David M. Rubin

Disparities in the Evaluation and Diagnosis of Abuse Among Infants With Traumatic Brain Injury

OBJECTIVE: To evaluate in a national database the association of race and socioeconomic status with radiographic evaluation and subsequent diagnosis of child abuse after traumatic brain injury (TBI) in infants. METHODS: We conducted a retrospective study of infants with non–motor vehicle–associated TBI who were admitted to 39 pediatric hospitals from January 2004 to June 2008. Logistic regression controlling for age, type, and severity of TBI and the presence of other injuries was performed to examine the association of race and socioeconomic status with the principal outcomes of radiographic evaluation for suspected abuse and diagnosis of abuse. Regression coefficients were transformed to probabilities. RESULTS: After adjustment for type and severity of TBI, age, and other injuries, publicly insured/uninsured infants were more likely to have had skeletal surveys performed than were privately insured infants (81% vs 59%). The difference in skeletal survey performance for infants with public or no insurance versus private insurance was greater among white (82% vs 53%) infants than among black (85% vs 75%) or Hispanic (72% vs 55%) infants (P = .022). Although skeletal surveys were performed in a smaller proportion of white than black or Hispanic infants, the adjusted probability for diagnosis of abuse among infants evaluated with a skeletal survey was higher among white infants (61%) than among black (51%) or Hispanic (53%) infants (P = .009). CONCLUSIONS: National data suggest continued biases in the evaluation for abusive head trauma. The conflicting observations of fewer skeletal surveys among white infants and higher rates of diagnosis among those screened elicit concern for overevaluation in some infants (black or publicly insured/uninsured) or underevaluation in others (white or privately insured).

Risk for Incident Diabetes Mellitus Following Initiation of Second-Generation Antipsychotics Among Medicaid-Enrolled Youths

IMPORTANCEnSecond-generation antipsychotics (SGAs) have increasingly been prescribed to Medicaid-enrolled children, either singly or in a medication combination. Although metabolic adverse effects have been linked to SGA use in youths, estimating the risk for type 2 diabetes mellitus, a rarer outcome, has been challenging.nnnOBJECTIVEnTo determine whether SGA initiation was associated with an increased risk for incident type 2 diabetes mellitus. Secondary analyses examined the risk associated with multiple-drug regimens, including stimulants and antidepressants, as well as individual SGAs.nnnDESIGN, SETTING, AND PARTICIPANTSnRetrospective national cohort study of Medicaid-enrolled youths between January 2003 and December 2007. In this observational study using national Medicaid Analytic eXtract data files, initiators and noninitiators of SGAs were identified in each month. Included in this study were US youths aged 10 to 18 years with a mental health diagnosis and enrolled in a Medicaid fee-for-service arrangement during the study. Those with chronic steroid exposure, a diagnosis of diabetes mellitus, or SGA use during a 1-year look-back period were ineligible. The mean follow-up time for all participants was 17.2 months. Youths were followed up until diagnosis of diabetes mellitus or end of follow-up owing to censoring caused by the transition into a Medicaid managed care arrangement or Medicaid ineligibility (the end of available data). Propensity weights were developed to balance observed demographic and clinical characteristics between exposure groups. Discrete failure time models were fitted using weighted logistic regression to estimate the risk for incident diabetes mellitus between initiators and noninitiators.nnnEXPOSUREnA filled SGA prescription.nnnMAIN OUTCOMES AND MEASURESnIncident type 2 diabetes mellitus identified through visit and pharmacy claims during the observation period.nnnRESULTSnAmong 107,551 SGA initiators and 1,221,434 noninitiators, the risk for incident diabetes mellitus was increased among initiators (odds ratio [OR], 1.51; 95% CI, 1.35-1.69; Pu2009<u2009.001). Compared with youths initiating only SGAs, the risk was higher among SGA initiators who used antidepressants concomitantly at the time of SGA initiation (OR, 1.54; 95% CI, 1.17-2.03; Pu2009=u2009.002) but was not significantly different for SGA initiators who were concomitantly using stimulants. As compared with a reference group of risperidone initiators, the risk was higher among those initiating ziprasidone (OR, 1.61; 95% CI, 0.99-2.64; Pu2009=u2009.06) and aripiprazole (OR, 1.58; 95% CI, 1.21-2.07; Pu2009=u2009.001) but not quetiapine fumarate or olanzapine.nnnCONCLUSIONS AND RELEVANCEnThe risk for incident type 2 diabetes mellitus was increased among youths initiating SGAs and was highest in those concomitantly using antidepressants. Compared with risperidone, newer antipsychotics were not associated with decreased risk.

