Acceptability of the Predicting Abusive Head Trauma (PredAHT) clinical prediction tool: A qualitative study with child protection professionals

The validated Predicting Abusive Head Trauma (PredAHT) tool estimates the probability of abusive head trauma (AHT) based on combinations of six clinical features: head/neck bruising; apnea; seizures; rib/long-bone fractures; retinal hemorrhages. We aimed to determine the acceptability of PredAHT to child protection professionals. We conducted qualitative semi-structured interviews with 56 participants: clinicians (25), child protection social workers (10), legal practitioners (9, including 4 judges), police officers (8), and pathologists (4), purposively sampled across southwest United Kingdom. Interviews were recorded, transcribed and imported into NVivo for thematic analysis (38% double-coded). We explored participants’ evaluations of PredAHT, their opinions about the optimal way to present the calculated probabilities, and their interpretation of probabilities in the context of suspected AHT. Clinicians, child protection social workers and police thought PredAHT would be beneficial as an objective adjunct to their professional judgment, to give them greater confidence in their decisions. Lawyers and pathologists appreciated its value for prompting multidisciplinary investigations, but were uncertain of its usefulness in court. Perceived disadvantages included: possible over-reliance and false reassurance from a low score. Interpretations regarding which percentages equate to ‘low’, ‘medium’ or ‘high’ likelihood of AHT varied; participants preferred a precise % probability over these general terms. Participants would use PredAHT with provisos: if they received multi-agency training to define accepted risk thresholds for consistent interpretation; with knowledge of its development; if it was accepted by colleagues. PredAHT may therefore increase professionals’ confidence in their decision-making when investigating suspected AHT, but may be of less value in court.     

The lifetime costs of pediatric abusive head trauma and a cost-effectiveness analysis of the Period of Purple crying program in British Columbia,Canada

BackgroundAbusive head trauma (AHT) is a severe form of child abuse causing devastating outcomes for children and families, but its economic costs in Canada has yet to be determined. The Period of PURPLE crying program (PURPLE) is an AHT prevention program implemented in British Columbia for which success in reducing AHT events was recently reported.ObjectiveThis study estimated the lifetime costs to society of incidental AHT events and compared the benefits and associated costs of AHT before and after the implementation of the PURPLE program.Participants and Setting: Children aged 0–24 months old with a definite diagnosis of AHT between 2002 and 2014 in British Columbia were included in this study.MethodsAn incidence-based cost-of-illness analysis, using the human capital approach was used to quantify the lifetime costs of AHT events according to their severity (least severe, severe and fatal). A cost-effectiveness analysis of the PURPLE program was conducted from both a societal and a health services’ perspectives using decision tree models.ResultsThere were sixty-four AHT events between 2002–2014, resulting in a total cost of $354,359,080 to society. The costs associated with fatal, severe and least severe AHT averaged $7,147,548, $6,057,761 and $1,675,099, respectively. The investment of $5 per newborn through the PURPLE program resulted in a $273.52 and $14.49 per child cost avoidance by society and by the healthcare system.ConclusionsThis study provides evidence to policymakers and health practitioners that investing upstream in well-developed AHT prevention programs, such as PURPLE, not only promote child safety and health, but also translates into avoided costs to society.     

Feasibility study of the calm baby gently program: An educational baby book intervention on safe practices related to infant crying

BackgroundAbusive head trauma (AHT) is a preventable form of child abuse.ObjectiveThis project used a mixed method design to assess the feasibility of the Calm Baby Gently educational baby book intervention for promoting safe practices related to infant crying in an effort to prevent AHT.Participants and settingThree pediatric practices participated between June 2016 and January 2018, including 1045 caregivers who attended their infant’s 2-month well-child visit.MethodsPediatric providers gave the educational baby book to caregivers at the 1-month well-child visit. Caregivers completed a survey at the 2-month well-child visit on their use and satisfaction with the book and responses to infant crying. Thematic analysis of qualitative feedback was performed. Responses to infant crying were compared quantitatively between caregivers who had and had not read the book.ResultsOf the 819 caregivers (78%) who received the book, 92% (754) read it, and 51% (421) had another caregiver read it. Caregivers considered the book approachable, understandable, validating, and helpful for improving knowledge and skills related to infant crying. The book was rated more helpful by caregivers of younger age, male gender, and non-white race. Controlling for age, gender, and race, caregivers who read the book were more confident (p = 0.033) and had more knowledge on how to respond appropriately to infant crying (p = 0.019) than caregivers who had not read it.ConclusionsCalm Baby Gently is a feasible and well-received AHT prevention program. Randomized controlled trials are needed to better understand its impact on knowledge, behavior, and AHT rates.     

