Andrew J. Schuman, MD, is a clinical assistant professor of pediatrics at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.

Andrew J. Schuman, MD

Many health care providers use paper questionnaires to screen pediatric patients for developmental concerns, such as autism, attention-deficit/hyperactivity disorder (ADHD), depression and anxiety, and high-risk behaviors, as recommended by the American Academy of Pediatrics. However, there are multiple computer- and tablet-accessible portals that can facilitate screening and provide actionable information for both patients and providers.

In 2001, 2 developmental pediatricians created the Child Health and Development Interactive System (CHADIS), a comprehensive web-based system for screening children for behavioral and developmental problems. The CHADIS online portal has received over $24 million in federal and foundation grants for research and development. To date, more than 5000 providers are using the CHADIS system, and it continues to grow in features and popularity. 

The CHADIS assessment tool allows parents to fill out age-appropriate screening tools online, then evaluates these forms, performs scoring when indicated, and alerts providers of issues that need discussed with parents. The CHADIS system allows health care providers to identify parental concerns and behavior issues that would have gone unidentified in the past. A CHADIS subscription costs approximately $1500 per provider per year, with discounts available for volume licenses.

CHADIS incorporates hundreds of screening tools, such as the Modified Checklist for Autism in Toddlers, Revised; Ages and Stages Questionnaires; Vanderbilt Assessment Scales; Patient Health Questionnaire for Adolescents; and Generalized Anxiety Disorder 7-item forms. CHADIS also provides a full library of resources for providers and parents to assist in management once a condition is diagnosed. The CHADIS reports can also be copied and pasted into your electronic health recordso the results of the screening are documented.

A clinical study published in 2011 demonstrated that an internet portal could improve ADHD care.

  The study involved 49 pediatric health care providers at 8 practices and demonstrated significantly higher rates of completed ADHD evaluations when the portal was used to expedite diagnosis. 

The portal was later commercialized as mehealth for ADHD. Parents seeking an evaluation for their child are enrolled in the online portal, where they can fill out both an initial medical history form and Vanderbilt screening forms. Parents can also invite their child’s teachers to the portal to fill out Vanderbilt forms. Once completed, all forms are scored and are available in the patient’s mehealth for ADHD record. A report is generated with detailed interpretation, which facilitates the discussion of the diagnosis. If a child begins medication therapy, questionnaires are automatically sent to parents and teachers at preselected intervals (eg, usually every 1 to 3 months) to help monitor the response to treatment and alert providers of any symptoms suggesting medication adverse effects. The report can be shared with parents via the portal or printed. Mehealth for ADHD is a free service, sponsored by a National Institutes of Health grant.

The Best-Kept Secret in Mental Health Screening

David Kraus, PhD, has been working diligently for the past 30 years developing a universal screening tool for children, adolescents, and adults. The Treatment Outcome Package (TOP) consists of 58 questions for adults and adolescents and 48 questions for children, and it takes less than 10 minutes to complete. The TOP can be administered online or via a paper form, with results available immediately when submitted electronically and within 15 minutes when submitted by fax.

The TOP screens adolescents and children for suicidal ideation, violent behavior, psychosis, depression, ADHD, conduct problems, school and work problems, substance abuse, and others. It also screens for eating disorders and anxiety in children. It is available via WellnessCheck.net, which facilitates the process of enrolling patients and parents, expediting completion of questionnaires. Questionnaires can be completed via tablet at the time of the patient encounter or via an email or a short message service text, which can be sent to the patient or parent to be completed on their own smart device. An alert is issued to the provider when a questionnaire is completed, and regular messages are sent to the provider if a requested questionnaire is not filled out. The service uses a prescription model and is available for less than $100 per provider per month.

The TOP has been validated in many clinical studies, showing that it is as effective as—if not more effective than—standard screening tools.

 Repeated testing during counseling shows how well the patient has responded to therapy and identifies areas that need more work. It is now being used by more than 30,000 therapists, and over 1 million screens have been performed to date.

Kraus has used the TOP to develop a system that has identified therapists who are particularly good with certain problems (eg, excellent in treating anxiety but poor in treating substance abuse)to find the best therapist fora particular patient. Kraus’ most recent study, published in 2021, indicates that better outcomes can be achieved in a shorter period when patients are matched with the most appropriate therapists.

 In fact, better-performing therapists are being compensated at higher rates from some insurance companies because the system provides an objective measure of results.

This article originally appeared in Drug Topics®’s sister publication,

1. Epstein JN, Langberg JM, Lichtenstein PK, Kolb R, Altaye M, Simon JO. Use of an internet portal to improve community-based pediatric ADHD care: a cluster randomized trial. Pediatrics. 2011;128(5):e1201-1208. doi:10.1542/peds.2011-0872

2. Baxter EE, Alexander PC, Kraus DR, Bentley JH, Boswell JF, Castonguay LG. Concurrent validation of the treatment outcome package (TOP) for children and adolescents. J Child Fam Stud.2016;25:2415-2422. doi:10.1007/s10826-016-0419-4

3. Youn SJ,Kraus DR, Castonguay LG. The treatment outcome package: facilitating practice and clinically relevant research. Psychotherapy (Chic).2012;49(2):115-122. doi:10.1037/a0027932

4. Constantino MJ, Boswell JF, Coyne AE, Swales TP, Kraus DR. Effect of matching therapists to patients vs assignment as usual on adult psychotherapy outcomes: arandomized clinical trial. JAMA Psychiatry.2021;78(9):960-969. doi:10.1001/jamapsychiatry.2021.1221

Articles

Online portals are accessible via tablet or computer and can streamline the mental health screening process. 

