Disclosure Is an Essential Component of Ethical Practice: "I Am the Child Abuse Pediatrician".

This Viewpoint explains the role of child abuse pediatricians and makes specific recommendations for communicating their role in medical care.

Is the emergency department used as a substitute or a complement to primary care in Medicaid?

Policies to decrease low-acuity emergency department (ED) use have traditionally assumed that EDs are a substitute for unavailable primary care (PC). However, such policies can exacerbate ED overcrowding, rather than ameliorate it, if patients use EDs to complement, rather than substitute, their PC use. We tested whether Medicaid managed care enrolees visit the ED for nonemergent and PC treatable conditions to substitute for or to complement PC. Based on consumer choice theory, we modelled county-level monthly ED visit rate as a function of PC supply and used 2012-2015 New York Statewide Planning and Research Cooperative System (SPARCS) outpatient data and non-linear least squares method to test substitution vs complementarity. In the post-Medicaid expansion period (2014-2015), ED and PC are substitutes state-wide, but are complements in highly urban and poorer counties during nights and weekends. There is no evidence of complementarity before the expansion (2012-2013). Analyses by PC provider demonstrate that the relationship between ED and PC differs depending on whether PC is provided by physicians or advanced practice providers. Policies to reduce low-acuity ED use via improved PC access in Medicaid are likely to be most effective if they focus on increasing actual appointment availability, ideally by physicians, in areas with low PC provider supply. Different aspects of PC access may be differently related to low-acuity ED use.

Physicians' Refusal to Wear Masks to Protect Vulnerable Patients-An Ethical Dilemma for the Medical Profession.

This Viewpoint discusses why clinician masking is still important for patients who are immunocompromised or disabled.

Medical Professional Reports and Child Welfare System Infant Investigations: An Analysis of National Child Abuse and Neglect Data System Data.

Background: Medical professionals are key components of child maltreatment surveillance. Updated estimates of reporting rates by medical professionals are needed. Methods: We use the National Child Abuse and Neglect Data System (2000-2019) to estimate rates of child welfare investigations of infants stemming from medical professional reporting to child welfare agencies. We adjust for missing data and join records to population data to compute race/ethnicity-specific rates of infant exposure to child welfare investigations at the state-year level, including sub-analyses related to pregnant/parenting people's substance use. Results: Between 2010 and 2019, child welfare investigated 2.8 million infants; ∼26% (n=731,705) stemmed from medical professionals' reports. Population-adjusted rates of these investigations stemming doubled between 2010 and 2019 (13.1-27.1 per 1000 infants). Rates of investigations stemming from medical professionals' reports increased faster than did rates for other mandated reporters, such as teachers and police, whose reporting remained relatively stable. In 2019, child welfare investigated ∼1 in 18 Black (5.4%), 1 in 31 Indigenous (3.2%), and 1 in 41 White infants (2.5%) following medical professionals' reports. Relative increases were similar across racial groups, but absolute increases differed, with 1.3% more of White, 1.7% of Indigenous, and 3.1% of Black infants investigated in 2019 than 2010. Investigations related to substance use comprised ∼35% of these investigations; in some states, this was almost 80%. Discussion: Rates of child welfare investigations of infants stemming from medical professional reports have increased dramatically over the past decade with persistent and notable racial inequities in these investigations.

Using Child Abuse Specialists to Reduce Unnecessary Child Protective Services Reports and Investigations.

This Viewpoint informs clinicians of the potential harms of unnecessary reporting of child abuse and highlights the possibility of consulting a child abuse pediatrician prior to reporting in a subset of cases in which the concern for child abuse is low.

New Directions in the Historiography of Psychiatry.

Gerald Grob's work in the history of psychiatry over the course of almost fifty years created a model for how historians might successfully situate mental health in its social and political context, and how inseparable it was from this context. Over the last twenty years, the field has grown tremendously. Historians have incorporated categories of analysis like gender and race, methodologies like cultural history and intellectual history, and sought to continue Grob's quest to understand American mental health history as a critical component of American history writ large. In this piece, we suggest several potential areas for future study. Building on Grob's work on the asylum, we focus on the continued need to explore the texture of lived experience for both practitioners and those experiencing mental illness, both within and beyond the institution. In an era when the politics of deinstitutionalization continue to shape the modern mental health enterprise, we suggest that further examination of the consequences of deinstitutionalization is both inherently rich and relevant to contemporary mental health practice. Finally, we discuss opportunities for historians to engage with policymaking and social justice, pointing to incarceration and juvenile justice as two especially relevant areas for further study.

Psychiatrists and the Transformation of Juvenile Justice in Philadelphia, 1965-1972.

In the late 1960s, Philadelphia psychiatrists evaluated every child who interacted with the city's juvenile courts. These evaluations had an important role in determining the placement and treatment of these children, and emphasized the therapeutic nature of the juvenile courts at the time. Relying on extensive case studies compiled by the Philadelphia Department of Public Welfare, this study reconstructs the roles of psychiatrists in the experiences of children interacting with the juvenile justice system, to shed light on a hitherto unknown aspect of these children's care. Gradually, the emphasis in juvenile justice shifted from a therapeutic approach to a more punitive one, from the mid 1970s and onwards. Yet the same structures of juvenile justice which allowed for individual discretion and "tailoring" of interventions to suit the child's perceived needs, rather than to fit the severity of his or her infraction, lost much of their therapeutic rationale. Still, many of these characteristics of the juvenile justice system, and in particular the practice of indeterminate sentencing, remain in place today. Questioning the role of mental health professionals in the creation and perpetuation of this flawed and often unfair infrastructure is an important first step in contemplating reforms.

Alone again: John Zubek and the troubled history of sensory deprivation research.

In the 1950s, sensory deprivation research emerged as an influential new field for behavioral science researchers, supported by the intelligence community. Within a few years, deprivation research had become ubiquitous; images of sensory deprivation were invoked to explain a wide range of phenomena, from religious revelations to the very structure of psychoanalysis. Yet within a decade and a half, this field of research became implicated in cases of torture and abuse. This article examines the history of University of Manitoba psychologist John Zubek, who remained one of the final researchers still conducting sensory deprivation research in the 1970s. It raises questions on how might it be possible to successfully and cautiously perform controversial research.

Vitamins for the soul: John Bowlby's thesis of maternal deprivation, biomedical metaphors and the deficiency model of disease.

In 1951 John Bowlby, British psychoanalyst and child psychiatrist, published his now famous report, Maternal Care and Mental Health, commissioned by the World Health Organization. In this report, Bowlby coined the term 'maternal deprivation', which quickly permeated into Western psychiatry and psychology. The implications of Bowlby's writings, while widely criticized and contested, generated a considerable amount of research and brought about significant changes in perceptions of separation between children and their mothers. This article examines the origins of the 'maternal deprivation' hypothesis, focusing on how the deficiency theory of disease influenced psychiatric discourse, and framed Bowlby's theory of maternal care. We argue that developments in paediatric medicine, and particularly in the field of nutritional deficiencies, provided Bowlby a prototype for conceptualizing his early views on the psychological needs of children and the development of psychopathology.