User login
American Academy of Pediatrics (AAP): 2016 National Conference and Exhibition
Treatment plan addresses circadian rhythm disorders from nighttime screen use
SAN FRANCISCO – Among the most significant concerns associated with youth’s increasing use of screen media is the impact on their sleep, according to two policy statements of the American Academy of Pediatrics on children and media use.
To help pediatricians better understand how media might affect sleep, Sujay Kansagra, MD, a pediatric neurologist at Duke University Medical Center in Durham, N.C., presented an overview of circadian rhythm disorders and how to address them during a program on electronic media at the AAP annual meeting.
Approximately 3 hours before waking, a person experiences a nadir in body temperature that designates “the point at which the light exposure flips from delaying your rhythm to advancing your rhythm,” Dr. Kansagra said. “Five minutes before this point, it delays your phase; 5 minutes after, it advances your phase.”
A significantly advanced or delayed sleep phase can become a circadian rhythm disorder, in which a person gets the normal amount and quality of sleep he or she needs – but not at the right times. “Those with circadian rhythm disorders have failed to entrain to their environmental cues,” such as light, food, and activity levels, he said.
In youth, particularly adolescents, the most common circadian rhythm disorder is delayed sleep-wake phase syndrome, defined in the International Classification of Sleep Disorders – Third Edition (ICSD-3) with four criteria:
• A significant delay in major sleep episode in relation to desired or required sleep time and waking time (often involving a sleep time around 4 a.m.).
• The symptoms are present for more than 3 months.
• When allowed to choose a schedule, the person will exhibit improved sleep quality/duration and maintain delayed phase.
• A sleep log and/or actigraphy demonstrates a delay in timing of the sleep period for at least 7 days.
Because nearly all screen media emit light, use of such media in the evenings may contribute to this disorder. “When you combine light exposure with someone who has that later chronotype, you’re setting yourself up for disaster,” Dr. Kansagra said.
Delayed sleep-wake phase disorder can greatly interfere with school, work, and normal daily activities, and Dr. Kansagra outlined the major steps in preventing and/or treating it, starting with avoiding light exposure at night, whether from the TV, tablets, laptops, or cell phones.
“If they can’t avoid light completely, the brightness is also important,” he said. “We know that the brighter the light, the more likely you are to suppress your brain’s melatonin.” Therefore, reducing the brightness on devices that must be used can mitigate the problem, as can using red- or yellow-tinted light, provided as a “night mode” on some devices, instead of the blue light emitted by the majority of devices.
Next, he recommended that individuals maintain a set bedtime and wake time each day, including on the weekends. Although he acknowledged the challenge this schedule might present, particularly in teenagers, he described how detrimental it can be to stay up late and sleep in late on the weekends. If teens stay up until 11 p.m. throughout the week, then a little later on Friday night, and then up to 2 a.m. on Saturday night, they will likely sleep in until around 11 a.m. on Sunday. But if they need to get up at 6 a.m. for school Monday morning, that’s the equivalent of flying from Hawaii to New York in terms of jet lag effects, he explained.
“They will spend the rest of the school week slowly advancing their clock until the weekend and do it all over again,” Dr. Kansagra said. “They are perpetually jet lagged. No wonder they’re so angry all the time,” he joked. “It’s social jet lag.”
Such social jet lag leads to sleepiness throughout the week, often mistaken for laziness by frustrated parents, he said.
“Sleepiness is not laziness,” he emphasized. “It’s a problem with the quality or quantity of sleep. It’s really important to get parents’ buy in on this because it’s a contentious topic in a lot of families.”
After getting the child or teen on a regular schedule, the next important step in realigning a circadian rhythm and then maintaining it is to expose the person to light early in the morning – but after that temperature nadir that occurs 3 hours before waking. Meanwhile, 2-6 hours before their sleep time, youth trying to adjust their clocks can take a low dose of melatonin, around 0.5-1 mg. But he pointed out a common misconception about how melatonin works.
“Melatonin plays no role in fixing insomnia; melatonin doesn’t make you sleepy,” Dr. Kansagra said. “Melatonin just tells your brain what to do when it’s dark. Melatonin is good for shifting your circadian rhythm.”
But all of these steps can be successful only if the pediatrician and/or parent can convince the child or teen that it’s important to adjust their circadian rhythm. This can include discussions that lead them to realize or conclude that they are unpleasant, angry, or irritable when they don’t get enough sleep. Perhaps they have been told they are rude by a classmate on days they don’t get enough sleep, or perhaps they realize they do not perform as well while playing sports when they don’t have the rest they need. Children who can make those connections can help get the buy in needed to follow all the previous steps.
Some individuals, however, can be particularly resistant to adjusting the circadian rhythm, which calls for a much more dramatic and difficult treatment called chronotherapy. This treatment begins very counterintuitively by flipping the script: The youth should now actually try to stay up later than their bedtime while playing video games, watching TV, using a computer, or engaging in similar activities. Ideally, they should stay up until 6 a.m. and then sleep in as late as they wish.
The next evening, they should stay up even later – until 8 a.m. – and again sleep in as late as they need to. Each successive day, they should go to bed 2 hours later – 10 a.m., 12 p.m., 2 p.m., and so forth – and sleep the adequate amount anyone would need, until they eventually are going to bed at the time they should be, such as 8 p.m. or 10 p.m. Although this is a dramatic treatment, it can be very effective at resetting a person’s clock when other methods have not succeeded, he said.
The key practice-altering elements of Dr. Kansagra’s talk focused on using melatonin as a “clock-shifting” medication instead of a “sleep-inducing one” and dosing children at the appropriate time, 2-6 hours before bed. If nighttime use of light cannot be eliminated, have patients reduce the brightness and duration, and change the color, of the light to lessen its effect on the brain’s melatonin release. Finally, help families understand the concept of “social jet lag” so they grasp the importance of regular sleep times and do not mistake sleepiness for laziness.
Dr. Kansagra reported no relevant financial disclosures or external funding.
SAN FRANCISCO – Among the most significant concerns associated with youth’s increasing use of screen media is the impact on their sleep, according to two policy statements of the American Academy of Pediatrics on children and media use.
To help pediatricians better understand how media might affect sleep, Sujay Kansagra, MD, a pediatric neurologist at Duke University Medical Center in Durham, N.C., presented an overview of circadian rhythm disorders and how to address them during a program on electronic media at the AAP annual meeting.
