Jared W. Parrish

National, Regional, and State Abusive Head Trauma: Application of the CDC Algorithm

OBJECTIVE: To examine national, regional, and state abusive head trauma (AHT) trends using child hospital discharge data by applying a new coding algorithm developed by the Centers for Disease Control and Prevention (CDC). METHODS: Data from 4 waves of the Kids’ Inpatient Database and annual discharge data from North Carolina were used to determine trends in AHT incidence among children <1 year of age between 2000 and 2009. National, regional, and state incidence rates were calculated. Poisson regression analyses were used to examine national, regional, and state AHT trends. RESULTS: The CDC narrow and broad algorithms identified 5437 and 6317 cases, respectively, in the 4 years of KID weighted data. This yielded average annual incidences of 33.4 and 38.8 cases per 100 000 children <1 year of age. There was no statistically significant change in national rates. There were variations by region of the country, with significantly different trends in the Midwest and West. State data for North Carolina showed wide annual variation in rates, with no significant trend. CONCLUSIONS: The new coding algorithm resulted in the highest AHT rates reported to date. At the same time, we found large but statistically insignificant annual variations in AHT rates in 1 large state. This suggests that caution should be used in interpreting AHT trends and attributing changes in rates as being caused by changes in policies, programs, or the economy.

Identifying Risk Factors for Child Maltreatment in Alaska A Population-Based Approach

BACKGROUND Child maltreatment has been linked to multiple negative health outcomes and many leading causes of death. Statewide population-based evaluations are needed to identify high-risk populations early in life for targeted interventions. PURPOSE To assess the utility of combining Pregnancy Risk Assessment Monitoring System (PRAMS) data with child protective services (CPS) records to identify risk factors associated with Protective Services Reports (PSR) suggestive of child maltreatment. METHODS This was a retrospective population-based cohort study conducted in the spring of 2010 using weighted survey data from Alaska PRAMS for birth years 1997-1999. PRAMS responses were linked with CPS records for the sampled child. The outcome of interest was any PSR made to CPS after the survey was returned through 48 months after birth. Validation of the PRAMS data set occurred through direct comparison between the total population and PRAMS weighted sample for birth certificate factors. Multivariate logistic regression models were constructed to identify risk groups. RESULTS In the final multivariate model among the main effect variables, three of the top five strongest associated factors were derived all or in part from PRAMS. Public aid as a source of income had a significant interaction with Alaska Native status, and among Alaska non-Natives had an AOR of 3.37 (95% CI=2.2, 5.1). Six significant modifiable factors were identified in the multivariate model. Three quarters (75%) of the maltreatment cases occurred among children with two or more of these factors, despite being found in about one third (32%) of the total population. CONCLUSIONS Although birth certificates remained a valuable source of risk factor information for child maltreatment, PRAMS identified additional risk factors not available from birth certificates.

Abusive head trauma among children in Alaska: a population-based assessment

Background Serious physical abuse resulting in a traumatic brain injury (TBI) has been implicated as an underreported cause of infant mortality. Nearly 80% of all abusive head trauma (AHT) occurs among children <2 years of age, with infants experiencing an incidence nearly 8 times that of 2-year olds. Objective This study describes the validation of the CDC Pediatric Abusive Head Trauma (PAHT) definitions when applied to a multi-source database at the state level and provides a robust annual incidence estimate of AHT among children <2 years of age in Alaska. Design AHT cases among children residing in Alaska during 2005–2010 were identified by applying the PAHT coding schema to a multi-source database which included vital death records, the Violent Death Reporting System (AK-VDRS), the Maternal Infant Mortality Review – Child Death Review (MIMR-CDR), the Alaska Trauma Registry (ATR), the inpatient Hospital Discharge Database (HDD) and Medicaid claims. Using these data, we calculated statewide AHT annual incidence rates. Results The databases with the highest case capture rates were the ATR and Medicaid systems, both at 51%, followed by HDD at 38%. Combined, the ATR, HDD and Medicaid systems captured 91% of all AHT cases. The linkage and use of the PAHT definitions yielded an estimated sensitivity of 91% and specificity of 98%. During the study period, we detected an annual average incidence of 34.4 cases per 100,000 children aged <2 years (95% CI 25.1, 46.1) and a case fatality proportion of 22% (10/45). Among the AHT cases, 82% were infants. Significant differences (p < 0.05) in AHT were noted by age and race, but not by sex. Conclusions In Alaska, applying the CDC PAHT definition to the multi-source database enabled us to capture 49% more AHT cases than any of the individual database used in this analysis alone.

