National survey of pediatricians' violence prevention counseling.

BACKGROUND: Recommendations for child health care providers to counsel patients and their families on violence prevention have been issued by a number of major health care organizations. OBJECTIVE: To assess the knowledge, attitudes, training, and practices of pediatricians concerning violence prevention counseling in the areas of family violence, discipline, television viewing, peer violence, and guns in the home. DESIGN: Survey. PARTICIPANTS: A national random sample of 1350 pediatricians, divided equally among residents in their final year of training, practitioners who had completed their residency training within the last 5 years, and those who had completed their training more than 5 years ago. MAIN OUTCOME MEASURES: Knowledge, attitudes, training, and current practices regarding violence prevention counseling. RESULTS: The overall response rate was 41%. When providing health supervision to patients, most pediatricians never or rarely screen for family and community violence, peer violence, and weapons. For example, 68% of residents and 73% of practitioners never or rarely screen for domestic violence, 56% of residents and 67% of practitioners never or rarely ask adolescents about their involvement in physical fighting, and 54% of residents and 56% of practitioners never or rarely identify families who have guns in the home. Regarding preparation for providing violence prevention counseling, 76% of residents and 83% of practitioners rated their training as inadequate. Receiving training in the prevention of child/adolescent violence in medical school (P<.001), residency (P<.001), or fellowship/continuing medical education (P=.002) were major determinants of more frequent violence prevention counseling. Pediatricians who believed that parents rarely or never follow through on a physician's advice about safe gun storage, switching to nonviolent disciplining techniques, or limiting their child's television viewing were less likely to ask or advise patients in these areas. CONCLUSIONS: Pediatricians are not adequately prepared to provide violence prevention counseling, and few currently screen for exposure to family and community violence, peer violence, and access to weapons. Comprehensive information about violence prevention should be integrated into medical education, and the efficacy of violence prevention counseling strategies should be evaluated.     

Violence prevention in the emergency department: clinician attitudes and limitations

OBJECTIVE: To assess emergency department (ED) clinicians' attitudes and behaviors regarding identification, assessment, and intervention for youth at risk for violence in the ED. DESIGN: Anonymous, cross-sectional written questionnaire. SETTING: The EDs of 3 urban hospitals. SUBJECTS: Emergency medicine residents and faculty, pediatric residents, pediatric emergency medicine fellows and faculty, and ED nurses. RESULTS: A total of 184 (88%) of 208 clinicians completed the questionnaire. Only 15% correctly recognized the lack of existing protocols for addressing youth violence. Clinicians reported being most active in identification of at-risk youth (93% asking context of injury and 82% determining relationships of victim and perpetrator), with pediatricians being more active than general ED clinicians (87% vs 68%; P<.01). Clinicians less often reported performing assessments or referrals of at-risk youth. Nurses and physicians were no different in their reported identification, assessment, or referral behaviors. Barriers identified include concern over upsetting family members, lack of time or skills, and concern for personal safety. Additional clinician training, information about community resources, and specially trained on-site staff were noted by respondents as potential solutions. CONCLUSIONS: Emergency department clinicians recognize the need for evaluation of youth at risk for violence. They are able to identify violently injured youth, but less often perform risk assessment to guide patients to appropriate follow-up resources. Further investigation should address clinician barriers to the complete care of violently injured youth in the ED.     

What are parents worried about? Health Problems and Health Concerns for Children

Patient-centered care requires pediatricians to address parents' health concerns, but their willingness to solicit parental concerns may be limited by uncertainty about which topics will be raised. The authors conducted surveys of parents to identify current health-related issues of concern. Methods Participants rated 30 items as health problems for children in their community (large, medium, small, or no problem) and volunteered concerns for their own children. Results A total of 1119 parents completed the survey. Allergies (69%), lack of exercise (68%), asthma (65%), attention deficit hyperactivity disorder (65%), Internet safety (63%), obesity (59%), smoking (58%), and bullying (57%) were identified as important problems (large or medium) with variation among demographic subgroups. Concerns for their own children included healthy nutrition; obesity; lack of exercise, healthy growth and development; safety and injury prevention; and mental health issues. Conclusion Parents' health concerns for children are varied and may differ from those routinely addressed during well-child care.     

