Maureen S. Durkin

Grand challenges in global mental health

A consortium of researchers, advocates and clinicians announces here research priorities for improving the lives of people with mental illness around the world, and calls for urgent action and investment.

Epidemiology and Prevention of Traffic Injuries to Urban Children and Adolescents

Objectives. To describe the incidence of severe traffic injuries before and after implementation of a comprehensive, hospital-initiated injury prevention program aimed at the prevention of traffic injuries to school-aged children in an urban community. Materials and Methods. Hospital discharge and death certificate data on severe pediatric injuries (ie, injuries resulting in hospital admission and/or death to persons age <17 years) in northern Manhattan over a 13-year period (1983–1995) were linked to census counts to compute incidence. Rate ratios with 95% CIs, both unadjusted and adjusted for annual trends, were calculated to test for a change in injury incidence after implementation of the Harlem Hospital Injury Prevention Program. This program was initiated in the fall of 1988 and continued throughout the study period. It included 1) school and community based traffic safety education implemented in classroom settings in a simulated traffic environment, Safety City, and via theatrical performances in community settings; 2) construction of new playgrounds as well as improvement of existing playgrounds and parks to provide expanded off-street play areas for children; 3) bicycle safety clinics and helmet distribution; and 4) a range of supervised recreational and artistic activities for children in the community. Primary Results. Traffic injuries were a leading cause of severe childhood injury in this population, accounting for nearly 16% of the injuries, second only to falls (24%). During the preintervention period (1983–1988), severe traffic injuries occurred at a rate of 147.2/100 000 children <17 years per year. Slightly <2% of these injuries were fatal. Pedestrian injuries accounted for two thirds of all severe traffic injuries in the population. Among school-aged children, average annual rates (per 100 000) of severe injuries before the intervention were 127.2 for pedestrian, 37.4 for bicyclist, and 25.5 for motor vehicle occupant injuries. Peak incidence of pedestrian and bicyclist injuries occurred during the summer months and afternoon hours, whereas motor vehicle occupant injuries showed little seasonal variation and were more common during evening and night-time hours. Age-specific rates showed peak incidence of pedestrian injuries among 6- to 10-year-old children, of bicyclist injuries among 9- to 15-year-old children, and of motor vehicle occupant injuries among adolescents between the ages of 12 and 16 years. The peak age for all traffic injuries combined was 15 years, an age at which nearly 3 of every 1000 children each year in this population sustained a severe traffic injury. Among children hospitalized for traffic injuries during the preintervention period, 6.3% sustained major head trauma (including concussion with loss of consciousness for ≥1 hour, cerebral laceration and/or cerebral hemorrhage), and 36.9% sustained minor head trauma (skull fracture and/or concussion with no loss of consciousness ≥1 hour and no major head injury). The percentage of injured children with major and minor head trauma was higher among those injured in traffic than among those injured by all other means (43.2% vs 14.2%, respectively; χ2 = 336; degrees of freedom = 1). The percentages of children sustaining head trauma were 45.4% of those who were injured as pedestrians, 40.2% of those who were injured as bicyclists, and 38.9% of those who were injured as motor vehicle occupants. During the intervention period, the average incidence of traffic injuries among school aged children declined by 36% relative to the preintervention period (rate ratio: .64; 95% CI: .58, .72). After adjusting for annual trends in incidence, pedestrian injuries declined during the intervention period among school aged children by 45% (adjusted rate ratio: .55; 95% CI: .38, .79). No comparable reduction occurred in nontargeted injuries among school-aged children (adjusted rate ratio: .89; 95% CI: .72, 1.09) or in traffic injuries among younger children who were not targeted specifically by the program (adjusted rate ratio: 1.32; 95% CI: .57, 3.07). Conclusion. Child traffic injuries, particularly those involving pedestrians, are a major public health problem in urban communities. Although the incidence of child pedestrian injuries is declining nationally and internationally, perhaps attributable to declines in walking, this trend may not be applicable in inner city communities such as northern Manhattan, in which walking remains a dominant mode of transportation. Community interventions involving the creation of safe and accessible play areas as well as traffic safety education and supervised activities for school-aged children may be effective in preventing traffic injuries to children in these communities. Additional controlled evaluations are needed to confirm the benefits of such interventions.