Epidemiology of abusive head trauma in West Virginia children <24 months: 2000–2010

BackgroundFew states have published statewide epidemiology of abusive head trauma (AHT).ObjectiveTo examine the statewide epidemiology of AHT in West Virginia (WV), with the primary objective of establishing AHT incidence for comparison to national data, and to use as a baseline for comparison to incidence post-implementation of a statewide AHT prevention program.Participants and settingAHT cases in children less than 2 years old were identified from the 3 tertiary pediatric centers in WV.MethodsCases were identified by using ICD-9 codes for initially identifying those with injuries which might be consistent with AHT, followed by medical record review to determine which of these met the criteria for inclusion as a case. Medical examiner data was used to find additional cases of AHT. Using the number of cases identified along with relevant census data, incidence of AHT was calculated.ResultsThere were 120 cases of AHT treated in WV hospitals from 2000 to 2010, 100 of which were WV residents. The incidence was 36.1/100,000 children <1 year of age and was 21.9 cases per 100,000 children <2 years of age. Incidence in infants increased during the latter years (2006–2010) of the study to 51.8/100,000 compared to the incidence during 2000–2005, which was 24.0/100,000 (p < .01).ConclusionsCompared to US national, state and regional figures, the WV incidence of AHT was among the highest. In addition, the incidence of AHT increased significantly over the study period. Possible factors contributing to the rise in incidence are discussed.     

Estimating the probability of abusive head trauma after abuse evaluation

BackgroundEvidence-based, patient-specific estimates of abusive head trauma probability can inform physicians’ decisions to evaluate, confirm, exclude, and/or report suspected child abuse.ObjectiveTo derive a clinical prediction rule for pediatric abusive head trauma that incorporates the (positive or negative) predictive contributions of patients’ completed skeletal surveys and retinal exams.Participants and Setting500 acutely head-injured children under three years of age hospitalized for intensive care at one of 18 sites between 2010 and 2013.MethodsSecondary analysis of an existing, cross-sectional, prospective dataset, including (1) multivariable logistic regression to impute the results of abuse evaluations never ordered or completed, (2) regularized logistic regression to derive a novel clinical prediction rule that incorporates the results of completed abuse evaluations, and (3) application of the new prediction rule to calculate patient-specific estimates of abusive head trauma probability for observed combinations of its predictor variables.ResultsApplying a mean probability threshold of >0.5 to classify patients as abused, the 7-variable clinical prediction rule derived in this study demonstrated sensitivity 0.73 (95% CI: 0.66-0.79) and specificity 0.87 (95% CI: 0.82-0.90). The area under the receiver operating characteristics curve was 0.88 (95% CI: 0.85-0.92). Patient-specific estimates of abusive head trauma probability for 72 observed combinations of its seven predictor variables ranged from 0.04 (95% CI: 0.02-0.08) to 0.98 (95% CI: 0.96-0.99).ConclusionsSeven variables facilitate patient-specific estimation of abusive head trauma probability after abuse evaluation in intensive care settings.     

