Maternal imperatives are often treated as a unitary form of directiveness despite serving distinct communicative functions. We examined how Spanish-speaking Latina mothers used imperatives during toy play and whether use varied by site and child gender. Forty-eight mother–child dyads from Mexico (n = 25) and the United States (n = 23) participated in semi-structured play interactions. Maternal imperatives were coded as encouragement, redirection, repetition, or scaffolding. Across 1,430 tokens, scaffolding was most frequent (36.4%), followed by encouragement (25.8%), redirection (23.6%), and repetition (14.3%). Lexical choice was strongly associated with communicative function, indicating systematic form–function patterning. Imperative use was largely similar across sites and child gender, although exploratory analyses identified greater repetition in the United States. Findings show that imperative frequency alone provides an incomplete account of maternal directiveness and underscore the importance of considering the interactional functions of direct linguistic forms.
Introduction Access to dental care is a critical aspect of children's healthcare. For these reasons, Medicaid and Children's Health Insurance Program (CHIP), administered by states, cover medically necessary services. Specialty providers can enroll and participate in state or state-contracted plans, but availability varies widely. Our research objective was to evaluate the availability of non-general dentist specialists in endodontics, oral and maxillofacial surgery, orthodontics/dentofacial orthopedics on the InsureKidsNow website for Medicaid/CHIP enrollees, on a state-by-state basis, and to compare these with pediatric dental availability. Methods This is an observational, cross-sectional descriptive study. InsureKidsNow.gov was searched to identify and compare available and participating endodontists, oral and maxillofacial surgeons, and orthodontic/dentofacial orthopedic surgeons with pediatric dentists. The percentages of specialists listed on InsureKidsNow were compared with the respective percentages as a proportion of the state's dental workforce. A subanalysis of 25 states that listed a single plan was conducted to determine the patient-to-listed location ratio for each specialist category. For the largest benefit program, the combined percentage of the three specialties was graphed by state along with pediatric dentists. Data were grouped by whether they accepted new pediatric patients and by the total number of specialty locations. Results Children enrolled in Medicaid have very limited or no access to endodontists, oral and maxillofacial surgeons, or orthodontic/dentofacial orthopedic surgeons in half of the U.S. states. Thirteen states showed no availability of any non-primary care specialist for new participants, with the shortage being most pronounced for endodontic services. Among states using only one benefit plan, 12 of 25 showed no availability for new endodontic patients. In contrast to the non-primary care specialties, pediatric dentists were open to new patients in most states. Conclusions Despite improved use of dental services among children, those covered by public plans have limited access to one or more specialty provider types in most states. This limited access is most pronounced for endodontic services and may result from relatively low availability and/or participation of endodontic locations.
Poor mental health among adolescents and young adults in the United States today is a critical concern. Sports team participation, combining physical activity and social belonging, may be an effective component of interventions to improve mental health among this population. This study examines both short and long-term associations between sports team participation in adolescence and anxiety and depression from adolescence to young adulthood, using the Future of Families and Child Wellbeing Study, a population-based longitudinal birth cohort study of urban US children. In this sample of 2766 young adults (52% female, Mage = 22.3), controlling for a rich set of child and family characteristics, including prior mental health, we found that frequent sports participation in adolescence (33% of the sample), compared to none, was associated with substantially lower depression and anxiety symptoms among all adolescents. We also found that sustained sports participation in adolescence was associated with a lower likelihood of depression in young adulthood, but only for young adult males. Exploring heterogeneity in associations further by race/ethnicity and socioeconomic status, the strongest associations were found among young adult males who are non-Hispanic white and Latino, and from higher socioeconomic backgrounds. These results suggest sustained sports team participation throughout adolescence may be a valuable intervention component for improving mental health among adolescents and young adults.
