Michelle Shouldice

Course of depression and anxiety symptoms during the transition to parenthood for female adolescents with histories of victimization

The aim of the current study was to increase understanding of how victimization history impacts the longitudinal course of depression and anxiety in a sample of 55 adolescents emerging into parenthood. Adolescents were interviewed about their victimization experiences during their second trimester of pregnancy, and interviews were subsequently classified according the Maltreatment Classification Scale (Barnett, Manly, & Cicchetti, 1993). Adolescents reported on their symptoms of depression and anxiety prenatally and 6 and 12 months postpartum. Growth curve modeling revealed that, on average, there was a steady linear decline in depression and anxiety symptoms across the transition to parenthood, with a rate of change of 25% and 20%, respectively, from the prenatal assessment to 12 months postpartum. Sexual abuse history attenuated the likelihood of a decrease in depressive symptoms over time. Neglect history was associated with higher prenatal levels of anxiety, as well as a steeper decline in anxiety symptoms over time. Future research is needed to determine the role of poly-victimization in predicting the onset and change of depression and anxiety symptoms. Findings from the current study have the potential to aid in the design of preventative and intervention efforts to reduce risks of mental health difficulties in adolescent parents.

Abusive head trauma: A perpetrator confesses

OBJECTIVES To present a detailed confession from a perpetrator of Shaken Baby syndrome. METHODS Case study. RESULTS We present a confession of Shaken Baby syndrome describing how the perpetrator severely injured a 3 year old with repeated bursts of acceleration-deceleration (shaking). The child sustained retinal and intracranial hemorrhage. Details of the confession and circumstances by which it was obtained lead us to believe its accuracy. CONCLUSIONS Accurate perpetrator confessions offer useful windows into realities and pathophysiology of abusive head trauma.

Characteristics of femur fractures in ambulatory young children

Objectives To determine and identify the characteristics and circumstances of femur fractures in ambulatory young children. Design and setting Retrospective review of 203 ambulatory children, between 1 and 5 years old, presenting with femur fractures to an urban paediatric hospital over a 10-year period. χ2 And Students t test were employed for statistical analysis. Results The mean age was 36.6 months, with 155 (76.2%) being male. The most frequent mechanism of injury was fall from a height (n=62, 30.5%). The highest number of injuries occurred in 2–3-year-olds. The most common history in 1–2-year-olds was stumbling on/over something causing a fall. For 4–5 year olds it was road traffic accidents. Other additional physical findings were infrequent (14.3%) and not suspicious of inflicted injury. Child protective services concluded three of the cases to be likely non-accidental, and four cases were inconclusive but requiring close follow-up. Of these seven children, six occurred in 1–2-year-olds. No distinguishing feature was noted in fracture type or location. Conclusions Femur fractures can occur with low velocity injury whether from a short fall or twisting/stumbling injury in young healthy ambulatory children.

Medical nonadherence in pediatric HIV: Psychosocial risks and intersection with the child protection system for medical neglect

Nonadherence to antiretroviral treatment has serious health implications for HIV-infected children, at times warranting referral to child protective services (CPS). The current study of 134 children with perinatally acquired HIV infection aimed to investigate rates of treatment adherence and CPS involvement, multilevel variables associated with nonadherence, and the manner in which these risks operated together in the prediction of adherence outcomes. Risk factors for nonadherence were grouped on the basis of confirmatory factor models, and factor score regression was carried out to determine which factors were uniquely predictive of adherence. A series of indirect effects models were then tested in order to examine how these factors operated together in the prediction of adherence. Results showed that almost half of the sample demonstrated suboptimal adherence to treatment, and in one-fifth, CPS was involved for medical neglect. Caregiver Health, Caregiver Involvement, Caregiver Acceptance, and Child Adaptation were predictive of nonadherence, and together explained 54% of the variance in treatment adherence. There were significant indirect effects of Caregiver Health on adherence that operated through Caregiver Involvement and Child Adaptation and an indirect effect of Caregiver Involvement on adherence through Child Adaptation. Findings extend current literature that has independently linked various factors predictive of medical adherence in pediatric HIV by showing separate but simultaneous associations with nonadherence and unique pathways to adherence involving multilevel risks. Healthcare and child welfare implications are discussed.

