Affordable housing through the low-income housing tax credit program and intimate partner violence-related homicide.

The most severe outcome of intimate partner violence (IPV) is IPV-related homicide. Access to affordable housing may both facilitate exit from abusive relationships and reduce financial stress in intimate relationships, potentially preventing IPV-related homicide. We examined the association of the availability of rental housing through the Low-Income Housing Tax Credit (LIHTC) program, a federal program providing tax incentives to support the development of affordable housing, with IPV-related homicide and assessed whether this association differed by eviction rates at the state-level. We used 2005-2016 National Violent Death Reporting System, LIHTC Property, and Eviction Lab data for 13 states and compared the rate of IPV-related homicide in state-years with ≥30 to state-years with <30 LIHTC units per 100,000 population, overall and stratified by eviction rates. We conducted analyses in fall 2020. Adjusting for potential state-level confounders, the rate of IPV-related homicide in state-years with ≥30 LIHTC units per 100,000 population was lower than in state-years with <30 LIHTC units per 100,000 population (RR = 0.89, 95% CI 0.81, 0.98). The reduction in the rate of IPV-related homicide was slightly larger in state-years with higher eviction rates (≥3500 evictions per 100,000 renter population; RR = 0.83, 95% CI 0.74, 0.93) compared to state-years with lower eviction rates (<3500 evictions per 100,000 renter population; RR = 0.91, 95% CI 0.81, 1.03). Overall, at the state-level, increased availability of affordable housing through the LIHTC program was associated with lower rates of IPV-related homicide. Increasing the availability of affordable housing may be one tool for preventing IPV-related homicide.

Invited Commentary: Gaze Aversion and Unnoticed Phenomena.

Child abuse is a social phenomenon that has been underresearched and undersupported. The scale of the problem is large, with over 3 million US children reported for abuse or neglect each year. An estimated 15% of confirmed victims may be placed in out-of-home care to ensure their safety. Studies have not previously examined the impact of losing a child into foster care on maternal health and mortality. Family and maternal risk factors, such as teen pregnancy, intimate partner violence, or drug and alcohol abuse, have been well documented as risk factors for maltreatment. The findings of Wall-Wieler et al. (Am J Epidemiol. 2018;187(6):1182-1188) are not so much unexpected as they are surprising in that the impact of foster care on maternal health has heretofore been largely unexamined. The innovative use of maternal sisters with children not in foster care as controls provides a powerful control for family genetics, and family environment with likely common early life experiences, in the mortality of the mothers whose children were removed. With over 3 million children reported for suspected maltreatment each year, the related health and social outcomes for both children and their families require more careful examination using public health methods.

Development and Prospective Validation of Tools to Accurately Identify Neurosurgical and Critical Care Events in Children With Traumatic Brain Injury.

OBJECTIVE: To develop and validate case definitions (computable phenotypes) to accurately identify neurosurgical and critical care events in children with traumatic brain injury. DESIGN: Prospective observational cohort study, May 2013 to September 2015. SETTING: Two large U.S. children's hospitals with level 1 Pediatric Trauma Centers. PATIENTS: One hundred seventy-four children less than 18 years old admitted to an ICU after traumatic brain injury. MEASUREMENTS AND MAIN RESULTS: Prospective data were linked to database codes for each patient. The outcomes were prospectively identified acute traumatic brain injury, intracranial pressure monitor placement, craniotomy or craniectomy, vascular catheter placement, invasive mechanical ventilation, and new gastrostomy tube or tracheostomy placement. Candidate predictors were database codes present in administrative, billing, or trauma registry data. For each clinical event, we developed and validated penalized regression and Boolean classifiers (models to identify clinical events that take database codes as predictors). We externally validated the best model for each clinical event. The primary model performance measure was accuracy, the percent of test patients correctly classified. The cohort included 174 children who required ICU admission after traumatic brain injury. Simple Boolean classifiers were greater than or equal to 94% accurate for seven of nine clinical diagnoses and events. For central venous catheter placement, no classifier achieved 90% accuracy. Classifier accuracy was dependent on available data fields. Five of nine classifiers were acceptably accurate using only administrative data but three required trauma registry fields and two required billing data. CONCLUSIONS: In children with traumatic brain injury, computable phenotypes based on simple Boolean classifiers were highly accurate for most neurosurgical and critical care diagnoses and events. The computable phenotypes we developed and validated can be used in any observational study of children with traumatic brain injury and can reasonably be applied in studies of these interventions in other patient populations.

