Brian Duncan Johnston

A preschool program for safety and injury prevention delivered by home visitors

Objective—To evaluate the feasibility, acceptability, and effectiveness of an injury prevention program delivered by school based home visitors to the families of low income children attending preschool enrichment programs in Washington State. Study sample—The families of children attending preschool Head Start programs in two regions were eligible. A total of 213 families (77.8% of those eligible) from intervention sites, and 149 families (71.9% of those eligible) from concurrent comparison sites, agreed to participate and completed the trial. Intervention—Trained school personnel conducted home safety inspections as part of a planned home visit. Intervention families were offered educational materials as well as smoke detectors, batteries, ipecac, and age appropriate car safety restraints based on results of the home inspection. Evaluation methods—At a repeat home visit three months later, the proportion of families with a positive change in injury prevention knowledge or behavior among those in the intervention group was compared with the proportion in the comparison group. Smoke detector presence and function were observed. Results—Among families without a working smoke detector at baseline, the intervention was associated with an increased probability of having a working detector at follow up (relative risk (RR) 3.3, 95% confidence interval (CI) 1.3 to 8.6). Intervention families were also more likely to report the presence of ipecac in the home (RR 4.7, 95% CI 3.0 to 7.3) at follow up and to have obtained an age appropriate booster seat (RR 4.1, 95% CI 1.9 to 8.8). The program was acceptable to client families and to the home visitors who conducted the intervention. Conclusions—Among the families of low income children enrolled in preschool enrichment programs, home safety inspections and the distribution of safety supplies by school based home visitors appears to improve knowledge and behavior related to poisoning, smoke detector installation, and car safety seat use over three months of follow up.

Preventive dental care for children in the United States: a national perspective.

OBJECTIVE. Preventive dental care is a cornerstone of optimal oral health. However, in 1996, only 38% of US children received preventive dental care. We used the National Survey of Childrens Health to (1) describe the proportion of US children with ≥1 preventive dental visit within the previous year, (2) identify factors that were associated with preventive dental care use, and (3) test the hypothesis that preventive dental care use by near-poor children is associated with State Child Health Insurance Program policies for covering dental care. METHODS. The National Survey of Childrens Health includes data from 102353 children, weighted to represent 72.7 million children, nationally. Our outcome of interest was ≥1 preventive dental visit in the past year. We conducted multivariate regression analysis to identify factors that were associated significantly with this outcome using Stata survey capabilities. RESULTS. In 2003, 72% of US children had a reported preventive dental care visit in the previous year. On multivariable analysis, we found that being young, black or multiracial relative to white, lower income, and lacking a personal doctor were variables with a significantly lower likelihood of a preventive dental visit. Children in states with State Child Health Insurance Program dental coverage and broadest income eligibility had a 24% higher likelihood of a preventive dental visit when compared with children in states with limited or no State Child Health Insurance Program coverage for dental services, on adjusted analysis. CONCLUSIONS. Although the proportion of US children with a preventive dental visit now is higher than previously reported, children who are at highest risk for dental problems still are those who are least likely to receive preventive dental care. When states cover preventive dental care at income eligibility levels ≥200% of the federal poverty level, there is a greater likelihood that near-poor children will receive preventive dental care.

The use of repeated head computed tomography in pediatric blunt head trauma: Factors predicting new and worsening brain injury

Objective: Opinion is divided on the value of repeat head computed tomography for guiding clinical management of pediatric patients with blunt head trauma. This study describes the prevalence of worsening brain injury on repeat computed tomography, predictors of worsening computed tomography findings, and the frequency of neurosurgical intervention after the repeat computed tomography. Design: Retrospective cohort study. Setting: All patients were admitted to a level I pediatric trauma center between 1994 and 2003. Patients: Children <15 yrs old with two or more head computed tomographies following hospital admission for blunt head trauma. Interventions: None. Measurements and Main Results: We reviewed the imaging reports to determine injury progression. Potential predictors of worsening computed tomography findings and neurosurgical intervention were recorded by chart review. Logistic regression and recursive partitioning were used to identify predictors. Twenty percent (50 of 257) of patients with mild head injury had worsening computed tomography findings, and three patients (1%) had subsequent neurosurgical intervention. Patients with moderate and severe head injuries were more likely to have worsening computed tomography findings (107 of 248; 43%) and to have neurosurgical intervention (15 of 248; 6%). In most surgical patients, repeat computed tomography was preceded by rapid decline in neurologic status or elevated intracranial pressure. Stratification based on four clinical factors (initial head injury severity, any intraparenchymal finding on initial computed tomography, normal findings on initial computed tomography, coagulopathy) identified 100% of the surgical patients and 89% of patients with worsening brain injuries on the repeat computed tomography. Conclusions: Repeat head computed tomography imaging is frequently used. About 30% of repeated computed tomographies showed new or worsening brain injury. However, worsening brain injury on repeat computed tomography rarely resulted in neurosurgical intervention. Patients with moderate or severe head injury and intraparenchymal injuries were more likely to show worsening brain injury and undergo neurosurgical intervention.

