"In the News" and New Resources for February 2010

• Realizing the Promise of Home Visitation: A Guide for Policy Makers is designed to help policymakers and advocates build a national policy framework to maximize the effectiveness and reach of early childhood home-visiting programs. The policy brief is the culmination of many efforts over the last year including a meeting held in October 2009 in Washington, DC, to support the expansion of home-visitation services in the United States. Following a brief overview of home visitation, the authors discuss home visiting and domestic violence, the link between domestic violence and child abuse and neglect, improving outcomes for children by addressing domestic violence, promising programs to address domestic violence within home visitation, and opportunities for integrating domestic violence into federal home visitation initiatives. Federal policy recommendations, practice recommendations, and additional considerations are included.
• Children's Health Insurance Program Reauthorization Act: One Year Later -- Connecting Kids to Coverage reviews the past year's accomplishments in finding and enrolling children in health coverage. The report highlights features of the Children's Health Insurance Program Reauthorization Act (CHIPRA) that will help states and communities boost participation rates among eligible children. Topics include express lane eligibility, outreach and enrollment grants, the performance bonus, data matches, and automatic eligibility for newborns. Eligibility and enrollment improvements, strategies to ensure further improvements, core quality measures and quality demonstrations, and access to oral health care are also addressed. A call to action, a state map of eligibility levels, and state-by-state CHIPRA coverage improvements in 2009 are included.
• Screening for Depression During and After Pregnancy Obstetrics and Gynecology 115(2, Part 1):394-395. This report addresses the potential benefit of screening for, diagnosing, and treating depression; available screening tools; and billing for services. "Screening for depression has the potential to benefit a woman and her family and should be strongly considered."
  
  According to the authors:
  * There are multiple depression-screening tools available. Sensitivity should be the determining factor to maximize the number of women with depression identified.
  * Depression is very common during pregnancy and the postpartum period.
  
  At this time there is insufficient evidence to support a firm recommendation for universal antepartum or postpartum screening. There are also insufficient data to recommend how often screening should take place. Women with a positive assessment require follow-up evaluation and treatment, if indicated. Medical practices should have a referral process for identified cases. Women with current depression or a history of major depression warrant particularly close monitoring and evaluation. The appropriate diagnosis code depends on the nature of the woman's depression. Medical practices should check with all payers concerning coverage for mental health services before billing for these services.
• Implementing developmental screening and referrals: Lessons learned from a national project. King TM, Tandon SD, Macias MM, et al. 2010. Pediatrics 125(2):350-360. "By the end of the 9-month D-PIP [Developmental Surveillance and Screening Policy Implementation Pilot] . . . nearly all participating practices had successfully implemented AAP's [the American Academy of Pediatrics'] recommendations on developmental surveillance and screening . . . , [however] many clinics chose not to implement certain AAP recommendations," state the authors.
  
  AAP released a revised policy statement on developmental surveillance and screening for children from birth to age 3. The policy statement recommended that primary care health professionals conduct developmental surveillance at all well-child visits and structured developmental screening using a standardized instrument at ages 9, 18, and 30 (or 24) months. It also recommended that children judged to be at risk for developmental delays be referred for detailed developmental and medical evaluation and for early-intervention services. The release of the policy statement was paired with an implementation project (D-PIP) to assess the feasibility of implementing the policy statement in a variety of practice settings.
  
  The article presents project findings on (1) the degree to which participating practices could implement the AAP recommendations for developmental screening and referral and (2) the factors that staff at participating practices felt contributed to the successes or shortcomings of their efforts.
  
  The authors found that:
  * Fifteen of the 17 practices selected one or both of two parent-completed screening instruments.
  * The factor most commonly cited in selecting screening instruments was concern about clinic flow.
  * During the 9-month implementation period, monthly screening rates across practices increased from 68 percent to 86 percent of children who presented for recommended screening visits.
  * During the last 4 months of the project, practices consistently screened more than 85 percent of all target children.*
  Monthly referral rates among children with failed screens ranged from a high of 78 percent in September 2006 to a low of 48 percent in January 2007, averaging 61 percent over the entire study.
  * Most clinics divided responsibilities among staff at multiple levels, and most identified the need for change by reviewing systematically collected data on rates of screen distribution and completion.
  * Common challenges in implementing developmental screening included the following: distributing screening instruments to children at screening ages but not to other children, screening consistently when clinics were busy, and staff turnover.
  * Many clinics chose not to implement a 30-month well-child visit, routine screening when surveillance had already suggested delays, and dual referral of all children to both medical subspecialists and early-intervention programs.
  * The nine practices that attempted to track outcomes of their referrals found that referral tracking required a clinic-wide implementation system distinct from their system for developmental screening.
  
