The youngest victims of child maltreatment: what happens to infants in a court sample?

Current data show that infants represent an increasing proportion of cases of child maltreatment. To learn more about how infants fare in the current system and to provide baseline data against which to compare outcomes following recent legislative reforms, this study examined a subsample of infants in a sample of 200 care and protection cases brought before the Boston Juvenile Court in 1994. Child, parent, and case characteristics of infants 0 to 3 months of age (n = 46) were compared with characteristics of older children in the sample. All cases were followed prospectively for 4 years, and data were abstracted from court records. Results revealed that the infants were primarily children of substance abusers who had extensive prior histories of child protective service system involvement. Although the majority of the infants were eventually permanently removed from parental custody and adopted, many experienced time delays and multiple placements before achieving permanent homes.

What progress has been made in meeting the needs of seriously maltreated children? The course of 200 cases through the Boston Juvenile Court.

OBJECTIVES: The study examined child, parent, and case characteristics in a sample of 200 cases of serious child maltreatment brought before the Boston Juvenile Court (BJC) on Care and Protection petitions in 1994. Whether recent changes in Massachusetts law have been effective in reducing delays in adjudication and helping children achieve permanent placements more quickly was also examined. METHOD: Data were abstracted from court records by the research team. The 200 cases were followed prospectively for 4 years. Retrospective data on the families' previous involvement with the protective service system were also abstracted from the records. Data from the 1994 cases were compared to that obtained from a sample of cases brought before the BJC in 1985-1986. RESULTS: Children permanently removed from parental custody in the 1994 sample required less time post-disposition to achieve permanent placements. However, overall, time frames for the 1994 cases remained remarkably similar to those in 1985-1986: children were in the protective service system an average of 5 years; cases required an average of 1.6 years in court; and half of the children permanently removed from parental custody were still in "temporary" foster care at 4-year follow-up. CONCLUSIONS: Although some improvements have occurred since 1985-1986, the system still fails to meet the needs of seriously maltreated children to achieve permanent placements promptly. The implications of the findings for system reform are discussed.

Psychosocial morbidity: the economic burden in a pediatric health maintenance organization sample.

OBJECTIVES: To evaluate psychosocial morbidity in pediatric primary care and to determine displaced health care utilization. DESIGN AND SETTING: A cross-sectional sample of parent-child dyads was screened using the Pediatric Symptom Checklist (PSC) at 6 pediatric sites of a health maintenance organization (HMO). Cost and utilization data were retrieved from regional databases for this sample. PARTICIPANTS: Parent-child dyads from an HMO in northern California (N = 1840). The children ranged in age from 2 to 18 years. RESULTS: In all, 13.0% of children exhibited psychosocial dysfunction. The rate of children's chronic illness was 18.4%. Multiple regression analyses measured utilization and cost of health and psychiatric care for the selected population for the previous year; the average log cost of health care per child was $393. The average health care cost for children with anxious, depressed symptoms was $805. Chronically ill children were the highest utilizers of health care, with an average log cost of $1138. When psychosocial dysfunction was present, regression models showed that health care spending was highest for young children. CONCLUSIONS: Health care utilization was higher for children with psychosocial morbidity, was higher among younger children, and decreased with age as psychiatric costs progressively increased.

Psychosocial profile of adults with complex congenital heart disease.

OBJECTIVE: Despite the increasing number of adults with congenital heart disease (CHD), little is known of the emotional life of these long-term survivors; hence, we undertook a study to establish a psychological profile of these individuals so as to optimize their care. PATIENTS AND METHODS: We performed psychiatric evaluation by both interview and questionnaire on 29 ambulatory patients with CHD (mean age, 38 years; range, 26-56 years). RESULTS: Although many met symptomatic criteria for psychiatric diagnosis, most were functional in day-to-day life and used denial in adapting to their CHD. In childhood, extended absences from school, cyanosis, scars, and sports restrictions hindered friendships and conflicted with a sense of "normalcy"; teasing and low self-esteem were more notable in boys; girls more readily hid behind makeup, nail polish, and clothing. In adulthood most were concerned about shortened life expectancy, disability, and childbearing and child rearing. Virtually all were highly committed to both school and work performance. All but those with complete, uncomplicated early repair expressed unresolved frustration, anger, and fears of a future that might include further medical complications. CONCLUSION: Listening to this selected group of patients offers insight that may be helpful to the clinical care of patients with CHD and other patients with lifelong disease.

Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study.

