Screening children for developmental behavioral problems: principles for the practitioner

Behavioral and developmental problems are commonly seen in children who are cared for by primary care clinicians. This article discusses practical screening tools that can be used by clinicians to screen for these problems and make appropriate referrals to consultants for behavioral and developmental disorders of children.     

Patient race and ethnicity in primary care management of child behavior problems: a report from PROS and ASPN. Pediatric Research in Office Settings. Ambulatory Sentinel Practice Network.

BACKGROUND: Minority persons have less access to many specialty treatments and services, possibly because of clinician biases. It is not clear whether any such biases exist in primary care settings, especially for children with psychosocial problems. OBJECTIVES: The objective was to compare primary care recognition and treatment of pediatric psychosocial problems among African American, Hispanic American and European American patients. DESIGN: A survey was made of parents and respective clinicians in primary care offices in two large practice-based research networks (PROS and ASPN) from 44 states, Canada, and Puerto Rico. Mixed regression analyses were employed to control for patient, clinician, and practice effects. SUBJECTS: The subjects were 14,910 children aged 4 to 15 years seen consecutively for non-emergent care by 286 primary care clinicians in office-based practice. MEASURES: Measures were parents' report for sociodemographics and behavioral symptoms using the Pediatric Symptom Checklist, and clinicians' report of psychosocial problems, type, management, and severity. RESULTS: Of the sample, 8.0% were African American youth, 9.5% were Hispanic American youth, and 82.5% were European American youth. After controlling for other factors, race and ethnicity were not associated with any differences in psychotropic drug prescribing, counseling, referral, or recognition of psychosocial problems. Clinicians reported spending slightly more time with minority patients. CONCLUSION: Race and ethnic status were not related to receipt of mental health services for children in primary care offices, suggesting that clinician biases may not be the primary cause of the racial differences in services noted earlier research. Improving services for minority youth may require increasing access to office-based primary care.     

Reporting medical neglect effectively: a guide for nurse practitioners working with child protective services

Health care providers who suspect or observe medical neglect of chronic health problems in children are obligated to report the findings to Child Protective Services (CPS). Such reporting results in uneasiness for clinicians, who may jeopardize their therapeutic relationships with the patient and family, or worse, provoke them to withdraw from treatment. To the contrary, reporting medical neglect and discussing it openly and empathetically with the family can foster more cohesive teamwork and prompt families to address their problems. Knowing your state's child abuse laws, how to effectively report medical neglect, and how to communicate and collaborate with CPS caseworkers may result in the provision of therapeutic services to families. Enhancing family functioning can result in increased efforts toward caring for their child's medical problem.     

Respite care services to caretakers of chronically ill children in California.

Caring for chronically ill and/or technology-dependent children at home can be emotionally, physically, psychologically, and financially exhausting for the caregiver. Caregivers require temporary relief from the burden of day-to-day care of these children. Respite care offers the opportunity for this relief. A study was conducted to survey the availability of respite care for chronically ill and technology-dependent children in California. Survey findings from 45 agencies indicated that 38% provided respite care for chronically ill and/or technology-dependent children. Fifty percent of agencies provided care for less than 10 chronically ill and/or technology-dependent children per year. Major problems associated with provision of respite services were inadequate reimbursement and insufficient request for services.     

Tools for the job: why relying on risk assessment tools is still a risky business

This theoretical review paper examines the applicability of assessment tools, guidelines and protocols in mental health and substance use care on the basis of the construction of such tools and their reliance on aggregate and actuarial methodologies. Evidence-based practice leads clinicians to increasing reliance on tools for assessment of health status, risk and prediction for a range of clinical needs for individual clients. In the longer-term management of people with enduring and chronic mental health and substance misuse problems, clinicians are often dealing with complex and unstable health needs. The tools available, however, are developed on the basis of majority population evidence and on presumptions of similarity and stability over time. This paper provides explanation of the basis for the development of such tools and argues that clinicians need to be able to evaluate the applicability of tools used for their clients and not just evaluate the internal validity of the tools used to make individual and contextual decisions about individual clients.     

