Telemedicine in Pediatric Training: A National Needs Assessment of the Current State of Telemedicine Education in Pediatric Training

PurposeTo describe the current state of telemedicine within pediatric training programs to inform development of a national telemedicine training curriculum for pediatric trainees.MethodsWe conducted an anonymous cross-sectional survey of pediatric residency (Fall 2020) and fellowship program directors (Spring 2021) on their current telemedicine practices in pediatric post-graduate training.ResultsForty-eight US pediatric residency programs (n = 48/198, 24%) and 422 fellowship programs completed the survey (n = 422/872, 48%); combined response rate 44% (n = 470/1070). Pre-COVID-19, 12% (n = 57/470) of programs surveyed reported using telemedicine in their training program, but during the pandemic 71% (n = 334/470) reported telemedicine use with trainees. Over 71% (n = 334/470) agreed that a formalized curriculum is important, yet 69% (n = 262/380) of programs reporting telemedicine use either did not have a curriculum or were unsure if one existed at their program. Respondents who were unsure/not likely to add a telemedicine curriculum and/or indicated that a telemedicine curriculum would not be important (52% n = 243/470), cited “time” (55%, n = 136/243) most frequently as a barrier.ConclusionsOur needs assessment indicates marked increase in use of telemedicine with trainees by respondent pediatric training programs, with fewer than 50% reporting a formalized training curriculum and most agreeing that a curriculum is important.     

Parent-child interaction therapy: an evidence-based treatment for child maltreatment

It is common practice to augment efficacious treatment protocols for special populations (Durlak & DuPre, 2008), but this is often done before establishing that standard services are not appropriate. In this randomized controlled trial with families at risk or with a history of maltreatment (N = 151), we investigated the effectiveness of standard 12-session Parent-Child Interaction Therapy (PCIT). This is in contrast to other PCIT studies with similar parents, which have allowed for longer and sometimes variable treatment length and with modifications to PCIT protocol. After treatment and compared to Waitlist, mothers reported fewer child externalizing and internalizing behaviors, decreased stress, and were observed to have more positive verbalizations and maternal sensitivity. These outcomes were equivalent or better than outcomes of our previous PCIT trial with high-risk families (Thomas & Zimmer-Gembeck, 2011) when treatment length was variable and often longer. These findings support standard protocol PCIT as an efficacious intervention for families in the child welfare system.     

Telemedicine and Outpatient Subspecialty Visits Among Pediatric Medicaid Beneficiaries

ObjectiveLive interactive telemedicine is increasingly covered by state Medicaid programs, but whether telemedicine is improving equity in utilization of subspecialty care is not known. We examined patterns of telemedicine use for outpatient pediatric subspecialty care within the state Medicaid programs.MethodsWe identified children ≤17 years old in 2014 Medicaid Analysis eXtract data for 12 states. We identified telemedicine-using and telemedicine-nonusing medical and surgical subspecialists. Among children cared for by telemedicine-using subspecialists, we assessed child and subspecialist characteristics associated with any telemedicine visit using logistic regression with subspecialist-level random effects. Among children cared for by telemedicine-using and nonusing subspecialists, we compared visit rates across child characteristics by assessing negative binomial regression interaction terms.ResultsOf 12,237,770 pediatric Medicaid beneficiaries, 2,051,690 (16.8%) had ≥1 subspecialist visit. Of 42,695 subspecialists identified, 146 (0.3%) had ≥1 telemedicine claim. Among children receiving care from telemedicine-using subspecialists, likelihood of any telemedicine use was increased for rural children (odds ratio [OR] 10.4, 95% confidence interval [CI] 6.3–17.1 compared to large metropolitan referent group) and those >90 miles from the subspecialist (OR 13.4, 95% CI 10.2–17.7 compared to 0–30 mile referent group). Compared to children receiving care from telemedicine-nonusing subspecialists, matched children receiving care from telemedicine-using subspecialists had larger differences in visit rates by distance to care, county rurality, ZIP code median income, and child race/ethnicity (P < .001 for interaction terms).ConclusionsChildren in rural communities and at distance to subspecialists had increased likelihood of telemedicine use. Use overall was low, and results indicated that early telemedicine policies and implementation did not close disparities in subspecialty visit rates by child geographic and sociodemographic characteristics.     

