Acute and Posttraumatic Stress in Family Members of Children With a Prolonged Stay in a PICU: Secondary Analysis of a Randomized Trial.

OBJECTIVES: To identify the prevalence of screening criteria for acute and posttraumatic stress disorders (PTSDs) and stress symptoms among family members of children in the PICU for more than 8 days and examine risk factors for stress symptoms. DESIGN: Secondary analysis of data from a randomized trial of a palliative care intervention conducted between 2010 and 2014. SETTING: An urban pediatric hospital in Seattle, WA. SUBJECTS: The sample included 377 family members of 220 children. INTERVENTIONS: Family Communication Study. MEASUREMENTS AND MAIN RESULTS: Outcomes were symptom scores and diagnostic screening criteria for acute stress disorder (ASD) and PTSD. Predictors included demographic- and admission-related characteristics and hypothesized risk factors for developing stress-related mental health disorders. The mean score for acute stress symptoms during the ICU stay was 40.3 (sd = 13.8) and 59 family members in total met diagnostic screening criteria for ASD during hospitalization (15.6%). At 3-month follow-up, the mean score for posttraumatic stress symptoms was 30.8 (sd = 12.9) and 52 family members met diagnostic criteria for PTSD (13.8%). Factors associated with meeting ASD screening criteria were unplanned admission and poorer family relationships. Factors associated with PTSD symptoms and diagnosis were longer length of stay, meeting ASD criteria during admission, child's death, and less perceived social support. CONCLUSIONS: Meeting screening criteria for PTSD was associated with demographic, length of stay, and family relationships among family members of seriously ill children. PTSD outcomes were higher among family members whose child died. This study helps identify risk factors that can be used to target needed psychosocial screening, monitoring and support during and following a prolonged PICU admission, as well as family-centered interventions and supportive bereavement intervention for the family members of a deceased child.

Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature.

OBJECTIVE: Currently, there is debate in the eating disorders field regarding how to define atypical anorexia (AAN), how prevalent it is in community and clinical settings, and how AAN rates compare with low-weight AN. This systematic review assesses AAN literature from 2007 to 2020, to investigate: (a) the demographic characteristics of AAN studies, (b) the prevalence of AAN compared with AN, (c) the range of operational definitions of AAN and the implications of these definitions, and (d) the proportion of patients with AAN and AN represented in consecutive admission and referral samples. METHOD: PsychINFO, CINAHL, PubMed, Greylit.org, and ProQuest databases were searched according to methods for Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic reviews, yielding 3,184 potential articles. Seventy-five eligible studies were coded for sixty-one variables. RESULTS: Clinical samples predominantly included younger, female, white samples with limited diversity. In epidemiological designs, AAN was typically as common or more common than AN, and AAN rates varied significantly based on the population studied and operational definitions. In consecutive clinical samples, AAN was frequently less represented. DISCUSSION: Although AAN appears to occur more frequently than AN in communities, fewer patients with AAN are being referred and admitted to eating disorder specific care, particularly in the United States. Given the significant medical and psychosocial consequences of AAN, and the importance of early intervention, this represents a crucial treatment gap. Additionally, results suggest the need for fine-tuning diagnostic definitions, greater diversity in AAN studies, and increased screening and referral for this vulnerable population.

OBJETIVO: Actualmente, hay debate en el campo de los trastornos alimenticios sobre cómo definir la anorexia atípica (ANA), cuán prevalente es en entornos comunitarios y clínicos, y cómo las tasas de ANA se comparan con AN de bajo peso. Esta revisión sistemática evalúa la literatura de ANA de 2007 a 2020, para investigar: 1) las características demográficas de los estudios de ANA, 2) la prevalencia de ANA en comparación con AN, 3) el rango de definiciones operativas de ANA y las implicaciones de estas definiciones, y 4) la proporción de pacientes con ANA y AN representados en muestras consecutivas de admisión y derivación. MÉTODO: Las bases de datos de PsychINFO, CINAHL, PubMed, Greylit.orgy y ProQuest fueron buscados de acuerdo con los métodos preferidos para el reporte de ítems para Revisiones Sistemáticas y Metanálisis de Revisiones Sistemáticas, dando lugar a 3184 artículos potenciales. Setenta y cinco estudios elegibles fueron codificados para 61 variables. RESULTADOS: Las muestras clínicas incluían predominantemente muestras de femeninas, más jóvenes, y blancas con diversidad limitada. En los diseños epidemiológicos, la ANA era típicamente tan común o más común que AN, y las tasas de ANA variaban significativamente en función de la población estudiada y las definiciones operacionales. En muestras clínicas consecutivas, la ANA fue frecuentemente menos representada. DISCUSIÓN: Aunque ANA parece ocurrir con más frecuencia que AN en las comunidades, menos pacientes con ANA están siendo referidos y admitidos a la atención específica del trastorno alimentario, particularmente en los Estados Unidos. Dadas las importantes consecuencias médicas y psicosociales de ANA, y la importancia de la intervención temprana, esto representa una brecha de tratamiento crucial. Además, los resultados sugieren la necesidad de ajustar las definiciones diagnósticas, una mayor diversidad en los estudios de ANA y un mayor cribado y referencia a tratamiento para esta población vulnerable.

