Factors linked to bacterial vaginosis in nonpregnant women.

OBJECTIVES: The purposes of this study were to test the hypothesis that vaginal douching is linked to bacterial vaginosis in both symptomatic and asymptomatic women and to identify other demographic, reproductive, and lifestyle factors associated with bacterial vaginosis. METHODS: In this cross-sectional study involving 3 clinic sites, 496 nonpregnant women completed a self-administered questionnaire. Their vaginal smears were assessed and cross-validated for bacterial vaginosis. RESULTS: The prevalence of bacterial vaginosis across clinics ranged from 15% to 30%. In analyses restricted to site 1, adjusted odds ratios (ORs) for bacterial vaginosis remained significant for African American women with 13 or fewer years of education (OR = 5.5, 95% confidence interval [CI] = 2.1, 14.5), hormone use within the past 6 months (OR = 0.5, 95% CI = 0.2, 0.8), and vaginal douching within the past 2 months (OR = 2.9, 95% CI = 1.5, 5.6). CONCLUSIONS: Two lifestyle factors emerge as strongly associated with bacterial vaginosis: systemic contraceptives appear protective, whereas douching is linked to an increase in prevalence. The temporal relationship between douching and bacterial vaginosis needs further clarification.

Referrals to a hospital-based child abuse committee: a comparison of the 1960s and 1990s.

OBJECTIVE: Although reports of child maltreatment have increased yearly since national data were first collected in 1976, little information is available about changes in the characteristics of children reported. Therefore, to examine changes over time in recognition and reporting in a medical setting, we compared referrals to a hospital-based child abuse committee in the late 1960s and early 1990s. DESIGN: Retrospective, cross-sectional review of medical records and logs of the hospital's child abuse committee. SETTINGS: Ambulatory, emergency, and inpatient services at Yale-New Haven Hospital. PATIENTS: Medical records were reviewed for 101 of the 165 children referred to the child abuse committee in 1968-1969 (early group) and 107 of the 843 children referred in 1990-1991 (late group). Cases of sexual abuse were excluded. RESULTS: Referrals for nonsexual abuse cases increased from 80 children per year in the early group to 181.5 per year in the late group; the late group was characterized by a larger number of newborn referrals (1% vs. 52%, p < .001). When non-newborns were compared, the two groups were similar with respect to gender and race, but the late group had fewer patients with private insurance (31% vs. 12%, p < .05). The late group also had more female-headed households (32% vs. 67%, p < .05) and more parents with a history of substance abuse (4% vs. 49%, p < .001). Excluding newborns, who were all classified as "at-risk," the types of problems were classified as abuse (41% early vs. 29% late), neglect (41% vs. 35%), and "at-risk" (16% vs. 35%). Although the types of injuries were similar: superficial injuries (20% vs. 16%), burns (9% vs. 8%), and fractures (6% vs. 4%), fewer maltreated children suffered physical injuries in the late group (71% vs. 49%, p < .05). CONCLUSIONS: A substantial change has occurred in referrals to the hospital's child abuse committee for abuse or neglect. Most referrals have become socially high-risk newborns and children or children with minimal injuries. This shift is likely due to broader definitions of maltreatment and earlier recognition of troubled families.

The timing and predictors of the early termination of breastfeeding.

OBJECTIVE: To determine the prevalence and correlates of the early discontinuation of breastfeeding by mothers eligible for the Women, Infants, and Children Program (WIC). METHODOLOGY: A longitudinal observational study in which we enrolled English-speaking mothers who initiated breastfeeding after delivering healthy-term infants at Yale-New Haven Hospital and planned to bring their infants to the hospital's primary care center. Data on mother's baseline knowledge, attitudes, beliefs, and problems regarding breastfeeding were collected by semistructured interviews within 48 hours after delivery, at 1 and 2 weeks' postpartum, and by chart reviews at 2 and 4 months. A nonparticipating control group was used to test the Hawthorne effect. RESULTS: Of the 64 participating mothers, the majority were minority (56% black, 34% of Puerto Rican origin), single (75%), and already enrolled in WIC (91%). The rates of discontinuation of breastfeeding were 27%, 37%, 70%, and 89% by 1 week, 2 weeks, 2 months, and 4 months, respectively. The mother's knowledge and problems of lactation were not associated with the early discontinuation of breastfeeding. After using logistic regression to control for potential confounders, mothers who lacked confidence at baseline that they would still be breastfeeding at 2 months (risk ratio: 2.38, 95% confidence interval: 1.82-6.18), and those who believed that the baby prefers formula (risk ratio: 1.68, 95% confidence interval: 1.04-2.71) were more likely to stop breastfeeding within the first 2 weeks postpartum. CONCLUSIONS: The results of this study demonstrate that interventions aimed at prolonging the duration of breastfeeding in this population will need to shift focus from increasing knowledge and managing problems of lactation to enhancing the mother's confidence regarding breastfeeding, while also addressing beliefs regarding an infant's preferences.