Approximately 3 hours before waking, a person experiences a nadir in body temperature that designates “the point at which the light exposure flips from delaying your rhythm to advancing your rhythm,” Dr. Kansagra said. “Five minutes before this point, it delays your phase; 5 minutes after, it advances your phase.”
A significantly advanced or delayed sleep phase can become a circadian rhythm disorder, in which a person gets the normal amount and quality of sleep he or she needs – but not at the right times. “Those with circadian rhythm disorders have failed to entrain to their environmental cues,” such as light, food, and activity levels, he said.
In youth, particularly adolescents, the most common circadian rhythm disorder is delayed sleep-wake phase syndrome, defined in the International Classification of Sleep Disorders – Third Edition (ICSD-3) with four criteria:
• A significant delay in major sleep episode in relation to desired or required sleep time and waking time (often involving a sleep time around 4 a.m.).
• The symptoms are present for more than 3 months.
• When allowed to choose a schedule, the person will exhibit improved sleep quality/duration and maintain delayed phase.
• A sleep log and/or actigraphy demonstrates a delay in timing of the sleep period for at least 7 days.
Because nearly all screen media emit light, use of such media in the evenings may contribute to this disorder. “When you combine light exposure with someone who has that later chronotype, you’re setting yourself up for disaster,” Dr. Kansagra said.
Delayed sleep-wake phase disorder can greatly interfere with school, work, and normal daily activities, and Dr. Kansagra outlined the major steps in preventing and/or treating it, starting with avoiding light exposure at night, whether from the TV, tablets, laptops, or cell phones.
“If they can’t avoid light completely, the brightness is also important,” he said. “We know that the brighter the light, the more likely you are to suppress your brain’s melatonin.” Therefore, reducing the brightness on devices that must be used can mitigate the problem, as can using red- or yellow-tinted light, provided as a “night mode” on some devices, instead of the blue light emitted by the majority of devices.
Next, he recommended that individuals maintain a set bedtime and wake time each day, including on the weekends. Although he acknowledged the challenge this schedule might present, particularly in teenagers, he described how detrimental it can be to stay up late and sleep in late on the weekends. If teens stay up until 11 p.m. throughout the week, then a little later on Friday night, and then up to 2 a.m. on Saturday night, they will likely sleep in until around 11 a.m. on Sunday. But if they need to get up at 6 a.m. for school Monday morning, that’s the equivalent of flying from Hawaii to New York in terms of jet lag effects, he explained.
“They will spend the rest of the school week slowly advancing their clock until the weekend and do it all over again,” Dr. Kansagra said. “They are perpetually jet lagged. No wonder they’re so angry all the time,” he joked. “It’s social jet lag.”
Such social jet lag leads to sleepiness throughout the week, often mistaken for laziness by frustrated parents, he said.
“Sleepiness is not laziness,” he emphasized. “It’s a problem with the quality or quantity of sleep. It’s really important to get parents’ buy in on this because it’s a contentious topic in a lot of families.”
After getting the child or teen on a regular schedule, the next important step in realigning a circadian rhythm and then maintaining it is to expose the person to light early in the morning – but after that temperature nadir that occurs 3 hours before waking. Meanwhile, 2-6 hours before their sleep time, youth trying to adjust their clocks can take a low dose of melatonin, around 0.5-1 mg. But he pointed out a common misconception about how melatonin works.
“Melatonin plays no role in fixing insomnia; melatonin doesn’t make you sleepy,” Dr. Kansagra said. “Melatonin just tells your brain what to do when it’s dark. Melatonin is good for shifting your circadian rhythm.”
But all of these steps can be successful only if the pediatrician and/or parent can convince the child or teen that it’s important to adjust their circadian rhythm. This can include discussions that lead them to realize or conclude that they are unpleasant, angry, or irritable when they don’t get enough sleep. Perhaps they have been told they are rude by a classmate on days they don’t get enough sleep, or perhaps they realize they do not perform as well while playing sports when they don’t have the rest they need. Children who can make those connections can help get the buy in needed to follow all the previous steps.
Some individuals, however, can be particularly resistant to adjusting the circadian rhythm, which calls for a much more dramatic and difficult treatment called chronotherapy. This treatment begins very counterintuitively by flipping the script: The youth should now actually try to stay up later than their bedtime while playing video games, watching TV, using a computer, or engaging in similar activities. Ideally, they should stay up until 6 a.m. and then sleep in as late as they wish.
The next evening, they should stay up even later – until 8 a.m. – and again sleep in as late as they need to. Each successive day, they should go to bed 2 hours later – 10 a.m., 12 p.m., 2 p.m., and so forth – and sleep the adequate amount anyone would need, until they eventually are going to bed at the time they should be, such as 8 p.m. or 10 p.m. Although this is a dramatic treatment, it can be very effective at resetting a person’s clock when other methods have not succeeded, he said.
The key practice-altering elements of Dr. Kansagra’s talk focused on using melatonin as a “clock-shifting” medication instead of a “sleep-inducing one” and dosing children at the appropriate time, 2-6 hours before bed. If nighttime use of light cannot be eliminated, have patients reduce the brightness and duration, and change the color, of the light to lessen its effect on the brain’s melatonin release. Finally, help families understand the concept of “social jet lag” so they grasp the importance of regular sleep times and do not mistake sleepiness for laziness.
Dr. Kansagra reported no relevant financial disclosures or external funding.
SAN FRANCISCO – Among the most significant concerns associated with youth’s increasing use of screen media is the impact on their sleep, according to two policy statements of the American Academy of Pediatrics on children and media use.
To help pediatricians better understand how media might affect sleep, Sujay Kansagra, MD, a pediatric neurologist at Duke University Medical Center in Durham, N.C., presented an overview of circadian rhythm disorders and how to address them during a program on electronic media at the AAP annual meeting.
Approximately 3 hours before waking, a person experiences a nadir in body temperature that designates “the point at which the light exposure flips from delaying your rhythm to advancing your rhythm,” Dr. Kansagra said. “Five minutes before this point, it delays your phase; 5 minutes after, it advances your phase.”
A significantly advanced or delayed sleep phase can become a circadian rhythm disorder, in which a person gets the normal amount and quality of sleep he or she needs – but not at the right times. “Those with circadian rhythm disorders have failed to entrain to their environmental cues,” such as light, food, and activity levels, he said.
