Patterns of skin injury in nonaccidental and accidental injury.

The patterns of soft tissue injuries in a group of 154 children reported to protective services for child abuse or neglect were compared with patterns of soft tissue injury found in a group of 91 emergency room patients who sustained an accidental injury and 105 children seen in a pediatric ambulatory clinic. All children in the three groups were 1 to 12 years old. Children in the suspected child abuse and neglect group had significantly more (P less than .01) soft tissue injuries over the cheeks, trunk, genitals, and upper legs. Lacerations were significantly more common (P less than .001) in the emergency room group.

Pediatric residency training in the normal newborn nursery. A national survey.

OBJECTIVE: To determine how and what pediatric residency programs are teaching residents about normal newborn care in the nursery. DESIGN: A mailed survey distributed in 1994. PARTICIPANTS: All 237 known pediatric residency programs in the United States, Canada, and Puerto Rico. RESULTS: Survey response rate was 77% (184 of 237 questionnaires were returned and completed). In 40% of the programs, neonatologists were primarily responsible or co-responsible for teaching residents about management of normal newborns. A normal newborn nursery curriculum had been developed and implemented in 56% of the programs, 30% of programs were developing one, and 13% reported no curriculum. Specific instruction about breast-feeding was not offered in 16% of programs. Circumcisions were most commonly performed by obstetricians; anesthetic use was low (overall median use, 10%) but was more common (P < .002) when circumcisions were performed by pediatricians. The hospital environment and lack of faculty time were cited as the main barriers to teaching residents about normal newborn care. CONCLUSIONS: Although general pediatricians spend a substantial amount of practice time on newborn care, neonatologists were responsible for this teaching in almost half of the pediatric residency programs. Many programs have not developed a curriculum. Instruction about breast-feeding was not universal. Most pediatric residents do not learn to perform circumcisions. General pediatricians should be more involved in the development, implementation, and evaluation of comprehensive newborn nursery curricula to improve training in this important aspect of general pediatric practice.

Correlates of multigravida women's binge drinking during pregnancy. A longitudinal study.

OBJECTIVE: To refine our understanding of prenatal psychosocial factors associated with binge drinking during pregnancy and the contribution of binge drinking during pregnancy to the duration of newborn hospitalization. DESIGN: Prospective cohort. SETTING: A large urban medical center in Wisconsin. PARTICIPANTS: One hundred thirty-nine women (106 multigravida) who were invited to participate during a prenatal clinic visit early in their third trimester. MEASURES: Prenatal measures included social support (Maternal Social Support Index), depression (Center for Epidemiologic Studies Depression Scale), stress (Difficult Life Circumstances), substance use (Monitoring the Future Substance Use Questionnaire and T-ACE Scale [a screen with questions about tolerance, annoyance, cutting down, and using alcohol as an eye-opener), and maternal-fetal attachment (Maternal-Fetal Attachment Scale). After delivery, a mothers' and infants' medical record review form was used. RESULTS: Multigravida pregnant women (n = 106) were older than primigravida pregnant women (n = 33) (25.8 +/- 0.6 vs. 20.5 +/- 0.5 years; P = .001), with more children at home (2.3 +/- 0.2 vs 1.3 +/- 0.3; P = .01) and less social support (Maternal Social Support Index, 20.1 +/- 0.6 vs 22.9 +/- 1.0; P = .03). All of the binge-drinking women in this sample were in the unmarried multigravida subgroup (17/101 [17%]). Compared with multigravida pregnant women who did not binge drink during pregnancy, binge-drinking pregnant women were older (28.1 +/- 1.3 vs 25.1 +/- 0.6 years; P = .03) and more socially isolated (Maternal Social Support Index, 17.2 +/- 1.3 vs 20.7 +/- 0.7; P = .04) and were more likely to smoke during the pregnancy (82% vs 39%; P = .001). Even after controlling for a number of other important biologic and psychosocial factors (duration of pregnancy, maternal gravidity, racial heritage, education, social support at second trimester, and birth weight), by hierarchical multiple linear regression, binge drinking within the last 2 weeks before the late second-trimester interview continued to explain a significant amount of variance in duration of newborn hospitalization (total R2 = .48, partial R2 = .04; P = .01). CONCLUSIONS: This study suggests that binge drinking during pregnancy is related to longer newborn hospitalizations. Effective prenatal interventions to improve the outcome of pregnancies for women who abuse alcohol during pregnancy should use early screening and provide augmentation of mothers' social support.

