TBD Meeting (3199-20)

In addition to screening adolescent patients at least once a year for substance use, it’s important that pediatricians build relationships with other behavioral health providers and develop a strategy for ensuring that teens with substance use issues continue returning to your practice as their medical home, according to Lucien Gonzalez, MD, assistant professor of psychiatry and behavioral sciences at the University of Minnesota, Minneapolis.

In a presentation at the annual meeting of the American Academy of Pediatrics, held virtually this year, Dr. Gonzalez discussed some of the common challenges pediatricians face in appropriately screening, diagnosing, and managing or referring youth when it comes to substance use.
 

Substance use screening

One of these included picking the right assessment tool and frequency for screening patients for substance use. A number of validated tools are out there, including the Screening to Brief Intervention (S2BI) and CRAFFT Screening Tool for Adolescent Substance Abuse. Regardless of which screening tool providers choose, “the important thing is to use a tool that is validated in the pediatric population and ideally has frequency results in it,” Dr. Gonzalez said.

In terms of frequency, screening young people at least once a year is fairly standard, but it may be necessary to screen adolescents more often or to screen them at acute visits.

“As many of you who work with adolescents know, you can’t always rely on the yearly well child visit because after a certain age, you start to see drop-off,” Dr. Gonzalez said. “They often aren’t coming for well child visits, and they often are then only showing up for acute visits.”

That means doctors need to think about how their clinics operate, how often they see their teen patients, and other factors – including how much can happen in a single year of adolescence – to ensure that screening captures these patients at least once a year, but more if that works within the practice.
 

Screening vs. diagnosis

Dr. Gonzalez also addressed the difference between screening and diagnosis, a very familiar distinction to physicians in other areas of medicine but often a source of confusion in the area of substance use.

“Screening is the presumptive identification of unrecognized disease in apparently healthy people who don’t have symptoms, using assessments that can be used rapidly,” Dr. Gonzalez said. “When we move into the diagnostic realm, these are people who present with symptoms or they have positive results on our screening test prompting further investigation.”

Sonia Khan, MD, a pediatrician and the medical director of the substance use disorder counseling program in the department of health and human services in Fremont, Calif., who heard the talk, particularly appreciated this point about screening versus diagnosis.

“As soon as you get a hint that there’s a problem with the kid, you’re no longer screening. You’re doing diagnostic investigation,” Dr. Khan, also the human relations commissioner for the city of Fremont, Calif., said in an interview. “Screening is about the kids you don’t know about. It seems like a small point to make a big deal out of, but it’s not.”

Sometimes a screening tool can serve as an introductory interview guide when beginning a clinical investigation with a patient who already shows symptoms, but that doesn’t mean it’s a screen.

Dr. Gonzalez emphasized the importance of not prescreening.

“A prescreener looks at a kid and decides whether or not they need to be screened,” Dr. Gonzalez said. “We have research that demonstrates that that doesn’t work. Physicians are not good at determining this by eyeballing it, and it’s fraught with bias. Universal screening with a validated screening tool is what works.”

Again, the idea of confronting one’s own personal biases and how they could interfere with screening really resonated with Dr. Khan.

“When it comes to the prescreening, if you’re only screening the ones you [think you] need to screen, you’re introducing bias into your screening,” she said. “It’s usually judgmental. It’s important to focus on really getting the bias out of what you’re doing because it’s a field fraught with bias and expectations.”


 

Brief interventions

Another area of confusion for many providers is what qualifies as a brief intervention and how to deliver it. The brief intervention needs to focus on increasing the patient’s knowledge, insights, and awareness when it comes to their own substance use and how it affects others. It should also support motivation in the patient to make behavioral changes. “It is always given in a nonjudgmental, supportive manner,” Dr. Gonzalez said.

Though motivational interviewing is often discussed as though it’s a brief intervention, it is actually the mechanism for delivering the intervention – not the intervention itself.

Dr. Gonzalez highly recommended that providers seek motivational interviewing training if they haven’t already. He went on to caution attendees about behavior goals in interventions: They should be the patient’s change goals, not the provider’s, and the provider is there to facilitate the teen’s clarification of those goals.

“It’s very important to use those listening skills that we have and honor their decision-making and listen to their language in establishing their own goals,” he said. It’s also important to keep cultural relevance and respect in mind when delivering the intervention. He shared a chart showing the dominant and nondominant groups along various demographic cultural influences, including age, disability status, faith, race/ethnicity, indigenous heritage, socioeconomic status, national origin, gender and sexuality.

For example, the dominant age groups are the young and middle-aged while the nondominant are children and elderly. The dominant faith in the United States is Christian or secular, and the dominant sexuality is heterosexual; the corresponding nondominant groups would be non-Christian and nonheterosexual. It’s important for providers to consider the child’s needs within that entire behavioral context to understand where they’re coming from.

“Have you ever characterized a kid’s situation with regard to substance use and diagnoses based on certain characteristics?” Dr. Gonzalez asked attendees. “We like to think that we don’t, but research on diagnostic disparities indicates otherwise.”

A way to help avoid this is to know who you are in the room and who you’re with in terms of dominant and nondominant groups. “Oftentimes a kid’s cultural make-up holds a big part of the answer to what they need,” Dr. Gonzalez said. He provided the example of a patient who was witnessing domestic violence in the home. A key part to helping him meet his goal of reducing cannabis and alcohol use was understanding his relationship with his dad, his response to trauma, and his depression, all within his cultural and religious background.
 

Preserving the medical home

Finally, when it comes to referrals, consider what are you referring a patient for and whom are you referring them to because not all programs and all clinicians are created equal. Create, build, and maintain relationships with as many behavioral health clinicians and practices as you can, he advised.

Further, it’s important to preserve the medical home, though that can require extra effort, particularly with children who have seen a lot of providers. Each physician will need to develop their own strategy for how to do this. Sometimes kids feel passed around and there’s poor communication within programs, leaving kids and their families feeling unwelcome at your practice.

“No child is a hot potato,” he said. Because they may feel like they’re being bounced around among different providers, programs, emergency departments, facilities, and such, it’s important to convey strongly that you want to continue to care for them.

“Whether we’ve been part of that or not, we become part of that,” Dr. Gonzalez said. “They may think that you don’t want to see them again. You want to keep them, and you might have to continue giving repeated messages. Sometimes we need to be very overt and repeat ourselves and say no, ‘I really, really, really want you to come back. This is your home and I want you to come back.’ ”

Dr. Gonzalez and Dr. Khan have no disclosures.

In addition to screening adolescent patients at least once a year for substance use, it’s important that pediatricians build relationships with other behavioral health providers and develop a strategy for ensuring that teens with substance use issues continue returning to your practice as their medical home, according to Lucien Gonzalez, MD, assistant professor of psychiatry and behavioral sciences at the University of Minnesota, Minneapolis.

In a presentation at the annual meeting of the American Academy of Pediatrics, held virtually this year, Dr. Gonzalez discussed some of the common challenges pediatricians face in appropriately screening, diagnosing, and managing or referring youth when it comes to substance use.
 

Substance use screening

One of these included picking the right assessment tool and frequency for screening patients for substance use. A number of validated tools are out there, including the Screening to Brief Intervention (S2BI) and CRAFFT Screening Tool for Adolescent Substance Abuse. Regardless of which screening tool providers choose, “the important thing is to use a tool that is validated in the pediatric population and ideally has frequency results in it,” Dr. Gonzalez said.

In terms of frequency, screening young people at least once a year is fairly standard, but it may be necessary to screen adolescents more often or to screen them at acute visits.

“As many of you who work with adolescents know, you can’t always rely on the yearly well child visit because after a certain age, you start to see drop-off,” Dr. Gonzalez said. “They often aren’t coming for well child visits, and they often are then only showing up for acute visits.”

That means doctors need to think about how their clinics operate, how often they see their teen patients, and other factors – including how much can happen in a single year of adolescence – to ensure that screening captures these patients at least once a year, but more if that works within the practice.
 

Screening vs. diagnosis

Dr. Gonzalez also addressed the difference between screening and diagnosis, a very familiar distinction to physicians in other areas of medicine but often a source of confusion in the area of substance use.

“Screening is the presumptive identification of unrecognized disease in apparently healthy people who don’t have symptoms, using assessments that can be used rapidly,” Dr. Gonzalez said. “When we move into the diagnostic realm, these are people who present with symptoms or they have positive results on our screening test prompting further investigation.”

Sonia Khan, MD, a pediatrician and the medical director of the substance use disorder counseling program in the department of health and human services in Fremont, Calif., who heard the talk, particularly appreciated this point about screening versus diagnosis.

“As soon as you get a hint that there’s a problem with the kid, you’re no longer screening. You’re doing diagnostic investigation,” Dr. Khan, also the human relations commissioner for the city of Fremont, Calif., said in an interview. “Screening is about the kids you don’t know about. It seems like a small point to make a big deal out of, but it’s not.”

Sometimes a screening tool can serve as an introductory interview guide when beginning a clinical investigation with a patient who already shows symptoms, but that doesn’t mean it’s a screen.

Dr. Gonzalez emphasized the importance of not prescreening.

“A prescreener looks at a kid and decides whether or not they need to be screened,” Dr. Gonzalez said. “We have research that demonstrates that that doesn’t work. Physicians are not good at determining this by eyeballing it, and it’s fraught with bias. Universal screening with a validated screening tool is what works.”

Again, the idea of confronting one’s own personal biases and how they could interfere with screening really resonated with Dr. Khan.

“When it comes to the prescreening, if you’re only screening the ones you [think you] need to screen, you’re introducing bias into your screening,” she said. “It’s usually judgmental. It’s important to focus on really getting the bias out of what you’re doing because it’s a field fraught with bias and expectations.”


 

Brief interventions

Another area of confusion for many providers is what qualifies as a brief intervention and how to deliver it. The brief intervention needs to focus on increasing the patient’s knowledge, insights, and awareness when it comes to their own substance use and how it affects others. It should also support motivation in the patient to make behavioral changes. “It is always given in a nonjudgmental, supportive manner,” Dr. Gonzalez said.

Though motivational interviewing is often discussed as though it’s a brief intervention, it is actually the mechanism for delivering the intervention – not the intervention itself.

Dr. Gonzalez highly recommended that providers seek motivational interviewing training if they haven’t already. He went on to caution attendees about behavior goals in interventions: They should be the patient’s change goals, not the provider’s, and the provider is there to facilitate the teen’s clarification of those goals.

“It’s very important to use those listening skills that we have and honor their decision-making and listen to their language in establishing their own goals,” he said. It’s also important to keep cultural relevance and respect in mind when delivering the intervention. He shared a chart showing the dominant and nondominant groups along various demographic cultural influences, including age, disability status, faith, race/ethnicity, indigenous heritage, socioeconomic status, national origin, gender and sexuality.

For example, the dominant age groups are the young and middle-aged while the nondominant are children and elderly. The dominant faith in the United States is Christian or secular, and the dominant sexuality is heterosexual; the corresponding nondominant groups would be non-Christian and nonheterosexual. It’s important for providers to consider the child’s needs within that entire behavioral context to understand where they’re coming from.

“Have you ever characterized a kid’s situation with regard to substance use and diagnoses based on certain characteristics?” Dr. Gonzalez asked attendees. “We like to think that we don’t, but research on diagnostic disparities indicates otherwise.”

A way to help avoid this is to know who you are in the room and who you’re with in terms of dominant and nondominant groups. “Oftentimes a kid’s cultural make-up holds a big part of the answer to what they need,” Dr. Gonzalez said. He provided the example of a patient who was witnessing domestic violence in the home. A key part to helping him meet his goal of reducing cannabis and alcohol use was understanding his relationship with his dad, his response to trauma, and his depression, all within his cultural and religious background.
 

Preserving the medical home

Finally, when it comes to referrals, consider what are you referring a patient for and whom are you referring them to because not all programs and all clinicians are created equal. Create, build, and maintain relationships with as many behavioral health clinicians and practices as you can, he advised.

Further, it’s important to preserve the medical home, though that can require extra effort, particularly with children who have seen a lot of providers. Each physician will need to develop their own strategy for how to do this. Sometimes kids feel passed around and there’s poor communication within programs, leaving kids and their families feeling unwelcome at your practice.

“No child is a hot potato,” he said. Because they may feel like they’re being bounced around among different providers, programs, emergency departments, facilities, and such, it’s important to convey strongly that you want to continue to care for them.

“Whether we’ve been part of that or not, we become part of that,” Dr. Gonzalez said. “They may think that you don’t want to see them again. You want to keep them, and you might have to continue giving repeated messages. Sometimes we need to be very overt and repeat ourselves and say no, ‘I really, really, really want you to come back. This is your home and I want you to come back.’ ”

Dr. Gonzalez and Dr. Khan have no disclosures.

In addition to screening adolescent patients at least once a year for substance use, it’s important that pediatricians build relationships with other behavioral health providers and develop a strategy for ensuring that teens with substance use issues continue returning to your practice as their medical home, according to Lucien Gonzalez, MD, assistant professor of psychiatry and behavioral sciences at the University of Minnesota, Minneapolis.

In a presentation at the annual meeting of the American Academy of Pediatrics, held virtually this year, Dr. Gonzalez discussed some of the common challenges pediatricians face in appropriately screening, diagnosing, and managing or referring youth when it comes to substance use.
 

Substance use screening

One of these included picking the right assessment tool and frequency for screening patients for substance use. A number of validated tools are out there, including the Screening to Brief Intervention (S2BI) and CRAFFT Screening Tool for Adolescent Substance Abuse. Regardless of which screening tool providers choose, “the important thing is to use a tool that is validated in the pediatric population and ideally has frequency results in it,” Dr. Gonzalez said.

In terms of frequency, screening young people at least once a year is fairly standard, but it may be necessary to screen adolescents more often or to screen them at acute visits.

“As many of you who work with adolescents know, you can’t always rely on the yearly well child visit because after a certain age, you start to see drop-off,” Dr. Gonzalez said. “They often aren’t coming for well child visits, and they often are then only showing up for acute visits.”

That means doctors need to think about how their clinics operate, how often they see their teen patients, and other factors – including how much can happen in a single year of adolescence – to ensure that screening captures these patients at least once a year, but more if that works within the practice.
 

Screening vs. diagnosis

Dr. Gonzalez also addressed the difference between screening and diagnosis, a very familiar distinction to physicians in other areas of medicine but often a source of confusion in the area of substance use.

“Screening is the presumptive identification of unrecognized disease in apparently healthy people who don’t have symptoms, using assessments that can be used rapidly,” Dr. Gonzalez said. “When we move into the diagnostic realm, these are people who present with symptoms or they have positive results on our screening test prompting further investigation.”

Sonia Khan, MD, a pediatrician and the medical director of the substance use disorder counseling program in the department of health and human services in Fremont, Calif., who heard the talk, particularly appreciated this point about screening versus diagnosis.

“As soon as you get a hint that there’s a problem with the kid, you’re no longer screening. You’re doing diagnostic investigation,” Dr. Khan, also the human relations commissioner for the city of Fremont, Calif., said in an interview. “Screening is about the kids you don’t know about. It seems like a small point to make a big deal out of, but it’s not.”

Sometimes a screening tool can serve as an introductory interview guide when beginning a clinical investigation with a patient who already shows symptoms, but that doesn’t mean it’s a screen.

Dr. Gonzalez emphasized the importance of not prescreening.

“A prescreener looks at a kid and decides whether or not they need to be screened,” Dr. Gonzalez said. “We have research that demonstrates that that doesn’t work. Physicians are not good at determining this by eyeballing it, and it’s fraught with bias. Universal screening with a validated screening tool is what works.”

Again, the idea of confronting one’s own personal biases and how they could interfere with screening really resonated with Dr. Khan.

“When it comes to the prescreening, if you’re only screening the ones you [think you] need to screen, you’re introducing bias into your screening,” she said. “It’s usually judgmental. It’s important to focus on really getting the bias out of what you’re doing because it’s a field fraught with bias and expectations.”


 

Brief interventions

Another area of confusion for many providers is what qualifies as a brief intervention and how to deliver it. The brief intervention needs to focus on increasing the patient’s knowledge, insights, and awareness when it comes to their own substance use and how it affects others. It should also support motivation in the patient to make behavioral changes. “It is always given in a nonjudgmental, supportive manner,” Dr. Gonzalez said.

Though motivational interviewing is often discussed as though it’s a brief intervention, it is actually the mechanism for delivering the intervention – not the intervention itself.

Dr. Gonzalez highly recommended that providers seek motivational interviewing training if they haven’t already. He went on to caution attendees about behavior goals in interventions: They should be the patient’s change goals, not the provider’s, and the provider is there to facilitate the teen’s clarification of those goals.

“It’s very important to use those listening skills that we have and honor their decision-making and listen to their language in establishing their own goals,” he said. It’s also important to keep cultural relevance and respect in mind when delivering the intervention. He shared a chart showing the dominant and nondominant groups along various demographic cultural influences, including age, disability status, faith, race/ethnicity, indigenous heritage, socioeconomic status, national origin, gender and sexuality.

For example, the dominant age groups are the young and middle-aged while the nondominant are children and elderly. The dominant faith in the United States is Christian or secular, and the dominant sexuality is heterosexual; the corresponding nondominant groups would be non-Christian and nonheterosexual. It’s important for providers to consider the child’s needs within that entire behavioral context to understand where they’re coming from.

“Have you ever characterized a kid’s situation with regard to substance use and diagnoses based on certain characteristics?” Dr. Gonzalez asked attendees. “We like to think that we don’t, but research on diagnostic disparities indicates otherwise.”

