Meghan E. Shanahan

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.

PROMOTING SUPPORTIVE PARENTING IN NEW MOTHERS WITH SUBSTANCE-USE PROBLEMS: A PILOT RANDOMIZED TRIAL OF RESIDENTIAL TREATMENT PLUS AN ATTACHMENT-BASED PARENTING PROGRAM

This pilot randomized trial tested the feasibility and efficacy of supplementing residential substance-abuse treatment for new mothers with a brief, yet rigorous, attachment-based parenting program. Twenty-one predominantly (86%) White mothers and their infants living together in residential substance-abuse treatment were randomly assigned to the program (n = 11) or control (n = 10) group. Program mothers received 10 home-based sessions of Doziers Attachment and Biobehavioral Catch-up (ABC) intervention. Postintervention observations revealed more supportive parenting behaviors among the randomly assigned ABC mothers.

Effectiveness of a Statewide Abusive Head Trauma Prevention Program in North Carolina

IMPORTANCE Abusive head trauma (AHT) is a serious condition, with an incidence of approximately 30 cases per 100,000 person-years in the first year of life. OBJECTIVE To assess the effectiveness of a statewide universal AHT prevention program. DESIGN, SETTING, AND PARTICIPANTS In total, 88.29% of parents of newborns (n = 405 060) in North Carolina received the intervention (June 1, 2009, to September 30, 2012). A comparison of preintervention and postintervention was performed using nurse advice line telephone calls regarding infant crying (January 1, 2005, to December 31, 2010). A difference-in-difference analysis compared AHT rates in the prevention program state with those of other states before and after the implementation of the program (January 1, 2000, to December 31, 2011). INTERVENTION The Period of PURPLE Crying intervention, developed by the National Center on Shaken Baby Syndrome, was delivered by nurse-provided education, a DVD, and a booklet, with reinforcement by primary care practices and a media campaign. MAIN OUTCOMES AND MEASURES Changes in proportions of telephone calls for crying concerns to a nurse advice line and in AHT rates per 100,000 infants after the intervention (June 1, 2009, to September 30, 2011) in the first year of life using hospital discharge data for January 1, 2000, to December 31, 2011. RESULTS In the 2 years after implementation of the intervention, parental telephone calls to the nurse advice line for crying declined by 20% for children younger than 3 months (rate ratio, 0.80; 95% CI, 0.73-0.87; P < .001) and by 12% for children 3 to 12 months old (rate ratio, 0.88; 95% CI, 0.78-0.99; P = .03). No reduction in state-level AHT rates was observed, with mean rates of 34.01 person-years before the intervention and 36.04 person-years after the intervention. A difference-in-difference analysis from January 1, 2000, to December 31, 2011, controlling for economic indicators, indicated that the intervention did not have a statistically significant effect on AHT rates (β coefficient, -1.42; 95% CI, -13.31 to 10.45). CONCLUSIONS AND RELEVANCE The Period of PURPLE Crying intervention was associated with a reduction in telephone calls to a nurse advice line. The study found no reduction in AHT rates over time in North Carolina relative to other states. Consequently, while this observational study was feasible and supported the program effectiveness in part, further programmatic efforts and evaluation are needed to demonstrate an effect on AHT rates.

Process evaluation of a statewide abusive head trauma prevention program

The current study used four dimensions of the RE-AIM framework (Reach, Adoption, Implementation, and Maintenance) to evaluate the implementation of a statewide abusive head trauma prevention program. Numerous methods, including telephone surveys, paper and pencil questionnaires, site visits, and program administrative data were used to conduct the process evaluation. Results indicate that the intervention was successfully implemented in all birthing hospitals (n=86) across the state with a high degree of fidelity. Furthermore, the majority of the hospitals reported incorporating the program into unit procedures and employee training. More than three-fourths indicated that they plan to continue the program after the study ends. The RE-AIM framework was applied and served as a useful guide for the process evaluation of a multifaceted, multi-system, universal public health intervention.

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.

