Intimate partner violence (IPV) is prevalent, costly, and detrimental to children's health and development. It often co-occurs with child abuse and neglect. Most children referred to child protective services (CPS) have witnessed IPV and are at increased risk for subsequent exposure, as well as repeat maltreatment. For CPS referred children, there is often a missed opportunity to interrupt family violence and prevent future occurrences. Fathers for Change (F4C) is a family level intervention designed to reduce IPV by improving emotion regulation and reflective functioning in fathers. To date, no study has examined whether F4C is associated with reduced recidivism in families referred to CPS. Using propensity score matching (PSM) to simulate an experimental design, the current study tests the hypothesis that families with fathers who completed F4C will have significantly lower rates of new CPS reports over a 12-month period compared to a PSM sample of families of fathers not referred to F4C. Data were extracted from a state CPS electronic case records system on all accepted child maltreatment reports received between January 1, 2015, and April 30, 2020. PSM was successful in balancing potential confounders (e.g., race, number of prior maltreatment reports, risk level, date of report), resulting in a comparison group approximate to one that could be achieved via a randomized control trial. Logistic regression analyses of 1:1 PSM pairs revealed that control fathers were 2.4 times more likely to have a repeat maltreatment report during the 12-month follow-up period than F4C fathers. These findings suggest that F4C may provide an effective approach for reducing risk of repeat maltreatment among CPS referred children with identified IPV exposure.

Background Child maltreatment is poorly documented in clinical data. The International Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM) represents the first time that confirmed and suspected child maltreatment can be distinguished in medical coding. The utility of this distinction in practice remains unknown. This study aims to evaluate the application of these codes by patient demographic characteristics and injury type. Methods We conducted secondary data analysis of emergency department (ED) discharge records of children under 18 years with an ICD-10-CM code for confirmed (T74) or suspected (T76) child maltreatment. Child age, sex, race/ethnicity, insurance status and co-occurring injuries (S00-T88) were compared by maltreatment type (confirmed or suspected). Results From 2016 to 2018, child maltreatment was documented in 1650 unique ED visits, or 21.7 per 10 000 child ED visits. Suspected maltreatment was documented most frequently (58%). Half of all maltreatment-related visits involved sexual abuse, most often in females and individuals of non-Hispanic white race. Physical abuse was coded in 36% of visits; injuries to the head were predominant. Non-Hispanic black children were more frequently documented with confirmed physical abuse than suspected (38.7% vs 23.7%, p<0.01). The rate of co-occurring injuries documented with confirmed and suspected maltreatment differed by 30% (9.2 vs 12.5 per 10 000 ED visits, respectively). Conclusions The ability to discriminate confirmed and suspected maltreatment may help mitigate clinical barriers to maltreatment surveillance associated with delayed diagnosis and subsequent intervention. Racial disparities in suspected and confirmed cases were identified which may indicate biased diagnostic behaviours in the ED.

Child maltreatment identified by medical professionals is poorly represented in records of child protection. International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes may better represent the burden of maltreatment treated in clinical settings. Using emergency department (ED) discharge data from 2011 to 2014, we enumerated presentations of maltreatment treated in Connecticut EDs for children under 10 years. Of 790 080 discharges, child maltreatment was explicitly documented in 265 (0.03%) unique ED visits, consistent with prior studies. Sexual maltreatment was most prevalent. A total of 3634 visits included an ICD-9-CM code suggestive of maltreatment. Children with these codes were significantly younger, more likely to be of white race, and use private insurance. Use of ICD codes in child maltreatment surveillance may elucidate characteristics of maltreatment not captured by child welfare data. Combining ICD codes for explicit and suggestive maltreatment will aid in understanding the extent of this problem.

Background Racism and discrimination are psychosocial stressors that affect the health of minority populations. While discrimination has been associated with poor mental health, little is known about the relationship between discrimination and mental health outcomes in youth nationally. Furthermore, mental and behavioral health consequences of discrimination may differ in different minority groups. Objective The goal of this study is to determine (1) how common perceptions of discrimination are in a nationally representative sample of African-American (AA) and Afro-Caribbean (AC) teens, (2) the relationship between discrimination and mental health conditions, and (3) whether discrimination has different associations with mental health in AA and AC youth. Design Cross-sectional comparison study Setting National Survey of American Life-Adolescent Supplement, a nationwide sample of African-American and Afro-Caribbean youth drawn from a nationally representative household survey of AA and AC population Participants One thousand, one hundred and seventy AA and AC youth between 13 and 17 years Exposure Experiences with discrimination (Everyday Discrimination Scale) Main Outcomes Lifetime and past 12-month major depression and anxiety Results Ninety percent of AA and 87% of AC youth experienced discrimination. Discrimination was significantly associated with lifetime and 12-month major depression and lifetime and 12-month anxiety. There were no differences in the associations between discrimination and mental health between AA and AC youth except for lifetime anxiety: as discrimination increased, the likelihood of lifetime anxiety disorder increased at a higher rate among AC youth compared to AA. Conclusions Discrimination is a common psychosocial stressor in African-American and Afro-Caribbean youth. It is associated with poor mental health outcomes. There was no difference in the occurrence of discrimination between African-American and Afro-Caribbean youth or in its mental health consequences.

