Wendy Gwirtzman Lane

Pediatric Primary Care to Help Prevent Child Maltreatment: The Safe Environment for Every Kid (SEEK) Model

CONTEXT. Effective strategies for preventing child maltreatment are needed. Few primary care–based programs have been developed, and most have not been well evaluated. OBJECTIVE. Our goal was to evaluate the efficacy of the Safe Environment for Every Kid model of pediatric primary care in reducing the occurrence of child maltreatment. METHODS. A randomized trial was conducted from June 2002 to November 2005 in a university-based resident continuity clinic in Baltimore, Maryland. The study population consisted of English-speaking parents of children (0–5 years) brought in for child health supervision. Of the 1118 participants approached, 729 agreed to participate, and 558 of them completed the study protocol. Resident continuity clinics were cluster randomized by day of the week to the model (intervention) or standard care (control) groups. Model care consisted of (1) residents who received special training, (2) the Parent Screening Questionnaire, and (3) a social worker. Risk factors for child maltreatment were identified and addressed by the resident physician and/or social worker. Standard care involved routine pediatric primary care. A subset of the clinic population was sampled for the evaluation. Child maltreatment was measured in 3 ways: (1) child protective services reports using state agency data; (2) medical chart documentation of possible abuse or neglect; and (3) parental report of harsh punishment via the Parent-Child Conflict Tactics scale. RESULTS. Model care resulted in significantly lower rates of child maltreatment in all the outcome measures: fewer child protective services reports, fewer instances of possible medical neglect documented as treatment nonadherence, fewer children with delayed immunizations, and less harsh punishment reported by parents. One-tailed testing was conducted in accordance with the study hypothesis. CONCLUSIONS. The Safe Environment for Every Kid (SEEK) model of pediatric primary care seems promising as a practical strategy for helping prevent child maltreatment. Replication and additional evaluation of the model are recommended.

Screening for Depression in an Urban Pediatric Primary Care Clinic

OBJECTIVES. The goals were to estimate the prevalence of parental depressive symptoms among parents at a pediatric primary care clinic and to evaluate the stability, sensitivity, specificity, and positive and negative predictive values of a very brief screen for parental depression. METHODS. A total of 216 mothers (because 96% of caregivers were mothers, we use this term) bringing in children <6 years of age for child health supervision completed a parent screening questionnaire in a primary care clinic. The parent screening questionnaire, a brief screen for psychosocial problems developed for the study, includes 2 questions on depressive symptoms. Mothers then completed the computerized study protocol within 2 months. This included the parent screening questionnaire as well as the Beck Depression Inventory II. Different combinations of the depression questions were evaluated against Beck Depression Inventory II clinical cutoff values. RESULTS. Twelve percent of the mothers met the Beck Depression Inventory II clinical cutoff value for at least moderate depressive symptoms. There was moderate stability of the screening questions. When a positive response to either or both of the 2 questions was considered, the sensitivity was 74%, the specificity was 80%, the positive predictive value was 36%, and the negative predictive value was 95%. CONCLUSIONS. Maternal depressive symptoms are prevalent. A very brief screen can identify reasonably those who could benefit from additional evaluation and possible treatment. This should benefit mothers, families, and children.

The SEEK Model of Pediatric Primary Care: Can Child Maltreatment Be Prevented in a Low-Risk Population?

