Interventions to Prevent Child Maltreatment: US Preventive Services Task Force Recommendation Statement

Reports of Maltreatment in a Children's Hospital: Evaluation of the Epidemiological Profile and Its Relationship with the Outcome in Fractures

Objective  To describe suspected/confirmed cases of child maltreatment related to fractures in a pediatric hospital in southern Brazil. Method  Study of the Information System of Notifiable Diseases notifications and the victims' medical records between January/2016 and December/2020. Variables related to the victim, the perpetrator, the type of abuse, the presence of fractures, and their anatomical location and death were evaluated. Logistic regression was performed to identify fracture-related variables, adjusted for sex and age. The results were expressed in odds ratios and their respective 95% confidence intervals. It was considered significant p  < 0.05. Results  There were 276 cases, 73 infants (26.4%), male predominance (151, 54.7%), with authorship of the mistreatment by relatives (245, 96,0%), 85 (31,5%), they presented fractures, with five deaths (1.9%). Factors related to the presence of fracture: age of the victim (less than two years old; n  = 82; or 2.48; 95% CI: 1.45 - 4.25), having more than two aggressors involved ( n  = 144; or 2.09; 95% CI: 1.16-3.75), the medium being traffic/automobile accident, ( n  = 52; or 2.65; 95% CI: 1.04-6.75), consult an orthopedist ( n  = 91; or 6.77 / 95% CI: 3.66-12.51), and the need for surgical intervention ( n  = 15; OR 36.72; 95% CI: 8.22-164.03). Conclusions  The importance of suspicion, early identification of aggression, and the correct completion of notifications for activating the system of guaranteeing rights and removal of the aggressor was emphasized.

Primary Care Interventions to Prevent Child Maltreatment: US Preventive Services Task Force Recommendation Statement

Importance

Child maltreatment, which includes child abuse and neglect, can have profound effects on health, development, survival, and well-being throughout childhood and adulthood. The prevalence of child maltreatment in the US is uncertain and likely underestimated. In 2021, an estimated 600 000 children were identified by Child Protective Services as experiencing abuse or neglect and an estimated 1820 children died of abuse and neglect.

Objective

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate benefits and harms of primary care-feasible or referable behavioral counseling interventions to prevent child maltreatment in children and adolescents younger than 18 years without signs or symptoms of maltreatment.

Population

Children and adolescents younger than 18 years who do not have signs or symptoms of or known exposure to maltreatment.

Evidence Assessment

The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of primary care interventions to prevent child maltreatment in children and adolescents younger than 18 years without signs or symptoms of or known exposure to maltreatment.

Recommendation

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. (I statement).

Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences.

Objective

To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force.

Data Sources

PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023.

Study Selection

English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment.

Data Extraction and Synthesis

Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.

Main Outcomes and Measures

Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms.

Results

Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health.

Conclusion and Relevance

The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.

Exploring Screening Practices for Child Sexual Abuse in School Settings: An Integrative Review

Child sexual abuse (CSA) is a pervasive public health problem. If left undetected, CSA can result in immediate and long-term health problems, which can be mitigated through early identification. Schools are an ideal environment to implement screening measures, and school nurses (SN) are uniquely poised to intervene and respond early. The aim of this review was to systematically examine and synthesize the international evidence related to screening for early identification of CSA in schools. Themes emerging from the analysis were SN behaviors relative to screening, potential instruments or approaches for screening, and SN and school professionals' beliefs about CSA screening practices. This review found little evidence that CSA screening is occurring in schools. However, SNs are aware that screening falls within their scope of practice and many SNs feel they should be screening for it. A constant proactive approach by SNs is necessary to improve early identification and subsequent intervention.

Ophthalmologists' Attitudes, Knowledge, and Willingness to Report Child Abuse

The aim of the present study was to explore ophthalmologists' attitudes, knowledge, and willingness to report child abuse. One-hundred-and-seven ophthalmologists employed in various hospitals in Israel completed an online questionnaire. Less than half the ophthalmologists (44.9%) reported that they had treated children whom they identified or suspected as being victims of child abuse, while only 43.9% of these reported child abuse. Despite generally positive attitudes towards reporting of child abuse among the ophthalmologists, their average level of knowledge was low. Ophthalmologists who had received training on child abuse and residents displayed a higher level of knowledge. In addition, female ophthalmologists tended to agree more that ophthalmologists are obligated to screen for and report child abuse. Moreover, female ophthalmologists expressed higher willingness to report child abuse. The present study reveals that underreporting of child abuse, and more precisely the discrepancy between identification and reporting, is present among ophthalmologists. It seems that lack of knowledge regarding identification and reporting of child abuse is the main barrier to reporting, especially among medical specialists. These findings underscore the importance of training programs on child abuse, both during formal education in medical school, and post-qualification, for all ophthalmologists, irrespective of seniority.

Evidence-Based Home Visiting Provisions and Child Maltreatment Report Rates: County-Level Analysis of US National Data From 2016 to 2018

This observational ecological study examined county-level associations between evidence-based home visiting (EHV) provisions and child maltreatment report (CMR) rates, using national county-level data from 2016-2018. We found that longitudinal changes of EHV provisions were significantly negatively associated with county CMR rates while controlling for potential confounders. Our model estimated that after EHV provisions were launched in counties, their CMR rates decreased (or after they were ceased, rates increased) by 2.21 per 1000 children overall, 2.88 per 1000 children aged 0-5, 2.59 per 1000 children aged 6-11, 2.13 per 1000 male children, and 2.24 per 1000 female children. When limiting attention to EHV provisions funded by the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program, we found no significant association perhaps because MIECHV-funded EHV provisions were a small subset of all EHV provisions. These findings propose potential protective impacts of county EHV provisions on overall county CMR rates. Yet, the small effect sizes suggest that EHV provisions should be considered as a part of a complete response to child maltreatment rather than in isolation. Given that EHV is provided to a very small part of the population, nevertheless, our findings suggest that expanding coverage would increase effect sizes.

