It''s time: The future of school health in Australia

School medical services in Australia have a long tradition of providing community-based services to school-aged children, and in some states to preschool children. Conceived as a public health measure early this century, doctors and nurses worked in schools to address the health issues of the time, which were largely to do with nutrition, hygiene, and infectious diseases. It was perceived that many children had poor access to medical care, and began school with unaddressed health problems which often had a deleterious effect on their learning. Doctors were often employed by education authorities and only transferred to health departments many years later. In some states the service was expanded subsequently to include preschool children, based on the concept that the earlier problems were detected the earlier they could be treated appropriately and the greater the benefits to the child. While social structures, community needs and paediatric morbidity patterns have changed dramatically over recent years, there is a widespread perception that in some states school medical services have not yet embraced fully the changing needs of the population of school children they are designed to serve. Hamstrung by political expediency (with decision-making driven by political rather than scientific considerations) and bureaucratic inertia, school nurses and doctors often operate in structures and systems that are urgently in need of review and reorganization. In this paper the rationale for current processes will be reviewed critically, a model of school health services focused on contemporary paediatric needs is proposed, and a set of factors which are considered essential to the development of the school health services of the future is outlined.     

Child and youth mental health: Integrated health care using contemporary competency-based teams

Mental health teams have long been the foundation for mental health services provided to children and youth. Changes in professional practices, the emergence of evidence-based care, the importance of integrating mental health into primary health care delivery, the decrease in professional ‘ownership’ of mental health care competencies and other factors now challenge the traditional structure and function of these teams. New and novel frameworks will be needed to address mental health care needs for problems that do not require ‘traditional’ mental health service interventions, to enable integration of mental health care into usual health services, to promote specialist mental health care delivery for those in need, and to facilitate the development and translation of mental health research into practice. In all of these new team structures, the active participation of young people and their families will be necessary.     

Transkulturelle Pädiatrie – Vielfalt und Kindergesundheit

In Germany, children of immigrant families represent almost one-quarter of the population under the age of 18 years. Due to differing life course determinants of health, there is large heterogeneity in the health status and health care needs among children/adolescents from immigrant families. Health care organizations need to take action to meet the diverse needs of patients. At the level of the individual child health professional, management of a diverse pediatric population requires the development of transcultural skills, and demonstration of behaviors and attitudes that are appropriate to care for pediatric patients with a wide range of sociocultural attributes. There is a special need for support for recently immigrated minors and children/adolescents with chronic diseases. Significant health care inequities persist among refugee minors whom face numerous barriers to accessing an appropriate level of health care, which has implications for both individual and public health.     

Human factors engineering and patient safety

The pediatric population has features different from those of adults and that are dynamic during the pediatric age range. Pediatric-specific issues result in potential risks for harm during medical care. Basic and applied human factors research has resulted in improvements in the performance of health adults and those adults who have functional limitations. Future work should focus on systematically understanding the human factors needs of children with the goal of redesigning systems of health care to optimize the safety of children and the performance of their care providers.     

Health of Australian children in out-of-home care: needs and carer recognition

Aim: Following research highlighting high levels of health need in New South Wales children in out‐of‐home care, this study aimed to quantify health need in a sample of Queensland children in care based on multidisciplinary child health assessments. The study also sought to examine the concordance between foster carers' health concerns for children for whom they are providing care and health need as established through referrals made as a result of health assessment. Methods: Children entering out‐of‐home care in the north Brisbane area within the previous month were referred for baseline child health assessment. Child health was assessed by paediatricians and clinical nurses utilising a pro forma‐based methodology. Analysis of initial carer concerns, health referrals and immunisation status in the sample was undertaken. Results: Of the 63 children assessed, 70% were found to require multiple referrals to various health services. The most frequently made referrals included paediatrician follow‐up (41% of children), counselling services (30%) and audiology (26%). Only 68% of the sample was found to be fully immunised. A discrepancy was noted between foster carers' child health concerns and level of referral need established during assessment. Conclusions: Queensland children in care have high health needs similar to those evidenced by children in care in other areas of Australia. Foster carers appear to underestimate the health needs of children in their care, demonstrating the necessity of multidisciplinary health screens and foster carer training in order to detect child health problems in this population.     

