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Examine factors impacting U.S. parents' intention to vaccinate their children against COVID-19.Data were collected February-May 2021 from parents living in six geographically diverse locations. The COVID-19 Exposure and Family Impact Survey assessed perceived susceptibility and severity to adverse outcomes from the pandemic. Semi-structured interviews assessed perceptions about benefits and risks of vaccinating children.Fifty parents of 106 children (newborn-17 years) were included; half were Spanish-speaking and half English-speaking. 62% were hesitant about vaccinating their children against COVID-19. Efficacy and safety were the main themes that emerged: some parents perceived them as benefits while others perceived them as risks to vaccination. Parent hesitancy often relied on social media, and was influenced by narrative accounts of vaccination experiences. Many cited the lower risk of negative outcomes from COVID-19 among children, when compared with adults. Some also cited inaccurate and constantly changing information about COVID-19 vaccines.Main drivers of parent hesitancy regarding child COVID-19 vaccination include perceived safety and efficacy of the vaccines and lower severity of illness in children.Many vaccine-hesitant parents may be open to vaccination in the future and welcome additional discussion and data.

Background Prior single-site evaluations of Child Adult Relationship Enhancement in Primary Care (PriCARE), a 6-session group parent training, demonstrated reductions in child behavioral problems and improvements in positive parenting attitudes. Objective To measure the impact of PriCARE on disruptive child behaviors, parenting stress, and parenting attitudes in a multisite study. Methods Caregivers of children 2- to 6-year-old with behavior concerns recruited from 4 pediatric primary care practices were randomized 2:1 to PriCARE intervention (n = 119) or waitlist control (n = 55). Seventy-nine percent of caregivers identified as Black and 59% had annual household incomes under $22,000. Child behavior, parenting stress, and parenting attitudes were measured at baseline and 2 to 3 months after intervention using the Eyberg Child Behavior Inventory, Parenting Stress Index, and Adult-Adolescent Parenting Inventory-2. Marginal standardization implemented in a linear regression compared mean change scores from baseline to follow-up by treatment arm while accounting for clustering by site. Results Mean change scores from baseline to follow-up demonstrated greater improvements (decreases) in Eyberg Child Behavior Inventory problem scores but not intensity scores in the PriCARE arm compared to control, (problem: −4.4 [−7.5, −1.2] vs −1.8 [−4.1, 0.4], P= .004; intensity: −17.6 [−28.3, −6.9] vs −10.4 [−18.1, −2.6], P= .255). Decreases in parenting stress were greater in the PriCARE arm compared to control (−3.3 [−4.3, −2.3] vs 0 [−2.5, 2.5], P= .025). Parenting attitudes showed no significant changes (all P> .10). Conclusions PriCARE showed promise in improving parental perceptions of the severity of child behaviors and decreasing parenting stress but did not have an observed impact on parenting attitudes.

Although pediatricians routinely counsel parents about preventing childhood injuries, we know little about parents’ locus of control (LOC) in regards to preventing their children from being injured. We performed an observational analysis of sociodemographic differences in LOC for injury prevention, as measured by four items adapted from the Parental Health Beliefs Scales, in English- and Spanish-speaking parents of infants participating in the treatment arm of an obesity prevention study. First, we examined associations of parental LOC for injury prevention at the time their children were 2 months old with parents’ age, race/ethnicity, income, and education. Next, we analyzed time trends for repeated LOC measures when the children were 2, 6, 9, 12, and 24 months old. Last, we examined the association between injury-related LOC items and children’s injury (yes/no) at each time point. Of 452 parents, those with lower incomes had both lower internal and higher external LOC. Lower educational achievement was associated with higher external LOC. Both internal and external LOC scores decreased over time. Injuries were more common in children whose parents endorsed low internal and high external LOC. Future studies should examine whether primary care-based interventions can increase parents’ sense of control over their children’s safety and whether that, in turn, is associated with lower injury rates. Clinical Trial Registration: NCT01040897.

