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may occur with other high risk behaviors. Students who carry weapons, smoke, and drink alcohol are at higher risk for engag ing in bullying. Negative parenting behavior is related to a moderately increased risk of becoming a bullyvictim (youth who are both perpe trators and targets) and small to moderate effects on being targeted for bullying at school. Some risk factors may be specific to cyberbullying. Among pre adolescent children, more access to technology (e.g., cell phone own ership) predicts cyberbullying behaviors and some types of digital victimization. Also, communications through digital technology can be misperceived as hostility, and those misperceptions can in turn increase electronic forms of bullying. Consequences of Bullying Involvement in any type of bullying is associated with poorer psycho social adjustment; perpetrators, targets, and those both perpetrator and target report greater health problems and poorer emotional and social adjustment. Consequences of both traditional and cyber forms of bullying are particularly significant in the areas of physical health, mental health, and academic achievement. Being the target of bullying is typically viewed as particularly stressful. The impact of this stress has been shown to affect the developing brain and to be associated with changes to the stress response system, which confers an increased risk for future health and academic difficulties. The long term conse quences of being bullied as a child include increased risk for depres sion, poor self esteem, and abusive relationships. Negative outcomes for perpetrating bullying include higher risks of depression and sub stance abuse. Mental health consequences for both perpetrator and target include, across types of bullying, increased risks of depression, poor self esteem, increased suicidality, and anxiety. Academic difficul ties include increased risk of poor school performance, school failure, and dropping out. SCHOOL VIOLENCE Epidemiology School violence is a significant problem in the United States. Almost 40 of U.S. schools report a least one violent incident to police, with 600,000 victims of violent crime per year. Among 9th to 12th grad ers, 8 were threatened or injured on school property in the last 12 months, and 14 were involved in a physical fight over the last year. Still, school associated violent deaths are rare. Seventeen homicides of children aged 5 18 years occurred at school during the 20092010 school year. Of all youth homicides, 2 occur at school. Although urban schools experience more episodes of violence, the rare rampage gun violence that happens in rural and suburban schools demonstrates that no region is immune to lethal violence. Risk Factors Bullying and weapon carrying may be important precursors to more serious school violence. Among perpetrators of violent deaths at school, 20 had been bullying victims, and 6 carried a weapon to school in the last 30 days. Nonlethal violence, mental health problems, racial tensions, student attacks on teachers, and the effects of rapid economic change in communities can all lead to school violence. Indi vidual risk factors for violence include prior history of violence, drug, alcohol, or tobacco use, association with delinquent peers, poor family
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functioning, poor grades in school, and poverty in the community. Family risk factors include early childbearing, low parental attach ment and involvement, authoritarian or permissive parenting styles (see Chapter 20), and poverty. There is more school violence in areas with higher crime rates and more street gangs, which take away stu dents ability to learn in a safe environment and leave many children with traumatic stress and grief reactions. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 102 Part I u The Field of Pediatrics TREATMENT AND PREVENTION OF BULLYING AND SCHOOL VIOLENCE Pediatric providers are in a unique position to screen, treat, and advo cate for reducing the impact of bullying and school violence by assist ing those affected and seeking to prevent further occurrences. Signs and Symptoms Signs of a child being involved in bullying or exposed to school violence include physical complaints such as insomnia, stomachaches, headaches, and new onset enuresis. Psychologic symptoms, such as depression (see Chapter 39), loneliness, anxiety (see Chapter 38), and suicidal ideation, may occur. Behavioral changes, such as irritability, poor concentration, school avoidance, and substance abuse, are common. School problems, such as academic failure, social problems, and lack of friends, can also occur. Additional vigilance is warranted for those children who repre sent vulnerable groups for bullying and aggression, including youth with disabilities; obesity; or minority, immigrant, or LGBTQ status. Screening for Bullying Assessing bullying and cyberbullying involvement is an important part of pediatric visits. Several tools can be helpful for clinicians, includ ing the Bright Futures Guidelines, which recommend screening at each well child visit. In these discussions, begin by normalizing the conver sation; for example, practitioners can let the patient know that bullying is a topic they discuss with all their patients. It is advisable to define bullying based on the uniform definition but using readily understand able and developmentally appropriate language. Physicians can ask patients if they have had experiences where there was repeated cruelty or mean actions between peers, either as a target of that cruelty or seeing the cruelty, or even being angry or mean toward others. Asking a patient if he or she is a bully is not likely to generate either trust or an honest answer. Asking about exposures to peer victimization or school violence is also important. Throughout these discussions, it is critical to provide support and empathy while engaging a patient. One tool to help providers begin and navigate these discussions is a Practice Enhancement Tool developed by the Massachusetts Aggres sion Reduction Center (MARC) and Childrens Hospital Boston (Fig. 15.1). It begins by defining bullying in readily understandable language and then asks, Is there any one kid, or a bunch of kids, that pick on you or make you feel bad over and over again? The tool also guides the practitioner in asking about problematic digital
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experiences and asks whom the child has spoken to about the problem and whether that has helped. Finally, it guides the practitioner through emphasizing the usefulness of talking about social problems and discusses how the physician can assist the patient. Children who are aggressive, overly confident, lacking in empathy, or have persistent conduct problems may need careful screening. It is important to bear in mind that bullying is a dynamic process, and a child may be involved as both a perpetrator and a target at different time points. The physical, behavioral, psychologic, and academic symp toms of bullying may overlap with other conditions, such as medical illness, learning problems, and psychologic disorders. Thus labeling the behavior as bullying rather than the child as a bully is recommended. Management of bullying and school violence involves several steps. First, ensure that all parties understand the relevant information (the patient, parents, and school). Second, assess a childs need for special ized counseling or social skills interventions. Extracurricular activities (e.g., drama clubs, mentoring programs, sports) can be discussed as avenues to help increase the childs social skills and self esteem. Third, ensure that the patient has adequate support, including at home and at school. Peers are a particularly effective source of support, and patients can be encouraged to spend time with friends, but parents and educa tors are also important sources of emotional support. Many children benefit from planning their actions in unstructured settings (e.g., dis cussing where they could sit during lunch), whereas some benefit from role playing. Finally, the clinician should identify safety issues, such as suicidal ideation and plans, substance abuse, and other high risk behaviors. When bullying or cyberbullying is suspected or confirmed, the parents and child should be offered education and resources. Some resources include the government supported website www.stopbullying.gov, as well as MARC. Both provide free downloadable literature that can be offered to parents and families. Addressing cases of bullying or exposure to violence in clinic often requires a cross disciplinary approach. Involving teachers or school counselors, as well as outside referrals to psychologists, social workers, or counselors, may be warranted. Parental mental health and resource risk factors should also be addressed. Prevention Pediatric clinicians can reasonably expect their patients schools to pro vide violence and bullying prevention programs. Rather than focus ing on only changing a target of bullying, successful interventions use whole school approaches that involve multiple stakeholders. School climate has been shown to have significant effects on bullying preva lence, so these approaches are essential to primary prevention. These broad based programs simultaneously include school wide rules and sanctions, teacher training, classroom curriculum, and high levels of student engagement. Addressing access to firearms, involving commu nity organizations and parents, and supporting youth mental health are important in creating a safe school climate. Prevention programs for cyberbullying are at a nascent stage, reflect ing uncertainty about the prevalence of the practice, who is perpetrating it and from where, and how students respond when they are victimized.
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Many schools have established cyberbullying policies and are increas ingly involved with teaching youth about guidelines for appropriate online interactions and monitoring for cyberbullying problems. As of 2016, 23 states included cyberbullying in their state antibullying laws, and 48 states included electronic harassment. Although legal remedies are frequently not the most productive answer to bullying and cyberbul lying incidents, pediatric clinicians should be aware of local laws and be prepared to refer parents to more information about these laws when necessary. Studies suggest that preventive interventions designed to address bullying have effects on cyberbullying, and vice versa. The American Academy of Pediatrics (AAP) provides a free online Family Media Use Plan that allows families to develop rules for digital media use and prompts for discussions about safety and online relation ships with the goal of preventing negative consequences of online behav ior and interactions. The tool is designed for ongoing discussions with family members about online experiences and family rules and values. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. 15.2 Media Violence Megan A. Moreno Todays youth are growing up in a media rich environment of both traditional and digital media. Traditional media includes television (TV), radio, and periodicals; digital media includes online content that promotes interactive and social engagement. The online world allows youth instant access to entertainment, information, and knowledge; social contact; and marketing. Social and interactive media allow users to act as both creators and consumers of content. Examples include applications (apps), social media, multiplayer video games, YouTube videos, and video blogs (vlogs). One of the earliest studies that has been linked to media effects on aggression and violence was the bobo doll experiment in which children who observed an aggressive adult model were more likely to be aggressive toward a doll afterward. It has been widely accepted that media exposure can affect behavior; the advertising industry is grounded in the concept that media exposure can change pur chasing behavior. Exposure to sexual content in media has been linked to earlier sexual initiation; exposure to pro alcohol content Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 15 u Impact of Violence Exposure on Children 103 Fig. 15.1 MARCBACPAC pediatric questionnaire on bullying and cyberbullying. Massachusetts Aggression Reduction Center and Bullying and Cyberbullying Prevention and Advocacy Collaborative. (Copyright 2013 Peter C. Raffalli, MD, and Elizabeth Englander, PhD.) Continued Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 104 Part I u The Field of Pediatrics Fig. 15.1 contd Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 15 u Impact
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of Violence Exposure on Children 105 Fig. 15.1 contd Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 106 Part I u The Field of Pediatrics has been linked to earlier alcohol initiation. However, applying these same constructs to media violence has been controversial. Some suggest that other concepts may be important to consider, such as dose response effects of media or gene environment interactions. There are three main types of media in which children may be exposed to violence: video games, traditional media, and social media. Violent video game exposure is associated with several outcomes, including increases in composite aggression score, aggressive behavior, aggressive cognitions, aggressive affect, and desensitization; decreased empathy; and increased physiologic arousal. Several mechanisms for these outcomes have been studied. These have included evaluating links between video game violence and the limbic or reward areas of the brain, as well as through other cognitive processes, including skill acquisition, cognitive control, and attention. Traditional media such as movies and TV often model violent behavior for the purposes of entertainment. Media violence does not always portray the real human cost or suffering caused by violence. Special effects can make virtual violence more believable and appeal ing than in the real world. For some children, exposure to media vio lence can lead to anxiety, depression, posttraumatic stress disorder, or sleep disorders and nightmares. Repeated exposure to the behavioral scripts provided by entertainment media can lead to increased feelings of hostility, expectations for aggression, desensitization to violence, and increased likelihood of interacting and responding to others with violence. Social media presents similar risks of exposure to virtual violence, but because of the interactive nature of the medium, this content can feel more personal, relevant, or targeted. Social media combines peer and media effects and thereby represents a powerful motivator of behavior, whether content created by adolescents themselves or con tent they find and share with peers. The Facebook Influence Model describes 13 distinct constructs in which social media may influence users, such as establishing social norms and connection to identity. Thus exposure to violent content on social media may have an influ ence in promoting a social norm or connecting this type of content to ones own identity. SCREENING It is important for pediatricians to screen and counsel patients and families about media use and exposure to violent content. Both the quantity and the quality of media are critical factors in media effects on children. When heavy media use by a child is identified, pediatri cians should evaluate the child for aggressive behaviors, fears, or sleep disturbances and intervene appropriately. RECOMMENDATIONS (SEE TABLE 15.1) Pediatricians can counsel parents to help their children avoid exposure to any form of media violence under age 8 years. These younger children do not have the capacity to distinguish fantasy from reality. Parents should select and co view media with
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their children, including playing video games with them, watching movies together, and co viewing social media content. Parents can then assess these games and shows in regard to what they are teaching about communi cation and interactions with others. Parents should feel empowered to place restrictions on games or shows that reward shooting, killing, or harming other people. Media are powerful teachers, and parents can make choices about how much violence they want their children to learn. Parents can use industry ratings, such as from the Motion Picture Association of America and the Entertainment Software Ratings Board for movies and TV, as well as resources such as Commonsense Media (which also includes video game reviews), to guide media selections. Visit Elsevier Ebooks at eBooks.Health.Elsevier.com to read this chapter. 15.3 Effects of War on Children Isaiah D. Wexler and Eitan Kerem The adverse consequences of war on children are devastating and long lastingdeath, injury, loss of family members, conflict associated sexual violence, food insecurity, forced relocation (prejudice and discrimination in the receiving country), coercive conscription, child abduction, and psychologic trauma. Human rights organizations and the Secretary General of the United Nations annually detail the extent and impact of war on children. These reports clearly establish that war is a global phenomenon associ ated with a staggering intensity of human rights violations involv ing children. Approximately 426 million live in a conflict zone, and 1.6 billion children (0 18 years) live in a conflict affected country (Fig. 15.2). The recent onset of largescale hostilities between Rus sia and Ukraine in 2022 has had a significant impact on children, especially displacement. During the last decade, there has been an increase in armed conflict associated exploitation in the form of human trafficking, slavery, forced marriages, prostitution, and child labor. Displacement and forced reloca tion are on the rise as a result of the increasing number of intrastate con flicts, especially in the Middle East and Africa. In 2020, UNHCR (Office of the United Nations High Commissioner for Refugees) reported the Conflictaffected countries Conflict zones Fig. 15.2 Conflict affected countries and conflict zones, 2019. Overlays of the conflict affected countries with the conflict zones where actual fighting took place in 2019. Conflicts are usually concentrated in limited geographical areas within countries. (From stby G, Rustad SA, Tollefsen AF. Children affected by armed conflict, 19902019. Conflict Trends, vol 6. Oslo: PRIO;2020: Figure 1. https:www.prio.orgpublications12527.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 15 u Impact of Violence Exposure on Children 107 astounding statistic of 82.4 million people forcibly displaced worldwide, with most of the refugees being sheltered in developing countries that lack adequate resources to deal with large scale humanitarian crises. In Ukraine, the United Nations Office for the Coordination of Humanitar ian Affairs reported that 2 million children had been internally displaced at the end of 2022. Reemergence
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of polio or cholera and the increased virulence of tuberculosis have been associated with conflict affected regions and large population displacements. The COVID 19 pandemic that began in 2020 has worsened the existing situation, with widespread disruption of health and educational services provided by domestic healthcare systems and humanitarian organizations. Mortality and morbidity related to the long term effects of war and civil strife are as significant as those occurring during actual fighting. War and violence are rarely listed as leading causes of childhood mortality, but the regions with the highest levels of child mortality, especially among children 5 years of age, are the same locations involved in military con flicts. Nations experiencing conflict often devote substantial portions of their budgets to military expenditures at the expense of the healthcare infrastructure; a substantial proportion of deaths attributed to malnutri tion, environmentally related infectious disease, or inadequate immuni zation are related to the effects of war. Children experiencing the trauma of wartime violence are at risk for long term health sequelae, with greater risk for obesity, hypertension, stroke, and cardiovascular disease. During wartime, customary patterns of behavior are forced to change, overcrowding is frequent, and essential resources, such as water and food staples, may be polluted or contaminated. There is a growing understanding that war and climate change are linked. Armed conflict can worsen the impact of spreading desertification, and com petition for scarce resources can serve as a stimulus for war. The morbidity of children exposed to conflicts is significant and long term (Table 15.2). Many more children are physically harmed than killed. Children bear the psychologic scars of war resulting from exposure to violent events, loss of primary caregivers, and forced removal from their homes. Impressment of children into ser vice as soldiers is a form of exploitation associated with long term problems of adjustment. Child soldiers often lack the appropriate education and socialization, and thus their moral compass is often misaligned. They are often incapable of understanding the sources of conflict or why they have been targeted. Their thought processes are more concrete; it is easier for them to dehumanize their adver saries. Children, who themselves are exposed to violence and cru elty, frequently become the worst perpetrators of atrocities. After cessation of hostilities, children are still at risk for life endangering injuries from landmines, unexploded ordinance, and other explosive remnants of war. Before the signing of the inter national treaty to ban landmines in 1997, an estimated 20,000 25,000 casualties occurred annually from landmines. Despite the ban, there are still a significant amount of casualties reported, with over 7,000 casualties in 2020 according to Landmine and Cluster Munition Monitor, a nongovernmental organization monitoring adherence to the international treaty. Approximately 30 of these casualties occur in children, with a predominance of males. The continued proliferation of small arms and light weapons, which are easily handled by children, also continues to take its toll on human life and hinders stabilization in post conflict societies. SUSCEPTIBILITY OF CHILDREN IN TIMES
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OF WAR Children do not have the physical or intellectual capabilities to defend themselves. It is easier for adults to victimize children than other adults. Older childrens curiosity, desire for adventure, and imperfect assessment of risk often lead them to participate in dan gerous behavior. Younger children, because of their small size and immature physiology, are more susceptible to disease and starvation and are more likely to sustain fatal injuries from ballistic projectiles and explosive devices such as mines. Blast injuries, a common cause of violence related injuries, have a more devastating impact on chil dren than on adults. Specific types of military engagement can have a disproportionate effect on children. In a survey of war related mor tality in Iraq from 2003 to 2008, it was found that approximately 10 of the violence related fatalities were children. Most children suc cumbed to either small arms gunfire or suicide bombs (35). Data collected during the Syrian civil war from 2011 to 2016 showed that 17 of the approximately 100,000 fatal civilian casualties were chil dren, with over 70 of male children succumbing as a result of artil lery shelling or aerial bombardments. During times of war, there is a breakdown of social inhibitions and cultural norms. Exploitation of children, such as forced mar riages or involuntary conscription, are rationalized as being benefi cial for the greater cause. Aberrant behavior such as rape, torture, and pillaging, which would be inconceivable in times of peace, is common during war. Children may be attacked, kidnapped, or used as human shields. The changing nature of war has adversely affected children. Conventional warfare in which armies of professional soldiers representing different countries battle each other has become less common since World War II, with the notable exception of the RussiaUkraine war Intrastate conflicts in the form of civil war or insurgency predominate. In 2020, there were over 50 active intra state armed conflicts in the world, as documented by the Uppsala Conflict Data Program (UCDP). These conflicts are often rooted in factious ethnic, political, or religious ideologies, and the partici pants are frequently nonprofessional irregulars who lack discipline and accountability to higher echelons and are directed by those who do not acknowledge or respect international accords governing war fare. Often the military resources of the antagonists are dispropor tionate, leading the weaker protagonist to develop compensatory Table 15.2 Impact of War on Children PHYSICAL Death Sexual violence (pregnancy, genital trauma, STIs) Amputations and fractures Head trauma Ballistic wounds Blast injuries Burns Chemical and biologic induced respiratory disease Malnutrition and starvation Infectious disease Toxicity from polluted natural resources Torture PSYCHOSOCIAL Abduction Displacement Loss of caregivers and family members (orphaned) Child assuming adult roles (labor, parenting sibling) Separation from community Lack of education Inappropriate socialization Acute stress reaction Posttraumatic stress disorder Depression Maladaptive behavior EXPLOITATION Conscription as soldiers Coerced involvement in terrorist activities Prostitution Slavery Forced adoption STI, Sexually transmitted infection. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April
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20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 108 Part I u The Field of Pediatrics tactics that can include guerrilla, paramilitary, and terrorist activi ties, while the stronger side often resorts to the disproportionate use of force. Low intensity conflicts have become more common. These types of conflicts are often characterized by military activities targeting civilian populations with the goal of disrupting normal routines and generating publicity for the perpetrators. Sites of vio lence can be remote from the battleground when one or both parties to a conflict resort to terrorist activities. Terrorism and organized urban based gang warfare have become prevalent. Violence perpetrated by terrorist groups or gangs is designed to coerce and intimidate both individuals and entire soci eties. Children are often intended victims of political or religious motivated violence because this serves to maximize the impact of terrorism. The destruction of the New York City World Trade Cen ter Towers in 2001 and the nearly 3,000 fatalities showed that highly organized and motivated terrorists have few inhibitions and can strike anywhere. Biologic and chemical weapons of mass destruc tion have been employed, with the most recent example being the use of poisonous gases in the Syrian civil war. Children are more susceptible to chemical and biologic toxins because of their higher respiratory rates, more permeable skin, and other developmental vulnerabilities (see Chapter 763). The media and the internet have had a significant role in exac erbating the effects of war on children. Media coverage of war and terrorist events is extensive and visual, and social media promul gated via the internet is a convenient tool for disseminating pro paganda and graphic video material designed to recruit volunteers and shock opponents. Children, more impressionable than adults, often view this material uncontrolled. Uncensored pictures of victims, unbridled violence, people in shock, or family members searching through ruins for relatives may traumatize children and even encourage inappropriate behavior. Overt broadcast propa ganda glorifying war and violence may sway children to participate in militaristic or antisocial activities (see Chapter 15.2). PSYCHOLOGIC IMPACT OF WAR Exposure to war and violence can have a significant impact on a childs psychosocial development. Displacement, loss of caregivers, physical suffering, and the lack of appropriate socialization all con tribute to abnormal child development. Often the reactions are age specific (Table 15.3). Preschoolers may have an increase in somatic complaints and sleep disturbances and display acting out behav iors such as tantrums or excessively clinging behavior. School aged children may show regressive behavior such as enuresis and thumb sucking. They, too, have an increase in somatic complaints; there is often a negative impact on school performance. For teenagers, psychologic withdrawal and depression are common. Adolescents often exhibit trauma stimulated acting out behavior. Motivated by the desire for revenge, they may be quick to join in the violence and contribute to the continuation of conflict. There is an increased incidence of both acute stress reactions and posttraumatic
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stress disorder (PTSD; see Chapter 38). The true incidence is difficult to assess because of the heterogeneous nature of war, degree of exposure to violence, and methodologic challenges related to the precise characterization of PTSD. Risk factors for having a more serious psychologic response to a violent event include severity of the incident, personal involvement (physi cal injury, proximity, loss of a relative), prior history of exposure to traumatic events, female gender, and a dysfunctional parental response to the same event. Children may develop PTSD many years after the traumatic event. Children do not have to be directly exposed to violent activity, and media coverage of terrorist events may be sufficient to trigger PTSD like symptomatology. The trauma experienced by children during war can have lifelong effects. Studies on children imprisoned in concentration camps or evacuated from their homes in London during the Battle of Britain show that these individuals were at greater risk for PTSD, anxiety disorders, and a higher level of dissatisfaction with life when sur veyed decades after the traumatic events. Depression is often a comorbid condition associated with PTSD among children exposed to armed conflict. Trauma may have a transgenerational effect, with biologic stress responses and environmental influences caus ing children of PTSD victims to display a wide variety of psycho logic disorders. On the positive side, children are more resilient than adults. With appropriate support from family and community, together with timely and intensive psychologic intervention, chil dren can recover and lead normal, productive lives despite the sear ing trauma that they may have experienced. EFFORTS TO PROTECT CHILDREN FROM THE EFFECTS OF WAR International Conventions War and terror violate the human rights of children, including the right to life, the right to be nurtured and protected, the right to develop appropriately, the right to be with family and community, and the right to a healthy existence. Several international treaties and conventions have been ratified, beginning with the Fourth Geneva Convention (1949) that set forth guidelines regarding appropriate treatment of children in times of war. The United Nations Conven tion on the Rights of the Child (1990) delineated specific human rights inherent to every child (defined as any individual younger than 18 years) and the subsequent First Optional Protocol (2000), which prohibits conscripting or recruiting children for military activities. The Third Optional Protocol in 2014 established meth ods for communicating complaints of human rights violations involving children to the United Nations Committee on the Rights of the Child and sets up procedures by which the committee can Table 15.3 Manifestations of Stress Reactions in Children and Adolescents Exposed to Armed Conflict CHILDREN 6 YR Excessive fear of separation Clinging behavior Uncontrollable crying or screaming Freezing (persistent immobility) Sleep disorders Terrified affect Regressive behavior Expressions of helplessness and passivity CHILDREN 7 11 YR Decline in school performance Truancy Sleep disorders Somatization Depressive affect Abnormally aggressive or violent behavior Irrational fears Regressive and childish behavior Expressions of fearfulness, withdrawal, and worry ADOLESCENTS 12 17 YR Decline in
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school performance Sleep disturbances Flashbacks Emotional numbness Antisocial behavior Substance abuse Revenge fantasies Suicidal ideation Withdrawal Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 15 u Impact of Violence Exposure on Children 109 conduct inquiries into alleged human rights violations among sig natory nations. The Rome Statute of the International Criminal Court enacted in 2002 declared that the conscription or enlist ment of children younger than 15 years is a prosecutable war crime. Despite these conventions and better documentation, human rights violations have not abated. In the past decade there has even been an upswing in the recruitment of child soldiers as combatants by nonstate armed groups (NSAGs). Although these treaties and conventions define the extent of protection afforded to children, the means of enforcement avail able to the international community is limited. Individuals, moti vated by religious fervor, nationalistic zeal, or ethnic xenophobia, are unlikely to curb their activities because of fear of prosecu tion. These treaties better serve in heightening awareness regard ing the protected status of children in wartime, and perhaps deter high ranking leaders who fear being held accountable for war crimes. Humanitarian Efforts Several organizations, either nongovernmental or under UN aus pices, are involved in mitigating the effects of war on children. The International Red Cross, UNICEF, UNHCR, International Rescue Committee, World Health Organization (WHO), and Mdicins Sans Frontires (Doctors Without Borders) have had a significant impact on reducing violence related casualties in war torn regions. During the RussiaUkraine war, many countries sent medical teams including pediatricians to Ukraine and neighboring countries hosting refugees to provide assistance. The infusion of humanitarian aid into developing countries often improves overall mortality and morbidity by increasing the level of medical and social services available to the general popula tion. Other organizations, such as Amnesty International, Stockholm International Peace Research Institute, and Physicians for Human Rights, actively monitor human rights abuses involving children and other civilian groups. In 2005 the UN Security Council approved the establishment of a monitoring and reporting system designed to pro tect children exposed to war. UN led task forces conduct active sur veillance in war stricken regions reporting on the six grave violations against children during armed conflict: the killing or injuring of chil dren, recruitment of child soldiers, attacks directed against schools or hospitals, sexual violence against children, abduction of children, and denial of humanitarian access for children. ROLE OF PEDIATRICIANS AND ALLIED HEALTH PROFESSIONALS War is a chronic condition, and health providers need to be prepared to treat childhood casualties resulting from military or terrorist activ ity, as well as caring for children suffering from the aftermath of war or related violence. Community and hospital pediatricians need to be involved in community disaster planning. General disaster planning should not ignore the unique needs and requirements of children; in planning for a possible chemical attack, appropriate
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resuscitation equipment suitable for children needs to be stockpiled. The signs of biologic infection, chemical intoxication, or radiation injury are dif ferent for children, and pediatricians and emergency personnel need to be aware of these differences (see Chapters 758 and 763). Surveys of pediatricians and other healthcare providers indicate that many feel unprepared for bioterrorism attacks. Professional organizations (e.g., WHO, American Academy of Pediatricians AAP, Centers for Disease Control and Prevention CDC) have published posi tion papers, and the AAP Red Book presents guidelines for treating specific pathogens likely to be used in biologic warfare. In regions where violent terrorist activity is likely, pediatricians, nurses, and rescue personnel should obtain certification provided by Red Cross Basic and Advanced Trauma Life Support programs. The U.S. Depart ment of Health and Human Services sponsors a Technical Resources, Assistance Center, and Information Exchange (TRACIE) website that includes information for health service providers related to disas ter management and preparedness for incidents involving children (asprtracie.hhs.gov). Pediatricians need to be aware of the potential effects of war and terror on parents and children. Loss or separation from parents or care givers has a devastating impact on children (see Chapter 30). Parents, who themselves are under tremendous strain, may not be sensitive to the effects that the same stressors have on their children. Parents and caregivers must be made cognizant of the effect that media coverage can have on their children and their role in the intermediation of the repetitive broadcast of real time acts of violence and incendiary com munications designed to enlist support for specific causes. Pediatri cians should draw out both parents and children and encourage them to talk freely about their feelings. Child healthcare providers can be instrumental in educating parents to be more aware of inappropriate responses by children to war and violence. When necessary, pediatri cians can serve their families by referring them to appropriate support services. Just as it is important to administer first aid for physical trauma, it is also critical to provide psychologic first aid to victims of trauma. An excellent source of online information for both providers and caregivers is the U.S. governmentsponsored National Child Traumatic Stress Network (nctsn.org). In day to day patient inter actions, a pediatrician is most likely to confront situations related to stress reactions such as PTSD or depressive disorders. Recogni tion of PTSD is essential so that early treatment can be initiated. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) stipulates that for a diagnosis of PTSD, there has to be manifestations from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and altera tions in arousal and reactivity. DSM 5 also established a special pre school subtype of PTSD that has the same four symptom clusters but with specific manifestations typical of preschoolers exposed to trauma. Clues to the presence of PTSD and acute anxiety reac tions include changes in behavior, school performance, affect, and sleep patterns and an increase in somatic