In youth, particularly adolescents, the most common circadian rhythm disorder is delayed sleep-wake phase syndrome, defined in the International Classification of Sleep Disorders – Third Edition (ICSD-3) with four criteria:
• A significant delay in major sleep episode in relation to desired or required sleep time and waking time (often involving a sleep time around 4 a.m.).
• The symptoms are present for more than 3 months.
• When allowed to choose a schedule, the person will exhibit improved sleep quality/duration and maintain delayed phase.
• A sleep log and/or actigraphy demonstrates a delay in timing of the sleep period for at least 7 days.
Because nearly all screen media emit light, use of such media in the evenings may contribute to this disorder. “When you combine light exposure with someone who has that later chronotype, you’re setting yourself up for disaster,” Dr. Kansagra said.
Delayed sleep-wake phase disorder can greatly interfere with school, work, and normal daily activities, and Dr. Kansagra outlined the major steps in preventing and/or treating it, starting with avoiding light exposure at night, whether from the TV, tablets, laptops, or cell phones.
“If they can’t avoid light completely, the brightness is also important,” he said. “We know that the brighter the light, the more likely you are to suppress your brain’s melatonin.” Therefore, reducing the brightness on devices that must be used can mitigate the problem, as can using red- or yellow-tinted light, provided as a “night mode” on some devices, instead of the blue light emitted by the majority of devices.
Next, he recommended that individuals maintain a set bedtime and wake time each day, including on the weekends. Although he acknowledged the challenge this schedule might present, particularly in teenagers, he described how detrimental it can be to stay up late and sleep in late on the weekends. If teens stay up until 11 p.m. throughout the week, then a little later on Friday night, and then up to 2 a.m. on Saturday night, they will likely sleep in until around 11 a.m. on Sunday. But if they need to get up at 6 a.m. for school Monday morning, that’s the equivalent of flying from Hawaii to New York in terms of jet lag effects, he explained.
“They will spend the rest of the school week slowly advancing their clock until the weekend and do it all over again,” Dr. Kansagra said. “They are perpetually jet lagged. No wonder they’re so angry all the time,” he joked. “It’s social jet lag.”
Such social jet lag leads to sleepiness throughout the week, often mistaken for laziness by frustrated parents, he said.
“Sleepiness is not laziness,” he emphasized. “It’s a problem with the quality or quantity of sleep. It’s really important to get parents’ buy in on this because it’s a contentious topic in a lot of families.”
After getting the child or teen on a regular schedule, the next important step in realigning a circadian rhythm and then maintaining it is to expose the person to light early in the morning – but after that temperature nadir that occurs 3 hours before waking. Meanwhile, 2-6 hours before their sleep time, youth trying to adjust their clocks can take a low dose of melatonin, around 0.5-1 mg. But he pointed out a common misconception about how melatonin works.
“Melatonin plays no role in fixing insomnia; melatonin doesn’t make you sleepy,” Dr. Kansagra said. “Melatonin just tells your brain what to do when it’s dark. Melatonin is good for shifting your circadian rhythm.”
But all of these steps can be successful only if the pediatrician and/or parent can convince the child or teen that it’s important to adjust their circadian rhythm. This can include discussions that lead them to realize or conclude that they are unpleasant, angry, or irritable when they don’t get enough sleep. Perhaps they have been told they are rude by a classmate on days they don’t get enough sleep, or perhaps they realize they do not perform as well while playing sports when they don’t have the rest they need. Children who can make those connections can help get the buy in needed to follow all the previous steps.
Some individuals, however, can be particularly resistant to adjusting the circadian rhythm, which calls for a much more dramatic and difficult treatment called chronotherapy. This treatment begins very counterintuitively by flipping the script: The youth should now actually try to stay up later than their bedtime while playing video games, watching TV, using a computer, or engaging in similar activities. Ideally, they should stay up until 6 a.m. and then sleep in as late as they wish.
The next evening, they should stay up even later – until 8 a.m. – and again sleep in as late as they need to. Each successive day, they should go to bed 2 hours later – 10 a.m., 12 p.m., 2 p.m., and so forth – and sleep the adequate amount anyone would need, until they eventually are going to bed at the time they should be, such as 8 p.m. or 10 p.m. Although this is a dramatic treatment, it can be very effective at resetting a person’s clock when other methods have not succeeded, he said.
The key practice-altering elements of Dr. Kansagra’s talk focused on using melatonin as a “clock-shifting” medication instead of a “sleep-inducing one” and dosing children at the appropriate time, 2-6 hours before bed. If nighttime use of light cannot be eliminated, have patients reduce the brightness and duration, and change the color, of the light to lessen its effect on the brain’s melatonin release. Finally, help families understand the concept of “social jet lag” so they grasp the importance of regular sleep times and do not mistake sleepiness for laziness.
Dr. Kansagra reported no relevant financial disclosures or external funding.
EXPERT ANALYSIS FROM AAP 16
Telementoring expands PCPs’ role in managing pediatric chronic disease
SAN FRANCISCO – Telementoring empowers primary care pediatric providers (PCPs) to take on a greater role in managing their patients’ chronic diseases, new data suggest. Leaders in this emerging field gave a snapshot of early experience with the model at the annual meeting of the American Academy of Pediatrics.
“About a quarter of children live with chronic health conditions, and there is an increasing need for specialty care. But many children don’t have access to the quality specialty care that they really need, particularly in rural and medically underserved areas,” explained Dr. Sucheta M. Joshi, a pediatric neurologist and epileptologist at the University of Michigan, Ann Arbor. “The goal of telementoring is to build the capacity of primary care doctors.”
“We need to empower primary care providers to work ‘at the top of their license’ because we don’t have enough specialists,” agreed Dr. David
Telementoring first gained recognition through the University of New Mexico’s Project Extension for Community Healthcare Outcomes (ECHO), which links specialists at an academic “hub” with PCPs in local communities, or “spokes,” in a learning network.
Through regular, interactive, multisite telementoring sessions, ECHO provides training to increase PCPs’ knowledge, self-efficacy, and comfort in managing chronic diseases not typically considered within their scope of practice. Sessions combine short didactic presentations and case-based learning.
