Opinion
EDITORIAL
Group-Based Parenting-Skills Training in Primary Care Offices Are We Ready for the Challenge? Martin T. Stein, MD
Behavioral differences among children illuminate a major aspect of early childhood. It begins with the recognition of temperament in the first year of life as a trait that describes a broad spectrum comprising the easy baby (cheerful, adaptable, regular routines) and the difficult baby (irregular, slow to acRelated article page 16 cept change, tends to respond negatively).1 With developmental progress, a toddler strives for autonomy by learning from successes and failures as he or she negotiates objects and interacts with caregivers. The quality and intensity of these experiences are regulated by temperament differences. Selma Fraiberg observed that “the new problems that appear in infancy and childhood appear at the juncture points of new developmental phases. The onset of independent locomotion (promotes) body independence in the second year and an emerging sense of an independent self brings forth a period of negativism.… Each child reacts in his own way to the problems presented by new phases of development.”2 For most children, the terrible 2s is a healthy developmental phase when a child experiences frustration as he or she engages in play or resists the expectations of adults around feeding, bathing, dressing, and sleep time. Between 2 and 4 years of age, some children demonstrate persistent disruptive behaviors; many parents and caregivers do not have the tools to respond effectively. Disruptive behaviors are often called disruptive because a child literally disrupts the people and activities around him or her with angry outbursts, arguments, and disobedience. Pediatricians discover these behavior patterns through concerns revealed by parents or from a screening test during a health supervision visit.3 Disruptive behaviors are only occasionally witnessed in a pediatric office. When disruptive behaviors are mild to moderate in severity, pediatricians have the knowledge and experience to teach the principles of behavior modification through a focused discussion with parents, written material, and, if a teachable moment occurs, through demonstrating an appropriate response with an oppositional or difficult child. More severe disruptive behaviors that are persistent and impairing child and family function require a more intense and nuanced intervention. A referral to a child mental health specialist in many communities is often associated with multiple barriers including
lack of insurance, limited availability of qualified therapists in the community, and parental perceptions of mental health leading to resistance to therapy for their child.4 Most children with mental health conditions severe enough to impair their functioning are not receiving any treatment.5 This long-standing dilemma is frustrating for pediatricians and parents. Recent studies point to a solution. Comer et al6 conducted a meta-analysis of 36 randomized clinical trials (3042 children aged 2.0-7.7 years) of psychosocial treatments for disruptive behavior problems. Behaviors in these children included aggression, serious rule violation, oppositional behaviors, noncompliance, hyperactivity, and impulsivity. The most frequently studied evidencebased psychosocial treatments included Parent-Child Interaction Therapy, Incredible Years, Helping the Noncompliant Child, and the Triple P–Positive Parenting Program. These programs use behavioral modification techniques to train parents to increase positive feedback for appropriate behaviors, ignore mild disruptive behaviors, and provide consistent timeout for noncompliance. A pooled analysis showed a large, sustained, and significant effect of psychosocial treatments on early disruptive behavior problems as documented by parent and teacher reports. Effects were greatest for general disruptive externalizing problems, oppositional behaviors, and noncompliance. In this issue of JAMA Pediatrics, Perrin et al7 evaluated the effects of one of these evidence-based programs, the Incredible Years (IY), on disruptive behavior in preschool-aged children. The IY is a 10-week, manual-guided program that encourages proactive, nurturing parenting, while discouraging harsh and punitive approaches using videotaped modeling, group discussions, and role play.8 Twelve pediatric practices, representing private practice groups and urban health centers, participated in the study. The race and ethnicity of the children were similar to demographic data from the larger community; the socioeconomic status of participating families was diverse. Parents were eligible for the study if their child scored at the 80th percentile or greater on the Toddler-Infant SocialEmotional Assessment Scale. A total of 150 parents were randomly assigned to 1 of 2 groups: the parent-training group (PTG) or the waiting-list (WL) control group. Each group consisted of 6 to 12 parents. When an inadequate number of parents were identified in 6 study practices, these parents were assigned (nonrandomly) to a PTG
jamapediatrics.com
JAMA Pediatrics January 2014 Volume 168, Number 1
Copyright 2014 American Medical Association. All rights reserved.
