Mental health service use among mothers involved in public family law proceedings: linked data cohort study in South London 2007-2019

PURPOSE

Mental health problems and substance misuse are common among the mothers of children who experience court-mandated placement into care in England, yet there is limited research characterising these health needs to inform evidence-based policy. In this descriptive study, we aimed to generate evidence about the type, severity, and timing of mental health and substance misuse needs among women involved in public family law proceedings concerning child placement into care ('care proceedings').

METHODS

This is a retrospective, matched cohort study using linked family court and mental health service records for 2137 (66%) of the 3226 women involved in care proceedings between 2007 and 2019 in the South London and Maudsley NHS Mental Health Trust (SLaM) catchment area. We compared mental health service use and risk of dying with 17,096 female-matched controls who accessed SLaM between 2007 and 2019, aged 16-55 years, and were not involved in care proceedings.

RESULTS

Most women (79%) were known to SLaM before care proceedings began. Women had higher rates of schizophrenia spectrum disorders (19% vs 11% matched controls), personality disorders (21% vs 11%), and substance misuse (33% vs 12%). They were more likely to have a SLaM inpatient admission (27% vs 14%) or to be sectioned (19% vs 8%). Women had a 2.15 (95% CI 1.68-2.74) times greater hazard of dying, compared to matched controls, adjusted for age.

CONCLUSION

Women involved in care proceedings experience a particularly high burden of severe and complex mental health and substance misuse need. Women's increased risk of mortality following proceedings highlights that interventions responding to maternal mental health and substance misuse within family courts should offer continued, long-term support.

Linking data on women in public family law court proceedings concerning their children to mental health service records in South London

INTRODUCTION

Maternal mental health problems and substance misuse are key risk factors for child neglect or abuse and court-mandated placement into care. Linkage between mental health records and family court data could raise awareness about parent mental health needs and inform approaches to address them.

OBJECTIVES

To evaluate data linkage between administrative family court data and electronic mental health records for a population-based mental health service for 1.3 million people in South London.

METHODS

We deterministically linked administrative family court data for women (n=5463) involved in care proceedings in South London with service user records from the South London and Maudsley NHS Mental Health Trust (SLaM). We restricted the cohort to women involved in proceedings between 2007 and 2019, in local authorities where SLaM solely provides secondary/tertiary mental health services and the Improving Access to Psychological Therapies (IAPT) (n=3226). We analysed the associations between match status and sociodemographic/case characteristics using multivariable logistic regression.

RESULTS

Two-thirds (2317/3226; 66%) of women linked to a SLaM service user record at some point; most (91%) who linked accessed secondary/tertiary mental health services, indicating serious mental illness. Accounting for possible missed matches, we estimated that 70-83% of women accessed SLaM services at some point. Older women at index proceedings (>35yrs OR: 0.69, 95%CI: 0.54-0.88vs <25yrs) and Black women or women from other ethnic groups (Black ethnic groups 0.65, 0.50-0.83; other ethnicity 0.59, 0.43-0.81 vs White ethnic groups) had lower odds of linking. Odds of linking were higher for women with an infant in proceedings (1.42, 1.18-1.71), or with curtailed/terminated parental responsibility (1.44, 1.20-1.73).

CONCLUSION

Our linkage supports growing evidence of a high burden of mental health problems and substance misuse among women whose children enter care in England, compared to the general population. Research using this linkage should inform strategies to address the considerable mental health needs of vulnerable women and their children.

Using Linked Administrative Health and Family Court Data to Evaluate Maternal Mental Health-Related Risk Factors for Repeated Child Removals

IntroductionEvidence suggests that many women whose children enter care via family court proceedings (care proceedings) in England experience mental health and substance misuse problems. Further, an estimated 22% of women will return to court within 5 years for subsequent proceedings, often returning quickly with a new infant and with little time to address underlying health-related problems. With growing pressures on England’s family justice system and the wider children’s social care sector, there is a need to identify opportunities to engage with women in a healthcare setting to reduce the likelihood of (recurrent) care proceedings. Objectives and ApproachWe used linked family court and mental health service data (n = 2843) for mothers who were referred to mental health services and were involved in care proceedings in South London between 2007 and 2019. We (1) describe differences in the frequency, type and timing of mental health and addictions service use between mothers who return to court and those who do not and (2) evaluate risk/protective factors for returning to court. ResultsAfter resolving duplicate matches (n = 2808), 1028 women (36.6%) referred to mental health services over the study period subsequently returned to court. We will describe differences in characteristics of service use and care proceedings between women who return to court and those that do not. We will also explore a range of potential risk/protective factors for returning to court, including maternal age at first child, indicators for failure to engage with services, mental disorder type, substance misuse, and maternal neighbourhood deprivation status. Conclusion / ImplicationsBetter understanding of how women use mental health and addictions services before, during and after proceedings, and identification of key risk/protective factors for returning to court, would inform strategies to reduce recurrent involvement in care proceedings among this population group.