Functional Status Scale in Children With Traumatic Brain Injury: A Prospective Cohort Study.

OBJECTIVES: In children with traumatic brain injury, 1) to describe the hospital discharge functional outcome and change from baseline function using the Functional Status Scale and 2) to determine any associations between discharge Functional Status Scale and age, injury mechanism, neurologic examination, imaging, and other predictors of outcome. DESIGN: Prospective observational cohort study, May 2013 to November 2015. SETTING: Two U.S. children's hospitals designated as American College of Surgeons level 1 pediatric trauma centers. PATIENTS: Children less than 18 years old admitted to an ICU with acute traumatic brain injury and either a surgical or critical care intervention within the first 24 hours or in-hospital mortality. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital discharge Functional Status Scale. Most, 133 of 196 (68%), had severe traumatic brain injury (admission Glasgow Coma Scale, 3-8). Overall hospital mortality was 14%; 20% among those with severe traumatic brain injury. Hospital discharge Functional Status Scale had an inverse relationship with Glasgow Coma Scale: for each increase in admission Glasgow Coma Scale by 1, the discharge Functional Status Scale decreased by 0.5 (95% CI, 0.7-0.3). Baseline Functional Status Scale was collected at one site (n = 75). At that site, nearly all (61/62) of the survivors had normal or near-normal (≤ 7) preinjury Functional Status Scale. More than one-third, 23 of 62 (37%), of survivors had new morbidity at hospital discharge (increase in Functional Status Scale, ≥ 3). Among children with severe traumatic brain injury who had baseline Functional Status Scale collected, 21 of 41 survivors (51%) had new morbidity at hospital discharge. The mean change in Functional Status Scale from baseline to hospital discharge was 3.9 ± 4.9 overall and 5.2 ± 5.4 in children with severe traumatic brain injury. CONCLUSIONS: More than one-third of survivors, and approximately half of survivors with severe traumatic brain injury, will have new morbidity. Hospital discharge Functional Status Scale, change from baseline Functional Status Scale, and new morbidity acquisition can be used as outcome measures for hospital-based care process improvement initiatives and interventional studies of children with traumatic brain injury.

Variation in Acceptable Child Discipline Practices by Child Age: Perceptions of Community Norms by Medical and Legal Professionals.

Mandated child abuse reporters may judge specific disciplinary practices as unacceptable for young children, whereas child law professionals arbitrating allegations may be less inclusive. Do the views of these groups diverge, by child age, regarding discipline? Judgments of community norms across a wide range of children's ages were obtained from 380 medical and legal professionals. Because the Parent-Child Conflict Tactics Scale (PC-CTS) can be used to assess the epidemiology of child disciplinary behaviors and as a proxy to examine the incidence or prevalence of child abuse, the disciplinary practices described on the PC-CTS were presented as triggers for questions. Significant child age effects were found for disciplinary practices classified as "harsh." The consistencies between legal and medical professionals were striking. Both groups reflected changes in United States norms, as non-physical approaches were the most approved. We conclude that instruments estimating the prevalence of child maltreatment by parent-report should consider modifying how specific disciplinary practices are classified. Copyright © 2016 John Wiley & Sons, Ltd.

Affordable housing through the Low-Income Housing Tax Credit program and opioid overdose emergency department visits.

INTRODUCTION: The United States continues to experience an opioid overdose crisis. As a key social determinant of health, housing insecurity may contribute to initiation of substance use and can threaten outcomes for those with substance use disorders by increasing stress, risky substance use, discontinuity of treatment, and return to use, all of which may increase the risk of overdose. The Low-Income Housing Tax Credit (LIHTC) program supports access to rental housing for low-income populations. By facilitating access to affordable housing, this program may improve housing security, thereby reducing overdose risk. METHODS: We used data from LIHTC Property Data and the State Emergency Department Database (SEDD) to identify the number of LIHTC units available and opioid overdoses discharged from the emergency department (ED) in 13 states between 2005 and 2014. RESULTS: Between 2005 and 2014, mean opioid overdose ED visits were higher in states with fewer LIHTC units (<28 LIHTC units per 100,000 population) at 26.5 per 100,000 population as compared to states with higher LIHTC units (≥28 LIHTC units per 100,000 population) at 21.1 per 100,000. We find that greater availability of LIHTC units was associated with decreased rates of opioid overdose ED visits (RR 0.94; CI 0.90, 1.00). CONCLUSIONS: Given the importance of housing as a key social determinant of health, the provision of affordable housing may mitigate substance misuse and prevent nonfatal opioid overdose.