Background Conventional classroom Electronic Health Record (EHR) training is often insufficient for new EHR users. Studies suggest that enhanced training with a hands-on approach and closely supported clinical use is beneficial. Objectives Our goals were to develop an enhanced EHR learning curriculum for Post Graduate Year 1 (PGY1) residents and measure changes in EHR skill proficiency, efficiency, and self-efficacy. Methods A novel three-phase, multimodal enhanced EHR curriculum was designed for a cohort of PGY1 residents. After basic training, residents began phase 1 of enhanced training, including demonstrations, live practice, and order set review. Phase 2 involved skills-oriented assignments, role playing, and medication entry. Phase 3 included shadowing, scribing histories, and supervised order entry. Residents' EHR skills and attitudes were measured and compared before and after the enhanced curriculum via proficiency test and a survey of efficiency and self-efficacy. Results Nineteen of 26 PGY1 residents participated in the study (73%). There was significant improvement in mean proficiency scores and two of the five individual proficiency scores. There were significant improvements in most efficiency survey responses from pre- to postintervention. For the self-efficacy presurvey, many PGY1s reported to be “very” or “somewhat confident” performing each of the five tasks, and perceptions did not improve or worsened on most postsurvey responses. The greatest resource was the time required to design and deliver the enhanced training. Conclusion An enhanced training curriculum along with a proficiency assessment was developed and described here. An enhanced training curriculum significantly improved PGY1 EHR efficiency and some measures of proficiency but not self-efficacy. This intervention may support improved EHR-related clinic workflows, which ultimately could enable residents and preceptors to prioritize patient care and time for clinical education.

Objective. Energy insecurity may result in adverse consequences for children's health, particularly for children with special health needs or chronic health conditions. We aimed to determine whether a multimodal intervention addressing energy insecurity within the framework of a medical-legal partnership (MLP) resulted in an increase in the provision of certifications of medical need for utility coverage in an inner city academic primary care practice. Methods. Working within a medical-legal partnership, we standardized criteria for providers approving medical need utility certification requests. We compared prior-year utility certification requests and approvals (pre-intervention) with the intervention year for families who reported energy insecurity on a waiting-room screening questionnaire. Results. Between the first and second years of the study, certification of medical need approvals increased by 65%, preventing utility shut-offs for 396 more families with vulnerable children. Conclusions. Energy insecurity can be screened for and addressed in a busy urban practice, potentially improving the wellbeing of vulnerable children.

Objective: Gastrointestinal endoscopy in children has become a standard diagnostic and therapeutic modality. The aim of our study was to characterize the most memorable elements of the patient experience from the parent’s and patient’s perspective and determine ways to improve the overall quality of their experience. Methods: Using a structured questionnaire, we conducted 47 phone interviews with families who had recently undergone gastrointestinal endoscopic procedures. Results: Our study showed clear communication and mutual agreement on care decisions contributed to positive experiences. Inadequate communication of information regarding alternatives to the procedure and risk of complications during the informed consent discussion contributed to negative patient experiences. Standardization of postprocedure follow-up and timely communication of pathology findings also had potential for improvement. Conclusion: Our study revealed 2 areas for quality improvement interventions: The need to ensure that alternatives and complications are thoroughly discussed and the need for standardization of postprocedure follow-up.

Abstract Introduction Many pediatric residents in urban settings work with patients who are chronically exposed to community violence. In fact, the major cause of death for male adolescents in most urban centers is homicide. This interactive, 90-minute, case-based module was designed so that pediatric residents would become more knowledgeable about the prevalence of community violence and the risk and protective factors for injury from community violence. In addition, the module aims to teach residents about effective strategies that can be used to reduce their patient's risk of future injury. Methods The module is designed for three participants: one general pediatrician (instructor) and two pediatric interns. This exercise should take place in a private and quiet office or conference room with enough seating for at least the three individuals. The room should have a computer with internet access available for the instructor to identify online resources for families. This module takes place as a required component of the intern advocacy block. It requires a total of 120–200 minutes to complete (90 minutes for the small-group case-based discussion and 30–110 minutes to prepare for the discussion by reading articles or watching a documentary). Results This curriculum improved resident knowledge and comfort in regard to a number of community violence–related issues. While the module was well received by our pediatric residents, it did not significantly change their self-reported behaviors. Discussion It is clear that a single, 90-minute module on such a challenging topic is not sufficient to meaningfully change the behaviors of pediatrics residents. Residents will likely need more hands-on experiences (such as directly observed clinical encounters, observed simulated clinical encounters, or role-plays) to more effectively change behavior.

