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Influences and beliefs on vaccine hesitancy remain complex
ATLANTA – Before clinicians can learn new and effective strategies on addressing vaccine hesitancy in their practices, they need to understand both the “forest” and the “trees.” That is, it helps to understand the big picture in terms of national trends, and it’s equally important to understand the motivations and psychology of parents who refuse or remain hesitant about vaccines.
Paula Frew, PhD, MPH, of Emory University in Atlanta, pointed out that vaccination coverage of children under 3 years old in the United States remains consistently high. An estimated 93% of children have received at least three doses of the polio vaccine, 92% have received at least one dose of the MMR vaccine, 92% have received at least three doses of the hepatitis B vaccine, and 91% have received at least one dose of the varicella vaccine.
In fact, less than 1% of parents selectively or completely refuse all vaccines – but an estimated 13%-22% of parents intentionally delay vaccines, Dr. Frew said at a conference sponsored by the Centers for Disease Control and Prevention..
She described findings from a study she and colleagues conducted to assess the influence of vaccination decisions among parents of children under age 7 years. They categorized the parents as nonhesitant acceptors of vaccines, hesitant acceptors, delayers, or refusers. Surveys of 2,603 parents in 2012 and 2,518 parents in 2014 revealed that parents overwhelmingly cite their health care provider as their most trusted source of information on vaccines, including 99% of acceptors and 71% of refusers. Among hesitant acceptors, 49% of parents in 2012 and 48% of parents in 2014 said their doctor positively influenced their vaccination decision.
Qualitative findings from focus groups
Still, hesitancy is common enough that qualitative research is seeking to understand parents’ vaccine concerns. One such study involved focus groups with vaccine-hesitant mothers because mothers or other female guardians are the caregivers most often involved in their children’s health care decisions, according to Judith Mendel, MPH, of the U.S. Department of Health and Human Services.
Ms. Mendel’s study aimed to understand what drives vaccine-related confidence, how to overcome hesitancy over vaccines, and what messaging approaches might work most effectively. She and her colleagues recruited 61 women who participated in one of four groups in the Philadelphia area or one of four in the San Francisco area during April and May 2016. The women all were responsible for the health decisions of at least one child age 5 years or younger and had previously delayed or declined a recommended vaccine for their child.
Each group included six to nine women and involved a 2-hour semistructured discussion about health concerns; what vaccine confidence is; the mothers’ knowledge, attitudes, and beliefs about vaccines and immunization; and feedback on videos and info-graphics designed to educate others about immunization. The focus groups defined having confidence about vaccines as feeling trust, feeling good about a decision, having many years of research or practice, and being informed and knowledgeable.
“Three themes bubbled up together from the groups,” Ms. Mendel said. “Women had concerns about vaccine ingredients and their effects on physiology, about the recommended schedule, and about the medical system.”
Their concerns about vaccine ingredients and physiology would be familiar to pediatric providers:
• A persistent belief that autism is caused by vaccines.
• Concerns about vaccines made from weakened pathogens.
• Belief that vaccines replace a function that the body is equipped to handle on its own.
• Fears about short-term and long-term side effects.
• Little tolerance for established minor reactions to vaccines.
The mothers were accepting of the vaccines that had been on the schedule when they were children, such as polio, but they did not understand why vaccination starts so young and preferred “alternative” or catch-up schedules.
“They believed that when they were younger, the schedule started later,” Ms. Mendel said. “Some women felt there were too many injections given, while other women preferred not to use combination vaccines.”
Their concerns about the medical system, meanwhile, involved a general lack of trust for mainstream medicine and anyone involved in the immunization system. They believed that interactions with doctors today differ significantly from the way it was when they were children.
“They did not like feeling pressured by health care providers to vaccinate their kid,” Ms. Mendel said. “If they thought the provider was providing a somewhat authoritative or paternalistic stance with their recommendation, some of these women really shied from that and were dissuaded by that.”
What messages work?
The researchers then tested several messaging approaches with the women that included videos and printouts about vaccine safety, herd immunity, and how vaccines work. The materials received high ratings for being informative, coalescing around 4 on a Likert scale of 1-5, but “in terms of really swaying the needle on confidence, it was barely middle ground,” Ms. Mendel said, referring to scores ranging from 3.1 to 3.4.
“Despite someone thinking something was informative, it doesn’t necessarily change their attitudes or perceptions,” she said.
What the women liked about the materials were clear messaging with a respectful tone that was not patronizing, as well as statistics.
“They wanted information on both the pros and cons, the risks as well as the benefits,” Ms. Mendel said. “They also wanted to believe the information they were interacting with was coming from a reliable source,” although she added that “what we may consider a reliable source may not necessarily be what they consider a reliable source.”
Ultimately, no single message or approach worked well for all the mothers, but they all wanted “balanced messages,” although it wasn’t clear if giving more attention to possible risks would positively influence their beliefs about immunization.
“It’s clear that many sources really shape these views and perceptions around vaccines and immunization for these women,” Ms. Mendel said. “It’s really clear that these women are doing the best they can, or believe they can, to make the best health and wellness decisions for their children. However, as health communicators, I think there remains a lot of opportunities for us to help them do a better job.”
The researchers reported no disclosures and did not report external funding sources.
ATLANTA – Before clinicians can learn new and effective strategies on addressing vaccine hesitancy in their practices, they need to understand both the “forest” and the “trees.” That is, it helps to understand the big picture in terms of national trends, and it’s equally important to understand the motivations and psychology of parents who refuse or remain hesitant about vaccines.
Paula Frew, PhD, MPH, of Emory University in Atlanta, pointed out that vaccination coverage of children under 3 years old in the United States remains consistently high. An estimated 93% of children have received at least three doses of the polio vaccine, 92% have received at least one dose of the MMR vaccine, 92% have received at least three doses of the hepatitis B vaccine, and 91% have received at least one dose of the varicella vaccine.
In fact, less than 1% of parents selectively or completely refuse all vaccines – but an estimated 13%-22% of parents intentionally delay vaccines, Dr. Frew said at a conference sponsored by the Centers for Disease Control and Prevention..
She described findings from a study she and colleagues conducted to assess the influence of vaccination decisions among parents of children under age 7 years. They categorized the parents as nonhesitant acceptors of vaccines, hesitant acceptors, delayers, or refusers. Surveys of 2,603 parents in 2012 and 2,518 parents in 2014 revealed that parents overwhelmingly cite their health care provider as their most trusted source of information on vaccines, including 99% of acceptors and 71% of refusers. Among hesitant acceptors, 49% of parents in 2012 and 48% of parents in 2014 said their doctor positively influenced their vaccination decision.
Qualitative findings from focus groups
Still, hesitancy is common enough that qualitative research is seeking to understand parents’ vaccine concerns. One such study involved focus groups with vaccine-hesitant mothers because mothers or other female guardians are the caregivers most often involved in their children’s health care decisions, according to Judith Mendel, MPH, of the U.S. Department of Health and Human Services.
Ms. Mendel’s study aimed to understand what drives vaccine-related confidence, how to overcome hesitancy over vaccines, and what messaging approaches might work most effectively. She and her colleagues recruited 61 women who participated in one of four groups in the Philadelphia area or one of four in the San Francisco area during April and May 2016. The women all were responsible for the health decisions of at least one child age 5 years or younger and had previously delayed or declined a recommended vaccine for their child.
Each group included six to nine women and involved a 2-hour semistructured discussion about health concerns; what vaccine confidence is; the mothers’ knowledge, attitudes, and beliefs about vaccines and immunization; and feedback on videos and info-graphics designed to educate others about immunization. The focus groups defined having confidence about vaccines as feeling trust, feeling good about a decision, having many years of research or practice, and being informed and knowledgeable.
“Three themes bubbled up together from the groups,” Ms. Mendel said. “Women had concerns about vaccine ingredients and their effects on physiology, about the recommended schedule, and about the medical system.”
Their concerns about vaccine ingredients and physiology would be familiar to pediatric providers:
• A persistent belief that autism is caused by vaccines.
• Concerns about vaccines made from weakened pathogens.
• Belief that vaccines replace a function that the body is equipped to handle on its own.
• Fears about short-term and long-term side effects.
• Little tolerance for established minor reactions to vaccines.
The mothers were accepting of the vaccines that had been on the schedule when they were children, such as polio, but they did not understand why vaccination starts so young and preferred “alternative” or catch-up schedules.
“They believed that when they were younger, the schedule started later,” Ms. Mendel said. “Some women felt there were too many injections given, while other women preferred not to use combination vaccines.”
Their concerns about the medical system, meanwhile, involved a general lack of trust for mainstream medicine and anyone involved in the immunization system. They believed that interactions with doctors today differ significantly from the way it was when they were children.
“They did not like feeling pressured by health care providers to vaccinate their kid,” Ms. Mendel said. “If they thought the provider was providing a somewhat authoritative or paternalistic stance with their recommendation, some of these women really shied from that and were dissuaded by that.”
What messages work?
The researchers then tested several messaging approaches with the women that included videos and printouts about vaccine safety, herd immunity, and how vaccines work. The materials received high ratings for being informative, coalescing around 4 on a Likert scale of 1-5, but “in terms of really swaying the needle on confidence, it was barely middle ground,” Ms. Mendel said, referring to scores ranging from 3.1 to 3.4.
“Despite someone thinking something was informative, it doesn’t necessarily change their attitudes or perceptions,” she said.
What the women liked about the materials were clear messaging with a respectful tone that was not patronizing, as well as statistics.
“They wanted information on both the pros and cons, the risks as well as the benefits,” Ms. Mendel said. “They also wanted to believe the information they were interacting with was coming from a reliable source,” although she added that “what we may consider a reliable source may not necessarily be what they consider a reliable source.”
Ultimately, no single message or approach worked well for all the mothers, but they all wanted “balanced messages,” although it wasn’t clear if giving more attention to possible risks would positively influence their beliefs about immunization.
“It’s clear that many sources really shape these views and perceptions around vaccines and immunization for these women,” Ms. Mendel said. “It’s really clear that these women are doing the best they can, or believe they can, to make the best health and wellness decisions for their children. However, as health communicators, I think there remains a lot of opportunities for us to help them do a better job.”
The researchers reported no disclosures and did not report external funding sources.
ATLANTA – Before clinicians can learn new and effective strategies on addressing vaccine hesitancy in their practices, they need to understand both the “forest” and the “trees.” That is, it helps to understand the big picture in terms of national trends, and it’s equally important to understand the motivations and psychology of parents who refuse or remain hesitant about vaccines.
Paula Frew, PhD, MPH, of Emory University in Atlanta, pointed out that vaccination coverage of children under 3 years old in the United States remains consistently high. An estimated 93% of children have received at least three doses of the polio vaccine, 92% have received at least one dose of the MMR vaccine, 92% have received at least three doses of the hepatitis B vaccine, and 91% have received at least one dose of the varicella vaccine.
In fact, less than 1% of parents selectively or completely refuse all vaccines – but an estimated 13%-22% of parents intentionally delay vaccines, Dr. Frew said at a conference sponsored by the Centers for Disease Control and Prevention..
She described findings from a study she and colleagues conducted to assess the influence of vaccination decisions among parents of children under age 7 years. They categorized the parents as nonhesitant acceptors of vaccines, hesitant acceptors, delayers, or refusers. Surveys of 2,603 parents in 2012 and 2,518 parents in 2014 revealed that parents overwhelmingly cite their health care provider as their most trusted source of information on vaccines, including 99% of acceptors and 71% of refusers. Among hesitant acceptors, 49% of parents in 2012 and 48% of parents in 2014 said their doctor positively influenced their vaccination decision.
Qualitative findings from focus groups
Still, hesitancy is common enough that qualitative research is seeking to understand parents’ vaccine concerns. One such study involved focus groups with vaccine-hesitant mothers because mothers or other female guardians are the caregivers most often involved in their children’s health care decisions, according to Judith Mendel, MPH, of the U.S. Department of Health and Human Services.
Ms. Mendel’s study aimed to understand what drives vaccine-related confidence, how to overcome hesitancy over vaccines, and what messaging approaches might work most effectively. She and her colleagues recruited 61 women who participated in one of four groups in the Philadelphia area or one of four in the San Francisco area during April and May 2016. The women all were responsible for the health decisions of at least one child age 5 years or younger and had previously delayed or declined a recommended vaccine for their child.
Each group included six to nine women and involved a 2-hour semistructured discussion about health concerns; what vaccine confidence is; the mothers’ knowledge, attitudes, and beliefs about vaccines and immunization; and feedback on videos and info-graphics designed to educate others about immunization. The focus groups defined having confidence about vaccines as feeling trust, feeling good about a decision, having many years of research or practice, and being informed and knowledgeable.
“Three themes bubbled up together from the groups,” Ms. Mendel said. “Women had concerns about vaccine ingredients and their effects on physiology, about the recommended schedule, and about the medical system.”
Their concerns about vaccine ingredients and physiology would be familiar to pediatric providers:
• A persistent belief that autism is caused by vaccines.
• Concerns about vaccines made from weakened pathogens.
• Belief that vaccines replace a function that the body is equipped to handle on its own.
• Fears about short-term and long-term side effects.
• Little tolerance for established minor reactions to vaccines.
The mothers were accepting of the vaccines that had been on the schedule when they were children, such as polio, but they did not understand why vaccination starts so young and preferred “alternative” or catch-up schedules.
“They believed that when they were younger, the schedule started later,” Ms. Mendel said. “Some women felt there were too many injections given, while other women preferred not to use combination vaccines.”
Their concerns about the medical system, meanwhile, involved a general lack of trust for mainstream medicine and anyone involved in the immunization system. They believed that interactions with doctors today differ significantly from the way it was when they were children.
“They did not like feeling pressured by health care providers to vaccinate their kid,” Ms. Mendel said. “If they thought the provider was providing a somewhat authoritative or paternalistic stance with their recommendation, some of these women really shied from that and were dissuaded by that.”
What messages work?
The researchers then tested several messaging approaches with the women that included videos and printouts about vaccine safety, herd immunity, and how vaccines work. The materials received high ratings for being informative, coalescing around 4 on a Likert scale of 1-5, but “in terms of really swaying the needle on confidence, it was barely middle ground,” Ms. Mendel said, referring to scores ranging from 3.1 to 3.4.
