Child Maltreatment During the COVID-19 Pandemic: A Systematic Rapid Review

Training and Curriculum Development in Infant and Early Childhood Mental Health

Infant and early childhood mental health (IECMH) is an important field within psychiatry and related disciplines. Historically, IECMH has been absent from mental health training and curricula. However, evidence shows that young children do experience mental health symptoms with clear benefits from early intervention. Some training programs have developed IECMH curricula with good results. A multidisciplinary approach with the inclusion of reflective supervision is beneficial to trainees and professionals. Important themes in IECMH include addressing systemic disparities, finding a balance between telehealth and in-person services, centralized certification/endorsement efforts, and workforce support and retention, including diversity, equity, and inclusion efforts.

Child Maltreatment Data After Implementation of Hospital-Wide Protocol and Sexual Assault Forensic Examiners

BACKGROUND

Child maltreatment is a significant global health concern with significant morbidity and mortality. Sexual assault forensic examiners (SAFEs) provide a valuable skill set and may be utilized in child maltreatment evaluations.

AIM

The purpose of the study was to describe patient characteristics and trends after implementation of a hospital-wide standardized child maltreatment protocol including forensic examiners in child maltreatment cases.

METHODS

Data from January 2017 through December 2022 were retrospectively collected and reviewed on all children under 18 years old who had a child maltreatment evaluation after initiation of a standardized child maltreatment screening process and protocol incorporating SAFE forensic evaluations at a tertiary care Level 1 trauma center.

RESULTS

From January 2017 through December 2022, there were 764 child maltreatment evaluations of 742 total patients completed, with 763 (99.9%) evaluations completed by a trained SAFE. There were 378 examinations (49%) completed in children under 2 years old, 281 (37%) in children 2 years old until the 10th birthday, and the remaining 105 (14%) in children 10 years and older. The overall number of cases increased since the initiation of standardized screening and protocol from 68 cases in 2017 to 158 cases in 2022, with peak of 167 cases in 2020.

CONCLUSION

SAFE-trained providers can be successfully incorporated in the multidisciplinary evaluation of child maltreatment patients and can add invaluable education, forensic documentation, and standardization of practice in the care of this vulnerable population.

Recent Stressful Life Events and Perceived Stress as Serial Mediators of the Association between Adverse Childhood Events and Insomnia

Insomnia is common in college students and linked to poorer mental and physical health. There is growing evidence that adverse childhood experiences (ACEs) may contribute to insomnia in adulthood. However, beyond the need for additional replication of these findings, there is a need to identify underlying mechanisms that plausibly connect the two experiences. Based on a serial mediation model, the current study examined the role of two theoretically informed mediators: recent stressful life events and perceived stress. A cross-sectional survey of 2,218 college students at a large university in the southwestern United States was conducted between August 2020 and December 2021. The sample was predominantly Hispanic (96%) and female (73%), with a mean age of 20.7 years. Standardized measures of adverse childhood experiences, recent stressful life events, perceived stress, and insomnia were administered to participants online. Almost 20% of participants reported having experienced four or more adverse childhood experiences and 63% met the threshold for insomnia. Reporting four or more ACEs was associated with significantly greater insomnia severity, and this relationship was serially mediated by both recent stressful life events and perceived stress. However, recent stressful life events appeared to be the most powerful mediator. The results of the current study indicate that recent exposure to stressful life events serves as a plausible mechanism linking early adversity during childhood to adult insomnia and could therefore serve as a potential target for intervention. The findings suggest that students would benefit from university-wide efforts to reduce the number and/or intensity of common stressors.

2020 and 2021 web-based training program on children's mental health during the COVID-19 pandemic

COVID-19 adversely affected mental health care and service delivery globally. Continuing its thrust on improving child and adolescent mental health, the National Center for Global Health and Medicine conducted a training program in collaboration with the University of the Ryukyus, University of the Philippines Manila, the National Center for Mental Health, and the Philippine Society of Child and Adolescent Psychiatry in 2020 and 2021 to discuss the situation, challenges, and good practices in mental health treatment, care, and promotion for children and adolescents during the COVID-19 pandemic. Composed of 15 on-demand lectures and a webinar on three general mental health themes, the training identified the need for strengthening the provision of care not only in specialized health facilities but also in empowering communities in addressing children and adolescent mental health concerns. Collaboration between different stakeholders is needed to ensure child and adolescent well-being during public health emergencies.

Trends in changes of family functioning during different phases of the pandemic - findings across four population-based surveys between 2020 to 2023 in Germany

BACKGROUND

The COVID-19 pandemic and the associated measures have had a significant impact on millions of individuals and families worldwide. Although cross-sectional studies have demonstrated the considerable burden placed on families during the pandemic, trends over different phases of the pandemic including later stages and using population-based samples is scarce.

OBJECTIVE

In this study, we aimed to assess trends in family functioning across four population-based surveys between December 2020 and March 2023 using a repeated cross-sectional design. The surveys were conducted using a similar sampling strategy and measures. We included individuals residing in a household with at least one minor below the age of 16.

RESULTS

The most notable changes across surveys over time were related to quality of life. While 54.3% of respondents reported a decline in quality of life during the winter of 20/21 compared to pre-pandemic levels, this was observed in only 22.6% of participants during the spring of 23. The proportion of respondents who indicated a deterioration in their relations with their children also decreased during the pandemic. While 9.9% of respondents reported a deterioration in their relationship with their children during the winter of 20/21 in comparison to the initial phase of the pandemic, this was reported by only 5.2% in the spring 23. The relationship with one's partner and health status exhibited minimal fluctuations. Mental health problems were associated with a decline in quality of life, health status and relationships with children and partners compared to pre-pandemic levels at all time points. Moreover, lower income levels were associated with poorer relationship quality with the partner in the most recent wave.

CONCLUSIONS

Our findings demonstrate significant improvements in family functioning since the onset of the pandemic, indicating that individuals and families in our sample were generally adapting well. However, a subgroup of the population still reports suboptimal family functioning compared to before the pandemic. Psychosocial care and social policy support for families are needed.

