Development and Evaluation of a Community Advisory Board for Family Violence.

Although intimate partner violence (IPV) is an important risk factor for child physical abuse, most IPV-exposed children are not evaluated for abusive injuries. A Community Advisory Board (CAB) was formed to (a) optimize a program to evaluate IPV-exposed children for abusive injuries and (b) inform research methods to engage IPV victims and their children. The objectives of this study were to implement and to evaluate the family violence CAB. Following best practices on CAB formation, we recruited local stakeholders with key roles as service providers, community leaders, and knowledge experts in IPV, child abuse, and emergency care. Fourteen members met bimonthly to develop a family-centered intervention and to inform research and advocacy activities. A shared memorandum of understanding outlined goals and objectives. One year after the CAB's implementation, a research assistant interviewed CAB members to understand their experiences, perceived benefits of participation, and desired improvements. Eleven CAB members, including an IPV survivor, participated. Emerging categories included (a) motivations to join the CAB (victim advocacy), (b) benefits of participation (development of relationships among members and increased acceptability of research methods), (c) facilitators of sustainability (program adaptability and development of trust), and (d) desired improvements (case-based follow-up). The CAB was successfully implemented and facilitated the development of collaborative relationships among stakeholders with key roles in IPV and child abuse. The CAB led to community member-proposed changes in research activities and clinical care for victims of IPV.

Evaluation of Children after Caregiver Intimate Partner Violence: A Qualitative Study of Barriers, Facilitators, and Trauma- and Violence-Informed Care.

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.

State-Level Variation in the Cumulative Prevalence of Child Welfare System Contact, 2015-2019.

Background: Prior estimates of the cumulative risks of child welfare system contact illustrate the prominence of this system in the lives of children in the United States (U.S.). However, these estimates report national data on a system administered at the state and local levels and are unable to detail potential simultaneous geographic and racial/ethnic variation in the prevalence of these events. Methods: Using 2015-2019 data from the National Child Abuse and Neglect Data System and Adoption and Foster Care Analysis and Reporting System, we use synthetic cohort life tables to estimate cumulative state- and race/ethnicity-specific risks by age 18 of experiencing: (1) a child protective services investigation, (2) confirmed maltreatment, (3) foster care placement, and (4) termination of parental rights for children in the U.S. Results: In the U.S., state-level investigation risks ranged from 14% to 63%, confirmed maltreatment risks from 3% to 27%, foster care placement risks from 2% to 18%, and risks of parental rights termination from 0% to 8%. Racial/ethnic disparities in these risks varied greatly across states, with larger disparities at higher levels of involvement. Whereas Black children had higher risks of all events than white children in nearly all states, Asian children had consistently lower risks. Finally, ratios comparing risks of child welfare events show these prevalences did not move in parallel, across states or racial/ethnic groups. Contribution: This study provides new estimates of spatial and racial/ethnic variation in children's lifetime risks of maltreatment investigation, confirmed maltreatment, foster care placement, and termination of parental rights in the U.S., as well as relative risks of these events.

Creation and evaluation of a participatory child abuse and neglect workshop for medical students.

BACKGROUND: Since child abuse and neglect (CAN) is prevalent worldwide, medical students should acquire basic knowledge, skills, and confidence in identifying and addressing CAN. Although significant educational efforts have been previously described, none has focused on using participatory methods to teach medical students CAN. PURPOSE: To: 1) develop a participatory educational workshop in CAN for medical students, 2) gather, train, and establish a peer-to-peer teaching group, and 3) assess the effectiveness of the workshop in gain of knowledge and improvement of self-confidence for participants. METHODS: A two-hour workshop was created with role-playing, the use of mannikins and peer-to-peer teaching. A 15-item knowledge and a 9-item self-confidence questionnaire were used before, right after, and six months after each workshop. RESULTS: Nine workshops in two academic pediatric departments with a total attendance of 300 6th year medical students were conducted. For the 69 students who completed the questionnaires at all three times, there were statistically significant gains in knowledge right after (p < .001) and six months after (p < .0001) the workshops. Similarly, self-confidence increased right after (p < .0001) and six months after (p < .001) the workshops. Self-selection bias testing indicated that these 69 students who completed all three questionnaires were representative of those who completed the pre-testing and the testing right after. CONCLUSIONS: We successfully established a peer-to-peer teaching group to conduct nine participatory workshops that improved the participants' knowledge and self-confidence in CAN. This feasible and novel active learning approach may help address inadequacies in medical curricula.