Quantifying sources of bias in longitudinal data linkage studies of child abuse and neglect: measuring impact of outcome specification, linkage error, and partial cohort follow-up

BackgroundHealth informatics projects combining statewide birth populations with child welfare records have emerged as a valuable approach to conducting longitudinal research of child maltreatment. The potential bias resulting from linkage misspecification, partial cohort follow-up, and outcome misclassification in these studies has been largely unexplored. This study integrated epidemiological survey and novel administrative data sources to establish the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project. Using these data we evaluated and quantified the impact of non-linkage misspecification and single source maltreatment ascertainment use on reported maltreatment risk and effect estimates.MethodsThe ALCANLink project integrates the 2009–2011 Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) sample with multiple administrative databases through 2014, including one novel administrative source to track out-of-state emigration. For this project we limited our analysis to the 2009 PRAMS sample. We report on the impact of linkage quality, cohort follow-up, and multisource outcome ascertainment on the incidence proportion of reported maltreatment before age 6 and hazard ratios of selected characteristics that are often available in birth cohort linkage studies of maltreatment.ResultsFailure to account for out-of-state emigration biased the incidence proportion by 12% (from 28.3%w to 25.2%w), and the hazard ratio (HR) by as much as 33% for some risk factors. Overly restrictive linkage parameters biased the incidence proportion downwards by 43% and the HR by as much as 27% for some factors. Multi-source linkages, on the other hand, were of little benefit for improving reported maltreatment ascertainment.ConclusionUsing the ALCANLink data which included a novel administrative data source, we were able to observe and quantify bias to both the incidence proportion and HR in a birth cohort linkage study of reported child maltreatment. Failure to account for out-of-state emigration and low-quality linkage methods may induce bias in longitudinal data linkage studies of child maltreatment which other researchers should be aware of. In this study multi-agency linkage did not lead to substantial increased detection of reported maltreatment. The ALCANLink methodology may be a practical approach for other states interested in developing longitudinal birth cohort linkage studies of maltreatment that requires limited resources to implement, provides comprehensive data elements, and can facilitate comparability between studies.

Classification of maltreatment-related mortality by Child Death Review teams: How reliable are they?

Accurate estimation of the incidence of maltreatment-related child mortality depends on reliable child fatality review. We examined the inter-rater reliability of maltreatment designation for two Alaskan Child Death Review (CDR) panels. Two different multidisciplinary CDR panels each reviewed a series of 101 infant and child deaths (ages 0-4 years) in Alaska. Both panels independently reviewed identical medical, autopsy, law enforcement, child welfare, and administrative records for each death utilizing the same maltreatment criteria. Percent agreement for maltreatment was 64.7% with a weighted Kappa of 0.61 (95% CI 0.51, 0.70). Across maltreatment subtypes, agreement was highest for abuse (69.3%) and lowest for negligence (60.4%). Discordance was higher if the mother was unmarried or a smoker, if residence was rural, or if there was a family history of child protective services report(s). Incidence estimates did not depend on which panels data were used. There is substantial room for improvement in the reliability of CDR panel assessment of maltreatment related mortality. Standardized decision guidance for CDR panels may improve the reliability of their data.

Maternal Intimate Partner Violence Victimization Before and During Pregnancy and Postbirth Child Welfare Contact A Population-Based Assessment

We conducted a population-based prospective cohort study to help elucidate the predictive relationship between a maternal prebirth selfreported history of intimate partner violence (IPV) and any postbirth reported allegation to Child Protective Services (CPS) by age 2. We linked data from the 2009–2010 Alaska Pregnancy Risk Assessment Monitoring System with CPS data through 2012. Among this cohort, we found that 8.0%w self-reported experiencing IPV 12 months prior or during pregnancy, and 8.0%w of the offspring experienced at least one CPS report of alleged maltreatment during the study period. The predictive relationship varied by maternal educational attainment. Among mothers with 12+ years education completed, the odds of a CPS report were 3.9 times compared to those with no IPV, while among mothers with <12 years education completed, no association was noted. These results suggest that for a subset of Alaskan families, maternal history of IPV is a strong independent predictor of future CPS contact.

