A mixed method inquiry of early complementary feeding of infants in the Dominican Republic.

Exclusive breastfeeding (EBF) is infrequent and decreasing over time in the Dominican Republic. This study aimed to identify patterns of, and women's rationale for, early complementary feeding. Mothers of children under 12 months of age living in a low-resource peri-urban community had three opportunities to contribute: (i) responding to feeding questions embedded in a standardized questionnaire used at a well-baby clinic (n = 101), (ii) participating in focus groups (n = 31), and (iii) engaging in home-based, semi-structured individual interviews (n = 25). Quantitative questionnaire data were analyzed to identify feeding practices as a function of child age. Textual data from the individual interviews and focus groups were systematically reviewed and coded to identify key constructs through a qualitative descriptive approach. The majority (>86%) of mothers reported breastfeeding at all monthly age bands up to six months. However, EBF was rare, with more than half reporting use of other milks and other foods by the infants' second and fifth month, respectively. Overarching themes to explain early complementary feeding from the qualitative data can be broadly captured by the complementary perceptions that there are problems with relying on breastfeeding alone and that there are benefits to early complementary feeding in the early months of an infant's life. EBF was experienced as (A) insufficient, (B) not always available, (C) sometimes not safe, (D) having potentially negative effects on the mother, and (E) bringing challenges. Complementary feeding was identified as helpful in addressing each of these concerns. Although mothers typically endorsed breastmilk as the preferable and best option for infant feeding, this did not translate into EBF and was not presented as contradictory to the use and perceived benefits of early complementary feeds.

Cross-sector service use patterns among children with developmental disabilities in a district in Canada.

BACKGROUND: There is a lack of information about cross-sector service use by children with developmental disabilities despite their need for services from multiple sectors. METHODS: Responses to service use questions from a parent-completed survey on school-aged children who attended clinics specific for those with developmental disabilities at a Canadian children's hospital were examined. RESULTS: School meetings were the most common of three professional meeting types attended in the last 12 months (64.9%) for the sample of 205 children. Recreational services were the most common of five service types received in the same time period (79.0%). Using ordinal logistic regression models, a higher number of behavioural difficulties was the only variable consistently related to indices of more meeting types (school, physician, other) attended and more service types received (recreation, respite, etc.). CONCLUSIONS: The service relationship with behavioural problems, and not socio-demographic variables, is consistent with a needs-based oriented delivery system.

The relationship between profiles and transitions of internalizing and externalizing symptoms in children and suicidal thoughts in early adolescence.

BACKGROUND: Adolescence is a high-risk period for the onset of suicidal thoughts and behaviors. Identification of preceding patterns of internalizing and externalizing symptoms that are associated with subsequent suicidal thoughts may offer a better understanding of how to prevent adolescent suicide. METHODS: Data from the National Longitudinal Survey of Children and Youth, a prospective population-based Canadian cohort, contained Child Behavior Checklist items which were used to examine profiles and transitions of internalizing and externalizing symptoms in children, aged 6-11 years (n = 8266). The association between these profiles/transitions and suicidal thoughts in adolescents was examined using multivariate logistic regression modeling. RESULTS: Latent profile analyses identified four measurement invariant profiles of internalizing and externalizing symptoms at ages 6/7 and 10/11: (1) low on all symptoms, (2) moderate on all symptoms, (3) high on all symptoms, and (4) high on hyperactivity/inattention and internalizing. Recurrent (homotypic or heterotypic) and increasing symptoms from 6/7 to 10/11 were associated with suicidal thoughts in adolescence, compared to those with stable low symptoms. Those with decreasing symptoms from 6/7 to 10/11 were not at increased risk of suicidal thought in adolescence. CONCLUSIONS: While patterns of recurrent symptoms were associated with suicidal thoughts, a similar association was observed between profiles at age 10/11 years and suicidal thoughts. This suggests that the recent assessments of mental health symptoms in children may be as sufficient a predictor of adolescent suicidal thought as transition profiles.