Correlates of parent-youth discordance about youth-witnessed violence: a brief report.

Studies have consistently demonstrated a lack of agreement between youth and parent reports regarding youth-witnessed violence (YWV). However, little empirical investigation has been conducted on the correlates of disagreement. Concordance between youth and parents about YWV was examined in 766 parent-youth dyads from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). Results showed that significantly more youth (42%) than parents (15%) reported YWV. Among the dyads in which at least one informant reported YWV (N = 344), we assessed whether youth delinquency, parental monitoring, parent-child relationship quality, history of child maltreatment, income, and parental depression were predictive of parent-youth concordance. Findings indicated that youth engagement in delinquent activities was higher in the groups in which the youth reported violence exposure. More empirical study is needed to assess correlates of agreement in high-risk youth to better inform associations found between exposures and outcomes as well as practice and policy for violence exposed youth.

Lack of Maternal Social Capital Increases the Likelihood of Harsh Parenting.

Does low maternal social capital increase the likelihood of parents using harsh parenting behaviors? We analyzed random digit dial telephone survey data from 661 female primary caregivers across Colorado. Positive reports of the use of either physically or psychologically harsh parenting methods were classified as harsh parenting. Absence of social capital was assessed within the family and the community; lack of social capital within the family was measured in terms of an absence of support from a partner and an additional caregiver. Absence of social capital within the community was measured as lack of interpersonal resources from neighbors and religious activities. Nearly 30% admitted to one or more physically harsh parenting behaviors in the prior year, and 85.8% reported at least one psychologically harsh parenting behavior. Lower levels of neighborhood connectedness were associated with physically harsh parenting (odds ratio = 1.50). Conflict between partners (odd ratio = 2.50) and the absence of an additional caregiver (odds ratio = 1.88) increased psychologically harsh parenting. One practical implication is that mental health and medical providers should help new parents value, access, or develop social networks within the community to prevent children from experiencing harsh parenting.

The Association of Low-Income Housing Tax Credit Units and Reports of Child Abuse and Neglect.

INTRODUCTION: Poverty broadly and financial stress owing to housing insecurity specifically are associated with an increased risk of child maltreatment. Therefore, it is possible that a program designed to increase access to affordable housing such as the Low-Income Housing Tax Credit program could reduce child maltreatment. The purpose of this study is to examine the association of the availability of housing units through the Low-Income Housing Tax Credit Program with the rates of child maltreatment reports, including reports for physical abuse and neglect, at the state and county levels. METHODS: Data were from the 2005‒2015 National Child Abuse and Neglect Data System and the Low-Income Housing Tax Credit Program database. Generalized estimating equations were conducted in 2021 to calculate rate ratios and 95% CIs, adjusting for relevant confounders. RESULTS: At the state level, ≥25 compared with <25 Low-Income Housing Tax Credit Program units per 100,000 population was associated with a lower rate of overall child maltreatment (i.e., neglect and physical abuse; rate ratio=0.96, 95% CI=0.93, 0.99), neglect (rate ratio=0.96, 95% CI=0.94, 0.99), and physical abuse (rate ratio=0.96, 95% CI=0.93, 1.00) reports. Similarly, at the county level, ≥1 compared with 0 Low-Income Housing Tax Credit Program units per 100,000 population was associated with a lower rate of overall child maltreatment (rate ratio=0.94, 95% CI=0.92, 0.97), neglect (rate ratio=0.96, 95% CI=0.93, 0.98), and physical abuse (rate ratio=0.94, 95% CI=0.91, 0.98) reports. CONCLUSIONS: Increasing access to affordable housing may be an effective strategy to reduce child maltreatment at both the state and county levels.

