the confidence intervals do not exclude modest elevated risks, e.g. for sudden death/ventricular arrhythmia.
PMCID: PMC3559703  PMID: 23382829
9.  Shared Decision-Making and Health Care Expenditures Among Children With Special Health Care Needs 
Pediatrics  2012;129(1):99-107.
Background And Objectives
To understand the association between shared decision-making (SDM) and health care expenditures and use among children with special health care needs (CSHCN).
We identified CSHCN <18 years in the 2002–2006 Medical Expenditure Panel Survey by using the CSHCN Screener. Outcomes included health care expenditures (total, out-of-pocket, office-based, inpatient, emergency department [ED], and prescription) and utilization (hospitalization, ED and office visit, and prescription rates). The main exposure was the pattern of SDM over the 2 study years (increasing, decreasing, or unchanged high or low). We assessed the impact of these patterns on the change in expenditures and utilization over the 2 study years.
Among 2858 subjects representing 12 million CSHCN, 15.9% had increasing, 15.2% decreasing, 51.9% unchanged high, and 17.0% unchanged low SDM. At baseline, mean per child total expenditures were $2131. Over the 2 study years, increasing SDM was associated with a decrease of $339 (95% confidence interval: $21, $660) in total health care costs. Rates of hospitalization and ED visits declined by 4.0 (0.1, 7.9) and 11.3 (4.3, 18.3) per 100 CSHCN, and office visits by 1.2 (0.3, 2.0) per child with increasing SDM. Relative to decreasing SDM, increasing SDM was associated with significantly lower total and out-of-pocket costs, and fewer office visits.
We found that increasing SDM was associated with decreased utilization and expenditures for CSHCN. Prospective study is warranted to confirm if fostering SDM reduces the costs of caring for CSHCN for the health system and families.
PMCID: PMC3255469  PMID: 22184653
children with special health care needs; communication; decision-making; health care expenditures
10.  Shared decision making and behavioral impairment: a national study among children with special health care needs 
BMC Pediatrics  2012;12:153.
The Institute of Medicine has prioritized shared decision making (SDM), yet little is known about the impact of SDM over time on behavioral outcomes for children. This study examined the longitudinal association of SDM with behavioral impairment among children with special health care needs (CSHCN).
CSHCN aged 5-17 years in the 2002-2006 Medical Expenditure Panel Survey were followed for 2 years. The validated Columbia Impairment Scale measured impairment. SDM was measured with 7 items addressing the 4 components of SDM. The main exposures were (1) the mean level of SDM across the 2 study years and (2) the change in SDM over the 2 years. Using linear regression, we measured the association of SDM and behavioral impairment.
Among 2,454 subjects representing 10.2 million CSHCN, SDM increased among 37% of the population, decreased among 36% and remained unchanged among 27%. For CSHCN impaired at baseline, the change in SDM was significant with each 1-point increase in SDM over time associated with a 2-point decrease in impairment (95% CI: 0.5, 3.4), whereas the mean level of SDM was not associated with impairment. In contrast, among those below the impairment threshold, the mean level of SDM was significant with each one point increase in the mean level of SDM associated with a 1.1-point decrease in impairment (0.4, 1.7), but the change was not associated with impairment.
Although the change in SDM may be more important for children with behavioral impairment and the mean level over time for those below the impairment threshold, results suggest that both the change in SDM and the mean level may impact behavioral health for CSHCN.
PMCID: PMC3470977  PMID: 22998626
Children with Special Health Care Needs; Communication; Decision-Making
11.  Shared Decision-Making in Pediatrics: A National Perspective 
Pediatrics  2010;126(2):306-314.
To identify patterns of shared decision-making (SDM) among a nationally representative sample of US children with attention-deficit/hyperactivity disorder (ADHD) or asthma and determine if demographics, health status, or access to care are associated with SDM.