“Despite someone thinking something was informative, it doesn’t necessarily change their attitudes or perceptions,” she said.
What the women liked about the materials were clear messaging with a respectful tone that was not patronizing, as well as statistics.
“They wanted information on both the pros and cons, the risks as well as the benefits,” Ms. Mendel said. “They also wanted to believe the information they were interacting with was coming from a reliable source,” although she added that “what we may consider a reliable source may not necessarily be what they consider a reliable source.”
Ultimately, no single message or approach worked well for all the mothers, but they all wanted “balanced messages,” although it wasn’t clear if giving more attention to possible risks would positively influence their beliefs about immunization.
“It’s clear that many sources really shape these views and perceptions around vaccines and immunization for these women,” Ms. Mendel said. “It’s really clear that these women are doing the best they can, or believe they can, to make the best health and wellness decisions for their children. However, as health communicators, I think there remains a lot of opportunities for us to help them do a better job.”
The researchers reported no disclosures and did not report external funding sources.
Targeted interventions aid in HPV vaccination uptake
ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.
In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.
One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”
For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.
Ms. Groom provided three other recommended statements as well:
• “I strongly believe in the importance of this cancer-preventing vaccine.”
• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”
• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”
Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.
The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.
Ms. Groom reported no disclosures. No external funding was reported.
Communication strategies to improve HPV immunization
Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.
Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.
“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.
Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.
“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.
She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.
Ms. Garcia reported no disclosures. No external funding was reported.
This article was updated Dec. 2, 2016.
ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.
In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.
One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”
For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.
Ms. Groom provided three other recommended statements as well:
• “I strongly believe in the importance of this cancer-preventing vaccine.”
• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”
• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”
Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.
The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.
Ms. Groom reported no disclosures. No external funding was reported.
Communication strategies to improve HPV immunization
Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.
Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.
“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.
Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.
“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.
She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.
Ms. Garcia reported no disclosures. No external funding was reported.
This article was updated Dec. 2, 2016.
ATLANTA – Holly Groom, MPH, of the Center for Health Research at Kaiser Permanente Northwest, described the intervention to improve HPV vaccination rates within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years. About a quarter of patients reside in Washington, with the remainder in Oregon.
In addition to two in-person provider education and feedback sessions, the intervention included quarterly vaccine coverage, missed vaccination opportunity assessment reports, and a mailed parent survey. The staff education sessions covered six different cancers caused by HPV – cervical, anal, oropharyngeal, penile, vaginal, and vulvar – and their annual incidence, such as an estimated 10,000 oropharyngeal cancer cases in males and more than 11,000 cervical cancer cases in females each year.
One of the tip sheets distributed during provider and staff education offered specific language that providers could use to recommend the vaccine to parents and educate them about what HPV disease is and what cancers it can cause. For parents who are confused or concerned about why the vaccine is recommended at ages 11-12 years, for example, providers can respond, “We’re vaccinating today so your child will have the best protection possible long before the start of any kind of sexual activity. We vaccinate people well before they are exposed to an infection, as is the case with measles and the other recommended childhood vaccines.”
For those providers uneasy about mentioning sexual activity, Ms. Groom said, they can stick with telling parents the vaccine should be administered “long before the risk of infection” without mentioning the mechanism of infection.
Ms. Groom provided three other recommended statements as well:
• “I strongly believe in the importance of this cancer-preventing vaccine.”
• “I have given HPV vaccine to my son/daughter (or grandchild/niece/nephew/friend’s children).”
• “Experts, such as the American Academy of Pediatrics, cancer doctors, and the Centers for Disease Control and Prevention, also agree that getting the HPV vaccine is very important for your child.”
Feedback from the training sessions was “overwhelmingly positive,” with 87% of the respondents stating that they planned to implement the strategies and tools discussed and an additional 12% said they were already using those strategies and tools.
The parental survey, although it had only a 12% response rate, initially revealed that just over a third (36%) of parents weren’t sure if they were going to vaccinate their child when they went in for a well visit, but more than 90% of these parents did vaccinate their children.
Ms. Groom reported no disclosures. No external funding was reported.
Communication strategies to improve HPV immunization
Several communication strategies have been developed by the Centers for Disease Control and Prevention to help providers overcome barriers to improving HPV immunization coverage, Yvonne Garcia said at the National Immunization Conference.
Among providers’ barriers are hesitancy to make a recommendation for the HPV vaccine, and the need to understand the burden of the disease and the need for the vaccine, said Ms. Garcia, a health communications specialist for the CDC.
“Also, they overestimate parents’ concerns about the vaccine when what we have learned from parents is that they value the HPV vaccine, but they’re not hearing their child’s doctor recommend it,” she said.
Overcoming these barriers requires patient outreach and awareness of HPV coverage rates at the city and state levels, as well as their individual and practice rates. Providers should bundle their recommendation with the other vaccines recommended by the CDC at the ages of 11 and 12 years: “Your child is due for three vaccines today that offer protection against meningitis, HPV cancers, and whooping cough,” is one example of language to use, Ms. Garcia said.
“Effective patient outreach for HPV vaccination includes the reminder/recall system, scheduling remaining doses at the time of receiving the first doses, and creating parental expectation that HPV vaccination is a very normal part of the immunization process, and that it occurs at ages 11 and 12,” she said.
She also reviewed the barriers among parents for HPV vaccination that providers can address. To respond to parents’ lack of knowledge about the vaccine or the need for it, providers “need to stress that it’s needed for cancer prevention,” Ms. Garcia said.
Providers also can reassure parents with concerns about safety and side effects that extensive safety research exists regarding HPV immunization from the past 10 years.
For those worried that HPV vaccination gives “permission for sexual activity” or that kids are too young, providers can reassure parents that the shot is not linked with increased sexual activity, and that it’s recommended at ages 11 and 12 years because the vaccine induces a better immune response at those ages than later on, she said.
Ms. Garcia reported no disclosures. No external funding was reported.
This article was updated Dec. 2, 2016.
AT THE NATIONAL IMMUNIZATION CONFERENCE
Key clinical point: Targeted interventions to improve HPV vaccination can be effective.
Major finding: In one health care system’s intervention, 87% of providers found the tools and strategies for increasing HPV vaccination uptake helpful and worth using.
Data source: A study within the Kaiser Permanente NW health care system involving two hospitals and 31 medical offices, which serves 44,000 adolescents aged 11-17 years.
Disclosures: Dr. Groom reported no disclosures. No external funding was reported.
Cultural approach to vaccine hesitancy essential for ethnic communities
ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.
Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.
A 2000 study had shown Somali parents were generally supportive of immunization, but that perception had changed by summer of 2008, explained co-presenter Lynn Bahta, RN, PHN, an immunization clinical consultant at the Minnesota Department of Health Immunization Program. A local TV station ran a story about Somali parents’ concern that a disproportionately higher number of Somali children were in early childhood special education programs for autism.
“In the middle of the report, a parent stated, ‘It’s the vaccines,’ ” Ms. Bahta said. Because they did not have a word for autism in Somali, parents’ online searches led them to groups promoting the misconception that the MMR vaccine and autism were linked. Clinicians in Minnesota began to report Somali parents’ refusal to get their children’s 12-month vaccines. Then a 2011 measles outbreak led the Minnesota Department of Health to look at MMR vaccination rates among local Somalis.
Somalis had a higher rate of MMR coverage in 24-month-old children than did non-Somalis in 2004 – 90%, compared with 84% – according to the Minnesota Immunization Information Connection. But MMR rates among Somali 24-month-olds began dropping in 2005, reaching 82% in 2007 and 63% in 2009.
“The data we got instilled a bit of panic in the immunization team,” Ms. Bahta said. “Parents were still supporting immunizations, but they weren’t getting that MMR.”
Traditional strategies to increase vaccination – distributing travel immunization information, promoting YouTube videos about immunization and autism, using diverse media for information campaigns – failed.
So they joined with the community and family health department, where co-presenter Asli Ashkir, RN, MPH, is a senior nurse consultant in the Children & Youth with Special Health Needs program. They also hired Somali staff and began to improve their cultural knowledge and competence.
With Somalis, social life revolves around family ties, the community, and faith, explained Ms. Ashkir, a Somali woman herself. Somali culture is based on oral tradition, one that shares information among themselves and provides unsolicited advice to one another, and they persuade each other easily. But issues of health, life, and death are in the hands of Allah only, she said.
“There is a time you will die, whether you are vaccinated or not,” Ms. Ashkir explained. “That doesn’t mean we don’t practice preventive service or health promotion – we do – but at the back of our head, when our time is over, you’re going to go. These are the people we are working with.”
Two other potential obstacles involve Somali beliefs about sin and mental illness.
“We believe if someone is ill, their sins will be cleansed,” she said, explaining why Somalis with minor health problems don’t seek health care. “Parents with kids who have autism keep kids in their apartment until they are 8 years old because mental illness has a negative stigma.”
The Minnesota Department of Health conducted a study on the experience of having a child with autism in the Somali community and discovered four key themes. First, the parents greatly feared autism: Every Somali interviewed said they did not get the MMR because they wanted to avoid autism. Second, parents lacked information about normal child development, autism, and the diseases that vaccines prevent.
“We were expecting parents to identify developmental delays, but parents look not at the development but the growth, at the physical size of the child,” Ms. Ashkir said. And when they learned that the MMR prevented measles – the No. 3 killer of children in Somalia – parents often wanted the shot immediately.
The other two discoveries were that it was impossible to talk about immunization issues in isolation – they were too intricately entwined with discussions about autism – and that Somalis wanted to hear information from respected community sources.
These findings were applied in a pilot program that aimed to improve parents’ knowledge about child growth and development, autism, and vaccine-preventable diseases. Six mothers attended the training program, and tracking their contacts revealed that the information had traveled to 82 other family, friends, and neighbors within the first 3 months. All the women found the program “very helpful” with no negative responses.
The success of this program led to a more comprehensive approach that included training and outreach, engaging the community, disease mitigation and control, and creating and expanding partnerships with organizations such as the state American Academy of Pediatrics chapter, the Somali American Parent Association, the Minnesota Medical Association, and Parents in Community Action.
Training included all-Somali speakers with messages from spiritual leaders and parents of children with autism. Community outreach involved one-on-one conversations among Somalis at information tables in places such as malls, mosques, community centers, and libraries.
“Among this group, there are four parents who have children with autism,” Ms. Ashkir said. “Two of these parents are very, very vocal and talk about their children who have autism, and that they did not give them the MMR. They tell people ‘You have wrong information.’ ”
As of March 2016, the decline in MMR vaccination rates among Somalis had started to flatten. The annual drop of 5%-7% a year in MMR rates became 0.89% last year, which the Minnesota Department of Health finds encouraging.
“Our initial efforts, which included a typical repertoire of public health interventions, were ineffective, so we had to go back and dig deep to understand the core concerns,” Ms. Bahta said. “Our information had to address the core concerns of the community, not what we assumed to be the issue.”
Credibility came from the cultural relevancy of the message, and the fact that those providing the message were parents who had vaccinated their children, she said.
“Each cultural group needs unique approaches, and this is certainly true in this situation – to understand the unique perspective of the community and develop an effective approach required bringing in culturally competent staff and engaging the community,” Ms. Bahta said.
ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.
Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.
A 2000 study had shown Somali parents were generally supportive of immunization, but that perception had changed by summer of 2008, explained co-presenter Lynn Bahta, RN, PHN, an immunization clinical consultant at the Minnesota Department of Health Immunization Program. A local TV station ran a story about Somali parents’ concern that a disproportionately higher number of Somali children were in early childhood special education programs for autism.
“In the middle of the report, a parent stated, ‘It’s the vaccines,’ ” Ms. Bahta said. Because they did not have a word for autism in Somali, parents’ online searches led them to groups promoting the misconception that the MMR vaccine and autism were linked. Clinicians in Minnesota began to report Somali parents’ refusal to get their children’s 12-month vaccines. Then a 2011 measles outbreak led the Minnesota Department of Health to look at MMR vaccination rates among local Somalis.
Somalis had a higher rate of MMR coverage in 24-month-old children than did non-Somalis in 2004 – 90%, compared with 84% – according to the Minnesota Immunization Information Connection. But MMR rates among Somali 24-month-olds began dropping in 2005, reaching 82% in 2007 and 63% in 2009.
“The data we got instilled a bit of panic in the immunization team,” Ms. Bahta said. “Parents were still supporting immunizations, but they weren’t getting that MMR.”
Traditional strategies to increase vaccination – distributing travel immunization information, promoting YouTube videos about immunization and autism, using diverse media for information campaigns – failed.
So they joined with the community and family health department, where co-presenter Asli Ashkir, RN, MPH, is a senior nurse consultant in the Children & Youth with Special Health Needs program. They also hired Somali staff and began to improve their cultural knowledge and competence.
With Somalis, social life revolves around family ties, the community, and faith, explained Ms. Ashkir, a Somali woman herself. Somali culture is based on oral tradition, one that shares information among themselves and provides unsolicited advice to one another, and they persuade each other easily. But issues of health, life, and death are in the hands of Allah only, she said.
“There is a time you will die, whether you are vaccinated or not,” Ms. Ashkir explained. “That doesn’t mean we don’t practice preventive service or health promotion – we do – but at the back of our head, when our time is over, you’re going to go. These are the people we are working with.”
Two other potential obstacles involve Somali beliefs about sin and mental illness.
“We believe if someone is ill, their sins will be cleansed,” she said, explaining why Somalis with minor health problems don’t seek health care. “Parents with kids who have autism keep kids in their apartment until they are 8 years old because mental illness has a negative stigma.”
The Minnesota Department of Health conducted a study on the experience of having a child with autism in the Somali community and discovered four key themes. First, the parents greatly feared autism: Every Somali interviewed said they did not get the MMR because they wanted to avoid autism. Second, parents lacked information about normal child development, autism, and the diseases that vaccines prevent.