Infants who appear neurologically well and have fractures concerning for abuse are at increased risk for clinically occult head injuries. Evidence of excess variation in neuroimaging practices when abuse is suspected may indicate opportunity for quality and safety improvement.To quantify neuroimaging practice variation across children's hospitals among infants with fractures evaluated for abuse, with the hypothesis that hospitals would vary substantially in neuroimaging practices. As a secondary objective, factors associated with neuroimaging use were identified, with the hypothesis that age and factors associated with potential biases (ie, payer type and race or ethnicity) would be associated with neuroimaging use.This cross-sectional study included infants with a femur or humerus fracture or both undergoing abuse evaluation at 44 select US children's hospitals in the Pediatric Health Information System (PHIS) from January 1, 2016, through March 30, 2020, including emergency department, observational, and inpatient encounters. Included infants were aged younger than 12 months with a femur or humerus fracture or both without overt signs or symptoms of head injury for whom a skeletal survey was performed. To focus on infants at increased risk for clinically occult head injuries, infants with billing codes suggestive of overt neurologic signs or symptoms were excluded. Multivariable logistic regression was used to investigate demographic, clinical, and temporal factors associated with use of neuroimaging. Marginal standardization was used to report adjusted percentages of infants undergoing neuroimaging by hospital and payer type. Data were analyzed from March 2021 through January 2022.Covariates included age, sex, race and ethnicity, payer type, fracture type, presentation year, and hospital.Use of neuroimaging by CT or MRI.Of 2585 infants with humerus or femur fracture or both undergoing evaluations for possible child abuse, there were 1408 (54.5%) male infants, 1726 infants (66.8%) who were publicly insured, and 1549 infants (59.9%) who underwent neuroimaging. The median (IQR) age was 6.1 (3.2-8.3) months. There were 748 (28.9%) Black non-Hispanic infants, 426 (16.5%) Hispanic infants, 1148 (44.4%) White non-Hispanic infants. In multivariable analyses, younger age (eg, odds ratio [OR] for ages3 months vs ages 9 to12 months, 13.2; 95% CI, 9.54-18.2; P .001), male sex (OR, 1.47; 95% CI, 1.22-1.78; P .001), payer type (OR for public vs private insurance, 1.48; 95% CI, 1.18-1.85; P = .003), fracture type (OR for femur and humerus fracture vs isolated femur fracture, 5.36; 95% CI, 2.11-13.6; P = .002), and hospital (adjusted range in use of neuroimaging, 37.4% [95% CI 21.4%-53.5%] to 83.6% [95% CI 69.6%-97.5%]; P .001) were associated with increased use of neuroimaging, but race and ethnicity were not. Publicly insured infants were more likely to undergo neuroimaging (62.0%; 95% CI, 60.0%-64.1%) than privately insured infants (55.1%; 95% CI, 51.8%-58.4%) (P = .001).This study found that hospitals varied in neuroimaging practices among infants with concern for abuse. Apparent disparities in practice associated with insurance type suggest opportunities for quality, safety, and equity improvement.