Applications of Telemedicine in Child Abuse Pediatrics

Child abuse is a common and morbid condition that is frequently identified in the emergency department, but emergency departments far outnumber specialized child abuse pediatricians. The small size and slow growth of child abuse as a specialty requires innovative approaches to ensure that specialized services are available to all children who may have been abused.This review covers the history and core concepts of telemedicine in child abuse pediatrics, highlighting services including live patient visits, advice and consultation, and retrospective peer review. We describe a deliberate approach to establishing a telemedicine program. Training and practice help establish new competencies in this form of medicine. Evaluation and sound business planning lead to sustainable and positive change. We also discuss challenges unique to child abuse telemedicine including confidentiality, security, provider engagement, and specialized training.Child abuse is a common and pervasive problem whereas child abuse pediatricians are both few and far between. Telemedicine may provide a solution to problems of availability and distribution within our specialty.     

Parent-focused child maltreatment prevention: improving assessment, intervention, and dissemination with technology

The goal of this article is to examine how technology has been and can be utilized to enhance parent-focused child maltreatment (CM) prevention efforts. The authors begin with a brief discussion of the current state of the CM prevention field. In the sections that follow, they review studies that have examined the use of technology across three facets of prevention: identification of CM, administration/augmentation of CM prevention programs, and broad dissemination and implementation of evidenced-based CM prevention programs. They conclude with a discussion of limitations and problems related to the use of technology as a tool to enhance CM prevention and future directions.     

Child maltreatment training in doctoral programs in clinical,counseling, and school psychology: where do we go from here?

The American Psychological Association (APA) has called for improving knowledge regarding child abuse and neglect among psychologists by increasing training. The present study examined the extent of child abuse training provided by APA-accredited doctoral programs in clinical, counseling, and school psychology by surveying the training directors in 1992 and 2001. The survey assessed available coursework, practica, and research experience in the area of child maltreatment. Findings indicated that more than half of all programs cover child maltreatment in three or more courses, and most programs discuss child maltreatment in ethics/professional seminars. Most students have some exposure to clients with abuse-related problems, and some have opportunities to participate in maltreatment research. Nonetheless, training falls short of APA recommendations for minimal levels of competence in child maltreatment, with no change in training in the past decade. Recommendations for improving training include more discussion among program faculty, attention to essential competencies, and specific suggestions for developing interdisciplinary training.     

Child maltreatment investigations involving parents with cognitive impairments in Canada

The authors examined decision making and service referral in child maltreatment investigations involving children of parents with cognitive impairments using the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2003) core-data. The CIS-2003 includes process and outcome data on a total of 1,243 child investigations (n = 1,170 weighted) in which parental cognitive impairment was noted. Employing binary logistic regression analyses, the authors found that perceived parent noncooperation was the most potent predictor of court application. Alternative dispute resolution was rarely utilized. The findings from this study highlight the need for development and utilization of alternative dispute resolution strategies, worker training, dissemination of evidence-based parent training programs, and implementation of strategies to alleviate poverty and strengthen the social relationships of parents with cognitive impairments and promote a healthy start to life for their children.     

Community pediatrics: a consistent focus in residency training from 2002 to 2005.