“We were expecting parents to identify developmental delays, but parents look not at the development but the growth, at the physical size of the child,” Ms. Ashkir said. And when they learned that the MMR prevented measles – the No. 3 killer of children in Somalia – parents often wanted the shot immediately.
The other two discoveries were that it was impossible to talk about immunization issues in isolation – they were too intricately entwined with discussions about autism – and that Somalis wanted to hear information from respected community sources.
These findings were applied in a pilot program that aimed to improve parents’ knowledge about child growth and development, autism, and vaccine-preventable diseases. Six mothers attended the training program, and tracking their contacts revealed that the information had traveled to 82 other family, friends, and neighbors within the first 3 months. All the women found the program “very helpful” with no negative responses.
The success of this program led to a more comprehensive approach that included training and outreach, engaging the community, disease mitigation and control, and creating and expanding partnerships with organizations such as the state American Academy of Pediatrics chapter, the Somali American Parent Association, the Minnesota Medical Association, and Parents in Community Action.
Training included all-Somali speakers with messages from spiritual leaders and parents of children with autism. Community outreach involved one-on-one conversations among Somalis at information tables in places such as malls, mosques, community centers, and libraries.
“Among this group, there are four parents who have children with autism,” Ms. Ashkir said. “Two of these parents are very, very vocal and talk about their children who have autism, and that they did not give them the MMR. They tell people ‘You have wrong information.’ ”
As of March 2016, the decline in MMR vaccination rates among Somalis had started to flatten. The annual drop of 5%-7% a year in MMR rates became 0.89% last year, which the Minnesota Department of Health finds encouraging.
“Our initial efforts, which included a typical repertoire of public health interventions, were ineffective, so we had to go back and dig deep to understand the core concerns,” Ms. Bahta said. “Our information had to address the core concerns of the community, not what we assumed to be the issue.”
Credibility came from the cultural relevancy of the message, and the fact that those providing the message were parents who had vaccinated their children, she said.
“Each cultural group needs unique approaches, and this is certainly true in this situation – to understand the unique perspective of the community and develop an effective approach required bringing in culturally competent staff and engaging the community,” Ms. Bahta said.
ATLANTA – Research into vaccine hesitancy in the United States tends to focus on overall trends among native-born Americans or immigrants who have mostly assimilated into American culture. But the nation is dotted with tight-knit ethnic communities which have immigrated to the United States, including refugee communities that retain much of the culture and practices of their home country.
Developing interventions to address vaccine hesitancy in these communities may require a significantly different approach than it would in fully assimilated groups, with a need to start by learning about the culture, fears, values and priorities of that particular community.
A 2000 study had shown Somali parents were generally supportive of immunization, but that perception had changed by summer of 2008, explained co-presenter Lynn Bahta, RN, PHN, an immunization clinical consultant at the Minnesota Department of Health Immunization Program. A local TV station ran a story about Somali parents’ concern that a disproportionately higher number of Somali children were in early childhood special education programs for autism.
“In the middle of the report, a parent stated, ‘It’s the vaccines,’ ” Ms. Bahta said. Because they did not have a word for autism in Somali, parents’ online searches led them to groups promoting the misconception that the MMR vaccine and autism were linked. Clinicians in Minnesota began to report Somali parents’ refusal to get their children’s 12-month vaccines. Then a 2011 measles outbreak led the Minnesota Department of Health to look at MMR vaccination rates among local Somalis.
Somalis had a higher rate of MMR coverage in 24-month-old children than did non-Somalis in 2004 – 90%, compared with 84% – according to the Minnesota Immunization Information Connection. But MMR rates among Somali 24-month-olds began dropping in 2005, reaching 82% in 2007 and 63% in 2009.
“The data we got instilled a bit of panic in the immunization team,” Ms. Bahta said. “Parents were still supporting immunizations, but they weren’t getting that MMR.”
Traditional strategies to increase vaccination – distributing travel immunization information, promoting YouTube videos about immunization and autism, using diverse media for information campaigns – failed.
So they joined with the community and family health department, where co-presenter Asli Ashkir, RN, MPH, is a senior nurse consultant in the Children & Youth with Special Health Needs program. They also hired Somali staff and began to improve their cultural knowledge and competence.
With Somalis, social life revolves around family ties, the community, and faith, explained Ms. Ashkir, a Somali woman herself. Somali culture is based on oral tradition, one that shares information among themselves and provides unsolicited advice to one another, and they persuade each other easily. But issues of health, life, and death are in the hands of Allah only, she said.
“There is a time you will die, whether you are vaccinated or not,” Ms. Ashkir explained. “That doesn’t mean we don’t practice preventive service or health promotion – we do – but at the back of our head, when our time is over, you’re going to go. These are the people we are working with.”
Two other potential obstacles involve Somali beliefs about sin and mental illness.
“We believe if someone is ill, their sins will be cleansed,” she said, explaining why Somalis with minor health problems don’t seek health care. “Parents with kids who have autism keep kids in their apartment until they are 8 years old because mental illness has a negative stigma.”
The Minnesota Department of Health conducted a study on the experience of having a child with autism in the Somali community and discovered four key themes. First, the parents greatly feared autism: Every Somali interviewed said they did not get the MMR because they wanted to avoid autism. Second, parents lacked information about normal child development, autism, and the diseases that vaccines prevent.
“We were expecting parents to identify developmental delays, but parents look not at the development but the growth, at the physical size of the child,” Ms. Ashkir said. And when they learned that the MMR prevented measles – the No. 3 killer of children in Somalia – parents often wanted the shot immediately.
The other two discoveries were that it was impossible to talk about immunization issues in isolation – they were too intricately entwined with discussions about autism – and that Somalis wanted to hear information from respected community sources.
These findings were applied in a pilot program that aimed to improve parents’ knowledge about child growth and development, autism, and vaccine-preventable diseases. Six mothers attended the training program, and tracking their contacts revealed that the information had traveled to 82 other family, friends, and neighbors within the first 3 months. All the women found the program “very helpful” with no negative responses.
The success of this program led to a more comprehensive approach that included training and outreach, engaging the community, disease mitigation and control, and creating and expanding partnerships with organizations such as the state American Academy of Pediatrics chapter, the Somali American Parent Association, the Minnesota Medical Association, and Parents in Community Action.
Training included all-Somali speakers with messages from spiritual leaders and parents of children with autism. Community outreach involved one-on-one conversations among Somalis at information tables in places such as malls, mosques, community centers, and libraries.
“Among this group, there are four parents who have children with autism,” Ms. Ashkir said. “Two of these parents are very, very vocal and talk about their children who have autism, and that they did not give them the MMR. They tell people ‘You have wrong information.’ ”
As of March 2016, the decline in MMR vaccination rates among Somalis had started to flatten. The annual drop of 5%-7% a year in MMR rates became 0.89% last year, which the Minnesota Department of Health finds encouraging.
“Our initial efforts, which included a typical repertoire of public health interventions, were ineffective, so we had to go back and dig deep to understand the core concerns,” Ms. Bahta said. “Our information had to address the core concerns of the community, not what we assumed to be the issue.”
Credibility came from the cultural relevancy of the message, and the fact that those providing the message were parents who had vaccinated their children, she said.
“Each cultural group needs unique approaches, and this is certainly true in this situation – to understand the unique perspective of the community and develop an effective approach required bringing in culturally competent staff and engaging the community,” Ms. Bahta said.
AT THE NATIONAL IMMUNIZATION CONFERENCE
Key clinical point:
Major finding: The decline in MMR vaccination among Somali children in Minnesota went from a 5%-7% annual drop to a 0.89% drop in 2015.
Data source: The findings are based on a comprehensive training and outreach program developed at the Minnesota Department of Health.
Disclosures: The initiative was funded by the Minnesota Department of Health. Ms. Ashkir and Ms. Bahta reported they had no conflicts to disclose.
HPV vaccination rates tripled with practice’s comprehensive intervention
ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.
Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.
She described the critical components of a vaccination quality improvement project: set specific goals, know your practice’s actual rates, identify areas of weakness and/or opportunity, and then implement effective and sustainable processes for improvement. Their initial goal was to show any improvement at all in the first year and then to meet the highest national rates 2 years later.
“We started by agreeing we would become transparent to one another,” Dr. Casler explained. “This is called peer influence. What we didn’t want to be was the one who deviated from standard practice.”
As they got further along into their initiative, this transparency led physicians to ask others with better rates for help. “It’s not just a motivator in terms of not wanting to be the worse; it’s also a motivator in knowing how to get help,” said Dr. Casler, also at Florida State College of Medicine in Tallahassee and the University of Central Florida in Orlando.
Individual physicians’ rates were first shared privately with that physician, then shared with the department, and then published monthly and eventually only quarterly.
Then they developed the interventions to improve rates: verification and clean-up of their data, physician and staff education, physician incentives, previsit planning, electronic follow-up orders for the second and third doses, reminder calls, manufacturer tools, and clinical summaries.
The physician education program involved first making HPV vaccination a priority even when multiple competing priorities exist at each well visit.
“Our doctors felt, as all doctors feel, that we have 75 things to do and it’s not possible to do them all,” Dr. Casler said. “If we don’t have a fast and dirty way of doing something, it won’t get done.”
Part of prioritizing the vaccine was making physicians aware of how common HPV and HPV diseases were, which many did not realize. Then the training addressed providers’ discomfort about discussing the vaccine. They provided a script that included a clear recommendation for the HPV vaccine – sandwiched between the recommendations for the meningitis and Tdap vaccines – without adding unnecessary extra information unless the parent requested it.
During staff training, her practice found similar obstacles as with the doctors. “They had different competing priorities, they didn’t really know what HPV was, and they didn’t want to talk about sex,” Dr. Casler said.
Following training, they distributed tools such as posters and fact sheets to physicians and developed incentives: competition among each other, a quality bonus structure, and wine. “It’s amazing what will motivate people,” Dr. Casler said with a smile. “Again, this is the real world.”
Daily previsit planning meant documenting on patient lists the priorities for each patient, including the HPV vaccine as well as needs such as flu shots; other vaccines; screening for asthma, depression, and STIs; smoking assessment; diet and exercise counseling; and risk factor assessments.
“That is one of the most valuable interventions and got a tremendous amount of feedback from the staff,” Dr. Casler said. “Any practice can do this for free. I look at every metric that needs to be covered with that patient during that visit.”
Patients then are required to schedule their second and third doses on their way out. “If someone no-shows or doesn’t reschedule, my secretary knows what HPV is and what it does,” Dr. Casler said. “She will call the parents and leave a message, ‘Call me tomorrow to reschedule your appointment... so that your child doesn’t get cancer.”
In evaluating the program, Dr. Casler said the most popular interventions were the physician and staff education programs, scheduling subsequent doses in real time, and using manufacturer-supplied tools such as magnets and cling posters. Staff involvement turned out to be a critical resource in the overall intervention as well.
As a result of the program begun in August 2013, the practice’s rates of girls and boys receiving one dose of the HPV vaccine increased to 65% and 57%, respectively, by the end of 2014. Further, 43% of girls and 30% of boys received all three doses. By June 2016, 75% of girls and 72% of boys were receiving their first dose of HPV vaccine, and 55% of girls and 47% of boys were receiving all three doses.
Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.
ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.
Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.
She described the critical components of a vaccination quality improvement project: set specific goals, know your practice’s actual rates, identify areas of weakness and/or opportunity, and then implement effective and sustainable processes for improvement. Their initial goal was to show any improvement at all in the first year and then to meet the highest national rates 2 years later.
“We started by agreeing we would become transparent to one another,” Dr. Casler explained. “This is called peer influence. What we didn’t want to be was the one who deviated from standard practice.”
As they got further along into their initiative, this transparency led physicians to ask others with better rates for help. “It’s not just a motivator in terms of not wanting to be the worse; it’s also a motivator in knowing how to get help,” said Dr. Casler, also at Florida State College of Medicine in Tallahassee and the University of Central Florida in Orlando.
Individual physicians’ rates were first shared privately with that physician, then shared with the department, and then published monthly and eventually only quarterly.
Then they developed the interventions to improve rates: verification and clean-up of their data, physician and staff education, physician incentives, previsit planning, electronic follow-up orders for the second and third doses, reminder calls, manufacturer tools, and clinical summaries.
The physician education program involved first making HPV vaccination a priority even when multiple competing priorities exist at each well visit.
“Our doctors felt, as all doctors feel, that we have 75 things to do and it’s not possible to do them all,” Dr. Casler said. “If we don’t have a fast and dirty way of doing something, it won’t get done.”
Part of prioritizing the vaccine was making physicians aware of how common HPV and HPV diseases were, which many did not realize. Then the training addressed providers’ discomfort about discussing the vaccine. They provided a script that included a clear recommendation for the HPV vaccine – sandwiched between the recommendations for the meningitis and Tdap vaccines – without adding unnecessary extra information unless the parent requested it.
During staff training, her practice found similar obstacles as with the doctors. “They had different competing priorities, they didn’t really know what HPV was, and they didn’t want to talk about sex,” Dr. Casler said.
Following training, they distributed tools such as posters and fact sheets to physicians and developed incentives: competition among each other, a quality bonus structure, and wine. “It’s amazing what will motivate people,” Dr. Casler said with a smile. “Again, this is the real world.”
Daily previsit planning meant documenting on patient lists the priorities for each patient, including the HPV vaccine as well as needs such as flu shots; other vaccines; screening for asthma, depression, and STIs; smoking assessment; diet and exercise counseling; and risk factor assessments.
“That is one of the most valuable interventions and got a tremendous amount of feedback from the staff,” Dr. Casler said. “Any practice can do this for free. I look at every metric that needs to be covered with that patient during that visit.”
Patients then are required to schedule their second and third doses on their way out. “If someone no-shows or doesn’t reschedule, my secretary knows what HPV is and what it does,” Dr. Casler said. “She will call the parents and leave a message, ‘Call me tomorrow to reschedule your appointment... so that your child doesn’t get cancer.”
In evaluating the program, Dr. Casler said the most popular interventions were the physician and staff education programs, scheduling subsequent doses in real time, and using manufacturer-supplied tools such as magnets and cling posters. Staff involvement turned out to be a critical resource in the overall intervention as well.