ImportanceInformation about the trend in illicit substance ingestions among young children during the pandemic is limited.ObjectivesTo assess immediate and sustained changes in overall illicit substance ingestion rates among children younger than 6 years before and during the COVID-19 pandemic and to examine changes by substance type (amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids) while controlling for differing statewide medicinal and recreational cannabis legalization policies.Design, Setting, and ParticipantsRetrospective cross-sectional study using an interrupted time series at 46 tertiary care children’s hospitals within the Pediatric Health Information System (PHIS). Participants were children younger than 6 years who presented to a PHIS hospital for an illicit substance(s) ingestion between January 1, 2017, and December 31, 2021. Data were analyzed in February 2023.ExposureAbsence or presence of the COVID-19 pandemic.Main Outcome(s) and Measure(s)The primary outcome was the monthly rate of encounters for illicit substance ingestions among children younger than 6 years defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code(s) for poisoning by amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids. The secondary outcomes were the monthly rate of encounters for individual substances.ResultsAmong 7659 children presenting with ingestions, the mean (SD) age was 2.2 (1.3) years and 5825 (76.0%) were Medicaid insured/self-pay. There was a 25.6% (95% CI, 13.2%-39.4%) immediate increase in overall ingestions at the onset of the pandemic compared with the prepandemic period, which was attributed to cannabis, opioid, and ethanol ingestions. There was a 1.8% (95% CI, 1.1%-2.4%) sustained monthly relative increase compared with prepandemic trends in overall ingestions which was due to opioids. There was no association between medicinal or recreational cannabis legalization and the rate of cannabis ingestion encounters.Conclusions and RelevanceIn this study of illicit substance ingestions in young children before and during the COVID-19 pandemic, there was an immediate and sustained increase in illicit substance ingestions during the pandemic. Additional studies are needed to contextualize these findings in the setting of pandemic-related stress and to identify interventions to prevent ingestions in face of such stress, such as improved parental mental health and substance treatment services, accessible childcare, and increased substance storage education.

Background: This practical implementation report describes a primary care-based group parenting intervention—Child–Adult Relationship Enhancement in Primary Care (PriCARE)—and the approach taken to understand and strengthen the referral process for PriCARE within a pediatric primary care clinic through the deployment of synergistic implementation strategies to promote physician referrals. PriCARE has evidence of effectiveness for reducing child behavior problems, harsh and permissive parenting, and parent stress from three randomized controlled trials (RCTs). The integration of evidence-based parenting interventions into pediatric primary care is a promising means for widespread dissemination. Yet, even when integrated into this setting, the true reach will depend on parents knowing about and attending the intervention. A key factor in this process is the endorsement of and referral to the intervention by the child's pediatrician. Therefore, identifying strategies to improve physician referrals to parenting interventions embedded in primary care is worthy of investigation. Method: Through lessons learned from the RCTs and key informant interviews with stakeholders, we identified barriers and facilitators to physician referrals of eligible parent–child dyads to PriCARE. Based on this data, we selected and implemented five strategies to increase the PriCARE referral rate. We outline the selection process, the postulated synergistic interactions, and the results of these efforts. Conclusions: The following five discrete strategies were implemented: physician reminders, direct advertising to patients, incentives/public recognition, interpersonal patient narratives, and audit and feedback. These discrete strategies were synergistically combined to create a multifaceted approach to improve physician referrals. Following implementation, referrals increased from 13% to 55%. Continued development, application, and evaluation of implementation strategies to promote the uptake of evidence-based parenting interventions into general use in the primary care setting are discussed. Plain Language Summary There is strong evidence that parenting interventions are effective at improving child behavioral health outcomes when delivered in coordination with pediatric primary care. However, there is a lack of focus on the implementation, including the screening and referral process, of parenting interventions in the primary care setting. This is contributing to the delay in the scale-up of parenting interventions and to achieving public health impact. To address this gap, we identified barriers and facilitators to physician screening and referrals to a primary care-based parenting intervention, and selected and piloted five synergistic strategies to improve this critical process. This effort successfully increased physician referrals of eligible patients to the intervention from 13% to 55%. This demonstration project may help advance the implementation of evidence-based interventions by providing an example of how to develop and execute multilevel strategies to improve intervention referrals in a local context.