Adolescent violence prevention practices among California pediatricians

OBJECTIVES: To examine pediatricians' provision of violence prevention services to their adolescent patients and to identify factors associated with pediatricians' implementation of these services. DESIGN: A cross-sectional sample of California pediatricians completed a self-report questionnaire. The "Precede/Proceed" theoretical model guided the questionnaire in identification of factors associated with pediatricians' screening and intervening practices in preventing adolescent violence. RESULTS: Two hundred twenty pediatricians (54% female, 66% white, 24% Asian, 5% Latino, and 5% other) participated in the study. On average, participants screened their patients for violence-related risk factors 31% of the time for fighting, 39% of the time for violence in the home, and 29% of the time for weapon carrying. Participants provided their at-risk patients with violence-related interventions less than 50% of the time (on average) implementing the following interventions: written materials, follow-up appointments, discipline counseling, or referral to a community organization, Child Protective Services, or a specialized adolescent clinic. Factors associated with violence prevention screening practices included the following: positive attitudes and beliefs regarding screening for violence, familiarity with violence prevention guidelines, use of prompts in medical records, perceptions of greater skills, and positive reinforcement from patients and colleagues for providing violence prevention services (R(2)=0.44; P<.001). Factors associated with violence prevention intervention practices included: positive attitudes and beliefs in screening for violence, availability of resources, and positive reinforcement from patients and colleagues for providing violence prevention services (R(2)=0.37; P<.001). CONCLUSIONS: California pediatricians are not widely screening their adolescent patients for risk factors associated with adolescent violence, nor are they providing interventions to their adolescent patients who may be at risk for violence. The factors associated with pediatricians' implementation of violence prevention services may assist in the development of effective interventions designed to enhance their delivery of these services to their adolescent patients.     

Urban youths'' perspectives on violence and the necessity of fighting

OBJECTIVES: To assess youth perceptions of the causes and consequences of violence generally, the causes and consequences of fighting specifically, and to determine how best to approach fighting in the context of violence prevention activities. METHODS: Thirteen structured focus group interviews with youths from three high violence urban settings: a large, urban high school, a training center for disadvantaged youths, and a school for adjudicated youths. Participants were 120 urban, predominately African-American youths and young adults ages 14-22 years (mean: 17.2 years). Seven focus groups were conducted with females, and six with males. RESULTS: Adolescents identified the causes of violence on multiple levels including: individual, family, interpersonal, and community level factors. Most youths (89%) had been in a physical fight. Participants felt that fighting was not "right", but identified situations in which it was necessary. Specifically, fighting was used as a problem solving tool, and could prevent escalation of violence. Youths felt that the adults in their lives, including physicians, were generally ill equipped to give advice about violence, as adults' experiences were so removed from their own. Participants looked to experienced role models to offer problem solving and harm reduction strategies. Youths were open to receiving anticipatory guidance about violence and fighting from primary care physicians they felt comfortable with, and who showed respect for their experiences. CONCLUSIONS: Interventions that include blanket admonitions against fighting should be reassessed in light of youth perceptions that fighting plays a complex role in both inciting and preventing more serious violence.     

The emergency department approach to violently injured patient care: a regional survey.

OBJECTIVE: Since the early 1990s public health workers have challenged healthcare practitioners to take an active role in violence prevention with patients aged 10-24 years. Emergency department (ED) clinicians are uniquely positioned to identify, assess, and refer youth involved in violent events. The objective of this study was to describe ED directors' estimate of the number of violently injured youth seen, the presence of established protocols or guidelines for handling youth violence, and the type of training programs offered to ED physicians regarding this issue. METHODS: The authors conducted a survey of EDs (n = 64) in the Philadelphia metropolitan region to determine the standard of ED care for violently injured youths. Half of the EDs were in urban areas and half in suburban. RESULTS: A total of 41 out of 64 (64.1%) ED directors completed and returned the written questionnaire. In addition to treating the specific injuries sustained, ED responses to youth violence primarily involved talking with patients about the events surrounding the injury. The estimated number of violently injured youth seen per month varied considerably. Twenty four directors (58.5%) estimated that their institution treated fewer than 10 per month; 10 (24.4%) reported 11-30, and seven (17.1%) mostly large urban hospitals, saw more than 30 per month. Although most hospitals reported that the staff counsels patients about safety concerns, only 17% offered their staff formal training programs on youth violence. CONCLUSIONS: To address the prevention of youth violence, EDs need specific training programs for ED staff, as well as systematic risk assessment and referral resources for structured intervention and follow up.     