We performed a cross-sectional study of the 2002–2006 Medical Expenditure Panel Survey, which represents 2 million children with ADHD and 4 million children with asthma. The outcome, high SDM, was defined by using latent class models based on 7 Medical Expenditure Panel Survey items addressing aspects of SDM. We entered factors potentially associated with SDM into logistic regression models with high SDM as the outcome. Marginal standardization then described the standardized proportion of children’s households with high SDM for each factor.
For both ADHD and asthma, 65% of children’s households had high SDM. Those who reported poor general health for their children were 13% less likely to have high SDM for ADHD (64 vs 77%) and 8% less likely for asthma (62 vs 70%) when adjusting for other factors. Results for behavioral impairment were similar. Respondent demographic characteristics were not associated with SDM. Those with difficulty contacting their clinician by telephone were 26% (ADHD: 55 vs 81%) and 29% (asthma: 48 vs 77%) less likely to have high SDM than those without difficulty.
These findings indicate that households of children who report greater impairment or difficulty contacting their clinician by telephone are less likely to fully participate in SDM. Future research should examine how strategies to foster ongoing communication between families and clinicians affect SDM.
PMCID: PMC3373306  PMID: 20624804
ADHD; asthma; communication; decision-making; telephone care
12.  Cardiovascular Events and Death in Children Exposed and Unexposed to ADHD Agents 
Pediatrics  2011;127(6):1102-1110.
The objective of this study was to compare the rate of severe cardiovascular events and death in children who use attention-deficit/hyperactivity disorder (ADHD) medications versus nonusers.
We performed a large cohort study using data from 2 administrative databases. All children aged 3 to 17 years with a prescription for an amphetamine, atomoxetine, or methylphenidate were included and matched with up to 4 nonusers on the basis of data source, gender, state, and age. Cardiovascular events were validated using medical records. Proportional hazards regression was used to calculated hazard ratios.
We identified 241 417 incident users (primary cohort). No statistically significant difference between incident users and nonusers was observed in the rate of validated sudden death or ventricular arrhythmia (hazard ratio: 1.60 [95% confidence interval (CI): 0.19–13.60]) or all-cause death (hazard ratio: 0.76 [95% CI: 0.52–1.12]). None of the strokes identified during exposed time to ADHD medications were validated. No myocardial infarctions were identified in ADHD medication users. No statistically significant difference between prevalent users and nonusers (secondary cohort) was observed (hazard ratios for validated sudden death or ventricular arrhythmia: 1.43 [95% CI: 0.31–6.61]; stroke: 0.89 [95% CI: 0.11–7.11]; stroke/myocardial infarction: 0.72 [95% CI: 0.09–5.57]; and all-cause death: 0.77 [95% CI: 0.56–1.07).
The rate of cardiovascular events in exposed children was very low and in general no higher than that in unexposed control subjects. Because of the low number of events, we have limited ability to rule out relative increases in rate.
PMCID: PMC3387871  PMID: 21576311
children; adolescents; amphetamines; atomoxetine; methylphenidate; cardiovascular; death
13.  Contrasting Parents' and Pediatricians' Perspectives on Shared Decision-Making in ADHD 
Pediatrics  2010;127(1):e188-e196.
The goal was to compare how parents and clinicians understand shared decision-making (SDM) in attention-deficit/hyperactivity disorder (ADHD), a prototype for SDM in pediatrics.
We conducted semi-structured interviews with 60 parents of children 6 to 12 years of age with ADHD (50% black and 43% college educated) and 30 primary care clinicians with varying experience. Open-ended interviews explored how pediatric clinicians and parents understood SDM in ADHD. Interviews were taped, transcribed, and then coded. Data were analyzed by using a modified grounded theory approach.
Parents and clinicians both viewed SDM favorably. However, parents described SDM as a partnership between equals, with physicians providing medical expertise and the family contributing in-depth knowledge of the child. In contrast, clinicians understood SDM as a means to encourage families to accept clinicians' preferred treatment. These findings affected care because parents mistrusted clinicians whose presentation they perceived as biased. Both groups discussed how real-world barriers limit the consideration of evidence-based options, and they emphasized the importance of engaging professionals, family members, and/or friends in SDM. Although primary themes did not differ according to race, white parents more commonly received support from medical professionals in their social networks.