Health Implications and Counseling Considerations for Individuals With Piercings and Tattoos

Body art has become common and mainstream. Tattoos and body piercings represent highly individual expressions of identity and personal values. Health care services are enhanced when clinicians understand the anatomy and physiology, common discomforts, and real but rare serious risks of body modification and are prepared to provide compassionate support for individuals’ choices. Special consideration must be given to the needs of childbearing women. By opening channels of communication, clinicians can engage with clients in shared decision making to help those who possess or desire body art take steps to reduce the risk of adverse effects and obtain prompt and effective medical care when problems arise. Through respectful discussion of existing body art, the therapeutic relationship is strengthened, and greater insight into an individual’s health needs may be achieved.     

Contrasting experiences with child health care services by mothers and professional caregivers in transitional housing.

The study examined experiences of mothers and health care providers with preventive child health care services using qualitative methods at a primary care clinic located in transitional housing for homeless families in an urban community with predominantly Black American residents. Participants were 20 mothers and 4 health care professionals. Three major domains emerged: (a). the infrastructure of the clinic and health care delivery poses barriers to mothers' access and use of services for their children; (b). specialized, biomedical-driven care produces fragmented care delivery not responsive to the comprehensive nature of problems of mothers and their children; and (c). organizational strategies for improving access and use of health care services are directed by health care providers' value orientations. Findings support existence of infrastructural characteristics of the health care system that maintains differential value orientations and power structure, and care delivery processes that are non responsive to racially diverse and poor mothers.     

Review of the acuity scoring systems for the pediatric intensive care unit and their use in quality improvement

Acuity scoring systems quantitate the severity of clinical conditions and stratify patients according to presenting patient condition. In the pediatric intensive care unit, the complexity and number of clinical scoring systems are increasing as their applications for clinicians, health services researches, and quality improvement broaden. This article is a review of acuity scoring systems for the pediatric intensive care unit, including examples of scoring systems available, the methods used in assessing these tools, the ways in which these systems are used, and the utility of acuity scoring systems in accurate benchmarking. It is anticipated that with increasing health care costs and competition and increased focus on medical error reduction and quality improvement, the demands for risk-adjusted outcomes and institutional benchmarking will increase; therefore, as clinicians, academicians, and administrators, it is imperative that we be knowledgeable of the methods and applications of these acuity scoring systems to ensure their quality and appropriate use.     

Health assessment in child care centers: parent and staff perceptions

PURPOSE: The purpose of this study was to identify preschool children's health needs in child care centers, as perceived by parents and staff. METHOD: A Health Care Services Assessment was completed by 55 parents and 13 staff in four urban child care centers to identify the health services needed and children's common health problems. FINDINGS: The majority (69%) of the parents and staff reported that onsite health services were needed at least once a week. Helpful health services were identified as screening exams for respiratory illnesses (88%), other illnesses (87%), developmental problems (51%), and children with special needs (50%). The most commonly identified child health problems were colds (93%) and ear infections (75%). CONCLUSION: These findings indicate that efforts to protect the health of preschool children in child care centers might best begin with health services focused on prevention, such as screening children for illnesses and providing information on infection control.     

Difficult pain assessment and lack of clinician knowledge are ongoing barriers to effective pain management in children with cognitive impairment

Identification of barriers that inhibit effective pain treatment in children with cognitive impairment (CI) may facilitate targeted interventions to ensure that they receive optimal care. This study was undertaken to identify factors that impede effective treatment of pain in children with CI. Clinicians who provided direct care to children were surveyed regarding perceptions of pain management issues. 215 nurses and physicians completed and returned surveys. Difficulties with pain assessment, the lack of valid pain assessment tools, and poor documentation were ranked by the majority of clinicians as factors that impeded their ability to effectively manage pain in this population. Additionally, 88% believed that inadequate education impedes effective pain management in this population, and 88% would attend continuing education courses on pain in children. These data suggest that development of valid and clinically useful pain assessment tools, and focused continuing education may provide the best interventions toward the improvement of pain management in this and similar vulnerable populations.     

The influence of mothers' health beliefs on use of preventive child health care services and mothers' perception of children's health status

During the first three years of life, many health problems are preventable, and health maintenance visits present an excellent opportunity to prevent disease and disability. Unfortunately, preventive child health care services are underutilized. Children who do not adequately use preventive health care services are often seen late in the course of an illness. Thus, they do not receive the continuing care that could eliminate the onset of preventable health problems. In our research, we sought to determine whether mothers' health beliefs influence their use of preventive child health care services and whether their use of preventive child health care services influence their perceptions of the child's health status. The sample was composed of low-income mothers living in an urban environment. No significant relationships were found between the variables. These results indicate the need to develop more sensitive tools to measure these variables in a similar sample.     

