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Children are overrepresented in households with intimate-partner violence (IPV), and many suffer the double burden of being the subject of maltreatment and bearing the consequences of abuse to their mothers. Despite this situation, little information exists concerning parenting by women who have been abused by an intimate partner. We examine the relationship between women's experiences with IPV and the quality of maternal parenting using data from the National Survey of Child and Adolescent Well-Being. The sample consisted of 1,943 female caregivers of children younger than 10 years investigated for child maltreatment. Women who had experienced IPV in the past but were no longer victims of IPV had significantly better parenting scores than women who were currently experiencing IPV, when other risk factors were controlled. This study adds to the evidence that IPV does not necessarily impair maternal parenting. Women abused by an intimate partner deserve a thorough assessment of what services they need: parenting services should be offered as warranted on a case-by-case evaluation of the particular woman's parenting skills. [ABSTRACT FROM AUTHOR]

This article compares health outcomes in the United States with those prevailing in other nations, in terms of survival during the prime of life, ages 15 to 59 years. To seek to explain U.S. mortality excesses, age-gender-cause-specific mortality rates are compared for the United States and nine economically comparable nations, using World Health Organization national survival statistics (life tables) and age-gender-specific mortality rates by major causes. Additional data were drawn from the U.S. National Center for Health Statistics. Compared with other nations in the WHO's mortality database, in the United States 15-year-old girls rank 38th and 15-year-old boys rank 34th in their likelihood of reaching age 60. U.S. adults ages 15 to 64 years have higher total mortality than those in the nine other developed nations selected for the study (and in more nations as well), for both genders and for all the five decades of life considered. The authors identify the specific causes of excess U.S. mortality. Despite huge expenditures for medical care, U.S. citizens have embarrassingly high death rates during the prime of life. Nine issues are highlighted that may illuminate ways to improve health in the United States. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Diagnosing inflicted traumatic brain injury (TBI) in young children is difficult in practice. Comparisons of children with inflicted and noninflicted TBI may help to identify markers of inflicted TBI. The objective of this study was to compare inflicted and noninflicted TBI in terms of presenting complaints, clinical features, and hospital outcomes. METHODS: The presenting complaint, clinical finding, hospital course, and outcome of all children who were aged 2 years or younger in North Carolina and were admitted to a pediatric intensive care unit or died with a TBI in 2000 and 2001 were reviewed. Clinical presentation and injury types were compared between children with inflicted and noninflicted TBI. Risk ratios were used to compare clinical and outcome characteristics between the 2 groups. Among survivors, multivariate binomial regression was used to examine the adjusted risk of a poor outcome dependent on injury type. RESULTS: A total of 80 (52.6%) children had inflicted and 72 (47.3%) children had noninflicted TBI. Children with noninflicted TBI (not in a motor vehicle crash) were more likely to present to the emergency department asymptomatic (44.8% vs 8.3%) and to have a specific history of trauma than children with inflicted TBI. Retinal hemorrhage, metaphyseal fracture, rib fracture, and subdural hemorrhage were more commonly found in children with inflicted compared with noninflicted TBI. Skeletal survey and ophthalmologic examination combined would have missed 8 (10.0%) inflicted TBI cases. CONCLUSIONS: Manner of presentation and injury types are helpful in distinguishing inflicted TBI. Clinicians should not rule out inflicted TBI on the basis of skeletal survey and ophthalmoscopy alone but should proceed to computed tomography and/or magnetic resonance imaging. [ABSTRACT FROM AUTHOR]

Child maltreatment remains a significant pediatric health problem despite 25 years since the establishment of the National Center on Child Abuse and Neglect. Federal funding for research on the medical aspects of abuse and neglect has been inadequate and, over time, declining in adjusted dollars. Nevertheless, important research has been conducted without federal support. Landmark research has occurred in the areas of physical abuse, sexual abuse, and neglect. Some of these accomplishments are noted, and a research agenda for future work is suggested. [ABSTRACT FROM AUTHOR]