Bruising in Infants: An Approach to the Recognition of Child Physical Abuse.

Infants (children <12 months of age) are maltreated at more than twice the rate of any other child age group, and infants die because of maltreatment at 3 times the rate of any other age group in childhood. The incidence of hospitalization for serious physical abuse in children also is highest for infants. Successful recognition of medically mild signs of physical abuse in infants, such as certain bruising patterns, can, therefore, lead to lifesaving interventions. The importance of the recognition of medically mild injuries due to physical abuse is underscored by the finding that a high percentage of infants (27.5%) hospitalized with serious physical abuse were found to have previously sustained milder injuries, such as bruising. Clinicians must be aware of patterns of bruising suggestive of abuse to distinguish between infants who have been abused and those who have been accidentally injured. To maximize the likelihood that abused infants will be identified and protected, as well to minimize the likelihood that an accidentally injured infant will be mischaracterized as abused, the application of an evidence-based approach to the evaluation of bruised infants should be applied. A consistent, evidence-based practice in this setting also may reduce the influence of racial and socioeconomic bias and decrease disparities in care.

Characteristics That Distinguish Abusive From Nonabusive Causes of Sudden Unexpected Infant Deaths.

BACKGROUND: Fatal child abuse can be mistaken for sudden unexpected infant death (SUID) in the emergency department setting. It is unknown if there are characteristics that distinguish abusive from nonabusive causes of SUIDs in the emergency department. METHODS: Using a matched case-control design, we reviewed the medical examiner records of deaths of infants younger than 12 months who were found unresponsive at a residence, required cardiopulmonary resuscitation, and had a complete forensic autopsy between 2009 and 2015. Infants with a manner of death as homicide were cases; controls were those with the manner of death as accident, natural, or undetermined. Each case was matched with 5 controls based on age (months). Differences between cases and controls were evaluated with respect to demographic, parental, and household characteristics and clinical outcomes. RESULTS: We identified 12 cases (homicides) and 169 controls (nonhomicides), of which 60 were selected for the matched analysis. We found no significant differences between cases and controls with respect to age, race, sex, maternal substance use, Child Protective Services involvement prior to death, presence of male head of household, surviving siblings, or emergency medical services transport. Cases were more likely to have Child Protective Services involvement at the time of death (83% vs 38%; P = 0.01), sentinel injuries (odds ratio, 9.67; 95% confidence interval, 1.30-122.43), and return of spontaneous circulation (odds ratio, 29.99; 95% confidence interval, 3.70-241.30). CONCLUSIONS: Child Protective Services agency involvement at time of death, sentinel injury, and return of spontaneous circulation were more often associated with abusive causes of SUID. Further study is needed to confirm these findings.

Insurance Coverage for Children Impacts Reporting of Child Maltreatment by Healthcare Professionals.

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 470 876 018 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.

A national educational campaign to raise awareness of child physical abuse among health care professionals.

