Savoir détecter l'exposition des enfants à la violence entre partenaires intimes, qu'elle soit présumée ou divulguée, et savoir intervenir.

L'exposition des enfants à la violence entre partenaires intimes (EEVPI), qu'il s'agisse des parents ou d'autres proches, représente près de la moitié de tous les cas qui font l'objet d'une enquête et sont corroborés par les services de protection de l'enfance du Canada. Les atteintes affectives, physiques et comportementales associées à l'EEVPI sont semblables aux effets d'autres formes de maltraitance envers les enfants. Il peut être difficile d'établir quels enfants et adolescents sont exposés à la violence entre partenaires intimes (VPI) en raison des comportements non spécifiques parfois associés à une telle exposition, de même que de la stigmatisation et du secret entourant souvent ce type de violence. Par ailleurs, une intervention en toute sécurité auprès des enfants et des adolescents chez qui on présume une exposition à la VPI peut être compliquée par la nécessité d'également tenir compte de la sécurité et du bien-être d'un proche non contrevenant. Le présent document de principes propose une approche fondée sur des données probantes mise au point par le projet VEGA (Violence, Evidence, Guidance, Action ou violence, données probantes, conseils, action) pour détecter l'exposition des enfants et des adolescents à la VPI et intervenir en toute sécurité auprès d'eux.

Recognizing and responding to children with suspected exposure to intimate partner violence between caregivers.

Children's exposure to intimate partner violence (CEIPV) between parents and other caregivers accounts for nearly half of all cases investigated and substantiated by child welfare authorities in Canada. The emotional, physical, and behavioural impairments associated with CEIPV are similar to effects of other forms of child maltreatment. The identification of children and youth who have been exposed to intimate partner violence (IPV) can be challenging due to the non-specific behaviours sometimes associated with such exposure, and the stigma and secrecy that often characterize IPV. Also, responding safely to children and youth with suspected CEIPV can be complicated by the need to consider the safety and well-being of a non-offending caregiver. This position statement presents an evidence-informed approach developed by the Violence, Evidence, Guidance, Action (VEGA) Project for the safe recognition and response to children and youth who are suspected of being exposed to IPV.

Association of maternal risk factors with infant maltreatment: an administrative data cohort study.

OBJECTIVE: We aimed to evaluate the risk of infant maltreatment associated with commonly used criteria for home visiting programmes: young maternal age, maternal adversity (homelessness, substance abuse, intimate partner violence), newcomer status and mental health concerns in Ontario, Canada. DESIGN: This retrospective cohort study included infants born in hospital in Ontario from 1 April 2005 to 31 March 2017 captured in linked health administrative and demographic databases. Infants were followed from newborn hospitalisation until 1 year of age for child maltreatment captured in healthcare or death records. The association between type and number of maternal risk factors, and maltreatment, was analysed using multivariable logistic regression modelling, controlling for infant characteristics and material deprivation. Further modelling explored the association of each year of maternal age with maltreatment. RESULTS: Of 989 586 infants, 434 (0.04%) had recorded maltreatment. Maternal age <22 years conferred higher risk of infant maltreatment (adjusted OR (aOR) 5.5, 95% CI 4.5 to 6.8) compared with age ≥22 years. Maternal mental health diagnoses (aOR 2.0, 95% CI 1.6 to 2.5) were also associated with maltreatment, while refugee status appeared protective (aOR 0.6, 95% CI 0.4 to 1.0). The odds of maltreatment increased with higher numbers of maternal risk factors. Maternal age was associated with maltreatment until age 28 years. CONCLUSION: Infants born to young mothers are at greater risk of infant maltreatment, and this association remained until age 28 years. These findings are important for ensuring public health interventions are supporting populations experiencing structural vulnerabilities with the aim of preventing maltreatment.

Mental Illness Following Physical Assault Among Children.