Attentional dysfunction in children with encopresis

ABSTRACT. Encopresis and attentional dysfunction are common neurobehavioral disorders of childhood. The extent to which these disorders occur in association is unknown. The purpose of this study is to document the comorbidity of attentional dysfunction in a clinically identified population of encopresis patients. We used the Child Behavior Checklist (CBCL) to estimate the prevalence of disordered attention or hyperactivity in a group of children with encopresis seen at a tertiary care facility. Responses to CBCL questionnaires were analyzed to compare scores on the “hyperactive‘’ behavior subscale with published normative data. The number of encopretic respondents with T scores above 70 (<2 SD above the mean) on a hyperactivity subscale was ascertained for each age and gender cohort. From 347 eligible new clinic patients, responses from 167 were suitable for analysis. Overall, 23.4% of children with encopresis (95% confidence interval: 17.2%–30.5%) had T scores on the hyperactive subscale higher than 70. This prevalence (ten fold greater than expected in the normal population) was similar in both genders and across age groups. This association between attentional dysfunction and encopresis has significance for theories regarding etiology and for practical treatment strategies. J Dev Behav Pediatr 14:381–385, 1993. Index terms: attention deficit disorder, encopresis, comorbidity, Child Behavior Checklist.

Methodologic Issues in Pediatric Outcomes Research

Clinicians, health services researchers, and third-party payers, among others, are justifiably interested in the outcomes of pediatric medical care and are, therefore, supportive of research in this area. Pediatric populations pose some unique methodologic challenges for health services researchers. To date, however, many of the approaches, models, and techniques used in pediatric outcomes research have been imported uncritically from experience with adult populations. As a result, some of the most interesting and salient aspects of pediatric outcomes research have yet to be fully developed. These include the following: 1) the problems posed by the dynamics of childhood development, 2) an emphasis on health supervision, 3) the need to see children within the context of a family system and to appreciate the interrelatedness of child health domains, 4) the measurement of the effects of interventions that span sectors, and 5) the paucity of available data sources. This article reviews these problematic areas and argues for a broad conceptual definition of pediatric health, a systems approach to assessing outcomes, and increased interdisciplinary collaboration.

Immigrant families' perceptions on walking to school and school breakfast: a focus group study

BackgroundImmigrant children face an increased risk of being overweight. Little is known about how immigrant families perceive school programs that may help prevent obesity, such as walking to school and school breakfast.MethodsSix focus groups (n = 53) were conducted with immigrant parents of school-aged children, two each in three languages: Vietnamese, Spanish, and Somali. A facilitator and translator conducted the focus groups using a script and question guide. Written notes and audio transcripts were recorded in each group. Transcripts were coded for themes by two researchers and findings classified according to an ecological model.ResultsParticipants in each ethnic group held positive beliefs about the benefits of walking and eating breakfast. Barriers to walking to school included fear of childrens safety due to stranger abductions, distrust of neighbors, and traffic, and feasibility barriers due to distance to schools, parent work constraints, and large families with multiple children. Barriers to school breakfast participation included concerns children would not eat due to lack of appealing/appropriate foods and missing breakfast due to late bus arrival or lack of reminders. Although some parents acknowledged concerns about child and adult obesity overall, obesity concerns did not seem personally relevant.ConclusionImmigrant parents supported the ideals of walking to school and eating breakfast, but identified barriers to participation in school programs across domains of the ecological model, including community, institution, and built environment factors. Schools and communities serving immigrant families may need to address these barriers in order to engage parents and children in walking and breakfast programs.

High-risk periods for childhood injury among siblings.