Initial development of tools to identify child abuse and neglect in pediatric primary care

BACKGROUND

Child abuse and neglect (CAN) is prevalent, associated with long-term adversities, and often undetected. Primary care settings offer a unique opportunity to identify CAN and facilitate referrals, when warranted. Electronic health records (EHR) contain extensive information to support healthcare decisions, yet time constraints preclude most providers from thorough EHR reviews that could indicate CAN. Strategies that summarize EHR data to identify CAN and convey this to providers has potential to mitigate CAN-related sequelae. This study used expert review/consensus and Natural Language Processing (NLP) to develop and test a lexicon to characterize children who have experienced or are at risk for CAN and compared machine learning methods to the lexicon + NLP approach to determine the algorithm's performance for identifying CAN.

METHODS

Study investigators identified 90 CAN terms and invited an interdisciplinary group of child abuse experts for review and validation. We then used NLP to develop pipelines to finalize the CAN lexicon. Data for pipeline development and refinement were drawn from a randomly selected sample of EHR from patients seen at pediatric primary care clinics within a U.S. academic health center. To explore a machine learning approach for CAN identification, we used Support Vector Machine algorithms.

RESULTS

The investigator-generated list of 90 CAN terms were reviewed and validated by 25 invited experts, resulting in a final pool of 133 terms. NLP utilized a randomly selected sample of 14,393 clinical notes from 153 patients to test the lexicon, and .03% of notes were identified as CAN positive. CAN identification varied by clinical note type, with few differences found by provider type (physicians versus nurses, social workers, etc.). An evaluation of the final NLP pipelines indicated 93.8% positive CAN rate for the training set and 71.4% for the test set, with decreased precision attributed primarily to false positives. For the machine learning approach, SVM pipeline performance was 92% for CAN + and 100% for non-CAN, indicating higher sensitivity than specificity.

CONCLUSIONS

The NLP algorithm's development and refinement suggest that innovative tools can identify youth at risk for CAN. The next key step is to refine the NLP algorithm to eventually funnel this information to care providers to guide clinical decision making.

Is Academic Medicine Prepared to Teach About the Intersection of Childhood Experiences and Health? An Exploratory Survey of Faculty

INTRODUCTION

Childhood experiences affect health across the lifespan. Evidence-based strategies targeting early-life stress are emerging. Nevertheless, faculty physicians' preparation to incorporate this science into practice has not been well studied. This study explores medical faculty knowledge and beliefs, timing and route of knowledge acquisition, perceived relevance and application of study topics, and characteristics associated with concept mastery.

METHODS

The authors developed and administered an exploratory survey to faculty from six departments at two medical schools. The team analyzed responses using quantitative and qualitative methods.

RESULTS

Eighty-one (8.8%) eligible faculty completed the survey. Of respondents, 53 (65.4%) achieved high knowledge, 34 (42.0%) high beliefs, and 42 (59.1%) high concept exposure question scores, but only 6 (7.4%) through a formal route. Although 78 (96.8%) respondents indicated that survey concepts are relevant, only 18 (22.2%) reported fully incorporating them in their work, and 48 (59.2%) identified the need for additional coaching. Respondents reporting full incorporation were significantly more likely to attain high concept exposure scores (17 respondents, 94.4%, versus 25 respondents, 39.7%, P < .001). Quantitative and qualitative analysis highlighted limited respondent awareness of trauma prevalence among health care workers, lack of familiarity with interventions, and time and resource challenges addressing childhood adversity.

DISCUSSION

Although survey respondents had some familiarity with study concepts and perceived their relevance, most are not fully applying them. Results suggest that exposure to study concepts is associated with full incorporation. Therefore, intentional faculty development is essential to prepare faculty to include this science in practice.

Depression, Anxiety, and Stress in Pregnancy and Postpartum: A Longitudinal Study During the COVID-19 Pandemic

INTRODUCTION

Symptoms of depression, anxiety, and stress in pregnant women are generally highest in the first trimester and then decrease throughout pregnancy, reaching their lowest point in the postpartum period. Pregnant women are a high-risk population for mortality and mental health symptoms due to COVID-19. However, the extent to which the chronic stress of the COVID-19 pandemic alters the trajectory of depression, anxiety and stress symptoms in pregnant/postpartum women is unknown.

METHODS

Women (N=127) who were pregnant or who had given birth less than one month prior were recruited via online advertising during the COVID-19 pandemic. Participants were assessed up to three times during the pregnancy and at 1-month postpartum for depression (Edinburgh Postnatal Depression Scale), anxiety, and stress (Depression, Anxiety, and Stress Scale-21). Random intercepts models examined symptom change over time as well as predictors of elevated postpartum psychopathology.

RESULTS

On average, women completed their surveys at 8.5 weeks (first trimester), 21 weeks (second trimester), 32 weeks (third trimester) and 7-weeks postpartum. Women reported mild-moderate levels of depression, anxiety, and stress throughout pregnancy. There was a significant change in symptoms of depression and anxiety over time which was best represented by a quadratic rather than linear trajectory: symptoms increased until week 23-25 and then decreased. Stress levels remained consistently elevated over time. Higher symptom levels at 1-month postpartum were predicted by younger age, lower social support, and worry about going to a healthcare facility. Change in routine due to COVID-19 was not predictive of symptom trajectory from pregnancy to postpartum.