INTRODUCTION Child-Adult Relationship Enhancement in Primary Care (PriCARE) is a 6-session group training designed to teach positive parenting skills. Parent engagement in such programs is a common implementation barrier. Our objectives were to (1) examine the impact of a peer mentor on attendance and stigma and (2) replicate a previous study by measuring PriCARE's impact on child behavior and parenting practices. METHOD Parents of 2- to -6-year-old children without specific behavior problems were randomized to mentored PriCARE (n = 50), PriCARE (n = 50), or control (n = 50). Stigma was measured at 10 weeks. Child behavior and parenting practices were measured at baseline and 10 weeks using the Eyberg Child Behavior Inventory (ECBI) and Parenting Scale (PS). Analysis of variance models were used to examine differences across groups. RESULTS There was no significant difference in attendance between mentored PriCARE and PriCARE arms (mean 3.80 vs 3.36 sessions, p = 0.35). Parents randomized to the mentor reported lower stigma (3.75 vs 5.04, p = 0.02). Decreases in the mean ECBI scores between 0 and 10 weeks were greater in the PriCARE arms (n = 100) compared with the control arm (n = 50), reflecting larger improvements in behavior [intensity: -7 (-2 to -13) vs 4 (-3 to 12) to p = 0.014; problem: -3 (-1 to -4) vs 1 (-1 to 3) to p = 0.007]. Scores on all PS subscales reflected greater improvements in parenting behaviors in PriCARE arms compared with control (all p < 0.04). CONCLUSION Adapting PriCARE with a peer mentor may decrease stigma but does not improve program attendance. PriCARE shows promise in improving behavior in preschool-aged children and increasing positive parenting practices.

Objective Describe current practices in systematic screening for social determinants of health (SDH) in pediatric resident clinics enrolled in the Continuity Research Network (CORNET). Methods CORNET clinic directors were surveyed on demographics, barriers to screening, and screening practices for 15 SDH, including the screen source, timing of screening, process of administering the screen, and personnel involved in screening. Incidence rate ratios were tabulated to investigate relationships among screening practices and clinic staff composition. Results Clinic response rate was 41% (65/158). Clinics reported screening for between 0 and 15 SDH (median, 7). Maternal depression (86%), child educational problems (84%), and food insecurity (71%) were the items most commonly screened. Immigration status (17%), parental health literacy (19%), and parental incarceration (21%) were least commonly screened. Within 3 years, clinics plan to screen for 25% of SDH not currently being screened. Barriers to screening included lack of time (63%), resources (50%), and training (46%). Conclusions Screening for SDH in our study population of CORNET clinics is common but has not been universally implemented. Screening practices are variable and reflect the complex nature of screening, including the heterogeneity of the patient populations, the clinic staff composition, and the SDH encountered.

To examine the association between rachitic changes and vitamin D levels in children less than 2 years old with fractures. Children less than 2 years old who were admitted to a large children’s hospital for a fracture and underwent a skeletal survey were included. Two pediatric radiologists blinded to the children’s vitamin D levels independently reviewed the skeletal surveys for the following rachitic findings: demineralization, widened sutures, rachitic rosary, Looser zones, and metaphyseal changes. Kappa coefficients were calculated to assess inter-rater agreement. Logistic regression was used to test the association between vitamin D level and rachitic findings. There were 79 subjects (40 female and 39 male) with a median age of 4 months. Vitamin D levels ranged from 11.6 to 88.9 ng/ml and were low in 27. Questionable demineralization was noted in seven subjects; mild to moderate demineralization was observed in four subjects. Widened sutures were noted in seven subjects, many also with concurrent intracranial hemorrhage. Lower vitamin D levels were associated with increased odds of demineralization after adjusting for age, gender, and prematurity (P

A challenge of large-scale adoptions of Triple P is low uptake among accredited practitioners. The purpose of this study was to understand facilitators to program use among 249 practitioners in seven counties involved in a large-scale adoption of Triple P. In an adjusted ordinal logistic regression including length of accreditation and county, the frequency with which practitioners used Triple P was higher among those who perceived a more positive parent response to Triple P services and among those practitioners who perceived Triple P to fit better within their typical services. Agency support was not associated with frequency of use.