Importance: Physical assault during childhood is common and can lead to lasting mental health problems. Yet, there are few studies on the patterns of mental illness (ie, timing of onset, type, and acuity) in survivors of physical assault. Objective: To determine the risk of incident health record diagnoses of mental illness among children who experienced assault compared with children who did not. Design, Setting, and Participants: This population-based matched cohort study used linked health administrative data sets in Ontario, Canada. Children aged 0 to 13 years who experienced an incident physical assault between 2006 and 2014 were age-matched (1:4) to children who had not experienced assault and followed up for a minimum of 5 years. Data were analyzed from January 2020 to March 2022. Exposure: Physical assault resulting in hospitalization or an emergency department (ED) visit between the ages of 0 and 13 years. Main Outcomes and Measures: The primary outcome was incident health record diagnosis of mental illness measured as any physician or hospital mental health care use or completed suicide. Secondary outcome measures included the acuity of incident mental illness and mental illness diagnostic category. Cox proportional hazards regression analysis generated hazard ratios (HR) for incident mental illness. Results: A total of 21 948 children unexposed to assault and 5487 exposed to assault were included in the study with a mean (SD) age of 7.0 (4.6) years. There were more boys in the group that experienced assault (3006 individuals [54.8%]) compared with the group who did not (9909 individuals [45.1%]). Compared with children unexposed to assault, those exposed were more likely to be in the highest deprivation index quintile (standardized difference, 0.21) and live in rural areas (standardized difference, 0.48). Their mothers more often had active mental illness (standardized difference, 0.35). More than one-third of the exposed children had a health record diagnosis of mental illness (2219 children [38.6%]; incidence rate (IR), 53.3 per 1000 person-years) compared with 23.4% (5130 children; IR, 32.2 per 1000 person-years) of unexposed children, with an overall adjusted hazard ratio (aHR) of 1.96 (95% CI, 1.85-2.08). The greatest risk was observed in the first year following the assault (aHR, 3.08; 95% CI, 2.68-3.54). In both groups, nonpsychotic disorders were the most common type of mental illness. Initial mental illness diagnoses occurred in an acute care setting for 14.0% of exposed children (769 children) vs 2.8% of unexposed children (609 children). Conclusions and Relevance: In this population-based matched cohort study, children who experienced assault had, on average, a 2 times higher risk of receiving a mental illness diagnosis and were more likely than children who had not experienced assault to present to acute care for mental illness. Early intervention to support mental health of assaulted children is warranted, particularly in the first year following assault.

Subdural hemorrhages and severe retinal hemorrhages in a short fall with a rotational component.

We present the case of a 5-month-old referred for child abuse investigation with subdural hemorrhages and extensive retinal hemorrhages following a short fall from a swivel chair seen on video footage. Subdural hemorrhages with extensive retinal hemorrhages are not typically seen as the result of short household falls. Reviewing the footage, contributing factors may have included increased rotational and deceleration forces.

Concordance of Diagnosis of Autism Spectrum Disorder Made by Pediatricians vs a Multidisciplinary Specialist Team.