A way to help avoid this is to know who you are in the room and who you’re with in terms of dominant and nondominant groups. “Oftentimes a kid’s cultural make-up holds a big part of the answer to what they need,” Dr. Gonzalez said. He provided the example of a patient who was witnessing domestic violence in the home. A key part to helping him meet his goal of reducing cannabis and alcohol use was understanding his relationship with his dad, his response to trauma, and his depression, all within his cultural and religious background.
 

Preserving the medical home

Finally, when it comes to referrals, consider what are you referring a patient for and whom are you referring them to because not all programs and all clinicians are created equal. Create, build, and maintain relationships with as many behavioral health clinicians and practices as you can, he advised.

Further, it’s important to preserve the medical home, though that can require extra effort, particularly with children who have seen a lot of providers. Each physician will need to develop their own strategy for how to do this. Sometimes kids feel passed around and there’s poor communication within programs, leaving kids and their families feeling unwelcome at your practice.

“No child is a hot potato,” he said. Because they may feel like they’re being bounced around among different providers, programs, emergency departments, facilities, and such, it’s important to convey strongly that you want to continue to care for them.

“Whether we’ve been part of that or not, we become part of that,” Dr. Gonzalez said. “They may think that you don’t want to see them again. You want to keep them, and you might have to continue giving repeated messages. Sometimes we need to be very overt and repeat ourselves and say no, ‘I really, really, really want you to come back. This is your home and I want you to come back.’ ”

Dr. Gonzalez and Dr. Khan have no disclosures.

Pediatricians and other health care professionals who care for children are uniquely situated and qualified to educate the rest of the nation on how police brutality and overpolicing traumatizes children and teens and why those issues must be addressed, said Cornell William Brooks, JD, MDiv, a professor of public leadership and social justice at the Harvard Kennedy School of Government in Cambridge, Mass.

Mr. Brooks, also former president and CEO of the National Association for the Advancement of Colored People (NAACP), delivered an impassioned call to action during a plenary session at the annual meeting of the American Academy of Pediatrics, held virtually this year.

“In this moment, you enjoy an extraordinary measure of trust,” Mr. Brooks said. “As a consequence, I would argue that history and circumstance call upon to you to speak to this moment with a voice that is distinctive as a measure of expertise and unique as a measure of trust and credibility.”

The flood of comments throughout his live talk testified to how inspirational the AAP attendees found his words.

“We, as pediatricians, have a very powerful voice together,” wrote AAP President-elect Lee Savio Beers, MD.

“As pediatric staff we need to have our voices heard beyond the walls of our clinics, in our schools, in our legislative bodies and communities as a whole!” wrote Michelle Bucknor, MD, MBA, chief medical officer of United Healthcare of North Carolina.

Mr. Brooks opened his talk with images of Tamir Rice, Emmett Till, and George Floyd, explaining how images of Emmett Till’s dead body galvanized a movement in the same way that Rice, Floyd, Breonna Taylor, and other victims of police brutality are doing today.

“Emmett Till was killed by white racists in 1955 in Mississippi on the eve of the Montgomery boycott, and his death and his tragic image in death animated and inspired the Civil Rights movement,” Mr. Brooks said. Now “the country is divided along the fissures of class and the fault lines of race in a moment of generationally unprecedented policing. These images, tragic as they are, represent the countenance, the face of police brutality in this moment. “
 

How police brutality affects children

Since the death of George Floyd, at least 27 million Americans have participated in protests and demonstrations throughout at least 550 jurisdictions in the United States and throughout the world, Mr. Brooks said. But the harm of police brutality extends beyond police homicide victims.

“The harm is a matter of overpoliced patients and untreated children,” he said. Children are watching and listening as the nation grapples with police brutality and overpolicing, and the experience is traumatizing them in ways that shows up in school performance and health.

He shared findings from multiple different studies showing that exposure to police violence in the community is associated with declines in grade point averages, lower test scores, and poorer attendance. Risk of emotional disturbance is 15% greater in children exposed to police violence, and youth who have had contact with the police have reported worse health than those who hadn’t. Some of these effects increased with age, and they disproportionately fell almost entirely on Black and Hispanic students.

“Because of this trauma, school attendance and college enrollment declines,” Mr. Brooks said. “Police brutality has an impact on your patients, and beyond the patients who are right in front of you, there is a sea of millions of untreated, unattended children, and this trauma is reflected in the tremor of their voices, the trepidation, the apprehension, the fear that can be discerned in their spirits.”

Mr. Brooks shared several quotes from two qualitative studies that attempted to capture the experience of youths living in overpoliced communities and whose daily routines are criminalized. One respondent in this research said, “Sometimes I think to myself that I probably look suspicious, but I, like, shouldn’t think like that ‘cause I’m a human being.” Another said when he sees the police come around when there are groups of boys out, “I have my phone ready to record. I’m just waiting for something to happen.”
 

The voice of pediatricians

The voices of pediatric providers have a key role in the national discussion about this issue, Mr. Brooks said, because medical professionals have so much of America’s truth. One Pew Research Center survey found that 74% of Americans had a mostly positive view of medical doctors, compared with only 35% with a positive view of elected officials and 47% of the news media.

“As health care professionals dedicated to pediatrics, you are uniquely qualified, circumstantially and historically called in this moment to respond to this tragedy and trauma of police brutality as visited upon our children because you have been entrusted with America’s trust and credibility,” Mr. Brooks said.

He described several ways pediatricians can use storytelling to shift how the country perceives the issue of police brutality and the impact on children. Pediatricians can emphasize the humanity of children who are victimized, particularly when a different narrative competes for the public’s attention.

“Some children we deem to be sufficiently perfect that we can have sympathy and empathy for them,” Mr. Brooks said. “Other children are deemed to be so imperfect that we cannot have sympathy and empathy for them.” Within days of Michael Brown’s death by police in Ferguson, Mo., for example, a “post mortem character assassination” deemed Mr. Brown “too imperfect for empathy,” Mr. Brooks said.

“Dr. Brooks hit the nail on the head,” attendee Jeanette Callahan, MD, a pediatrician with Cambridge Health Alliance in Massachusetts, wrote during the session. “We must tell the stories that we hear every day from our patients.”

Pediatricians also can bring science and research into the public conversation to help people better understand children, just as the amicus briefs of pediatricians and neuroscientists in U.S. Supreme Court cases led the court to declare the death penalty and life sentences without parole as unconstitutional for minors.

“You as pediatricians, as physicians, as nurses, as health care professionals have the ability to cast doubt on things that people believe to be true and give them conviction with respect to things we know to be true as a consequence of data and our moral understanding,” Mr. Brooks said. He encouraged pediatricians to “engage in storytelling and justice-seeking by expanding and diversifying the resources we bring to public policy,” including science, data, and expertise.

Two recent examples of this professional activism include Massachusetts pediatrician Fiona Danaher’s testimony to the U.S. House of Representatives regarding current immigration policies’ impact on children and the work of Michigan pediatrician Mona Hanna-Attisha’s in exposing the Flint water crisis. Mr. Brooks shared a quote from Dr. Danaher: “For me, treating children humanely is a question of basic morality. I knew I couldn’t sit on the sidelines.”

Neither can pediatricians sit on the sidelines now with the issue of police brutality, Mr. Brooks said.

“You as pediatricians can call on America to engage in a Hippocratic approach to policing, that is to say, do no harm,” he said. “It’s not enough for us to content ourselves with children not becoming hashtags, not becoming police homicides. We have to also consider the trauma of overpolicing and oversurveilling our communities of color.”

He also recommended pediatricians remind the country that addressing social determinants of health also addresses social determinants of crime, providing an opportunity to disrupt the school-to-prison pipeline.

In the comments, attendees shared other ways pediatricians can influence policy in favor of children.

“Pediatricians can reach out to police departments, prosecutors, and public defender offices, the local judiciary, and local attorney associations, etc., to describe and explain the effects of policing on children and adolescents,” wrote Trina Anglin, MD, PhD, who retired in August 2019 as chief of the Adolescent Health Branch in the Health Resources and Services Administration’s Maternal and Child Health Bureau. “We can bring the voices of young people to others. At the community level, each professional group meets on a regular basis; each group also talks to the other groups.”

Others echoed these suggestions. “Expand your voice outside your office,” wrote Jimmell Felder, MD, of Pediatric Associates Greenwood in South Carolina. “Attend city council meetings and discuss the stories of our patients with the people who make the policies. It is part of our job to advocate for our patients.”

Joanna Betancourt, MD, a pediatrician with Salud Pediatrics in Algonquin, Ill., encouraged fellow attendees to “vote locally and nationally for people that are open to change legislation that supports the well-being of all children.”

Given all the trauma of 2020, Patricia Deffer-Valley, MD, of the University of Wisconsin School of Medicine and Public Health in Madison, said pediatricians cannot have “moral paralysis.”

Mr. Brooks had no relevant financial disclosures. Disclosure information was unavailable for others quoted in this article

Pediatricians and other health care professionals who care for children are uniquely situated and qualified to educate the rest of the nation on how police brutality and overpolicing traumatizes children and teens and why those issues must be addressed, said Cornell William Brooks, JD, MDiv, a professor of public leadership and social justice at the Harvard Kennedy School of Government in Cambridge, Mass.

Mr. Brooks, also former president and CEO of the National Association for the Advancement of Colored People (NAACP), delivered an impassioned call to action during a plenary session at the annual meeting of the American Academy of Pediatrics, held virtually this year.

“In this moment, you enjoy an extraordinary measure of trust,” Mr. Brooks said. “As a consequence, I would argue that history and circumstance call upon to you to speak to this moment with a voice that is distinctive as a measure of expertise and unique as a measure of trust and credibility.”

The flood of comments throughout his live talk testified to how inspirational the AAP attendees found his words.

“We, as pediatricians, have a very powerful voice together,” wrote AAP President-elect Lee Savio Beers, MD.

“As pediatric staff we need to have our voices heard beyond the walls of our clinics, in our schools, in our legislative bodies and communities as a whole!” wrote Michelle Bucknor, MD, MBA, chief medical officer of United Healthcare of North Carolina.

Mr. Brooks opened his talk with images of Tamir Rice, Emmett Till, and George Floyd, explaining how images of Emmett Till’s dead body galvanized a movement in the same way that Rice, Floyd, Breonna Taylor, and other victims of police brutality are doing today.

“Emmett Till was killed by white racists in 1955 in Mississippi on the eve of the Montgomery boycott, and his death and his tragic image in death animated and inspired the Civil Rights movement,” Mr. Brooks said. Now “the country is divided along the fissures of class and the fault lines of race in a moment of generationally unprecedented policing. These images, tragic as they are, represent the countenance, the face of police brutality in this moment. “
 

How police brutality affects children

Since the death of George Floyd, at least 27 million Americans have participated in protests and demonstrations throughout at least 550 jurisdictions in the United States and throughout the world, Mr. Brooks said. But the harm of police brutality extends beyond police homicide victims.

“The harm is a matter of overpoliced patients and untreated children,” he said. Children are watching and listening as the nation grapples with police brutality and overpolicing, and the experience is traumatizing them in ways that shows up in school performance and health.

He shared findings from multiple different studies showing that exposure to police violence in the community is associated with declines in grade point averages, lower test scores, and poorer attendance. Risk of emotional disturbance is 15% greater in children exposed to police violence, and youth who have had contact with the police have reported worse health than those who hadn’t. Some of these effects increased with age, and they disproportionately fell almost entirely on Black and Hispanic students.

“Because of this trauma, school attendance and college enrollment declines,” Mr. Brooks said. “Police brutality has an impact on your patients, and beyond the patients who are right in front of you, there is a sea of millions of untreated, unattended children, and this trauma is reflected in the tremor of their voices, the trepidation, the apprehension, the fear that can be discerned in their spirits.”

Mr. Brooks shared several quotes from two qualitative studies that attempted to capture the experience of youths living in overpoliced communities and whose daily routines are criminalized. One respondent in this research said, “Sometimes I think to myself that I probably look suspicious, but I, like, shouldn’t think like that ‘cause I’m a human being.” Another said when he sees the police come around when there are groups of boys out, “I have my phone ready to record. I’m just waiting for something to happen.”
 

The voice of pediatricians

The voices of pediatric providers have a key role in the national discussion about this issue, Mr. Brooks said, because medical professionals have so much of America’s truth. One Pew Research Center survey found that 74% of Americans had a mostly positive view of medical doctors, compared with only 35% with a positive view of elected officials and 47% of the news media.

“As health care professionals dedicated to pediatrics, you are uniquely qualified, circumstantially and historically called in this moment to respond to this tragedy and trauma of police brutality as visited upon our children because you have been entrusted with America’s trust and credibility,” Mr. Brooks said.

He described several ways pediatricians can use storytelling to shift how the country perceives the issue of police brutality and the impact on children. Pediatricians can emphasize the humanity of children who are victimized, particularly when a different narrative competes for the public’s attention.

“Some children we deem to be sufficiently perfect that we can have sympathy and empathy for them,” Mr. Brooks said. “Other children are deemed to be so imperfect that we cannot have sympathy and empathy for them.” Within days of Michael Brown’s death by police in Ferguson, Mo., for example, a “post mortem character assassination” deemed Mr. Brown “too imperfect for empathy,” Mr. Brooks said.

“Dr. Brooks hit the nail on the head,” attendee Jeanette Callahan, MD, a pediatrician with Cambridge Health Alliance in Massachusetts, wrote during the session. “We must tell the stories that we hear every day from our patients.”

Pediatricians also can bring science and research into the public conversation to help people better understand children, just as the amicus briefs of pediatricians and neuroscientists in U.S. Supreme Court cases led the court to declare the death penalty and life sentences without parole as unconstitutional for minors.

“You as pediatricians, as physicians, as nurses, as health care professionals have the ability to cast doubt on things that people believe to be true and give them conviction with respect to things we know to be true as a consequence of data and our moral understanding,” Mr. Brooks said. He encouraged pediatricians to “engage in storytelling and justice-seeking by expanding and diversifying the resources we bring to public policy,” including science, data, and expertise.

Two recent examples of this professional activism include Massachusetts pediatrician Fiona Danaher’s testimony to the U.S. House of Representatives regarding current immigration policies’ impact on children and the work of Michigan pediatrician Mona Hanna-Attisha’s in exposing the Flint water crisis. Mr. Brooks shared a quote from Dr. Danaher: “For me, treating children humanely is a question of basic morality. I knew I couldn’t sit on the sidelines.”

Neither can pediatricians sit on the sidelines now with the issue of police brutality, Mr. Brooks said.

“You as pediatricians can call on America to engage in a Hippocratic approach to policing, that is to say, do no harm,” he said. “It’s not enough for us to content ourselves with children not becoming hashtags, not becoming police homicides. We have to also consider the trauma of overpolicing and oversurveilling our communities of color.”

He also recommended pediatricians remind the country that addressing social determinants of health also addresses social determinants of crime, providing an opportunity to disrupt the school-to-prison pipeline.

In the comments, attendees shared other ways pediatricians can influence policy in favor of children.

“Pediatricians can reach out to police departments, prosecutors, and public defender offices, the local judiciary, and local attorney associations, etc., to describe and explain the effects of policing on children and adolescents,” wrote Trina Anglin, MD, PhD, who retired in August 2019 as chief of the Adolescent Health Branch in the Health Resources and Services Administration’s Maternal and Child Health Bureau. “We can bring the voices of young people to others. At the community level, each professional group meets on a regular basis; each group also talks to the other groups.”

Others echoed these suggestions. “Expand your voice outside your office,” wrote Jimmell Felder, MD, of Pediatric Associates Greenwood in South Carolina. “Attend city council meetings and discuss the stories of our patients with the people who make the policies. It is part of our job to advocate for our patients.”

Joanna Betancourt, MD, a pediatrician with Salud Pediatrics in Algonquin, Ill., encouraged fellow attendees to “vote locally and nationally for people that are open to change legislation that supports the well-being of all children.”

Given all the trauma of 2020, Patricia Deffer-Valley, MD, of the University of Wisconsin School of Medicine and Public Health in Madison, said pediatricians cannot have “moral paralysis.”

Mr. Brooks had no relevant financial disclosures. Disclosure information was unavailable for others quoted in this article

Pediatricians and other health care professionals who care for children are uniquely situated and qualified to educate the rest of the nation on how police brutality and overpolicing traumatizes children and teens and why those issues must be addressed, said Cornell William Brooks, JD, MDiv, a professor of public leadership and social justice at the Harvard Kennedy School of Government in Cambridge, Mass.

Mr. Brooks, also former president and CEO of the National Association for the Advancement of Colored People (NAACP), delivered an impassioned call to action during a plenary session at the annual meeting of the American Academy of Pediatrics, held virtually this year.

“In this moment, you enjoy an extraordinary measure of trust,” Mr. Brooks said. “As a consequence, I would argue that history and circumstance call upon to you to speak to this moment with a voice that is distinctive as a measure of expertise and unique as a measure of trust and credibility.”

The flood of comments throughout his live talk testified to how inspirational the AAP attendees found his words.

“We, as pediatricians, have a very powerful voice together,” wrote AAP President-elect Lee Savio Beers, MD.

“As pediatric staff we need to have our voices heard beyond the walls of our clinics, in our schools, in our legislative bodies and communities as a whole!” wrote Michelle Bucknor, MD, MBA, chief medical officer of United Healthcare of North Carolina.

Mr. Brooks opened his talk with images of Tamir Rice, Emmett Till, and George Floyd, explaining how images of Emmett Till’s dead body galvanized a movement in the same way that Rice, Floyd, Breonna Taylor, and other victims of police brutality are doing today.