Child abuse prevention

The past two decades have seen a dramatic rise in substantiated reports of child abuse in the United States. (cite NIS studies) National attention has followed with a shift toward focusing on prevention strategies to reduce the growing burden on the child welfare system. The shift of focus toward prevention of child abuse is not surprising, considering its appeal to a broader community, whether the goal is to provide more community based services or the strengthening of family values.

Emergency department visits and hospitalizations for injuries among infants and children following statewide implementation of a home visitation model.

To compare hospital-based utilization for early childhood injuries between program recipients and local-area comparison families following statewide implementation of an evidence-based home visitation program, and to describe site-level program variation. Propensity score matching on baseline characteristics was used to create a retrospective cohort of Nurse-Family Partnership (NFP) clients and local area matched comparison women. The main outcome, a count of injury visit episodes, was enumerated from Medicaid claims for injuries examined in an emergency department or hospital setting during the first 2xa0years of life of children born to included subjects. Generalized linear models with a Poisson distribution examined the association between injury episode counts and NFP participation, controlling for other non-injury utilization and stratifying by individual agency catchment area in a fixed effects analysis. The children of NFP clients were more likely in aggregate to have higher rates of injury visits in the first 2xa0years of life than the children of comparison women (415.2/1,000 vs. 364.2/1,000, Pxa0<xa00.0001). Significantly higher rates of visits among children of NFP clients for superficial injuries (156.6/1,000 vs. 132.6/1,000, Pxa0<xa00.0001) principally accounted for the attributable difference in injury visit rates between groups. Among more serious injuries, no significant difference in injury visit rates was found between NFP clients and comparison women. The proportion of children with at least one injury visit varied from 14.5 to 42.5% among individual sites. Contrary to prior randomized trial data, no reductions in utilization for serious early childhood injuries were demonstrated following statewide implementation of an evidence-based home visitation program. Significant program variation on outcomes underscores the challenges to successful implementation.

State Variation in Psychotropic Medication Use by Foster Care Children With Autism Spectrum Disorder

OBJECTIVE: The objective of this study was to compare on a national cohort of children with autism spectrum disorder (ASD) the concurrent use of ≥3 psychotropic medications between children in foster care and children who have disabilities and receive Supplemental Security Income, and to describe variation among states in the use of these medications by children in foster care. METHODS: Studied was the concurrent use of ≥3 classes of psychotropic medications, identified from the 2001 Medicaid claims of 43406 children who were aged 3 to 18 years and had ≥1 annual claim for ASD. Medicaid enrollment as a child in foster care versus a child with disabilities was compared. Multilevel logistic regression, clustered at the state level and controlling for demographics and comorbidities, yielded standardized (adjusted) estimates of concurrent use of ≥3 medications and estimated variation in medication use within states that exceeded 1 and 2 SDs from the average across states. RESULTS: Among children in foster care, 20.8% used ≥3 classes of medication concurrently, compared with 10.1% of children who were classified as having a disability. Differences grew in relationship to overall use of medications within a state; for every 5% increase in concurrent use of ≥3 medication classes by a states population with disabilities, such use by children in a states foster care population increased by 8.3%. Forty-three percent (22) of states were >1 SD from the adjusted mean for children who were using ≥3 medications concurrently, and 14% (7) of the states exceeded 2 SDs. CONCLUSIONS: Among children with ASD, children in foster care were more likely to use ≥3 medications concurrently than children with disabilities. State-level differences underscore policy or programmatic differences that might affect the receipt of medications in this population.