Identifying school performance problems in the pediatric office

The AAP has underscored the role and responsibility of pediatricians in screening their patients for developmental and learning problems and working with parents, schools, and other professionals to ensure that students with these problems receive appropriate educational and therapeutic interventions. We have proposed a model that is time-efficient and can be tailored to the level of interest and experience of the pediatrician. At a minimum, the primary care physician should elicit any parental concerns about school performance, affirm these, and direct the student and parents to appropriate resources in the community for further evaluation and intervention as necessary. Pediatricians who wish to understand more fully the nature and underpinnings of their patients' learning difficulties can formulate a preliminary diagnosis and develop a plan for treatment using a structured system of information gathering that can be combined with information about the child's medical status and supplemented by brief direct testing in the office setting. By following these approaches, primary care pediatricians can provide comprehensive care for their patients and their families in their medical home and also can derive considerable professional satisfaction.     

Prevention of behavioral disorders in primary care

PURPOSE OF REVIEW: This article reviews selected parenting programs for children aged 2-8 years old to inform primary-care pediatricians about options for families of children with behavior problems. RECENT FINDINGS: Young children with aggressive and oppositional behavior are at risk for serious antisocial behavior that may persist into adolescence and adulthood. Most parents wish to discuss parenting difficulties and their child's social and emotional development during well-child visits. Parent training programs are an effective option to promote positive parenting and discipline strategies and enhance a child's social skills, emotional self-regulatory skills, and problem-solving ability. Key parenting principles can be incorporated into developmental surveillance and anticipatory guidance during periodic well-child visits to prevent disruptive behavior problems, address parenting concerns, and nurture the optimal development of children's social-emotional competency. SUMMARY: The literature on the effectiveness of evidence-based parenting programs is growing. This information can enhance practicing pediatricians' understanding of available community resources and parenting support. These programs are feasible with families of various cultures and those at risk for parenting difficulties. Pediatricians can easily incorporate positive parenting principles into primary-care visits and developmental surveillance.     

Juvenile animal abuse: Practice and policy implications for PNPs.

Animal abuse has long been recognized as a sign of family violence and a warning sign of future aggression in children and adolescents. As leaders in youth violence prevention, pediatric nurse practitioners need to be aware of the prevalence and types of juvenile animal cruelty and its relationship to human violence. In doing so, they can champion for health care and related policies for this disturbing problem, described by Ascione as an underreported and understudied issue that may add to the understanding and prevention of youth violence."[One of the most dangerous things that can happen to a child] is when the child who kills or tortures [an animal] is not caught, or if caught is not punished." -Anthropologist Margaret Mead     

Parental perceptions regarding mandatory mouthguard use in competitive youth soccer

