"Instead of just taking my baby, they could've actually given me a chance": Experiences with plans of safe care among birth parents impacted by perinatal substance use.

BACKGROUND: Federal legislation mandates healthcare providers to notify child protective service (CPS) agencies and offer a voluntary care plan called a "plan of safe care" (POSC) for all infants born affected by prenatal substance use. While POSCs aim to provide supportive services for families impacted by substance use, little is known about birth parents' perceptions and experiences. OBJECTIVE: To examine birth parents' perceptions and experiences regarding POSC. PARTICIPANTS AND SETTING: Parents offered a POSC in Philadelphia in the prior year were included. METHODS: This is a qualitative interview study. Participants were recruited from birth hospitals and community-based programs with telephone consent and interview procedures. Transcripts were analyzed using an inductive, grounded theory approach to identify content themes. RESULTS: Twelve birth parents were interviewed (30.7 % of eligible, contacted individuals). Fear of CPS involvement and stigma were common. Some birth parents reported that the increased scrutiny related to POSCs negatively impacted their attitudes toward healthcare providers and medications for opioid use disorder (MOUD). While parents found the consolidated resource information helpful, many did not know how to access services. Finally, parents desired more individualized plans tailored to their unique family needs. CONCLUSIONS: Stigma, confusion, and fear of CPS involvement undermine the goal of POSCs to support substance-exposed infants and birth parents. Providers serving this population should be transparent regarding CPS notifications, provide compassionate, non-stigmatizing care, and offer coordination services to support engagement after discharge. Policymakers should consider separating POSCs from CPS to avoid exacerbating fear and mistrust.

Improving health and well-being for infants with prenatal substance exposure.

Substance use disorders (SUD) among caregiving adults has inexorable linkage to the health and well-being of millions of children in the U.S. This piece provides an overview of such linkages, examples of relevant policies and regulations, and the role of pediatric healthcare within the health trajectories of children and families at this intersection. A commonality throughout this work is need for non-stigmatizing engagement and support to facilitate connections to care and reduce barriers.

Observations of Positive Parenting from Online Parent-Child Interactions at Age 1.

Objective: Brief, reliable, and cost-effective methods to assess parenting are critical for advancing parenting research. Design: We adapted the Three Bags task and Parent Child Interaction Rating System (PCIRS) for rating online visits with 219 parent-child dyads (White, n = 104 [47.5%], Black, n = 115 [52.5%]) and combined the video data with survey data collected during pregnancy and when children were aged 1. Results: The PCIRS codes of positive regard, stimulation of child cognitive development, and sensitivity showed high reliability across the three parent-child interaction tasks. A latent positive parenting factor combining ratings across codes and tasks showed good model fit, which was similar regardless of parent self-identified race or ethnicity, age, socioeconomic disadvantage, marital/partnered status, and parity, as well as methodological factors relevant to the online video assessment method (e.g., phone vs. laptop/tablet). In support of construct validity, observed positive parenting was related to parent-reported positive parenting and child socioemotional development. Finally, parent reports of supportive relationships in pregnancy, but not neighborhood safety or pandemic worries, were prospectively related to higher positive parenting observed at age 1. With the exception of older parental age and married/partnered status, no other parent, child, sociodemographic, or methodological variables were related to higher overall video exclusions across tasks. Conclusions: PCIRS may provide a reliable approach to rate positive parenting at age 1, providing future avenues for developing more ecologically valid assessments and implementing interventions through online encounters that may be more acceptable, accessible, or preferred among parents of young children.

Assessment of substance exposures in nail clipping samples: A systematic review.

BACKGROUND: Studies of prenatal substance exposure often rely on self-report, urine drug screens, and/or analyses of blood or meconium biomarkers. Accuracy of these measures is limited when assessing exposure over many weeks or months of gestation. Nails are increasingly being considered as a matrix from which to assess substance exposure. This systematic review synthesizes data on the validity of detecting alcohol, nicotine, cannabis, and opioid from nail clippings, with an emphasis on prenatal exposure assessment. METHODS: The systematic review was conducted using PRISMA 2020 guidelines. Seven databases were searched with keywords relevant to the four substances of interest. Results were summarized grouping manuscripts by the exposure of interest with focus on accuracy and feasibility. RESULTS: Of 2384 papers initially identified, 35 manuscripts were included in our qualitative synthesis. Only a few studies specifically looked at pregnant individuals or mother-child dyads. Across the four substances, many studies demonstrated a dose-response relationship between exposure and concentration of analytes in nails. Nail assays appear to detect lower level of exposure compared to hair; however, sample insufficiency, especially for multi-substance assays, remains a limitation. CONCLUSIONS: Based on the reviewed studies, nail clippings are an acceptable and potentially preferable matrix for the evaluation of these four prenatal substances when sampling frequency and/or study design necessitates assessment of past exposures over an extended period. Nails have the advantage of infrequent sampling and minimal invasiveness to assess a broad exposure period. Future studies should examine validity of analytes in toenail versus fingernail clippings.