“Emmett Till was killed by white racists in 1955 in Mississippi on the eve of the Montgomery boycott, and his death and his tragic image in death animated and inspired the Civil Rights movement,” Mr. Brooks said. Now “the country is divided along the fissures of class and the fault lines of race in a moment of generationally unprecedented policing. These images, tragic as they are, represent the countenance, the face of police brutality in this moment. “
 

How police brutality affects children

Since the death of George Floyd, at least 27 million Americans have participated in protests and demonstrations throughout at least 550 jurisdictions in the United States and throughout the world, Mr. Brooks said. But the harm of police brutality extends beyond police homicide victims.

“The harm is a matter of overpoliced patients and untreated children,” he said. Children are watching and listening as the nation grapples with police brutality and overpolicing, and the experience is traumatizing them in ways that shows up in school performance and health.

He shared findings from multiple different studies showing that exposure to police violence in the community is associated with declines in grade point averages, lower test scores, and poorer attendance. Risk of emotional disturbance is 15% greater in children exposed to police violence, and youth who have had contact with the police have reported worse health than those who hadn’t. Some of these effects increased with age, and they disproportionately fell almost entirely on Black and Hispanic students.

“Because of this trauma, school attendance and college enrollment declines,” Mr. Brooks said. “Police brutality has an impact on your patients, and beyond the patients who are right in front of you, there is a sea of millions of untreated, unattended children, and this trauma is reflected in the tremor of their voices, the trepidation, the apprehension, the fear that can be discerned in their spirits.”

Mr. Brooks shared several quotes from two qualitative studies that attempted to capture the experience of youths living in overpoliced communities and whose daily routines are criminalized. One respondent in this research said, “Sometimes I think to myself that I probably look suspicious, but I, like, shouldn’t think like that ‘cause I’m a human being.” Another said when he sees the police come around when there are groups of boys out, “I have my phone ready to record. I’m just waiting for something to happen.”
 

The voice of pediatricians

The voices of pediatric providers have a key role in the national discussion about this issue, Mr. Brooks said, because medical professionals have so much of America’s truth. One Pew Research Center survey found that 74% of Americans had a mostly positive view of medical doctors, compared with only 35% with a positive view of elected officials and 47% of the news media.

“As health care professionals dedicated to pediatrics, you are uniquely qualified, circumstantially and historically called in this moment to respond to this tragedy and trauma of police brutality as visited upon our children because you have been entrusted with America’s trust and credibility,” Mr. Brooks said.

He described several ways pediatricians can use storytelling to shift how the country perceives the issue of police brutality and the impact on children. Pediatricians can emphasize the humanity of children who are victimized, particularly when a different narrative competes for the public’s attention.

“Some children we deem to be sufficiently perfect that we can have sympathy and empathy for them,” Mr. Brooks said. “Other children are deemed to be so imperfect that we cannot have sympathy and empathy for them.” Within days of Michael Brown’s death by police in Ferguson, Mo., for example, a “post mortem character assassination” deemed Mr. Brown “too imperfect for empathy,” Mr. Brooks said.

“Dr. Brooks hit the nail on the head,” attendee Jeanette Callahan, MD, a pediatrician with Cambridge Health Alliance in Massachusetts, wrote during the session. “We must tell the stories that we hear every day from our patients.”

Pediatricians also can bring science and research into the public conversation to help people better understand children, just as the amicus briefs of pediatricians and neuroscientists in U.S. Supreme Court cases led the court to declare the death penalty and life sentences without parole as unconstitutional for minors.

“You as pediatricians, as physicians, as nurses, as health care professionals have the ability to cast doubt on things that people believe to be true and give them conviction with respect to things we know to be true as a consequence of data and our moral understanding,” Mr. Brooks said. He encouraged pediatricians to “engage in storytelling and justice-seeking by expanding and diversifying the resources we bring to public policy,” including science, data, and expertise.

Two recent examples of this professional activism include Massachusetts pediatrician Fiona Danaher’s testimony to the U.S. House of Representatives regarding current immigration policies’ impact on children and the work of Michigan pediatrician Mona Hanna-Attisha’s in exposing the Flint water crisis. Mr. Brooks shared a quote from Dr. Danaher: “For me, treating children humanely is a question of basic morality. I knew I couldn’t sit on the sidelines.”

Neither can pediatricians sit on the sidelines now with the issue of police brutality, Mr. Brooks said.

“You as pediatricians can call on America to engage in a Hippocratic approach to policing, that is to say, do no harm,” he said. “It’s not enough for us to content ourselves with children not becoming hashtags, not becoming police homicides. We have to also consider the trauma of overpolicing and oversurveilling our communities of color.”

He also recommended pediatricians remind the country that addressing social determinants of health also addresses social determinants of crime, providing an opportunity to disrupt the school-to-prison pipeline.

In the comments, attendees shared other ways pediatricians can influence policy in favor of children.

“Pediatricians can reach out to police departments, prosecutors, and public defender offices, the local judiciary, and local attorney associations, etc., to describe and explain the effects of policing on children and adolescents,” wrote Trina Anglin, MD, PhD, who retired in August 2019 as chief of the Adolescent Health Branch in the Health Resources and Services Administration’s Maternal and Child Health Bureau. “We can bring the voices of young people to others. At the community level, each professional group meets on a regular basis; each group also talks to the other groups.”

Others echoed these suggestions. “Expand your voice outside your office,” wrote Jimmell Felder, MD, of Pediatric Associates Greenwood in South Carolina. “Attend city council meetings and discuss the stories of our patients with the people who make the policies. It is part of our job to advocate for our patients.”

Joanna Betancourt, MD, a pediatrician with Salud Pediatrics in Algonquin, Ill., encouraged fellow attendees to “vote locally and nationally for people that are open to change legislation that supports the well-being of all children.”

Given all the trauma of 2020, Patricia Deffer-Valley, MD, of the University of Wisconsin School of Medicine and Public Health in Madison, said pediatricians cannot have “moral paralysis.”

Mr. Brooks had no relevant financial disclosures. Disclosure information was unavailable for others quoted in this article

Integrating ADHD care into practice work flows is vitally important for all practitioners who care for children, said Herschel Lessin, MD, a senior partner of the Children’s Medical Group in Poughkeepsie, N.Y.

O_Lypa/iStock/Getty Images

Although not necessarily “easy” to do, it’s far less overwhelming than it seems when doctors take the time to thoughtfully set up protocols, train others in the office, and use the ADHD Toolkit sold by the American Academy of Pediatrics, Dr. Lessin told attendees at the annual meeting of the AAP, held virtually this year. Dr. Lessin is a coeditor of the AAP’s ADHD Toolkit 3rd Ed., although he does not receive royalties from it. The toolkit includes patient handouts, clinicians tools, and rating scales that help practices incorporate ADHD care into their practices.

“The biggest complaint is: ‘But I don’t have enough time to do all of this stuff,’ ” Dr. Lessin said. “The reality is, once you’re comfortable with the visits and you know how they progress and flow, they can be done much more quickly.” He emphasized that practices can make money by integrating ADHD care into practice as long as they have a strategic plan and invest the time into training and protocols.

Dr. Lessin gave multiple reasons it’s important to integrate ADHD care into practices, starting with the condition’s prevalence and the importance of building a medical home for patients.

“ADHD affects 8%-10% of your patient population, a truly enormous number, yet many pediatricians do not treat ADHD in their practices, depriving their patients of needed care and depriving themselves from economic benefits of the visits and the revenue,” he said. The pediatrician added that more than 80% of ADHD care takes place in pediatric offices, but much of it is “badly diagnosed and poorly treated” in both primary care and specialty offices.

Jesse Hackell, MD, a private practice pediatrician in a suburb of New York City and vice president of the New York AAP Chapter 3, attended the session and agreed with Dr. Lessin that pediatricians are best suited to manage ADHD over other practitioners.

“One of the things he pointed out is that it’s a pediatric issue,” Dr. Hackell said. “We’re better at this than psychiatrists, than neurologists, than psychologists because we’re really focused on the whole lifestyle of the child, how it impacts them at home, how it impacts them at school, and how it impacts them in the social sphere.”

There’s also been a substantial increase in mental health issues as a proportion of visits, particularly recently with the pandemic and accompanying lockdowns. Youth already have limited access to mental health resources, making general pediatricians’ roles even more important. “Who else is going to provide this much needed service if not pediatricians?” Dr. Lessin asked.

Again, Dr. Hackell agreed, noting that the AAP’s toolkit is especially helpful in providing this care.

“It’s something that pediatricians have often been afraid to deal with and who farm them out to these other specialties, and I don’t think the children are served as well,” Dr. Hackell said. “If you do the right forms and questionnaires, you can actually make it work for the kids and work it for your office, which generates a lot of visits and generates revenue.”
 

Where to start

Dr. Lessin began by recommending that all pediatricians read the AAP’s clinical practice guidelines for ADHD along with its supplemental material (Process of Care Algorithm, and Systemic Barriers to Care of Children and Adolescents with ADHD).

“The first thing is you must educate yourself,” he said. “You have to learn the medicine and what are you able and comfortable doing because few of us were ever trained in our residency programs about ADHD care.”

Providers also need to learn to manage barriers to care, including referral sources and insurance company and medication hassles. Then you need to figure out how to structure the visits, determine the most appropriate visit settings, and learn to document and code appropriately. These are not quick 10-minute visits, Dr. Lessin said. Doctors must schedule enough time for them, although they may be able to do them faster with practice.

Dr. Lessin offered encouraging words for those feeling overwhelmed: “Overcome your anxiety. This is not as hard as it seems. It’s a little bit harder with comorbidities, but many chronic diseases we manage are far worse.”

In addition to reading the guidelines and review articles, seeking out mental health training programs, and learning the medications available, Dr. Lessin told attendees to get comfortable with the fact that a lot of treatment comes down to trial and error.

Again, he emphasized the value of the toolkit, which Dr. Hackell echoed.

“It’s a really nice roadmap to be able to follow and to explain how it requires two or three or four visits to treat these children well and get them started on treatment,” Dr. Hackell said. “It’s something that I recommend people use if they have not already done so to integrate ADHD care into their practices.”
 

Beginning the process

In figuring out how to structure visits, avoid addressing ADHD as a “by-the-way” issue, such as when a parent mentions it at the end of an appointment, Dr. Lessin said. Instead, start with an intake visit to determine whether you’re the right person to evaluate the child and hand out Parent and Teacher Evaluation scales to begin the process. Next, do the evaluation, discuss the process with the family, determine how treatment will work, and then look at comorbidities.

Visit settings can be traditional face-to-face visits, which are particularly helpful for intake visits, Dr. Lessin said, or telehealth, especially during the pandemic. In-person visits allow you more easily to make eye contact with the child and observe the parent and child behaviors and interactions, but telehealth often is adequate for titrating medication, discussing side effects, monitoring, and similar follow-up.

“Coding practices are absolutely necessary to make your practice viable, much less make money,” Dr. Lessin said. “Doing good for people and doing well for yourself are not mutually exclusive. You have to figure out a way to make it work economically for the practice or else you’re just not going to do it.”

He reminded pediatricians to code for evaluation, monitoring scales, and care coordination, and to be prepared for the big change of new coding rules coming in 2021.

“For better or worse, documentation is the key to survival in medical practice these days,” Dr. Lessin said. “This is true for all medical care these days, but it’s particularly true for ADHD because visits are all high intensity codes and should be coded as such.”

Templates are fine, he said, but box-checking isn’t enough; leave space for a narrative that explains the case complexity and decision-making.
 

Training staff is essential

It’s utterly essential to train all office staff, Dr. Lessin said. “I can’t tell you how important this step is because no matter how much you know or how well you understand what you want to do, you’re going to be frustrated at every turn if your staff and colleagues don’t get this stuff.”

That includes training those who make appointments, front desk staff, clinical staff, and practice colleagues regarding coding, scheduling, visit protocols, and similar procedures. Cheat sheets can be helpful here.

“They must understand the structure of the visits, what happens at each visit, the time requirements for each visit, and the standard follow-up,” including, for clinical staff, what handouts and rating scales to use, he said. “And if they aren’t sure what the parents needs or what you want, make sure they know to contact you.”

Colleagues also need to learn to properly document visits to justify coding and complexity, and not dump all patients on you.

One challenge that Dr. Lessin acknowledged as a common problem is that many pediatricians don’t have subspecialists they can refer patients to.

“Sadly, this is true almost everywhere, in rural and in big cities, near big medical centers and only local hospitals,” Dr. Lessin said. “This another reason why I think you need to learn and treat this illness to the extent you can. Your families need you.”

Dr. Hackell particularly appreciated this point, emphasizing again how important it is that pediatricians manage ADHD care of their patients.

“We see their day-to-day life, and that’s where this impacts these kids and families,” he said. “It’s really rewarding to do from my personal experience because you can really make a really big difference in these kids’ lives when they’re younger and even as they get older. When you get the rewards, it makes the work all worthwhile.”

Dr. Lessin and Dr. Hackell said they have no relevant financial disclosures.

Integrating ADHD care into practice work flows is vitally important for all practitioners who care for children, said Herschel Lessin, MD, a senior partner of the Children’s Medical Group in Poughkeepsie, N.Y.

O_Lypa/iStock/Getty Images

Although not necessarily “easy” to do, it’s far less overwhelming than it seems when doctors take the time to thoughtfully set up protocols, train others in the office, and use the ADHD Toolkit sold by the American Academy of Pediatrics, Dr. Lessin told attendees at the annual meeting of the AAP, held virtually this year. Dr. Lessin is a coeditor of the AAP’s ADHD Toolkit 3rd Ed., although he does not receive royalties from it. The toolkit includes patient handouts, clinicians tools, and rating scales that help practices incorporate ADHD care into their practices.

“The biggest complaint is: ‘But I don’t have enough time to do all of this stuff,’ ” Dr. Lessin said. “The reality is, once you’re comfortable with the visits and you know how they progress and flow, they can be done much more quickly.” He emphasized that practices can make money by integrating ADHD care into practice as long as they have a strategic plan and invest the time into training and protocols.

Dr. Lessin gave multiple reasons it’s important to integrate ADHD care into practices, starting with the condition’s prevalence and the importance of building a medical home for patients.

“ADHD affects 8%-10% of your patient population, a truly enormous number, yet many pediatricians do not treat ADHD in their practices, depriving their patients of needed care and depriving themselves from economic benefits of the visits and the revenue,” he said. The pediatrician added that more than 80% of ADHD care takes place in pediatric offices, but much of it is “badly diagnosed and poorly treated” in both primary care and specialty offices.

Jesse Hackell, MD, a private practice pediatrician in a suburb of New York City and vice president of the New York AAP Chapter 3, attended the session and agreed with Dr. Lessin that pediatricians are best suited to manage ADHD over other practitioners.

“One of the things he pointed out is that it’s a pediatric issue,” Dr. Hackell said. “We’re better at this than psychiatrists, than neurologists, than psychologists because we’re really focused on the whole lifestyle of the child, how it impacts them at home, how it impacts them at school, and how it impacts them in the social sphere.”

There’s also been a substantial increase in mental health issues as a proportion of visits, particularly recently with the pandemic and accompanying lockdowns. Youth already have limited access to mental health resources, making general pediatricians’ roles even more important. “Who else is going to provide this much needed service if not pediatricians?” Dr. Lessin asked.

Again, Dr. Hackell agreed, noting that the AAP’s toolkit is especially helpful in providing this care.

“It’s something that pediatricians have often been afraid to deal with and who farm them out to these other specialties, and I don’t think the children are served as well,” Dr. Hackell said. “If you do the right forms and questionnaires, you can actually make it work for the kids and work it for your office, which generates a lot of visits and generates revenue.”
 

Where to start

Dr. Lessin began by recommending that all pediatricians read the AAP’s clinical practice guidelines for ADHD along with its supplemental material (Process of Care Algorithm, and Systemic Barriers to Care of Children and Adolescents with ADHD).

“The first thing is you must educate yourself,” he said. “You have to learn the medicine and what are you able and comfortable doing because few of us were ever trained in our residency programs about ADHD care.”

Providers also need to learn to manage barriers to care, including referral sources and insurance company and medication hassles. Then you need to figure out how to structure the visits, determine the most appropriate visit settings, and learn to document and code appropriately. These are not quick 10-minute visits, Dr. Lessin said. Doctors must schedule enough time for them, although they may be able to do them faster with practice.

Dr. Lessin offered encouraging words for those feeling overwhelmed: “Overcome your anxiety. This is not as hard as it seems. It’s a little bit harder with comorbidities, but many chronic diseases we manage are far worse.”

In addition to reading the guidelines and review articles, seeking out mental health training programs, and learning the medications available, Dr. Lessin told attendees to get comfortable with the fact that a lot of treatment comes down to trial and error.

Again, he emphasized the value of the toolkit, which Dr. Hackell echoed.

“It’s a really nice roadmap to be able to follow and to explain how it requires two or three or four visits to treat these children well and get them started on treatment,” Dr. Hackell said. “It’s something that I recommend people use if they have not already done so to integrate ADHD care into their practices.”
 

Beginning the process

In figuring out how to structure visits, avoid addressing ADHD as a “by-the-way” issue, such as when a parent mentions it at the end of an appointment, Dr. Lessin said. Instead, start with an intake visit to determine whether you’re the right person to evaluate the child and hand out Parent and Teacher Evaluation scales to begin the process. Next, do the evaluation, discuss the process with the family, determine how treatment will work, and then look at comorbidities.