CONCLUSIONS

During COVID-19, symptoms of depression and anxiety increased from early to mid-pregnancy but then declined slightly while stress levels remained elevated. Observed reductions in symptoms were small. Given the substantial persistent impact of perinatal distress and poor mental health on maternal and fetal health, providers should be aware of heightened levels of these symptoms in pregnant women during large-scale external health stressors such as COVID-19, and should implement screening procedures to identify and appropriately intervene with at-risk women.

Cost of Pediatric Trauma: A Comparison of Non-Accidental and Accidental Trauma in Pediatric Patients

BACKGROUND

Nonaccidental trauma (NAT) affects >100,000 children in the United States every year and is associated with significant mortality and morbidity. Little is known about the financial burden of NAT, particularly in comparison to accidental trauma (AT). We sought to compare hospital charges and outcomes between children presenting with NAT and AT.

METHODS

Pediatric (<16 y) trauma hospitalizations from 2006 to 2018 were identified using the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and Kid's Inpatient Sample (KID) databases. Hospitalizations were identified as NAT or AT based on ICD codes. Discharge weights were used to obtain national estimates and standardize them across the different sampling structures. Outcomes (hospital charges, length of stay (LOS), and mortality) were compared, and multivariate regression analyses were used to assess independent predictors of hospital charges and mortality.

RESULTS

Fifty-eight Thousand Two Hundred Seventy-five pediatric hospitalizations were included with 17,954 (0.3%) categorized as NAT. Children with NAT were younger, more female, less likely to identify as White, and more under public insurance than those with AT. Hospital charges were significantly higher in patients with NAT ($27,100 versus $19,900, P < 0.0001). Mortality (4.9% versus 0.0%, P < 0.0001) and LOS (3.2 d versus 1.5 d, P < 0.0001) were significantly higher among patients with NAT. Multivariable regression analyses identified NAT as a predictor of higher hospital charges, mortality, and LOS.

CONCLUSIONS

Nonaccidental trauma in pediatric patients is associated with significantly higher hospital charges, mortality, and LOS than accidental trauma. Ongoing research focused on the relative impact of known risk factors and resource utilization is needed.

Child Adult Relationship Enhancement in Primary Care (PriCARE): study design/protocol for a randomized trial of a primary care-based group parenting intervention to prevent child maltreatment

BACKGROUND

Child maltreatment (CM) is a pervasive public health problem and there is a critical need for brief, effective, scalable prevention programs. Problematic parent-child relationships lie at the heart of CM. Parents who maltreat their children are more likely to have punitive parenting styles characterized by high rates of negative interaction and ineffective discipline strategies with over-reliance on punishment. Thus, parenting interventions that strengthen parent-child relationships, teach positive discipline techniques, decrease harsh parenting, and decrease child behavioral problems hold promise as CM prevention strategies. Challenges in engaging parents, particularly low-income and minority parents, and a lack of knowledge regarding effective implementation strategies, however, have greatly limited the reach and impact of parenting interventions. Child Adult Relationship Enhancement in Primary Care (PriCARE)/Criando Niños con CARIÑO is a 6-session group parenting intervention that holds promise in addressing these challenges because PriCARE/CARIÑO was (1) developed and iteratively adapted with input from racially and ethnically diverse families, including low-income families and (2) designed specifically for implementation in primary care with inclusion of strategies to align with usual care workflow to increase uptake and retention.

METHODS

This study is a multicenter randomized controlled trial with two parallel arms. Children, 2-6 years old with Medicaid/CHIP/no insurance, and their English- and Spanish-speaking caregivers recruited from pediatric primary care clinics in Philadelphia and North Carolina will be enrolled. Caregivers assigned to the intervention regimen will attend PriCARE/CARIÑO and receive usual care. Caregivers assigned to the control regimen will receive usual care only. The primary outcome is occurrence of an investigation for CM by child protective services during the 48 months following completion of the intervention. In addition, scores for CM risk, child behavior problems, harsh and neglectful parenting behaviors, caregiver stress, and caregiver-child interactions will be assessed as secondary outcome measures and for investigation of possible mechanisms of intervention-induced change. We will also identify PriCARE/CARIÑO implementation factors that may be barriers and facilitators to intervention referrals, enrollment, and attendance.

DISCUSSION

By evaluating proximal outcomes in addition to the distal outcome of CM, this study, the largest CM prevention trial with individual randomization, will help elucidate mechanisms of change and advance the science of CM prevention. This study will also gather critical information on factors influencing successful implementation and how to optimize intervention referrals, enrollment, and attendance to inform future dissemination and practical applications.

TRIAL REGISTRATION

This trial was registered on ClinicalTrials.gov (NCT05233150) on February 1, 2022, prior to enrolling subjects.

A review of state regulations for child care: Preventing, recognizing and reporting child maltreatment

BACKGROUND

Prior to the COVID-19 pandemic, nearly 60% of children under 5 years of age were cared for in out-of-home child care arrangements in the United States. Thus, child care provides an opportunity to identify and address potential child maltreatment. However, during the pandemic, rates of reporting child maltreatment decreased-likely because children spent less time in the presence of mandated reporters. As children return to child care, states must have regulations in place to help child care providers prevent, recognize and report child maltreatment. However, little is known about the extent to which state regulations address child maltreatment. Therefore, the purpose of this cross-sectional study was to assess state regulations related to child maltreatment and compare them to national standards.

