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  • Documenting Psychosocial Problems in Children’s Electronic Health Records

    Dubowitz, Howard; Kressly, Susan J. (American Medical Association (AMA), 2023-09-01)
  • Initial Medical Assessment of Possible Child Sexual Abuse: History, History, History

    Dubowitz, Howard; Finkel, Martin; Feigelman, Susan; Lyon, Thomas (Elsevier, 2024)
    Primary care professionals (PCPs) can play a valuable role in the initial assessment of possible child sexual abuse (CSA), an all too prevalent problem. PCPs, however, are often reluctant to conduct these assessments. The goal of this paper is to help PCPs be more competent and comfortable playing a limited but key role. This is much needed as there may be no need for further assessment and also because of a relative paucity of medical experts in this area. While some children present with physical problems, the child's history is generally the critical information. This article therefore focuses on practical guidance regarding history-taking when CSA is suspected, incorporating evidence from research on forensic interviewing. We have been mindful of the practical constraints of a busy practice and the role of the public agencies in fully investigating possible CSA. The approach also enables PCPs to support children and their families.
  • Validation of the Swedish version of the safe environment for every kid (SEEK) parent screening questionnaire

    Engström, Maria; Lindqvist, Sara; Janson, Staffan; Feldman, Inna; Dubowitz, Howard; Lucas, Steven (Springer Science and Business Media LLC, 2023-10-12)
    Background: Psychosocial risk factors in the home may impair children's health and development and increase the risk of maltreatment. The Safe Environment for Every Kid (SEEK) model was developed to provide pediatric primary care professionals with a structured way to identify common psychosocial problems. The SEEK model includes use of the Parent Screening Questionnaire (SEEK-PSQ) at routine preventive child health visits, discussion with parents about their responses and, when indicated, referral to relevant services. The SEEK-PSQ has not previously been available in Swedish. The aim of the present study was to evaluate the psychometric properties of an adapted Swedish version of the SEEK-PSQ (PSQ-S). Methods: This study is part of a cluster-randomised controlled trial of SEEK in the Swedish child health services. To validate the PSQ-S, parents (n = 852) with children 0-18 months of age were invited to complete a survey including the PSQ-S as well as evidence-based standardized instruments for the targeted psychosocial risk factors: economic worries, depressive symptoms, parental stress, alcohol misuse and intimate partner violence (IPV). Baseline data from 611 (72%) parents were analysed regarding sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for each risk factor. Results: As a whole, the PSQ-S had a sensitivity of 93%, specificity of 52%, PPV of 67% and NPV of 87%. For mothers and fathers combined, sensitivity was 80% for economic worries, 89% for depressive symptoms, 78% for parental stress, 47% for intimate partner violence (IPV) and 70% for alcohol misuse. Specificity was highest for IPV and alcohol misuse (91%) and lowest for depressive symptoms (64%). NPV values were high (81-99%) and PPV values were low to moderate (22-69%) for the targeted problems. Sensitivity was higher for mothers compared to fathers for economic worries, depressive symptoms and IPV. This difference was particularly evident for IPV (52% for mothers, 27% for fathers). Conclusion: The SEEK-PSQ-S demonstrated good psychometric properties for identifying economic worries, depressive symptoms, parental stress and alcohol misuse but low sensitivity for IPV. The PSQ-S as a whole showed high sensitivity and NPV, indicating that most parents with or without the targeted psychosocial risk factors were correctly identified.
  • Assessment of Adoption and Early Implementation Barriers and Facilitators of the Safe Environment for Every Kid (SEEK) Model

    Palinkas, Lawrence A.; Belanger, Rosemarie; Newton, Stacey; Saldana, Lisa; Landsverk, John; Dubowitz, Howard (Elsevier, 2023)
    Objective: Although the use of interventions for screening for social determinants of health of families in pediatric primary care clinics has increased in the past decade, research on the barriers and facilitators of implementing such interventions has been limited. We explored barriers, facilitators, and the mechanisms clarifying their roles in the adoption and implementation of the Safe Environment for Every Kid (SEEK) model, an approach for strengthening families, promoting children's health and development, and preventing child maltreatment. Methods: A total of 28 semistructured interviews were completed with 9 practice champions, 11 primary care professionals, 5 behavioral health professionals, and 3 nursing/administrative staff representing 12 pediatric primary care practices participating in a larger randomized control trial of implementing SEEK. Results: We identified several barriers and facilitators in the stages of SEEK's adoption and early implementation. Barriers associated with outer and inner setting determinants and poor innovation-organization fit declined in importance over time, while facilitators associated with SEEK characteristics increased in importance based on participants' responses. Barriers and facilitators were linked by mechanisms of comparison and contrast of burdens and benefits, and problem-solving to address limited capacity with available resources. Conclusions: Any screening for and addressing social determinants of health demands greater attention to adoption and implementation mechanisms and the processes by which primary care professionals assess and utilize facilitators to address barriers. This occurs in a context defined by perceived burdens and benefits of innovation adoption and implementation, the capacity of the practice, and changes in perception with experiencing the innovation.
  • Addressing Adverse Childhood Experiences in Primary Care: Challenges and Considerations

