What Do Child Abuse and Neglect Medical Evaluation Consultation Notes Tell Researchers and Clinicians?

Child abuse and neglect (CAN) medical experts provide specialized multidisciplinary care to children when there is concern for maltreatment. Their clinical notes contain valuable information on child- and family-level factors, clinical concerns, and service placements that may inform the needed supports for the family. We created and implemented a coding system for data abstraction from these notes. Participants were 1,397 children ages 0-17 years referred for a consultation with a CAN medical provider at an urban teaching and research hospital between March 2013 and December 2017. Coding themes were developed using an interdisciplinary team-based approach to qualitative analysis, and descriptive results are presented using a developmental-contextual framework. This study demonstrates the potential value of developing a coding system to assess characteristics and patterns from CAN medical provider notes, which could be helpful in improving quality of care and prevention and detection of child abuse.

Child Sexual Abuse Documentation in Primary Care Settings.

Primary care providers (PCPs) can play an important role in the continuity of care for children who experience sexual abuse (SA). We performed a retrospective, chart-based study of children 3 to 17 years old with SA history. Primary care medical records were reviewed for 2 years after a subspecialty SA evaluation. Descriptive statistics and logistic regression were used to assess factors associated with documentation of SA history and mental health management by the PCP. Of 131 included patients, 43% had PCP documentation of their SA history, which was associated with care from resident providers (P < .01). There was greater mental health management and mental health referrals by PCPs for the group with documentation compared with the group without documentation (52% vs 23%, P < .001). Overall, child SA history was poorly documented in primary care settings. Identifying mechanisms to improve communication about a child's SA history with PCPs is important for the child's ongoing care.

Do children evaluated for maltreatment have higher subsequent emergency department and inpatient care utilization compared to a general pediatric sample?

BACKGROUND: Child maltreatment leads to substantial adverse health outcomes, but little is known about acute health care utilization patterns after children are evaluated for a concern of maltreatment at a child abuse and neglect medical evaluation clinic. OBJECTIVE: To quantify the association of having a child maltreatment evaluation with subsequent acute health care utilization among children from birth to age three. PARTICIPANTS AND SETTING: Children who received a maltreatment evaluation (N = 367) at a child abuse and neglect subspecialty clinic in an academic health system in the United States and the general pediatric population (N = 21,231). METHODS: We conducted a retrospective cohort study that compared acute health care utilization over 18 months between the two samples using data from electronic health records. Outcomes were time to first emergency department (ED) visit or inpatient hospitalization, maltreatment-related ED use or inpatient hospitalization, and ED use or inpatient hospitalization for ambulatory care sensitive conditions (ACSCs). Multilevel survival analyses were performed. RESULTS: Children who received a maltreatment evaluation had an increased hazard for a subsequent ED visit or inpatient hospitalization (hazard ratio [HR]: 1.3, 95 % confidence interval [CI]: 1.1, 1.5) and a maltreatment-related visit (HR: 4.4, 95 % CI: 2.3, 8.2) relative to the general pediatric population. A maltreatment evaluation was not associated with a higher hazard of health care use for ACSCs (HR: 1.0, 95 % CI: 0.7, 1.3). CONCLUSION: This work can inform targeted anticipatory guidance to aid high-risk families in preventing future harm or minimizing complications from previous maltreatment.

Gun violence among young adults with a juvenile crime record in North Carolina: Implications for firearm restrictions based on age and risk.

Youth who acquire a juvenile crime record may be at increased risk of perpetrating gun violence as adults. North Carolina and 22 other states permit young adults who were adjudicated by a juvenile court - even for some felony-equivalent offenses - to legally access firearms. Effectiveness of gun restrictions for adults with juvenile crime histories has not been systematically studied. This article reports findings from a longitudinal study of arrests and convictions for gun-involved and other offenses in 51,059 young adults in North Carolina, comparing those with gun-disqualifying and not-disqualifying juvenile records. The annualized rate of arrest for gun-involved crime in those with a felony-level juvenile record was 9 times higher than the rate of reported comparable offenses in the same age group in the North Carolina general population (3349 vs. 376 per 100,000). Among those with a felony-equivalent juvenile delinquency adjudication who became legally eligible to possess firearms at age 18, 61.8% were later arrested for any criminal offense, 14.3% for a firearm-involved offense. Crimes with guns were most likely to occur among young adults who had committed more serious (felony or equivalent) offenses before age 18; had been adjudicated at younger ages; acquired a felony conviction as a youth; and spent time in prison. The prevalence of arrests for crimes involving guns among young adults in North Carolina with a gun-disqualifying felony record acquired before age 18 suggests that the federal gun prohibitor conferred by a felony record is not highly effective as currently implemented in this population. From a risk-based perspective, these restrictions appear to be justified; better implementation and enforcement may improve their effectiveness. Gun crime prevention policies and interventions should focus on these populations and on limiting illegal access to firearms.