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Opinion Editorial
(NR-PTG). The groups were led by a clinical psychologist or a social worker; a co-leader was a member of the pediatric office staff. Among the 3 study groups, 54% to 73% completed at least 7 group sessions. Parent discipline practices and child disruptive behaviors were assessed with 2 standardized questionnaires completed by the parents at enrollment, immediately after the intervention, and 6 and 12 months after the intervention. In addition, a 20-minute videotaped observation of parentchild interactions during standardized tasks (free play, problem solving, and behavioral inhibition) was recorded at baseline, immediately posttreatment, and at the 12-month follow-up. Parent reports of their child’s behavior showed that negative discipline patterns were less than at baseline on all follow-up assessments in both parent-training conditions (PTG and NR-PTG). No differences were found for the WL group. The same pattern was seen on the questionnaire that assessed the presence and intensity of child disruptive behaviors with the exception of the 6-month follow-up. The standardized mean differences between the WL and intervention differences at all follow-up visits showed that PTG and NR-PTG were superior to WL. Videotaped observations demonstrated that negative parenting, child disruptive behaviors, and negative childparent interactions were lower at posttreatment and at the 12month follow-up compared with baseline observations in both the PTG and NR-PTG. No differences were found in the WL groups. My assessment of the significance of this study is influenced by a 40-year dual pediatric career in both general pediatrics and developmental-behavioral pediatrics. I am aware of the many challenges that primary care pediatricians experience when they counsel parents of young children about difficult behaviors. Colleagues with a high level of motivation to provide behavioral counseling for their patients arrange to see them during the noon hour or a time later in the day after scheduled patients have been seen. I found this to be effective, but it can serve only a limited number of patients. A recent report of the Academy of Pediatrics’ Mental Health Task Force provides practical guidelines on the diagnosis, management, and billing codes for behavioral encounters in primary care.9 This was a substantial step forward in supporting pediatricians in behavioral counseling. Several characteristics of the study by Perrin et al stand out as ways to potentially modify current primary care pediatric practice. The use of a group model to provide care is a radical departure from the way we typically practice pediatrics. Group care is not the focus of most pediatric practices. We rely on building a relationship with a family and provide care with one child and one parent or caretaker at a time. We recognize the value of a therapeutic relationship with a child and a family as a way to build mutual trust. Pediatricians believe that this relationship of trust is the foundation for effective counseling during health supervision visits10 and for guidance with behavioral problems. Our historical legacy of 1-to-1 care explains why few pediatricians have experience with group care. 8
The use of small groups in the study by Perrin et al meant that more parents could benefit from the intervention; it made the process of care more efficient. In addition, the behavioral program was not in a remote location; the parent groups met in pediatric offices and clinics. Including a member of each office staff as a co-leader indicated to the parents that the intervention was a significant part of overall care. Collaboration between pediatricians and mental health providers through colocation in a pediatric office is consistent with recommendations of the Mental Health Task Force.9 Potential benefits of small groups in the provision of pediatric care has also been demonstrated in the group well-child care model where 4 to 6 parent-infant pairs meet at the same time for a group wellchild visit in the first year of life. The pediatric clinician leads the group both as a teacher and a moderator to encourage the exchange of concerns, questions, and approaches to child care among the parents.11,12 There are several characteristics of the study design that add strength to the findings. Parents reported difficult behaviors in their children that extended beyond normal temperament differences or the terrible 2s. Disruptive behaviors in the toddlers and preschool-aged children were in the moderatesevere range. Parents who agreed to participate in the study were then randomized to a treatment or control group. In addition, the IY is a group-based parenting skills program with proven effectiveness in randomized clinical trials.8 The IY format is available commercially. The groups met in the offices and clinics of community-based pediatricians, and a member of the pediatric staff participated as a group co-leader. Finally, the evaluation of the intervention included parent-child videotaped observations during standardized tasks and parent questionnaires at 12 months following the intervention. Can the group method of behavioral training for parents of young children with significant disruptive behaviors be incorporated into most primary care pediatric practices? I suspect that the first hurdle for many pediatricians will be to overcome our historical focus on treating 1 patient at a time. Learning about the value of a group learning process will derive from a direct experience with group learning. The evidence base for a group intervention in this study is a strong attraction for replication. Many toddler and preschool-aged children with disruptive behaviors are diagnosed as having attention-deficit/hyperactivity disorder or oppositional behavior disorder and prescribed a medication. The American Academy of Pediatrics recommends behavior modification and medication as evidence-based therapies for children with attention-deficit/hyperactivity disorder; for preschool-aged children, behavior modification is first-line therapy13 and many parents prefer behavior therapy over medication. The effectiveness of group-based parent training for preschool-aged children with disruptive behavior has been established.14 We now have evidence that it can be applied within a pediatric office or clinic. The time is right for primary care pediatricians to bring behavior modification methods into the treatment plan for young children with disruptive behaviors. The study by Perrin et al is a good start in showing the way to accomplish this goal.