The extent and nature of a child's disclosure of sexual abuse is an important component of the medical diagnosis. This study examined the frequency of disclosure of abuse by the alleged victim, as well as the child, examiner, and case characteristics that might influence disclosure. One goal was to understand how our medical examination protocol might impede or encourage the child to disclose victimization. All records for 179 children who received an examination for sexual abuse during the period from July 1, 1991 through June 30, 1992 were reviewed. Data were abstracted about demographics, interviewer identity, the alleged acts, the alleged perpetrator, and family characteristics. The overall disclosure rate was 47%. Factors associated with child disclosure were child age, siblings in the home, perpetrator other than a biological parent, alleged oral-genital contact or penetration, previous disclosure, and interview conducted by the physician. The factors significant in regression analysis were: prior disclosure, age greater than four years, and interview by the physician rather than by a social worker or psychologist. The findings related to disclosure to the physician may be confounded by child age. Nevertheless, the findings suggest the need to consider the advantages the physician might bring to the conduct of the sexual abuse interview. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although the history of recognition of child abuse in Europe and North America extends over 40 years, recognition and data are lacking in other parts of the world. Cultural differences in child-rearing complicate cross-cultural studies of abuse. OBJECTIVE: To ascertain rates of harsh and less-harsh parenting behavior in population-based samples. METHODS: We used parallel surveys of parental discipline of children in samples of mothers in Brazil, Chile, Egypt, India, Philippines, and the United States. Data were collected between 1998 and 2003. The instrument used was a modification of the Parent-Child Conflict Tactics Scale, along with a study-developed survey of demographic characteristics and other parent and child variables. Women (N = 14 239) from 19 communities in 6 countries were surveyed. We interviewed mothers aged 15 to 49 years (18-49 years in the United States) who had a child younger than 18 years in her home. Sample selection involved either random sampling or systematic sampling within randomly selected blocks or neighborhoods. RESULTS: Nearly all parents used nonviolent discipline and verbal or psychological punishment. Physical punishment was used in at least 55% of the families. Spanking rates (with open hand on buttocks) ranged from a low of 15% in an educated community in India to a high of 76% in a Philippine community. Similarly, there was a wide range in the rates of children who were hit with objects (9%-74% [median: 39%]) or beaten by their parents (0.1%-28.5%). Extremely harsh methods of physical punishment, such as burning or smothering, were rare in all countries. It is concerning that >/=20% of parents in 9 communities admitted shaking children younger than 2 years. CONCLUSIONS: Physical and verbal punishments of children are common in high-, middle-, and low-income communities around the world. The forms and rates of punishment vary among countries and among communities within countries. A median of 16% of children experienced harsh or potentially abusive physical discipline in the previous year. [ABSTRACT FROM AUTHOR]

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., Competing Interests: Declaration of competing interest All authors: No conflicts declared., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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., (Copyright © 2022 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 American Journal of Preventive Medicine. All rights reserved.)

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., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Lindberg confirms that he had access to all the data in the study and has final responsibility for the decision to submit for publication; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

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.

Importance: Intracranial pressure (ICP) monitoring is a mainstay of therapy for children with traumatic brain injury (TBI), but its overall association with patient outcome is unclear., Objective: To test the hypothesis that ICP monitoring is associated with improved functional survival of children with severe TBI., Design, Setting, and Participants: A propensity-weighted effectiveness analysis was conducted using 2 linked national databases with data from 30 US children's hospitals from January 1, 2007, to December 31, 2012, on 3084 children with severe TBI. Clinical events including neurosurgical procedures were identified using validated computable phenotypes. Data analysis was conducted from September 1, 2016, to March 1, 2017., Exposure: Placement of an ICP monitor., Main Outcomes and Measures: A composite of hospital mortality, discharge to hospice, or survival with placement of new tracheostomy and gastrostomy tubes., Results: Of the 3084 children in the study (1128 girls and 1956 boys; mean [SD] age, 7.03 [5.44] years), 1002 (32.4%) underwent ICP monitoring, with substantial hospital variation (6% to 50% by hospital). Overall, 484 children (15.7%) experienced the primary composite outcome. A propensity approach using matching weights generated good covariate balance between those who did and those who did not undergo ICP monitoring. Using a propensity-weighted logistic regression model clustered by hospital, no statistically significant difference was found in functional survival between monitored and unmonitored patients (odds ratio of poor outcome among those who underwent ICP monitoring, 1.31; 95% CI, 0.99-1.74). In a prespecified secondary analysis, no difference in mortality was found (odds ratio, 1.16; 95% CI, 0.89-1.50). Prespecified subgroup analyses of children younger and older than 2 years of age and among those with unintentional and inflicted (intentional) injuries also showed no difference in outcome with ICP monitoring., Conclusions and Relevance: With the use of linked national data and validated computable phenotypes, no evidence was found of a benefit from ICP monitoring on functional survival of children with severe TBI. Intracranial pressure monitoring is a widely but inconsistently used technology with incompletely demonstrated effectiveness. A large prospective cohort study or randomized trial is needed.

