Health and Safety Checklist for Early Care and Education Programs to Assess Key National Health and Safety Standards.

OBJECTIVES: The project aims were to (1) develop an observational Health and Safety Checklist to assess health and safety practices and conditions in early care and education (ECE) programs using Stepping Stones To Caring For Our Children, 3rd Edition national standards, (2) pilot test the Checklist, completed by nurse child care health consultants, to assess feasibility, ease of completion, objectivity, validity, and reliability, and (3) revise the Checklist based on the qualitative and quantitative results of the pilot study. METHODS: The observable national health and safety standards were identified and then rated by health, safety, and child care experts using a Delphi technique to validate the standards as essential to prevent harm and promote health. Then, child care health consultants recruited ECE centers and pilot tested the 124-item Checklist. The pilot study was conducted in Arizona, California and North Carolina. The psychometric properties of the Checklist were assessed. RESULTS: The 37 participating ECE centers had 2627 children from ethnically-diverse backgrounds and primarily low-income families. The child care health consultants found the Checklist easy to complete, objective, and useful for planning health and safety interventions. The Checklist had content and face validity, inter-rater reliability, internal consistency, and concurrent validity. Based on the child care health consultant feedback and psychometric properties of the Checklist, the Checklist was revised and re-written at an 8th grade literacy level. CONCLUSION: The Health and Safety Checklist provides a standardized instrument of observable, selected national standards to assess the quality of health and safety in ECE centers.

Randomized, double-blind, placebo-controlled study of synbiotic yogurt effect on the health of children.

OBJECTIVE: To assess the effects of daily consumption of a synbiotic yogurt drink on the health, growth, and quality of life of healthy children 12-48 months of age in out-of-home child care. STUDY DESIGN: Healthy children attending child care centers were enrolled in a prospective, double-blind, placebo-controlled clinical trial. The intervention was a yogurt drink containing Streptococcus thermophilus, Lactobacillus bulgaricus, and Bifidobacterium animalis subspecies lactis (BB-12) (5 × 10(9) cfu/100 mL serving), and 1 g of inulin (synbiotic group) vs a similar nonsynbiotic-containing acidified milk drink (placebo group) once daily for 16 weeks. The end points were days of diarrhea, fever, vomiting, symptoms of upper respiratory tract infection, use of antibiotics, physician visits, child care absenteeism, parental work absenteeism, and quality of life (PedsQL 4.0; Mapi Research Trust, Lyon, France). RESULTS: Compared with placebo (n = 73), children receiving synbiotic (n = 76) had significantly fewer days of reported fever (1.85 vs 1.95, P < .05), significant improvement in social functioning (P < .035; pre-to-end intervention), and school functioning (P < .045; pre-to-mid intervention). More days with ≥ 3 loose/watery stools were reported in the synbiotic group (P < .05). CONCLUSIONS: Daily supplementation of children's diet with yogurt containing probiotic bacteria BB-12 and inulin significantly reduced days of fever and improved social and school functioning. The increased frequency of bowel movements may be explained by an accelerating effect of BB-12 and inulin on intestinal transit. Further research on the possible benefits of synbiotics on children's health is advised. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00653705.

Toxic metal levels in children residing in a smelting craft village in Vietnam: a pilot biomonitoring study.

BACKGROUND: In Vietnam, environmental pollution caused by small-scale domestic smelting of automobile batteries into lead ingot is a growing concern. The village of Nghia Lo is a smelting craft village located roughly 25 km southeast of Hanoi in the Red River Delta. Despite the concern of toxic metal exposure in the village, biomonitoring among susceptible populations, such as children, has not been previously conducted. The aim of this study was to determine the body burden of toxic metals in children residing in a smelting craft village. METHODS: Twenty children from Nghia Lo, Vietnam, ages 18 months to four years were selected for capillary whole blood and toenail biomonitoring. Whole blood lead levels (BLLs) were measured using a portable lead analyzer, and toenail levels of arsenic, cadmium, chromium, lead, manganese, and mercury were analyzed with inductively coupled plasma-mass spectrometry. RESULTS: The findings show that all of the 20 children had detectable BLLs, and every child had levels that exceeded the Centers for Disease Control and Prevention guideline level of 5 µg/dL. Eighty percent of tested subjects had BLLs higher than 10 µg/dL. Five children (25%) had BLLs greater than 45 µg/dL, the level of recommended medical intervention. In addition to blood lead, all of the children had detectable levels of arsenic, cadmium, chromium, lead, manganese, and mercury in toenail samples. Notably, average toenail lead, manganese, and mercury levels were 157 µg/g, 7.41 µg/g, and 2.63 µg/g respectively, well above levels previously reported in children. Significant Spearman's rank correlations showed that there were relationships between blood and toenail lead levels (r = 0.65, p < 0.05), toenail levels of lead and cadmium (r = 0.66, p < 0.05), and toenail levels of manganese and chromium (r = 0.72, p < 0.001). Linear regression showed that reducing the distance to the nearest active smelter by half was associated with a 116% increase in BLL (p < 0.05). CONCLUSIONS: The results suggest that children in battery recycling and smelting craft villages in Vietnam are co-exposed to toxic metals. There is an urgent need for mitigation to control metal exposure related to domestic smelting.

Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children's body mass index.

BACKGROUND: To address the public health crisis of overweight and obese preschool-age children, the Nutrition And Physical Activity Self Assessment for Child Care (NAP SACC) intervention was delivered by nurse child care health consultants with the objective of improving child care provider and parent nutrition and physical activity knowledge, center-level nutrition and physical activity policies and practices, and children's body mass index (BMI). METHODS: A seven-month randomized control trial was conducted in 17 licensed child care centers serving predominantly low income families in California, Connecticut, and North Carolina, including 137 child care providers and 552 families with racially and ethnically diverse children three to five years old. The NAP SACC intervention included educational workshops for child care providers and parents on nutrition and physical activity and consultation visits provided by trained nurse child care health consultants. Demographic characteristics and pre - and post-workshop knowledge surveys were completed by providers and parents. Blinded research assistants reviewed each center's written health and safety policies, observed nutrition and physical activity practices, and measured randomly selected children's nutritional intake, physical activity, and height and weight pre- and post-intervention. RESULTS: Hierarchical linear models and multiple regression models assessed individual- and center-level changes in knowledge, policies, practices and age- and sex-specific standardized body mass index (zBMI), controlling for state, parent education, and poverty level. Results showed significant increases in providers' and parents' knowledge of nutrition and physical activity, center-level improvements in policies, and child-level changes in children's zBMI based on 209 children in the intervention and control centers at both pre- and post-intervention time points. CONCLUSIONS: The NAP SACC intervention, as delivered by trained child health professionals such as child care health consultants, increases provider knowledge, improves center policies, and lowers BMI for children in child care centers. More health professionals specifically trained in a nutrition and physical activity intervention in child care are needed to help reverse the obesity epidemic. TRIAL REGISTRATION: National Clinical Trials Number NCT01921842.

Correlates of parent-youth discordance about youth-witnessed violence: a brief report.

Studies have consistently demonstrated a lack of agreement between youth and parent reports regarding youth-witnessed violence (YWV). However, little empirical investigation has been conducted on the correlates of disagreement. Concordance between youth and parents about YWV was examined in 766 parent-youth dyads from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). Results showed that significantly more youth (42%) than parents (15%) reported YWV. Among the dyads in which at least one informant reported YWV (N = 344), we assessed whether youth delinquency, parental monitoring, parent-child relationship quality, history of child maltreatment, income, and parental depression were predictive of parent-youth concordance. Findings indicated that youth engagement in delinquent activities was higher in the groups in which the youth reported violence exposure. More empirical study is needed to assess correlates of agreement in high-risk youth to better inform associations found between exposures and outcomes as well as practice and policy for violence exposed youth.

Influence of caregiver network support and caregiver psychopathology on child mental health need and service use in the LONGSCAN study.

Using structural equation modeling, this study examined the relationship of caregiver network support on caregiver and child mental health need, as well as child mental health service use among 1075 8-year-old children participating in the LONGSCAN study. The final model showed acceptable fit (χ(2) = 301.476, df = 136, p<0.001; RMSEA = 0.052; CFI = 0.95). Caregiver and child mental health needs were positively related. As predicted, caregiver network support exerted a protective effect, with greater levels of caregiver network support predictive of lower caregiver and child need. Contrary to prediction, however, caregiver network support was not directly related to child service use. Higher child need was directly related to child service use, especially among children whose caregivers had mental health problems. The findings appear to indicate that lower levels of caregiver network support may exert its impact on child service use indirectly by increasing caregiver and child need, rather than by directly increasing the likelihood of receiving services, especially for African American children.

Neglect in Childhood, Problem Behavior in Adulthood.