    Dubowitz, Howard; Finkelhor, David; Zolotor, Adam; Kleven, Jennifer; Davis, Neal (American Academy of Pediatrics (AAP), 2022-03-10)
    This article draws attention to the overlapping literature on social determinants of health and adverse childhood experiences, and the growing clinical interest in addressing them to promote children's and parents' health and well-being. We address important considerations and suggest solutions for leaders and practitioners in primary care to address social determinants of health/adverse childhood experiences. Priorities include: begin with a few prevalent conditions for which there are helpful resources; focus on conditions that are current or recent and where parents may be more apt to engage in services; focus initially on families with children aged <6 given the frequency of well-child visits and the especially strong relationships between primary care professionals and parents during this period; ensure training of primary care professionals and staff to help them play this role competently and comfortably; and have good referral processes to facilitate additional evaluation or help.
  • Neglect in Childhood, Problem Behavior in Adulthood

    Dubowitz, Howard; Roesch, Scott; Lewis, Terri; Thompson, Richard; English, Diana; Kotch, Jonathan B. (SAGE Publications, 2022-02-13)
    Few studies have reported problem behaviors in adulthood related to the timing of child neglect. The objective was to examine the relationship between classes of child neglect and later behavior. The sample included 473 participants from the prospective Longitudinal Studies of Child Abuse and Neglect (LONGSCAN); their mean age was 23.8 years. They completed an online survey regarding behaviors and experiences in early adulthood. Neglect was assessed via Child Protective Services (CPS) and self-reports of neglect. Latent class analysis (LCA) identified three classes: Late Neglect, Chronic Neglect, and Limited Neglect. There were significant differences between Limited and Late Neglect regarding later intimate partner aggression and violence (IPAV) and psychological distress, and among all classes for criminal behavior. High-risk youth experiencing neglect beginning in mid-adolescence appear especially vulnerable to later criminal behavior, psychological distress, and IPAV. Those working with such youth can help ensure that their needs are adequately met, to prevent or mitigate problems in adulthood.
  • Adolescent Neglect and Health Risk

    Kobulsky, Julia M.; Villodas, Miguel; Yoon, Dalhee; Wildfeuer, Rachel; Steinberg, Laurence; Dubowitz, Howard (SAGE Publications, 2021-10-19)
    This study examined relationships between adolescent neglect and abuse and later health risk in a sample of 1050 youth (53% female, 56% Black, and 24% White) from the Longitudinal Studies of Child Abuse and Neglect. At age 16, the youth reported any adolescent exposure to neglect and physical, sexual, and emotional abuse. At age 18, they reported risk behaviors (delinquency, substance use, and sexual behavior) and emotional and behavioral problems (externalizing and internalizing problems, suicidality). Control variables were childhood maltreatment (self-reports and early childhood child protective services reports), risk behaviors and emotional and behavioral problems at age 16, and demographics. Analysis confirmed a 5-factor model of adolescent neglect (Exposure to Risk, Inadequate Monitoring, Inattention to Basic Needs, Permitting Misbehavior, and Inadequate Support). Inadequate Support and Exposure to Risk were associated with more substances used; Exposure to Risk was also associated with delinquency and suicidality. Adolescent emotional abuse was associated with not using a condom use and internalizing and externalizing problems. Findings underscore the importance of preventing or addressing neglect during adolescence.
  • Social determinants of health, personalized medicine, and child maltreatment

    Lane, Wendy G.; Dubowitz, Howard (Springer Science and Business Media LLC, 2021)
    This review begins with a brief summary of the importance of child maltreatment as a major public health problem, given its prevalence and the substantial human and economic costs involved. The focus then shifts to consideration of personalized medicine and child maltreatment, including genetic and genomics factors, as well as the role of social determinants of health. Research on epigenetics related to child abuse and neglect is presented, followed by that pertaining to a few specific social factors, such as poverty, parental depression and substance use, and domestic (or intimate partner) violence. The review ends with a discussion of interventions to help address social determinants of health with brief descriptions of several model programs, and thoughts concerning the role of personalized medicine in addressing child maltreatment in the foreseeable future. IMPACT: This paper synthesizes knowledge on social determinants of health and advances in genetics and genomics related to the prevention of child maltreatment. It provides examples of model approaches to addressing the prevention of child maltreatment in primary care practices.
  • Public policy and parent-child aggression: Considerations for reducing and preventing physical punishment and abuse