Correlates of maternal depressive symptoms in a national Head Start program sample.

OBJECTIVE: To examine correlates of maternal depressive symptoms in a diverse, national sample of mothers whose kindergarten-aged children attended a Head Start program. DESIGN AND PARTICIPANTS: A cross-sectional study of 5820 mothers was conducted during their child's kindergarten year. MAIN OUTCOME MEASURE: Rates of maternal depressive symptoms were assessed by a validated 3-item depression screen. RESULTS: The ethnic makeup of the group of mothers was non-Hispanic white, 46%; African American, 30%; Hispanic, 13%; American Indian, 6%; Asian American, 1%; and other, 4%. The mean (SD) age of the mothers was 30.1 (5.55) years, 57% were unemployed, and 68% had at least a high school diploma or had earned a high school equivalency diploma. More than 40% of the mothers screened positive for depressive symptoms. The strongest associations after controlling for several biological and demographic variables were maternal chronic health problem (adjusted odds ratio, 2.77; 95% confidence interval, 1.98-3.87), homelessness (adjusted odds ratio, 2.00; 95% confidence interval, 1.45-2.77), and lowest income level (adjusted odds ratio, 1.56; 95% confidence interval, 1.30-1.88). CONCLUSIONS: Depressive symptoms were common among mothers of young children in this national sample. Interventions must be targeted at alleviating maternal depressive symptoms by decreasing poverty, providing support programs for single parents, and establishing accessible and affordable medical care for all parents and their children. Primary care physicians can play a key role in early identification and intervention.

Additive effects of psychostimulants, parent training, and self-control therapy with ADHD children.

Utilizing a double-blind, placebo design, the effects of a high (0.8 mg/kg) and a low (0.4 mg/kg) dose of methylphenidate alone and in combination with behavioral parent training plus child self-control instruction were evaluated with 96 attention deficit hyperactivity disorder children. No evidence of the superiority of the combined conditions relative to medication alone was found. Some limited support was found for the hypothesis that the effects of a high dose of psychostimulant medication could be achieved by combining the low dose with a behavioral intervention. The importance of the latter finding is highlighted by the fact that both the benefits and untoward effects of the psychostimulants appear to increase with the dose.

The effects of a multimodal intervention with attention-deficit hyperactivity disorder children: a 9-month follow-up.

Using a double-blind, placebo design, we evaluated 96 attention-deficit hyperactivity disordered children for the effects of methylphenidate alone and in combination with behavioral parent training plus child self-control instruction. Seventy one of the children completed the treatment protocol. As reported previously, main effects were found for medication at posttest; however, there was no evidence of additive effects. Nine months after the termination of the behavioral interventions and the withdrawal of the stimulant medication, we found limited support for the hypothesis that the combined conditions would produce greater maintenance of treatment gains than would medication alone.

Innovative approaches to educating medical students for practice in a changing health care environment: the National UME-21 Project.

In today's continually changing health care environment, there is serious concern that medical students are not being adequately prepared to provide optimal health care in the system where they will eventually practice. To address this problem, the Health Resources and Services Administration (HRSA) developed a $7.6 million national demonstration project, Undergraduate Medical Education for the 21st Century (UME-21). This project funded 18 U.S. medical schools, both public and private, for a three-year period (1998-2001) to implement innovative educational strategies. To accomplish their goals, the 18 UME-21 schools worked with more than 50 organizations external to the medical school (e.g., managed care organizations, integrated health systems, Area Health Education Centers, community health centers). The authors describe the major curricular changes that have been implemented through the UME-21 project, discuss the challenges that occurred in carrying out those changes, and outline the strategies for evaluating the project. The participating schools have developed curricular changes that focus on the core primary care clinical clerkships, take place in ambulatory settings, include learning objectives and competencies identified as important to providing care in the future health care system, and have faculty development and internal evaluation components. Curricular changes implemented at the 18 schools include having students work directly with managed care organizations, as well as special demonstration projects to teach students the knowledge, skills, and attitudes necessary for successfully managing care. It is already clear that the UME-21 project has catalyzed important curricular changes within 12.5% of U.S. medical schools. The ongoing national evaluation of this project, which will be completed in 2002, will provide further information about the project's impact and effectiveness.

