Academic Pediatrics最新文献

Background: Prior research on confessions of physical abuse (PA) has explored mechanisms of injury. Little is known about conditions supporting a confession of abuse or how confessions may influence case outcomes.

Methods: This cross-sectional study of suspected PA in children age <10 years at 10 centers participating in CAPNET, a multicenter child PA research network, included children with in-person Child Abuse Pediatrics (CAP) consultations between Feb 2021-Dec 2022 and excluded children without injury. Our focus was a confession of inflicted injury known to the CAP during clinical involvement. We compared child and clinical characteristics, out-of-home (OOH) placements, and arrests between cases with and without confessions. Multivariable models using generalized estimating equations (GEE) produced adjusted predicted probabilities (APP) clustering by CAPNET site.

Results: Confessions were known to CAPs in 115/4297 (2.7%) cases, with significant site variability. In a multivariable GEE model, confessions were more likely in cases with injuries with high-specificity for abuse (APP 6.0% vs 1.5%, p<0.001), near-fatality (APP 5.5% vs 2.3%, p<0.001), and older children (APP 4.8% vs 2.5%, p = 0.025). OOH placements and arrests were more common in cases with confessions. CAP awareness of confessions, OOH placements, and arrests did not follow racial or ethnic patterns seen in the US child welfare system. Lower socioeconomic status was associated with OOH placements and arrests but not CAP awareness of confessions.

Conclusions: Our findings highlight differences in case characteristics and outcomes where a confession is known to the CAP and raise questions about agency response based on child characteristics.

Unambiguous federal policy support of accessible public spaces and communications for individuals with disabilities has been in place for 35 years. Rigorous models of accessibility best practices, such as Universal Design (UD) and Human Centered Design, have existed for nearly as long. Despite the Americans with Disabilities Act's clear requirements, health care equity for disabled individuals - a large minority of the population - is still out of reach. Research shows that increasing health care professionals' broader understanding of accessibility best practices for adults is an important step toward creating more welcoming health care settings, yet medical schools continue to exclude disability education from their curriculum, and physicians continue to report discomfort with providing care for all ages of this population. Thoughtful, dignifying best practices in creating and evaluating supportive health care environments for children with disabilities are well documented, but there is little in the literature on tactical steps toward implementation or impact of these adapted environments. This article shows child health care professionals how to apply Universal Design theory to one's everyday practice, beginning with a single patient and her care team.

Objective: Well-child care visits are critical, but time is limited so we sought to better understand preventive care topic coverage and communication dynamics between parents and clinicians during early childhood well-child care visits.

Methods: We audio-recorded 104 well-visits in English and Spanish for children ages 2-24 months. Recordings were coded for content (e.g., feeding, sleep) and communication dynamics (e.g., provider question- asking). Following qualitative analysis, the number of codes for visit content and communication dynamics were calculated for further quantitative analysis. To assess general communication patterns between parents and clinicians, Mann-Whitney U tests were used to determine if the number of communication dynamic episodes differed significantly by parent language, visit length, and content discussed during the visit (e.g., development and behavior).

Results: 39% of visits were conducted in Spanish. Topics most often discussed related to physical health, nutrition, and growth. Instances of clinician and parent information giving happened significantly (p<0.001) more often in English compared to Spanish visits. Longer WCC visits have significantly (p<0.01) more instances of positive report building; visits with positive rapport building are more likely to include discussions related to developmental milestones (p<0.04), as well as parenting experience (p<0.03).

Conclusion: Parent-provider communication dynamics were enhanced when visits lasted over 15 minutes, and when positive rapport building was more frequent. Our findings highlight the importance of adequate time and rapport building during visits to facilitate engagement of parents in meaningful discussions.

Objective: Adverse childhood experiences (ACEs) are associated with poor health and educational outcomes on a population level. School-based health centers (SBHCs) may be uniquely positioned to support youth with ACEs, but little is known about ACEs screening and response in that setting. In this qualitative study, we characterized barriers and facilitators to addressing ACEs in SBHCs from the perspectives of SBHC clinicians.

Methods: We conducted semi-structured interviews with clinicians affiliated with a large public school district in Southern California that had implemented ACEs screening in its SBHCs. Interviews explored attitudes toward and experiences with ACEs screening in SBHCs, as well as differences between screening in SBHCs and other settings. We used a thematic analysis approach, continuing until thematic saturation was reached.

Results: The sample included 10 SBHC clinicians. Six major themes emerged. Three themes were considered opportunities: 1) SBHCs serve as a bridge to care and resources for youth with ACEs, 2) SBHC clinicians are versatile in their approach to addressing ACEs, and 3) structural elements of SBHCs facilitate ACEs screening and response. The remaining three were considered challenges: 1) SBHCs have limited capacity for follow-up for youth with ACEs, 2) providers experience challenges with obtaining accurate ACEs screening results, and 3) responding to ACEs screening is complex.

