Long-term impact of abusive head trauma in young children

ObjectiveAbusive head trauma is the leading cause of physical abuse deaths in children under the age of 5 and is associated with severe long-lasting health problems and developmental disabilities. This study evaluates the long-term impact of AHT and identifies factors associated with poor long-term outcomes (LTOs).MethodsWe used the Truven Health MarketScan Research Claims Database (2000–2015) to identify children diagnosed with AHT and follow them up until they turn 5. We identified the incidence of behavioral disorders, communication deficits, developmental delays, epilepsy, learning disorders, motor deficits, and visual impairment as our primary outcomes.ResultsThe incidence of any disability was 72% (676/940) at 5 years post-injury. The rate of developmental delays was 47%, followed by 42% learning disorders, and 36% epilepsy. Additional disabilities included motor deficits (34%), behavioral disorders (30%), visual impairment (30%), and communication deficits (11%). Children covered by Medicaid experienced significantly greater long-term disability than cases with private insurance. In a propensity-matched cohort that differ primarily by insurance, the risk of behavioral disorders (RD 36%), learning disorders (RD 30%), developmental delays (RD 30%), epilepsy (RD 18%), and visual impairment (RD 12%) was significantly higher in children with Medicaid than kids with private insurance.ConclusionAHT is associated with a significant long-term disability (72%). Children insured by Medicaid have a disproportionally higher risk of long-term disability. Efforts to identify and reduce barriers to health care access for children enrolled in Medicaid are critical for the improvement of outcomes and quality of life.     

Prior opportunities to identify abuse in children with abusive head trauma

Infants with minor abusive injuries are at risk for more serious abusive injury, including abusive head trauma (AHT). Our study objective was to determine if children with AHT had prior opportunities to detect abuse and to describe the opportunities. All AHT cases from 7/1/2009 to 12/31/2011 at four tertiary care children's hospitals were included. A prior opportunity was defined as prior evaluation by either a medical or child protective services (CPS) professional when the symptoms and/or referral could be consistent with abuse but the diagnosis was not made and/or an alternate explanation was given and accepted. Two-hundred-thirty-two children with AHT were identified; median age (IQR) was 5.40 (3.30, 14.60) months. Ten percent (22/232) died. Of the 232 patients diagnosed with AHT, 31% (n = 73) had a total of 120 prior opportunities. Fifty-nine children (25%) had at least one prior opportunity to identify abuse in a medical setting, representing 98 prior opportunities. An additional 14 (6%) children had 22 prior opportunities through previous CPS involvement. There were no differences between those with and without a prior opportunity based on age, gender, race, insurance, mortality, or institution. Children with prior opportunities in a medical setting were more likely to have chronic subdural hemorrhage (48 vs. 17%, p < 0.01) and healing fractures (31 vs. 19%, p = 0.05). The most common prior opportunities included vomiting 31.6% (38/120), prior CPS contact 20% (24/120), and bruising 11.7% (14/120). Improvements in earlier recognition of AHT and subsequent intervention might prevent additional injuries and reduce mortality.     

Violence towards children in the United States and Sweden

This paper reports the results of a cross-cultural comparison of violence towards children in the United States and Sweden. Data from the United States are based on interviews with a nationally representative sample of 1,146 households with at least one child between the ages of 3 and 17 years living at home. Data from Sweden are based on interviews with a nationally representative sample of 1,168 households with a child 3 to 17 years of age at home. Violence and abuse were measured using the Conflict Tactics Scales. In general, Swedish parents reported using less violence than did parents in the United States. There was no significant difference between the two countries in the rate of reported severe or abusive violence. The paper compares factors found associated with violence towards children in the two countries, including age, marital status, education, and parents' background. The results are analyzed by considering methodological and cultural factors that explain the similarities and differences in the use of violence towards children in the two countries.     