The role of prothrombotic factors in the ocular manifestations of abusive and non-abusive head trauma: A feasibility study

OBJECTIVES Retinal hemorrhage is a cardinal manifestation of abusive head injury. Thrombophilia is relatively common in the general population and in adults can be associated with retinal hemorrhage. The specificity of retinal hemorrhage for abusive head trauma in the presence of prothrombotic factors, in particular following non-abusive head trauma, has not been investigated. Our objective was to determine whether the hypothesis that prothrombotic factors affect specificity of retinal hemorrhage to AHT can be tested. This may have important ramifications both for diagnosis and expert witness testimony. METHODS To investigate the feasibility of studying this issue, we conducted a prospective cohort study of children with abusive and non-abusive head trauma. Thrombophilia screening and ophthalmic examinations were performed. RESULTS Six of 30 admitted children were fully enrolled. Enrollment obstacles included caregiver stress, animosity towards allegations of abuse, child protection services involvement, and research phlebotomy coordination. Prevalence of thrombophilia was high in children with retinal hemorrhage and in 1 case the question of hemorrhage adjudicated as abuse was considered in light of a history of a fall. CONCLUSION We estimate that to answer the critical question of retinal hemorrhage specificity for abuse in the presence of thrombophilia will require 53 centers for a 1 year study or 18 centers for a 3-year study. We identify potential obstacles and interventions.

Social pediatrics: weaving horizontal and vertical threads through pediatric residency

BackgroundSocial pediatrics teaches pediatric residents how to understand disease within their patients’ social, environmental and political contexts. It’s an essential component of pediatric residency training; however there is very little literature that addresses how such a broad-ranging topic can be taught effectively. The aim of this study was to determine and characterize social pediatric education in our pediatric residency training in order to identify strengths and gaps.MethodsA social pediatrics curriculum map was developed, attending to 3 different dimensions: (1) the intended curriculum as prescribed by the Objectives of Training for Pediatrics of the Royal College of Physicians and Surgeons of Canada (RCPSC), (2) the formal curriculum defined by rotation-specific learning objectives, and (3) the informal/hidden curriculum as reflected in resident and teacher experiences and perceptions.ResultsForty-one social pediatric learning objectives were extracted from the RCPSC Objectives of Training for Pediatrics, most were listed in the Medical Expert (51%) and Health Advocate competencies (24%). Almost all RCPSC social pediatric learning objectives were identified in more than one rotation and/or seminar. Adolescent Medicine (29.2%), Pediatric Ambulatory Medicine (26.2%) and Developmental Pediatrics (25%) listed the highest proportion of social pediatric learning objectives. Four (10%) RCPSC social pediatric objectives were not explicitly named within learning objectives of the formal curriculum. The informal curriculum revealed that both teachers and residents viewed social pediatrics as integral to all clinical encounters. Perceived barriers to teaching and learning of social pediatrics included time constraints, particularly in a tertiary care environment, and the value of social pediatrics relative to medical expert knowledge.ConclusionsDespite the lack of an explicit thematic presentation of social pediatric learning objectives by the Royal College and residency training program, social pediatric topics are integrated, taught and learned throughout the entire curriculum. Special attention needs to be given to the hidden curriculum and system barriers that may impede social pediatric education.

Obligation to Report and Normal Controls

There are no clear guidelines addressing whether a duty exists in a research-subject relationship to report child maltreatment and endangerment unveiled in research studies involving normal children. Researchers may have concerns about taking personal and professional risks by reporting suspected injury particularly if the researcher is not adequately trained in the area of abuse. Researchers may have concerns regarding the risk-benefit ratio of reporting, thresholds for reporting, and their own certainty about the information received. Researcher reporting may also be in conflict with ongoing child abuse interventions that are not known to the researcher. Research involving children and child endangerment relies upon children responding accurately to sensitive questions regarding abuse. If not, then data may be inaccurate or incomplete. There may also be obligations to forewarn parents/guardians that such information is being collected and what implications this may have in terms of reporting, intervention and protection.

Informed Consent and Deception

In this chapter, we discuss informed consent, assent, and deception. In child abuse research, several unique scenarios exist relating to obtaining informed consent. First, for a child subject whose parents may be suspected of abuse, it can be argued that they are not able to act in the child’s best interest and thus not able to provide consent. Second, a child who is a ward of the state/crown has substitute parents/foster parents with limited decision-making power. Lastly, situations may exist where information needs to be obtained from a third party (such as a school or daycare) as part of a research study. Each of these situations raises questions relating to informed consent. Assent of a child subject also introduces challenges in the context of child abuse research. How to obtain assent from an abused child and how much information is necessary are subjects of much debate. Finally, there are circumstances where the disclosure of the purpose of a research study to a potential subject could influence the participation and/or actions of that subject in the study. This concept of ‘non-disclosure’ is separate and distinct from ‘deception’ in that deception involves the process of misleading a subject.