Care taker blogs in caregiver fabricated illness in a child: A window on the caretaker's thinking?

Three recently diagnosed cases of caregiver-fabricated illness in a child at Seattle Children's Hospital shed light on a new manifestation of their caretakers’ attention seeking. The patients’ mothers were actively blogging about their children's reputed illnesses. Although it is not uncommon for parents of chronically ill children to blog about their child's medical course, specific themes in these blogs of parents suspected of medically abusing their children were noted. In particular, gross distortions of the information parents had received from medical providers were presented online, describing an escalation of the severity of their children's illnesses. The mothers reported contacting palliative care teams and Wish organizations, independently from their medical providers’ recommendations. They sought on-line donations for their children's health needs. We believe these blogs provide additional direct evidence of the suspected caregivers’ fabrications. Although we have not performed formal content analysis, blogs might also provide insight into the caretakers’ motivations. Protective Services and/or police investigators could consider querying the internet for blogs related to children at risk for caregiver-fabricated illness in a child. These blogs, if viewed in parallel with the children's medical records, could assist medical diagnosis and legal documentation of medical fabrication and assist in protective planning for the affected children.     

Understanding preservice teachers’ perceived preparedness to work with chronically ill young children

Many young children in the United States are faced with chronic illnesses that cause them unique challenges. It is imperative that all members of children’s support systems feel prepared to help meet those challenges. One integral component of this support team for children are their teachers. The purpose of this study was to assess preservice early childhood teachers’ perceived preparedness to work with chronically ill children. Additionally, the study explored preservice teachers’ ideas about the resources needed to effectively work with chronically ill children. Data were gathered from 32 preservice teachers pursuing a degree and licensure in Birth through Kindergarten (BK) education within a southeastern state university. A survey encompassing closed and open-ended questions related to perceived preparedness was utilized for the study. Results indicated that preservice BK teachers do not feel highly prepared to care for children who are chronically ill in their classroom. Preservice BK teachers suggested that additional classes, seminars, and experiences with chronically ill children would improve their feelings of preparedness. Implications regarding teacher education are discussed.     

The viability of pediatric hospices: a case study

This paper identifies the special characteristics needed by hospices caring for terminally ill children. It is based on a feasibility study conducted in 1979 for a pediatric hospital in New York City. From the analysis of statistical data and confidential interviews with health care professionals in the hospital and in the community, the study concludes that the needs of terminally ill children and their families are not being met currently and that the hospice is as appropriate for children as for adults. Three major differences in emphasis are noted, however. First, support of the family suffering the death of a child is of prime importance, because the grief is devastating and long lasting and because the number of family members affected is usually large. Second, the hospice emphasis on home care is even more imperative for children than for adults as it more significantly benefits both child and family; home care can be facilitated through supplementary care components such as day care. Third, there is a major need for both professional and public education in caring for terminally ill children and their families and in coping with childhood death. The author concludes that further research is needed in all aspects of pediatric terminal care.     

Child welfare services involvement among the children of young parents in foster care

Despite the high rate of early parenthood among youth in foster care as well as the increased risk of child maltreatment among children whose adolescent parents have been neglected or abused, very little is known about child welfare services involvement among children whose parents were in foster care when they were born. This study uses administrative data from the Illinois Department of Children and Family Services (DCFS) to examine the occurrence of child abuse and neglect investigations, indicated reports and out of home care placements among the children of youth in foster. Thirty-nine percent of the children were the subject of at least one CPS investigation, 17 percent had at least one indicated report and 11 percent were placed in out of home care at least once before their 5th birthday. Cox proportional hazard models are also estimated to identify characteristics of parenting foster youth and their placement histories associated with the risk of child welfare services involvement. Implications of the findings for policy and practice are discussed.     

Differential Treatment of Siblings: Interview and Diary Analyses Comparing Two Family Contexts

We assessed parental differential treatment of siblings (maternal time, affection, discipline) in normal and high-risk families. Differential treatment was measured using home interviews, nightly phone ratings, and daily diaries tracking how mothers spent their time. Subjects were 40 mothers of toddlers (average age 2 years) and preschoolers (average age 4 1/2 years): half were caring for a younger child with a chronic illness (i.e., cystic fibrosis), and half were caring for two healthy children. Little evidence of parental differential treatment was found in the home or phone interview data. However, on the diary variables, both quantitative and qualitative differences in parental treatment were found in cystic fibrosis (CF) versus comparison families. Specifically, mothers spent more individual time with younger, chronically ill children in play and mealtime activities than with their older, healthy siblings. Further, mothers in the CF group rated time spent with older children as significantly more negative than time spent with younger children. Convergence between measures of differential treatment and advantages of using a high-risk comparison approach are discussed.     