BACKGROUND: Thirty-day postoperative complications from unintended harm adversely affect patients and their families and increase institutional health care costs. A surgical checklist is an inexpensive tool that will facilitate effective communication and teamwork. Surgical team training has demonstrated the opportunity for stakeholders to professionally engage one another through leveling of the authority gradient to prevent patient harm. The American College of Surgeons National Surgical Quality Improvement Program database is an outcomes reporting tool capable of validating the use of surgical checklists.STUDY DESIGN: Three 60-minute team training sessions were conducted and participants were oriented to the use of a comprehensive surgical checklist. The surgical team used the checklist for high-risk procedures selected from those analyzed for the American College of Surgeons National Surgical Quality Improvement Program. Trained observers assessed the checklist completion and collected data about perioperative communication and safety-compromising events.RESULTS: Data from the American College of Surgeons National Surgical Quality Improvement Program were compared for 2,079 historical control cases, 246 cases without checklist use, and 73 cases with checklist use. Overall completion of the checklist sections was 97.26%. Comparison of 30-day morbidity demonstrated a statistically significant (p = 0.000) reduction in overall adverse event rates from 23.60% for historical control cases and 15.90% in cases with only team training, to 8.20% in cases with checklist use.CONCLUSIONS: Use of a comprehensive surgical safety checklist and implementation of a structured team training curriculum produced a statistically significant decrease in 30-day morbidity. Adoption of a comprehensive checklist is feasible with team training intervention and can produce measurable improvements in patient outcomes. (J Am Coll Surg 2012;215:766-776. (c) 2012 by the American College of Surgeons)

Background and Objectives:This prospective, randomized, double-blind study was designed to determine whether reduction in volume from 20 to 10 mL of ropivacaine 0.5% for ultrasound-guided interscalene block might decrease the incidence of diaphragmatic paresis and preserve pulmonary function.Method:Thirty patients scheduled for arthroscopic shoulder surgery were randomized to receive either 10 or 20 mL of ropivacaine 0.5% for interscalene block at the level of the cricoid cartilage. General anesthesia was administered for surgery, and the surgeon infiltrated lidocaine at the port sites. Hemidiaphragmatic excursion and pulmonary function tests were measured before block, 15 mins after block, and at the time of discharge from recovery room. Onset and duration of sensory dermatomal spread, motor block, pain scores, and analgesic consumption were recorded.Results:Hemidiaphragmatic paresis occurred 15 mins after block performance in 14 of 15 patients in each group. At postanesthesia care unit discharge, 13 of 15 patients in each group continued to demonstrate hemidiaphragmatic paresis. Significant reduction of spirometric values (forced vital capacity, forced expiratory volume at 1 sec, and peak expiratory flow) occurred to a similar degree in both groups after block. Sensory dermatomal spread, motor block, pain scores, and analgesic consumption were not significantly different between groups.Conclusions:Decreasing the volume for interscalene block from 20 to 10 mL did not reduce the incidence of hemidiaphragmatic paresis or impairment in pulmonary function, which persisted at discharge from recovery room. No significant differences in quality or duration of analgesia were observed.

Racism may be a factor contributing to poor health and health care disparities in minority children through multiple mechanisms, including effects on psychological and physical wellbeing. Little is known about the experiences of racism that children encounter in their lives. This study describes the occurrences of perceived racism in children, including the settings and contexts in which it occurs. A questionnaire was administered to a convenience sample of urban children (eight to 16 years of age) asking about settings and Situations in Which they perceived discrimination. Two hundred and seventy-seven children completed the questionnaire; 88 percent of the children had at least one experience with racial discrimination, and 11.6 percent had experienced racism in at least half (12) of the 23 situations addressed in the questionnaire. Settings included schools and community contexts, and both peers and adults were perceived to be perpetrators. There were few differences in perceptions of racist episodes among different ethnocultural minority groups. Racism is perceived to be a common occurrence in many minority children's lives. Studies investigating perceptions of racism and how they relate to health disparities need to be conducted.