Technology Tools for Mental Health Screening

No aspect of pediatric medicine has been as impactful on the health and well-being of our patients and communities as the vaccines that now routinely prevent 16 diseases that were once commonplace.

 Current vaccines include those based on live attenuated viruses (eg, varicella, rotovirus), killed whole organism (eg, rabies, hepatitis A), polysaccharide or native proteins (eg, pneumococcal, meningococcal), and recombinant or whole molecular modification (eg, hepatitis B, herpes zoster).

Today nearly 260 vaccines are in development. Many of these are directed at infectious diseases, but many novel vaccines are being developed to treat or prevent allergies, autoimmune disorders, cancers, and even Alzheimer disease.

 Following the emergence of severe acute respiratory syndrome (SARS) in 2003 and Middle East respiratory syndrome (MERS) in 2012, both deadly coronavirus infections, investigators spent subsequent years developing and perfecting innovative vaccines including adenovirus vector vaccines and messenger RNA (mRNA) vaccines.

Both vaccine types were rapidly adapted to combat the SARS-CoV-2 pandemic once the Chinese published the genetic sequence of SARS-CoV-2 in January 2020.2 These vaccines instruct cells to manufacture specific antigens—ie, the spike proteins in the case of the SARS-CoV-2 virus—so that the immune system manufactures spike protein antibodies. As of this writing, the United States has deployed 2 mRNA vaccines (Pfizer and Moderna), as well as a genetically engineered adenovirus vector vaccine (Johnson & Johnson).

Both vaccine technologies can easily be modified to target a litany of other viruses. To date, several adenovirus vector vaccines for HIV, Ebola virus, influenza virus, Mycobacterium tuberculosis, and Plasmodium falciparum are under human clinical trials, and others are being developed against rabies, dengue virus, and MERS. Currently, mRNA-based vaccines are in development against HIV, rabies, Zika, cytomegalovirus, respiratory syncytial virus (RSV), Ebola, and others.

These vaccine technologies have also shown great promise against several types of cancer. More than 150 clinical trials assessing mRNA vaccines and more than 200 clinical trials involving adenovirus vector vaccines for infectious diseases and cancers are currently ongoing, according to ClinicalTrials.gov. It is even anticipated that a universal flu vaccine based on these technologies will be developed, and it will no longer require seasonal modifications because it will target stable antigens among influenza viruses. It is also predicted that there will be new vaccines based on virus like particles (VLPs).

These are artificial viruses made up of copies of 1 or more viral proteins that self-assemble into nanoparticles. Current VLP vaccines include the hepatitis B vaccine (Energix-B) and the human papillomavirus vaccine (Gardasil). VLP vaccines are also being developed for chikungunya, Japanese encephalitis, yellow fever, Zika, and malaria, among other diseases.

Yet another new type of vaccine— against allergic asthma—is being investigated. Allergic asthma is characterized by mucus secretion, airway eosinophilia, and elevated levels of IgE antibodies and increased levels of cytokines IL-3 and IL-4. Recently, researchers produced an experimental conjugate vaccine against these interleukins that in animal models have shown prolonged reduction of IgE levels, airway hyperresponsiveness, eosinophilia, and mucus production.

Additionally, there are new vaccine delivery systems under development. The most common method of immunizing children to date has been the direct injection of vaccines either intramuscularly or subcutaneously. Several years ago, a live attenuated influenza intranasal vaccine was developed, which has benefited countless needle-phobic children and adults.

Now Altimmune has developed an adenovirus-vectored intranasal vaccine, now in phase 1 clinical trials, that generates a broad IgG, mucosal IgA, and T-cell response to SARS-CoV-2 and is stable at room temperature.5 Altimmune is also in clinical trials for intranasal vaccines for anthrax and influenza.

Several companies are developing a microneedle patch to administer vaccines. The microneedles are impregnated with vaccine that targets immune cells in the dermis.6 Best of all, these are pain free and stable at room temperature. The patch is applied via a preloaded applicator and removed after a few minutes, leaving the vaccine-impregnated tips embedded in the dermis, releasing vaccine over time.

These patches are being investigated as a potential alternative to intramuscular vaccines for influenza and COVID-19. Two more vaccine delivery systems may change the way patients are immunized. An oral vaccine mechanism, Vector-Adjuvant-Antigen Standardized Technology (VAAST), which targets mucosal IgA, is being perfected by Vaxart. VAAST has shown promising results for H5N1 influenza, H1N1 influenza, influenza B, norovirus, and RSV.