Telehealth for children with special health care needs: promoting comprehensive systems of care

This study identified ways that telehealth systems are used to enhance service delivery for children with special health care needs. Various health professionals utilize telehealth to provide physical and behavioral health care, to conduct developmental evaluations, and to address family/social concerns. Telehealth is used most for follow-up visits after in-person specialty care and for child evaluation with treatment recommendations to local care providers. Telehealth systems have the potential to increase access to specialized services and to enhance community-based services for rural and underserved children. However, inadequate reimbursement poses a significant barrier to the development of these services.     

Current status of pediatric practice-based research networks

PBRNs have become a major factor in the pediatric research landscape and hold great promise for generating new knowledge about child health. Much remains to be learned about the content of children's health care. More importantly, there is great room for improvement in the delivery of primary care to children. In wedding the knowledge and expertise of academic researchers and pediatric practitioners, PBRNs will become agents to transform and improve pediatric practice by identifying areas of care in need of improvement, developing and testing interventions to improve pediatric practice, and disseminating this knowledge to the pediatric community.     

Children's unmet need for mental health care within and outside metropolitan areas

BackgroundRural communities experience a lack of pediatric mental health providers. It is unclear if this leads to greater unmet needs for specialty mental health services among rural children.MethodsData from the 2016–2019 National Survey of Children's Health were used to identify children aged 6–17 years with a mental health condition. Caregiver-reported need and receipt of specialty mental health care for their child (met need, unmet need, or no need) was compared according to residence in a Metropolitan Statistical Area (MSA).ResultsThe analysis included 13,021 children (14% living outside MSAs). Unmet need for mental health services was reported for 9% of children, with no difference by rural-urban residence (p = 0.940). Multivariable analysis confirmed this finding and identified urban children as less likely to have no need for mental health services, compared to rural children (relative risk ratio of no need vs. met need: 0.79; 95% confidence interval: 0.65, 0.95; p = 0.015).ConclusionChildren with mental health conditions living in rural areas (outside MSAs) did not have higher rates of unmet needs for specialty mental health services, but they had lower rates of any caregiver-reported needs for such services. Further work is needed to examine caregivers’ demand for pediatric specialty mental health services.     

PNP roles and interventions with children with special needs and their families.

Pediatric nurse practitioners (PNPs) can create excellent professional roles caring for children with special health care needs (CSHCN) and their families. Children with chronic conditions represent an estimated 31% of the US population younger than 18 years (approximately 20 million children in 1988). Five percent of all children who have multiple special needs account for approximately 40% of all pediatric health care expenditures. Skill building is needed for PNPs who have traditionally focused on wellness and common acute illnesses in primary care settings. Role theory and research can guide PNPs in creating roles and interventions to improve the health, safety, and developmental outcomes for CSHCN and their families. Two roles are described, with examples of specific nursing interventions. Assisting child care centers to serve children and families with special needs is an ideal role for PNPs who have knowledge of health and regulatory issues. Another important PNP role is working with adolescents with special health care needs as they transition from pediatric to adult care. Many resources (such as those from the Maternal and Child Health Bureau) are available to assist PNPs to create new roles and interventions for CSHCN and their families.     

Providing a primary care medical home for children and youth with spina bifida

The pediatric primary care provider in the medical home has a central and unique role in the care of children with spina bifida. The primary care provider addresses not only the typical issues of preventive and acute health care but also the needs specific to these children. Optimal care requires communication and comanagement with pediatric medical and developmental subspecialists, surgical specialists, therapists, and community providers. The medical home provider is essential in supporting the family and advocating for the child from the time of entry into the practice through adolescence, which includes transition and transfer to adult health care. This report reviews aspects of care specific to the infant with spina bifida (particularly myelomeningocele) that will facilitate optimal medical, functional, and developmental outcomes.     

Health needs of Australian children living in out-of-home care

BACKGROUND: Children living in out-of-home care have high and frequently unidentified health needs. The Child Protection Unit at Sydney Children's Hospital offers comprehensive health screening to children in care. AIMS: To report the experience of the health screening clinic and the rates of identified health problems of children in care in this sample, and to compare these rates with the general child population and children in care overseas. METHODS: Comprehensive multidisciplinary health screens were offered to children in out-of-home care. RESULTS: High rates of physical, developmental and emotional health problems were identified. The rates of poor health were greater than the average child population of New South Wales, but similar to the rates of poor health reported in children in care overseas. CONCLUSIONS: Children in care are a vulnerable group of the child population who experience unacceptable levels of poor health. Comprehensive health screens can help identify previously undetected health problems.     