Few studies have reported problem behaviors in adulthood related to the timing of child neglect. The objective was to examine the relationship between classes of child neglect and later behavior. The sample included 473 participants from the prospective Longitudinal Studies of Child Abuse and Neglect (LONGSCAN); their mean age was 23.8 years. They completed an online survey regarding behaviors and experiences in early adulthood. Neglect was assessed via Child Protective Services (CPS) and self-reports of neglect. Latent class analysis (LCA) identified three classes: Late Neglect, Chronic Neglect, and Limited Neglect. There were significant differences between Limited and Late Neglect regarding later intimate partner aggression and violence (IPAV) and psychological distress, and among all classes for criminal behavior. High-risk youth experiencing neglect beginning in mid-adolescence appear especially vulnerable to later criminal behavior, psychological distress, and IPAV. Those working with such youth can help ensure that their needs are adequately met, to prevent or mitigate problems in adulthood.

Impact of poor oral health on children's school attendance and performance.

OBJECTIVES: We examined school days missed for routine dental care versus dental pain or infection to determine the relationship between children's oral health status and school attendance and performance. METHODS: We used 2008 data from the North Carolina Child Health Assessment and Monitoring Program. The study sample, weighted to reflect the state's population, included 2183 schoolchildren. Variables assessed included school absences and performance, oral health status, parental education, health insurance coverage, race, and gender. RESULTS: Children with poor oral health status were nearly 3 times more likely (odds ratio = 3.89; 95% confidence interval = 1.96, 7.75) than were their counterparts to miss school as a result of dental pain. Absences caused by pain were associated with poorer school performance (P < .05), but absences for routine care were not. Mediation analyses revealed that oral health status was associated with performance independent of absence for pain. CONCLUSIONS: Children with poorer oral health status were more likely to experience dental pain, miss school, and perform poorly in school. These findings suggest that improving children's oral health status may be a vehicle to enhancing their educational experience.

Toward a cumulative ecological risk model for the etiology of child maltreatment.

The purpose of the current study was to further the integration of cumulative risk models with empirical research on the etiology of child maltreatment. Despite the well-established literature supporting the importance of the accumulation of ecological risk, this perspective has had difficulty infiltrating empirical maltreatment research and its tendency to focus on more limited risk factors. Utilizing a sample of 842 mother-infant dyads, we compared the capacity of individual risk factors and a cumulative index to predict maltreatment reports in a prospective longitudinal investigation over the first sixteen years of life. The total load of risk in early infancy was found to be related to maternal cognitions surrounding her new role, measures of social support and well-being, and indicators of child cognitive functioning. After controlling for total level of cumulative risk, most single factors failed to predict later maltreatment reports and no single variable provided odd-ratios as powerful as the predictive power of a cumulative index. Continuing the shift away from simplistic causal models toward an appreciation for the cumulative nature of risk would be an important step forward in the way we conceptualize intervention and support programs, concentrating them squarely on alleviating the substantial risk facing so many of society's families.

Evaluation of knowledge, attitudes, and self-reported behaviors among 3-5 year old school children using an oral health and nutrition intervention.

METHODS: Ninety 3-5 year old children, 43 in the control group and 47 in the intervention group, participated in the study. An age and developmental appropriate prop-based oral health and nutrition intervention program was used. Subjects in the intervention group received a pre-test, an 8-10 minute prop-supported intervention, followed by an immediate post-test. The same test was repeated two weeks later The control group received a pre-test and post-test two weeks later but no intervention. RESULTS: Intervention improved scores in the immediate post-test but these improvements were not sustained two weeks later The only positive relationship found for the entire group between pre-and two week post-test scores was for oral health knowledge. There were no significant findings when adjusted for race, intervention type or group. CONCLUSIONS: Changing oral health and nutrition knowledge, attitude and behavior may require intense and repetitive interventions to have a significant effect in this age cohort.

Prospective study of etiologic agents of acute gastroenteritis outbreaks in child care centers.

OBJECTIVE: To investigate the etiology of outbreaks of acute gastroenteritis (AGE) in children attending childcare centers (CCCs) in North Carolina between October 2005 and March 2007. STUDY DESIGN: In this prospective study of outbreaks of AGE in CCCs, stool specimens from symptomatic children and environmental surface swabs were tested for adenovirus group F, astrovirus, norovirus (NoV), rotavirus group A, and sapovirus using real-time and conventional reverse transcription-polymerase chain reaction assays, and viruses were genotyped by sequencing. RESULTS: A total of 29 AGE outbreaks were evaluated, of which 13 (45%) were caused by a single virus, including rotavirus group A (17%), NoV (10%), astrovirus (10%), and sapovirus (7%). Multiple viruses were detected in 3 outbreaks (10%). Environmental swabs from 13 of 22 outbreaks (59%) tested positive for at least 1 virus and confirmed the findings of the same virus in the fecal specimens for 10 of the outbreaks (45%). CONCLUSIONS: This study confirms that viruses are major causes of AGE outbreak in CCCs. Our finding of widespread environmental contamination during such outbreaks suggests the need to study the effectiveness of current surface disinfectants against multiple gastroenteritis viruses in CCCs.