JAMA Pediatrics January 2014 Volume 168, Number 1
Copyright 2014 American Medical Association. All rights reserved.
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jamapediatrics.com
Editorial Opinion
ARTICLE INFORMATION Author Affiliation: Division of General Academic Pediatrics, Child Development and Community Health, University of California San Diego, Rady Children’s Hospital, La Jolla, California. Corresponding Author: Martin T. Stein, MD, Division of General Academic Pediatrics, Child Development and Community Health, University of California San Diego, Rady Children’s Hospital, 824 Forward St, La Jolla, CA 92037 ([email protected]) . Published Online: November 4, 2013. doi:10.1001/jamapediatrics.2013.3647. Conflict of Interest Disclosures: None reported. REFERENCES 1. Carey WB, McDevitt SC. Coping with Children’s Temperament: A Guide for Professionals. New York, NY: Basic Books; 1995. 2. Fraiberg S. The Magic Years. New York, NY: Fireside; 1996:75-76. 3. American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants. Elk Grove Village, IL: American Academy of Pediatrics; 2008.
4. Owens PL, Hoagwood K, Horwitz SM, et al. Barriers to children’s mental health services. J Am Acad Child Adolesc Psychiatry. 2002;41(6):731-738. 5. Burns BJ, Costello EJ, Angold A, et al. Children’s mental health service use across service sectors. Health Aff (Millwood). 1995;14(3):147-159
10. Tanner JL, Stein MT, Olson LM, Frintner MP, Radecki L. Reflections on well-child care practice: a national study of pediatric clinicians. Pediatrics. 2009;124(3):849-857. 11. Stein MT. The providing of well-baby care within parent-infant groups: “pediatricians are encouraged to explore the parent-infant group model in their practices.” Clin Pediatr (Phila). 1977;16(9):825-828.
6. Comer JS, Chow C, Chan PT, Cooper-Vince C, Wilson LA. Psychosocial treatment efficacy for disruptive behavior problems in very young children: a meta-analytic examination. J Am Acad Child Adolesc Psychiatry. 2013;52(1):26-36.
12. Osborn LM, Woolley FR. Use of groups in well child care. Pediatrics. 1981;67(5):701-706.
7. Perrin EC, Sheldrick RC, McMenamy JM, Henson BS, Carter AS. Improving parenting skills for families of young children in pediatric settings: a randomized clinical trial [published online November 4, 2013]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.2919. 8. Webster-Stratton C, Rinaldi J, Jamila MR. Long-term outcomes of incredible years parenting program: predictors of adolescent adjustment. Child Adolesc Ment Health. 2011;16(1):38-46. 9. Foy J; American Academy of Pediatrics Task Force on Mental Health. Enhancing pediatric mental health care: report from the American Academy of Pediatrics Task Force on Mental Health: introduction. Pediatrics. 2010;125(suppl 3):s69-s74.
13. Wolraich M, Brown L, Brown RT, et al; Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022. 14. Cunningham CE, Bremner R, Boyle M. Large group community-based parenting programs for families of preschoolers at risk for disruptive behaviour disorders: utilization, cost effectiveness, and outcome. J Child Psychol Psychiatry. 1995;36(7):1141-1159.