The model was initially tested in pediatrics as ECHO for Epilepsy, a partnership of the AAP and the University of New Mexico, Albuquerque. Topics covered ranged from first seizures to work-up to treatment, including when to refer to a neurologist, according to Dr. Joshi, who helped develop the curriculum. Encouraging findings among the 49 clinics participating in the first year led to expansion of the program to five more states.
Preliminary data from the full cohort show reductions from baseline to end of the program in the proportions of participants who felt not at all or not very knowledgeable about pharmacologic management of pediatric epilepsy (from 69% to 45%), related school and education issues (from 51% to 18%), pertinent state driving laws (from 69% to 45%), and when to refer to a specialist (from 34% to 0%), Dr. Joshi reported.
There were also reductions in the proportions of participants who felt not at all or not very confident about aspects of care such as medical testing in this population (from 52% to 45%), communicating with patients about the transition to adult care (from 52% to 27%), and communicating with families and caregivers about the impact of epilepsy on everyday life (from 59% to 36%).
“This has been a good demonstration to say that telementoring does improve provider knowledge and confidence,” Dr. Joshi maintained. “Everybody felt quite uniformly that the case discussions were useful, and it really fostered a sense of a community of learners and was very much an iterative process.”
The AAP has since been designated as a “superhub” for Project ECHO that can train others to start programs in specialty areas. Additional programs have been developed in pediatric endocrinology, sickle cell disease, and surgery.
The main costs of ECHO are the personnel and physician time, and financing has yet to be worked out. “Unlike traditional telemedicine, where it’s one patient and one physician, and you can actually bill for it, this is not a billable service,” Dr. Joshi noted. “What you can get is more of a downstream effect, which can take some time to become obvious.”
The key attraction for providers is obtaining CME credits, where offered. And a draw for institutions is the potential impact of ECHO in reducing provider turnover and improving value-based reimbursement.
“This is really an innovative program that can help us achieve the triple aim” of improving the patient’s experience, reducing costs, and achieving better health outcomes, Dr. Wood said. “I think this is a great enhancement to the medical home.”
Both Dr. Joshi and Dr. Wood disclosed that they had no relevant conflicts of interest.
SAN FRANCISCO – Telementoring empowers primary care pediatric providers (PCPs) to take on a greater role in managing their patients’ chronic diseases, new data suggest. Leaders in this emerging field gave a snapshot of early experience with the model at the annual meeting of the American Academy of Pediatrics.
“About a quarter of children live with chronic health conditions, and there is an increasing need for specialty care. But many children don’t have access to the quality specialty care that they really need, particularly in rural and medically underserved areas,” explained Dr. Sucheta M. Joshi, a pediatric neurologist and epileptologist at the University of Michigan, Ann Arbor. “The goal of telementoring is to build the capacity of primary care doctors.”
“We need to empower primary care providers to work ‘at the top of their license’ because we don’t have enough specialists,” agreed Dr. David
Telementoring first gained recognition through the University of New Mexico’s Project Extension for Community Healthcare Outcomes (ECHO), which links specialists at an academic “hub” with PCPs in local communities, or “spokes,” in a learning network.
Through regular, interactive, multisite telementoring sessions, ECHO provides training to increase PCPs’ knowledge, self-efficacy, and comfort in managing chronic diseases not typically considered within their scope of practice. Sessions combine short didactic presentations and case-based learning.
The model was initially tested in pediatrics as ECHO for Epilepsy, a partnership of the AAP and the University of New Mexico, Albuquerque. Topics covered ranged from first seizures to work-up to treatment, including when to refer to a neurologist, according to Dr. Joshi, who helped develop the curriculum. Encouraging findings among the 49 clinics participating in the first year led to expansion of the program to five more states.
Preliminary data from the full cohort show reductions from baseline to end of the program in the proportions of participants who felt not at all or not very knowledgeable about pharmacologic management of pediatric epilepsy (from 69% to 45%), related school and education issues (from 51% to 18%), pertinent state driving laws (from 69% to 45%), and when to refer to a specialist (from 34% to 0%), Dr. Joshi reported.
There were also reductions in the proportions of participants who felt not at all or not very confident about aspects of care such as medical testing in this population (from 52% to 45%), communicating with patients about the transition to adult care (from 52% to 27%), and communicating with families and caregivers about the impact of epilepsy on everyday life (from 59% to 36%).
“This has been a good demonstration to say that telementoring does improve provider knowledge and confidence,” Dr. Joshi maintained. “Everybody felt quite uniformly that the case discussions were useful, and it really fostered a sense of a community of learners and was very much an iterative process.”
The AAP has since been designated as a “superhub” for Project ECHO that can train others to start programs in specialty areas. Additional programs have been developed in pediatric endocrinology, sickle cell disease, and surgery.
The main costs of ECHO are the personnel and physician time, and financing has yet to be worked out. “Unlike traditional telemedicine, where it’s one patient and one physician, and you can actually bill for it, this is not a billable service,” Dr. Joshi noted. “What you can get is more of a downstream effect, which can take some time to become obvious.”
The key attraction for providers is obtaining CME credits, where offered. And a draw for institutions is the potential impact of ECHO in reducing provider turnover and improving value-based reimbursement.
“This is really an innovative program that can help us achieve the triple aim” of improving the patient’s experience, reducing costs, and achieving better health outcomes, Dr. Wood said. “I think this is a great enhancement to the medical home.”
Both Dr. Joshi and Dr. Wood disclosed that they had no relevant conflicts of interest.
SAN FRANCISCO – Telementoring empowers primary care pediatric providers (PCPs) to take on a greater role in managing their patients’ chronic diseases, new data suggest. Leaders in this emerging field gave a snapshot of early experience with the model at the annual meeting of the American Academy of Pediatrics.
“About a quarter of children live with chronic health conditions, and there is an increasing need for specialty care. But many children don’t have access to the quality specialty care that they really need, particularly in rural and medically underserved areas,” explained Dr. Sucheta M. Joshi, a pediatric neurologist and epileptologist at the University of Michigan, Ann Arbor. “The goal of telementoring is to build the capacity of primary care doctors.”
“We need to empower primary care providers to work ‘at the top of their license’ because we don’t have enough specialists,” agreed Dr. David
Telementoring first gained recognition through the University of New Mexico’s Project Extension for Community Healthcare Outcomes (ECHO), which links specialists at an academic “hub” with PCPs in local communities, or “spokes,” in a learning network.