METHOD

We reviewed state regulations for all 50 states and the District of Columbia for child care centres ('centres') and family child care homes ('homes') through 31 July 2021 and compared these regulations to eight national health and safety standards on child maltreatment. We coded regulations as either not meeting, partially meeting or fully meeting each standard.

RESULTS

Three states (Colorado, Utah and Washington) had regulations for centres, and one state (Washington) had regulations for homes that at least partially met all eight national standards. Nearly all states had regulations consistent with the standards requiring that caregivers and teachers are mandated reporters of child maltreatment and requiring that they be trained in preventing, recognizing and reporting child maltreatment. One state (Hawaii) did not have regulations consistent with any of the national standards for either centres or homes.

CONCLUSIONS

Generally, states lacked regulations related to the prevention, recognition and reporting of child maltreatment for both centres and homes. Encouraging states to adopt regulations that meet national standards and further exploring their impact on child welfare are important next steps.

The lasting consequences of childhood sexual abuse on human capital and economic well-being

Childhood sexual abuse is a prevalent problem, yet understanding of later-in-life outcomes is limited due to unobservable determinants. I examine impacts on human capital and economic well-being by estimating likely ranges around causal effects, using a nationally representative U.S. sample. Findings suggest that childhood sexual abuse leads to lower educational attainment and worse labor market outcomes. Results are robust to partial identification methods applying varying assumptions about unobservable confounding, using information on confounding from observables including other types of child abuse. I show that associations between childhood sexual abuse and education outcomes and earnings are at least as large for males as for females. Childhood sexual abuse by someone other than a caregiver is as influential or more so than caregiver sexual abuse in predicting worse outcomes. Considering the societal burden of childhood sexual abuse, findings could inform policy and resource allocation decisions for development and implementation of best practices for prevention and support.

Injuries Associated With Subsequent Child Maltreatment Diagnosis: By Age, Race, Gender, and Medicaid Status

This study examined injuries that may precede a child maltreatment (CM) diagnosis, by age, race/ethnicity, gender, and Medicaid status using a retrospective case-control design among child members of a large integrated healthcare system (N = 9152 participants, n = 4576 case). Injury categories based on diagnosis codes from medical visits were bruising, fractures, lacerations, head injury, burns, falls, and unspecified injury. Results showed that all injury categories were significant predictors of a subsequent CM diagnosis, but only for children < 3 years old. Specifically, fracture and head injury were the highest risk for a subsequent CM diagnosis. All injury types were significant predictors of maltreatment diagnosis for Hispanic children < 3 years, which was not the case for the other race/ethnicities. Overall, these findings suggest that all types of injury within these specific categories should have a more thorough assessment for possible abuse for children under 3 years. This work can inform the development of clinical decision support tools to aid healthcare providers in detecting abusive injuries.

Risk and protective factors for mental disorders beyond genetics: an evidence-based atlas

Decades of research have revealed numerous risk factors for mental disorders beyond genetics, but their consistency and magnitude remain uncer-tain. We conducted a "meta-umbrella" systematic synthesis of umbrella reviews, which are systematic reviews of meta-analyses of individual studies, by searching international databases from inception to January 1, 2021. We included umbrella reviews on non-purely genetic risk or protective factors for any ICD/DSM mental disorders, applying an established classification of the credibility of the evidence: class I (convincing), class II (highly suggestive), class III (suggestive), class IV (weak). Sensitivity analyses were conducted on prospective studies to test for temporality (reverse causation), TRANSD criteria were applied to test transdiagnosticity of factors, and A Measurement Tool to Assess Systematic Reviews (AMSTAR) was employed to address the quality of meta-analyses. Fourteen eligible umbrella reviews were retrieved, summarizing 390 meta-analyses and 1,180 associations between putative risk or protective factors and mental disorders. We included 176 class I to III evidence associations, relating to 142 risk/protective factors. The most robust risk factors (class I or II, from prospective designs) were 21. For dementia, they included type 2 diabetes mellitus (risk ratio, RR from 1.54 to 2.28), depression (RR from 1.65 to 1.99) and low frequency of social contacts (RR=1.57). For opioid use disorders, the most robust risk factor was tobacco smoking (odds ratio, OR=3.07). For non-organic psychotic disorders, the most robust risk factors were clinical high risk state for psychosis (OR=9.32), cannabis use (OR=3.90), and childhood adversities (OR=2.80). For depressive disorders, they were widowhood (RR=5.59), sexual dysfunction (OR=2.71), three (OR=1.99) or four-five (OR=2.06) metabolic factors, childhood physical (OR=1.98) and sexual (OR=2.42) abuse, job strain (OR=1.77), obesity (OR=1.35), and sleep disturbances (RR=1.92). For autism spectrum disorder, the most robust risk factor was maternal overweight pre/during pregnancy (RR=1.28). For attention-deficit/hyperactivity disorder (ADHD), they were maternal pre-pregnancy obesity (OR=1.63), maternal smoking during pregnancy (OR=1.60), and maternal overweight pre/during pregnancy (OR=1.28). Only one robust protective factor was detected: high physical activity (hazard ratio, HR=0.62) for Alzheimer's disease. In all, 32.9% of the associations were of high quality, 48.9% of medium quality, and 18.2% of low quality. Transdiagnostic class I-III risk/protective factors were mostly involved in the early neurodevelopmental period. The evidence-based atlas of key risk and protective factors identified in this study represents a benchmark for advancing clinical characterization and research, and for expanding early intervention and preventive strategies for mental disorders.