Education is necessary to improve child physical abuse detection and management. A few studies have described national child abuse training programs, but none has measured changes in knowledge among participants. A collaboration of child abuse experts from the USA, an academic pediatric department, and a non-governmental organization in child protection aimed at (a) training hospital physicians in a train-the-trainer course for the detection and management of child physical abuse and (b) conducting workshops and measuring attendance and gain of knowledge of participants. A train-the-trainer and a national curriculum were created. A 78-item and a 20-item knowledge questionnaire were used pre and post the train-the-trainer course and all workshops, respectively. Nineteen physicians from all pediatric departments of the seven medical schools in Greece attended the course. Eight workshops in seven cities took place with a total attendance of 1220 health care professionals. Gain of knowledge was demonstrated for participants in the train-the-trainer course (p = 0.0015) and local workshops (p < 0.001).Conclusion: We successfully engaged physicians from all medical schools in Greece and conducted a train-the-trainer module and eight workshops in major cities that improved the participants' knowledge in child physical abuse. This approach may help address physician deficiencies in emerging areas of child abuse clinical practice. What is Known: • Education is necessary to improve child physical abuse detection and management. • Although national training programs have been described, none has measured participants' changes in knowledge. What is New: • A collaboration of child abuse experts, all medical schools in Greece, and a non-governmental organization resulted in a national educational campaign in child physical abuse and gains in knowledge for participants. • This approach may help address deficiencies in emerging areas of clinical practice.

Early Involvement of the Child Protection Team in the Care of Injured Infants in a Pediatric Emergency Department.

BACKGROUND: Physical abuse is a significant cause of infant morbidity and mortality. Early detection in the emergency department (ED) is crucial. OBJECTIVE: We describe the impact of a clinical pathway focused on early involvement of the child protection team (CPT) and social work (SW) team for infants presenting to a pediatric emergency department with an injury concerning for abuse. METHODS: The pathway lists 10 injuries associated with abuse in infants and directs consultation of the CPT and SW. It was implemented at a single site on April 1, 2014. Seasonally matched data were collected 12 months before and after implementation on all children < 12 months of age with a qualifying injury. Demographics, CPT and SW consults, referral to Child Protective Services, diagnostic studies, and ultimate determination of abuse by the CPT were collected. RESULTS: Implementation of the pathway was associated with an increase in consultation of the CPT from 17% to 47% (p < 0.001) and SW from 33% to 52% (p < 0.001). CPT and SW consultations were obtained more frequently for those on public compared to private insurance prior to implementation but not after (CPT: odds ratio [OR] 4.32; p = 0.046; 95% confidence interval [CI] 1.03-18.15; SW: OR 3.23, p = 0.034; 95% CI 1.09-9.74). Diagnostic testing increased in the post-pathway period. There was no difference in the detection of abusive injury or number of missed cases. CONCLUSIONS: These findings suggest that this clinical pathway was successful in increasing involvement of the CPT and SW teams and reducing socioeconomic disparity in the evaluation of infants with injuries concerning for abuse.

Emergency Medical Responders and Adolescents With Autism Spectrum Disorder.

OBJECTIVES: Because of the high prevalence of Autism Spectrum Disorder (ASD) and wandering behavior, emergency medical responders (EMRs) will likely encounter children and adolescents with ASD. The objectives were to describe interactions between EMRs and children and adolescents with ASD, to evaluate EMRs' ability to recognize ASD in a simulated trauma setting, and to determine if EMRs' demographic characteristics affected their interactions with ASD youth. METHODS: A study of 75 videos of a simulated school bus crash was performed. The simulation included an adolescent with ASD portrayed by an actor. Videos were coded based on 5 domains: (1) reassurance attempts by the EMR, (2) quality of the EMR's interactions, (3) EMR's elicitation of information, (4) EMR's interactions with others, and (5) EMR's recognition of a disability. Two clinicians coded the videos independently, and consensus was reached for any areas of disagreement. RESULTS: Of 75 interactions, 27% provided reassurance to the adolescent with ASD, 1% elicited information, 11% asked bystanders for information or assistance, and 35% suggested a disability with 13% considering ASD. No differences across domains were found based on the EMR's sex. Emergency medical responders with greater than or equal to 5 years of experience were significantly more likely to elicit information than those with less than 5 years of experience, and paramedics had significantly higher total performance scores than paramedic students or those with EMT-Basic. CONCLUSIONS: Few EMRs in this study optimally interacted with adolescents with ASD or recognized a disability. These findings suggest a strong need for targeted educational interventions.