Through regular, interactive, multisite telementoring sessions, ECHO provides training to increase PCPs’ knowledge, self-efficacy, and comfort in managing chronic diseases not typically considered within their scope of practice. Sessions combine short didactic presentations and case-based learning.
The model was initially tested in pediatrics as ECHO for Epilepsy, a partnership of the AAP and the University of New Mexico, Albuquerque. Topics covered ranged from first seizures to work-up to treatment, including when to refer to a neurologist, according to Dr. Joshi, who helped develop the curriculum. Encouraging findings among the 49 clinics participating in the first year led to expansion of the program to five more states.
Preliminary data from the full cohort show reductions from baseline to end of the program in the proportions of participants who felt not at all or not very knowledgeable about pharmacologic management of pediatric epilepsy (from 69% to 45%), related school and education issues (from 51% to 18%), pertinent state driving laws (from 69% to 45%), and when to refer to a specialist (from 34% to 0%), Dr. Joshi reported.
There were also reductions in the proportions of participants who felt not at all or not very confident about aspects of care such as medical testing in this population (from 52% to 45%), communicating with patients about the transition to adult care (from 52% to 27%), and communicating with families and caregivers about the impact of epilepsy on everyday life (from 59% to 36%).
“This has been a good demonstration to say that telementoring does improve provider knowledge and confidence,” Dr. Joshi maintained. “Everybody felt quite uniformly that the case discussions were useful, and it really fostered a sense of a community of learners and was very much an iterative process.”
The AAP has since been designated as a “superhub” for Project ECHO that can train others to start programs in specialty areas. Additional programs have been developed in pediatric endocrinology, sickle cell disease, and surgery.
The main costs of ECHO are the personnel and physician time, and financing has yet to be worked out. “Unlike traditional telemedicine, where it’s one patient and one physician, and you can actually bill for it, this is not a billable service,” Dr. Joshi noted. “What you can get is more of a downstream effect, which can take some time to become obvious.”
The key attraction for providers is obtaining CME credits, where offered. And a draw for institutions is the potential impact of ECHO in reducing provider turnover and improving value-based reimbursement.
“This is really an innovative program that can help us achieve the triple aim” of improving the patient’s experience, reducing costs, and achieving better health outcomes, Dr. Wood said. “I think this is a great enhancement to the medical home.”
Both Dr. Joshi and Dr. Wood disclosed that they had no relevant conflicts of interest.
EXPERT ANALYSIS FROM AAP 16
Tap the power of words when counseling about divorce
SAN FRANCISCO – By choosing your words carefully, counseling families about divorce can tactfully address sensitive issues and help parents and children better cope with this life transition, Nerissa S. Bauer, MD, said at the annual meeting of the American Academy of Pediatrics.
About one in five children born within a marriage and one in two of those born within a cohabiting union will experience breakup of that relationship by the age of 9 years, she said.
You must, therefore, be prepared to monitor for and identify outcomes that commonly result from divorce, and to counsel families about how to help children cope and manage. Yet, you may feel uneasy or ill-prepared to do so.
“Turn this thought of ‘I wasn’t trained for this’ into ‘I can help,’ ” recommended Dr. Bauer, who is a specialist in behavioral pediatrics at the Indiana University in Indianapolis.
Risk and protective factors
Divorce can have an impact on all facets of a child’s life: behavior, physical and mental health, academic performance, social relationships, delinquency, substance use, and more. A variety of factors determine how well kids adjust to this stressor, for better or worse.
Marital conflict, both during and after divorce, is a more important predictor than the divorce itself. “The biggest risk factor to consider is the ongoing parental fighting and how that plays out,” Dr. Bauer elaborated. Although parents may report that they try to limit altercations in front of their children, kids usually sense what is going on anyway.
“One of the ways that I like to phrase this when I’m trying to figure out how bad the conflict is in the household is, ‘Has Johnny ever witnessed your arguments, and if so, have those arguments ever been more than just yelling?’ Or another way to say it is, ‘How do adults in your home resolve conflicts?’ ” she shared.
Divorce may negatively affect children through its impact on the household’s socioeconomic status too. For example, the standard of living often declines and the mother’s economic resources can take a hit, possibly forcing a move to a less expensive neighborhood with weaker schools and more crime.
To sound parents out on this sensitive issue, “You can say something like, ‘I’m really sorry that you’re going through this right now. Sometimes, it can cause a lot of stress and strain, especially when it comes to making ends meet, making sure you can get food on the table, and making sure you’re paying the bills. Do you have worries like this now?’ ” Dr. Bauer suggested.
Factors that are known to protect children from adverse divorce outcomes include a good relationship with at least one parent or caregiver, parental warmth, sibling support, and for teens, good self-esteem and peer support. Joint custody with shared decision making and greater paternal involvement also are protective.
“I like to say, ‘So I can understand how this affects your daily life, can you describe what your current arrangements are between you and your ex?’ just to sort of probe into that custody situation,” she said. “Or, ‘How are you (parents) handling this?’ ”
Surveillance and monitoring
“Perform surveillance on family structure and conflict at all well-child visits, as well as with any new family that comes to your practice,” Dr. Bauer recommended. You can do this by simply chatting with the family or by using screening tools such as the Family Psychosocial Screen or the Finding Your ACE Score.
Once you know that a family is dealing with divorce, perform ongoing monitoring for warning signs in the child: sleep problems; school problems, such as poor concentration, acting out, or not doing schoolwork; angry outbursts; withdrawal; and no longer participating in activities once enjoyed.
You may worry about getting dragged into the conflict. “You may feel that you’re in this position of being the mediator, but that’s not really your role. And you shouldn’t offer legal advice,” she cautioned. “You should make it clear that although you are there to support the child and the parents, your role is really to monitor how the child responds and adjusts.”
Parents will sometimes ask whether and how best to tell their children about the divorce. “I oftentimes coach parents to use kid-friendly terms, saying things such as, ‘Mommy and Daddy are having a hard time getting along, and you’ve probably noticed we argue or fight a lot.’ Just throwing it out there and pausing and waiting to see what the child says, and then always following that by answering their questions as they bring them up,” Dr. Bauer said.
Parents should be counseled not to rush children as they will vary in the time needed to process information. Additionally, they should be forewarned that children’s reactions can vary widely and that their feelings can change and resurface at any moment, particularly as they mature and at events that stir up emotions.
