Public health, science, and policy debate: being right is not enough.

Public health is usually enacted through public policies, necessitating that the public engage in debates that, ideally, are grounded in solid scientific findings. Mistrust in science, however, has compromised the possibility of deriving sound policy from such debates, partially owing to justified concerns regarding undue interference and even outright manipulation by commercial interests. This situation has generated problematic impasses, one of which is the emergence of an anti-vaccination movement that is already affecting public health, with a resurgence in the United States of preventable diseases thought to have been eradicated. Drawing on British sociologist Harry Collins' work on expertise, we propose a theoretical framework in which the paralyzing, undue public distrust of science can be analyzed and, it is hoped, overcome.

Twenty-five years of child and family homelessness: where are we now?

Family homelessness emerged as a major social and public health problem in the United States during the 1980s. We reviewed the literature, including journal articles, news stories, and government reports, that described conditions associated with family homelessness, the scope of the problem, and the health and mental health of homeless children and families. Much of this literature was published during the 1980s and 1990s. This raises questions about its continued applicability for the public health community. We concluded that descriptions of the economic conditions and public policies associated with family homelessness are still relevant; however, the homeless family population has changed over time. Family homelessness has become more prevalent and pervasive among poor and low-income families. We provide public health recommendations for these homeless families.

Proposed changes to the American Psychiatric Association diagnostic criteria for autism spectrum disorder: implications for young children and their families.

The American Psychiatric Association has revised the diagnostic criteria for their DSM-5 manual. Important changes have been made to the diagnosis of the current (DSM-IV) category of Pervasive Developmental Disorders. This category includes Autistic Disorder (autism), Asperger's Disorder, and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). The DSM-5 deletes Asperger's Disorder and PDD-NOS as diagnostic entities. This change may have unintended consequences, including the possibility that the new diagnostic framework will adversely affect access to developmental interventions under Individuals with Disabilities Education Act (IDEA) programs, Early Intervention (for birth to 2 years olds) and preschool special education (for 3 and 4 years olds). Changing the current diagnosis of PDD-NOS to a "Social Communication Disorder" focused on language pragmatics in the DSM-5 may restrict eligibility for IDEA programs and limit the scope of services for affected children. Young children who meet current criteria for PDD-NOS require more intensive and multi-disciplinary services than would be available with a communication domain diagnosis and possible service authorization limited to speech-language therapy. Intensive behavioral interventions, inclusive group setting placements, and family support services are typically more available for children with an autism spectrum disorder than with diagnoses reflecting speech-language delay. The diagnostic distinction reflective of the higher language and social functioning between Asperger's Disorder and autism is also undermined by eliminating the former as a categorical diagnosis and subsuming it under autism. This change may adversely affect treatment planning and misinform parents about prognosis for children who meet current criteria for Asperger's Disorder.

Regional variations in early intervention utilization for children with developmental delay.

We tested whether state-level variations in early intervention program (EI) participation were consistent with rates of key risk factors for early developmental delay. Based on the results of prior studies, we focused on child poverty and low birth weight as risk factors, included state threshold for EI eligibility by category (classified as broad/moderate or narrow), and aggregated the states into regions. Bivariate analyses were done in SPSS 15.0. All data were for 2009. Results were tested against data for prior years to ascertain whether findings for 2009 were anomalous. Nationally, 2.67 % of the age-eligible population was served in EI (range among states, 1.24-6.51 %). Variation in EI participation was significant at the regional level. Early intervention participation was lowest in the south and highest in the northeast (p < 0.01). Regional variations in low birth weight (p < 0.01) and child poverty (p < 0.01) were also significant. Both were highest in the south. While EI participation varied significantly by state eligibility standards, this factor did not entirely explain variance in utilization. Results for 2009 were representative of multi-year trend data. National EI utilization rates consistently lagged behind need as identified in epidemiologic studies from multiple sources. The results strongly suggest that there is a significant population of infants and toddlers who need but do not receive EI services, especially in the south.

The health care home model: primary health care meeting public health goals.