OBJECTIVE To examine the effectiveness of the Safe Environment for Every Kid (SEEK) model of enhanced pediatric primary care to help reduce child maltreatment in a relatively low-risk population. METHODS A total of 18 pediatric practices were assigned to intervention or control groups, and 1119 mothers of children ages 0 to 5 years were recruited to help evaluate SEEK by completing assessments initially and after 6 and 12 months. Childrens medical records and Child Protective Services data were reviewed. The SEEK model included training health professionals to address targeted risk factors (eg, maternal depression), the Parent Screening Questionnaire, parent handouts, and a social worker. Maltreatment was assessed 3 ways: 1) maternal self-report, 2) childrens medical records, and 3) Child Protective Services reports. RESULTS In the initial and 12-month assessments, SEEK mothers reported less Psychological Aggression than controls (initial effect size = -0.16, 95% confidence interval [95% CI] -0.27, -0.05, P = .006; 12-month effect size = -0.12, 95% CI -0.24, -0.002, P = .047). Similarly, SEEK mothers reported fewer Minor Physical Assaults than controls (initial effect size = -0.16, 95% CI -0.29, -0.03, P = .019; 12-month effect size = -0.14, 95% CI -0.28, -0.005, P = .043). There were trends in the same positive direction at 6 months, albeit not statistically significant. There were few instances of maltreatment documented in the medical records and few Child Protective Services reports. CONCLUSIONS The SEEK model was associated with reduced maternal Psychological Aggression and Minor Physical Assaults. Although such experiences may not be reported to protective services, ample evidence indicates their potential harm. SEEK offers a promising and practical enhancement of pediatric primary care.

What factors affect the identification and reporting of child abuse-related fractures?

Child abuse is a serious problem in the United States. Because orthopaedic surgeons are responsible for identifying and reporting suspicious fractures to child protective services, we asked two primary questions: (1) How skilled are orthopaedists in distinguishing abuse-related from noninflicted fractures and making appropriate child protective services reports?; and (2) Are decisions influenced by orthopaedist training or by the race or socioeconomic status of injured children? We developed and mailed a questionnaire containing 10 case vignettes to 974 US orthopaedists. Respondents assessed the likelihood of abuse and need to report to child protective services. Two versions of the questionnaire differed by the race and socioeconomic status of vignette families. Average respondent scores were 79% for correct diagnoses and 73% for correct reporting decisions. Pediatric orthopaedists had higher adjusted scores for identifying abuse-related versus noninflicted injuries (82% versus 73%) and for appropriately reporting to child protective services (76% versus 66%) compared with general orthopaedists. Both groups had difficulty distinguishing abuse-related from noninflicted long-bone fractures in infants and toddlers. We found no differences in appropriate identification or reporting of fractures by race but did find differences by social class. Additional training in identifying abuse-related long-bone fractures appears necessary. Orthopaedists should consider the potential for bias when assessing children with fractures for possible abuse.

Screening for Intimate Partner Violence in a Pediatric Primary Care Clinic

OBJECTIVES. To estimate the prevalence of intimate partner violence among parents at a pediatric primary care clinic and to evaluate the stability, sensitivity, specificity, positive and negative predictive values, and likelihood ratios of a very brief screen for intimate partner violence. METHODS. A total of 200 parents (mostly mothers) bringing in children less than 6 years of age for child health supervision completed the Parent Screening Questionnaire in a primary care clinic. The Parent Screening Questionnaire, a brief screen for psychosocial problems developed for the study, includes 3 questions on intimate partner violence. Mothers then completed the computerized study protocol within 2 months. This included the Parent Screening Questionnaire as well as the Revised Conflict Tactics Scale. Different combinations of the intimate partner violence questions were evaluated against the Revised Conflict Tactics Scale. RESULTS. A total of 12.0% of the mothers answered “yes” to at least one of the screening questions. On the standardized Revised Conflict Tactics Scale, responses ranged from 9% reporting a physical injury in the past year to 76% reporting psychological aggression. There was moderate stability of the screening questions. A single question, “Have you ever been in a relationship in which you were physically hurt or threatened by a partner?” in relation to the “physically injured” Revised Conflict Tactics Scale subscale was most effective. Sensitivity was 29%, specificity was 92%, positive predictive value was 41%, and negative predictive value was 88%. The positive likelihood ratio was 3.8, and the negative likelihood ratio was 0.77. CONCLUSIONS. Intimate partner violence is a prevalent problem. A very brief screen can reasonably identify some mothers who could benefit from additional evaluation and possible services. Additional research is needed to find a more sensitive screen and to examine whether identifying intimate partner violence leads to interventions that benefit mothers, families, and children.