OBJECTIVE: To understand factors that influence parental perceptions regarding mandatory mouthguard use in competitive youth soccer. Setting and subjects: A web based survey of parents whose 8-14 year old children participated in outdoor competitive youth soccer during the fall of 2002. Questions focused on: previous injury, education provided, dentist/physician recommendations, and parental perceptions of mouthguard use. MAIN OUTCOME MEASURE: The outcome variable was parental agreement with the statement "mouthguards should be mandatory for competitive youth soccer". Logistic regression and chi(2) were performed using STATA 8.0. RESULTS: Altogether 120 parents participated. The children had a mean (SD) age of 11.8 (1.5) years and 48% were female; 14% wore mouthguards and 11% suffered orofacial injuries. Nineteen percent of parents reported receiving educational material from the youth soccer organization. Although 92% of parents believed that mouthguards were effective in reducing orofacial injuries, only one half agreed that mouthguards should be mandatory. Thirty percent of respondents reported that their dentist/physician recommended mouthguards for competitive youth soccer. Logistic regression showed that dentist/physician recommendation and parental female gender were independently associated with parental agreement for mandatory mouthguard use (odds ratio 2.9, 95% confidence interval (CI) 1.2 to 7.3; odds ratio 3.0, 95% CI 1.1 to 6.5). CONCLUSIONS: Few athletes wear mouthguards during competitive youth soccer. Health care professionals in this study did not capitalize on the apparent influence they have on parental beliefs regarding mouthguard use. Efforts are needed by both health professionals and soccer organizations to educate parents about orofacial injuries and mouthguard use in competitive youth soccer.     

Identification of violence in the home: pediatric and parental reports

OBJECTIVES: To compare the rates of domestic violence reported by mothers with those identified by physicians, to compare the rates of harsh discipline practices reported by mothers with the rates of abuse identified by physicians, and to examine the relationship between reported domestic violence and harsh discipline practices. DESIGNS: Interviews with parents and pediatricians to compare pediatric detection of domestic violence and child abuse with parental reports of domestic violence and harsh discipline practices. SETTING: Community-based pediatric practices in the 13-town greater New Haven, Conn, area. PARTICIPANTS: Of the 23 practices invited, 19 agreed to participate. Of the 2,006 parents of eligible 4- to 8-year-olds asked to participate, 1,886 (94%) completed the Child Behavior' Checklist. Of those invited into the interview portion, 1,148 (83%) completed the 90-minute in-person interview. MAIN OUTCOME MEASURES: Percentages of cases of domestic violence identified by pediatricians and reported by mothers. Percentages of cases of child abuse detected by pediatricians and percentages of mothers reporting that they have hit their children and left a mark. RESULTS: Pediatricians detected domestic violence in 0.3% of the cases, but parents reported domestic violence in 4.2% kappa= 0.106 [95% confidence interval, -0.007 to 0.219]). Pediatricians identified physical abuse of children in 0.5% of the cases, while mothers reported hitting their children and leaving a mark in 21.6% (kappa = 0.003 [95% confidence interval, -0.018 to 0.024]). Mothers reporting domestic violence were significantly more likely to report hitting hard enough to leave a mark (relative risk, 1.6 ([95% confidence interval, 1.09-2.38]) compared with those not reporting domestic violence. Physicians identifying domestic violence were not significantly more likely to report child abuse than those not identifying domestic violence. CONCLUSIONS: Parents report more cases of violence than pediatricians detect. Pediatricians should ask parents directly about domestic violence and harsh discipline.     

Determinants of parental discipline practices: a national sample from primary care practices

National guidelines urge pediatricians to address discipline as part of anticipatory guidance, yet pediatricians know little about what leads parents to use different discipline approaches. Parents seen in Pediatric Research in Office Settings practices participated in an office-based survey before the well-child visit for children 2 to 11 years old (N = 2134). Parents reported using the following discipline approaches frequently: time-outs (42%), removal of privileges (41%), sent to bedroom (27%), yelling (13%), and spanking (9%). A third of parents believe their discipline approach to be ineffective. This directs the pediatric provider to help families develop effective discipline practices tailored to their context.     

How much time is spent on well-child care and vaccinations?