Do Differences in Prelacteal Feeding Explain Differences in Subsequent Breastfeeding Between Haiti and the Dominican Republic?

OBJECTIVE: Although Haiti and the Dominican Republic (DR) share the same island of Hispaniola, exclusive breastfeeding is much higher in Haiti. As prelacteal feeding also differs between the two countries, it was hypothesize that prelacteal feeding would account for the subsequent differences in breastfeeding exclusivity between the two countries, while controlling for other potentially influencing differences. METHODS: Data for infants under 6 months of age were extracted from the cross-sectional Demographic and Health Surveys from Haiti (2012) and the DR (2013). Bivariate analysis and ordered logistic regression models were used. RESULTS: Data were available for 686 Haitian infants [mean age: 2.9 (SD: 1.6) months] and 264 Dominican infants [mean age: 2.6 (SD: 1.6) months]. Haitian infants were more likely to be exclusively breastfed than Dominican infants, 41.3% versus 8.0%, at the time of the survey, and less likely to have been exposed to any prelacteal feeds, 20.1% versus 69.8%, respectively. Furthermore, Dominican infants were more likely to have been exposed to milk-based prelacteal feeds. Dominican status, any prelacteal feeds, and milk-based prelacteal feeds significantly and independently reduced the odds of breastfeeding exclusivity. CONCLUSIONS FOR PRACTICE: Identification of factors beyond prelacteal feeding are necessary to explain the substantially lower breastfeeding exclusivity in the DR compared to Haiti and to determine why so many Dominican infants are exposed to milk-based prelacteal feeds.

Dual Diagnosis: A Problematic Construct When Applied to Persons with Intellectual Disabilities.

The term dual diagnosis can refer to the co-occurrence of an intellectual disability and a mental disorder. While such a term may have some advocacy rationale aimed at facilitating improved mental health care for those with intellectual disabilities, it is proposed that the construct has flawed underpinnings, and its application may problematize mental health service delivery. A core concern is the promotion of categorical diagnostic models, whereas dimensional models may more accurately reflect underlying continuums for both cognitive and mental health challenges. A categorical diagnostic approach may also contribute to questionable dichotomization of mental health difficulties in persons with intellectual disabilities into "problem or challenging behaviours" versus "mental disorders." Organizing services based on beliefs that such distinctions and categorical classifications are accurate may contribute to unnecessary and inappropriate fractionation of interventions and create additional service barriers for a vulnerable population. It is proposed that the term dual diagnosis be abandoned and replaced by systematic use of a dimensional approach to help facilitate assessment, intervention evaluation, and equitable service access.

Erratum: Screening for disruptive behaviour problems in preschool children in primary health care settings.

[This corrects the article DOI: 10.1093/pch/pxx128.]

Changes over time in early complementary feeding of breastfed infants on the island of Hispaniola.

OBJECTIVE: To describe and contrast early complementary feeding (ECF) over time in breastfed infants in the Dominican Republic (DR) and Haiti, the two countries that share the island of Hispaniola. METHODS: Secondary data analysis was conducted on cross-sectional data from Demographic and Health Surveys administered at four different time-points in both countries between 1994 and 2013. Extracted samples were composed of breastfed infants < 6 months of age whose caregivers had responded to dietary questions on food consumption in the previous 24 hours. RESULTS: Plain water was the most frequently consumed complementary substance in both countries. However, the prevalence of water consumption increased in the DR over time, whereas in Haiti it decreased. Milk (non-breast) use was also common and followed a similar pattern as water over time in the two countries. Expanded use of water and milk in the DR are the major contributors to its drop in exclusive breastfeeding (EBF) rates over time. Whereas in Haiti, a reduction in a broader array of liquids and semi-solids/solids overtime appears to have contributed to its markedly improved EBF rates. CONCLUSION: Determining contributors to the differential trends in water and milk (non-breast) use between these two countries may identify targets for addressing the persistent gaps in EBF on the island of Hispaniola.

Screening for disruptive behaviour problems in preschool children in primary health care settings.

