Poverty and Health Inequities in Children Investigated by Child Protective Services.

The objective of our study was to examine the association between poverty and child health outcomes in school-age children referred to child protective services. We conducted a secondary analysis of children aged 5 to 9 years in the Second National Survey of Child and Adolescent Well-Being, a nationally representative longitudinal observational data set of children referred to protective services for maltreatment (2008-2012). We analyzed the association of poverty, defined as family income below the federal poverty level (FPL), with caregiver report of the child's overall health, primary care, and emergency department visits using Pearson's chi-squared test. Children below FPL compared with children above it had poorer overall health (29.8% vs 18.0%, P = .03). We also conducted a longitudinal multivariable logistic regression analysis and found poverty was associated with the child's poorer overall health at 36 months (odds ratios 2.78, 95% confidence interval 1.55-5.01). Future studies and interventions to improve health in this at-risk population should target poverty.

A Longitudinal Study of Risk Factors for Sexual Victimization in Puerto Rican Youth.

OBJECTIVE: To determine whether youth, family, and neighborhood factors and minoritized status are associated with youth-reported sexual victimization from childhood through young adulthood. METHODS: We analyzed longitudinal data from 2 population-based samples of Puerto Rican youth living in the South Bronx (as a minoritized group) and Puerto Rico (as a nonminoritized group). Waves 1 to 3 were collected annually beginning in 2000 (youth age 5-13). Wave 4 was collected 2013 to 2017 (youth age 15-29). We estimated multivariable associations between youth, family, and neighborhood factors and minoritized status at Wave 1 (independent variables); and youth-reported sexual victimization at Waves 1 to 4 (dependent variables). RESULTS: None of the factors was associated with youth-reported sexual victimization at Wave 1 (N = 1911). Among youth reporting no previous history of sexual victimization at Wave 1 (n = 1823), youth in the South Bronx vs Puerto Rico were more likely to report sexual victimization at Waves 2 or 3 (odds ratio (OR) [95% confidence interval (CI)] = 3.62 [1.46-8.97]). Older youth were less likely to report sexual victimization (OR [95% CI] = 0.77 [0.65-0.91]) (all P < .01). Among youth reporting no history of sexual victimization at Waves 1 to 3 (n = 1782), youth in the South Bronx (OR [95% CI] = 2.53 [1.52-4.22]), female youth (OR [95% CI] = 2.81 [1.83-4.30]), and youth whose parents had more than a high school degree (OR [95% CI] = 2.25 [1.38-3.67]) were more likely to report sexual victimization at Wave 4 than their counterparts (all P ≤ .001). CONCLUSIONS: Future research should investigate how living as a minoritized youth may contribute to an increased risk of sexual victimization.

Racial/Ethnic Disparities in Depression Treatment for Caregivers Investigated by the US Child Welfare System.

OBJECTIVE: To determine whether there are racial/ethnic differences in depression treatment for caregivers investigated by the US child welfare system. METHODS: This cross-sectional study used baseline data from the Second National Survey of Child and Adolescent Well-being, a nationally representative sample of children and caregivers investigated by US child welfare agencies (February 2008-April 2009). We included permanent caregivers who met criteria for major depression and had available covariate data (n = 908). In multivariable logistic regression models, we estimated the associations between caregiver race/ethnicity and past-year receipt of: any depression treatment, minimally adequate depression treatment, and depression treatment from 4 sectors (general medical, psychiatry, nonpsychiatry mental health, and human services). We controlled for clinical need and access variables according to the Institute of Medicine's definition of health care disparities. RESULTS: Black caregivers had the lowest rates of treatment receipt of any racial/ethnic group, with 42.2% receiving any depression treatment and 17.2% receiving minimally adequate depression treatment in the past year. In multivariable analyses controlling for clinical need and access variables, Black caregivers were less likely than White caregivers to receive any depression treatment (odds ratio [OR] = 0.49 [95% CI: 0.24-0.97]), minimally adequate depression treatment (OR = 0.37 [95% CI: 0.16-0.85]), and depression treatment from the general medical sector (OR = 0.40 [95% CI: 0.18-0.89]) in the past year (all P< .05). CONCLUSIONS: Future research should examine the underlying mechanisms of Black-White disparities in depression treatment for caregivers involved with the US child welfare system and develop targeted interventions to promote equitable mental health care for this highly vulnerable population.