Interventions to build resilience and to ameliorate negative psychosocial effects of the COVID-19 pandemic on children and adolescents: a systematic review and meta-analysis

The psychosocial health of children and adolescents has been particularly affected by the COVID-19 pandemic. Containment measures have restricted social development, education and recreational activities, may have increased family conflicts and, in many cases, led to feelings of loneliness, sleep disturbances, symptoms of anxiety and depression. We conducted a systematic review to identify interventions that seek to ameliorate these detrimental effects of the COVID-19 pandemic and to build resilience in children and adolescents. Literature searches were conducted in the databases MEDLINE, EMBASE, PsycINFO, CENTRAL, WHO COVID-19 Global literature on coronavirus disease and Cochrane COVID-19 Study Register (up to 30 June 2022). The searches retrieved 9557 records of which we included 13 randomized-controlled trials (RCTs) for evidence synthesis. Included studies predominantly implemented online group sessions for school-aged children with either a psychological component, a physical activity component, or a combination of both. A meta-analysis of seven studies on anxiety and five on depressive symptoms provided evidence for a positive effect of interventions by reducing anxiety (Standardized Mean Difference (SMD) (95% CI): - 0.33 (- 0.59; - 0.06)) and depressive symptoms (SMD (95% CI): - 0.26 (- 0.36; - 0.16)) compared to the control interventions. Studies also showed improvements in positive mental health outcomes, such as resilience (n = 2) and mental and psychological wellbeing (n = 2). Exploratory subgroup analyses suggested a greater effectiveness of interventions that (i) are of higher frequency and duration, (ii) enable personal interaction (face-to-face or virtually), and (iii) include a physical activity component. Almost all studies were judged to be at high risk of bias and showed considerable heterogeneity. Further research may focus on the contribution of different intervention components or distinct subgroups and settings, and should examine children and adolescents over longer follow-up periods.

The effects of COVID-19 on the development of reported incidents of child maltreatment over time: A systematic literature review

BACKGROUND

During the COVID-19 pandemic, the life of families all over the world changed unprecedentedly, risks and vulnerabilities for child maltreatment might have altered. While several studies and reviews look at altered reports to child protective services and other organizations in the child protection system, particularly during the first lockdown in spring 2020, there is a gap in research on trends of reported child maltreatment incidents over time.

OBJECTIVE

To bridge the gap on mid- to long-term developments and trends of changes over time, we aimed at summarizing findings on monthly breakdowns of CM reports over time during the pandemic.

METHODS

In systematic searches of academic literature databases, we have identified 11 articles that adhere to the inclusion criteria of monthly breakdown data from child protective services during the COVID-19 pandemic with a pre-pandemic comparison period. Three additional grey literature reports haven been identified. Both studies and reports had to be published in either English, Arabic, French, German, Portuguese, or Spanish.

RESULTS

Notably, overall, the level of reported incidents has decreased compared to the years before the COVID-19 pandemic. Overall, no clear and reliable picture emerges in developments by different types of reporters. If the number of reports decreases overall, consequently, the overall number or responses to reports does. Some studies, however, report an altered proportion of responses that increased.

CONCLUSION

There is still a lot to be investigated and understood when it comes to the impact of the COVID-19 pandemic on CM. Policy-makers are called to not only invest into more research on the topic, but, first and foremost, to anticipate a potentially surging need in improved responses to a vulnerable group.

Comparison between Thai and Indian Adolescents' Self-Figure Drawing as Child Abuse Art-Based Assessment

BACKGROUND/OBJECTIVES

The current study compared Self-Figure drawings from Thai and Indian adolescents to assess the cross-cultural applicability of a child abuse assessment tool. The research aims to understand the extent to which distinctions or similarities arise in Self-Figure drawings among adolescents from two culturally similar yet distinct backgrounds characterized by differences in religious affiliations, socioeconomic contexts, and political environments.

METHODS

Employing a mixed-methods approach, the study utilized quantitative measures, including the Traumatic Events Checklist (TEQ-5) and Medical Somatic Dissociation Questionnaire (MSDQ), alongside a qualitative analysis of Self-Figure drawings. Ethical approval was obtained with waived informed consent, and a convenience sample of 386 adolescents aged 13-18 years (193 from Thailand [M = 14.8, SD = 1.73; 135 females (69.9%) and 58 males (30.1%)], and 193 from India [M = 15.2, SD = 1.64; 135 females (69.9%) and 58 males (30.1%)]), who reported experiencing child abuse, participated in the study by completing questionnaires and drawing themselves.

RESULTS

The analysis revealed that Thai adolescents had higher MSDQ scores, while Indian adolescents exhibited more prominent pictorial indicators. Indian participants reported experiencing a broader range of event types, whereas Thai adolescents predominantly depicted verbal or emotional abuse. Variations in pictorial indicators were found significant, except for hair, cheek or chin, omitted legs or feet, and omitted eyes.

CONCLUSIONS

These findings contribute to the understanding of how cultural factors influence adolescents' self-representations through drawing. The differences in pictorial indicators highlight the nuanced variations within similar cultures, emphasizing the cultural specificity of self-expression.

Lipschütz ulcers due to SARS-CoV-2 infection: a neglected diagnosis in emergency room

Background

Primary acute genital ulcers, or Lipschütz ulcers (LU), are nonsexually transmitted, painful, self-limiting, nonrecurrent vulvar ulcers with unclear pathogenesis, representing a challenging diagnosis in emergency setting. LU have recently been described in association with severe acute respiratory syndrome coronaVirus 2 (SARS-CoV-2) infection and vaccination.

Objective

The aim of this study is to describe 2 cases of LU due to SARS-CoV-2 infection, highlighting the diagnostic process, differential diagnosis, disease course, and management options.

Methods

We describe 2 young females (12 and 9 years old) who presented to pediatric emergency room with the sudden onset of well-demarcated, painful, vulvar ulcers with fibrinous necrotic center.

Results

Both patients tested positive to SARS-CoV-2 nasal swab, and, at physical examination, no other lesions were found in other cutaneous or mucosal sites. Sexual abuse was excluded in both cases, as well as infectious and autoimmune diseases. Supportive analgesic therapy was administered, and complete remission of lesions was observed at follow-up visits without evidence of scarring.

Limitations

The main limitation of this work is represented by the small number of cases described.

Conclusion

Even though extremely rare, LU related to COVID-19 are an emerging entity to be considered in the diagnosis of acute genital ulcerations. Multidisciplinary diagnostic workup of genital ulcers must be established in order to exclude sexual child abuse, to ensure patient safety, and to avoid unnecessary treatment and familial anxiety.

Child abuse and neglect during the COVID-19 pandemic: An umbrella review

BACKGROUND

During the COVID-19 pandemic, multiple child health experts postulated that the stay-at-home orders would negatively impact child abuse and neglect.