CONTEXT: Because well-child care represents the most important prevention opportunity in the health care system, a growing number of activities and indicators have been proposed for it. OBJECTIVE: To measure the time spent in the various components of well-child care. DESIGN: Time-and-motion study. SETTING: Five private pediatric practices and 2 public providers in Rochester, NY. PARTICIPANTS: One hundred sixty-four children younger than 2 years. MAIN OUTCOME MEASURE: Duration of family's encounters with the primary care provider (physician or nurse practitioner), nurse, and other personnel. RESULTS: The median encounter times and their component parts in minutes were: (1) primary care provider, 16.3 (physical examination, 4.9; vaccination discussion, 1.9; discussion of other health issues, 9.5; vaccination administration, 0); (2) nurse, 5.6 (physical examination, 3.5; vaccination discussion, 0; other health discussion, 0; vaccine administration, 1.6); and (3) other personnel, 0 for all categories. Public provider setting, African American race of the child, and administration of 4 vaccinations were significantly associated with an increase (3-4 minutes) in the duration of the primary care provider encounter. Only 8 (5%) of families read vaccine information materials. CONCLUSIONS: Depending on whether a child makes the usual 3 or recommended 6 number of well-child visits, the total time of well-child care is 45 to 90 minutes during the first year of life and declines to less than 30 minutes per year thereafter as the number of recommended visits diminish. Because high-risk children make half as many well-child care visits as other children, a 3 to 4 minute increase in encounter time is insufficient to provide them with the same level of care as other children.     

Violence prevention in the primary care setting: a program for pediatric residents.

OBJECTIVE: To measure the effect of a violence prevention program on pediatric residents' violence prevention guidance during well-child visits. DESIGN: Prospective study of an educational intervention. SETTING: Inner-city tertiary care hospital and satellite site. PARTICIPANTS: Pediatric residents. INTERVENTIONS: A 2(1/2)-hour violence prevention program, consisting of an introductory talk, role playing, a printed resident guide, and supplemental reading materials. MAIN OUTCOME MEASURES: Parent or guardian report of violence prevention guidance offered during the well-child visit, using a postvisit survey. RESULTS: Three hundred eight patient encounters were included in the survey: 93 prior to the program, 106 just afterward, and 109 after 6 months. Before the program, guns or violence was discussed at 9.7% of visits; this increased to 19.1% of visits after the program (odds ratio, 2.20; 95% confidence interval, 1.02-4.74). The improvement was sustained 6 months after the program. More than 80% of residents felt the program increased their fund of knowledge and taught them skills, and 93% stated that they would use these skills in the future. CONCLUSION: This one-time educational intervention significantly increased the amount of violence prevention guidance provided by pediatric residents to their patients and families. The effect was sustained after 6 months. Residents regarded the program as a successful method of providing the skills and knowledge needed to address the issue of interpersonal violence in their primary care encounters.     

Behavior-oriented approaches to reducing youth gun violence

Advocacy groups on both sides of the guns issue frequently point to changing personal behavior--of both parents and children--as a key element in reducing gun violence among youth. Efforts to bring about these changes range from community-based campaigns, to laws and programs that encourage parents to store their guns safely, to educational initiatives that focus on keeping young children away from guns and encouraging youth to resolve disputes without violence. Unfortunately, these behavior-oriented programs have not shown great success in reducing youth gun violence. This article reviews the research surrounding behavioral approaches to gun violence prevention and highlights obstacles that hamper the effectiveness of these programs. Supportive communities can play a key role in protecting youth from violence in general, but the few community-based violence prevention programs that focus on youth have not been shown to decrease youth access to or use of guns. By and large, behavioral programs and legal interventions aimed at parents have not been proven to reduce youth gun violence. This may be due in part to parental misperceptions about children's risk of injury and ability to protect themselves. Children and youth are particularly difficult targets for behavioral change programs. Cognitive immaturity among younger children and perceptions of invulnerability among adolescents may be part of the reason. Most programs that seek to persuade youth to stay away from guns have not been proven effective. The author concludes that, although behavioral programs could be improved, overall they hold only limited promise for reducing youth gun violence.     

Clinician practice patterns: linking to community resources for childhood aggression

Creating links to community resources for childhood aggression is one component of office-based violence prevention. Evidence is lacking regarding the effect of training clinicians to make these referrals and families' responses to them. Clinicians who received training (n=47) and parents (1093) were queried on the provision of referrals immediately after the visit. Fewer than half of clinicians (45%) reported making a community referral. A third of providers (37%) noted difficulty in identifying local resources. Training clinicians to utilize community resources for childhood aggression does not often result in creating community links for this purpose.     