Care to underserved children: Residents' attitudes and experiences.

OBJECTIVES: To examine: 1) the relationship between residents' responses toward caring for underserved children and families during residency and their perceptions of their continuity clinic experience; and 2) which characteristics are related to continuing to care for the underserved after completion of training. DESIGN: Cross-sectional descriptive study. METHODS: A 49-item questionnaire was mailed to 210 third-year pediatric residents at 12 urban training programs in the Northeast in May 1995. Information was collected about residents' emotional responses toward caring for underserved families, their assessments of clinic operations, their sense of effectiveness in caring for underserved patients in continuity clinic, preresidency experiences with the underserved, and their intent to care for the underserved after training. RESULTS: Of 210 surveys mailed, 71% were returned. Thirty-six percent of residents planned to pursue a career in primary care, 53% did not, and 11% did not answer or were planning a year as chief resident. Fifty-seven percent of all residents planned to devote a portion of their practice toward caring for the underserved after training. Residents whose emotional responses toward caring for the underserved included: 1) not worrying that they had become numb to children's psychosocial difficulties, 2) not feeling angry with how families cared for their children, and 3) feeling more empathy with the underserved had significantly higher mean scores on both their assessment of clinic operations and their sense of effectiveness. The only demographic characteristic associated with a greater sense of effectiveness was being black. To better characterize which residents planned to care for the underserved after training, we examined a subsample of 46 residents who recalled an interest in caring for the underserved during residency training and who were pursuing a career in primary care. Residents that did not recall an interest in caring for the underserved at the onset of residency training were unlikely to have plans to care for the underserved after the completion of training. Within this group residents who planned to care for the underserved after training differed significantly from residents who did not plan to continue this work by feeling a greater sense of effectiveness in clinic, feeling less worried about becoming numb, and having greater empathy for underserved families. CONCLUSIONS: There are a number of identifiable emotional responses residents develop toward caring for the underserved that relate to their perceptions of continuity clinic and whether a resident chooses to continue to care for the underserved after training.

Intergenerational continuity of child physical abuse: how good is the evidence?

BACKGROUND: There is widespread belief that individuals who were physically abused during childhood are more likely to abuse their own children than those who were not abused, but the empirical studies examining this belief have not been systematically reviewed. The aim of this study was to evaluate systematically, based on eight methodological standards derived from a hypothetical randomised controlled trial, the design of studies investigating the intergenerational transmission of child physical abuse. METHODS: We reviewed studies published between 1965 and 2000 in English that provided information about physical maltreatment in two generations and included a comparison group. Two investigators independently assessed whether each study met the methodological standards. FINDINGS: In the ten studies identified (four cohort, one cross-sectional, and five case-control), the relative risks of maltreatment in the children of parents who were abused during childhood were significantly increased in four studies (relative risks 4.75-37.8), but in three other studies the relative risks were less than 2. Most study reports provided a clear description of abuse of parents during childhood and abuse of their children. Five studies failed to avoid recall and detection bias; five did not ensure that controls were not themselves maltreated; eight did not provide adequate follow-up; and in six the report did not state whether the enrolled parent was responsible for the maltreatment. Most studies did not control for intervening factors, such as sociodemographic characteristics during the time of abuse of the parent generation and at the time their children were abused. Only one study met all eight criteria (relative risk of abuse transmission 12.6 [95% CI 1.82-87.2]) and one met six (1.05 [0.53-2.06]). INTERPRETATION: The one study that met all eight methodological standards provided evidence for the intergenerational continuity of child physical abuse, but that which met six standards did not support the hypothesis. Use of our model and methodological standards should improve the scientific quality of studies examining the effects of risk factors for adverse outcomes that may continue across generations.