Visit settings can be traditional face-to-face visits, which are particularly helpful for intake visits, Dr. Lessin said, or telehealth, especially during the pandemic. In-person visits allow you more easily to make eye contact with the child and observe the parent and child behaviors and interactions, but telehealth often is adequate for titrating medication, discussing side effects, monitoring, and similar follow-up.

“Coding practices are absolutely necessary to make your practice viable, much less make money,” Dr. Lessin said. “Doing good for people and doing well for yourself are not mutually exclusive. You have to figure out a way to make it work economically for the practice or else you’re just not going to do it.”

He reminded pediatricians to code for evaluation, monitoring scales, and care coordination, and to be prepared for the big change of new coding rules coming in 2021.

“For better or worse, documentation is the key to survival in medical practice these days,” Dr. Lessin said. “This is true for all medical care these days, but it’s particularly true for ADHD because visits are all high intensity codes and should be coded as such.”

Templates are fine, he said, but box-checking isn’t enough; leave space for a narrative that explains the case complexity and decision-making.
 

Training staff is essential

It’s utterly essential to train all office staff, Dr. Lessin said. “I can’t tell you how important this step is because no matter how much you know or how well you understand what you want to do, you’re going to be frustrated at every turn if your staff and colleagues don’t get this stuff.”

That includes training those who make appointments, front desk staff, clinical staff, and practice colleagues regarding coding, scheduling, visit protocols, and similar procedures. Cheat sheets can be helpful here.

“They must understand the structure of the visits, what happens at each visit, the time requirements for each visit, and the standard follow-up,” including, for clinical staff, what handouts and rating scales to use, he said. “And if they aren’t sure what the parents needs or what you want, make sure they know to contact you.”

Colleagues also need to learn to properly document visits to justify coding and complexity, and not dump all patients on you.

One challenge that Dr. Lessin acknowledged as a common problem is that many pediatricians don’t have subspecialists they can refer patients to.

“Sadly, this is true almost everywhere, in rural and in big cities, near big medical centers and only local hospitals,” Dr. Lessin said. “This another reason why I think you need to learn and treat this illness to the extent you can. Your families need you.”

Dr. Hackell particularly appreciated this point, emphasizing again how important it is that pediatricians manage ADHD care of their patients.

“We see their day-to-day life, and that’s where this impacts these kids and families,” he said. “It’s really rewarding to do from my personal experience because you can really make a really big difference in these kids’ lives when they’re younger and even as they get older. When you get the rewards, it makes the work all worthwhile.”

Dr. Lessin and Dr. Hackell said they have no relevant financial disclosures.

Integrating ADHD care into practice work flows is vitally important for all practitioners who care for children, said Herschel Lessin, MD, a senior partner of the Children’s Medical Group in Poughkeepsie, N.Y.

O_Lypa/iStock/Getty Images

Although not necessarily “easy” to do, it’s far less overwhelming than it seems when doctors take the time to thoughtfully set up protocols, train others in the office, and use the ADHD Toolkit sold by the American Academy of Pediatrics, Dr. Lessin told attendees at the annual meeting of the AAP, held virtually this year. Dr. Lessin is a coeditor of the AAP’s ADHD Toolkit 3rd Ed., although he does not receive royalties from it. The toolkit includes patient handouts, clinicians tools, and rating scales that help practices incorporate ADHD care into their practices.

“The biggest complaint is: ‘But I don’t have enough time to do all of this stuff,’ ” Dr. Lessin said. “The reality is, once you’re comfortable with the visits and you know how they progress and flow, they can be done much more quickly.” He emphasized that practices can make money by integrating ADHD care into practice as long as they have a strategic plan and invest the time into training and protocols.

Dr. Lessin gave multiple reasons it’s important to integrate ADHD care into practices, starting with the condition’s prevalence and the importance of building a medical home for patients.

“ADHD affects 8%-10% of your patient population, a truly enormous number, yet many pediatricians do not treat ADHD in their practices, depriving their patients of needed care and depriving themselves from economic benefits of the visits and the revenue,” he said. The pediatrician added that more than 80% of ADHD care takes place in pediatric offices, but much of it is “badly diagnosed and poorly treated” in both primary care and specialty offices.

Jesse Hackell, MD, a private practice pediatrician in a suburb of New York City and vice president of the New York AAP Chapter 3, attended the session and agreed with Dr. Lessin that pediatricians are best suited to manage ADHD over other practitioners.

“One of the things he pointed out is that it’s a pediatric issue,” Dr. Hackell said. “We’re better at this than psychiatrists, than neurologists, than psychologists because we’re really focused on the whole lifestyle of the child, how it impacts them at home, how it impacts them at school, and how it impacts them in the social sphere.”

There’s also been a substantial increase in mental health issues as a proportion of visits, particularly recently with the pandemic and accompanying lockdowns. Youth already have limited access to mental health resources, making general pediatricians’ roles even more important. “Who else is going to provide this much needed service if not pediatricians?” Dr. Lessin asked.

Again, Dr. Hackell agreed, noting that the AAP’s toolkit is especially helpful in providing this care.

“It’s something that pediatricians have often been afraid to deal with and who farm them out to these other specialties, and I don’t think the children are served as well,” Dr. Hackell said. “If you do the right forms and questionnaires, you can actually make it work for the kids and work it for your office, which generates a lot of visits and generates revenue.”
 

Where to start

Dr. Lessin began by recommending that all pediatricians read the AAP’s clinical practice guidelines for ADHD along with its supplemental material (Process of Care Algorithm, and Systemic Barriers to Care of Children and Adolescents with ADHD).

“The first thing is you must educate yourself,” he said. “You have to learn the medicine and what are you able and comfortable doing because few of us were ever trained in our residency programs about ADHD care.”

Providers also need to learn to manage barriers to care, including referral sources and insurance company and medication hassles. Then you need to figure out how to structure the visits, determine the most appropriate visit settings, and learn to document and code appropriately. These are not quick 10-minute visits, Dr. Lessin said. Doctors must schedule enough time for them, although they may be able to do them faster with practice.

Dr. Lessin offered encouraging words for those feeling overwhelmed: “Overcome your anxiety. This is not as hard as it seems. It’s a little bit harder with comorbidities, but many chronic diseases we manage are far worse.”

In addition to reading the guidelines and review articles, seeking out mental health training programs, and learning the medications available, Dr. Lessin told attendees to get comfortable with the fact that a lot of treatment comes down to trial and error.

Again, he emphasized the value of the toolkit, which Dr. Hackell echoed.

“It’s a really nice roadmap to be able to follow and to explain how it requires two or three or four visits to treat these children well and get them started on treatment,” Dr. Hackell said. “It’s something that I recommend people use if they have not already done so to integrate ADHD care into their practices.”
 

Beginning the process

In figuring out how to structure visits, avoid addressing ADHD as a “by-the-way” issue, such as when a parent mentions it at the end of an appointment, Dr. Lessin said. Instead, start with an intake visit to determine whether you’re the right person to evaluate the child and hand out Parent and Teacher Evaluation scales to begin the process. Next, do the evaluation, discuss the process with the family, determine how treatment will work, and then look at comorbidities.

Visit settings can be traditional face-to-face visits, which are particularly helpful for intake visits, Dr. Lessin said, or telehealth, especially during the pandemic. In-person visits allow you more easily to make eye contact with the child and observe the parent and child behaviors and interactions, but telehealth often is adequate for titrating medication, discussing side effects, monitoring, and similar follow-up.

“Coding practices are absolutely necessary to make your practice viable, much less make money,” Dr. Lessin said. “Doing good for people and doing well for yourself are not mutually exclusive. You have to figure out a way to make it work economically for the practice or else you’re just not going to do it.”

He reminded pediatricians to code for evaluation, monitoring scales, and care coordination, and to be prepared for the big change of new coding rules coming in 2021.

“For better or worse, documentation is the key to survival in medical practice these days,” Dr. Lessin said. “This is true for all medical care these days, but it’s particularly true for ADHD because visits are all high intensity codes and should be coded as such.”

Templates are fine, he said, but box-checking isn’t enough; leave space for a narrative that explains the case complexity and decision-making.
 

Training staff is essential

It’s utterly essential to train all office staff, Dr. Lessin said. “I can’t tell you how important this step is because no matter how much you know or how well you understand what you want to do, you’re going to be frustrated at every turn if your staff and colleagues don’t get this stuff.”

That includes training those who make appointments, front desk staff, clinical staff, and practice colleagues regarding coding, scheduling, visit protocols, and similar procedures. Cheat sheets can be helpful here.

“They must understand the structure of the visits, what happens at each visit, the time requirements for each visit, and the standard follow-up,” including, for clinical staff, what handouts and rating scales to use, he said. “And if they aren’t sure what the parents needs or what you want, make sure they know to contact you.”

Colleagues also need to learn to properly document visits to justify coding and complexity, and not dump all patients on you.

One challenge that Dr. Lessin acknowledged as a common problem is that many pediatricians don’t have subspecialists they can refer patients to.

“Sadly, this is true almost everywhere, in rural and in big cities, near big medical centers and only local hospitals,” Dr. Lessin said. “This another reason why I think you need to learn and treat this illness to the extent you can. Your families need you.”

Dr. Hackell particularly appreciated this point, emphasizing again how important it is that pediatricians manage ADHD care of their patients.

“We see their day-to-day life, and that’s where this impacts these kids and families,” he said. “It’s really rewarding to do from my personal experience because you can really make a really big difference in these kids’ lives when they’re younger and even as they get older. When you get the rewards, it makes the work all worthwhile.”

Dr. Lessin and Dr. Hackell said they have no relevant financial disclosures.

Across the United States, an explosive growth in recreational facilities boasting trampolines coincides with alarming growth in trampoline-related injuries in children, including those to the spine, according to new research.

Among youths, the risk for trampoline park–related fractures is about three times higher than for home-based trampoline fractures, said study author Serena Freiman, MD, of Washington University, St. Louis.

Recreational sports facilities with trampolines “pose a public health hazard,” Dr. Freiman said during a presentation at the virtual American Academy of Pediatrics 2020 National Conference.

“There aren’t any set regulations for these parks, so the American Society for Testing and Materials released a set of standards, but only Michigan and Arizona enforced those,” Dr. Freiman explained.

“Hopefully, since we’re showing a significant increased risk of injuries, the federal government will enforce regulations throughout the United States,” she said in an interview.

The first trampoline park in the United States opened in 2004, Dr. Freiman said. By 2018, there were more than 800 recreational facilities with trampolines across the country. This rapid growth coincided with a 45% increase in ED visits for trampoline-related injuries, from 61,509 in 2014 to more than 89,000 in 2017.

“There’s been exponential growth since their founding,” she said, “and with that we’ve also seen an exponential growth in injuries, whereas home injuries [from trampolines] remained stable during that time period.”

To assess the rates of trampoline-related injuries, Dr. Freiman and colleague analyzed data from the National Electronic Injury Surveillance System (NEISS). They included all patients whose records include a code for trampoline injury and who presented to a hospital ED between 1998 and 2017. They compared home trampoline injuries with those sustained at recreational facilities.

During the study period, more than 1.37 million patients presented to the ED for trampoline-related injuries. Of those, 125,473 occurred at recreational facilities, and 1.22 million occurred at home. Injuries at trampoline parks increased 90-fold between 2004 and 2017 (0.04 per 10,000 ED visits in 2004 to 0.9 per 10,000 in 2017), with 69% of those injuries occurring between 2012 and 2017.

Home-based trampoline injuries dropped during the study period, from 2.8 per 10,000 ED visits in 2014 to 1.6 in 2017.

Patients injured at trampoline facilities tended to present at large hospitals, Dr. Freiman noted, likely because of these parks being located in more populated regions.

The type of injury differed between locations. Severe injuries, such as spine fractures, occurred three times as often at trampoline parks than at home (2.7% vs. 0.9%; P = .016).

Internal organ injuries occurred more frequently on home-based trampolines (20.1% vs. 2.3% ; P < .001), whereas strains and sprains were more common at trampoline parks (32% vs. 51%; P < .001).

“Since home trampolines are often off the ground, I would speculate that you’re more likely to hit the edge of the trampoline or fall from it,” she said, “whereas at recreational sports facilities, there are often multiple jumpers, and you’re not falling off ― you’re falling in general or colliding with other jumpers.”

The authors noted that lower-extremity fractures occurred more often in trampoline parks (35.6% home vs. 51.7% parks; P < .0001), and upper-extremity fractures were more prevalent from home trampolines (60.2% vs. 42.5%; P < .0001). Also, a larger proportion of trampoline park injuries occurred among adolescents and young adults aged 15-34 years in comparison with home-based injuries (28.2% vs. 13.6%). No race or gender differences were noted.

Dr. Freiman noted one possible study limitation. The NEISS data only included patients tagged as being injured on trampolines, so “it may be incomplete,” she said. “Also, anyone presenting to their personal physician or urgent care centers weren’t included, so there’s likely an underestimation of cases.

“We hope people gain a better understanding of risks associated with these facilities and dive further into research and [to] identify areas that can be improved within these facilities,” Dr. Freiman added.

To drive home the importance of caution, physicians should relay data about trampoline injuries to parents and children, said Amber Hardeman, MD, MPH, MBA, of Tulane University, New Orleans.

Because most injuries at trampoline parks occur among people aged 15-34 years, Dr. Hardeman said, babysitters or parents may also “be indulging as well” when they take their young charges there to jump.

“They need to understand how to set a good example and teach kids proper safety precautions, such as not jumping too close together or maybe not doing things like splits,” she said.

Dr. Hardeman said in an interview that “there’s a lot of truth” to the study’s conclusion that recreational sports facilities with trampolines pose a public health hazard. Additional research should focus on what types of safety measures trampoline parks may be taking. Such measures could include increased padding, hiring more staff, or placing firmer limits on how many people can jump in each area at a time.

“Some centers don’t have as much padding around as others, and some allow multiple children to jump in the same area at the same time,” she said. “What exact scenarios are kids encountering more so than being on a trampoline at home?

“Trampoline centers are exciting and fun, but they are a hazard, and the fact that such an aggregate population being impacted by increasing numbers shows it’s definitely an issue right now,” Dr. Hardeman added.

Dr. Freiman and Dr. Hardeman have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Across the United States, an explosive growth in recreational facilities boasting trampolines coincides with alarming growth in trampoline-related injuries in children, including those to the spine, according to new research.

Among youths, the risk for trampoline park–related fractures is about three times higher than for home-based trampoline fractures, said study author Serena Freiman, MD, of Washington University, St. Louis.

Recreational sports facilities with trampolines “pose a public health hazard,” Dr. Freiman said during a presentation at the virtual American Academy of Pediatrics 2020 National Conference.

“There aren’t any set regulations for these parks, so the American Society for Testing and Materials released a set of standards, but only Michigan and Arizona enforced those,” Dr. Freiman explained.

“Hopefully, since we’re showing a significant increased risk of injuries, the federal government will enforce regulations throughout the United States,” she said in an interview.

The first trampoline park in the United States opened in 2004, Dr. Freiman said. By 2018, there were more than 800 recreational facilities with trampolines across the country. This rapid growth coincided with a 45% increase in ED visits for trampoline-related injuries, from 61,509 in 2014 to more than 89,000 in 2017.

“There’s been exponential growth since their founding,” she said, “and with that we’ve also seen an exponential growth in injuries, whereas home injuries [from trampolines] remained stable during that time period.”

To assess the rates of trampoline-related injuries, Dr. Freiman and colleague analyzed data from the National Electronic Injury Surveillance System (NEISS). They included all patients whose records include a code for trampoline injury and who presented to a hospital ED between 1998 and 2017. They compared home trampoline injuries with those sustained at recreational facilities.

During the study period, more than 1.37 million patients presented to the ED for trampoline-related injuries. Of those, 125,473 occurred at recreational facilities, and 1.22 million occurred at home. Injuries at trampoline parks increased 90-fold between 2004 and 2017 (0.04 per 10,000 ED visits in 2004 to 0.9 per 10,000 in 2017), with 69% of those injuries occurring between 2012 and 2017.

Home-based trampoline injuries dropped during the study period, from 2.8 per 10,000 ED visits in 2014 to 1.6 in 2017.

Patients injured at trampoline facilities tended to present at large hospitals, Dr. Freiman noted, likely because of these parks being located in more populated regions.

The type of injury differed between locations. Severe injuries, such as spine fractures, occurred three times as often at trampoline parks than at home (2.7% vs. 0.9%; P = .016).

Internal organ injuries occurred more frequently on home-based trampolines (20.1% vs. 2.3% ; P < .001), whereas strains and sprains were more common at trampoline parks (32% vs. 51%; P < .001).

“Since home trampolines are often off the ground, I would speculate that you’re more likely to hit the edge of the trampoline or fall from it,” she said, “whereas at recreational sports facilities, there are often multiple jumpers, and you’re not falling off ― you’re falling in general or colliding with other jumpers.”

The authors noted that lower-extremity fractures occurred more often in trampoline parks (35.6% home vs. 51.7% parks; P < .0001), and upper-extremity fractures were more prevalent from home trampolines (60.2% vs. 42.5%; P < .0001). Also, a larger proportion of trampoline park injuries occurred among adolescents and young adults aged 15-34 years in comparison with home-based injuries (28.2% vs. 13.6%). No race or gender differences were noted.

Dr. Freiman noted one possible study limitation. The NEISS data only included patients tagged as being injured on trampolines, so “it may be incomplete,” she said. “Also, anyone presenting to their personal physician or urgent care centers weren’t included, so there’s likely an underestimation of cases.

“We hope people gain a better understanding of risks associated with these facilities and dive further into research and [to] identify areas that can be improved within these facilities,” Dr. Freiman added.