Community-based domestic violence services

Community-based domestic violence services have grown significantly since their emergence in the 1970s. Now more than 2,000 in number, domestic violence organizations have expanded their range of programs. In addition to crisis-oriented services, such as telephone hot lines and temporary shelter, many of these agencies provide legal, health, mental health, or vocational services or referrals, and assistance in finding housing, relocating, and planning for safety. Most recently, in response to increasing knowledge about the deleterious effects of exposure to domestic violence on children, community-based service providers have developed programs addressing children's mental health, health, educational, and safety needs. This article describes and analyzes trends in service delivery by these community-based organizations to children affected by domestic violence. It concludes that, although there has been significant growth in services, substantial segments of the target population still are not reached, and most organizations do not yet have a sufficient range of services to meet children's diverse needs. Challenges posed by inadequate funding, needs for specialized staffing, and a dearth of data on the efficacy of current intervention programs hamper domestic violence service providers' ability to meet children's needs. However, this article highlights promising new directions in service delivery. Community-based domestic violence organizations increasingly are using innovative strategies to address children's service needs. These agencies are expanding community outreach efforts and attempts to educate the public and professionals about domestic violence and children. In addition, these organizations are building important collaborative relationships with other agencies concerned with children's welfare, such as child protective services, law enforcement, schools, and health care facilities. These and related developments suggest cautious optimism that future years will see continuing progress in attempts by community-based organizations to address the needs of children whose well-being is jeopardized by their exposure to domestic violence.     

Longitudinal Evaluation of Transition Services ("LETS Study"): Protocol for outcome evaluation

ABSTRACT: BACKGROUND: Because of advances in medical treatment, most children with physical disabilities can expect to achieve near normal life spans. Typically, coordinated teams of health care providers in specialized pediatric settings care for these children. As these children reach adulthood, however, the availability of services and expertise changes because the adult health care system has different processes designed to meet their specialized needs. Gaps in continuity of care during the transition from pediatric to adult services, and associated poor health outcomes are well documented. In response, new models of care are being introduced to address the complex process of health care transition. This paper describes a study protocol of a client-centered, prospective, longitudinal, mixed-method evaluation of linked model of health care across the lifespan (the LIFEspan Model), offered by a pediatric rehabilitation center and an adult rehabilitation center. METHOD: This project will include a process and an outcome evaluation of the LIFEspan Model. The process evaluation will detail the specific service delivery that occurs with respect to preparation for transition and transfer of care through chart audits of pediatric medical records and qualitative interviews with LIFEspan staff. The outcome evaluation will measure the effect of the model on: 1) maintaining continuity within the health care system from pediatric to adult care; and 2) secondary outcomes related to health, well-being, social participation, transition readiness, and health care utilization of youth with cerebral palsy and acquired brain injury. Standardized instruments will include Health Utilities Inventory, Assessment of Life Habits, Arc's Self-Determination, Assessment of Health-Related Quality of Life, Partners in Health Questionnaire, Social Support Questionnaire, and Self-Efficacy for Managing Chronic Disease. DISCUSSION: The LETS study will be original in its undertaking of a prospective examination of outcomes 1-year post-transition, use of multiple comparison groups, and absence of disability-related exclusion criteria ensuring that the transition experiences of varied populations of young people and their families will be represented. Trial registration www.clinicaltrials.gov, ID NCT00975338.     

The changing pattern of primary pediatric care: update for one community

The changing pattern of pediatric practice in the Rochester, New York, community between the late 1960s and the late 1970s is described, and some extrapolations for the next decade are discussed. The child population shrunk from 243,000 in 1970 to 192,000 in 1980 and is expected to decrease further to 160,000 in 1990, possibly stabilizing at 140,000 by 2000. The number of pediatric beds as well as occupancy rates declined, but the number of full-time equivalent practicing pediatricians increased slightly. One third of them are now practicing out of neighborhood health centers or health maintenance organizations. Problems of manpower shortage and inadequate access to care for the inner city residents have long since disappeared. Utilization rates by race and socioeconomic area are similar once the children enter the care system. For "well child" care, however, there may still be lower utilization for blacks, especially for older children. The high "market penetration" for child health services by pediatricians, and the high proportion of well child visits (40%) among all visits, may be atypical for the nation as a whole, but is probably indicative of what pediatric care elsewhere will be in the future. Fewer children, and less acute care per child, will allow pediatricians to focus increasingly on preventive, developmental, and psychosocial needs.     

