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Biomedical subjects

Lawrence S Wissow

Publications and source records attributed to Lawrence S Wissow.

At least 19 recordsLinked to original sources
PubMed2007

Identification of youth psychosocial problems during pediatric primary care visits.

This investigation applied the Gateway Provider Model (GPM) of child mental health services to investigate whether characteristics of the child, family, visit, and provider were related to the identification of youth psychosocial problems during primary care visits. Data were gathered during 774 visits to 54 primary care providers (PCPs) at 13 clinics. Similar to previous investigations in primary care settings, 42% of youth demonstrated at least a sub-threshold clinical mental health problem. Most PCPs reported high job satisfaction and control, but reported varying access to mental health specialists. PCPs generally had positive attitudes and beliefs about treating psychosocial problems but many reported that doing so was burdensome. Identification was more likely when the visit was for a mental health problem, when issues related to psychosocial problems were discussed during the visit, when the youth demonstrated mental health symptoms, impairment, or burden to the family, and when the youth was older, uninsured, or received Medicaid. Identification was less likely when the PCP reported greater burden associated with treating psychosocial problems and when the PCP reported greater accessibility to mental health specialists. These results suggest that identification is associated with the interaction of multilevel factors and that the GPM is a useful model to investigate points of intervention for improving the identification of children's mental health problems in primary care settings.

Adolescent↗
PubMed2005

Autonomy-related behaviors of patient companions and their effect on decision-making activity in geriatric primary care visits.

The objective of this study, undertaken in the USA, was to investigate the consequences of autonomy-related companion behaviors on patient decision-making activity during geriatric primary care visits. Videotapes were analyzed to characterize patient and companion decision-making activity and related companion behaviors. These behaviors were coded throughout the visit using an autonomy-based framework that included both autonomy enhancing (i.e. facilitating patient understanding, patient involvement, and doctor understanding) and detracting behaviors, (i.e. controlling the patient and building alliances with the physician). Patients (N = 93) in this cross-sectional sample range in age from 65 to 95 years and are mostly white (n = 73, 79%) and female (n = 67, 72%). Companions are spouses (n = 42, 46%), adult children (n = 33, 36%), or other relatives and friends (n = 15, 16%) of patients. Companions are active participants in medical visits and engage in more autonomy enhancing than detracting behaviors. Companions of sicker (compared with less sick) patients were more likely to facilitate patient understanding, p < .05; doctor understanding, p < .01; and patient involvement, p = .06, in care. Patients whose companions facilitated their involvement in the medical visit by asking the patient questions, prompting the patient to talk, and asking for the patient's opinion were more than four times as likely to be active in decision-making as patients whose companions did not assist in this manner (unadjusted OR 3.5, CI 1.4-8.7, p < .01; adjusted OR 4.5, CI 1.6-12.4, p < .01). Companions can play an important role in the visits of geriatric patients by facilitating communication throughout the visit as well as patient activity in decision-making.

Aged↗
PubMed2005

Pediatric residents' responses that discourage discussion of psychosocial problems in primary care.

