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Is There a “Bright Future” for Another Screening Test in Pediatrics?: Comment on: “The Parenting Responsibility and Emotional Preparedness (PREP) Screening Tool”

Is There a “Bright Future” for Another Screening Test in Pediatrics?: Comment on: “The Parenting... In this issue of the Archives, Lanzi et al1 present a 3-question screening tool (the PREP) that, when given to pregnant adolescents, identifies those whose infants are at increased risk for a host of adverse socioemotional and cognitive outcomes. These findings are timely and relevant to the aims of pediatrics. Improving the socioemotional outcomes of young children and preventing toxic stress has been recently promoted in a policy statement by the American Academy of Pediatrics.2 An ingenious and effective part of the PREP question set is the indirect question “Now that you are pregnant, are there some new areas in which you are accepting responsibility or want to become responsible in?” A “no” answer to this question detected the most risk. Another commendable aspect of this tool is that the PREP is brief. Brevity is a critical quality of screening tools vying for a place in an overburdened primary care practice.3 Already, pediatricians are covering less than half of the recommended Bright Futures agenda during well-child visits.4 Of course, physicians themselves do not need to do every screening test that is recommended. Other office staff could be assigned this job. This would in turn allow physicians to spend more time “working up to their license”—interpreting and acting on the results of screening instruments and prescribing therapy. However, in most practices (I know), the nonphysician staff has no more free time than the physicians. In economic terms, the marginal increase in revenue associated with hiring administrative personnel to do this work does not cover its costs. Screening tests must have a low false-negative rate and a low false-positive rate and be able to identify a treatable condition. In the case of the PREP, while we know that the infants of at-risk mothers fare worse, we do not know these basic test characteristics of the tool. Targeted screening of teenage mothers instead of universal screening for parenting preparedness would leave a substantial number of at-risk children undetected. On the other hand, infants of adolescent mothers are rarely raised solely by their mother; often the infant's maternal grandmother and other female members of the family are involved. How actively the infant's other relatives “step up” is highly determinative of the infant's outcome. So, it seems unlikely that only asking the mother about her own preparedness without including some estimate of support from the extended family would be highly predictive of outcome. Even if the PREP performs well as a screening test, are we then able to improve the long-term socioemotional, cognitive, and health outcomes of at-risk infants? Personally, I think so but the evidence for that is mixed and even the value of a program as comprehensive as the Head Start Program is being questioned for underperforming in this regard.5 Given these considerations and the fact that the future of primary pediatric care will be geared to meeting quality performance measures and outcomes that are much easier to change and measure than the socioemotional outcomes of children, the PREP does not seem to have a “bright future” in the context of standard well-child care. On the other hand, the co-location of mental health professionals who work in partnership with a pediatric practice to provide socioemotional screening and parenting services is one creative way to address this agenda that capitalizes on the universal and nonstigmatizing access that pediatric practices have to infants and toddlers.6 The challenges, of course, are in scaling these efforts up and funding them. Back to top Article Information Correspondence: Dr Belamarich, Division of General Pediatrics, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Rosenthal 4, Bronx, NY 10467 (pbelamar@montefiore.org). Financial Disclosure: None reported. References 1. Lanzi RG, Ramey SL, Bert SC. The Parenting Responsibility and Emotional Preparedness (PREP) Screening Tool: a 3-item screen that identifies teen mothers at high risk for nonoptimal parenting. Arch Pediatr Adolesc Med. 2012;166(8):749-755Google Scholar 2. Garner AS, Shonkoff JP.Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012;129(1):e224-e23122201148PubMedGoogle ScholarCrossref 3. Belamarich PF, Gandica R, Stein RE, Racine AD. Drowning in a sea of advice: pediatricians and American Academy of Pediatrics policy statements. Pediatrics. 2006;118(4):e964-e97817015516PubMedGoogle ScholarCrossref 4. Norlin C, Crawford MA, Bell CT, Sheng X, Stein MT. Delivery of well-child care: a look inside the door. Acad Pediatr. 2011;11(1):18-2621272820PubMedGoogle ScholarCrossref 5. Mervis J. Giving children a head start is possible—but it's not easy. Science. 2011;333(6045):956-95721852484PubMedGoogle ScholarCrossref 6. Briggs RD, Stettler EM, Silver EJ, et al. Social-emotional screening for infants and toddlers in primary care. Pediatrics. 2012;129(2):e377-e38422232304PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

Is There a “Bright Future” for Another Screening Test in Pediatrics?: Comment on: “The Parenting Responsibility and Emotional Preparedness (PREP) Screening Tool”