OBJECTIVES

We aimed to examine the impact of the COVID-19 pandemic on child abuse and neglect in children ages 18 and under; and review author recommendations for future emergency lockdown procedures.

METHODS

We completed a systematic search of articles across five databases. Review-level studies were included if they examined any abuse or neglect related outcomes in children and youth (e.g., injuries, case openings), and were published in English. We completed quality appraisals of each included article using the Health Evidence™ tool. We categorized the findings by data source including administrative and survey data, or other data sources. We also narratively summarized reported recommendations.

RESULTS

In total, 11 reviews were included. Two reviews were of strong quality, 7 moderate, and 2 were weak. Overall, studies within reviews that reported from administrative data sources demonstrated decreased child abuse and neglect outcomes compared to before the pandemic. Studies using cross-sectional data demonstrated increases. Reviews with mixed results often reported increases in emotional, neglect and psychological abuse cases and decreases physical and sexual abuse cases.

CONCLUSIONS

This study found consistent results across reviews; depending on the data source and study design, child abuse and neglect outcomes either increased or decreased during the COVID-19 pandemic. Future work should enhance data collection methods for surveillance and intervention of child abuse and neglect during public health emergencies when traditional mechanisms are limited, with an increased focus on the rigor of reporting.

Rates of Trauma Exposure and Posttraumatic Stress in a Pediatric Digital Mental Health Intervention: Retrospective Analysis of Associations With Anxiety and Depressive Symptom Improvement Over Time

BACKGROUND

More than 2 out of 3 children and adolescents in the United States experience trauma by the age of 16 years. Exposure to trauma in early life is linked to a range of negative mental health outcomes throughout the lifespan, particularly co-occurring symptoms of posttraumatic stress (PTS), anxiety, and depression. There has been an increasing uptake of digital mental health interventions (DMHIs) among youths, particularly for anxiety and depression. However, little is known regarding the incidence of trauma exposure and PTS symptoms among youths participating in DMHIs and whether PTS symptoms impact anxiety and depressive symptom treatment response. Moreover, it is unclear whether participation in a DMHI for anxiety and depressive symptoms is associated with secondary effects on PTS symptoms among trauma-exposed youths.

OBJECTIVE

This study aims to use retrospective data from youths participating in a DMHI to (1) characterize rates of trauma, PTS, and comorbid anxiety and depressive symptoms; (2) determine whether trauma exposure and elevated PTS symptoms impact the improvement of comorbid anxiety and depressive symptoms throughout participation in care; and (3) determine whether participation in a non-posttraumatic DMHI is linked to reductions in PTS symptoms.

METHODS

This study was conducted using retrospective data from members (children ages 6 to 12 years) involved in a pediatric collaborative care DMHI. Participating caregivers reported their children's trauma exposure. PTS, anxiety, and depressive symptom severity were measured monthly using validated assessments.

RESULTS

Among eligible participants (n=966), 30.2% (n=292) reported at least 1 traumatic event. Of those with trauma exposure and elevated symptoms of PTS (n=119), 73% (n=87) exhibited elevated anxiety symptoms and 50% (n=59) exhibited elevated depressive symptoms. Compared to children with no trauma, children with elevated PTS symptoms showed smaller reductions per month in anxiety but not depressive symptoms (anxiety: F2,287=26.11; P<.001). PTS symptoms also decreased significantly throughout care, with 96% (n=79) of participants showing symptom reductions.

CONCLUSIONS

This study provides preliminary evidence for the frequency of trauma exposure and comorbid psychiatric symptoms, as well as variations in treatment response between trauma-exposed and nontrauma-exposed youths, among participants in a pediatric collaborative care DMHI. Youths with traumatic experiences may show increased psychiatric comorbidities and slower treatment responses than their peers with no history of trauma. These findings deliver compelling evidence that collaborative care DMHIs may be well-suited to address mental health symptoms in children with a history of trauma while also highlighting the critical need to assess symptoms of PTS in children seeking treatment.

The Utility of Administrative Data in Understanding the COVID-19 Pandemic's Impact on Child Maltreatment: Learning From the Scotland Experience

The COVID-19 pandemic and associated public health 'stay at home' restrictions have intensified familial risk factors. Children would appear to be at increased risk of harm and abuse, yet administrative data from the early months of the pandemic showed falling cases of child maltreatment. Using weekly administrative data from Scotland, UK that span the first 17 months of the pandemic, this article found that child maltreatment activity levels fluctuated as 'stay at home' restrictions changed. During lockdown periods, the number of children subject to Inter-agency Referral Discussion fell but a higher number of children were placed on the Child Protection Register. When restrictions were eased, the number of Inter-agency Referral Discussions increased but the number of children placed on the Child Protection Register fell. To explain the fluctuations, the article asserts that the pandemic's impact on services' ability to engage directly with children and families has been critical, but the limitations of administrative data in providing an accurate measure of child maltreatment levels also need to be recognised. The article advocates that analysis of administrative data is best done in tandem with wider quantitative and qualitative sources in order to understand the impact of crisis events on children and families.

Identifying child maltreatment during virtual medical appointments through the COVID-19 pandemic: A physician-based survey

Background

Throughout the COVID-19 pandemic there has been a documented decline in reports to child protective services, despite an increased incidence of child maltreatment. This is concerning for increasing missed cases. This study aims to examine if and how Canadian paediatricians are identifying maltreatment in virtual medical appointments.

Methods

A survey was sent through the Canadian Paediatric Surveillance Program (CPSP) to 2770 practicing general and subspecialty paediatricians. Data was collected November 2021 to January 2022.

Results

With a 34% (928/2770) response rate, 704 surveys were eligible for analysis. At least one case of child maltreatment was reported by 11% (78/700) of respondents following a virtual appointment. The number of cases reported was associated with years in medical practice (P = 0.026) but not with the volume (P = 0.735) or prior experience (P = 0.127) with virtual care, or perceived difficulty in identifying cases virtually (Cramer's V = 0.096). The most common factors triggering concern were the presence of social stressors, or a clear disclosure. The virtual physical exam was not contributory. Nearly one quarter (24%, 34/143) required a subsequent in-person appointment prior to reporting the case and 32% (207/648) reported concerns that a case had been identified late, or missed, following a virtual appointment. Some commented that clear harm resulted.