OBJECTIVE: Studies spanning nearly 4 decades demonstrate that doctors ignore or dismiss many patient bids for discussion of psychosocial topics. We sought to understand characteristics of doctors, patients, and visits in which this occurs. METHODS: Reanalysis of 167 audiotapes from 2 studies of parent-doctor communication in a pediatric residents' continuity clinic was performed. Tapes included visits by 100 mothers or female guardians to 55 residents who were the children's primary care providers. Coders identified mentions of psychosocial topics and noted the content and the doctor's response. Responses were classified with an adaptation of a previously described, psychoanalytically derived typology of avoidant or discouraging responses. RESULTS: Discouraging responses occurred in 34 (77%) of 44 discussions that involved corporal punishment and 51 (34%) of 64 discussions that involved other psychosocial topics. The particular topic (parent/family versus routine parenting issue) and how the topic was framed (as a problem versus simply mentioned) were associated with doctors' discouraging responses (OR: 3.07; 95% confidence interval: 1.56-6.05; and OR: 7.57; 95% confidence interval: 3.50-16.44; respectively). Discouraging responses were not related to the doctor's gender, parent's ethnicity, length of the parent-doctor relationship, or doctor's overall interview style (patient-centeredness). Discouraging responses to routine problems tended to be dismissive, but 41% of discouraging responses to parent/family problems were failed attempts to provide advice. CONCLUSIONS: Discouraging responses seem to be related less to doctor or patient characteristics than to the type and acuity of the psychosocial topic. These responses may originate with doctors' discomfort with particular subject areas and thus might be approached with training that combines communication and emotion-handling skills with clinical tools such as Bright Futures in Practice: Mental Health or the International Classification of Diseases, 10th Revision, Primary Care.

Adolescent↗
PubMed2004

Pediatric residents' response to ambiguous words about child discipline and behavior.

Frequently, doctors have been noted to seemingly ignore or brush off patients' bids to discuss sensitive issues. In some of these cases, however, apparent ignoring could be the result of the doctor mistakenly interpreting the meaning of potentially ambiguous terms used by the patient. This study demonstrates the frequency with which parents use and pediatricians clarify ambiguous terms describing child behavior and physical punishment. Sixty-one (26%) of 234 audiotapes from a systematic cross-sectional sample of non-urgent visits with pediatric residents included at least one episode in which such words were used by a parent. Discussion following each use was classified as: (a) clarifying its meaning, (b) discussing without clarification, (c) ignoring the use of the word, or (d) contradicting the negative attribution. In 61 visits, the parent or child was the first to use the potentially ambiguous term. Physicians clarified 7 (11%) of the terms, ignored 23 (38%), contradicted 7 (11%), and discussed without clarification 24 (39%). Clarifying and contradicting were associated with a shorter doctor-patient relationship than ignoring or discussing without clarification. Doctors who sought clarification were the least dominant. A non-dismissive response to ambiguous words may be a marker for both the stage of the doctor-patient relationship and a doctor's overall interactive style. Considering clarification may be helpful in understanding doctors' responses to patients' cues.

Adult↗
PubMed2004

Promoting advance directives among elderly primary care patients.

OBJECTIVE: To determine efficient ways of promoting advance directives among heterogeneous populations of elderly ambulatory patients. DESIGN: One-year quasi-experimental trial. SETTING: Five suburban and urban health centers in one region of a large managed care organization. One additional suburban center served as a control site. PARTICIPANTS: Individuals ages 65 and older (N= 2,120) who were continuously enrolled and had a health maintenance visit with their primary care provider during the study year. INTERVENTION: Physician education (oral and written) and physician and patient prompts to discuss advance directives. MAIN RESULTS: Sixty-six (7.8%) of patients at the intervention centers completed new advance directives, versus 9 of 1,277 (<1%) at the comparison center (P <.001). Patients 75 and older were twice as likely (odds ratio [OR], 2.0; 95% confidence limits [CL], 1.2 to 3.3) as those 65 to 74 to file a new advance directive, and the odds were twice as great (OR, 2.6; 95% CL, 1.4 to 4.6) at centers serving communities with median household income over the state median. Gender, recent hospitalization, emergency room visits, and number of chronic conditions were not related to making new directives nor was predominant ethnicity of the center community (African-American versus white). Adjusted for these factors, the intervention resulted in a 20-fold increase (95% CL, 10.4 to 47.8) in the odds of creating a new advance directive. Doctors reported barriers of time and unwillingness to press discussions with patients. CONCLUSIONS: A replicable intervention largely targeting doctors achieved a modest increase in advance directives among elderly ambulatory patients. Future interventions may need to target lower-income patients, "younger" elderly, and more specifically address doctors' attitudes and comfort discussing advance directives.