Predictors of Receipt of Clinical Preventive Services in Adolescents and Adults with Down Syndrome Accessing Medicaid.

BACKGROUND: Persons with Down syndrome (DS) require preventive care that addresses their age-/gender- and syndrome-specific needs. Yet, adolescents and adults with DS do not receive these preventive care services as recommended. OBJECTIVE/HYPOTHESIS: To identify factors that predict receipt of age-/gender- and syndrome-specific preventive healthcare among adolescents and adults with DS. We hypothesized that more healthcare encounters and greater medical complexity would increase receipt of preventive care due to more opportunities to complete these activities. METHODS: Using Medicaid claims (2006-2010) for California, Colorado, Michigan, and Pennsylvania, we conducted a retrospective cohort study of adolescents and adults with DS (≥12 years old). We modeled receipt of both ≥1 wellness examination and ≥1 thyroid function test (TFT) in 2009-2010 as a function of receipt of those same healthcare activities in 2006-08, adjusting for demographics, key comorbidities, and medical complexity using multivariable logistic regression. RESULTS: In this cohort of 3487 adolescents and adults with DS accessing Medicaid, 17% received both ≥1 wellness examination and ≥1 TFT in 2006-2008, 15% in 2009-2010, and only 7% during both time periods. Despite medical complexity and frequent healthcare interactions, the best predictor of future receipt of these activities was past receipt. State of residence variably impacted receipt of these preventive activities. CONCLUSIONS: Although past receipt of wellness examination and TFT was the best predictor of future receipt of these activities, overall rates were quite low in this cohort of adolescents and adults with DS. Further work is needed to improve preventive healthcare delivery to this vulnerable population.

Low Rates of Preventive Healthcare Service Utilization Among Adolescents and Adults With Down Syndrome.

INTRODUCTION: People with Down syndrome have health risks that require specific lifelong preventive health care. With increasing life expectancy, people with Down syndrome also face health conditions typical of their unaffected peers and thus need coordinated health care. The purpose of this study is to describe rates of age/sex- and Down syndrome-specific preventive healthcare activities among adolescents and adults with Down syndrome. METHODS: Using Medicaid claims (2006-2010) in California, Colorado, Michigan, and Pennsylvania, the cohort was defined as people with Down syndrome aged ≥12 years seen by primary care providers and enrolled in Medicaid for ≥45 of 60 months without dual Medicare enrollment (n=3,501). Age focus-consistent primary care providers were defined as having a focus concordant with a patient's age: 12-17 years, child or mixed-focus; ≥26 years, adult or mixed-focus; 18-25 years, any focus. Differences in healthcare activities were evaluated using Pearson's chi-square, Fisher's exact, and Kruskal-Wallis tests. Analyses were performed in 2015-2017. RESULTS: Of the cohort, 79% had an age focus-consistent primary care provider. However, 40% of adults aged ≥26 years received care from a child-focused primary care provider. Only 43% with an age focus-consistent provider had ≥1 well examination (age focus-inconsistent primary care provider: 35%, p<0.001). Most preventive activities had poor rates (<50%) regardless of age focus consistency between provider and patient age or whether they were age/sex- or Down syndrome-specific (well examinations; vaccinations; sleep apnea; hearing; and breast, cervical, and colon cancer screenings). Lipids, vision, and thyroid screenings reached moderate levels (50% to <80%). CONCLUSIONS: Rates of age/sex- and Down syndrome-specific preventive recommendations were low among adolescents and adults with Down syndrome, regardless of the age focus consistency of their primary care provider. This represents a significant opportunity to improve primary care in this vulnerable population.

Unexplained gastrointestinal symptoms after abuse in a prospective study of children at risk for abuse and neglect.