Disruptive behaviour problems in preschool children are significant risk factors for, and potential components of, neurodevelopmental and mental health disorders. Some noncompliance, temper tantrums and aggression between 2 and 5 years of age are normal and transient. However, problematic levels of disruptive behaviour, specifically when accompanied by functional impairment and/or significant distress, should be identified because early intervention can improve outcome trajectories. This position statement provides an approach to early identification using clinical screening at periodic health examinations, followed by a systematic mental health examination that includes standardized measures. The practitioner should consider a range of environmental, developmental, family and parent-child relationship factors to evaluate the clinical significance of disruptive behaviours. Options within a management plan include regular monitoring, accompanied by health guidance and parenting advice, referral to parent behaviour training as a core evidence-based intervention, and referral to specialty care for preschool children with significant disruptive behaviours, developmental or mental health comorbidities, or who are not responding to first-line interventions.

Changes in caesarean section rates and milk feeding patterns of infants between 1986 and 2013 in the Dominican Republic.

OBJECTIVE: The relationship between caesarean sections (C-sections) and infant feeding varies between different samples and indicators of feeding. The current study aimed to determine the relationship between C-sections and five indicators of infant milk feeding (breast-feeding within 1 h after delivery, at the time of the survey (current) and ever; milk-based prelacteal feeds; and current non-breast milk use) over time in a country with a rapidly rising C-section rate. DESIGN: Secondary data analysis on cross-sectional data from Demographic and Health Surveys from six different time points between 1986 and 2013. SETTING: Dominican Republic. SUBJECTS: Infants under 6 months of age. RESULTS: Over 90 % of infants were ever breast-fed in each survey sample. However, non-breast milk use has expanded over time with a concomitant drop in predominant breast-feeding. C-section prevalence has increased over time reaching 63 % of sampled infants in the most recent survey. C-sections remained significantly related to three infant feeding practices - the child not put to the breast within 1 h after delivery, milk-based prelacteal feeds and current non-breast milk use - in multivariate models that included sociodemographic control variables. However, current non-breast milk use was no longer related to C-sections when milk-based prelacteal feeds were factored into the model. CONCLUSIONS: Reducing or avoiding milk-based prelacteal feeds, particularly among those having C-sections, may improve subsequent breast-feeding patterns. Simultaneously, efforts are needed to understand and help reduce the exceptionally high C-section rate in the Dominican Republic.

Routine primary care screening for intimate partner violence and other adverse psychosocial exposures: what's the evidence?

BACKGROUND: Family physicians and other primary care practitioners are encouraged or expected to screen for an expanding array of concerns and problems including intimate partner violence (IPV). While there is no debate about the deleterious impact of violence and other adverse psychosocial exposures on health status, the key question raised here is about the value of routine screening in primary care for such exposures. DISCUSSION: Several characteristics of IPV have led to consideration for routine IPV screening in primary care and during other healthcare encounters (e.g., emergency room visits) including: its high prevalence, concern that it may not be raised spontaneously if not prompted, and the burden of suffering associated with this exposure. Despite these factors, there are now three randomized controlled trials showing that screening does not reduce IPV or improve health outcomes. Yet, recommendations to routinely screen for IPV persist. Similarly, adverse childhood experiences (ACEs) have several characteristics (e.g., high frequency, predictive power of such experiences for subsequent health problems, and concerns that they might not be identified without screening) suggesting they too should be considered for routine primary care screening. However, demonstration of strong associations with health outcomes, and even causality, do not necessarily translate into the benefits of routine screening for such experiences. To date, there have been no controlled trials examining the impact and outcomes - either beneficial or harmful - of routine ACEs screening. Even so, there is an expansion of calls for routine screening for ACEs. While we must prioritize how best to support and intervene with patients who have experienced IPV and other adverse psychosocial exposures, we should not be lulled into a false sense of security that our routine use of "screeners" results in better health outcomes or less violence without evidence for such. Decisions about implementation of routine screening for psychosocial concerns need similar rigorous debate and scrutiny of empirical evidence as that recommended for proposed physical health screening (e.g., for prostate and breast cancer).