As a result of the program begun in August 2013, the practice’s rates of girls and boys receiving one dose of the HPV vaccine increased to 65% and 57%, respectively, by the end of 2014. Further, 43% of girls and 30% of boys received all three doses. By June 2016, 75% of girls and 72% of boys were receiving their first dose of HPV vaccine, and 55% of girls and 47% of boys were receiving all three doses.
Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.
ATLANTA – A multifaceted comprehensive intervention significantly improved human papillomavirus (HPV) vaccination rates in a Florida pediatric health care group practice.
Alix G. Casler, MD, chief of pediatrics at Orlando Health Physician Associates, described how her practice put into place practices to improve the overall HPV vaccination rate of their clients.
She described the critical components of a vaccination quality improvement project: set specific goals, know your practice’s actual rates, identify areas of weakness and/or opportunity, and then implement effective and sustainable processes for improvement. Their initial goal was to show any improvement at all in the first year and then to meet the highest national rates 2 years later.
“We started by agreeing we would become transparent to one another,” Dr. Casler explained. “This is called peer influence. What we didn’t want to be was the one who deviated from standard practice.”
As they got further along into their initiative, this transparency led physicians to ask others with better rates for help. “It’s not just a motivator in terms of not wanting to be the worse; it’s also a motivator in knowing how to get help,” said Dr. Casler, also at Florida State College of Medicine in Tallahassee and the University of Central Florida in Orlando.
Individual physicians’ rates were first shared privately with that physician, then shared with the department, and then published monthly and eventually only quarterly.
Then they developed the interventions to improve rates: verification and clean-up of their data, physician and staff education, physician incentives, previsit planning, electronic follow-up orders for the second and third doses, reminder calls, manufacturer tools, and clinical summaries.
The physician education program involved first making HPV vaccination a priority even when multiple competing priorities exist at each well visit.
“Our doctors felt, as all doctors feel, that we have 75 things to do and it’s not possible to do them all,” Dr. Casler said. “If we don’t have a fast and dirty way of doing something, it won’t get done.”
Part of prioritizing the vaccine was making physicians aware of how common HPV and HPV diseases were, which many did not realize. Then the training addressed providers’ discomfort about discussing the vaccine. They provided a script that included a clear recommendation for the HPV vaccine – sandwiched between the recommendations for the meningitis and Tdap vaccines – without adding unnecessary extra information unless the parent requested it.
During staff training, her practice found similar obstacles as with the doctors. “They had different competing priorities, they didn’t really know what HPV was, and they didn’t want to talk about sex,” Dr. Casler said.
Following training, they distributed tools such as posters and fact sheets to physicians and developed incentives: competition among each other, a quality bonus structure, and wine. “It’s amazing what will motivate people,” Dr. Casler said with a smile. “Again, this is the real world.”
Daily previsit planning meant documenting on patient lists the priorities for each patient, including the HPV vaccine as well as needs such as flu shots; other vaccines; screening for asthma, depression, and STIs; smoking assessment; diet and exercise counseling; and risk factor assessments.
“That is one of the most valuable interventions and got a tremendous amount of feedback from the staff,” Dr. Casler said. “Any practice can do this for free. I look at every metric that needs to be covered with that patient during that visit.”
Patients then are required to schedule their second and third doses on their way out. “If someone no-shows or doesn’t reschedule, my secretary knows what HPV is and what it does,” Dr. Casler said. “She will call the parents and leave a message, ‘Call me tomorrow to reschedule your appointment... so that your child doesn’t get cancer.”
In evaluating the program, Dr. Casler said the most popular interventions were the physician and staff education programs, scheduling subsequent doses in real time, and using manufacturer-supplied tools such as magnets and cling posters. Staff involvement turned out to be a critical resource in the overall intervention as well.
As a result of the program begun in August 2013, the practice’s rates of girls and boys receiving one dose of the HPV vaccine increased to 65% and 57%, respectively, by the end of 2014. Further, 43% of girls and 30% of boys received all three doses. By June 2016, 75% of girls and 72% of boys were receiving their first dose of HPV vaccine, and 55% of girls and 47% of boys were receiving all three doses.
Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.
AT THE NATIONAL IMMUNIZATION CONFERENCE
Key clinical point: A multifaceted comprehensive intervention significantly improved HPV vaccination rates in a pediatric health care group practice.
Major finding: Girls and boys receiving any HPV vaccine dose increased from 23% and 12% in 2013 to 75% and 72% in June 2016, respectively. Rates of three doses increased from 14% of girls and 3% of boys in 2013 to 55% of girls and 47% of boys in June 2016.
Data source: The findings are based on internal assessment of an intervention at a large multispecialty health care group with 22 pediatricians and with 23,000 patients at least 11 years old.
Disclosures: Dr. Casler reported previous consulting and speaking for Merck and Sanofi Pasteur. No external funding was reported.
Parental online sharing involves balancing risks, benefits
SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.
Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.
“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.
She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.
“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”
The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.
The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.
The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.
More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.
Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.
“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”
A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.
But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.
Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.
“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”
Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.
“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.
For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.
Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.
“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.
Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.
“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”
Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.
SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.
Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.
“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.
She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.
“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”
The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.
The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.
The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.
More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.
Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.
“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”
A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.
But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.
Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.
“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”
Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.
“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.
For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.
Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.
“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.
Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.
“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”
Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.
SAN FRANCISCO – More than two-thirds of parents worry about their children’s privacy online and/or that photos of their children might be reshared on the wider Web, according to a survey conducted by C.S. Mott Children’s Hospital.
Those fears are not baseless, and they need to be considered more often by parents themselves in posting about their children online, presenters agreed at a symposium on the media at the annual meeting of the American Academy of Pediatrics.
“The first children of social media are just now entering adulthood, entering the job market,” said Stacey Steinberg, JD, a legal skills professor at the University of Florida Levin College of Law, Gainesville. She is also with the law school’s center on children and families.
She and Bahareh Keith, DO, a pediatrician at the University of Florida, discussed the challenges and risks of “sharenting” – parents’ sharing information and photos of their children online – and pediatricians’ role in advising parents and looking out for children’s best interests.
“The dearth of discussion on this topic leaves even the most well-intentioned parents without enough information to thoroughly analyze this,” Ms. Steinberg said. “We’re not sitting here saying we know what the answers are. But we’re saying this is an important issue that affects families, and these children require a voice in this discussion.”
The way social media and blogging have changed the landscape for children coming of age today means that they often have a digital footprint shaped by their parents long before they create their own first account. This reality means it’s necessary to consider how to balance children’s right to privacy with parents’ right to free speech and expression.
The 2015 C.S. Mott survey asked 569 parents of children aged 4 years and younger about how they use social media as parents, and reported that more than half of mothers (56%) and a third of fathers (34%) discuss parenting and child health topics on Facebook, Twitter, blogs, online forums, and other online platforms.
The risks of this sharenting can range from embarrassment of the child to significantly more sinister repercussions. Just over half of the parents (52%) in the Mott survey reported that they are concerned their child might feel embarrassed when they grow older and discover what their parents shared online. But that embarrassment also can lead to bullying or determent of psychosocial development, Ms. Steinberg and Dr. Keith explained.
More serious, if less common, risks include the possibility that data brokers could access and use information about the children or that online child pornographers could repurpose the photos inappropriately. One worst case scenario of the former is digital kidnapping, a disturbing practice in which a stranger uses baby photos and information that is not their own to pass off the child as their own or to invite others to “invent” identities for the child. The Children’s Online Privacy Protection Rule of the Federal Trade Commission addresses only online use by those under age 13 years, not others’ use of those images.
Regarding the latter, Ms. Steinberg and Dr. Keith showed an example of a bare-bottomed baby standing in front of a bathtub that had been reshared hundreds of times, but other images that have been shared on child pornography sites depict children in everyday situations such as playing on a playground, running at the beach, or doing gymnastics.
“These are images that many of us would think are innocent, but pornographers would categorize these into folders,” Dr. Keith said. “It’s not even naked or half-naked pictures.”
A study conducted by an e-safety commission in Australia, for example, found that half of the thousands of photos shared on a sample of child pornography sites had originated from parental sharing.
But Ms. Steinberg and Dr. Keith pointed out that benefits of parents’ online sharing exist as well, as the Mott survey found. In that survey, 72% of parents who discuss parenting and/or their children on social media reported that doing so helps them feel less alone. Similarly, 70% said they learn what not to do through those experiences, 67% said they receive advice from more experienced parents, and 62% said they consequently worry less. Common topics they discussed included sleep, nutrition, discipline, day care, and behavior management.
Other benefits, Ms. Steinberg pointed out, are that families geographically spread apart can stay connected, and communities can grow stronger with shared communal experiences of parents meeting others online.
“For some parents, it gives them an opportunity for advocacy work and raises awareness for important social issues,” Ms. Steinberg said, although she added, “If you’re going to share your children’s behavioral problems, consider sharing anonymously.”
Neither Ms. Steinberg and Dr. Keith said they had simple solutions to these challenges. Rather, they recommended using the public health model of raising awareness and encouraging open dialogue among pediatricians, parents, and their children to look for ways to balance competing interests.
“Social media offers many positive benefits, and we don’t want to silence the many voices of parents who take part in online sharing,” Ms. Steinberg explained. But she and Ms. Keith said it’s also worth considering children’s potential interest in controlling what their digital footprint is as they become adults.
For example, one study they cited found that, among 249 pairs of parents and their children, three times more children than parents wanted the parents to have and follow rules regarding what they could share on social media about their children.
Although guidance for parents on monitoring children’s social media use is a part of the AAP policy statement on media, only one recommendation obliquely addresses how parents should or shouldn’t use social media by advising them to model appropriate use for their children.
“It’s just like any medical decision: What is the benefit, and what is the risk, and does the benefit outweigh the risk?” said Wendy Sue Swanson, MD, executive director of digital health at Seattle Children’s Hospital. She recommended that parents ask their child for permission before posting a story or photo if their kids are aged 6 or older.
Ms. Steinberg and Dr. Keith recommended that pediatricians broach this subject with parents to help them think about risks they simply might not have considered before.
“When we looked at what sorts of best practices could be encouraged or doctors could talk to parents about – the tangible harms, such as whether data brokers or people interested in child pornography could access the information – we didn’t want to create any unnecessary panic,” Ms. Steinberg said. “But we did find some concerns that were troublesome, and we thought that parents or at least physicians [should] be aware of those potential risks.”
Ms. Steinberg and Dr. Keith reported that they had no relevant financial disclosures.
AT AAP 2016
Managing stress in children, parents can reduce obesity risk
SAN FRANCISCO – Obesity is a multifactorial problem, influenced by factors ranging from genetics to lifestyle to the environment. Yet stress can play an outsize role in obesity as well, Elizabeth Prout Parks, MD, said at the annual meeting of the American Academy of Pediatrics.
Although the calorie-in/calorie-out model of energy balance has driven much of the thought about obesity, it’s not that simple, suggested Dr. Parks, the medical director of the Healthy Weight Adolescent Bariatrics Program at the Children’s Hospital of Philadelphia. Physical activity accounts for an estimated 15%-30% of energy expenditure, and thermogenesis accounts for an estimated 10%. But the energy expenditure required for basal metabolism can range from 60% to 75%, a sufficiently wide range for significant variation across different individuals.
The psychosocial effects can lead to anxiety, depression, disordered eating behaviors such as emotional eating, a sedentary lifestyle, poor sleep, and low maintenance with self-care activities. Further, poor sleep on its own is additionally associated with childhood obesity. The combination of these physiologic and psychosocial effects can increase the risk of metabolic syndrome, type 2 diabetes, and cardiovascular disease or events. While acute stress and chronic stress follow similar pathways in the brain, it’s chronic stress that carries the greater risk of behavioral and physical conditions.
Measuring and understanding child and parental stress
Several clinical assessments can measure stress in children, including the Daily Hassles Scale, which looks at everyday interactions in the environment and factors such as children’s school, family, neighborhood, peers, and lack of resources. The Multidimensional Life Events Rating Questionnaire and Adolescent Stress Questionnaire both are more appropriate for middle school and older adolescents.
In children, the primary biologic indicators of stress are cortisol levels, heart rate, and blood pressure, but it is perceived stress that has been most clearly linked to emotional eating and other disordered eating behaviors, Dr. Parks said. One 2008 study found perceived stress to be associated with emotional eating among middle school students both with and without obesity. A high level of perceived stress in adolescents was associated with a greater waist circumference and body mass index in a 2009 study.
The findings are somewhat more mixed, however, when it comes to parental stress and child weight. A 2012 study identified a link between parents’ perception of their stress and increased fast food consumption in their children, and a 2008 study identified a link between parenting stress and both overweight and underweight children. Yet a different study in 2008 found no association between child obesity and parenting stress. Research in 2011 found a relationship between children’s consumption of fruits and vegetables and their family’s overall functioning, as well as parental psychological stress and child behavior. Within a family, stress can come from financial strain (such as poverty or changes in employment or insurance), the family’s structure, and changes in physical or mental health of one or more family members.
Addressing the effects of stress on diet
Clinicians can help families manage the ways stress can lead to obesity by helping them with ideas for increasing fruit and vegetable intake, and planning ahead for on-the-go eating. For example, to ensure children get in their recommended five servings of fruit and vegetables each day, parents can serve fruit with breakfast every day and offer vegetables and/or fruit as a snack. Including side salads and a frozen vegetable with dinner will add two more servings, and children can munch on chopped veggies while parents prepare dinner. Offering fruit as a dessert provides another opportunity to bump up kids’ fruit and veggie intake, Dr. Parks said.
To manage the risk of unhealthy eating when out and about, Dr. Parks recommends planning ahead by packing a snack such as yogurt, fruit and vegetables, a sandwich or wrap, and water.
She described the “apple test” for determining whether someone is eating because of boredom or stress or because of actual hunger.“The next time you are thinking about a mini meal or second helpings at a meal, ask yourself, ‘Would I eat an apple instead?’ ” Dr. Parks said. “If the answer is no, then you probably are not really hungry and just need to get away from food.”