Does Having a Minor Child Affect Criminal Charges and Sanctions Imposed on Female Defendants?

This study examined effects of having a minor child(ren) on the probability of being prosecuted, convicted, and if convicted, the sanctions that were imposed. Data were state-wide court and birth records of criminally-charged women in North Carolina, a state with sentencing guidelines. We hypothesized that (a) prosecutors would be less likely to prosecute and more likely to lower an offense class and (b) judges (when they had discretion) would be more lenient for women in sentencing with minor children than without. Having a minor child(ren) reduced the probability of prosecution; given prosecution, conviction rates fell. When the judge had discretion, having minor children reduced the probability of an active sentence. Having a minor child had no effect on minimum sentence length for women with active sentences. Presence of a minor child affects prosecutorial and judicial decisions affecting women charged with a criminal offense.

Embryonic heart rate correlates with maternal temperature and developmental stage in viviparous snakes.

Interactions between the environment and maternal and embryonic physiology can have critical ramifications for early-life phenotypes and survival in a range of species. A major component of the environment-maternal-embryonic nexus is the regulation of embryonic heart rate, which can have important ramifications for developmental phenology, but remains relatively unexplored in viviparous reptiles. The goal of this study was to test for a relationship between embryonic heart rate and maternal body temperature in two species of viviparous garter snakes. The embryonic heart rates of Thamnophis elegans and T. sirtalis were assessed using a field-portable ultrasound. For both T. elegans and T. sirtalis, embryonic heart rate was strongly correlated to maternal temperature. Interestingly, there was also a strong correlation between embryonic and maternal heart rate that was most likely mediated by a common response to maternal body temperature, in spite of the effects of handling during ultrasound on maternal heart rate. Furthermore, embryos at earlier developmental stages had lower heart rates. To our knowledge, this study is the first to explore embryonic heart rate in viviparous reptiles, providing a foundation for future work using ultrasonography to test ecological and evolutionary hypotheses related to developmental dynamics in free-ranging viviparous species.

Criminally Involved Parents Who Misuse Substances and Children's Odds of Being Arrested as a Young Adult: Do Drug Treatment Courts Mitigate the Risk?

This paper examined (1) the association between parents who are convicted of a substance-related offense and their children's probability of being arrested as a young adult and (2) whether or not parental participation in an adult drug treatment court program mitigated this risk. The analysis relied on state administrative data from North Carolina courts (2005-2013) and from birth records (1988-2003). The dependent variable was the probability that a child was arrested as a young adult (16-21). Logistic regression was used to compare groups and models accounted for the clustering of multiple children with the same mother. Findings revealed that children whose parents were convicted on either a substance-related charge on a non-substance-related charge had twice the odds of being arrested as young adult, relative to children whose parents had not been observed having a conviction. While a quarter of children whose parents participated in a drug treatment court program were arrested as young adults, parental completion this program did not reduce this risk. In conclusion, children whose parents were convicted had an increased risk of being arrested as young adults, irrespective of whether or not the conviction was on a substance-related charge. However, drug treatment courts did not reduce this risk. Reducing intergenerational links in the probability of arrest remains a societal challenge.

Parental Criminal Justice Involvement and Children's Involvement With Child Protective Services: Do Adult Drug Treatment Courts Prevent Child Maltreatment?