The Influence of Pandemic-Related Worries During Pregnancy on Child Development at 12 Months.

The COVID-19 pandemic has been linked to increased risk for perinatal anxiety and depression among parents, as well as negative consequences for child development. Less is known about how worries arising from the pandemic during pregnancy are related to later child development, nor if resilience factors buffer negative consequences. The current study addresses this question in a prospective longitudinal design. Data was collected from a sub-study (n = 184) of a longitudinal study of pregnant individuals (total n = 1173). During pregnancy (April 17-July 8, 2020) and the early postpartum period (August 11, 2020-March 2, 2021), participants completed online surveys. At 12 months postpartum (June 17, 2021-March 23, 2022), participants completed online surveys and a virtual laboratory visit, which included parent-child interaction tasks. We found more pregnancy-specific pandemic worries were prospectively related to lower levels of child socioemotional development based on parent report (B = - 1.13, SE = .43, p = .007) and observer ratings (B = - 0.13, SE = .07, p = .045), but not to parent-reported general developmental milestones. Parental emotion regulation in the early postpartum period moderated the association between pregnancy-specific pandemic worries and child socioemotional development such that pregnancy-specific pandemic worries did not relate to worse child socioemotional development among parents with high (B = - .02, SE = .10, t = - .14, p = .89) levels of emotion regulation. Findings suggest the negative consequences of parental worry and distress during pregnancy on the early socioemotional development of children in the context of the COVID-19 pandemic. Results highlight that parental emotion regulation may represent a target for intervention to promote parental resilience and support optimized child development.

Brain Growth Charts for Quantitative Analysis of Pediatric Clinical Brain MRI Scans with Limited Imaging Pathology.

Background Clinically acquired brain MRI scans represent a valuable but underused resource for investigating neurodevelopment due to their technical heterogeneity and lack of appropriate controls. These barriers have curtailed retrospective studies of clinical brain MRI scans compared with more costly prospectively acquired research-quality brain MRI scans. Purpose To provide a benchmark for neuroanatomic variability in clinically acquired brain MRI scans with limited imaging pathology (SLIPs) and to evaluate if growth charts from curated clinical MRI scans differed from research-quality MRI scans or were influenced by clinical indication for the scan. Materials and Methods In this secondary analysis of preexisting data, clinical brain MRI SLIPs from an urban pediatric health care system (individuals aged ≤22 years) were scanned across nine 3.0-T MRI scanners. The curation process included manual review of signed radiology reports and automated and manual quality review of images without gross pathology. Global and regional volumetric imaging phenotypes were measured using two image segmentation pipelines, and clinical brain growth charts were quantitatively compared with charts derived from a large set of research controls in the same age range by means of Pearson correlation and age at peak volume. Results The curated clinical data set included 532 patients (277 male; median age, 10 years [IQR, 5-14 years]; age range, 28 days after birth to 22 years) scanned between 2005 and 2020. Clinical brain growth charts were highly correlated with growth charts derived from research data sets (22 studies, 8346 individuals [4947 male]; age range, 152 days after birth to 22 years) in terms of normative developmental trajectories predicted by the models (median r = 0.979). Conclusion The clinical indication of the scans did not significantly bias the output of clinical brain charts. Brain growth charts derived from clinical controls with limited imaging pathology were highly correlated with brain charts from research controls, suggesting the potential of curated clinical MRI scans to supplement research data sets. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Ertl-Wagner and Pai in this issue.

The impact of postpartum social support on postpartum mental health outcomes during the COVID-19 pandemic.