    McGuier, Elizabeth A.; Kolko, David J.; Dubowitz, Howard (Elsevier, 2022)
    Parent-child physical aggression, including both physical punishment and abuse, remains a prevalent problem in the United States. In this paper, we briefly review the prevalence and harms of parent-child aggression and discuss changes in social norms and policies over the past several decades. Then, we discuss broad social policies influencing risk for parent-child physical aggression, policies relevant to reducing and preventing physical abuse, and policies relevant to reducing and preventing physical punishment. We close by considering future directions to strengthen research and evaluation and accelerate progress toward ending parent-child physical aggression.
  • Addressing Children’s Exposure to Violence and the Role of Health Care

    Dubowitz, Howard (American Medical Association (AMA), 2021-05-12)
  • Desialylated Host-Derived MUC1 Ectodomain and Bacterially-Derived Flagellin are Biomarkers for Airway Colonization and Infection with Pseudomonas aeruginosa in Mechanically Ventilated and Cystic Fibrosis Patients

    Verceles, Avelino C.; Bhat, Pavan; Nagaria, Zain; Martin, Destiny; Patel, Harsh; Ntem-Mensah, Afua; Hyun, Sang Won; Hahn, Andrea; Jeudy, Jean; Goldblum, Simeon E.; et al. (2020-05)
  • Addressing Children's Exposure to Violence and the Role of Health Care

    Dubowitz, Howard (American Medical Association, 2021-05-12)
  • Psychometric Properties of a Self-Report Measure of Neglect during Mid-Adolescence

    Kobulsky, Julia M.; Villodas, Miguel T.; Dubowitz, Howard (Springer Nature, 2020-04-01)
    Developmentally specific measures of neglect remain lacking, especially concerning neglect in adolescence. The current study examines the Mid-Adolescent Neglect Scale (MANS), a 45-item youth, self-reported measure of neglect. Sixteen-year-old participants (N = 802) in the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) completed the MANS, and they and their parents completed measures of parent-child relationship quality and parental monitoring. Reports of alleged neglect were coded from child protective services records. The sample was randomly assigned into two groups. Exploratory factor analysis was conducted in the first group (n = 397) and confirmatory factor and convergent validity analyses (n = 405) were conducted in the second group. Five dimensions of adolescent neglect were identified: Inadequate Monitoring, Inattention to Basic Needs, Permitting Misbehavior, Exposure to Risky Situations, and Inadequate Support. Confirmatory factor analysis largely supported the measurement model (CFI = 0.951, TLI =.948, RMSEA = 0.058, 90% RMSEA = 0.055, 0.061), as did convergent validity analyses. Results establish psychometric properties of an adolescent neglect scale that may be valuable to researchers studying neglect during this important developmental period.
  • Cost effectiveness of SEEK: A primary care-based child maltreatment prevention model

    Dubowitz, Howard; Frick, Kevin D; Semiatin, Josh; Magder, Laurence S.; Lane, Wendy G. (Elsevier Ltd., 2020-11-14)
    Background: Funding for prevention interventions is often quite limited. Cost-related assessments are important to best allocate prevention funds. Objectives: To determine the (1) overall cost for implementing the Safe Environment for Every Kid (SEEK) model, (2) cost of implementation per child, and (3) cost per case of maltreatment averted. Design: Cost-effective analysis of a randomized controlled trial. Participants and setting: 102 pediatric providers at 18 pediatric primary care practices. 924 families with children < 6 years receiving care by those providers. Methods: Practices and their providers were randomized to either SEEK training and implementation or usual care. Families in SEEK and control practices were recruited for evaluation. Rates of psychological and physical abuse were calculated by parent self-report 12 months following recruitment. Model costs were calculated including salaries for team members, provider time for training and booster sessions, and development and distribution of materials. Results: Implementing SEEK in all 18 practices would have cost approximately $265,892 over 2.5 years; $3.59 per child per year; or $305.58 ($229.18-$381.97) to prevent one incident. Based on a very conservative cost estimate of $2779 per maltreatment incident, SEEK would save an estimated $2,151,878 in health care costs for 29,610 children. Conclusions: The SEEK model is cost saving. Cost per case of psychological and physical abuse averted were significantly lower than the short-term costs of medical and mental health care for maltreated children. SEEK model expansion has the potential to significantly decrease medical, mental health, and other related costs associated with maltreatment.
  • Child Maltreatment, Early Adult Substance Use, and Mediation by Adolescent Behavior Problems