Advance Directives↗
PubMed2004

Spanking in early childhood and later behavior problems: a prospective study of infants and young toddlers.

OBJECTIVE: To explore the relationship of spanking frequency before age 2 with behavior problems near time of entry into school. METHODS: Children who were younger than 2 years were followed up approximately 4 years later, after they had entered school. The likelihood of significant behavior problems at follow-up was estimated in multivariate analyses that controlled for baseline spanking frequency and other characteristics. Participants were mothers from a large-scale national study and their children. Statistical analysis included an ethnically diverse sample of 1966 children aged 0 to 23 months at baseline. Two dichotomous indicators of behavior problems were used. The first indicated that maternal rating of child behavior problems exceeded a threshold. The second indicated that a mother met with a school administrator to discuss her child's behavior problems. RESULTS: White non-Hispanic children who were spanked more frequently before age 2 were substantially more likely to have behavior problems after entry into school, controlling for other factors. For Hispanic and black children, associations between spanking frequency and behavior problems were not statistically significant and were not consistent across outcome measures. CONCLUSION: Among white non-Hispanic children but not among black and Hispanic children, spanking frequency before age 2 is significantly and positively associated with child behavior problems at school age. These findings are consistent with those reported in studies of children older than 2 years but extend these findings to children who are spanked beginning at a relatively early age.

Child↗
PubMed2004

Parents' discipline of young children: results from the National Survey of Early Childhood Health.

OBJECTIVE: To examine the use and predictors of different discipline practices by parents of very young children using data from the 2000 National Survey of Early Childhood Health (NSECH). METHODS: NSECH is a nationally representative telephone survey of 2068 parents of young children between the ages of 4 and 35 months conducted by the National Center for Health Statistics. The survey includes questions about parents' use of 5 discipline practices: yelling, spanking, time out, toy removal, and explanations. chi2 analyses and logistic multivariate regression were used to examine associations between discipline practices and child, parent, and demographic factors. RESULTS: Among young children aged 19 to 35 months, frequent parental use of discipline strategies ranged from 26% (spanking) to 65% (taking away toy or treat), 67% (yelling), 70% (using time out), and 90% (providing explanations). In multivariate analyses, child age predicts reports of more frequent spanking and yelling, and child developmental risk is associated with increased reports of yelling. Parent frustration predicts frequent use of every discipline practice, including a greater inclination to use aversive practices. Lower parental emotional well-being is associated with reports of frequent yelling and spanking. Black ethnicity and maternal age predict more frequent spanking, and Spanish-speaking parents reported less frequent use of time out and taking away a toy. CONCLUSION: Child age and developmental risk and parents' ethnicity, emotions, and mental health are closely associated with discipline practices in the first 3 years of life. These factors are important for pediatricians to recognize in providing anticipatory guidance about discipline.

Adolescent↗
PubMed2003

Parents' and children's attitudes toward the enrollment of minors in genetic susceptibility research: implications for informed consent.

PURPOSE: Children at high risk of future disease may be recruited for participation in disease susceptibility research involving genetic testing. This study was aimed at assessing parents' and children's reactions to such research, and their perceptions of risks and benefits of participating. METHODS: Parents and children (ages 10-17) from families at increased risk for breast cancer (n = 16 dyads) and heart disease (n = 21 dyads) participated in separate audiotaped interviews and a follow-up family interview one year later. We asked about reactions, risks and benefits, and informational needs regarding participation in hypothetical research involving genetic testing on a saliva sample. Audiotape transcripts were analyzed qualitatively. RESULTS: All children would initially participate because they viewed the research as low risk. When thinking about learning their test result and sharing it with others, or the uncertainties of testing, many children became hesitant about participating. Many parents thought their child might worry about a positive result, making them unlikely to enroll their child, or to choose not to tell the child test results. Both children and parents thought the benefits of participating included early detection or treatment (breast cancer families), prevention (heart disease families) and helping others. Children's questions about research participation centered on details of the study design and purpose, while parents' questions related to the genetic test itself. CONCLUSIONS: Children's first reaction to participating in research involving genetic susceptibility testing research may not indicate an adequate appreciation of risks and benefits; if encouraged to personalize the impact of genetic testing, children are able to engage in a more informed decision-making process.