At-risk and maltreated children exposed to intimate partner aggression/violence: what the conflict looks like and its relationship to child outcomes.

Despite increasing research on children's exposure to intimate partner aggression/violence (IPAV), and co-occurrence of IPAV and maltreatment, little is known about IPAV in at-risk and maltreating families. We explored the nature of IPAV in 554 homes where children were identified as at risk or reported for maltreatment and examined differences between emotional and behavioral outcomes for children in homes where one or both intimate partners is the alleged perpetrator of IPAV. We found in this sample that IPAV primarily took the form of verbal aggression with differences in perpetrator gender for verbal, minor, and severe violence. There were few child outcomes predicted by perpetrator gender: Significant child behavior problems were found with all types of IPAV and both genders as perpetrators. Results suggest the need for comprehensive assessments of IPAV when assessing risk, safety, and harm issues for children reported as being at risk or victims of maltreatment.

Timing and chronicity of child neglect and substance use in early adulthood.

BACKGROUND: Neglect is the most common form of child maltreatment with consequences that appear to be as serious as for abuse. Despite this, the problem has received less than its due attention. OBJECTIVE: To examine the relationship between the timing and chronicity of neglect during childhood and substance use in early adulthood. PARTICIPANTS AND SETTING: The sample consisted of a subset of 475 participants from the prospective Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) consortium from five geographic areas around the U.S. METHOD: Neglect was assessed using abstracted information from CPS reports (birth-18) and self-reports of neglect (12-18). Participants completed a follow-up online survey (mean age of 24 years) that probed their use of substances. RESULTS: The prevalence of substance use during the past year was comparable in this high-risk sample to the general population. Latent class analysis supported the presence of three groups related to the presence and timing of neglect: Chronic Neglect, Late Neglect and Limited Neglect. Late Neglect was the pattern most strongly linked to substance use in early adulthood. CONCLUSIONS: High-risk youth experiencing neglect beginning in mid- adolescence are especially vulnerable to later substance use. Those working with such youth and their families can play a valuable role helping ensure their basic needs are adequately met, and recognizing early signs of substance use and abuse.

Reporting participants in research studies to Child Protective Services: limited risk to attrition.

This study examines the impact of Child Protective Services (CPS) reports made by research study staff on participant retention and discusses human subjects protocols that may minimize either the need to make such reports or the negative impact of reporting on participants and on participant retention. Among 1, 354 primary caregiver-child pairs in the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) studies, a total of 15 were reported to CPS by study staff. Within this group, rates of study-generated reports and study participation subsequent to having been reported by researchers were examined. There was an overall retention rate of 93% across a minimum of three interview waves in this sample. Reporting research participants to CPS may have little impact on attrition.

Characteristics of Child Maltreatment and Adolescent Marijuana Use: A Prospective Study.

There has been increasing acceptance of marijuana use in the United States in recent years, and rates among adolescents have risen. At the same time, marijuana use during adolescence has been linked to an array of health and social problems. Maltreated children are at risk for marijuana use, but the relationships among characteristics of maltreatment and marijuana use are unclear. In this article, we examine how the type and the extent of maltreatment are related to the level of adolescent marijuana use. Data analyses were conducted on a subsample of maltreated adolescents (n = 702) from the Longitudinal Studies of Child Abuse and Neglect project. Approximately half the sample had used marijuana, and maltreatment was associated with its use. Multivariate regression models showed that being male, extensive maltreatment, and peer marijuana use were associated with heavy use of marijuana. These findings suggest the importance of comprehensively assessing children's maltreatment experiences and their peers' drug use to help prevent or address possible marijuana use in these high-risk adolescents.

Describing maltreatment: do child protective service reports and research definitions agree?