Disentangling the effect of out-of-home care on child mental health

BackgroundChildren in out-of-home care are consistently found to have poor mental health compared to children in the general population. However, UK research has so far failed to disentangle the impact of the care system on children’s mental health outcomes from the effects of the adverse circumstances that led to their admission to care.ObjectiveThis research investigated the association between care placement and the presence of child mental health problems after controlling for children’s pre-care experiences. It also identified factors associated with mental health problems among children in care.Participants and SettingThe sample comprised three groups of children involved with child welfare services due to maltreatment, including children in out-of-home care (n = 122), reunified children (n = 82) and those who had never been in care (n = 159).MethodsThe mental health of the children in the three groups was compared, using information collected from their parents/foster carers and social workers.ResultsThe odds of a child in out-of-home care having a mental health problem were not significantly higher than those of a child who had never been in care (AOR = 1.24; p = 0.462). However, the odds of a child in out-of-home care having reactive attachment disorder (RAD) were significantly higher than those of a child who had never been in care (AOR=1.92; p = 0.032).ConclusionsThese findings make an important contribution to international debates about whether placing children in care is beneficial or detrimental to their wellbeing, and highlight a range of inter-linking factors associated with the mental health of children in out-of-home care.     

Promoting resilience and wellbeing in children exposed to intimate partner violence: A qualitative study with mothers

BackgroundChildren exposed to intimate partner violence (IPV) are at increased risk of disruptions to their health and development. Few studies have explored mothers’ perceptions of what helps their children cope throughout this experience.ObjectiveThe aim of the study was to explore mothers’ perceptions of their children’s resilience and coping following IPV exposure, and the strategies they have used to support their children and promote resilience.MethodsIn depth semi-structured interviews were conducted with nine women from the Maternal Health Study (MHS), a prospective study of women during pregnancy and following the birth of their first child. All women involved in the qualitative interviews reported experiencing IPV during their involvement in the MHS. Transcribed interviews were analysed using interpretative phenomenological analysis which has a focus on how individuals make meaning of their experience.ResultsWomen discussed parenting strategies such as role modelling, stable and consistent parenting, and talking with their children about healthy relationships to promote their children’s resilience. Mothers also spoke about the ways they tried to reduce their child’s direct exposure to IPV, as well as reflecting on the difficulty of attending to their child emotionally when they were experiencing distress.ConclusionsThis study highlights that there are many strategies used by mothers who experience IPV to promote resilience and wellbeing in their children. Understanding what mothers see as useful for their children is essential in providing appropriate services to families following experiences of family violence.     

Parental alienation,coaching and the best interests of the child: Allegations of child sexual abuse in the Family Court of Australia

BackgroundAllegations of child sexual abuse provide complex challenges to family court systems.ObjectivesDespite being highly criticised in the academic research, this analysis examined whether and how the gendered concepts of parental alienation syndrome or parental alienation more broadly are still being used to rebut allegations of child sexual abuse in family court cases in Australia. Parental Alienation is broadly understood as the deliberate actions of one parent to disrupt and prevent children’s ongoing relationships with their other parent, in this case through allegations of abuse.MethodsWe examined 357 publicly available judgements of the Family Court of Australia between 2010 and 2015. Judgements were analysed qualitatively for key themes using N-VIVO software.ResultsFive themes emerged in the data, including use of the concept of parental alienation, coaching, mothers as manipulative, mothers as mentally ill, and impact of the best interest of the child.ConclusionsResults indicate that judgements made in the Family Court of Australia are both similar and divergent from those made in other jurisdictions internationally. The complexity of responding to allegations of child sexual abuse for parents is discussed.     

Self-reported adverse childhood experiences and quality of life among children in the two last grades of Dutch elementary education

BackgroundAdverse Childhood Experiences (ACEs) may have a life-long impact on mental health and are related to physical disease, such as diabetes and cardiovascular diseases in adulthood. Research on ACEs suffers from recall bias when performed with adults.ObjectiveTo estimate the prevalence of ACEs and the interrelationships between ACEs as reported by children, and to determine the impact on their self-reported quality of life (QoL). Children’s opinions on the ACE-Questionnaire were also obtained.MethodA cross-sectional study was conducted with a child version of the ACE-Questionnaire. This questionnaire assesses parental separation or divorce, physical and emotional child abuse and neglect, sexual violence, domestic violence, household substance abuse, psychological issues or suicide, and incarceration of a household member. QoL was measured with the Kidscreen-10.Participants and settingThe questionnaire was completed by 644 children at a mean age of 11 years (range 9–13 years), in the two last grades of regular elementary schools, recruited throughout the Netherlands.ResultsData were weighted by ethnicity to obtain a representative sample of children in Dutch elementary education. Of all children, 45.3% had one or more out of ten ACEs. Child maltreatment was experienced by 26.4%. ACEs often co-occurred. A higher number of ACEs correlated with a lower mean level of QoL (p < 0.001). Mean QoL was 8.5 points lower (Cohen’s d = 0.8) in children who experienced child maltreatment. Children’s opinions on the questionnaire were positive in 82.4%.ConclusionPrevention of ACEs, professional training and trauma-focus in schools are urgently needed.     