Novel Linkage of Administrative Health and Family Court Data to Examine Mental Health Need Among Women Whose Children Enter Care

IntroductionAn estimated 23% of children in England are exposed to maternal mental health problems, with growing concern around how maternal mental health affects parenting capacity and entries into public care for their children. There is limited evidence on the prevalence of mental health service need among women whose children enter care and on whether these needs are sufficiently met. With England’s family justice system and children’s social care sector increasingly overstretched, there is a need to identify opportunities for an improved response to maternal mental health. Objectives and ApproachWe linked administrative family court data for women (n = 5463) involved in public family court proceedings (care proceedings) across eight London boroughs between 2007 and 2019, with patient records from South London and Maudsley NHS mental health trust (SLaM). Work is ongoing to (1) describe the frequency, type and timing of mental health service use among women who link and (2) compare these findings to general population trends. Results2843 (52%) women linked to a SLaM patient record via deterministic linkage. Matches had better recording of identifiers and were more likely to have returned to court than non-matches (36% vs 26%). The majority of women (75.0%) were referred for treatment before the start of their (first) care proceeding, while 34.8% had a diagnosis recorded in a structured field. To appraise linkage quality, we manually reviewed de-identified clinician notes for 100 randomly selected women who linked; we confirmed ‘true’ match status for 95 women and found no evidence contradicting match status for the remainder. Conclusion / ImplicationsThis novel linkage between mental health and family court data supports growing evidence that women whose children enter care in England have high prevalence of mental health problems. Research using this linkage will help to inform strategies to improve maternal mental health and outcomes for vulnerable women and their children.

Characterizing newborn and older infant entries into care in England between 2006 and 2014

BACKGROUND

The risk of entry to state care during infancy is increasing, both here in England and abroad, with most entering within a week of birth ('newborns'). However, little is known about these infants or of their pathways through care over early childhood.

OBJECTIVE

To characterize infant entries to care in England.

PARTICIPANTS AND SETTING

All children in England who first entered care during infancy, between April 2006 and March 2014 (n = 42,000).

METHODS

We compared sociodemographic and care characteristics for infants entering care over the study period by age at first entry (newborn: <1wks, older infant 1-51wks). Among those who entered before April 2010, we further characterized care over follow-up (i.e. 4 years from first entry) and employed latent class analysis to uncover any common pathways through care.

RESULTS

Almost 40 % of infants first entered care as a newborn. Most infants first entered care under s 20 arrangements (i.e. out-of-court, 60 % of newborns vs 47 % of older infants). Among infants entering before April 2010, most were adopted over follow-up (60 % vs 37 %), though many were restored to parental care (20 % vs 32 %) or exited care to live with extended family (13 % vs 19 %). One in six infants (17.7 %) had particularly unstable care trajectories over early childhood, typified by three or more placements or failed reunification.

CONCLUSIONS

Evidence-based strengthening of pre-birth social work support is needed to improve preventive interventions before birth, to more effectively target infant placement into care. Linkages between child protection records and information on parents are needed to inform preventive strategies.

Data Resource: Children and Family Court Advisory and Support Service (Cafcass) public family law administrative records in England

Introduction

In England, in cases of child maltreatment or neglect, the state can intervene through the family court to remove children from their family home and place them in out-of-home care. The Children and Family Court Advisory and Support Service (Cafcass) collects and maintains administrative records of all public family law cases in England. While these national records are primarily used to monitor and manage the workflow of Cafcass teams across England, researchers have re-purposed this data for analysis to understand the drivers and outcomes of public family law intervention.

Data contents

The administrative dataset is a reflection of the cases Cafcass is involved with and the extent of that involvement. The dataset contains information about the local authority that makes an application to initiate public family law proceedings, the children and families involved, and the duration and details of the case. Between 1 April 2007 and 31 March 2019, Cafcass captured information on approximately 172,100 public family law cases, involving 282,300 children, and 349,600 adults (of which 289,300 are recorded as biological parents). Amongst the information recorded are the relations between adults and children, making it possible for researchers to identify family groups. Additionally, recording practices at Cafcass have improved over time, this has increased the availability of demographic information of all those involved, as well as child's final legal outcome.