Despite national guidelines prioritizing SDM in ADHD, challenges to implementing the process persist. Results suggest that, to support SDM in ADHD, modifications are needed at the practice and policy levels, including clinician training, incorporation of decision aids and improved strategies to facilitate communication, and efforts to ensure that evidence-based treatment is accessible.
PMCID: PMC3010085  PMID: 21172996
shared decision-making; attention-deficit/hyperactivity disorder
14.  Hyperuricemia and Coronary Heart Disease: A Systematic Review and Meta-Analysis 
Arthritis care & research  2010;62(2):170-180.
The role of serum uric acid as an independent risk factor for cardiovascular disease remains unclear although hyperuricemia is associated with cardiovascular disease such as coronary heart disease (CHD), stroke and hypertension.
A systematic review and meta-analysis using a random-effects model was conducted to determine the risk of CHD associated with hyperuricemia in adults. Studies of hyperuricemia and CHD were identified by searching major electronic databases using the Medical Subject Headings and keywords without language restriction (through February 2009). Only prospective cohort studies were included if they had data on CHD incidences or mortalities related to serum uric acid levels in adults.
26 eligible studies of 402,997 adults were identified. Hyperuricemia was associated with an increased risk of CHD incidence (unadjusted risk ratio (RR) 1.34; 95% confidence interval (CI) 1.19-1.49) and mortality (unadjusted RR 1.46; 95% CI 1.20-1.73). When adjusted for potential confounding, the pooled RR was 1.09 (95% CI: 1.03-1.16) for CHD incidence and 1.16 (95% CI: 1.01-1.30) for mortality. For each increase of 1 mg/dl in uric acid level, the pooled multivariate RR for CHD mortality was 1.12 (95% CI: 1.05-1.19). Subgroup analyses showed no significant association between hyperuricemia and CHD incidence/mortality in men, but an increased risk for CHD mortality in women (RR 1.67; 95% CI: 1.30-2.04).
Hyperuricemia may marginally increase the risk of CHD events, independently of traditional CHD risk factors. A more pronounced increased risk for CHD mortality in women should be investigated in future research.
PMCID: PMC3156692  PMID: 20191515
hyperuricemia; coronary heart disease; meta-analysis
15.  Performance measures of the specialty referral process: a systematic review of the literature 
Performance of specialty referrals is coming under scrutiny, but a lack of identifiable measures impedes measurement efforts. The objective of this study was to systematically review the literature to identify published measures that assess specialty referrals.
We performed a systematic review of the literature for measures of specialty referral. Searches were made of MEDLINE and HealthSTAR databases, references of eligible papers, and citations provided by content experts. Measures were eligible if they were published from January 1973 to June 2009, reported on validity and/or reliability of the measure, and were applicable to Organization for Economic Cooperation and Development healthcare systems. We classified measures according to a conceptual framework, which underwent content validation with an expert panel.
We identified 2,964 potentially eligible papers. After abstract and full-text review, we selected 214 papers containing 244 measures. Most measures were applied in adults (57%), assessed structural elements of the referral process (60%), and collected data via survey (62%). Measures were classified into non-mutually exclusive domains: need for specialty care (N = 14), referral initiation (N = 73), entry into specialty care (N = 53), coordination (N = 60), referral type (N = 3), clinical tasks (N = 19), resource use (N = 13), quality (N = 57), and outcomes (N = 9).
Published measures are available to assess the specialty referral process, although some domains are limited. Because many of these measures have been not been extensively validated in general populations, assess limited aspects of the referral process, and require new data collection, their applicability and preference in assessment of the specialty referral process is needed.
PMCID: PMC3155905  PMID: 21752285
Primary Care; Specialists; Referral-Consultation; Coordination; Quality of Care
16.  Hyperuricemia and Risk of Stroke: A Systematic Review and Meta-analysis 
Arthritis and rheumatism  2009;61(7):885-892.