Effect of Insulin Degludec vs Insulin Glargine U100 on Hypoglycemia in Patients With Type 1 Diabetes: The SWITCH 1 Randomized Clinical Trial.

Importance Hypoglycemia, common in patients with type 1 diabetes, is a major barrier to achieving good glycemic control. Severe hypoglycemia can lead to coma or death. Objective To determine whether insulin degludec is noninferior or superior to insulin glargine U100 in reducing the rate of symptomatic hypoglycemic episodes. Design, Setting, and Participants Double-blind, randomized, crossover noninferiority trial involving 501 adults with at least 1 hypoglycemia risk factor treated at 84 US and 6 Polish centers (January 2014-January 12, 2016) for two 32-week treatment periods, each with a 16-week titration and a 16-week maintenance period. Interventions Patients were randomized 1:1 to receive once-daily insulin degludec followed by insulin glargine U100 (n = 249) or to receive insulin glargine U100 followed by insulin degludec (n = 252) and randomized 1:1 to morning or evening dosing within each treatment sequence. Main Outcomes and Measures The primary end point was the rate of overall severe or blood glucose-confirmed (<56 mg/dL) symptomatic hypoglycemic episodes during the maintenance period. Secondary end points included the rate of nocturnal symptomatic hypoglycemic episodes and proportion of patients with severe hypoglycemia during the maintenance period. The noninferiority criterion for the primary end point and for the secondary end point of nocturnal hypoglycemia was defined as an upper limit of the 2-sided 95% CI for a rate ratio of 1.10 or lower; if noninferiority was established, 2-sided statistical testing for superiority was conducted. Results Of the 501 patients randomized (mean age, 45.9 years; 53.7% men), 395 (78.8%) completed the trial. During the maintenance period, the rates of overall symptomatic hypoglycemia were 2200.9 episodes per 100 person-years’ exposure (PYE) in the insulin degludec group vs 2462.7 episodes per 100 PYE in the insulin glargine U100 group for a rate ratio (RR) of 0.89 (95% CI, 0.85-0.94; P < .001 for noninferiority; P < .001 for superiority; rate difference, −130.31 episodes per 100 PYE; 95% CI, −193.5 to −67.16). The rates of nocturnal symptomatic hypoglycemia were 277.1 per 100 PYE in the insulin degludec group vs 428.6 episodes per 100 PYE in the insulin glargine U100 group, for an RR of 0.64 (95% CI, 0.56-0.73; P < .001 for noninferiority; P < .001 for superiority; rate difference, −61.94 episodes per 100 PYE; 95% CI, −83.85 to −40.03). A lower proportion of patients in the insulin degludec than in the insulin glargine U100 group experienced severe hypoglycemia during the maintenance period (10.3%, 95% CI, 7.3%-13.3% vs 17.1%, 95% CI, 13.4%-20.8%, respectively; McNemar P = .002; risk difference, −6.8%; 95% CI, −10.8% to −2.7%). Conclusions and Relevance Among patients with type 1 diabetes and at least 1 risk factor for hypoglycemia, 32 weeks’ treatment with insulin degludec vs insulin glargine U100 resulted in a reduced rate of overall symptomatic hypoglycemic episodes. Trial Registration clinicaltrials.gov Identifier: NCT02034513