To drive home the importance of caution, physicians should relay data about trampoline injuries to parents and children, said Amber Hardeman, MD, MPH, MBA, of Tulane University, New Orleans.

Because most injuries at trampoline parks occur among people aged 15-34 years, Dr. Hardeman said, babysitters or parents may also “be indulging as well” when they take their young charges there to jump.

“They need to understand how to set a good example and teach kids proper safety precautions, such as not jumping too close together or maybe not doing things like splits,” she said.

Dr. Hardeman said in an interview that “there’s a lot of truth” to the study’s conclusion that recreational sports facilities with trampolines pose a public health hazard. Additional research should focus on what types of safety measures trampoline parks may be taking. Such measures could include increased padding, hiring more staff, or placing firmer limits on how many people can jump in each area at a time.

“Some centers don’t have as much padding around as others, and some allow multiple children to jump in the same area at the same time,” she said. “What exact scenarios are kids encountering more so than being on a trampoline at home?

“Trampoline centers are exciting and fun, but they are a hazard, and the fact that such an aggregate population being impacted by increasing numbers shows it’s definitely an issue right now,” Dr. Hardeman added.

Dr. Freiman and Dr. Hardeman have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Across the United States, an explosive growth in recreational facilities boasting trampolines coincides with alarming growth in trampoline-related injuries in children, including those to the spine, according to new research.

Among youths, the risk for trampoline park–related fractures is about three times higher than for home-based trampoline fractures, said study author Serena Freiman, MD, of Washington University, St. Louis.

Recreational sports facilities with trampolines “pose a public health hazard,” Dr. Freiman said during a presentation at the virtual American Academy of Pediatrics 2020 National Conference.

“There aren’t any set regulations for these parks, so the American Society for Testing and Materials released a set of standards, but only Michigan and Arizona enforced those,” Dr. Freiman explained.

“Hopefully, since we’re showing a significant increased risk of injuries, the federal government will enforce regulations throughout the United States,” she said in an interview.

The first trampoline park in the United States opened in 2004, Dr. Freiman said. By 2018, there were more than 800 recreational facilities with trampolines across the country. This rapid growth coincided with a 45% increase in ED visits for trampoline-related injuries, from 61,509 in 2014 to more than 89,000 in 2017.

“There’s been exponential growth since their founding,” she said, “and with that we’ve also seen an exponential growth in injuries, whereas home injuries [from trampolines] remained stable during that time period.”

To assess the rates of trampoline-related injuries, Dr. Freiman and colleague analyzed data from the National Electronic Injury Surveillance System (NEISS). They included all patients whose records include a code for trampoline injury and who presented to a hospital ED between 1998 and 2017. They compared home trampoline injuries with those sustained at recreational facilities.

During the study period, more than 1.37 million patients presented to the ED for trampoline-related injuries. Of those, 125,473 occurred at recreational facilities, and 1.22 million occurred at home. Injuries at trampoline parks increased 90-fold between 2004 and 2017 (0.04 per 10,000 ED visits in 2004 to 0.9 per 10,000 in 2017), with 69% of those injuries occurring between 2012 and 2017.

Home-based trampoline injuries dropped during the study period, from 2.8 per 10,000 ED visits in 2014 to 1.6 in 2017.

Patients injured at trampoline facilities tended to present at large hospitals, Dr. Freiman noted, likely because of these parks being located in more populated regions.

The type of injury differed between locations. Severe injuries, such as spine fractures, occurred three times as often at trampoline parks than at home (2.7% vs. 0.9%; P = .016).

Internal organ injuries occurred more frequently on home-based trampolines (20.1% vs. 2.3% ; P < .001), whereas strains and sprains were more common at trampoline parks (32% vs. 51%; P < .001).

“Since home trampolines are often off the ground, I would speculate that you’re more likely to hit the edge of the trampoline or fall from it,” she said, “whereas at recreational sports facilities, there are often multiple jumpers, and you’re not falling off ― you’re falling in general or colliding with other jumpers.”

The authors noted that lower-extremity fractures occurred more often in trampoline parks (35.6% home vs. 51.7% parks; P < .0001), and upper-extremity fractures were more prevalent from home trampolines (60.2% vs. 42.5%; P < .0001). Also, a larger proportion of trampoline park injuries occurred among adolescents and young adults aged 15-34 years in comparison with home-based injuries (28.2% vs. 13.6%). No race or gender differences were noted.

Dr. Freiman noted one possible study limitation. The NEISS data only included patients tagged as being injured on trampolines, so “it may be incomplete,” she said. “Also, anyone presenting to their personal physician or urgent care centers weren’t included, so there’s likely an underestimation of cases.

“We hope people gain a better understanding of risks associated with these facilities and dive further into research and [to] identify areas that can be improved within these facilities,” Dr. Freiman added.

To drive home the importance of caution, physicians should relay data about trampoline injuries to parents and children, said Amber Hardeman, MD, MPH, MBA, of Tulane University, New Orleans.

Because most injuries at trampoline parks occur among people aged 15-34 years, Dr. Hardeman said, babysitters or parents may also “be indulging as well” when they take their young charges there to jump.

“They need to understand how to set a good example and teach kids proper safety precautions, such as not jumping too close together or maybe not doing things like splits,” she said.

Dr. Hardeman said in an interview that “there’s a lot of truth” to the study’s conclusion that recreational sports facilities with trampolines pose a public health hazard. Additional research should focus on what types of safety measures trampoline parks may be taking. Such measures could include increased padding, hiring more staff, or placing firmer limits on how many people can jump in each area at a time.

“Some centers don’t have as much padding around as others, and some allow multiple children to jump in the same area at the same time,” she said. “What exact scenarios are kids encountering more so than being on a trampoline at home?

“Trampoline centers are exciting and fun, but they are a hazard, and the fact that such an aggregate population being impacted by increasing numbers shows it’s definitely an issue right now,” Dr. Hardeman added.

Dr. Freiman and Dr. Hardeman have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Concussions resulting from assaults and sports may not be entirely similar in children and youth, researchers report. For example, more than twice as many children who experience assault-related concussions report declines in school grades, compared with those with sports-related concussions.

The researchers also saw trends suggesting there are clinically meaningful differences between the groups in terms of longer periods before return to school, symptom resolution, and full physician clearance after injury. Patients with assault-related concussion were also less likely to be referred to specialists and to receive initial visio-vestibular testing.

The research, conducted over a 2-year period with 124 children and adolescents aged 8-18 years, stands out by focusing on lesser-understood outcomes of concussions related to assault, said study author Margaret Means, MD, of Children’s Hospital of Philadelphia.

“From my standpoint as a pediatrician and training to be a pediatric neurologist, I want to make sure I come into each patient encounter with as much understanding as I can and to treat all the associated factors adequately,” Dr. Means said.

“It’s so important to recognize that one disease process, as we categorize it, such as concussion, doesn’t mean all your patients are going to have the same needs or outcomes,” Dr. Means said in an interview. “We focus a lot on sports-related concussion, and that’s very important, but unless we recognize [that] a child who presents to the emergency department after assault could have a concussion, they are much less likely to be screened for certain concussion aspects.”

The research was presented at the virtual American Academy of Pediatrics National Conference.

Dr. Means and her colleagues undertook a retrospective chart review comparing 62 patients with assault-related concussions to the same number with sports- and recreation-related concussion between 2012 and 2014.

Patients with assault-related concussion were more likely to be Black, publicly insured, and to initially present to the emergency department. Markedly fewer patients with assault-related concussions received visio-vestibular testing at their first visit, compared with sports concussion patients (25% vs. 75%; P < .001).

Although the total number of reported physical, cognitive, emotional, and sleep symptoms didn’t differ between the groups during their recovery period, patients with assault-related concussions reported drops in school grades more than twice as often as those youths with sports concussion (47% vs. 20%; P = .012).

“The decline in grades in this group suggests it takes longer for children to become asymptomatic from concussion related to an assault,” Dr. Means explained. “We need to investigate that further to hopefully address that difference and help kids to not experience that decline in grades.”

Clinically meaningful but not statistically significant differences were revealed in the rate of specialist referral for those with assault-related vs. sports-related concussions (53% vs. 40%; P = .086). Patients with assault-related concussions also tended to take longer to return to school than patients with sports-related concussions (11 days vs. 8 days; P = .252); to experience symptom resolution (13.5 days vs. 11.5 days; P = .389); and to receive full physician clearance (35 days vs. 24 days; P = .332).

“With a child experiencing interpersonal assault, obviously there are a lot of different factors that need to be addressed in terms of the emotional and physical response to the trauma,” Dr. Means said. “But in terms of to-dos – and I’d love for the medical community to recognize this more readily – maybe we could develop some type of screening tool for the population experiencing assault so we might be more aware they’ve also experienced concussion.

“As a clinician, it’s important to understand research like this so you see some nuances to how each patient experiences this,” she added, “and tailor your approach to them for the best treatment and outcomes.”

Carrie Esopenko, PhD, of Rutgers University in Newark, N.J., agreed with Dr. Means that focusing on youth concussions that are not the result of sports has been largely neglected.

“We haven’t really realized concussion is occurring more on a milder scale of abusive head injuries,” said Dr. Esopenko, who conducts research on intimate partner violence but wasn’t involved in the new study.

“Head injury is the key phrase in sports right now, and I think we’re just starting to realize how prevalent the issue is in interpersonal and intimate partner violence,” Dr. Esopenko said in an interview.

“Clinicians need to do a full concussion battery on kids coming in and be aware these symptoms can be treated similarly even if they’re from a different mechanism,” she added. “It’s still the same organ impacted. These kids are still struggling, even though they’re not injured on a sports field.”

Dr. Means and Dr. Esopenko have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Concussions resulting from assaults and sports may not be entirely similar in children and youth, researchers report. For example, more than twice as many children who experience assault-related concussions report declines in school grades, compared with those with sports-related concussions.

The researchers also saw trends suggesting there are clinically meaningful differences between the groups in terms of longer periods before return to school, symptom resolution, and full physician clearance after injury. Patients with assault-related concussion were also less likely to be referred to specialists and to receive initial visio-vestibular testing.

The research, conducted over a 2-year period with 124 children and adolescents aged 8-18 years, stands out by focusing on lesser-understood outcomes of concussions related to assault, said study author Margaret Means, MD, of Children’s Hospital of Philadelphia.

“From my standpoint as a pediatrician and training to be a pediatric neurologist, I want to make sure I come into each patient encounter with as much understanding as I can and to treat all the associated factors adequately,” Dr. Means said.

“It’s so important to recognize that one disease process, as we categorize it, such as concussion, doesn’t mean all your patients are going to have the same needs or outcomes,” Dr. Means said in an interview. “We focus a lot on sports-related concussion, and that’s very important, but unless we recognize [that] a child who presents to the emergency department after assault could have a concussion, they are much less likely to be screened for certain concussion aspects.”

The research was presented at the virtual American Academy of Pediatrics National Conference.

Dr. Means and her colleagues undertook a retrospective chart review comparing 62 patients with assault-related concussions to the same number with sports- and recreation-related concussion between 2012 and 2014.

Patients with assault-related concussion were more likely to be Black, publicly insured, and to initially present to the emergency department. Markedly fewer patients with assault-related concussions received visio-vestibular testing at their first visit, compared with sports concussion patients (25% vs. 75%; P < .001).

Although the total number of reported physical, cognitive, emotional, and sleep symptoms didn’t differ between the groups during their recovery period, patients with assault-related concussions reported drops in school grades more than twice as often as those youths with sports concussion (47% vs. 20%; P = .012).

“The decline in grades in this group suggests it takes longer for children to become asymptomatic from concussion related to an assault,” Dr. Means explained. “We need to investigate that further to hopefully address that difference and help kids to not experience that decline in grades.”

Clinically meaningful but not statistically significant differences were revealed in the rate of specialist referral for those with assault-related vs. sports-related concussions (53% vs. 40%; P = .086). Patients with assault-related concussions also tended to take longer to return to school than patients with sports-related concussions (11 days vs. 8 days; P = .252); to experience symptom resolution (13.5 days vs. 11.5 days; P = .389); and to receive full physician clearance (35 days vs. 24 days; P = .332).

“With a child experiencing interpersonal assault, obviously there are a lot of different factors that need to be addressed in terms of the emotional and physical response to the trauma,” Dr. Means said. “But in terms of to-dos – and I’d love for the medical community to recognize this more readily – maybe we could develop some type of screening tool for the population experiencing assault so we might be more aware they’ve also experienced concussion.

“As a clinician, it’s important to understand research like this so you see some nuances to how each patient experiences this,” she added, “and tailor your approach to them for the best treatment and outcomes.”

Carrie Esopenko, PhD, of Rutgers University in Newark, N.J., agreed with Dr. Means that focusing on youth concussions that are not the result of sports has been largely neglected.

“We haven’t really realized concussion is occurring more on a milder scale of abusive head injuries,” said Dr. Esopenko, who conducts research on intimate partner violence but wasn’t involved in the new study.

“Head injury is the key phrase in sports right now, and I think we’re just starting to realize how prevalent the issue is in interpersonal and intimate partner violence,” Dr. Esopenko said in an interview.

“Clinicians need to do a full concussion battery on kids coming in and be aware these symptoms can be treated similarly even if they’re from a different mechanism,” she added. “It’s still the same organ impacted. These kids are still struggling, even though they’re not injured on a sports field.”

Dr. Means and Dr. Esopenko have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Concussions resulting from assaults and sports may not be entirely similar in children and youth, researchers report. For example, more than twice as many children who experience assault-related concussions report declines in school grades, compared with those with sports-related concussions.

The researchers also saw trends suggesting there are clinically meaningful differences between the groups in terms of longer periods before return to school, symptom resolution, and full physician clearance after injury. Patients with assault-related concussion were also less likely to be referred to specialists and to receive initial visio-vestibular testing.

The research, conducted over a 2-year period with 124 children and adolescents aged 8-18 years, stands out by focusing on lesser-understood outcomes of concussions related to assault, said study author Margaret Means, MD, of Children’s Hospital of Philadelphia.

“From my standpoint as a pediatrician and training to be a pediatric neurologist, I want to make sure I come into each patient encounter with as much understanding as I can and to treat all the associated factors adequately,” Dr. Means said.

“It’s so important to recognize that one disease process, as we categorize it, such as concussion, doesn’t mean all your patients are going to have the same needs or outcomes,” Dr. Means said in an interview. “We focus a lot on sports-related concussion, and that’s very important, but unless we recognize [that] a child who presents to the emergency department after assault could have a concussion, they are much less likely to be screened for certain concussion aspects.”

The research was presented at the virtual American Academy of Pediatrics National Conference.

Dr. Means and her colleagues undertook a retrospective chart review comparing 62 patients with assault-related concussions to the same number with sports- and recreation-related concussion between 2012 and 2014.

Patients with assault-related concussion were more likely to be Black, publicly insured, and to initially present to the emergency department. Markedly fewer patients with assault-related concussions received visio-vestibular testing at their first visit, compared with sports concussion patients (25% vs. 75%; P < .001).

Although the total number of reported physical, cognitive, emotional, and sleep symptoms didn’t differ between the groups during their recovery period, patients with assault-related concussions reported drops in school grades more than twice as often as those youths with sports concussion (47% vs. 20%; P = .012).

“The decline in grades in this group suggests it takes longer for children to become asymptomatic from concussion related to an assault,” Dr. Means explained. “We need to investigate that further to hopefully address that difference and help kids to not experience that decline in grades.”

Clinically meaningful but not statistically significant differences were revealed in the rate of specialist referral for those with assault-related vs. sports-related concussions (53% vs. 40%; P = .086). Patients with assault-related concussions also tended to take longer to return to school than patients with sports-related concussions (11 days vs. 8 days; P = .252); to experience symptom resolution (13.5 days vs. 11.5 days; P = .389); and to receive full physician clearance (35 days vs. 24 days; P = .332).

“With a child experiencing interpersonal assault, obviously there are a lot of different factors that need to be addressed in terms of the emotional and physical response to the trauma,” Dr. Means said. “But in terms of to-dos – and I’d love for the medical community to recognize this more readily – maybe we could develop some type of screening tool for the population experiencing assault so we might be more aware they’ve also experienced concussion.

“As a clinician, it’s important to understand research like this so you see some nuances to how each patient experiences this,” she added, “and tailor your approach to them for the best treatment and outcomes.”

Carrie Esopenko, PhD, of Rutgers University in Newark, N.J., agreed with Dr. Means that focusing on youth concussions that are not the result of sports has been largely neglected.

“We haven’t really realized concussion is occurring more on a milder scale of abusive head injuries,” said Dr. Esopenko, who conducts research on intimate partner violence but wasn’t involved in the new study.

“Head injury is the key phrase in sports right now, and I think we’re just starting to realize how prevalent the issue is in interpersonal and intimate partner violence,” Dr. Esopenko said in an interview.

“Clinicians need to do a full concussion battery on kids coming in and be aware these symptoms can be treated similarly even if they’re from a different mechanism,” she added. “It’s still the same organ impacted. These kids are still struggling, even though they’re not injured on a sports field.”

Dr. Means and Dr. Esopenko have disclosed no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

“I worry that vaccines are going to be sold like magic powder that we sprinkle across the land and make the virus go away,” Paul Offit, MD, said at the virtual American Academy of Pediatrics (AAP) 2020 National Conference. “That’s not true.”

Even after effective vaccines for SARS-CoV-2 are in widespread use, wearing masks will still be advisable to prevent COVID-19, according to Dr. Offit, director of the Vaccine Education Center and an attending physician in the Division of Infectious Diseases at Children’s Hospital of Philadelphia.