Anemia Screening and Treatment Outcomes of Children in a Low-resource Community in the Dominican Republic.

Iron is often initiated for children with low hemoglobin values in the absence of other indicators of iron deficiency in low-resource settings. Unfortunately, there are few reports describing outcomes from such an approach outside of clinical trials. This study examined outcomes of an anemia screening and treatment service in a low-resource community in the Dominican Republic. Complete blood counts (CBC) and receipt of iron supplementation were extracted from health records of young children participating in a well-baby clinic in the targeted community. Of the 265 children screened, 68.7% had hemoglobin values <11.0 g/dl; 61.5% of these anemic children had follow-up CBCs. While 72.3% of those with follow-up CBCs picked-up some iron supplements, only 21.4% had a follow-up hemoglobin ≥11.0 g/dl. Amount of iron given was not related to change in hemoglobin at follow-up. More follow-up monitoring of quality and impact of community care is required with associated evidence-informed benchmark targets.

Understanding attention deficit hyperactivity disorder as a continuum.

OBJECTIVE: To review research findings that consider whether attention deficit hyperactivity disorder (ADHD) is a discrete entity or whether it is more consistent with an extreme end-of-trait distribution in the population and to then grapple with the potential clinical implications. QUALITY OF EVIDENCE: Peer-reviewed publications in the past 5 years, drawing from diverse fields (taxonomy, epidemiology, genetics, neurobiology, and neuropsychology), were identified through searches in MEDLINE and PsycINFO. MAIN MESSAGE: Accumulating research findings are most consistent with a predominately dimensional rather than a qualitatively distinct existence for ADHD. This does not negate the clinical needs of those who have substantial ADHD symptom clusters, nor the risks that such symptoms entail. However, the lack of discontinuity in the distribution of such traits in the population creates great uncertainty as to what thresholds should prompt explicit intervention. CONCLUSION: The implications of this pattern of findings might include the need to de-emphasize categorical conceptualizations of ADHD, produce evidence to better inform risk-benefit ratios of interventions along a spectrum of symptom and functional severity, and more coherently triage and arrange service delivery on the basis of symptom and functional severity rather than artificial diagnostic categorizations.

A Youth Suicide Prevention Plan for Canada: A Systematic Review of Reviews.

OBJECTIVE: We conducted an expedited knowledge synthesis (EKS) to facilitate evidence-informed decision making concerning youth suicide prevention, specifically school-based strategies and nonschool-based interventions designed to prevent repeat attempts. METHODS: Systematic review of review methods were applied. Inclusion criteria were as follows: systematic review or meta-analysis; prevention in youth 0 to 24 years; peer-reviewed English literature. Review quality was determined with AMSTAR (a measurement tool to assess systematic reviews). Nominal group methods quantified consensus on recommendations derived from the findings. RESULTS: No included review addressing school-based prevention (n = 7) reported decreased suicide death rates based on randomized controlled trials (RCTs) or controlled cohort studies (CCSs), but reduced suicide attempts, suicidal ideation, and proxy measures of suicide risk were reported (based on RCTs and CCSs). Included reviews addressing prevention of repeat suicide attempts (n = 14) found the following: emergency department transition programs may reduce suicide deaths, hospitalizations, and treatment nonadherence (based on RCTs and CCSs); training primary care providers in depression treatment may reduce repeated attempts (based on one RCT); antidepressants may increase short-term suicide risk in some patients (based on RCTs and meta-analyses); this increase is offset by overall population-based reductions in suicide associated with antidepressant treatment of youth depression (based on observational studies); and prevention with psychosocial interventions requires further evaluation. No review addressed sex or gender differences systematically, Aboriginal youth as a special population, harm, or cost-effectiveness. Consensus on 6 recommendations ranged from 73% to 100%. CONCLUSIONS: Our EKS facilitates decision maker access to what is known about effective youth suicide prevention interventions. A national research-to-practice network that links researchers and decision makers is recommended to implement and evaluate promising interventions; to eliminate the use of ineffective or harmful interventions; and to clarify prevention intervention effects on death by suicide, suicide attempts, and suicidal ideation. Such a network could position Canada as a leader in youth suicide prevention.