Association between mothers’ problematic Internet use and maternal recognition of child abuse

BackgroundThere are few studies about mothers’ problematic Internet use (PIU). Mothers’ PIU may lead to inadequate parenting and child abuse.ObjectiveThis cross-sectional study aimed to clarify the association between mothers’ PIU and their recognition of child abuse.Participants and settingWe analyzed data collected of health examinations of children aged 4 months, 1.5 years, and 3 years which were carried out in Matsue City, Shimane Prefecture, Japan between April 2016 and March 2017. The number of the subjects were 1685, 1729, 1674, respectively.MethodsWe used logistic regression analysis to clarify the association between mothers’ PIU (Young’s Diagnostic Questionnaire for Internet Addiction score: ≥5) and their recognition of child abuse (selecting < True of me > for < I sometimes think that I am abusing my child > on a questionnaire survey), which was adjusted for covariates such as maternal age, number of children, daytime caretaker, social support, postpartum depression, and current smoking status of the parents.ResultsBased on the multivariate logistic regression analysis, the mothers’ PIU was significantly correlated with their recognition of child abuse for children aged 4 months, 1.5 years, or 3 years [odds ratio (OR): 13.30, 95% confidence interval (CI): 1.26–139.98, OR: 7.02, 95% CI: 1.28–38.55, and OR: 28.06, 2.48–317.93, respectively].ConclusionThis study revealed the possibility that mothers with PIU recognize child abuse more than mothers without PIU. However, further studies should be conducted to increase reliability and validity.     

Associations between childhood deaths and adverse childhood experiences: An audit of data from a child death overview panel

BackgroundDespite strong associations between adverse childhood experiences (ACEs) and poor health, few studies have examined the cumulative impact of ACEs on causes of childhood mortality.MethodsThis study explored if data routinely collected by child death overview panels (CDOPs) could be used to measure ACE exposure and examined associations between ACEs and child death categories. Data covering four years (2012–2016) of cases from a CDOP in North West England were examined.ResultsOf 489 cases, 20% were identified as having ≥4 ACEs. Deaths of children with ≥4 ACEs were 22.26 (5.72–86.59) times more likely (than those with 0 ACEs) to be classified as ‘avoidable and non-natural’ causes (e.g., injury, abuse, suicide; compared with ‘genetic and medical conditions’). Such children were also 3.44 (1.75–6.73) times more likely to have their deaths classified as ‘chronic and acute conditions’.ConclusionsThis study evidences that a history of ACEs can be compiled from CDOP records. Measurements of ACE prevalence in retrospective studies will miss individuals who died in childhood and may underestimate the impacts of ACEs on lifetime health. Strong associations between ACEs and deaths from ‘chronic and acute conditions’ suggest that ACEs may be important factors in child deaths in addition to those classified as ‘avoidable and non-natural’. Results add to an already compelling case for ACE prevention in the general population and families affected by child health problems. Broader use of routinely collected child death records could play an important role in improving multi-agency awareness of ACEs and their negative health and mortality risks as well in the development of ACE informed responses.     