Prenatal correlates of indigent mothers' attitudes about spoiling their young infants: a longitudinal study.

The purpose of this study was to investigate factors associated with indigent mothers' attitudes about spoiling their young infants. Mothers who believe that young infants can be spoiled may be more likely to misperceive their infants' basic needs for nurturing and thus undermine their infants' sense of security and trust. One hundred twenty-nine consecutive pregnant women who were at approximately 15 weeks' gestation completed measures to assess depressive symptoms (Center for Epidemiologic Studies Depression Scale) and social support (Maternal Social Support Index). One hundred seventeen mothers (91%) completed a simple three-question Spoiling Index when their infants were about 1 month old. Fifty-eight percent were single, never married, 73% multiparous, 66% Euro-American, 28% African-American, and 84% at least 20 years old. Fifty-eight percent of mothers believed infants younger than 5 months old could be spoiled. After including maternal age, race, marital status, prenatal social support, and number of prenatal clinic visits in the hierarchical logistic regression model, "spoilers" were more likely to be primigravida mothers (odds ratio = 2.71; 95% confidence interval, 1.05 to 7.06) and more likely to be depressed during pregnancy (odds ratio = 2.83; 95% confidence interval, 1.29 to 6.19). Primigravida indigent mothers and mothers with higher levels of prenatal depressive symptoms are more likely to believe they can spoil their young infants.

Temperament of preterm infants at 4 months of age: maternal ratings and perceptions.

The purpose of this study was to compare temperament of preterm infants born at 34 weeks gestation or earlier with that of healthy, term infants at 4 months of age by maternal ratings and maternal perceptions and to examine the role of social support on maternal assessments of infant temperament. The mothers of preterm infants completed the Early Infancy Temperament Questionnaire (EITQ) and the Maternal Social Support Index when the child reached 4 months adjusted age. The EITQ assesses infant temperament by maternal ratings of specific infant behaviors and by mothers' global perceptions of infant temperament. Mothers of healthy term infants completed the same instruments when they brought their 4-month-old infant for a pediatric visit. Mothers rated preterm infants as having more negative mood (p = .01) and being less adaptable (p = .03) than term infants. However, mothers perceived that preterm infants were more difficult overall (p = .00001), had more negative mood (p < .005), were less regular (p = .02), and were less adaptable (p = .03). Mothers perceive preterm infant temperament to be more difficult than that of term infants and to be more difficult than is indicated by ratings of individual infant behaviors.

Help with prenatal household tasks and newborn birth weight: is there an association?

Although prenatal psychosocial factors influence pregnancy outcome, the specific components of prenatal social support which affect infants' birth weight have not been examined prospectively. To define those elements of prenatal social support which are associated with newborn birth weights, we studied 198 indigent mothers seen consecutively by a social worker at a community hospital-based obstetrical clinic. At the first prenatal clinic visit, we used the Maternal Social Support Index (MSSI) to assess the availability of help with daily tasks, a communicative male and other adults, emergency child care, and community involvement. The only MSSI item related to low birth weight (LBW less than or equal to 2,500 g) for both multigravida and primigravida mothers was daily task sharing. Help with grocery shopping and the process of paying bills (p = 0.0007) were both significantly associated with LBW for multigravida mothers. Significant items for primigravida mothers included help with inside cleaning (p = 0.03) and working outside (p = 0.005). Help with things around the house was associated with LBW for both multigravida (p = 0.02) and primigravida (p = 0.04) mothers. Car availability was associated with low birth weight only for multigravida mothers (p = 0.006). Stepwise discriminant function analysis was performed for multigravida mothers. Low birth weight was the dependent variable. Eight well-known risk factors for low birth weight (excluding daily tasks) were the independent variables. The "best" function included marital status, maternal age, gravidity, and smoking during pregnancy. The addition of daily task-sharing to this model increased sensitivity (low birth weight classified low birth weight by the model) from 21% to 50%.(ABSTRACT TRUNCATED AT 250 WORDS)

Perinatal precursors of home stimulation in families of sick newborns.