Extent of microcytic anemia among children in a low-income, peri-urban community in the Dominican Republic using different cut-points.

Response to anemia in low-resource settings may entail presumptive iron treatment for those with Hemoglobin (Hb) levels falling below certain cut points. This study aimed to inform an anemia screening and treatment service in a low-income community in the Dominican Republic by determining (i) the prevalence of anemia in young children attending this service using different Hb cut points and (ii) the extent of microcytosis using different recommended cut points for the mean corpuscular volume (MCV). Using the WHO recommended cut point of <11.0 g/dl, 69.9% of 292 children would be classified as anemic, while using a more conservative cut point, <10.0 g/dl, 34.6% would be identified. Depending on the Hb cut point and which of two age-based MCV cut points are used, the prevalence of microcytosis within the anemic subsamples ranged from 23.5% to 80.2%. With increasing availability of complete blood counts in low resource settings (vs. Hb only), more sophisticated management algorithms are necessary to guide primary care efforts.

Behavioural treatment recommendations in clinical practice guidelines for attention-deficit/hyperactivity disorder: a scoping review.

BACKGROUND: The extent of behavioural treatment recommendations described in attention-deficit/hyperactivity disorder (ADHD) practice guidelines has not been examined. METHOD: A scoping review identified eight agency-based ADHD practice guidelines. Key components of behavioural treatment recommendations were summarized. RESULTS: All guidelines mentioned behavioural treatment as a consideration for managing ADHD, however, the extent to which they were detailed varied. Most guidelines provided lists of behavioural techniques but with minimal specifics regarding treatment delivery. CONCLUSIONS: There is far less detailing of behavioural approaches compared to pharmacological treatments for ADHD. Greater detailing of evidence-based behavioural approaches may foster improved delivery of high-quality behaviour treatment.

Routine screening for adverse childhood experiences (ACEs) still doesn't make sense.

When a serious health or social problem is identified as both prevalent and in need of attention, a common response is to propose that various systems implement routine identification, such as universal screening. However, these well-intentioned responses often fail to consider the key requirements necessary to determine whether benefits outweigh harms. Unfortunately, this continues to be the case for calls to implement routine screening for Adverse Childhood Experiences (ACEs). Persistent evidence gaps for this type of screening include the lack of any randomized controlled trials demonstrating that ACEs screening programs lead to any benefits. Rather than being informed by established screening principles, the calls to proceed with ACEs screening appear to rely on the assumption that simply identifying risk factors can lead to beneficial outcomes that outweigh any risk of harms. This may reflect a gap in understanding that patterns identified at the population level (e.g., that more ACEs are associated with more health and social problems) cannot be directly translated to practices at the level of the individual. This commentary does not question the importance of ACEs; rather it identifies that directing limited resources to screening approaches for which there is no evidence that benefits outweigh harms is problematic. Instead, we advocate for the investment in high-quality trials of prevention interventions to determine where best to direct limited resources to reduce the occurrence of ACEs, and for the prioritization of evidence-based treatment services for those with existing health and social conditions, whether or not they are attributed to ACEs.

Service Use Patterns by Children With Down Syndrome in a Canadian Region.

Children with Down syndrome require services from different sectors over time to optimize health and development, however, there is little information on longitudinal, cross-sector service use. Parents of children with Down syndrome attending a Canadian children's hospital participated in semistructured interviews covering life-time multiple sector service use. Five key service patterns were identified: (1) primary care physicians playing a circumscribed role; (2) a marked shift in public habilitative service receipt from development agencies in the preschool years to exclusive school delivery after school entry; (3) families obtaining private services to address gaps from public sector services; (4) a prominent role for parents to identify additional services; and (5) service variability as a function of timing and severity of medical comorbidity.