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.

Although child maltreatment medical research has benefited from several multi-center studies, the new specialty of child abuse pediatrics has not had a sustainable network capable of pursuing multiple, prospective, clinically-oriented studies. The Child Abuse Pediatrics Network (CAPNET) is a new multi-center research network dedicated to child maltreatment medical research. In order to establish a relevant, practical research agenda, we conducted a modified Delphi process to determine the topic areas with highest priority for such a network. Research questions were solicited from members of the Ray E. Helfer Society and study authors and were sorted into topic areas. These topic areas were rated for priority using iterative rounds of ratings and in-person meetings. The topics rated with the highest priority were missed diagnosis and selected/indicated prevention. This agenda can be used to target future multi-center child maltreatment medical research., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

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.

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., (Copyright © 2016 John Wiley & Sons, Ltd.)

Importance: Abusive head trauma (AHT) is a serious condition, with an incidence of approximately 30 cases per 100,000 person-years in the first year of life., Objective: To assess the effectiveness of a statewide universal AHT prevention program., Design, Setting, and Participants: In total, 88.29% of parents of newborns (n = 405 060) in North Carolina received the intervention (June 1, 2009, to September 30, 2012). A comparison of preintervention and postintervention was performed using nurse advice line telephone calls regarding infant crying (January 1, 2005, to December 31, 2010). A difference-in-difference analysis compared AHT rates in the prevention program state with those of other states before and after the implementation of the program (January 1, 2000, to December 31, 2011)., Intervention: The Period of PURPLE Crying intervention, developed by the National Center on Shaken Baby Syndrome, was delivered by nurse-provided education, a DVD, and a booklet, with reinforcement by primary care practices and a media campaign., Main Outcomes and Measures: Changes in proportions of telephone calls for crying concerns to a nurse advice line and in AHT rates per 100,000 infants after the intervention (June 1, 2009, to September 30, 2011) in the first year of life using hospital discharge data for January 1, 2000, to December 31, 2011., Results: In the 2 years after implementation of the intervention, parental telephone calls to the nurse advice line for crying declined by 20% for children younger than 3 months (rate ratio, 0.80; 95% CI, 0.73-0.87; P < .001) and by 12% for children 3 to 12 months old (rate ratio, 0.88; 95% CI, 0.78-0.99; P = .03). No reduction in state-level AHT rates was observed, with mean rates of 34.01 person-years before the intervention and 36.04 person-years after the intervention. A difference-in-difference analysis from January 1, 2000, to December 31, 2011, controlling for economic indicators, indicated that the intervention did not have a statistically significant effect on AHT rates (β coefficient, -1.42; 95% CI, -13.31 to 10.45)., Conclusions and Relevance: The Period of PURPLE Crying intervention was associated with a reduction in telephone calls to a nurse advice line. The study found no reduction in AHT rates over time in North Carolina relative to other states. Consequently, while this observational study was feasible and supported the program effectiveness in part, further programmatic efforts and evaluation are needed to demonstrate an effect on AHT rates.

Objective: Child physical abuse is commonly missed, putting abused children at risk for repeated injury and death. Several so-called sentinel injuries have been suggested to be associated with high rates of abuse, and to imply the need for routine testing for other, occult traumatic injuries. Our objective was to determine rates of abuse evaluation and diagnosis among children evaluated at leading children's hospitals with these putative sentinel injuries., Methods: This is a retrospective secondary analysis of the Pediatric Health Information System database. We identified 30 355 children with putative sentinel injuries. We measured rates of abuse diagnosis and rates of testing commonly used to identify occult injuries., Results: Among all visits for children <24 months old to Pediatric Health Information System hospitals, the rate of abuse diagnosis was 0.17%. Rates of abuse diagnosis for children with at least 1 putative sentinel injury ranged from 3.5% for children <12 months old with burns to 56.1% for children <24 months with rib fractures. Rates of skeletal survey and other testing that can identify occult traumatic injury were highly variable between centers and for different injuries., Conclusions: Several putative sentinel injuries are associated with high rates of physical abuse. Among eligible children with rib fracture(s), abdominal trauma, or intracranial hemorrhage, rates of abuse were more than 20%. Future work is warranted to test whether routine testing for abuse in these children can improve early recognition of abuse., (Copyright © 2015 by the American Academy of Pediatrics.)