Group parenting programs based on cognitive-behavioral and social learning principles are effective in improving child behavior problems and positive parenting. However, most programs target non-Hispanic, White, English-speaking families and are largely inaccessible to a growing Hispanic and non-White population in the United States. We sought to examine the extent to which researchers have culturally adapted group parenting programs by conducting a systematic review of the literature. We identified 41 articles on 23 distinct culturally adapted programs. Most cultural adaptations focused on language translation and staffing, with less focus on modification of concepts and methods, and on optimizing the fit between the target cultural group and the program goals. Only one of the adapted programs engaged a framework to systematically record and publish the adaptation process. Fewer than half of the culturally adapted programs were rigorously evaluated. Additional investment in cultural adaptation and subsequent evaluation of parenting programs is critical to meet the needs of all US families.Los programas grupales de crianza basados en principios cognitivo-conductuales y de aprendizaje social son eficaces a la hora de mejorar los problemas de conducta de los niños y la crianza positiva. Sin embargo, la mayoría de los programas están orientados a familias no hispanas, blancas y angloparlantes, y son, en su gran mayoría, inaccesibles para una población hispana y no blanca cada vez mayor de los Estados Unidos. Nos propusimos analizar el grado en el cual los investigadores han adaptado culturalmente los programas grupales de crianza realizando un análisis sistemático de las publicaciones. Identificamos 41 artículos sobre 23 programas diferentes adaptados culturalmente. La mayoría de las adaptaciones culturales se centraron en la traducción a idiomas y la contratación de personal, haciendo menos hincapié en la modificación de conceptos y métodos, y en la optimización de la compatibilidad entre el grupo cultural meta y los objetivos del programa. Solo uno de los programas adaptados incorporó un marco para registrar sistemáticamente y publicar el proceso de adaptación. Menos de la mitad de los programas culturalmente adaptados se evaluaron rigurosamente. Es fundamental que se invierta más en adaptación cultural y en evaluaciones posteriores de los programas de crianza para satisfacer las necesidades de todas las familias de los Estados Unidos.基于认知行为和社会学习原则的群体教养计划在改善儿童行为问题和促进积极孩童养育方面是颇有成效的。然而，大多数项目的目标人群是非西班牙裔、白人、讲英语的家庭。在美国，有越来越多的西班牙裔和非白人人口，他们无法接触到这些项目。我们试图通过对文献的系统回顾来考察研究人员在文化上适应群体养育项目的程度。我们确定了关于23个不同的文化适应项目的41篇文章。大多数文化适应侧重于语言翻译和人员配备，较少关注观念和方法的提升修订，也顾及不到对目标文化群体与项目目标之间的契合度的优化。只有一个项目进行了文化调适修订，采用了一个系统记录和发布调适修改过程的框架。只有不到一半的文化适应项目得到了严格的评估。在文化适应方面加大关注力度和投资以及随后的对父母教养孩童项目的评估，这些对于满足所有美国家庭的需求至关重要。.

We examined the impact of the implementation of The Triple P-Positive Parenting Program in North Carolina (NC) on reducing child maltreatment, a serious public health problem in the US with lasting harmful effects on children. In 2012 and 2013, 34 of 100 counties in NC implemented Triple P. A panel data set with county-level child welfare data and emergency department (ED) discharge data from 2008 to 2015 for 100 counties in NC was constructed. A quasi-experimental design using difference-in-differences analysis estimated the association between the implementation of Triple P and the rate of (1) investigated child maltreatment reports; (2) entry into foster care; and (3) ED visits concerning for child maltreatment. Implementation of Triple P was associated with in a 4% decrease in the county rate of investigated reports of child maltreatment (RR = 0.96, 95% CI [0.93, 0.99]) and a 7% decrease in the county rate of children in foster care (RR = 0.93, 95% CI [0.88, 0.98]). Each of these findings was robust to one but not both sensitivity tests performed. There was no reduction in county-level rates of ED visits with ICD-9-CM codes concerning for child maltreatment. Implementation of Triple P in NC outside of the parameters of scientific study is associated with small reductions in the rates of child maltreatment reports and foster care placements. Additional research is needed to understand whether such small reductions justify the substantial investment communities are making in Triple P.