Psychological Impacts and Ways of Coping Reported by Spousal Caregivers of Hematopoietic Cell Transplant Recipients: A Qualitative Analysis.

Allogeneic hematopoietic cell transplantation (HCT) is a demanding treatment with well-established medical and psychosocial sequelae. Impacts on significant others are tremendous. Using an unfiltered qualitative approach, we asked spouses (n = 15) of HCT recipients to talk about their thoughts and feelings regarding the transplantation and their role as caregiver. Recordings were transcribed and independently coded to identify recurrent patterns. Caregivers mentioned both negative and positive psychological impacts of HCT, but the number of negative impacts was greater: 164 versus 34 instances. The most frequently mentioned negative psychological impacts were anxiety/worry (30 instances), fear (20 instances), feeling overloaded/overwhelmed (19 instances), and uncertainty (17 instances). Other emergent categories were roles/responsibilities (49 instances) such as parenting, work, and treatment-related tasks, and coping strategies (55 instances). The latter included both adaptive and maladaptive strategies (75% and 25%, respectively). Despite the preponderance of negatively toned thoughts and feelings, signs of adjustment emerged, with mentions of positive psychological states, such as optimism and gratitude, and adaptive coping strategies, such as active coping, use of emotional support, and self-care. Interventions intended to facilitate adaptation to the HCT experience should involve strategies to help caregivers manage symptoms of distress and promote adaptive coping.

\Defining Patient Advocacy for the Context of Clinical Ethics Consultation: A Review of the Literature and Recommendations for Consultants.

The idea of patient advocacy as a function of clinical ethics consultation (CEC) has been debated in the bioethics literature. In particular, opinion is divided as to whether patient advocacy inherently is in conflict with the other duties of the ethics consultant, especially that of impartial mediator. The debate is complicated, however, because patient advocacy is not uniformly conceptualized. This article examines two literatures that are crucial to understanding patient advocacy in the context of bioethical deliberations: the CEC literature and the literature on advocacy in the social work profession. A review of this literature identifies four distinct approaches to patient advocacy that are relevant to CEC: (1) the best interest approach, (2) the patient rights approach, (3) the representational approach, and (4) the empowerment approach. After providing a clearer understanding of the varied meanings of patient advocacy in the context of CEC, we assert that patient advocacy is not inherently inconsistent with the function of the ethics consultant and the CEC process. Finally, we provide a framework to help consultants determine if they should adopt an advocacy role.

Negative and Positive Factors Associated With the Well-Being of Lesbian, Gay, Bisexual, Transgender, Queer, and Questioning (LGBTQ) Youth.

Factors associated with the well-being of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth were qualitatively examined to better understand how these factors are experienced from the youths' perspectives. Largely recruited from LGBTQ youth groups, 68 youth participated in focus groups (n = 63) or individual interviews (n = 5). The sample included 50% male, 47% female, and 3% transgender participants. Researchers used a consensual methods approach to identify negative and positive factors across 8 domains. Negative factors were associated with families, schools, religious institutions, and community or neighborhood; positive factors were associated with the youth's own identity development, peer networks, and involvement in the LGBTQ community. These findings suggest a pervasiveness of negative experiences in multiple contexts, and the importance of fostering a positive LGBTQ identity and supportive peer/community networks. Efforts should work towards reducing and eliminating the prejudicial sentiments often present in the institutions and situations that LGBTQ youth encounter.

The Domestic Violence Fatality Review: Can It Mobilize Community-Level Change?