Importance: Wait times for autism spectrum disorder (ASD) diagnosis are lengthy because of inadequate supply of specialist teams. General pediatricians may be able to diagnose some cases of ASD, thereby reducing wait times. Objective: To determine the accuracy of ASD diagnostic assessments conducted by general pediatricians compared with a multidisciplinary team (MDT). Design, Setting, and Participants: This prospective diagnostic study was conducted in and a specialist assessment center in Toronto, Ontario, Canada, and Ontario general pediatrician practices from June 2016 to March 2020. Children were younger than 5.5 years, referred with a developmental concern, and without an existing ASD diagnosis. Data analysis was performed from October 2021 to February 2022. Exposures: The pediatrician and MDT each conducted blinded assessments and recorded a decision as to whether the child had ASD. Main Outcomes and Measures: Main outcomes included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). A logistic regression was performed to identify factors associated with accurate pediatrician assessment for children with or without an ASD diagnosis. Results: Seventeen pediatricians (12 women [71%]) participated in the study and referred 106 children (79 boys [75%]; mean [SD] age, 41.9 [13.3] months). Sixty participants (57%) were from minoritized racial and ethnic groups (eg, Black, Asian, Hispanic, Middle Eastern, and multiracial). Seventy-two participants (68%) received a diagnosis of ASD by the MDT. Sensitivity and specificity of the pediatrician assessments compared with MDT were 0.75 (95% CI, 0.67-0.83) and 0.79 (95% CI, 0.62-0.91), respectively. The PPV of the pediatrician assessments was 0.89 (95% CI, 0.80-0.94) (ie, 89% agreement with the MDT), and NPV was 0.60 (95% CI, 0.49-0.70) (ie, 60% agreement with the MDT). Higher pediatrician certainty (odds ratio [OR], 3.33; 95% CI, 1.71-7.34; P = .001) was associated with increased diagnostic accuracy for children with ASD. Lower accuracy was seen for children with higher Visual Reception subscale developmental skills (OR, 0.93; 95% CI, 0.89-0.97; P = .001), speaking abilities (OR, 0.17; 95% CI, 0.03-0.67; P = .03), and White race (OR, 0.32; 95% CI, 0.10-0.97; P = .04). Age, gender, and Autism Diagnostic Observation Schedule, 2nd Edition composite scores were not significantly associated with the accuracy of assessments. All 7 children with a sibling with ASD received an accurate diagnosis; otherwise, no significant factors were identified for accuracy in children without ASD. Conclusions and Relevance: This study of concordance of autism assessment between pediatricians and an expert MDT in young children found high accuracy when general pediatricians felt confident and lower accuracy when ruling out ASD. These findings suggest that children with co-occurring delays may be potential candidates for community assessment.

Development of a Novel Multi-Disciplinary Specialized Care Service for Children and Adolescents with Autism Spectrum Disorder and/or Intellectual/Developmental Disability in a Tertiary Children's Hospital Setting.

Children and adolescents with autism spectrum disorder (ASD) and/or Intellectual/Developmental Disability (IDD) are at greater risk of developing comorbid medical conditions, mental health diagnoses, behavioral challenges, and having overall poorer physical and mental health outcomes. Hospital environments present unique stressors and challenges for children and adolescents with ASD/IDD including a change in familiar environment, unpredictable routines, and exposure to sensory stimuli that may be overwhelming. While many school boards have specialized multi-disciplinary special needs support teams and services made up of professionals with expertise in supporting students with ASD/IDD, most hospitals do not have a formal multi-disciplinary ASD/IDD support team in place to support patients, families, and health care staff across the hospital. There is an emerging recognition of the need for specialized multi-disciplinary developmental-behavioral and mental health expertise in hospital inpatient settings. This paper describes the framework for the development of an innovative multi-disciplinary program to better support children and adolescents with ASD/IDD within a tertiary children's hospital setting.

Building skills and resilience in child abuse pediatricians: A novel program to address Secondary Traumatic Stress.

BACKGROUND: Secondary traumatic Stress (STS) is an increasingly recognized phenomenon experienced by clinicians working with patients who have experienced trauma firsthand. STS is experienced in a range of clinical settings; medical trainees and those working in Child Abuse Pediatrics (CAP) are at particular risk of experiencing STS. To date, there are no interventions described to address STS experienced by medical trainees in the context of CAP training. OBJECTIVE: The aim of this project was to design and pilot an innovative program to increase resilience and address STS symptoms among fellows in a CAP training program. PARTICIPANTS AND SETTING: The Therapeutic Group Sessions (TGS) program was developed for CAP fellows at the Hospital for Sick Children, Toronto, Canada. METHODS: The intervention involved mandatory, monthly small group sessions facilitated by a consistent mental health professional throughout fellowship. Sessions included low intensity focusing activities, sharing impactful work-related experiences, mental health professional-led discussion of strategies and reflection on the session. Written evaluations were completed to understand the perceived impact on fellows and were analyzed for themes. RESULTS: Fellows reported improvements in perceived STS symptoms and increased feelings of resilience. Unanticipated positive outcomes were described including, a highly bonded fellowship group and transferrable skills gained in supportive communication. Programs developed to support clinicians in other settings are reviewed and compared to the TGS program. CONCLUSIONS: This is the first program aimed at improving resilience and addressing STS among child abuse fellows. Outcomes demonstrated numerous positive impacts that are widely applicable to the broader clinical setting.