Social support is an influential component of postpartum recovery, adjustment, and bonding, which was disrupted by social distancing recommendations related to the COVID-19 pandemic. This study reports on changes in the availability of social support for postpartum women during the pandemic, investigates how those changes may have contributed to postpartum mental health, and probes how specific types of social support buffered against poor postpartum mental health and maternal-infant bonding impairment. Participants were 833 pregnant patients receiving prenatal care in an urban USA setting and using an electronic patient portal to access self-report surveys at two time points, during pregnancy (April-July 2020) and at ~12 weeks postpartum (August 2020-March 2021). Measures included an assessment of COVID-19 pandemic-related change in social support, sources of social support, ratings of emotional and practical support, and postpartum outcomes including depression, anxiety, and maternal-infant bonding. Overall self-reported social support decreased during the pandemic. Decreased social support was associated with an increased risk of postpartum depression, postpartum anxiety, and impaired parent-infant bonding. Among women reporting low practical support, emotional support appeared to protect against clinically significant depressive symptoms and impaired bonding with the infant. Decreases in social support are associated with a risk for poor postpartum mental health outcomes and impaired maternal-infant bonding. Evaluation and promotion of social support are recommended for healthy adjustment and functioning of postpartum women and families.

Child Welfare System-Level Factors Associated with All-Cause Mortality Among Children in Foster Care in the United States, 2009-2018.

Little is known about the impact of child welfare system-level factors on child mortality as an outcome within foster care. Using data from the Adoption and Foster Care Analysis and Reporting System, 2009-2018, we examined the associations between county-level sociodemographic, foster care performance, and judicial reform characteristics with all-cause mortality rates. Results of random effects negative binomial regression analyses showed that higher proportions of younger children (<1 year: IRR = 1.06, 95% CI [1.02, 1.11]; 5-9 years: IRR = 1.05, 95% CI [1.01, 1.09]); children of color (i.e., non-Hispanic Asian: IRR = 1.07, 95% CI [1.01, 1.13]; multiracial: IRR = 1.03, 95% CI [1.01, 1.04]; non-Hispanic Black: IRR = 1.02, 95% CI [1.01, 1.02]; Hispanic: IRR = 1.01, 95% CI [1.01, 1.02]); and male children (IRR = 1.10, 95% CI [1.05, 1.15]) were associated with higher mortality risks at the county level. Current class action lawsuits (IRR = 0.79, 95% CI [0.63, 0.99]) and active consent decrees (IRR = 0.77, 95% CI [0.63, 0.94]) were associated with lower mortality risks. None of the foster care performance characteristics (e.g., foster care entry, placement stability, permanency) were associated with mortality risks. These findings have implications for addressing health disparities and reforming foster care systems through programmatic and policy efforts.

The Influence of Pandemic-Related Worries During Pregnancy on Child Development at 12 Months.

The COVID-19 pandemic has been linked to increased risk for perinatal anxiety and depression among parents, as well as negative consequences for child development. Less is known about how worries arising from the pandemic during pregnancy are related to later child development, nor if resilience factors buffer negative consequences. The current study addresses this question in a prospective longitudinal design. Data was collected from a sub-study ( n = 184) of a longitudinal study of pregnant individuals (total n = 1,173). During pregnancy (April 17-July 8, 2020) and the early postpartum period (August 11, 2020-March 2, 2021), participants completed online surveys. At 12 months postpartum (June 17, 2021-March 23, 2022), participants completed online surveys and a virtual laboratory visit, which included parent-child interaction tasks. We found more pregnancy-specific pandemic worries were prospectively related to lower levels of child socioemotional development based on parent report (B=-1.13, SE = .43, p = .007) and observer ratings (B=-0.13, SE = .07, p = .045), but not to parent-reported general developmental milestones. Parental emotion regulation in the early postpartum period moderated the association between pregnancy-specific pandemic worries and child socioemotional development such that pregnancy-specific pandemic worries did not related to worse child socioemotional development among parents with high (B=-.02, SE = .10, t=-.14, p = .89) levels of emotion regulation. Findings suggest the negative consequences of parental worry and distress during pregnancy on the early socioemotional development of children in the context of the COVID-19 pandemic. Results highlight that parental emotion regulation may represent a target for intervention to promote parental resilience and support optimized child development.

Patterns of Change in Race Category in the Electronic Medical Record of a Pediatric Population.

This cross-sectional study sought to quantify the frequency of change in race category in the electronic medical record (EMR) of a pediatric population.

Expansion and commentary on a two generation approach to prenatal opioid exposure - a commentary on Conradt et al. (2023).

