Child abuse treatment and follow-up: Can the pediatrician help improve outcome?

The pediatric role in the management of child abuse and neglect has been largely limited to detecting and reporting cases, with little involvement in long-term treatment and follow-up. A review of published clinical experience indicates that customary protective services' “treatment” strategies are all too often ineffective at preventing reabuse, improving child health and developmental status, and improving family functioning. When foster care is used as a treatment modality, children run the added risk of never returning home, nor being freed for adoption, and they may suffer the emotional harm of repeated foster placements. This situation is likely to worsen, in the light of recent cutbacks in social service programs, at a time of rising reports of maltreatment. The pediatrician is widely recognized as an expert in children's health and development, and he can effectively use his position to influence the management of cases and thereby the outcome, by actively participating in treatment decision making and providing close follow-up in a limited but important way. In order to do this, he must first become acquainted with the effects of maltreatment upon children's health and development and with the general principles and available modalities of treatment. He must be sympathetic and supportive of the difficult role of the protective service worker who must make treatment decisions. His role is to assist the worker by making medical resources available in order to adequately define the child's needs and the capacity of the family to meet those needs. Essential to answering these questions is the availability of a child development clinic and mental health resources. After ensuring that the child and family are thoroughly assessed and the treatment plan tailored to the child's and family's needs, the pediatrician provides continual longitudinal follow-up, monitoring the child's health and developmental status. If the child is placed in foster care, the physician observes the child's adjustment and provides advice and consultative assistance when needed to help foster parents manage health, developmental or behavior problems. Periodically he also meets with the natural family to keep them informed about their children's health and development and to ensure they are making good use of treatment. Finally, he communicates closely with the child protective service worker and participates in interdisciplinary staff meetings to review and evaluate treatment progress in the hopes of shortening the time needed to make decisions regarding placement.     

Toma el Tiempo: The Wisdom of Migrant Families in Consultation

Children of migrant farm working families often live and learn in conditions that conspire against both health and education. At the same time, these children are as capable as any in our nation. Education and health care professionals are frequently in positions to support these capabilities and migrant families can be significant contributors to the success of education and health programs. However, the variables obstructing collaboration with migrant families are numerous and often go unidentified. More invisible are the variables supporting natural and positive inclusion of these families in problem-solving processes. This article reveals both barriers and avenues to connecting with migrant farm working families so their children may gain greater benefits from health and educational services.     

A systems perspective on research and treatment with abused and neglected children

OBJECTIVE: To discuss two systems-level changes in the organization and financing of mental health and child welfare services that will increasingly affect abused and neglected children: the implementation of managed care processes and the incorporation of accountability mechanisms in the management of mental health and child welfare services, particularly the use of systematic outcomes assessments. A central goal of the paper is to identify critical research questions which will help us to understand the impact of these changes on maltreated children. METHOD: These two systems-level changes are described, and ways they may affect maltreated children are addressed. RESULTS: Both managed care and the growing focus on managing services by monitoring outcomes may positively or negatively affect maltreated children. Both of these trends are affecting the mental health and child welfare systems. It is likely that they will affect maltreated children's access to and the quality, cost, and outcomes of mental health and child welfare services. CONCLUSIONS: Systematic research on the impact of these large-scale changes can increase the likelihood that these changes will benefit maltreated children. A number of critical areas are identified for future research.     

The State of Sexual Health Education in U.S. Medicine

Although studies have shown that patients want to receive sexual health services from their physicians, doctors often lack the knowledge and skills to discuss sexual health with their patients. There is little consistency among medical schools and residency programs in the United States regarding comprehensiveness of education on sexual health. Sexuality education in U.S. medical schools and residency programs is reviewed, highlighting schools that go beyond the national requirements for sexuality education. Increasing the amount of sexuality instruction provided for medical education and training, standardizing sexuality education requirements in medical school and residency programs, incorporating different learning models, establishing means of consistently assessing and evaluating sexuality knowledge and skills, and creating national certification standards for the practice of sexual medicine are recommended.     