In November 2010, the American Public Health Association endorsed the health care home model as an important way that primary care may contribute to meeting the public health goals of increasing access to care, reducing health disparities, and better integrating health care with public health systems. Here we summarize the elements of the health care home (also called the medical home) model, evidence for its clinical and public health efficacy, and its place within the context of health care reform legislation. The model also has limitations, especially with regard to its degree of involvement with the communities in which care is delivered. Several actions could be undertaken to further develop, implement, and sustain the health care home.

Persistence of mental health needs among children affected by Hurricane Katrina in New Orleans.

BACKGROUND: Hurricane Katrina made landfall in August 2005 and destroyed the infrastructure ofNew Orleans. Mass evacuation ensued. The immediate and long-lasting impact of these events on the mental health of children have been reported in survey research. This study was done to describe the nature of mental health need of children during the four years after Hurricane Katrina using clinical data from a comprehensive healthcare program. Medical and mental health services were delivered on mobile clinics that traveled to medically underserved communities on a regular schedule beginning immediately after the hurricane. Patients were self-selected residents of New Orleans. Most had incomes below the federal poverty level and were severely affected by the hurricane. METHODS: Paper charts of pediatric mental health patients were reviewed for visits beginning with the establishment of the mental health program from 01 July 2007 through 30 June 2009 (n = 296). Demographics, referral sources, presenting problems, diagnoses, and qualitative data describing Katrina-related traumatic exposures were abstracted. Psychosocial data were abstracted from medical charts. Data were coded and processed for demographic, referral, and diagnostic trends. RESULTS: Mental health service needs continued unabated throughout this period (two to nearly four years post-event). In 2008, 29% of pediatric primary care patients presented with mental health or developmental/learning problems, including the need for intensive case management. The typical presentation of pediatric mental health patients was a disruptive behavior disorder with an underlying mood or anxiety disorder. Qualitative descriptive data are presented to illustrate the traumatic post-disaster experience of many children. School referrals for mental health evaluation and services were overwhelmingly made for disruptive behavior disorders. Pediatric referrals were more nuanced, reflecting underlying mood and anxiety disorders. Histories indicated that many missed opportunities for earlier identification and intervention. CONCLUSIONS: Mental health and case management needs persisted four years after Hurricane Katrina and showed no signs of abating. Many children who received mental health services had shown signs of psychological distress prior to the hurricane, and no causal inferences are drawn between disaster experience and psychiatric disorders. Post-disaster mental health and case management services should remain available for years post-event. To ensure timely identification and intervention of child mental health needs, pediatricians and school officials may need additional training.

The effect of music reinforcement for non-nutritive sucking on nipple feeding of premature infants.

In this randomized, controlled multi-site study, the pacifier-activated-lullaby system (PAL) was used with 68 premature infants. Dependent variables were (a) total number of days prior to nipple feeding, (b) days of nipple feeding, (c) discharge weight, and (d) overall weight gain. Independent variables included contingent music reinforcement for non-nutritive sucking for PAL intervention at 32 vs. 34 vs. 36 weeks adjusted gestational age (AGA), with each age group subdivided into three trial conditions: control consisting of no PAL used vs. one 15-minute PAL trial vs. three 15-minute PAL trials. At 34 weeks, PAL trials significantly shortened gavage feeding length, and three trials were significantly better than one trial. At 32 weeks, PAL trials lengthened gavage feeding. Female infants learned to nipple feed significantly faster than male infants. It was noted that PAL babies went home sooner after beginning to nipple feed, a trend that was not statistically significant.

Building integrated mental health and medical programs for vulnerable populations post-disaster: connecting children and families to a medical home.