Messages of reassurance are essential. “The messages should always contain, ‘We are always going to be your parents no matter what’ and ‘We love you no matter what,’ and probably the most important, ‘This is not your fault.’ This is a message that kids need to hear again and again,” Dr. Bauer said.
Ongoing counseling
Over time, parents may consult you about specific situations that arise because of the divorce. For example, they may become frustrated by differences in how things are handled in the two households.
“The most important message to convey is that we can control only what we can control,” Dr. Bauer said. “Regardless of divorce or separation, kids thrive on structure and routine. Divorce is often messy, and it sometimes means that families have to find a new rhythm between households, but routines in each house should be as consistent as possible.”
Acrimony between the mother and father may persist or escalate. As children don’t want to have to choose between parents, parents should be encouraged not to undermine or talk negatively about each other in front of the child. If necessary, you can arrange to have time separately with parents to allow them to air their grievances.
If parents give permission to broach the topic of divorce, you can role model conversational strategies during visits. “You can say something like, ‘I understand there are a lot of changes going on. Through it all, your mom and dad will always be your parents. I know this isn’t easy for anybody, especially for you. Kids in this situation feel a lot of things from sadness to anger but know that you can always talk to me or your parents about your feelings,’” Dr. Bauer elaborated.
“Listening is key,” she stressed; therefore, parents should be encouraged to just sit in silence and let their children process their feelings. “In these types of situations, there’s no right or wrong: When the child has feelings, they have feelings. We can’t force them to feel a certain way, we have to acknowledge that. So tell parents to try this: ‘Thanks for telling me how you feel. I want you to know that you can always come to me when you feel this way.’ See what happens.”
Parents should be advised not to be too quick to dismiss their child’s concerns, Dr. Bauer recommended. “So, instead of saying, ‘Oh honey, you don’t have to worry about that, I’ll take care of it,’ try this: ‘It sounds like you are sad and upset right now. What can I do to help?’ Sometimes a kid will say, ‘I don’t know,’ but that’s okay. Then the parent can respond in kind and say, ‘I don’t know either, but how about a hug? Let’s start there.’ ”
Some kids simply aren’t talkers and shouldn’t be forced to share, she pointed out. This group can be given other ways to express their feelings, such as journaling, drawing, art, music, yoga, or writing a letter that they then throw away or put in a drawer.
Finally, “reminding parents that even giving children a little control with daily things – what they wear, how they do their chores, and homework, and what to make for dinner – can also help,” she noted. “Those little things can represent a lot for children who don’t feel like they have any control.”
Building resources
Explore various media and online tools to develop a set of resources on divorce for families, Dr. Bauer recommended.
Books on the topic can be great conversation starters, and many are available for various age-groups, she noted. Examples include “Was It the Chocolate Pudding? A Story for Little Kids About Divorce” (Washington: Magination Press, 2005) for ages 4-7 years, “Divorced but Still My Parents” (Longmont, Colo. : Springboard Publications, 1997) for ages 6-12 years, and “My Mom and Dad Don’t Live Together Anymore: A Drawing Book for Children of Separated or Divorced Parents” (Washington: Magination Press, 2002) for ages 8-12 years.
Sesame Street has a toolkit on divorce that offers printable materials, songs, and an app that features conversation starters and vignettes, according to Dr. Bauer; go to sesamestreet.org and type in “divorce.” Additionally, the documentary SPLIT at splitfilm.org follows real families going through divorce and helps show the child’s perspective.
When parents ask about legal references, they can be referred to the UpToParents website, a free resource and curriculum developed by attorneys on topics such as divorce, in both English and Spanish.
Finally, familiarize yourself with resources available in your local community, such as divorce education programs, and services offered for divorce and custody mediation, so that you can link parents to them as needed.
Dr. Bauer said she has no relevant financial disclosures.
SAN FRANCISCO – By choosing your words carefully, counseling families about divorce can tactfully address sensitive issues and help parents and children better cope with this life transition, Nerissa S. Bauer, MD, said at the annual meeting of the American Academy of Pediatrics.
About one in five children born within a marriage and one in two of those born within a cohabiting union will experience breakup of that relationship by the age of 9 years, she said.
You must, therefore, be prepared to monitor for and identify outcomes that commonly result from divorce, and to counsel families about how to help children cope and manage. Yet, you may feel uneasy or ill-prepared to do so.
“Turn this thought of ‘I wasn’t trained for this’ into ‘I can help,’ ” recommended Dr. Bauer, who is a specialist in behavioral pediatrics at the Indiana University in Indianapolis.
Risk and protective factors
Divorce can have an impact on all facets of a child’s life: behavior, physical and mental health, academic performance, social relationships, delinquency, substance use, and more. A variety of factors determine how well kids adjust to this stressor, for better or worse.
Marital conflict, both during and after divorce, is a more important predictor than the divorce itself. “The biggest risk factor to consider is the ongoing parental fighting and how that plays out,” Dr. Bauer elaborated. Although parents may report that they try to limit altercations in front of their children, kids usually sense what is going on anyway.
“One of the ways that I like to phrase this when I’m trying to figure out how bad the conflict is in the household is, ‘Has Johnny ever witnessed your arguments, and if so, have those arguments ever been more than just yelling?’ Or another way to say it is, ‘How do adults in your home resolve conflicts?’ ” she shared.
Divorce may negatively affect children through its impact on the household’s socioeconomic status too. For example, the standard of living often declines and the mother’s economic resources can take a hit, possibly forcing a move to a less expensive neighborhood with weaker schools and more crime.
To sound parents out on this sensitive issue, “You can say something like, ‘I’m really sorry that you’re going through this right now. Sometimes, it can cause a lot of stress and strain, especially when it comes to making ends meet, making sure you can get food on the table, and making sure you’re paying the bills. Do you have worries like this now?’ ” Dr. Bauer suggested.
Factors that are known to protect children from adverse divorce outcomes include a good relationship with at least one parent or caregiver, parental warmth, sibling support, and for teens, good self-esteem and peer support. Joint custody with shared decision making and greater paternal involvement also are protective.
“I like to say, ‘So I can understand how this affects your daily life, can you describe what your current arrangements are between you and your ex?’ just to sort of probe into that custody situation,” she said. “Or, ‘How are you (parents) handling this?’ ”
Surveillance and monitoring
“Perform surveillance on family structure and conflict at all well-child visits, as well as with any new family that comes to your practice,” Dr. Bauer recommended. You can do this by simply chatting with the family or by using screening tools such as the Family Psychosocial Screen or the Finding Your ACE Score.