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complaints. Even when the triggering event is neither temporally nor physically proximate, it should not dissuade the pediatrician from making an appropriate referral to mental health professionals who are expert in childhood stress disorders. Medical professional standards demand that the physician treat all patients equitably without regard to their background. Both international law and professional medical societies ban physi cians from actively participating in torture or other activities that infringe on human rights, including those of children. It is diffi cult to countenance any situation in which a health professional, even acting as a representative of their country, might directly or indirectly injure a minor. On the positive side, many pediatricians and other physicians have treated children during war either as members of the armed services or volunteers, often under adverse conditions, refusing to abandon their patients even when it has put their own lives at risk. Pediatricians and pediatric organizations have been at the forefront in advocating for peaceful coexistence, assisting in relief efforts, and attempting to alleviate the disparities in healthcare resulting from war. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 110 Part I u The Field of Pediatrics Human trafficking violates the fundamental human rights of affected children, adolescents, and adults and affects families, com munities, and societies. Trafficked persons originate from countries worldwide and may belong to any racial, ethnic, religious, socio economic, or cultural group. They may be of any gender. Accord ing to the United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons, child trafficking refers to the recruitment, transportation, transfer, harboring or receipt of a person under 18 years old for purposes of exploitation. Two major types of traf ficking involve forced labor and sexual exploitation (Table 16.1). Whereas adult sex trafficking requires demonstration of force, fraud, coercion, deception, or the abuse of power as a means of exploitation, these are not required for persons younger than 18 years. Interpretation of the international protocol varies across the globe; U.S. law does not require movement of a victim to qualify as human trafficking. In addition, minors who consent to com mercial sex in the absence of a third party (trafficker) are victims of commercial sexual exploitation, because their age precludes true informed consent. Child trafficking may occur within the confines of the childs home country (domestic trafficking) or may cross national borders (interna tional, or transnational, trafficking). Globally, individuals tend to be trafficked within their own country or to a country in the same region. In the United States, most identified children and adolescents experi encing sex trafficking are U.S. citizens or legal residents; few statistical data exist on minors who are trafficked for labor. Variations in defini tions of terms, problems with data collection, and underrecognition of affected individuals complicate estimates of the prevalence of human trafficking,
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but the International Labour Organization estimates that approximately 3.3 million children and adolescents across the globe experienced forced labor in 2021, of whom approximately 1.7 million were subjected to commercial sexual exploitation. In a global study of officially identified trafficked persons, the United Nations Office on Drugs and Crime estimated that approximately 19 were girls and 15 boys. However, laws that define sexual exploitation in terms of females and women, as well as cultural views regarding gender roles, lead to underreporting of males, especially as victims of sex trafficking, so their numbers may be higher than estimated. Factors creating vulnerability to human trafficking exist at the individual, relationship, community, and societal levels (Table 16.2). Age is an important risk factor for adolescents because they are at a stage in their development at which they have limited life experience, a desire to demonstrate their independence from parental control, and a level of brain maturation that favors risk taking and impul sive behaviors over careful situational analysis and other executive functions. They are also very interested in social media and are savvy at internet use, which render them susceptible to online recruitment and solicitation. Recruitment of children and adolescents for labor or sex trafficking often involves false promises of romance, job opportunities, or a better life. Individuals may remain in their exploitative situation for a num ber of reasons, including fear of violence to themselves or their loved ones should they attempt to leave their situation; guilt and shame for believing the fraudulent recruitment scheme or engaging in illegal and or socially condemned activities; humiliation and fear of criticism by authorities; debt bondage (believing they owe the trafficker exorbitant amounts of money and cannot leave until the debt is paid); and fear of arrest andor deportation. Many children and adolescents do not view their situation as exploitative. Females who believe their trafficker is a boyfriend may view their commercial sexual activities as demonstra tions of their love; males engaging in commercial sex to obtain shelter or food while living on the street may feel they are exploiting buyers rather than being victimized themselves. Traffickers may use violence, economic manipulation, and psychologic manipulation to control individuals. CLINICAL PRESENTATION Children and adolescents who experience trafficking may seek medical care for any of the myriad physical and emotional condi tions associated with exploitation. They may present with traumatic injuries inflicted by traffickers, buyers, or others or injuries related to unsafe working conditions. They may present with a history of sexual assault or symptomssigns of sexually transmitted infections (STIs) and infections related to overcrowded, unsanitary conditions. They may request testing for HIV or complain of signssymptoms of HIV or infections endemic to their home country (e.g., malaria, schistosomiasis, tuberculosis). Other clinical presentations may involve pregnancy and complications of pregnancy or abortion; malnutrition andor dehydration; exhaustion; conditions related to exposure to toxins, chemicals, and dust; and signs and symptoms of posttraumatic stress disorder (PTSD), major depression, suicid ality, behavioral problems including aggression, and somatization. Some children and
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adolescents may have preexisting chronic medi cal conditions that have been inadequately treated before or during the exploitation (e.g., diabetes, seizure disorder, asthma). Individu als who are trafficked may also seek medical care for their children. Many of the same factors that prevent children and adolescents from leaving their exploitative conditions also preclude them from disclosing their situation to others. Most affected individuals presenting for medical care at clinics, hospitals, and emergency departments do not spontane ously self identify as trafficked persons. Consequently, it is incumbent on the medical professional to be aware of risk factors so that those being trafficked and those at risk may be recognized and offered services. A trafficked individual may present to a medical facility alone, in the com pany of a parentguardian (who may or may not be aware of the traffick ing situation), a friend or other person not involved in the trafficking, a person working for the trafficker (who may pose as a friend or relative), Chapter 16 Child Trafficking for Sex and Labor V. Jordan Greenbaum Table 16.1 Types of Exploitation Included in Child Trafficking Sexual Exploitation Prostitution of a child Production of child sexual exploitation materials (child pornography) Exploitation in context of travel and tourism Having a minor perform sex acts in a sexual venue (e.g., strip club) Child marriage or forced marriage Live online sexual abuse Labor Exploitation Agriculture, manufacturing, textiles, foodhospitality services Domestic work Construction Magazine sales Health and beauty Cleaning services Forced Begging Forced Criminality Forced Engagement in Armed Conflict Illegal Adoption Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 16 u Child Trafficking for Sex and Labor 111 or the trafficker. Traffickers may be male or female, adult or juvenile, and they may be family members, acquaintances, friends, or strangers. On occasion, children and adolescents are brought in by law enforcement or child protective services because of concerns of trafficking. Table 16.3 lists potential red flags for labor or sex trafficking. In some cases, the red flag may be the chief complaint, which may involve a condition fre quently associated with trafficking (e.g., STI symptomssigns, especially with history of prior STI, and a preventable work related injury such as a toxic exposure). The practitioner may become concerned about possible trafficking on recognizing the presence of one or more risk factors (e.g., runaway status, recent migration and current work in a sector known for labor trafficking). APPROACH TO THE PATIENT AT RISK FOR TRAFFICKING When interacting with a patient who may have experienced labor or sex trafficking, the medical provider should use a trauma informed, human rightsbased, culturally appropriate, and gender sensitive approach (Table 16.4). This involves an awareness that trauma experienced by a young person may influence the childs thoughts about themselves and others, their beliefs and perceptions of the world, and their behavior. Hostility, withdrawal, or distrust may
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be reactions to trauma and should be met with a sensitive, nonjudgmental, empathic response by the pro vider. Physical safety of the patient and staff are critical, and protocols should be in place to address security issues that may arise if the trafficker is on the premises. Psychologic safety of the patient may be facilitated by separating them from any accompanying person when obtaining the medical history, conducting the visit in a warm, child friendly environ ment, and taking adequate time to build rapport and begin to establish trust. When interpretation is needed, a professional interpreter should be used. This person needs to be trained in trauma informed care and should not be from the same community as the patient. When possible, the patients preference for gender of clinician and interpreter should be respected. Respect for the patients rights is essential, including the right to an explanation regarding the purpose of the questions being asked and the reasons for, and elements of, the examination and diagnostic evaluation. Informed assent by the patient for all steps of the process should be obtained whenever possible. Every attempt should be made to understand and respect cultural, gender based, and religious factors that may affect the individuals views of their bodies, their condition, and their desired treatment. The limits of confidentiality should be explained in a way the patient understands so that they are able to choose what information to dis close. This should occur before asking sensitive questions. As appro priate to developmental stage and the context of the visit, the provider should discuss how sensitive information is to be documented in the individuals medical record and work collaboratively to honor the patients preferences and desire for privacy and confidentiality (within the bounds of laws, policies, and the need to ensure appropriate con tinuity of care). Currently, there are limited child trafficking screening tools designed for the healthcare setting. The Short Screen for Child Sex Trafficking (SSCST) is validated for youth 11 17 years who pres ent to emergency departments, child abuse clinics, and teen clinics; this tool screens for risk factors associated with sex trafficking; a positive screen indicates a child is at risk, and additional follow up questions are needed to assess the level of risk and to determine next steps (e.g., specific service referrals, mandatory reporting). It does not screen for labor trafficking. The Quick Youth Indicators of Trafficking (QYIT) is a short screen designed for young adults Table 16.3 Potential Red Flags for Child Trafficking RED FLAGS AT PRESENTATION Chief complaint of acute physical or sexual assault Chief complaint of suicide attempt or ideation Patient accompanied by unrelated adult or juvenile Patient or parent accompanied by domineering person who appears in hurry to leave Patient or parent appears intimidated or fearful Patient or accompanying person provides inconsistent or unlikely history of events Patient unfamiliar with citytown, cannot provide address where staying PHYSICAL FINDINGS Patient withdrawn and with flat affect, fearful, very anxious, intoxicated, or with inappropriate affect Evidence of
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remote or acute inflicted injury (suspicious burns, bruising, signs of strangulation, fractures, closed head injury, thoracoabdominal trauma) Evidence of preventable work injury, toxic exposure, overuse injury, or untreated injury Malnutrition with or without dehydration Poor dentition andor dental trauma Late presentation of illnessinjury Table 16.2 Risk Factors for Child Trafficking INDIVIDUAL Member of marginalized group (e.g., racial, ethnic, sexual minority, caste) History of sexualphysical abuse or neglect Limited education Unaccompanied immigrant status Substance misuse Homelessrunaway status; told to leave home History of child welfare andor juvenile justice involvement (U.S., sex trafficking) Untreated mental or behavioral health condition RELATIONSHIP Family poverty Family violence, substance misuse, or other dysfunction Forced migration Familypeers involved in trafficking Intolerance of LGBTQ status Significantly older intimate partner COMMUNITY Limited resources (economic, educational, social support) Tolerance of traffickingexploitation Natural disaster Community violence Limited knowledge of traffickingexploitation Increased tourism, travel to area SOCIETAL Cultural beliefs about roles and rights of children Gender biasdiscrimination Cultural beliefs and practices that marginalize and disempower groups (e.g., transphobia, xenophobia) Tolerance of exploitation Systemic racism and discrimination Tolerance of violence Societaleconomichealth inequity and inequality Social or political upheaval Inadequate laws regarding trafficking; corruption LGBTQ, Lesbian, gay, bisexual, transgender, queerquestioning, and other. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 112 Part I u The Field of Pediatrics (18 25) seeking services at a homeless shelter; it screens for both labor and sex trafficking. When a provider is speaking with a child at perceived risk for traffick ing, additional questions may be asked once trust has been established. These should be asked using a trauma informed approach. For example, Many children who are living on the street have a hard time getting money for food and shelter. Sometimes they have to exchange sex to get what they need. Has this ever happened to you or anyone you know? When asking about sexual history: Has anyone ever asked you or forced you to have sex with another person? Do you feel comfortable telling me about it? If you feel comfortable, can you tell me a little bit about your job? Is the work you do what you expected when you agreed to the job? Are you allowed to keep all of the money you earn or send it home? Where, and with whom, do you live? When you are not working, are you allowed to come and go from the place you stay? Such questions may open the door to a discussion of exploitation and facilitate the provider identifying appropriate resources and referrals. All elements of the medical history and review of systems are important, but special attention should be paid to reproductive his tory (including sexual orientation and gender identity, prior history of sex partners, STIs, pregnancy and terminations, and condom use); injury history; substance usemisuse; and mental health history and current symptoms. Rates of substance misuse, PTSD,
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depression, and suicidality are very high among individuals experiencing human traf ficking, and questioning may highlight the need for emergency care or nonurgent referrals. It also provides an opportunity for anticipatory guidance aimed at harm reduction: a discussion of condom use, STIs, HIVAIDS, and substance use may prove invaluable, because many youth lack accurate information on these topics. It is important to identify any chronic conditions, especially if untreated, and to assess vaccination status. Many individuals who have experienced traffick ing have had very poor healthcare in the past and lack basic primary care. It is important to ask questions about signssymptoms of infec tions endemic to the childs home country or to countries in which the child has been trafficked (e.g., tuberculosis, dengue, malaria; see Chapter 11). EXAMINATION AND DIAGNOSTIC TESTING A thorough physical examination allows the provider to assess and treat acute and chronic medical conditions, collect forensic evidence (as appropriate), assess nutritional and developmental status, and document recent and remote injuries. Diagnostic testing may identify pregnancy, STIs, HIV seroconversion, nonsexually transmitted infec tions, vitamin and mineral deficiencies, anemia, toxic exposures, and drug or alcohol use. A sexual assault evidence kit may reveal trace evi dence or DNA from offenders. Informed assent for the exam, assault kit, and diagnostic tests is important, as is careful explanation of each step during the process and monitoring of the patient for signs of dis tress and anxiety. Those who have been sex trafficked may experience particular distress during the anogenital examination, the oral exam, and when injuries are photographed. A trauma trained chaperone is very helpful in providing comfort and support to the patient. The examination should be conducted outside the presence of anyone sus pected of being involved in the trafficking situation. After the exam the provider should explain the results, ask the patient if they have any questions about the exam, and give them the opportunity to discuss concerns about their bodies. Individuals who experience trafficking may harbor anxiety about a variety of issues, including possible infer tility, future health, or possible permanent damage from work related injuries and toxic conditions. Providers may follow U.S. Centers for Disease Control and Preven tion (CDC) guidelines on STI testing and prophylaxis. Additional resources on laboratory testing for sexually and nonsexually transmit ted diseases may be obtained from the CDC (https:www.cdc.gov) or World Health Organization (WHO) websites (http:www.who.in ten). In general, STIs of greatest relevance include Neisseria gonor rhoeae, Chlamydia trachomatis, Trichomonas vaginalis, HIV, syphilis, and hepatitis B and C viruses. Methods of testing and decisions to treat (e.g., positive test results vs prophylaxis vs syndromic treatment) will depend on national guidelines and on medical resources, which may be limited in some countries or regions. However, consideration should be given to the high likelihood that the patient may be lost to follow up after the visit, so the decision to delay treatment until test results are available may lead to lack of needed medication. Testing and treatment decisions need to be outlined
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in a protocol. Emergency contraception and other methods of birth control (especially long acting reversible contraception) should be discussed with the patient as feasible. Many individuals who have been trafficked (and children of trafficked adults) have experienced nutritional deprivation, lack of immuniza tions, and general poor health, especially if they are from low resource countries or are born into the trafficking situation. Guidance on medical screening and care for immigrant children (see Chapter 11) also may be obtained from the CDC (https:www.cdc.govimmigrantrefugeehealth guidelinesrefugeeguidelines.html) or American Academy of Pediatrics Table 16.4 Elements of a Human RightsBased, Trauma Informed Approach to Patient Care BASIC RIGHTS Best interest of the child to be primary concern in all actions involving the child Protection from discrimination because of gender, race, ethnicity, culture, socioeconomic status, disability, religion, language, country of origin, or other status Right to express views and be heard appropriate to the childs age and development Right to obtain information relevant to the child to be given in a way that the child can understand Right to privacy and confidentiality Right to the highest attainable standard of health and to access healthcare services Right to dignity and self respect Right to consideration of special needs (e.g., age, disability) Right to respect of cultural and religious beliefs and practices TRAUMA INFORMED CARE A strengthbased approach that facilitates patient resilience and empowerment. Obtain medical history in a private, safe place, outside the presence of persons accompanying the patient to the visit. Explain all processes in way the patient understands, and obtain assent for each step; discuss the limits of confidentiality and mandated reporting. Encourage the patient to express views and to participate in decision making regarding referrals and care. Foster the patients sense of control during the evaluation. Ask only the questions needed to assess safety, health, and well being. Avoid asking irrelevant questions about trauma to avoid unnecessarily triggering anxiety and distress. Minimize retraumatization during history, examination, and diagnostic testing (avoid triggers of stress when possible). Monitor for signs of distress, both verbal and nonverbal. Allow the patient to choose the gender of the provider, if feasible. Have trained personnel present during the examination to assist with providing support and reassurance. Avoid making promises the provider cannot fulfill. Put information gathered to good use. Work with the child to conduct a safety assessment and create a plan. Be prepared to make referrals and offer resources. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 16 u Child Trafficking for Sex and Labor 113 (AAP) Red Book or Immigrant Child Health Toolkit (https:aapca1.org resourceaapimmigrantchildhealthtoolkit). Consideration should be given to vaccine preventable diseases (including tetanus if there are open wounds) and common diseases in the patients home country. Trafficked individuals may have iron deficiency, hemoglobinopathies, vitamin D deficiency, and undiagnosed vision or hearing problems. Crowded, unhygienic living conditions during the trafficking
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period raise the risks of tuberculosis, scabies, and diarrheal illnesses. Toxic levels of lead or chemicals may be present, and vitaminmineral deficiencies should be considered. A developmental or educational assessment is important, given the high likelihood of poor primary care in the past and possible harsh living conditions. Documentation of overall health and identified injuries is extremely important and should be detailed and accurate. Body diagrams and photographs (if not traumatizing to the patient) are helpful, as are written descriptions of injury location, type (e.g., contusion, lacera tion), size, shape, and color. All photographs should include patient identifiers and a measuring instrument when possible. Distance photo graphs to establish injury location may be supplemented with close up photographs from various angles. Physical signs of untreated illness, malnutrition, and other conditions need to be documented carefully. When documenting the medical history, direct quotes should be used when possible (quotes of provider and of patient statements). Records, including written, video, audio, and photographic records, should be stored in a secure health information system, with limited access and password protection. Strict protocols for patient confidentiality and privacy should be established and followed. REFERRALS AND RESOURCES Before discharge, the provider should ensure the patient understands the results of the evaluation and has the opportunity to ask questions. A risk assessment should be done by the provider or other qualified staff, to include a discussion with the individual of safety concerns (involv ing current risks and perceived risks after discharge). The provider should engage the patient in establishing a treatment plan as devel opmentally appropriate. Transparency and shared decision making are key elements of a trauma informed approach. Healthcare providers must comply with mandatory reporting laws in their state or country, but in doing so, should make every effort to avoid causing harm to the patient or their family. If a mandatory report is necessary, this should be discussed with the patient before making the call to authorities, so the individual is aware of actions being taken. For nonmandated refer rals, patient permission is needed. For those practicing within the United States, assistance on inter preting laws, working with individuals who may have been trafficked, making reports to authorities, and identifying local referral sources may be obtained by contacting the National Human Trafficking Hotline (1 888 373 7888). The hotline has trained staff to assist traf ficked persons and professionals alike, including interpreters for over 200 languages. Additional assistance may be obtained by contacting state or local law enforcement and antitrafficking task forces or local child advocacy centers (free standing or hospital based facilities that provide services for children and families who have experienced child abuse andor neglect). In other countries, helplines and hotlines may be used to seek assistance for those who are being trafficked and those at risk. It is important for the healthcare provider to be aware of local, state, and national resources for individuals experiencing human trafficking. Affected patients have numerous needs that extend beyond the range of the healthcare providers
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ability to respond. A multidisciplinary team approach is needed to ensure the child is provided with necessary food, shelter, crisis management, language interpretation, immigration assis tance, mental health and medical care, educational needs, and other services. Such a team may include local victim service providers, shelter staff, behavioral health professionals, child protective services (CPS) workers, law enforcement, child advocacy center staff, representatives of sexual assault crisis centers, and victim advocates. Potential health related referrals may be found in Table 16.5. To increase the likelihood that the patient and family will obtain the services they desire, it is help ful for the provider to make a warm handoff to a referral agency, either contacting agency staff directly or allowing the patienttrusted caregiver to make the call to the agency before leaving the health facility. Children and adolescents who experience trafficking may face considerable discrimination and social stigma from the public and from professionals. They may be viewed as consenting par ticipants, illegal immigrants who somehow deserve maltreat ment, or bad youth who are responsible for their own actions. They may face discrimination related to risk factors such as pov erty, gender identity, or systemic racism. In some countries, laws on sexual exploitation do not include boys, and cultural beliefs foster the attitude that males cannot be victimized. This complicates ser vice provision and support for male patients who have experienced trafficking. Variations in the age of consent may result in a child being considered an adult in one country and a child in another, the former condition limiting access to adequate support or increas ing the likelihood of being viewed as a criminal offender. For these reasons and others, it is important for the healthcare provider to advocate for the patients best interests when interacting with other professionals and emphasize the need for comprehensive, sustained, trauma informed services. If responsible for long term care of the patient, the provider should consider that treatment needs change over time, so treat ment plans must be reevaluated periodically. Continuity of care is important but can be challenging when the individual is moved to another city, is transported back to the home country, or is retraf ficked. Ongoing communication with external agencies and other healthcare providers can be extremely helpful, along with assign ment of a case manager to help ensure referrals are in place in des tination towns or villages. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. Table 16.5 Potential Health Referrals for Trafficked Persons Behavioral health assessment and treatment (emergent or non urgent): trauma focused, preferably conducted by a professional trained in trauma therapies Substance use assessmenttreatment Obstetriciangynecologist Specialized medical service Primary medical home (for immunizations including HPV; HIV PrEP; periodic STI testing; monitoring of growth and development; family planning and reproductive health; anticipatory guidance; and nutritionhygiene counseling) Physical therapy, occupational therapy Developmental assessment Dentist Optometrist or audiologist Resources for LGBTQ individuals HIV clinic Child advocacy center (for second opinion on anogenital exam; forensic interview, behavioral health services) Appropriate therapy may differ with
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victims from varied cultures; there is a limited evidence base for the effectiveness of behavioral health therapy for children experiencing trafficking. However, in the United States, therapies with an evidence base for child sexual assaultabuse are often adapted for use. HPV, Human papillomavirus; HIV PrEP: human immunodeficiency virus pre exposure prophylaxis; STI, sexually transmitted infection; LGBTQ, lesbian, gay, bisexual, transgender, queerquestioning, and other. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 114 Part I u The Field of Pediatrics The abuse and neglect (maltreatment) of children are pervasive problems worldwide, with short and long term physical and men tal health, cognitive, social, and economic consequences. Primary care professionals (PCPs) serving children have an important role in helping address this problem. In addition to their responsibil ity to identify maltreated children and help ensure their protection, health, and well being, PCPs can also play vital roles related to pre vention, treatment, and advocacy. While securing a childs safety is a priority, the child welfare system also aims to improve families functioning and enable them to adequately care for their children. DEFINITIONS Abuse is defined as acts of commission, neglect as acts of omission. The U.S. government offers a minimal definition of child abuse as any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm. Many states include other household members and a broader set of circumstances. Children may face situations in which no actual harm has occurred and no imminent risk of serious harm is evident, yet potential harm is a concern. Many states include potential harm in their child abuse laws. This is critical to preventing maltreat ment, although predicting harm is inherently difficult. Two aspects should be considered: the likelihood and the severity of the potential harm. Physical abuse includes beating, shaking, burning, drowning, suf focating, and biting. Physical punishment remains controversial, although it is increasingly being prohibited. The Global Initiative to End All Physical Punishment of Children reported that 62 countries have banned physical punishment in all settings, including the home; 135 have done so for schools, and governments in 27 other countries have committed to full prohibition. In the United States, physical pun ishment in the home remains lawful in all states, and 20 still permit it in schools. The threshold for when physical punishment should be consid ered as abuse is unclear. One can consider any injury beyond tran sient redness such as from a slap as abuse. Proponents of physical punishment suggest that if parents spank a child, it should be lim ited to the buttocks, be over clothing, and should never involve the head and neck. When parents use objects other than a hand, the
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potential for serious harm increases. Acts of serious violence (e.g., throwing a hard object, slapping an infants face) should be seen as abusive even if no injury ensues; significant potential harm exists. Although some PCPs think that hitting is acceptable under limited conditions, almost all prefer more constructive approaches to dis cipline. The American Academy of Pediatrics issued a policy state ment clearly opposing the use of physical punishment. Although many agree that hitting a child should never be accepted, and research has amply documented the potential harm, there remains a reluctance in the United States to label hitting as abuseunless there is an injury. Clearly the emotional impact of being hit may leave the most worrisome and lasting scars, long after the bruises fade and the fractures heal. Neglect refers to omissions in care resulting in actual or poten tial harm. Omissions include inadequate healthcare, education, supervision, or protection from hazards in the environment and unmet physical needs (e.g., clothing, food) and inadequate emo tional support. A preferable alternative to focusing on caregiver omissions is to instead consider the basic needs (or rights) of chil dren (e.g., adequate food, clothing, shelter, healthcare, education, nurturance). Neglect occurs when a need is not adequately met and results in actual or potential harm, whatever the reasons. A broad definition concerned with childrens needs fosters a more compre hensive understanding of what contributes to neglect in addition to the potential parental role. A child focused definition also offers a more constructive approach to ensure a childs needs are adequately met in contrast to one that narrowly focuses on and blames par ents. A child whose health is jeopardized or harmed by not receiv ing necessary care experiences medical neglect. This view enables professionals to approach the problem in terms of what the child needs, rather than focusing on what parents did badly. Not all such situations necessarily require a referral to child protective services (CPS); less intrusive initial efforts may be appropriate. Psychologic abuse includes verbal abuse and humiliation and acts that scare or terrorize a child. Although this form of abuse may be extremely harmful to children, resulting in problems such as depression, anxiety, poor self esteem, and lack of empathy, CPS seldom becomes involved because of the difficulty in proving such allegations. PCPs should still carefully consider this form of mal treatment, even if the concern fails to reach a legal or agency thresh old for referral. These children and families can still benefit from counseling and other services. Many children experience more than one form of maltreatment; CPS is more likely to address psycho logic abuse in the context of other forms of maltreatment. INCIDENCE AND PREVALENCE Abuse and neglect mostly occur behind closed doors and often remain a dark, well kept secret. Rates of maltreatment are thus difficult to estimate. Nevertheless, the problem is globally prevalent. Global Situation The World Health Organization (WHO) estimates that nearly 3 in 4 children, or 300 million children aged 2 4 years, regularly
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suffer physi cal punishment andor psychologic violence at the hands of parents. In addition, as many as 1 in 5 women and 1 in 13 men report having been sexually abused as a child. Less international research has been done on child neglect. Nevertheless, neglect too is clearly a global prob lem. For example, a large study (n 41,194) of Balkan countries found lifetime rates of neglect ranging from 23 in Romania to 48 in Bos nia. Among Hong Kong adults, 45 reported a history of childhood neglect. Rates as high as 94 of children for emotional neglect and 89 for physical neglect were found in Burundi, a country severely affected by civil war and political violence. Varying definitions, poli cies, and practices concerning child maltreatment preclude comparing rates across countries. United States There were 4.4 million reports to CPS involving 7.9 million chil dren in the United States in 2019. Of the 656,000 children with substantiated reports (8.9 per 1,000 children), 75 experienced neglect (including 2.3 medical neglect), 17.5 physical abuse, 9.3 sexual abuse, and 6.8 psychologic maltreatment. Neglect is by far the most common form of maltreatment referred to CPS, involving 7 per 1,000 children. Although there had been a welcome decline in rates beginning in the early 1990s, rates increased in 2014 and 2015 and stayed stable until the COVID 19 pandemic, when reports of physical abuse increased. Medical personnel made 11 of all reports. Sources other than official CPS statistics indicate that the incidence of maltreatment is far greater than what gets reported to CPS. In a community survey, for example, 3 of parents reported using very severe violence (e.g., hitting with fist, burning, using gun or knife) toward their child in the prior year. Chapter 17 Abused and Neglected Children Howard Dubowitz and Wendy G. Lane Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 17 u Abused and Neglected Children 115 ETIOLOGY Child maltreatment seldom has a single cause; rather, multiple and interacting biopsychosocial risk factors at four levels usually interact and contribute to the problem. At the individual level, a childs disability or behavioral challenges or a parents depression or substance use pre dispose a child to maltreatment. At the familial level, intimate partner (or domestic) violence jeopardizes childrens health and development. Influential community factors include stressors such as dangerous neighborhoods with few supports or recreational facilities. Professional inaction may contribute to neglect, such as when the treatment plan is not clearly communicated or risk factors are ignored. Broad societal factors, such as poverty and its many associated burdens, also contrib ute significantly to maltreatment. The WHO estimates the rate of child homicide is approximately twofold higher in low income compared to high income countries (2.58 vs 1.21 per 100,000 population). Neverthe less, children at all income levels can be maltreated, and PCPs need to guard against