Objective: Despite growing evidence of links between adverse childhood experiences (ACEs) and long-term health outcomes, there has been limited longitudinal investigation of such links in youth. The purpose of these analyses was to describe the patterns of exposure to ACEs over time and their links to youth health., Methods: The current analyses used data from LONGSCAN, a prospective study of children at risk for or exposed to child maltreatment, who were followed from age 4 to age 18. The analyses focused on 802 youth with complete data. Cumulative exposure to ACEs between 4 and 16 was used to place participants in 3 trajectory-defined groups: chronic ACEs, early ACEs only, and limited ACEs. Links to self-reported health at age 18 were examined using linear mixed models after controlling for earlier health status and demographics., Results: The chronic ACEs group had increased self-reported health concerns and use of medical care at 18 but not poorer self-rated health status. The early ACEs only group did not significantly differ from limited ACEs on outcomes., Conclusions: In addition to other negative outcomes, chronic ACEs appear to affect physical health in emerging adulthood. Interventions aimed at reducing exposure to ACEs and early mitigation of their effects may have lasting and widespread health benefits., (Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: To examine national, regional, and state abusive head trauma (AHT) trends using child hospital discharge data by applying a new coding algorithm developed by the Centers for Disease Control and Prevention (CDC)., Methods: Data from 4 waves of the Kids' Inpatient Database and annual discharge data from North Carolina were used to determine trends in AHT incidence among children <1 year of age between 2000 and 2009. National, regional, and state incidence rates were calculated. Poisson regression analyses were used to examine national, regional, and state AHT trends., Results: The CDC narrow and broad algorithms identified 5437 and 6317 cases, respectively, in the 4 years of KID weighted data. This yielded average annual incidences of 33.4 and 38.8 cases per 100,000 children <1 year of age. There was no statistically significant change in national rates. There were variations by region of the country, with significantly different trends in the Midwest and West. State data for North Carolina showed wide annual variation in rates, with no significant trend., Conclusions: The new coding algorithm resulted in the highest AHT rates reported to date. At the same time, we found large but statistically insignificant annual variations in AHT rates in 1 large state. This suggests that caution should be used in interpreting AHT trends and attributing changes in rates as being caused by changes in policies, programs, or the economy.

Objective: Evaluate the rate of, and risk factors for, abusive head trauma (AHT) among infants born to military families and compare with civilian population rates., Methods: Electronic International Classification of Diseases data from the US Department of Defense (DoD) Birth and Infant Health Registry were used to identify infants born to military families from 1998 through 2005 (N = 676 827) who met the study definition for AHT. DoD Family Advocacy Program data were used to identify infants with substantiated reports of abuse. Rates within the military were compared with civilian population rates by applying an alternate AHT case definition used in a civilian study., Results: Applying the study definition, the estimated rate of substantiated military AHT was 34.0 cases in the first year of life per 100 000 live births. Using the alternate case definition, the estimated AHT rate was 25.6 cases per 100 000 live births. Infant risk factors for AHT included male sex, premature birth, and a diagnosed major birth defect. Parental risk factors included young maternal age (<21 years), lower sponsor rank or pay grade, and current maternal military service., Conclusions: This is the first large database study of AHT with the ability to link investigative results to cases. Overall rates of AHT were consistent with civilian populations when using the same case definition codes. Infants most at risk, warranting special attention from military family support programs, include infants with parents in lower military pay grades, infants with military mothers, and infants born premature or with birth defects.