Prepubescent Female Genital Examination Images: Evidence-Informed Learning Opportunities.

OBJECTIVES: To determine diagnoses and image features that are associated with difficult prepubescent female genital image interpretations. DESIGN AND SETTING: This was a mixed-methods study conducted at a tertiary care pediatric center using images from a previously developed education platform. PARTICIPANTS: Participants comprised 107 medical students, residents, fellows, and attendings who interpreted 158 cases to derive case difficulty estimates. INTERVENTIONS: This was a planned secondary analysis of participant performance data obtained from a prospective multi-center cross-sectional study. An expert panel also performed a descriptive review of images with the highest frequency of diagnostic error. MAIN OUTCOME MEASURES: We derived the proportion of participants who interpreted an image correctly, and features that were common in images with the most frequent diagnostic errors. RESULTS: We obtained 16,906 image interpretations. The mean proportion correct scores for each diagnosis were as follows: normal/normal variants 0.84 (95% confidence interval [CI] 0.82, 0.87); infectious/dermatology pathology 0.59 (95% CI 0.45, 0.73); anatomic pathology 0.61 (95% CI 0.41, 0.81); and, traumatic pathology 0.64 (95% CI 0.49, 0.79). The mean proportion correct scores varied by diagnosis (P < .001). The descriptive review demonstrated that poor image quality, infant genitalia, normal variant anatomy, external material (eg, diaper cream) in the genital area, and nonspecific erythema were common features in images with lower accuracy scores. CONCLUSIONS: A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. These data can be used to inform the design of teaching interventions to improve skill in this area.

PANDAS/PANS in childhood: Controversies and evidence.

Since first defined in 1998, paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and its later, broader iteration, paediatric acute-onset neuropsychiatric syndrome (PANS), have garnered significant attention and controversy. The role of streptococcal infection in children with explosive onset obsessive-compulsive disorder and new onset tics, the natural history of this entity, and the role of symptomatic and disease-modifying therapies, including antibiotics, immunotherapy, and psychoactive drugs, are all issues that have yet to be definitively addressed. While definitive proof of the autoimmune hypothesis of PANDAS is lacking, given the heightened attention to this entity and apparent rise in use of this diagnostic category, addressing questions around diagnosis, treatment, and etiology is imperative. In this paper, we review current working definitions of PANDAS/PANS, discuss published evidence for interventions related to this entity, and propose a clinical approach to children presenting with acute symptoms satisfying criteria for PANDAS/PANS.

Traumatic macular retinoschisis in infants and children.

PURPOSE: To provide detailed description of pediatric traumatic retinoschisis. METHODS: The medical records of children with either abusive head trauma and traumatic macular retinoschisis seen at a single center from 1993 to 2006 were reviewed retrospectively. Clinical details were extracted from the record and photographic documentation. Evaluation regarding abuse excluded ophthalmology findings to avoid circular reasoning. RESULTS: Of 134 patients with suspected abusive head trauma, 31 had retinoschisis. Mean age was 9 months. Of the 31, 22 (71%) offered a history of injury, and 9 (29%) were found unresponsive without history of injury; 6 were reportedly shaken. All patients had seizures, vomiting, and/or altered responsiveness. All had subdural hemorrhage, with cerebral edema in 17 (55%). In 10 (32%), there were findings of blunt force head injuries; in 4 of these there was no impact history. Retinal hemorrhages were present in all cases. Agreement between sidedness of retinoschisis and subdural hemorrhage was poor. Eleven patients had retinal folds, 3 of which had a hemorrhagic edge to the schisis. Nine patients had extracranial manifestations of abuse. Multidisciplinary team adjudications were as follows: of the 31 cases, 18 were suspicious for abuse, 11 were indeterminate, and 2 were possibly accounted for by accidental severe crush injury. Three children died, and 11 suffered neurological sequelae. CONCLUSIONS: Traumatic retinoschisis in children is highly associated with subdural hemorrhage, neurologic symptoms, and poor outcomes. Even with a conservative approach to opinion formulation, traumatic retinoschisis was associated with likely abuse.