Domestic Violence Fatality Review (DVFR) teams are a means of identifying systems' gaps in the coordinated response to domestic violence. While the number of homicide reviews has grown, little is known about whether DVFRs facilitate change in the community-level response to domestic violence. This research evaluated whether the recommendations made by one state-level DVFR had an effect on community and organizational priorities and practices. The results indicate that the recommendations influence countywide priorities, but less was done to implement the recommendations. DVFRs have the capacity to influence community-level change agendas; however, organizations need support moving from issue prioritization to implementation.

"You Don't Look Anorexic": Atypical anorexia patient experiences of weight stigma in medical care.

Eating disorders (ED) and weight stigma pose significant healthcare challenges. Patients at higher weights, like some with atypical anorexia (AAN), may face increased challenges due to weight stigma. This study analyzed patients' lived experiences with weight stigma in healthcare. Thirty-eight adult patients with AAN completed in-depth, semi-structured interviews regarding healthcare experiences. Guided by narrative inquiry approaches, transcripts were thematically coded. Across the illness trajectory (ED development, pre-treatment, treatment, post-treatment), patients reported that weight stigma in healthcare contributed to initiation and persistence of ED behaviors. Themes included "providers pathologizing patient weight," which patients reported triggered ED behaviors and relapse, "provider minimization and denial" of patients' EDs, which contributed to delays in screening and care, and "overt forms of weight discrimination," leading to healthcare avoidance. Participants reported that weight stigma prolonged ED behaviors, delayed care, created suboptimal treatment environments, deterred help-seeking, and lowered healthcare utilization. This suggests that many providers (pediatricians, primary care providers, ED treatment specialists, other healthcare specialists) may inadvertently reinforce patients' EDs. Increasing training, screening for EDs across the weight spectrum, and targeting health behavior promotion rather than universal weight loss, could enhance quality of care and improve healthcare engagement for patients with EDs, particularly those at higher weights.

Palliative care in the pediatric ICU: challenges and opportunities for family-centered practice.

The culture of pediatric intensive care units (PICUs) is focused on curative or life-prolonging treatments for seriously ill children. We present empirically-based approaches to family-centered palliative care that can be applied in PICUs. Palliative care in these settings is framed by larger issues related to the context of care in PICUs, the stressors experienced by families, and challenges to palliative care philosophy within this environment. Innovations from research on family-centered communication practices in adult ICU settings provide a framework for development of palliative care in PICUs and suggest avenues for social work support of critically ill children and their families.

How Research Evidence is Defined, Acquired, and Shared Across Systems That Address Intimate Partner Violence.

This exploratory study examined the flow of research evidence through systems that address intimate partner violence (IPV), including victim services, law enforcement, and criminal justice organizations. Qualitative interviews with representatives of these disciplines assessed how respondents define, acquire, and share research evidence. Findings suggest that research evidence is defined more broadly in the field than in academic settings, and is accessed primarily from trusted intermediaries within professional networks. State IPV coalitions and victim service providers are key intermediaries across sectors. Findings suggest the need for more tangible supports to support sharing of research information within and across service sectors.

The prevalence and correlates of depressive symptoms among adolescent mothers: results from a 17-year longitudinal study.

The objective of the authors in this study was to examine the prevalence and correlates of elevated depressive symptoms in a 17-year cohort study of 173 women who were unmarried, pregnant adolescents between June 1988 and January 1990. Multiple logistic regression was used to estimate the associations between correlates and elevated depressive symptoms during five distinct developmental periods of the life course. Depressive symptoms were measured by the Brief Symptom Inventory depression subscale. The prevalence of elevated depressive symptoms in adolescent mothers significantly increased over the 17 years of the study from 19.8% to 35.2%. In adjusted analyses, antenatal depressive symptoms were positively and significantly associated with elevated depressive symptoms at every developmental period. Intimate partner violence was positively and significantly associated with elevated depressive symptoms during all but one developmental period. Other significant correlates of elevated depressive symptoms included welfare receipt, smoking, and parity, all of which were significant at some, but not other, developmental periods. Antenatal depressive symptoms and intimate partner violence were positively and significantly associated with elevated depressive symptoms. Given the public health consequences associated with maternal depression, clinical and community-based interventions should be developed to identify and to treat adolescent mothers at-risk for antenatal depression and intimate partner violence.

Development of a Web-based educational intervention to improve cross-cultural communication among hospice providers.