Importance: Child maltreatment and other adverse childhood experiences, especially when recent and ongoing, affect adolescent health. Efforts to intervene and prevent adverse childhood exposures should begin early in life but continue throughout childhood and adolescence., Objectives: To examine the relationship between previous adverse childhood experiences and somatic concerns and health problems in early adolescence, as well as the role of the timing of adverse exposures., Design: Prospective analysis of the Longitudinal Studies of Child Abuse and Neglect interview and questionnaire data when target children were 4, 6, 8, 12, and 14 years old., Setting: Children with reported or at risk for maltreatment in the South, East, Midwest, Northwest, and Southwest United States Longitudinal Studies of Child Abuse and Neglect sites., Participants: A total of 933 children who completed an interview at age 14 years, including health outcomes., Exposures: Eight categories of adversity (psychological maltreatment, physical abuse, sexual abuse, neglect, caregiver's substance use/alcohol abuse, caregiver's depressive symptoms, caregiver treated violently, and criminal behavior in the household) experienced during the first 6 years of life, the second 6 years of life, the most recent 2 years, and overall adversity., Main Outcomes and Measures: Child health problems including poor health, illness requiring a doctor, somatic concerns, and any health problem at age 14 years., Results: More than 90% of the youth had experienced an adverse childhood event by age 14 years. There was a graded relationship between adverse childhood exposures and any health problem, while 2 and 3 or more adverse exposures were associated with somatic concerns. Recent adversity appeared to uniquely predict poor health, somatic concerns, and any health problem., Conclusions and Relevance: Childhood adversities, particularly recent adversities, already show an impact on health outcomes by early adolescence. Increased efforts to prevent and mitigate these experiences may improve the health outcome for adolescents and adults.

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.

In cases of suspected child sexual abuse (CSA) some professionals routinely recommend multiple interviews by the same interviewer because any additional details provided might improve decision-making and increase perpetrator convictions. We analyzed alternative policies about child interviewing to estimate the probability that a policy of all children receiving multiple interviews will increase criminal convictions and better protect children. Using decision analysis, we prepared a decision tree reflecting the structure through which a case of possible CSA passes through the health care, welfare, and legal systems with an estimated probability of conviction of the offender. We reviewed the CSA disclosure, criminal justice, and child welfare literature to obtain estimates for the median and range of rates for the steps of disclosure, substantiation, criminal charges, and conviction. Using the R statistical package, our decision analysis model was populated using literature-based estimates. Once the model was populated, we simulated the experiences of 1,000 cases at 250 sets of plausible parameter values representing different hypothetical communities. Multiple interviews increase the likelihood that an offender will be convicted by 6.1% in the average community. Simulations indicate that a policy in which all children seen for a CSA medical evaluation receive multiple interviews would cost an additional $100,000 for each additional conviction. We estimate that approximately 17 additional children would need to be interviewed on more than one occasion to yield one additional conviction. A policy of multiple interviews has implications for the children, for the costs of care, for protecting other children, and for the risk of false prosecution.

Objective: The present study applied person-centered data analytic techniques to identify groups of youth with allegations for combinations of maltreatment types during preschool, early and late childhood., Method: Latent Class Analyses were conducted using officially reported child maltreatment data for five types of maltreatment (i.e., failure-to-provide and lack-of-supervision neglect, and physical, sexual and emotional abuse) from 788 youth in a large prospective study during preschool, early, and late childhood., Results: Three similar classes were identified during preschool and early childhood, characterized by no maltreatment allegations, allegations for neglect and emotional maltreatment, and allegations for all maltreatment types. During late childhood, four classes were identified characterized by no maltreatment allegations, mixed patterns of maltreatment allegations, physical and emotional abuse allegations, and allegations for all maltreatment types. Youth in maltreated classes were more likely to be re-victimized during subsequent developmental periods, often by similar maltreatment combinations. Youth in maltreated classes characterized by physically violent maltreatment types had higher Externalizing and Total behavior problems at each age., Conclusions: These findings confirm the vulnerability of maltreated youth to re-victimization, particularly by similar combinations of maltreatment. They also indicate that youth's susceptibilities to specific forms of maltreatment may vary across developmental periods.