Hyperuricemia is hypothesized to be a risk factor for stroke and other cardiovascular disease, but to date results from observational studies are conflicting.
We conducted a systematic review and meta-analysis to assess the association between hyperuricemia and risk of stroke incidence and mortality. Studies were identified by searching major electronic databases using the Medical Subject Headings and keywords without restriction in languages. Only prospective cohort studies were included if they had data on stroke incidences or mortalities related to serum uric acid levels in adults. Pooled risk ratios (RRs) for the association of stroke incidence and mortality with serum uric acid levels were calculated.
A total of 16 studies including 238,449 adults were eligible and abstracted. Hyperuricemia was associated with a significantly higher risk of both stroke incidence [N=6 studies, RR 1.41, 95% confidence interval (CI): 1.05–1.76] and mortality [N=6 studies, RR 1.36, 95% CI: 1.03–1.69] in our meta-analyses of unadjusted study estimates. Subgroup analyses of studies adjusting for known risk factors such as age, hypertension, diabetes, and cholesterol still showed that hyperuricemia was significantly associated with both stroke incidence [N=4 studies, RR 1.47, 95% CI: 1.19–1.76] and mortality [N=6 studies, RR 1.26, 95% CI: 1.12–1.39]. The pooled estimate of multivariate RRs did not differ much by gender.
Our study suggests that hyperuricemia may modestly increase the risks of both stroke incidence and mortality. Future research is needed to determine whether lowering uric acid level has any beneficial effects on stroke.
PMCID: PMC2714267  PMID: 19565556
hyperuricemia; stroke; systematic review; meta-analysis
17.  Survey of Mental Health Consultation and Referral Among Primary Care Pediatricians 
Academic pediatrics  2009;9(2):123-127.
To determine availability of and test whether on-site mental health providers (MHP) is associated with greater odds of reported mental health consultation and referral among primary care pediatricians.
Pediatricians were identified from the American Medical Association's 2004 Physician Directory, stratified by region, and 600 were randomly selected to receive a mail survey. The main independent variable was on-site MHP. The dependent variable was reported frequency (4-point rating) of mental health consultation and referral. Estimates were weighted to account for survey design and non-response.
Overall response rate was 51%. The majority of respondents were male (56%), age ≥46 years old (59%), white (68%), and practicing in suburban locations (52%). Approximately half reported consultation with (44%) or referral to (51%) MHP always or often, but few (17%) reported on-site MHP. After adjustment for demographic and practice characteristics, pediatricians with on-site MHP were more likely to consult (Odds Ratio [OR] 6.58, 95% confidence interval [CI] 3.55-12.18) or refer (OR 4.25, 95% CI 2.19-8.22) than those without on-site MHP. Among those without on-site MHP, pediatricians with greater practice burden were less likely to consult (OR 0.69, 95% CI 0.48-0.99) or refer (OR 0.75, 95% CI 0.54-1.04) than those with lesser burden.
Most pediatricians in the U.S. experienced practice-related burdens that limit mental health collaboration, but those with collocated services reported a greater likelihood of consultation and referral. Policy changes that encourage collocation of mental health services and limit practice burden may facilitate mental health consultation and referral.
PMCID: PMC2663807  PMID: 19329104
mental health; child; primary health care; health surveys; referral and consultation
18.  Development and Psychometric Assessment of the Collaborative Care for Attention Deficit Disorders Scale 
To describe the development and assess the validity and reliability of the Collaborative Care for Attention Deficit Disorders Scale (CCADDS), a measure of collaborative care processes for children with ADHD who attend primary care practices.
Collaborative care was conceptualized as a multidimensional construct. The 41-item CCADDS was developed from an existing instrument, review of the literature, focus groups, and an expert panel. The CCADDS was field tested in a national mail survey of 600 stratified and randomly selected practicing general pediatricians. Psychometric analysis included assessments of factor structure, construct validity, and internal consistency.