BACKGROUND: In light of evidence showing reduced criminal recidivism and cost savings, adult drug treatment courts have grown in popularity. However, the potential spillover benefits to family members are understudied. OBJECTIVES: To examine: (1) the overlap between parents who were convicted of a substance-related offense and their children's involvement with child protective services (CPS); and (2) whether parental participation in an adult drug treatment court program reduces children's risk for CPS involvement. METHODS: Administrative data from North Carolina courts, birth records, and social services were linked at the child level. First, children of parents convicted of a substance-related offense were matched to (a) children of parents convicted of a nonsubstance-related offense and (b) those not convicted of any offense. Second, we compared children of parents who completed a DTC program with children of parents who were referred but did not enroll, who enrolled for <90 days but did not complete, and who enrolled for 90+ days but did not complete. Multivariate logistic regression was used to model group differences in the odds of being reported to CPS in the 1 to 3 years following parental criminal conviction or, alternatively, being referred to a DTC program. RESULTS: Children of parents convicted of a substance-related offense were at greater risk of CPS involvement than children whose parents were not convicted of any charge, but DTC participation did not mitigate this risk. Conclusion/Importance: The role of specialty courts as a strategy for reducing children's risk of maltreatment should be further explored.

Intergenerational effects of parental substance-related convictions and adult drug treatment court participation on children's school performance.

This study examined the intergenerational effects of parental conviction of a substance-related charge on children's academic performance and, conditional on a conviction, whether completion of an adult drug treatment court (DTC) program was associated with improved school performance. State administrative data from North Carolina courts, birth records, and school records were linked for 2005-2012. Math and reading end-of-grade test scores and absenteeism were examined for 5 groups of children, those with parents who: were not convicted on any criminal charge, were convicted on a substance-related charge and not referred by a court to a DTC, were referred to a DTC but did not enroll, enrolled in a DTC but did not complete, and completed a DTC program. Accounting for demographic and socioeconomic factors, the school performance of children whose parents were convicted of a substance-related offense was worse than that of children whose parents were not convicted on any charge. These differences were statistically significant but substantially reduced after controlling for socioeconomic characteristics; for example, mother's educational attainment. We found no evidence that parent participation in an adult DTC program led to improved school performance of their children. While the children of convicted parents fared worse on average, much--but not all--of this difference was attributed to socioeconomic factors, with the result that parental conviction remained a risk factor for poorer school performance. Even though adult DTCs have been shown to have other benefits, we could detect no intergenerational benefit in improved school performance of their children.

Barriers to reporting child maltreatment: do emergency medical services professionals fully understand their role as mandatory reporters?

BACKGROUND: Child maltreatment is underreported in the United States and in North Carolina. In North Carolina and other states, mandatory reporting laws require various professionals to make reports, thereby helping to reduce underreporting of child maltreatment. This study aims to understand why emergency medical services (EMS) professionals may fail to report suspicions of maltreatment despite mandatory reporting policies. METHODS: A web-based, anonymous, voluntary survey of EMS professionals in North Carolina was used to assess knowledge of their agency's written protocols and potential reasons for underreporting suspicion of maltreatment (n=444). Results were based on descriptive statistics. Responses of line staff and leadership personnel were compared using chi-square analysis. RESULTS: Thirty-eight percent of respondents were unaware of their agency's written protocols regarding reporting of child maltreatment. Additionally, 25% of EMS professionals who knew of their agency's protocol incorrectly believed that the report should be filed by someone other than the person with firsthand knowledge of the suspected maltreatment. Leadership personnel generally understood reporting requirements better than did line staff. Respondents indicated that peers may fail to report maltreatment for several reasons: they believe another authority would file the report, including the hospital (52.3%) or law enforcement (27.7%); they are uncertain whether they had witnessed abuse (47.7%); and they are uncertain about what should be reported (41.4%). LIMITATIONS: This survey may not generalize to all EMS professionals in North Carolina. CONCLUSIONS: Training opportunities for EMS professionals that address proper identification and reporting of child maltreatment, as well as cross-agency information sharing, are warranted.

Calmodulin regulation and identification of calmodulin binding region of type-3 ryanodine receptor calcium release channel.