Conclusions

Many barriers to detecting child maltreatment were identified by paediatricians who used virtual care. This survey reveals that virtual care may be an important factor in missed cases of child maltreatment and may present challenges to timely identification.

Medical Knowledge Acquisition during a Pandemic: Pediatric Subspecialty in-Training Examination and Board Certification Exam Passing Rate

OBJECTIVE

The COVID-19 pandemic resulted in training programs restructuring their curricula. Fellowship programs are required to monitor each fellow's training progress through a combination of formal evaluations, competency tracking, and measures of knowledge acquisition. The American Board of Pediatrics administers subspecialty in-training examinations (SITE) to pediatric fellowship trainees annually and board certification exams at the completion of the fellowship. The objective of this study was to compare SITE scores and certification exam passing rates before and during the pandemic.

METHODS

In this retrospective observational study, we collected summative data on SITE scores and certification exam passing rates for all pediatric subspecialties from 2018 to 2022. Trends over time were assessed using analysis of variance (ANOVA) analysis to test for trends across years within one group and t-test analysis to compare groups before and during the pandemic.

RESULTS

Data were obtained from 14 pediatric subspecialties. Comparing prepandemic to pandemic scores, Infectious Diseases, Cardiology, and Critical Care Medicine saw statistically significant decreases in SITE scores. Conversely, Child Abuse and Emergency Medicine saw increases in SITE scores. Emergency Medicine saw a statistically significant increase in certification exam passing rates, while Gastroenterology and Pulmonology saw decreases in exam passing rates.

CONCLUSIONS

The COVID-19 pandemic resulted in restructuring didactics and clinical care based on the needs of the hospital. There were also societal changes affecting patients and trainees. Subspecialty programs with declining scores and certification exam passing rates may need to assess their educational and clinical programs and adapt to the needs of trainees' learning edges.

Domestic Violence in the Context of the COVID-19 Pandemic: A Synthesis of Systematic Reviews

The current systematic meta-review aimed to map out, characterize, analyze, and synthesize the overarching findings of systematic reviews on domestic violence (DV) in the context of COVID-19. Specifically, a systematic meta-review was conducted with three main objectives: (1) to identify what types and aspects of DV during COVID-19 have been reviewed systematically to date (research trends), (2) to synthesize the findings from recent systematic reviews of the theoretical and empirical literature (main findings), and (3) to discuss what systematic reviewers have proposed about implications for policy and practice as well as for future primary research (implications). We identified, appraised, and synthesized the evidence contained in systematic reviews by means of a so-called systematic meta-review. In all, 15 systematic reviews were found to be eligible for inclusion in the current review. Thematic codes were applied to each finding or implication in accordance with a set of predetermined categories informed by the DV literature. The findings of this review provide clear insight into current knowledge of prevalence, incidence, and contributing factors, which could help to develop evidence-informed DV prevention and intervention strategies during COVID-19 and future extreme events. This systematic meta-review does offer a first comprehensive overview of the research landscape on this subject. It allows scholars, practitioners, and policymakers to recognize initial patterns in DV during COVID-19, identify overlooked areas that need to be investigated and understood further, and adjust research methods that will lead to more robust studies.

Advancing early relational health: a collaborative exploration of a research agenda

Here, we introduce the Early Relational Health (ERH) Learning Community's bold, large-scale, collaborative, data-driven and practice-informed research agenda focused on furthering our mechanistic understanding of ERH and identifying feasible and effective practices for making ERH promotion a routine and integrated component of pediatric primary care. The ERH Learning Community, formed by a team of parent/caregiver leaders, pediatric care clinicians, researchers, and early childhood development specialists, is a workgroup of Nurture Connection-a hub geared toward promoting ERH, i.e., the positive and nurturing relationship between young children and their parent(s)/caregiver(s), in families and communities nationwide. In response to the current child mental health crisis and the American Academy of Pediatrics (AAP) policy statement promoting ERH, the ERH Learning Community held an in-person meeting at the AAP national headquarters in December 2022 where members collaboratively designed an integrated research agenda to advance ERH. This agenda weaves together community partners, clinicians, and academics, melding the principles of participatory engagement and human-centered design, such as early engagement, co-design, iterative feedback, and cultural humility. Here, we present gaps in the ERH literature that prompted this initiative and the co-design activity that led to this novel and iterative community-focused research agenda, with parents/caregivers at the core, and in close collaboration with pediatric clinicians for real-world promotion of ERH in the pediatric primary care setting.

Child Maltreatment

Child maltreatment is associated with significant morbidity, and prevention is a public health priority. Given evidence of interpersonal and structural racism in child protective service assessment and response, equity must be prioritized for both acute interventions and preventive initiatives aimed at supporting children and their families. Clinicians who care for children are well positioned to support families, and the patient-centered medical home, in collaboration with community-based services, has unique potential as a locus for maltreatment prevention services. Clinicians can advocate for policies that support families and decrease the risk of child maltreatment.

Changing patterns in the burden of paediatric injuries during the COVID-19 pandemic: a study in Mozambique's central hospitals

INTRODUCTION

There is a substantial body of knowledge on the effects of the COVID-19 pandemic on injuries showing frequent but inconsistent reductions in both volume and pattern. Yet, studies specifically addressing children are less common, not least from low- and middle-income countries. This study investigated whether changes in the pattern and outcome of paediatric injury admissions to Mozambique's four regional referral hospitals during 2020.

METHODS

Clinical charts of paediatric patients presenting to the targeted hospitals with acute injuries were reviewed using a set of child, injury, and outcome characteristics during each of two consecutive restriction periods in 2020 using as a comparator the same periods in 2019, the year before the pandemic. Differences between 2020 and 2019 proportions for any characteristic were examined using the t-test (significance level 0.05).

RESULTS

During both restriction periods, compared with the previous year, reductions in the number of injuries were noticed in nearly all aspects investigated, albeit more remarkably during the first restriction period, in particular, greater proportions of injuries in the home setting and from burns (7.2% and 11.5% respectively) and a reduced one of discharged patients (by 2.5%).

CONCLUSION

During the restrictions implemented to contend the pandemic in Mozambique in 2020, although each restriction period saw a drop in the volume of injury admissions at central hospitals, the pattern of child, injury and outcome characteristics did not change much, except for an excess of home and burn injuries in the first, more restrictive period. Whether this reflects the nature of the restrictions only or, rather, other mechanisms that came into play, individual or health systems related, remains to be determined.