Other things people can consider when about to eat something are whether they are actually hungry and whether a distraction such as the television is contributing to distracted eating. “People may eat when they’re happy, sad, or bored,” Dr. Parks said, noting that outside messages such as commercials, advertisements, and passing restaurants may make someone feel like eating even if they don’t need sustenance at that moment. “Consider whether you really are hungry before you eat,” she said.
Avoiding emotional eating and using mindfulness
Additionally, parents and children can avoid emotional eating by skipping the food when they feel angry, tired, nervous, bored, or sad, instead choosing activities such as journaling, taking a walk, listening to music, reading a book, or taking deep breaths while thinking pleasant thoughts. It’s only time to eat if you physically feel hungry, your stomach is rumbling, you are not craving some specific sweet or salty food, or it’s a meal or snack time (or at least 2.5-4 hours since the last time you ate).
Dr. Parks also reviewed ways that mindfulness may help reduce the risk of obesity by reducing stress, enhancing a person’s ability to regulate their everyday behaviors, and teaching individuals to accept discomfort. Another stress reduction strategy is repeated use of “4-7-8 breathing,” which begins with exhalation while the mouth is closed. Then, inhale through the nose for 4 seconds, hold the breath for 7 seconds and slowly exhale out the mouth for 8 seconds.
Reducing the risk of obesity from stress comes from learning to manage stress. Clinicians can play a role in helping both parents and children learn strategies to manage and cope with stress in the short term while developing resilience over the longer term and reducing the likelihood of poor eating and emotional eating.
Dr. Parks reported no disclosures.
SAN FRANCISCO – Obesity is a multifactorial problem, influenced by factors ranging from genetics to lifestyle to the environment. Yet stress can play an outsize role in obesity as well, Elizabeth Prout Parks, MD, said at the annual meeting of the American Academy of Pediatrics.
Although the calorie-in/calorie-out model of energy balance has driven much of the thought about obesity, it’s not that simple, suggested Dr. Parks, the medical director of the Healthy Weight Adolescent Bariatrics Program at the Children’s Hospital of Philadelphia. Physical activity accounts for an estimated 15%-30% of energy expenditure, and thermogenesis accounts for an estimated 10%. But the energy expenditure required for basal metabolism can range from 60% to 75%, a sufficiently wide range for significant variation across different individuals.
The psychosocial effects can lead to anxiety, depression, disordered eating behaviors such as emotional eating, a sedentary lifestyle, poor sleep, and low maintenance with self-care activities. Further, poor sleep on its own is additionally associated with childhood obesity. The combination of these physiologic and psychosocial effects can increase the risk of metabolic syndrome, type 2 diabetes, and cardiovascular disease or events. While acute stress and chronic stress follow similar pathways in the brain, it’s chronic stress that carries the greater risk of behavioral and physical conditions.
Measuring and understanding child and parental stress
Several clinical assessments can measure stress in children, including the Daily Hassles Scale, which looks at everyday interactions in the environment and factors such as children’s school, family, neighborhood, peers, and lack of resources. The Multidimensional Life Events Rating Questionnaire and Adolescent Stress Questionnaire both are more appropriate for middle school and older adolescents.
In children, the primary biologic indicators of stress are cortisol levels, heart rate, and blood pressure, but it is perceived stress that has been most clearly linked to emotional eating and other disordered eating behaviors, Dr. Parks said. One 2008 study found perceived stress to be associated with emotional eating among middle school students both with and without obesity. A high level of perceived stress in adolescents was associated with a greater waist circumference and body mass index in a 2009 study.
The findings are somewhat more mixed, however, when it comes to parental stress and child weight. A 2012 study identified a link between parents’ perception of their stress and increased fast food consumption in their children, and a 2008 study identified a link between parenting stress and both overweight and underweight children. Yet a different study in 2008 found no association between child obesity and parenting stress. Research in 2011 found a relationship between children’s consumption of fruits and vegetables and their family’s overall functioning, as well as parental psychological stress and child behavior. Within a family, stress can come from financial strain (such as poverty or changes in employment or insurance), the family’s structure, and changes in physical or mental health of one or more family members.
Addressing the effects of stress on diet
Clinicians can help families manage the ways stress can lead to obesity by helping them with ideas for increasing fruit and vegetable intake, and planning ahead for on-the-go eating. For example, to ensure children get in their recommended five servings of fruit and vegetables each day, parents can serve fruit with breakfast every day and offer vegetables and/or fruit as a snack. Including side salads and a frozen vegetable with dinner will add two more servings, and children can munch on chopped veggies while parents prepare dinner. Offering fruit as a dessert provides another opportunity to bump up kids’ fruit and veggie intake, Dr. Parks said.
To manage the risk of unhealthy eating when out and about, Dr. Parks recommends planning ahead by packing a snack such as yogurt, fruit and vegetables, a sandwich or wrap, and water.
She described the “apple test” for determining whether someone is eating because of boredom or stress or because of actual hunger.“The next time you are thinking about a mini meal or second helpings at a meal, ask yourself, ‘Would I eat an apple instead?’ ” Dr. Parks said. “If the answer is no, then you probably are not really hungry and just need to get away from food.”
Other things people can consider when about to eat something are whether they are actually hungry and whether a distraction such as the television is contributing to distracted eating. “People may eat when they’re happy, sad, or bored,” Dr. Parks said, noting that outside messages such as commercials, advertisements, and passing restaurants may make someone feel like eating even if they don’t need sustenance at that moment. “Consider whether you really are hungry before you eat,” she said.
Avoiding emotional eating and using mindfulness
Additionally, parents and children can avoid emotional eating by skipping the food when they feel angry, tired, nervous, bored, or sad, instead choosing activities such as journaling, taking a walk, listening to music, reading a book, or taking deep breaths while thinking pleasant thoughts. It’s only time to eat if you physically feel hungry, your stomach is rumbling, you are not craving some specific sweet or salty food, or it’s a meal or snack time (or at least 2.5-4 hours since the last time you ate).
Dr. Parks also reviewed ways that mindfulness may help reduce the risk of obesity by reducing stress, enhancing a person’s ability to regulate their everyday behaviors, and teaching individuals to accept discomfort. Another stress reduction strategy is repeated use of “4-7-8 breathing,” which begins with exhalation while the mouth is closed. Then, inhale through the nose for 4 seconds, hold the breath for 7 seconds and slowly exhale out the mouth for 8 seconds.
Reducing the risk of obesity from stress comes from learning to manage stress. Clinicians can play a role in helping both parents and children learn strategies to manage and cope with stress in the short term while developing resilience over the longer term and reducing the likelihood of poor eating and emotional eating.
Dr. Parks reported no disclosures.
SAN FRANCISCO – Obesity is a multifactorial problem, influenced by factors ranging from genetics to lifestyle to the environment. Yet stress can play an outsize role in obesity as well, Elizabeth Prout Parks, MD, said at the annual meeting of the American Academy of Pediatrics.
Although the calorie-in/calorie-out model of energy balance has driven much of the thought about obesity, it’s not that simple, suggested Dr. Parks, the medical director of the Healthy Weight Adolescent Bariatrics Program at the Children’s Hospital of Philadelphia. Physical activity accounts for an estimated 15%-30% of energy expenditure, and thermogenesis accounts for an estimated 10%. But the energy expenditure required for basal metabolism can range from 60% to 75%, a sufficiently wide range for significant variation across different individuals.
The psychosocial effects can lead to anxiety, depression, disordered eating behaviors such as emotional eating, a sedentary lifestyle, poor sleep, and low maintenance with self-care activities. Further, poor sleep on its own is additionally associated with childhood obesity. The combination of these physiologic and psychosocial effects can increase the risk of metabolic syndrome, type 2 diabetes, and cardiovascular disease or events. While acute stress and chronic stress follow similar pathways in the brain, it’s chronic stress that carries the greater risk of behavioral and physical conditions.
Measuring and understanding child and parental stress
Several clinical assessments can measure stress in children, including the Daily Hassles Scale, which looks at everyday interactions in the environment and factors such as children’s school, family, neighborhood, peers, and lack of resources. The Multidimensional Life Events Rating Questionnaire and Adolescent Stress Questionnaire both are more appropriate for middle school and older adolescents.
In children, the primary biologic indicators of stress are cortisol levels, heart rate, and blood pressure, but it is perceived stress that has been most clearly linked to emotional eating and other disordered eating behaviors, Dr. Parks said. One 2008 study found perceived stress to be associated with emotional eating among middle school students both with and without obesity. A high level of perceived stress in adolescents was associated with a greater waist circumference and body mass index in a 2009 study.
The findings are somewhat more mixed, however, when it comes to parental stress and child weight. A 2012 study identified a link between parents’ perception of their stress and increased fast food consumption in their children, and a 2008 study identified a link between parenting stress and both overweight and underweight children. Yet a different study in 2008 found no association between child obesity and parenting stress. Research in 2011 found a relationship between children’s consumption of fruits and vegetables and their family’s overall functioning, as well as parental psychological stress and child behavior. Within a family, stress can come from financial strain (such as poverty or changes in employment or insurance), the family’s structure, and changes in physical or mental health of one or more family members.
Addressing the effects of stress on diet
Clinicians can help families manage the ways stress can lead to obesity by helping them with ideas for increasing fruit and vegetable intake, and planning ahead for on-the-go eating. For example, to ensure children get in their recommended five servings of fruit and vegetables each day, parents can serve fruit with breakfast every day and offer vegetables and/or fruit as a snack. Including side salads and a frozen vegetable with dinner will add two more servings, and children can munch on chopped veggies while parents prepare dinner. Offering fruit as a dessert provides another opportunity to bump up kids’ fruit and veggie intake, Dr. Parks said.
To manage the risk of unhealthy eating when out and about, Dr. Parks recommends planning ahead by packing a snack such as yogurt, fruit and vegetables, a sandwich or wrap, and water.
She described the “apple test” for determining whether someone is eating because of boredom or stress or because of actual hunger.“The next time you are thinking about a mini meal or second helpings at a meal, ask yourself, ‘Would I eat an apple instead?’ ” Dr. Parks said. “If the answer is no, then you probably are not really hungry and just need to get away from food.”
Other things people can consider when about to eat something are whether they are actually hungry and whether a distraction such as the television is contributing to distracted eating. “People may eat when they’re happy, sad, or bored,” Dr. Parks said, noting that outside messages such as commercials, advertisements, and passing restaurants may make someone feel like eating even if they don’t need sustenance at that moment. “Consider whether you really are hungry before you eat,” she said.
Avoiding emotional eating and using mindfulness
Additionally, parents and children can avoid emotional eating by skipping the food when they feel angry, tired, nervous, bored, or sad, instead choosing activities such as journaling, taking a walk, listening to music, reading a book, or taking deep breaths while thinking pleasant thoughts. It’s only time to eat if you physically feel hungry, your stomach is rumbling, you are not craving some specific sweet or salty food, or it’s a meal or snack time (or at least 2.5-4 hours since the last time you ate).
Dr. Parks also reviewed ways that mindfulness may help reduce the risk of obesity by reducing stress, enhancing a person’s ability to regulate their everyday behaviors, and teaching individuals to accept discomfort. Another stress reduction strategy is repeated use of “4-7-8 breathing,” which begins with exhalation while the mouth is closed. Then, inhale through the nose for 4 seconds, hold the breath for 7 seconds and slowly exhale out the mouth for 8 seconds.
Reducing the risk of obesity from stress comes from learning to manage stress. Clinicians can play a role in helping both parents and children learn strategies to manage and cope with stress in the short term while developing resilience over the longer term and reducing the likelihood of poor eating and emotional eating.
Dr. Parks reported no disclosures.
Recognizing, addressing giftedness can be challenging
SAN FRANCISCO – Gifted children are far too commonly misunderstood, mislabeled, and misdiagnosed, leading to a mismatch between their needs and others’ perceptions of their needs, Dan Peters, PhD, a licensed psychologist and executive director of the Summit Center in the greater San Francisco and Los Angeles areas, explained at the annual meeting of the American Academy of Pediatrics.
Too often, one or more of these children’s health, developmental, social-emotional or learning needs are overlooked, or they receive an inappropriate mental health, developmental and/or learning disorder diagnosis. In fact, many of the risk factors for giftedness resemble those of other conditions: underachievement, difficulties with peers, social isolation, power struggles, perfectionism, anxiety, and depression.
Further, those who are culturally or linguistically diverse may not be recognized if a non-English first language obscures their performance ability or their socioeconomic status or lack of resources and enrichment opportunities leads them to be overlooked. It’s therefore important that practitioners understand what giftedness actually is and the characteristics gifted children might exhibit.
Understanding giftedness
A simple definition of giftedness is demonstrating a performance or the capacity for performance that significantly exceeds age or grade-level expectations, according to one school district’s gifted and talented education program.
A more involved description provided by the Columbus Group in 1991 defines giftedness as an “asynchronous development in which advanced cognitive abilities and heightened intensity combine to create inner experiences and awareness that are qualitatively different from the norm.” This asynchrony increases with higher intellectual capacity, they wrote. “The uniqueness of the gifted renders them vulnerable and requires modifications in parenting, teaching, and counseling in order for them to develop optimally.”
The level of a child’s giftedness makes a difference in their needs as well; these levels include advanced learners (IQ of 120-129), moderately gifted (130-144), highly gifted (145-159), exceptionally gifted (160-179), and profoundly gifted (180 and greater). Different spheres of giftedness can include intellectual ability, creative or productive thinking, leadership ability, and visual or performing arts. Consider the list of common characteristics of gifted children that Dr. Peters provided:
- Rapid learners.
- Strong memory.
- Large vocabulary.
- Advanced comprehension of nuances.
- Largely self-taught.
- Unusual emotional depth.
- Abstract/complex/logical/insightful thinking.
- Idealism and a sense of justice.
- Intense feelings and reactions.
- Highly sensitive.
- Long attention span and persistence.
- Preoccupied with own thoughts.
- Impatient with self and others’ inabilities and slowness.
- Asks probing questions (able to go beyond what is taught).
- Wide range of interests.
- Highly developed curiosity.
- Interest in experimenting and doing things differently.
- Divergent thinking.
- Keen and unusual sense of humor.