Ryanodine receptors (RyRs) are a family of intracellular Ca(2+) channels that are regulated by calmodulin (CaM). At low Ca(2+) concentrations (<1 microM), CaM activates RyR1 and RyR3 and inhibits RyR2. At elevated Ca(2+) concentrations (>1 microM), CaM inhibits all three RyR isoforms. Here we report that the regulation of recombinant RyR3 by CaM is sensitive to redox regulation. RyR3 in the presence of reduced glutathione binds CaM with 10-15-fold higher affinity, at low and high Ca(2+) concentrations, compared to in the presence of oxidized glutathione. However, compared to RyR1 assayed at low Ca(2+) concentrations under both reducing and oxidizing conditions, CaM binds RyR3 with reduced affinity but activates RyR3 to a greater extent. Under reducing conditions, RyR1 and RyR3 activities are inhibited with a similar affinity at [Ca(2+)] > 1 microM. Mutagenesis studies demonstrate that RyR3 contains a single conserved CaM binding site. Corresponding amino acid substitutions in the CaM binding site differentially affect CaM binding and CaM regulation of RyR3 and those of the two other isoforms. The results support the suggestion that other isoform dependent regions have a major role in the regulation of RyRs by CaM [Yamaguchi et al. (2004) J. Biol. Chem. 279, 36433-36439].

Different regions in skeletal and cardiac muscle ryanodine receptors are involved in transducing the functional effects of calmodulin.

Calmodulin (CaM) inhibits the skeletal muscle ryanodine receptor-1 (RyR1) and cardiac muscle RyR2 at micromolar Ca(2+) but activates RyR1 and inhibits RyR2 at submicromolar Ca(2+) by binding to a single, highly conserved CaM-binding site. To identify regions responsible for the differential regulation of RyR1 and RyR2 by CaM, we generated chimeras encompassing and flanking the CaM-binding domain. We found that the exchange of the N- and C-terminal flanking regions differentially affected RyR1 and RyR2. A RyR1/RyR2 chimera with an N-terminal flanking RyR2 substitution (RyR2 amino acid (aa) 3537-3579) was activated by CaM in single channel measurements at both submicromolar and micromolar Ca(2+). A RyR2/RyR1 chimera with a C-terminal flanking the 86-amino acid RyR1 substitution (RyR1 aa 3640-3725) bound (35)S-CaM but was not inhibited by CaM at submicromolar Ca(2+). In this region, five non-conserved amino acid residues (RyR1 aa 3680 and 3682-3685 and RyR2 aa 3647 and 3649-3652) differentially affect RyR helical probability. Substitution of the five amino acid residues in RyR1 with those of RyR2 showed responses to CaM comparable with wild type RyR1. In contrast, substitution of the five amino acid residues in RyR2 with those of RyR1 showed loss of CaM inhibition, whereas substitution of the five RyR2 sequence residues in the RyR2 chimera containing the RyR1 calmodulin-binding domain and C-flanking sequence restored wild type RyR2 inhibition by CaM at submicromolar Ca(2+). The results suggest that different regions are involved in CaM modulation of RyR1 and RyR2. They further suggest that five non-conserved amino acids in the C-terminal region flanking the CaM-binding domain have a key role in CaM inhibition of RyR2.

Molecular basis of calmodulin binding to cardiac muscle Ca(2+) release channel (ryanodine receptor).

Calmodulin (CaM) is a ubiquitous Ca2+-binding protein that regulates the ryanodine receptors (RyRs) by direct binding. CaM inhibits the skeletal muscle ryanodine receptor (RyR1) and cardiac muscle receptor (RyR2) at >1 microm Ca2+ but activates RyR1 and inhibits RyR2 at <1 microm Ca2+. Here we tested whether CaM regulates RyR2 by binding to a highly conserved site identified previously in RyR1. Deletion of RyR2 amino acid residues 3583-3603 resulted in background [35S]CaM binding levels. In single channel measurements, deletion of the putative CaM binding site eliminated CaM inhibition of RyR2 at Ca2+ concentrations below and above 1 microm. Five RyR2 single or double mutants in the CaM binding region (W3587A, L3591D, F3603A, W3587A/L3591D, L3591D/F3603A) eliminated or greatly reduced [35S]CaM binding and inhibition of single channel activities by CaM depending on the Ca2+ concentration. An RyR2 mutant, which assessed the effects of 4 amino acid residues that differ between RyR1 and RyR2 in or flanking the CaM binding domain, bound [35S]CaM and was inhibited by CaM, essentially identical to wild type (WT)-RyR2. Three RyR1 mutants (W3620A, L3624D, F3636A) showed responses to CaM that differed from corresponding mutations in RyR2. The results indicate that CaM regulates RyR1 and RyR2 by binding to a single, highly conserved CaM binding site and that other RyR type-specific sites are likely responsible for the differential functional regulation of RyR1 and RyR2 by CaM.