Pathway to Hope: an indigenous approach to healing child sexual abuse

Background The Alaska Native (AN) population has endured multiple historical traumatic events. This population has poorer health outcomes on nearly all factors compared with Alaska non-Natives with more than 75% reportedly being physically assaulted in their lifetime, and child sexual abuse nearly 6 times the national average. Objective This article describes the Pathway to Hope (PTH) program, which is an indigenous approach to ending silence and denial related to child sexual abuse and encourages multigenerational healing. Design PTH was developed by ANs who believe that each community is unique, thus strategies for ending denial and support for healing must be woven from the historical context, cultural strengths of individual communities. Strengths-based solutions built on truth, honesty, compassion and shared responsibility for healing and protecting todays children have been profound and successful. The PTH curriculum addresses child sexual abuse from a historical perspective; that the higher rates of sexual abuse among certain Tribes, regions and communities is linked in part to years of victimisation, but may also be perpetuated by internalised oppression and lateral violence among Tribal members. Results Data suggest that community-based dialogue and wisdom of Native elders and spiritual leaders paired with readiness of community service providers are necessary for sustained change. At all levels, this Indigenous model for learning, sharing, helping and healing brings hope for an end to denial and silence about child sexual abuse for Native people. Conclusion The PTH program utilises the wisdom and values that have sustained Native people for generations. Ending silence and denial about child sexual abuse and building upon strengths have assisted many Indigenous communities begin the journey toward wellness. Through the PTH, communities have taken steps to accept the challenges associated with establishing safety for children, supporting child victims in healing and to holding offenders accountable.

288 Inter-rater reliability of Child Death Review team classification of child maltreatment

Background The US Child Death Review (CDR) multi-disciplinary team consensus process uses tiered maltreatment definitions that allow for a degree of uncertainty. Individual heterogeneity is thought to normalise within the context of the CDR team resulting in reliable consensus determinations. This assumption has never been tested. The Alaska CDR tiered maltreatment designations were used to assess the polytomous maltreatment classification. Methods We used a mixed-methods inter-rater reliability framework to test the reliability of abuse, neglect, and gross-negligence classifications through CDR consensus review. All children born in 2009–10 who died in Alaska through 2014 were eligible for inclusion (n = 116); after exclusions 101 cases were re-reviewed. Approximately half of the cases were included with normal monthly reviews, the rest were reviewed at an annual committee “blitz” review. Results Total percent agreement was 64.7% with a weighted Kappa of 0.61 (95% CI: 0.51, 0.70). The percent agreement was 69.3% for abuse, 64.4% for neglect, and 60.4% for gross-negligence. Agreement was much less among infant deaths compared to child deaths (0.48 vs 0.77; p = 0.001) and unmarried mothers at birth (0.47 vs 0.74; p = 0.005). Incidence estimates per 1,000 live births are statistically equivalent between the initial and subsequent review for yes/yes probably any maltreatment and by maltreatment type. Conclusions This is the first known reliability study of CDR team classification of tiered maltreatment death classification. Not unexpectedly, substantial agreement was observed for abuse and only moderate agreement for neglect and negligence classifications. Discordance is related to missing or unknown information and the interpretation of identified risk factors. Due to these limitations, standardised death scene investigations for all infant and child deaths are invaluable and implementing a systematic decision tree metric is necessary to produce more reliable estimates.

660 Child death review: an effective approach to understanding and preventing child injury deaths

Background Child Death Review (CDR) is the multi-disciplinary case review of preventable child deaths. All fifty states in the United States, several Indian Tribes and Guam have well established CDR programs. A number of other countries, including Australia, New Zealand and the United Kingdom also have CDR programs. There is wide variation in the quality of CDR reviews. A majority of states utilise the National CDR Case Reporting System, a standardised system that collects and allows analysis of findings from the reviews. This educational session will present. Objectives Understand the purpose and function of child death review. Develop knowledge and skills in establishing a multidisciplinary CDR team that reviews all injury deaths of children ages 0–19. Develop skills in conducting an effective review team meeting. Develop skills in developing recommendations for evidence-based prevention strategies. using CDR findings and data. Results This session is designed to provide an overview on CDR, a description of the status of CDR in the United States and other countries, and then provide information on developing and implementing quality CDR reviews. Attendees will be given program materials from the US CDR Resource Centre at the National Centre of Fatality Reviews. Participants will participate in a mock case review of child injury deaths including infant suffocation, drowning, motor vehicle and child abuse. The intent of the session is to build capacity of participants to effectively develop and manage their own review programs within their own local context. Data from the US CDR Case reporting system will be shared so that participants understand how review data can be used effectively to develop and implement policies, practices and programs that prevent child injury deaths. Conclusions is an effective approach to galvanising community and state level injury prevention programs and policy.