Growth in the Concurrent Use of Antipsychotics With Other Psychotropic Medications in Medicaid-Enrolled Children

OBJECTIVEnSecond-generation antipsychotics (SGAs) have increasingly been prescribed to Medicaid-enrolled children; however, there is limited understanding of the frequency of concurrent SGA prescribing with other psychotropic medications. This study describes the epidemiology of concurrent SGA use with 4 psychotropic classes (stimulants, antidepressants, mood stabilizers, and α-agonists) among a national sample of Medicaid-enrolled children and adolescents 6 to 18 years old between 2004 and 2008.nnnMETHODnRepeated cross-sectional design was used, with national Medicaid Analytic eXtract data (10.6 million children annually). Logit and Poisson regression, standardized for year, demographics, and Medicaid eligibility group, estimated the probability and duration of concurrent SGA use with each medication class over time and examined concurrent SGAs in relation to clinical and demographic characteristics.nnnRESULTSnWhile SGA use overall increased by 22%, 85% of such use occurred concurrently. By 2008, the probability of concurrent SGA use ranged from 0.22 for stimulant users to 0.52 for mood stabilizer users. Concurrent SGA use occurred for long durations (69%-89% of annual medication days). Although the highest users of concurrent SGA were participants in foster care and disability Medicaid programs or those with behavioral hospitalizations, the most significant increases over time occurred among participants who were income-eligible for Medicaid (+13%), without comorbid ADHD (+15%), were not hospitalized (+13%), and did not have comorbid intellectual disability (+45%).nnnCONCLUSIONnConcurrent SGA use with other psychotropic classes increased over time, and the duration of concurrent therapy was consistently long term. Concurrent SGA regimens will require further research to determine efficacy and potential drug-drug interactions, given a practice trend toward more complex regimens in less-impaired children/adolescents.

Home visitation program effectiveness and the influence of community behavioral norms: a propensity score matched analysis of prenatal smoking cessation

BackgroundThe influence of community context on the effectiveness of evidence-based maternal and child home visitation programs following implementation is poorly understood. This study compared prenatal smoking cessation between home visitation program recipients and local-area comparison women across 24 implementation sites within one state, while also estimating the independent effect of community smoking norms on smoking cessation behavior.MethodsRetrospective cohort design using propensity score matching of Nurse-Family Partnership (NFP) clients and local-area matched comparison women who smoked cigarettes in the first trimester of pregnancy. Birth certificate data were used to classify smoking status. The main outcome measure was smoking cessation in the third trimester of pregnancy. Multivariable logistic regression analysis examined, over two time periods, the association of NFP exposure and the association of baseline county prenatal smoking rate on prenatal smoking cessation.ResultsThe association of NFP participation and prenatal smoking cessation was stronger in a later implementation period (35.5% for NFP clients vs. 27.5% for comparison women, pu2009<u20090.001) than in an earlier implementation period (28.4% vs. 25.8%, pu2009=u20090.114). Cessation was also negatively associated with county prenatal smoking rate, controlling for NFP program effect, (ORu2009=u20090.84 per 5 percentage point change in county smoking rate, pu2009=u20090.002).ConclusionsFollowing a statewide implementation, program recipients of NFP demonstrated increased smoking cessation compared to comparison women, with a stronger program effect in later years. The significant association of county smoking rate with cessation suggests that community behavioral norms may present a challenge for evidence-based programs as models are translated into diverse communities.