The relationship between biological, psychosocial, and demographic perinatal factors and the adequacy of the children's home environment was evaluated in a sample of 69 families 3 years after their children had been discharged from a newborn intensive care unit. Almost 40% of the variance (p = .0001) in the amount of home stimulation was explained by income, race, and maternal age. Three maternal perinatal psychosocial characteristics explained an additional 12% of the variance (p = .0001). Both maternal demographic and psychosocial factors appear to contribute to the preschool home environment. Research focused on the precursors of an adequate early home environment could suggest specific interventions for the primary prevention of parenting problems.

The association between mothers' social support and provision of stimulation to their children.

Specific forms of maternal social support were analyzed for their relationship to a validated measure of home stimulation (the Inventory of Home Stimulation). The 69 study families were chosen to represent a wide variability of social support at the time of the child's birth. All index children had been discharged from a neonatal intensive care unit 3 years before the study. The overall Maternal Social Support Index (MSSI) developed for the study explained a significant (p less tha 0.1) amount of variance in the home stimulation of 3-year-olds after income, race, maternal age, and other possible confounding variables had been controlled. In addition, specific MSSI items were strongly associated with various forms of environmental stimulation. The data suggest that augmentation of specific aspects of mothers' social support networks may increase their children's informal learning opportunities.

Family psychosocial screening: should we focus on high-risk settings?

The objective of this study was to address the question of whether or not psychosocial screening should be focused on "high-risk" populations. A cross-sectional survey of mothers of young children was conducted in various clinics: 758 in teaching clinics, 444 in private practices, and 202 at a military clinic. The self-administered questionnaire covered demographic factors, problems in mothers family of origin, maternal depression, and substance abuse. Mothers in the teaching clinics were younger and had less education and lower incomes than mothers in private practices, with intermediate levels in the military clinic. However, a substantial proportion of mothers seen in all sites reported psychosocial problems. Approximately 20% of mothers in all sites reported a family history of alcoholism. Positive screens for maternal depression ranged from about 15% to 35%. Binge drinking was reported by 10% to 20% at different sites. Psychosocial problems were common even among families seen in "low-risk" settings. Focusing screening only on high-risk clinics would miss many families with psychosocial problems.

The reliability and validity of the Maternal Social Support Index for primiparous mothers: a brief report.

The Maternal Social Support Index (MSSI) is an 18-item questionnaire designed to quickly assess qualitative and quantitative aspects of a mother's social support. This study examines a sample of primiparous mothers during the first nine months following delivery. Mothers were interviewed within 72 hours after delivery and again at six weeks and nine months. Using Spearman coefficients, the correlation for total MSSI scores between birth and nine months was .75. The correlations for individual items between birth and nine months ranged from .22 to .76. The MSSI at birth was strongly correlated with the Dyadic Adjustment Scale at nine months (r = .41, P = .001). Scores on the Center for Epidemiologic Studies Depression Scale at birth were inversely and significantly associated with the MSSI at six weeks postpartum (r = .50, P = .004). The MSSI assesses important elements of a new mother's environment which are related to her satisfaction with an intimate other, as well as depressive symptoms. These findings are similar to those in earlier reports.

Correlates of first trimester care in a public health prenatal clinic.

Early access to prenatal care is a major issue in the prevention of low birth weight. Therefore, the authors studied 107 indigent women seen consecutively for their initial visits at a public health department's prenatal clinic to ascertain factors associated with first trimester care. The questionnaire included items on individual health behaviors, attitudes toward medical care, perceived social support, depression, and demographics. Data were collected over 12 weeks by a clinic nurse, and all patients agreed to participate. Using logit estimated odds ratios (OR), none of the independent variables examined were associated with first trimester care for married women. For unmarried women first trimester care was related to finding the clinic by word of mouth (OR = 5.5, 95% CI, 1.2-22.9) and maternal depression (OR = 4.0, 95% CI, 1.1-15.3). Finding the prenatal clinic by word of mouth and maternal depression were still associated with first trimester care after controlling for maternal education and health attitudes. These data suggest that subsequent explanatory research should explore the association between informal social support of unmarried women and first trimester prenatal care.