In recent years, discrimination toward Hispanic/Latino Americans has escalated, threatening the health of Hispanic/Latino families and children. Previous research in African American families demonstrates the importance of parent–child communication in interrupting the pathway between childhood discrimination and poor health outcomes, but parent–child communication regarding discrimination has not been well-studied in Hispanic/Latino families. This study uses the minority child development model to explore how Hispanic/Latino parents discuss anti-Latino and anti-immigrant discrimination, bias, and unfair treatment with their children. In-depth interviews were performed with Hispanic/Latino immigrant parents ( N = 14) of 25 children ages 5–17 years. Interviews were analyzed using phenomenological thematic analysis. Seven major strategies utilized by Hispanic/Latino parents emerged: (1) champion success; (2) comfort and encourage; (3) advocate, appeal, and defend; (4) understand, ignore, and accept; (5) learn from it; (6) teach tolerance; and (7) prepare for bias. The development of resources to enhance parent skills in this area is discussed.

Objective Child–Adult Relationship Enhancement in Primary Care (PriCARE) is a 6-session group parent training designed to teach positive parenting skills. Our objective was to measure PriCARE's impact on child behavior and parenting attitudes. Methods Parents of children 2 to 6 years old with behavior concerns were randomized to PriCARE (n = 80) or control (n = 40). Child behavior and parenting attitudes were measured at baseline (0 weeks), program completion (9 weeks), and 7 weeks after program completion (16 weeks) using the Eyberg Child Behavior Inventory (ECBI) and the Adult Adolescent Parenting Inventory 2 (AAPI2). Linear regression models compared mean ECBI and AAPI2 change scores from 0 to 16 weeks in the PriCARE and control groups, adjusted for baseline scores. Results Of those randomized to PriCARE, 43% attended 3 or more sessions. Decreases in mean ECBI intensity and problem scores between 0 and 16 weeks were greater in the PriCARE group, reflecting a larger improvement in behavior problems [intensity: −22 (−29, −16) vs −7 (−17, 2), P = .012; problem: −5 (−7, −4) vs −2 (−4, 0), P = .014]. Scores on 3 of the 5 AAPI2 subscales reflected greater improvements in parenting attitudes in the PriCARE group compared to control in the following areas: empathy toward children's needs [0.82 (0.51, 1.14) vs 0.25 (−0.19, 0.70), P = .04], corporal punishment [0.22 (0.00, 0.45) vs −0.30 (−0.61, 0.02), P = .009], and power and independence [0.37 (−0.02, 0.76) vs −0.64 (−1.19, −0.09), P = .003]. Conclusions PriCARE shows promise in improving parent-reported child-behavior problems in preschool-aged children and increasing positive parenting attitudes.

Dog bites are an important public health problem and often require significant medical and surgical care, especially among younger children. Although decades of research and clinical experience have revealed specific risk factors and potential avenues for the prevention of dog bite injuries

In 2014, Family Success Alliance (FSA) was formed as a place-based initiative to build a pipeline of programs to reduce the impact of poverty on outcomes for children living in Orange County, North Carolina. In this study, FSA parents’ perception of child health, parent and child adverse childhood experiences (ACEs), and resilience were obtained by parent interview. Receipt of recommended health services were abstracted from primary care medical records of FSA children. Correlation coefficients investigated relationships among health, ACEs, and resilience. Among 87 parent-child dyads, 65% were Spanish speaking. At least 1 of the 7 ACEs measured was reported in 37% of children and 70% of parents. Parent perceptions of child health were lower than national averages. Routine preventive services included the following: autism screening at 18 months (15%) and 24 months (31%); ≥4 fluoride varnish applications (10%); lead screening (66%); and receipt of immunizations (94%). Parent perception of child health was moderately correlated with resilience.

Children enter foster care with a myriad of exposures and experiences, which can threaten their physical and mental health and development. Expanding evidence and evolving guidelines have helped to shape the care of these children over the past two decades. These guidelines address initial health screening, comprehensive medical evaluations, and follow-up care. Information exchange, attention to exposures, and consideration of how the adversities, which lead to foster placement, can impact health is crucial. These children should be examined with a trauma lens, so that the child, caregiver, and community supports can be assisted to view their physical and behavioral health from the perspective of what we now understand about the impact of toxic stress. Health care providers can impact the health of foster children by screening for the negative health consequences of trauma, advocating for trauma-informed services, and providing trauma-informed anticipatory guidance to foster parents. By taking an organized and comprehensive approach, the health care provider can best attend to the needs of this vulnerable population.

