Ellen Jamieson

Screening for Intimate Partner Violence in Health Care Settings: A Randomized Trial

CONTEXT Whether intimate partner violence (IPV) screening reduces violence or improves health outcomes for women is unknown. OBJECTIVE To determine the effectiveness of IPV screening and communication of positive results to clinicians. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial conducted in 11 emergency departments, 12 family practices, and 3 obstetrics/gynecology clinics in Ontario, Canada, among 6743 English-speaking female patients aged 18 to 64 years who presented between July 2005 and December 2006, could be seen individually, and were well enough to participate. INTERVENTION Women in the screened group (n=3271) self-completed the Woman Abuse Screening Tool (WAST); if a woman screened positive, this information was given to her clinician before the health care visit. Subsequent discussions and/or referrals were at the discretion of the treating clinician. The nonscreened group (n=3472) self-completed the WAST and other measures after their visit. MAIN OUTCOME MEASURES Women disclosing past-year IPV were interviewed at baseline and every 6 months until 18 months regarding IPV reexposure and quality of life (primary outcomes), as well as several health outcomes and potential harms of screening. RESULTS Participant loss to follow-up was high: 43% (148/347) of screened women and 41% (148/360) of nonscreened women. At 18 months (n = 411), observed recurrence of IPV among screened vs nonscreened women was 46% vs 53% (modeled odds ratio, 0.82; 95% confidence interval, 0.32-2.12). Screened vs nonscreened women exhibited about a 0.2-SD greater improvement in quality-of-life scores (modeled score difference at 18 months, 3.74; 95% confidence interval, 0.47-7.00). When multiple imputation was used to account for sample loss, differences between groups were reduced and quality-of-life differences were no longer significant. Screened women reported no harms of screening. CONCLUSIONS Although sample attrition urges cautious interpretation, the results of this trial do not provide sufficient evidence to support IPV screening in health care settings. Evaluation of services for women after identification of IPV remains a priority. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00182468.

The relationship between parental psychiatric disorder and child physical and sexual abuse: findings from the Ontario health supplement

OBJECTIVE The studys goal was to examine the relationship between a history of parental psychiatric disorder and a history of child abuse in a general population sample of Ontario residents. METHOD A representative community sample of 8548 respondents who participated in the Ontario Mental Health Supplement (OHSUP) were interviewed about parental psychiatric history and completed a self-report measure of childhood physical and sexual abuse. RESULTS The lifetime prevalence of either parent with a psychiatric disorder was as follows: 14.1% for depression, 3.7% for manic depression, 2.4% for schizophrenia, 2.4% for antisocial behavior, and 17.3% for any parental psychiatric disorder. Respondents reporting a parental history of depression, mania, or schizophrenia had a two to threefold increase in the rates of physical, sexual, or any abuse. Parental history of antisocial disorder increased the risk of exposure to physical abuse (adjusted odds ratios [OR 6.1] and any abuse [OR 7.5]). There was no statistically significant difference between parental psychiatric disorder and childhood physical or sexual abuse by gender of the respondent. There was a trend for increasing risk associated with father only, mother only, and both parents having any psychiatric disorder. CONCLUSIONS The elevated risk for physical and sexual abuse among respondents reporting a parental history of psychiatric illness highlights the need to examine the mechanism for this association. Such information is important in developing approaches to assist families where the risk of child maltreatment is increased.

Predicting the One-Year Course of Adolescent Major Depression

OBJECTIVE To identify specific clinical and social functioning variables that predict persistence of major depression over a 1-year period of follow-up. METHOD The sample consisted of 67 adolescents with major depression, drawn from consecutive referrals to psychiatric clinics in a defined, geographic catchment area. Clinical interviews and questionnaires measuring behaviors, symptoms, and social functioning were administered to both the adolescent and a parent at inception and at follow-up. Discriminant function analyses were used to identify inception variables that predicted clinical course independent of severity of depressive symptoms and global functioning. RESULTS At 1-year follow-up, major depression remitted in 66% of subjects. Persisters were characterized at inception as older, more likely to have substance use or anxiety disorders, less involved with fathers, and less responsive to mothers discipline compared with remitters. The effect of these prognostic factors was independent of symptom severity and global functioning. CONCLUSION These variables appear to reflect perpetuating and ameliorating factors influencing the short-term course of major depression. The findings suggest that treatments for adolescent depression that aim to enhance parent-adolescent relationships, and that specifically target coexisting disorders, should be evaluated for effectiveness.