“I think we can get a vaccine that’s 75%-80% effective at preventing mild to moderate disease, but that means one of every four people can still get moderate to severe disease,” Dr. Offit continued.

And that’s if there is high uptake of the vaccine, which may not be the case. Recent polls have suggested there is considerable concern about the pending vaccines.

“It’s somewhat understandable,” Dr. Offitt acknowledged, especially given the “frightening” language used to describe vaccine development. Terms such as “warp speed” may suggest that haste might trump safety considerations. Before COVID-19, the fastest vaccine ever developed was for mumps, he said, with the virus isolated in 1963 and a commercial product available in 1967.
 

Addressing hesitancy in clinics

In a wide-ranging livestream plenary presentation, Dr. Offit, coinventor of a rotavirus vaccine, shed light on SARS-CoV-2 vaccine development and his impressions of vaccine hesitancy among patients and families. He also offered advice for how to reassure those skeptical of the safety and efficacy of any SARS-COV-2 vaccine, given the accelerated development process.

With more than 180 different vaccines in various stages of investigation, Dr. Offit called the effort to develop COVID-19 vaccines “unprecedented.” Part of that is a result of governments relieving pharmaceutical companies of much of the typical financial risk – which often climbs to hundreds of millions of dollars – by underwriting the costs of vaccine development to battle the pandemic-inducing virus, he said.

But this very swiftness is also stoking antivaccine sentiment. Dr. Offit, part of vaccine advisory groups for the National Institutes of Health and U.S. Food and Drug Administration, cited recent research reporting nearly half of American adults definitely or probably would not get a COVID-19 vaccine if it were available today.

“One way you convince skeptics is with data presented in a clear, compassionate, and compelling way,” he said.

“The other group is vaccine cynics, who are basically conspiracy theorists who believe pharmaceutical companies control the world, the government, the medical establishment. I think there’s no talking them down from this.”

Numerous strategies are being used in COVID-19 vaccine development, he noted, including messenger RNA, DNA, viral vectors, purified protein, and whole killed virus. Dr. Offit believes any candidates approved for distribution will likely be in the range of 75% effective at preventing mild to moderate symptoms.

But clinicians should be ready to face immediate questions of safety. “Even if this vaccination is given to 20,000 [trial participants] safely, that’s not 20 million,” Dr. Offit said. “Anyone could reasonably ask questions about if it causes rare, serious side effects.

“The good news is, there are systems in place,” such as adverse event reporting systems, to identify rare events, even those that occur in one in a million vaccine recipients. Reminding patients of that continued surveillance can be reassuring.

Another reassuring point is that COVID-19 vaccine trial participants have included people from many diverse populations, he said. But children, notably absent so far, should be added to trials immediately, Dr. Offit contends.

“This is going to be important when you consider strategies to get children universally back into school,” he said, which is a “critical issue” from both learning and wellness standpoints. “It breaks my heart that we’ve been unable to do this when other countries have.”
 

Transparency will be paramount

While presenting data transparently to patients is key in helping them accept COVID-19 vaccination, Dr. Offit said, he also believes “telling stories” can be just as effective, if not more so. When the varicella vaccine was approved in 1995, he said, the “uptake the first few years was pretty miserable” until public service messaging emphasized that some children die from chickenpox.

“Fear works,” he said. “You always worry about pushback of something being oversold, but hopefully we’re scared enough about this virus” to convince people that vaccination is wise. “I do think personal stories carry weight on both sides,” Dr. Offit said.

Mark Sawyer, MD, of University of California San Diego School of Medicine and Rady Children’s Hospital in San Diego, California, said Offit’s presentation offered important takeaways for clinicians about how to broach the topic of COVID-19 vaccination with patients and families.

“We need to communicate clearly and transparently to patients about what we do and don’t know” about the vaccines, Dr. Sawyer said in an interview. “We will know if they have common side effects, but we will not know about very rare side effects until we have used the vaccines for a while.

“We will know how well the vaccine works over the short-term, but we won’t know over the long term,” added Dr. Sawyer, a member of the AAP Committee on Infectious Diseases.

“We can reassure the community that SARS-CoV-2 vaccines are being evaluated in trials in the same way and with the same thoroughness as other vaccines have been,” he said. “That should give people confidence that shortcuts are not being taken with regard to safety and effectiveness evaluations.”

Dr. Offit and Dr. Sawyer have disclosed no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.

“I worry that vaccines are going to be sold like magic powder that we sprinkle across the land and make the virus go away,” Paul Offit, MD, said at the virtual American Academy of Pediatrics (AAP) 2020 National Conference. “That’s not true.”

Even after effective vaccines for SARS-CoV-2 are in widespread use, wearing masks will still be advisable to prevent COVID-19, according to Dr. Offit, director of the Vaccine Education Center and an attending physician in the Division of Infectious Diseases at Children’s Hospital of Philadelphia.

“I think we can get a vaccine that’s 75%-80% effective at preventing mild to moderate disease, but that means one of every four people can still get moderate to severe disease,” Dr. Offit continued.

And that’s if there is high uptake of the vaccine, which may not be the case. Recent polls have suggested there is considerable concern about the pending vaccines.

“It’s somewhat understandable,” Dr. Offitt acknowledged, especially given the “frightening” language used to describe vaccine development. Terms such as “warp speed” may suggest that haste might trump safety considerations. Before COVID-19, the fastest vaccine ever developed was for mumps, he said, with the virus isolated in 1963 and a commercial product available in 1967.
 

Addressing hesitancy in clinics

In a wide-ranging livestream plenary presentation, Dr. Offit, coinventor of a rotavirus vaccine, shed light on SARS-CoV-2 vaccine development and his impressions of vaccine hesitancy among patients and families. He also offered advice for how to reassure those skeptical of the safety and efficacy of any SARS-COV-2 vaccine, given the accelerated development process.

With more than 180 different vaccines in various stages of investigation, Dr. Offit called the effort to develop COVID-19 vaccines “unprecedented.” Part of that is a result of governments relieving pharmaceutical companies of much of the typical financial risk – which often climbs to hundreds of millions of dollars – by underwriting the costs of vaccine development to battle the pandemic-inducing virus, he said.

But this very swiftness is also stoking antivaccine sentiment. Dr. Offit, part of vaccine advisory groups for the National Institutes of Health and U.S. Food and Drug Administration, cited recent research reporting nearly half of American adults definitely or probably would not get a COVID-19 vaccine if it were available today.

“One way you convince skeptics is with data presented in a clear, compassionate, and compelling way,” he said.

“The other group is vaccine cynics, who are basically conspiracy theorists who believe pharmaceutical companies control the world, the government, the medical establishment. I think there’s no talking them down from this.”

Numerous strategies are being used in COVID-19 vaccine development, he noted, including messenger RNA, DNA, viral vectors, purified protein, and whole killed virus. Dr. Offit believes any candidates approved for distribution will likely be in the range of 75% effective at preventing mild to moderate symptoms.

But clinicians should be ready to face immediate questions of safety. “Even if this vaccination is given to 20,000 [trial participants] safely, that’s not 20 million,” Dr. Offit said. “Anyone could reasonably ask questions about if it causes rare, serious side effects.

“The good news is, there are systems in place,” such as adverse event reporting systems, to identify rare events, even those that occur in one in a million vaccine recipients. Reminding patients of that continued surveillance can be reassuring.

Another reassuring point is that COVID-19 vaccine trial participants have included people from many diverse populations, he said. But children, notably absent so far, should be added to trials immediately, Dr. Offit contends.

“This is going to be important when you consider strategies to get children universally back into school,” he said, which is a “critical issue” from both learning and wellness standpoints. “It breaks my heart that we’ve been unable to do this when other countries have.”
 

Transparency will be paramount

While presenting data transparently to patients is key in helping them accept COVID-19 vaccination, Dr. Offit said, he also believes “telling stories” can be just as effective, if not more so. When the varicella vaccine was approved in 1995, he said, the “uptake the first few years was pretty miserable” until public service messaging emphasized that some children die from chickenpox.

“Fear works,” he said. “You always worry about pushback of something being oversold, but hopefully we’re scared enough about this virus” to convince people that vaccination is wise. “I do think personal stories carry weight on both sides,” Dr. Offit said.

Mark Sawyer, MD, of University of California San Diego School of Medicine and Rady Children’s Hospital in San Diego, California, said Offit’s presentation offered important takeaways for clinicians about how to broach the topic of COVID-19 vaccination with patients and families.

“We need to communicate clearly and transparently to patients about what we do and don’t know” about the vaccines, Dr. Sawyer said in an interview. “We will know if they have common side effects, but we will not know about very rare side effects until we have used the vaccines for a while.

“We will know how well the vaccine works over the short-term, but we won’t know over the long term,” added Dr. Sawyer, a member of the AAP Committee on Infectious Diseases.

“We can reassure the community that SARS-CoV-2 vaccines are being evaluated in trials in the same way and with the same thoroughness as other vaccines have been,” he said. “That should give people confidence that shortcuts are not being taken with regard to safety and effectiveness evaluations.”

Dr. Offit and Dr. Sawyer have disclosed no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.

“I worry that vaccines are going to be sold like magic powder that we sprinkle across the land and make the virus go away,” Paul Offit, MD, said at the virtual American Academy of Pediatrics (AAP) 2020 National Conference. “That’s not true.”

Even after effective vaccines for SARS-CoV-2 are in widespread use, wearing masks will still be advisable to prevent COVID-19, according to Dr. Offit, director of the Vaccine Education Center and an attending physician in the Division of Infectious Diseases at Children’s Hospital of Philadelphia.

“I think we can get a vaccine that’s 75%-80% effective at preventing mild to moderate disease, but that means one of every four people can still get moderate to severe disease,” Dr. Offit continued.

And that’s if there is high uptake of the vaccine, which may not be the case. Recent polls have suggested there is considerable concern about the pending vaccines.

“It’s somewhat understandable,” Dr. Offitt acknowledged, especially given the “frightening” language used to describe vaccine development. Terms such as “warp speed” may suggest that haste might trump safety considerations. Before COVID-19, the fastest vaccine ever developed was for mumps, he said, with the virus isolated in 1963 and a commercial product available in 1967.
 

Addressing hesitancy in clinics

In a wide-ranging livestream plenary presentation, Dr. Offit, coinventor of a rotavirus vaccine, shed light on SARS-CoV-2 vaccine development and his impressions of vaccine hesitancy among patients and families. He also offered advice for how to reassure those skeptical of the safety and efficacy of any SARS-COV-2 vaccine, given the accelerated development process.

With more than 180 different vaccines in various stages of investigation, Dr. Offit called the effort to develop COVID-19 vaccines “unprecedented.” Part of that is a result of governments relieving pharmaceutical companies of much of the typical financial risk – which often climbs to hundreds of millions of dollars – by underwriting the costs of vaccine development to battle the pandemic-inducing virus, he said.

But this very swiftness is also stoking antivaccine sentiment. Dr. Offit, part of vaccine advisory groups for the National Institutes of Health and U.S. Food and Drug Administration, cited recent research reporting nearly half of American adults definitely or probably would not get a COVID-19 vaccine if it were available today.

“One way you convince skeptics is with data presented in a clear, compassionate, and compelling way,” he said.

“The other group is vaccine cynics, who are basically conspiracy theorists who believe pharmaceutical companies control the world, the government, the medical establishment. I think there’s no talking them down from this.”

Numerous strategies are being used in COVID-19 vaccine development, he noted, including messenger RNA, DNA, viral vectors, purified protein, and whole killed virus. Dr. Offit believes any candidates approved for distribution will likely be in the range of 75% effective at preventing mild to moderate symptoms.

But clinicians should be ready to face immediate questions of safety. “Even if this vaccination is given to 20,000 [trial participants] safely, that’s not 20 million,” Dr. Offit said. “Anyone could reasonably ask questions about if it causes rare, serious side effects.

“The good news is, there are systems in place,” such as adverse event reporting systems, to identify rare events, even those that occur in one in a million vaccine recipients. Reminding patients of that continued surveillance can be reassuring.

Another reassuring point is that COVID-19 vaccine trial participants have included people from many diverse populations, he said. But children, notably absent so far, should be added to trials immediately, Dr. Offit contends.

“This is going to be important when you consider strategies to get children universally back into school,” he said, which is a “critical issue” from both learning and wellness standpoints. “It breaks my heart that we’ve been unable to do this when other countries have.”
 

Transparency will be paramount

While presenting data transparently to patients is key in helping them accept COVID-19 vaccination, Dr. Offit said, he also believes “telling stories” can be just as effective, if not more so. When the varicella vaccine was approved in 1995, he said, the “uptake the first few years was pretty miserable” until public service messaging emphasized that some children die from chickenpox.

“Fear works,” he said. “You always worry about pushback of something being oversold, but hopefully we’re scared enough about this virus” to convince people that vaccination is wise. “I do think personal stories carry weight on both sides,” Dr. Offit said.

Mark Sawyer, MD, of University of California San Diego School of Medicine and Rady Children’s Hospital in San Diego, California, said Offit’s presentation offered important takeaways for clinicians about how to broach the topic of COVID-19 vaccination with patients and families.

“We need to communicate clearly and transparently to patients about what we do and don’t know” about the vaccines, Dr. Sawyer said in an interview. “We will know if they have common side effects, but we will not know about very rare side effects until we have used the vaccines for a while.

“We will know how well the vaccine works over the short-term, but we won’t know over the long term,” added Dr. Sawyer, a member of the AAP Committee on Infectious Diseases.

“We can reassure the community that SARS-CoV-2 vaccines are being evaluated in trials in the same way and with the same thoroughness as other vaccines have been,” he said. “That should give people confidence that shortcuts are not being taken with regard to safety and effectiveness evaluations.”

Dr. Offit and Dr. Sawyer have disclosed no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.

Practice management is the responsibility of every pediatrician, and leadership is more important than ever in a crisis like the COVID-19 pandemic.

kevajefimija/iStock/Getty Images

“Ultimately you have a critical role in ensuring that your practice remains sustainable so that you can continue to deliver great care,” Sue Kressly, MD, a retired pediatrician from Warrington, Pa., said at the virtual annual meeting of the American Academy of Pediatrics. “None of us escaped some impact of the COVID crisis, and many of us are going to experience lasting change.”

Dr. Kressly and Suzanne Berman, MD, a pediatrician in central Tennessee, presented a live online session on how the pandemic is affecting practices and how pediatricians can effectively address those challenges.
 

Three ways a crisis impacts practices

“When a practice experiences a crisis, it really exposes what your practice is made of, for better or for worse,” Dr. Berman said. “The COVID crisis has been profound and broad and long enough to really stress the core tensile strength of practices along at least three axes.” Those are staffing, financial health, and partnerships.

It’s a normal human response to enter survival mode during a crisis, so staff management becomes more important than ever. Some things to consider are whether you have a truly collaborative team culture in your practice and whether you’re really listening to the staff’s struggles and suggestions.

“Staffing challenges can be very difficult,” Dr. Berman said. “Permitting staff to work from home is the single biggest thing you can do when staff needs to self-isolate.”

Financially, most medical practices have adequate cash on hand not to have to pay close attention to the numbers, Dr. Kressly said, but if physicians are looking at their books for the first time during a crisis, they have no way of knowing what their baseline expectations should be or how much to worry about their finances. It’s important to understand your practice’s or department’s budget.

Jesse Hackell, MD, a private practice pediatrician in a suburb of New York City and vice president of the New York AAP Chapter 3, attended the session and appreciated this point on finances.

“In order to provide good quality care to kids, you need to be financially successful because otherwise you’ll close your doors,” Dr. Hackell said in an interview. “It’s making yourself available to be able to provide care.”

Stressors among partners during a crisis arise from responding to the challenges of the crisis, such as who should be impacted by pay cuts or furloughs, how to account for overhead, how to distribute revenue and how to divide the work equitably. Other issues include how to protect higher risk providers fairly and how to shift schedules or case load based on unforeseen events, including quarantining.

“There is no ‘fair’ in a crisis,” Dr. Berman said. “We must use the equity paradigm to be sure everyone has what they need to survive and have the best outcome possible.”

The speakers also discussed the importance of a practice’s situation before the pandemic began, a point that resonated with attendee Jason Terk, MD, a pediatrician who practices in a large pediatric health care system near Fort Worth, Texas.

“Just like the pandemic impacts the health of people in different ways based upon their baseline health, the pandemic impacts practices in different ways based on the practice’s baseline health,” he said in an interview. “If you had good operations, a good culture, good communication and all those other good indicators of practice health before, then you stood a much better chance of surviving the pandemic as a practice than practices that had weaknesses before.”

The size of a practice did not necessarily predict the impact of the crisis, Dr. Berman said. Rather, practices with good patient engagement, active recall programs, and good fiscal planning did better.

“One of the most useful takeaways is that flexibility is key,” Dr. Hackell said. “We had never seen anything like this before,” he said in an interview. “From the start we had no idea what was going to work. Try something and see if it works. If it fails, try something else. We were all operating blind here.”

The focus of most practices in the spring was on well visits, chronic care follow-up, and telehealth. Going into fall and winter, innovation will be necessary to provide appropriate care for all children while keeping in mind that the choices pediatricians make will have long-lasting implications for their staff and patients. The speakers stressed the importance of communication and transparency within the office team and to patients and the community.

Dr. Hackell appreciated the speakers’ point that kids need care, and pediatricians need to meet that need.

“Kids need well care and immunizations, and kids get sick and need sick care,” he said. “Parents need a lot more reassurance during times like this. We need to be able to provide that care and be sure that we do it safely. To give the right care at the right time in the right location is key.”
 