Adolescent↗
PubMed2003

Longitudinal care improves disclosure of psychosocial information.

BACKGROUND: While longitudinal primary care is thought to promote patient rapport and trust, it is not known if longitudinality helps overcome barriers to communication that may occur when the patient and physician are of different ethnicities and/or sexes. OBJECTIVE: To examine if longitudinal pediatric care ameliorates disparities in parent disclosure of psychosocial information associated with ethnic and gender discordance between parent and physician. DESIGN: Longitudinal, observational study of parent-physician interaction at early visits and over the course of 1 year. PARTICIPANTS: Parents (90% African American and 10% white mothers or female guardians) and their infant's assigned primary care physician (white first- and second-year pediatric residents). MAIN OUTCOME MEASURE: Parents' psychosocial information giving measured by the Roter Interaction Analysis System. RESULTS: Sex- and race-related barriers to disclosure of psychosocial information were evident early in the parent-physician relationship. At early visits, African American mothers made 26% fewer psychosocial statements than white mothers; this discrepancy was not affected by physician sex. At early visits, white mothers made twice as many psychosocial statements when seeing white female compared with white male physicians. CONCLUSIONS: Patient-centeredness is an important factor promoting psychosocial information giving for African American and white mothers, regardless of physician sex. Longitudinal relationships facilitate mothers' disclosure to physicians of a different ethnicity or sex, but only if physicians remain patient-centered.

Adolescent↗
PubMed2003

Guidelines for Adolescent Preventive Services: the GAPS in practice.

DESIGN: Pre- and post-Guidelines for Adolescent Preventive Services (GAPS) comparison of outcomes gathered via chart audit. SETTING: A rural hospital-based general pediatric clinic. PARTICIPANTS: Adolescents who underwent annual examinations between April 1, 1998, and March 31, 2001. A random sample of 441 medical records was reviewed. INTERVENTION: Training in the GAPS model and use of the questionnaire began in April 1998. MAIN OUTCOME MEASURES: Detection of, discussion of, and referrals for GAPS-related risk behavior. RESULTS: The medical records of 162 younger adolescents (aged 11-15 years) and 279 older adolescents (aged 16-19 years) were audited. Detection of risk behaviors increased from 19% at baseline to 95% with the initial GAPS and 87% with the periodic GAPS. The most prevalent risk factor was having a rifle or gun in the home (younger adolescents, 47% and older adolescents, 39%). The mean number of risk behaviors and health concerns documented was higher in the initial GAPS (4.8 and 1.3, respectively) than in the periodic GAPS (3.8 and 0.7) (P =.01 and.006). The GAPS questionnaires detected lower levels of risk behavior compared with a local Youth Risk Behavior Survey. Controlling for sex, age, and clinician, discussion of psychosocial topics increased during the study period; however, there was considerable variation among clinicians regarding the topics addressed. The GAPS-related referral rate did not change significantly. CONCLUSION: The GAPS model increases clinicians' detection and discussion of risk behaviors.

Adolescent↗
PubMed2003

Informed consent for enrolling minors in genetic susceptibility research: a qualitative study of at-risk children's and parents' views about children's role in decision-making.