Minor Illnesses,Temperament, and Toddler Social Functioning

Research Findings: Minor illnesses, such as upper respiratory infections, stomachaches, and fevers, have been associated with children's decreased activity and increased irritability. This multi-method investigation of 110 day care–attending children examined whether experience with recurrent, minor illnesses and negative emotionality worked together to predict young children's social functioning. Minor illness experience was assessed via weekly health screenings conducted by nurses. Toddlers' negative emotionality and social behavior were assessed using mothers' and fathers' reports. The two dimensions of negative emotionality and minor illness experience operated in different ways to predict children's functioning. Toddlers rated as more temperamentally angry displayed less social competence, especially when they also experienced high proportions of minor illness. Temperamentally fearful children exhibited more externalizing problems when they experienced a higher frequency of illness, whereas fearfulness was not associated with externalizing problems for children who were not frequently ill. Practice or Policy: Children's frequent experience with minor illnesses combined with negative emotionality appears to place toddlers at a heightened risk for exhibiting behavior problems. These findings have implications for child and family well-being as well as interactions with child care providers and peers within child care settings. Interventions could be developed to target “at risk” children.     

Adolescents at risk for mistreating their children. Part II: A home- and clinic-based prevention program

OBJECTIVE: To determine if adding an intensive home visitation component to a comprehensive adolescent-oriented maternity program prevents child abuse and neglect. METHODS: We studied 171 participants in a comprehensive, adolescent-oriented maternity program who were deemed to be at high risk for child abuse and neglect. Half were randomly assigned to receive in-home parenting instruction. Major disruptions of primary care-giving by the adolescent mother were classified hierarchically as abuse, neglect, and abandonment. RESULTS: Compliance with home visits varied in relation to the support the teenage mothers received from their families and the fathers of their babies (p < .0001). There were no significant treatment group differences in the pattern of health care utilization, the rate of postpartum school return, repeat pregnancies, or child abuse and neglect. The incidence of maltreatment rose in tandem with the predicted risk status of the mother. Ultimately, 19% of the children were removed from their mother's custody. CONCLUSIONS: Prediction efforts were effective in identifying at-risk infants, but this intensive home- and clinic-based intervention did not alter the incidence of child maltreatment or maternal life course development. A parenting program that was more inclusive of the support network might be more popular with teenagers and therefore more effective. Our findings also emphasize the importance of including counseling specifically designed to prevent teenagers from abandoning their children.     

Bruising and hemophilia: accident or child abuse?

Recognition and prompt reporting of suspect child abuse or neglect is necessary to institute programs aimed at preventing further neglect, re-injury or possible death. The families of children with chronic medical conditions, such as hemophilia, may be affected by economic and emotional stresses which may be expressed as abuse or neglect. Because the manifestations of even slight trauma are so common in children with bleeding problems, the physician may not routinely inquire about the cause of injury, delays in seeking medical attention, or accident prevention efforts in the home. Early referral of children with hemophilia to a multidisciplinary team providing medical, psychological, and social care is recommended.     

Early Full-Time Day Care,Mother–Child Attachment,and Quality of the Home Environment in Chile: Preliminary Findings

Research Findings: Two longitudinal studies are reported examining the effects of full-time day care in Mapuche and non-Mapuche families in Chile. First, the Magellan-Leiden Childcare Study (MLCS) used a sample of 95 mothers with children younger than 1 year old (n = 36 in day care). Second, we partially cross-validated our results in a large and representative sample of 10,723 mothers and their children from the Chilean Encuesta Longitudinal de la Primera Infancia (Early Childhood Longitudinal Survey). In both studies, the quality of care for children provided at home was measured with the Home Observation for Measurement of the Environment. In the MLCS study, additional indicators of the mother–child relationship were measured. Day care was not negatively associated with the mother–child relationship and maternal sensitivity, compared to maternal care, or with the quality of the home environment. Positive changes in attachment security were found in Mapuche children who attended day care centers. Practice or Policy: We were able to confirm that type of care was not differentially associated with quality of the home environment.     

