RESUMO
OBJECTIVE: To identify barriers and facilitators of evaluating children exposed to caregiver intimate partner violence (IPV) and develop a strategy to optimize the evaluation. STUDY DESIGN: Using the EPIS (Exploration, Preparation, Implementation, and Sustainment) framework, we conducted qualitative interviews of 49 stakeholders, including emergency department clinicians (n = 18), child abuse pediatricians (n = 15), child protective services staff (n = 12), and caregivers who experienced IPV (n = 4), and reviewed meeting minutes of a family violence community advisory board (CAB). Researchers coded and analyzed interviews and CAB minutes using the constant comparative method of grounded theory. Codes were expanded and revised until a final structure emerged. RESULTS: Four themes emerged: (1) benefits of evaluation, including the opportunity to assess children for physical abuse and to engage caregivers; (2) barriers, including limited evidence about the risk of abuse in these children, burdening a resource-limited system, and the complexity of IPV; (3) facilitators, including collaboration between medical and IPV providers; and (4) recommendations for trauma- and violence-informed care (TVIC) in which a child's evaluation is leveraged to link caregivers with an IPV advocate to address the caregiver's needs. CONCLUSIONS: Routine evaluation of IPV-exposed children may lead to the detection of physical abuse and linkage to services for the child and the caregiver. Collaboration, improved data on the risk of child physical abuse in the context of IPV and implementation of TVIC may improve outcomes for families experiencing IPV.
Assuntos
Maus-Tratos Infantis , Violência Doméstica , Violência por Parceiro Íntimo , Criança , Humanos , Cuidadores , Maus-Tratos Infantis/diagnóstico , Pesquisa QualitativaRESUMO
OBJECTIVES: Children's insurance coverage, through increased access and use of the healthcare system, may increase the likelihood that healthcare professionals (HCPs) will detect and report child maltreatment. We sought to estimate the association between insurance coverage for children and reporting of child maltreatment by HCPs. STUDY DESIGN: We conducted a cross-sectional study of US counties from 2008 to 2015 using data from the US Census Bureau's Small Area Health Insurance Estimates, National Center for Health Statistics, and National Child Abuse and Neglect Data System. The primary predictor was counties' percent of children insured. We controlled for counties' children living at ≤200% federal poverty level, race/ethnicity demographics, and urban-rural status. The primary outcome was the rate of maltreatment reporting from HCPs. Generalized linear mixed effects models with repeated measures across years tested associations. RESULTS: We included 5517 county-year observations involving 470â876â018 child-years. Counties' percent of children insured ranged from 74.6% to 99.2% with a median of 93.7% (IQR, 91.0-95.4). For every 1 percentage point increase in counties' percent of children insured, there was an associated 2% increase in child maltreatment reporting by HCPs (adjusted incidence rate ratio, 1.02; 95% CI, 1.02-1.03). If counties' percentage of insured children had been 1 percentage point greater in 2015, a predicted 5620 (95% CI, 5620-8089) additional reports would have been generated. CONCLUSIONS: Among its other benefits for children's well-being, insurance coverage may also contribute to child protection by increasing the reporting of maltreatment among HCPs.
Assuntos
Atitude do Pessoal de Saúde , Maus-Tratos Infantis/diagnóstico , Cobertura do Seguro , Notificação de Abuso , Criança , Estudos Transversais , Humanos , Cobertura do Seguro/estatística & dados numéricos , Estados UnidosRESUMO
OBJECTIVE: To assess interrater reliability and accuracy of an expert panel in classifying injuries of patients as abusive or accidental based on comprehensive case information. STUDY DESIGN: Data came from a prospective, observational, multicenter study investigating bruising characteristics of children younger than 4 years. We enrolled 2166 patients with broad ranges of illnesses and injuries presenting to one of 5 pediatric emergency departments in whom bruises were identified during examination. We collected comprehensive data regarding current and past injuries and illnesses, and provided deidentified, standardized case information to a 9-member multidisciplinary panel of experts with extensive experience in pediatric injury. Each panelist classified cases using a 5-level ordinal scale ranging from definite abuse to definite accident. Panelists also assessed whether report to child protective services (CPS) was warranted. We calculated reliability coefficients for likelihood of abuse and decision to report to CPS. RESULTS: The interrater reliability of the panelists was high. The Kendall coefficient (95% CI) for the likelihood of abuse was 0.89 (0.87, 0.91) and the kappa coefficient for the decision to report to CPS was 0.91 (0.87, 0.94). Reliability of pairs and subgroups of panelists were similarly high. A panel composite classification was nearly perfectly accurate in a subset of cases having definitive, corroborated injury status. CONCLUSIONS: A panel of experts with different backgrounds but common expertise in pediatric injury is a reliable and accurate criterion standard for classifying pediatric injuries as abusive or accidental in a sample of children presenting to a pediatric emergency department.