Anogenital Findings in 3569 Pediatric Examinations for Sexual Abuse/Assault.

STUDY OBJECTIVE: Accurate interpretation of anogenital examination findings in the context of suspected child and adolescent sexual abuse/assault is essential, because misinterpretation has significant child protection and criminal justice implications. A consensus approach to the interpretation of anogenital examination findings is widely used to support accurate diagnosis; however, a large-scale study using this standardized approach is lacking. The objectives of this study were to: (1) determine the proportion of anogenital examinations for sexual abuse concerns with findings diagnostic of trauma and/or sexual contact; (2) determine whether frequency of diagnostic findings varies according to age, gender, and timing of examination; and (3) characterize diagnostic findings. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Retrospective records of children aged 0-18 years evaluated for sexual abuse/assault were reviewed. Case details of 3569 patients were extracted and anogenital examination findings were reinterpreted using a published consensus approach. RESULTS: Anogenital examination findings diagnostic of trauma and/or sexual contact were present in 173 of 3569 patients (4.8%). The prevalence of diagnostic findings was significantly higher in adolescents than in children younger than 12 years of age (13.9%, 114/823 vs 2.2%, 59/2657), in female vs male patients (5.7%, 164/2866 vs 1.5%, 9/614), and in examinations within 72 hours for children younger than 12 years (14.2%, 91/643 vs 4.5%, 45/997). Acute injuries were the most common type of diagnostic finding. CONCLUSION: Diagnostic findings are present in a small proportion of children and adolescents examined for suspected sexual abuse/assault. It is essential that practitioners who interpret examination findings be adequately trained and familiar with the current consensus approach and are aware of case characteristics associated with higher likelihood of findings.

Community General Pediatricians' Perspectives on Providing Autism Diagnoses in Ontario, Canada: A Qualitative Study.

OBJECTIVE: Community general pediatricians (CGPs) are a potential resource to increase capacity for autism spectrum disorder (ASD) diagnostic assessments. The objective of this study was to explore factors influencing CGPs' perspectives on and practices of providing ASD diagnoses. METHODS: This qualitative study used a constructivist modified grounded theory approach. Participants included CGPs who had attended ASD educational events or had referred a child with suspected ASD to a tertiary rehabilitation center. Individual in-depth interviews with CGPs were recorded, transcribed, and coded. An explanatory framework was developed from the data. A summary of the framework was sent to participants, and responses indicated that no changes were needed. RESULTS: Eleven CGPs participated. Assessment for ASD consists of 3 stages: (1) determining the diagnosis; (2) communicating the diagnosis; and (3) managing next steps after diagnosis. Each of these stages of ASD diagnostic assessment exists within an ecological context of child/family factors, personal CGP factors, and contextual/systems factors that all influence diagnostic decision making. CONCLUSION: Community general pediatrician ASD diagnostic capacity must be considered within the larger context of ASD care. Suggestions to improve diagnostic capacity include preparing families for the diagnosis, changing CGP perceptions of ASD, providing community-based training, improving financial remuneration, and providing service navigation. Further study is needed to ensure that CGPs are providing accurate, high-quality assessments.

Social pediatrics: weaving horizontal and vertical threads through pediatric residency.

BACKGROUND: Social 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. METHODS: A 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. RESULTS: Forty-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. CONCLUSIONS: Despite 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.

Demographic characteristics and needs of the Canadian urban adolescent mother and her child.