Mental health in pediatric settings: distribution of disorders and factors related to service use.

OBJECTIVES: To examine child psychiatric disorders in pediatric settings and identify factors associated with parents' use of pediatricians as resources concerning emotional/behavioral issues and use of mental health services. METHOD: The sample consists of 5- to 9-year-olds (mean = 7.17 years, SD = 1.41) from a representative sample (N = 1,060) of pediatric practices. Parent interviews included assessments of psychiatric disorders with the Diagnostic Interview Schedule for Children (DISC-R), parental depression/anxiety, possible child abuse, stress, support, and the use of mental health services. RESULTS: The prevalence of any DISC disorder was 16.8%. Parental depression/anxiety and possible child abuse were associated independently with 2- to 3-times higher rates of disorder. Many parents (55%) who reported any disorder did not report discussing behavioral/emotional concerns with their pediatrician. Factors associated with discussing behavioral/emotional issues were the presence of any disorder and financial stress. Factors related to seeing a mental health professional were discussing behavioral/emotional issues with the pediatrician, single parenthood, and stressful life events. CONCLUSIONS: The prevalence rates of disorders in this setting suggest that pediatricians are well-placed to identify and refer children with psychiatric disorders. However, most parents do not discuss behavioral/emotional issues with their pediatrician. Methods for improving rates of identification and referral (e.g., routine screening) are considered.

Identification of violence in the home: pediatric and parental reports.

OBJECTIVES: To compare the rates of domestic violence reported by mothers with those identified by physicians, to compare the rates of harsh discipline practices reported by mothers with the rates of abuse identified by physicians, and to examine the relationship between reported domestic violence and harsh discipline practices. DESIGNS: Interviews with parents and pediatricians to compare pediatric detection of domestic violence and child abuse with parental reports of domestic violence and harsh discipline practices. SETTING: Community-based pediatric practices in the 13-town greater New Haven, Conn, area. PARTICIPANTS: Of the 23 practices invited, 19 agreed to participate. Of the 2,006 parents of eligible 4- to 8-year-olds asked to participate, 1,886 (94%) completed the Child Behavior' Checklist. Of those invited into the interview portion, 1,148 (83%) completed the 90-minute in-person interview. MAIN OUTCOME MEASURES: Percentages of cases of domestic violence identified by pediatricians and reported by mothers. Percentages of cases of child abuse detected by pediatricians and percentages of mothers reporting that they have hit their children and left a mark. RESULTS: Pediatricians detected domestic violence in 0.3% of the cases, but parents reported domestic violence in 4.2% kappa= 0.106 [95% confidence interval, -0.007 to 0.219]). Pediatricians identified physical abuse of children in 0.5% of the cases, while mothers reported hitting their children and leaving a mark in 21.6% (kappa = 0.003 [95% confidence interval, -0.018 to 0.024]). Mothers reporting domestic violence were significantly more likely to report hitting hard enough to leave a mark (relative risk, 1.6 ([95% confidence interval, 1.09-2.38]) compared with those not reporting domestic violence. Physicians identifying domestic violence were not significantly more likely to report child abuse than those not identifying domestic violence. CONCLUSIONS: Parents report more cases of violence than pediatricians detect. Pediatricians should ask parents directly about domestic violence and harsh discipline.

Prevalence and effects of child sexual abuse in a poor, rural community in El Salvador: a retrospective study of women after 12 years of civil war.

OBJECTIVE: The purpose of this retrospective study was to examine the epidemiology of child sexual abuse (CSA) among women in a poor, rural community in El Salvador, which was recovering from a 12-year civil war. METHODS: A cross-sectional, door-to-door survey was administered to 83 women. The LA Times Sexual Abuse Survey was used to determine the prevalence of CSA. The Hopkins Symptom Checklist (HCL) was used to measure long-term psychological sequelae of abuse (somatization, anxiety, depression, interpersonal sensitivity, and obsessive-compulsive traits). Information also was obtained about participation and number of relatives killed in the country's 12-year civil war. RESULTS: Of the 83 women interviewed, 14 (17%) reported a total of 21 experiences of CSA. The median age of abuse was 14 years. The majority of perpetrators (90.4%) were strangers, friends, or neighbors. None was a parent. The only significant difference between abused and non-abused women was on the depression measure, where abused women showed more pathology. After controlling for the number of relatives killed in the war, however, that difference failed to reach statistical significance. CONCLUSIONS: Differences in the epidemiology of CSA from that of other countries may be secondary to a different social structure in the rural Salvadoran community and non-disclosure by the women surveyed. The lack of difference in psychological symptoms between abused and non-abused women may be related to the different characteristics of the abuse and perpetrators. It also may be secondary to adverse social conditions such as poverty and war, which could obscure the long-term effects of CSA.