OBJECTIVE: To assess changes in community pediatrics training from 2002 to 2005. METHODS: Pediatric residency program directors were surveyed in 2002 and 2005 to assess resident training experiences in community pediatrics. Program directors reported on the following: provision of training in community settings; inclusion of didactic and practical teaching on community health topics; resident involvement in legislative, advocacy, and community-based research activities; and emphasis placed on specific resources and training during resident recruitment. Cross-sectional and matched-pair analyses were conducted. RESULTS: A total of 168 program directors participated in 2002 (81% response rate), and 161 participated in 2005 (79% response rate). In both years, more than 50% of programs required resident involvement with schools, child care centers, and child protection teams. Compared with 2002, in 2005, more programs included didactic training on legislative advocacy (69% vs 53%, P < .01) and offered a practical experience in this area (53% vs 40%, P < .05). In 2005, program directors reported greater resident involvement in providing legislative testimony (P < .05), and greater emphasis was placed on child advocacy training during resident recruitment (P < .01). CONCLUSIONS: In the last several years, there has been a consistent focus on legislative activities and child advocacy in pediatric residency programs. These findings suggest a strong perceived value of these activities and should inform efforts to rethink the content of general pediatric residency training in the future.     

What residents know about child abuse. Implications of a survey of knowledge and attitudes

Residency training programs are the appropriate milieu in which physicians should receive specialized training in the diagnosis and management of child abuse. The purposes of the present study were to assess and compare residents' knowledge of child abuse and their attitudes toward the propriety of different forms of childhood discipline. We surveyed 192 residents from seven different training programs with questionnaires probing their knowledge of child abuse and their attitudes toward childhood disciplinary measures; 161 (84%) of the questionnaires were satisfactorily completed by residents in pediatrics (n = 87), family medicine (n = 51), and surgery (n = 23). Both pediatric residents and family medicine residents outperformed surgery residents in one subscale and the total score on the test. Scores were not related to year of training or attitudes toward childhood discipline but were correlated with self-reports of previous child abuse teaching. Residents' performance on a childhood disciplinary measure demonstrated wide latitude in their rating of the acceptability of 23 different modes of childhood discipline. Our findings indicate a need for a more systematic approach to residents' education in childhood intentional injuries and some value clarification of their attitudes toward various forms of childhood discipline.     

A novel early intervention for preschool depression: findings from a pilot randomized controlled trial

Background: Validation for depression in preschool children has been established; however, to date no empirical investigations of interventions for the early onset disorder have been conducted. Based on this and the modest efficacy of available treatments for childhood depression, the need for novel early interventions has been emphasized. Large effect sizes (ES) for preschool psychotherapies for several Axis I disorders suggest that earlier intervention in depression may also be promising. Therefore, a novel form of treatment for preschool depression, Parent–Child Interaction Therapy Emotion Development (PCIT‐ED) was developed and tested. Methods: A preliminary randomized controlled trial (RCT) was conducted comparing PCIT‐ED to psycho‐education in depressed 3‐ to 7‐year‐olds and their caregivers. A total of 54 patients met symptom criteria for DSM–IV major depressive disorder and were randomized, 19 patients completed the active treatment (n = 8 dropouts) and 10 completed psycho‐education (n = 17 dropouts). Results: Both groups showed significant improvement in several domains, with PCIT‐ED showing significance in a greater number of domains. An intent‐to‐treat analysis suggested that PCIT‐ED was significantly more effective than psycho‐education on executive functioning (p = .011, ES = 0.12) and emotion recognition skills (p = .002, ES = 0.83). Conclusions: The RCT proved feasible and suggests an individual control condition should be used in future trials to minimize differential dropout. These pilot data, although limited by power, suggest that PCIT‐ED may be a promising early intervention for depression. Larger scale randomized controlled trials of PCIT‐ED for depressed preschoolers are now warranted.     

Therapists' attitudes toward evidence-based practices and implementation of parent-child interaction therapy

Child abuse and neglect affects many families each year, but evidence-based parent training programs can be instrumental in reducing maltreatment. Parent-Child Interaction Therapy, a parent training program developed for treatment of disruptive child behavior, has demonstrated effectiveness with families at risk of or exposed to child maltreatment. However, methods for disseminating this evidence-based intervention in community settings are not well understood. This study examined the association between community-based therapists' attitudes toward evidence-based practices (EBPs) and their participation in an implementation research project in which they received two forms of consultation. Results showed that therapists' self-reported unwillingness to diverge from EBPs was positively associated with their use of phone consultation and satisfaction with consultation. The degree to which therapists found EBPs appealing was positively associated with satisfaction as well. Open therapist attitudes toward EBPs were associated with greater attendance for online consultation. The next step in this line of research is to examine how therapists' attitudes toward EBPs can be improved, if changing attitudes affects therapist acquisition of treatment skills, and if such improvements enhance implementation efforts.     

