<p><b>OBJECTIVE: </b>Reducing overuse of second-generation antipsychotics among Medicaid-enrolled children is a national priority, yet little is known about how service organization affects use. This study compared differences in second-generation antipsychotic utilization among Medicaid-enrolled children across fee-for-service, integrated managed care, and managed behavioral health carve-out organizational structures.</p><p><b>METHODS: </b>Organizational structures of Medicaid programs in 82 diverse counties in 34 states were categorized and linked to child-level cross-sectional claims data from the Medicaid Analytic Extract covering fiscal years 2004, 2006, and 2008. To approximate the population at risk of antipsychotic treatment, the sample was restricted to stimulant-using children ages three to 18 (N=419,226). The sample was stratified by Medicaid eligibility group, and logistic regression models were estimated for probability of second-generation antipsychotic use. Models included indicators of county-level organizational structure as main predictors, with sequential adjustment for personal and county-level covariates.</p><p><b>RESULTS: </b>With adjustment for person-level covariates, second-generation antipsychotic use was 31% higher among youths in foster care in fee-for-service counties than for youths in counties with carve-outs (odds ratio [OR]=1.69, 95% confidence interval [CI]=1.26-2.27). Foster care youths in integrated counties had the second highest adjusted odds (OR=1.31, CI=1.08-1.58). Similar patterns of use also were found for youths eligible for Supplemental Security Income but not for those eligible for Temporary Assistance for Needy Families. Differences persisted after adjustment for county-level characteristics.</p><p><b>CONCLUSIONS: </b>Carve-outs, versus other arrangements, were associated with lower second-generation antipsychotic use. Future research should explore carve-out features (for example, tighter management of inpatient or restricted access, as well as care coordination) contributing to lower second-generation antipsychotic use.</p>

<p><b>BACKGROUND: </b>Home visiting programs represent an important primary prevention strategy for adverse prenatal health behaviors; the various ways in which home visiting programs impact prenatal smoking cessation and reduction behaviors remain understudied.</p><p><b>METHODS: </b>Mixed methods approach using a retrospective cohort of propensity score matched home visiting clients and local-area comparison women with first births between 2008-2014 in a large Northeast state. Multivariable logistic and linear regression estimated third trimester prenatal tobacco smoking cessation and reduction. Additionally, qualitative interviews were conducted with 76 home visiting clients.</p><p><b>RESULTS: </b>A program effect was seen for smoking cessation such that clients who smoked less than ten cigarettes per day and those who smoked 20 or more cigarettes per day during the first trimester were more likely to achieve third trimester cessation than comparison women (p &lt;0.01 and p = 0.01, respectively). Only for heavy smokers (20 or more cigarettes during the first trimester) was there a significant reduction in number of cigarettes smoked by the third trimester versus comparison women (p = 0.01). Clients expressed the difficulty of cessation, but addressed several harm-reduction strategies including reducing smoking in the house and wearing a smoking jacket. Clients also described smoking education that empowered them to ask others to not smoke or adopt other harm reducing behaviors when around their children.</p><p><b>CONCLUSIONS: </b>While a significant impact on smoking cessation was seen, this study finds a less-clear impact on smoking reduction among women in home visiting programs. As home visiting programs continue to expand, it will be important to best identify effective ways to support tobacco-related harm reduction within vulnerable families.</p>

<p><strong>OBJECTIVES: </strong>The aim of this study was to evaluate cervical magnetic resonance imaging (MRI) and computed tomography (CT) practices and cervical spine injuries among young children with non-motor vehicle crash (MVC)-associated traumatic brain injury (TBI).</p>

<p><strong>METHODS: </strong>We performed a retrospective study of a stratified, systematic random sample of 328 children younger than 2 years with non-MVC-associated TBI at 4 urban children's hospitals from 2008 to 2012. We defined TBI etiology as accidental, indeterminate, or abuse. We reported the proportion, by etiology, who underwent cervical MRI or CT, and had cervical abnormalities identified.</p>