Background Leisure participation is essential for children's health and well-being and is also a fundamental human right; however, children and youth with disabilities face significant barriers to participation compared with their peers without disabilities. The Jooay App was developed to address gaps in information and access to adaptive and inclusive leisure activities. A new gamification-based version of the Jooay App was co-designed with users, including youth with disabilities, parents, and health care professionals. Objective This study aims to describe a study protocol to implement and evaluate the gamified version of the Jooay App using a patient-oriented approach to increase awareness about adaptive and inclusive leisure activities and promote participation in leisure among children and youth with disabilities. Methods A hybrid type II effectiveness-implementation study will be conducted. The Consolidated Framework for Implementation Research (CFIR) will guide implementation strategies, including the expansion of knowledge broker (KB) networks to raise the profile of adaptive and inclusive leisure activities in Canada. An interrupted time series (ITS) design will be used to evaluate implementation outcomes across 5 provinces in Canada. Process evaluation will analyze inner and outer setting characteristics, KB strategies, and community resource mobilization. Effectiveness outcomes will be assessed through two phases: (1) a nonrandomized mixed methods pilot feasibility study of the app, where acceptability, engagement, implementation, and potential benefits will be measured, and (2) an ITS at the population level, where overall app usage (eg, clicks, logins, and time spent), individual gamification feature metrics, and user feedback will assess effectiveness outcomes. Results The project was funded by the CHILD-BRIGHT (Child Health Initiatives Limiting Disability-Brain Research Improving Growth and Health Trajectories) Network through the Strategy for Patient-Oriented Research, Canadian Institutes of Health Research, in September 2025, and data collection is expected to occur from March 2026 to June 2027. As of manuscript submission, 12 KBs have been recruited, the ITS study and data analysis have not yet begun, and the study results for the implementation and effectiveness components are expected to be published in fall 2027. Findings will be disseminated via peer-reviewed publications, conference presentations, educational materials, social media, community events, and reports. Outputs will include a summary of findings in lay language, in both French and English, including short videos, infographics, and posters for various social media platforms. Community organizations will assist in further dissemination through their networks. Conclusions This study will evaluate both the effectiveness and the implementation of the gamified Jooay mobile app to promote participation in leisure among children and youth with disabilities using a hybrid effectiveness-implementation design. By applying the CFIR framework, this study aims to generate evidence about how the Jooay App can be effectively implemented across Canada and expand scholarship on the implementation of technology for equity-deserving groups.
Objective Firearm injury is the leading cause of death among children. Evidence shows that counseling around firearm safety from trusted clinicians increases safe storage practices. The American Academy of Pediatrics (AAP) has recommended pediatricians provide counseling on the topic to patients and caregivers, yet gaps remain in understanding how counseling is delivered, especially in the Southeastern US. This study aimed to describe patterns of and barriers to firearm anticipatory guidance among pediatric clinicians in the Southeast. Methods A cross-sectional survey was developed to assess awareness of recommendations/provision of firearm safety counseling. The survey was distributed between July 30-December 10, 2025 across six Southern states through AAP chapters and direct emails from physician champions. Descriptive analyses were conducted to describe the sample and summarize responses to survey questions. Results Among respondents (n = 131), 92.0% report ever counseling on firearm safety. Counseling was driven mostly by perceived risk (50.4%) and age-specific well visits (61.7%) and delivered during well (83.3%) and behavioral health visits (45.6%). Time was the dominant barrier to delivering counseling (60.0%). Conclusions Delivery of firearm safety counseling is inconsistent and dependent on context and perceived risk. Structural barriers limit delivery of messaging. Opportunities exist to standardize safety counseling in pediatric care.
Background/Objectives: Online health information (OHI) is used by adolescents and caregivers to manage pediatric rheumatic diseases (PRDs). Little is known about the lived experiences of this group as they navigate complex, evolving online healthcare information and services. This study aimed to explore the lived experiences and indicators of digital health literacy (DHL) among adolescents with PRD and caregivers of children and adolescents with PRD through their use of OHI to learn about and manage their disease. Methods: Qualitative interviews using Interpretive Description methodology was utilized. Adolescent and caregiver participants were recruited using purposeful sampling from one rheumatology clinic in Saskatchewan, Canada. After completing a pre-interview questionnaire, one-on-one semi-structured telephone interviews were completed, audio-recorded, transcribed verbatim, and analyzed using constant comparative analysis. Results: A total of 10 caregivers and 7 adolescents completed the interviews. Three key themes emerged: (1) OHI offers knowledge without imposing on PRD practitioners. Participants were motivated to use OHI for symptom management, reassurance, and medication administration. (2) Participants had difficulty finding OHI, resulting from their search strategies, desire for answers to complex problems, lack of information for novel biologic medications, the absence of adolescent-focused OHI, and confusion around pediatric to adult disease names. (3) Although aware of misinformation, participants discussed and demonstrated inadequate appraisal of OHI. Conclusions: Participants relied on inappropriate indicators of medical accuracy and misplaced trust in OHI sources, leading to exposure to misinformation. Proactively addressing these concerns, including OHI prescriptions, fostering independent OHI appraisal, and development of age-appropriate OHI, may improve DHL and aid PRD management.
In the United States (US), the highest incidence of invasive meningococcal disease (IMD) is among infants aged ≤ 1 year (y). While most IMD cases in US infants are caused by meningococcal serogroup B (MenB), there is no MenB vaccine approved or recommended for US children < 10 y. This study sought to understand general attitudes toward vaccination, knowledge of IMD, and MenB vaccine preferences among parents/caregivers of children ≤ 18 months. An online survey was conducted in November-December 2024 among US parents/caregivers of children ≤ 18 months. Survey responses were analyzed descriptively. Overall, 1,051 parents/caregivers participated in the study. Most parents'/caregivers' children had received all age-appropriate immunizations (73.4%). Of the 266 respondents (25.3%) whose children had received some or no immunizations, 59.8% reported concerns regarding potential vaccine side effects. Most parents/caregivers were familiar with IMD, but knowledge gaps exist regarding its risk and presentation in infants. Two-thirds of parents/caregivers (66.3%) would accept a MenB vaccine for their child if it were included in the Centers for Disease Control and Prevention immunization schedule as optional and recommended by a healthcare provider (HCP); acceptance increased to 72.1% following receipt of IMD information. Perceived barriers to uptake of a potential MenB vaccine focused on HCP-driven communication and guidance. Most US parents/caregivers understood the importance of vaccination and indicated acceptance of a potential MenB vaccine for their child ≤ 18 months. This study highlights the critical role of HCPs in addressing concerns and knowledge gaps to promote IMD prevention in US children ≤ 18 months.