Data access

Researchers can apply to the Secure Anonymised Information Linkage databank (SAIL) for access to the Cafcass pseudonymised administrative data extract, where it is refreshed bi-annually.

Keywords

children, out of home care, family relations, family law.

The hemodynamic effects of inhaled nitric oxide and endogenous nitric oxide synthesis blockade in newborn piglets during infusion of heat-killed group B streptococci

OBJECTIVE

To determine the effects of therapy with inhaled nitric oxide (NO) gas and partial or complete blockade of endogenous NO synthesis with N(omega)nitro-L-arginine (L-NA) on the hemodynamic responses to group B streptococci infusion in newborn piglets.

DESIGN

Randomized, acute intervention study.

SETTING

Animal research laboratory.

SUBJECTS

Twenty-five anesthetized piglets younger than 3 days of age divided into five groups.

INTERVENTIONS

Heat-killed group B streptococci (GBS) were infused systemically until a 50% increase in pulmonary artery pressure (PAP) was obtained, and the infusion was continued for another 2 hrs. The five groups were designed as follows: group 1, sepsis control: continuous GBS infusion, with two brief trials (10 mins) of inhaled NO given after the initial development of pulmonary hypertension and again 2 hrs later; group 2, continuous inhaled NO: NO was given at 40 ppm for 2 hrs during GBS infusion; group 3, high-dose L-NA pretreatment: 10 mg/kg L-NA bolus followed by 1 mg/kg/min before, and continuing throughout, GBS infusion; group 4, high-dose L-NA: same dose as in group 3, but given after the start of the GBS infusion with continuous inhaled NO at 40 ppm; and group 5, low-dose L-NA: 3 mg/kg bolus given after start of GBS infusion with continuous inhaled NO at 40 ppm.

MEASUREMENTS AND MAIN RESULTS

The sepsis controls, group 1, had an increase in PAP, which took 15-45 mins to develop, from a mean of 3.4 (SD 0.7) to 5.9 (1.9) kPa (p < .05), at which time the cardiac index had decreased from 169 (28) to 146 (46) mL/kg/min (p < .05). Brief inhaled NO during the early phase decreased PAP to normal. Two hours later, PAP had increased to 6.1 (0.2) kPa and cardiac index had decreased to 88 (31) mL/kg/min. Inhaled NO after 2 hrs decreased PAP to 3.2 (0.5) kPa and increased cardiac index to 106 (44) ml/kg/min (p < .05). Continuous inhaled NO (group 2) ameliorated the deterioration in cardiac index, which at 2 hrs was 140 (30) mL/kg/min (significantly greater than in the sepsis controls) (p < .05). The L-NA-pretreated animals (group 3) had a greater increase in PAP and pulmonary vascular resistance index when GBS infusion was started. PAP increased from 3.0 (0.7) to 7.3 (1.5) kPa within 15 mins, and cardiac index simultaneously decreased to 68 (20) mL/kg/min. Cardiac index subsequently rapidly deteriorated to 48 (21) mL/kg/min, and only one of five animals survived for 2 hrs. Group 4 animals also developed a rapid deterioration in cardiac output, and only two of five survived for 2 hrs. Group 5 animals had results indistinguishable from group 2 animals.

CONCLUSION

Pulmonary hypertension and shock resulting from GBS infusion in newborn piglets are much worse if endogenous NO production is completely inhibited. Continuous inhaled NO with or without low-dose L-NA inhibits the decrease in cardiac output.

Systemic, pulmonary and mesenteric perfusion and oxygenation effects of dopamine and epinephrine