Reducing Abuse and Neglect Recurrence Among Young Foster Children Reunified With Their Families

BACKGROUND AND OBJECTIVES

Child maltreatment (CM) is a recurrent adverse life event known to cause enduring psychiatric impairment throughout life. For young children in protective custody for a first episode of CM, specialized court-coordinated intervention to optimize reunification has shown promise for preventing CM recidivism, with case series documenting short-term successes.

METHODS

We tracked 10-year (Nov 2011-March 2022) court re-entry outcomes in a cohort of 272 young children, birth to six years, reunited with their families following placement in protective custody and court referral to the SYNCHRONY Project, a voluntary clinical service providing Incredible YearsTM parenting education, parental psychiatric care, and serial dyadic clinical evaluation to inform medical recommendations on safety for visitation and reunification. Re-entry was operationalized as rereferral to any Missouri Court and proportions compared with contemporaneous State and national data.

RESULTS

SYNCHRONY-enrolled/reunified children experienced frequencies of guardianship (22%) and reunification (46%), in keeping with Missouri averages. In these categories, 3.4% and 7.1% respectively were re-referred to the Court over the 10-year follow-up. In care as usual nationally for this age group, the re-referral proportions are 18% (OR 7.5, P < .0001) and 35% (OR 6.1, P < .0001) respectively. In care as usual in Missouri across all ages, the re-referral proportion is 16% (odds ratio [OR] 3.09, P < .0001).

CONCLUSIONS

Judicious implementation of evidence-based parenting education, 2-generation psychiatric care, and clinical consultation were associated with marked reduction in court re-entry versus care-as-usual and warrant consideration in intervention standards for young children in foster care.

Associations between experiences of childhood maltreatment and perceived acceptability of child maltreatment: A cross-cultural and exploratory study

BACKGROUND

Acceptable parental behaviors and practices toward a child vary across countries and may impact the risk of exposure to maltreatment. Conversely, prior experiences of maltreatment as a child may influence the acceptability of child maltreatment (CM) behaviors.

OBJECTIVE

This exploratory study examined the association between CM experiences and perceived acceptability of CM using data from four countries representing different cultures, living standards, and gross national income.

PARTICIPANTS AND SETTING

We recruited a convenience sample of 478 adults from Cameroon (n = 111), Canada (n = 137), Japan (n = 108), and Germany (n = 122) through online postings on social media.

METHODS

We administered questionnaires and conducted a three-stage hierarchical multiple regression with perceived acceptability of CM subscales as the dependent variable.

RESULTS

In all countries, higher scores of childhood neglect were associated with greater perceived acceptability of neglect in one's community (p < .001). Equally, our results showed that higher scores of childhood neglect or sexual abuse were associated with greater perceived acceptability of sexual abuse (p < .044). However, we did not find a significant relationship between other forms of CM (i.e., physical abuse, emotional maltreatment, exposure to domestic violence), and their perceived acceptability.

CONCLUSIONS

Our findings suggest that experiences of some CM types, namely neglect and sexual abuse, may be associated with the perception that these are more acceptable within one's community. Perceived acceptability of CM might be a driver that can either prevent or perpetuate CM. Therefore, intervention and prevention programs could incorporate a deeper cross-cultural understanding and assessment of these social norms in order to foster meaningful behavioral changes.

A bad time for kids in lockdown: The relationship between negative pandemic events, parenting stress, and maltreatment related parenting behaviors

BACKGROUND

To date, several studies have shown that parenting stress, a kind of role strain, is related to child maltreatment. However, few studies have examined how the effects of crises, such as negative pandemic-related events on the household, may be related to parenting stress and maltreatment-related behavior.

OBJECTIVE

This study examines the impact of negative Covid-related events on parenting stress and parenting behaviors during a period that was likely to have been a peak point of stress for many parents during the Covid-19 pandemic.

PARTICIPANTS

Respondents were female caregivers (N = 720) of children under the age of six located in the Midwestern United States.

RESULTS

Three or more Covid-related impacts on the household were positively associated with parenting stress (B = 0.177, p < 0.05). Parenting stress fully mediated the weak relationship between these impacts and maltreatment-related behavior. Mothers of different employment statuses, including those who were recently laid off or who chose to stay at home, did not have significantly different probabilities of parenting stress or maltreatment-related behaviors. Contrary to theory, similar null results were found across other socio-demographic variables.

CONCLUSIONS

These null findings suggest that crises have effects that encompass family systems, potentially raising parenting stress levels in many groups that are typically considered low-risk for child maltreatment. Results have implications for scholarship on parenting stress, the targeting of social supports to mothers of young children, and rapid interventions to reduce stress, such as the stimulus check relief program.

The Crisis in Children's Mental Health: What About the Babies?

The American Academy of Child and Adolescent Psychiatry (AACAP), the American Academy of Pediatrics (AAP), and the Children's Hospital Association (CHA) declared a national emergency in children's mental health.¹ Much of the reporting has focused on children and teens, particularly with regard to increased emergency department visits and suicide attempts. Very little has been publicized about children between birth and 5 years of age, who may be among the most vulnerable to the psychosocial impacts of COVID-19. This commentary will outline some of the impacts of COVID-19 on very young children and their families and highlight activities of members of the Infant and Preschool Committee to address these impacts.

Parental stress and physical violence against children during the second year of the COVID-19 pandemic: results of a population-based survey in Germany

BACKGROUND

Parents and caregivers belonged to those with the highest burdens during the COVID-pandemic. Considering the close link between parental stress and child maltreatment, identifying families with high parental stress is of utmost importance to prevent violence against children. Within this study, we thus aimed to investigate the interplay of parental stress, changes in parental stress, and physical violence against children during the second year of the COVID-pandemic on an exploratory level.

METHODS

We conducted a cross-sectional, observational study in Germany from July to October 2021. By using different sampling steps, a representative probability sample of the German population was generated. A subsample of these participants with children under the age of 18 was included for analysis within this study (N = 453, 60.3% females, M_age = 40.08; SD = 8.53).

RESULTS

Higher parental stress levels were associated with more physical violence against children, higher levels of own experiences of child maltreatment, and mental health symptoms. An increase in parental stress during the pandemic was associated with female sex, the use of physical violence against children, and parental experience of child maltreatment. Parents who have ever used physical violence against their children have been characterized by higher parental stress levels, a stronger increase in parental stress during the pandemic, own experience of child maltreatment, mental health symptoms and sociodemographic characteristics. Higher parental stress levels, a stronger increase of parental stress during the pandemic, having pre-existing psychiatric disorders, and parental experience of child maltreatment predicted an increased use of physical violence against children during the pandemic.

