Child Abuse, Incarceration, and Decisions About Life-sustaining Treatment.

Most critical care interventions for children occur in the framework of a supportive environment with loving parents that are present at the bedside to help to guide medical interventions through shared decision-making. What happens, however, if the parents are precluded from being at the bedside because of legal entanglements? How should clinical decisions progress in those cases? In this Ethics Rounds, we present the case of an infant with severe hypoxic-ischemic encephalopathy at birth whose mother was incarcerated shortly after delivery. We explore clinical and legal challenges that the medical team faces in determining best interests for the infant in this context and difficulties in deciding what therapies to provide and for how long.

Medical Decision Making for Medically Complex Children in Foster Care: Who Knows the Child's Best Interests?

Aproximately one in 10 children in foster care are medically complex and require intensive medical supervision, frequent hospitalization, and difficult medical decision making. Some of these children are in foster care because their parents cannot care for their medical needs; other parents are responsible for their child's medical needs due to abuse or neglect. In either case, there can be uncertainty about the role that a child's biological parents should play in making serious medical decisions. Here we highlight some of the ethical challenges inherent in making these decisions for children in foster care, as seen through the lenses of a child welfare provider, an inpatient care physician, and a primary care pediatrician.

The importance of early parenting in at-risk families and children's social-emotional adaptation to school.

OBJECTIVE: The aim of this study was to determine the specific aspects of early parenting in psychosocially at-risk families most strongly related to children's social-emotional adaptation to school. METHODS: A cohort study of families (N = 318) identified as at risk for maltreatment of their newborns was conducted. Quality of early parenting was observed in the home when the child was 1 year old. Social-emotional adaptation to school was reported by teachers in first grade. Multivariable models assessed the independent influence of early parenting variables on social-emotional adaptation. RESULTS: Early parenting and social-emotional adaptation to school varied greatly across families. Parental warmth was associated with lower teacher ratings of shyness, concentration problems, and peer rejection. Parental lack of hostility was associated with decreased teacher ratings of concentration problems and peer rejection. Parental encouragement of developmental advance was associated with lower ratings of aggression and peer rejection. Provision of materials to promote learning and literacy was associated with lower ratings of concentration problems. CONCLUSIONS: In this sample of families with multiple psychosocial risks for child maltreatment, specific aspects of early parenting were associated with better social-emotional adaptation to school in the first grade in theoretically predicted ways. Improving parental knowledge about positive parenting via anticipatory guidance should be a focus of well-child visits. Well-child visit-based interventions to improve the quality of early parenting, especially among at-risk families, should be studied for their impact on parenting behavior and on children's successful social-emotional adaptation to school. Primary care providers should reinforce complementary services, such as home visiting, that seek to promote positive parenting.