<p><strong>RESULTS: </strong>Of children with non-MVC-associated TBI, 39.4% had abusive head trauma (AHT), 52.2% had accidental TBI, and in 8.4% the etiology was indeterminate. Advanced cervical imaging (CT and/or MRI) was obtained in 19.1% of all children with TBI, with 9.3% undergoing MRI and 11.7% undergoing CT. Cervical MRI or CT was performed in 30.9% of children with AHT, in 11.7% of accidental TBI, and in 10.7% of indeterminate-cause TBI. Among children imaged by MRI or CT, abnormal cervical findings were found in 22.1%, including 31.3% of children with AHT, 7.1% of children with accidental TBI, and 0% of children with indeterminate-cause TBI. Children with more severe head injuries who underwent cervical imaging were more likely to have cervical injuries.</p>

<p><strong>CONCLUSIONS: </strong>Abusive head trauma victims appear to be at increased risk of cervical injuries. Prospective studies are needed to define the risk of cervical injury in children with TBI concerning for AHT and to inform development of imaging guidelines.</p>

<p><strong>OBJECTIVE: </strong>Soldier deployment can create a stressful environment for U.S. Army families with young children. Prior research has identified elevated rates of child maltreatment in the 6 months immediately following a soldier's return home from deployment. In this study, we longitudinally examine how other child- and family-level characteristics influence the relationship of deployment to risk for maltreatment of dependent children of U.S. Army soldiers.</p>

<p><strong>METHODS: </strong>We conducted a person-time analysis of substantiated reports and medical diagnoses of maltreatment among the 73,404 children of 56,087 U.S. Army soldiers with a single deployment between 2001 and 2007. Cox proportional hazard models estimated hazard rates of maltreatment across deployment periods and simultaneously considered main effects for other child- and family-level characteristics across periods.</p>

<p><strong>RESULTS: </strong>In adjusted models, maltreatment hazard was highest in the 6 months following deployment (hazard ratio [HR] = 1.63, p &lt; 0.001). Children born prematurely or with early special needs independently had an increased risk for maltreatment across all periods (HR = 2.02, p &lt; 0.001), as well as those children whose soldier-parent had been previously diagnosed with a mental illness (HR = 1.68, p &lt; 0.001). In models testing for effect modification, during the 6 months before deployment, children of female soldiers (HR = 2.22, p = 0.006) as well as children of soldiers with a mental health diagnosis (HR = 2.78, p = 0.001) were more likely to experience maltreatment, exceeding the risk at all other periods.</p>

<p><strong>CONCLUSIONS: </strong>Infants and children are at increased risk for maltreatment in the 6 months following a parent's deployment, even after accounting for other known family- and child-level risk factors. However, the risk does not appear to be the same for all soldiers and their families in relation to deployment, particularly for female soldiers and those who had previously diagnosed mental health issues, for whom the risk appears most elevated before deployment. Accounting for the unique needs of high-risk families at different stages of a soldier's deployment cycle may allow the U.S. Army to better direct resources that prevent and address child maltreatment.</p>

<p>Many families rely on employer-sponsored health insurance for their children. However, the rise in the cost of such insurance has outpaced growth in family income, potentially making public insurance (Medicaid or the Children's Health Insurance Plan) an attractive alternative for affordable dependent coverage. Using data for 2008-13 from the Medical Expenditure Panel Survey, we quantified the coverage rates for children from low- or moderate-income households in which a parent was offered employer-sponsored insurance. Among families in which parents were covered by such insurance, the proportion of children without employer-sponsored coverage increased from 22.5&nbsp;percent in 2008 to 25.0&nbsp;percent in 2013. The percentage of children with public insurance when a parent was covered by employer-sponsored insurance increased from 12.1&nbsp;percent in 2008 to 15.2&nbsp;percent in 2013. This trend was most pronounced for families with incomes of 100-199&nbsp;percent of the federal poverty level, for whom the share of children with public insurance increased from 22.8&nbsp;percent to 29.9&nbsp;percent. Among families with incomes of 200-299&nbsp;percent of poverty, uninsurance rates for children increased from 6.0&nbsp;percent to 9.2&nbsp;percent. These findings suggest a movement away from employer-sponsored insurance and toward public insurance for children in low-income families, and growth in uninsurance among children in moderate-income families.</p>

<p><strong>OBJECTIVES: </strong>More childhood deaths are attributed to trauma than all other causes combined. Our objectives were to provide the first national description of the proportion of injured children treated at pediatric trauma centers (TCs), and to provide clarity to the presumed benefit of pediatric TC verification by comparing injury mortality across hospital types.</p>