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biases concerning minoritized and low income families. In contrast, protective factors, such as family supports or a par ents concern for their child, may buffer risk factors and protect children from maltreatment. Deliberately identifying and incorpo rating protective factors is vital to intervening effectively. One can say to a parent who did not fill a prescription, for example, I can see how much you love childs name. What can we do to keep them out of the hospital? In sum, child maltreatment results from a complex interplay among risk and protective factors. A single parent who has a colicky baby and who recently lost their job has multiple risk factors, but a loving grandparent may be protective. A good assessment and understanding of both risk and protective factors guide an appropriate response. OUTCOMES All forms of child maltreatment jeopardize childrens physical and emotional health and their cognitive and social development, mani festing in a wide array of possible problemsin the short and the long term. Problems in adolescence and adulthood include health risk behaviors (e.g., smoking, alcohol, and substance use), men tal health problems (e.g., anxiety, depression, suicide attempt), and physical health problems (e.g., heart disease, cancer). Mal treated children are also at risk for becoming maltreating parents. The impact of neuroendocrine stress responses to child abuse and neglect on the developing brain may partly explain some of these sequelae. Some maltreated children appear to be resilient and function rela tively well, perhaps owing to protective factors or interventions. Still, PCPs and parents need to be sensitive to the possibility of later prob lems (sleeper effects). The benefits of intervention have been found in even the most severely neglected children, such as those rescued from Romanian orphanages in the early 1990s, who were adopted the earlier, the better. That said, resilience is a relative concept, and few severely maltreated children escape unscathed. CLINICAL MANIFESTATIONS Child abuse and neglect can manifest in a myriad of ways (Table 17.1). A critical element of physical abuse is the lack of a plausible history other than inflicted trauma. The onus is on the clinician to carefully consider the differential diagnosis and not jump to conclusions. Bruises are the most common manifestation of physical abuse. Features suggestive of abuse include (1) bruising in a preambulatory infant (occurring in just 2 of such infants), (2) bruising of padded and less exposed areas (buttocks, cheeks, ears, neck, genitalia), (3) pat terned bruising conforming to the shape of an object (Fig. 17.1), and (4) multiple bruises, especially if clearly of different ages. Earlier sug gestions for estimating the age of bruises, however, have long been discredited. It is very difficult to precisely age bruises. The TEN 4 FACESp mnemonic is useful for when to suspect abuse in children under 4 years of age: torso, ear, neck, frenulum, angle of jaw, cheeks fleshy, eyelids, subconjunctivae, and patterned, as well as any bruise in children under 4 months, helps identify suspicious bruises. This prediction rule is 95.6 sensitive and 87.1
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specific for identifying abuse. In nonmobile infants, bruises are considered a sentinel injury because of the low likelihood of noninflicted injury. Bruises are the most common injury to be missed or misdiagnosed among children who later present with fatal or near fatal injuries. Other sentinel injuries include oropharyngeal injuries in children 6 months of age and subconjunctival hemorrhage in healthy children under 4 years of age. Conditions such as birthmarks, including slate gray nevus (congeni tal dermal melanocytosis or Mongolian spots), can be confused with bruises and abuse. Other mimics are noted in Table 17.2. These skin markings are not tender and do not rapidly change color or size. An underlying medical explanation for bruises may exist, such as blood dyscrasias (hemophilia) or connective tissue disorders (Ehlers Danlos syndrome). The history or examination usually provides clues to these conditions. Hemorrhagic edema of infancy and IgA vasculitis (Henoch Schnlein purpura) is the most common vasculitis in young Table 17.1 Injury Patterns METHOD OF INJURY IMPLEMENT PATTERN OBSERVED Gripgrab Relatively round marks that correspond to fingertips andor thumb Closed fist punch Series of round bruises that correspond to the knuckles of the hand Slap Parallel, linear bruises (usually petechial) separated by areas of central sparing Beltelectrical cord Loop marks or parallel lines of petechiae (the width of the beltcord) with central sparing, may see triangular marks from the end of the belt, small circular lesions caused by the holes in the tongue of the belt, andor a buckle pattern Rope Areas of bruising interspersed with areas of abrasion Other objects household implements Injury in shape of objectimplement (e.g., rods, switches, and wires cause linear bruising) Human bite Two arches forming a circular or oval shape, may cause bruising andor abrasion Strangulation Petechiae of the head andor neck, including mucous membranes; may see subconjunctival hemorrhages Bindingligature Marks around the wrists, ankles, or neck; sometimes accompanied by petechiae or edema distal to the ligature mark Punishment by kneeling on salt or other rough substance Abrasionsburns, especially to knees Hair pulling Traumatic alopecia; may see petechiae on underlying scalp or swelling or tenderness of the scalp (from subgaleal hematoma) Tattooing or intentional scarring Abusive cases have been described but can also be a cultural phenomenon (e.g., Mori body ornamentation); may also be a symbol of ownership in a youth being sexually trafficked Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 116 Part I u The Field of Pediatrics children, and may be confused with abuse. The pattern and location of bruises caused by abuse are usually different from those caused by a coagulopathy. Noninflicted bruises are characteristically anterior and over bony prominences, such as shins and foreheads. However, the presence of a medical disorder does not preclude abuse. Cultural practices can cause bruising. Cao gio, or coining, is a South east Asian folkloric therapy. A hard object is vigorously
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rubbed on the skin, causing petechiae or purpura. Cupping is another approach, popular in the Middle East. A heated glass is applied to the skin, often on the back. As it cools, a vacuum forms, leading to perfectly circular bruises. The context here is important, and such circumstances should not be considered abusive (see Chapter 12). A careful history of bleeding problems in the patient and first degree relatives is needed. If a bleeding disorder is suspected, a complete blood count, including platelet count, prothrombin time, and partial throm boplastin time, should be obtained. More extensive testing, such as for factors VIII, IX, and XIII activity and von Willebrand disease, should be considered in consultation with a hematologist. Bites have a characteristic pattern of one or two opposing arches with multiple bruises. They can be inflicted by an adult, another child, an animal, or the patient. Forensic odontologists developed guidelines for distinguishing adult from child and human from animal bites. How ever, several recent studies have identified problems with the accuracy and consistency of bite mark analysis. Burns may be inflicted, noninflicted, or the result of inadequate supervision. Scalding burns may result from immersion or splash. Immersion burns, when a child is forcibly held in hot water, show a clear delineation between the burned and healthy skin and uni form depth (Fig. 17.2). They may have a sock or glove distribution. Splash marks are usually absent, unlike when a child inadvertently encounters hot water. Symmetric burns are strongly suggestive of abuse, as are burns of the buttocks and perineum. Although most often noninflicted, splash burns may also result from abuse. Burns from hot objects such as curling irons, radiators, steam irons, metal grids, hot knives, and cigarettes leave patterns indicating the object (Fig. 17.3). A child is likely to try to rapidly escape from a hot object; thus burns that are extensive and deep reflect more than fleeting contact and suggest abuse. Several conditions mimic abusive burns, such as brushing against a hot radiator, car seat burns, congenital insensitivity to pain syndromes, and folk remedies such as moxibustion. Impetigo may resemble ciga rette burns. Cigarette burns are usually 7 10 mm across, whereas impe tigo has lesions of varying size. Noninflicted cigarette burns are usually oval and superficial. Neglect frequently contributes to childhood burns. Children left home alone may be burned in house fires. A parent taking drugs may cause a fire and be unable to protect a child. Exploring children left unattended may pull hot liquids onto themselves. Liquids cool as they flow downward so that the burn is most severe and broad proximally, often in an inverted triangle pattern. If the child is wear ing a diaper or clothing, the fabric may absorb the hot water and cause burns worse than otherwise expected. Burns through clothing tend to have an irregular pattern. Some circumstances are difficult to foresee, and a single burn resulting from a momentary lapse in supervision should not automatically be construed as neglect. Concluding whether
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a burn was inflicted depends on the history, burn pattern, and the childs capabilities. A delay in seeking healthcare may result from the burn initially appearing minor, before blistering or becoming infected. This circumstance may represent reasonable behavior and should not be automatically deemed neglectful. A scene investigation by law enforcement is often valuable (e.g., testing the water temperature). Fractures that strongly suggest abuse include those of the pos terior ribs, scapula, sternum, and spinous processes and classic metaphyseal lesionsespecially in young children (Table 17.3). These fractures all require more force than would be expected from a minor fall or routine handling and activities of a child. Rib and sternal fractures rarely result from cardiopulmonary resuscitation, even when performed by untrained adults. The recommended two finger or two thumb technique for infants may, however, produce anterolateral rib fractures. Most common in abused infants are rib (Fig. 17.4), metaphyseal (Fig. 17.5), and skull fractures. Femo ral and humeral fractures in nonambulatory infants are also very worrisome for abuse. In contrast, with increasing mobility and running, toddlers can fall with enough rotational force to cause a spiral, femoral fracture. Multiple fractures in various stages of heal ing are suggestive of abuse. In some circumstances, such as when there are multiple or repeated fractures or a family history of such, underlying medical conditions need to be considered. Clavicular, femoral, supracondylar humeral, and distal extremity fractures in children older than 2 years are most likely noninflicted unless they are multiple or accompanied by other signs of abuse. Few fractures are pathognomonic of abuse; all must be considered together with the history and childs development. The differential diagnosis includes conditions that increase sus ceptibility to fractures, such as osteopenia and osteogenesis imper fecta, metabolic and nutritional disorders (e.g., scurvy, rickets), renal osteodystrophy, osteomyelitis, congenital syphilis, and neo plasia (see Table 17.2). Some have pointed to possible rickets and low but subclinical levels of vitamin D as being responsible for frac tures thought to be due to abuse. The evidence, however, refutes this supposition. Features of congenital or metabolic conditions Fig. 17.1 A variety of instruments may be used to inflict injury on a child. Often the choice of an instrument is a matter of convenience. Marks tend to silhouette or outline the shape of the instrument. The possibility of in tentional trauma should prompt a high degree of suspicion when injuries to a child are geometric, paired, mir rored, of various ages or types, or on relatively protected parts of the body. Early recognition of intentional trauma is important to provide therapy and prevent escalation to more serious injury. Belt buckle Belt Looped cord MARKS from INSTRUMENTS Stickwhip Fly swatter Coat hanger Board or spatula Handknuckles Bite Sauce pan Paddles Hair brush Spoon Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 17 u Abused and Neglected Children 117
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associated with noninflicted fractures include family history of recurrent fractures after minor trauma, abnormally shaped cra nium, dentinogenesis imperfecta, blue sclera, impaired hearing, craniotabes, ligamentous laxity, bowed legs, hernia, and translucent skin. Subperiosteal new bone formation is a nonspecific finding seen in infectious, traumatic, and metabolic disorders. In young infants, new bone formation may be a normal physiologic finding; it is usu ally bilateral, symmetric, and less than 2 mm in depth. The evaluation of a fracture should include a skeletal survey in children less than 24 months of age when abuse seems possible (Table 17.4). Multiple radiographs with different views are needed; babygrams (one or two films of the entire body) should be avoided. If a fracture is found or when the survey is normal but concern for an occult injury remains, a follow up survey should be completed 2 weeks later, as it may reveal fractures not apparent initially. Omission of skull, spine, and pelvis films on repeat survey reduces radiation exposure while still capturing most occult fractures. In corroborating the history and the injury, the age of a fracture can be crudely estimated (Table 17.5). Soft tissue swelling subsides in 2 21 days. Subperiosteal new bone is visible within 4 21 days. Loss of defi nition of the fracture line and visible soft callus formation occur on a similar timeline. Hard callus is visible between 14 and 90 days. These ranges are shorter in infancy and longer in children with poor nutri tional status or a chronic underlying disease. Fractures of flat bones such as the skull do not form a callus and cannot be aged, although soft tissue swelling indicates recency (i.e., within the prior week). Abusive head trauma (AHT) results in significant morbidity and mortality. Abusive injury may be caused by direct impact, asphyxia, shaking, or a combination. Subdural hematomas (Fig. 17.6); retinal hemorrhages, especially when extensive and involving multiple lay ers; brain parenchymal injury; and fractures (often rib and classic metaphyseal lesions) strongly suggest AHT, especially when they occur together. Infants poor neck muscle tone and relatively large heads make them vulnerable to acceleration deceleration forces if severely shaken, leading to AHT. Children may lack external signs of injury, even with serious intracranial trauma. The clinical presentation var ies, ranging from nonspecific lethargy, to vomiting (without diarrhea), changing neurologic status or seizures, or coma. In all preverbal chil dren, the possibility of AHT should be considered when children pres ent with these signs or symptoms. Acute intracranial trauma is best evaluated via CT. CT helps iden tify bone and soft tissue injury. Some centers use fast sequence MRI to reduce radiation exposure, but the sensitivity may not be as good as CT. MRIs are helpful in differentiating extraaxial fluid, determin ing the approximate time of injuries, assessing parenchymal injury, and identifying vascular anomalies. Neck imaging may identify spinal subdural blood and ligamentous, spinal cord, and nerve root injuries. MRIs are best obtained 5 7 days after an acute injury. Other causes of subdural hemorrhage
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in infants include arteriovenous malforma tions, coagulopathies, birth trauma, tumor, and infections (see Table 17.2). Glutaric aciduria type 1 can present with intracranial bleeding and should be considered. When AHT is suspected, possible injuries elsewhereespecially skeletal and abdominalshould be ruled out. Retinal hemorrhages are an important marker of AHT (Fig. 17.7). When ever AHT is being considered, a dilated indirect eye examination by a pedi atric ophthalmologist should be performed. Although retinal hemorrhages can be found in other conditions, hemorrhages that are multiple, involve more than one retinal layer, and extend to the periphery are very suspi cious for abuse. The mechanism is likely repeated acceleration deceleration caused by shaking. Traumatic retinoschisis points strongly to abuse. With other causes of retinal hemorrhages, the pattern is usually dif ferent from that seen in child abuse. After birth, many newborns have them, but they disappear by 2 6 weeks. Coagulopathies (particularly leukemia), retinal diseases, carbon monoxide poisoning, and glutaric aciduria may be responsible. Severe noninflicted direct crush injury to the head can rarely cause an extensive hemorrhagic retinopathy. Car diopulmonary resuscitation rarely, if ever, causes retinal hemorrhages in infants and children; if present, there are only a few hemorrhages in the posterior pole. Hemoglobinopathies, diabetes mellitus, routine play, minor noninflicted head trauma, and vaccinations do not appear to cause retinal hemorrhage in children. Severe coughing or seizures rarely cause retinal hemorrhages that could be confused with AHT. The dilemma frequently posed is whether minor, everyday forces can explain the findings seen in AHT. Simple linear skull fractures in the absence of other suggestive evidence can be explained by a short fall, although even that is unusual (12); underlying brain injury from short falls is exceedingly rare. Timing of brain injuries in cases of abuse is not precise. In fatal cases, however, the trauma most likely occurred very soon before the child became symptomatic. Other manifestations of AHT may be seen. Raccoon eyes are asso ciated with subgaleal hematomas after traction on the anterior hair and scalp or a blow to the forehead. Neuroblastoma can present simi larly. Bruises from attempted strangulation may be visible on the neck. Choking or suffocation can cause hypoxic brain injury, often with no external signs. Oral lesions may present as bruised lips, bleeding, torn frenulum, and dental trauma or multiple caries (neglect). Abdominal trauma also accounts for significant morbidity and mortality in abused children. Young children are especially vulner able because of their relatively large abdomens and lax abdominal musculature. A forceful blow or kick can cause hematomas of solid organs (liver, spleen, kidney) from compression against the spine, as well as hematomas (duodenal) or rupture (stomach) of hollow organs. Intra abdominal bleeding may result from trauma to an organ or from Table 17.2 Mimics of Nonaccidental Trauma CUTANEOUS LESIONS Accidental trauma Congenital coagulation defects (hemophilia, von Willebrand disease) Acquired coagulation defects (aplastic anemia, ITP, leukemia, vitamin K deficiency) Ehlers Danlos syndrome Vitamin C deficiency Impetigo Vasculitis (IgA vasculitis: Henoch Schnlein purpura) Dermal melanocytosis (Mongolian spots) Cupping
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Coining Spooning SKELETAL LESIONS Osteogenesis imperfecta Obstetric trauma Caffey disease Rickets (not just low 25 hydroxy vitamin D levels) Hyper IgE syndrome Recurrent multifocal osteomyelitis Skeletal dysplasias HEAD TRAUMA Birth trauma Hemophilia Factor XIII deficiency Vitamin K deficiency (malabsorption) Cobalamin C defect Osteogenesis imperfecta Ehlers Danlos syndrome Glutaric aciduria type I Menkes syndrome Vasculitis (primary CNS, systemic) Benign enlargement of subarachnoid spaces ITP, Immune thrombocytopenic purpura; IgA, immunoglobulin A; IgE, immunoglobulin E; CNS, central nervous system. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 118 Part I u The Field of Pediatrics C DA B Fig. 17.2 Immersion injury patterns. A, Sparing of flexural creases. B, Immersion sock burn. C, Immersion glove burn. D, Immersion buttocks burn. (From Jenny C. Child abuse and neglect: diagnosis, treatment, and evidence. Philadelphia: Saunders;2011: Fig. 28 3, p. 225.) Fig. 17.3 Marks from heated objects cause burns in a pattern that dupli cates that of the object. Familiarity with the common heated objects that are used to traumatize children fa cilitates recognition of possible inten tional injuries. The location of the burn is important in determining its cause. Children tend to explore surfaces with the palmar surface of the hand and rarely touch a heated object repeat edly or for a long time. Hot plate Light bulb Curling iron Car cigarette lighter Steam iron Knife Grid Cigarette Forks Immersion BURN MARKS Table 17.3 Specificity of Radiologic Findings HIGH SPECIFICITY Classic metaphyseal lesions Rib fractures, especially posteromedial Scapular fractures Spinous process fractures Sternal fractures MODERATE SPECIFICITY Multiple fractures, especially bilateral Fractures of different ages Epiphyseal separations Vertebral body fractures and subluxations Digital fractures Complex skull fractures Pelvic fractures COMMON BUT LOW SPECIFICITY Subperiosteal new bone formation Clavicular fractures Long bone shaft fractures Linear skull fractures Highest specificity applies in infants From Kleinman PK. Diagnostic imaging of child abuse, 3rd ed. Cambridge, UK: Cambridge University Press;2015: 24. Fig. 17.4 High detail oblique view of the ribs of a 6 month old infant shows multiple healing posteromedial rib fractures (arrowheads). The level of detail in the image is far greater that what would be present on a standard chest radiograph. (From Dwek JR. The radiographic approach to child abuse. Clin Orthop Relat Res. 2011;469:776789, Fig. 4.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 17 u Abused and Neglected Children 119 shearing of a vessel. More than one organ may be affected. Children may present with cardiovascular failure or an acute abdomen, often after a delay in care. Bilious vomiting without fever or peritoneal irrita tion suggests a duodenal hematoma, often the result of abuse. The manifestations of abdominal trauma are often subtle, even with severe injuries. Bruising of the abdominal wall is unusual,
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and symp toms may evolve slowly. Delayed perforation may occur days after the injury; bowel strictures or a pancreatic pseudocyst can develop weeks or months later. PCPs should consider screening for occult abdomi nal trauma when other evidence of physical abuse exists. Screening should include liver and pancreatic enzyme levels and testing urine for blood. When results indicate possible injury or if there is concern about possible splenic, adrenal, or hepatic injury, an abdominal CT is indicated. Neglect is the most prevalent form of child maltreatment, with potentially severe and lasting sequelae. It may manifest in many ways, depending on which basic needs are not adequately met. Nonadherence to medical treatment, for example, may aggravate the condition, as may a delay in seeking healthcare. Inadequate food may manifest as impaired growth; inattention to obesity is also a problem. Poor hygiene may contribute to infected cuts or lesions. Inadequate supervision contributes to injuries and ingestions. Childrens needs for mental healthcare, dental care, and other healthcare may be inadequately met, manifesting as neglect. Educational needs, particularly for children with learning disabilities, are often not adequately met. GENERAL PRINCIPLES FOR ASSESSING POSSIBLE PHYSICAL ABUSE AND NEGLECT The heterogeneity of circumstances in situations of child maltreatment precludes specific detailing of varied assessments. The following are useful general principles: Given the complexity and possible ramifications of determining child maltreatment, an interdisciplinary assessment is optimal, with input from all involved professionals. Consultation with a phy sician expert in child abuse pediatrics is recommended. A thorough history should be obtained from the parent(s), optimal ly via separate interviews. Verbal children should be interviewed separately in a developmen tally appropriate manner. Open ended questions (e.g., Tell me what happened) are best. Some children need more directed A CB Posterior Fig. 17.5 A, Metaphyseal fracture of the distal tibia in a 3 month old infant admitted to the hospital with severe head injury. There is also periosteal new bone formation of the tibia, perhaps from previous injury. B, Bone scan of the same infant. The initial chest x ray showed a single fracture of the right posterior fourth rib. A radionuclide bone scan performed 2 days later revealed multiple previously unrecognized fractures of the posterior and lateral ribs. C, Follow up radiograph 2 weeks later showed multiple healing rib fractures. This pattern of fractures is highly specific for child abuse. The mechanism of these injuries is usually violent squeezing of the chest. Table 17.4 Radiologic Skeletal Survey for Infants and Children under 2 Years of Age Anteroposterior (AP) and lateral views of skull (Townes view optional; add if any fracture seen) Lateral spine (cervical spine C spine may be included on skull radiographs; AP spine is included on AP chest and AP pelvis views to include entire spine) AP view, right posterior oblique, left posterior oblique view of chest rib technique AP pelvis AP view of each femur AP view of each leg AP view of each humerus AP view of each forearm Posteroanterior (PA) view of each hand
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AP (dorsoventral) view of each foot Images are checked by a radiologist before the patient leaves. Poorly positioned or otherwise suboptimal images should be repeated. Lateral views are added for positive or equivocal findings in the extremities. Coned views of positive or equivocal findings (i.e., at ends of long bones, ribs) may be obtained. Adapted from Coley BD. Caffeys pediatric diagnostic imaging, 12th ed. Philadelphia: Mosby;2013: Box 144 1, p. 1588. Table 17.5 Timetable of Radiologic Changes in Childrens Fractures CATEGORY EARLY PEAK LATE 1. SPNBF 4 10 days 10 14 days 14 21 days 2. Loss of fracture line definition, days 10 14 days 14 21 days 3. Soft callus 10 14 days 14 21 days 4. Hard callus 14 21 days 21 42 days 42 90 days The time points tend to increase from early infancy into childhood. Repetitive injuries may prolong all categories. SPNBF, Subperiosteal new bone formation. From Kleinman PK. Diagnostic imaging of child abuse, 3rd ed. Cambridge, UK: Cambridge University Press;2015: p. 215. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 120 Part I u The Field of Pediatrics questioning (e.g., How did you get that bruise? ); others need multiple choice questions. Leading questions must be avoided (e.g., Did your daddy hit you?). A thorough physical examination is necessary. Careful documentation of the history and physical is essential. Ver batim quotes are valuable, including the question that prompted the response. Photographs are helpful. For abuse, the assessment should answer these questions: What is the evidence for concluding abuse? Have other diagnoses been ruled out? What is the likely mechanism of the injury? When did the in jury likely occur? For neglect, the assessment should answer these questions: Do the circumstances indicate that the childs needs have not been ad equately met? Is there evidence of actual harm? Is there evidence of potential harm and on what basis? Suboptimal treatment adherence may not be ideal but lead to few or no consequences. What is the nature of the neglect? Is there a pattern of neglect? It may be difficult to be certain regarding the likelihood of abuse or neglect. The use of possible or probable is recommended when uncertain. Inadequacies in the care children receive naturally fall along a continuum, requiring a range of responses tailored to the in dividual familys situation. Legal considerations or CPS practice may discourage PCPs from labeling many circumstances as neglect. Even if neglect does not meet a threshold for referring to CPS, profession als can still help ensure childrens needs are adequately met. Are there indications of other forms of maltreatment? Has there been prior CPS involvement? A childs safety is a paramount concern. What is the risk of immi nent harm and of what severity? What is contributing to the maltreatment? Consider the categories described in the section on etiology. What strengthsresources
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are there? This is as important as identi fying problems. What treatment or services do the child and family need? What interventions have been tried and with what results? Knowing the nature of these interventions can be useful, especially from the par ents perspective. What is the prognosis? Is the family motivated to improve the cir cumstances and accept help, or are they resistant? Are needed re sources, formal and informal, available? Are there other children in the home who should be assessed for maltreatment? GENERAL PRINCIPLES FOR ADDRESSING PHYSICAL ABUSE AND NEGLECT The heterogeneity of circumstances also precludes specific details regarding how to address different types of maltreatment. The follow ing are general principles: Treat any medical problems. Help ensure the childs safety, often in conjunction with CPS; this is a priority. In some instances, hospitalization is the prudent approach. Convey concerns of maltreatment to parents, kindly but forthrightly. Avoid blaming. It is natural to feel anger towards parents of mal treated children, but they need support and deserve respect. Have a means of addressing the difficult emotions child maltreat ment can evoke in us. Self care is important. Be empathic and state interest in helping or suggest another health care professional. Know the laws andor local CPS policies on referring child maltreat ment. In the United States, the legal threshold for referring is typi cally reason to believe (or reason to suspect); one does not need to be certain. Physical abuse and moderate to severe neglect warrant a referral. In less severe neglect, less intrusive interventions may be an appropriate initial response. For example, if an infants mild fail ure to gain sufficient weight is caused by an error in mixing the for mula, parent education and perhaps a visiting nurse should be tried. In contrast, severe growth faltering may require hospitalization, and, if the contributing factors are particularly serious (e.g., a psychotic mother), out of home placement may be needed. CPS can assess the home environment and provide valuable insights. Referring child maltreatment to public agencies is never easy. Pa rental inadequacy or culpability is at least implicit, and parents may become angry. PCPs should supportively inform families directly of the referral to CPS; it can be explained constructively as an effort to clarify the situation and provide help, as well as a professional (and legal) responsibility. Words matter, and refer ral avoids the stigma of report, and it is what we commonly A B Fig. 17.6 CT scan indicating intracranial bleeding. A, Older blood. B, New blood. Fig. 17.7 Retinal hemorrhages. Arrows point to hemorrhages of varying sizes. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 17 u Abused and Neglected Children 121 do in healthcare. Explaining what the ensuing process is likely to entail (e.g., a visit from a CPS worker and sometimes a po lice officer) may
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ease a parents anxiety. Parents are frequently concerned that they might lose their child. PCPs can cautiously reassure parents that CPS is responsible for helping children and families and that, in most instances, children remain with their parents. When CPS does not accept a referral or when it is not substantiated, they may still facilitate supportive services such as food, shelter, parenting resources, and childcare. PCPs can be a useful liaison between the family and the public agencies and should try to remain involved after referring to CPS. Help address contributory factors, prioritizing those that are most important to the family and amenable to being remedied. Concrete needs should not be overlooked; accessing food programs, obtaining health insurance, enrolling children in preschool, and help finding housing can make a valuable difference. Parents may need their own problems addressed to enable them to adequately care for their chil dren. Establish specific objectives (e.g., no hitting, diabetes will be adequately controlled), with measurable outcomes (e.g., urine dipsticks, hemoglobin A1c). Similarly, advice should be specific and limited to a few reasonable steps. A written (and perhaps signed) contract can help establish the agreed upon plan and help ensure it pans out. Engage the family in developing the plansolicit their input and agreement. Motivational interviewing (MI) offers a fundamen tally different approach to working with parents (and older chil dren and teens), forging a partnership, and understanding their perceptions of an issue and how they think they can address it. Knowledge and skills regarding MI can enhance the effectiveness of PCPs (see Chapter 18). Deliberately identify protective factors or strengthswithin and outside the family; there are always some. Incorporating these in ones approach is a valuable way to engage parents and ensure plans get implemented. Encourage informal supports (e.g., family, friends; invite fathers to office visits). This is where most people get their support, not from professionals. Consider support available through a familys reli gious affiliation. Consider childrens specific needs. Too often, maltreated children do not receive needed services. Be knowledgeable about community resources and facilitate appro priate referrals. Consider how to help ensure referrals pan out. Provide support, follow up, and review of progress, and adjust the plan if needed. Recognize that maltreatment often requires long term intervention with ongoing support and monitoring. PREVENTION OF PHYSICAL ABUSE AND NEGLECT An important aspect of prevention is that many of the efforts to strengthen families and support parents should promote childrens health, development, well being, and safety and prevent maltreat ment. Medical responses to child maltreatment have typically occurred after the fact; preventing the problem is preferable. PCPs can help in several ways. An ongoing relationship offers opportu nities to develop trust and knowledge of a familys circumstances. Astute observation of parentchild interactions can reveal useful information. Parent and child education regarding medical conditions helps to ensure implementation of the treatment plan and to prevent neglect. Possible barriers to treatment should be addressed. Practical strategies such as writing down the plan can help. In addition,
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anticipatory guid ance helps with positive parenting (see Chapter 20), diminishing the risk of maltreatment. Hospital based programs that educate parents about caring for a crying infant and the risks of shaking may help pre vent AHT. Screening for and addressing major psychosocial risk factors for maltreatment such as parental depression, substance use, intimate partner violence, major stress, and helping address identified prob lems, often via referrals, can help prevent maltreatment. Primary care offers excellent opportunities to screen briefly for psychosocial problems. The traditional organ systemfocused review of systems can be expanded to probe areas such as feelings about the child, the parents own functioning, the relationship, possible depression, disciplinary approaches, stressors, and supports. The Safe Environ ment for Every Kid (SEEK) model offers an evidence informed approach for pediatric primary care to identify and help address prevalent adverse childhood experiences (ACEs) (e.g., exposure to intimate partner violence, parental depression, or substance use) or social determinants of health (e.g., food insecurity, severe paren tal stress) that are also risk factors for child maltreatment. This approach should incorporate working with protective factors and use of MI principles in developing a plan jointly with the family. Obtaining information directly from children or youth is also important, especially given that separate interviews with teens have become the norm. Any concerns identified on such screens require at least a brief assessment and initial management, which may lead to a referral for further evaluation and treatment. More frequent office visits can be scheduled for support and counseling while monitoring the situation. Other key family members (e.g., father, a grandparent) might be invited to participate, thereby encouraging informal support. Some practices arrange parent groups through which problems and solutions are shared. PCPs also need to rec ognize their limitations and facilitate referrals to other community resources. ADVOCACY PCPs can assist in understanding what contributed to a childs mal treatment. When advocating for the best interest of the child and family, addressing contributory factors at the individual, family, and community levels is optimal. At the individual level, an example of advocating on behalf of a child is explaining to a parent that an active toddler is behaving normally and not intentionally annoying the parent. Encouraging a parent to seek help dealing with a vio lent spouse, saying, for example, You and your life are very impor tant; asking about substance use; and helping parents obtain health insurance for their children are all forms of advocacy. Efforts to improve family functioning, such as encouraging fathers involvement in the lives of their children, are also examples of advocacy. Remaining involved after a referral to CPS and helping ensure needed services are provided is advocacy as well. In the com munity, PCPs can be influential advocates for improving resources devoted to children and families. These include parenting pro grams, services for abused women and children, and recreational facilities. They can be strong advocates for policies and programs at the local, state, and national levels to benefit children and families. The