The pediatrician workforce: current status and future prospects

The effective and efficient delivery of children's health care depends on the pediatrician workforce. The number, composition, and distribution of pediatricians necessary to deliver this care have been the subject of long-standing policy and professional debate. This technical report reviews current characteristics and recent trends in the pediatric workforce and couples the workforce to a conceptual model of improvement in children's health and well-being. Important recent changes in the workforce include (1) the growth in the number of pediatricians in relation to the child population, (2) increased numbers of female pediatricians and their attainment of majority gender status in the specialty, (3) the persistence of a large number of international medical graduates entering training programs, (4) a lack of ethnic and racial diversity in pediatricians compared with children, and (5) the persistence of marked regional variation in pediatrician supply. Supply models projecting the pediatric workforce are reviewed and generally indicate that the number of pediatricians per child will increase by 50% over the next 20 years. The differing methods of assessing workforce requirements are presented and critiqued. The report finds that the pediatric workforce is undergoing fundamental changes that will have important effects on the professional lives of pediatricians and children's health care delivery.     

Successful Integration of Pediatrics Into State Health Care Reform Efforts

Health care reform in Vermont promotes patient-centered medical homes (PCMH) and multi-disciplinary community health teams to support population health. This qualitative study describes the expansion of Vermont's health care reform efforts, initially focused on adult primary care, to pediatrics through interviews with project managers and facilitators, CHT members, pediatric practitioners and care coordinators, and community-based providers. Analyses used grounded theory, identifying themes confirmed by repeat occurrence across respondents. Respondents believed that PCMH recognition and financial and community supports would improve care for pediatric patients and families. Respondents shared three main challenges with health care reform efforts: achieving PCMH recognition, adapting community health teams for pediatric patients and families, and defining roles for care coordinators. For health care reform efforts to support pediatric patients and be family-centered, states may need additional resources to understand how pediatric and adult primary care differ and how best to support pediatrics during health care reform efforts.     

Adolescent parents and their children �C The paediatrician��s role

Adolescent parents and their children have a number of health issues that require attention from the health care provider. Both the adolescent and their child have health needs, and the young parent often requires significant support in their parenting role. Paediatricians should be aware of the areas in which problems can develop, including maternal nutrition and emotional health, and infant growth and development. The literature addressing these areas of concern will be reviewed and general recommendations for the care of this patient population will be provided.     

Pediatric nurse practitioners: primary care providers and case managers for chronically ill children at home.

A new role has been developed for pediatric nurse practitioners that is home based and provides primary care and case management for chronically ill children. In a pilot program at Children's Hospital and Health Center in San Diego, pediatric nurse practitioners address the complex needs of chronically ill children who require comprehensive care, education, psychosocial support, and coordination of services. This article describes the population, program, and expanded role for PNPs, emphasizing case management, management of chronic illness, minor illnesses, and management of well child care. Clinical impressions of the benefits of the role to the child and family are presented.     

Addressing the developmental and mental health needs of young children in foster care

Research over the past two decades has consistently documented the high rates of young children entering the child protective services/child welfare system with developmental and mental health problems. There is an emerging evidence base for the role of early intervention services in improving outcomes for children with developmental and mental health problems in the general population that heavily relies on accurate and appropriate screening and assessment practices. The Child Welfare League of America, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry have all published guidelines concerning the importance of comprehensive assessments and appropriate referral to early intervention services for children entering out-of-home care. Recent federal legislation (P.L. 108-36) calls for increased collaboration between child welfare and public agencies to address the developmental and mental health needs of young children in foster care. This paper provides a framework for health, developmental, and mental health professionals seeking to partner with child welfare to develop and implement programs addressing these critical issues.     

Adolescent medicine: workforce trends and recommendations

The academic successes of AM during the past 2 decades are marked by board certification, fellowship program accreditation, residency curricula creation, and the evolution of a remarkably respected scientific journal, the Journal of Adolescent Health. These same accomplishments have increased professional and public recognition of unmet population needs and the specialists who can help address them. The adolescent population is large, diverse, underserved, and characterized by increasingly complex medical and behavioral issues. Meeting their health care needs is a national priority. Primary care professionals who treat adolescents want and need adolescent-specific training in anticipatory guidance, screening, counseling, and management of common adolescent problems. A larger workforce of AM physicians is needed to provide this training, consult on complex medical and psychosocial issues when requested, and lead research efforts that will advance knowledge in the field. Developing this workforce will require improved recruitment into fellowship training; mentorship, policies, and resources that support trainee and faculty diversity; and articulation of the skills that define an AM physician.