Are Critical Deterioration Events the Right Metric to Determine the Impact of Rapid Response Systems? Rashid Alobaidi, MD, FRCPC; Ari R. Joffe, MD, FRCPC
It has been difficult to show whether implementing a rapid response system (RRS) is effective in reducing important patient outcomes of hospital mortality or cardiopulmonary arrest (CA).1 Part of the problem has been that these are rare events in a children’s hospital, and studies thus far have Related article page 25 only involved comparisons with historical controls. 2 3 Bonafide et al report an interesting approach to demonstrating RRS effectiveness. Using their newly created critical deterioration event (CDE) metric, they report a statistically significant adjusted reduction in CDE (by 62%) due to both less mechanical ventilation use (by 83%) and less vasopressor use (by 80%) after RRS implementation. Bonafide and colleagues suggest that CDE is a better metric to measure RRS effectiveness than the rare, catastrophic metrics of hospital mortality or CA. The strengths of the study include the large contemporary urban tertiary children’s hospital context; evaluating 1810 unplanned transfers from the general medical and surgical wards to the pediatric and neonatal intensive care units (ICUs) that occurred during 370 504 non-ICU patient-days; and the data collection and analysis methods. The limitations of the study are mentioned by the authors, including the following: the study design (a single-center before-and-after study using comparisons with historical controls); exclusion of cardiol-
ogy wards and the cardiac pediatric ICU; the lack of a feasible adjusted analysis for ward CA, intubation, and code blue call rates; and the lack of data on overall hospital mortality in the 2 periods. Given the inherent limitation of the study design, this is quite a well-done and well-reported study. Nevertheless, we believe it is premature to conclude that RRSs are effective or to adopt the CDE metric to demonstrate this, for 2 main reasons. First, the CDE is a “proximate” (or surrogate) outcome, potentially useful to enable smaller, faster, cheaper clinical trials. However, favorable effects on surrogate outcomes do not necessarily translate into benefits. Svensson et al show that “surrogates have repeatedly and dangerously failed as guides to appropriate treatment”4; relying on surrogate outcomes “confer[s] an often false sense of understanding and control”4 based on assumptions about how treatments are “supposed” to work. In this regard, it is interesting that there was no statistically significant change in traditional clinical outcomes, including ward CA and ward intubations. Indeed, implementation of an RRS intended to “intervene before respiratory or cardiac arrest occurs”3 was associated with a trend to increased code blue calls. Moreover, there was a reduction in adjusted CDE, with no change in adjusted unplanned ICU transfer and no change in hospital mortality among unplanned transfers to the ICU; given that CDE was associated with a 4.97-fold increased risk of death, this is a puzzling finding to explain.
jamapediatrics.com
JAMA Pediatrics January 2014 Volume 168, Number 1
Copyright 2014 American Medical Association. All rights reserved.
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EDITORIAL
Group-Based Parenting-Skills Training in Primary Care Offices Are We Ready for the Challenge? Martin T. Stein, MD
Behavioral differences among children illuminate a major aspect of early childhood. It begins with the recognition of temperament in the first year of life as a trait that describes a broad spectrum comprising the easy baby (cheerful, adaptable, regular routines) and the difficult baby (irregular, slow to acRelated article page 16 cept change, tends to respond negatively).1 With developmental progress, a toddler strives for autonomy by learning from successes and failures as he or she negotiates objects and interacts with caregivers. The quality and intensity of these experiences are regulated by temperament differences. Selma Fraiberg observed that “the new problems that appear in infancy and childhood appear at the juncture points of new developmental phases. The onset of independent locomotion (promotes) body independence in the second year and an emerging sense of an independent self brings forth a period of negativism.… Each child reacts in his own way to the problems presented by new phases of development.”2 For most children, the terrible 2s is a healthy developmental phase when a child experiences frustration as he or she engages in play or resists the expectations of adults around feeding, bathing, dressing, and sleep time. Between 2 and 4 years of age, some children demonstrate persistent disruptive behaviors; many parents and caregivers do not have the tools to respond effectively. Disruptive behaviors are often called disruptive because a child literally disrupts the people and activities around him or her with angry outbursts, arguments, and disobedience. Pediatricians discover these behavior patterns through concerns revealed by parents or from a screening test during a health supervision visit.3 Disruptive behaviors are only occasionally witnessed in a pediatric office. When disruptive behaviors are mild to moderate in severity, pediatricians have the knowledge and experience to teach the principles of behavior modification through a focused discussion with parents, written material, and, if a teachable moment occurs, through demonstrating an appropriate response with an oppositional or difficult child. More severe disruptive behaviors that are persistent and impairing child and family function require a more intense and nuanced intervention. A referral to a child mental health specialist in many communities is often associated with multiple barriers including