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problems underpinning child maltreatment, such as poverty, parental stress, substance use, and limited child rearing resources, require policies and programs that enhance families abilities to care for their children at least adequately. Examples in the United States include Medicaid, the Supplemental Nutrition Assistance Program (SNAP), the Women, Infants, and Children (WIC) program, paid family and medical leave, the Earned Income Tax Credit (EITC), and childcare subsidies. Child maltreatment is a complex problem without simple solu tions. Through partnerships with parents and colleagues in child protection, mental health, education, and law enforcement, PCPs can make an enormous difference in the lives of many children and families. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 122 Part I u The Field of Pediatrics 17.1 Sexual Abuse Wendy G. Lane and Howard Dubowitz See also Chapter 162. Approximately 18 of females and 7 of males in the United States are sexually abused at some point during childhood. Primary care professionals (PCPs) serving children can play several roles in addressing sexual abuse, including identification, referring to child protective services (CPS) andor law enforcement, testing for and treating sexually transmitted infections, providing support and reassurance, and providing guidance to prevent future sexual abuse. In many jurisdictions throughout the United States, PCPs play a mostly triage role, with the definitive medical evaluation conducted by a child abuse specialist. DEFINITION Sexual abuse has been defined as the involvement of dependent, developmentally immature children and adolescents in sexual activi ties which they do not fully comprehend, to which they are unable to give consent, or that violate the social taboos of family roles. Sexual abuse includes exposure to sexually explicit materials, oral genital contact, genital to genital contact, genital to anal contact, and geni tal fondling. Any touching of private parts by parents or caregivers in a context other than necessary care is inappropriate. It is impor tant to note that sexual abuse does not have to involve direct touch ing or physical contact by the perpetrator. Showing pornography to a child, filming or photographing a child in sexually explicit poses, and encouraging or forcing a child to perform sex acts on another all constitute sexual abuse. When these acts occur for financial gain or in exchange for something of value, it is considered sexual exploitation. Recruiting, enticing, harboring, transporting, providing, obtaining, andor maintaining a minor for the purpose of engaging in sexual acts are forms of sex trafficking (see Chapter 16), a subset of sexual exploitation. Some legal definitions distinguish sexual abuse from sexual assault; the former being committed by a parent or caregiver or household member, and the latter being committed by someone without a custo dial or any relationship to the child. For this chapter, the term sexual abuse encompasses abuse, assault, and exploitation. PRESENTATION OF SEXUAL ABUSE Because physical findings are
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uncommon and behavioral findings are often nonspecific, a more reliable means of identifying sexual abuse is through a childs history. Some children provide a clear, spontaneous description of abuse to a trusted adult. Other children provide less clear histories, such as not wanting to visit a partic ular persons home or vaguely saying something bad happened. Preschool aged children and those with limited language skills may be developmentally unable to provide details about sexual acts or timing. Such lack of detail may unfortunately dissuade adults from trusting the account and referring. Because PCPs are mandated reporters, they should have a low threshold for referring young children. Sexual abuse may be discovered when another person witnesses the abuse or discovers evidence such as sexually explicit photographs or videos. There are also children, with and without symptoms, who will not be identified at any point during their childhood, and perhaps never. Behavioral changes may be the first indication of possible abuse. Children may exhibit sexually explicit behavior outside the norm for their age and developmental level. It can be tricky to distin guish normal from concerning behavior, especially given childrens increasing and prevalent exposure to sexual material and informa tion over recent decades. For preschool and school age children, behavior thought to be normal includes curiosity about their own body and differences between boys and girls. Touching their own genitals, masturbation, and undressing in front of others are also common. Worrisome sexual behavior includes compulsive mastur bation (i.e., continuing in public areas even after being told to stop), attempting to perform sex acts on adults or other children, or asking adults or children to perform sex acts on them. Teen sexual behav ior thought to be normal includes interest in media with sexual themes, looking up sexual information on the internet, demanding more privacy, masturbation, and sexual contact with teens of the same or opposite sex. Worrisome teenage behaviors include sexual promiscuity, engaging in prostitution, and engaging in sexual acts with younger children or with animals. Sexting has become com mon among teenagers and requires a discussion between parents and teens about its risks. Sexting that involves extortion or traffick ing is very concerning; in many states trafficking requires mandated reporting to CPS. It is important to recognize that in addition to sexual abuse, some sexualized behavior could also result from other exposure (e.g., a child who enters their parents bedroom at night to find their parents having sex), from neglect (e.g., parents watching pornographic movies where a child can see them), from exposure to sexual behavior by other chil dren who may have been abused or exposed to inappropriate sexual behavior or materials, or from information discussed and shared by peers. A number of other behavior changes, although not specific for sexual abuse, are common among children who have been sexu ally abused. These include social withdrawal, acting out, increased clinginess or fearfulness, distractibility, learning difficulties, and behavioral regression such as secondary enuresis. Teenagers may become depressed, experiment with drugs or
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alcohol, or run away from home. Therefore sexual abuse should usually be considered when addressing a wide variety of child behavior and mental health problems. Physical signs of sexual abuse are uncommon and are seen in only about 5 of children who undergo medical examination, usually soon after the abuse occurred. The absence of physical findings can often be explained by the type and timing of sexual contact. Abusive acts such as fondling or even digital penetration may not cause any injury. In addition, many children do not disclose abuse until days, weeks, months, or even years after the abuse occurred. Because geni tal injuries usually heal within days, injuries are generally not seen by the time a child presents for medical evaluation. Clearly, a normal genital exam does not rule out the possibility or probability of abuse and should not influence the decision to refer to CPS. Physical find ings that may indicate sexual abuse include genital or anal pain, ano genital bleeding, or discharge. Sexually transmitted infections (STIs), including gonorrhea, chlamydia, and trichomonas beyond the neo natal period, are highly suspicious for abuse. Pregnancy, too, may be the result of abuse. Rarely, there are physical signs of healed trauma, such as a complete hymenal transection (i.e., part of the posterior hymen is missing). All 50 U.S. states mandate that professionals refer suspected sex ual abuse to CPS, and many require reporting of sex trafficking. The specific criteria or threshold for reason to suspect is generally not defined by state law. Clearly, referrals do not require certainty that abuse occurred. Therefore it may be appropriate to refer a child with worrisome sexual behavior when no alternative explanation is plausible and the child does not clearly confirm or deny abuse. THE ROLE OF THE PCP IN ASSESSING AND ADDRESSING POSSIBLE SEXUAL ABUSE Speaking with parents about possible abuse: When a parent raises concern for sexual abuse, PCPs should have the child leave the room before obtaining additional information from the parent alone to avoid influencing the child. The child healthcare professional should gather details regarding the parents concern to help discriminate between possible sexual abuse and other behavioral or health issues. For exam ple, parents may be worried about a childs normal sexual behavior, or they may assume that a nonspecific finding such as vulvar irritation is the result of abuse. In these situations, reassurance and treatment Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 17 u Abused and Neglected Children 123 of the medical issue may suffice. PCPs should document the parental concerns, clearly indicating the source of the information. If a child reported abuse to a parent, documentation should include what ques tions the parent asked to elicit the disclosure or what triggered it. Addi tional evaluation should include a review of systems for behavioral and urogenital problems. Parents should be
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asked whether there are other children in the home, school, or childcare who may have been exposed to the alleged offender; this information should be shared with CPS, as these children may benefit from a precautionary interview or exam at the local child advocacy center (CAC). Parents who have expe rienced sexual abuse themselves may disclose this information to the child healthcare professional, and they may have a heightened concern about abuse of their children and the sequelae. In these situations, the PCP should discuss mental health services for the parent. Some states require reporting of sexual abuse even when the survivor is an adult. Speaking with children about possible abuse: Children with sus pected sexual abuse may present to the PCPs office with a clear his tory of abuse or more subtle indicators. A private, brief conversation between PCP and child provides an opportunity for the child to speak in their own words. Doing this may be especially important when the parent does not believe or support the child. Telling parents that a pri vate conversation is standard in such circumstances can be reassuring. When speaking with a child, it is essential to first establish rap port, starting with general and open ended questions; for example: Tell me about school and What are your favorite things to do? It helps to explain the purpose of the evaluation and why it is being done. For example, Your mom is worried that someone may have hurt you and we want to make sure youre healthy and safe. Ques tions about sexual abuse should focus on a minimally adequate history (i.e., gathering enough information to determine if sexual abuse may have happened and whether there is a need to refer to CPS). If a referral is made to CPS, a multidisciplinary investigation will likely be initiated, including an extensive forensic interview. Questions should also be nonleading (e.g., avoid asking questions such as who touched you there?). It helps to explain that some times children are hurt or bothered by others and that one wonders whether that might have happened to the child. Open ended ques tions, such as Can you tell me more about that? allow the child to add information and clarification in their own words. The PCP should document the childs statements in quotation marks and the source. Documenting the questions that elicited the childs response should clarify whether questions were leading or not. Very young children and those with developmental delay may lack the verbal skills to describe what happened. In this situation, the parents his tory may provide enough information to warrant a CPS referral without interviewing the child. Medical referral: Because delayed disclosure is common, most children do not need an urgent expert medical evaluation (Fig. 17.8). Indications for one include recent abuse (i.e., within the past 3 5 days), current pain or bleeding, and severe child or parental emotional distress. It is optimal for children suspected of having been sexually abused to be evaluated in a
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child friendly setting and by professionals skilled in this field. Because emergency depart ments may not have a child abuse expert and can be busy, noisy, and lacking in privacy, examination at an alternative location such as a CAC or outpatient clinic is preferable, when possible. If the exam is not urgent, it is best that the evaluation be done at a time when the child is not tired and cranky. Referring PCPs should be familiar with the triage procedures in their communities, including the referral sites for both acute and nonacute evaluations, timeframes for when an evaluation is con sidered acute, and whether there are different referral sites for pre pubertal and postpubertal children. Depending on the jurisdiction, the site may be an emergency department, a CAC, or an outpatient clinic. For the prepubertal child, if abuse is thought to have occurred in the previous 72 hours and history suggests direct contact, foren sic evidence collection (e.g., external genital, vaginal, anal, and oral swabs, sometimes referred to as a rape kit) may be indicated, and the child should be referred to a site equipped to do this. Some centers may have shorter or longer cutoffs (e.g., 24 hours or 5 days). If the last suspected incident of abuse occurred more than 72 hours prior, the likelihood of recovering forensic evidence is extremely low, making forensic evidence collection unnecessary. For postpubertal females, it is recommended that forensic evidence be collected up to 120 hours after the abuseas for adult women. The extended timeframe relates to semen possibly remaining in the postpuber tal vaginal vault for more than 72 hours. Some jurisdictions extend the time for collecting forensic evidence up to 10 15 days if there has been penetration and possible ejaculation. The National Insti tute of Justice suggests considering a 9 day time frame based on one study. Physical examination of the child with suspected sexual abuse: Children suspected of having been sexually abused may benefit from a brief evaluation and examination of their anogenital area to determine whether and when an expert medical evaluation is needed. Unfortunately, many physicians are unfamiliar with geni tal anatomy, particularly in the prepubertal girl (Figs. 17.9 and 17.10). Nevertheless, signs of trauma such as bruising, abrasions, and bleeding or of infection may be apparent. Because about 95 of children who undergo a medical evaluation after sexual abuse have normal exams, the role of the PCP is often simply to be able to distinguish a normal exam from findings indicative of common medical concerns (e.g., diaper dermatitis) or trauma, or to reas sure a parent whose preschooler is touching themself. Unsuspected injuries or medical problems such as labial adhesions, imperforate hymen, or urethral prolapse may be identified. In addition, reassur ance about the childs physical health may often allay anxiety for the child and family. When concerns about sexual abuse arise because of genital find ings or complaints, it is important to assess for and rule out medical problems that can be confused with
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abuse. Several genital findings may raise concern about abuse but often have alternative explana tions. For example, genital redness in a prepubertal child is usually caused by nonspecific vulvovaginitis, diaper dermatitis, or infection with a nonsexually transmitted organism such as staphylococcus or Abuse suspected Report to child protective services and police Abuse likely occurred within past 72 hours (prepubertal) or 120 hours (postpubertal) Yes Yes No No Send child to acute sexual abuse referral center for urgent exam and possible forensic evidence collection Acute symptoms, e.g., genital pain, or bleeding Acute psychiatric issues Urgent exam not necessary. Nonacute exam should be performed by health professional with expertise in the medical evaluation of child sexual abuse. Fig. 17.8 Triage protocol for children with suspected sexual abuse. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 124 Part I u The Field of Pediatrics group A streptococcus. It is often apparent that the diffuse redness is unlikely to be the result of trauma. Lichen sclerosis is an uncom mon cause of redness and usually presents with vulvar andor peri anal atrophy and hypopigmentation, often in a figure 8 pattern. Vaginal discharge can be caused by STIs, but also by poor hygiene, foreign body, the onset of puberty, or infection with Salmonella, Shigella, or Yersinia. Genital ulcers can be caused by herpes simplex virus (HSV) and syphilis, but also by Epstein Barr virus, varicella zoster, Crohns disease, and Behets disease. Genital bleeding can be caused by urethral prolapse, vaginal foreign body, or nonin flicted trauma. The medical exam should begin with a general exam of the child. Doing so enables the child to become comfortable with the exam pro cess before the genital exam and may identify other evidence of mal treatment or health problems. For prepubertal children, the parent should be present to provide comfort and reassurance. Older children should be given the option of having a parent present. The American Academy of Pediatrics (AAP) recommends that whenever private parts are examined (i.e., genitals, breast, anus), a chaperone should be present. In prepubertal children, this can be a parent. For ado lescents, the chaperone should be a clinical staff member, unless the teen objects. If so, the PCP may have a parent be present if all three A D F G E B C Urethra Membrane covering opening Fig. 17.9 Types of hymens. A, Crescentic. B, Annular. C, Redundant. D, Microperforate. E, Septated. F, Imperforate. G, Hymeneal tags. (AD and G from McCann JJ, Kerns DL. The Anatomy of Child and Adolescent Sexual Abuse. St. Louis: InterCorp, 1999; E and F from Perlman SE, Nakajima ST, Hertweck SP. Clinical Protocols in Pediatric and Adolescent Gynecology. London: Parthenon Publishing Group, 2004. Figs. 25.5 and 25.9.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No
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other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 17 u Abused and Neglected Children 125 are amenable. The PCP may decline to do an exam if the teen refuses a chaperone. The female genital exam is done with the child in the frog leg supine position or the adolescent in the lithotomy position. Labial separation and labial traction, with gentle tugging apart and down of the labia majora, provide a view of the hymen. Any suspected abnormalities should be confirmed by also examining the child in the prone knee chest position. Supine knee chest is the best way to examine the anus. Internal vaginal and anal exams are rarely needed. If there is significant bleeding or a persistent discharge, a referral to an expert in child abuse is recommended. Referral to a child abuse specialist: Referral to a child abuse spe cialist will help ensure that findings indicative or suggestive of abuse are appropriately identified and documented. It is considered the standard of care to use a colposcope or camera for the genital exam to magnify the genital and anal tissues for improved visualization and to take photographs or video as potential evidence and for peer review. Child abuse experts can identify mimics of sexual abuse, test for and treat STIs, and address child or parental concerns. Testing for STIs: Testing for STIs is not indicated for most chil dren but is warranted in certain situations (Table 17.6). Culture was considered the gold standard for diagnosing vaginal gonorrhea (Chapter 238) and chlamydia (Chapter 272) infections in children. Nucleic acid amplification testing (NAAT) for gonorrhea and chla mydia by either vaginal swab or urine in prepubertal girls is as, or more, sensitive than culture. Guidelines from the Centers for Dis ease Control and Prevention (CDC) allow for such NAAT testing as an alternative to culture. Because obtaining vaginal swabs can be uncomfortable, particularly for prepubertal girls, urine testing is preferable, using a Food and Drug Administration (FDA)approved assay. Although the FDA has not approved NAATs for the diagnosis of gonorrhea or chlamydia infections of the throat or anus, they may be used if the laboratory has performed internal validation with reference standards. Although little data on the use of urine NAAT testing in prepubertal boys are available, the CDC has indi cated that there is no reason to suspect that test performance in children and youth would be different from adults. Thus urine test ing of them too appears adequate. For all NAAT testing in females and males, the child should not receive presumptive treatment at the time of testing. Instead, a posi tive NAAT test should be confirmed by repeating the test on the original sample or on a new sample. Whereas the CDC previously recommended confirmatory testing with a different FDA approved assay, the 2021 Sexually Transmitted Infection Treatment Guide lines no longer require this. Gonorrhea and chlamydia in prepu bertal children rarely cause ascending infection; thus waiting for a definitive diagnosis before treatment holds
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little risk for pelvic inflammatory disease. Testing for Trichomonas vaginalis is by culture, NAAT, or wet mount. Wet mount requires the presence of vaginal secretions, view ing must be immediate for optimal results, and sensitivity is only Labia minora Urethral opening Hymen Moundbump on hymen Fossa navicularis Posterior fourchette Normal vestibular vascularity Vaginal opening Vestibular support band Shallow hymen notches a b Hymen transection (complete cleft) Bruising on hymen A B C Fig. 17.10 A, Photograph taken with a camera attached to colposcope at 10 magnification. Note the increased vascularity and redness in the vestibule adjacent to the hymen on the right and left. This is a normal finding and not to be mistaken for signs of trauma. B, Photograph taken with a camera attached to colposcope at 10magnification shows the appearance of the hymen in an adolescent. Shallow notches in the hymen are evident at the 9 and 11 oclock positions, as well as hymen transection at approximately 7 oclock. There is no hymen tissue between arrow a and arrow b, confirming that the defect extends all the way through the hymen tissue. C, Photograph taken with a camera attached to a colposcope shows bruising of the hymen at the 7 to 8 oclock position and the suggestion of a possible hymen laceration. Examination of additional positions and other examination techniques would be required to determine if a hymen laceration is also present at this location. (From Adams JA, Kellog ND, Moles R. Medical care for children who may have been sexually abused: an update for 2016. J Pediatr Adolesc Gynecol. 2015;17(4):255263. Figs. 1, 2, and 4.) Table 17.6 Indications for STI Screening in Children with Suspected Sexual Abuse 1. The child has experienced penetration or has evidence of recent or healed penetrative injury to the genitals, anus, or oropharynx. 2. The child has been abused by a stranger. 3. The child has been abused by an assailant known to be infected with an STI or at high risk for STIs (e.g., injecting drug user, men who have sex with men, persons with multiple sexual partners, or person with a history of STIs). 4. The child has a sibling, other relative, or another person in the household with an STI. 5. The child lives in an area with a high rate of STIs in the community. 6. The child has signs or symptoms of STIs (e.g., vaginal discharge or pain, genital itching or odor, urinary symptoms, or genital lesions or ulcers). 7. The child or parent requests STI testing. 8. The child is unable to verbalize details of the assault. STI, Sexually transmitted infection. From Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1184. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 126 Part I u The Field of Pediatrics 4468; therefore false negative
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tests are common. NAAT tests for Trichomonas should only be performed using FDA approved prod ucts. Positive tests should be confirmed using the same sample or a repeat collection. Point of care tests for Trichomonas, done at the PCPs office, have not been validated for prepubertal children and should not be used. Obtaining a blood sample for HIV, syphilis, and hepatitis B test ing should be considered, particularly if there has been vaginal or anal penetration with pain, bleeding, or ejaculation. To limit pain ful procedures, some experts begin with genital, anal, andor throat testing and do the blood testing if the earlier testing is positive. Because HIV testing identifies antibodies to the virus, it may take several months for seroconversionrepeat testing at 6 weeks and 3 months after the last suspected exposure is indicated. Repeat test ing for syphilis and hepatitis B is also recommended at the same intervals. INTERPRETATION OF FINDINGS History: A clear disclosure of abuse by a child or adolescent, partic ularly with details that can be corroborated, is strong evidence that abuse has occurred. A strong denial could indicate that abuse did not occur, but could also be the result of fear, threats from the per petrator, or pressure from family members to remain silent. Limited language skills or a long length of time since the abuse occurred may limit the specificity of the disclosure. Alternatively, a vague dis closure may lead a parent to assume abuse when none has occurred. Infrequently, a child may be coached by a parent to describe abuse, sometimes in the context of a custody dispute. More commonly, an abusive parent will allege coaching to protect themself and enable ongoing access to the child. Findings indicative of trauma: Abrasions, lacerations, and bruis ing of the labia, vulva, penis, scrotum, perianal tissues, or perineum indicate recent trauma. Hymenal bruising and lacerations and deep perianal lacerations (vs superficial fissures) indicate penetrating trauma. Anogenital scars indicate older trauma. Hymnal scars often appear as changes in the usual anatomy and pallor. It is noteworthy that such findings that are exactly midline are likely normal embry onic remnants. A complete transection of the hymen all the way to the base below 3 and 9 oclock in the supine position (i.e., absence or gap of hymenal tissue posteriorly) is considered diagnostic for penetrating trauma (see Fig. 17.10). For all these findings, the cause of injury must be elucidated through the child and parent history, as trauma may also be the result of a noninflicted injury or consensual sexual activity. If there is any concern that the finding may be the result of sexual abuse, CPS should be notified, and a medical evalu ation should be performed by a medical specialist with expertise in child sexual abuse. STIs: A number of STIs raise serious concern for abuse (Table 17.7). In a prepubertal child, gonorrhea, trichomonas, or syphi lis beyond the neonatal period indicates that the child had contact with infected genital secretions, almost always as a result
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of sexual abuse. There is some evidence to indicate that chlamydia in chil dren up to 3 years of age may be perinatally acquired. Chlamydia in children older than 3 years is diagnostic of contact with infected genital secretions almost always because of abuse. HIV is diagnostic for sexual abuse if other means of transmission have been excluded. Because of the potential for human papillomavirus (HPV) transmis sion, either perinatally or through nonsexual contact, the presence of genital warts has a low specificity for sexual abuse. Nevertheless, the possibility of abuse should be briefly probed with the family, especially in children whose warts first appear beyond 5 years of age. Type 1 or 2 herpes simplex virus (HSV) in the anogenital area is concerning for sexual abuse, but not diagnostic given other possi ble routes of transmission. PCPs should consider referring patients with HPV and HSV to CPS. Integration of Information Because most sexually abused children have normal exams, it is often not possible to make a diagnosis of sexual abuse by the exam alone. Ideally, the determination of abuse should be made as part of a multi disciplinary team process, where information from interviews, medi cal evaluation, forensic kit, and laboratory test results are integrated. Determinations by CPS as to whether abuse occurred may not align directly with a decision to prosecute alleged offenders because criminal cases require a higher level of proof (beyond a reasonable doubt) than do CPS cases, which rely on the preponderance of evidence (i.e., more likely than not). Table 17.7 Implications of Commonly Encountered Sexually Transmitted or Sexually Associated Infections for Diagnosis and Reporting of Sexual Abuse Among Infants and Prepubertal Children INFECTION EVIDENCE FOR SEXUAL ABUSE SUGGESTED ACTION Gonorrhea Diagnostic Report Syphilis Diagnostic Report HIV Diagnostic Report Chlamydia trachomatis Diagnostic Report Trichomonas vaginalis Diagnostic Report Anogenital herpes Suspicious Consider report, Condylomata acuminata (anogenital warts) Suspicious Consider report,, Anogenital molluscum contagiosum Inconclusive Medical follow up Bacterial vaginosis Inconclusive Medical follow up If unlikely to be perinatally acquired and vertical transmission, which is rare, is excluded. Reports should be made to the local or state agency mandated to receive reports of suspected child abuse or neglect If unlikely to have been acquired perinatally or through transfusion. Unless a clear history of autoinoculation exists. Report if evidence exists to suspect abuse, including history, physical examination, or other identified infections. Lesions appearing for the first time in a child aged 5 yr are more likely to have been caused by sexual transmission. From Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1184. Adapted from Kellogg N, American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics. 2005;116:506512; Adams JA, Farst KJ, Kellogg ND. Interpretation of medical findings in suspected child abuse: An update for 2018. J Pediatr Adolesc Gynecol. 2018;31:225231. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal
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use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 17 u Abused and Neglected Children 127 Recommendations for Children and Families At the conclusion of the medical evaluation, the PCP should let the child and parent know that the child is physically healthy but should also explain to them why a normal exam does not rule out abuse. It is often helpful to reinforce that in most cases, what is most impor tant in determining whether sexual abuse occurred is what the child has said. When there are findings indicative of abuse, these should also be clearly explained. Of note, injuries to the anogenital area typically heal without complications, and most STIs respond well to treatment. Thus comforting and reassuring children and families is generally appropriate, even when injuries andor infection occurs. PCPs should tell children that the abuse was not their fault and encourage parents to be supportive of their child. Although most children will not need medical follow up, a visit with their PCP can be helpful to monitor psychosocial progress and to support the child and family. Some will need repeat HIV, syphilis, and hepatitis B testing. Hepatitis B and HPV vaccination (for children 9 years) should be given if the child has not been adequately vaccinated. Most children and their parents benefit from therapy or counseling. A mental health evaluation for other children in the home should be considered; the stress of coping with abuse and its ramifications can be difficult for the entire family. Parents are often very stressed by the sexual abuse of their child, even when it is uncertain what happened. This is compounded by the legal processes and implica tions. If emotional or behavior problems arise later, the PCP should try to refer the child to a mental health professional with experience in addressing trauma. SEXUAL ABUSE PREVENTION PCPs can play a role in the prevention of sexual abuse by educating parents and children about sexual safety at well child visits. During the genital exam the PCP can inform the child that only the doctor and select adult caregivers should be permitted to see their private parts and that a trusted adult should be told if anyone else attempts to do so. Parents and children should be encouraged to use correct terms (vagina, vulva, penis, breasts) to demystify the genitals. The pedia trician can teach parents, children, and youth how to minimize the opportunity for perpetrators to access children, for example, by limit ing one adultone child situations outside the home (e.g., in daycare or school) and being sensitive to another adults unusual interest in young children. In addition, PCPs can model for parents talking with children about what to do if confronted with a potentially abusive situation. Some examples include telling children to say no, to leave, and to tell a parent andor another trusted adult. Conversations with children of all ages can include a discussion of consent before touching another person. Conversations with teens
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can include information about statu tory rape and electronic dissemination of sexual photos, along with their risks. Finally, PCPs can encourage open communication between parents and children; children need to hear that their parent is there to protect them and will not be angry with them if they hear something bad. Instead, they need to know. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. 17.2 Factitious Disorder Imposed on Another: Medical Child Abuse (Munchausen Syndrome by Proxy) Howard Dubowitz and Wendy G. Lane Munchausen syndrome describes situations in which adults falsify their own symptoms to obtain healthcare. In Munchausen syndrome by proxy, a parent, typically a mother, simulates or causes signs andor symptoms in her child, resulting in unnecessary healthcare. Several terms describing this phenomenon focus on the abuse or neglect experienced by a child, including pediatric condition falsi fication, caregiver fabricated illness in a child, and medical child abuse (MCA). Factitious disorder imposed on another (FDIA) is a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edi tion (DSM 5) psychiatric diagnosis focused on the psychopathology in the responsible parent attempting to meet their own psychologic needs. FDIA may encompass all other titles. In some instances, such as partial suffocation, child abuse may be most appropriate. Because milder forms of MCA often go undetected, its incidence is unclear, although 0.5 2 per 100,000 children is commonly cited, and it appears to be a global problem. The core dynamic is that a parent falsely presents a child for healthcare. This may be via fab ricating a history, such as reporting seizures or apnea that never occurred. A parent may directly cause a childs illness, for example, by exposing a child to a toxin, medication, or infectious agent (e.g., injecting stool into an intravenous line) or smothering a child. Signs or symptoms may also be manufactured, such as when a parent withholds medication or alters laboratory samples or temperature measurements. Parents may also withhold information about nor mal procedures or testing done elsewhere. Preverbal children are usually involved, although older children may be convinced by par ents that they have a particular problem and become dependent on the increased attention; this may lead to feigning symptoms. They may also be coached to corroborate false histories. Each of these actions may lead clinicians to suspect a health problem and thus to provide unnecessary healthcare, including intrusive tests and surgeries. When to suspect FDIAMCA? Consideration of MCA may be triggered when the described symptoms, their course, test results, or response to standard treatment is incompatible with any known disease or condition. The reported symptoms may be repeatedly noted by only one parent or occur only when one caregiver is alone with the child. Other risk indicators include parents who appear to need a lot of attention from physicians or who insist that the child cannot cope without them. They may refuse to leave the bedside for days. Parents with experience in a medical field may be adept at con structing plausible presentations, although the