OBJECTIVE: The National Research Council identified inadequate research definitions for abuse and neglect as barriers to research in child maltreatment. We examine the concordance between child protective services (CPS) classifications of maltreatment type with the determinations of type from two research coding systems. We contrast the two coding systems and the CPS classification, in their ability to predict subsequent difficulties in the psychological functioning of maltreated children at age 8. METHOD: The sample included 545 children who were enrolled in Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) with a report of child maltreatment, had data collected at approximately 4 and 8 years of age, and had a lifetime review of CPS records to age 8. CPS Maltreatment reports were coded using LONGSCAN's modification of the Maltreatment Classification System (MMCS) and the Second National Incidence Study maltreatment coding system (NIS-2). The first analyses used reports as the unit of analysis to examine agreement between CPS and research determinations of allegation type. Validation analyses examined outcomes for each type of maltreatment experienced after age 4 under each coding system using the Child Behavior Checklist (CBCL), Trauma Symptom Checklist-Alternative form, and the Vineland Screener as the measures of outcome. Control variables were the CBCL and Battelle Developmental Screener, measured at age 4. RESULTS: There were a total of 1980 reports of maltreatment for 545 study children although only 1593 CPS reports specified at least one type of maltreatment. There were differences between the type of maltreatment recorded in child protective service records and the conclusions reached by either research classification system. CPS classifications were most discordant with the research systems for emotional abuse and neglect. Nearly 10% of physical and sexual abuse reports, as determined by the MMCS, were classified as neglect by the child protective service agencies. The NIS-2 system and the MMCS had very high Kappa statistics for agreement for physical and sexual abuse. The validity of the research definitions for physical and sexual abuse was demonstrated in models predicting children's functioning at age 8. Prediction of child functioning was significantly but modestly improved in several domains compared to the CPS classifications. CONCLUSION: Both research classification systems moderately improved on the prediction of the adverse effects of maltreatment compared to the characterization of a maltreatment exposure as recorded by CPS.

Defining maltreatment according to substantiation: distinction without a difference?

OBJECTIVE: To examine whether children with substantiated maltreatment reports between 4 and 8 years of age differ from children with unsubstantiated reports on any of 10 behavioral and developmental outcomes. METHOD: Longitudinal data from 806 children and their adult caregivers collected in four US study sites were pooled and analyzed using Analysis of Variance (ANOVA) and multivariate linear regression. RESULTS: There were no significant differences between the mean scores of children with unsubstantiated and substantiated maltreatment reports filed between 4 and 8 years of age for any of the 10 behavioral and developmental outcomes. In the multivariate analysis, substantiation status was not significantly associated with any of the 10 outcomes after adjusting for prior functioning, prior maltreatment status, and sociodemographic characteristics. Findings from within-site analyses were generally consistent with the pooled analyses in finding no association between substantiation status and the outcomes examined. CONCLUSIONS: In this high-risk sample, the behavioral and developmental outcomes of 8-year-old children with unsubstantiated and substantiated maltreatment reports filed between ages 4 and 8 were indistinguishable. Future research should attempt to replicate these findings on probability samples that represent the full range of childhood maltreatment risk and with models that control for the impact of social services.

Trajectories of Adverse Childhood Experiences and Self-Reported Health at Age 18.

OBJECTIVE: Despite growing evidence of links between adverse childhood experiences (ACEs) and long-term health outcomes, there has been limited longitudinal investigation of such links in youth. The purpose of these analyses was to describe the patterns of exposure to ACEs over time and their links to youth health. METHODS: The current analyses used data from LONGSCAN, a prospective study of children at risk for or exposed to child maltreatment, who were followed from age 4 to age 18. The analyses focused on 802 youth with complete data. Cumulative exposure to ACEs between 4 and 16 was used to place participants in 3 trajectory-defined groups: chronic ACEs, early ACEs only, and limited ACEs. Links to self-reported health at age 18 were examined using linear mixed models after controlling for earlier health status and demographics. RESULTS: The chronic ACEs group had increased self-reported health concerns and use of medical care at 18 but not poorer self-rated health status. The early ACEs only group did not significantly differ from limited ACEs on outcomes. CONCLUSIONS: In addition to other negative outcomes, chronic ACEs appear to affect physical health in emerging adulthood. Interventions aimed at reducing exposure to ACEs and early mitigation of their effects may have lasting and widespread health benefits.

The effects of the Women, Infants, and Children's Supplemental Food Program on dentally related Medicaid expenditures.

OBJECTIVE: This study estimates the effects of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on dentally related Medicaid expenditures for young children. METHODS: We used a five-year cohort study design to compare dentally related Medicaid expenditures for children enrolled in WIC versus those not enrolled for each year of life up to age 5 years. There were 49,795 children born in North Carolina in 1992 who met the inclusion criteria for the study. Their birth records were linked to Medicaid enrollment and claims files, WIC master files, and the Area Resource File. Our analysis strategy included a logit and OLS two-part model with CPI dollar adjustments. RESULTS: Children who participated in WIC at ages 1 and 2 years had significantly less dentally related expenditures than those who did not participate. WIC participation at age 3 years did not have a significant effect. Fewer WIC children received dental care under general anesthesia than non-WIC children. CONCLUSIONS: The WIC program has the potential for decreasing dentally related costs to the Medicaid program, while increasing use of dental services.