The profile and progress of neglected and abused children in long-term foster care

ObjectivesThis study compared the profile of neglected and abused children in the Australian foster care system as well as differences between maltreatment types in relation to parental contact, reunification and psychosocial progress in care.MethodThe case files of 235 children entering foster care were examined and their social workers were administered standardised questionnaires at the point of intake. All measures were repeated for those remaining in care 1 year and then again 2 years later.ResultsNeglected children were younger than non-neglected children, more likely to have a physical or mental disability, more likely to experience multiple forms of maltreatment and less likely to pose conduct problems for carers. Neglected children were more likely than non-neglected children to experience a decline in parental contact over time, and were less likely to be reunified with their families of origin. There was minimal difference between neglected and non-neglected in their psychosocial progress while in care. Aboriginal children were more likely to be reunified than non-Aboriginal children when neglect was attributable to transient factors (parental incapacity) but the reverse was true for non-neglected children.ConclusionsThe fact that neglected children more often require a second form of maltreatment before being removed from home suggests that children's services workers are less inclined to remove children for neglect than for other forms of maltreatment. As a consequence, those neglected children who are in care tend to come from more dysfunctional families than non-neglected children do, as evidenced by the relatively poorer parental contact and reunification results of neglected children.Practice implicationsNeglected children differ systematically from non-neglected children and suffer relative disadvantage in relation to multiple forms of maltreatment, parental contact, and reunification. The fact that declines in parental contact among neglected children in care occurred only when indirect contact was provided suggests that, wherever possible, care plans should include face-to-face visits and overnight stays rather than being restricted to less direct forms of contact. The difference in the success of reunification according to type of neglect (chronic or transient) also suggests that parental intervention programs need to focus their efforts on chronic factors rather than transient parental factors.     

The effect of Alaska's home visitation program for high-risk families on trends in abuse and neglect

OBJECTIVES: At 6 sites serving 21 communities, Alaska implemented Healthy Families Alaska, a home visitation program using paraprofessionals designed to decrease child abuse and neglect. The primary study objective was to compare changes over time in Child Protective Services outcomes by Healthy Families Alaska enrollment status. METHODS: Enrollment status was linked to birth certificates for birth years 1996-2002 which in turn was linked to the Alaska Child Protective Services database for outcome years 1996-2004. All children were followed through the study databases until age 2 years. RESULTS: There were 40,099 children born during 1996-2002 to residents of Healthy Families Alaska communities and 985 were enrolled in the program. Physical abuse referrals among enrolled children decreased from 73 to 42 per 1000 child-years of follow-up from 1996-1998 to 2000-2002 (p=.005); all of this decrease occurred among children who received 20 or more home visitations. This decrease may have been unrelated to program impact as a similar decrease in referral was seen among unenrolled high-risk children. Compared to unenrolled high-risk children, enrolled children had a modest decrease in the proportion with substantiated neglect but no difference in the proportion with neglect referral or physical abuse referral or substantiation. CONCLUSIONS: Little evidence exists that Alaska's home visitation program had a measurable impact on child maltreatment outcomes. PRACTICE IMPLICATIONS: Within Alaskan communities that had a home visitation program targeting families at high risk for child abuse, changes in Child Protective Services outcomes among children less than 2 years of age were followed over time by program enrollment status. Enrollment was associated with a substantial decrease in physical abuse referrals, but a similar decrease was seen among unenrolled high-risk children. No improvement was seen in physical abuse substantiation. A greater number of home visitations was not associated with fewer abuse outcomes. This work supports most of the recent literature, which questions the field effectiveness of home visitation programs. In combination with other studies, the current work may lead decision-makers and funding agencies to re-examine the usefulness of home visitation programs, particularly those using a methodology similar to that implemented in Alaska.     

Environmental and individual attributes associated with child maltreatment resulting in hospitalization or death

Maltreatment continues to be a leading cause of death for young children. Researchers are beginning to uncover which neighborhood attributes may be associated with maltreatment outcomes. However, few studies have been able to explore these influences while controlling for individual family attributes, and none have been able to parse out the most severe outcomes—injuries resulting in hospitalization or death. This study utilizes a retrospective, case-control design on a dataset containing both individual and environmental level attributes of children who have been hospitalized or died due to maltreatment to explore the relative influence of attributes inside and outside the household walls. Binary conditional logistic regression was used to model the outcome as a function of the individual and environmental level predictors. Separate analyses also separated the outcome by manner of maltreatment: abuse or neglect. Finally, a sub-analysis included protective predictors representing access to supportive resources. Findings indicate that neighborhood attributes were similar for both cases and controls, except in the neglect only model, wherein impoverishment was associated with higher odds of serious maltreatment. Dense housing increased risk in all models except the neglect only model. In a sub-analysis, distance to Family Resource Centers was inversely related to serious maltreatment. In all models, variables representing more extreme intervention and/or removal of the victim and/or perpetrator from the home (foster care or criminal court involvement) were negatively associated with the risk of becoming a case. Medi-Cal insurance eligibility of a child was also negatively associated with becoming a case. Government interventions may be playing a critical role in child protection. More research is needed to ascertain how these interventions assert their influence.     