The response of the systemic, pulmonary, hepatic and portal circulations to infusion of dopamine and epinephrine was studied in newborn piglets 1 to 3 d of age. Anesthetized animals were instrumented to measure cardiac index (CI), hepatic arterial flow, and portal venous blood flow. Catheters were inserted for measurement of systemic arterial pressure (SAP), pulmonary arterial pressure (PAP), and for sampling of arterial, portal venous, and mixed venous oxygen saturations and plasma lactate levels. Systemic, pulmonary and mesenteric vascular resistance indices (SVRI, PVRI, MVRI), and systemic and mesenteric oxygen extraction were calculated. Dopamine and epinephrine were infused in doses of 2, 10, 32 microg/kg/min and 0.2, 1.0, 3.2 microg/kg/min respectively, given in random order. Significant increases in SAP, PAP, and CI were demonstrated with 32 microg/kg/min of dopamine and the two higher doses (1.0 and 3.2 microg/kg/min) of epinephrine. There were no significant changes in SVRI and PVRI with dopamine infusions. Epinephrine at 3.2 microg/kg/min significantly elevated SVRI and PVRI. The SAP/PAP ratio was decreased with 32 microg/kg/min of dopamine whereas epinephrine did not affect the ratio. Dopamine had no significant effect on hepatic arterial flow, portal venous flow, or mesenteric vascular resistance. Epinephrine infusion at 3.2 microg/kg/min decreased portal venous blood flow, total hepatic blood flow, and hepatic oxygen delivery with an increase in calculated mesenteric vascular resistance. Systemic and mesenteric oxygen extraction were not affected by dopamine or epinephrine infusions. Plasma lactate levels were significantly elevated with epinephrine infusion 3.2 microg/kg/min. The differential responses of dopamine and epinephrine on pulmonary and mesenteric circulations may be significant in the pathophysiology and management of persistent fetal circulation and necrotizing enterocolitis.

Dopaminergic receptor-mediated effects in the mesenteric vasculature and renal vasculature of the chronically instrumented newborn piglet

OBJECTIVE

To determine the effects of stimulation of vascular dopaminergic receptor subtype 1 (dopamine-1) receptors in the renal and mesenteric vascular beds of a neonatal model.

DESIGN

Prospective, unblinded, dose-response evaluation in an awake animal.

SETTING

University research laboratory.

SUBJECTS

Thirty newborn piglets, obtained and instrumented at 1 to 3 days of age and studied 48 hrs later.

INTERVENTIONS

Animals were chronically instrumented with transit time ultrasound flow probes around the left renal and superior mesenteric arteries. They were then intravenously infused with either dopamine (2 to 32 micrograms/kg/min) or fenoldopam (1 to 100 micrograms/kg/min), which is a selective agonist of the dopamine-1 receptor.

MEASUREMENTS AND MAIN RESULTS

Blood pressure was only significantly increased by the highest infusion rate of dopamine (32 micrograms/kg/min), from a mean of 78 mm Hg at baseline to 87 mm Hg. Mesenteric and renal vascular resistances were unchanged by dopamine at any dose. Dopamine at 32 micrograms/kg/min decreased renal blood flow by 16.6 +/- 19.6 (SD) % and increased renal vascular resistance by 39.6 +/- 41.1% (p < .05). Mesenteric blood flow increased by 15% at 32 micrograms/kg/min (p < .05) but mesenteric vascular resistance was not affected by dopamine. Fenoldopam reduced blood pressure at infusion rates of 5, 10, and 100 micrograms/kg/min. Fenoldopam had no effect on renal vascular resistance at any dose. Fenoldopam reduced mesenteric vascular resistance at 5 micrograms/kg/min and at all higher doses.

CONCLUSIONS

These data demonstrate the absence of dopaminergic receptor-mediated vasodilation in the porcine neonatal renal vascular bed. In the mesenteric artery, dopamine-1 receptor-mediated vasodilation may be obtained. Dopamine itself, probably because of stimulation of other receptors, causes renal artery vasoconstriction and does not increase superior mesenteric artery blood flow.

Open tube thoracoscopy: does it have a role in modern thoracic surgery?

To determine the role of open tube thoracoscopy in the diagnosis and management of thoracic diseases, a retrospective review of 48 patients was conducted. A mediastinoscope was used for open tube thoracoscopy. Eleven patients underwent diagnostic thoracoscopy, and 4 patients had thoracoscopy for cancer staging. All 11 diagnostic procedures yielded a diagnosis, and thoracic malignancies were staged accurately in all patients. Thirty-three patients underwent therapeutic thoracoscopy. Twelve therapeutic thoracoscopies were done for pneumothorax, 9 for loculated parapneumonic effusion or empyema, 4 for malignant effusions, 2 for traumatic hemothorax, 2 for wedge resection of peripheral lung cancers, and 4 for other indications. All but 1 therapeutic procedure were successful. Three patients experienced complications specific to thoracoscopy (empyema 1, prolonged air leak 1, chest tube site leakage 1). There were 5 deaths, but none were related to thoracoscopy. Open tube thoracoscopy is very effective for evacuation of loculated pleural fluid, pus, or blood, and it appears to have advantages over video thoracoscopy in these settings. Although open tube thoracoscopy is satisfactory for other simple pleural procedures and wedge resections of lung are possible, video thoracoscopic techniques are now preferred for these indications.