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internet provides other parents with easy access to medical information. A convincing seizure history may be offered, as a normal electroencephalogram cannot fully rule out the possibility of a seizure disorder. Even after extensive testing fails to lead to a diagnosis or treatment proves inef fective, clinicians may think they are confronting a new or rare dis ease and may unwittingly contribute to unnecessary testing and to a parents belief that a real problem exists. Efforts to carefully pursue a diagnosis along with difficulty accepting uncertainty may lead cli nicians to persist with testing. Clinicians generally rely on and trust parents to provide an accurate history. As with other forms of child maltreatment, accurate diagnosis of MCA requires that profession als maintain a healthy skepticism under certain circumstances; this can be difficult. Clinicians, including mental health experts, may think that they are skilled at detecting deception. Most do poorly when attempting to do so during a clinical interview. At a systems level, limited communication among treating pro fessionals may delay the diagnosis of MCA. The problems often recur repeatedly over several years. The time from first presenta tion until the diagnosis is made averages about 2 years. Ultimately, a diagnosis of MCA rests on clear evidence of a child repeatedly being subjected to unnecessary tests and treatment, primarily stemming from a parents exaggeration, fabrication, or induction of symptoms or signs suggesting an illness or condition. CLINICAL MANIFESTATIONS Mothers are the most frequent perpetrators of MCA. They may present as devoted or even model parents who form close rela tionships with members of the healthcare team. Although appear ing very interested in their childs condition, they may be distant emotionally. Negative test results may meet with disappointment, and they may insist on further evaluation. They may have a history Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 128 Part I u The Field of Pediatrics of Munchausen syndrome, though not necessarily diagnosed as such. MCA varies in nature and severity. Males and females are equally involved. Most of the victims are infants and toddlers, but approxi mately 25 of cases occur in children over 6 years of age. Siblings are commonly affected. Approximately 69 of cases are fatal, with fatali ties most often the result of poisoning or suffocation. It is important to note that children who really do have health problems can also be victims of MCA; up to 30 of patients with MCA have been found to have a medical problem. Many medical or behavioral conditions can be falsified. The following are examples of relatively common ways MCA presents: Bleeding may be caused by adding dyes to samples, adding blood (e.g., from the mother) to the childs sample, or giving the child an anticoagulant (e.g., warfarin). Blood group testing may be needed. Seizures are easy to fabricate and difficult to rule out. A
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par ent may report that another physician diagnosed seizures, and the myth may be perpetuated if there is no effort to confirm the original diagnosis. Alternatively, seizures may be induced by toxins, medi cations (e.g., insulin), water, or salt. Clinicians need to be familiar with the substances available to families and their risks. Apnea may be falsified or created by partial suffocation. A history of a sibling with the same problem, perhaps dying from it, should raise concern. Parents of children hospitalized for a brief resolved unex plained event (BRUE) have been videotaped attempting to suffocate their child while in the hospital. Gastrointestinal problems such as vomiting and diarrhea are com mon. Forced ingestion of medications such as ipecac may induce chronic vomiting, or laxatives may cause diarrhea. Toxicology testing is indicated in such circumstances. Allergies may be fabricated. Sometimes, allergies may be diagnosed or considered, and a parent persists in viewing this as a problem even after it has subsequently been ruled out. Urinary tract infections and hematuria account for about 25 of cases. Behavior problems such as self harm or harming others, learning disabilities, hyperactivity, or autism may be falsely described. EVALUATION AND DIAGNOSIS It is critical that clinicians consider the possibility of MCA in their differential diagnosis when facing the previously noted presenta tions. Further, it helps to focus on the actual or potential harm to a child, rather than the parents possible motivation. Once MCA is suspected, gathering and critically reviewing all the childs medical records from all sources is an onerous but critical first step, best done by someone knowledgeable about MCA. Child protective services (CPS) can help gather the records, and a hospital based child protection team might be able to review the case. Important documentation at each health contact includes date, location, rea son for contact, reported signssymptoms as stated by the caregiver, objective observations documented by the physician, conclusions diagnosis made, treatment provided, effectiveness of treatment, and other comments or observations. It is important to confer with other treating physicians about what specifically was conveyed to the family; they may have been reluctant to document concerns in the childs record. A parent may report that a certain test was done at the insistence of a physician, when they, in fact, had demanded it. It is also sometimes necessary to confirm the exact basis for a given diagnosis, rather than simply accepting a parents account (e.g., seizure). Depending on the nature of the presenting problem, hospitaliza tion may be needed. Verbal children should be interviewed alone, and the family history should probe for unusual and frequent ill nesses. Close observation of a child can be valuable. There may be a history of poor appetite and vomiting, yet the child is observed to eat well without problems. Symptoms may only be described when the parent is present and otherwise noted to be absent. In some instances, such as BRUEs, covert video surveillance accompanied by monitoring (to rapidly intervene if a parent attempts to suffocate
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a child) can be valuable. In addition to helping clarify the diagnosis, video surveillance can identify a true medical problem. It is prudent to consult with risk management and hospital legal staff before ini tiating surveillance. Specimens should be carefully collected, with no opportunity for tampering with them. Similarly, temperature measurements should be closely observed. Coordination among treating professionals is essential, especially as some may side with the parent and resent even the possibility of MCA being raised. Ideally, parents should not be informed of the evaluation for MCA until the diagnosis is made. Doing so could influence their behavior and jeopardize establishing the diagno sis. In summarizing the review of health records and gathering additional information, careful and chronologic documentation is important. This includes who witnessed symptoms, direct informa tion from other clinicians who made diagnoses, what guidance was given to the family, whether a parent insisted on testing or treat ment, and suspected tampering with equipment or records as well as other concerning behavior. It may be necessary to block parents at least temporarily from accessing part of the electronic health record. The diagnosis of MCA hinges on a child receiving unnecessary healthcare that is actually or potentially harmful and that is instigated by a parent or caregiver. Three questions to be answered in considering MCA include: 1. Are the history, signs, and symptoms credible? 2. Is the child receiving unnecessary and harmful or potentially harm ful medical care? 3. If so, who is instigating the evaluations or treatments? Comprehensive practice guidelines regarding MCA are available from the American Academy of Pediatrics (AAP) and the American Professional Society on the Abuse of Children (APSAC). In addition, consultation with a board certified child abuse pediatrician is strongly recommended. Related circumstances: In assessing possible MCA, several other circumstances should be considered in addition to a true health problem. Some parents may be extremely anxious and genuinely concerned about a possible problem. There may be many reasons underpinning the vulnerable child syndrome, such as the death of neighbors child or something read on the internet. Alternatively, parents may believe something told to them by a trusted clinician despite subsequent evidence to the contrary and efforts to correct the earlier misdiagnosis (e.g., persistent belief that the child has multiple food allergies). Secondary gain, such as qualifying for a disability benefit, may be the impetus for malingering. A childs anxiety, especially in the context of complex medical conditions, may lead to psychosomatic symptoms and consideration of MCA. In addition, parents of such children may be extremely stressed, and this may contribute to an approach that is overly medicalized (e.g., reluctance to wean a child off medication). There is also a need to discern commonly used hyperbole (e.g., exaggerating the height of a fever) to evoke concern and perhaps justify a clinic visit. Whatever the possible underlying dynamics, children who receive unneces sary healthcare as a result of parental actions can be diagnosed with MCA. TREATMENT MCA is a form of child abuse or
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neglect and needs to be referred to CPS even when one is less than certain of the diagnosis; law enforcement may also need to be involved. CPS staff often lack knowledge of and experience with MCA and may need to be edu cated regarding this condition. Once the diagnosis of MCA is Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 18 u Strategies for Health Behavior Change 129 established, the medical team and CPS should determine the treat ment and safety plan, which may require out of home placement and should include mental healthcare for the offending parent; psy chiatric decompensation and maternal suicide have been reported. Further medical care should be carefully coordinated through one primary care professional. CPS should be encouraged to meet with the family only after the medical team has informed the offending parent of the diagnosis, together with the other parent or another supportive adult if possible. Direct CPS involvement with the fam ily during the assessment may jeopardize clarifying the diagnosis. If the plan is to place the child out of home, it is optimal that CPS plan the necessary steps in advance. Parents often respond with resistance, denial, and threats. It may be prudent to have hospital security in the vicinity in case of physical aggression or an attempt to remove the child from the hospital against medical advice. CPS should assess the safety of other children in the home. All fam ily members may be affected by an MCA diagnosis; mental health care is recommended specifically for the parent involved with FDIA. Assessing and addressing MCA can be time intensive and chal lenging. Clinicians may face the dilemma of when to accept that all plausible diagnoses have been reasonably ruled out, the circum stances fit MCA, and when testing and treatment should cease. The likelihood of MCA must be balanced with concerns about possibly missing an important diagnosis. Consultation with a child abuse pediatrician is recommended for making the diagnosis and for helping plan ongoing healthcare if the child remains in or returns to the home. Good communication among treating clinicians is needed to adequately monitor the situation; long term monitoring may be needed. OUTCOMES There may be lasting physical harms associated with unnecessary and sometimes invasive evaluations and interventions, including scarring, surgical complications, brain damage, and death. There are also potentially serious and lasting social and psychologic sequelae as a result of missing school and extracurricular activi ties and viewing themselves as disabled. Victims of MCA may be overly compliant or aggressive and may develop poor self esteem, posttraumatic stress disorder, and eating problems. Indirectly, other family members and friends, professionals, and even community members may be affected. Recidivism has been reported in 1750 of cases. Successful treatment of the abusive parent appears rare and hinges on acknowledging their role and being willing and
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able to change their behavior. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. To improve the health of children, pediatricians often ask patients and caregivers to make behavioral changes. These may be lifestyle changes to manage a chronic condition (e.g., obesity, asthma), adherence with the recommended timing and frequency of medi cations, or recommendations to seek assistance from other health providers (e.g., dieticians; mental health providers; physical, Chapter 18 Strategies for Health Behavior Change Cori M. Green occupational, or speech therapists). However, change is difficult and can cause distress, and families often express reluctance or ambivalence to change because of perceived barriers. When fami lies do not believe change is needed or possible, pediatricians may become discouraged or uncomfortable in providing care. This can make it difficult for clinicians to form an alliance with families, which is central to finding a solution to most problems identified in the medical setting. Many healthcare problems may require complex, multifaceted interventions, but the first step is always to engage the family in identifying the healthcare problem driving the need for behavior change. Once a problem is identified and agreed on, clinicians and families need to set an achievable goal and identify specific behaviors that can help families reach their goal. It is important to be specific and precise about the actual behavior and not simply identify the category of the behavior. When counseling a patient on weight loss for obesity, for example, one might discuss three possible approaches: making dietary changes, increasing exercise, and decreasing screen time. The choice of which behavior to focus on should come from the patient but needs to be specific. It is not enough for the patient to state he or she will exercise more. Instead, the clinician should help the patient identify a more specific goal, such as playing basketball with friends 3 times a week at the park near home. This takes into account the action, context, setting, and time of the new behavioral goal. Specific examples of problems that would necessitate a behavior change to improve outcomes are used throughout the chapter. UNIFIED THEORY OF BEHAVIOR CHANGE There are several theories of health related behavior change. Each highlights a different concept, but frameworks that unite these theories suggest that the factor most predictive of whether one will perform a behavior is the intention to do so. The unified theory of behavior change examines behavior along two dimensions: influences on intent and moderators of the intention behavior relationship (Fig. 18.1). Five main factors that influence ones decision to perform a behavior are expectancies, social normsnormative influences, self conceptself image, emotions, and self efficacy. Table 18.1 provides specific exam ples on how to explore influences of intent when guiding families in decision making, such as deciding to start a stimulant medication for a child diagnosed with attention deficithyperactivity disorder (ADHD). It is not necessary to ask about each influence, but these principles are particularly useful when guiding patients who may be resistant to change. Once a decision to
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make a change is made, four factors determine whether an intention leads to carrying out the behavior: knowledge and skills, environmental facilitators and constraints, salience of the behavior, and habits. The pediatrician can help ensure intent leads to behavior change by addressing these factors during the visit. In the ADHD example, the clinician can help the family build their knowledge by providing handouts on stimulants, nutritional pamphlets on how to minimize the appetite suppressant effects of the medication on weight, and information on how the family can explain to others the need for medication. Asking about morning routines will help identify potential barriers in remembering to take the medication. Lastly, clinicians can help families think about cues for remembering to give the medication in the morning, because their morning routines, or habits, will have to be adjusted to adhere to this medication. By using these principles of behavior change, clinicians can guide their patients toward change during an encounter by ensuring they leave with (1) a strong positive intention to perform the behavior; (2) the perception that they have the skills to accomplish it; (3) a belief that the behavior is socially acceptable and consistent with their self image; (4) a positive feeling about the behavior; (5) spe cific strategies in overcoming potential barriers in performing the behavior; and (6) a set of identified cues and enablers to help build new habits. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 130 Part I u The Field of Pediatrics Table 18.1 Influences of Intent and Possible Use During a Patient Encounter (Specifically, Starting a Stimulant for ADHD) INFLUENCE OF INTENT STRATEGIES TO ENGAGE FAMILIES USING INFLUENCES OF INTENT POSSIBLE FACTORS INFLUENCING THE DECISION Beliefs and expectancies Perceived advantages and disadvantages of performing a behavior. Ask questions about their beliefs and experiences. What do you know already know about stimulants? Have you heard about other childrens experiences taking stimulants? What do you expect will happen if your child takes a stimulant? Ask permission to give information addressing their prior beliefs or experiences. Is it all right if I give you some information addressing your concerns? I know that stimulants helped my nephew do better in school. I heard stimulants stunt childrens growth. Social norms Pressures to (or not) perform a behavior because of what is standard among social groups. Share information about the normative nature of the behavior and ways to cope if performing a behavior that is not the social norm. I have a lot of patients who have improved in school after starting a stimulant. Do other parents give their children stimulants if they are diagnosed with ADHD? What would my mother think if she found out my child was taking a stimulant? Self conceptself image Overall sense of self and whether behavior is congruent with that and with the image they want to
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project to others. Interact with family in a partnering, supportive, respectful manner. Identify strengths. Reframe any negative images they foresee may happen with the behavior. I am sure your in laws will be so happy when your child is doing better in school. Am I a good parent if I give my child medications that affect their brain? What will other parents at school think if I allow my child to start a stimulant? What will my in laws think? Emotions Emotional reactions to performing behaviors in terms of intensity and direction (positive or negative). Allow patients to express their feelings. Suggest ways to manage negative or avoidant feelings. Many parents are scared to start stimulants at first. However, once their child is succeeding in school, they realize the benefits outweighed the risks. Lets talk more about your fears. I am so nervous about my child starting to take a stimulant. I am so upset with how my child is doing in school and really do not know what to do next. I am so relieved that there is a medication that may help improve my childs grades and chance of going to college. Self efficacy Perceived confidence they can perform the behavior. Provide information, model the behavior, encourage success, and teach skills. Explore what obstacles they foresee and how confident they are they can overcome obstacles. Help strategize ways to overcome obstacles. Do you feel confident you will be able to get your child to take the medication? Lets brainstorm how we can prevent any of the side effects. Many of my patients have a large breakfast before taking the medication. Can I help you figure out how to fit that into your schedule? Will I be able to remember to give my child this medication every day? Will I be able to make sure my child has a large breakfast in the morning before taking the medication? ADHD, Attention deficithyperactivity disorder. Statements and questions are examples of what caregivers may be thinking. Problem Identification Behavioral Beliefs and Expectancies Social Norms Normative Influences Knowledge and Skills Habit and Automatic Processes Intention to Perform Behavior Behavior Needed to Achieve Goal SelfConcept Social Image Affect and Emotions SelfEfficacy Environmental Constraints Facilitators Salience of Behavior Goal Fig. 18.1 The five constructs that influence ones intent to perform a behavior and the four influences that determine whether an intent will lead to performing the behavior. Problem identification (box at upper right) is where the process of thinking about health behavior changes begins. A clinician can then help the patient decide which behavior can help them meet the health goal. Once this is decided, to help with behavior change, clinicians should think about intent, influences of intent, and the factors that may facilitate or impede intent from leading to action. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved.
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Chapter 18 u Strategies for Health Behavior Change 131 TRANSTHEORETICAL MODEL OF HEALTH BEHAVIOR CHANGE It is difficult to counsel families to change a behavior when they may not agree there is a problem or when they are not ready to build an intention to change. The transtheoretical model of health behavior change places an individuals motivation and readiness to change on a continuum. The premise of this model is that behavior change is a process, and as someone attempts to change, they move through five stages (although not always in a linear fashion): pre contemplation (no current intention of making a change), contem plation (considering change), preparation (creating an intention, planning, and committing to change), action (has changed behavior for a short time), and maintenance (sustaining long term change). Assessing a patients stage of change and then targeting counseling toward that stage can help build a therapeutic alliance, in contrast to counseling a patient to do something she or he is not ready for, which can disrupt the therapeutic alliance and lead to resistance. Table 18.2 further describes stages of change and gives examples for counseling that target the adolescents stage of change in reducing marijuana smoking. COMMON FACTORS APPROACH Conversations around behavior change are most effective when they take place in a context of a trusting, mutually respectful relationship. The traditional medical model assumes that patients and their fami lies come with questions and needs and that the pediatricians job is to offer specific advice and advocate for its acceptance. This approach fails when families are reluctant, ambivalent, demoralized, or unfamiliar with the healthcare system or the treatment choices offered. A context more supportive of behavior change can be developed when clinicians use communication strategies that facilitate collaboration and building a therapeutic alliance. The common factors approach is an evidence based communica tion strategy that is effective in facilitating behavior change. The skills central to a common factors approach are consistent across multiple forms of psychotherapy and therefore can be considered transdiagnos tic. Common factors and processes can be viewed as generic aspects of treatment that can be used across a wide range of symptoms to build a therapeutic alliance between the physician and patient. This alliance predicts outcomes of counseling more than the specific modality of treatment. The common factors approach has been implemented and Table 18.2 Stages of Change and Strategies for Counseling STAGEDEFINITION GOAL AND STRATEGY SPECIFIC EXAMPLES Precontemplation Not considering change. May be unaware that a problem exists. Establish a therapeutic relationship. Increase awareness of need to change. I understand you are only here because your parents are worried and that you dont feel that smoking marijuana is a big deal. Can I ask if smoking marijuana has created any problems for you now? I know your parents were worried about your grades. Its up to you to decide if and when you are ready to cut back on smoking marijuana. Is it okay if I give you some information about marijuana use? I
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know it can be hard to change a habit when you feel under pressure. It is totally up to you to decide if cutting back is right for you. Is it okay if I ask you about this during our next visit? Contemplation Beginning to consider making a change, but still feeling ambivalent about making a change. Identify ambivalence. Help develop discrepancy between goals and current behaviors. Ask about pros and cons of changing problem behavior. Support patient toward making a change. Im hearing that you do agree that sometimes your marijuana use does get in the way, especially with school. However, it helps relax you and it would be hard to make a change right now. What would be one benefit of cutting back? What would be a drawback to cutting back? Do you think your smoking will cause problems in the future? After talking about this, if you feel you want to cut back, the next step would be to think about how to best do that. We wouldnt need to jump right into a plan. Why dont you think about what we discussed, and we can meet next week if you are ready to make a plan? Preparation Preparing for action. Reduced ambivalence and exploration of options for change. Help patient set a goal and prepare a concrete plan. Offer a menu of choices. Identify supports and barriers. Its great that you are thinking about ways to cut back on your smoking. I understand your initial goal is to stop smoking during the week. I can give you some other options of how to relax and reduce stress during the week. We need to figure out how to react to your friends after school who you normally smoke with. Do you have other friends who you can see after school instead, who would support this decision? Action Taking action; actively implementing plan. Provide positive feedback. Identify unexpected barriers and create coping strategies. Congratulations on cutting back. Have you noticed any differences in your schoolwork? Im so happy to hear your grades improved. Has it been difficult to not see your friends after school? How have you reacted when they get annoyed you dont want to smoke with them? Lets continue to track your progress. Maintenance Continues to change behavior and maintains healthier lifestyle. Reinforce commitment and affirm ability to change. Create coping plans when relapse does occur. Manage triggers. You really are committed to going to a good college and improving your grades. Im so happy the hard work has paid off. I understand that it was hard to say no to smoking with your friends last week when it was someones birthday. How did you feel after? Are there triggers that we can think about preventing in the future? This table uses an example of an adolescent who is initially resistant to cutting back on smoking marijuana. His parents caught him smoking in his room and arranged for him to see the pediatrician. Adapted from Implementing
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Mental Health Priorities in Practice: Substance Use, American Academy of Pediatrics. https:www.aap.orgen usadvocacy and policyaap health initiativesMental HealthPagessubstance use.aspx. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 132 Part I u The Field of Pediatrics studied in pediatric primary care for children with mental health prob lems. Children who were treated by pediatricians trained in the com mon factors approach had improved functioning compared to those who saw pediatricians without this training. A common factors approach distinguishes between the impact of the patient provider alliance and the pediatricians use of skills that influ ence patient behavior change across a broad range of conditions. Inter personal skills that help build alliances with patients include showing empathy, warmth, and positive regard. Skills that influence behav ior change include a clinicians ability to provide optimism, facilitate treatment engagement, and maintain the focus on achievable goals. This can be done by clearly explaining the condition and treatment approaches while keeping the discussion focused on immediate and practical concerns. Interpersonal Skills: HEL2P3 The interpersonal skills that facilitate an effective bond between the patient and clinician can be remembered by the HEL2P3 mnemonic (Table 18.3). These skills include providing hope, empathy, and loy alty; using the patients language; partnering with the family; asking permission to raise more sensitive questions or to give advice; and cre ating a plan that is initiated by the family. These interpersonal skills should help operationalize the common factors approach by increasing a patients optimism, feelings of well being, and willingness to work toward improved health, while also targeting feelings of anger, ambiva lence, and hopelessness. Structuring a patient encounter using common factors to facili tate behavior change uses these steps: eliciting concerns while setting an agenda and agreeing on the nature of the problem; estab lishing a plan; and responding to anger and demoralization and emphasizing hope. Elicit Concerns: Set the Agenda and Agree on the Problem The first step of the visit is to elicit both the childs and the parents concerns and agree on the focus for the visit. This can be accom plished by using open ended questions and asking anything else? until nothing else is disclosed. It is important to show you have time and are interested in their concerns by making eye contact, listening attentively, minimizing distractions, and responding with empathy and interest. Engage both the child and the parent by tak ing turns eliciting their concerns. It is helpful to summarize their story to reassure them you have heard and understand what they are saying. Keep the session organized, and manage rambling by gently interrupting, paraphrasing, asking for additional concerns, and refocusing the conversation. These same principles apply for telehealth visits. Make sure you are looking into the camera and use exaggerated responses. It is particularly helpful to frequently sum marize the childs and parents concerns, voice observations, and
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use reflective statements during telehealth visits so the family does see that you are listening to them. By the end of this step in the visit, all parties should feel reassured that their problems were heard and accurately described. The next step is to agree on the problem to be addressed during that visit. If the par ent and child do not agree on the issue, try to find a common thread that will address the concerns of both. Establish a Plan Once a problem is agreed on, the clinician can partner with families to develop acceptable and achievable plans for treatment or further evalu ation. Families should take the lead in developing goals and the strategies to attain them, and information should be given in response to patients expressed needs. Pediatricians can involve families by offering choices and asking for feedback. Advice should be given only after asking a fam ilys permission to do so. If the family asks for advice, the clinician should respond by considering principles of behavior change, as described ear lier. Advice should be tailored toward the familys willingness to act, con cerns for barriers, and attitudes and should be as specific and practical as possible. Once an initial plan is established, it is important to partner in monitoring responses and to provide continued support. Respond to Anger and Demoralization and Emphasize Hope The common factors approach is particularly helpful in engaging families in situations where anger and demoralization could prevent patients from being able to use the clinicians advice. Focusing the con versation on goals for the future and how to achieve them is more pro ductive than discussing how problems began. This solution focused therapy approach grew out of the need for clinicians to help people in a brief encounter. Hopelessness can be relieved by pediatricians help ing patients to identify and build on strengths and past success, refram ing events and feelings, and breaking down overwhelming goals into small, concrete steps that are more readily accomplished. In general, pediatricians can use the elicit provide elicit model. After eliciting a concern or hearing about patients goals, ask if they want to hear your thoughts about the situation. Provide guidance in a neutral way, and then ask the family what they think about what you just stated. Table 18.4 provides an example of how to use common factors in practice using a scenario of an adolescent female who has been teased for using albuterol before physical education class for her exercise induced asthma. The clinician in the scenario attempts to address both the patients and her mothers concerns. Table 18.3 Hope, Empathy, Language, Loyalty, Permission, Partnership, Plan (HEL2P3) SKILL EXAMPLES Hope for improvement: Develop strengths. I have seen other children like you with similar feelings of sadness, and they have gotten better. Empathy: Listen attentively. It must be hard for you that you no longer get pleasure in playing soccer. Language: Use familys language. Check understanding. Let me make sure I understand what you
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are saying. You no longer feel like doing things that made you happy in the past? Loyalty: Express support and commitment. You are free to talk to me about anything while we work through this. Permission: Ask permission to explore sensitive subjects. Offer advice. Partnership: Identify and overcome barriers. I would like to ask more questions that you may find more sensitive, is that okay? Is it okay with you if I give you my opinion on what may be the problem here? Can we discuss together possible solutions to overcoming your discomfort in getting therapy? Plan: Establish a plan, or at least a first step the family can take. If we work together, maybe we can think through solutions for the problems you identified. This table illustrates the interpersonal skills highlighted in the common factors approach. In this example the clinician is responding to an adolescent struggling with depression and resistant to seeking help. Adapted with data from Foy JM, Kelleher KJ, Laraque D. American Academy of Pediatrics Task Force on Mental Health. Enhancing pediatric mental health care: Strategies for preparing a primary care practice. Pediatrics. 2010;125 Suppl 3:S87S108. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 18 u Strategies for Health Behavior Change 133 MOTIVATIONAL INTERVIEWING Motivational interviewing (MI) is a goal oriented, supportive counsel ing style that complements the HEL2P3 framework and is useful when patients or families remain ambivalent about making health related behavior changes. MI is designed to enhance intrinsic motivation in patients by exploring their perspectives and ambivalence. It is also aligned with the transtheoretical models continuum of change, where the clinician not only tailors counseling to a patients stage of change but does so with the goal of moving the patient toward the next stage. It is particularly effective for those not interested in change or not ready to make a commitment. MI has been shown to be an effective intervention strategy for decreasing high risk behaviors, improving chronic disease control, and increasing adherence to preventive health measures. MI is a collaborative approach in which the pediatrician respects patients perspectives and treats them as the expert on their values, beliefs, and goals. Collaboration, acceptance, compassion, and evoca tion are the foundation of MI and are referred to as the spirit of the approach. The clinician is a guide, respecting patients autonomy and their ability to make their own decision to change. The pedia trician expresses genuine concern and demonstrates that he or she understands and validates the patients or familys struggle. Using open ended questions, the pediatrician evokes the patients own motivation for change. Expressing empathy facilitates behavior change by accepting the patients beliefs and behaviors. This contrasts with direct persuasion, which often leads to resistance. The pediatrician must reinforce that ambivalence is normal and use skillful reflective listening, showing the patient an understanding of the
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situation. Developing a discrepancy between current behaviors (or treatment choices) and treatment goals motivates change and helps move the patient from the precontemplative stage to the contemplative stage or from the contemplative stage to preparation, as described in the transtheoretical model. Through MI the clinician can guide patients in understanding that their current behaviors may not be consistent with their stated goals and values. Rolling with resistance, or not pushing back when suggestions are declined, is a strategy again to align with the patient. Resistance is Table 18.4 Common Factors Approach in Practice GOAL SPECIFIC SKILLS EXAMPLES Elicit childs and parents concerns. Use open ended questions and ask, What else? until nothing else is listed, while engaging both parties and demonstrating empathy. Hi, Jacqueline and Mrs. Smith. How have things been since last time? What are your biggest concerns for today? What else do you think we should put on the agenda for today? I am sorry to hear that you have had more asthma symptoms around gym time, Jacqueline. Id like to ask you a few more questions to get a better understanding of what has changed, if thats okay with you. I understand this is upsetting you, Mrs. Smith, and that you worry that Jacqueline is not going to the nurse before gym to use her inhaler pump anymore. Lets hear from Jacqueline. Agree on the problem. Can we all agree that managing the asthma symptoms around gym time is the most pressing issue for today? Should we focus on that today? Manage rambling. What youre saying is really important, but I want to be sure we have time to talk about controlling your daughters asthma symptoms during gym. Is it okay if we go back to that topic? Partner with families to find acceptable forms of treatment. Develop acceptable plans for treatment of further diagnoses. I believe we can develop a plan to help deal with this. Is it okay to start talking about next steps? I am happy to give suggestions on how to more easily use your inhaler before gym, without the other kids noticing. But what were you thinking, Jacqueline? Lets brainstorm how you would respond to your classmates if they see you using your inhaler. Address barriers to treatment. Is there anything that makes you worry that this may not work? Increase expectations that treatment will be helpful. Respond to hopelessness, anger, and frustration. I realize it wasnt your choice to come here, Jacqueline, but Im interested in hearing how you feel about this issue. It must be really hard for you, Jacqueline, when the kids tease you about your inhaler. Discussing this with your mom and me was very brave, and now we can help you. It must be frustrating for the school nurse to call you in the middle of the day at work, Mrs. Smith. I would be angry, too, if I felt my mom didnt understand how it felt when I got teased for going to the nurses office.