Objective: Studies have consistently demonstrated a lack of agreement between youth and parent reports regarding youth-witnessed violence. However, little is known about whether disagreement is associated with poorer outcomes and less utilization of mental health services. The purpose of the current study was to examine disagreement among youth and parents about youth witnessed violence, and determine whether concordance predicted trauma symptoms and recognition of need and receipt of counseling services., Methods: Concordance about youth-witnessed violence was examined in 766 dyads from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). Youth participants self-reported trauma symptoms, caregivers indicated youth need for and receipt of services. Both youth and parents provided information about youth-witnessed violence exposure in the last year., Results: Results showed youth and caregivers differed significantly about youth-witnessed violence. Specifically, 42% of youth reported youth-witnessed violence, compared to only 15% of parents. For those parents who reported youth-witnessed violence, only 29% reported an identified need for services and only 17% reported the youth had received any mental health services. Concordance between parent-youth dyads was associated with greater identified need for services but was not associated with the use of counseling services or trauma symptoms., Conclusions: Youth who reported witnessing violence reported more frequent trauma symptoms regardless of concordance. Parents from dyads in which both informants reported youth-witnessed violence were more likely to endorse need for, but not receipt of counseling services. Given this association between youth-witnessed violence and mental health problems, more work is needed to identify barriers to concordance as well as service utilization., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objectives: Few studies have explored the impact of different types of neglect on children's development. Measures of cognition, language, behavior, and parenting stress were used to explore differences between children experiencing various forms of neglect, as well as to compare children with and without a history of early neglect., Methods: Children, ages 3 to 10 years with a history of familial neglect (USN), were compared to children with a history of institutional rearing (IA) and children without a history of neglect using the Differential Abilities Scale, Test of Early Language Development, Child Behavior Checklist, and Parenting Stress Index. Factors predicting child functioning were also explored., Results: Compared with youth that were not neglected, children with a history of USN and IA demonstrated lower cognitive and language scores and more behavioral problems. Both internalizing and externalizing behavior problems were most common in the USN group. Externalizing behavior problems predicted parenting stress. Higher IQ could be predicted by language scores and an absence of externalizing behavior problems. When comparing the two neglect groups, shorter time spent in a stable environment, lower scores on language skills, and the presence of externalizing behavior predicted lower IQ., Conclusion: These findings emphasize the importance of early stable, permanent placement of children who have been in neglectful and pre-adoptive international settings. While an enriching environment may promote resilience, children who have experienced early neglect are vulnerable to cognitive, language and behavioral deficits and neurodevelopmental and behavioral evaluations are required to identify those in need of intervention.

Spanking is common in the United States but less common in many European countries in which it has been outlawed. Being spanked has been associated with child abuse victimization, poor self-esteem, impaired parent-child relationships, and child and adult mental health, substance abuse, and behavioral consequences. Being spanked as a child has also been shown to increase the likelihood of abusing one's own children or spouse as an adult. Spanking of very young children less than two is almost never recommended even among experts that consider spanking as reasonable in some circumstances. Using a cross-sectional anonymous telephone survey, we describe spanking rates among a representative sample of North Carolina mothers of children less than 2 years old and the association of spanking with demographic characteristics. A substantial proportion of mothers admit to spanking their very young children. The rate of spanking in the last year among all maternal respondents was 30%. Over 5% of the mothers of 3-month olds reported spanking. Over 70% of the mothers of 23-month olds reported spanking. Increased spanking was associated with higher age of the child and lower maternal age. With every month of age, a child had 27% increased odds of being spanked. Early spanking has been shown to be associated with poor cognitive development in early childhood. Further, early trauma has been shown to have significant effects on the early developing brain. It is therefore critical that health and human services professionals address the risk of corporal punishment as a method of discipline early in the life of the child. The spanking of very young children may be an appropriate locus for policy and legislative debates regarding corporal punishment.

Witnessed violence has significant negative consequences for youth behavior and mental health. However, many findings on the impact of witnessed violence have been based on a single informant. There is a general lack of consistency between caregiver and youth reports on both witnessed violence and behavioral problems. This study included data from both caregivers and youth and incorporated a multisource analytic approach to simultaneously examine the association between youth witnessed violence and externalizing and internalizing behavior problems. Data from 875 caregivers and 812 youth were collected as part of the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). Findings showed that youth reported more witnessed violence than did their caregivers, and caregivers reported more externalizing and internalizing behavior problems than did youth. Further, the source of information had a significant impact on the association between witnessed violence and internalizing behaviors. These findings highlight the need to incorporate multiple sources and multi-informant analytic techniques to eliminate methodological limitations to understanding the effect of witnessed violence on youth behavioral problems., (© 2010 American Orthopsychiatric Association.)

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.

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.