Classifying Injuries in Young Children as Abusive or Accidental: Reliability and Accuracy of an Expert Panel Approach.

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.

Diagnosing abusive head trauma: the challenges faced by clinicians.

This article highlights five important aspects of the clinical problem of evaluating young children who are suspected of having abusive head trauma: 1) the clinical questions to be addressed, 2) challenges when evaluating young children with suspected abuse, 3) key aspects of clinical practice and data collection, 4) a framework for decision-making and 5) key articles in the literature that can help inform a sound clinical decision about the likelihood of abuse.

The Circumstances Surrounding Fatal Pediatric Opioid Poisonings, 2004-2020.

OBJECTIVES: There is little understanding of the circumstances behind fatal pediatric opioid poisonings. Our objective was to characterize opioid fatalities according to child, family, and household factors. METHODS: We used data from the National Fatality Review-Case Reporting System to describe the circumstances behind the deaths of children 0 to 17 years of age who died of an opioid poisoning (ie, prescription opioid, heroin, illicit fentanyl) between 2004 and 2020. Decedents were stratified into age groups: 0-4, 5-9, 10-14, and 15-17 years. RESULTS: The majority (65.3%) of the 1696 fatal opioid poisonings occurred in the child's own home. Prescription opioids contributed to 91.8% of deaths, heroin contributed to 5.4%, and illicit fentanyl to 7.7%. Co-poisonings with nonopioid substances occurred in 43.2% of deaths. Among 0- to 4-year-olds, 33.9% died of homicide and 45.0% had a primary caregiver with a history of substance use/abuse. Among 10- to 14-year-olds and 15- to 17-year-olds, respectively, 42.0% and 72.8% of decedents had a history of substance use/abuse. In each age group, at least 25.0% of children were victims of previous child maltreatment. CONCLUSIONS: A history of maltreatment and substance use-whether on the part of the caregiver or the child-are common factors surrounding fatal pediatric opioid poisonings, the majority of which occur in the child's own home. Families with children of all ages would benefit from interventions focused on opioid prescribing, storage, disposal, and misuse. These findings also underscore the urgency of ensuring that access to naloxone becomes universal for families with a history of maltreatment and/or substance use.

Estimating Surveillance Bias in Child Maltreatment Reporting During Home Visiting Program Involvement.

It is unclear if surveillance bias (increased reports to Child Protective Services [CPS] related to program involvement) has a substantial impact on evaluation of home visiting (HV) prevention programs. We estimated surveillance bias using data from Connecticut's HV program, birth certificates, CPS, and hospitals. Using propensity score matching, we identified 15,870 families similar to 4015 HV families. The difference-in-differences approach was used to estimate surveillance bias as the change in investigated reports from the last 6 months of program involvement to the next 6 months. The median age of the children at program exit was 1.2 years (range: 60 days, 5 years). We estimated that 25.6% of investigated reports in the HV group resulted from surveillance bias. We reviewed CPS reports of 194 home-visited families to determine if a home visitor made the report and found that 10% were directly from home visitors. Program evaluations should account for surveillance bias.

Hospital Readmissions Among Infants With Neonatal Opioid Withdrawal Syndrome.