The overall response rate was 51%. The majority of respondents were male (56%), age 46 years old and above (59%), and white (69%). Common factor analysis identified 3 subscales: beliefs, collaborative activities, and connectedness. Internal consistency reliability (coefficient α) for the overall scale was 0.91, and subscale scores ranged from 0.80 to 0.89. The CCADDS correlated with a validated measure of provider psychosocial orientation (r =−0.36, p <0.001) and with self-reported frequency of mental health referrals or consultations (r =−0.24 to r =−0.42, p <0.001). CCADD scores were similar among physicians by race/ethnicity, gender, age group, and practice location.
Scores on the CCADDS were reliable for measuring collaborative care processes in this sample of primary care clinicians who provide treatment for children with ADHD. Evidence for validity of scores was limited. Future research is needed to confirm its psychometric properties and factor structure and provide guidance on score interpretation.
PMCID: PMC2245876  PMID: 18191777
mental health; ADHD; primary health care; health care surveys
19.  Correlates of Behavioral Care Management Strategies used by Primary Care Pediatric Providers 
To identify correlates of behavioral management strategies and to test whether children with more severe behavioral problems have care transferred to mental health specialists.
Secondary analysis of the Child Behavior Study. Children ages 4 to 15 years old were identified with new behavioral problems at non-urgent visits to primary care clinicians. Treatment strategies were categorized into mutually exclusive groups: primary care (psychotropic prescription and/or office-based counseling), mental healthcare (referral for or ongoing specialist mental healthcare), joint care (primary care and mental healthcare) or observation. Child-, family-, clinician-, and practice-level characteristics were assessed for association with management strategies using multivariate methods.
A total of 1377 children from 201 practices in 44 states and Puerto Rico were newly identified with behavioral problems. Behavioral/conduct (41%), attentional/hyperactivity (37%), adjustment (32%), and emotional (22%) problems were most commonly identified. Children with comorbid behavioral problems were more likely to be managed with joint care than other treatment strategies. In addition, clinicians who were male or who had greater mental health orientation were more likely to provide joint care than mental healthcare only.
Clinicians were more likely to manage new behavioral problems jointly with mental health providers than use other strategies if children had coexisting mental health problems or if providers had stronger beliefs about psychosocial aspects of care. These results do not support the hypothesis that children with more severe behavioral problems are transferred to specialists but suggest that primary care and mental healthcare clinicians may benefit from collaborating on treatment plans.
PMCID: PMC1832082  PMID: 17368411
mental health; child; decision making; therapeutics
20.  Fragmented Care for Inner-city Minority Children with Attention-Deficit/Hyperactivity Disorder 
Pediatrics  2005;116(4):e512-e517.
To identify systematic problems in coordinating care for inner-city minority youth with attention-deficit/hyperactivity disorder (ADHD).
Focus group study.
We recruited participants from inner-city minority communities in a single metropolitan area. We held separate meetings for pediatricians, mental health therapists, school staff, and parents (both African-American and Latino).
We audiotaped and transcribed the meetings. We identified themes by consensus and used Root Cause Analysis as a conceptual framework to guide our analysis.
We held 13 focus group meetings. Participants uniformly perceived insufficient communication and coordination of care. Five themes representing system and human factors emerged that contributed to this fragmentation in care: 1) a lack of consensus about who should oversee care; 2) changes in health care providers or teachers; 3) uncertainty in the diagnosis, insufficient training, and few resources; 4) distrust and blame that emerged when relationships among people caring for the child were absent or otherwise inadequate; 5) lack of support from employers, friends, and family to engage in collaborative care.
Using a Root Cause Analysis framework, we identified system- and human-level factors that were perceived to impede communication and coordination of care for this population of children with ADHD. These results suggest that better organizational policies that define provider responsibilities and accountability, support the coordination of care, bridge relationships between agencies, and provide additional education and resources may improve collaboration. Further study is needed to assess the generalizability of these finding to other settings.