Child Abuse and Chronic Pain in a Community Survey of Women

This study examined the relationship between a self-reported history of child physical and sexual abuse and chronic pain among women (N = 3381) in a provincewide community sample. Chronic pain was significantly associated with physical abuse, education, and age of the respondents and was unrelated to child sexual abuse alone or in combination with physical abuse, mental disorder (anxiety, depression, or substance abuse), or low income. Number of health problems and mental health disorders did not mediate the relationship between physical abuse and chronic pain. Despite considerable evidence from the clinical literature linking exposure to child maltreatment and chronic pain in adulthood, this may well be the first population-based study to investigate this relationship for child physical and sexual abuse independently. The significant association between childhood history of physical abuse and pain in adulthood calls for a greater awareness of the potential for chronic pain problems associated with this type of maltreatment. Further research is needed to understand the mechanism for this complex relationship.

Development of a Policy-Relevant Child Maltreatment Research Strategy

Child maltreatment is associated with a huge burden of suffering, yet there are serious gaps in knowledge about its epidemiology and approaches to intervention. This article describes the development of a proposed national research framework in child maltreatment, as requested by the Department of Justice, Canada, based on (1) a review of the literature, (2) consultation with experts, and (3) application of evaluation criteria for considering research priorities. The article identifies gaps in knowledge about child maltreatment in Canada and proposes a research agenda to make evidence-based policy decisions more likely. Although this work was driven by gaps in Canadas knowledge about child maltreatment, the international scope of the review and consultation process could make the findings useful to broader research and policy audiences.

The health of Canada's Aboriginal children: results from the First Nations and Inuit Regional Health Survey

Objectives. Reports on child health in Canada often refer to the disproportionate burden of poor health experienced by Aboriginal children and youth, yet little national data are available. This paper describes the health of First Nations and Inuit children and youth based on the First Nations and Inuit Regional Health Survey (FNIRHS). Study design. The FNIRHS combines data from 9 regional surveys conducted in 1996–1997 in Aboriginal reserve communities in all provinces. The target population consisted of all onreserve communities. All households or a random sample of households or adults (depending on province) were selected based on their population representation. Methods. One child was randomly selected from each participating household, except in Ontario and Nova Scotia, where children were randomly selected based upon their population representation. Alberta did not include the section on children’s health in their regional survey. Results. Approximately 84% of adults, who were proxy respondents for their child, rated their children’s health as very good or excellent. The most frequently reported conditions were ear problems (15%), followed by allergies (13%) and asthma (12%). Broken bones or fractures were the most frequently reported injuries (13%). Respondents reported that 17% of children had behavioural or emotional problems. Overall, 76% of children were reported to get along with the family “very well” or “quite well.” Conclusions. While most respondents rated their child’s health as very good or excellent, injuries, emotional and behavioural problems, respiratory conditions and ear problems were reported among many Aboriginal children. Issues such as substance abuse, exposure to violence and academic performance were not addressed in the 10 core survey questions. Clearly there is a need for more in-depth information about both the physical and emotional health of Aboriginal children and youth.

Who is Identified by Screening for Intimate Partner Violence

BACKGROUND Intimate partner violence (IPV) against women is prevalent and has significant physical and mental health consequences; accurate identification of IPV in health settings can be an important first step in appropriate response and referral to services for women. METHODS As part of a randomized controlled trial assessing IPV screening, we assessed exposure to IPV in the past year in 5,607 women visiting one of 26 health care sites across Ontario, Canada, between August 2005 and December 2006. Women completed both the brief (8-item) Woman Abuse Screening Tool (WAST) and the longer (30-item) Composite Abuse Scale (CAS), which served as the criterion standard. This paper describes the agreement between these 2 instruments, and identifies covariates associated with being positive on both the screen and the criterion standard versus positive on the screen only. RESULTS The WAST identified 22.1% of women as experiencing past year abuse, in contrast with the CAS, which identified 14.4% (kappa = .63; standard error [SE], .01). Women were more likely to have the following characteristics when identified as IPV positive on both the WAST and CAS than on the WAST alone: being married (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.3-5.5; p = .009), having a mental health issue (OR, 2.3; 95% CI, 1.3-4.0; p = .002), having a drug problem (OR, 1.7; 95% CI, 1.1-2.9; p = .036), and having a partner with a substance problem (OR, 2.0; 95% CI, 1.2-3.2; p = .006). CONCLUSION Screening in health care settings may overidentify IPV and care needs to be taken in decisions regarding how abuse is identified. However, screening alone may underidentify specific characteristics of women, partners, and relationships that could enable more accurate identification of abuse and specific mental health concerns through clinical case finding.