The Impact of Child Sexual Abuse Discovery on Caregivers and Families: A Qualitative Study.

In this qualitative study with nonoffending caregivers of suspected child sexual abuse victims, we aimed to explore the perceived impact of sexual abuse discovery on caregivers and their families, and caregivers' attitudes about mental health services for themselves. We conducted semistructured, in-person interviews with 22 nonoffending caregivers of suspected sexual abuse victims <13 years old seen at a child advocacy center in Philadelphia. Interviews were audio-recorded, transcribed, coded, and analyzed using modified grounded theory. Recruitment continued until thematic saturation was reached. We found that caregivers experienced significant emotional and psychological distress, characterized by anger, depressed mood, and guilt, after learning that their child may have been sexually abused. We identified four specific sources of caregiver distress: concerns about their child, negative beliefs about their parenting abilities, family members' actions and behaviors, and memories of their own past maltreatment experiences. Some caregivers described worsening family relationships after discovery of their child's sexual abuse, while others reported increased family cohesion. Finally, we found that most caregivers in this study believed that mental health services for themselves were necessary or beneficial to help them cope with the impact of their child's sexual abuse. These results highlight the need for professionals working with families affected by sexual abuse to assess the emotional and psychological needs of nonoffending caregivers and offer mental health services. Helping caregivers link to mental health services, tailored to their unique needs after sexual abuse discovery, may be an acceptable strategy to improve caregiver and child outcomes after sexual abuse.

Perceptions of the Implementation of Pediatric Behavioral Health Integration in 3 Community Health Centers.

Pediatric behavioral health integration (BHI) represents a promising approach to address unmet child mental health need but little research exists to guide BHI implementation. Through in-depth interviews with 38 professionals involved in a comprehensive pediatric BHI initiative at 3 community health centers, we explored perceptions of the impact of BHI on clinical practice, and facilitators and barriers to BHI implementation. Professionals identified 2 overarching themes about the impact of BHI on clinical practice (greater interdisciplinary collaboration/communication and enhanced provider wellness); 5 themes about facilitators of BHI (staff buy-in for BHI, leadership support, staff belonging to the same team culturally and/or structurally, co-location with close physical proximity, and data-driven quality improvement); and 5 themes about barriers to BHI (inadequate clinician staffing, insufficient space, limited provider time, billing/reimbursement issues, and care coordination challenges). Future pediatric BHI efforts may consider these findings to develop strategies to promote facilitators and reduce barriers during implementation.

Association Between Health Literacy and Parental Self-Efficacy among Parents of Newborn Children.

OBJECTIVE: To determine whether health literacy was associated with parental self-efficacy in a diverse sample of parents of newborns. We hypothesized that parents with lower health literacy would have lower parental self-efficacy. STUDY DESIGN: We conducted a cross-sectional analysis of baseline surveys from 253 English and Spanish speaking parents >18 years old with newborns <28 days old enrolled in a trial testing a multisite primary care-based parenting intervention. Surveys assessed parental, child, and environmental characteristics, and used validated instruments to measure health literacy and parental self-efficacy (total and 4 subtypes). Bivariate analyses identified parental, child, and environmental characteristics associated with parental self-efficacy. Multivariable linear regression models examined the associations between health literacy and parental self-efficacy, adjusting for covariates. RESULTS: Parents (median age, 29 years) were 92.1% female, 54.5% black/African American, and 29.6% Hispanic/Latino. More than one-half (58.9%) had completed some college education or more, 49.0% spoke mostly English, and 16.2% had low health literacy. In bivariate analyses, parental self-efficacy was significantly lower in parents with fewer household residents. In multivariable analyses, parents with low compared with high health literacy had significantly lower parental self-efficacy scores (total and 4 subtypes including caretaking procedures, evoking behaviors, reading behaviors and signaling, and situational beliefs). CONCLUSIONS: Lower health literacy was associated with lower parental self-efficacy in parents of newborns. To maximize impact on positive parenting behaviors and child outcomes, interventions assisting parents with low parental self-efficacy should consider strategies to address low health literacy.

Multi-level prevention of human trafficking: The role of health care professionals.