Outpatient mental health services for children in foster care: a national perspective

OBJECTIVE: To determine factors influencing the use of outpatient mental health services provided by mental health professionals (OMHS) for children in foster care using a national probability sample in the United States. METHOD: As part of the National Survey of Child and Adolescent Well-being, detailed survey data were collected on 462 children, ages 2-15, who had been in out-of-home care for approximately 12 months at the time of sampling. A multivariate logistic regression model was used to determine how clinical need, as measured by a Total Problem, Externalizing, or Internalizing Scale T-score of 64 or greater on the Achenbach Child Behavior Checklist (CBCL), and non-clinical factors affected OSMHS use. RESULTS: Over half of the children in the sample received at least one OMHS. Need, older age, and history of sexual abuse history all positively predicted OMHS. A history of physical neglect negatively predicted OSMHS. African-Americans used fewer services than children of Caucasian ancestry at all values on the CBCL. This finding was particularly salient at lower levels of CBCL scores; at higher levels, the discrepancy in the use of services diminished but the proportion of children receiving services remained lower for African-American children. CONCLUSIONS: This national study confirms previous findings regarding the use of mental health services based on regional data. Limitations in the use of services imposed by non-clinical factors, specifically, age, race/ethnicity and type of abuse, need to be examined in order to address implicit and explicit policies and practices that may result in inequitable distribution of services.     

The role of educators of the deaf in the early identification of hearing loss

About 16,000 babies each year will be identified with hearing loss by age 3 months once universal newborn hearing screening becomes a reality. Identification of hearing loss in infancy, followed by appropriate intervention by age 6 months, can result in normal language development, regardless of degree of hearing loss. As the average age of identification of hearing loss moves downward toward 2 months, children with hearing loss will enter the educational system earlier and with language skills commensurate with those of their hearing peers. In order to provide appropriate services to children with hearing loss and their families, early interventionists will need to forge links to health care providers involved in universal newborn hearing screening programs, to have specialized training in deafness and hearing loss, and to have expertise in providing services to very young children and to children with hearing loss in the broad range from mild to profound.     

The Reform Religious Schools of New York City; A Decade of Progress — 1940–1950

The focus of my remarks will be narrow: Title V of S.1141, the “AMERICA 2000 Excellence in Education Act.” This section of the bill, entitled “Parental Choice of Schools,” authorizes the appropriation of federal grants for local educational agencies that implement educational choice programs; assures that Chapter I remedial educational services will be available for children participating in educational choice programs; and provides special grants for educational choice programs of national significance. A key aspect of these provisions—and one of its most controversial — is the requirement that an “educational choice program” must include both public and nonpublic educational options. Thus, for example, section 523(b) defines “educational choice program” as:

a program adopted by a State or by a local educational agency under which

(1) parents select the school, including private schools, in which their children will be enrolled; and

(2) sufficient financial support is provided to enable a significant number or percentage of parents to enroll their children in a variety of schools and educational programs, including private schools.     

Integration and Segregation in Mainstreaming Programs for Children and Adolescents with Hearing Impairments

This article describes an investigation of 26 mainstreaming programs for students with hearing impairments from pre‐kindergarten through high school. The purpose of the study was to examine selection criteria, quality and quantity of mainstreaming time, and available support services. Students were found to be mainstreamed according to a number of criteria reported in the literature such as academic performance, hearing loss, and interpersonal skills, but also were affected by the willingness of regular education teachers to accept them into their classrooms. Academic mainstreaming was infrequent, and classroom observations showed that children with hearing impairments often appeared to be not well integrated into classroom activities. Programs varied considerably on all variables examined, including support services; in particular sign language interpreting was offered in some programs, available to a limited extent in others, but in many cases not at all. Clearer definitions of mainstreaming are a necessity and regular education teachers need to be informed of the special requirements of children with hearing impairments.     

Disqualifying Specified Students from the Campus Psychological Service

Abstract

Inasmuch as college mental health programs are ordinarily mandated and designed to provide a wide range of services, modalities of treatment, and a competent professional staff determined to assist students in various states of crisis, there is usually little thought or attention given to denying services to particular students. Nevertheless, most college mental health programs are, from time to time, beset by students who attempt to utilize their services in a manner that is highly inappropriate, sometimes quite disruptive, and, in extreme cases, even dangerous. This article will provide certain guidelines and criteria that may be used, when and if necessary, for disqualifying such students from utilizing the campus psychological service.     