Access to care for patients with insulin-requiring diabetes in developing countries: case studies of Mozambique and Zambia

OBJECTIVE: The objective of this study was to assess the barriers to care for patients with insulin-requiring diabetes in Mozambique and Zambia. RESEARCH DESIGN AND METHODS: We used the Rapid Assessment Protocol for Insulin Access to collect information through interviews, discussions, site visits, and document reviews. Government organizations, health facilities, care givers, and patients were asked about care for people with insulin-requiring diabetes. Between 100 and 200 interviews/discussions per country were undertaken in and around the capital city and the regional capital and in a rural area. RESULTS: Insulin was present in both countries in sufficient quantities, although the financial burden for health services and patients meant that problems with supply exist. There are problems with quantification of needs and equitable distribution of insulin. Problems with availability of syringes and testing equipment were noted, particularly in Mozambique. This lack of tools and infrastructure for diagnosis and follow-up coupled with low levels of health care worker training and lack of diagnostic reagents resulted in a substantial risk of misdiagnosis or failure to detect diabetes. The estimated prevalence of insulin-requiring diabetes differs more than 10-fold between urban and rural areas in Mozambique and 4-fold between Mozambique and Zambia, suggesting that problems in diagnosis and care result in substantial worsening of prognosis for such patients. CONCLUSIONS: Insulin is necessary but not sufficient to improve prognosis for diabetic patients. A Rapid Assessment Protocol methodology can be used to define problems in health care delivery for diabetes. Proper care for insulin-requiring diabetes necessitates health systems able to provide trained personnel, medicines in sufficient quantity, and diagnostic and monitoring facilities.     

Acutely ill children within ward areas-care provision and possible development strategies

This report presents the key findings of a travel scholarship to selected paediatric centres in the United Kingdom (UK), Australasia and the United States of America, where services provision for the care of acutely ill children within ward areas was investigated. In total, 15 centres were visited over a 5-month period, and comprehensive programs of information exchange were arranged in all locations. Key areas of interest discussed were the concepts of paediatric critical care outreach services and the use of paediatric early warning assessment tools. Information was collated and applied to the existing service provision within a tertiary children's hospital in the UK. It is hoped that the information gained during this professional study tour will add to the current available literature. It has helped to clarify the position of other key centres with regard to the care provision for acutely ill children in ward areas and confirmed the potential value of a support system and/or use of clinical assessment tool for staff caring for these children.     

Demand management: another marketing tool or a way to quality care?

Demand management tools are population-based strategies used to control costs and improve utilization of services by assisting health consumers in maintaining their health and seeking appropriate health care. These tools are increasingly used by health care delivery systems and, in the US, by fiscal intermediaries, such as insurance companies. If these tools are not properly applied, there is a clear possibility that their use may lead a reduction of health care services with no improvement in clinical, humanistic, or economic outcomes. Demand management effectiveness has not been rigorously examined by the medical industry or academia. Before adopting or purchasing demand management technologies, health care systems should examine them carefully to determine how the tools were developed and who they were intended to serve. Once implemented, careful tracking of population outcomes is as necessary with these technologies as with any other technologies that can affect health care.     

Initial assessment of young people in the emergency department

One of the most important aspects of care for children in emergency departments (EDs) is the initial assessment of their conditions and circumstances. Paediatric nurses, or other nurses who have had adequate training and skills in the care of children and younger people, should use the appropriate tools to undertake these assessments so that they can identify and manage children's physical, mental or social problems. This article discusses the use of such tools in the initial assessments of children at Ipswich Hospital NHS Trust ED, and how this use has improved practice while raising the profile of paediatric emergency care.     