Global health training in pediatric residency: a qualitative analysis of faculty director insights

ObjectiveInterest and participation in global health (GH) has been growing rapidly among pediatric residents. Residency programs are responding by establishing formal GH programs. We sought to define key insights in GH education from pediatric residency programs with formal GH tracks.MethodsSeven model pediatric residency programs with formal GH training were identified in 2007. Faculty directors representing 6 of these programs participated in expert interviews assessing 6 categories of questions about GH tracks: understanding how GH tracks establish partnerships with global sites; defining organizational and financing structure of GH tracks; describing resident curriculum and pre-trip preparation; describing clinical experiences of residents in GH tracks; defining evaluation of residents and GH tracks; and defining factors that affect development and ongoing implementation of GH tracks. Data were analyzed using qualitative methodology.ResultsAll programs relied on faculty relationships to establish dynamic partnerships with global sites. All programs acknowledged resident burden on GH partners. Strategies to alleviate burden included improving resident supervision and providing varying models of GH curricula and pre-trip preparation, generally based on core residency training competencies. Support and funding for GH programs are minimal and variable. Resident experiences included volunteer patient care, teaching, and research. Commitment of experienced faculty and support from institutional leadership facilitated implementation of GH programs.ConclusionsDirectors of 6 model GH programs within pediatric residencies provided insights that inform others who want to establish successful GH partnerships and resident training that will prepare trainees to meet global child health needs.     

Child abduction: an overview of current and historical perspectives

This article summarizes research findings in the area of child abduction. Topics addressed include incidence rates and operational definitions of child abduction (legal and social), victim and offender characteristics, and motivation (e.g., maternal desire, sex, retribution, profit, and desire to kill). Risk factors for child abduction are discussed including offender reports of victim selection methodology. Practical application of research findings are considered including the development of more scientifically sound, effective child safety training programs and improved investigative resource management and search methodologies.     

Prevention of shaken baby syndrome: Never shake a baby

Shaken baby syndrome (SBS) represents injuries to the head, skeleton and eyes of a young child and is the leading cause of fatal or life-threatening child abuse. SBS is preventable. The dangers and consequences of shaking a baby are not well appreciated by the general public. Simple educational programs and community nursing support programs have been shown to be helpful. Inadequate physician training and knowledge in child maltreatment have also been identified as problems. This article outlines the evidence for interventions in the prevention of SBS and recommendations for health care providers and educators.     

Editorial: Expanded MCH services

The family planning aspect of health care effectiveness in maternal and child health programs (MCH) can be predicted thorough the use of the multiplicative mathematical model where delivery systems, technology and elgible population are interacting factors. Additionally, health personnel are considered a key factor in the delivery system and an attempt is made to identify this factor through a model which demonstrates that the active learning by personnel is a crucial element in determining effectiveness of a program. Equations are also used to determine the effectiveness of both the nutrition component and foreign assistance in MCH family planning programs.     

Commentary on using new technologies in the child maltreatment field

The articles in this special issue describe how different types of technology can be applied in the child maltreatment field to improve activities. This commentary suggests that though new technology does not necessarily make for better content, it does create exciting new possibilities that creative minds can use to advance the field. The projects described in this issue are examples of such creativity and give a glimpse of the future. However, advances in technology applications do not come without some cost and some loss. Technological approaches may reduce human interaction and result in the loss of its intangible benefits. The commentary suggests that the child maltreatment field appears ripe for broad-based application of technology in three areas: web-based professional training, self-directed interventions and prevention programs, and use of social networking technology. Finally, ideas are proposed for understanding the true cost of developing, implementing, and maintaining technological applications.     