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
1072-4710
eISSN
1538-3628
DOI
10.1001/archpediatrics.2012.762
Publisher site
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Abstract

In this issue of the Archives, Lanzi et al1 present a 3-question screening tool (the PREP) that, when given to pregnant adolescents, identifies those whose infants are at increased risk for a host of adverse socioemotional and cognitive outcomes. These findings are timely and relevant to the aims of pediatrics. Improving the socioemotional outcomes of young children and preventing toxic stress has been recently promoted in a policy statement by the American Academy of Pediatrics.2 An ingenious and effective part of the PREP question set is the indirect question “Now that you are pregnant, are there some new areas in which you are accepting responsibility or want to become responsible in?” A “no” answer to this question detected the most risk. Another commendable aspect of this tool is that the PREP is brief. Brevity is a critical quality of screening tools vying for a place in an overburdened primary care practice.3 Already, pediatricians are covering less than half of the recommended Bright Futures agenda during well-child visits.4 Of course, physicians themselves do not need to do every screening test that is recommended. Other office staff could be assigned this job. This would in turn allow physicians to spend more time “working up to their license”—interpreting and acting on the results of screening instruments and prescribing therapy. However, in most practices (I know), the nonphysician staff has no more free time than the physicians. In economic terms, the marginal increase in revenue associated with hiring administrative personnel to do this work does not cover its costs. Screening tests must have a low false-negative rate and a low false-positive rate and be able to identify a treatable condition. In the case of the PREP, while we know that the infants of at-risk mothers fare worse, we do not know these basic test characteristics of the tool. Targeted screening of teenage mothers instead of universal screening for parenting preparedness would leave a substantial number of at-risk children undetected. On the other hand, infants of adolescent mothers are rarely raised solely by their mother; often the infant's maternal grandmother and other female members of the family are involved. How actively the infant's other relatives “step up” is highly determinative of the infant's outcome. So, it seems unlikely that only asking the mother about her own preparedness without including some estimate of support from the extended family would be highly predictive of outcome. Even if the PREP performs well as a screening test, are we then able to improve the long-term socioemotional, cognitive, and health outcomes of at-risk infants? Personally, I think so but the evidence for that is mixed and even the value of a program as comprehensive as the Head Start Program is being questioned for underperforming in this regard.5 Given these considerations and the fact that the future of primary pediatric care will be geared to meeting quality performance measures and outcomes that are much easier to change and measure than the socioemotional outcomes of children, the PREP does not seem to have a “bright future” in the context of standard well-child care. On the other hand, the co-location of mental health professionals who work in partnership with a pediatric practice to provide socioemotional screening and parenting services is one creative way to address this agenda that capitalizes on the universal and nonstigmatizing access that pediatric practices have to infants and toddlers.6 The challenges, of course, are in scaling these efforts up and funding them. Back to top Article Information Correspondence: Dr Belamarich, Division of General Pediatrics, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Rosenthal 4, Bronx, NY 10467 (pbelamar@montefiore.org). Financial Disclosure: None reported. References 1. Lanzi RG, Ramey SL, Bert SC. The Parenting Responsibility and Emotional Preparedness (PREP) Screening Tool: a 3-item screen that identifies teen mothers at high risk for nonoptimal parenting. Arch Pediatr Adolesc Med. 2012;166(8):749-755Google Scholar 2. Garner AS, Shonkoff JP.Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2012;129(1):e224-e23122201148PubMedGoogle ScholarCrossref 3. Belamarich PF, Gandica R, Stein RE, Racine AD. Drowning in a sea of advice: pediatricians and American Academy of Pediatrics policy statements. Pediatrics. 2006;118(4):e964-e97817015516PubMedGoogle ScholarCrossref 4. Norlin C, Crawford MA, Bell CT, Sheng X, Stein MT. Delivery of well-child care: a look inside the door. Acad Pediatr. 2011;11(1):18-2621272820PubMedGoogle ScholarCrossref 5. Mervis J. Giving children a head start is possible—but it's not easy. Science. 2011;333(6045):956-95721852484PubMedGoogle ScholarCrossref 6. Briggs RD, Stettler EM, Silver EJ, et al. Social-emotional screening for infants and toddlers in primary care. Pediatrics. 2012;129(2):e377-e38422232304PubMedGoogle ScholarCrossref

Journal

Archives of Pediatrics & Adolescent MedicineAmerican Medical Association

Published: Aug 1, 2012

Keywords: emotions,pediatrics,parenting behavior,screening,screening test

References