Funding realities: child abuse diagnostic evaluations in the health care setting.

OBJECTIVE: This study examines staffing, funding sources, reimbursement, and financing of medically-oriented child protection teams. METHOD: A 16-item questionnaire on the composition, size, and services of the team, program costs, revenue sources, reimbursement rates, and perceptions of funding stability was mailed to a sample of 118 medically-oriented child protection teams. RESULTS: After excluding 10 programs, an overall response rate of 68% was obtained. Teams varied in configuration, services, charges, and funding. Over 50% identified funding as being important, yet, demonstrated varying levels of awareness of budget and reimbursement issues. Many generally relied on patient care reimbursement from health care and government payers. Some programs seemed to be doing well financially while others were struggling. Approximately one-third of the respondents indicated that funding was unstable. CONCLUSIONS: Many programs are innovatively knitting together patch-works of funding and support to serve children and families in need. Team leaders should increase their knowledge of fiscal issues in order to be effective advocates at the institutional level for continued team support. A potential way of accomplishing this would be to utilize the existing structure of a national professional association and its national meeting to provide a forum for relatively successful programs to showcase their "ideal models" of team financing.

Epidemiology of sexual abuse of children: old problems, new directions.

Over the last 2 decades, the science of epidemiology has made important contributions to the understanding of sexual abuse of children. Well-designed epidemiological studies conducted during the next two decades should help refine our knowledge of the frequency of the problem, as well as further our understanding of risk factors and consequences.

Types of abuse and cocaine use in pregnant women.

Previous research has found an association between childhood and adult physical and sexual abuse and substance abuse, but has not examined or compared specific dimensions of the abuse experience, such as its age of onset or the type, severity, or frequency. Women receiving perinatal care (N = 1189) at an inner-city hospital clinic were systematically questioned about their lifetime and current cocaine use and experiences of abuse. We found an association between a history of abuse in childhood and lifetime and current cocaine use, as well as physical and sexual abuse during childhood and pregnancy. There was no difference in the rates of cocaine use between women whose onset of abuse was in childhood versus adulthood. Childhood sexual abuse (alone or in combination with physical abuse) was more associated with lifetime cocaine use than was physical abuse alone. Cocaine use was related to the severity, but not the frequency of abuse.

Identification of psychosocial problems in pediatric primary care: do family attitudes make a difference?

OBJECTIVE: To evaluate the affect of families' attitudes about the appropriateness of discussing psychosocial concerns on pediatric providers' identification of psychosocial problems. DESIGN: These data were collected as part of the Greater New Haven Child Health Study, New Haven, Conn. The study design was a prospective cohort. SETTING: Families were recruited from a stratified random sample of all primary care practices in the greater New Haven area. Nineteen of 23 invited practices agreed to participate including 2 prepaid practices, 2 neighborhood health centers, and 7 fee-for-service group and 8 fee-for-service solo practices. PARTICIPANTS: All families of children aged 4 to 8 years who attended these practices during 2 separate 3-week periods (1 in fall 1987 and 1 in spring 1988) were invited to participate in the study. Families were invited to participate only once, on the first contact with any eligible child, using approved procedures. Of 2006 eligible families, 1886 (94%) chose to participate. MAIN OUTCOME MEASURE: The outcome variable for these analyses is the identification of any behavioral, emotional, or developmental problem by the pediatrician on the 13-category checklist. Overall, pediatric clinicians identified 27.5% of children with 1 or more psychosocial problems. RESULTS: Our data suggest that there is a great deal of discrepancy between what parents report is appropriate to do when their children have psychosocial problems and what they actually do when they recognize such problems in their children. Most (81.1%) believed it was appropriate to discuss 4 or more of the 6 hypothetical situations with their children's physician, while only 40.9% actually did discuss any of these problems with a physician when a problem occurred. Given the correlates of parents who intended to discuss such problems (higher education, older age, Euro-American ethnicity, higher income, married, availability of medical insurance) the possibility that parents are providing socially acceptable responses to such questions seems likely. Further, our data indicate that parents' actual reports of discussions of psychosocial problems is unrelated to whether physicians identified those problems in children. CONCLUSIONS: Pediatricians'judgments about the presence of psychosocial problems in their young patients seem to be based on their own observations rather than on what parents report. Physician-parent communication about psychosocial problems will be increasingly important as primary care physicians assume their role as gatekeepers to more expensive services such as mental health interventions.