lack of insurance, limited availability of qualified therapists in the community, and parental perceptions of mental health leading to resistance to therapy for their child.4 Most children with mental health conditions severe enough to impair their functioning are not receiving any treatment.5 This long-standing dilemma is frustrating for pediatricians and parents. Recent studies point to a solution. Comer et al6 conducted a meta-analysis of 36 randomized clinical trials (3042 children aged 2.0-7.7 years) of psychosocial treatments for disruptive behavior problems. Behaviors in these children included aggression, serious rule violation, oppositional behaviors, noncompliance, hyperactivity, and impulsivity. The most frequently studied evidencebased psychosocial treatments included Parent-Child Interaction Therapy, Incredible Years, Helping the Noncompliant Child, and the Triple P–Positive Parenting Program. These programs use behavioral modification techniques to train parents to increase positive feedback for appropriate behaviors, ignore mild disruptive behaviors, and provide consistent timeout for noncompliance. A pooled analysis showed a large, sustained, and significant effect of psychosocial treatments on early disruptive behavior problems as documented by parent and teacher reports. Effects were greatest for general disruptive externalizing problems, oppositional behaviors, and noncompliance. In this issue of JAMA Pediatrics, Perrin et al7 evaluated the effects of one of these evidence-based programs, the Incredible Years (IY), on disruptive behavior in preschool-aged children. The IY is a 10-week, manual-guided program that encourages proactive, nurturing parenting, while discouraging harsh and punitive approaches using videotaped modeling, group discussions, and role play.8 Twelve pediatric practices, representing private practice groups and urban health centers, participated in the study. The race and ethnicity of the children were similar to demographic data from the larger community; the socioeconomic status of participating families was diverse. Parents were eligible for the study if their child scored at the 80th percentile or greater on the Toddler-Infant SocialEmotional Assessment Scale. A total of 150 parents were randomly assigned to 1 of 2 groups: the parent-training group (PTG) or the waiting-list (WL) control group. Each group consisted of 6 to 12 parents. When an inadequate number of parents were identified in 6 study practices, these parents were assigned (nonrandomly) to a PTG
jamapediatrics.com
JAMA Pediatrics January 2014 Volume 168, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a J H Quillen College User on 06/04/2015
7
Opinion Editorial
(NR-PTG). The groups were led by a clinical psychologist or a social worker; a co-leader was a member of the pediatric office staff. Among the 3 study groups, 54% to 73% completed at least 7 group sessions. Parent discipline practices and child disruptive behaviors were assessed with 2 standardized questionnaires completed by the parents at enrollment, immediately after the intervention, and 6 and 12 months after the intervention. In addition, a 20-minute videotaped observation of parentchild interactions during standardized tasks (free play, problem solving, and behavioral inhibition) was recorded at baseline, immediately posttreatment, and at the 12-month follow-up. Parent reports of their child’s behavior showed that negative discipline patterns were less than at baseline on all follow-up assessments in both parent-training conditions (PTG and NR-PTG). No differences were found for the WL group. The same pattern was seen on the questionnaire that assessed the presence and intensity of child disruptive behaviors with the exception of the 6-month follow-up. The standardized mean differences between the WL and intervention differences at all follow-up visits showed that PTG and NR-PTG were superior to WL. Videotaped observations demonstrated that negative parenting, child disruptive behaviors, and negative childparent interactions were lower at posttreatment and at the 12month follow-up compared with baseline observations in both the PTG and NR-PTG. No differences were found in the WL groups. My assessment of the significance of this study is influenced by a 40-year dual pediatric career in both general pediatrics and developmental-behavioral pediatrics. I am aware of the many challenges that primary care pediatricians experience when they counsel parents of young children about difficult behaviors. Colleagues with a high level of motivation to provide behavioral counseling for their patients arrange to see them during the noon hour or a time later in the day after scheduled patients have been seen. I found this to be effective, but it can serve only a limited number of patients. A recent report of the Academy of Pediatrics’ Mental Health Task Force provides practical guidelines on the diagnosis, management, and billing codes for behavioral encounters in primary care.9 This was a substantial step forward in supporting pediatricians in behavioral counseling. Several characteristics of the study by Perrin et al stand out as ways to potentially modify current primary care pediatric practice. The use of a group model to provide care is a radical departure from the way we typically practice pediatrics. Group care is not the focus of most pediatric practices. We rely on building a relationship with a family and provide care with one child and one parent or caretaker at a time. We recognize the value of a therapeutic relationship with a child and a family as a way to build mutual trust. Pediatricians believe that this relationship of trust is the foundation for effective counseling during health supervision visits10 and for guidance with behavioral problems. Our historical legacy of 1-to-1 care explains why few pediatricians have experience with group care. 8