Family violence is a common public health problem that will be encountered by physicians and other health-care providers. The roots of the most common adulthood diseases are in violence and adverse experiences that occur within the family context and during childhood. Sometimes the violence is between partners (intimate partner violence); other times it is between parents and their young children (child maltreatment) or older parents and their adult children (elder maltreatment). Understanding and addressing this transgenerational violence are critical to improving the health of our patients. Identifying suspected maltreatment and reporting concerns to protective services can be one of the most challenging and important responsibilities of the health-care provider.

Objective The purpose of this study was to understand pediatric emergency department (ED) and primary care (PC) health care provider attitudes and beliefs regarding the intersection between childhood adversities and health care. Methods We conducted in-depth, semistructured interviews in 2 settings (ED and PC) within an urban health care system. Purposive sampling was used to balance the sample among 3 health care provider roles. Interview questions were based on a modified health beliefs model exploring the "readiness to act" among providers. Interviews were recorded, transcribed, and coded. Interviews continued until theme saturation was reached. Results Saturation was achieved after 26 ED and 19 PC interviews. Emergency department/primary care providers were similar in their perception of patient susceptibility to childhood adversity. Childhood mental health problems were the most frequently referenced adverse outcome, followed by poor childhood physical health. Adult health outcomes because of childhood adversity were rarely mentioned. Many providers felt that knowing about childhood adversity in the medical setting was important because it relates to provision of tangible resources. There were mixed opinions about whether or not pediatric health care providers should be identifying childhood adversities at all. Conclusions Although providers exhibited knowledge about childhood adversity, the perceived effect on health was only immediate and tangible. The effect of childhood adversity on lifelong health and the responsibility and potential accountability health systems have in addressing these important health determinants was not recognized by many respondents in our study. Addressing these provider perspectives will be a critical component of successful transformation toward more accountable health care delivery systems.

Although symptom burden and symptom profile severity are independent predictors of post-concussion symptom duration, few studies have examined their effects on prolonged recovery simultaneously. This study examined differences in symptom burden and symptom profile scores between concussed children with prolonged recovery and those with typical recovery. We conducted a retrospective case-control study of concussed children aged 10&ndash, 18 years. Prolonged recovery was defined as symptom duration beyond 28 days post-injury. Symptom burden was measured as total symptom score (TSS) at injury. Symptom profiles included: (1) vestibular, (2) ocular, (3) cognitive/fatigue, (4) migraine, and (5) anxiety. A total of 4380 unique concussions sustained by 3777 patients were included, 80.3% white, 60.0% male, and 44.0% aged 13&ndash, 15 years. The prolonged recovery group had a significantly higher TSS and greater number of symptoms than the typical recovery group (p &lt, 0.001 and p &lt, 0.001, respectively). The prolonged recovery group had significantly higher scores on all five symptom profiles, including vestibular (p &lt, 0.001), ocular (p &lt, 0.001), cognitive/fatigue (p &lt, 0.001), migraine (p &lt, 0.001) and anxiety (p &lt, 0.001), than the typical recovery group, even after adjusting for number of symptoms and other covariates. Further studies using prospective cohort designs are needed to better understand the influence of symptom burden and profiles on pediatric concussion recovery.

Intimate partner violence (IPV) affects millions of adults and children each year. The associated risks for child maltreatment are significant, and IPV exposure can have significant harmful consequences for the child. Routine IPV screening in the context of the health care visit for a child in the emergency department can offer the opportunity to effectively identify child risks and provide appropriate intervention to improve child health and well-being. This article provides an overview of the importance of this issue for pediatric emergency physicians and other pediatric health care providers, the challenges to screening, innovative approaches to screening, and follow-up efforts.