INTRODUCTION: Hurricane Katrina, a Category 3 hurricane, made landfall in August 2005. Approximately 1,500 deaths have been directly attributed to the hurricane, primarily in Louisiana and Mississippi. In New Orleans, Louisiana, most of the healthcare infrastructure was destroyed by flooding, and > 200,000 residents became homeless. Many of these internally displaced persons received transitional housing in trailer parks ("villages") under the auspices of the [US] Federal Emergency Management Agency (FEMA). PROBLEM: The FEMA villages are isolated from residential communities, lack access to healthcare services, and have become unsafe environments. The trailers that house families have been found to be contaminated with formaldehyde. METHODS: The Children's Health Fund, in partnership with the Mailman School of Public Health at Columbia University, began a program ("Operation Assist") to provide health and mental health services within a medical home model. This program includes the Baton Rouge Children's Health Project (BRCHP), which consists of two mobile medical units (one medical and one mental health). Licensed professionals at the FEMA villages and other isolated communities provide care on these mobile units. Medical and psychiatric diagnoses from the BRCHP are summarized and case vignettes presented. RESULTS: Immediately after the hurricane, prescription medications were difficult to obtain. Complaints of headache, nosebleeds, and stomachache were observed at an unusually frequent degree for young children, and were potentially attributable to formaldehyde exposure. Dermatological conditions included eczema, impetigo, methicillin-resistant staphylococcus aureus (MRSA) abscesses, and tinea corporis and capitis. These were especially difficult to treat because of unhygienic conditions in the trailers and ongoing formaldehyde exposure. Signs of pediatric under-nutrition included anemia, failure to thrive, and obesity. Utilization of initial mental health services was low due to pressing survival needs and concern about stigma. Once the mental health service became trusted in the community, frequent diagnoses for school-age children included disruptive behavior disorders and learning problems, with underlying depression, anxiety, and stress disorders. Mood and anxiety disorders and substance abuse were prevalent among the adolescents and adults, including parents. CONCLUSIONS: There is a critical and long-term need for medical and mental health services among affected populations following a disaster due to natural hazards. Most patients required both medical and mental health care, which underscores the value of co-locating these services.

Asthma among homeless children in New York City: an update.

Homeless children in New York City had an extremely high asthma prevalence-40%-in a cross-sectional study at 3 shelters (n=740) during 1998 to 1999. We used the same protocol to summarize subsequent data through December 2002. Asthma prevalence was 33% (n=1636); only 15% of the children previously diagnosed were taking an asthma controller medication. Emergency department use was 59%. These data were used to support a class action lawsuit that was resolved in favor of homeless children with asthma in New York City.

The health of homeless children revisited.

To the extent that representative data are available for specific health conditions (eg, under-immunization, asthma prevalence), the authors' data suggest that the gap between the health status of homeless children and housed children in minority, low-income families is narrowing. Studies of the health status of homeless children allow a window into the health status of medically underserved children whose needs may not be readily documented because of their lack of access to the health care system. Although prevalence rates of most of the health conditions discussed in this article exceeded national norms, they were generally consistent with rates characteristic of health disparities based on race-ethnicity and income. It must be emphasized that in most instances, children were seen for their first pediatric visit within weeks of entering the homeless shelter system. The health conditions identified were often present before the child and family became homeless. The high prevalence of asthma among homeless children should therefore be a matter of concern to health providers and payors, because the authors' data strongly suggest that this is not confined to children in homeless shelters as a special population. Similarly, childhood obesity predates homelessness (or at least the episode of homelessness during which health care was provided) and as such the authors' data may indicate the extent of this problem more generally among medically underserved children in the communities of origin. These conditions seem to be exacerbated by the specific conditions associated with homeless shelter life. Asthma care, assuming it was previously available, is disrupted when housing is lost, and shelter conditions may have multiple asthma triggers. Nutrition often suffers as a result of inadequate access to nutritious food and cooking facilities in shelters, as indicated by the high rate of iron-deficiency anemia among very young children. It is clear that homeless children in shelters require enhanced access to primary and specialist care. Shelter placement necessarily disrupts prior health care relationships (if any), while simultaneously placing additional stress on the child's physical and emotional well being. A medical home model is strongly recommended to allow for continuous, culturally competent care. Developmental and mental health problems are also more prevalent among homeless children. These conditions may jeopardize life successes. The overcrowding associated with homeless shelters and the housing conditions that frequently precede episodes of homelessness are associated with the higher prevalence of otitis media found among young children. This in turn is associated with developmental delay. Also contributing to the developmental risk associated with homelessness is exposure to DV, which is also frequently an antecedent of homelessness. Developmental surveillance for young, homeless children, monitoring of school attendance and academic performance, and assessment of mental status for homeless adolescents are recommended to facilitate early identification of problems and delivery of necessary interventions. For young children, providers of health care to the homeless should be well networked into the Early Intervention and Preschool Special Education programs in their locality. Given the multiplicity of needs for homeless families, which of course includes help finding affordable housing, health care providers serving this population should also develop linkages with community agencies, including those that can help parents develop the skills necessary for economic self-sufficiency and long-term ability to sustain independent housing.