The use of small groups in the study by Perrin et al meant that more parents could benefit from the intervention; it made the process of care more efficient. In addition, the behavioral program was not in a remote location; the parent groups met in pediatric offices and clinics. Including a member of each office staff as a co-leader indicated to the parents that the intervention was a significant part of overall care. Collaboration between pediatricians and mental health providers through colocation in a pediatric office is consistent with recommendations of the Mental Health Task Force.9 Potential benefits of small groups in the provision of pediatric care has also been demonstrated in the group well-child care model where 4 to 6 parent-infant pairs meet at the same time for a group wellchild visit in the first year of life. The pediatric clinician leads the group both as a teacher and a moderator to encourage the exchange of concerns, questions, and approaches to child care among the parents.11,12 There are several characteristics of the study design that add strength to the findings. Parents reported difficult behaviors in their children that extended beyond normal temperament differences or the terrible 2s. Disruptive behaviors in the toddlers and preschool-aged children were in the moderatesevere range. Parents who agreed to participate in the study were then randomized to a treatment or control group. In addition, the IY is a group-based parenting skills program with proven effectiveness in randomized clinical trials.8 The IY format is available commercially. The groups met in the offices and clinics of community-based pediatricians, and a member of the pediatric staff participated as a group co-leader. Finally, the evaluation of the intervention included parent-child videotaped observations during standardized tasks and parent questionnaires at 12 months following the intervention. Can the group method of behavioral training for parents of young children with significant disruptive behaviors be incorporated into most primary care pediatric practices? I suspect that the first hurdle for many pediatricians will be to overcome our historical focus on treating 1 patient at a time. Learning about the value of a group learning process will derive from a direct experience with group learning. The evidence base for a group intervention in this study is a strong attraction for replication. Many toddler and preschool-aged children with disruptive behaviors are diagnosed as having attention-deficit/hyperactivity disorder or oppositional behavior disorder and prescribed a medication. The American Academy of Pediatrics recommends behavior modification and medication as evidence-based therapies for children with attention-deficit/hyperactivity disorder; for preschool-aged children, behavior modification is first-line therapy13 and many parents prefer behavior therapy over medication. The effectiveness of group-based parent training for preschool-aged children with disruptive behavior has been established.14 We now have evidence that it can be applied within a pediatric office or clinic. The time is right for primary care pediatricians to bring behavior modification methods into the treatment plan for young children with disruptive behaviors. The study by Perrin et al is a good start in showing the way to accomplish this goal.
JAMA Pediatrics January 2014 Volume 168, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a J H Quillen College User on 06/04/2015
jamapediatrics.com
Editorial Opinion
ARTICLE INFORMATION Author Affiliation: Division of General Academic Pediatrics, Child Development and Community Health, University of California San Diego, Rady Children’s Hospital, La Jolla, California. Corresponding Author: Martin T. Stein, MD, Division of General Academic Pediatrics, Child Development and Community Health, University of California San Diego, Rady Children’s Hospital, 824 Forward St, La Jolla, CA 92037 ([email protected]) . Published Online: November 4, 2013. doi:10.1001/jamapediatrics.2013.3647. Conflict of Interest Disclosures: None reported. REFERENCES 1. Carey WB, McDevitt SC. Coping with Children’s Temperament: A Guide for Professionals. New York, NY: Basic Books; 1995. 2. Fraiberg S. The Magic Years. New York, NY: Fireside; 1996:75-76. 3. American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants. Elk Grove Village, IL: American Academy of Pediatrics; 2008.
4. Owens PL, Hoagwood K, Horwitz SM, et al. Barriers to children’s mental health services. J Am Acad Child Adolesc Psychiatry. 2002;41(6):731-738. 5. Burns BJ, Costello EJ, Angold A, et al. Children’s mental health service use across service sectors. Health Aff (Millwood). 1995;14(3):147-159
10. Tanner JL, Stein MT, Olson LM, Frintner MP, Radecki L. Reflections on well-child care practice: a national study of pediatric clinicians. Pediatrics. 2009;124(3):849-857. 11. Stein MT. The providing of well-baby care within parent-infant groups: “pediatricians are encouraged to explore the parent-infant group model in their practices.” Clin Pediatr (Phila). 1977;16(9):825-828.