Hospital‐to‐school transition for children with chronic illness: Meeting the new challenges of an evolving health care system

Chronic illness is common and has a profound impact on the education of affected children. A variety of approaches and programs to facilitate the transition from hospital to school for children with chronic health problems has been described in the literature. Traditional transition plans may no longer be effective because medical service delivery has changed to reduce long‐term hospital stays while increasing outpatient care. As a result, comprehensive hospital‐to‐school transitions increasingly emphasize home and family involvement that includes homebound instruction strategies, flexible school days, using differentiated instructional strategies, increasing child autonomy, and addressing affective issues. This article describes the needs of children with chronic illness, identifies educational programming consistent with the current health care system, and describes current hospital‐to‐school transition plans that integrate systemic needs of schools and health care systems with the needs of children with chronic illness. © 2007 Wiley Periodicals, Inc.     

Do early care and education services improve language development for maltreated children? Evidence from a national child welfare sample

Young children under 6 years old are over-represented in the U.S. child welfare system (CWS). Due to their exposure to early deprivation and trauma, they are also highly vulnerable to developmental problems, including language delays. High quality early care and education (ECE) programs (e.g. preschool, Head Start) can improve children's development and so policymakers have begun calling for increased enrollment of CWS-supervised children in these programs. However, it is not a given that ECE will benefit all children who experience maltreatment. Some types of maltreatment may result in trauma-related learning and behavior challenges or developmental deficits that cause children to respond to ECE settings differently. The current study uses data from a nationally representative survey of children in the U.S. child welfare system, the National Survey of Child and Adolescent Well-Being II, to assess whether young CWS-supervised children (N = 1,652) who were enrolled in ECE had better language development outcomes 18 months later than those not enrolled in ECE. We also explore whether the type of maltreatment that brought children to the CWS’ attention moderates the relationship between ECE and children's language development. After controlling for children's initial scores on the Preschool Language Scale (PLS-3), type(s) of maltreatment experienced, and child and caregiver demographics, we found that ECE participation predicted better PLS-3 scores at follow-up, with a positive interaction between ECE participation and supervisory neglect. ECE seems to be beneficial for CWS-involved children's early language development, especially for children referred to the CWS because they lack appropriate parent supervision at home.     

Chronic Illness and Preterm Infants: Family Stress and Support Issues

As the survival rate for children with complex medical conditions has increased, the body of knowledge regarding childhood chronic illness has grown. While the initial focus of this literature was the effect of the illness on the child, recent studies have focused on chronic illness and broader family issues. The transactional and family systems perspectives suggest the need for longitudinal studies of chronically ill infants from the point of diagnosis. Although a few studies of relatively healthy preterm infants have documented family stress levels, there is a paucity of research on the effects of parenting a very low birthweight infant with complex medical needs. The Chronically Ill Infant Intervention (CIII) Project and its broad based interdisciplinary intervention is used to illustrate the changing needs of this population. Preliminary analyses of specific intervention needs during the infants' first 18 months are discussed in relation to the reduction of family stress.     

The handicapped child and child abuse

For a group of children with handicaps, growth and development are also affected by abuse or neglect. Our understanding of the problems of the abused, handicapped child emerges from experience with 37 children with cerebral palsy who have been maltreated, coupled with a review of the literature in related areas. We identify the following four problems as crucial to the study of abuse and neglect to the child with handicaps: (1) abuse that causes handicaps, (2) abuse that occurs to the handicapped child, (3) compromises in care that can occur when the handicapped child becomes involved with the medical and legal systems, and (4) arrangements for foster care or other out-of-home placement for the child with handicaps. We conclude that the very systems designed to protect and care for the child often fail, leaving the handicapped child without opportunity to reach developmental potential. In light of our observations, we recommend that the pediatrician not only be aware of the existence of abuse and neglect in the population of handicapped children, but also serve in the dual role of coordinator of services and advocate for these children.     

Chronic Illness and Preterm Infants: Family Stress and Support Issues

As the survival rate for children with complex medical conditions has increased, the body of knowledge regarding childhood chronic illness has grown. While the initial focus of this literature was the effect of the illness on the child, recent studies have focused on chronic illness and broader family issues. The transactional and family systems perspectives suggest the need for longitudinal studies of chronically ill infants from the point of diagnosis. Although a few studies of relatively healthy preterm infants have documented family stress levels, there is a paucity of research on the effects of parenting a very low birthweight infant with complex medical needs. The Chronically Ill Infant Intervention (CIII) Project and its broad based interdisciplinary intervention is used to illustrate the changing needs of this population. Preliminary analyses of specific intervention needs during the infants' first 18 months are discussed in relation to the reduction of family stress.