Predicting clinician injury prevention counseling for young children

BACKGROUND: Injury is the primary cause of morbidity and mortality in children and an important topic for counseling. OBJECTIVE: To describe and explain clinicians' reported counseling behavior during the well-child examinations for children aged 5 years and younger on the following 4 injury prevention topics: motor vehicle crashes, toxic ingestion, drowning, and firearm injuries. METHODS: A random sample of 465 pediatricians, family physicians, and pediatric nurse practitioners in an urban setting received mailed questionnaires; 325 (69.9%) responded. Multivariate logistic regression predicting counseling on each injury prevention topic was performed. RESULTS: Most reported discussing motor vehicle occupant protection (66.2%) and toxic ingestion prevention (62.1%) during the well-child examination. Only 31.8% stated they counseled on drowning prevention and 15.7%, on firearm injury prevention. Knowledge of injury mortality and morbidity rates was not associated with counseling. For most topics, female respondents were more likely to counsel than male respondents (motor vehicle crash odds ratio [OR], 2.24 [P = .03]; toxic ingestion OR, 1.82 [P = .05]; drowning OR, 1.97 [P = .04]). Health maintenance organization settings predicted injury prevention counseling for most topics (motor vehicle crash OR, 2.52 [P = .04]; toxic ingestion OR, 2.77 [P = .01]; firearm injury OR, 2.97 [P = .001]). Clinicians placing lower importance on counseling were less likely to counsel on drowning and firearm injury (drowning OR, 0.73 [P = .006]; firearm injury OR, 0.58 [P<.001]). CONCLUSIONS: Clinicians' knowledge of local injury epidemiology did not influence their counseling on these topics. Clinicians and their patients might benefit by using programs such as The Injury Prevention Program to help them standardize their approach to injury prevention counseling during the routine well-child examination.     

Community physician's role in case management of children with chronic illnesses

There is general agreement that case management should be provided to children with chronic illnesses, yet it is not clear who should provide this service. A survey of physicians and parents of children with chronic illnesses was conducted to evaluate the practice and views of pediatricians and compare their assessments with those of parents. Surveys were mailed to 360 physicians and 519 families with response rates of 39% and 63%, respectively. The majority of physicians (74%) thought that the primary care physician should provide case management. When compared with parents, physicians underestimated the parental need for information about the child's diagnosis (8% vs 52%, P less than .001), treatments (3% vs 54%, P less than .01), and prognosis (30% vs 78%, P less than .01). They also overestimated parental needs for information regarding financial aid (70% vs 58%, P less than .01), vocations (78% vs 54%, P less than .01), and insurance (62% vs 51%, P less than .05). Four services ranked by need by parents in the top 10 were not ranked in the top 10 by physicians. Rural physicians noted that services were more difficult to obtain than did those in nonrural areas. The physicians surveyed made several recommendations for steps that could be implemented to facilitate their role as case managers. If primary care physicians are to be effective case managers, alterations in the current system of care will be required including continuing education related to chronic illness, information about community resources, reimbursement for the time required to perform case management, and better communication between physician and parents.     

The role of schools in combating illicit substance abuse

Disturbingly high levels of illicit drug use remain a problem among American teenagers. As the physical, social, and psychological "home away from home" for most youth, schools naturally assume a primary role in substance abuse education, prevention, and early identification. However, the use of random drug testing on students as a component of drug prevention programs requires additional, more rigorous scientific evaluation. Widespread implementation should await the result of ongoing studies to address the effectiveness of testing and evaluate possible inadvertent harm. If drug testing on students is conducted, it should never be implemented in isolation. A comprehensive assessment and therapeutic management program for the student who tests positive should be in place before any testing is performed. Schools have the opportunity to work with parents, health care professionals, and community officials to use programs with proven effectiveness, to identify students who show behavioral risks for drug-related problems, and to make referrals to a student's medical home. When use of an illicit substance is detected, schools can foster relationships with established health care experts to assist them. A student undergoing individualized intervention for using illicit substances merits privacy. This requires that awareness of the student's situation be limited to parents, the student's physician, and only those designated school health officials with a need to know. For the purposes of this statement, alcohol, tobacco, and inhalants are not addressed.