Children and megadisasters: lessons learned in the new millennium.

Many specific lessons were learned from recent megadisasters in the United States at the expense of children who suffered from a government and a citizenry that was desperately unprepared to respond to and recover from the disaster's short- and long-term effects. During the 9/11 attacks, the nation learned a new sense of vulnerability as the specter of terrorism was delivered repeatedly to our collective consciousness. As this article has emphasized, children experienced significant and widespread psychological effects from this event, and many did not receive adequate treatment. Hurricane Katrina exploited the weaknesses of an already strained child mental health system and vividly demonstrated the liability of poor preparedness and inadequate communication by both families and governments. The impact of Katrina continues to affect many thousands of children over a year later, as the systems that were intended to care for them have largely moved on. Indeed, there was no mention of Hurricane Katrina, the Gulf Coast, or the storm's survivors in the 2007 State of the Union address by the President. After 9/11 and the unprecedented federal spending that occurred to increase our nation's readiness, it is discouraging that the response to Hurricane Katrina fell so short of what had the potential to be the greatest disaster response and recovery story in the history of our nation. It is unlikely that further uncontained expenditures will solve the problems that were exposed in the Gulf Coast. There is not a solution that money can buy. One need only look a few hundred miles south to the Cuban disaster response system to appreciate where some of our shortfalls lie. Cuba has succeeded where the United States has not in part because its citizens are participants in their own preparedness. They engage their children and their families in preparedness planning and they rely upon other members of their community to strengthen their ability to survive as individuals. The American mentality of "dial 911 in an emergency and wait for help" works only as long as there are enough resources to match the need. In a disaster, this approach has proven to be inadequate over and over again. In America, we are well positioned to be leaders in responding to the needs of children affected by disaster. The resources of our government and the resourcefulness of our people should offer much promise for the future. By analyzing our past shortfalls and taking practical steps to mitigate the existing barriers to preparedness, our children, we hope, will fare much better the next time a megadisaster strikes. Box 7 includes suggestions for national priorities for child disaster care.

Value of musical instruments used by the therapist to elicit responses from individuals in various stages of Alzheimer's disease.

The purpose of this study was to determine the value of designated musical instruments used by the therapist to elicit responses from persons with Alzheimer's disease (AD) during group sessions. In Experiment 1, 15 individuals in the early and middle stages of AD echoed rhythm patterns played by the therapist via the djembe, claves, paddle drum, and maraca. Results indicated significance for the rhythm patterns used, p < .05, and the types of instruments used, p < .05. A significant difference occurred for interaction of instruments by rhythms, p < .001. Rhythmic accuracy was highest when the therapist presented rhythms on the djembe, followed by the paddle drum, maraca, and claves. The most accurate rhythm pattern was 8 eighth-notes, the second most accurate was 4 quarter-notes, and the third was 2 eighths followed by a quarter note, repeated. Ten individuals in the middle to later stages of AD participated in Experiment 2. The treatment conditions consisted of 6 musical instruments used by the therapists to elicit responses during movement, singing, and rhythm activities. Average participation at any level (singing and moving/playing, singing only, and moving/playing only) in the 6 treatment conditions was highest during a cappella singing (63%), followed by djembe (61%), keyboard (60%), guitar and djembe (57%), and then guitar (54%) and autoharp (54%). Average participation at any level in the four activities, without any consideration of instruments, was as follows: 83% for the rhythm activity, 51% for the movement activity, and 49% for the first as well as second singing activity. Results indicated significant differences for the treatment conditions, p < .001, and for types of activities, p < .05. Significant difference, p < .01, occurred for interaction of treatment condition by activity.