Dr. Peters cited Kazimierz Dabrowski, MD, PhD, a Polish psychiatrist of the mid-20th century, as explaining the sensitivity and intensity experienced by many gifted individuals in terms of overexcitabilities – a “greater capacity to be stimulated by and respond to external and internal stimuli.”
“Overexcitability permeates a gifted person’s existence and gives energy to their intelligence, talents, and personality,” Dr. Peters explained of Dabrowski’s ideas. This enhancement manifests in psychomotor terms as a strong drive, a lot of energy or movement, or extended bouts of activity. Intellectually, gifted children have an “insatiable curiosity, and voracious appetite and capacity for intellectual effort and stimulation,” Dr. Peters said. They may have heightened sensual experience in seeing, smelling, tasting, touching, or hearing, and they have an active imaginary and fantasy life. They also exhibit a capacity for great emotional depth and empathy – they deeply feel their own and others’ emotions.
How giftedness can be misdiagnosed
It is the combination of these very characteristics that can lead gifted children to receive an inappropriate mental or developmental diagnosis instead of being recognized as gifted.
“By current estimates, at any given time, approximately 11%-20% of children in the United States have a behavioral or emotional disorder as defined in the DSM-5,” Dr. Peters cited. Further, one study found that diagnoses of attention-deficit/hyperactivity disorder have increased 66% between 2000 and 2010, with 90% of those children taking psychostimulant medications – yet a study in the Journal of Health Economics estimated that one in five children diagnosed with ADHD are probably misdiagnosed and are receiving those medications.
Other incorrect diagnoses besides ADHD that gifted youth may commonly receive include anger diagnoses, ideational or anxiety disorders, developmental and personality disorders, mood disorders, and learning disorders.
Twice exceptionalism (2e)
Even more challenging are twice exceptional children, or 2e, those who are both gifted and have a learning or emotional disability or challenge. Common dual diagnoses in gifted children include anxiety disorders, depression (or existential depression), sleep disorders (such as nightmares, night terrors, or sleep walking), allergies, asthma, ADHD, oppositional-defiant disorder, obsessive-compulsive personality disorder, autism spectrum disorder, nonverbal learning disability, social/pragmatic communication disorder, and learning disorders such as dyslexia, dyscalculia, central auditory processing disorder, or sensory-motor integration disorder.
“It’s very complex. What happens is, a lot of people think you’re either gifted or not,” Dr. Peters said. “In the classroom, sometimes the advanced ability overshadows the weakness and so we get a lot of readers with an IQ of 130-150 and reading at the 50% percentile, and everyone says they’re fine, but they’re dyslexic.”
Other times, the weakness overshadows the strength, and sometimes they’re right in the middle where neither their giftedness nor their disability is recognized or addressed, Peters said. 2e children are very difficult to diagnose but also at higher risk for difficulties if one or both (or more) of their diagnoses are missed.
Maximizing gifted children’s developmental potential
Pediatricians have an opportunity to support gifted children by recognizing and accepting them for who they are, while also acknowledging that they want to feel “normal,” and therefore need extra reassurance and support from adults. Pediatricians should seek information about giftedness and 2e children from state and national gifted organizations, and, in the office, frame conversations with families and children’s differential diagnoses in terms of a child’s giftedness. If a pediatrician is themself gifted, they may be “a supportive and kindred spirit” to the child, Dr. Peters said.
In daily life, as well, gifted children need to be accepted for who they are, provided opportunities to be with their intellectual and academic peers, and provided challenges in their areas of strength, interests, or passions. Parents and teachers should follow their lead in learning: Keep up the pace for those who want to learn fast, and go deeper for those who want slower, more in-depth learning. Adults also need to understand their intensities and sensitivities and lead with their strengths in discussions.
Dr. Peters reported no disclosures.
SAN FRANCISCO – Gifted children are far too commonly misunderstood, mislabeled, and misdiagnosed, leading to a mismatch between their needs and others’ perceptions of their needs, Dan Peters, PhD, a licensed psychologist and executive director of the Summit Center in the greater San Francisco and Los Angeles areas, explained at the annual meeting of the American Academy of Pediatrics.
Too often, one or more of these children’s health, developmental, social-emotional or learning needs are overlooked, or they receive an inappropriate mental health, developmental and/or learning disorder diagnosis. In fact, many of the risk factors for giftedness resemble those of other conditions: underachievement, difficulties with peers, social isolation, power struggles, perfectionism, anxiety, and depression.
Further, those who are culturally or linguistically diverse may not be recognized if a non-English first language obscures their performance ability or their socioeconomic status or lack of resources and enrichment opportunities leads them to be overlooked. It’s therefore important that practitioners understand what giftedness actually is and the characteristics gifted children might exhibit.
Understanding giftedness
A simple definition of giftedness is demonstrating a performance or the capacity for performance that significantly exceeds age or grade-level expectations, according to one school district’s gifted and talented education program.
A more involved description provided by the Columbus Group in 1991 defines giftedness as an “asynchronous development in which advanced cognitive abilities and heightened intensity combine to create inner experiences and awareness that are qualitatively different from the norm.” This asynchrony increases with higher intellectual capacity, they wrote. “The uniqueness of the gifted renders them vulnerable and requires modifications in parenting, teaching, and counseling in order for them to develop optimally.”
The level of a child’s giftedness makes a difference in their needs as well; these levels include advanced learners (IQ of 120-129), moderately gifted (130-144), highly gifted (145-159), exceptionally gifted (160-179), and profoundly gifted (180 and greater). Different spheres of giftedness can include intellectual ability, creative or productive thinking, leadership ability, and visual or performing arts. Consider the list of common characteristics of gifted children that Dr. Peters provided:
- Rapid learners.
- Strong memory.
- Large vocabulary.
- Advanced comprehension of nuances.
- Largely self-taught.
- Unusual emotional depth.
- Abstract/complex/logical/insightful thinking.
- Idealism and a sense of justice.
- Intense feelings and reactions.
- Highly sensitive.
- Long attention span and persistence.
- Preoccupied with own thoughts.
- Impatient with self and others’ inabilities and slowness.
- Asks probing questions (able to go beyond what is taught).
- Wide range of interests.
- Highly developed curiosity.
- Interest in experimenting and doing things differently.
- Divergent thinking.
- Keen and unusual sense of humor.
Dr. Peters cited Kazimierz Dabrowski, MD, PhD, a Polish psychiatrist of the mid-20th century, as explaining the sensitivity and intensity experienced by many gifted individuals in terms of overexcitabilities – a “greater capacity to be stimulated by and respond to external and internal stimuli.”
“Overexcitability permeates a gifted person’s existence and gives energy to their intelligence, talents, and personality,” Dr. Peters explained of Dabrowski’s ideas. This enhancement manifests in psychomotor terms as a strong drive, a lot of energy or movement, or extended bouts of activity. Intellectually, gifted children have an “insatiable curiosity, and voracious appetite and capacity for intellectual effort and stimulation,” Dr. Peters said. They may have heightened sensual experience in seeing, smelling, tasting, touching, or hearing, and they have an active imaginary and fantasy life. They also exhibit a capacity for great emotional depth and empathy – they deeply feel their own and others’ emotions.
How giftedness can be misdiagnosed
It is the combination of these very characteristics that can lead gifted children to receive an inappropriate mental or developmental diagnosis instead of being recognized as gifted.
“By current estimates, at any given time, approximately 11%-20% of children in the United States have a behavioral or emotional disorder as defined in the DSM-5,” Dr. Peters cited. Further, one study found that diagnoses of attention-deficit/hyperactivity disorder have increased 66% between 2000 and 2010, with 90% of those children taking psychostimulant medications – yet a study in the Journal of Health Economics estimated that one in five children diagnosed with ADHD are probably misdiagnosed and are receiving those medications.
Other incorrect diagnoses besides ADHD that gifted youth may commonly receive include anger diagnoses, ideational or anxiety disorders, developmental and personality disorders, mood disorders, and learning disorders.
Twice exceptionalism (2e)
Even more challenging are twice exceptional children, or 2e, those who are both gifted and have a learning or emotional disability or challenge. Common dual diagnoses in gifted children include anxiety disorders, depression (or existential depression), sleep disorders (such as nightmares, night terrors, or sleep walking), allergies, asthma, ADHD, oppositional-defiant disorder, obsessive-compulsive personality disorder, autism spectrum disorder, nonverbal learning disability, social/pragmatic communication disorder, and learning disorders such as dyslexia, dyscalculia, central auditory processing disorder, or sensory-motor integration disorder.
“It’s very complex. What happens is, a lot of people think you’re either gifted or not,” Dr. Peters said. “In the classroom, sometimes the advanced ability overshadows the weakness and so we get a lot of readers with an IQ of 130-150 and reading at the 50% percentile, and everyone says they’re fine, but they’re dyslexic.”
Other times, the weakness overshadows the strength, and sometimes they’re right in the middle where neither their giftedness nor their disability is recognized or addressed, Peters said. 2e children are very difficult to diagnose but also at higher risk for difficulties if one or both (or more) of their diagnoses are missed.
Maximizing gifted children’s developmental potential
Pediatricians have an opportunity to support gifted children by recognizing and accepting them for who they are, while also acknowledging that they want to feel “normal,” and therefore need extra reassurance and support from adults. Pediatricians should seek information about giftedness and 2e children from state and national gifted organizations, and, in the office, frame conversations with families and children’s differential diagnoses in terms of a child’s giftedness. If a pediatrician is themself gifted, they may be “a supportive and kindred spirit” to the child, Dr. Peters said.
In daily life, as well, gifted children need to be accepted for who they are, provided opportunities to be with their intellectual and academic peers, and provided challenges in their areas of strength, interests, or passions. Parents and teachers should follow their lead in learning: Keep up the pace for those who want to learn fast, and go deeper for those who want slower, more in-depth learning. Adults also need to understand their intensities and sensitivities and lead with their strengths in discussions.
Dr. Peters reported no disclosures.
SAN FRANCISCO – Gifted children are far too commonly misunderstood, mislabeled, and misdiagnosed, leading to a mismatch between their needs and others’ perceptions of their needs, Dan Peters, PhD, a licensed psychologist and executive director of the Summit Center in the greater San Francisco and Los Angeles areas, explained at the annual meeting of the American Academy of Pediatrics.
Too often, one or more of these children’s health, developmental, social-emotional or learning needs are overlooked, or they receive an inappropriate mental health, developmental and/or learning disorder diagnosis. In fact, many of the risk factors for giftedness resemble those of other conditions: underachievement, difficulties with peers, social isolation, power struggles, perfectionism, anxiety, and depression.
Further, those who are culturally or linguistically diverse may not be recognized if a non-English first language obscures their performance ability or their socioeconomic status or lack of resources and enrichment opportunities leads them to be overlooked. It’s therefore important that practitioners understand what giftedness actually is and the characteristics gifted children might exhibit.
Understanding giftedness
A simple definition of giftedness is demonstrating a performance or the capacity for performance that significantly exceeds age or grade-level expectations, according to one school district’s gifted and talented education program.
A more involved description provided by the Columbus Group in 1991 defines giftedness as an “asynchronous development in which advanced cognitive abilities and heightened intensity combine to create inner experiences and awareness that are qualitatively different from the norm.” This asynchrony increases with higher intellectual capacity, they wrote. “The uniqueness of the gifted renders them vulnerable and requires modifications in parenting, teaching, and counseling in order for them to develop optimally.”
The level of a child’s giftedness makes a difference in their needs as well; these levels include advanced learners (IQ of 120-129), moderately gifted (130-144), highly gifted (145-159), exceptionally gifted (160-179), and profoundly gifted (180 and greater). Different spheres of giftedness can include intellectual ability, creative or productive thinking, leadership ability, and visual or performing arts. Consider the list of common characteristics of gifted children that Dr. Peters provided:
- Rapid learners.
- Strong memory.
- Large vocabulary.
- Advanced comprehension of nuances.
- Largely self-taught.
- Unusual emotional depth.
- Abstract/complex/logical/insightful thinking.
- Idealism and a sense of justice.
- Intense feelings and reactions.
- Highly sensitive.
- Long attention span and persistence.
- Preoccupied with own thoughts.
- Impatient with self and others’ inabilities and slowness.
- Asks probing questions (able to go beyond what is taught).
- Wide range of interests.
- Highly developed curiosity.
- Interest in experimenting and doing things differently.
- Divergent thinking.
- Keen and unusual sense of humor.
Dr. Peters cited Kazimierz Dabrowski, MD, PhD, a Polish psychiatrist of the mid-20th century, as explaining the sensitivity and intensity experienced by many gifted individuals in terms of overexcitabilities – a “greater capacity to be stimulated by and respond to external and internal stimuli.”
“Overexcitability permeates a gifted person’s existence and gives energy to their intelligence, talents, and personality,” Dr. Peters explained of Dabrowski’s ideas. This enhancement manifests in psychomotor terms as a strong drive, a lot of energy or movement, or extended bouts of activity. Intellectually, gifted children have an “insatiable curiosity, and voracious appetite and capacity for intellectual effort and stimulation,” Dr. Peters said. They may have heightened sensual experience in seeing, smelling, tasting, touching, or hearing, and they have an active imaginary and fantasy life. They also exhibit a capacity for great emotional depth and empathy – they deeply feel their own and others’ emotions.
How giftedness can be misdiagnosed
It is the combination of these very characteristics that can lead gifted children to receive an inappropriate mental or developmental diagnosis instead of being recognized as gifted.
“By current estimates, at any given time, approximately 11%-20% of children in the United States have a behavioral or emotional disorder as defined in the DSM-5,” Dr. Peters cited. Further, one study found that diagnoses of attention-deficit/hyperactivity disorder have increased 66% between 2000 and 2010, with 90% of those children taking psychostimulant medications – yet a study in the Journal of Health Economics estimated that one in five children diagnosed with ADHD are probably misdiagnosed and are receiving those medications.
Other incorrect diagnoses besides ADHD that gifted youth may commonly receive include anger diagnoses, ideational or anxiety disorders, developmental and personality disorders, mood disorders, and learning disorders.