Training Psychologists in Integrated Primary Care and Child Maltreatment: Trainee and Supervisor Perspectives on Lessons Learned

Psychologists are key team members in the delivery of integrated behavioral healthcare. Healthcare reform has supported a shift toward a team-based, interdisciplinary model of service delivery, with increasing emphasis on primary care services, prevention, and health promotion. In conjunction with this shift has been a greater focus on psychosocial problems and social determinants of health, particularly childhood adversity. Psychologists in primary care are uniquely positioned to advance efforts to prevent and ameliorate childhood adversity, which are essential to improving care for underserved populations and reducing health disparities. Targeted training efforts are needed to increase the number of psychologists equipped to work in primary care settings with underserved populations. This paper provides an overview of a training program designed to provide psychology trainees with specialized training in both integrated primary care and child maltreatment. The overarching goal of the program is to provide trainees with the skillset to work within integrated primary care settings and the expertise needed to further efforts to address and prevent child maltreatment, as well as childhood adversity more broadly, to improve outcomes for underserved populations. The paper reviews strengths, challenges, and lessons learned from this program.

Risk of postpartum depression and very early child mistreatment among mothers reporting higher autistic traits: Evidence from the Japan Environment and Children's Study

BACKGROUND

Little is known about how mothers who report higher autistic traits face new parenthood. This study examined the association between antenatal non-clinical autistic traits and the risks of both postpartum depression (PPD) and child mistreatment at one-month postpartum and if these associations were mediated by preexisting social support.

METHODS

Participants included 73,532 singleton mothers without histories of psychiatric conditions from the Japan Environment and Children's Study, a nationwide birth cohort. Autistic traits were measured during the second/third trimesters using the short-version of the Autism Quotient-Japanese version. Participants were classified into three groups (i.e., typical-range, moderate-range, and high-range). PPD was measured using the Japanese version of the Edinburgh Postnatal Depression Scale, while participants self-reported experiences of child mistreatment (i.e., hit or shake the child); both assessments were conducted at one-month postpartum. Individual social support was reported during pregnancy. Data analyses were conducted through Poisson regressions.

RESULTS

A total of 7,147 (9.7%) participants reported PPD, while 12,994 (17.7%) reported child mistreatment at one-month postpartum. Autistic traits were associated with increased PPD risk (adjusted-relative risk [aRR] =1.74, 95%CI=1.64-1.84 for moderate-range; aRR=2.33, 2.13-2.55 for high-range) and child mistreatment (aRR=1.19, 1.13-1.24 for moderate-range; aRR=1.39, 1.28-1.50 for high-range) independently of confounders. Social support mediated 26-31% of these associations for moderate/high-range groups (both risks).

LIMITATIONS

Self-reported measurements were used.

CONCLUSIONS

Mothers who reported moderate-to-high autistic traits in the general population were vulnerable to PPD and newborn mistreatment at one-month postpartum, which was partially explained by the lack of social support during pregnancy.

ADHD and Exposure to Maltreatment in Children and Youth: a Systematic Review of the Past 10 Years

PURPOSE OF THE REVIEW

The purpose of the current paper was to review and summarize the literature on ADHD and maltreatment over the past 10 years.

RECENT FINDINGS

The majority of research on ADHD and exposure to maltreatment focuses on the high rates of comorbidity, including international studies from Asia, South America, North America, and Europe. Longitudinal studies showed that early exposure to maltreatment is a risk factor for ADHD symptoms later in development; however, this finding was not consistent. There were some preliminary studies on the neurological and genetic mechanisms underlying the link between ADHD and exposure to maltreatment. Finally, ADHD and exposure to maltreatment were found to have an additive effect on clinically salient outcomes (e.g., aggression, suicide attempts). Results from the review have direct clinical and future implications, including the need to understand the effect of comorbid ADHD and exposure to maltreatment in treatment studies.

Mood disorders, childhood maltreatment, and medical morbidity in US adults: An observational study

OBJECTIVE

Mood disorders, child maltreatment, and medical morbidity are associated with enormous public health burden and individual suffering. The effect of mood disorders on medical morbidity, accounting for child maltreatment, has not been studied prospectively in a large, representative sample of community-dwelling US adults. This study tested the effects of mood disorders and child maltreatment on medical morbidity, and variation by subtypes.

METHODS

Participants were noninstitutionalized US adults in the National Epidemiologic Survey on Alcohol and Related Conditions (N = 43,093 wave 1, N = 34,653 wave 2). Mood disorders included lifetime DSM-IV episodes of depression, dysthymia, mania, or hypomania. Child maltreatment was defined as sexual, physical, or emotional abuse, or physical or emotional neglect before age 18. Survey-weighted zero-inflated poisson regression was used to study effects on medical morbidity, a summary score of 11 self-reported medical conditions. Results were adjusted for age, sex, ethnicity/race, income, substance use disorders, smoking, and obesity.

RESULTS

Mood disorders and child maltreatment additively associated with medical morbidity at study entry and three years later, with similar magnitude as obesity and smoking. Mania/hypomania (incidence rate ratio [IRR] 1.06, 95% CI 1.01-1.10) and child sexual (IRR 1.08, 95% CI 1.04-1.11) and emotional (IRR 1.05, 95% CI 1.01-1.10) abuse were associated with higher medical morbidity longitudinally.

CONCLUSIONS

Child maltreatment is common, and its long-range negative effect on medical morbidity underscores the importance of trauma-informed care, and consideration of early life exposures. History of mania/hypomania should be considered in medical practice, and physical health must be emphasized in mental health care.