<p><strong>METHODS: </strong>We performed a population-based cohort study using the 2006 Healthcare Cost and Utilization Project Kids Inpatient Database combined with national TC inventories. We included pediatric discharges (≤16 y) with the International Classification of Diseases, Ninth Revision code(s) for injury. Descriptive analyses were performed evaluating proportions of injured children cared for by TC level. Multivariable logistic regression models were used to estimate differences in in-hospital mortality by TC type (among level-1 TCs only). Analyses were survey-weighted using Healthcare Cost and Utilization Project sampling weights.</p>

<p><strong>RESULTS: </strong>Of 153,380 injured children, 22.3% were admitted to pediatric TCs, 45.2% to general TCs, and 32.6% to non-TCs. Overall mortality was 0.9%. Among level-1 TCs, raw mortality was 1.0% pediatric TC, 1.4% dual TC, and 2.1% general TC. In adjusted analyses, treatment at level-1 pediatric TCs was associated with a significant mortality decrease compared to level-1 general TCs (adjusted odds ratio, 0.6; 95% confidence intervals, 0.4-0.9).</p>

<p><strong>CONCLUSIONS: </strong>Our results provide the first national evidence that treatment at verified pediatric TCs may improve outcomes, supporting a survival benefit with pediatric trauma verification. Given lack of similar survival advantage found for level-1 dual TCs (both general/pediatric verified), we highlight the need for further investigation to understand factors responsible for the survival advantage at pediatric-only TCs, refine pediatric accreditation guidelines, and disseminate best practices.</p>

<p><strong>OBJECTIVE: </strong>Child Adult Relationship Enhancement in Primary Care (PriCARE) is a 6-session group parent training designed to teach positive parenting skills. Our objective was to measure PriCARE's impact on child behavior and parenting attitudes.</p>

<p><strong>METHODS: </strong>Parents of children 2 to 6 years old with behavior concerns were randomized to PriCARE (n=80) or control (n=40). Child behavior and parenting attitudes were measured at baseline (0 weeks), program completion (9 weeks), and 7 weeks following program completion (16 weeks) using the Eyberg Child Behavior Inventory (ECBI) and the Adult Adolescent Parenting Inventory-2 (AAPI2). Linear regression models compared mean ECBI and AAPI2 change scores from 0 to 16 weeks in the PriCARE and control groups, adjusted for baseline scores.</p>

<p><strong>RESULTS: </strong>Of those randomized to PriCARE, 43% attended 3 or more sessions. Decreases in mean ECBI intensity and problem scores between 0 and 16 weeks were greater in the PriCARE group, reflecting a larger improvement in behavior problems [intensity: -22 (-16, -29) vs -7 (2, -17), p=0.012; problem: -5 (-4, -7) vs -2 (0, -4), p=0.014]. Scores on 3 of the 5 AAPI2 sub-scales reflected greater improvements in parenting attitudes in the PriCARE group compared to control in the following areas: empathy towards children's needs [0.82 (1.14, 0.51) vs 0.25 (0.70, -0.19), p=0.04], corporal punishment [0.22 (0.45, 0.00) vs -0.30 (0.02, -0.61), p=0.009], and power and independence [0.37 (0.76, -0.02) vs -0.64 (-0.09, -1.19), p=0.003].</p>

<p><strong>CONCLUSIONS: </strong>PriCARE shows promise in improving parent-reported child-behavior problems in preschool-aged children and increasing positive parenting attitudes.</p>

<p><strong>PURPOSE: </strong>To analyze the relationship of the gender of the clinician, child, and guardian to the child's receipt of human papilloma virus (HPV) vaccine, which prevents a sexually transmitted infection, compared to tetanus, diphtheria, acellular pertussis (Tdap) and meningococcal dose 1&nbsp;(MCV4) vaccines, which do not.</p>