Twice exceptionalism (2e)
Even more challenging are twice exceptional children, or 2e, those who are both gifted and have a learning or emotional disability or challenge. Common dual diagnoses in gifted children include anxiety disorders, depression (or existential depression), sleep disorders (such as nightmares, night terrors, or sleep walking), allergies, asthma, ADHD, oppositional-defiant disorder, obsessive-compulsive personality disorder, autism spectrum disorder, nonverbal learning disability, social/pragmatic communication disorder, and learning disorders such as dyslexia, dyscalculia, central auditory processing disorder, or sensory-motor integration disorder.
“It’s very complex. What happens is, a lot of people think you’re either gifted or not,” Dr. Peters said. “In the classroom, sometimes the advanced ability overshadows the weakness and so we get a lot of readers with an IQ of 130-150 and reading at the 50% percentile, and everyone says they’re fine, but they’re dyslexic.”
Other times, the weakness overshadows the strength, and sometimes they’re right in the middle where neither their giftedness nor their disability is recognized or addressed, Peters said. 2e children are very difficult to diagnose but also at higher risk for difficulties if one or both (or more) of their diagnoses are missed.
Maximizing gifted children’s developmental potential
Pediatricians have an opportunity to support gifted children by recognizing and accepting them for who they are, while also acknowledging that they want to feel “normal,” and therefore need extra reassurance and support from adults. Pediatricians should seek information about giftedness and 2e children from state and national gifted organizations, and, in the office, frame conversations with families and children’s differential diagnoses in terms of a child’s giftedness. If a pediatrician is themself gifted, they may be “a supportive and kindred spirit” to the child, Dr. Peters said.
In daily life, as well, gifted children need to be accepted for who they are, provided opportunities to be with their intellectual and academic peers, and provided challenges in their areas of strength, interests, or passions. Parents and teachers should follow their lead in learning: Keep up the pace for those who want to learn fast, and go deeper for those who want slower, more in-depth learning. Adults also need to understand their intensities and sensitivities and lead with their strengths in discussions.
Dr. Peters reported no disclosures.
EXPERT ANALYSIS FROM AAP 16
Distinguishing early puberty from pathology
SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?
The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.
“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.
Normal puberty
Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).
Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.
Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).
But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.
This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.
When to be concerned
Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.
Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.
With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.
Without proper testing, however, a physician might as well be guessing at the cause of the early development.
“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.
If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.
“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.
Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.
Dr. Styne reported that he had no relevant financial disclosures.
SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?
The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.
“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.
Normal puberty
Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).
Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.
Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).
But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.
This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.
When to be concerned
Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.
Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.
With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.
Without proper testing, however, a physician might as well be guessing at the cause of the early development.
“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.
If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.
“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.
Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.
Dr. Styne reported that he had no relevant financial disclosures.
SAN FRANCISCO – You have a female patient come in with apparent breast development but no dark pubic hair – and she’s 7 years old. Is it a case of early puberty, a warning sign to test for possible conditions, or an unremarkable departure from typical development that does not require any intervention?
The answer to situations such as these varies, explained Dennis Styne, MD, professor of pediatrics, and Yocha Dehe Endowed Chair in Pediatric Endocrinology, at the University of California, Davis.
“We don’t know why puberty begins when it does even though we know many of the controlling factors,” Dr. Styne said at the annual meeting of the American Academy of Pediatrics, but it’s important to understand when “early” is so early that you should order lab evaluations, as opposed to simply letting an outlier’s body development continue as it would.
Normal puberty
Dr. Styne reviewed the Tanner stages of puberty for girls’ breast and pubic hair development and boys’ genital and pubic hair development, noting that the classic lower ages of pubertal onset are age 8 years in girls and 9 years in boys. Yet the normal curve may actually start earlier than those ages for U.S. girls, he noted. He shared the results of a 1997 Pediatrics study of 17,077 girls, in which by age 7 years, more than a quarter of black girls (27%) and 7% of white girls had reached at least Tanner stage 2. At age 8, nearly half of black girls (48%) and 15% of white girls had reached at least stage 2 (Pediatrics. 1997 Apr;99[4]:505-12).
Further, breast development, menarche, and early pubic hair development (pubarche) all occur earlier with increased body mass index, which has been increasing among children overall. Another study identified earlier breast development without increased body mass index: Stage 2 development occurred an average 10 months earlier in girls in 2006 than in 1991, regardless of BMI, even though no difference in LH or FSH levels occurred at these ages and estradiol level was even lower. The authors of that Danish study concluded some other factors besides pubertal hormones had to account for the increasingly earlier breast development in girls. Endocrine-disrupting chemicals are a possible cause.
Similarly, puberty in boys is occurring a bit earlier, but less dramatically so: A 2012 study of 4,131 boys found that 5.75% of black boys, 0.54% of white boys, and 1.16% of Hispanic boys had stage 2 pubic hair development by age 6. Meanwhile, 10.9% of black boys, 2% of white boys, and 2.5% of Hispanic boys began puberty with stage 2 pubic hair development at age 8 (Pediatrics 2012;130:e1058-68).
But the boys differ in one key way from the girls: Boys with obesity tend to begin puberty later than those with normal or overweight BMIs, even though overweight boys begin puberty earlier than those with normal weights.
This leaves age 8 years as a normal age to begin puberty in boys but leaves the ages for girls’ start less certain – perhaps 7 years for white girls and 6 years for black girls – but still controversial.
When to be concerned
Various neurotransmitters in the central nervous system control puberty by suppression during childhood, until a trigger for onset occurs that remains mysterious. But gene mutations, such as MKRN3 in girls, as well as brain tumors or trauma, can remove that disinhibition, prompting further investigation. Brain tumors causing precocious puberty are more common in boys than girls.
Rapid growth and bone age advancement, elevated serum levels of sex steroids, and breast development in girls could all indicate precocious puberty. If these signs are accompanied by a rise in gonadotropin values to pubertal levels, early central precocious puberty, which follows the normal course of puberty except that it is earlier, is likely.
With both sex steroids and gonadotropins in the pubertal range, a GnRH agonist could be used to control gonadal steroid production and stop bone age advancement, allowing children to reach a greater adult height if started before age 6 years. If the early puberty is slowly progressing and more subtle, no treatment at all may be necessary if there are no pathologic findings.
Without proper testing, however, a physician might as well be guessing at the cause of the early development.
“You need a highly sensitive assay, and you need pediatric standards, so you’ll probably have to send blood samples out to a national laboratory,” Dr. Styne said.
If sex hormones are being secreted at a higher rate with suppression of gonadotropins, the source is most likely autonomous secretion by the gonads or the adrenal glands.
“If you see a boy with precious puberty, with testes that are not as big as they should be for the pubertal testosterone levels, it could be that the source is the adrenal glands,” Dr. Styne said.
Meanwhile, about 75% of boys will have gynecomastia to some degree during puberty, likely because of a subtle early pubertal imbalance between estrogen and testosterone, Dr. Styne said. The condition usually regresses, but “if it doesn’t regress, there’s a chance scar tissue will develop and remain, leading to the need for surgical correction. Klinefelter syndrome must be ruled out in cases of gynecomastia or, alternatively, rarer cases of disorders of sexual development.
Dr. Styne reported that he had no relevant financial disclosures.
AT AAP 16
Confront youth opioid misuse head on
SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.
Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).
“Silence is deadly,” she said. “What’s going to stop this problem? Not being silent, not being quiet about it.
“I hear a lot of people still saying, ‘I don’t have enough resources; I don’t know where to send them to; what am I going to do?’ ” she said. “There are a lot of illnesses that we look for, that we get the diagnosis for, and the outcome may be supportive or may be a difficult conversation with the family, but just because at this point resources aren’t what we want them to be does not mean not to look.”
Understanding the problem
Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.
“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).
The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.
Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).
What pediatricians can do
“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”
The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.
She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”
“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”
At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.
Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”
Dr. Gonzalez had no disclosures.
SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.
Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).
“Silence is deadly,” she said. “What’s going to stop this problem? Not being silent, not being quiet about it.
“I hear a lot of people still saying, ‘I don’t have enough resources; I don’t know where to send them to; what am I going to do?’ ” she said. “There are a lot of illnesses that we look for, that we get the diagnosis for, and the outcome may be supportive or may be a difficult conversation with the family, but just because at this point resources aren’t what we want them to be does not mean not to look.”
Understanding the problem
Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.
“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).
The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.
Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).
What pediatricians can do
“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”
The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.
She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”
“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”
At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.
Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”
Dr. Gonzalez had no disclosures.
SAN FRANCISCO – Clinicians treating children should seek out and advocate for resources needed to treat opioid addiction rather than shying away from doing so because of a feeling of helplessness, Pamela Gonzalez, MD, said at the annual meeting of the American Academy of Pediatrics.
Opioid poisonings have nearly doubled among children and adolescents over the past decade and a half, a retrospective analysis of 13,052 national hospital discharge records found. Pediatric hospitalizations for opioid poisonings increased nearly twofold from 1997 to 2012. That is, the annual incidence of hospitalizations for opioid poisonings per 100,000 children aged 1-19 years rose from 1.40 to 3.71, an increase of 165% (P less than.001) (JAMA Pediatr. 2016 Oct 31. doi: 10.1001/jamapediatrics.2016.2154).
“Silence is deadly,” she said. “What’s going to stop this problem? Not being silent, not being quiet about it.
“I hear a lot of people still saying, ‘I don’t have enough resources; I don’t know where to send them to; what am I going to do?’ ” she said. “There are a lot of illnesses that we look for, that we get the diagnosis for, and the outcome may be supportive or may be a difficult conversation with the family, but just because at this point resources aren’t what we want them to be does not mean not to look.”
Understanding the problem
Dr. Gonzalez pointed out how accessible opioids are for children and adolescents. Most youth access prescription opioids for misuse or nonmedical use from legitimate prescriptions diverted from an intended use. The largest source of diverted medication is prescribing to adults, and the problem is worsened by the fact that some youth have an enhanced vulnerability to misuse or nonmedical use of opioids.
“Therapeutic use is still exposure,” she explained, citing a one-third increased risk of nonmedical use during ages 19-23 among youth who were prescribed opioids before 12th grade. Those prescribed opioids before their senior year also have a 2.7 times greater risk of using the opioids recreationally to get high (Pediatrics. 2015 Nov;136[5]:e1169-77).
The problem is exacerbated by the fact that patients at higher risk for substance use disorder also happen to be more likely to be prescribed chronic opioid therapy. Children and teens with preexisting psychiatric conditions have a 2.4 times greater risk of receiving long-term opioids than not receiving opioids at all, and they are 1.8 times more likely to receive long-term opioids than some opioids.
Prescription opioids have begun to replace heroin as the starting point on the path toward opioid use disorder, Dr. Gonzalez pointed out. A study in 2014 found that more than 80% of individuals who began taking opioids in the 1960s started with heroin, whereas 75% of users in the 2000s began their addiction with prescription opioids (JAMA Psychiatry. 2014;71[7]:821-6).
What pediatricians can do
“When our primary and secondary prevention efforts don’t work, we’re going to need to look at treatment options” for opioid use disorder, Dr. Gonzalez said. “Kids do better on some kind of medication than not.”
The most effective medications are buprenorphine and injectable naltrexone, but these are frequently unavailable to the adolescents who need them, she said. One way to begin saving lives is to increase the number of pediatricians who are trained and approved to provide buprenorphine to youth. Physicians can seek a waiver to be able to prescribe buprenorphine to youth with opioid use disorder and learn about treatment with naltrexone by taking an 8-hour online course that is free to AAP members at www.aap.org/mat.
She acknowledged that more resources are needed to address the problem of opioid misuse, something the surgeon general has made a priority as well, but that resource deficit should not be an excuse not to take action. Federal funding is available for states to treat opioid addiction, but some states, such as Minnesota, where Dr. Gonzalez works, may not qualify if there is “not enough of a problem.”
“If every state can’t get it to help with their treatment and prevention resources, that’s not enough money earmarked for it,” she said, “but we can advocate for it.”
At the same time, pediatricians can work toward prevention by screening for mental health symptoms and for substance use – two separate screenings – at every pediatric visit starting no later than age 11 years and at any visit where opioids are being prescribed. Further, before prescribing opioids to youth, doctors should weigh the need to reduce pain against the risks of future addiction to determine if opioids are really the best option for that patient.
Dr. Gonzalez concluded her plenary speech with a plea to her colleagues: “It begins with one pill, but the end begins with us. Every kid matters. We’re not going to save them all. We have to start with one kid at a time. We’re not going to save everybody, but one life for everybody in this room is a lot of kids. Help me save one life today.”
Dr. Gonzalez had no disclosures.
EXPERT ANALYSIS FROM AAP 16
Challenges of influenza, measles, pertussis guide outbreak management
SAN FRANCISCO – Recent U.S. outbreaks of pertussis, influenza, and measles have revealed shifts in the diseases’ epidemiology, shifts that pose new prevention and management challenges, explained Yvonne Maldonado, MD, at the annual meeting of the American Academy of Pediatrics.
Routine immunizations prevent 33,000 child deaths a year in the United States, having reduced vaccine-preventable diseases by more than 90%, but outbreaks still occur, she said. The recent announcement that measles was eliminated from the Western Hemisphere, for example, doesn’t mean we won’t see cases, said Dr. Maldonado, vice chair of the AAP Committee on Infectious Diseases and chief of the division of pediatric infectious diseases at Stanford (Calif.) University.
Dr. Maldonado reviewed specific challenges for flu, pertussis, and measles.
Influenza
The biggest challenges with controlling influenza are the failure to vaccinate children and the variable circulating strains each season, which can impact the performance of that year’s vaccine. Those changing strains and other factors also mean that the populations most at risk for serious complications also vary each season.
The two new mechanisms of change in influenza strains are antigenic drift and antigenic shift. Antigenic drift involves mutations that occur during repeated replications in the RNA strains of the virus, shifting its configuration over time so that it may not respond to the same antigens that the original strain responded to. Antigenic shift, however, is responsible for the periodic pandemics, when a complete genetic reassortment abruptly occurs because a new major protein from a strain jumps from an animal population into the human population, forming a new hybrid strain in humans.