As a major public health issue, human trafficking (HT) affects individuals, families, communities, and societies around the world. A public health approach to combating HT has been advocated. Such an approach seeks to prevent HT by engaging diverse stakeholder groups in addressing risk factors at multiple levels. As a key stakeholder group, health care professionals (HCPs) play a critical role in HT prevention. Herein, we use the Centers for Disease Control (CDC) Social-Ecological Model as a framework to present potential HT prevention strategies for health care professionals. As clinicians, HCPs may deliver tailored interventions to patients and families to address individual- and relationship-level risk factors for HT in the health care setting. As educators, advocates, and researchers, HCPs may collaborate across sectors to implement community- and society-level prevention strategies. Such strategies may include enhancing awareness of HT through education; advocating for local and national policies that promote community health and wellness; combating social or cultural norms that contribute to HT; and building a strong evidence-base to guide future HT prevention programs. Guided by the CDC Social-Ecological Model, we recommend that HCPs use their diverse skills to target risk factors for HT at multiple levels and thereby expand their impact in preventing this form of exploitation.

Factors associated with mental health services referrals for children investigated by child welfare.

Although child welfare caseworkers are responsible for facilitating mental health services access for maltreated children, little is known about caseworkers' decisions to refer children to services. We aimed to identify factors associated with caseworker referral of children to mental health services after a maltreatment investigation. We analyzed data from 1956 children 2-17 years old from the Second National Survey of Child and Adolescent Well-being. We examined associations of children's predisposing, enabling, and need-related factors and caseworkers' work environment characteristics with referral to mental health services. Caseworkers referred 21.0% of children to mental health services. In multivariable analyses controlling for potential covariates, factors associated with increased odds of caseworker referral included: older child age; child sexual abuse (versus neglect); child out-of-home placement; caregiver mental health problems; prior maltreatment reports; clinically significant child behavioral problems; and child welfare agency collaborative ties with mental health providers (all p < .05). Factors associated with decreased odds of caseworker referral included child Black race (versus White race) and lack of insurance (versus Private insurance) (all p < .05). In summary, children's need for mental health services was positively associated with caseworker referral to services but certain predisposing and enabling factors and caseworker work environment characteristics also correlated with services referral. Interventions to reduce disparities in services referral by race and insurance type are critically needed. These may include child welfare agency implementation of policies for mental health screening, assessment, and services referral based on clinical need and establishment of child welfare-mental health agency collaborative ties.

Identifying Local Hot Spots of Pediatric Chronic Diseases Using Emergency Department Surveillance.

OBJECTIVE: To use novel geographic methods and large-scale claims data to identify the local distribution of pediatric chronic diseases in New York City. METHODS: Using a 2009 all-payer emergency claims database, we identified the proportion of unique children aged 0 to 17 with diagnosis codes for specific medical and psychiatric conditions. As a proof of concept, we compared these prevalence estimates to traditional health surveys and registry data using the most geographically granular data available. In addition, we used home addresses to map local variation in pediatric disease burden. RESULTS: We identified 549,547 New York City children who visited an emergency department at least once in 2009. Though our sample included more publicly insured and uninsured children, we found moderate to strong correlations of prevalence estimates when compared to health surveys and registry data at prespecified geographic levels. Strongest correlations were found for asthma and mental health conditions by county among younger children (0.88, P = .05 and 0.99, P < .01, respectively). Moderate correlations by neighborhood were identified for obesity and cancer (0.53 and 0.54, P < .01). Among adolescents, correlations by health districts were strong for obesity (0.95, P = .05), and depression estimates had a nonsignificant, but strong negative correlation with suicide attempts (-0.88, P = .12). Using SaTScan, we also identified local hot spots of pediatric chronic disease. CONCLUSIONS: For conditions easily identified in claims data, emergency department surveillance may help estimate pediatric chronic disease prevalence with higher geographic resolution. More studies are needed to investigate limitations of these methods and assess reliability of local disease estimates.

Caregiver perceptions about mental health services after child sexual abuse.