Objective. To determine whether the risk of unintentional injury requiring emergency department (ED) or inpatient care in children is transiently increased over a 90-day period after injury to a sibling. Design. Retrospective cohort. Setting. King County, Washington. Participants. A total of 41 242 children 0 to 15 years of age continuously enrolled in Medicaid and living in King County during the period October 1, 1992 through September 30, 1993 (27 450 child-years). Outcome Measures. The outcome was an unintentional injury treated in the ED or inpatient setting. Incidence rates and hazard ratios were calculated for children whose sibling had been injured in the previous 90 days, compared with children without such exposure. Multivariate analysis was used to adjust for age, gender, race, sibling group size, and noninjury ED use. Results. There were 4921 injuries treated only in the ED and 82 hospital admissions. The incidence of ED treated injury was 305 per 1000 child-years among children whose sibling had been injured in the previous 90 days and 174 per 1000 child-years among children without this exposure (relative risk: 1.75; 95% confidence interval: 1.56–1.95). The incidence of injury-related hospitalization was 1.7 per 1000 child-years among children whose sibling had been injured in the previous 90 days, compared with 3.0 per 1000 child-years among children without this exposure (relative risk: .57; 95% confidence interval: .07–2.12). Injury risk peaked in the period 4 to 10 days after a siblings injury and returned toward, but did not attain, baseline risk over the subsequent 2½ months. The magnitude of this effect depended on the childs age; the relative risk of injury was higher among older children. Conclusions. Injuries treated in the ED or inpatient setting appear to cluster within sibling groups over brief periods of time. Shared social or environmental exposures may contribute to this clustering and may be amenable to targeted, time-limited prevention interventions.

The Teen Driver

For many teenagers, obtaining a driver’s license is a rite of passage, conferring the ability to independently travel to school, work, or social events. However, immaturity, inexperience, and risky behavior put newly licensed teen drivers at risk. Motor vehicle crashes are the most common cause of mortality and injury for adolescents and young adults in developed countries. Teen drivers (15–19 years of age) have the highest rate of motor vehicle crashes among all age groups in the United States and contribute disproportionately to traffic fatalities. In addition to the deaths of teen drivers, more than half of 8- to 17-year-old children who die in car crashes are killed as passengers of drivers younger than 20 years of age. This policy statement, in which we update the previous 2006 iteration of this policy statement, is used to reflect new research on the risks faced by teen drivers and offer advice for pediatricians counseling teen drivers and their families.

Surveillance: to what end?

There is a belief, widely held in the injury prevention community, that injury surveillance is an important—perhaps crucial—prerequisite for effective injury control. The argument is typically made that surveillance systems are needed to demonstrate the magnitude of an injury problem, to identify target populations (defined demographically, geographically or on the basis of a shared risk factor) or high-priority injury mechanisms, and to monitor trends in incidence over time (presumably, I suppose, as these improve in response to prevention programs implemented). In response to this belief, there is a great deal of effort spent promoting, designing, and administering surveillance systems. Recognizing that the greatest burden of injury is borne by persons in the developing world, the WHO published guidelines in 2001 to “provide practical advice on how to develop information systems for the collection of systematic data on injuries … in settings where resources, including trained staff and electronic equipment, are limited.”1 The guidelines are thoughtful, practical, and clearly designed to be implementable by individuals operating in less-resourced environments. The developers, to their credit, included a scheme for evaluating any surveillance mechanism thus created. In this issue of the journal, Liu and colleagues (see page 105) report their experience using the WHO approach to design an injury surveillance system in an urban Chinese emergency department and then evaluating that system using the metrics suggested by the WHO.2 The results are interesting in so far as they illustrate where the guidelines could be improved, where surveillance systems fall short and—ultimately—why the focus on …

Child Injury Control: Trends, Themes, and Controversies

Injury is a major cause of morbidity and mortality among US children, and an important driver of health status globally. Despite its enormous burden, injury is preventable. Over the last 10 years, significant progress has been made in the reduction of unintentional injury among US children. However, aggregate trends mask important disparities by age group, region, and injury mechanism. Basic and translation research is needed to develop and test prevention strategies to address these new or recalcitrant problems. Motor vehicle occupant injury has fallen to historic lows, but challenges remain in protecting novice drivers and managing the distraction of new technologies. Injury to pedestrians has also declined, but likely as a result of decreased exposure as fewer children walk. This calls for a broader public health perspective to promote activity while enhancing safety. Deaths due to drowning are common and illustrate the difficulty in measuring and promoting appropriate supervision. Environmental modification and use of protective products may be a more appropriate response. Concussion in sport is another challenging issue: public health laws promote identification and appropriate management of concussed athletes, but less progress has been made on primary prevention of these injuries. Unintentional poisoning is on the rise, attributable to misuse of, and overdose with, prescription opioids. Injury deaths to infants are also increasing. This trend is driven in part by better death investigation that classifies more sleep-related deaths as suffocation events. Finally, we examine a sample of cross-cutting themes and controversies in injury control that might be amenable to empiric evaluation.