Once you know that a family is dealing with divorce, perform ongoing monitoring for warning signs in the child: sleep problems; school problems, such as poor concentration, acting out, or not doing schoolwork; angry outbursts; withdrawal; and no longer participating in activities once enjoyed.
You may worry about getting dragged into the conflict. “You may feel that you’re in this position of being the mediator, but that’s not really your role. And you shouldn’t offer legal advice,” she cautioned. “You should make it clear that although you are there to support the child and the parents, your role is really to monitor how the child responds and adjusts.”
Parents will sometimes ask whether and how best to tell their children about the divorce. “I oftentimes coach parents to use kid-friendly terms, saying things such as, ‘Mommy and Daddy are having a hard time getting along, and you’ve probably noticed we argue or fight a lot.’ Just throwing it out there and pausing and waiting to see what the child says, and then always following that by answering their questions as they bring them up,” Dr. Bauer said.
Parents should be counseled not to rush children as they will vary in the time needed to process information. Additionally, they should be forewarned that children’s reactions can vary widely and that their feelings can change and resurface at any moment, particularly as they mature and at events that stir up emotions.
Messages of reassurance are essential. “The messages should always contain, ‘We are always going to be your parents no matter what’ and ‘We love you no matter what,’ and probably the most important, ‘This is not your fault.’ This is a message that kids need to hear again and again,” Dr. Bauer said.
Ongoing counseling
Over time, parents may consult you about specific situations that arise because of the divorce. For example, they may become frustrated by differences in how things are handled in the two households.
“The most important message to convey is that we can control only what we can control,” Dr. Bauer said. “Regardless of divorce or separation, kids thrive on structure and routine. Divorce is often messy, and it sometimes means that families have to find a new rhythm between households, but routines in each house should be as consistent as possible.”
Acrimony between the mother and father may persist or escalate. As children don’t want to have to choose between parents, parents should be encouraged not to undermine or talk negatively about each other in front of the child. If necessary, you can arrange to have time separately with parents to allow them to air their grievances.
If parents give permission to broach the topic of divorce, you can role model conversational strategies during visits. “You can say something like, ‘I understand there are a lot of changes going on. Through it all, your mom and dad will always be your parents. I know this isn’t easy for anybody, especially for you. Kids in this situation feel a lot of things from sadness to anger but know that you can always talk to me or your parents about your feelings,’” Dr. Bauer elaborated.
“Listening is key,” she stressed; therefore, parents should be encouraged to just sit in silence and let their children process their feelings. “In these types of situations, there’s no right or wrong: When the child has feelings, they have feelings. We can’t force them to feel a certain way, we have to acknowledge that. So tell parents to try this: ‘Thanks for telling me how you feel. I want you to know that you can always come to me when you feel this way.’ See what happens.”
Parents should be advised not to be too quick to dismiss their child’s concerns, Dr. Bauer recommended. “So, instead of saying, ‘Oh honey, you don’t have to worry about that, I’ll take care of it,’ try this: ‘It sounds like you are sad and upset right now. What can I do to help?’ Sometimes a kid will say, ‘I don’t know,’ but that’s okay. Then the parent can respond in kind and say, ‘I don’t know either, but how about a hug? Let’s start there.’ ”
Some kids simply aren’t talkers and shouldn’t be forced to share, she pointed out. This group can be given other ways to express their feelings, such as journaling, drawing, art, music, yoga, or writing a letter that they then throw away or put in a drawer.
Finally, “reminding parents that even giving children a little control with daily things – what they wear, how they do their chores, and homework, and what to make for dinner – can also help,” she noted. “Those little things can represent a lot for children who don’t feel like they have any control.”
Building resources
Explore various media and online tools to develop a set of resources on divorce for families, Dr. Bauer recommended.
Books on the topic can be great conversation starters, and many are available for various age-groups, she noted. Examples include “Was It the Chocolate Pudding? A Story for Little Kids About Divorce” (Washington: Magination Press, 2005) for ages 4-7 years, “Divorced but Still My Parents” (Longmont, Colo. : Springboard Publications, 1997) for ages 6-12 years, and “My Mom and Dad Don’t Live Together Anymore: A Drawing Book for Children of Separated or Divorced Parents” (Washington: Magination Press, 2002) for ages 8-12 years.
Sesame Street has a toolkit on divorce that offers printable materials, songs, and an app that features conversation starters and vignettes, according to Dr. Bauer; go to sesamestreet.org and type in “divorce.” Additionally, the documentary SPLIT at splitfilm.org follows real families going through divorce and helps show the child’s perspective.
When parents ask about legal references, they can be referred to the UpToParents website, a free resource and curriculum developed by attorneys on topics such as divorce, in both English and Spanish.
Finally, familiarize yourself with resources available in your local community, such as divorce education programs, and services offered for divorce and custody mediation, so that you can link parents to them as needed.
Dr. Bauer said she has no relevant financial disclosures.
SAN FRANCISCO – By choosing your words carefully, counseling families about divorce can tactfully address sensitive issues and help parents and children better cope with this life transition, Nerissa S. Bauer, MD, said at the annual meeting of the American Academy of Pediatrics.
About one in five children born within a marriage and one in two of those born within a cohabiting union will experience breakup of that relationship by the age of 9 years, she said.
You must, therefore, be prepared to monitor for and identify outcomes that commonly result from divorce, and to counsel families about how to help children cope and manage. Yet, you may feel uneasy or ill-prepared to do so.
“Turn this thought of ‘I wasn’t trained for this’ into ‘I can help,’ ” recommended Dr. Bauer, who is a specialist in behavioral pediatrics at the Indiana University in Indianapolis.
Risk and protective factors
Divorce can have an impact on all facets of a child’s life: behavior, physical and mental health, academic performance, social relationships, delinquency, substance use, and more. A variety of factors determine how well kids adjust to this stressor, for better or worse.
Marital conflict, both during and after divorce, is a more important predictor than the divorce itself. “The biggest risk factor to consider is the ongoing parental fighting and how that plays out,” Dr. Bauer elaborated. Although parents may report that they try to limit altercations in front of their children, kids usually sense what is going on anyway.