Association of perpetrator relationship to abusive head trauma clinical outcomes

The diagnosis of abusive head trauma (AHT) remains a significant public health problem with limited prevention success. Providing protection from further harm is often challenged by the difficulty in identifying the alleged perpetrator (AP) responsible for this pediatric trauma. The objective of this study was to evaluate demographic and clinical characteristics of children with AHT and the relationship between APs and their victims in a large, multi-site sample. Understanding the AHT risks from various caregivers may help to inform current prevention strategies. A retrospective review of all cases of AHT diagnosed by child protection teams (CPT) from 1/1/04 to 6/30/09 at four children's hospitals was conducted. Clinical characteristics of children with AHT injured by non-parental perpetrators (NPP) were compared to parental perpetrators (PP). There were 459 children with AHT; 313 (68%) had an identified AP. The majority of the 313 children were <1 year of age (76%), Caucasian (63%), male (58%), receiving public assistance (80%), and presented without a history of trauma (62%); mortality was 19%. Overall, APs were: father (53%), parent partner (22%), mother (8%), babysitter (8%), other adult caregiver (5%); NPP accounted for 39% of APs. NPPs were more likely to cause AHT in children ≥1 year (77% vs. 23%, p < 0.001) compared to PP. Independent associations to NPP included: older child, absence of a history of trauma, retinal hemorrhages, and male perpetrator gender. While fathers were the most common AP in AHT victims, there is a significant association for increased risk of AHT by NPPs in the older child, who presents with retinal hemorrhages, in the hands of a male AP. Further enhancement of current prevention strategies to address AHT risks of non-parental adults who provide care to children, especially in the post-infancy age seems warranted.     

Trajectories of traumatic stress reactions in children exposed to intimate partner violence

BackgroundUnderstanding different longitudinal patterns of traumatic stress reactions in children exposed to intimate partner violence (IPV) can promote early identification of at-risk children.ObjectiveOur study aims to explore trajectories of traumatic stress reactions following childhood IPV exposure, and their relation with parental traumatic stress and child emotional security in the interparental subsystem.Participants and SettingThe sample comprised 303 children (age 3–10, M = 6.20) from families referred to institutions for IPV. Data were collected at home.MethodsThree waves of parent-reported questionnaire data were analyzed using latent class growth analysis and linear regression.ResultsFive trajectories were identified: ‘resilient’, ‘moderate stable’, ‘struggling’, ‘improving’, and ‘elevated adjusting’. Only the ‘struggling’ trajectory had dysfunctional symptom levels at the final wave. Higher parental traumatic stress predicted ‘improving’ trajectory membership (β = 0.17, p = .033), whereas lower parental traumatic stress (β = −0.20, p = .003) and child emotional insecurity (β = −0.45, p = < .001) predicted ‘resilient’ trajectory membership. Higher child emotional insecurity predicted membership in trajectories with higher initial traumatic stress (improving: β = 0.26, p < .001; struggling: β = 0.31, p < .001; elevated adjusting: β = 0.27, p < .001). Child emotional security did not buffer the effect of parental traumatic stress on likelihood of dysfunctional trajectory membership (β = 0.04, p =.380).ConclusionsChildren exposed to IPV show different trajectories of traumatic stress reactions, partly corresponding to trajectories identified in other populations. Child emotional security and parental traumatic stress predict trajectory membership.     

Parents’ PTSD symptoms and child abuse potential during the perinatal period: Direct associations and mediation via relationship conflict

BackgroundPosttraumatic stress disorder (PTSD) symptoms are associated with parental aggression towards children, but little is known about the relation between parents’ PTSD symptoms and their risk for perpetrating child physical abuse during the early parenting years, when the potential for prevention of abuse may be highest.ObjectiveTo examine direct associations between mothers’ and fathers’ PTSD symptoms and child abuse potential, as well as indirect effects through couple relationship adjustment (i.e., conflict and love) in a high-risk sample of parents during the perinatal period, most of whom were first-time parents.Participants and settingFrom March 2013 to August 2016, data were collected from 150 expecting or new parental dyads in which the mother was participating in a home visiting program.MethodsData were analyzed using the Actor-Partner Interdependence Mediation Model.ResultsFor mothers and fathers, there were direct associations between PTSD symptom severity and child abuse potential (βs = .51, ps <.001), and this association for fathers was stronger at higher levels of mothers’ PTSD symptoms (β = .15, p = .03). In addition, parents’ own and their partners’ PTSD symptoms were each indirectly associated with parents’ own child abuse potential through parents’ report of interparental conflict (standardized indirect effects = .052–.069, ps = .004) but not love.ConclusionsAddressing parents’ PTSD symptoms and relationship conflict during the perinatal period using both systemic and developmental perspectives may uniquely serve to decrease the risk of child physical abuse and its myriad adverse consequences.     