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Emphasize hope. Weve managed difficult things before. Remember when Jacqueline kept getting admitted for her asthma when she was younger? We have come a long way since then, and Im sure we can manage this as well. Jacqueline is an adolescent female who has had asthma since she was an infant. Despite multiple hospitalizations as an infant, her asthma had been under control except for during exercise, including physical education (PE) class. She had been going to the nurses office to take albuterol before PE class, but recently she had been teased for having to take medication before PE. She has begun to skip treatments to avoid the teasing. However, her mother has now been called a few times to pick her up from school because of her asthma symptoms. Jacquelines caregiver is a single parent who cannot miss work and is very frustrated. She was not aware of the bullying Jacqueline has undergone. This scenario is adapted from the American Academy of Pediatrics curricula on common factors. https:www.aap.orgen usadvocacy and policyaap health initiativesMental HealthPagesModule 1 Brief Intervention.aspx. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 134 Part I u The Field of Pediatrics Table 18.5 Counseling for Obesity Using a Motivational Interviewing (MI) Approach ACTION SPECIFIC SKILLS EXAMPLES Engagement Open ended questions Now that we have finished the majority of the visit, Id like to talk about your weight. Is that okay? How do you feel about your size? How do you feel about Jimmys weight? (directed toward caregiver) Affirmations You definitely have shown how strong you are having dealt with kids teasing you about your size. Remember when you were having difficulties with your schoolwork? You were able to make a few changes, and now you are doing well. I am confident we can do the same with your weight. Reflective listening You are feeling like your son is the same size as everyone in your family, and you arent concerned right now. I hear that as a working parent, watching TV before bed really works for your family. Youre not terribly excited about having to think of ways to cook differently. Summary statements So far, we have discussed how challenging it would be to lose weight and make changes for the whole family, but you are willing to consider some simple changes. Focusing Set the agenda. We could talk about increasing the amount of exercise Jimmy has every week, reducing screen time, or making a dietary change. What do you think would work best? Great, so we will talk about soda. What do you like about it? How many times a week do you drink it? Evocation Reinforce any change talk. Change ruler. Those are great reasons for thinking about cutting back on soda. On a scale of 1 to 10, how confident are you (or how important is it) that
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you can cut back on soda? A 5. Why didnt you answer a 3? What would it take to bring it to a 7? Planning Focus on how to make the change, not why anymore. Be concrete. Maybe completely eliminating soda is too difficult right now. Do you want to think of a couple of times during the week where you can reward yourself with a soda? What will you drink after school instead of soda? OARS is used to engage the patient and build rapport. Adapted from Changing the Conversation About Childhood Obesity, American Academy of Pediatrics, Institute for Healthy Childhood Weight. https:www.aap.orgen usabout the aapaap press roompagesChanging the conversation about Childhood Obesity.aspx. usually a sign that a different approach is needed. As necessary, the clinician can ask permission to give new perspectives. Self efficacy, or a patients belief in her or his ability to perform the behavior, is a key element for change and a powerful motivator. Clini cians can express confidence in the patients ability to achieve change and support the patients self efficacy. The process by which MI is used in a patient encounter involves the following four parts: 1. Engagement is the rapport building part of the encounter. In addi tion to using the skills presented in the HEL2P3 framework, the MI approach highlights the use of open ended questions, affirmations, reflective listening, and summaries (OARS). Open ended questions should be inviting and probing, enabling the patient to think through and come to a better understanding of the problem and elicit their internal motivation. Affirmations provide positive feedback, express appreciation about a patients strengths, and can reinforce autonomy and self efficacy. Reflective listening demonstrates that the clinician understands the patients thoughts and feelings without judgement or interruption. It should be done frequently and can encourage the pa tient to be more open. Summarizing the conversation in a succinct way reinforces that you are listening, pulls together all information, and al lows the patient to hear his or her own motivations and ambivalence. 2. Focusing the visit is done to clarify the patients priorities and stage of readiness and to identify the problem where there is ambivalence. If a patient remains resistant to change, ask permission to give infor mation or share ideas and then ask for feedback on what they think about what you said. In the elicit ask elicit model, a clinician can deliver information about an unhealthy behavior or lifestyle decision in a nonpaternalistic manner. 3. Evocation is when the clinician assesses their patients reasons for change and helps them to explore advantages, disadvantages, and barriers to change. It is important to reinforce the patients change talk. Examples of change talk include an expression of desire (I want to), ability (I can), reasons (There are good reasons to), or a need for change (I need to). Clinicians can use readiness rulers by asking their patients to rate on a scale from 1 to 10 how important and confident they are in making a
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change. The clinician should then respond by asking why the patient did not choose a lower number and should follow up by asking what it would take to bring it to a higher number. 4. The planning stage is similar to that described in the discussion of a common factors approach and occurs once a patient is in the prep aration stage on the continuum of change. A clinician can guide their patient through this stage by having them write down re sponses to statements such as, The changes I want to make are, The most important reasons to make this change are, Some people who can support me are, and They can help me by. A concrete plan should include specific actions and a way to factor in accountability and rewards. Table 18.5 uses a visit for counseling about obesity to demonstrate the process of MI. SHARED DECISION MAKING Shared decision making (SDM) has many similarities to the processes previously described in that it emphasizes moving clinicians away from a paternalistic approach in dictating treatment to one where patients and clinicians collaborate in making a medical decision, par ticularly when multiple evidence based treatment options exist. The overall goal is to approach medical decisions using patient centered strategies that are based on the best evidence available while aligning with family values. By definition, (1) SDM must involve two parties (clinician and patientfamily); (2) information must be exchanged in both directions; (3) both parties must be aware of all treatment options; and (4) the clinician and patientfamily must both bring their own knowledge and values equally into the decision making Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 18 u Strategies for Health Behavior Change 135 process. This approach is only possible when there is more than one management strategy and SDM does not put a patient at risk. SDM is often facilitated by using evidence based decision aids such as pamphlets, videos, web based tools, or educational workshops. Condition specific or more generic decision aids have been created and facilitate the process of SDM. Studies in adults show that such aids improve knowledge and satisfaction, reduce decisional conflict, and increase the alignment between patient preferences and treat ment options. Although SDM is widely used and has been studied in adult populations, it is more complicated in pediatric settings because the caregiver (a surrogate for the patient) is also involved in decision making. It important to involve the child or adolescent in SDM, as the more they are involved in SDM, the better their outcomes may be. Options must be explained in a developmentally appropriate way. Then both the parent and clinician need to assess how much the patient truly understands regarding their stated preference. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from
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ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 136 PART II Growth, Development, and Behavior The field of pediatrics is dedicated to optimizing the growth and development of each child. Pediatricians require knowledge of nor mal growth, development, and behavior to effectively monitor chil drens progress, identify delays or abnormalities in development, help obtain needed services, and counsel parents and caretakers. To alter factors that increase or decrease risk and resilience, pediatricians need to understand how biologic and social forces interact within the par entchild relationship, within the family, and between the family and the larger society. Growth is an indicator of overall well being, status of chronic disease, and interpersonal and psychologic stress. By monitor ing children and families over time, pediatricians are uniquely situated to observe the interrelationships between physical growth and cogni tive, motor, and emotional development. Observation is enhanced by familiarity with developmental and behavioral theories that inform one about typical patterns of development and provide guidance for prevention or intervention for behavior problems. Familiarity with theories of health behavior may assist clinicians in guiding patients and families in disease management and wellness care. BIOPSYCHOSOCIAL MODEL AND ECOBIODEVELOPMENTAL FRAMEWORK: MODELS OF DEVELOPMENT The medical model presumes that a patient presents with signs and symptoms and a physician focuses on diagnosing and treating diseases of the body. This model neglects the social and psychologic aspect of a person who exists in the larger realm of the family and society. In the biopsychosocial model, societal and community systems are simulta neously considered along with more proximal systems that make up the person and the persons environment (Fig. 19.1). A patients symp toms are examined and explained in the context of the patients exis tence. This multidimensional model can be used to understand health and both acute and chronic disease, and this model has been increas ingly used to develop care models over the past few decades. With the advances in neurology, genomics (including epigenetics), molecular biology, and the social sciences, a broader model, the eco biodevelopmental framework, has emerged. This framework empha sizes how the ecology of childhood (social and physical environments) interacts with biologic processes to determine outcomes and life tra jectories. Early influences, particularly those producing toxic levels of stress, affect the individual through their impact on the bodys stress response systems, brain development, and modification of gene expres sion. Epigenetic changes, such as DNA methylation and histone acetyla tion, may be influenced by early life experiences (the environment) and impact gene expression without changing the DNA sequence. These changes can produce long lasting effects on the health and well being of the individual and may be passed on to future generations (Fig. 19.2). Critical to learning and remembering (and therefore development) is neuronal plasticity, which permits the central nervous system to reorganize neuronal networks in response to environmental stimula tion, both positive and negative. An overproduction of neuronal pre cursors
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eventually leads to about 100 billion neurons in the adult brain. Each neuron develops on average 15,000 synapses by 3 years of age. Dur ing early childhood, synapses in frequently used pathways are preserved, whereas less used ones atrophy, a process termed pruning. Changes in the strength and number of synapses and reorganization of neuronal circuits also play important roles in brain plasticity. Increases or decreases in syn aptic activity result in persistent increases or decreases in synaptic strength. Thus experience (environment) has a direct effect on the physical and therefore functional properties of the brain. Children with different talents and temperaments (already a combination of genetics and environment) further elicit different stimuli from their varying environments. Periods of rapid development generally correlate with periods of great changes in synaptic numbers in relevant areas of the brain. Accordingly, sensory deprivation during the time when synaptic changes should be occurring has profound effects. The effects of stra bismus leading to amblyopia occur quickly during early childhood; patching the eye with good vision to reverse amblyopia is less effective in late childhood (see Chapter 663). Early experience is particularly important because learning proceeds more efficiently along established synaptic pathways. However, some plasticity of the brain continues into adolescence, with further development of the prefrontal cortex, which is important in decision making, future planning, and emotional con trol; neurogenesis persists in adulthood in certain areas of the brain. Early traumatic experiences modify the expression of stress media tors (in particular the hypothalamic pituitary adrenal axis) and neu rotransmitters, leading to changes in brain connectivity and function. These effects may be persistent, leading to alterations and dysfunc tion in the stress response throughout life. Chronic stress has negative effects on cognitive functions, including memory and emotional regu lation. Positive and negative experiences do not determine the ultimate outcome but shift the probabilities by influencing the childs ability to respond adaptively to future stimuli. There is increasing evidence that positive experiences and relation ships can buffer the impact of negative or traumatic experience and toxic stress. In fact, there is a recent call for pediatrics to recognize and promote relational health as a protective factor. By promoting positive relationships, labeled safe, stable, and nurturing relationships (SSNRs) within primary care, healthcare providers can work with families to build relational health, thereby combatting the deleterious effects of toxic stress and promoting resilience. Pediatric care can do this by employing a public health approach, partnering with families and com munities, to build healthy relationships by connecting to and integrat ing with primary, secondary, and tertiary prevention programs. This can include embedding interventions within primary care and creating robust referral networks to connect families to needed services. Biologic Influences Biologic influences on development include genetics, in utero exposure to teratogens, the long term negative effects of low birthweight (neonatal morbidities plus increased rates of subsequent adult onset obesity, coro nary heart disease, stroke, hypertension, and type 2 diabetes), postnatal illnesses, exposure to hazardous substances, and maturation. Adoption and twin
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studies consistently show that heredity accounts for approxi mately 40 of the variance in IQ and in other personality traits, such as sociability and desire for novelty, whereas shared environment accounts for another 50. The negative effects on development of prenatal expo sure to teratogens, such as mercury and alcohol, and of postnatal insults, such as meningitis and traumatic brain injury, have been extensively stud ied (see Chapters 117, 122, and 146). Any chronic illness can affect growth and development, either directly or through changes in factors such as nutrition, parenting, school attendance, peer interactions, or self esteem. Most children follow similar motor developmental sequences despite great variability in child rearing practices. The attainment of skills such as the use of complex sentences is less tightly bound to a Chapter 19 Developmental and Behavioral Theories Margo Candelaria and Susan Feigelman Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 19 u Developmental and Behavioral Theories 137 maturational schedule. Maturational changes also generate behavioral challenges at predictable times. Decrements in growth rate and sleep requirements around 2 years of age often generate concern about poor appetite and refusal to nap. Although it is possible to accelerate many developmental milestones (toilet training a 12 month old or teaching a 3 year old to read), the long term benefits of such precocious accomplish ments are questionable. In addition to physical changes in size, body proportions, and strength, maturation brings about hormonal changes. Sexual differen tiation, both somatic and neurologic, begins in utero. Both stress and reproductive hormones affect brain development as well as behavior throughout development. Steroid production by the fetal gonads leads to differences in brain structures between males and females. Temperament describes the stable, early appearing individual varia tions in behavioral dimensions, including emotionality (crying, laugh ing, sulking), activity level, attention, sociability, and persistence. The classic theory proposes nine dimensions of temperament (Table 19.1). These characteristics lead to three common constellations: (1) the easy, highly adaptable child, who has regular biologic cycles; (2) the difficult child, who is inflexible, moody, and easily frustrated; and (3) the slow to warm up child, who needs extra time to adapt to new circumstances. Various combinations of these clusters also occur. Temperament has long been described as biologic or inherited. Monozygotic twins are rated by their parents as temperamentally similar more often than are dizygotic twins. Estimates of heritability suggest that genetic differences account for 2060 of the variability of temperament within a population. The remainder of the variance is attributed to the childs environment. Mater nal prenatal stress and anxiety is associated with child temperament, possibly through stress hormones. However, certain polymorphisms of specific genes moderate the influence of maternal stress on infant temper ament. Children who are easily frustrated, fearful, or irritable may elicit negative parental reactions, making these children even more susceptible to negative parenting behaviors
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and to poor adjustment to adversity. Lon gitudinal twin studies of adult personality indicate that changes in per sonality over time largely result from dissimilar environmental influences, whereas stability of temperament appears to result from genetic factors. The concept of temperament can help parents understand and accept the characteristics of their children without feeling responsible for hav ing caused them. Children who have difficulty adjusting to change may have behavior problems when a new baby arrives or at the time of school entry. In addition, pointing out the childs temperament may allow for adjustment in parenting styles. Behavioral and emotional problems may develop when the temperamental characteristics of chil dren and parents are in conflict. If parents who keep an irregular sched ule have a child who is not readily adaptable, behavioral difficulties are more likely than if the child has parents who have predictable routines. Psychologic Influences: Attachment and Contingency The influence of the child rearing environment dominates most current models of development. Infants in hospitals and orphanages, devoid of opportunities for attachment, have severe developmental deficits. Attachment refers to a biologically determined tendency of a young child to seek proximity to the parent during times of stress and to the relationship that allows securely attached children to use their parents to reestablish a sense of well being after a stressful experience. Insecure attachment may be predictive of later behavioral and learning problems. At all stages of development, children progress optimally when they have adult caregivers who pay attention to their verbal and nonverbal cues and respond accordingly. In early infancy, such contingent responsiveness to signs of overarousal or underarousal helps maintain infants in a state of quiet alertness and fosters autonomic self regulation. Consistent contin gent responses (reinforcement depending on the behavior of the other) to nonverbal gestures create the groundwork for the shared attention and reciprocity that are critical for later language and social development. Social Factors: Family Systems and the Ecologic Model Contemporary models of child development recognize the critical impor tance of influences outside the motherchild dyad. Fathers play critical roles, both in their direct relationships with their children and in sup porting mothers. As traditional nuclear families become less dominant, the influence of other family members and caregivers (grandparents, foster and adoptive parents, same sex partners) becomes increasingly important. Furthermore, the presence of nurturing and stable caregivers, in or out of the nuclear family, can help to buffer the impact of a parent who may struggle with mental illness, substance use, or other afflictions. As children grow within their larger ecosystem, it is important to recog nize and include all relevant caregivers in the childs care. Families function as systems, with internal and external bound aries, subsystems, roles, and rules for interaction. In families with rigidly defined parental subsystems, children may be denied any decision making, exacerbating rebelliousness. In families with poorly defined parentchild boundaries, children may be required to take on responsibilities beyond their years or may be recruited to play a spousal
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role. Family systems theory recognizes that individuals within systems adopt implicit roles. Although birth order does not have long term effects on personality development, within families the members take on different roles. One child may be the troublemaker, whereas another is the negotiator and another is quiet. Changes in one persons behav ior affects every other member of the system; roles shift until a new equilibrium is found. The birth of a new child, attainment of develop mental milestones such as independent walking, the onset of nighttime fears, diagnosis of a chronic illness, or death of a family member are all changes that require renegotiation of roles within the family and have the potential for healthy adaptation or dysfunction. The family system, in turn, functions within the larger systems of extended family, subculture, culture, and society. Bronfenbrenners ecologic model depicts these relationships as concentric circles, with the parentchild dyad at the center (with associated risks and protec tive factors) and the larger society at the periphery. Changes at any level are reflected in the levels above and below. Furthermore, these systems and their interactions change over time, with some influences being persistent and chronic and others being temporary. The shift from an industrial economy to one based on service and information and the influence of systemic racism are examples of how society has profound effects on families and children. Understanding the childs greater eco system is important to understand their family and the context of their Molecule Organelle Cell Tissue OrganOrgan systems Nervous system Person Community Family Two person CultureSubculture SocietyNation Biosphere Fig. 19.1 Continuum and hierarchy of natural systems in the biopsy chosocial model. (From Engel GL. The clinical application of the biopsy chosocial model. Am J Psychiatry. 1980;137:535544.) Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 138 Part II u Growth, Development, and Behavior growth. Factors such as poverty, systemic racism, access to education, transportation, food, housing, parental employment, and local support systems are influential factors in a childs well being. Whenever pos sible, identifying community supports and assets for families can help promote health and development. Unifying Concepts: The Transactional Model, Risk, and Resilience The transactional model proposes that a childs status at any point in time is a function of the interaction between biologic and social influences. The influences are bidirectional: biologic factors, such as temperament and health status, affect the child rearing environ ment and are affected by it. A premature infant may cry little and sleep for long periods; the infants depressed parent may welcome this behavior, setting up a cycle that leads to poor nutrition and inadequate growth. The childs failure to thrive may reinforce the parents sense of failure as a parent. At a later stage, impulsivity and inattention associated with early, prolonged undernutrition may lead to aggressive behavior. The cause of the aggression in this
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case is not the prematurity, the undernutrition, or the mater nal depression, but the interaction of all these factors (Fig. 19.3). Conversely, children with biologic risk factors may nevertheless do Ecology Biology Health and development Policy and Program Levers for Innovation Primary health care Public health Childcare and early education Child welfare Early intervention Family economic stability Community development Private sector actions Time and commitment Financial, psychologic, and institutional resources Skills and knowledge Stable, responsive relationships Healthrelated behaviors Educational achievement and economic productivity Physical and mental health Gene environment interaction Physiologic adaptations or disruptions Appropriate nutrition Cumulative over time Embedded during sensitive periods Safe, supportive environments Caregiver and Community Capacities Foundations of Healthy Development Biology of Health and Development Outcomes in Lifelong WellBeing An Ecobiodevelopmental Framework for Early Childhood Policies and Programs Fig. 19.2 Ecobiodevelopmental framework for early childhood policies and programs. (Adapted from Center on the Developing Child. The foun dations of lifelong health are built in early childhood. 2010; Available at: http:www.developingchild.harvard.edu.) Table 19.1 Temperamental Characteristics: Descriptions and Examples CHARACTERISTIC DESCRIPTION EXAMPLES Activity level Amount of gross motor movement Shes constantly on the move. He would rather sit still than run around. Rhythmicity Regularity of biologic cycles Hes never hungry at the same time each day. You could set a watch by her nap. Approach and withdrawal Initial response to new stimuli She rejects every new food at first. He sleeps well in any place. Adaptability Ease of adaptation to novel stimulus Changes upset him. She adjusts to new people quickly. Threshold of responsiveness Intensity of stimuli needed to evoke a response (e.g., touch, sound, light) He notices all the lumps in his food and objects to them. She will eat anything, wear anything, do anything. Intensity of reaction Energy level of response She shouts when she is happy and wails when she is sad. He never cries much. Quality of mood Usual disposition (e.g., pleasant, glum) He does not laugh much. It seems like she is always happy. Distractibility How easily diverted from ongoing activity She is distracted at mealtime when other children are nearby. He doesnt even hear me when he is playing. Attention span and persistence How long a child pays attention and sticks with difficult tasks He goes from toy to toy every minute. She will keep at a puzzle until she has mastered it. Typical statements of parents, reflecting the range for each characteristic from very little to very much. Based on data from Chess S, Thomas A. Temperament in Clinical Practice. New York: Guilford; 1986. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 19 u Developmental and Behavioral Theories 139 well developmentally if the child rearing environment is support ive. Premature infants with electroencephalographic evidence of neurologic immaturity may be at increased risk for cognitive delay. When parentchild interactions are optimal, risk of developmental disability
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is reduced. An estimate of developmental risk can begin with risk factors, such as low income, low literacy, and lack of neighborhood resources. Stress and anxiety in pregnancy are associated with cognitive, behav ioral, and emotional problems in the child. Early stress may have effects on aging mediated by shortening of telomere length, a link to health disparities. Risk for negative outcomes over time increases exponentially as a result of declining plasticity and accumulation of risk factors (both behavioral and environmental). Interventions are most effective in young children; over time, risk increases as the abil ity to change decreases. Children growing up in poverty experience multiple levels of developmental risk: increased exposure to biologic risk factors, such as environmental lead and inadequate nutrition; lack of stimu lation in the home; and decreased access to interventional educa tion and therapeutic experiences. As they respond by withdrawal or acting out, they further discourage positive stimulation from those around them. Children of adolescent mothers are also at risk. When early intervention programs provide timely, intensive, comprehen sive, and prolonged services, at risk children show marked and sustained upswings in their developmental trajectory. Early iden tification of children at developmental risk, along with early inter vention to support parenting, is critically important (see Chapter 20). Promoting relational health and identifying supportive com munity resources and interventions can buffer the negative impact of environmental risk factors. Children can have appropriate developmental trajectories despite childhood trauma. Resilience is the ability to withstand, adapt to, and recover from adversities. There are several modifiable resilience fac tors: a positive appraisal or outlook and good executive functioning (see Chapter 49); nurturing parenting; good maternal mental health, self care skills, and consistent household routines; and an under standing of trauma. The personal histories of children who overcome poverty often include at least one trusted adult (parent, grandparent, teacher) with whom the child has a special, supportive, close relation ship. Pediatric providers are positioned to target and bolster resil ience in their patients and families. Developmental Domains and Theories of Emotion and Cognition Child development can also be tracked by the childs developmental progress in particular domains, such as gross motor, fine motor, social, emotional, language, and cognition. Within each of these catego ries are developmental sequences of changes leading up to particular attainments. Development in the gross motor domain, from rolling to creeping to independent walking, are clear. Others, such as the line leading to the development of conscience, are subtler. The concept of a developmental line implies that a child passes through successive stages. Several developmental theories are based on stages as qualitatively different epochs in the development of emotion and cognition (Table 19.2). In contrast, behavioral theories rely less on qualitative change and more on the gradual modification of behavior and accumulation of competence. Psychoanalytic Theories At the core of Freudian theory is the idea of body centered (or broadly, sexual) drives; the emotional health of both the child and the adult depends on adequate resolution of conflicts
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brought about by these drives. Although Freudian ideas have been challenged, they opened the door to subsequent theories of development. Erikson recast Freuds stages in terms of the emerging personal ity (see Table 19.2). The childs sense of basic trust develops through the successful negotiation of infantile needs. As children progress through these psychosocial stages, different issues become salient. It is predictable that a toddler will be preoccupied with establishing a sense of autonomy, whereas a late adolescent may be more focused on establishing meaningful relationships and an occupational identity. Erikson recognized that these stages arise in the context of Western European societal expectations; in other cultures, the salient issues may be quite different. Eriksons work calls attention to the intrapersonal challenges fac ing children at different ages in a way that facilitates professional intervention. Knowing that the salient issue for school age children is industry vs inferiority, pediatricians inquire about a childs expe riences of mastery and failure and (if necessary) suggest ways to ensure adequate successes. Cognitive Theories Cognitive development is best understood through the work of Piaget. A central tenet of Piagets work is that cognition changes in quality, not just quantity (see Table 19.2). During the sensorimo tor stage, an infants thinking is tied to immediate sensations and a childs ability to manipulate objects. The concept of in is embod ied in a childs act of putting a block into a cup. With the arrival of language, the nature of thinking changes dramatically; symbols increasingly take the place of objects and actions. Piaget described how children actively construct knowledge for themselves through the linked processes of assimilation (taking in new experiences according to existing schemata) and accommodation (creating new patterns of understanding to adapt to new information). In this way, children are continually and actively reorganizing cogni tive processes. There have been challenges to some of the Piagets basic con cepts. Children may reach the stages at variable ages. Of undeniable Fig. 19.3 Theoretical model of mutual influences on maternal depression and child adjustment. (From Elgar FJ, McGrath PJ, Waschbusch DA, et al. Mutual influenc es on maternal depression and child adjustment prob lems, Clin Psychol Rev 2004;24:441459.) Biologic Mechanisms Genetics, in utero influences on fetal development Social Capital Income, social resources Psychosocial Mechanisms Attachment, child discipline, modeling, family functioning Maternal Depression Child Adjustment Problems Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 140 Part II u Growth, Development, and Behavior importance is Piagets focus on cognition as a subject of empiri cal study, the universality of the progression of cognitive stages, and the image of a child as actively and creatively interpreting the world. Piagets work is of special importance to pediatricians for three reasons: (1) Piagets observations provide insight into many puzzling behaviors of infancy, such as the common exacerbation of sleep problems at 9 and 18 months
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of age; (2) Piagets observa tions often lend themselves to quick replication in the office, with little special equipment; and (3) open ended questioning, based on Piagets work, can provide insights into childrens understanding of illness and hospitalization. However, other studies have found that even young children and infants are natural scientists and able to integrate new informa tion through experimentation. Young childrens learning is highly similar to the scientific thought process, including inductive rea soning, making predictions, and hypothesis testing. Hypotheses and conclusions about the world are constantly being revised based on the childs experience. When children are faced with evidence that conflicts with expected outcomes (expectancy violation), they are motivated to explore and resolve ambiguities. Children can alter their beliefs when given new evidence. That children utilize proba bilistic models and exploration to resolve unexpected outcomes has strong implications for the advancement of educational theory. Based on cognitive development, Kohlberg developed a theory of moral development in six stages, from early childhood through adulthood. Preschoolers earliest sense of right and wrong is ego centric, motivated by externally applied controls. In later stages, children perceive equality, fairness, and reciprocity in their under standing of interpersonal interactions through perspective taking. Most youth will reach stage 4, conventional morality, by midto late adolescence. The basic theory has been modified to distinguish morality from social conventions. Whereas moral thinking consid ers interpersonal interactions, justice, and human welfare, social conventions are the agreed on standards of behavior particular to a social or cultural group. Within each stage of development, children are guided by the basic precepts of moral behavior, but they also may take into account local standards, such as dress code, class room behavior, and dating expectations. There is a broader under standing of moral development of even young infants and children theorizing an innate capacity to relate to others. Moral development can be found in very young infants, toddlers, and preschoolers who have a concept of self in relation to others, empathy and caring for others, and may incorporate their cultural context in a way that influences how and when moral development occurs. Behavioral Theory This theoretical perspective distinguishes itself by its lack of con cern with a childs inner experience. Its focus is on observable behaviors and measurable factors that either increase or decrease the frequency with which these behaviors occur. No stages are implied; children, adults, and indeed animals all respond in the same way. In its simplest form, the behaviorist orientation asserts that behaviors that are reinforced occur more frequently; behaviors that are punished or ignored occur less frequently. Reinforcement may be further divided into positive reinforcement, when a reward or attention increases the chance of a behavior occurring, and nega tive reinforcement, when removal of an aversive stimulus increases the frequency of the behavior. A teacher who allows students who complete the homework Monday through Thursday not to have an assignment on Friday is using negative reinforcement to motivate homework completion during the week. The strengths of
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behavioral theory are its simplicity, wide applicabil ity, and conduciveness to scientific verification. A behavioral approach lends itself to interventions for various common problems, such as temper tantrums, aggressive preschool behavior, and eating disorders, in which behaviors are broken down into discrete units. In cognitively limited chil dren and children with autism spectrum disorder, behavioral interventions using applied behavior analysis approaches have demonstrated the abil ity to teach new, complex behaviors. Applied behavior analysis has been particularly useful in the treatment of early diagnosed autism spectrum disorder (see Chapter 58). However, when misbehavior is symptomatic of an underlying emotional, perceptual, or family problem, an exclusive reliance on behavior therapy risks leaving the cause untreated. Behavioral approaches can be taught to parents for application at home. Theories Used in Behavioral Interventions An increasing number of programs or interventions (within and outside the physicians office) are designed to influence health behaviors; some of these models are based on behavioral or cog nitive theory or may have attributes of both. The most commonly employed models are the Health Belief Model, Theory of Reasoned Action, Theory of Planned Behavior, Social Cognitive Theory, and Transtheoretical Model, also known as Stages of Change Theory (see Chapter 18). Pediatricians should be aware of these models and their similarities and differences (Table 19.3). Interventions based on these theories have been designed for children and adolescents in community, clinic, and hospital based settings. Motivational interviewing (MI) is a technique often used in clinical settings to bring about behavior change (Chapter 18). Briefly, the goal is to enhance an individuals motivation to change behavior by explor ing and overcoming ambivalence. The therapist is a partner rather than an authority figure and recognizes that, ultimately, the patient has control over his or her choices. Pediatric providers can learn brief MI techniques. Statistics Used in Describing Growth and Development See Chapter 27. In everyday use, the term normal is synonymous with healthy. In a statistical sense, normal means that a set of values generates a Table 19.2 Classic Developmental Stage Theories INFANCY (0 1 YR) TODDLERHOOD (2 3 YR) PRESCHOOL (3 6 YR) SCHOOL AGE (6 12 YR) ADOLESCENCE (12 20 YR) Freud: psychosexual Oral Anal Phallicoedipal Latency Genital Erikson: psychosocial Basic trust vs mistrust Autonomy vs shame and doubt Initiative vs guilt Industry vs inferiority Identity vs role diffusion Piaget: cognitive Sensorimotor Sensorimotor Preoperational Concrete operations Formal operations Kohlberg: moral Preconventional: avoid punishmentobtain rewards (stages 1 and 2) Conventional: conformity (stage 3) Conventional: law and order (stage 4) Postconventional: moral principles Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 19 u Developmental and Behavioral Theories 141 Table 19.4 Relationship Between Standard Deviation (SD) and Normal Range for Normally Distributed Quantities OBSERVATIONS INCLUDED IN THE NORMAL RANGE PROBABILITY OF A NORMAL MEASUREMENT DEVIATING FROM THE MEAN BY THIS AMOUNT SD SD 1 68.3 1 16.0