Prevention of Psychosis: Advances in Detection, Prognosis, and Intervention

IMPORTANCE

Detection, prognosis, and indicated interventions in individuals at clinical high risk for psychosis (CHR-P) are key components of preventive psychiatry.

OBJECTIVE

To provide a comprehensive, evidence-based systematic appraisal of the advancements and limitations of detection, prognosis, and interventions for CHR-P individuals and to formulate updated recommendations.

EVIDENCE REVIEW

Web of Science, Cochrane Central Register of Reviews, and Ovid/PsychINFO were searched for articles published from January 1, 2013, to June 30, 2019, to identify meta-analyses conducted in CHR-P individuals. MEDLINE was used to search the reference lists of retrieved articles. Data obtained from each article included first author, year of publication, topic investigated, type of publication, study design and number, sample size of CHR-P population and comparison group, type of comparison group, age and sex of CHR-P individuals, type of prognostic assessment, interventions, quality assessment (using AMSTAR [Assessing the Methodological Quality of Systematic Reviews]), and key findings with their effect sizes.

FINDINGS

In total, 42 meta-analyses published in the past 6 years and encompassing 81 outcomes were included. For the detection component, CHR-P individuals were young (mean [SD] age, 20.6 [3.2] years), were more frequently male (58%), and predominantly presented with attenuated psychotic symptoms lasting for more than 1 year before their presentation at specialized services. CHR-P individuals accumulated several sociodemographic risk factors compared with control participants. Substance use (33% tobacco use and 27% cannabis use), comorbid mental disorders (41% with depressive disorders and 15% with anxiety disorders), suicidal ideation (66%), and self-harm (49%) were also frequently seen in CHR-P individuals. CHR-P individuals showed impairments in work (Cohen d = 0.57) or educational functioning (Cohen d = 0.21), social functioning (Cohen d = 1.25), and quality of life (Cohen d = 1.75). Several neurobiological and neurocognitive alterations were confirmed in this study. For the prognosis component, the prognostic accuracy of CHR-P instruments was good, provided they were used in clinical samples. Overall, risk of psychosis was 22% at 3 years, and the risk was the highest in the brief and limited intermittent psychotic symptoms subgroup (38%). Baseline severity of attenuated psychotic (Cohen d = 0.35) and negative symptoms (Cohen d = 0.39) as well as low functioning (Cohen d = 0.29) were associated with an increased risk of psychosis. Controlling risk enrichment and implementing sequential risk assessments can optimize prognostic accuracy. For the intervention component, no robust evidence yet exists to favor any indicated intervention over another (including needs-based interventions and control conditions) for preventing psychosis or ameliorating any other outcome in CHR-P individuals. However, because the uncertainty of this evidence is high, needs-based and psychological interventions should still be offered.

CONCLUSIONS AND RELEVANCE

This review confirmed recent substantial advancements in the detection and prognosis of CHR-P individuals while suggesting that effective indicated interventions need to be identified. This evidence suggests a need for specialized services to detect CHR-P individuals in primary and secondary care settings, to formulate a prognosis with validated psychometric instruments, and to offer needs-based and psychological interventions.

Life Course Violence: Child Maltreatment, IPV, and Elder Abuse Phenotypes in a US Chinese Population

OBJECTIVES

To examine the associations between violence experiences including phenotypes (psychological, physical/sexual abuse, financial exploitation, caregiver neglect) of child maltreatment (CM), intimate partner violence (IPV), and elder abuse (EA).

DESIGN

Cross-sectional data collected during 2011-2013.

SETTING

US Chinese community in Chicago, Illinois.

PARTICIPANTS

A total of 3157 community-dwelling older adults (aged ≥60 y).

MEASUREMENTS

Cases of CM, IPV, and EA.

RESULTS

Prevalence of violence was 11.4% for CM (physical/sexual = 10.2%; psychological = 2.4%), 6.5% for IPV (psychological = 5.3%; physical/sexual = 2.8%), and 15.2% for EA (caregiver neglect = 11.2%; psychological = 9.8%; financial exploitation = 9.3%; physical/sexual = 1.2%). After adjusting for potential confounding variables, CM psychological was associated with increased risks for IPV psychological (odds ratio [OR] = 7.60; 95% confidence interval [CI] = 4.29-13.45), IPV physical/sexual (OR = 4.06; CI = 1.71-9.63), EA psychological (OR = 3.79; 95% CI = 2.20-6.51), and EA financial exploitation (OR = 2.07; 95% CI = 1.12-3.81). CM physical/sexual was associated with increased risks for IPV physical/sexual (OR = 1.86; 95% CI = 1.02-3.38), EA psychological (OR = 1.70; 95% CI = 1.20-2.42), and EA financial exploitation (OR = 2.38; 95% CI = 1.72-3.30). IPV psychological and physical/sexual were associated with 5 to 8 times increased risks for EA psychological, 6 to 9 times increased risks for EA physical/sexual, and 3 times increased risks for EA financial exploitation.

CONCLUSION

Healthcare professionals working with older adults should be informed that a history of violence might further predispose a person to different types of EA. The cumulative impact of violence should also be considered when providing services or care to violence victims. J Am Geriatr Soc 67:S486-S492, 2019.