Mindfulness and trauma symptoms predict child abuse potential in risk-exposed,men and women during pregnancy

BackgroundNearly a third of adults report childhood trauma in their youth and approximately 700,000 cases of child maltreatment were reported in 2016. Both history of childhood trauma and current trauma symptoms in adults are linked to child maltreatment, although many trauma-exposed individuals are warm and nurturing parents. Identifying resiliency factors in adults with risk factors for harsh parenting may illuminate new pathways to sensitive parenting. Mindfulness is reported to improve trauma and mental health symptoms but the relationship between mindfulness, trauma, and child abuse potential is not yet understood.ObjectiveThis cross-sectional study investigated the relationship between mindfulness, childhood trauma experiences, trauma symptoms and child abuse potential.Participants and settingOur participants were 102 expectant parents recruiting from obstetric clinics and agencies Detroit, MI (58.8% African American, 27.5% Caucasian).MethodBivariate correlations were examined using validated, self-report questionnaires. Significant variables were included in a hierarchical linear regression to identify predicting factors that contribute to child abuse potential scores.ResultsSignificant correlations between child abuse potential with current trauma symptoms (r = .53, p < .01) and mindfulness (r = −.32, p < .01) were found, but no link with past childhood trauma experiences and child abuse potential were identified. The model significantly predicts child abuse potential (ΔR² = .10, F(5, 96), = 12.48, p < .001). Trauma symptoms (B = .09, p < .001, 95% confidence interval [CI][−.40, −.07]) and mindfulness nonreactivity (B = −.24, p < .01, 95% CI[.05, .14]) predicted higher potential for child abuse scores.ConclusionFindings suggest increased mindfulness, especially nonreactivity to one’s own thoughts, may be an important factor to protect against child abuse potential. Interventions to increase parental mindfulness may reduce child abuse potential and improve child well-being, but further mechanistic research is needed to determine this.     

Paternal support for child sexual abuse victims: A qualitative study

BackgroundThe current state of knowledge regarding the role of non-offending fathers in supporting their sexually abused children is very scarce.ObjectiveThe objective of this study is to further our understanding of fathers’ roles following disclosure of their children’s sexual abuse (SA) by evaluating fathers’ perceptions of the impact of disclosure on their involvement and support of their children.Participants and methodThis qualitative study relies on individual semi-structured interviews conducted with 17 fathers of allegedly abused children.ResultsInductive thematic analysis first highlighted that some reported a period of disengagement from the child during which they put into question their role and attitudes, followed by a period of re-involvement. This period of difficulties experienced by some fathers in regard to their involvement towards their children was due to either their own important psychological distress, their ambivalence towards their child or even because of feelings of uneasiness experienced during physical contact with them. Despite this, findings indicate the presence of thoughts and attitudes that suggest children are a source of concern for fathers. The four forms of abuse-specific support previously observed among mothers (believing the child, seeking out professional services, protecting him/her from the offender, supporting him/her emotionally) were also observed among fathers. In accordance with the activation theory, a form of support specific to fathers, namely, encouraging the child to open up to and explore the world outside the family, thereby, fostering the child’s self-esteem development, was observed and constitutes a relevant finding.ConclusionClinical and empirical implications are discussed.     

Understanding how social worker compassion fatigue and years of experience shape custodial decisions

BackgroundCompassion fatigue (i.e., a worker’s diminished ability to empathize with clients) is common among “helping workers” and can result in psychological detachment from clients as a coping mechanism.ObjectiveIn the present research, we explored the relationship between social workers’ compassion fatigue and years of job experience on hypothetical child custody case judgments.Participants and settingIn two separate studies, individuals with experience working with children in child dependency court (predominantly social workers, Study 1: N = 173, Study 2: N = 119) were recruited on Amazon’s Mechanical Turk and read a vignette depicting a mother attempting to regain custody.ResultsSupporting hypotheses, compassion fatigue significantly mediated the relationship between increased years of social worker job experience on recommendations that a neglectful mother receive custody, Indirect Effect = .06, CIs [.026, .127] (Study 1). We also found preliminary support for our hypothesized theoretically derived serial path model, in which (a) social worker compassion fatigue predicts anticipated secondary traumatic stress associated with the child neglect case, B = .54, p = .0001; (b) secondary traumatic stress predicts detachment from the neglected child, B = .27, p = .0003; (c) detachment from the child predicts job efficacy cynicism B = .65, p < .0001; and (d) job efficacy cynicism predicts decisions to allocate custody to the neglectful mother, B = .46, p = .005 (Study 2).ConclusionOur research shows that compassion fatigue among social workers may change the lens through which they perceive cases of child abuse.     