Psychosoziale Aspekte bei motorischen Behinderungen

Stepping Stones Triple P offers behavioural parenting training for families with a handicapped child and has already been successfully evaluated in its country of origin, Australia. As part of a multicentre study involving several social paediatric centers (SPCs) and other clinical institutions, it has been established as a group parenting training in Germany and proved its effectiveness in terms of reducing dysfunctional parenting behaviour, parental stress and child behavioural problems. The present study indicates that a favourable psychosocial context has a positive influence on functional parenting in both the short and medium term. Stepping Stones improves the behaviour of physically handicapped children most favourably while simultaneously reducing parental stress.     

Update on child physical abuse, sexual abuse, and prevention

PURPOSE OF REVIEW: The most recent literature regarding assessment and management of child maltreatment will be considered. The current status of abuse prevention activity will also be reviewed. RECENT FINDINGS: Clinical practice continues to be burdened by the general lack of training and knowledge of the presenting signs and symptoms of child maltreatment by general practitioners. The need for better training is emphasized. Physician engagement in child protection is further inhibited by imprecise reporting obligations and an inadequate child protective services response by the state. Several randomized, controlled trials of home-visiting programs by professionals have demonstrated modest effects in the primary prevention of child abuse and neglect; however, the prevention of recurrent maltreatment of children who remain in the home has proved elusive. SUMMARY: Current clinician training in child maltreatment is inadequate. Research into effective education of clinicians and program effectiveness is plainly needed, and should be supported by increased funding.     

Telemedicine applications in pediatric cardiology

Echocardiography is often used to diagnose and exclude important cardiac diagnoses in children. Evolving telemedicine technology has the potential to improve access to echocardiography diagnoses in the intensive care unit, emergency room, and newborn nursery. The two primary modes of telemedicine practice are "store and forward" and "real-time" videoconferencing. A digital echocardiogram (often several one cardiac cycle loops) can be stored at one site and forwarded across a telemedicine network to a receiving station for review at a later time. Pediatric cardiologists often favor "real-time" telemedicine because of the ability to guide sonographers with limited experience in congenital heart disease. A complete telemedicine system requires a modified computer, a low- or high-speed connection, and telemedicine inputs. Several adult and pediatric clinical studies have shown telemedicine to be accurate, improve patient care, be cost-effective, enhance echocardiogram quality and sonographer proficiency, and promote practice expansion. Obstacles to widespread implementation of telemedicine include lack of standardization of telemedicine components, confusing legal issues and licensure requirements, and poor reimbursement.     

A block rotation in community health and child advocacy: improved competency of pediatric residency graduates.

CONTEXT: Despite increasing recognition of the importance of community health and child advocacy activities by pediatricians, residency programs have had little experience providing this education. There are no known reports examining the effects of such training on residency graduates. OBJECTIVE: To determine whether a program for educating residents in community health and child advocacy, Pediatric Links With the Community (PLC), improved attitudes and competencies of residency graduates. DESIGN: Survey of all graduates of the Rochester Pediatric Residency Program from 1991-2001. Graduates before institution of PLC (pre-PLC) were compared with graduates after institution of PLC (post-PLC). PARTICIPANTS: A total of 137 (81%) of 169 graduates participated; 78 (85%) of 92 were in the pre-PLC group and 59 (77%) of 77 were in the post-PLC group. INTERVENTION: PLC provides all pediatric residents with a 2-week rotation working with multiple community-based organizations. OUTCOME MEASURES: Differences between pre-PLC and post-PLC graduates in self-reported attitudes and competencies in multiple community health and child advocacy activities on 4-point Likert scales. RESULTS: The pre-PLC and post-PLC groups' attitudes toward community health activities were equally positive (3.4 vs 3.5, P =.08). The post-PLC group rated its competency higher in 8 of 12 activities (P <.05); its overall rating of competency was also higher (2.8 vs 2.3, P <.001). CONCLUSIONS: Although all pediatricians surveyed had positive attitudes toward community health and child advocacy activities, those who participated in PLC had higher self-perceived competency in most activities. Residency training programs can increase graduates' competence in community health skills.