Validity of the Ten Questions screen for childhood disability: Results from population-based studies in Bangladesh, Jamaica, and Pakistan

An international study to validate the Ten Questions screen for serious childhood disability was undertaken in communities in Bangladesh, Jamaica, and Pakistan, where community workers screened more than 22,000 children ages 2–9 years. All children who screened positive, as well as random samples of those who screened negative, were referred for clinical evaluations. Applying comparable diagnostic criteria, the sensitivity of the screen for serious cognitive, motor, and seizure disabilities is acceptable (80–100%) in all three populations, whereas the positive predictive values range from 3 to 15%. These results confirm the usefulness of the Ten Questions as a low-cost and rapid screen for these disabilities, although not for vision and hearing disabilities, in populations where few affected children have previously been identified and treated. They also show that the value of the Ten Questions for identifying disability in underserved populations is limited to that of a screen; more thorough evaluations of children screened positive are necessary to distinguish true- from false-positive results and to identify the nature of the disability if present.

Environment and obesity in the National Children's Study.

Objective In this review we describe the approach taken by the National Children’s Study (NCS), a 21-year prospective study of 100,000 American children, to understanding the role of environmental factors in the development of obesity. Data sources and extraction We review the literature with regard to the two core hypotheses in the NCS that relate to environmental origins of obesity and describe strategies that will be used to test each hypothesis. Data synthesis Although it is clear that obesity in an individual results from an imbalance between energy intake and expenditure, control of the obesity epidemic will require understanding of factors in the modern built environment and chemical exposures that may have the capacity to disrupt the link between energy intake and expenditure. The NCS is the largest prospective birth cohort study ever undertaken in the United States that is explicitly designed to seek information on the environmental causes of pediatric disease. Conclusions Through its embrace of the life-course approach to epidemiology, the NCS will be able to study the origins of obesity from preconception through late adolescence, including factors ranging from genetic inheritance to individual behaviors to the social, built, and natural environment and chemical exposures. It will have sufficient statistical power to examine interactions among these multiple influences, including gene–environment and gene–obesity interactions. A major secondary benefit will derive from the banking of specimens for future analysis.

Measures of socioeconomic status for child health research : comparative results from Bangladesh and Pakistan

This paper examines the reliability and validity of several hypothesized indicators of socioeconomic status for use in epidemiologic research, particularly in studies of child health in the less developed world. Population-based surveys of child health and disability were completed in Bangladesh and Pakistan using standard questionnaires designed to measure four domains of household socioeconomic status: wealth, housing, parental education and occupation. Test-retest data indicate moderate to excellent reliability of most of the socioeconomic indicators in both countries. Loadings from factor analyses of the survey data provide further evidence of the reliability of the data, and confirm that the questionnaire measures housing and wealth as distinct domains in both countries. Parental education and occupation are correlated with housing and/or wealth in these data sets. Bivariate logistic regression analyses show that, although 11 of 12 dichotomous indicators of low socioeconomic status constructed from the data are predictive of child death in at least one of the four sub-populations studied (rural and urban Bangladesh, and rural and urban areas of Karachi, Pakistan), no single indicator is predictive of child death in all four sub-populations. These along with multivariate results demonstrate the importance of including multiple measures of distinct domains if the research aims include investigation and/or control of the effects of socioeconomic status on health in diverse populations.

Children who are shot: A 30-year experience

Three data sets describe the pattern of gunshot injuries to children from 1960 to 1993: The Harlem Hospital pediatric trauma registry (HHPTR), the northern Manhattan injury surveillance system (NMISS) a population-based study, and the National Pediatric Trauma Registry (NPTR). A small case-control study compares the characteristics of injured children with a control group. Before 1970 gunshot injuries to Harlem children were rare. In 1971 an initial rise in pediatric gunshot admissions occurred, and by 1988 pediatric gunshot injuries at Harlem Hospital had peaked at 33. Population-based data through NMISS showed that the gunshot rate for Central Harlem children 10 to 16 years of age rose from 64.6 per 100,000 in 1986 to 267.6 per 100,000 in 1987, a 400% increase. The case fatality for children admitted to Harlem Hospital (1960 to 1993) was 3%, usually because of brain injury, but the majority of deaths occurred before hospitalization. During the same period, felony drug arrests in Harlem increased by 163%. The neighboring South Bronx experienced the same increase in gunshot wound admissions and felony arrests from 1986 to 1993. The NPTR showed a similar injury pattern for other communities in the United States. In a case-control analysis. Harlem adolescents who had sustained gunshot wounds were more likely to have dropped out of school, to have lived in a household without a biological parent, to have experienced parental death, and to have known of a relative or friend who had been shot than community adolescents treated for other medical or surgical problems.(ABSTRACT TRUNCATED AT 250 WORDS)