Mitigating opioid errors in inpatient palliative care: A qualitative study

BackgroundOpioids are a high-risk medicine used in high doses and volumes in specialist palliative care inpatient services to manage palliative patients’ pain and other symptoms. Despite the high volume of opioid use in this care setting, serious errors with opioids are exceedingly rare. However, little is known about the factors that mitigate opioid errors in specialist palliative care inpatient services.AimTo explore palliative care clinicians’ perceptions of factors that mitigate opioid errors in specialist palliative care inpatient services.Methods and designA qualitative study using focus groups and semi-structured interviews.Participants and settingRegistered nurses, doctors, and/or pharmacists (‘clinicians’) who were involved with and/or had oversight of the services’ opioid delivery and/or opioid quality and safety processes, employed by one of three specialist palliative care inpatient services in metropolitan NSW.FindingsFifty-eight participants took part in this study, three-quarters (76%) of which were palliative care nurses. A positive opioid safety culture was central to mitigating opioid errors in specialist palliative care inpatient services. This culture of opioid safety was founded on clear and consistent safety messages from leadership, clinicians empowered to work together and practise safely, and a non-punitive approach to errors when they occurred. The clinical nurse educator was seen as pivotal to shaping, driving and reinforcing safe opioid delivery practices across the palliative care service.ConclusionCreating and sustaining a positive opioid safety culture, and promoting a non-punitive approach to opioid error and reporting, is essential to mitigating opioid errors in the specialist palliative care inpatient setting.     

Parents' reports of children's medical care access: are there Mexican-American versus non-Hispanic white disparities?

OBJECTIVES: We investigated whether there were Mexican-American versus non-Hispanic white disparities in parents' reports of problems with 4 dimensions of children's medical care access after controlling for a range of demographic, social, economic, and health status factors. METHODS: Data were collected through a telephone survey of 5941 parents residing in Texas. The survey questionnaire included measures of the parent's demographic and socioeconomic status and the child's health-related quality of life. The behavioral model was used to guide the inclusion of factors in multivariate logistic regression analyses of parents' reports of their children's ability to obtain an appointment for routine/regular care, obtain care for illness/injury, obtain help/advice over the phone when calling the doctor's office, and having to wait more than 15 minutes in the doctor's office. RESULTS: Mexican-American parents had worse reports of all 4 dimensions of their children's access even after controlling for predisposing, enabling, and need factors. Among Mexican-Americans, there were no differences between those who primarily spoke English versus Spanish. Other factors that were significantly associated with at least 2 reports of access were household income, the child's insurance status, and the child's health-related quality of life. CONCLUSIONS: Mexican-American children face problems accessing medical care in a timely manner that are not fully explained by parents' demographic, social, and economic status or children's health-related quality of life. Health policy makers, managers, and clinicians should further consider how they could reduce the inequity of access to medical services among Mexican-American children.     

Development and use of standardised data collection tools to support and inform musculoskeletal practice

Clinicians all over the world are increasingly being faced with the need to demonstrate and account for the way in which clinical services are delivered and the quality of the delivery. It is also imperative to develop a comprehensive profile of who is accessing these services, who benefits from these services; how much these services cost in terms of clinicians time, the use of other healthcare resources and the effectiveness of interventions utilised in relation to quality outcomes. Clinicians are themselves keen to have mechanisms to identify what approaches are being utilised in their own practice setting, how they work best and how they can be improved from a professional development perspective. They are also anxious to improve their skills based on informed reflective practice and identify gaps in their knowledge and skills. This masterclass identifies how standardised data collection (SDC) tools can be utilised in practice to gather the information required in a robust, agreed and accessible way. It summarises a method of SDC tool development and gives some examples of how SDC has been implemented in physiotherapy National Health Services and in physiotherapy private practice in the United Kingdom. The global relevance is that increasingly all physiotherapy services are being held and will be accountable for the quality and equity of care. In addition clinicians can find it useful to have benchmarks with which to compare their own and their departmental performance in terms of clinical activities and outcomes.     

Outcome measurement tools currently used to assess pediatric burn patients: an occupational therapy and physiotherapy perspective

Given the high incidence of burn injuries in children, it is important that all clinicians involved in the care of these patients, including occupational therapists and physiotherapists, are able to assess patients with valid, sensitive, and reliable measurement tools to optimize outcomes and clinical management. The aims of this study were to identify therapist- relevant outcome measurement tools that have been previously used with pediatric burn patients and to ascertain the outcome measurement tools currently used by occupational therapists and physiotherapists working in pediatric burns units. A literature review was undertaken to identify therapist-relevant outcome measurement tools that have been used in the pediatric burn population. A survey involving therapists working in Australian pediatric burns units was then conducted to identify outcome measurement tools in common usage. Few outcome measurement tools were identified that had been specifically validated for use, or were in common usage in Australia, with pediatric patients with burn injury. The lack of validated and widely used measurement tools adversely impacts on the ability of therapists to accurately assess outcomes of treatment and undertake clinical research involving pediatric patients with burn injury.