6. Comer JS, Chow C, Chan PT, Cooper-Vince C, Wilson LA. Psychosocial treatment efficacy for disruptive behavior problems in very young children: a meta-analytic examination. J Am Acad Child Adolesc Psychiatry. 2013;52(1):26-36.
12. Osborn LM, Woolley FR. Use of groups in well child care. Pediatrics. 1981;67(5):701-706.
7. Perrin EC, Sheldrick RC, McMenamy JM, Henson BS, Carter AS. Improving parenting skills for families of young children in pediatric settings: a randomized clinical trial [published online November 4, 2013]. JAMA Pediatr. doi:10.1001/jamapediatrics.2013.2919. 8. Webster-Stratton C, Rinaldi J, Jamila MR. Long-term outcomes of incredible years parenting program: predictors of adolescent adjustment. Child Adolesc Ment Health. 2011;16(1):38-46. 9. Foy J; American Academy of Pediatrics Task Force on Mental Health. Enhancing pediatric mental health care: report from the American Academy of Pediatrics Task Force on Mental Health: introduction. Pediatrics. 2010;125(suppl 3):s69-s74.
13. Wolraich M, Brown L, Brown RT, et al; Subcommittee on Attention-Deficit/Hyperactivity Disorder; Steering Committee on Quality Improvement and Management. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022. 14. Cunningham CE, Bremner R, Boyle M. Large group community-based parenting programs for families of preschoolers at risk for disruptive behaviour disorders: utilization, cost effectiveness, and outcome. J Child Psychol Psychiatry. 1995;36(7):1141-1159.
Are Critical Deterioration Events the Right Metric to Determine the Impact of Rapid Response Systems? Rashid Alobaidi, MD, FRCPC; Ari R. Joffe, MD, FRCPC
It has been difficult to show whether implementing a rapid response system (RRS) is effective in reducing important patient outcomes of hospital mortality or cardiopulmonary arrest (CA).1 Part of the problem has been that these are rare events in a children’s hospital, and studies thus far have Related article page 25 only involved comparisons with historical controls. 2 3 Bonafide et al report an interesting approach to demonstrating RRS effectiveness. Using their newly created critical deterioration event (CDE) metric, they report a statistically significant adjusted reduction in CDE (by 62%) due to both less mechanical ventilation use (by 83%) and less vasopressor use (by 80%) after RRS implementation. Bonafide and colleagues suggest that CDE is a better metric to measure RRS effectiveness than the rare, catastrophic metrics of hospital mortality or CA. The strengths of the study include the large contemporary urban tertiary children’s hospital context; evaluating 1810 unplanned transfers from the general medical and surgical wards to the pediatric and neonatal intensive care units (ICUs) that occurred during 370 504 non-ICU patient-days; and the data collection and analysis methods. The limitations of the study are mentioned by the authors, including the following: the study design (a single-center before-and-after study using comparisons with historical controls); exclusion of cardiol-
ogy wards and the cardiac pediatric ICU; the lack of a feasible adjusted analysis for ward CA, intubation, and code blue call rates; and the lack of data on overall hospital mortality in the 2 periods. Given the inherent limitation of the study design, this is quite a well-done and well-reported study. Nevertheless, we believe it is premature to conclude that RRSs are effective or to adopt the CDE metric to demonstrate this, for 2 main reasons. First, the CDE is a “proximate” (or surrogate) outcome, potentially useful to enable smaller, faster, cheaper clinical trials. However, favorable effects on surrogate outcomes do not necessarily translate into benefits. Svensson et al show that “surrogates have repeatedly and dangerously failed as guides to appropriate treatment”4; relying on surrogate outcomes “confer[s] an often false sense of understanding and control”4 based on assumptions about how treatments are “supposed” to work. In this regard, it is interesting that there was no statistically significant change in traditional clinical outcomes, including ward CA and ward intubations. Indeed, implementation of an RRS intended to “intervene before respiratory or cardiac arrest occurs”3 was associated with a trend to increased code blue calls. Moreover, there was a reduction in adjusted CDE, with no change in adjusted unplanned ICU transfer and no change in hospital mortality among unplanned transfers to the ICU; given that CDE was associated with a 4.97-fold increased risk of death, this is a puzzling finding to explain.
jamapediatrics.com
JAMA Pediatrics January 2014 Volume 168, Number 1
Copyright 2014 American Medical Association. All rights reserved.
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9