<p><strong>METHODS: </strong>We extracted electronic health record data from visits by adolescents 11-18&nbsp;years of age to 27 primary care practices from 2009 to 2014. Visits with pediatricians, physician assistants, and nurse practitioners were included if they were the first at which HPV vaccine was due (n&nbsp;=&nbsp;102,736). After stratifying by visit type (preventive/acute), generalized estimating equations with robust variance estimators accounted for clustering of visits within practices. Adjusting for all covariates, these models were used to estimate standardized proportions of "captured opportunities" (vaccine due and given) for HPV dose 1 (HPV), Tdap, and MCV4.</p>

<p><strong>RESULTS: </strong>Fewer opportunities were captured at acute versus preventive visits. Although rates were low, female clinicians delivered all three vaccines at higher rates than male clinicians at acute (HPV: 2.7% vs. 1.2%, p &lt; .001; Tdap: 6.4% vs. 4.1%, p&nbsp;= .013; MCV4: 6.0% vs. 3.7%, p&nbsp;= .013) but not preventive visits. Girls received HPV vaccine at higher rates than boys early in the study period, but the gap closed over time (p &lt; .001). Guardian gender was not associated with vaccination.</p>

<p><strong>CONCLUSIONS: </strong>Clinician gender was associated with vaccination at acute, but not preventive, visits. In the context of efforts to increase acute visit vaccination, differences between female and male clinicians' rates might reflect alternate practice styles by gender that deserve future study.</p>

<p><strong>OBJECTIVE: </strong>We aimed to examine abusive head trauma (AHT) incidence before, during and after the recession of 2007-2009 in 3 US regions and assess the association of economic measures with AHT incidence.</p>

<p><strong>METHODS: </strong>Data for children &lt;5 years old diagnosed with AHT between January 1, 2004, and December 31, 2012, in 3 regions&nbsp;were linked to county-level economic data using an ecologic time series analysis. Associations between county-level AHT rates and recession period as well as employment growth, mortgage delinquency, and foreclosure rates were examined using zero-inflated Poisson regression models.</p>

<p><strong>RESULTS: </strong>During the 9-year period, 712 children were diagnosed with AHT. The mean rate of AHT per 100,000 child-years increased from 9.8 before the recession to 15.6 during the recession before decreasing to 12.8 after the recession. The AHT rates after the recession were higher than the rates before the recession (incidence rate ratio 1.31, P&nbsp;=&nbsp;.004) but lower than rates during the recession (incidence rate ratio 0.78, P = .005). There was no association between the AHT rate and employment growth, mortgage delinquency rates, or foreclosure rates.</p>

<p><strong>CONCLUSIONS: </strong>In the period after the recession, AHT rate was lower than during the recession period yet higher than the level before the recession, suggesting a lingering effect of the economic stress of the recession on maltreatment risk.</p>

<p><strong>OBJECTIVES: </strong>Cervical imaging practices are poorly understood in young children with Traumatic Brain Injury (TBI). We therefore sought to: identify child-level and hospital-level factors associated with performance of cervical imaging of children with TBI from falls and abusive head trauma (AHT); and describe across-hospital variation in cervical imaging performance. We hypothesized that imaging decisions would be influenced by hospital volume of young injured children.</p>

<p><strong>METHODS: </strong>We performed a retrospective study of children younger than 2 years of age with TBI from 2009-2013 in the Premier Perspective Database. After adjustment for observed patient characteristics, we evaluated variation in advanced cervical imaging (computed tomography or magnetic resonance imaging) in children with AHT and TBI from falls.</p>

<p><strong>RESULTS: </strong>Of 2,347 children with TBI, 18.7% were from abuse, and 57.1% were from falls. Fifteen percent of children with TBI underwent advanced cervical imaging. Moderate or severe head injuries were associated with increased odds of cervical imaging in AHT (OR 7.10; 95% CI 2.75, 18.35) and falls (OR 2.25; 95% CI 1.19, 4.27). There was no association between annual hospital volume of injured children and cervical imaging performance. The adjusted probability of imaging across hospitals ranged from 4.3 to 84.3% in AHT and 3.1 to 39.0% in TBI from falls (P &lt; 0.001).</p>

<p><strong>CONCLUSIONS: </strong>These results highlight variation across hospitals in adjusted probability of cervical imaging in AHT (nearly twenty-fold) and TBI from falls (over ten-fold) not explained by observed patient characteristics. This variation suggests opportunities for further research to inform imaging practices.</p>