INTRODUCTION: There is a paucity of Canadian-based literature on urban adolescent mothers and their children. To inform clinical assessment and interventions and to mitigate the risks that adolescent mothers and their children face, it is essential to understand the characteristics of this high-risk population. METHODS: A retrospective review of 116 adolescent mothers attending an urban academic hospital-based outpatient clinic in Canada from 2005 to 2009 was conducted. The following information was collected: demographic characteristics, maternal maltreatment history, substance use, postpartum depression symptoms, and child socioemotional and developmental functioning. RESULTS: The mean maternal age was 16.1 years and the mean education level was grade 9. Ninety-nine percent of adolescent mothers were single, 47% had a history of child welfare involvement and 18% had previous involvement with the judicial system. More than one-half of participants reported a history of both maltreatment and substance abuse, and 20% of adolescent mothers scored in the clinical range for postpartum depression. A substantial proportion of children scored in the clinical range for behavioural problems, regulatory difficulties and suspected developmental delays. CONCLUSION: The present study serves to illustrate the high-risk nature of urban adolescent mothers. These observations can be used to improve clinical practice for health care providers in community and hospital-based settings working with this population.

INTRODUCTION: Peu de publications scientifiques canadiennes portent sur les mères adolescentes et leur enfant en milieu urbain. Pour attester les évaluations et interventions cliniques et réduire les risques que courent les mères adolescentes et leurs enfants, il est essentiel de comprendre les caractéristiques de cette population à haut risque. MÉTHODOLOGIE: Les chercheurs ont réalisé une analyse rétrospective auprès de 116 mères adolescentes qui fréquentaient la clinique ambulatoire d'un hôpital universitaire canadien en milieu urbain entre 2005 et 2009. L'information suivante a été colligée : caractéristiques démographiques, antécédents de maltraitance des mères, consommation de substances psychoactives, symptômes de dépression postpartum et fonctionnement socio-affectif et développemental des enfants. RÉSULTATS: Les mères avaient un âge moyen de 16,1 ans et un niveau de scolarité moyen de 9e année. De plus, 99 % des mères adolescentes étaient monoparentales, 47 % avaient déjà été en contact avec les services de protection de l'enfance et 18 % avaient déjà eu des démêlés avec la justice. Plus de la moitié avait des antécédents de maltraitance et de consommation de substances psychoactives, et 20 % obtenaient un score clinique de dépression postpartum. Une forte proportion d'enfants obtenait un score clinique de troubles de comportement, de troubles de régulation et de présomptions de retards de développement. CONCLUSION: La présente étude démontre le haut risque que courent les mères adolescentes en milieu urbain. Ces observations peuvent contribuer à améliorer la pratique clinique des travailleurs de la santé en milieu communautaire et hospitalier qui œuvrent auprès de cette population.

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.

Association between abuse history and adolescent pregnancy: a meta-analysis.

PURPOSE: Although a purported risk factor for early pregnancy is abuse history, the strength of this association has been inconsistent across studies and may vary as a function of abuse type. The purpose of this meta-analysis was to examine the extent to which sexual, physical, and emotional abuse, as well as neglect, increased the risk of adolescent pregnancy. METHODS: A search of studies through MEDLINE, EMBASE, PsycINFO, Social Work Abstracts, and Web of Science was conducted. Studies were retained if they included (1) women who became pregnant before 20 years of age; (2) a comparison group of nonpregnant adolescents; and (3) abuse experience (<18 years of age). RESULTS: Thirty-eight independent samples provided 70 estimates of effect sizes, derived from 75,390 participants. Both sexual and physical abuse were associated with an increased risk of adolescent pregnancy (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.75-2.38 and OR, 1.48; CI, 1.24-1.76, respectively). The strongest effect was for the co-occurrence of sexual and physical abuse (OR, 3.83; CI, 2.96-4.97]). Nonsignificant effect sizes were found for emotional abuse (OR, 1.01; CI, .70-1.47) and neglect (OR, 1.29; CI, .77-2.17]), although these were moderated by journal impact factor, that is, greater effect sizes were reported in higher impact journals. CONCLUSIONS: The results of this meta-analysis reveal that the strength of the association between abuse and adolescent pregnancy varies as a function of abuse subtype. Sexual and physical abuse were associated with increased risk for adolescent pregnancy, whereas emotional abuse and neglect were not.

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.

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. χ(2) And Student's 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.