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2 95.4 2 2.3 3 99.7 3 0.13 Table 19.3 Similar or Identical Elements Within Six Theories of Health Behavior CONCEPT GENERAL TENET OF ENGAGING IN THE BEHAVIOR IS LIKELY IF... HEALTH BELIEF MODEL THEORY OF REASONED ACTION THEORY OF PLANNED BEHAVIOR SOCIAL COGNITIVE THEORY TRANS THEORETICAL MODEL (STAGES OF CHANGE) SOCIAL NORMS THEORY ATTITUDINAL BELIEFS Appraisal of positive negative aspects of the behavior and expected outcome Positive aspects outweigh negative aspects Benefits vs. barriers; health motive Behavioral beliefs and evaluation of those beliefs (attitudes) Outcome expectation; expectancies Pros, cons (decision balance) Perceptions of peer attitudes and behaviors SELFEFFICACYBELIEF ABOUT CONTROL OVER THE BEHAVIOR Belief in ones ability to perform the behavior; confidence Belief that one can perform the behavior Selfefficacy Perceived behavioral control Selfefficacy Selfefficacy temptation NORMATIVE AND NORMRELATED BELIEFS AND ACTIVITIES Belief that others are supportive of the behavior Belief that others support the behavior change Cues from media, friends Normative beliefs and motivation to comply (subjective norms) Social support Helping relationships (process of change) Misperceptions of actual vs. perceived norms Belief that others are engaging in the behavior Other people are engaging in the behavior Social environment; modeling Social liberation (process of change) Misperceptions of actual vs. perceived norms Responses that increase or decrease the likelihood of engaging in the behavior; reminders Receives positive reinforcement Cues to action Reinforcement Reinforcement management stimulus control Change in perceptions through media; social messaging RISKRELATED BELIEFS AND EMOTIONAL RESPONSES Belief that one is at risk if not engaging in the behavior; consequences may be severe Belief that one is at risk for negative outcome or disease Perceived susceptibility severity (perceived threat) Emotional coping responses expectancies about environmental cues Dramatic relief (process of change) INTENTIONCOMMITMENTPLANNING Intending or planning to perform the behavior setting goals Forms strong intentions to engage in the behaviormakes a commitment Behavioral intentions Selfcontrol selfregulation Contemplation preparation; selfliberation (process of change) Understanding actual norms leads to change Adapted from Noar SM, Zimmerman RS. Health behavior theory and cumulative knowledge regarding health behaviors: are we moving in the right direction? Health Educ Res. 2005; 20:275290, Table 1. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 142 Part II u Growth, Development, and Behavior normal (bell shaped or gaussian) distribution. This is the case with anthropometric quantities, such as height and weight, and with many developmental measures, such as IQ. For a normally distrib uted measurement, a histogram with the quantity (height, age) on the x axis and the frequency (the number of children of that height, or the number who stand on their own at that age) on the y axis gen erates a bell shaped curve. In an ideal bell shaped curve, the peak corresponds to the arithmetic mean (average) of the sample, as well as to the median and the mode. The median is the value above and below which 50 of
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the observations lie; the mode is the value with the highest number of observations. Distributions are termed skewed if the mean, median, and mode are not the same number. The extent to which observed values cluster near the mean deter mines the width of the bell and can be described mathematically by the standard deviation (SD). In the ideal normal curve, a range of values extending from 1 SD below the mean to 1 SD above the mean includes approximately 68 of the values, and each tail above and below that range contains 16 of the values. A range encompass ing 2 SD includes 95 of the values (with the upper and lower tails each comprising approximately 2.5 of the values), and 3 SD encompasses 99.7 of the values (Table 19.4 and Fig. 19.4). For any single measurement, its distance away from the mean can be expressed in terms of the number of SDs (also called a z score); one can then consult a table of the normal distribution to find out what percentage of measurements fall within that distance from the mean. Software to convert anthropometric data into z scores for epidemiologic purposes is available. A measurement that falls outside the normal range (arbitrarily defined as 2, or sometimes 3, SDs on either side of the mean) is atypical, but not necessarily indicative of illness. The further a measurement (height, weight, IQ) falls from the mean, the greater is the probability that it repre sents not simply normal variation, but rather a different, potentially pathologic condition. Another way of relating an individual to a group uses percentiles. The percentile is the percentage of individuals in the group who have achieved a certain measured quantity (e.g., height of 95 cm) or a devel opmental milestone (e.g., walking independently). For anthropometric data, the percentile cutoffs can be calculated from the mean and SD. The 5th, 10th, and 25th percentiles correspond to 1.65 SD, 1.3 SD, and 0.7 SD, respectively. Figure 19.4 demonstrates how frequency dis tributions of a particular parameter (height) at different ages relate to the percentile lines on the growth curve. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. 3 95 50 5 95 50 5 Age (yr) Growth Chart Frequency distribution for 3 yr olds102.0 95 94.9 50 89 5 Height (cm) Percentile Height (cm) 4 5 Fig. 19.4 Relationship between percentile lines on the growth curve and frequency distributions of height at different ages. No single force may be more important to a childs development than the environment in which they are raised. Many factors, both posi tive and negative, contribute to this environment. Parenting practices provide a foundation to promote healthy child development, protect against adverse outcomes, and foster resilience. The term positive par enting describes an approach to parenting that achieves these goals. THE IMPORTANCE OF PARENTING Interactions between parents and their children provide stimulation that promotes the development of language, early cognitive skills, and school readiness. Less frequent participation in interactive parenting practices, such as
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reading aloud to children, eating family meals, and participating in family outings, predicts an increased risk of develop mental delay in low income families. Interventions that increase par ents reading to children promote positive developmental outcomes such as early language and literacy development. The affective nature of the parentchild interaction is important for both cognitive and social emotional development. Persistent maternal depression has been linked to decreases in child IQ scores at school entry. Early exposure to positive parenting has been associated with lower rates of childhood depression, risky behavior, delinquency, inju ries, behavior problems, and bullying, and with increased likelihood of empathy and prosocial behavior. The beneficial effects of early mater nal sensitivity on social competence have been found to persist into adulthood, contributing to the growing evidence that early parent child interactions have a long term impact. Positive parenting practices, such as using a warm, supportive approach during conflict, and negative practices, such as maternal aggression, have been associated with MRI changes in adolescent brain development in males. Animal models have been used to dem onstrate the detrimental effects of stressful early life experiences. Offspring raised in these environments were more likely to exhibit fearful behavior and had differences in brain architecture and in epigenetic changes that alter gene expression. Importantly in these animal models, increased maternal nurturing could protect against these changes. THE ROLE OF THE FAMILY Parenting occurs in the context of the family, and yet a one size fits all approach to understanding families does not suffice. To understand the influence of the family environment on parenting practices, it is important to appreciate the evolving diversity among U.S. families with respect to culture, raceethnicity, and family makeup. The U.S. popu lation continues to become more raciallyethnically diverse (61.1 in 2020 vs 54.9 in 2010). Over the last several decades, the percentage of children raised in single parent homes has continued to grow to nearly 25 in 2020, up from 9 in 1960. It is also important to appreciate that many families face disparities in health and developmental outcomes related to racism and other forms of discrimination that may occur on the basis of religion, sexualitygender, disability, and socioeconomic status among other factors. For many children these factors interact to further increase risk for disparities in outcomes. Children living in single parent homes experience poverty at a higher rate than those liv ing in two parent homes. Chapter 20 Positive Parenting and Support Rebecca A. Baum and Samantha Schilling Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 20 u Positive Parenting and Support 143 Chronic stress and adverse experiences in childhood can have far reaching consequences that negatively affect health and developmental outcomes (see Chapters 1 and 2). However, parentingin the form of safe, stable, and nurturing relationships (SSNRs)has been suggested as one of a number of strategies that
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can promote resilience and buffer adversity and turn potentially toxic stress responses into tolerable or positive responses. PARENTING STYLES Parenting practices are significantly influenced by culture, defined as a pattern of social norms, values, language, and behavior shared by a group of individuals. Approaches to self regulation, for example, vary across cultures with respect to promoting attention, compli ance, delayed gratification, executive function, and effortful control. In examining parent practices, it is important to recognize the role of structural racism and bias on the design and interpretation of parent ing research. Three styles of parenting have been described: authoritative, authoritarian, and permissive. Each style has varying approaches to parental control and responsiveness. A fourth style, neglect ful parenting, has also been suggested. Authoritative parenting describes a parenting style that is warm, responsive, and accepting but that also sets expectations for behavior and achievement. Dif ferences are approached with reasoning and discussion rather than by exerting control. Authoritarian parenting is characterized by a high degree of parental control in which obedience is expected. Punishment is often employed to foster compliance rather than ver bal discussion. Permissive parenting refers to an approach charac terized by warmth and acceptance with the childs autonomy being highly valued, but with few rules or expectations. This contrasts with neglectful parenting, similarly characterized by few rules or expectations but also by limited parental warmth or responsiveness. An authoritative parenting style is most likely to be associated with positive child outcomes across multiple domains, including educa tional achievement and social emotional competence. Parental super vision, consistency, and open communication reduce risky behaviors in adolescents. Harsh, inconsistent, and coercive discipline and physi cal punishment have been associated with increases in emotional and behavioral problems. Child physical abuse is often preceded by corpo ral punishment. In addition to a higher rate of aggression and behav ioral problems, children who have experienced physical punishment have been found to have lower IQs and smaller prefrontal cortexes compared to those who have not. Much of the initial research on par enting styles was based on select U.S. populations (White middle class families). CHILD TEMPERAMENT As evidenced by the effects of family structure, cultureethnicity, and economics, parenting does not occur in isolation. The child also brings to the parentchild relationship their own personality, or temperament, a collection of traits that stay relatively constant over time (see Chapter 19). The initial temperament research iden tified nine traits: activity level, predictability of behavior, reaction to new environments, adaptability, intensity, mood, distractibility, persistence, and sensitivity. Most infants (65) fit into one of three groups, easy (40), difficult (10), and slow to warm up (15), and these patterns are relatively stable over time. Although variations in temperament traits are part of normal human variations, certain behavioral difficulties have been associated with certain tempera ment types. For example, a difficult temperament has been associ ated with the development of externalizing behavior (e.g., acting out, disruptive, and aggressive behavior) and, not surprisingly, a slow to warm up temperament with internalizing
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behavior (e.g., anxious and moody behavior). Temperament traits are relatively stable, but how the child func tions is affected by the environment, especially by parenting and the goodness of fit between the parent and child. Children with difficult temperament characteristics respond more negatively to neglectful parenting, and children of all temperament groups respond positively to responsive and sensitive parenting. Moreover, childhood traits such as low adaptability, impulsivity, and low frus tration tolerance may lead some parents to engage in more negative parenting practices. These findings illustrate the interactive nature between parent and child, with parental behavior shaping child behavior, and vice versa. CHILD BEHAVIORAL PROBLEMS Emotional and behavioral problems are common in childhood. Early behavioral problems impact at least one in five children under age 5 in the United States and are associated with impairments in multiple domains, including family, academic, and social function ing, which often continue into adulthood. Emotional and behav ioral problems have been associated with single parent households and poverty. Children in underserved populations experience life circumstances and structural barriers to care that place them at greater risk of behavior problems and unmet needs. High rates of socioeconomic disadvantage, inadequate social infrastructure, neighborhood exposure to violence, repetitive experiences of dis crimination, and chronic exposure to racism among minoritized children can have significant adverse effects on childrens physical and mental health. Although negative parenting may contribute to and exacerbate such problems, positive parenting practices have been shown to buffer against poor outcome for children growing up in such adversity. Other risk factors for the development of challenging behavior include trauma and developmental problems. Adverse childhood experiences (ACEs), defined as abuse and neglect, caregiver sub stance use, caregiver mental health problems, and domestic violence or criminality, are often present during childhood (see Chapter 1). In the National Survey of Child and Adolescent Well Being there was a cumulative relationship between emotional and behavioral problems and ACE exposure, with children exposed to four or more ACEs being almost five times more likely to have internalizing prob lems than children not exposed to ACEs. A similar relationship was found for externalizing problems. Studies involving children with developmental disabilities suggest emotional and behavioral prob lems occur more frequently in this group than in typically devel oping children. These children may have delays in self regulation and communication skills as well as increased family stress, which contribute to the increased likelihood of behavioral challenges. DEFINING POSITIVE PARENTING The precise definition of the components of positive parenting is lacking. Positive parenting must ensure the childs safety, health, and nutrition as well as developmental promotion. Common attri butes of positive parenting include caring, leading, providing, teaching, and communicating with the child in a consistent and unconditional manner. To account for the long term goals of suc cessful parenting in promoting optimal emotional, behavioral, and developmental outcomes, some suggest the term purposeful par enting and related characteristics (Table 20.1). The characterization of an ideal approach to parenting will evolve with ever changing societal norms, but
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key components such as those in Table 20.1 will likely remain fundamental. PARENTING AS AN INTERVENTION The influence of parenting practices on child behavior, development, and overall adjustment has led to efforts to teach parenting as a method of primary prevention. The Video Interaction Project (VIP) uses a coaching and education model with recorded parentchild interac tions to foster positive parenting behavior. These parenting behaviors range from reading aloud to encouraging interactive play. In an urban, low income, primary care setting, parent and child outcomes for the VIP group were compared to those from a lower intensity intervention (parent mailings encouraging positive parenting behaviors) and a con trol group. VIP produced the most robust impacts on socioemotional outcomes, including decreased distress with separation, hyperactivity, and externalizing behavior in toddlers. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 144 Part II u Growth, Development, and Behavior Positive parenting as a public health intervention has resulted in decreased rates of substantiated child maltreatment cases, out of home placements, and child maltreatment injuries. Other effective public health approaches include home visiting programs, which have been deployed to at risk families in an effort to improve mater nal and child outcomes. The Maternal, Infant and Early Childhood Home Visiting Program, authorized as part of the Affordable Care Act of 2010 and again in 2015, is part of the Medicare Access and Childrens Health Insurance Program (CHIP) Reauthorization Act. A key component of home visiting programs is the promotion of positive parenting behavior to foster child developmental and school readiness. Group parenting programs have been deployed as primary prevention to promote emotional and behavioral adjust ment in young children. There is moderate quality evidence that group based parenting programs may improve parentchild inter actions. These programs typically employ praise, encouragement, and affection and have been associated with improved self esteem and social and academic competence. Parenting behaviors have also been employed as an intervention to treat emotional and behavioral problems in young children. Par enting interventions such as Incredible Years, Triple P Positive Par enting Program, New Forrest Parenting Program, and Child Adult Relationship Enhancement in Primary Care are effective for at least short term improvements in child conduct problems, parental mental health, and parenting practices. Also called parent training programs, most teach the importance of play, rewards, praise, and consistent discipline and allow parents to practice new skills. This active learning component distinguishes parent training programs from educational programs, which have been shown to be less effective. Teaching emotional communication skills and positive parent child interaction skills are associated with parent training programs that demonstrate a greater increase in parenting skills (Table 20.2). Several components are associated with programs that show greater improvements in child externalizing behavior including teaching parents to interact positively and respond consistently to their chil dren as well as to use time out correctly.
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All successful programs require parents to practice parenting skills during the program. Parents have been found to benefit from participation in parenting programs. Before their participation, parents experienced a loss of con trol, self blame, social isolation, and difficulty dealing with their childs emotional and behavioral problems, all of which improved after par ticipation. The few studies that have assessed the long term efficacy of parent training programs suggest overall positive child outcomes but also periods of relapse during which the use of positive parenting skills decreased. Use of social supports is associated with positive child out comes and may be an important program component when consider ing long term success. THE ROLE OF THE PEDIATRICIAN Pediatricians and other pediatric practitioners have a primary respon sibility to support the needs of parents and their children. Numerous programs and interventions have been developed to be delivered effec tively and efficiently in the primary care setting. Table 20.1 Components of Purposeful Parenting ATTRIBUTE DEFINING ACTIONS Protective Ensure the childs emotional, developmental, and physiologic needs are met. Provide a safe environment. Balance the need for safety with the childs need for exploration and independence. Personal Show unconditional love and acceptance. Be kind and gentle. Avoid name calling and harsh language. Label emotions and behaviors to help children understand their feelings. Teach and model helpful behavior rather than just saying no. Progressive Adapt parenting skills and discipline to meet the childs developmental needs. Learn about child development to know what to expect. Notice and praise new skills and desirable behaviors. Positive Be warm, supportive, and optimistic, even during times of misbehavior. Avoid harsh or physical punishments. Provide encouragement and reward effort, not just a positive result. Playful Enjoy child led time together to encourage exploration, foster creativity, and learn new skills. Read together. Purposeful Take care of your needs as a parent. Keep the long term goals of parenting in mind. Preferentially use teaching instead of punishment to encourage desirable behavior. Be consistent with routines and expectations. Try to understand the reason behind the childs behavior. Adapted from the work of Andrew Garner and the Ohio Chapter, American Academy of Pediatrics. http:ohioaap.orgwp contentuploads201307BPoMPurposefulPare nting.pdf. Table 20.2 Parent Training Program Components COMPONENT ACTIVITIES Knowledge about child development and behavior Providing developmentally appropriate environment Learning about child development Promoting positive emotional development Positive parentchild interactions Learning the importance of positive, nondiscipline focused interactions Using skills that promote positive interactions Providing frequent positive attention Responsiveness and warmth Responding sensitively to the childs emotional needs Providing appropriate physical contact and affection Emotional communication Using active listening to foster communication Helping children identify and express emotion Disciplinary communication Setting clear, appropriate, and consistent expectations Establishing limits and rules Choosing and following through with appropriate consequences Discipline and behavior management Understanding child misbehavior Understanding appropriate discipline strategies Using safe and appropriate monitoring and supervision practices Using reinforcement techniques Using problem solving for challenging behavior Being consistent Promoting childrens social skills and prosocial behavior Teaching children to share, cooperate, and get
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along with others Using good manners Promoting childrens cognitive or academic skills Fostering language and literacy development Promoting school readiness Adapted from U.S. Centers for Disease Control and Prevention: Parent training programs: insight for practitioners, Atlanta, CDC;2009. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 20 u Positive Parenting and Support 145 The American Academy of Pediatrics (AAP) publishes Bright Futures and the associated Guidelines for Preventive Care to standardize child health promotion and prevention in primary care. A substantial amount of the content in Bright Futures maps to the positive parenting domains of safety, feeding, developmental promotion, and protection. Implementing Bright Futures guidelines in health supervision visits is an important way for pediatric practitioners to support the promotion of positive parenting in practice. The AAPs policy statement titled Pre venting Childhood Toxic Stress: Partnering with Families and Com munities to Promote Relational Health describes the importance of the parentchild relationship in building the foundation for healthy child development as well as buffering the effects of more significant stressors. Reading aloud to children is a powerful strategy to promote language development, early literacy, and positive parentchild interaction. The Reach Out and Read program is a primary care based intervention that trains practitioners to encourage parents to read with their child and provides books to at risk families. In the absence of a formal partnership with Reach Out and Read, practi tioners should promote the benefits of reading aloud to children and support parents in their efforts to develop habits that incorpo rate reading into daily routines. In addition to VIP described earlier, other primary care mod els to promote parenting have been studied. The Healthy Steps for Young Children program is a strengths based approach delivered in the primary care setting from infancy to age 3 years. Healthy Steps promotes changes in parents knowledge, beliefs, and psy chologic health and changes in parenting behaviors using a variety of methods delivered in the office setting by the practitioner and Healthy Steps specialists and through home visits. Extensive evalu ations have shown improvements in parental well being, parenting practices, and parentchild attachment and decreased child behav ior problems. Another promising approach uses community health workers and nurses to provide parenting education and allow moth ers to practice parenting skills outside the office setting. If participation in a formal parenting program is not possible, pedi atric practitioners can still implement a systematic approach to sup port the needs of parents and their children. Practitioners can take advantage of materials in the public domain from national organiza tions devoted to child and family health, such as ZERO TO THREE (https:www.zerotothree.org) and AAP (https:www.aap.org). The U.S. Centers for Disease Control and Prevention (CDC) also provides evidenced based parenting resources (https:www.cdc.govparents essentialsindex.html). Additional components include early identifi cation of parents concerns, addressing concerns in a supportive and nonjudgmental way,
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and providing linkage to treatment services when appropriate. Parents want more information about child development, but parents of children with behavior problems often feel stigmatized and isolated. Practitioners are encouraged to be supportive and optimistic in their interactions with families and to develop a part nership aimed at promoting parent and child health (see Chapter 18). Practitioners may also encourage parents to practice new skills briefly in the office setting before trying a new skill at home. Active modeling by the practitioner using teachable moments may also be effective. DISCIPLINEPUNISHMENT Discipline is meant to teach children to learn good behavior and thus enhance child development. There are many positive parenting approaches to discipline that help avoid confrontations and to also correct behavior without conflict or physical punishment (Tables 20.3 and 20.4) (see Chapters 25 and 26). In addition, parents should teach by example; rather than prompting a child to say thank you, the parents saying thank you is a behavior that an imitating child will follow. Furthermore, when possible, give the child a choice between positive activities, thus enhancing autonomy and prevent ing conflict. In verbal children, it is helpful to engage the child in problem solving by asking how can we make this better? Corporal (physical) punishment is viewed as a violation of the childs right of protection by the United Nations Convention on the Rights of Children. It is viewed by the CDC as a form of child abuse. Corporal punishment is the use of force to produce harm, pain, or discomfort in a dependent child for the purpose of correcting behav ior or showing disapproval. It may be manifest by hitting, striking, smacking, slapping, whupping, pinching, kicking, shaking, burning scalding, pulling hair, washing the mouth with soap or other harmful substances, forcing the child to assume a painful or prolonged pos tureposition, or using an object to inflict harm. Parents who use cor poral punishment may have experienced this punishment as a child. Use of corporal punishment is also associated with adults who misuse drugs, are depressed, or experience intimate partner violence. The consequences of corporal punishment to the child include wors ening behavioral problems including aggression and adverse effects on cognitive development and mental health (anxiety, depression). In addition, corporal punishment does not correct the behavior. Further more, there may be a dose response relationship between the frequency of corporal punishment and adverse child behaviors and development. For age related approaches to discipline see Chapters 24, 25, and 26. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. Table 20.3 UNICEF Approach to Positive Discipline Create one on one times for engagement Praise good behavior Set clear and realistic expectations Distract to a more positive activity Calm (not shouting) realistic consequences (ifthen) Data from United Nations Childrens Fund (UNICEF). How to discipline your child the smart and healthy way. https:www.unicef.orgparentingchild carehow discipline your child smart and healthy way. Table 20.4 CDC Time Out Steps 1. Identify behavior and give warning 2. Explain why time out 3. Go to
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time out space No talking No playing No lecturing No scolding No excuses from child Ignore protesting or promise to be good Time for both parent and child to calm down 4. End time out 5. Explain why there was a time out 6. Praise next positive behavior Time out duration rule is 1 minute per child age in years Adapted from U.S. Centers for Disease Control and Prevention (CDC). Using discipline and consequences. https:www.cdc.govparentsessentialsconsequencesindex.html. Accessed 14 March 2022. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 146 Part II u Growth, Development, and Behavior The developing fetus is affected by social and environmental influ ences, including maternal nutritional status, substance use (both legal and illicit), and psychologic trauma. Correspondingly, the psychologic alterations experienced by the parents during the gestation profoundly impact the lives of all members of the family. The complex interplay among these forces and the somatic and neurologic transformations occurring in the fetus influence growth and behavior at birth, through infancy, and potentially throughout the individuals life. SOMATIC DEVELOPMENT Embryonic Period Table 21.1 lists milestones of prenatal development. By 6 days post conception age, as implantation begins, the embryo consists of a spherical mass of cells with a central cavity (the blastocyst). By 2 weeks, implantation is complete and the uteroplacental circulation has begun; the embryo has two distinct layers, endoderm and ectoderm, and the amnion has started to form. By 3 weeks, the third primary germ layer (mesoderm) has appeared, along with a primitive neural tube and blood vessels. Paired heart tubes have begun to pump. During weeks 4 8, lateral folding of the embryologic plate, followed by growth at the cranial and caudal ends and the budding of arms and legs, produces a human like shape. Precursors of skeletal muscle and vertebrae (somites) appear, along with the branchial arches that will form the mandible, maxilla, palate, external ear, and other head and neck structures. Lens placodes appear, marking the site of future eyes; the brain grows rapidly. By the end of week 8, as the embryonic period closes, the rudiments of all major organ systems have developed; the crown rump length is 3 cm. Fetal Period From the ninth week on (fetal period), somatic changes consist of rapid body growth as well as differentiation of tissues, organs, and organ systems. Figure 21.1 depicts changes in body proportion. By week 10, the face is recognizably human. The midgut returns to the abdomen from the umbilical cord, rotating counterclockwise to bring the stomach, small intestine, and large intestine into their normal positions. By week 12, the gender of the external genitals becomes clearly distinguishable. Lung development proceeds, with the bud ding of bronchi, bronchioles, and successively smaller divisions. By weeks 20 24, primitive alveoli have formed and surfactant produc tion has begun; before that time, the absence of alveoli renders the
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lungs useless as organs of gas exchange. During the third trimester, weight triples and length doubles as body stores of protein, fat, iron, and calcium increase. NEUROLOGIC DEVELOPMENT During the third week, a neural plate appears on the ectodermal surface of the trilaminar embryo. Infolding produces a neural tube that will become the central nervous system and a neural crest that will become the peripheral nervous system. Neuroectodermal cells differentiate into neurons, astrocytes, oligodendrocytes, and epen dymal cells, whereas microglial cells are derived from mesoderm. By the fifth week, the three main subdivisions of forebrain, mid brain, and hindbrain are evident. The dorsal and ventral horns of the spinal cord have begun to form, along with the peripheral motor and sensory nerves. Myelination begins at midgestation and contin ues for years. By the end of the embryonic period (week 8), the gross structure of the nervous system has been established. On a cellular level, neurons migrate outward to form the six cortical layers. Migration is complete by the sixth month, but differentiation continues. Axons and dendrites form synaptic connections at a rapid pace, making the central nervous system vulnerable to teratogenic or hypoxic influences throughout ges tation. Figure 21.2 shows rates of increase in DNA (a marker of cell number), overall brain weight, and cholesterol (a marker of myelin ization). Epigenetic modifications are made in the presence of fetal gonadal steroids, directing masculinization of the male brain. The prenatal and postnatal peaks of DNA probably represent rapid growth of neurons and glia, respectively. The glial cells are important in shap ing the brain and neuronal circuits. The various types of glial cells are needed for the formation of axonal myelin sheaths, a range of functions in the formation and maintenance of neural pathways, and removal of waste (the brain has no lymphoid system for this task). By the time of birth, the structure of the brain is complete. However, many cells will undergo apoptosis (cell death). Synapses will be pruned back substantially, and new connections will be made, largely as a result of experience. Many psychiatric and developmental disorders are thought to result at least in part from disruptions in the functional connectivity of brain networks. Disorders of connectivity may begin during fetal life; MRI studies provide a developmental timetable for such connections that lend support to the possible role of disruptions in the establishment of such connections. BEHAVIORAL DEVELOPMENT No behavioral evidence of neural function is detectable until the third month. Reflexive responses to tactile stimulation develop in a cranio caudal sequence. By weeks 13 14, breathing and swallowing motions appear. The grasp reflex appears at 17 weeks and is well developed by 27 weeks. Eye opening occurs around 26 28 weeks. By midgestation, the full range of neonatal movements can be observed. During the third trimester, fetuses respond to external stimuli with heart rate elevation and body movements, which can be observed with ultrasound (see Chapter 117). Reactivity to auditory (vibroacoustic) and visual (bright light) stimuli vary, depending
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on their behavioral state, which can be characterized as quiet sleep, active sleep, or awake. Individual differences in the level of fetal activity are usually noted by mothers. Fetuses will preferentially turn to light patterns in the con figuration of the human face. Fetal movement is affected by maternal medications and diet, increasing after ingestion of caffeine. Behavior may be entrained to the mothers diurnal rhythms: asleep during the day, active at night. Abnormal fetal movement patterns are found in neonates with subsequent muscular or neurologic abnormalities. Fetal movement increases in response to a sudden auditory tone but decreases after several repetitions. This demonstrates habitua tion, a basic form of learning in which repeated stimulation results in a response decrement. If the tone changes in pitch, the movement increases again, which is evidence that the fetus distinguishes between a familiar, repeated tone and a novel tone. Habituation improves in older fetuses and decreases in neurologically impaired or physically stressed fetuses. Similar responses to visual and tactile stimuli have been observed. PSYCHOLOGIC CHANGES IN PARENTS Many psychologic changes occur during pregnancy. An unplanned pregnancy may be met with anger, denial, or depression. Ambivalent feelings are common, whether or not the pregnancy was planned. Ela tion at the thought of producing a baby and the wish to be the perfect parent compete with fears of inadequacy and of the lifestyle changes that parenting will impose. Parents of an existing child may feel protec tive of the child, worried that the child may feel less valued. Old con flicts may resurface as a woman psychologically identifies with her own mother and with herself as a child. The father to be faces similar mixed feelings, and problems in the parental relationship may intensify. Tangible evidence that a fetus exists as a separate being, whether as a result of ultrasonic visualization or awareness of fetal move ments known as quickening (at 16 20 weeks), often heightens a Chapter 21 Assessment of Fetal Growth and Development Alexander S. Whitaker and Susan Feigelman Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 21 u Assessment of Fetal Growth and Development 147 womans feelings. Parents worry about the fetuss healthy devel opment and mentally rehearse what they will do if the child is malformed, including their response to evidence of abnormality through ultrasound, amniocentesis, or other fetal laboratory tests. Toward the end of pregnancy, a woman becomes aware of patterns of fetal activity and reactivity and begins to ascribe to her fetus an individual personality and an ability to survive independently. Appreciation of the psychologic vulnerability of the expectant par ents and of the powerful contribution of fetal behavior facilitates supportive clinical intervention. THREATS TO FETAL DEVELOPMENT Mortality and morbidity are highest during the prenatal period (see Chapter 114). An estimated 50 of all pregnancies end in spontaneous abortion, including 1015 of
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all clinically recognized pregnancies. The majority occur in the first trimester. Many spontaneous abor tions occur as a result of chromosomal abnormalities, most commonly aneuploidies. Teratogens associated with gross physical and mental abnormalities include various infectious agents (e.g., toxoplasmosis, rubella, syphilis, Zika virus), chemical agents (e.g., mercury, thalidomide, antiepileptic medications, retinoids, ethanol), high temperature, and radiation (see Chapters 117 and 758). Teratogenic effects may also result in decreased growth and cog nitive or behavioral deficits that only become apparent later in life. Nicotine has vasoconstrictor properties and may disrupt dopaminer gic and serotonergic pathways. Prenatal exposure to cigarette smoke is associated with lower birthweight, stunting, and smaller head cir cumference. It is also associated with changes in neonatal neurode velopmental assessments; later, these children are at increased risk for learning problems, attention and behavior disorders, and other long term health effects. Alcohol is a common teratogen affecting physi cal development, cognition, and behavior (see Chapter 146). Prenatal exposure to opiates can result in neonatal abstinence syndrome (NAS) characterized by irritability, poor feeding, tremors and temperature instability in newborn infants. Affected infants may require treatment with low dose opiates to abate the symptoms. School age children with a history of NAS are significantly more likely to have educational dis abilities, even when controlling for external factors such as maternal educational attainment and gestational age. The effects of prenatal exposure to cocaine, also occurring through alternations in placental blood flow and in direct toxic effects to the developing brain, have been followed in several cohorts and are less dramatic than previously believed. Exposed adolescents show small but significant effects in behavior and functioning but may not show cognitive impairment. Associated risk factors including alcohol and tobacco use, and postnatal environments frequently characterized by toxic stress, may explain some of the observed negative developmental outcomes. (see Chapters 1, 15, and 17). The association between an inadequate nutrient supply to the fetus and low birthweight has been recognized for decades; this adaptation Fig. 21.1 Changes in body proportions. Approximate changes in body proportions from fetal life through adulthood. (From Leifer G. Introduction to Maternity Pediatric Nursing. Philadelphia: WB Saunders;2011: pp 347385, Fig. 15 2.) Table 21.1 Milestones of Prenatal Development WK DEVELOPMENTAL EVENTS 1 Fertilization and implantation; beginning of embryonic period 2 Endoderm and ectoderm appear (bilaminar embryo) 3 First missed menstrual period; mesoderm appears (trilaminar embryo); somites begin to form 4 Neural folds fuse; folding of embryo into human like shape; arm and leg buds appear; crown rump length 4 5 mm 5 Lens placodes, primitive mouth, digital rays on hands 6 Primitive nose, philtrum, primary palate 7 Eyelids begin; crown rump length 2 cm 8 Ovaries and testes distinguishable 9 Fetal period begins; crown rump length 5 cm; weight 8 g 12 External genitals distinguishable 20 Usual lower limit of viability; weight 460 g; length 19 cm 25 Third trimester begins; weight 900 g; length 24 cm 28 Eyes open; fetus turns head down; weight 1,000 1,300 g 38 Term Downloaded for