A National Program for Injury Prevention in Children and Adolescents: The Injury Free Coalition for Kids

Injury is the leading cause of death and a major source of preventable disability in children. Mechanisms of injury are rooted in a complex web of social, economic, environmental, criminal, and behavioral factors that necessitate a multifaceted, systematic injury prevention approach. This article describes the injury burden and the way physicians, community coalitions, and a private foundation teamed to impact the problem first in an urban minority community and then through a national program. Through our injury prevention work in a resource-limited neighborhood, a national model evolved that provides a systematic framework through which education and other interventions are implemented. Interventions are aimed at changing the community and home environments physically (safe play areas and elimination of community and home hazards) and socially (education and supervised extracurricular activities with mentors). This program, based on physician-community partnerships and private foundation financial support, expanded to 40 sites in 37 cities, representing all 10 US trauma regions. Each site is a local adaptation of the Injury Free Coalition model also referred to as the ABC’s of injury prevention: A, “analyze injury data through local injury surveillance”; B, “build a local coalition”; C, “communicate the problem and raise awareness that injuries are a preventable public health problem”; D, “develop interventions and injury prevention activities to create safer environments and activities for children”; and E, “evaluate the interventions with ongoing surveillance.” It is feasible to develop a comprehensive injury prevention program of national scope using a voluntary coalition of trauma centers, private foundation finaccial and technical support, and a local injury prevention model with a well-established record of reducing and sustaining lower injury rates for inner-city children and adolescents.

A Comparison of Efficacy of the Key Informant and Community Survey Methods in the Identification of Childhood Disability in Jamaica

A comparison of the efficacy of the key informant and the community survey methods for identifying children with disability was carried out in the Jamaican component of an international epidemiological study of childhood disability. Approximately 130 key informants were exposed to a 2-day workshop giving information on signs of disability, aspects of the project, and available services. Questionnaires were given to enable the informants to refer children and they were reminded 6 months later. In the survey method, eight community workers completed a house-to-house survey of all families and administered the 10-question screen with probes on 5475 children, 2 to 9 years old. Seventeen referrals were made by the key informants; of these, two were found to have disabilities. Of the 821 children who tested positive on the 10-question screen in the house-to-house survey, 193 had disabilities. We concluded that the key informant method would not be a satisfactory way of identifying cases of childhood disability.

Studies of children in developing countries. How soon can we prevent neurodisability in childhood

Neurodevelopmental disability is a functional limitation due to a neurological disorder with an onset early in life and occurs across a range of domains: cognition, movement, seizure disorders, vision, hearing, and behaviour. Disability can occur within a single domain or involve more than one domain in the case of multiple disabilities. Disabilities can be caused by a variety of etiological insults, many of which are preventable at a primary, secondary, or tertiary level. Neurodevelopmental disabilities are an important but largely unaddressed problem in low-income countries (Durkin et al. 1991). For this paper, the term ‘developing countries’ includes low-income countries with few professional and institutional health resources and inadequate infrastructure to deliver known effective preventive or rehabilitative measures nationally. It is understood that higher-income countries may also fail to address the challenges faced in preventing disability or in effective rehabilitation. Though many of the causes of neurodevelopmental disabilities in children in developing countries are identical to those in developed countries, there are causes which have an impact solely in developing countries such as cerebral malaria or trachoma. The prevalence of a disabilitywill increase or decrease in any given population depending on a variety of factors: for example, age distribution of the population, prevalence of the causal agents, availability of preventive measures or of initial treatment, and the longevity of those at risk. As a result, the epidemiology of neurodevelopmental disabilities show a markedly different pattern in developing countries than in the developed world.

Classification of mental retardation.

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