DOI: 10.1542/peds.2005-2209 2006;118;1109-1115 PediatricsEdward De Vos, Howard Spivak, Elizabeth Hatmaker-Flanigan and Robert D. Sege Youth Violence PreventionA Delphi Approach to Reach Consensus on Primary Care Guidelines RegardingThis information is current as of November 14, 2006 http://www.pediatrics.org/cgi/content/full/118/4/e1109located on the World Wide Web at: The online version of this article, along with updated information and services, isrights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Grove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elkpublication, it has been published continuously since 1948. PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly at Vanderbilt University - Eskind Biomedical Library on November 14, 2006 www.pediatrics.orgDownloaded fromARTICLEA Delphi Approach to Reach Consensus on PrimaryCare Guidelines Regarding YouthViolence PreventionEdward De Vos, EdDa, Howard Spivak, MDa, Elizabeth Hatmaker-Flanigan, MSb, Robert D. Sege, MD, PhDaaPediatric and Adolescent Health Research Center, Floating Hospital for Children at Tufts-New England Medical Center, Boston, Massachusetts;bAmerican Academy ofPediatrics, Elk Grove Village, IllinoisThe authors have indicated they have no financial relationships relevant to this article to disclose.ABSTRACTOBJECTIVE. Anticipatory guidance is a cornerstone of modern pediatric practice. Inrecognition of its importance for child well being, injury prevention counseling isa standard element of that guidance. Over the last 20 years, there has beengrowing recognition that intentional injury or violence is one of the leading causesof morbidity and mortality among youth. The US Surgeon General identifiedyouth violence as a major public health issue and a top priority. Yet, only recentlyhas the scope of injury prevention counseling been expanded to include violence.Pediatric health care providers agree that youth violence–prevention counselingshould be provided, yet the number of topics available, the already lengthy list ofother anticipatory guidance topics to be covered, developmental considerations,and the evidence base make the selection of an agreed-on set a considerablechallenge. The purpose of this study was to systematically identify and prioritizespecific counseling topics in violence prevention that could be integrated intoanticipatory guidance best practice.DESIGN. A modified electronic Delphi process was used to gain consensus among 50national multidisciplinary violence-prevention experts. Participants were unawareof other participants’ identities.METHODS. The process consisted of 4 serial rounds of inquiry beginning with a broadopen-ended format for the generation of anticipatory guidance and screeningtopics across 5 age groups (infant, toddler, school age, adolescent, and all ages).Each subsequent round narrowed the list of topics toward the development of amanageable set of essential topics for screening and counseling about positiveyouth development and violence prevention.RESULTS. Forty-seven unique topics were identified, spanning birth to age 21 years.Topics cover 4 broad categories (building blocks): physical safety, parent centered,child centered, and community connection. Participants placed topics into theirdevelopmentally appropriate visit-based schedule and made suggestions for anwww.pediatrics.org/cgi/doi/10.1542/peds.2005-2209doi:10.1542/peds.2005-2209Key Wordsanticipatory guidance, child development,Delphi technique, pediatrics, violencepreventionAbbreviationsAAP—American Academy of PediatricsTFOV—Task Force on ViolenceVIPP—Violence Intervention andPrevention ProgramAccepted for publication Apr 28, 2006Address correspondence to Edward De Vos,EdD, Pediatric and Adolescent HealthResearch Center, Tufts-New England MedicalCenter, 750 Washington St, NEMC Box 531,Boston, MA 02111. E-mail: [email protected] (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Copyright © 2006 by theAmerican Academy of PediatricsPEDIATRICS Volume 118, Number 4, October 2006 e1109 at Vanderbilt University - Eskind Biomedical Library on November 14, 2006 www.pediatrics.orgDownloaded fromappropriate topic reinforcement schedule. The resultingschedule provides topics for introduction and reinforce-ment at each visit.CONCLUSIONS. The Delphi technique proved a useful ap-proach for accessing expert opinion, for analyzing andsynthesizing results, for achieving consensus, and forsetting priorities among the numerous anticipatory guid-ance and assessment topics relevant for raising resilient,violence-free youth.THE AMERICAN ACADEMY of Pediatrics (AAP) logo pro-claims the commitment: “dedicated to the health ofall children.” Increasingly, the greatest threats to childhealth are part of what has been called the “new mor-bidity.”1More than a decade ago, the AAP’s Committeeon Psychosocial Aspects of Child and Family Health ap-proved a policy statement advocating better preparationof pediatricians to address the behavioral and psychoso-cial factors that threatened child health with increasingprevalence.1More recently, the AAP’s commitment hasbeen reaffirmed.2In recognition of the newer morbidi-ties, such as violence, suicide, substance abuse, andschool problems, the committee concluded, “These arethe morbidities that place our patients at risk. In otherwords, after infancy, children in the United States aremore likely to die from injuries or violence and suicidethan from infectious disease.”2Increasingly, pediatricians are called on to addressthese new morbidities, effectively and efficiently, notonly through diagnosis, treatment, and referral, butthrough prevention as well. Preventive care is a corner-stone of pediatric practice, but the new morbidities re-quire new approaches from physicians: “To effectivelyaddress these new morbidities, pediatricians will need amodel that encompasses expanded areas of competencein child behavior, development, and family function.”2Violence ranks highly among the clear threats to childhealth. The World Health Organization operationallydefined violence as “the intentional use of physical forceor power, threatened or actual, against oneself, anotherperson, or against a group or community, that eitherresults in or has a high likelihood of resulting in