Cancer mortality in West Virginia

Cancer rates have risen in West Virginia since 1950, especially in men. In the 1980s, the increase was in older citizens and for most cancers. An analysis conducted by Dr. Jack Riggs stated that this increase is not the result of environmental hazards, but because we all have to die and other causes of death are decreasing. However, we are dying at an older age.

Mammography in West Virginia

A questionnaire was sent in 1988 to all sites conducting mammographic studies registered with the radiologic licensing division of the West Virginia State Department of Health Laboratory Services to determine the number of women served and the costs of the procedures. The number of sites, 61, appears excessive in view of the small number of women many of them screened during the course of a year and the high charges. Copies of the report on the questionnaire results were sent to agencies and other groups within the state to urge initiation of a more cost-effective system; however, four years later the number of units had increased substantially, and no coherent plan had been formulated. The report was helpful to members of the state legislature in their decision to mandate insurance coverage for women according to the American Cancer Society guidelines.

Mortality from working in the aluminum reduction industry

Next to oxygen and silicon, aluminum is the most common element on this planet's surface. Studies of potential carcinogenics in aluminum workers have been reported to be equivocal, and consequently can give rise to serious global concern. However, studies have not taken into consideration smoking histories. Also a review of published articles suggests that the conclusions have been unduly conservative, and that criteria for causation have not been met.

Early intervention in low back disability among coal miners in West Virginia: negative findings

A major issue in the field of workers' compensation is cost containment, not only of medical costs, but of extended disability costs as well. For a 9-month period in 1985 to 1986, the West Virginia Workers' Compensation Fund tested an early intervention case management approach begun within 2 weeks after injury and found it not to be cost effective. In a controlled study of 284 reported back injuries among underground coal miners, medical costs increased with the case management intervention, although only to the extent of the added costs of the intervention, and disability costs and time lost from work did not decrease. Permanent partial disability awards, litigation rates, number of hospitalizations, and return to work were similar between both the experimental and control groups. Regression analyses of 25 factors identified factors most highly predictive of disability and medical costs, but in predicting extended disability, although the factors were 100% sensitive, they were only 43.6% specific. The case management approach was insufficient to prevent extended disability or to lower medical costs.

Epidemiology course for medical students focuses on proposal writing

Teaching epidemiology to medical students is often seen as a difficult, if not impossible, task. After experimenting with several other approaches, faculty at the West Virginia University School of Medicine have developed a course centered around the production of a research proposal using National Institutes of Health criteria and format. The course content, while comprehensive, emphasizes the clinical uses of epidemiology. Lectures are combined with self-study and individualized teaching to assist the students as they explore their chosen topic. This problem-solving approach to teaching and learning epidemiology in medical school has proved both effective and more acceptable to students, as evidenced by the quality of their research proposals, National Medical Examination Board Scores, student evaluations, and improved faculty-student interaction.

The preventive medicine physician: a national study

Following the 1980 Graduate Medical Education National Advisory Committee report, postal questionnaires were sent to a random sample of physicians self-designated as preventive medicine specialists primarily in an effort to verify the committee's assumption that preventive medicine is not a clinical specialty. The questionnaires represented each of the preventive medicine subspecialties: general preventive medicine, public health, occupational medicine, and aerospace medicine. After three reminders, 419 out of 942 (44%) responded. Seventy percent of the physicians who responded engage in clinical activities for at least part of their workweek. Preventive medicine is practiced in a wide variety of settings. For the majority of preventive medicine physicians, prevention plays an important role in their practice. They perceive that they practice medicine differently from their colleagues who are not preventive medicine specialists because of their prevention focus. Many of these physicians have made career changes, and some have made many such changes, as board certification in one of the subspecialties does not preclude practice in another subspecialty. The specialty appears to allow considerable flexibility. The preventive medicine physician is prepared to incorporate prevention into clinical practice and seems well equipped to integrate community and individual clinical approaches.

The challenge of helping the handicapped

Disabled persons represent a special problem for health and welfare services, as the services are usually specialized but the patient needs are multiple and need coordination. A brief description is given as to how in Ottawa, Canada, in the mid 1970s, voluntary efforts by health and welfare providers and patients and friends combined to smooth the road for at least some disabled persons.

Significance of retrospective studies

Examples of retrospective studies are presented to demonstrate some facets of such studies, both good and bad, pointing out the need for good controls. Also important are a clear idea of the question to be answered, and careful planning around that answer as the study progresses.

Working-time in general practice. How general practitioners use their time

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