Importance: Although cases of neonatal opioid withdrawal syndrome (NOWS) increased 5-fold in recent years, no study has examined national hospital readmission rates for these infants. Objective: To examine hospital readmissions for infants with and without NOWS. Design, Setting, and Participants: This retrospective cohort study analyzed serial cross-sectional samples of US hospital discharge records from the Nationwide Readmissions Database for calendar years 2016 to 2020. Infants with NOWS were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. The data analysis was performed between January 5, 2023, and May 6, 2024. Exposure: Neonatal opioid withdrawal syndrome. Main Outcome and Measures: Survey-weighted logistic regression was used to examine 90-day all-cause and cause-specific hospital readmissions. Multivariable models adjusted for sex, low birth weight, gestational age, multiple gestation, type of insurance, and year of birth. Results: Of the 13 855 246 newborns identified in this weighted analysis, 89 018 (0.6%) were diagnosed with NOWS, of whom 53.8% were male and 81.1% born full-term (>36 weeks gestation). The 90-day all-cause readmission rate was 4.2% for infants with NOWS compared with 3.0% for those without NOWS (P < .001). After risk adjustment, the odds of all-cause readmission were higher among infants with NOWS (adjusted odds ratio [AOR], 1.18; 95% CI, 1.08-1.29). Infants with NOWS had significantly higher odds of readmissions for seizures (AOR, 1.58; 95% CI, 1.01-2.46), failure to thrive (AOR, 1.99; 95% CI, 1.36-2.93), traumatic brain injury (AOR, 2.95; 95% CI, 1.76-4.93), and skull fractures (AOR 3.72; 95% CI, 2.33-5.93). Infants with NOWS had higher odds of receiving a diagnosis of confirmed maltreatment (AOR, 4.26; 95% CI, 2.19-8.27), including for neglect (AOR, 14.18; 95% CI, 5.55-36.22) and physical abuse (AOR, 2.42; 95% CI, 0.93-6.29); however, the latter finding was not statistically significant. Conclusions and Relevance: In this nationally representative cohort study, infants with NOWS were at increased risk of readmission for any cause as well as for trauma and confirmed maltreatment. These findings may in part reflect the dual stressors that mothers with opioid use disorder face in caring for a newborn with NOWS in the context of a substance use disorder and underscore the need for family-based, in-home services that focus concurrently on substance use treatment and parenting support.

Acceptability and feasibility of trauma- and violence-informed care for intimate partner violence.

BACKGROUND/OBJECTIVES: Intimate partner violence (IPV) and child physical abuse frequently co-occur, yet IPV-exposed children are not routinely evaluated for abuse. Furthermore, IPV survivors often seek care for their children but not for themselves, making pediatric visits an opportunity to address IPV. We developed a trauma- and violence-informed care (TVIC)-based model that 1) evaluated IPV-exposed children and 2) linked survivor-caregivers to an IPV advocate. We aimed to assess the feasibility and acceptability of the model. PARTICIPANTS: Children < 3 who were reported to Child Protective Services (CPS) for exposure to IPV and their survivor-caregiver. METHODS: To examine feasibility, we calculated the percentage of 1) eligible children evaluated and 2) caregivers who met with an IPV advocate during the child's visit and followed up with the advocate. To assess acceptability, we conducted qualitative interviews with 30/41 caregivers about their perceptions of the model. RESULTS: From 7/1/20-6/30/22, 49 (22.7 %) of 216 eligible children were evaluated. Of 41 caregivers, six already were receiving IPV services; Of the remaining 35, 24 (68.6 %) met with an IPV advocate, and 22 (91.7 %) had ≥1 follow-up visit with an advocate. We identified three themes: 1) Motivations for the visit, 2) Engagement with the model, and 3) Benefits. Caregivers attended the visit due to behavioral concerns about the child and a desire to comply with CPS. Engagement occurred as medical providers established rapport and provided support without judgment. Benefits included recognizing the impact of IPV on the child and immediate linkage to advocacy services. CONCLUSION: A TVIC-based model is feasible and acceptable and could improve caregivers' engagement with the evaluation of IPV-exposed children for abuse and with IPV services, which have the potential to improve safety and promote well-being.

Identification of physical abuse cases in hospitalized children: accuracy of International Classification of Diseases codes.

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.

Markers of maternal depressive symptoms in an urban pediatric clinic.

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.