Association of childhood abuse and prescription opioid use in early adulthood

INTRODUCTION Previous research has examined the association of childhood abuse with opioid misuse and dependence in adulthood. However, little research has focused specifically on prescription opioids, and no studies have examined associations with prescription opioid use, a potential pathway to later opioid misuse and dependence. The aim of the present study was to examine the association of childhood emotional, physical, and sexual abuse with prescription opioid use in early adulthood. METHODS We used data from Waves I (12-18years) and IV (24-32years) of the National Longitudinal Study of Adolescent to Adult Health. At Wave IV, respondents reported experiences of childhood abuse occurring prior to age 18years and prescription opioid use in the last four weeks. We conducted multivariable logistic regression to examine associations of childhood abuse with recent prescription opioid use. RESULTS In multivariable models adjusted for respondent sex, race/ethnicity, age, and socioeconomic status, childhood emotional abuse (OR=1.57, 95% CI 1.29, 1.90), physical abuse (OR=1.46, 95% CI 1.14, 1.87), and any childhood abuse (OR=1.51, 95% CI 1.24, 1.82) were significantly associated with recent prescription opioid use. CONCLUSIONS Given continued increases in prescription opioid use and opioid-related morbidity and mortality in the U.S., understanding upstream social and environmental factors associated with prescription opioid use is important to strengthening and expanding current prevention and intervention strategies. Future research is needed to examine factors potentially mediating the association between childhood abuse and prescription opioid use in order to provide additional insights for prevention and intervention efforts.

A Systematic Review of Interventions for Women Parenting in the Context of Intimate Partner Violence

Intimate partner violence (IPV) victimization is widespread among women with children and has negative consequences for both women’s and children’s well-being. Despite mixed evidence regarding the effect of IPV on women’s parenting ability and behaviors, there is an increasing focus on mothering in the context of IPV, particularly among the child welfare and child protection systems. To help respond to this increasing focus, several interventions have been developed that specifically target parenting among IPV-affected women. Given the growing numbers of these interventions, a comprehensive review is needed to help elucidate the approaches that are most effective in meeting the needs of IPV-affected women and children. Therefore, we conducted an in-depth systematic review of the literature to examine the approaches and effects of interventions designed to address aspects of parenting among IPV-affected women. We identified 26 articles concerned with 19 distinct interventions for review. We found substantial heterogeneity in intervention delivery, format, length, and focus. We noted several limitations of the existing studies in terms of study sample, measures, design, and implementation. Given the heterogeneity of the existing interventions and the limitations of the current research base, it is not yet clear which interventions or intervention components are most effective in addressing the unique needs of women parenting in the context of IPV. Further research is needed to address these limitations, and professionals working with IPV-affected families should be aware that current services may not meet women’s and children’s needs.

Prescription Opioid Use Among Young Parents in the United States: Results from the National Longitudinal Study of Adolescent to Adult Health

Objectives No estimates exist regarding the extent of prescription opioid use among US adults who are the primary caregivers to children. Methods Data were from Wave IV of the National Longitudinal Study of Adolescent to Adult Health. Respondents were age 24 to 32 years. We compared the prevalence of prescription opioid use in the last four weeks and medical conditions with the potential to precipitate use among parents (i.e., one or more children living in the household) and nonparents. We then examined demographics and substance use behaviors among parents with and without recent prescription opioid use. Results A significantly higher percentage of parents (6.7%) compared with nonparents (3.9%) had taken a prescription opioid in the last four weeks, but a significantly lower percentage of parents compared with nonparents reported medical conditions with the potential to precipitate use such as an injury in the last four weeks (2.8% vs 4.0%). A higher percentage of parents with recent prescription opioid use reported financial hardship (44.1% vs 28.2%) and met criteria for risky substance use behaviors such as prescription opioid misuse (26.3% vs 11.8%) compared with parents without recent prescription opioid use. Conclusions Results suggest notable prescription opioid use among young parents in the United States and that parents with recent prescription opioid use are more likely to have a history of inappropriate use of substances. These results highlight the need for additional research regarding the effects of prescription opioid use on parenting behaviors.

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.