Background. The purpose of this paper is to contribute to a global perspective on corporal punishment by examining differences between mothers' and fathers' use of corporal punishment with daughters and sons in nine countries. Methods. Interviews were conducted with 1398 mothers, 1146 fathers, and 1417 children (age range = 7 to 10 years) in China, Colombia, Italy, Jordan, Kenya, the Philippines, Sweden, Thailand, and the United States. Results. Across the entire sample, 54% of girls and 58% of boys had experienced mild corporal punishment, and 13% of girls and 14% of boys had experienced severe corporal punishment by their parents or someone in their household in the last month. Seventeen percent of parents believed that the use of corporal punishment was necessary to rear the target child. Overall, boys were more frequently punished corporally than were girls, and mothers used corporal punishment more frequently than did fathers. There were significant differences across countries, with reports of corporal punishment use lowest in Sweden and highest in Kenya. Conclusion. This work establishes that the use of corporal punishment is widespread, and efforts to prevent corporal punishment from escalating into physical abuse should be commensurately widespread.

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.

Objective: To develop a child victimization survey among a diverse group of child protection experts and examine the performance of the instrument through a set of international pilot studies., Methods: The initial draft of the instrument was developed after input from scientists and practitioners representing 40 countries. Volunteers from the larger group of scientists participating in the Delphi review of the ICAST P and R reviewed the ICAST C by email in 2 rounds resulting in a final instrument. The ICAST C was then translated and back translated into six languages and field tested in four countries using a convenience sample of 571 children 12-17 years of age selected from schools and classrooms to which the investigators had easy access., Results: The final ICAST C Home has 38 items and the ICAST C Institution has 44 items. These items serve as screeners and positive endorsements are followed by queries for frequency and perpetrator. Half of respondents were boys (49%). Endorsement for various forms of victimization ranged from 0 to 51%. Many children report violence exposure (51%), physical victimization (55%), psychological victimization (66%), sexual victimization (18%), and neglect in their homes (37%) in the last year. High rates of physical victimization (57%), psychological victimization (59%), and sexual victimization (22%) were also reported in schools in the last year. Internal consistency was moderate to high (alpha between .685 and .855) and missing data low (less than 1.5% for all but one item)., Conclusions: In pilot testing, the ICAST C identifies high rates of child victimization in all domains. Rates of missing data are low, and internal consistency is moderate to high. Pilot testing demonstrated the feasibility of using child self-report as one strategy to assess child victimization., Practice Implications: The ICAST C is a multi-national, multi-lingual, consensus-based survey instrument. It is available in six languages for international research to estimate child victimization. Assessing the prevalence of child victimization is critical in understanding the scope of the problem, setting national and local priorities, and garnering support for program and policy development aimed at child protection.

Objective: Child maltreatment is a problem that has longer recognition in the northern hemisphere and in high-income countries. Recent work has highlighted the nearly universal nature of the problem in other countries but demonstrated the lack of comparability of studies because of the variations in definitions and measures used. The International Society for the Prevention of Child Abuse and Neglect has developed instrumentation that may be used with cross-cultural and cross-national benchmarking by local investigators. DESIGN AND SAMPLING: The instrument design began with a team of expert in Brisbane in 2004. A large bank of questions were subjected to two rounds of Delphi review to develop the fielded version of the instrument. Convenience samples included approximately 120 parent respondents with children under the age of 18 in each of six countries (697 total)., Results: This paper presents an instrument that measures parental behaviors directed at children and reports data from pilot work in 6 countries and 7 languages. Patterns of response revealed few missing values and distributions of responses that generally were similar in the six countries. Subscales performed well in terms of internal consistency with Cronbach's alpha in very good range (0.77-0.88) with the exception of the neglect and sex abuse subscales. Results varied by child age and gender in expected directions but with large variations among the samples. About 15% of children were shaken, 24% hit on the buttocks with an object, and 37% were spanked. Reports of choking and smothering were made by 2% of parents., Conclusion: These pilot data demonstrate that the instrument is well tolerated and captures variations in, and potentially harmful forms of child discipline., Practice Implications: The ISPCAN Child Abuse Screening Tool - Parent Version (ICAST-P) has been developed as a survey instrument to be administered to parents for the assessment of child maltreatment in a multi-national and multi-cultural context. It was developed with broad input from international experts and subjected to Dephi review, translation, and pilot testing in six countries. The results of the Delphi study and pilot testing are presented. This study demonstrates that a single instrument can be used in a broad range of cultures and languages with low rates of missing data and moderate to high internal consistency.