Background Children exposed to parental violence (CEPV) may experience a range of adverse outcomes compared to non-exposed peers yet may demonstrate resilience shaped by both internal and external protective factors. Objective To longitudinally explore the profiles of protective factors in children across the continuum of resilience (i.e., low, moderate, high, and exceptional). Participants and setting Parent-reported data were collected on behalf of 211 CEPV (Mage = 10.11, SD = 2.21) residing across Canada. Methods Grounded in Resiliency Theory, this longitudinal study used online surveys administered at three timepoints to assess children's resilience and protective factors. Results Decision tree modelling at baseline found that children with exceptional resilience were more likely to have better health (χ2 = 56.23, p < 0.001), with whole-family support further bolstering resilience (χ2 = 20.66, p < 0.001; χ2 = 21.76, p < 0.001). At T2, exceptional resilience was associated with perceiving child welfare services as supportive (χ2 = 76.55, p < 0.001), with additional benefits from economic support (χ2 = 35.08, p < 0.001). At T3, high resilience was linked to perceived supportiveness of therapy services (χ2 = 122.91, p < 0.001), further strengthened by caregiver perceptions of women's shelter support (χ2 = 25.55, p < 0.001). Conclusions These findings suggest that supporting CEPV resilience requires attention to individual assets, safety and stability needs, and access to supportive services addressing violence exposure. This underscores the necessity of trauma- and violence-informed, integrated approaches that extend beyond individual- and family-level factors.
Problem Across low- and middle-income countries (LMICs), an estimated 1.7 billion children lack access to safe surgical and perioperative care. In Latin America, pediatric postoperative mortality remains several-fold higher than in high-income countries, driven largely by preventable airway and critical-care complications. Following the death of an infant after an unplanned extubation in El Salvador, system-level gaps in airway safety, sedation, and communication were identified, motivating development of a scalable intervention to strengthen postoperative critical care for intubated children. Setting This work was designed at Hospital Nacional de Niños Benjamín Bloom, in San Salvador and subsequently tested at Fundación Hospital Infantil Napoleón Franco Pareja in Cartagena, Colombia. Both institutions faced high unplanned extubation rates, variable airway-safety practices, and limited structured training. Approach Using Ariadne Labs ARC (Design-Test-Scale) implementation pathway, we created a bilingual, online pediatric airway and critical-care curriculum alongside a telesimulation-based emergency team-training program. Forty-five short, multilingual video modules addressed airway management, sedation, respiratory therapy, nursing priorities, and teamwork. Remote, high-fidelity simulation reinforced crisis resource management and role clarity, with local champions trained to run courses independently. Results In El Salvador, early implementation was associated with reductions in unplanned extubations and PICU mortality. In Colombia, 101 clinicians completed the curriculum and 39 completed telesimulation training, with mortality declining from 22.4% to 9.5% post-intervention. Lessons learned A combined digital curriculum and telesimulation model can strengthen airway safety, communication, and crisis readiness in resource-constrained PICUs. Following successful design and testing, the model is positioned for scale across LMIC pediatric intensive care settings.
Background Children's increasing use of digital platforms elevates their risk for online sexual exploitation (OSE), especially among those with sexual abuse histories. Despite known risk, data on prevalence and related characteristics remain limited. Digital safety screening (DSS) offers child abuse professionals a tool to assess risk or prior exploitation but is not standardized. Objective To examine age-related variation in OSE disclosure within a clinically relevant population and characterize how DSS is applied in this clinical setting. Participants and setting A retrospective chart review was conducted of 307 patients aged 10-18 years who received forensic interviews (FIs) for evaluation for suspected sexual abuse by a single social worker between 2022 and 2024 at a Child Advocacy Center in the Midwestern United States. Methods FI notes were analyzed through content analysis to characterize the utilization of DSS and patient disclosure or denial of OSE. Descriptive statistics revealed prevalence: logistic regression examined associations between patient age and OSE. Results Of 307 patients, 96.1% received DSS. Among 299 who discussed OSE, 41.5% reported at least one experience. Odds of reporting increased with age, beginning at 12.0% at age 10, 27.3% at 11, and increasing to 60.0% at age 16. Conclusions OSE exposure likely increases with age and may vary by sex assigned at birth. Findings underscore the need for routine, standardized DSS validated across developmental stages and languages, as well as further research on prevalence and risk and prevention and response strategies.