Conclusions: SBHCs have the potential to support identification and response among youth with ACEs, though challenges remain. Policy and practice recommendations may consider how SBHCs can be leveraged as a unique context to support vulnerable populations at risk of toxic stress.

Objective: Trainee assessments have demonstrated gender and race or ethnicity biases across specialties. Assessment based on the Entrustable Professional Activity(EPA) framework involves assigning a supervision level for the professional activities included in the EPA. We analyzed Clinical Competency Committee (CCC) assigned EPA supervision levels for differences by gender and race or ethnicity among pediatric subspecialty fellows.

Methods: This is a secondary analysis of two de-identified datasets. CCCs provided supervision levels for each fellow for the Pediatric Subspecialty EPAs from fall 2018 through spring 2022. These data were linked to fellows who participated in a well-being study during residency that included their gender, race, and ethnicity. Based on race or ethnicity, fellows were categorized as underrepresented in medicine, Asian, or White. For each EPA, we fitted an ordinal mixed effects model to supervision ratings, with training year, gender, and race category as covariates, adjusting for clustering of ratings within fellow and institution, and multiple comparisons.

Results: Demographic data were linked for 561 fellows. Asian fellows were more likely to receive a lower supervision level for the Consultation EPA compared with White fellows (adjusted odds-ratio 0.48, 95% CI:0.31-0.77). No other significant differences were found among the common Subspecialty EPAs.

Conclusion: EPA-based assessments of pediatric subspecialty fellows demonstrated no differences by gender and a single difference based on race or ethnicity. Given the national trend toward using EPA-based assessments in medical education for health professions, it's reassuring that this first study in pediatric subspecialty fellows demonstrated almost no bias in these assessments.

Objective: Elicit the perspectives of mothers with substance use disorder (SUD) on child well-being and parental substance use.

Methods: We conducted semi-structured focus groups of mothers with SUD on parenting, child well-being, naloxone, and experiences with medical care and child protective services (CPS). Focus group transcripts were iteratively reviewed to generate a codebook, which was applied in NVivo by two independent coders. We used inductive thematic analysis to examine codes relevant to child well-being, harm reduction, and clinician reporting to CPS.

Results: Twenty-three women participated in five focus groups. Four themes emerged: 1) mothers felt their substance use negatively impacted their ability to provide attentive supervision and emotional support; 2) mothers discussed strategies to minimize harm to children but had limited familiarity with naloxone use for unintentional ingestions; 3) mothers viewed child well-being as a spectrum but felt that clinicians often approached well-being as a binary of "safe" or "unsafe"; and 4) mothers recognized that clinicians are obligated to report child abuse or neglect and recommended transparent CPS reporting.

Conclusions: Participants viewed child well-being in the setting of parental substance use as a multi-dimensional construct. Mothers acknowledged potential emotional harms of substance use, an important target for family-based intervention. Mothers used harm reduction strategies to keep their children safe, but not all were aware that naloxone could be used to reverse pediatric overdoses. Improved provider guidance on comprehensively assessing child well-being, supporting harm reduction, and trauma-informed CPS reporting may help clinicians partner with families to support child health and safety.

Objective: Child sexual abuse is associated with mental health (MH) challenges across the lifespan. Black and Latino children are less likely to receive MH services than children of other backgrounds. We aimed to identify facilitators and barriers to MH services for Black and Latino children after sexual abuse.

Methods: We conducted semi-structured interviews with 30 Black and Latino, English and Spanish-speaking caregivers of children who have experienced sexual abuse. Interviews were completed in caregivers' preferred language and modality (phone, video conferencing, or in person). Caregivers were asked about their opinions and experiences with initiating child MH services after sexual abuse. Interviews were audio-recorded, transcribed, and analyzed using thematic analysis.

Results: Caregivers (27% Black, 47% Latino, 27% Black and Latino) were mostly biological mothers (87%). Half were born outside the U.S. Caregivers reported three facilitators to MH services after sexual abuse: 1) perceived benefits of MH services; 2) trust in MH providers; and 3) support from frontline professionals and systems. Caregivers reported timely support when there was cross-system care coordination. Caregivers described five barriers to MH services after sexual abuse: 1) perceived harms of MH services; 2) concerns about misjudgment and discrimination by MH providers; 3) stigma of sexual abuse; 4) youth's lack of engagement in MH services; and 5) structural obstacles to MH services.

Conclusions: Black and Latino caregivers identified multiple facilitators and barriers to MH services after sexual abuse. Our findings can inform the development and testing of evidence-based strategies to improve MH engagement and outcomes after sexual abuse.