Screening for Occult Abdominal Trauma in Children with Suspected Physical Abuse

OBJECTIVES: The goals were (1) to determine the prevalence of occult abdominal trauma (OAT) in a sample of children with suspected physical abuse, (2) to assess the frequency of OAT screening, and (3) to assess factors associated with screening. METHODS: Charts of children evaluated for abusive injury were identified through a search of hospital discharge codes. Identified charts were reviewed to determine whether OAT screening occurred. Data on results of screening tests, abusive injuries identified, family demographic features, and characteristics of the emergency department visit were collected. RESULTS: Screening occurred for 51 (20%) of 244 eligible children. Positive results were identified for 41% of those screened and 9% of the total sample; 5% of children 12 to 23 months of age had OAT identified through imaging studies. Screening occurred more often in children presenting with probable abusive head trauma (odds ratio [OR]: 20.4 [95% confidence interval [CI]: 3.6–114.6]; P < .01), compared with those presenting with other injuries. Consultation with the child protection team (OR: 8.5 [95% CI: 3.5–20.7]; P < .01) and other subspecialists (OR: 24.3 [95% CI: 7.1–83.3]; P < .01) also increased the likelihood that OAT screening would occur. CONCLUSIONS: Our findings support OAT screening with liver and pancreatic enzyme measurements for physically abused children. This study also supports the importance of subspecialty input, especially that of a child protection team. Although many identified injuries may not require treatment, their role in confirming or demonstrating increased severity of maltreatment may be critical.

Comparison of 3 Data Collection Methods for Gathering Sensitive and Less Sensitive Information

OBJECTIVE When gathering sensitive information about personal experiences such as child abuse, drug and alcohol use, and intimate partner violence (IPV), it is especially important for both research and clinical purposes to use optimal methods to limit socially desirable responses. The purpose of this paper is to determine which of the following 3 methods is optimal for gathering data: 1) face-to-face interviews, 2) self-administered paper and pencil questionnaires, or 3) audio computer-assisted self-interviews (ACASI). METHODS The sample consisted of 514 parents bringing their preschoolers (0-5 years) to a pediatric primary care clinic for a checkup. The parent screening questionnaire (PSQ) addressing psychosocial problems was completed by participants themselves. Participants completed the PSQ in 1 of 3 ways: paper and pencil, face-to-face interview, or directly onto a computer (ACASI). RESULTS In general, ACASI yielded the highest rates for sensitive problems such as social isolation and parental stress, with face-to-face interviews occupying an intermediate position. The differences between ACASI and self-administered paper and pencil questionnaires were significant for many items. The differences between ACASI and face-to-face interviews, however, were modest. There were no significant group differences among the 3 methods in the prevalence rates of the neutral, less sensitive items. CONCLUSION ACASI resulted in greater disclosure of sensitive information than did a paper and pencil approach. No significant differences were observed between the computer-assisted interview and the face-to-face interview, both done in a research setting. The 3 methods appeared similar when gathering less sensitive data.

Child abuse prevention

The past two decades have seen a dramatic rise in substantiated reports of child abuse in the United States. (cite NIS studies) National attention has followed with a shift toward focusing on prevention strategies to reduce the growing burden on the child welfare system. The shift of focus toward prevention of child abuse is not surprising, considering its appeal to a broader community, whether the goal is to provide more community based services or the strengthening of family values.

Update on child abuse prevention

Purpose of review Child abuse remains a significant problem in the United States with 2.9 million reports and 825 000 indicated cases in 2005. This report will highlight recent efforts toward child abuse prevention, focusing on home visiting programs, abusive head trauma primary prevention, parent training programs, sexual abuse prevention, and the effectiveness of laws banning corporal punishment. Recent findings Most home visitation programs have demonstrated a lack of effectiveness in recent randomized trials. One exception is the Nurse Family Partnership, which remains the most effective and longest enduring intervention for high-risk families. Child sexual abuse prevention programs and parent training programs need further evaluation with more rigorous methodology and outcome measures. Providing universal parent education about coping with crying infants appears to be effective in lowering the incidence of abusive head trauma. Although advocated for, further study will determine the effectiveness of laws banning corporal punishment or mandating abusive head trauma education to parents of newborns. Summary Pediatricians play an important role in the prevention of child maltreatment. Their knowledge of the effectiveness of different programs can help guide parents toward appropriate services.