In this article, the authors describe the theoretical foundation, development, and content of a Web-based educational intervention to improve cross-cultural communication about end-of-life concerns and report on the preliminary evaluation of this intervention using a qualitative study design. The data were collected with non-structured questions in a convenience sample of 21 hospice providers. Participants reported that they found the training appropriate and useful. Participants also reported finding the online delivery convenient and the interactive format valuable. Improving the quality of cross-cultural patient-provider communication can contribute to reducing disparities at end-of-life.

Toward a multi-level, ecological approach to the primary prevention of sexual assault: prevention in peer and community contexts.

Although sexual assault prevention programs have been increasingly successful at improving knowledge about sexual violence and decreasing rape-supportive attitudes and beliefs among participants, reducing sexually assaultive conduct itself remains an elusive outcome. This review considers efforts to support change for individuals by creating prevention strategies that target peer network and community-level factors that support sexual violence. To this end, the article examines successful ecological prevention models from other prevention fields, identifies the components of multilevel prevention that appear critical to efficacy and discusses their application to existing and emerging sexual violence prevention strategies.

Mediating pathways explaining psychosocial functioning and revictimization as sequelae of parental violence among adolescent mothers.

Adolescent mothers are at high risk for negative life events, such as previous childhood physical abuse, impaired psychosocial functioning, and young adulthood revictimization. However, little is known about the potential pathways in these events; hence, little is known about opportunities for intervention. This study used structural equation modeling to investigate mediators of the effects of parental child abuse on later psychosocial functioning and revictimization (in the form of intimate partner violence and sexual violence) among adolescent mothers, with longitudinal data spanning 2.4 years. On psychological distress in the final time period, parental physical child abuse had an early and then maintained effect but also effects mediated by earlier psychological distress and revictimization. Psychological distress rather than substance use appeared as the primary psychosocial factor mediating the effects of parental violence on both future distress and revictimization. For prevention of further psychosocial impairment and revictimization, these findings indicate the need for early intervention with adolescent mothers who come from abusive families and who display higher levels of psychological distress.

Predictors of sexually coercive behavior in a nationally representative sample of adolescent males.

Data from male participants in the National Longitudinal Study of Adolescent Health are used to examine childhood predictors of late adolescent and early adulthood sexually coercive behavior and adolescent mediators of these relationships. A path analysis shows that experiencing sexual abuse as a child has a direct effect on perpetrating subsequent coercion that is partially mediated by early sexual initiation. Involvement in delinquent activities in adolescence was the only additional significant predictor of sexually coercive behavior and completely mediated the relationship between physical abuse in childhood and later sexual coercion. Of note, more than half of men reporting sexually aggressive acts had no history of childhood victimization, so pathways to sexually coercive behavior for this group remain unidentified. In addition to the universal prevention approaches currently in use in the field, these findings suggest that targeted prevention programs need to be formulated for youth with histories of childhood sexual or physical abuse.

The long-term effects of intimate partner violence on adolescent mothers' depressive symptoms.

Adolescent mothers are at high risk of experiencing intimate partner violence (IPV) which may increase their likelihood of depressive symptoms in adulthood, yet little is known about the long-term effects of IPV on adolescent mothers' trajectories of depressive symptoms. The study reported here uses prospective data spanning 14 years from a study of 229 adolescent mothers from Washington State, USA to evaluate the effects of adolescent exposure to IPV on the trajectories of depressive symptoms over time, as well as the likelihood of depressive symptoms at age 28 years. After controlling for levels of economic insecurity, the results indicate that adolescent IPV and an early vulnerability to depression were significantly related to the intercept, but not the slope of the adult depressive symptom trajectories. Both cumulative and concurrent IPV predicted the likelihood of depressive symptoms at age 28 years. Follow-up analyses indicate that adolescent IPV is associated with greater levels of adult IPV, and that women who report both adolescent and adult IPV have the highest mean levels of depressive symptoms. These findings suggest that exposure to IPV in adolescence may alter the life course of young women, increasing their risk for continuing exposure to intimate partner violence in adulthood and its concomitant negative mental health effects. Efforts aimed at prevention and early intervention in IPV among adolescent mothers are important components of the clinical care of young mothers.

Reconceptualizing and operationalizing context in survey research on intimate partner violence.