OBJECTIVE: The goal was to examine the impact of a teaching module on immunization pain reduction practices in pediatric offices 1 and 6 months after the intervention. METHODS: Fourteen practices were selected randomly to receive a 1-hour teaching session on immunization pain reduction techniques, and 13 completed the study. Before the intervention, telephone interviews were conducted with parents concerning their children's recent immunization experiences. At 1 and 6 months after the intervention, parents of children who had recent immunizations were interviewed by using the same questionnaires. Clinicians also were surveyed at baseline and at 6 months. RESULTS: A total of 839 telephone interviews and 92 clinician surveys were included. Significant changes from baseline were identified at 1 and 6 months after the intervention. At 1 month, parents were more likely to report receiving information (P = .04), using strategies to reduce pain (P < .01), learning something new (P < .01), using a ShotBlocker (P < .01), using sucrose (P < .01), and having higher levels of satisfaction (P = .015). At 6 months, all rates remained significantly higher than baseline findings (all P < .01) except for satisfaction. Clinician surveys revealed significant increases in the use of longer needles, sucrose, pinwheels, focused breathing, and ShotBlockers at 6 months. CONCLUSIONS: A 1-hour teaching session had measurable effects on the use of pain-reducing strategies at 1 and 6 months after the intervention. This research supports the hypothesis that small-group teaching sessions at the site of care can be associated with changes in practice behaviors.

Experiences of racial discrimination have been demonstrated to be related to racial and ethnic disparities in mental and physical health and healthcare. There has been little study, however, of the relationship between racism and health in children, and few psychometrically valid and reliable instruments to measure Perceptions of Racism in Children and Youth (PRaCY) exist. This paper reports on the development and testing of such an instrument, the PRaCY. Development of the instrument began with open-ended qualitative interviews, from which a proto-questionnaire was created. The questionnaire gathered information on the prevalence, attribution, emotional responses, and coping responses to 23 situations identified by participants in the qualitative phase. The proto-questionnaire was administered to 277 children between the ages of 8 and 18 years (38% Latino/a, 31% African-American, 19% multiracial/multicultural, 7% West Indian/Caribbean, and 5% Other). Item analysis resulted in two developmentally appropriate 10-item instruments (one for ages 7-13, another for ages 14-18). Internal consistency reliability was strong (alpha = 0.78 for both versions of the instrument). Confirmatory factor analysis demonstrated good fit for both versions (younger-Comparative Fit Index (CFI): 0.967, Root Mean Square Error of Approximation (RMSEA): 0.047; older-CFI: 0.934, RMSEA: 0.056). Differential item functioning analyses demonstrated no group-specific biases in item response. PRaCY scores were appropriately associated with higher depressive symptom scores and elevated anxiety scores in the younger sample. Results indicate that the PRaCY is a valid and reliable instrument that measures perceptions of racism and discrimination in children and youth aged 8-18 from diverse racial/ethnic backgrounds.

PURPOSE: Since reduced physical activity is an independent predictor of outcome in patients with COPD, its measurement is desirable. We evaluated an activity-monitoring device, the Intelligent Device for Energy Expenditure and Activity (IDEEA). This has 5 sensors attached to the skin; these send motion input via 3 wire leads to a device worn at the waist.

From the Departments of Pediatrics and Surgery, St. Francis Hospital and Medical Center, University of Connecticut School of Medicine, CT; and Department of Anthropology, University of Connecticut, Storrs, CT. Received March 2008; accepted September 2008. Address for reprints: Bruce A. Bernstein, PhD, Department of Pediatrics, St. Francis Hospital & Medical Center, 114 Woodland Street, Hartford, CT 06105; e-mail: [email protected].

OBJECTIVE. This study's aim was to elicit the perspectives of minority parents on their expectations of pediatric health care providers as a source of advice on “raising their child” and whether they would seek advice from these providers. A secondary aim was to demonstrate the value of qualitative methods for assessing parental attitudes in pediatric research. METHODS. Mothers with children between 3 and 12 years of age who identified themselves as African American, Jamaican, Haitian, or Puerto Rican were recruited from community sites. Audiotaped focus groups were conducted by trained moderators using an interview guide, to obtain the perspectives of the participants regarding the role of pediatric providers in the provision of parenting advice. RESULTS. Ninety-one mothers participated in a total of 20 focus groups, with 4 to 6 discussions per ethnocultural group. The focus groups revealed that, in general, parents do not look to child health care providers for advice on raising their children. The identified themes emphasized the importance of the relationship between providers and families. A few parents had the type of relationship within which the pediatrician already functioned as a provider of parenting advice. Physicians were considered skilled in the maintenance of physical health. The parents expressed a desire to receive more anticipatory guidance on developmental and behavioral stages and milestones. Pediatricians also served specific administrative functions valued by parents. CONCLUSIONS. Minority parents of preschool-aged and school-aged children do not view the primary care provider's role as including the provision of parenting advice. Expectations must be modified to enable health care professionals to function effectively in the role of advisor regarding parenting issues.