CONCLUSIONS

Our results underscore the importance of parental stress for the risk of physical violence against children, more so in times of overall increased stress due to the pandemic and underline the need for low threshold support for families at risk in times of crises.

Risk factors of self-reported physical child abuse during the COVID-19 pandemic in Japan: work-related changes in men and fear of COVID-19 in women

Background

There is no global consensus on whether pandemic-related factors are related to child abuse. How the pandemic reinforces the risk factors of child abuse might depend largely on individuals' current and past lifestyles in each country. Some changes of lifestyles continue after the pandemic, and it is important to understand which factors are strongly associated with child abuse. We analyzed the pandemic-related characteristics of offenders and non-offenders of self-reported child physical abuse from Internet survey data in Japan and discussed how the pandemic affected physical child abuse and what caused the difference by gender.

Methods

We conducted a cross-sectional study on physical child abuse by caregivers based on the Internet survey conducted from September to October 2021. We divided the participants who were living with their child aged less than 14 years into offenders and non-offenders based on the answer to the question about physical child abuse. The population distribution of the sample was compared to that of caregivers under the same conditions in a large Japanese dataset. The association between their characteristics and physical child abuse was analyzed by univariable and multivariable analysis.

Results

The caregivers analyzed in the cohort had similar population distributions to those in the large Japanese dataset. As risk factors of male offenders, "work from home 4-7 days/week," "decreased work," "normal relationships with household members (compared to good relationships)," "COVID-19 infected, both themselves and household members, within a year," "unwillingness to receive COVID-19 vaccination because the license process of the vaccine is doubtful," "high levels of benevolent sexism," and "history of child abuse" were observed. As risk factors of female offenders, "bad relationships with household members (compared to good relationships)," "fear of COVID-19," "COVID-19 infected, both themselves and household members, within a year," "feelings of discrimination related to COVID-19 in the past two months," and "history of child verbal abuse" were observed.

Conclusions

Among male offenders, a significant relationship was observed regarding work-related changes, which may have been reinforced by the pandemic. Furthermore, the extent of the influence and fear of losing jobs caused by these changes may have varied according to the strength of gender roles and financial support in each country. Among female offenders, a significant relationship was observed regarding fear of infection itself, which is consistent with the findings of other studies. In terms of factors related to dissatisfaction with families, in some countries with prominent stereotyped gender roles, men are thought to experience difficulties adapting to work-related changes induced by crises, while women are thought to experience intense fear of the infection itself.

The Fast and the Furious: The Rapid Implementation of Tele-mental Health Practices Within a Children’s Advocacy Center

We work at a large, urban children’s advocacy center (CAC) that provides treatment and services to approximately 2000 children and families each year who have experienced child abuse and other forms of trauma. While the complexity and impact of the COVID-19 pandemic on both physical and mental health are only beginning to be understood, families with histories of abuse and other traumatic experiences are particularly vulnerable to the negative impacts of isolation due to the extended lockdown. When the COVID-19 pandemic was identified as a public health crisis, the team of providers at the CAC pivoted to meet the newly emerging needs of the children and families served. Tele-mental health practices (TMH) were immediately implemented that required a deep understanding of the imminent safety concerns related to conducting TMH when the client may not feel safe at home. Further, while most of the clients referred for services have experienced child abuse and/or other types of trauma, COVID-19 is its own potentially traumatic event that can further exacerbate an individual’s lack of safety and vulnerability to trauma. The current paper provides an overview of the rapid implementation of TMH practices within a large, urban CAC setting. We share the specific tele-mental health practices and implementation strategies that were put into place because of COVID-19 and how they align with the Consolidated Framework for Implementation Research, as well as recommendations for how agency leadership can better facilitate the implementation of innovative practices in similar settings.

Documenting Opportunity for Systematic Identification and Mitigation of Risk for Child Maltreatment

This is a communication of preliminary data as a matter of priority in relation to Clinical Trials protocol ID 2018110118; NCT04438161. This protocol represents, to our knowledge, a first-ever attempt to convert an epidemiologic discovery on risk for child maltreatment (CM) into a readily deployable modification of obstetrical practice designed to offset risk for CM and its psychiatric sequelae. Before¹ and during the coronavirus disease 2019 (COVID-19 pandemic),^2,3 CM has incurred a burden of epidemic proportions to U.S. children, with confirmed incidents occurring on the order of 12% of the population. Wu et al.⁴ and Putnam-Hornstein and Needell⁵ previously established that profiles of risk ascertained exclusively from birth records identified specific groups of newborns at highly elevated risk for official-report CM. For example, infants with the joint characteristics of low birth weight, more than 2 siblings, and maternal characteristics of being unmarried, on Medicaid, and smoking during pregnancy (ascertained separately) were found to have a 7-fold risk for maltreatment compared with the population average.⁴ Putnam-Hornstein and Needell showed that newborns with 3 or more risk factors ascertained from birth records (including any of the above, delayed prenatal care, less than high school maternal education, and maternal age less than 24 years) comprised 15% of an epidemiologic birth cohort but accounted for more than half of all the children in the cohort who experienced substantiated official-report maltreatment by the age of 5 years. This study explored whether prospective implementation of birth records screening in an urban obstetrical service recapitulated the association with CM observed in an epidemiologic context and whether families in higher echelons of risk (ascertained in this manner through birth records) could be prospectively engaged in supportive interventions of demonstrated effect in reducing the occurrence of CM. This work follows on promising efforts elsewhere to use birth records information to prioritize support services for young families,⁶ though such innovations have yet to be systematically incorporated into obstetrical or newborn medical services of U.S. health systems.