PMCID: PMC1255962  PMID: 16199679
attention deficit disorder with hyperactivity; children; qualitative research
21.  Meta-analytic methods for pooling rates when follow-up duration varies: a case study 
Meta-analysis can be used to pool rate measures across studies, but challenges arise when follow-up duration varies. Our objective was to compare different statistical approaches for pooling count data of varying follow-up times in terms of estimates of effect, precision, and clinical interpretability.
We examined data from a published Cochrane Review of asthma self-management education in children. We selected two rate measures with the largest number of contributing studies: school absences and emergency room (ER) visits. We estimated fixed- and random-effects standardized weighted mean differences (SMD), stratified incidence rate differences (IRD), and stratified incidence rate ratios (IRR). We also fit Poisson regression models, which allowed for further adjustment for clustering by study.
For both outcomes, all methods gave qualitatively similar estimates of effect in favor of the intervention. For school absences, SMD showed modest results in favor of the intervention (SMD -0.14, 95% CI -0.23 to -0.04). IRD implied that the intervention reduced school absences by 1.8 days per year (IRD -0.15 days/child-month, 95% CI -0.19 to -0.11), while IRR suggested a 14% reduction in absences (IRR 0.86, 95% CI 0.83 to 0.90). For ER visits, SMD showed a modest benefit in favor of the intervention (SMD -0.27, 95% CI: -0.45 to -0.09). IRD implied that the intervention reduced ER visits by 1 visit every 2 years (IRD -0.04 visits/child-month, 95% CI: -0.05 to -0.03), while IRR suggested a 34% reduction in ER visits (IRR 0.66, 95% CI 0.59 to 0.74). In Poisson models, adjustment for clustering lowered the precision of the estimates relative to stratified IRR results. For ER visits but not school absences, failure to incorporate study indicators resulted in a different estimate of effect (unadjusted IRR 0.77, 95% CI 0.59 to 0.99).
Choice of method among the ones presented had little effect on inference but affected the clinical interpretability of the findings. Incidence rate methods gave more clinically interpretable results than SMD. Poisson regression allowed for further adjustment for heterogeneity across studies. These data suggest that analysts who want to improve the clinical interpretability of their findings should consider incidence rate methods.
PMCID: PMC481068  PMID: 15248899
22.  Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis 
BMJ : British Medical Journal  2003;326(7402):1308.
Objective To determine the effectiveness of educational programmes for the self management of asthma in children and adolescents.
Data sources Databases of the Cochrane Airways Group, PsychINFO, reference lists of review papers, and eligible studies.
Review methods Eligible studies were published randomised controlled trials or controlled clinical trials of educational programmes for the self management of asthma in children and adolescents that reported lung function, morbidity, self perception of asthma control, or utilisation of healthcare services. Eligible studies were abstracted, assessed for methodological quality, and pooled with fixed effects and random effects models.
Results 32 of 45 identified trials were eligible, totalling 3706 patients aged 2 to 18 years. Education in asthma was associated with improved lung function (standardised mean difference 0.50, 95% confidence interval 0.25 to 0.75) and self efficacy (0.36, 0.15 to 0.57) and reduced absenteeism from school (-0.14, -0.23 to -0.04), number of days of restricted activity (-0.29, -0.33 to -0.09), and number of visits to an emergency department (-0.21, -0.33 to -0.09). When pooled by the fixed effects model but not by the random effects model, education was also associated with a reduced number of nights disturbed by asthma. The effect on morbidity was greatest among programmes with strategies based on peak flow, interventions targeted at the individual, and participants with severe asthma.
Conclusions Educational programmes for the self management of asthma in children and adolescents improve lung function and feelings of self control, reduce absenteeism from school, number of days with restricted activity, number of visits to an emergency department, and possibly number of disturbed nights. Educational programmes should be considered a part of the routine care of young people with asthma.
PMCID: PMC161636  PMID: 12805167
24.  Attention deficit hyperactivity disorder 
Western Journal of Medicine  2001;175(3):189-193.
PMCID: PMC1071540  PMID: 11527851

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