The objective of this study was to describe caregiver perceptions about mental health services (MHS) after child sexual abuse (CSA) and to explore factors that affected whether their children linked to services. We conducted semi-structured, in-person interviews with 22 non-offending caregivers of suspected CSA victims<13 years old seen at a child advocacy center in Philadelphia. Purposive sampling was used to recruit caregivers who had (n=12) and had not (n=10) linked their children to MHS. Guided by the Health Belief Model framework, interviews assessed perceptions about: CSA severity, the child's susceptibility for adverse outcomes, the benefits of MHS, and the facilitators and barriers to MHS. Interviews were audio-recorded, transcribed, coded, and analyzed using modified grounded theory. Recruitment ended when thematic saturation was reached. Caregivers expressed strong reactions to CSA and multiple concerns about adverse child outcomes. Most caregivers reported that MHS were generally necessary for children after CSA. Caregivers who had not linked to MHS, however, believed MHS were not necessary for their children, most commonly because they were not exhibiting behavioral symptoms. Caregivers described multiple access barriers to MHS, but caregivers who had not linked reported that they could have overcome these barriers if they believed MHS were necessary for their children. Caregivers who had not linked to services also expressed concerns about MHS being re-traumatizing and stigmatizing. Interventions to increase MHS linkage should focus on improving communication with caregivers about the specific benefits of MHS for their children and proactively addressing caregiver concerns about MHS.

An unexpected clinical course in a 29-day-old infant with ethanol exposure.

Ethanol exposure can affect all pediatric age groups but occurs most commonly in ambulatory children and adolescents. Infants are less likely to ingest ethanol because they have limited ability to explore their environments. However, ethanol exposures in infants can occur. We report the case of a 29-day-old (3.5 kg) baby girl who presented with a blood alcohol level of 301 mg/dL after ingesting formula that had been prepared with gin. To our knowledge, she is the youngest reported child with such an elevated ethanol level in the medical literature. Despite her markedly elevated blood alcohol level, she had an unexpectedly mild clinical course, exhibiting subtle neurologic symptoms but no hypothermia, hypoglycemia, or cardiorespiratory impairment. This case demonstrates that the ethanol-exposed infant may lack typical or clear symptoms of acute intoxication. Therefore, the clinician must have a low threshold for pursuing blood alcohol testing in infants and young children with altered mental status. A prompt diagnosis of ethanol exposure is important for ensuring the health and safety of the child.

Prevalence and predictors of abnormal liver enzymes in young women with anorexia nervosa.

OBJECTIVE: To determine the prevalence and predictors of abnormal liver enzyme levels in ambulatory young women with anorexia nervosa (AN). STUDY DESIGN: In this cross-sectional study of 53 females with AN, serum concentrations of liver enzymes and hormones were measured. Anthropometric, dietary, and body composition information was collected. Correlational analyses were performed between liver enzyme concentrations and these variables. RESULTS: Elevated alanine aminotransferase (ALT) and gamma-glutamyl transpeptidase (GGT) levels were found in 14 subjects (26%) and 5 subjects (9%), respectively. ALT and GGT were inversely correlated with body mass index (r = -0.27 to -0.30, P < .049) and percentage body fat (r = -0.36 to -0.47, P < .007) but showed no relationship with lean body mass. Subjects with percentage body fat < 18% had higher ALT levels than those above this threshold (median 26.5 vs 18.0 U/L, P = .01). Liver enzyme concentrations did not correlate with dietary variables, except for GGT and percentage of calories from protein (r = 0.28, P = .04). CONCLUSIONS: Serum ALT and GGT concentrations are inversely related to adiposity in young women with AN. Future studies are needed to determine whether these liver enzyme elevations signify unrecognized, clinically relevant liver disease.

Brain-derived neurotrophic factor is essential for opiate-induced plasticity of noradrenergic neurons.

Chronic opiate exposure induces numerous neurochemical adaptations in the noradrenergic system, including upregulation of the cAMP-signaling pathway and increased expression of tyrosine hydroxylase (TH), the rate-limiting enzyme in catecholamine biosynthesis. These adaptations are thought to compensate for opiate-mediated neuronal inhibition but also contribute to physical dependence, including withdrawal after abrupt cessation of drug exposure. Little is known about molecules that regulate the noradrenergic response to opiates. Here we report that noradrenergic locus ceruleus (LC) neurons of mice with a conditional deletion of BDNF in postnatal brain respond to chronic morphine treatment with a paradoxical downregulation of cAMP-mediated excitation and lack of dynamic regulation of TH expression. This was accompanied by a threefold reduction in opiate withdrawal symptoms despite normal antinociceptive tolerance in the BDNF-deficient mice. Although expression of TrkB, the receptor for BDNF, was high in the LC, endogenous BDNF expression was absent there and in the large majority of other noradrenergic neurons. Therefore, a BDNF-signaling pathway originating from non-noradrenergic sources is essential for opiate-induced molecular adaptations of the noradrenergic system.