OBJECTIVE: To examine rates of recommended of testing and prophylaxis for chlamydia, gonorrhea, and pregnancy in adolescents diagnosed with sexual assault across pediatric emergency departments (EDs) and to determine whether specialized sexual assault pathways and teams are associated with performance of recommended testing and prophylaxis. METHODS: In this retrospective study of 12- to 18-year-old adolescents diagnosed with sexual assault at 38 EDs in the Pediatric Hospital Information System database from 2004 to 2013, information regarding routine practice for sexual assault evaluations and presence and year of initiation of specialized ED sexual assault pathways and teams was collected via survey. We examined across-hospital variation and identified patient- and hospital-level factors associated with testing and prophylaxis using logistic regression models, accounting for clustering by hospital. RESULTS: Among 12 687 included cases, 93% were female, 79% were CONCLUSIONS: Evaluation and treatment of adolescent sexual assault victims varied widely across pediatric EDs. Adolescents cared for in EDs with specialized sexual assault pathways were more likely to receive recommended prophylaxis.

This article provides an overview of child physical abuse and neglect, and describes the magnitude of the problem and the triggers and factors that place children at risk for abuse and neglect. After examining the legal and clinical definitions of child abuse and neglect, common clinical outcomes and therapeutic strategies are reviewed, including the lifelong poor physical and mental health of victims and evidence-supported treatment interventions. Mandated reporting laws, and facilitating collaboration among child welfare, judicial, and health care systems are considered. Important tools and resources for addressing child maltreatment in clinical practice are discussed, and future approaches posited.

OBJECTIVE: To examine vitamin D levels in children with (1) suspected abusive and accidental fractures, (2) single and multiple fractures, and (3) fracture types highly associated with inflicted trauma. DESIGN AND METHODS: A study of children younger than 2 years of age with fractures admitted to a large children's hospital was performed. Bivariate analysis and test for trend were performed to test for the association of vitamin D status and biochemical markers of bone health with the primary outcomes of fracture etiology, number, and type. RESULTS: Of 118 subjects in the study, 8% had deficient vitamin D levels ( CONCLUSIONS: Vitamin D insufficiency was common in young children with fractures but was not more common than in previously studied healthy children. Vitamin D insufficiency was not associated with multiple fractures or diagnosis of child abuse. Nonaccidental trauma remains the most common cause of multiple fractures in young children.

OBJECTIVE: To evaluate in a national database the association of race and socioeconomic status with radiographic evaluation and subsequent diagnosis of child abuse after traumatic brain injury (TBI) in infants. METHODS: We conducted a retrospective study of infants with non–motor vehicle–associated TBI who were admitted to 39 pediatric hospitals from January 2004 to June 2008. Logistic regression controlling for age, type, and severity of TBI and the presence of other injuries was performed to examine the association of race and socioeconomic status with the principal outcomes of radiographic evaluation for suspected abuse and diagnosis of abuse. Regression coefficients were transformed to probabilities. RESULTS: After adjustment for type and severity of TBI, age, and other injuries, publicly insured/uninsured infants were more likely to have had skeletal surveys performed than were privately insured infants (81% vs 59%). The difference in skeletal survey performance for infants with public or no insurance versus private insurance was greater among white (82% vs 53%) infants than among black (85% vs 75%) or Hispanic (72% vs 55%) infants (P = .022). Although skeletal surveys were performed in a smaller proportion of white than black or Hispanic infants, the adjusted probability for diagnosis of abuse among infants evaluated with a skeletal survey was higher among white infants (61%) than among black (51%) or Hispanic (53%) infants (P = .009). CONCLUSIONS: National data suggest continued biases in the evaluation for abusive head trauma. The conflicting observations of fewer skeletal surveys among white infants and higher rates of diagnosis among those screened elicit concern for overevaluation in some infants (black or publicly insured/uninsured) or underevaluation in others (white or privately insured).