Making practice adaptations

In balancing risk and access to care, Dr. Kressly described the importance of multiple interventions, including managing some patients out of the office and making physical changes, such as putting in physical barriers and eliminating waiting rooms.

“Many practices are highly focused on PPE [personal protective equipment],” Dr. Kressly said, but even Centers for Disease Control and Prevention guidance emphasizes that PPE is the last line of defense. “There are many things we can do to protect our teams and our patients, and we know that not one single adaption is going to be 100% effective. But like the Swiss cheese model indicates, when you layer all of these efforts on top of one another, many defenses allow for the protection of the majority of people.”

Other changes include restricting office visitors to one per patient, implementing social distancing, requiring visitors to wear masks, and considering alternate locations for visits, including car and parking lot visits.

“No idea is too crazy, and some of the best ideas come from your staff,” Dr. Kressly said. She also recommended asking families where they feel most comfortable meeting.

“Don’t make any assumptions about where they want to be seen, but ask and together decide where the patient can most safely and effectively be given appropriate care,” she said.

Dr. Kressly also noted the new CPT code, 99072, that can be used to bill for “additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other nonfacility service(s), when performed during a public health emergency as defined by law, due to respiratory-transmitted infectious disease.”

Pediatricians should think of ways they can remove barriers to access, such as adjusting no-show cancellation penalties and adjusting practice policies as needed when things change. “Avoid creating a culture where families do not disclose all information for fear of not being seen,” Dr. Kressly said.

A slower pace because of delays and hiccups is also normal at this time, Dr. Berman said. “If you feel like you’re just not as efficient as you were prior to COVID, it’s not just you,” she said. “It’s true. Everyone has to grapple with new things now. It takes longer.”

Things that add time include remote check-in and paperwork, more time to don and doff PPE and disinfect, dealing with technology failures, adjusting to new procedures or policies, and the general mental fatigue of adhering to PPE best practices. Patience is vital during this time, Dr. Berman said.

Several ways to improve efficiency include cutting out unnecessary steps, using standing orders and Advance Beneficiary Notice of Noncoverage (ABNs) for flu vaccinations, keeping credit card numbers on file for contactless payment, and considering the clinical and financial value of lab testing before ordering it.

“Effective triage helps patient satisfaction, access to care, and efficiency of your office workload,” Dr. Kressly said. “Use technology where it’s appropriate, but then add people where it’s needed. Connections to caring people matter even more in a time of crisis.”

The speakers also highlighted the importance of early flu vaccinations.

“One of the single biggest things you can do for value in COVID is to get your flu vaccine numbers up,” Dr. Berman said. “Severely reducing the burden of influenza will help flatten the curve, it will reduce febrile respiratory illness, and it will protect your most fragile patients.”

Two ways to do that include flu clinics and making a strong push for immunizations during the first 8 weeks after getting the vaccines. Dr Berman shared numbers from two practices showing how many more total immunizations were done in the practice that began vaccinating in early August versus early September.
 

A crisis is an opportunity

The speakers closed on an optimistic note that emphasized the opportunities that can grow out of the challenges presented by the pandemic, a point Dr Terk elaborated on.

“One of the most important things is realizing how we can potentially use a crisis to transform our practices,” Dr. Terk said in the interview. “As had been said before, a crisis is a terrible thing to waste. Those practices that have the gumption to innovate and find different ways to improve the way they provide care are probably going to be in better shape as we go forward.”

Critical to that success is taking risks, he added.

“When you’re innovating, failure has to be something you are permissive of because if you’re risk-averse and failure-averse, you’re not going to have the opportunity to grow and innovate, and this is another opportunity to innovate,” Dr. Terk said.

He also stressed the value of learning from one another. “We need to help each other by sharing our good practices, and on the flip side, be open to learning from each other,” he said. “Those pediatricians who are struggling need to be open-minded and open-hearted to understanding how we can operate our practices better and know that the things we think are barriers we can’t change are probably things we probably haven’t allowed ourselves to think about changing.”

Dr. Kressly and Dr. Berman recommended several specific actions for pediatricians to take:

• Creating a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis regarding your practice management response to the pandemic.
• Articulating three goals for improving your understanding or the implementation of management in your practice.
• Creating a working group to identify and implement ways to improve clinical work flow and communication strategies.

“Now is the time to meaningfully address disparities of access to appropriate health care and the impact of social determinants of health,” Dr. Kressly said. It’s also an opportunity to build meaningful relationships with patient families based on trust, science, and “true shared decision-making with health literacy in mind.”

Dr Kressly is the medical director of and owns shares in Office Practicum. Dr. Berman is the assistant medical director of and owns shares in Office Practicum, and is the owner of Script Doctor LLC. Dr. Terk and Dr. Hackell had no relevant financial disclosures.

Practice management is the responsibility of every pediatrician, and leadership is more important than ever in a crisis like the COVID-19 pandemic.

kevajefimija/iStock/Getty Images

“Ultimately you have a critical role in ensuring that your practice remains sustainable so that you can continue to deliver great care,” Sue Kressly, MD, a retired pediatrician from Warrington, Pa., said at the virtual annual meeting of the American Academy of Pediatrics. “None of us escaped some impact of the COVID crisis, and many of us are going to experience lasting change.”

Dr. Kressly and Suzanne Berman, MD, a pediatrician in central Tennessee, presented a live online session on how the pandemic is affecting practices and how pediatricians can effectively address those challenges.
 

Three ways a crisis impacts practices

“When a practice experiences a crisis, it really exposes what your practice is made of, for better or for worse,” Dr. Berman said. “The COVID crisis has been profound and broad and long enough to really stress the core tensile strength of practices along at least three axes.” Those are staffing, financial health, and partnerships.

It’s a normal human response to enter survival mode during a crisis, so staff management becomes more important than ever. Some things to consider are whether you have a truly collaborative team culture in your practice and whether you’re really listening to the staff’s struggles and suggestions.

“Staffing challenges can be very difficult,” Dr. Berman said. “Permitting staff to work from home is the single biggest thing you can do when staff needs to self-isolate.”

Financially, most medical practices have adequate cash on hand not to have to pay close attention to the numbers, Dr. Kressly said, but if physicians are looking at their books for the first time during a crisis, they have no way of knowing what their baseline expectations should be or how much to worry about their finances. It’s important to understand your practice’s or department’s budget.

Jesse Hackell, MD, a private practice pediatrician in a suburb of New York City and vice president of the New York AAP Chapter 3, attended the session and appreciated this point on finances.

“In order to provide good quality care to kids, you need to be financially successful because otherwise you’ll close your doors,” Dr. Hackell said in an interview. “It’s making yourself available to be able to provide care.”

Stressors among partners during a crisis arise from responding to the challenges of the crisis, such as who should be impacted by pay cuts or furloughs, how to account for overhead, how to distribute revenue and how to divide the work equitably. Other issues include how to protect higher risk providers fairly and how to shift schedules or case load based on unforeseen events, including quarantining.

“There is no ‘fair’ in a crisis,” Dr. Berman said. “We must use the equity paradigm to be sure everyone has what they need to survive and have the best outcome possible.”

The speakers also discussed the importance of a practice’s situation before the pandemic began, a point that resonated with attendee Jason Terk, MD, a pediatrician who practices in a large pediatric health care system near Fort Worth, Texas.

“Just like the pandemic impacts the health of people in different ways based upon their baseline health, the pandemic impacts practices in different ways based on the practice’s baseline health,” he said in an interview. “If you had good operations, a good culture, good communication and all those other good indicators of practice health before, then you stood a much better chance of surviving the pandemic as a practice than practices that had weaknesses before.”

The size of a practice did not necessarily predict the impact of the crisis, Dr. Berman said. Rather, practices with good patient engagement, active recall programs, and good fiscal planning did better.

“One of the most useful takeaways is that flexibility is key,” Dr. Hackell said. “We had never seen anything like this before,” he said in an interview. “From the start we had no idea what was going to work. Try something and see if it works. If it fails, try something else. We were all operating blind here.”

The focus of most practices in the spring was on well visits, chronic care follow-up, and telehealth. Going into fall and winter, innovation will be necessary to provide appropriate care for all children while keeping in mind that the choices pediatricians make will have long-lasting implications for their staff and patients. The speakers stressed the importance of communication and transparency within the office team and to patients and the community.

Dr. Hackell appreciated the speakers’ point that kids need care, and pediatricians need to meet that need.

“Kids need well care and immunizations, and kids get sick and need sick care,” he said. “Parents need a lot more reassurance during times like this. We need to be able to provide that care and be sure that we do it safely. To give the right care at the right time in the right location is key.”
 

Making practice adaptations

In balancing risk and access to care, Dr. Kressly described the importance of multiple interventions, including managing some patients out of the office and making physical changes, such as putting in physical barriers and eliminating waiting rooms.

“Many practices are highly focused on PPE [personal protective equipment],” Dr. Kressly said, but even Centers for Disease Control and Prevention guidance emphasizes that PPE is the last line of defense. “There are many things we can do to protect our teams and our patients, and we know that not one single adaption is going to be 100% effective. But like the Swiss cheese model indicates, when you layer all of these efforts on top of one another, many defenses allow for the protection of the majority of people.”

Other changes include restricting office visitors to one per patient, implementing social distancing, requiring visitors to wear masks, and considering alternate locations for visits, including car and parking lot visits.

“No idea is too crazy, and some of the best ideas come from your staff,” Dr. Kressly said. She also recommended asking families where they feel most comfortable meeting.

“Don’t make any assumptions about where they want to be seen, but ask and together decide where the patient can most safely and effectively be given appropriate care,” she said.

Dr. Kressly also noted the new CPT code, 99072, that can be used to bill for “additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other nonfacility service(s), when performed during a public health emergency as defined by law, due to respiratory-transmitted infectious disease.”

Pediatricians should think of ways they can remove barriers to access, such as adjusting no-show cancellation penalties and adjusting practice policies as needed when things change. “Avoid creating a culture where families do not disclose all information for fear of not being seen,” Dr. Kressly said.

A slower pace because of delays and hiccups is also normal at this time, Dr. Berman said. “If you feel like you’re just not as efficient as you were prior to COVID, it’s not just you,” she said. “It’s true. Everyone has to grapple with new things now. It takes longer.”

Things that add time include remote check-in and paperwork, more time to don and doff PPE and disinfect, dealing with technology failures, adjusting to new procedures or policies, and the general mental fatigue of adhering to PPE best practices. Patience is vital during this time, Dr. Berman said.

Several ways to improve efficiency include cutting out unnecessary steps, using standing orders and Advance Beneficiary Notice of Noncoverage (ABNs) for flu vaccinations, keeping credit card numbers on file for contactless payment, and considering the clinical and financial value of lab testing before ordering it.

“Effective triage helps patient satisfaction, access to care, and efficiency of your office workload,” Dr. Kressly said. “Use technology where it’s appropriate, but then add people where it’s needed. Connections to caring people matter even more in a time of crisis.”

The speakers also highlighted the importance of early flu vaccinations.

“One of the single biggest things you can do for value in COVID is to get your flu vaccine numbers up,” Dr. Berman said. “Severely reducing the burden of influenza will help flatten the curve, it will reduce febrile respiratory illness, and it will protect your most fragile patients.”

Two ways to do that include flu clinics and making a strong push for immunizations during the first 8 weeks after getting the vaccines. Dr Berman shared numbers from two practices showing how many more total immunizations were done in the practice that began vaccinating in early August versus early September.
 

A crisis is an opportunity

The speakers closed on an optimistic note that emphasized the opportunities that can grow out of the challenges presented by the pandemic, a point Dr Terk elaborated on.

“One of the most important things is realizing how we can potentially use a crisis to transform our practices,” Dr. Terk said in the interview. “As had been said before, a crisis is a terrible thing to waste. Those practices that have the gumption to innovate and find different ways to improve the way they provide care are probably going to be in better shape as we go forward.”

Critical to that success is taking risks, he added.

“When you’re innovating, failure has to be something you are permissive of because if you’re risk-averse and failure-averse, you’re not going to have the opportunity to grow and innovate, and this is another opportunity to innovate,” Dr. Terk said.

He also stressed the value of learning from one another. “We need to help each other by sharing our good practices, and on the flip side, be open to learning from each other,” he said. “Those pediatricians who are struggling need to be open-minded and open-hearted to understanding how we can operate our practices better and know that the things we think are barriers we can’t change are probably things we probably haven’t allowed ourselves to think about changing.”

Dr. Kressly and Dr. Berman recommended several specific actions for pediatricians to take:

• Creating a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis regarding your practice management response to the pandemic.
• Articulating three goals for improving your understanding or the implementation of management in your practice.
• Creating a working group to identify and implement ways to improve clinical work flow and communication strategies.

“Now is the time to meaningfully address disparities of access to appropriate health care and the impact of social determinants of health,” Dr. Kressly said. It’s also an opportunity to build meaningful relationships with patient families based on trust, science, and “true shared decision-making with health literacy in mind.”

Dr Kressly is the medical director of and owns shares in Office Practicum. Dr. Berman is the assistant medical director of and owns shares in Office Practicum, and is the owner of Script Doctor LLC. Dr. Terk and Dr. Hackell had no relevant financial disclosures.

Practice management is the responsibility of every pediatrician, and leadership is more important than ever in a crisis like the COVID-19 pandemic.

kevajefimija/iStock/Getty Images

“Ultimately you have a critical role in ensuring that your practice remains sustainable so that you can continue to deliver great care,” Sue Kressly, MD, a retired pediatrician from Warrington, Pa., said at the virtual annual meeting of the American Academy of Pediatrics. “None of us escaped some impact of the COVID crisis, and many of us are going to experience lasting change.”

Dr. Kressly and Suzanne Berman, MD, a pediatrician in central Tennessee, presented a live online session on how the pandemic is affecting practices and how pediatricians can effectively address those challenges.
 

Three ways a crisis impacts practices

“When a practice experiences a crisis, it really exposes what your practice is made of, for better or for worse,” Dr. Berman said. “The COVID crisis has been profound and broad and long enough to really stress the core tensile strength of practices along at least three axes.” Those are staffing, financial health, and partnerships.

It’s a normal human response to enter survival mode during a crisis, so staff management becomes more important than ever. Some things to consider are whether you have a truly collaborative team culture in your practice and whether you’re really listening to the staff’s struggles and suggestions.

“Staffing challenges can be very difficult,” Dr. Berman said. “Permitting staff to work from home is the single biggest thing you can do when staff needs to self-isolate.”

Financially, most medical practices have adequate cash on hand not to have to pay close attention to the numbers, Dr. Kressly said, but if physicians are looking at their books for the first time during a crisis, they have no way of knowing what their baseline expectations should be or how much to worry about their finances. It’s important to understand your practice’s or department’s budget.

Jesse Hackell, MD, a private practice pediatrician in a suburb of New York City and vice president of the New York AAP Chapter 3, attended the session and appreciated this point on finances.

“In order to provide good quality care to kids, you need to be financially successful because otherwise you’ll close your doors,” Dr. Hackell said in an interview. “It’s making yourself available to be able to provide care.”

Stressors among partners during a crisis arise from responding to the challenges of the crisis, such as who should be impacted by pay cuts or furloughs, how to account for overhead, how to distribute revenue and how to divide the work equitably. Other issues include how to protect higher risk providers fairly and how to shift schedules or case load based on unforeseen events, including quarantining.

“There is no ‘fair’ in a crisis,” Dr. Berman said. “We must use the equity paradigm to be sure everyone has what they need to survive and have the best outcome possible.”

The speakers also discussed the importance of a practice’s situation before the pandemic began, a point that resonated with attendee Jason Terk, MD, a pediatrician who practices in a large pediatric health care system near Fort Worth, Texas.

“Just like the pandemic impacts the health of people in different ways based upon their baseline health, the pandemic impacts practices in different ways based on the practice’s baseline health,” he said in an interview. “If you had good operations, a good culture, good communication and all those other good indicators of practice health before, then you stood a much better chance of surviving the pandemic as a practice than practices that had weaknesses before.”

The size of a practice did not necessarily predict the impact of the crisis, Dr. Berman said. Rather, practices with good patient engagement, active recall programs, and good fiscal planning did better.

“One of the most useful takeaways is that flexibility is key,” Dr. Hackell said. “We had never seen anything like this before,” he said in an interview. “From the start we had no idea what was going to work. Try something and see if it works. If it fails, try something else. We were all operating blind here.”

The focus of most practices in the spring was on well visits, chronic care follow-up, and telehealth. Going into fall and winter, innovation will be necessary to provide appropriate care for all children while keeping in mind that the choices pediatricians make will have long-lasting implications for their staff and patients. The speakers stressed the importance of communication and transparency within the office team and to patients and the community.

Dr. Hackell appreciated the speakers’ point that kids need care, and pediatricians need to meet that need.

“Kids need well care and immunizations, and kids get sick and need sick care,” he said. “Parents need a lot more reassurance during times like this. We need to be able to provide that care and be sure that we do it safely. To give the right care at the right time in the right location is key.”
 

Making practice adaptations

In balancing risk and access to care, Dr. Kressly described the importance of multiple interventions, including managing some patients out of the office and making physical changes, such as putting in physical barriers and eliminating waiting rooms.

“Many practices are highly focused on PPE [personal protective equipment],” Dr. Kressly said, but even Centers for Disease Control and Prevention guidance emphasizes that PPE is the last line of defense. “There are many things we can do to protect our teams and our patients, and we know that not one single adaption is going to be 100% effective. But like the Swiss cheese model indicates, when you layer all of these efforts on top of one another, many defenses allow for the protection of the majority of people.”