Assuntos
Acidentes , Maus-Tratos Infantis/classificação , Maus-Tratos Infantis/diagnóstico , Ferimentos e Lesões/classificação , Ferimentos e Lesões/etiologia , Pré-Escolar , Serviço Hospitalar de Emergência , Feminino , Humanos , Lactente , Masculino , Estudos Prospectivos , Reprodutibilidade dos Testes , Ferimentos e Lesões/diagnósticoRESUMO
We conducted a critical review of the many studies that have tried to determine whether breastfeeding has a beneficial effect on intellect...
Assuntos
Masculino , Feminino , Humanos , Recém-Nascido , Lactente , Aleitamento Materno , Classe Social , Inteligência , Apoio NutricionalRESUMO
OBJECTIVE: Hospital discharge databases are being increasingly used to track the incidence of child physical abuse in the United States. These databases use International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to categorize illnesses and injuries in hospitalized patients. We assessed the accuracy of the assignment of these codes for cases of child physical abuse. STUDY DESIGN: Participants were all children (N = 133) evaluated by a child abuse pediatrician (CAP) for suspicion of abuse at Yale-New Haven Children's Hospital from January 1, 2007-December 31, 2010. These children included both those judged to have injuries from abuse and those judged to have injuries accidental/medical in nature. We compared the ICD-9-CM codes entered in the hospital discharge database for each child with the decisions made by the CAPs, as documented in their child abuse registry. The CAPs' decisions were considered to be the gold standard. Sensitivity and specificity were calculated. Medical records were reviewed for cases in which the ICD-9-CM codes disagreed with the CAP's decision. RESULTS: In 133 cases of suspected child physical abuse, the sensitivity and specificity of ICD-9-CM codes for abuse were 76.7 % (CI 61.4%, 88.2%) and 100% (CI 96.0%, 100%), respectively. Analysis of the 10 cases of abuse not receiving ICD-9-CM codes for abuse revealed that errors in physician documentation (n = 5) and in coding (n = 5) contributed to the reduction in sensitivity. CONCLUSIONS: Despite high specificity in identifying child physical abuse, the sensitivity of ICD-9-CM codes is 77%, indicating that these codes underestimate the occurrence of abuse.
Assuntos
Maus-Tratos Infantis/diagnóstico , Classificação Internacional de Doenças , Criança Hospitalizada , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Reprodutibilidade dos TestesRESUMO
OBJECTIVE: To identify markers of maternal depressive symptoms in medical records of children aged 1-6 years. STUDY DESIGN: Using a case-control methodology, mothers who were screened for depressive symptoms with the Quick Inventory of Depressive Symptomatology Self-Rated Questionnaire (QIDS-SR) at well-child visits between June 2006 and June 2008 in an inner-city pediatric clinic were grouped into cases with depressive symptoms (QIDS-SR score ≥ 11) and controls with no symptoms (QIDS-SR score ≤ 5). Potential markers for maternal depressive symptoms were collected from the children's medical record and grouped into 3 domains: (1) child health and development (eg, maternal concerns/negative attributions regarding the child's behavior); (2) child health care utilization (eg, missed appointments); and (3) maternal psychosocial factors (eg, single parent). The association between maternal depressive symptoms and each factor was determined using multiple logistic regression to calculate aORs. RESULTS: Maternal depressive symptoms were significantly associated with reports of concerns/negative attributions about the child's behavior (aOR, 2.35; P = .01) and concerns about speech (aOR, 2.40; P = .04) and sleep (aOR, 7.75; P < .001); these were identified at the visit when the depression screening was done. Other associations included history of maternal depression (aOR, 4.94; P = .001) and a previous social work referral (aOR, 1.98; P = .01). CONCLUSION: Information readily available to pediatricians was associated with maternal depressive symptoms and can serve as clinical markers to help identify at-risk mothers during well-child visits.