Eight-year outcome of implementation of abusive head trauma prevention

Low incidence rates and economic recession have hampered interpretation of educational prevention efforts to reduce abusive head trauma (AHT). Our objective was to determine whether the British Columbia experience implementing a province-wide prevention program reduced AHT hospitalization rates. A 3-dose primary, universal education program (the Period of PURPLE Crying) was implemented through maternal and public health units and assessed by retrospective-prospective surveillance. With parents of all newborn infants born between January 2009 and December 2016 (n = 354,477), nurses discussed crying and shaking while delivering a booklet and DVD during maternity admission (dose 1). Public health nurses reinforced Talking Points by telephone and/or home visits post-discharge (dose 2) and community education was instituted annually (dose 3). During admission, program delivery occurred for 90% of mothers. Fathers were present 74.4% of the time. By 2–4 months, 70.9% of mothers and 50.5% of fathers watched the DVD and/or read the booklet. AHT admissions decreased for <12-month-olds from 10.6 (95% CI: 8.3–13.5) to 7.1 (95% CI: 4.8–10.5) or, for <24-month-olds, from 6.7 (95% CI: 5.4–8.3) to 4.4 (95% CI: 3.1–6.2) cases per 100,000 person-years. Relative risk of admission was 0.67 (95% CI: 0.42–1.07, P = 0.090) and 0.65 (95% CI: 0.43-0.99, P = 0.048) respectively. We conclude that the intervention was associated with a 35% reduction in infant AHT admissions that was significant for <24-month-olds. The results are encouraging that, despite a low initial incidence and economic recession, reductions in AHT may be achievable with a system-wide implementation of a comprehensive parental education prevention program.     

The Epidemiology of Suicide Among Students at Colleges and Universities in the United States

All published studies and selected unpublished reports on the incidence of suicide among students at colleges and universities in the United States are reviewed. Compared with studies relying upon official (i.e., governmental) records of suicide, studies relying on informal sources are found to underestimate the incidence of student suicide by about 30 percent. Both sources of data, however, indicate that the incidence of student suicide is significantly and dramatically lower (about 46 percent) than that of non-students. For female students it is only marginally lower (about 91 percent). Institutional size and prestige are not significantly related to the incidence of student suicide, nor is class standing. The presence of psychosis is the most discriminating individual difference variable, increasing the risk of suicide by a factor of 200 over baseline rates in the student population. Contact with campus mental health services is also associated with a significant (six fold) increase in risk for suicide. Depression is upiquitous and signals only a doubling of risk for suicide among students. Method of suicide is a particularly noteworthy variable. Most importantly, male students are half as likely as males generally to employ the most common means of suicide, firearms. The same trend is found for female students. There is suggestive evidence that student suicides occur more frequently than would be expected during the months of September, January and March. The incidence of student suicide is significantly elevated during weekdays (Monday-Thursday. Student suicide occurs disproportionately often during the midnight to 6:00am period, but this finding is only suggestive and may not be a contrast with non-student suicides. The implication of these findings for the prevention of student suicide are briefly discussed. Suggestions for further epidemiologic studies of student suicide are made.     

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.     

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.     

现行美国教育体制

美国现行的教育体制构建在两个理想的前提上,一是必须保证所有的人接受基础教育,但由于各州经济状况的不同而导致基础教育发展不平衡;一是必须保证所有人都有接受高等教育的权利和机会。美国教育体制下存在公助和私助两种办学模武,他们更强调教会学生创新和独立思考,一些学校正进行改革试验,并取得了一定成效。     

美国RISE科学教育计划及其启示

RISE是由美国国家科学院与国家研究理事会共同设立的一项科学教育计划。旨在通过研讨会和研究帮助参与该计划的科学家和工程师,并倡导他们参与幼儿园和中小学科学教育。本文将从RISE计划理论上的教育方式和实践中的教学项目等方面对其加以介绍,以期对我国目前的科学教育改革有所启示。     

独在异乡为异客：美国移民

移民究竟是福还是祸，美国的学者和民众对此一直众说纷纭，莫衷一是，但没人可以否认移民对于美国社会的影响。同样，由美国移民衍生出来的问题我们也可以考虑一下中国的民工问题。     

美国人心目中的家

家是一个让人放松的地方．一个让人放下一切、展示真实自我的地方。因此,无论走到哪里,家都是一个你想回的地方。因此,基本上所有的人都非常渴望拥有一个家。对于大多数美国人来说．家最重要的应该是舒适。     

The development of young children of immigrants in australia, Canada, the United kingdom, and the United States

In spite of important differences in some of the resources immigrant parents have to invest in their children, and in immigrant selection rules and settlement policies, there are significant similarities in the relative positions of 4- and 5-year-old children of immigrants in Australia, Canada, the United Kingdom, and the United States. Children of immigrants underperform their counterparts with native-born parents in vocabulary tests, particularly if a language other than the official language is spoken at home, but are not generally disadvantaged in nonverbal cognitive domains, nor are there notable behavioral differences. These findings suggest that the cross-country differences in cognitive outcomes during the teen years documented in the existing literature are much less evident during the early years.