PURPOSE: To better understand the process by which families at increased risk of disease would decide to enroll their children in genetic susceptibility research in order to develop recommendations regarding the informed consent process by which at-risk children are enrolled in such research in the future [corrected]. METHODS: Parents and children (ages 10-17 years) from families at increased risk for heart disease (n = 21 dyads) or breast cancer (n = 16 dyads) participated in two face-to-face, audio-taped, semi-structured interviews: Initial interviews were conducted with parents and children separately, and follow-up family interviews were conducted 1 year later. Interview transcripts were coded based on common themes. RESULTS: Families vary in the stage at which, and degree to which, children would be involved in decision-making about research participation. In general, the older/more mature the child, the less risky the research and the more open the communication style, the greater the likelihood that decisions would be made jointly. Most children wanted some parental input, but still thought the final decision should be theirs. Most parents would want to make the initial decision about whether it would be reasonable to consider enrolling their child in the research being proposed, but none opposed the child having some time alone with the researcher. All parents and children in our study placed extreme importance on not forcing children to participate in nontherapeutic research if they do not want to. CONCLUSIONS: Decision-making about enrolling children in genetic susceptibility research should be based on an informed consent process that (a) gives parents and children sufficient opportunity to ask questions of the researcher(s) and to communicate with one another, and (b) gives children the opportunity to exercise their right to refuse participation without parental influence. This process should be tailored to the child's maturity level and style of communication in the family.

Adolescent↗
PubMed2003

Effectiveness of anticipatory guidance: recent developments.

PURPOSE OF REVIEW: Anticipatory guidance is a key component of child health supervision. This review discusses the latest evidence on the effectiveness of anticipatory guidance and its impact on child and family functioning. RECENT FINDINGS: Anticipatory guidance on parent-infant interaction, sleep patterns, and injury prevention improve functional outcomes of children and their families. Recent findings also demonstrate that encouraging parents to share books with their children and free book distribution during well child care visits are associated with improved child language development and increased home literacy activities. Guidance promoting injury prevention and reading at home is supported by the best evidence. SUMMARY: Future models of child health supervision should address missed opportunities for anticipatory guidance and parents' desire for more information about what they can do to enhance their children's growth, development, and functioning.

Child Development↗
PubMed2002

Mechanisms behind the failure of residents' longitudinal primary care to promote disclosure and discussion of psychosocial issues.

CONTEXT: Longitudinality (care by a single physician over time) and continuity (receipt of most care from a single physician) are believed to enhance patient-physician relationships and facilitate disclosure of emotional distress, but some studies suggest this potential goes unrealized. OBJECTIVES: To determine whether care in a pediatric residents' continuity clinic promotes, over time, increased discussion, disclosure, and detection of parents' social and emotional distress and to understand physicians' communication behaviors underlying changes with time. DESIGN: Longitudinal, observational study of parent-physician interaction over the course of 1 year. PARTICIPANTS: One hundred ninety parents (90% African American) and their infants' primary care physicians (31 [4 Asians and 27 whites] first- and second-year pediatric residents). MAIN OUTCOME MEASURES: Frequency with which parents and physicians raised topics related to parental mood and family or social functioning; proportion of distressed parents discussing mood or functioning; and physicians' detection of parent distress. RESULTS: Physician initiation of psychosocial topics fell in the course of longitudinal relationships (odds of initiation in visits > or =6 vs odds of initiation in visits 1-5 = 0.46 [95% confidence limits, 0.31%, 0.67%]); parent initiation did not change over time nor was it increased by greater levels of continuity. Length of relationship was not associated with increased physician detection of parental distress or with increased rates of disclosure by distressed parents. Physicians' positively framed leading questions, and their avoidant responses to prior parental disclosures were significantly associated with decreased odds of problem disclosure. In contrast, visits in which parents or physicians raised psychosocial topics were characterized, on average, by 40% higher levels of physicians' "patient-centeredness" (increases of about 100 utterances per visit [95% confidence limits, 65.7%, 133.9%]). CONCLUSIONS: Longitudinal relationships between residents and patients may not be sufficient to promote the discussion, disclosure, and detection of psychosocial issues. Training in communication skills may help residents achieve the potential and goals of longitudinal care.

Adult↗