“One of the ways that I like to phrase this when I’m trying to figure out how bad the conflict is in the household is, ‘Has Johnny ever witnessed your arguments, and if so, have those arguments ever been more than just yelling?’ Or another way to say it is, ‘How do adults in your home resolve conflicts?’ ” she shared.
Divorce may negatively affect children through its impact on the household’s socioeconomic status too. For example, the standard of living often declines and the mother’s economic resources can take a hit, possibly forcing a move to a less expensive neighborhood with weaker schools and more crime.
To sound parents out on this sensitive issue, “You can say something like, ‘I’m really sorry that you’re going through this right now. Sometimes, it can cause a lot of stress and strain, especially when it comes to making ends meet, making sure you can get food on the table, and making sure you’re paying the bills. Do you have worries like this now?’ ” Dr. Bauer suggested.
Factors that are known to protect children from adverse divorce outcomes include a good relationship with at least one parent or caregiver, parental warmth, sibling support, and for teens, good self-esteem and peer support. Joint custody with shared decision making and greater paternal involvement also are protective.
“I like to say, ‘So I can understand how this affects your daily life, can you describe what your current arrangements are between you and your ex?’ just to sort of probe into that custody situation,” she said. “Or, ‘How are you (parents) handling this?’ ”
Surveillance and monitoring
“Perform surveillance on family structure and conflict at all well-child visits, as well as with any new family that comes to your practice,” Dr. Bauer recommended. You can do this by simply chatting with the family or by using screening tools such as the Family Psychosocial Screen or the Finding Your ACE Score.
Once you know that a family is dealing with divorce, perform ongoing monitoring for warning signs in the child: sleep problems; school problems, such as poor concentration, acting out, or not doing schoolwork; angry outbursts; withdrawal; and no longer participating in activities once enjoyed.
You may worry about getting dragged into the conflict. “You may feel that you’re in this position of being the mediator, but that’s not really your role. And you shouldn’t offer legal advice,” she cautioned. “You should make it clear that although you are there to support the child and the parents, your role is really to monitor how the child responds and adjusts.”
Parents will sometimes ask whether and how best to tell their children about the divorce. “I oftentimes coach parents to use kid-friendly terms, saying things such as, ‘Mommy and Daddy are having a hard time getting along, and you’ve probably noticed we argue or fight a lot.’ Just throwing it out there and pausing and waiting to see what the child says, and then always following that by answering their questions as they bring them up,” Dr. Bauer said.
Parents should be counseled not to rush children as they will vary in the time needed to process information. Additionally, they should be forewarned that children’s reactions can vary widely and that their feelings can change and resurface at any moment, particularly as they mature and at events that stir up emotions.
Messages of reassurance are essential. “The messages should always contain, ‘We are always going to be your parents no matter what’ and ‘We love you no matter what,’ and probably the most important, ‘This is not your fault.’ This is a message that kids need to hear again and again,” Dr. Bauer said.
Ongoing counseling
Over time, parents may consult you about specific situations that arise because of the divorce. For example, they may become frustrated by differences in how things are handled in the two households.
“The most important message to convey is that we can control only what we can control,” Dr. Bauer said. “Regardless of divorce or separation, kids thrive on structure and routine. Divorce is often messy, and it sometimes means that families have to find a new rhythm between households, but routines in each house should be as consistent as possible.”
Acrimony between the mother and father may persist or escalate. As children don’t want to have to choose between parents, parents should be encouraged not to undermine or talk negatively about each other in front of the child. If necessary, you can arrange to have time separately with parents to allow them to air their grievances.
If parents give permission to broach the topic of divorce, you can role model conversational strategies during visits. “You can say something like, ‘I understand there are a lot of changes going on. Through it all, your mom and dad will always be your parents. I know this isn’t easy for anybody, especially for you. Kids in this situation feel a lot of things from sadness to anger but know that you can always talk to me or your parents about your feelings,’” Dr. Bauer elaborated.
“Listening is key,” she stressed; therefore, parents should be encouraged to just sit in silence and let their children process their feelings. “In these types of situations, there’s no right or wrong: When the child has feelings, they have feelings. We can’t force them to feel a certain way, we have to acknowledge that. So tell parents to try this: ‘Thanks for telling me how you feel. I want you to know that you can always come to me when you feel this way.’ See what happens.”
Parents should be advised not to be too quick to dismiss their child’s concerns, Dr. Bauer recommended. “So, instead of saying, ‘Oh honey, you don’t have to worry about that, I’ll take care of it,’ try this: ‘It sounds like you are sad and upset right now. What can I do to help?’ Sometimes a kid will say, ‘I don’t know,’ but that’s okay. Then the parent can respond in kind and say, ‘I don’t know either, but how about a hug? Let’s start there.’ ”
Some kids simply aren’t talkers and shouldn’t be forced to share, she pointed out. This group can be given other ways to express their feelings, such as journaling, drawing, art, music, yoga, or writing a letter that they then throw away or put in a drawer.
Finally, “reminding parents that even giving children a little control with daily things – what they wear, how they do their chores, and homework, and what to make for dinner – can also help,” she noted. “Those little things can represent a lot for children who don’t feel like they have any control.”
Building resources
Explore various media and online tools to develop a set of resources on divorce for families, Dr. Bauer recommended.
Books on the topic can be great conversation starters, and many are available for various age-groups, she noted. Examples include “Was It the Chocolate Pudding? A Story for Little Kids About Divorce” (Washington: Magination Press, 2005) for ages 4-7 years, “Divorced but Still My Parents” (Longmont, Colo. : Springboard Publications, 1997) for ages 6-12 years, and “My Mom and Dad Don’t Live Together Anymore: A Drawing Book for Children of Separated or Divorced Parents” (Washington: Magination Press, 2002) for ages 8-12 years.
Sesame Street has a toolkit on divorce that offers printable materials, songs, and an app that features conversation starters and vignettes, according to Dr. Bauer; go to sesamestreet.org and type in “divorce.” Additionally, the documentary SPLIT at splitfilm.org follows real families going through divorce and helps show the child’s perspective.
When parents ask about legal references, they can be referred to the UpToParents website, a free resource and curriculum developed by attorneys on topics such as divorce, in both English and Spanish.
Finally, familiarize yourself with resources available in your local community, such as divorce education programs, and services offered for divorce and custody mediation, so that you can link parents to them as needed.
Dr. Bauer said she has no relevant financial disclosures.
EXPERT ANALYSIS FROM AAP 16