Early child neurodevelopment, including psychopathology, is influenced by a myriad of factors and interactions. These factors are both intrinsic to the caregiver-child dyad such as genetics and epigenetics as well as extrinsic such as social environment and enrichment. Additional layers of complexity may be at play within families with parental substance use, as outlined by Conradt et al. (2023) in their review article titled "Prenatal Opioid Exposure: A Two-Generation Approach to Conceptualizing Risk for Child Psychopathology.". Conradt et al. provide an overarching synthesis of many findings related to substance use that goes beyond the in utero exposure to the transgenerational interface of pregnancy and early childhood, including biologic sensitivities such as genetic predisposition, overrepresentation of social risk factors including early adversities of caregivers and poverty, and transgenerational interactional susceptibilities. Altered dyadic interactions may relate to joint changes in neurobehavior and are not isolated from the influence of infant genetics, epigenetics, and environment. The early neurodevelopmental correlates of prenatal substance exposure including risks of childhood psychopathology are then a composite of many different forces. This nuanced reality, described as an "inter-generational cascade," does not centralize parental substance use or prenatal exposure as a singularly causative moment but positions it within the ecologic milieu of the total lived experience.

Association between Asthma and Suicidality in 9-12-Year-Old Youths.

PURPOSE: Suicidal ideation and attempts in youth are a growing health concern, and more data are needed regarding their biological underpinnings. Asthma is a common chronic inflammatory disorder in youth and has been associated with suicidal ideation and attempts in adolescent and adult populations, but data in younger children and early adolescents are lacking. We wished to study associations of asthma with childhood suicidality considering asthma's potential as a clinically relevant model for childhood chronic immune dysregulation. METHODS: Using data from the Adolescent Brain Cognitive Development (ABCD) Study (n = 11,876, 47.8% female, mean age 9.9 years at baseline assessment and 12.0 years at two-year follow-up), we assessed associations between asthma and suicidal ideation and attempts through baseline to two-year follow-up. RESULTS: Asthma history as defined by parent report (n = 2282, 19.2% of study population) was associated with suicide attempts (SA) (odds ratio (OR) = 1.44, p = 0.01), and this association remained significant even when controlling for demographics, socioeconomic factors, and environmental factors (OR = 1.46, p = 0.028). History of asthma attacks was associated with both suicidal ideation (SI) and SA when controlling for demographics, socioeconomic factors, and environmental factors (OR = 1.27, p = 0.042; OR = 1.83, p = 0.004, respectively). The association of asthma attack with SA remained significant when controlling for self-reported psychopathology (OR = 1.92, p = 0.004). The total number of asthma attacks was associated with both SI and SA (OR = 1.03, p = 0.043; OR = 1.06, p = 0.05, respectively). CONCLUSIONS: Findings suggest an association between asthma and suicidality in early adolescence. Further research is needed to investigate mechanisms underlying this relationship.

Clinician-reported childbirth outcomes, patient-reported childbirth trauma, and risk for postpartum depression.

Childbirth trauma is common and increases risk for postpartum depression (PPD). However, we lack brief measures to reliably identify individuals who experience childbirth trauma and who may be at greater prospective risk for PPD. To address this gap, we used data from a racially diverse prospective cohort (n=1082). We collected survey data during pregnancy and at 12 weeks postpartum, as well as clinician-reported data from medical records. A new three-item measure of patient-reported childbirth trauma was a robust and independent risk factor for PPD, above and beyond other known risk factors for PPD, including prenatal anxiety and depression. Cesarean birth, greater blood loss, and preterm birth were each associated with greater patient-reported childbirth trauma. Finally, there were prospective indirect pathways whereby cesarean birth and higher blood loss were related to higher patient-reported childbirth trauma, in turn predicting greater risk for PPD. Early universal postpartum screening for childbirth trauma, targeted attention to individuals with childbirth complications, and continued screening for depression and anxiety can identify individuals at risk for PPD. Such efforts can inform targeted interventions to improve maternal mental health, which plays a vital role in infant development.

Emergency Department Child Abuse Evaluations During COVID-19: A Multicenter Study.