Pertussis
Unlike flu, pertussis did become very uncommon because of widespread vaccination up until the early 2000s. But rates have begun to climb again, largely because of problems with the vaccine over time. Until the 1990s, the DTP vaccine, which includes a whole pertussis bacterium, was highly effective at preventing pertussis but could cause febrile seizures, an adverse event that proved too intolerable for many families.
It was replaced with the acellular pertussis vaccine DTaP, but research in the past 5-10 years has revealed that the effectiveness of DTaP and Tdap vaccines wanes much more quickly than anticipated. Subsequently, pertussis rates have almost continuously climbed from the early 2000s through the present, reaching an incidence of more than 100 cases per 100,000 among children younger than 1 year.
One of the biggest challenges now is improving vaccination rates among pregnant women, who were recommended in 2015 to get the Tdap vaccine in every pregnancy so that the newborn would have some passively acquired protection during the first few months of life.
Ongoing outbreaks then become exacerbated by pockets of lower vaccination rates among children in general.
Measles
The only chink in the armor against measles is failure to vaccinate against it, Dr. Maldonado said. Though the disease was eliminated from the United States in 2000, measles cases peaked recently in 2014, when 31 outbreaks involving 667 cases occurred because of imported cases from the Philippines. The next year, 60% of the 189 cases in 2015 resulted from the multistate measles outbreak starting at Disneyland in California.
Most of the individuals in both those years’ outbreaks were not vaccinated or had an unknown vaccination status. Of the 110 individuals with measles in California from the Disneyland outbreak, 45% were not immunized. Twelve were too young for vaccination, but 37 were eligible to have been vaccinated, and 67% of these were not vaccinated because of personal beliefs.
Vaccination rates for measles must be considerably higher, around 92%-94% of the population, to prevent outbreaks than for most other diseases, because the virus is so incredibly contagious.
“Measles is so infectious because it can exist in tiny microdroplets less than 5 mcg that can sit in the air up to 2 hours,” Dr. Maldonado explained. Yet only 92.6% of kindergartners had had both their MMR doses in 2014, compared with the peak of 97% between 2002 to 2007.
When children across all ages who have not received both doses of the vaccine are taken into account, 12.5% of all U.S. children and adolescents are currently susceptible to measles – and a quarter of those aged 3 years and younger are, Maldonado said.
The keys to preventing measles are high national coverage rates, an aggressive public health response (because early diagnosis can limit transmission), and improved implementation of health care worker recommendations.
“We have to keep measles in mind whenever we see fevers and rashes,” Dr. Maldonado cautioned. “Unfortunately, we see fevers and rashes all the time, so what really helps is a history of international travel or a parent with international travel.”
For families planning overseas travel, parents are recommended to give their infants the MMR as young as 6 months. But that dose does not count toward the child’s two doses recommended by the Centers for Disease Control and Prevention schedule.
“It’s a very tough call with measles, because we never know when it might pop up,” Dr. Maldonado said. “Measles will be sporadic, but when it happens, it’s a really big deal. You basically have to reach out to your entire patient log for several days before the child came in.”
Managing suspected/confirmed outbreaks
To prepare for and manage suspected outbreaks of an infectious disease, Dr. Maldonado advised taking the following steps:
• Establish a plan for evaluating suspected or confirmed infectious disease outbreaks in your office setting.
• Identify and eliminate the source of the infection, such as providing a separate waiting room for coughing children.
• Prevent additional cases using screening questions at the front desk.
• Provide prompt and consistent ongoing evaluation to prevent or minimize transmission to others.
• Track disease trends and advice from the AAP, CDC, and local county public health officials and disease experts to engage in ongoing surveillance and communication.
• Identify the initial source and route of exposure to understand why an outbreak occurred and how to prevent similar ones in the future.
Dr. Maldonado reporting being a member of a data safety monitoring board for Pfizer.
SAN FRANCISCO – Recent U.S. outbreaks of pertussis, influenza, and measles have revealed shifts in the diseases’ epidemiology, shifts that pose new prevention and management challenges, explained Yvonne Maldonado, MD, at the annual meeting of the American Academy of Pediatrics.
Routine immunizations prevent 33,000 child deaths a year in the United States, having reduced vaccine-preventable diseases by more than 90%, but outbreaks still occur, she said. The recent announcement that measles was eliminated from the Western Hemisphere, for example, doesn’t mean we won’t see cases, said Dr. Maldonado, vice chair of the AAP Committee on Infectious Diseases and chief of the division of pediatric infectious diseases at Stanford (Calif.) University.
Dr. Maldonado reviewed specific challenges for flu, pertussis, and measles.
Influenza
The biggest challenges with controlling influenza are the failure to vaccinate children and the variable circulating strains each season, which can impact the performance of that year’s vaccine. Those changing strains and other factors also mean that the populations most at risk for serious complications also vary each season.
The two new mechanisms of change in influenza strains are antigenic drift and antigenic shift. Antigenic drift involves mutations that occur during repeated replications in the RNA strains of the virus, shifting its configuration over time so that it may not respond to the same antigens that the original strain responded to. Antigenic shift, however, is responsible for the periodic pandemics, when a complete genetic reassortment abruptly occurs because a new major protein from a strain jumps from an animal population into the human population, forming a new hybrid strain in humans.
Pertussis
Unlike flu, pertussis did become very uncommon because of widespread vaccination up until the early 2000s. But rates have begun to climb again, largely because of problems with the vaccine over time. Until the 1990s, the DTP vaccine, which includes a whole pertussis bacterium, was highly effective at preventing pertussis but could cause febrile seizures, an adverse event that proved too intolerable for many families.
It was replaced with the acellular pertussis vaccine DTaP, but research in the past 5-10 years has revealed that the effectiveness of DTaP and Tdap vaccines wanes much more quickly than anticipated. Subsequently, pertussis rates have almost continuously climbed from the early 2000s through the present, reaching an incidence of more than 100 cases per 100,000 among children younger than 1 year.
One of the biggest challenges now is improving vaccination rates among pregnant women, who were recommended in 2015 to get the Tdap vaccine in every pregnancy so that the newborn would have some passively acquired protection during the first few months of life.
Ongoing outbreaks then become exacerbated by pockets of lower vaccination rates among children in general.
Measles
The only chink in the armor against measles is failure to vaccinate against it, Dr. Maldonado said. Though the disease was eliminated from the United States in 2000, measles cases peaked recently in 2014, when 31 outbreaks involving 667 cases occurred because of imported cases from the Philippines. The next year, 60% of the 189 cases in 2015 resulted from the multistate measles outbreak starting at Disneyland in California.
Most of the individuals in both those years’ outbreaks were not vaccinated or had an unknown vaccination status. Of the 110 individuals with measles in California from the Disneyland outbreak, 45% were not immunized. Twelve were too young for vaccination, but 37 were eligible to have been vaccinated, and 67% of these were not vaccinated because of personal beliefs.
Vaccination rates for measles must be considerably higher, around 92%-94% of the population, to prevent outbreaks than for most other diseases, because the virus is so incredibly contagious.
“Measles is so infectious because it can exist in tiny microdroplets less than 5 mcg that can sit in the air up to 2 hours,” Dr. Maldonado explained. Yet only 92.6% of kindergartners had had both their MMR doses in 2014, compared with the peak of 97% between 2002 to 2007.
When children across all ages who have not received both doses of the vaccine are taken into account, 12.5% of all U.S. children and adolescents are currently susceptible to measles – and a quarter of those aged 3 years and younger are, Maldonado said.
The keys to preventing measles are high national coverage rates, an aggressive public health response (because early diagnosis can limit transmission), and improved implementation of health care worker recommendations.
“We have to keep measles in mind whenever we see fevers and rashes,” Dr. Maldonado cautioned. “Unfortunately, we see fevers and rashes all the time, so what really helps is a history of international travel or a parent with international travel.”
For families planning overseas travel, parents are recommended to give their infants the MMR as young as 6 months. But that dose does not count toward the child’s two doses recommended by the Centers for Disease Control and Prevention schedule.
“It’s a very tough call with measles, because we never know when it might pop up,” Dr. Maldonado said. “Measles will be sporadic, but when it happens, it’s a really big deal. You basically have to reach out to your entire patient log for several days before the child came in.”
Managing suspected/confirmed outbreaks
To prepare for and manage suspected outbreaks of an infectious disease, Dr. Maldonado advised taking the following steps:
• Establish a plan for evaluating suspected or confirmed infectious disease outbreaks in your office setting.
• Identify and eliminate the source of the infection, such as providing a separate waiting room for coughing children.
• Prevent additional cases using screening questions at the front desk.
• Provide prompt and consistent ongoing evaluation to prevent or minimize transmission to others.
• Track disease trends and advice from the AAP, CDC, and local county public health officials and disease experts to engage in ongoing surveillance and communication.
• Identify the initial source and route of exposure to understand why an outbreak occurred and how to prevent similar ones in the future.
Dr. Maldonado reporting being a member of a data safety monitoring board for Pfizer.
SAN FRANCISCO – Recent U.S. outbreaks of pertussis, influenza, and measles have revealed shifts in the diseases’ epidemiology, shifts that pose new prevention and management challenges, explained Yvonne Maldonado, MD, at the annual meeting of the American Academy of Pediatrics.
Routine immunizations prevent 33,000 child deaths a year in the United States, having reduced vaccine-preventable diseases by more than 90%, but outbreaks still occur, she said. The recent announcement that measles was eliminated from the Western Hemisphere, for example, doesn’t mean we won’t see cases, said Dr. Maldonado, vice chair of the AAP Committee on Infectious Diseases and chief of the division of pediatric infectious diseases at Stanford (Calif.) University.
Dr. Maldonado reviewed specific challenges for flu, pertussis, and measles.
Influenza
The biggest challenges with controlling influenza are the failure to vaccinate children and the variable circulating strains each season, which can impact the performance of that year’s vaccine. Those changing strains and other factors also mean that the populations most at risk for serious complications also vary each season.
The two new mechanisms of change in influenza strains are antigenic drift and antigenic shift. Antigenic drift involves mutations that occur during repeated replications in the RNA strains of the virus, shifting its configuration over time so that it may not respond to the same antigens that the original strain responded to. Antigenic shift, however, is responsible for the periodic pandemics, when a complete genetic reassortment abruptly occurs because a new major protein from a strain jumps from an animal population into the human population, forming a new hybrid strain in humans.
Pertussis
Unlike flu, pertussis did become very uncommon because of widespread vaccination up until the early 2000s. But rates have begun to climb again, largely because of problems with the vaccine over time. Until the 1990s, the DTP vaccine, which includes a whole pertussis bacterium, was highly effective at preventing pertussis but could cause febrile seizures, an adverse event that proved too intolerable for many families.
It was replaced with the acellular pertussis vaccine DTaP, but research in the past 5-10 years has revealed that the effectiveness of DTaP and Tdap vaccines wanes much more quickly than anticipated. Subsequently, pertussis rates have almost continuously climbed from the early 2000s through the present, reaching an incidence of more than 100 cases per 100,000 among children younger than 1 year.
One of the biggest challenges now is improving vaccination rates among pregnant women, who were recommended in 2015 to get the Tdap vaccine in every pregnancy so that the newborn would have some passively acquired protection during the first few months of life.
Ongoing outbreaks then become exacerbated by pockets of lower vaccination rates among children in general.
Measles
The only chink in the armor against measles is failure to vaccinate against it, Dr. Maldonado said. Though the disease was eliminated from the United States in 2000, measles cases peaked recently in 2014, when 31 outbreaks involving 667 cases occurred because of imported cases from the Philippines. The next year, 60% of the 189 cases in 2015 resulted from the multistate measles outbreak starting at Disneyland in California.
Most of the individuals in both those years’ outbreaks were not vaccinated or had an unknown vaccination status. Of the 110 individuals with measles in California from the Disneyland outbreak, 45% were not immunized. Twelve were too young for vaccination, but 37 were eligible to have been vaccinated, and 67% of these were not vaccinated because of personal beliefs.
Vaccination rates for measles must be considerably higher, around 92%-94% of the population, to prevent outbreaks than for most other diseases, because the virus is so incredibly contagious.
“Measles is so infectious because it can exist in tiny microdroplets less than 5 mcg that can sit in the air up to 2 hours,” Dr. Maldonado explained. Yet only 92.6% of kindergartners had had both their MMR doses in 2014, compared with the peak of 97% between 2002 to 2007.
When children across all ages who have not received both doses of the vaccine are taken into account, 12.5% of all U.S. children and adolescents are currently susceptible to measles – and a quarter of those aged 3 years and younger are, Maldonado said.
The keys to preventing measles are high national coverage rates, an aggressive public health response (because early diagnosis can limit transmission), and improved implementation of health care worker recommendations.
“We have to keep measles in mind whenever we see fevers and rashes,” Dr. Maldonado cautioned. “Unfortunately, we see fevers and rashes all the time, so what really helps is a history of international travel or a parent with international travel.”
For families planning overseas travel, parents are recommended to give their infants the MMR as young as 6 months. But that dose does not count toward the child’s two doses recommended by the Centers for Disease Control and Prevention schedule.
“It’s a very tough call with measles, because we never know when it might pop up,” Dr. Maldonado said. “Measles will be sporadic, but when it happens, it’s a really big deal. You basically have to reach out to your entire patient log for several days before the child came in.”
Managing suspected/confirmed outbreaks
To prepare for and manage suspected outbreaks of an infectious disease, Dr. Maldonado advised taking the following steps:
• Establish a plan for evaluating suspected or confirmed infectious disease outbreaks in your office setting.
• Identify and eliminate the source of the infection, such as providing a separate waiting room for coughing children.
• Prevent additional cases using screening questions at the front desk.
• Provide prompt and consistent ongoing evaluation to prevent or minimize transmission to others.
• Track disease trends and advice from the AAP, CDC, and local county public health officials and disease experts to engage in ongoing surveillance and communication.
• Identify the initial source and route of exposure to understand why an outbreak occurred and how to prevent similar ones in the future.
Dr. Maldonado reporting being a member of a data safety monitoring board for Pfizer.
FROM AAP 16