The effect of a medical journal club on residents' knowledge of clinical epidemiology and biostatistics.

BACKGROUND: We performed a prospective controlled trial of a monthly journal club to determine if it would increase pediatric residents' knowledge of clinical epidemiology and biostatistics. METHODS: Intervention residents received two didactic sessions before the journal club started. Eight monthly journal club sessions followed. Pediatric residents at another institution served as controls. Intervention and control residents completed a pre- and post-test on clinical epidemiology and biostatistics. RESULTS: Neither the intervention nor the control group showed a significant change in test scores over the 9-month period. CONCLUSION: A more intensive and more structured approach is needed to effectively teach clinical epidemiology and biostatistics to residents.

The reliability and validity of the maternal social support index.

The Maternal Social Support Index (MSSI) is a 21-item questionnaire designed to quickly assess qualitative and quantitative aspects of a mother's social support. Previous studies have found an association between scores on the MSSI and home stimulation of preschool children, child maltreatment, and low birthweight. This report examines the test-retest reliability, internal consistency and concurrent and predictive validity of the MSSI in three samples of mothers (N = 488) from a prenatal clinic, pediatric clinic, and psychology clinic. The MSSI was found to have a test-retest correlation of .72 (P less than 0.001) over six to eight weeks. Coefficient alphas ranged from .60 to .63 across the three samples, denoting moderate internal consistency. In the psychology clinic sample, the MSSI was found to be positively correlated with the Dyadic Adjustment Scale (r = .393, P less than 0.001) and inversely correlated with the Center for Epidemiologic Studies Depression Scale (r = .296, P less than 0.001). The MSSI is a brief, reliable instrument with acceptable internal consistency and concurrent and predictive validity. It may be employed in the primary care arenas of clinical research and patient care to provide an organized assessment of maternal social support.

Development of positive feelings in primiparous mothers toward their normal newborns. A descriptive study.

Though mothers' development of positive feelings about their newborns is the first step in maternal attachment, little research has described factors which may influence the process. This descriptive study reports normative data for primiparous mothers with normal newborns. The authors interviewed 100 primiparous mothers on the postpartum ward within 72 hours after delivery at a community hospital to ascertain factors associated with the development of positive feelings. Over one third (39%) of mothers studied reported their first positive feeling during the prenatal period, 42 percent during birthing or the first day and 19 percent on the second or third day. A majority of mothers (70%) described their strong positive feelings toward their newborns (i.e., "love") as a sense of caring, commitment and concern. Several demographic, biological and environmental factors were associated with the development of first positive feelings in primiparous mothers. One half of mothers who planned to become pregnant developed positive feelings prenatally, while 57 percent of mothers who did not plan to become pregnant reported their first positive feelings during birth or the first day. Delay in first positive feelings until after the first day was associated with labor longer than 8 hours, disappointment with the "bonding" experience, breast-feeding, and high depressive symptoms.

Essential concepts in clinical epidemiology for pediatric practice.

Providing the best possible health care requires the integration of individual clinical experience with external clinical information, often derived from published research papers. This article reviews several important concepts in clinical epidemiology that should help the pediatric clinician become a more active and critical reader. Among the basic concepts reviewed are measurement of disease occurrence, relative risk, and screening within the context of the pediatric practice.

The Wisconsin Primary Care Organizations Consortium: a forum for the primary care medical specialties.

The Wisconsin Primary Care Organizations Consortium (WI-PCOC) is composed of the leadership of Wisconsin's primary care medical specialties whose four professional societies have a combined membership of about 3,900 physicians. Since 1992, WI-PCOC has explored the priorities and issues of importance of each organization, and has reviewed organizational resources to synchronize agendas and to avoid conflict. WIPCOC articulates policy supported by its member societies with a common voice; it does not set policy. WI-PCOC has worked with legislators, medical school deans, other specialty societies and other groups interested in primary care service and education. WI-PCOC member organizations aspire to work together to improve the level of health of Wisconsin citizens and their communities.