Other changes include restricting office visitors to one per patient, implementing social distancing, requiring visitors to wear masks, and considering alternate locations for visits, including car and parking lot visits.

“No idea is too crazy, and some of the best ideas come from your staff,” Dr. Kressly said. She also recommended asking families where they feel most comfortable meeting.

“Don’t make any assumptions about where they want to be seen, but ask and together decide where the patient can most safely and effectively be given appropriate care,” she said.

Dr. Kressly also noted the new CPT code, 99072, that can be used to bill for “additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other nonfacility service(s), when performed during a public health emergency as defined by law, due to respiratory-transmitted infectious disease.”

Pediatricians should think of ways they can remove barriers to access, such as adjusting no-show cancellation penalties and adjusting practice policies as needed when things change. “Avoid creating a culture where families do not disclose all information for fear of not being seen,” Dr. Kressly said.

A slower pace because of delays and hiccups is also normal at this time, Dr. Berman said. “If you feel like you’re just not as efficient as you were prior to COVID, it’s not just you,” she said. “It’s true. Everyone has to grapple with new things now. It takes longer.”

Things that add time include remote check-in and paperwork, more time to don and doff PPE and disinfect, dealing with technology failures, adjusting to new procedures or policies, and the general mental fatigue of adhering to PPE best practices. Patience is vital during this time, Dr. Berman said.

Several ways to improve efficiency include cutting out unnecessary steps, using standing orders and Advance Beneficiary Notice of Noncoverage (ABNs) for flu vaccinations, keeping credit card numbers on file for contactless payment, and considering the clinical and financial value of lab testing before ordering it.

“Effective triage helps patient satisfaction, access to care, and efficiency of your office workload,” Dr. Kressly said. “Use technology where it’s appropriate, but then add people where it’s needed. Connections to caring people matter even more in a time of crisis.”

The speakers also highlighted the importance of early flu vaccinations.

“One of the single biggest things you can do for value in COVID is to get your flu vaccine numbers up,” Dr. Berman said. “Severely reducing the burden of influenza will help flatten the curve, it will reduce febrile respiratory illness, and it will protect your most fragile patients.”

Two ways to do that include flu clinics and making a strong push for immunizations during the first 8 weeks after getting the vaccines. Dr Berman shared numbers from two practices showing how many more total immunizations were done in the practice that began vaccinating in early August versus early September.
 

A crisis is an opportunity

The speakers closed on an optimistic note that emphasized the opportunities that can grow out of the challenges presented by the pandemic, a point Dr Terk elaborated on.

“One of the most important things is realizing how we can potentially use a crisis to transform our practices,” Dr. Terk said in the interview. “As had been said before, a crisis is a terrible thing to waste. Those practices that have the gumption to innovate and find different ways to improve the way they provide care are probably going to be in better shape as we go forward.”

Critical to that success is taking risks, he added.

“When you’re innovating, failure has to be something you are permissive of because if you’re risk-averse and failure-averse, you’re not going to have the opportunity to grow and innovate, and this is another opportunity to innovate,” Dr. Terk said.

He also stressed the value of learning from one another. “We need to help each other by sharing our good practices, and on the flip side, be open to learning from each other,” he said. “Those pediatricians who are struggling need to be open-minded and open-hearted to understanding how we can operate our practices better and know that the things we think are barriers we can’t change are probably things we probably haven’t allowed ourselves to think about changing.”

Dr. Kressly and Dr. Berman recommended several specific actions for pediatricians to take:

• Creating a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis regarding your practice management response to the pandemic.
• Articulating three goals for improving your understanding or the implementation of management in your practice.
• Creating a working group to identify and implement ways to improve clinical work flow and communication strategies.

“Now is the time to meaningfully address disparities of access to appropriate health care and the impact of social determinants of health,” Dr. Kressly said. It’s also an opportunity to build meaningful relationships with patient families based on trust, science, and “true shared decision-making with health literacy in mind.”

Dr Kressly is the medical director of and owns shares in Office Practicum. Dr. Berman is the assistant medical director of and owns shares in Office Practicum, and is the owner of Script Doctor LLC. Dr. Terk and Dr. Hackell had no relevant financial disclosures.

Pediatric fractures dropped by 2.5-fold during the early months of the COVID-19 pandemic, but more breaks happened at home and on bicycles, and younger kids were more affected, new research indicates.

The study of 1,745 patients also found that those with distal radius torus fractures were more likely to receive a Velcro splint during the pandemic. Experts said this key trend points toward widespread shifts to streamline treatment, which should persist after the pandemic.

“We expected to see a drop in fracture volume, but what was a bit unexpected was the proportional rise in at-home injuries, which we weren’t immediately aware of,” said senior author Apurva Shah, MD, MBA, of Children’s Hospital of Philadelphia (CHOP) and the University of Pennsylvania in Philadelphia.

“As time went on, it became more apparent that trampoline and bicycle injuries were on the rise, but at the beginning of the pandemic, we didn’t intuitively expect that,” he added.

“Whenever there’s a major shift in how the world is working, we want to understand how that impacts child safety,” Dr. Shah said in an interview. “The message to get out to parents is that it’s obviously difficult to supervise kids while working from home” during the pandemic “and that supervision obviously is not always working as well as intended.”

Joshua T. Bram, a medical student, presented the study at the virtual American Academy of Pediatrics (AAP) 2020 National Conference.

Dr. Bram, Dr. Shah, and colleagues compared patients with acute fractures who presented at CHOP between March and April 2020 with those who presented during the same months in 2018 and 2019.

Overall, the number of patients with pediatric fractures who presented to CHOP fell to an average of just under 10 per day, compared with more than 22 per day in prior years (P < .001). In addition, the age of the patients fell from an average of 9.4 years to 7.5 years (P < .001), with fewer adolescents affected in 2020.

“I think when you cancel a 14-year-old’s baseball season” because of the pandemic, “unfortunately, that lost outdoor time might be substituted with time on a screen,” he explained. “But canceling a 6-year-old’s soccer season might mean substituting that with more time outside on bikes or on a trampoline.”

As noted, because of the pandemic, a higher proportion of pediatric fractures occurred at home (57.8% vs. 32.5%; P < .001) or on bicycles (18.3% vs. 8.2%; P < .001), but there were fewer organized sports–related (7.2% vs. 26.0%; P < .001) or playground-related injuries (5.2% vs. 9.0%; P < .001).

In the study period this year, the researchers saw no increase in the amount of time between injury and presentation. However, data suggest that, in more recent months, “kids are presenting with fractures late, with sometimes great consequences,” Dr. Shah said.

“What has changed is that a lot of adults have lost their jobs, and as a consequence, a lot of children have lost their access to private insurance,” he said. “But fracture is really a major injury, and this is a reminder for pediatricians and primary care physicians to recognize that families are going through these changes and that delays in care can really be detrimental to children.”
 

Velcro splints more common

A potential upside to shifts seen during the pandemic, Dr. Shah said, is the finding that distal radius torus fractures were more likely to be treated with a Velcro splint than in previous years (44.2% vs. 25.9%; P = .010).

“This is hitting on something important – that sometimes it’s crisis that forces us as physicians to evolve,” he said. “This is something I think is here to stay.

“Although research had already been there suggesting a close equivalent between splints and casting, culturally, a lot of surgeons hadn’t made that shift when historically the gold standard had been casting,” Dr. Shah added. “But with the pandemic, the shift to minimize contact with the health care system to keep families safe in their COVID bubble helped [usage of] splints take off.

“I suspect – and we’ll only know when we’re on the other side of this – when physicians see good results in splints in their own patients, they’re going to adopt those strategies more permanently,” he said.

Benjamin Shore, MD, MPH, of Boston Children’s Hospital, agreed with Dr. Shah’s prediction that fracture care will be more streamlined after the pandemic. Dr. Shore, who wasn’t involved in the study, said not only are more orthopedic providers treating patients with Velcro splints and bivalve casts, but they are also monitoring patients via telehealth.

“All of these are great examples of innovation, and one of the unique parts of the pandemic is it created a lot of rapid change across healthcare because it caused us to scrutinize the ways we practice and make a change,” Dr. Shore said in an interview.

“It wasn’t a very fancy study, but it’s very important in terms of demonstrating a change in practice,” Dr. Shore said. “The research here basically validated what many of us are seeing and hopefully will help us in future pandemics – which hopefully won’t happen – to tell families what to be proactive about.”

Dr. Shah and Dr. Shore agreed that, because fewer fractures are occurring in kids during the pandemic, there is an opportunity to redeploy orthopedic providers to other clinical areas on the basis of volume and need.

Dr. Shah and Dr. Shore have disclosed no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.

Pediatric fractures dropped by 2.5-fold during the early months of the COVID-19 pandemic, but more breaks happened at home and on bicycles, and younger kids were more affected, new research indicates.

The study of 1,745 patients also found that those with distal radius torus fractures were more likely to receive a Velcro splint during the pandemic. Experts said this key trend points toward widespread shifts to streamline treatment, which should persist after the pandemic.

“We expected to see a drop in fracture volume, but what was a bit unexpected was the proportional rise in at-home injuries, which we weren’t immediately aware of,” said senior author Apurva Shah, MD, MBA, of Children’s Hospital of Philadelphia (CHOP) and the University of Pennsylvania in Philadelphia.

“As time went on, it became more apparent that trampoline and bicycle injuries were on the rise, but at the beginning of the pandemic, we didn’t intuitively expect that,” he added.

“Whenever there’s a major shift in how the world is working, we want to understand how that impacts child safety,” Dr. Shah said in an interview. “The message to get out to parents is that it’s obviously difficult to supervise kids while working from home” during the pandemic “and that supervision obviously is not always working as well as intended.”

Joshua T. Bram, a medical student, presented the study at the virtual American Academy of Pediatrics (AAP) 2020 National Conference.

Dr. Bram, Dr. Shah, and colleagues compared patients with acute fractures who presented at CHOP between March and April 2020 with those who presented during the same months in 2018 and 2019.

Overall, the number of patients with pediatric fractures who presented to CHOP fell to an average of just under 10 per day, compared with more than 22 per day in prior years (P < .001). In addition, the age of the patients fell from an average of 9.4 years to 7.5 years (P < .001), with fewer adolescents affected in 2020.

“I think when you cancel a 14-year-old’s baseball season” because of the pandemic, “unfortunately, that lost outdoor time might be substituted with time on a screen,” he explained. “But canceling a 6-year-old’s soccer season might mean substituting that with more time outside on bikes or on a trampoline.”

As noted, because of the pandemic, a higher proportion of pediatric fractures occurred at home (57.8% vs. 32.5%; P < .001) or on bicycles (18.3% vs. 8.2%; P < .001), but there were fewer organized sports–related (7.2% vs. 26.0%; P < .001) or playground-related injuries (5.2% vs. 9.0%; P < .001).

In the study period this year, the researchers saw no increase in the amount of time between injury and presentation. However, data suggest that, in more recent months, “kids are presenting with fractures late, with sometimes great consequences,” Dr. Shah said.

“What has changed is that a lot of adults have lost their jobs, and as a consequence, a lot of children have lost their access to private insurance,” he said. “But fracture is really a major injury, and this is a reminder for pediatricians and primary care physicians to recognize that families are going through these changes and that delays in care can really be detrimental to children.”
 

Velcro splints more common

A potential upside to shifts seen during the pandemic, Dr. Shah said, is the finding that distal radius torus fractures were more likely to be treated with a Velcro splint than in previous years (44.2% vs. 25.9%; P = .010).

“This is hitting on something important – that sometimes it’s crisis that forces us as physicians to evolve,” he said. “This is something I think is here to stay.

“Although research had already been there suggesting a close equivalent between splints and casting, culturally, a lot of surgeons hadn’t made that shift when historically the gold standard had been casting,” Dr. Shah added. “But with the pandemic, the shift to minimize contact with the health care system to keep families safe in their COVID bubble helped [usage of] splints take off.

“I suspect – and we’ll only know when we’re on the other side of this – when physicians see good results in splints in their own patients, they’re going to adopt those strategies more permanently,” he said.

Benjamin Shore, MD, MPH, of Boston Children’s Hospital, agreed with Dr. Shah’s prediction that fracture care will be more streamlined after the pandemic. Dr. Shore, who wasn’t involved in the study, said not only are more orthopedic providers treating patients with Velcro splints and bivalve casts, but they are also monitoring patients via telehealth.

“All of these are great examples of innovation, and one of the unique parts of the pandemic is it created a lot of rapid change across healthcare because it caused us to scrutinize the ways we practice and make a change,” Dr. Shore said in an interview.

“It wasn’t a very fancy study, but it’s very important in terms of demonstrating a change in practice,” Dr. Shore said. “The research here basically validated what many of us are seeing and hopefully will help us in future pandemics – which hopefully won’t happen – to tell families what to be proactive about.”

Dr. Shah and Dr. Shore agreed that, because fewer fractures are occurring in kids during the pandemic, there is an opportunity to redeploy orthopedic providers to other clinical areas on the basis of volume and need.

Dr. Shah and Dr. Shore have disclosed no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.

Pediatric fractures dropped by 2.5-fold during the early months of the COVID-19 pandemic, but more breaks happened at home and on bicycles, and younger kids were more affected, new research indicates.

The study of 1,745 patients also found that those with distal radius torus fractures were more likely to receive a Velcro splint during the pandemic. Experts said this key trend points toward widespread shifts to streamline treatment, which should persist after the pandemic.

“We expected to see a drop in fracture volume, but what was a bit unexpected was the proportional rise in at-home injuries, which we weren’t immediately aware of,” said senior author Apurva Shah, MD, MBA, of Children’s Hospital of Philadelphia (CHOP) and the University of Pennsylvania in Philadelphia.

“As time went on, it became more apparent that trampoline and bicycle injuries were on the rise, but at the beginning of the pandemic, we didn’t intuitively expect that,” he added.

“Whenever there’s a major shift in how the world is working, we want to understand how that impacts child safety,” Dr. Shah said in an interview. “The message to get out to parents is that it’s obviously difficult to supervise kids while working from home” during the pandemic “and that supervision obviously is not always working as well as intended.”

Joshua T. Bram, a medical student, presented the study at the virtual American Academy of Pediatrics (AAP) 2020 National Conference.

Dr. Bram, Dr. Shah, and colleagues compared patients with acute fractures who presented at CHOP between March and April 2020 with those who presented during the same months in 2018 and 2019.

Overall, the number of patients with pediatric fractures who presented to CHOP fell to an average of just under 10 per day, compared with more than 22 per day in prior years (P < .001). In addition, the age of the patients fell from an average of 9.4 years to 7.5 years (P < .001), with fewer adolescents affected in 2020.

“I think when you cancel a 14-year-old’s baseball season” because of the pandemic, “unfortunately, that lost outdoor time might be substituted with time on a screen,” he explained. “But canceling a 6-year-old’s soccer season might mean substituting that with more time outside on bikes or on a trampoline.”

As noted, because of the pandemic, a higher proportion of pediatric fractures occurred at home (57.8% vs. 32.5%; P < .001) or on bicycles (18.3% vs. 8.2%; P < .001), but there were fewer organized sports–related (7.2% vs. 26.0%; P < .001) or playground-related injuries (5.2% vs. 9.0%; P < .001).

In the study period this year, the researchers saw no increase in the amount of time between injury and presentation. However, data suggest that, in more recent months, “kids are presenting with fractures late, with sometimes great consequences,” Dr. Shah said.

“What has changed is that a lot of adults have lost their jobs, and as a consequence, a lot of children have lost their access to private insurance,” he said. “But fracture is really a major injury, and this is a reminder for pediatricians and primary care physicians to recognize that families are going through these changes and that delays in care can really be detrimental to children.”
 

Velcro splints more common

A potential upside to shifts seen during the pandemic, Dr. Shah said, is the finding that distal radius torus fractures were more likely to be treated with a Velcro splint than in previous years (44.2% vs. 25.9%; P = .010).

“This is hitting on something important – that sometimes it’s crisis that forces us as physicians to evolve,” he said. “This is something I think is here to stay.

“Although research had already been there suggesting a close equivalent between splints and casting, culturally, a lot of surgeons hadn’t made that shift when historically the gold standard had been casting,” Dr. Shah added. “But with the pandemic, the shift to minimize contact with the health care system to keep families safe in their COVID bubble helped [usage of] splints take off.

“I suspect – and we’ll only know when we’re on the other side of this – when physicians see good results in splints in their own patients, they’re going to adopt those strategies more permanently,” he said.

Benjamin Shore, MD, MPH, of Boston Children’s Hospital, agreed with Dr. Shah’s prediction that fracture care will be more streamlined after the pandemic. Dr. Shore, who wasn’t involved in the study, said not only are more orthopedic providers treating patients with Velcro splints and bivalve casts, but they are also monitoring patients via telehealth.

“All of these are great examples of innovation, and one of the unique parts of the pandemic is it created a lot of rapid change across healthcare because it caused us to scrutinize the ways we practice and make a change,” Dr. Shore said in an interview.

“It wasn’t a very fancy study, but it’s very important in terms of demonstrating a change in practice,” Dr. Shore said. “The research here basically validated what many of us are seeing and hopefully will help us in future pandemics – which hopefully won’t happen – to tell families what to be proactive about.”

Dr. Shah and Dr. Shore agreed that, because fewer fractures are occurring in kids during the pandemic, there is an opportunity to redeploy orthopedic providers to other clinical areas on the basis of volume and need.

Dr. Shah and Dr. Shore have disclosed no relevant financial relationships.
 

A version of this article originally appeared on Medscape.com.