BACKGROUND AND OBJECTIVE: The reported impacts of the COVID-19 pandemic on child maltreatment in the United States have been mixed. Encounter trends for child physical abuse within pediatric emergency departments may provide insights. Thus, this study sought to determine the change in the rate of emergency department encounters related to child physical abuse. METHODS: A retrospective study within the Pediatric Emergency Care Applied Research Network Registry. Encounters related to child physical abuse were identified by 3 methods: child physical abuse diagnoses among all ages, age-restricted high-risk injury, or age-restricted skeletal survey completion. The primary outcomes were encounter rates per day and clinical severity before (January 2018-March 2020) and during the COVID-19 pandemic (April 2020-March 2021). Multivariable Poisson regression models were fit to estimate rate ratios with marginal estimation methods. RESULTS: Encounter rates decreased significantly during the pandemic for 2 of 3 identification methods. In fully adjusted models, encounter rates were reduced by 19% in the diagnosis-code cohort (adjusted rate ratio: 0.81 [99% confidence interval: 0.75-0.88], P <.001), with the greatest reduction among preschool and school-aged children. Encounter rates decreased 10% in the injury cohort (adjusted rate ratio: 0.90 [confidence interval: 0.82-0.98], P = .002). For all 3 methods, rates for lower-severity encounters were significantly reduced whereas higher-severity encounters were not. CONCLUSIONS: Encounter rates for child physical abuse were reduced or unchanged. Reductions were greatest for lower-severity encounters and preschool and school-aged children. This pattern calls for critical assessment to clarify whether pandemic changes led to true reductions versus decreased recognition of child physical abuse.

Copy Number Variant Risk Scores Associated With Cognition, Psychopathology, and Brain Structure in Youths in the Philadelphia Neurodevelopmental Cohort.

Importance: Psychiatric and cognitive phenotypes have been associated with a range of specific, rare copy number variants (CNVs). Moreover, IQ is strongly associated with CNV risk scores that model the predicted risk of CNVs across the genome. But the utility of CNV risk scores for psychiatric phenotypes has been sparsely examined. Objective: To determine how CNV risk scores, common genetic variation indexed by polygenic scores (PGSs), and environmental factors combine to associate with cognition and psychopathology in a community sample. Design, Setting, and Participants: The Philadelphia Neurodevelopmental Cohort is a community-based study examining genetics, psychopathology, neurocognition, and neuroimaging. Participants were recruited through the Children's Hospital of Philadelphia pediatric network. Participants with stable health and fluency in English underwent genotypic and phenotypic characterization from November 5, 2009, through December 30, 2011. Data were analyzed from January 1 through July 30, 2021. Exposures: The study examined (1) CNV risk scores derived from models of burden, predicted intolerance, and gene dosage sensitivity; (2) PGSs from genomewide association studies related to developmental outcomes; and (3) environmental factors, including trauma exposure and neighborhood socioeconomic status. Main Outcomes and Measures: The study examined (1) neurocognition, with the Penn Computerized Neurocognitive Battery; (2) psychopathology, with structured interviews based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children; and (3) brain volume, with magnetic resonance imaging. Results: Participants included 9498 youths aged 8 to 21 years; 4906 (51.7%) were female, and the mean (SD) age was 14.2 (3.7) years. After quality control, 18 185 total CNVs greater than 50 kilobases (10 517 deletions and 7668 duplications) were identified in 7101 unrelated participants genotyped on Illumina arrays. In these participants, elevated CNV risk scores were associated with lower overall accuracy on cognitive tests (standardized ß = 0.12; 95% CI, 0.10-0.14; P = 7.41 × 10-26); lower accuracy across a range of cognitive subdomains; increased overall psychopathology; increased psychosis-spectrum symptoms; and higher deviation from a normative developmental model of brain volume. Statistical models of developmental outcomes were significantly improved when CNV risk scores were combined with PGSs and environmental factors. Conclusions and Relevance: In this study, elevated CNV risk scores were associated with lower cognitive ability, higher psychopathology including psychosis-spectrum symptoms, and greater deviations from normative magnetic resonance imaging models of brain development. Together, these results represent a step toward synthesizing rare genetic, common genetic, and environmental factors to understand clinically relevant outcomes in youth.

A Venn diagram of vulnerability: The convergence of pediatric palliative care and child maltreatment a narrative review, and a focus on communication.

Child maltreatment and end-of-life care independently represent two of the most emotion-laden and uncomfortable aspects of pediatric patient care. Their overlap can be uniquely distressing. This review explores ethical and legal principles in such cases and provides practical advice for clinicians. The review focuses on three archetypal scenarios of overlap: life-limiting illness in a child for whom parental rights have been terminated; life-threatening injury under CPS investigation; and complex end-of-life care which may warrant CPS involvement. While each scenario presents unique challenges, one consistent theme is the centrality of effective communication. This includes empathic communication with families and thoughtful communication with providers and community stakeholders. In almost all cases, everyone genuinely wants to do what is in the best interest of the child in these unthinkable circumstances. Transparent and collaborative communication can ensure that broad perspectives are considered to ensure that each child gets the best possible care in a manner adherent with ethical and legal standards, as they apply to each case.