Trajectories of child protective services contact among Alaska Native/American Indian and non-Native children

BackgroundContact with child protective services (CPS) functions as an independent marker of child vulnerability. Alaska children are an important population for understanding patterns of CPS contact given high rates of contact overall and among specific demographic groups.ObjectiveWe aimed to identify longitudinal trajectory classes of CPS contact among Alaska Native/American Indian (AN/AI) and non-Native children and examine preconception and prenatal risk factors associated with identified classes.Participants and settingWe used data from the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project, a linkage of 2009–2011 Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) births with administrative data including CPS records.MethodsWe conducted growth mixture modeling to identify trajectory classes of CPS contact from birth to age five years. We used Vermunt’s three-step approach to examine associations with preconception and prenatal risk factors.ResultsAmong AN/AI children, we identified three classes: 1) no/low CPS contact (75.4%); 2) continuous CPS contact (19.6%), and 3) early, decreasing CPS contact (5.0%). Among non-Native children, we identified four classes: 1) no CPS contact (81.3%); 2) low, increasing CPS contact (9.5%); 3) early, rapid decline CPS contact (5.8%); and 4) high, decreasing CPS contact (3.3%). Maternal substance use had the largest impact on probabilities of class membership, increasing the probability of membership in classes characterized by CPS contact, among both AN/AI and non-Native children.ConclusionsResults reveal heterogeneity in longitudinal patterns CPS contact across early childhood among Alaska children and identify maternal substance use as an important target for primary prevention.     

Toward instituting a chaperone policy in outpatient pediatric clinics

ObjectivesWe sought to evaluate child, parent and medical provider preferences for chaperones for outpatient encounters and to evaluate the acceptability and frequency of utilization following institution of a chaperone policy. Secondarily, we sought to understand what medical history and examinations teens consider “sensitive.”DesignWe conducted an observational study 1 month before and 1 month after institution of outpatient clinic chaperone policy. Post clinic questionnaires were used for patients ≥12 years old, parents, and clinicians. A research assistant observed chaperone use.SettingAdolescent Medicine, Urology, and Rehabilitation Clinics at a regional, tertiary-care pediatric hospital, in a major metropolitan area were studied.ParticipantsConvenience sample: 117 clinic patients during control period and 119 after policy implementation.Main outcome measuresPreferences for and satisfaction with chaperone use were documented.ResultsAlthough non-parent chaperones were usually declined (99.6%), offers were appreciated. Non-parent chaperone use increased modestly (5.3–18.1%).Most patients preferred not to have non-parent chaperones. This preference was greater among older patients (88%), than early teens (52%). After experiencing sensitive examinations, more young adolescent patients (89%) wished their parent had been present than older patients (38%). Patients’ opinions about what constitutes “sensitive” questions and examinations and chaperone preferences varied widely. Providers often did not recognize issues patients and parents considered sensitive questioning (21% agreement), but recognized sensitive physical examinations better (74% agreement). Providers felt chaperones had been a detriment to examination and exams would have gone better without one only 1% of the time.ConclusionsAlthough usually declined, offers of chaperones were appreciated and use of non-parent chaperones increased modestly. Offering chaperones for sensitive examinations may remind providers about appropriate, respectful patient encounters. Implications for children's hospitals’ patient safety and satisfaction, and institutional staff protection and costs are significant.Practice implicationsQuestions and examinations which patients consider sensitive vary widely. Asking patients for their preferences for examination chaperones may reassure them about the appropriateness of examinations, remind staff to conduct respectful examinations and protect providers from accusations of impropriety. Since most chaperone offers are declined, the cost of asking is likely to be minimal.