Providing medical evaluations for possible child maltreatment to children with special health care needs

OBJECTIVE: Children with special health care needs are known to be at increased risk of all forms of child maltreatment when compared to children without such needs. We describe a health care team's experience providing medical evaluations for suspected child maltreatment to children with special health care needs. METHOD: Consecutive cases seen as outpatients in the Abuse Referral Clinic for Children with Disabilities were abstracted and analyzed. Mail and telephone follow-up contact was attempted after the medical evaluation to determine adherence with treatment recommendations. A subsample of cases for which complete financial information was available was reviewed to determine a reimbursement rate. RESULTS: During the study, 49 children received complete outpatient evaluations. Ages ranged from 3 to 16 years old, and 54% were males. Special needs spanned a wide range of physical, developmental/cognitive and behavioral conditions. The largest number of referrals came from child protective services (42%) followed by referrals from physicians (27%). After the team's comprehensive evaluation, 18% of the children were found to have a history or physical examination that was diagnostic for child maltreatment, 13% were thought to be at high risk, 25% were thought to be at low risk and 44% were thought to have non-abusive etiologies. The collection rate was 14% for an average reimbursement of $38 per case. Only 29 caregivers could be found at follow-up and 22 remembered the recommendations made by the team. Of the 25 cases that were referred for outpatient mental health counseling, 12 (48%) complied. CONCLUSION: Children with a wide range of special health care needs were evaluated in an outpatient special health care needs clinic that offered comprehensive medical evaluations for possible child maltreatment. Medical evaluation services for this group of children were poorly reimbursed. Mental health services were frequently recommended but often not accessed. Child maltreatment teams seeking to serve children with special health care needs will need to plan for service delivery to a potentially diverse group of children and families who may experience difficulty in carrying through on the team's treatment recommendations.     

Funding realities: child abuse diagnostic evaluations in the health care setting.

OBJECTIVE: This study examines staffing, funding sources, reimbursement, and financing of medically-oriented child protection teams. METHOD: A 16-item questionnaire on the composition, size, and services of the team, program costs, revenue sources, reimbursement rates, and perceptions of funding stability was mailed to a sample of 118 medically-oriented child protection teams. RESULTS: After excluding 10 programs, an overall response rate of 68% was obtained. Teams varied in configuration, services, charges, and funding. Over 50% identified funding as being important, yet, demonstrated varying levels of awareness of budget and reimbursement issues. Many generally relied on patient care reimbursement from health care and government payers. Some programs seemed to be doing well financially while others were struggling. Approximately one-third of the respondents indicated that funding was unstable. CONCLUSIONS: Many programs are innovatively knitting together patch-works of funding and support to serve children and families in need. Team leaders should increase their knowledge of fiscal issues in order to be effective advocates at the institutional level for continued team support. A potential way of accomplishing this would be to utilize the existing structure of a national professional association and its national meeting to provide a forum for relatively successful programs to showcase their "ideal models" of team financing.     

Therapeutic Classes: The Israeli Concept of Resource Programs

The effectiveness of resource programs is of critical importance for the mainstreaming of handicapped children. Efficacy studies have demonstrated the value of such programs in increasing academic achievement. The Israeli resource room (therapeutic class) defines the teacher's role as providing varied support services, promoting both mental health and academic achievement. The aim of the present study was to specify significant variables in the efficacy of the Israeli therapeutic class. Children improved in academic and behavioral areas; age, sex or causes of referral were not significantly associated with levels of improvement. The effect of the program on hyperactive children was limited. Levels of cooperation with the regular teacher, however, did differentiate significantly between improvement levels, endorsing the role of the regular teacher as an agent of change and promoter of goodwill for handicapped children attending regular classes.     

Using Qualitative Evaluation Methods to Identify Exemplary Practices in Early Childhood Education

The proliferation of early childhood programs for children with and without disabilities has occurred without clear indicators or standards of program quality. Evaluations of these programs often consist of compliance monitoring or outcome assessment. Little attention is given to program context or the quality of individual components of the program. In this paper, an alternative evaluation model, a connoisseurship or professional review model using on-site observations, interviews, and document review, was used to identify exemplary practices in early childhood education in one large midwestern state. The results indicated that with proper training and support, early childhood professionals without experience in qualitative methods can become proficient in interviewing techniques, observation, and document review. The resulting case study reports were useful for identifying and describing exemplary practices across the state, demonstrating the potential for this alternative approach to evaluation in early childhood education.     

Using Qualitative Evaluation Methods to Identify Exemplary Practices in Early Childhood Education

The proliferation of early childhood programs for children with and without disabilities has occurred without clear indicators or standards of program quality. Evaluations of these programs often consist of compliance monitoring or outcome assessment. Little attention is given to program context or the quality of individual components of the program. In this paper, an alternative evaluation model, a connoisseurship or professional review model using on-site observations, interviews, and document review, was used to identify exemplary practices in early childhood education in one large midwestern state. The results indicated that with proper training and support, early childhood professionals without experience in qualitative methods can become proficient in interviewing techniques, observation, and document review. The resulting case study reports were useful for identifying and describing exemplary practices across the state, demonstrating the potential for this alternative approach to evaluation in early childhood education.     