Associations of connectedness and parental behaviors with adolescent physical activity and mental health during COVID-19: A mediation analysis using the 2021 adolescent behaviors and experiences survey

The purpose of this study was to examine the associations of connectedness and parental behaviors with adolescent physical activity (PA) and mental health during COVID-19. Participants were a representative sample of US high school students who completed the 2021 Adolescent Behaviors and Experiences Survey (ABES; N = 7705; 50.4% female). ABES was completed online during the spring of 2021 and data were analyzed during the spring of 2022. Independent variables were items asking about perceived school and virtual connectedness, parental emotional abuse, and parental monitoring. Latent variables represented both PA and mental health. Two weighted structural equation models tested the associations between connectedness, parental behaviors, and mental health mediated through PA (Model 1) and between connectedness, parental behaviors, and PA mediated through mental health (Model 2) with indirect effect confidence intervals obtained using Monte Carlo simulations. School connectedness directly associated with better mental health in Model 1 (β = 0.17, p < 0.001) and with higher PA in Model 2 (β = 0.19, p < 0.001) while virtual connectedness directly associated with higher PA in Model 2 (β = 0.08, p < 0.001). Parental emotional abuse directly associated with poorer mental health in Model 1 (β = -0.43, p < 0.001). Standardized indirect effects to better mental health mediated through higher PA were observed for school connectedness (IE = 0.017, p < 0.001) and virtual connectedness (IE = 0.007, p < 0.001) and indirect effects to lower PA mediated through poorer mental health were observed for parental emotional abuse (IE = -0.050, p < 0.001). Perceptions of school and virtual connectedness and parental emotional abuse both directly and indirectly impacted adolescent PA and mental health during the COVID-19 pandemic.

Understanding emergency placements for Nova Scotian children in foster care

To cope with a critical lack of foster families, Nova Scotia’s Department of Community Services uses rented private facilities staffed by subcontracted companies, known as “places of safety”. Similar models are used across the country, with places of safety intended to be used for emergency placements only. The mean length of stay in a place of safety was 255 nights in 2020. Male children are far overrepresented, as are Indigenous children. Despite the increasing use of places of safety, little is known about the impacts of these short-term and unhomelike environments. Previous research on placement disruption shows that placement change and multiple placements impact children’s health, mental health, and attachment behaviour. This paper presents data on the use of places of safety in Nova Scotia and synthesizes existing research on placement disruption to present advocacy priorities and directions for further research.

Emergency Department Child Abuse Evaluations During COVID-19: A Multicenter Study

BACKGROUND AND OBJECTIVE

The reported impacts of the COVID-19 pandemic on child maltreatment in the United States have been mixed. Encounter trends for child physical abuse within pediatric emergency departments may provide insights. Thus, this study sought to determine the change in the rate of emergency department encounters related to child physical abuse.

METHODS

A retrospective study within the Pediatric Emergency Care Applied Research Network Registry. Encounters related to child physical abuse were identified by 3 methods: child physical abuse diagnoses among all ages, age-restricted high-risk injury, or age-restricted skeletal survey completion. The primary outcomes were encounter rates per day and clinical severity before (January 2018-March 2020) and during the COVID-19 pandemic (April 2020-March 2021). Multivariable Poisson regression models were fit to estimate rate ratios with marginal estimation methods.

RESULTS

Encounter rates decreased significantly during the pandemic for 2 of 3 identification methods. In fully adjusted models, encounter rates were reduced by 19% in the diagnosis-code cohort (adjusted rate ratio: 0.81 [99% confidence interval: 0.75-0.88], P <.001), with the greatest reduction among preschool and school-aged children. Encounter rates decreased 10% in the injury cohort (adjusted rate ratio: 0.90 [confidence interval: 0.82-0.98], P = .002). For all 3 methods, rates for lower-severity encounters were significantly reduced whereas higher-severity encounters were not.

CONCLUSIONS

Encounter rates for child physical abuse were reduced or unchanged. Reductions were greatest for lower-severity encounters and preschool and school-aged children. This pattern calls for critical assessment to clarify whether pandemic changes led to true reductions versus decreased recognition of child physical abuse.

The voices of parents in child protective services: A qualitative analysis of families' struggles with COVID-19

The pandemic of the Coronavirus disease 2019 (COVID-19) has affected children and families worldwide, disrupting their daily lives and well-being. A small-scale study involving 13 parents in Child Protective Services in Estonia was conducted using in-depth, semi-structured interviews to explore parents' experiences with COVID-19 and its impact on their families' well-being. The findings indicated that one of the areas most impacted by the COVID-19 pandemic was schooling, as the implementation of remote schooling often created tensions and conflicts at home. Parents reported regression in daily functioning, attributing this to the lack of supportive services during lockdown and additional distress resulting from increased workload at home and problems with balancing home and work life. Parents were exhausted by the various problems caused by the pandemic and questioned their ability to provide their children the support they needed. Discontinuation of services intensified existing challenges for both parents and children. Furthermore, a lack of trust in Child Protective Services was identified, serving as a barrier to asking for help in times of crisis.

Rate and severity of radiological features of physical abuse in children during the first UK-wide COVID-19 enforced national lockdown

Rate and severity of radiological features of physical abuse in children during the first UK-wide COVID-19 enforced national lockdown.

OBJECTIVE

To assess the number, type and outcome of radiological investigations for children presenting to hospital with suspected physical abuse (SPA; including abusive head trauma) during the first national COVID-19 enforced lockdown compared with the prelockdown period.

DESIGN

Multicentre, retrospective, observational, interrupted time series analysis.

SETTING

Eight secondary/tertiary paediatric centres between January 2018 and July 2020 inclusive.

PARTICIPANTS

1587 hospital assessed children undergoing radiographic skeletal surveys (SkS) and head CT imaging performed for SPA/child protection concerns.

MAIN OUTCOME MEASURES

Incidence and severity of fractures identified on SkS; head injury (composed of incidence rates and ratios of skull fracture, intracranial haemorrhage (ICH) and hypoxic ischaemic injury (HII)) on head CT imaging; and ratio of antemortem and postmortem SkS.

RESULTS

1587 SkS were performed: 1282 (81%) antemortem, 762 (48%) male, and positive findings in 582 (37%). Median patient age was 6 months. There were 1.7 fractures/child prelockdown versus 1.1 fractures/child during lockdown. There was no difference between positive/negative SkS rates, the absolute ratio of antemortem/postmortem SkS or absolute numbers of head injury occurring between January 2018 and February 2020 and the lockdown period April-July 2020. Likewise, prelockdown incidence and rates of skull fracture 30/244 (12%), ICH 28/220 (13%) and HIE 10/205 (5%) were similar to lockdown, 142/1304 (11%), 171/1152 (15%) and 68/1089 (6%), respectively.

CONCLUSION

The first UK COVID-19 lockdown did not lead to an increase in either the number of antemortem or postmortem radiological investigations performed for SPA, or the number or severity of fractures and intracranial injuries identified by these investigations.

