Disparities in Shared Decision Making and Service Receipt Among Children With Special Health Care Needs and Developmental Delay: A National Survey Analysis.

Shared decision making (SDM) is associated with increased service satisfaction among pediatric patients. Our objective was to examine the association between SDM and service use experiences across racial/ethnic child groups. This secondary data analysis used the 2009-2010 National Survey of Children with Special Health Care Needs (CSHCN) and 2011 Pathways to Diagnosis and Services Survey. We used a rank-and-replace matching approach consistent with Institute of Medicine recommendations for health disparities research. We included CSHCN aged 6 to 17 years. The exposure of interest was parents of CSHCN reporting engagement in SDM with clinicians. There were 4032 CSHCN included in analysis. CSHCNs experiencing SDM had a 16% higher probability of reporting service use compared to those not experiencing it (95% CI, 14.24-19.42). Black children experiencing SDM reported seeing all needed care providers at a lower rate than whites (79% and 87.6% respectively; 95% CI, -14.05-3.27). The benefit of SDM over not experiencing it for blacks was 12.2% less than for whites for the outcome of seeing all needed care providers. For the outcome of receiving all needed treatments and services, the SDM benefit was 9.1% lower for Hispanics compared with whites. SDM can improve service experiences but implementation flexibility may be needed.

A Prospective Study of the Causes of Bruises in Premobile Infants.

OBJECTIVE: This study had 2 objectives. First, to determine the behavior of physicians evaluating premobile infants with bruises. Second, and most importantly, to learn whether infants with unexplained bruising who had been initially evaluated by primary care and emergency department (ED) physicians are as likely to have their bruises attributed to child abuse as those children evaluated by child abuse physicians. METHODS: Primary care, ED, and child abuse pediatricians (CAPs) in King County, Washington, San Mateo, Calif, Albuquerque, NM, La Crosse, Wis, and Torrance, Calif prospectively identified and studied infants younger than 6 months with less than 6 bruises, which were judged by the evaluating clinician to be explained or unexplained after their initial clinical examination. RESULTS: Between March 1, 2010, and March 1, 2017, 63 infants with initially explained and 46 infants with initially unexplained bruises were identified. Infants with unexplained bruises had complete coagulation and abuse evaluations less frequently if they were initially identified by primary care pediatricians or ED providers than by CAPs. After imaging, laboratory, and follow-up, 54.2% (26) of the infants with initially unexplained bruises, including 2 who had been initially diagnosed with accidental injuries, were diagnosed as abused. Three (6.2%) infants had accidental bruising, 6 (12.4%) abuse mimics, 1 (2.5%) self-injury, 1 (2.5%) medical injury, and 11 (22.9%) remained of unknown causation. None had causal coagulation disorders. A total of 65.4% of the 26 abused infants had occult injuries detected by their imaging and laboratory evaluations. Six (23.1%) abused infants were not diagnosed until after they sustained subsequent injuries. Three (11.5%) were recognized abused by police investigation alone. Thirty-eight percent of the abused, bruised infants had a single bruise. Clinicians' estimates of abuse likelihood based on their initial clinical evaluation were inaccurate. Primary care, ED, and child abuse physicians identified abused infants at similar rates. CONCLUSIONS: More than half of premobile infants with initially unexplained bruises were found to be abused. Abuse was as likely for infants identified by primary care and ED providers as for those identified by CAPs. Currently, physicians often do not obtain full abuse evaluations in premobile infants with unexplained bruising. Their initial clinical judgment about abuse likelihood was inadequate. Bruised infants often have clinically occult abusive injuries or will sustain subsequent serious abuse. Bruised infants should have full abuse evaluations and referral for Protective Services and police assessments.

Commercial Sexual Exploitation and Sex Trafficking of Children and Adolescents: A Narrative Review.

Commercial sexual exploitation and sex trafficking of children and adolescents represent a severe form of child abuse and an important pediatric health concern. Youth who are commercially sexually exploited have a constellation of clinical risk factors and high rates of unmet physical and mental health needs, including conditions that directly result from their victimization. Common physical health needs among commercially sexually exploited children and adolescents include violence-related injuries, pregnancy, sexually transmitted infections, and other acute infections. Common mental health conditions include substance use disorders, post-traumatic stress disorder, depression and suicidality, and anxiety. The existing literature indicates that trauma-informed approaches to the care of commercially sexually exploited youth are recommended in all aspects of their health care delivery. Additionally, medical education that attunes providers to identify and appropriately respond to the unique needs of this highly vulnerable group of children and adolescents is needed. The available research on commercial sexual exploitation and sex trafficking of children and adolescents remains fairly limited, yet is expanding rapidly. Especially relevant to the field of pediatrics, future research to guide health professionals in how best to identify and care for commercially sexually exploited children and adolescents in the clinical setting signifies a key gap in the extant literature and an important opportunity for future study.

Cultural considerations and child maltreatment: in search of universal principles.

Cultural diversity poses challenges within the health care setting, particularly regarding the question of how health professionals can resolve the tension between respecting cultural norms or child-rearing practices and the importance of determining what constitutes harm and child maltreatment. Cultural competency and respect for cultural diversity does not imply universal tolerance of all practices. The United Nations provides a standard of universal child rights, protecting them from harmful practices. Pediatric providers must respect cross-cultural differences while maintaining legal and ethical standards of safety and wellbeing for children, promoting evidence-based prevention of maltreatment, and advocating for child wellness across all cultures.