    Dubowitz, Howard; Roesch, Scott; Lewis, Terri (SAGE Publications Inc., 2020-07-22)
    The purpose of the current study was to examine the potential mediating effects of internalizing and externalizing problems at ages 14, 16 and 18 between types of childhood maltreatment and alcohol and marijuana use problems and disorders in young adulthood. Data were from 473 young adults who participated in the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). Path analysis was conducted to examine pathways between maltreatment type (birth through age 12), internalizing and externalizing problems at three time points during adolescence, and alcohol and marijuana problem use in young adulthood. Findings indicated significant pathways between physical abuse and internalizing problems at 14, which was associated with alcohol-related substance use disorder in adulthood. Externalizing problems and internalizing problems at age 14 mediated the relationship between physical abuse and marijuana-related symptoms in young adulthood. Emotional and sexual abuse were not associated with substance use problems. Implications for practice are discussed.
  • Neuraminidase-1 Desialylates the MUC1 Ectodomain to Release a Decoy Receptor that Protects against Lethal Pseudomonas aeruginosa Lung Infection

    Lillehoj, Erik P.; Guang, Wei; Hyun, Sang Won (2020)
    Background: Pseudomonas aeruginosa (Pa) is a major opportunistic pathogen of human airways, but the host response to infection is incompletely understood. Epithelial cells lining the airways express numerous surface receptors that recognize infectious agents such as Pa. One such receptor, MUC1, recognizes Pa flagellin, the major structural protein of the bacterial flagellum. MUC1 consists of an NH2-terminal, highly O-glycosylated ectodomain (MUC1-ED) attached to the cell surface through a membrane-spanning domain. MUC1-ED is proteolytically processed and shed from the epithelial cell surface following cleavage at a juxtamembranous Gly-Ser peptide bond. We previously demonstrated that stimulation of human airway epithelial cells with Pa flagellin increased MUC1-ED shedding in vitro (Lillehoj et al., J. Biol. Chem. 290:18316, 2015). Using an intact, physiologically relevant murine model of Pa pneumonia, here we asked whether Pa and its flagellin might also stimulate NEU1-dependent MUC1-ED desialylation in vivo to release a hyperadhesive decoy receptor that provides a novel, protective host response to Pa lung infection. Results: Intranasal administration of e5.0x103 colony forming units of Pa strain K (PAK) to BALB/c mice increased MUC1-ED shedding into the bronchoalveolar compartment. MUC1-ED levels increased as early as 12 h, peaked at 24-48 h, reaching up to a 7.8-fold increase, and decreased by 72 h. The a-type flagellin-expressing PAK strain and the b-type flagellin-expressing PAO1 strain stimulated comparable levels of MUC1-ED shedding. A flagellindeficient isogenic PAK mutant provoked dramatically reduced MUC1-ED shedding compared with the wild-type strain, and purified flagellin recapitulated the wild-type effect. In lung tissues, Pa increased MUC1-ED desialylation by peanut agglutinin lectin blotting. NEU1-selective sialidase inhibition with C9-BA-DANA, or use of a catalytically-inactive NEU1-G68V mutant, protected against Pa-induced MUC1-ED desialylation and shedding. MUC1-ED inhibition of in vitro Pa adhesion and flagellin binding to airway epithelial cells was localized to its protein backbone and not to its glycans. Finally, co-administration of Pa with human recombinant (r)MUC1-ED expressed in E. coli diminished lung and BALF bacterial burden, proinflammatory cytokine levels, and pulmonary leukostasis, and enhanced 5-day survival from 0% to 75%. Conclusions: These combined data indicate that Pa flagellin provokes NEU1-mediated airway shedding of MUC1-ED as a decoy receptor that protects against lethal Pa lung infection. Human rMUC1-ED might someday be harnessed as a therapeutic intervention to target Pa lung infections, including those associated with multi-drug resistant organisms.
  • NEU1 Sialidase Associates with the MUC1 Cytoplasmic Domain and not the MUC1 Ectodomain

    Lillehoj, Erik P.; Hyun, Sang Won; Piepenbrink, Kurt H.; Guang, Wei; Goldblum, Simeon E.
  • Preschool Children of Adolescent Parents Benefit from Supportive Mother-partner Relationships but not from Three-generation Households

    Black, M.M.; Kerr, M.; Dubowitz, H.; Hunter, W.; English, D.; Schneider, M.; Hussey, J.M. (American Academy of Pediatrics, 2000)
  • Maternal Substance Use and Neglectful Parenting: Relationships with Children's Development

    Harrington, D.; Dubowitz, H.; Black, M.M.; Binder, A. (Routledge, 1995)

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