The mental health of children and young people living in big cities in a revolving postpandemic world

PURPOSE OF REVIEW

The world's population is increasingly urban, with most children and young people growing up and living in cities. Evidence suggests that urbanicity is linked to an increased risk for the development of mental health disorders. Rather than an accumulation of risk factors, urbanization is a complex process that profoundly structures living conditions. In this sense, it is timely to discuss what are the social and structural determinants of mental health of children and young people in such settings.

RECENT FINDINGS

Three domains of determinants of mental health were selected for discussion: economics and living conditions, crime and violence, and urban layouts. For each, we debated realities faced by urban children and young people, providing an overview of recent evidence on implications for mental disorders and well being. We also discuss the potential impacts of the covid-19 pandemic on each domain, as well as recommendations for future action.

SUMMARY

Structural factors are of major relevance for the mental health of children and young people living in cities. The agenda of mental health promotion and prevention must include whole-of-society interventions aimed at improving living conditions, including economic and social capital, violence prevention and urbanistic planning.

The relationship between emergency medical services use and social service needs in a pediatric emergency department population

BACKGROUND

Emergency Medical Services (EMS) use for children is correlated with areas of resource deprivation as well as child maltreatment. Households using EMS may have more social needs and be willing to accept services.

OBJECTIVE

To compare social service needs and willingness to accept services in families arriving to a pediatric emergency department (ED) via EMS vs non-EMS, before and during COVID-19.

PARTICIPANTS AND SETTING

Caregivers of children 0-5 years old in a quaternary pediatric ED, with a 1:1 ratio of EMS vs non-EMS arrivals.

METHODS

Participants completed a survey of demographics, social service needs, and willingness to accept services, before and during COVID-19.

RESULTS

Of 220 participants, 84 were enrolled before COVID-19. The EMS group reported less full-time employment (34.6% vs 51.8%, p < 0.05) and more social service needs (2.47 vs 1.76 needs, p < 0.05). Mean score for willingness to accept a service provider in the home was 3.62 for EMS and 3.19 for non-EMS (p = 0.09). Mean score for accepting a phone referral was 3.84 for EMS and 3.40 for non-EMS (p = 0.07). COVID-19 impacted needs for both groups (20.9% EMS vs 30.3% non-EMS). For all subjects presenting to the ED, COVID-19 was associated with decreased food insecurity (28.6% vs 15.4%) and children with a chronic medical condition (31.0% vs 12.5%).

CONCLUSIONS

The EMS group had more social service needs. There was no difference in social services acceptance. COVID-19 affected both groups' needs. Future interventions may use EMS systems to mitigate social service needs which may be risk factors for child abuse.

Co-occurrence of adult abuse and child abuse: analysis of the phenomenon

BACKGROUND

The purpose of this study was to analyze the co-occurrence of adult and child abuse based on the reports collected from the Polish police and social welfare institutions.

METHODS

The study involved data concerning 468 households in Szczecin (Poland) inhabited by children where acts of violence between adults took place. The presented data refer to the years 2012-2103. The data came from so called Blue Card files, i.e. documents issued by the police and social workers in cases of domestic abuse, providing information about its forms, perpetrators, and victims.

RESULTS

Domestic violence usually occurs between spouses and cohabitees (78%). The perpetrator was usually a man (88%). Violence usually lasted from 1 up to 3 years (30.0%). The most common forms of physical abuse against adults and children included pushing (79.5% of adults, 22.4% of children) and hitting (64.7% of adults, 16.6% of children), and psychologically abusive behaviors were mostly insults (91.9% of adults, 27.5% of children) and criticism (79.1% of adults, 21.5% of children). This work has shown that the longer the psychological abuse between adults lasts, the greater probability is that it will also be used against children. Child abuse is also associated with putting up resistance to the police by perpetrators.

CONCLUSIONS

Summing up, in households where violence between adults is observed, actions should be taken to prevent violence against children.

[Analytical morphometry in the study of biological forms: description of the procedure and oriented software]

Background

More than 2 out of 3 children and adolescents in the United States experience trauma by the age of 16 years. Exposure to trauma in early life is linked to a range of negative mental health outcomes throughout the lifespan, particularly co-occurring symptoms of posttraumatic stress (PTS), anxiety, and depression. There has been an increasing uptake of digital mental health interventions (DMHIs) among youths, particularly for anxiety and depression. However, little is known regarding the incidence of trauma exposure and PTS symptoms among youths participating in DMHIs and whether PTS symptoms impact anxiety and depressive symptom treatment response. Moreover, it is unclear whether participation in a DMHI for anxiety and depressive symptoms is associated with secondary effects on PTS symptoms among trauma-exposed youths.

Objective

This study aims to use retrospective data from youths participating in a DMHI to (1) characterize rates of trauma, PTS, and comorbid anxiety and depressive symptoms; (2) determine whether trauma exposure and elevated PTS symptoms impact the improvement of comorbid anxiety and depressive symptoms throughout participation in care; and (3) determine whether participation in a non–posttraumatic DMHI is linked to reductions in PTS symptoms.

Methods

This study was conducted using retrospective data from members (children ages 6 to 12 years) involved in a pediatric collaborative care DMHI. Participating caregivers reported their children’s trauma exposure. PTS, anxiety, and depressive symptom severity were measured monthly using validated assessments.

Results

Among eligible participants (n=966), 30.2% (n=292) reported at least 1 traumatic event. Of those with trauma exposure and elevated symptoms of PTS (n=119), 73% (n=87) exhibited elevated anxiety symptoms and 50% (n=59) exhibited elevated depressive symptoms. Compared to children with no trauma, children with elevated PTS symptoms showed smaller reductions per month in anxiety but not depressive symptoms (anxiety: F 2,287=26.11; P <.001). PTS symptoms also decreased significantly throughout care, with 96% (n=79) of participants showing symptom reductions.

Conclusions

This study provides preliminary evidence for the frequency of trauma exposure and comorbid psychiatric symptoms, as well as variations in treatment response between trauma-exposed and nontrauma-exposed youths, among participants in a pediatric collaborative care DMHI. Youths with traumatic experiences may show increased psychiatric comorbidities and slower treatment responses than their peers with no history of trauma. These findings deliver compelling evidence that collaborative care DMHIs may be well-suited to address mental health symptoms in children with a history of trauma while also highlighting the critical need to assess symptoms of PTS in children seeking treatment.