Age-of-Onset Classification of Conduct Disorder: Reliability and Validity in a Prospective Cohort Study

OBJECTIVE To test in a prospective clinical cohort study the reliability and validity of the age-of-onset subtyping of conduct disorder. METHOD Participants were adolescents referred to psychiatric clinics who met DSM-III-R criteria for conduct disorder by structured diagnostic interview. Age of onset was the reported age of the first conduct disorder symptom. The reliability of age-of-onset report was tested by assessing agreement within informant on interviews 2 to 4 weeks apart. Age-of-onset groups were compared within informant on rates of correlates and symptom and social functioning outcomes over a period of 3 years. RESULTS The reliability of age-of-onset report was low (kappa of 0.1 and 0.4 by adolescent and parent informant, respectively). Although the early-onset group had elevated rates of attention-deficit/hyperactivity disorder, family disadvantage, and aggressive and nonaggressive antisocial behaviors at inclusion, growth curve analysis showed that age-of-onset subtyping had no predictive validity. CONCLUSIONS The reliability of ascertainment of age of onset of antisocial behavior requires further study. While age-of-onset subtyping has heuristic value with respect to the study of the causal pathways to conduct disorder, it is premature to use this system in clinic settings.

THE EFFECTIVENESS AND EFFICIENCY OF HEALTH PROMOTION IN SPECIALTY CLINIC CARE

Chronic illnesses make up the majority of health problems in North America. Many chronically ill persons adjust over time to their illnesses; however, there remains a small but important group of those less adjusted, who are concentrated in specialty clinics and are high users of health care resources. This randomized clinical trial investigated the impact of health promotion interventions in the form of problem-solving counseling or phone support that augmented conventional clinic medical care. Chronically ill, poorly adjusted outpatients (n = 293) attending clinics were randomly assigned to receive additional problem-solving counseling, phone call support, or neither. Psychosocial adjustment to illness, utilization, and expenditures of health services were the main outcomes measured. There were no overall significant differences between groups in their change in psychosocial adjustment and expenditures for health and social care. However, interaction analyses (P < 0.05) gave an indication of who might benefit from these interventions. Those who lived alone and infrequently used problem-solving behaviors to cope with their illness significantly improved their adjustment to illness and had fewer health service expenditures if they received problem-solving counseling. Supportive telephone calls were most effective for those who lived with someone and frequently used problem-solving coping behaviors. These findings suggest that health promotion services should be targeted to outpatients described by specific social support and coping characteristics.

Are Clinicians Being Prepared to Care for Abused Women? A Survey of Health Professional Education in Ontario, Canada

BackgroundThe current project undertook a province-wide survey and environmental scan of educational opportunities available to future health care providers on the topic of intimate partner violence (IPV) against women.MethodsA team of experts identified university and college programs in Ontario, Canada as potential providers of IPV education to students in health care professions at the undergraduate and post-graduate levels. A telephone survey with contacts representing these programs was conducted between October 2005 and March 2006. The survey asked whether IPV-specific education was provided to learners, and if so, how and by whom.ResultsIn total, 222 eligible programs in dentistry, medicine, nursing and other allied health professions were surveyed, and 95% (212/222) of programs responded. Of these, 57% reported offering some form of IPV-specific education, with undergraduate nursing (83%) and allied health (82%) programs having the highest rates. Fewer than half of undergraduate medical (43%) and dentistry (46%) programs offered IPV content. Postgraduate programs ranged from no IPV content provision (dentistry) to 41% offering content (nursing).ConclusionSignificant variability exists across program areas regarding the methods for IPV education, its delivery and evaluation. The results of this project highlight that expectations for an active and consistent response by health care professionals to women experiencing the effects of violence may not match the realities of professional preparation.