  "Future studies on the potential benefits of developmental screening, therefore, should include robust referral systems . . . that provide better explanations to families of the reasons for developmental referrals, as well as better monitoring of referral outcomes," state the authors.
• Is income inequality related to childhood dental caries in rich countries? Bernabe E, Hobdell MH. 2010. Journal of the American Dental Association 141(2):143-149. "The results of this study provide strong support for the income inequality hypothesis that once a country reaches a certain stage of economic development, income inequality surpasses per capita income as the primary determinant of health," state the authors. Studies of the relationship between dental caries and the socioeconomic status of populations have found significant correlations between dental caries and national socioeconomic factors. The article presents findings from a study to examine the issues of per capita growth in gross national income (GNI), income inequality (the gap between the wealthiest 20 percent of a population and the poorest 20 percent of the same population), and dental caries prevalence in young children at the population level.
  
  The authors found that:
  * In the entire sample of countries, income but not income inequality was significantly correlated with the dmft index.
  * Higher levels of national income were related to lower dmft scores among children ages 5 and 6.
  * Among rich countries, income inequality but not income was significantly correlated with the dmft index.
  * Greater income inequality was related to higher dmft scores among children ages 5 and 6.
  * In rich countries, adjusting for income inequality did not change the lack of association between income and the dmft index. On the other hand, income inequality remained significantly correlated with the dmft index after adjusting for income.
  
  "Our study . . . demonstrates the importance of income inequality to health and the need to focus on the entire population regardless of income," state the authors. "Beyond a certain level of economic growth, income inequality surpasses per capita income as the primary determinant of childhood dental caries," they conclude.
• Improving Early Identification and Treatment of Adolescent Depression: Considerations and Strategies for Health Plans reviews recommendations and tools for primary care health professionals to identify and treat adolescent depression and shares opportunities for health plans to support them. Topics include the prevalence of adolescent depression, consequences of unidentified depression, and costs of screening and treatment. Graphs, charts, and tables present data from a variety of sources, as well as information on how to access selected screening tools.
• The Surgeon General's Vision for a Healthy and Fit Nation focuses on opportunities to prevent obesity by implementing interventions in multiple settings. Contents include background information on obesity, including trends, disparities, measurement, consequences, and causes. Opportunities for creating healthy home environments, child care settings, schools, and work sites; mobilizing the medical community; and improving communities are also discussed.
• Effectiveness of weight management interventions in children: A targeted systematic review for the USPSTF. Whitlock EP, O’Connor EA, Williams SB, et al. 2010. Pediatrics 125(2):e396-e418. "The research on weight-management interventions for obese children and adolescents has improved in terms of quality and quantity in the past several years," write the authors. In 2005, the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against routine primary care screening for overweight in children and adolescents as a means of preventing adverse health outcomes. The USPSTF recently decided to update its recommendation.
  
  The authors found that:
  * At 6 to 12 months follow-up, children and adolescents in comprehensive intervention groups were 0.3 to 3.3 kg/m2 lighter than controls.
  * Intervention effectiveness tended to increase with more intensive interventions, with the largest effects (between-group BMI differences of 1.9-3.3 kg/m2) reported for three moderate- to high-intensity comprehensive weight-management programs. In the single comprehensive medium- to high-intensity trial with 12 additional months of follow-up, benefits were maintained.
  * Pharmacologic adjuncts to behavioral interventions among obese adolescents ages 12 to 18 provide superior benefits compared with behaviorally based treatment alone.
  * BMI reduction in the sibutramine-treated group was 2.9 kg/m2 compared with 0.3 kg/m2 in the control group.
  * BMI reduction in the orlistat-treated group was 0.55 kg/m2 compared with a gain of 0.3 kg/m2 in the control group.
  * Longer-term follow-up of weight loss after active treatment with sibutramine or orlistat was not reported for any trial.
  
  The authors conclude that "current research suggests that behavioral interventions are probably safe in children aged 4 to 18 years and can be effective, particularly moderate- to high-intensity comprehensive programs. " They continue, "combined behavioral-pharmacologic interventions may be useful for obese adolescents, particularly if research confirms that weight loss can be maintained after pharmacologic treatment ends."

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