Survey research in the field of intimate partner violence is notably lacking in its attention to contextual factors. Early measures of intimate partner violence focused on simple counts of behaviors, yet attention to broader contextual factors remains limited. Contextual factors not only shape what behaviors are defined as intimate partner violence but also influence the ways women respond to victimization, the resources available to them, and the environments in which they cope with abuse. This article advances methods for reconceptualizing and operationalizing contextual factors salient to the measurement of intimate partner violence. The analytic focus of the discussion is on five dimensions of the social context: the situational context, the social construction of meaning by the survivor, cultural and historical contexts, and the context of systemic oppression. The authors consider how each dimension matters in the measurement of intimate partner violence and offer recommendations for systematically assessing these contextual factors in future research.

Screening for domestic violence in public welfare offices: an analysis of case manager and client interactions.

Despite a high prevalence of domestic violence among welfare clients, most studies of the implementation of the Family Violence Option (FVO) under welfare reform find that women rarely receive domestic violence services in welfare offices. This study reviews findings from current research on the factors that improve the likelihood that women will reveal their domestic violence experiences to service personnel, and uses the guidelines drawn from this review to evaluate domestic violence screening practices in welfare offices using 782 transcribed interviews between welfare workers and clients from 11 sites in four states. The analysis found that only 9.3% of case encounters involved screening for domestic violence. Screening rates differed by state, interview type, and length of worker employment. Qualitative analysis of the interviews showed that the majority of screening by workers was routine or consisted of informing clients of the domestic violence policy without asking about abuse. Only 1.2% of the interviews incorporated at least two of the procedures that increase the likelihood of disclosure among domestic violence survivors, suggesting deeply inadequate approaches to screening for abuse within the context of welfare offices, and a need for improved training, protocol, and monitoring of FVO implementation.

Elizabeth: Typical or Troubled Teen? A Training Case for Health Professionals to Recognize and Report Child Maltreatment.

Introduction: Training on the recognition and reporting of child maltreatment is a critical component of any health professional education program. Unfortunately, it is nationally recognized that health care professional training on recognition and reporting suspected child maltreatment is insufficient. Similarly, recent attention has been given to the need for interprofessional learning opportunities targeting to advanced health profession trainees such as doctor of nursing practice, masters in social work, physician assistant, and family medicine residents. Methods: An interprofessional case-writing faculty team convened to develop this case and the affiliated materials, including video vignettes, faculty training, comprehensive faculty guide, evaluations, and trainee resources. Trainees were divided into interprofessional teams and advised to develop a prioritized plan of care for a complex patient case, though it was not revealed that the case involved child maltreatment. An initial video vignette showed an adolescent female and her mother during a provider visit to establish care. Teams developed a prioritized plan of care following the vignette. Additional case details unfold during the second vignette, and teams revised their initial plan based on this new information. Interprofessional faculty facilitators guided discussions using prompts from the faculty guide. Results: Postsession surveys revealed that the learning objectives were met, and that both facilitators (N = 20) and trainees (N = 69) were very satisfied with the overall curriculum. Challenges centered around focusing on care priorities rather than provider critique. Discussion: This curriculum is relevant for a variety of trainees and is an important complement to the curricula of many professions.

When and Why Do Neonatal and Pediatric Critical Care Physicians Consult Palliative Care?

BACKGROUND: Parents of children admitted to neonatal and pediatric intensive care units (ICUs) are at increased risk of experiencing acute and post-traumatic stress disorder. The integration of palliative care may improve child and family outcomes, yet there remains a lack of information about indicators for specialty-level palliative care involvement in this setting. OBJECTIVE: To describe neonatal and pediatric critical care physician perspectives on indicators for when and why to involve palliative care consultants. METHODS: Semistructured interviews were conducted with 22 attending physicians from neonatal, pediatric, and cardiothoracic ICUs in a single quaternary care pediatric hospital. Transcribed interviews were analyzed using content and thematic analyses. RESULTS: We identified 2 themes related to the indicators for involving palliative care consultants: (1) palliative care expertise including support and bridging communication and (2) organizational factors influencing communication including competing priorities and fragmentation of care. CONCLUSIONS: Palliative care was most beneficial for families at risk of experiencing communication problems that resulted from organizational factors, including those with long lengths of stay and medical complexity. The ability of palliative care consultants to bridge communication was limited by some of these same organizational factors. Physicians valued the involvement of palliative care consultants when they improved efficiency and promoted harmony. Given the increasing number of children with complex chronic conditions, it is important to support the capacity of ICU clinical teams to provide primary palliative care. We suggest comprehensive system changes and critical care physician training to include topics related to chronic illness and disability.