Health care and hospitalizations of young children born to cocaine-using women.

OBJECTIVES: To examine the health care and hospitalizations of young children (birth to age 2 years) born to cocaine-using women and to assess the extent to which premature births account for differences between these children and comparison children. DESIGN: A retrospective cohort design using a repeat-matching method: comparison children were matched to subjects with exposure to cocaine on 6 sociodemographic variables, first, without attention to gestational age and then using the gestational age as additional matching variable. SETTING: City hospitals and primary care clinics. SUBJECTS: Children of women giving birth at a single hospital. MAIN OUTCOME MEASURES: Hospital admission and indexes of health care use for children from birth to age 2 years. RESULTS: Of the 139 subjects with exposure to cocaine, 23% were born prematurely compared with only 6% in the first comparison ( P < .001). At birth, children with exposure to cocaine remained in the hospital longer (P < .01), but this difference was explained by the increased prevalence of prematurity. By age 2 years, these children had significantly fewer visits for health care maintenance (P < .001), were less likely to have completed immunizations (P < .05), and spend more days in the hospital than comparison children. These differences were not related to prematurity, but were explained by differences in sociodemographic characteristics. CONCLUSION: Although prematurity is the major reason for lengthier hospital stays at birth of children with exposure to cocaine, adverse social factors contribute most to inadequate preventive health care and increased stays in the hospital in subsequent years.

Maltreatment of children born to women who used cocaine during pregnancy: a population-based study.

BACKGROUND: Previous studies of maltreatment of children born to women who used cocaine during pregnancy have relied on either selected samples of infants identified at birth or biased, high-risk samples referred to protective services. OBJECTIVE: To determine the relative risk of either maltreatment or placement outside the home during the first 2 years of life in children born to women who used cocaine during pregnancy compared with a sociodemographically similar comparison group. PATIENTS: We reviewed the medical records of consecutive deliveries at Yale-New Haven Hospital from August 1, 1989 through September 30, 1990. Of the 1140 women who were eligible for the study, 173 had a positive history and/or a positive urine test for cocaine; 139 of the infants were included in the study. A comparison group of infants was chosen from 526 women whose obstetric records indicated that they had not used cocaine during pregnancy based on at least two separate notations in the record. For each of the 139 cocaine-exposed infants, an infant was chosen from the comparison group based on seven matching characteristics: date of birth, race, method of payment for the hospitalization, gestational age, mother's parity, mother's age at delivery, and timing of the first prenatal visit. MAIN OUTCOME MEASURES: Children's medical records at the only two hospitals in the region, the two neighborhood health centers, and the only health maintenance organization were reviewed from birth to 2 years of age. Each injury was classified by two independent reviewers who used predefined criteria to distinguish maltreatment (physical abuse, neglect, or abandonment) from unintentional injuries. Placements outside the home were categorized according to whether the placement was in foster care or with a relative. MAIN RESULTS: The children were mainly African-Americans (80%), and most were enrolled in Medicaid (96.5%). By 2 years of age, 9.3% of the infants in the cocaine-exposed group versus 1.4% in the comparison group had been maltreated [matched relative risk = 6.5; 95% confidence interval (CI) = 1.47, 28.80], and 25.9% vs 8.6% had spent some time in placement (matched relative risk = 5.0; 95% CI = 2.08, 12.01). After controlling for differences between the groups in baseline clinical and social variables, the adjusted odds ratios for both maltreatment (3.98; 95% CI = .81, 22.80) and placement (1.66; 95% CI = .74, 17. 83) decreased and were no longer statistically significant. CONCLUSION: In this population-based study, children born to women who used cocaine during pregnancy were at a substantially increased risk of maltreatment or placement outside the home compared with a sociodemographically similar comparison group. Differences in baseline variables between the two groups, however, partially accounted for this increased risk. Therefore, a mother's use of cocaine is more likely a marker of increased risk rather than a single explanatory variable.