Child abuse prevention and child home visitation: Making sure we get it right

Home visitation to at-risk families is an important strategy for improving early-childhood outcomes. On the heels of numerous trials demonstrating many positive and sustained outcomes for mothers and children, the Affordable Care Act in 2010 allocated

Effect of Maternal–Child Home Visitation on Pregnancy Spacing for First-Time Latina Mothers

1.5 billion to this initiative and recently, the White House proposed an appropriation of

Second-Generation Antipsychotic Use Among Stimulant-Using Children, by Organization of Medicaid Mental Health

15 billion over 10 years to strengthen and expand programs across the United States. This substantial public investment in home visiting is a tremendous achievement for researchers who have focused on early childhood as a crucial time period to pursue strategies that alter lifetime trajectories of at-risk children. As these programs rapidly disseminate across the country, researchers must address issues and challenges that may arise and strengthen programs as needed. To this point, child abuse prevention strikes a cautionary note. Prevention of child maltreatment has been a significant position of advocacy for home-visiting programs. This outcome is frequently cited as one of the service’s strengths and moreover, has been included in estimates of program cost-effectiveness.1,2 However, a deeper review of the trial evidence is inconclusive. First, the lack of standard outcomes has made comparison of outcomes between program models difficult. Studies vary from more proximal outcomes of harsh parenting practice to health care encounters for injury or official child protective service reports. When comparisons have been made, the results are mixed. The most recent 2013 US Preventive Services Task Force systematic review of homevisitation programs found that when compared with earlier trials, 2 programs (Child First and the Nurse Family Partnership) either reduced reports of abuse or of death due to all causes over a long follow-up. The review also included 4 other high-quality randomized controlled trials that did not find effects on reported child maltreatment.1 An earlier review by Reynolds et al3 characterized the overall evidence base as relatively weak because of a lack of shared benefit across program models. Second, interpreting trial data has also been challenging due to limitations in study design and risk of bias. Many trials lacked power to detect the rare outcome of abuse over reasonable follow-up durations. Furthermore, many investigators suggest that surveillance bias among visited families might explain the lack of effect observed in some studies. Yet research on the effect of surveillance on child abuse reporting by parent support programs found small influence during the period families were actively enrolled, no excess bias attributed to home visitation, and no evidence that homevisited families were reported for less-severe maltreatment.4 Additionally, many home-visitation programs struggle to retain families once the child is born, weakening this argument. Researchers must therefore be careful to write off inconclusive data as solely the product of a surveillance bias, masking the program’s true benefit—such is a tenuous position. Uncertainty around the benefit of home-visiting services on child maltreatment reduction is a strong argument for the continued investment in postimplementation evaluation. This is also a time of great opportunity because the implementation environment will expose much larger groups of families to home-visiting services, allowing for robust analysis on a rare outcome such as child maltreatment, and obviating the concerns about power from the original trials. At this time, evaluators should understand that the challenges of expanding programs will be great because implementation across diverse social service agencies and into geographic areas and populations not well-studied in smaller trials may be problematic. Many programs will operate without the resources of clinical trials and face local barriers to implementation and program fidelity.5 Such concerns make it even more important for programs to sustain their commitment to successful implementation and continuing robust evaluations. Although postimplementation data are beginning to emerge, 2 recent studies suggest home-visitation programs may be encountering some challenges. The first, a quasi-experimental evaluation of Nurse Family Partnership in Pennsylvania following the program’s statewide dissemination, found that over a 6-year period, 5016 nurse-visited families were no less likely than 16 704 matched nonvisited families to have serious head injuries or other injuries suspicious for abuse.6 After statewide implementation of Healthy Families Massachusetts (a program using the Healthy Families America curriculum with paraprofessional home visitors), a randomized controlled trial conducted among 840 women at 18 sites found mothers in the home-visiting group were equally, if not more likely, to have a substantiated report of child maltreatment than those in the nonvisited group.7 Certainly researchers should be cautious about the limitations of these postimplementation studies, but should not completely discount them. Although one study was a randomized trial,7 the other was an observational study.6 The observational design might introduce selection bias in the absence of randomization, and even the best attempts at controlling for confounding can be incomplete. However, observational studies include much larger samples and report real-world outcomes and distribution of resources. Generalizability is also a concern because the programs studied in both evaluations represented 1 model in a single state and therefore might not be representative of the performance of other program models or even the same program models implemented VIEWPOINT