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mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 148 Part II u Growth, Development, and Behavior on the part of the fetus presumably increases the likelihood that the fetus will survive until birth. For any potential fetal insult, the extent and nature of its effects are determined by characteristics of the host as well as the dose and timing of the exposure. Inherited differences in the metabolism of ethanol, timing of exposure, and the mothers diet may explain the variability in fetal alcohol effects. Organ systems are most vulnerable during periods of maximum growth and differentia tion, generally during the first trimester (organogenesis) (http:www .epa.govchildrenchildren are not little adults details critical periods and specific developmental abnormalities). Fetal adaptations or responses to an adverse situation in utero, termed fetal programming or developmental plasticity, have life long implications. Fetal programming may prepare the fetus for an environment that matches that experienced in utero. Fetal pro gramming in response to some environmental and nutritional sig nals in utero increases the risk of cardiovascular disease, diabetes, and obesity in later life. These adverse long term effects appear to represent a mismatch between environmental conditions faced by a fetus or neonate and the conditions that the individual will confront later in life. A fetus deprived of adequate calories may or may not face famine as a child or adolescent. One proposed mechanism for fetal programming is epigenetic imprinting, in which one of two alleles is turned off through environmentally induced epigenetic modification (see Chapter 97). Many environmental factors have been found to play a role in producing epigenetic modifications that are both transgenerational (direct effect on the developing fetus) and intergenerational (changes in the germ cells that will affect future generations). Just as the fetal adaptations to the in utero environment may increase the likelihood of later metabolic conditions, the fetus adapts to the mothers psychologic distress. In response to the stressful environment, physiologic changes involving the hypothalamic pituitary adrenal axis and the autonomic nervous system occur. Dysregulation of these sys tems may explain the associations observed in some but not all studies between maternal distress and negative infant outcomes. These nega tive outcomes include low birthweight, spontaneous abortion, prema turity, and decreased head circumference. In addition, children born to mothers experiencing high stress levels have been found to have higher rates of inattention, impulsivity, conduct disorders, and nega tive cognitive changes. Although these changes may have been adaptive in primitive cultures, they are maladaptive in modern societies, leading to psychopathology. Genetic variability, timing of stress during sensi tive periods, and the quality of postnatal parenting can attenuate or exacerbate these associations. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. 10 2.5 5 In cr em en ts p er ce nt a du lt fiv e w ee ks 7.5 0 0 20 40 6 12 18 24 MonthsBirthWeeks Fig. 21.2
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Velocity curves of the various components of human brain growth. Blue line, DNA; red line, brain weight; green line, cholesterol. From Brasel JA, Gruen RK. In Falkner F, Tanner JM, eds: Human Growth: a comprehensive treatise. New York: Plenum Press; 1986: pp 7895. See also Chapter 115. Regardless of gestational age, the newborn (neonatal) period begins at birth and includes the first month of life. During this time, marked physiologic transitions occur in all organ systems, and the infant learns to respond to many forms of external stimuli. Because infants thrive physically and psychologically only in the context of their social relationships, any description of the newborns devel opmental status has to include consideration of the parents role as well. PARENTAL ROLE IN PARENTINFANT ATTACHMENT Parenting a newborn infant requires dedication because a newborns needs are urgent, continuous, and often unclear. Parents must attend to an infants signals and respond empathically. Many factors influence parents ability to assume this role. Prenatal Factors Pregnancy is a period of psychologic preparation for the profound demands of parenting. Expectant parents may experience ambiv alence, particularly (but not exclusively) if the pregnancy was unplanned. Financial concerns, physical illness, prior miscarriages or stillbirths, or other crises may interfere with future bonding. For adolescent parents, the demand that they relinquish their own developmental agenda, such as an active social life, may be espe cially burdensome. The transition to parenthood is a unique developmental phase, and a stressful one. Lifetime experiences of parents, particularly traumatic ones, may affect their approaches to developing a nurtur ing relationship with their infant (Table 22.1). It has been shown that an increasing number of adverse childhood experiences (ACEs) may be associated with increased parental stress, a more authoritarian style of parenting, increased risk for child abuse, and greater insecurity in parentchild attachment (bonding). Identify ing parental ACEs and addressing them with community resources, including parenting classes, parent aides, and parent support groups may help provide parents with the resilience to mitigate the effects of ACEs. Chapter 22 The Newborn Elisa Hampton and John M. Olsson Table 22.1 Prenatal Risk Factors for Attachment Recent death of a loved one Previous loss of or serious illness in another child Prior removal of a child History of depression or serious mental illness History of infertility or pregnancy loss Troubled relationship with parents Financial stress or job loss Marital discord or poor relationship with the other parent Recent move or no community ties No friends or social network Unwanted pregnancy No good parenting model Experience of poor parenting Drug andor alcohol use Extreme immaturity From Dixon SD, Stein MT. Encounters With Children: Pediatric Behavior and Development. 4th ed. Philadelphia: Mosby, 2006. p 131. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 148 Part II u Growth, Development, and Behavior on the part of the fetus presumably increases the likelihood
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that the fetus will survive until birth. For any potential fetal insult, the extent and nature of its effects are determined by characteristics of the host as well as the dose and timing of the exposure. Inherited differences in the metabolism of ethanol, timing of exposure, and the mothers diet may explain the variability in fetal alcohol effects. Organ systems are most vulnerable during periods of maximum growth and differentia tion, generally during the first trimester (organogenesis) (http:www .epa.govchildrenchildren are not little adults details critical periods and specific developmental abnormalities). Fetal adaptations or responses to an adverse situation in utero, termed fetal programming or developmental plasticity, have life long implications. Fetal programming may prepare the fetus for an environment that matches that experienced in utero. Fetal pro gramming in response to some environmental and nutritional sig nals in utero increases the risk of cardiovascular disease, diabetes, and obesity in later life. These adverse long term effects appear to represent a mismatch between environmental conditions faced by a fetus or neonate and the conditions that the individual will confront later in life. A fetus deprived of adequate calories may or may not face famine as a child or adolescent. One proposed mechanism for fetal programming is epigenetic imprinting, in which one of two alleles is turned off through environmentally induced epigenetic modification (see Chapter 97). Many environmental factors have been found to play a role in producing epigenetic modifications that are both transgenerational (direct effect on the developing fetus) and intergenerational (changes in the germ cells that will affect future generations). Just as the fetal adaptations to the in utero environment may increase the likelihood of later metabolic conditions, the fetus adapts to the mothers psychologic distress. In response to the stressful environment, physiologic changes involving the hypothalamic pituitary adrenal axis and the autonomic nervous system occur. Dysregulation of these sys tems may explain the associations observed in some but not all studies between maternal distress and negative infant outcomes. These nega tive outcomes include low birthweight, spontaneous abortion, prema turity, and decreased head circumference. In addition, children born to mothers experiencing high stress levels have been found to have higher rates of inattention, impulsivity, conduct disorders, and nega tive cognitive changes. Although these changes may have been adaptive in primitive cultures, they are maladaptive in modern societies, leading to psychopathology. Genetic variability, timing of stress during sensi tive periods, and the quality of postnatal parenting can attenuate or exacerbate these associations. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. 10 2.5 5 In cr em en ts p er ce nt a du lt fiv e w ee ks 7.5 0 0 20 40 6 12 18 24 MonthsBirthWeeks Fig. 21.2 Velocity curves of the various components of human brain growth. Blue line, DNA; red line, brain weight; green line, cholesterol. From Brasel JA, Gruen RK. In Falkner F, Tanner JM, eds: Human Growth: a comprehensive treatise. New York: Plenum Press; 1986: pp 7895. See also Chapter 115. Regardless of gestational
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age, the newborn (neonatal) period begins at birth and includes the first month of life. During this time, marked physiologic transitions occur in all organ systems, and the infant learns to respond to many forms of external stimuli. Because infants thrive physically and psychologically only in the context of their social relationships, any description of the newborns devel opmental status has to include consideration of the parents role as well. PARENTAL ROLE IN PARENTINFANT ATTACHMENT Parenting a newborn infant requires dedication because a newborns needs are urgent, continuous, and often unclear. Parents must attend to an infants signals and respond empathically. Many factors influence parents ability to assume this role. Prenatal Factors Pregnancy is a period of psychologic preparation for the profound demands of parenting. Expectant parents may experience ambiv alence, particularly (but not exclusively) if the pregnancy was unplanned. Financial concerns, physical illness, prior miscarriages or stillbirths, or other crises may interfere with future bonding. For adolescent parents, the demand that they relinquish their own developmental agenda, such as an active social life, may be espe cially burdensome. The transition to parenthood is a unique developmental phase, and a stressful one. Lifetime experiences of parents, particularly traumatic ones, may affect their approaches to developing a nurtur ing relationship with their infant (Table 22.1). It has been shown that an increasing number of adverse childhood experiences (ACEs) may be associated with increased parental stress, a more authoritarian style of parenting, increased risk for child abuse, and greater insecurity in parentchild attachment (bonding). Identify ing parental ACEs and addressing them with community resources, including parenting classes, parent aides, and parent support groups may help provide parents with the resilience to mitigate the effects of ACEs. Chapter 22 The Newborn Elisa Hampton and John M. Olsson Table 22.1 Prenatal Risk Factors for Attachment Recent death of a loved one Previous loss of or serious illness in another child Prior removal of a child History of depression or serious mental illness History of infertility or pregnancy loss Troubled relationship with parents Financial stress or job loss Marital discord or poor relationship with the other parent Recent move or no community ties No friends or social network Unwanted pregnancy No good parenting model Experience of poor parenting Drug andor alcohol use Extreme immaturity From Dixon SD, Stein MT. Encounters With Children: Pediatric Behavior and Development. 4th ed. Philadelphia: Mosby, 2006. p 131. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 22 u The Newborn 149 Social support during pregnancy, particularly support from the partner and close family members, is also important. Family support can promote resilience in the face of ACEs as described earlier. Many decisions have to be made by parents in anticipation of the birth of their child. One important choice is how the infant will be nourished. Among the important benefits of breastfeeding is
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its pro motion of bonding. Providing breastfeeding education for the parents during prenatal pediatric or obstetric care can increase maternal confi dence in breastfeeding after delivery, reduce stress during the newborn period, and promote increased breastfeeding rates and duration (see Chapter 61). Peripartum and Postpartum Influences The continuous presence of a support person during labor results in shorter labor and fewer obstetric complications (including cesar ean section). These beneficial effects may be even more pronounced when the support person is specially trained and present solely for the purpose of continuous support (a doula). Early skin to skin contact between mothers and infants immediately after birth is asso ciated with an increased rate and longer duration of breastfeeding. Most new parents value even a brief period of uninterrupted time in which to get to know their new infant, and increased motherinfant contact over the first days of life may improve long term mother child interactions. Nonetheless, early separation, although predict ably very stressful, does not inevitably impair a mothers ability to bond with her infant. Postpartum mood and anxiety disorder (PMAD) may occur in the first week or up to 6 months after delivery and can adversely affect neonatal growth and development. Screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS), are available for use during neonatal and infant visits to the pediatric provider. Screening mothers for PMAD is recommended at the 1, 2, 4, and 6 month well child visit. PMAD is also seen in partners of postpartum women, but peaks later at 3 6 months. Pediatric providers should consider screening partners at the 6 month well child visit using the EPDS. A score of 10 or higher, or a positive response to question 10 (suicidal thoughts), in either postpartum women or their partners warrants referral for evaluation (Table 22.2). THE INFANTS ROLE IN PARENTINFANT ATTACHMENT The in utero environment contributes greatly but not completely to the future growth and development of the fetus. Abnormalities in maternal fetal placental circulation and maternal glucose metabo lism or the presence of maternal infection can result in abnormal fetal growth. Infants may be small or large for gestational age as a result. These abnormal growth patterns not only predispose infants to an increased requirement for medical intervention, but they also may affect their ability to respond behaviorally to their parents. Physical Examination Examination of the newborn should include an evaluation of growth (see Chapter 21) and an observation of behavior. The aver age term newborn weighs approximately 3.4 kg (7.5 lb); boys are slightly heavier than girls. The average length and head circumfer ence are about 50 cm (20 in) and 35 cm (14 in), respectively, in term infants. Each newborns growth parameters should be plotted on growth curves specific for that infants gestational age to determine the appropriateness of size. Specific growth charts for conditions associated with variations in growth patterns have also been devel oped. It is important to note that in the United States, significant disparities exist in low
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birthweight (2,500 g) rates with higher rates in low socioeconomic status (SES) groups and in minoritized populations. The infants response to being examined may be useful in assess ing its vigor, alertness, and tone. Observing how the parents handle their infant, their comfort, and affection is also important. The order of the physical examination should be from the least to the most intrusive maneuvers. Assessing visual tracking and response to sound and noting changes of tone with level of activity and alert ness are very helpful. Performing this examination and sharing impressions with parents is an important opportunity to facilitate bonding (see Chapter 115). Interactional Abilities Soon after birth, neonates are alert and ready to interact and nurse. This first alert awake period may be affected by maternal analgesics and anesthetics or fetal hypoxia. Neonates are nearsighted, having a fixed focal length of 8 12 inches, approximately the distance from the breast to the mothers face, as well as an inborn visual prefer ence for faces. Hearing is well developed, and infants preferentially turn toward a female voice. These innate abilities and predilections increase the likelihood that when a mother gazes at her newborn, the baby will gaze back. The initial period of social interaction, usually lasting about 40 minutes, is followed by a period of somnolence. After that, briefer periods of alertness or excitation alternate with sleep. If a mother misses her babys first alert awake period, she may not experience as long a period of social interaction for several days. The hypothalamic midbrain limbic paralimbic cortical circuits of the parents brain together support responses to the infant that are critical for effective parenting (e.g., emotion, attention, motivation, empathy, decision making). Modulation of Arousal Adaptation to extrauterine life requires rapid and profound physi ologic changes, including aeration of the lungs, rerouting of the circulation, and activation of the intestinal tract. The necessary behavioral changes are no less profound. To obtain nourishment, to avoid hypo and hyperthermia, and to ensure safety, neonates must react appropriately to an expanded range of sensory stimuli. Infants must become aroused in response to stimulation, but not so over aroused that their behavior becomes disorganized. Underaroused infants are not able to feed and interact; overaroused infants show signs of autonomic instability, including flushing or mottling, peri oral pallor, hiccupping, vomiting, uncontrolled limb movements, and inconsolable crying. Behavioral States The organization of infant behavior into discrete behavioral states may reflect an infants inborn ability to regulate arousal. Six states have been described: quiet sleep, active sleep, drowsy, alert, fussy, and crying. In the alert state, infants visually fixate on objects or faces and follow them horizontally and (within a month) vertically; they also reliably turn toward a novel sound, as if searching for its source. When overstimulated, they may calm themselves by looking away, yawning, or sucking on their lips or hands, thereby increas ing parasympathetic activity and reducing sympathetic nervous system activity. The behavioral state determines an infants muscle tone, spontaneous movement, electroencephalogram pattern, and
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response to stimuli. In active sleep, an infant may show progres sively less reaction to a repeated heelstick (habituation), whereas in the drowsy state, the same stimulus may push a child into fussing or crying. Mutual Regulation Parents actively participate in an infants state regulation, alternately stimulating and soothing. In turn, they are regulated by the infants signals, responding to cries of hunger with a letdown of milk (or with a bottle). Such interactions constitute a system directed toward furthering the infants physiologic homeostasis and physical growth. At the same time, they form the basis for the emerging psychologic relationship between parent and child. Infants come to associate the presence of the parent with the pleasurable reduction of tension (as Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Table 22.2 Edinburgh Postnatal Depression Scale INSTRUCTIONS FOR USERS 1. The mother is asked to underline the response that comes closest to how she has been feeling in the previous 7 days. 2. All 10 items must be completed. 3. Care should be taken to avoid the possibility of the mother discussing her answers with others. 4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading. 5. The Edinburgh Postnatal Depression Scale may be used at 6 8 wk to screen postnatal women. The child health clinic, a postnatal checkup, or a home visit may provide a suitable opportunity for its completion. EDINBURGH POSTNATAL DEPRESSION SCALE Name: Address: Babys age: Because you have recently had a baby, we would like to know how you are feeling. Please underline the answer that comes closest to how you have felt in the past 7 days, not just how you feel today. Here is an example, already completed. I have felt happy: Yes, all the time Yes, most of the time No, not very often No, not at all This would mean: I have felt happy most of the time during the past week. Please complete the other questions in the same way. In the past 7 days: 1. I have been able to laugh and see the funny side of things As much as I always could Not quite so much now Definitely not so much now Not at all 2. I have looked forward with enjoyment to things As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all 3. I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No, never 4. I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often 5. I have felt scared or panicky for no very good reason Yes, quite a lot Yes, sometimes No, not much No, not
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at all 6. Things have been getting on top of me Yes, most of the time I havent been able to cope at all Yes, sometimes I havent been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever 7. I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all 8. I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all 9. I have been so unhappy that I have been crying Yes, most of the time Yes, quite often Only occasionally No, never 10. The thought of harming myself has occurred to me Yes, quite often Sometimes Hardly ever Never Response categories are scored 0, 1, 2, and 3 according to increased severity of the symptom. Items marked with an asterisk () are reverse scored (i.e., 3, 2, 1, and 0). The total score is calculated by adding the scores for each of the 10 items. Users may reproduce the scale without further permission provided they respect copyright (which remains with the British Journal of Psychiatry) by quoting the names of the authors, the title, and the source of the paper in all reproduced copies. Adapted from Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10 item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782 786; reproduced from Currie ML, Rademacher R. The pediatricians role in recognizing and intervening in postpartum depression. Pediatr Clin North Am. 2004;51(3):785xi. Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 23 u The First Year 151 in feeding) and show this preference by calming more quickly for their parent than for a stranger. This response in turn strengthens a parents sense of efficacy and their connection with their baby. IMPLICATIONS FOR THE PEDIATRICIAN The pediatrician can support healthy newborn development in several ways. Optimal Practices A prenatal pediatric visit allows pediatricians to assess both the strengths of the expectant parents and any needs they may have in anticipation of the birth of their infant. This should include assess ment of social determinants of health and may consist of addressing needs such as baby supplies, financial assistance, and parental men tal health support. Supportive hospital policies include the use of birthing rooms rather than operating suites and delivery rooms; encouraging the partner or a trusted relative or friend to remain with the mother during labor or the provision of a professional doula; the practice of giving the newborn infant to the mother immediately after drying and a brief assessment; keeping the newborn with the mother rather than in a central nursery; and avoiding in hospital distribution of infant formula. Such policies (Baby Friendly
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Hos pital) have been shown to significantly increase breastfeeding rates (see Chapter 115.3). After discharge, home visits by nurses and lactation counselors can reduce early feeding problems and iden tify emerging medical conditions in either mother or baby. Infants requiring transport to another hospital should be brought to see the mother first, if at all possible. Timing of hospital discharge should be individualized for each maternalinfant dyad based on the mode of delivery, presence or absence of specific risk factors, and any problems identified during the birth hospitalization. Some healthy term newborns may be discharged before 48 hours of life, and these newborns should be evaluated with a follow up visit by 3 5 days after birth and within 48 72 hours after discharge. The timing of the first visit for newborns with a longer initial hospital stay will depend on the newborns specific issues and identified needs. Assessing ParentInfant Interactions During a feeding or when infants are alert and face to face with their parents, it is normal for the dyad to appear absorbed in one another. Infants who become overstimulated by the parents voice or activity may turn away or close their eyes, leading to a premature termination of the encounter. Alternatively, the infant may be ready to interact, but the parent may appear preoccupied. Asking a new mother about her own emotional state, and inquiring specifically about a history of depression, facilitates referral for therapy, which may provide long term benefits to the child. Teaching About Individual Competencies The Newborn Behavior Assessment Scale (NBAS) provides a formal measure of an infants neurodevelopmental competencies, including state control, autonomic reactivity, reflexes, habituation, and orientation toward auditory and visual stimuli. This examina tion can also be used to demonstrate to parents an infants capa bilities and vulnerabilities. Parents might learn that they need to undress their infant to increase the level of arousal or to swaddle the infant to reduce overstimulation by containing random arm move ments. The NBAS can be used to support the development of posi tive early parentinfant relationships. Demonstration of the NBAS to parents in the first week of life has been shown to correlate with improvements in the caretaking environment months later. Visit Elsevier eBooks at eBooks.Health.Elsevier.com for Bibliography. The prenatal period and the first year of life provide the platform for remarkable growth and development, setting the trajectory for a childs life. Neural plasticity, the ability of the brain to be shaped by expe rience, both positive and negative, is at its peak. Total brain volume doubles in the first year of life and increases by an additional 15 over the second year. Total brain volume at age 1 month is approximately 36 of adult volume but by age 1 year is approximately 72 (83 by 2 years) (Fig. 23.1). The acquisition of seemingly simple skills, such as swallow ing, reflects a series of intricate and highly coordinated processes involving multiple levels of neural control distributed among sev eral physiologic systems whose nature and
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relationships mature throughout the first year of life. Substantial learning of the basic tools of language (phonology, word segmentation) occurs during infancy. Speech processing in older individuals requires defined and precise neuronal networks; the infant brain possesses a struc tural and functional organization similar to that of adults, sug gesting that structural neurologic processing of speech may guide infants to discover the properties of their native language. Myelina tion of the cortex begins at 7 8 months gestation and continues into adolescence and young adulthood. It proceeds posterior to ante rior, allowing progressive maturation of sensory, motor, and finally associative pathways. Given the importance of iron, cholesterol, and other nutrients in myelination, adequate stores throughout infancy are critical (see Chapter 61). Insufficient interactions with caregiv ers or the wider environment may alter experience dependent pro cesses that are critical to brain structure development and function during infancy. Although for some processes, subsequent stimula tion may allow catch up; as the periods of plasticity close during the rapid developmental changes occurring in infancy, more per manent deficits may result. The infant acquires new competences in all developmental domains. The concept of developmental trajectories recognizes that complex skills build on simpler ones; it is also important to realize how development in each domain affects functioning in all the others. All growth parameters should be plotted using the World Health Organization charts, which show how children from birth through 72 months should grow under optimal circumstances (see Figs. 24.1 and 24.2). Table 23.1 presents an overview of key milestones by domain; Table 23.2 presents similar information arranged by age. Table 23.3 presents age at time of x ray appearance of centers of ossification. Parents often seek information about normal development during this period and should be directed to reliable sources, including the American Academy of Pediatrics web site (www.healthychildren.org) or the Center for Disease Control website (www.cdc.govncbdddactearlymilestonesindex.html). AGE 0 2 MONTHS In the full term infant, myelination is present by the time of birth in the dorsal brainstem, cerebellar peduncles, and posterior limb of the inter nal capsule. The cerebellar white matter acquires myelin by 1 month of age and is well myelinated by 3 months. The subcortical white matter of the parietal, posterior frontal, temporal, and calcarine cortex is partially myelinated by 3 months of age. In this period the infant experiences tre mendous growth. Physiologic changes allow the establishment of effec tive feeding routines and a predictable sleepwake cycle. The social interactions that occur as parents and infants accomplish these tasks lay the foundation for cognitive and emotional development. Chapter 23 The First Year Mutiat T. Onigbanjo and Susan Feigelman Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 152 Part II u Growth, Development, and Behavior 1250000 1000000 750000 500000 250000 0 BA 0 12 Age in months Volume of the Cortical Hemispheres V ol
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um e in m m 3 24 1000000 750000 500000 250000 0 D 0 12 Age in months Subcortical and Brainstem V ol um e in m m 3 24 1500000 100000 50000 0 C 0 12 Age in months Cerebellum V ol um e in m m 3 24 1250000 1000000 750000 500000 250000 0 0 12 Age in months Total Brain Volume V ol um e in m m 3 24 Fig. 23.1 Scatterplots showing brain growth in the first 2 years of life. A, Total brain volume by age at scan. B, Cortical hemispheres. C, Cerebellum. D, Subcortical region and brainstem. (From Knickmeyer RC, Gouttard S, Kang C, et al. A structural MRI study of human brain development from birth to 2 years. J Neurosci. 2008;28:1217612182.) Physical Development A newborns weight may initially decrease 10 (vaginal delivery) to 12 (cesarean section) below birthweight in the first week as a result of excre tion of excess extravascular fluid and limited nutritional intake. Nutri tion improves as colostrum is replaced by higher fat content breast milk, infants learn to latch on and suck more efficiently, and mothers become more comfortable with feeding techniques. Infants regain or exceed birthweight by 2 weeks of age and should grow at approximately 30 g (1 oz) per day during the first month (see Table 27.1). This is the period of fastest postnatal growth. Arms are held to the sides. Limb movements consist largely of uncontrolled writhing, with apparently purposeless opening and closing of the hands. Smiling occurs involuntarily. Eye gaze, head turning, and sucking are under better control and thus can be used to demonstrate infant perception and cognition. An infants preferential turning toward the mothers voice is evidence of recognition memory. Six behavioral states have been described (see Chapter 22). Initially, sleep and wakefulness are evenly distributed throughout the 24 hour day (Fig. 23.2). Neurologic maturation accounts for the consolidation of sleep into blocks of 5 or 6 hours at night, with brief awake, feeding periods. Learning also occurs; infants whose parents are consistently more interactive and stimulating during the day learn to concentrate their sleeping during the night. Cognitive Development Infants can differentiate among patterns, colors, and consonants. They can recognize facial expressions (smiles) as similar, even when they appear on different faces. They also can match abstract properties of stimuli, such as contour, intensity, or temporal pattern, across sensory modalities. Infants at 2 months of age can discriminate rhythmic pat terns in native vs nonnative language. Infants appear to seek stimuli actively, as though satisfying an innate need to make sense of the world. These phenomena point to the integration of sensory inputs in the cen tral nervous system. Caretaking activities provide visual, tactile, olfac tory, and auditory stimuli, all of which support the development of cognition. Infants habituate to the familiar, attending less to repeated stimuli and increasing their attention to novel stimuli. Emotional Development The infant is dependent on the environment to meet its needs. The con sistent
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availability of a trusted adult to meet the infants urgent needs creates the conditions for secure attachment. Basic trust vs mistrust, the first of Eriksons psychosocial stages (see Chapter 19), depends on attachment and reciprocal maternal bonding. Crying occurs in response to stimuli that may be obvious (a soiled diaper) but are often obscure (see Chapter 23.1). Infants who are consistently picked up and held in response to distress cry less at 1 year and show less aggressive behavior at 2 years. Infants of adolescent mothers who are trained to carry their babies demonstrate secure attachment. Infants cry in response to the cry of another infant, which has been interpreted as an early sign of empathy. Implications for Parents and Pediatricians Success or failure in establishing feeding and sleep cycles influences parents feelings of competence. When things go well, the parents anxiety and ambivalence, as well as the exhaustion of the early weeks, decrease. Infant issues (e.g., colic) or familial conflict may prevent this from occurring. With physical recovery from delivery and hormonal Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. Chapter 23 u The First Year 153 normalization, the mild postpartum blues that affects many mothers passes. If the mother continues to feel sad, overwhelmed, or anxiety, the possibility of moderate to severe postpartum depression or anxi ety, found in 2025 of postpartum women, needs to be considered. Major depression that arises during pregnancy or in the postpartum period threatens the motherchild relationship and is a risk factor for later cognitive and behavioral problems. Postpartum depression is often reported in mothers and can also occur in fathers. It can pres ent over the course of a year with symptoms of depression or irrita bility. The pediatrician may be the first professional to encounter the depressed parent and should be instrumental in assisting the parent in seeking treatment (see Chapter 22). AGE 2 6 MONTHS At about age 2 months, the emergence of voluntary (social) smiles and increasing eye contact mark a change in the parentchild relationship, heightening the parents sense of being loved reciprocally. During the next months, an infants range of motor and social control and cognitive engagement increases dramatically. Mutual regulation takes the form of complex social interchanges, resulting in strong mutual attachment and enjoyment. Routines are established. Parents are less fatigued. Physical Development Between 3 and 4 months of age, the rate of growth slows to approxi mately 20 gday (see Table 27.1 and Figs. 24.1 and 24.2). By age 4 months, birthweight is doubled. Early reflexes that limited voluntary movement recede (e.g., primitive reflexes; see Chapter 630). Disap pearance of the asymmetric tonic neck reflex means that infants can begin to examine objects in the midline and manipulate them with both hands. Waning of the early grasp reflex allows infants both to hold objects and to let them go
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voluntarily. A novel object may elicit purposeful, although inefficient, reaching. The quality of spontaneous movements also changes, from larger (proximal) writhing to smaller, circular (distal) movements that have been described as fidgety. Abnormal or absent fidgety movements may constitute a risk factor for later neurologic abnormalities. Increasing control of truncal flexion makes intentional rolling pos sible. Once infants can hold their heads steady while sitting, they can Table 23.1 Developmental Milestones in First 2 Years of Life MILESTONE AVERAGE AGE OF ATTAINMENT (MO) DEVELOPMENTAL IMPLICATIONS GROSS MOTOR Holds head steady while sitting 2 Allows more visual interaction Pulls to sit, with no head lag 3 Muscle tone Brings hands together in midline 3 Self discovery of hands Asymmetric tonic neck reflex gone 4 Can inspect hands in midline Sits without support 6 Increasing exploration Rolls back to stomach 6.5 Truncal flexion, risk of falls Walks alone 12 Exploration, control of proximity to parents Runs 16 Supervision more difficult FINE MOTOR Grasps rattle 3.5 Object use Reaches for objects 4 Visuomotor coordination Palmar grasp gone 4 Voluntary release Transfers object hand to hand 5.5 Comparison of objects Thumb finger grasp 8 Able to explore small objects Turns pages of book 12 Increasing autonomy during book time Scribbles 13 Visuomotor coordination Builds tower of two cubes 15 Uses objects in combination Builds tower of six cubes 22 Requires visual, gross, and fine motor coordination COMMUNICATION AND LANGUAGE Smiles in response to face, voice 1.5 More active social participant Monosyllabic babble 6 Experimentation with sound, tactile sense Inhibits to no 7 Response to tone (nonverbal) Follows one step command with gesture 7 Nonverbal communication Follows one step command without gesture 10 Verbal receptive language (e.g., Give it to me) Says mama or dada 10 Expressive language Points to objects 10 Interactive communication Speaks first real word 12 Beginning of labeling Speaks 4 6 words 15 Acquisition of object and personal names Speaks 10 15 words 18 Acquisition of object and personal names Speaks two word sentences (e.g., Mommy shoe) 19 Beginning grammatization, corresponds with 50 word vocabulary COGNITIVE Stares momentarily at spot where object disappeared 2 Lack of object permanence (out of sight, out of mind; e.g., yarn ball dropped) Stares at own hand 4 Self discovery, cause and effect Bangs two cubes 8 Active comparison of objects Uncovers toy (after seeing it hidden) 8 Object permanence Egocentric symbolic play (e.g., pretends to drink from cup) 12 Beginning symbolic thought Uses stick to reach toy 17 Able to link actions to solve problems Pretend play with doll (e.g., gives doll bottle) 17 Symbolic thought Downloaded for mohamed ahmed (dr.mms2020gmail.com) at University of Southern California from ClinicalKey.com by Elsevier on April 20, 2024. For personal use only. No other uses without permission. Copyright 2024. Elsevier Inc. All rights reserved. 154 Part II u Growth, Development, and Behavior Table 23.2 Emerging Patterns of Behavior During the First Year of Life NEONATAL PERIOD (04 WK) Prone: Lies in flexed attitude; turns head from side to side;
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