PURPOSE: Unexplained gastrointestinal symptoms are more common in adults who recall abuse as a child; however, data available on children are limited. The aim of this study was to investigate the association of childhood maltreatment and early development of gastrointestinal symptoms and whether this relation was mediated by psychological distress. METHODS: Data were obtained from the Longitudinal Studies of Child Abuse and Neglect, a consortium of 5 prospective studies of child maltreatment. The 845 children who were observed from the age of 4 through 12 years were the subjects of this study. Every 2 years information on gastrointestinal symptoms was obtained from parents, and maltreatment allegations were obtained from Child Protective Services (CPS). At the age of 12 years children reported gastrointestinal symptoms, life-time maltreatment, and psychological distress. Data were analyzed by logistic regression. RESULTS: Lifetime CPS allegations of sexual abuse were associated with abdominal pain at age 12 years (odds ratio [OR] = 1.75; 95% confidence interval [CI] = 1.1-2.47). Sexual abuse preceded or coincided with abdominal pain in 91% of cases. Youth recall of ever having been psychologically, physically, or sexually abused was significantly associated with both abdominal pain and nausea/vomiting (range, OR = 1.5 [95% CI, 1.1-2.0] to 2.1 [95% CI, 1.5-2.9]). When adjusting for psychological distress, most effects became insignificant except for the relation between physical abuse and nausea/vomiting (OR = 1.5; 95% CI, 1.1-2.2). CONCLUSION: Youth who have been maltreated are at increased risk for unexplained gastrointestinal symptoms, and this relation is partially mediated by psychological distress. These findings are relevant to the clinical care for children who complain of unexplained gastrointestinal symptoms.

Delineating the maladaptive pathways of child maltreatment: a mediated moderation analysis of the roles of self-perception and social support.

The current study investigated concurrent and longitudinal mediated and mediated moderation pathways among maltreatment, self-perception (i.e., loneliness and self-esteem), social support, and internalizing and externalizing behavior problems. For both genders, early childhood maltreatment (i.e., ages 0-6) was related directly to internalizing and externalizing behavior problems at age 6, and later maltreatment (i.e., ages 6-8) was directly related to internalizing and externalizing behavior problems at age 8. Results of concurrent mediation and mediated moderation indicated that early maltreatment was significantly related to internalizing and externalizing behavior problems at age 6 indirectly both through age 6 loneliness and self-esteem for boys and through age 6 loneliness for girls. Significant moderation of the pathway from early maltreatment to self-esteem, and for boys, significant mediated moderation to emotional and behavioral problems were found, such that the mediated effect through self-esteem varied across levels of social support, though in an unexpected direction. No significant longitudinal mediation or mediated moderation was found, however, between the age 6 mediators and moderator and internalizing or externalizing problems at age 8. The roles of the hypothesized mediating and moderating mechanisms are discussed, with implications for designing intervention and prevention programs.

Trajectories of childhood sexual abuse and early adolescent HIV/AIDS risk behaviors: the role of other maltreatment, witnessed violence, and child gender.

Childhood sexual abuse (CSA) has been associated with HIV/AIDS risk behavior; however, much of this work is retrospective and focuses on women. The current study used semi-parametric mixture modeling with youth (n = 844; 48.8% boys) from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) to examine the link between trajectories of CSA (2 to 12 years old) and HIV/AIDS risk behavior at age 14 (i.e., sexual intercourse & alcohol use). Trajectory analyses revealed a link between a history of CSA and the development of risky behavior. In addition, trajectories for physical and emotional abuse, but not neglect or witnessed violence, contributed to risky behavior over and above the role of CSA. Child gender did not moderate the findings. Findings highlight the significance of CSA histories, as well as the broader context of maltreatment, for better understanding the development of risk behaviors in both girls and boys.

Feasibility and Accuracy of Fast MRI Versus CT for Traumatic Brain Injury in Young Children.

BACKGROUND: Computed tomography (CT) is commonly used for children when there is concern for traumatic brain injury (TBI) and is a significant source of ionizing radiation. Our objective was to determine the feasibility and accuracy of fast MRI (motion-tolerant MRI sequences performed without sedation) in young children. METHODS: In this prospective cohort study, we attempted fast MRI in children <6 years old who had head CT performed and were seen in the emergency department of a single, level 1 pediatric trauma center. Fast MRI sequences included 3T axial and sagittal T2 single-shot turbo spin echo, axial T1 turbo field echo, axial fluid-attenuated inversion recovery, axial gradient echo, and axial diffusion-weighted single-shot turbo spin echo planar imaging. Feasibility was assessed by completion rate and imaging time. Fast MRI accuracy was measured against CT findings of TBI, including skull fracture, intracranial hemorrhage, or parenchymal injury. RESULTS: Among 299 participants, fast MRI was available and attempted in 225 (75%) and completed in 223 (99%). Median imaging time was 59 seconds (interquartile range 52-78) for CT and 365 seconds (interquartile range 340-392) for fast MRI. TBI was identified by CT in 111 (50%) participants, including 81 skull fractures, 27 subdural hematomas, 24 subarachnoid hemorrhages, and 35 other injuries. Fast MRI identified TBI in 103 of these (sensitivity 92.8%; 95% confidence interval 86.3-96.8), missing 6 participants with isolated skull fractures and 2 with subarachnoid hemorrhage. CONCLUSIONS: Fast MRI is feasible and accurate relative to CT in clinically stable children with concern for TBI.