Generalizing findings from a randomized controlled trial to a real-world study of the iLookOut, an online education program to improve early childhood care and education providers' knowledge and attitudes about reporting child maltreatment

In recent years, real-world studies (RWS) are gaining increasing interests, because they can generate more realistic and generalizable results than randomized controlled clinical trials (RCT). In 2017, we published a RCT in 741 early childhood care and education providers (CCPs). It is the Phase I of our iLookOut for Child Abuse project (iLookOut), an online, interactive learning module about reporting suspected child maltreatment. That study demonstrated that in a RCT setting, the iLookOut is efficient at improving CCPs’ knowledge of and attitudes towards child maltreatment reporting. However, the generalizability of that RCT’s results in a RWS setting remains unknown. To address this question, we design and conduct this large RWS in 11,065 CCPs, which is the Phase II of the iLookOut. We hypothesize replication of the earlier RCT findings, i.e., the iLookOut can improve CCPs’ knowledge of and attitudes toward child maltreatment reporting in a real world setting. In addition, this RWS also explores whether demographic factors affect CCPs’ performance. Results of this RWS confirmed the generalizability of the previous RCT’s results in a real world setting. It yielded similar effect sizes for knowledge and attitudes as were found in the earlier RCT. Cohen’s d for knowledge improvement was 0.95 in that RCT, 0.96 in this RWS; Cohen’s d for attitude improvement was 0.98 in that RCT, 0.80 in this RWS. Also, we found several significant differences in knowledge and attitude improvement with regard to age, race, education, and employment status. In conclusion, iLookOut improves knowledge and attitudes of CCPs about child maltreatment prevention and reporting in a real-world setting. The generalizability of the initial RCT findings to this RWS provides strong evidence that the iLookout will be effective in other real world settings. It can be a useful model for other interventions aimed at preventing child maltreatment.

Clinical trial registration for the original RCT: NCT02225301 (ClinicalTrials.gov Identifier)

The transmission of violence and trauma across development and environmental contexts: Intimate partner violence from the perspective of men with histories of perpetration

BACKGROUND

Research has established a relation between ecological contexts and intimate partner violence (IPV), but little is known about how environmental factors affect childhood development over time and culminate in IPV perpetration from the perspective of men who perpetrated IPV.

METHODS

Using grounded theory, this study employed focus groups with 32 predominately low-income, African American men in batterer intervention programs to explore factors and processes through which families, neighborhoods, and policy influence men's development, contributing to their use of IPV. Using an inductive approach, the researchers cycled between data collection and analysis resulting in a parsimonious conceptual model validated by participants.

RESULTS

Three core categories emerged from focused and axial coding: adverse childhood experiences (ACEs) and trauma, structural forces, and systemic forces. Theoretical coding illuminated how these core categories relate to each other, producing a collective narrative illustrating how environmental contexts contributed to men's development. Study participants described childhood exposure to adversity and trauma within the home that diminished essential foundations of trust and safety. Positive (e.g., Old Heads, matriarchs) and negative (e.g., gangs, community violence) structural neighborhood forces influenced the social learning of violence and exposed participants to re-traumatization outside the home during their adolescence. Finally, key macro forces such as mass incarceration exacerbated violence and trauma exposure through the proliferation of high-risk neighborhoods, predisposing men toward IPV as young adults.

CONCLUSIONS

Findings reinforce the notion that environmental stress not buffered by protective adults profoundly affects development and behavior. From the perspective of male perpetrators, our results help identify those stressors and how they might contribute to male-to-female IPV.

Social Determinants as a Preventive Service: U.S. Preventive Services Task Force Methods Considerations for Research

The body of research on social determinants of health is rapidly accumulating. The U.S. Preventive Services Task Force is conducting evaluations to consider the inclusion of screening and counseling for social risks as a clinical preventive service. Yet, for many social risks, evidence is still likely needed before the U.S. Preventive Services Task Force can recommend universal screening or counseling. This manuscript offers a brief review of the social determinants of health that may be germane to the U.S. Preventive Services Task Force, the methods the U.S. Preventive Services Task Force uses to evaluate relevant evidence, and current evidence gaps for social risks. Key methods for making clinical preventive service recommendations are applied for considering the integration of social and clinical care. These methods include determining the certainty of the evidence, assessing the net benefit, defining appropriate prevention frameworks, defining health outcomes versus intermediate outcomes, fully assessing the harms, and defining to what populations and care contexts the evidence applies. This road map for research is intended to spark ingenuity and purpose in the next generation of research studies, thereby ensuring that future recommendations to address and prevent social risks in primary care are informed by high-quality evidence. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

[Current status of neglect among children aged 3-6 years in rural areas of Urumqi, China and risk factors for child neglect]

OBJECTIVE

To investigate the current status of neglect in children aged 3-6 years in the rural areas of Urumqi, China and risk factors for neglect.

METHODS

Stratified random cluster sampling was performed to select 1 326 children, aged 3-6 years, from 6 kindergartens in the rural areas of Urumqi. A self-designed questionnaire and "Chinese Neglect Evaluation Questionnaire for Rural Children Aged 3-6 Years" were used for investigation.

RESULTS

Of the 1 326 children, the neglect rate was 51.89% (688 cases), and the degree of neglect was 49±6. There were significant differences in the neglect rate and the degree of neglect between the children in different age groups (P<0.01). The single-parent families and the remarried families had significantly higher child neglect rate and degree of neglect than the families of three generations under one roof and the core families (P<0.01). The children in left-behind status had a significantly higher degree of neglect (P<0.01). The multivariate logistic regression analysis showed that younger children, mothers with low education level, employment status of the mother as a migrant worker, single-parent and remarried families, low-income families, and left-behind status were risk factors for child neglect (P<0.05).