The second is a vaccine capsule filled with nanoparticles, injected subcutaneously, that would slowly release the vaccine over time, potentially eliminating the need for immunization booster doses.7 Enesi Pharma is developing a universal vaccine implant (UVI) using their ImplaVax needle-free delivery device to inject each UVI up to 7 mm into the dermis (Figure 2). Preclinical studies have shown this method to be as effective as intramuscular or subcutaneous injections, with less pain associated with injection, according to the company.

Vaccine technologies in development may facilitate a rapid and effective response to new threats and likely will target not only infectious diseases but also allergies, autoimmune conditions, and cancers. Additionally, new vaccine delivery systems will overcome production and storage obstacles that have slowed the response to the COVID-19 pandemic. Pediatricians and parents, recognizing how much vaccines improve the health and well-being of young patients, have much to look forward to.

Vaccine technologies in development may facilitate a rapid and effective response to new threats and likely will target not only infectious diseases but also allergies, autoimmune conditions, and cancers. 

Vaccinology: New Vaccine Technology for Autoimmune, Cancers, Infectious Diseases

The first population-based vaccine registry in the United States launched in Delaware in 1974 and did not begin to flourish until the Robert Wood Johnson Foundation launched their All Kids Count program in 1991. Government funding for immunization registries became available when President Bill Clinton included immunization registries in his Childhood Immunization Initiative in 1993.

There are currently 63 registries, now called immunization information systems (IISs), in the United States. These include state-, island-, and city-based IISs, each operating independently under its respective local and state policies with their own rules around collection and use of data, analysis, and operational routines.

Figure 1 shows the percentage of children under 6 participating in a state-based IIS as of 2019.

An ISS is a confidential, population-based, computerized database that records all immunization doses administered by participating providers within a geographic area. IISs provide a consolidated record of administered vaccines for the benefit of the patient, their family, and the greater public health. An IIS keeps a record of vaccinations given, dates, and manufacturing details, and can identify when a future or missed vaccination should be given.

IISs have many advantages; they can improve immunization rates, reduce vaccination errors, identify opportunities to vaccinate, provide epidemiological insights when there is a community outbreak of a vaccine-preventable disease, and allow access by patients, families, schools, and other health care providers. 

An IIS can also reduce time spent entering data and track vaccine inventory, especially if it is connected through your electronic health record (EHR) system. An IIS can make a child’s immunization portable when the family changes practices, moves from one location to another, or seeks care outside the medical home.

The administering site is credentialed by the individual IIS under licensed providers who can designate access for data entry and/or viewing by staff. Access to view is allowed for the patient, parents, and specified agencies, such as schools, pharmacies, urgent care facilities, and hospitals. 

There are federal requirements for documenting vaccines established by the CDC, which includes the specific vaccine, manufacturer, lot number, the date and location, and that the patient and/or family was given a vaccine information statement (VIS) to review with its publication date.3 Most systems will identify when a dose of a specific vaccine should be given and have specific time intervals that are not forgiven when a sequential dose is given too early.

It is the responsibility of the administering site to enter the required data, and it can be a burden to staff when they need to enter the data in multiple locations, such as the registry, the EHR, and the patient vaccination card. Most pediatric-specific EHRs are certified and connect with a local IIS, requiring only 1 point of data entry that will be shared with the IIS, the medical record, and the patient copy.

There is significant evidence that IISs improve vaccination rates and reduce missed opportunities for administering immunizations. Australia implemented a national IIS in 1996 and demonstrated an increase in full immunization among 2-year-old children from 64% in 1997 to 93% in 2007.4 Australia has a national health care system that facilitates implementation and utilization of IISs. Although the United States has yet to implement a national IIS, studies have repeatedly demonstrated that

IISs improve vaccination rates, reduce missed opportunities for vaccinations, and facilitate responses to community outbreaks of diseases.

The most significant problem with existing vaccine registries in the US is the lack of interoperability between them. Few nonpediatric-specific EHRs can currently extract data from local and state registries, or deposit immunization information directly into them. This necessitates office staff performing double entries of immunizations into the office EHR and the local IIS, which is time-consuming and unwieldly.

One method of speeding up data entry is the integration of barcode scanning into EHRs. After receiving a shipment of vaccine, the shipment form is scanned into a vaccine inventory, which is integrated into the EHR. When vaccines are ordered for a patient, the barcode on the vial is scanned again and screened by the connected IIS. 

Warnings appear if the vaccine is being given too soon, is not age appropriate, is attributed to the wrong funding source (eg, Vaccines for Children Program), or has expired. The staff manually enters the other vaccine administration details into the EHR and the information is electronically sent to the appropriate IIS. Over the next few years, it is anticipated that a growing number of EHRs will have this capability.

There is no uniform rule requiring an administering site to enter that data into the IIS, which further complicates the potential for interoperability. However, the COVID-19 pandemic and the CARES Act may be creating a new opportunity for data sharing between EHRs and the IISs. 

All sites administering COVID-19 vaccines must report all vaccinations into a database that allows for capturing the event and providing reminders for a second dose as indicated by the vaccine given. It may open the opportunity to connect all vaccine registries into a national database, accessible from anywhere.

Immunization Information Systems provide confidential, population-based, computerized database that records all immunization doses administered by participating providers within a geographic area. 