The challenges of assessing the incidence of inflicted traumatic brain injury: a world perspective.

OBJECTIVE: Commentary on the methods available for ascertaining the incidence of inflicted traumatic brain injury (inflicted TBI) and the difficulties involved in defining and measuring this condition in young children. DESIGN: Review of published and unpublished international data regarding parental shaking of infants compared to studies assessing incidence. RESULTS: Review of parental report data reveal that the shaking of young children is a surprisingly common act in a wide variety of countries and cultures. While 2.6% of parents of children aged under 2 years in the U.S. report shaking their child as an act of "discipline," survey data from lesser-developed countries on four continents indicate that shaking, as a form of discipline, may be many times more common among infants in their countries and that the consequences, short of hospitalization or death, are inadequately studied. Methodologic challenges to epidemiologic work to develop better estimates are discussed. CONCLUSIONS: These data highlight the challenges faced in ascertaining the epidemiology of inflicted TBI in young children. While there is scientific evidence that the shaking of young children can produce profound destruction of children's brains and lives, these data reveal that there are many other children who are shaken by their caregivers but escape the acute clinical presentation of "shaken baby syndrome" or for whom the injuries are not recognized as due to inflicted TBI. The impact of these private acts must be further studied as there may be other long-lasting and serious intracranial impacts that have not been characterized.

Defining an ideal system to establish the incidence of inflicted traumatic brain injury: summary of the consensus conference.

A conference addressing how to establish the incidence of inflicted traumatic brain injury in young children provided the opportunity to examine issues of definitions, passive versus active surveillance, study designs, proxy measures, and statistical issues. Data were presented that had been collected in alternative ways. The participants concluded that an ideal system for measurement of the incidence does not yet exist. A new surveillance system will take a significant amount of time and money to establish. Such a system will require a combination of ascertainment approaches, attention to case finding, a large population, careful attention to coding and data quality. The ethical issues involved in measuring stigmatized and illegal behavior are not inconsequential. In an ideal system data from different sources-medical, legal, and social service, among others-will need to be linked. Perhaps most importantly, any surveillance approach will need to be maintained so that trend data can be used to assess the effectiveness of prevention efforts.

Speak softly--and forget the stick. Corporal punishment and child physical abuse.

BACKGROUND: Previous studies have shown an association between spanking and child physical abuse. However, the relationship between more frequent and severe corporal punishment and abuse remains unknown. The objective of this study was to examine the associations between reported spanking, spanking frequency, or spanking with an object and the odds of physical abuse in a representative sample of mothers from North and South Carolina. METHODS: This study is a cross-sectional, anonymous telephone survey of adult mothers with children aged<18 years living in the Carolinas in 2002. The analysis was conducted in 2007. Survey responses were used to determine the association between corporal punishment (spanking, spanking frequency, and spanking with an object) and an index of harsh physical punishment consistent with physical abuse (beating, burning, kicking, hitting with an object somewhere other than the buttocks, or shaking a child aged<2 years). RESULTS: Mothers who report that the child was spanked are 2.7 (95% CI=1.2, 6.3) times more likely to report abuse. Increases in the frequency of reported spanking in the last year are also associated with increased odds of abuse (OR=1.03, 95% CI=1.01, 1.06). Mothers reporting spanking with an object are at markedly increased odds of reporting abuse (OR=8.9, 95% CI=4.1, 19.6). CONCLUSIONS: Although reported spanking increases the odds of reported physical abuse, the relationship between the reported hitting of a child with an object and reported abuse is much stronger. Reduction in this form of discipline through media, educational, and legislative efforts may reduce child physical abuse.