Speech and language therapy provision for children using augmentative and alternative communication systems

A proportion of children with physical impairments experience significant difficulties in communicating with others and may be recommended augmentative and alternative communication (AAC) systems such as speech synthesizers and symbol charts to support ‘natural’ communication skills. However, AAC systems are often under-utilized. Parents have identified barriers to AAC system use to include the organization of speech and language therapy. Speech and language therapists are developing services to school-aged children in response to changes in education, health reforms and models of speech and language development. However, there is little evidence for commissioners of children's services about what constitutes ‘enough’ or ‘good’ speech and language therapy. This paper examines speech and language therapy provision to 23 children using AAC systems in six London authorities. Research strategies include documenting the amount, type, organization and objectives of provision. Evidence for collaboration between school staff and therapists is explored, analysis is made of child characteristics associated with provision and criteria for decision-making documented through interviews with therapists. However, little conjunction exists between what therapists said guided their decision-making concerning provision and observed provision. For the children surveyed in this study it seems that that provision in amount of therapy is related to educational placement rather than individual needs.     

The impact of English language learner status on screening for emotional and behavioral disorders: A differential item functioning (DIF) study

There have been significant changes in the racial/ethnic and linguistic background of students attending public schools in the United States. The number of public‐school students who are English language learners (ELLs) participating in programs of language assistance has more than doubled over the past two decades. In 1993–1994, 5.1% of public‐school students in the United States were ELLs, or an estimated 2.1 million students. As of 2014–2015, 9.4% of students were ELLs, or an estimated 4.6 million students. It is estimated that by 2030, upward of 40% of school children will speak English as a second language. Meeting the needs of students who are not proficient in English is challenging for school professionals and even more so if they are identified for special services. Researchers have found that ELL students live in situations with numerous high‐risk factors, including poverty, inadequate schools, poor and violent neighborhoods, and limited access to adequate health care, mental health services, and schools. As a group, these students are more likely to underperform academically, have a lower grade point average, and drop out of school compared to non‐ELL Latino students.     

Long-term follow-up of children conceived through assisted reproductive technology

Children conceived via assisted reproductive technologies (ART) are nowadays a substantial proportion of the population. It is important to follow up these children and evaluate whether they have elevated health risks compared to naturally conceived (NC) children. In recent years there has been a lot of work in this field. This review will summarize what is known about the health of ART-conceived children, encompassing neonatal outcomes, birth defects, growth and gonadal developments, physical health, neurological and neurodevelopmental outcomes, psychosocial developments, risk for cancer, and epigenetic abnormalities. Most of the children conceived after ART are normal. However, there is increasing evidence that ART-conceived children are at higher risk of poor perinatal outcome, birth defects, and epigenetic disorders, and the mechanism(s) leading to these changes have not been elucidated. Continuous follow-up of children after ART is of great importance as they progress through adolescence into adulthood, and new ART techniques are constantly being introduced.     

Identification of Effective Strategies to Promote Language in Deaf Children With Cochlear Implants

Parental involvement and communication are essential for language development in young children. However, hearing parents of deaf children face challenges in providing language input to their children. This study utilized the largest national sample of deaf children receiving cochlear implants, with the aim of identifying effective facilitative language techniques. Ninety‐three deaf children (≤ 2 years) were assessed at 6 implant centers prior to and for 3 years following implantation. All parent–child interactions were videotaped, transcribed, and coded at each assessment. Analyses using bivariate latent difference score modeling indicated that higher versus lower level strategies predicted growth in expressive language and word types predicted growth in receptive language over time. These effective, higher level strategies could be used in early intervention programs.     

A Cross-Cultural Comparison of Services for Young Children with Disabilities Using the ACEI Global Guidelines Assessment (GGA)

Because young children with special needs frequently experience unequal access to quality education worldwide, understanding characteristics of services currently provided to them is critical to identifying practices that work as well as gaps in services and the reasons behind these trends. Two studies were conducted using the ACEI Global Guidelines Assessment (GGA) to investigate the access to and quality of special education services in early childhood care and education (ECCE) programs across eight countries in the Americas and Asia. Study I included 138 participants in 69 programs across five Latin American countries and Study II included 336 participants in 168 programs across four countries and six sites. Results from both studies indicate that ECCE programs strive to provide equal access to young children regardless of ethnicity, religion, language, gender, and socio-economic status. However, insufficient resources and policies were cited as a barrier to services for children with disabilities. This situation was especially true in rural communities. Therefore, national policies are needed to improve the quality of service and to make funds consistently available for services for young children with special needs. This finding is congruent with international reports.