CONCLUSIONS

The neglect of children aged 3-6 years in the rural areas of Urumqi is serious, and more attention should be paid to younger children, children whose mothers with low education level, left-behind children, and children from single-parent families, remarried families and low-income families.

Understanding and managing intimate partner violence in the pediatric primary care setting: a review

PURPOSE OF REVIEW

To highlight the impact of intimate partner violence (IPV), also known as domestic violence, on children and families and to provide a framework for pediatricians in managing IPV-affected families.

RECENT FINDINGS

Children living with a victim of IPV are at a much higher risk of being physically abused themselves. Exposure to IPV places children at high risk for multiple adverse childhood experiences, long-term health morbidity, and increased chance of intergenerational transmission of child abuse and future IPV. Exposure to a violent home environment alone is considered a form of child maltreatment. Furthermore, recent studies have proposed that maternal posttraumatic stress disorder and ineffective parenting styles by a victim of IPV mediate children's negative developmental outcomes, such as aggressive or internalizing behavior, mental health issues, and developmental delays. Trauma-informed care and a better understanding of the child abuse reporting process allow pediatricians to address specific needs of children and families exposed to IPV, to serve as mandated reporters with sensitivity and empathy, and to promote resiliency in families.

SUMMARY

IPV is a public health issue that affects children in a variety of ways. Pediatricians can better manage this very serious and personal issue in their offices through an understanding of the unique healthcare needs of children and families impacted by IPV.

Associations of Child Maltreatment and Intimate Partner Violence With Elder Abuse in a US Chinese Population

IMPORTANCE

People who have experienced abuse as a child or violence with an intimate partner might have higher odds of being abused again, but this has been insufficiently investigated regarding elder abuse. More conclusive evidence might be critical to assessment and prevention strategies.

OBJECTIVE

To examine the associations of child maltreatment and intimate partner violence with elder abuse.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional data of 3157 community-dwelling US Chinese older adults (60 years or older) in Chicago, Illinois, were collected during 2011 through 2013.

EXPOSURES

Cases of child maltreatment and intimate partner violence.

MAIN OUTCOMES AND MEASURES

Cases of elder abuse.

RESULTS

Of the 3157 US Chinese older adults included in the study, 1328 (42.1%) were men, and the mean (SD) age was 72.8 (8.3) years. The prevalence of elder abuse, child maltreatment, and intimate partner violence in the cohort was 15.2%, 11.4%, and 6.5%, respectively. After adjusting for sociodemographic variables, health status, quality of life, and health change, individuals reporting child maltreatment had increased odds of intimate partner violence (13.4% vs 5.6%; adjusted odds ratio [aOR], 2.57; 95% CI, 1.78-3.71) and elder abuse (25.2% vs 13.8%; aOR, 2.08; 95% CI, 1.57-2.75) than those not reporting child maltreatment. Individuals reporting intimate partner violence had increased odds of elder abuse than those not reporting intimate partner violence (48.8% vs 12.9%; aOR, 5.53; 95% CI, 4.01-7.64).

CONCLUSIONS AND RELEVANCE

Prior abuse across major lifespan stages is associated with higher odds of elder abuse. Health care professionals should be more aware of the possibility of abuse when there is a known history of violence in a patient and consider the cumulative effect of violence among those exposed to elder abuse.

Assessment of Rates of Child Maltreatment in States With Medicaid Expansion vs States Without Medicaid Expansion

IMPORTANCE

Physical abuse and neglect affect a significant number of children in the United States. The 2014 Medicaid expansion, in which several states opted to expand their Medicaid programs, is associated with parental financial stability and access to mental health care.

OBJECTIVE

To determine whether Medicaid expansion is associated with changes in physical abuse and neglect rates.

DESIGN, SETTING, AND PARTICIPANTS

This ecological study used state-level National Child Abuse and Neglect Data Systems (NCANDS) data from January 1, 2010, through December 31, 2016, to compare the change in physical abuse and neglect rates in states that chose to expand Medicaid vs those that did not. All cases of physical abuse and neglect of children younger than 6 years during the study period that were referred to state-level Child Protective Services and screened in for further intervention after having met a maltreatment risk threshold were included. Cases with only documented sexual or emotional abuse were excluded. A difference-in-difference analysis was conducted from April 12, 2018, through March 26, 2019.

EXPOSURES

State-level Medicaid expansion status.

MAIN OUTCOMES AND MEASURES

Incidence rate of screened-in referrals for physical abuse or neglect per 100 000 children younger than 6 years per year by state.

RESULTS

Data were analyzed for 31 states and the District of Columbia that expanded Medicaid and 19 states that did not during the study period, with baseline neglect counts of 646 463 and 388 265, respectively. After Medicaid expansion, 422 fewer cases of neglect per 100 000 children younger than 6 years (95% CI, -753 to -91) were reported each year after adjusting for confounders for comparison of postexpansion and preexpansion rates in states that expanded Medicaid contrasting with the change during that time in nonexpansion states. From 2013 to 2016, Medicaid coverage for adults with dependent children increased a median 1.9% (interquartile range, 0.4% to 4.3%) in the states that did not expand Medicaid and 4.2% (interquartile range, 0.9% to 6.0%) in the states that did. No associations were found between Medicaid coverage or Medicaid eligibility criteria and physical abuse or neglect rates.

CONCLUSIONS AND RELEVANCE

Medicaid expansion was associated with a reduction in the reported child neglect rate, but not the physical abuse rate. These findings suggest that expanding Medicaid may help prevent child neglect.