BACKGROUND: Routine use of a brief psychosocial screening instrument has been proposed as a means of improving recognition, management, and referral of children's psychosocial morbidity in primary care. OBJECTIVE: To assess the feasibility of routine psychosocial screening using the Pediatric Symptom Checklist (PSC) in pediatrics by using a brief version of the checklist in a large sample representative of the full range of pediatric practice settings in the United States and Canada. We evaluated large-scale screening and the performance of the PSC in detecting psychosocial problems by (1) determining whether the prevalence of psychosocial dysfunction identified by the PSC was consistent with findings in previous, smaller samples; (2) assessing whether the prevalence of positive PSC screening scores varied by population subgroups; and (3) determining whether the PSC was completed by a significant proportion of parents from all subgroups and settings. PATIENTS AND METHODS: Twenty-one thousand sixty-five children between the ages of 4 and 15 years were seen in 2 large primary care networks: the Ambulatory Sentinel Practice Network and the Pediatric Research in Office Settings network, involving 395 pediatric and family practice clinicians in 44 states, Puerto Rico, and 4 Canadian provinces. Parents were asked to complete a brief questionnaire that included demographic information, history of mental health services, the 35-item PSC, and the number of pediatric visits within the past 6 months. RESULTS: The overall prevalence rates of psychosocial dysfunction as measured by the PSC in school-aged and preschool-aged pediatric outpatients (13% and 10%, respectively) were nearly identical to the rates that had been reported in several smaller samples (12%-14% among school-aged children and 7%-14% among preschoolers). Consistent with previous findings, children from low-income families were twice as likely to be scored as dysfunctional on the PSC than were children from higher-income families. Similarly, children from single-parent as opposed to those from 2-parent families and children with a past history of mental health services showed an elevated risk of psychosocial impairment. The current study was the first to demonstrate a 50% increase in risk of impairment for male children. The overall rate of completed forms was 97%, well within an acceptable range, and at least 94% of the parents in each sociodemographic subgroup completed the PSC form. CONCLUSIONS: Use of the PSC offers an approach to the recognition of psychosocial dysfunction that is sufficiently consistent across groups and locales to become part of comprehensive pediatric care in virtually all outpatient settings. In addition to its clinical utility, the consistency and widespread acceptability of the PSC make it well suited for the next generation of pediatric mental health services research, which can address whether earlier recognition of and intervention for psychosocial problems in pediatrics will lead to cost-effective outcomes.

Use of the pediatric symptom checklist in the pediatric neurology population.

The purpose of this study was to evaluate the effectiveness of the Pediatric Symptom Checklist (PSC) as a mental health screening instrument in a busy pediatric neurology population in comparison with more lengthy, time-consuming assessment methods. One hundred two children were screened using the PSC. PSC results were compared with scores on the Child Behavior Checklist (CBCL), results from structured interviews, and ratings of adaptive functioning using the Children's Global Assessment Scale (CGAS). Thirty-nine of the patients (38%) scored 63 or above on the CBCL, indicating psychosocial impairment. Using a cutoff score of 22, the PSC correctly identified 35 of these 39 positive cases (sensitivity 89.7) and 48 of the 63 children with CBCL scores below 63 (specificity 76.2). CGAS scores were significantly negatively correlated with PSC scores (r = -0.60, P < 0.05). The PSC correctly identified 85.9% of children who scored 70 or below on the CGAS. Among the 53 children with psychiatric diagnoses on the basis of the interview, 41 scored above the cutoff of 22 on the PSC. Results suggest that the PSC is an efficient and accurate screen for identification of mental health problems in the pediatric neurology population.

Supporting child psychiatric services using current managed care approaches: you can't get there from here.

For-profit behavioral health care companies have transformed the way mental health services are provided for children. Using marketplace approaches, companies have "carved out" mental health services for many patients receiving care from pediatricians. This report details specific approaches used by these firms to maximize profits, minimize the role of child and adolescent psychiatrists, and limit clinical services. Understanding for-profit carveouts will help primary care pediatricians appreciate the likely consequences of such reimbursement incentives for the care of children and their families.

Historical clues to the diagnosis of the dysfunctional child and other psychiatric disorders in children.

This article focuses on selected historical clues that can help the busy pediatrician identify children who are at risk for or already suffering from psychosocial dysfunction. Certain historical elements have been chosen because they reveal either common areas of childhood dysfunction or potentially dire outcomes. The major function realms of a child's life are covered, such as family, school, peer relationships, activities, and emotions, as well as related topics such as injury, poverty, substance abuse, and risk-taking behavior. Questions designed to elicit the relevant historical clues are suggested. Used as a set, these questions are intended to bring to light sufficient psychosocial history for pediatricians to identify most dysfunctional children.

Relationship between hunger and psychosocial functioning in low-income American children.

OBJECTIVE: Using large-scale surveys from nine states, the Community Childhood Hunger Identification Project (CCHIP) estimates that 8% of American children under the age of 12 years experience hunger each year. CCHIP operationalizes child hunger as multiple experiences of parent-reported food insufficiency due to constrained resources. The current study examined the relationship between food insufficiency and school-age, low-income children's psychosocial functioning. The study also assessed the interinformant (parent versus child) reliability and time-to-time reliability of the CCHIP measure. METHOD: Two hundred four school-age children and their parents from four inner-city public schools were interviewed using parent, teacher, and clinician report measures of psychosocial functioning. Ninety-six children and their parents were reinterviewed 4 months later. RESULTS: Hungry and at-risk for hunger children were twice as likely as not-hungry children to be classified as having impaired functioning by parent and child report. Teachers reported higher levels of hyperactivity, absenteeism, and tardiness among hungry/at-risk children than not-hungry children. Parent and child reports of hunger were significantly related to each other, and time-to-time reliability of the CCHIP measure was acceptable. CONCLUSIONS: Results of this study suggest that intermittent experiences of food insufficiency and hunger as measured by CCHIP are associated with poor behavioral and academic functioning in low-income children. The current study also supports the validity and reliability of the CCHIP measure for assessing hunger in children.