Supporting Parents With Mental Health Needs in Systems of Care

Summary: Community-based systems of care (SOCs) must address both the needs of parents with mental illness and the needs of their children. Learning more about the challenges faced by SOCs in this area, and the strategies they implement to overcome them, provides insights with implications for the broader field. This project was intended to learn more about efforts to assess parents’ mental health needs, effectively engage and support them, and improve system coordination and access to services to inform service delivery and system reform, especially for those involved in both child welfare and mental health. This report presents information gathered from a small sample of federally funded SOC communities between March and October 2010. Project directors, lead family contacts, clinical supervisors, family partners, and other staff , along with representatives of partner organizations, especially child welfare, generously shared information about their approaches to policies and practices designed to support whole families—children, youth, and parents or other caregivers

Estimating Percentile-Specific Causal Effects: A Case Study of Micronutrient Supplementation, Birth Weight, and Infant Mortality

In developing countries, higher infant mortality is partially caused by poor maternal and fetal nutrition. Clinical trials of micronutrient supplementation are aimed at reducing the risk of infant mortality by increasing birth weight. Because infant mortality is greatest among the low birth weight infants (LBW) (• 2500 grams), an effective intervention may need to increase the birth weight among the smallest babies. Although it has been demonstrated that supplementation increases the birth weight in a trial conducted in Nepal, there is inconclusive evidence that the supplementation improves their survival. It has been hypothesized that a potential benefit of the treatment on survival among the LBW is partly compensated by a null or even harmful effects among the largest infants. Thus, two key scientific questions are whether the effect of the treatment on survival differs across the birth weight distribution (e.g. is largest among the LBW), and whether the effect of the treatment on survival is mediated wholly or in part by increases in birth weight. Motivated by a community trial in Nepal, this paper defines population and causal parameters for estimating the treatment effects on birth weight and on survival as functions of the percentiles of the birth weight distribution. We develop a model with potential outcomes and implement principal stratification for estimating and comparing the causal effects of the treatment on mortality in sub-populations of babies defined by their birth weights. We use a Bayesian approach with data augmentation to approximate the posterior distributions of the parameters taking into account uncertainty associated with the imputation of the counterfactuals. This approach is particularly suitable for exploring the sensitivity of the results to modelling assumptions and other prior beliefs. Our analysis shows that the average causal effect of the treatment on birth weight is equal to 68 grams (95% posterior regions 25 to 110) and that this causal effect is largest among the LBW. Posterior inferences about average causal effects of the treatment on birth weight are robust to modelling assumptions. However inferences about causal effects for babies at the tails of the birth weight distribution can be highly sensitive to the unverifiable assumption about the correlation between the observed and the counterfactuals birth weights. Among the LBW infants who have a large causal effect of the treatment on birth weight, we found that a baby receiving the treatment has 5% to 7% less chance of death if the same baby had received the control. Among the LBW,we found weak evidence supporting an additional beneficial effect of the treatment on mortality independent of birth weight

Does the Effect of Micronutrient Supplementation on Neonatal Survival Vary with Respect to the Percentiles of the Birth Weight Distribution?

Scientific Background: In developing countries, higher infant mortality is partially caused by poor maternal and fetal nutrition. Clinical trials of micronutrient supplementation are aimed at reducing the risk of infant mortality by increasing birth weight. Because infant mortality is greatest among the low birth weight infants (LBW) (less than or equal to 2500 grams), an effective intervention might be needed to increase birth weight among the smallest babies. Although it has been demonstrated that supplementation increases the birth weight in a trial conducted in Nepal, there is inconclusive evidence that the supplementation improves their survival. It has been hypothesized that a potential benefit of the treatment on survival among the LBW infants is partly compensated by a null or even harmful effects among the largest infants. Exploratory analyses have suggested that the treatment effect on birth weight might vary with respect to the percentiles of the birth weight distribution. Data: The methods in this paper are motivated by a double-blind randomized community trial in rural Nepal (Christian et al. 2003a,b). The investigators implemented an intervention program to evaluate benefits of the following micronutrient supplementations: folic acid and vitamin A (F+A); folic acid, iron, and vitamin A (F+I+A); folic acid, iron, zinc, and vitamin A (F+I+Z+A); multiple nutrients and vitamin A (M+A). Each micronutrient supplement was administered weekly to 1000 pregnant women, who ultimately delivered approximately 800 live-born infants. The team measured the birth weight within 72 hours of delivery and then followed the infants for one year to determine whether or not they survived. In addition, they measured several characteristics of the mother (maternal age, parity, maternal height, arm circumference) and of the infant (weight, length, head and chest circumference). In this case study we focus on the supplementations F + I + A and M + A as compared to vitamin A only and we address the following scientific questions: 1. Is there an overall effect of the treatments on birth weight? Does this effect vary with the percentiles of the birth weight distribution; in particular, is it largest among the LBW infants? 2. Is there an overall effect of the treatments on survival? Does this effect vary with the percentiles of the birth weight distribution; in particular, is it largest among the LBW infants? 3. Do these percentile-specific effects on birth weight and survival differ by micronutrients? Statistical Approach: The data analysis is challenged by measurement error and informative missing data in birth weight and survival. In community-based interventions in developing countries, most births occur in the home without assistance from trained birth attendants. Approximately 88% of the babies are measured within 72 hours of the delivery. The remaining 12% are measured between the 72 and the 2000 hours approximately. Hence, weights are obtained at varying times following birth and therefore they are imprecise measures of the true weight at birth . In addition, a high proportion of deaths of young infants occur in the first few hours after birth. If there is a delay in reaching the mother and infant, then many of these infants would be weighed because they have already died. For example in the F +1+ A group, approximately 7% of the birth weight measurements are missing and among this 7%, approximately 34% of the babies have died right within 24 hours of the delivery. These babies are likely to have been of lower birth weight than those who survived to be weighed, and therefore, these missing birth weights due to death are likely to be informative. In this paper we develop a measurement error model with counterfactual variables that address the scientific questions for this birth weight-mortality case study. Our approach integrates Bayesian methods and data augmentation (Tanner and Wong, 1987; Tanner, 1991; Albert and Chib, 1993; Chib and Greenberg, 1998) with a counterfactual model and principal stratification (Rubin, 1978; Holland, 1986; Frangakis and Rubin, 2002). We calculate marginal posterior distributions of the treatment effects on birth weight and infant mortality that are allowed to vary with the percentiles of the birth weight distributions. We compare our posterior inferences with two simpler approaches. The first still relies on a Bayesian approach but ignores the uncertainty in the imputation and prediction of the birth weight and does account for the mother\u27s covariates. The second is a simpler re-sampling approach that imputes the missing birth weights (Rubin, 1987). Results and Public Health Impact: First we found that both F+I+A and M+A increase birth weight. However, the F+I+A increases birth weight mainly among the LBW infants, whereas M + A increases birth weight across the entire birth weight distribution compared to vitamin A only. The F+I+A reduces the risk of infant mortality, whereas the M+A slightly increases the risk of early infant mortality, especially among the larger infants. Currently recommendations exist to supplement pregnant women in developing countries. This case study provides critical information toward the evaluation and planning of these public health interventions

Submitted for publication October 14

Purpose. To examine the concordance of the Glaucoma Hemifield Test and other global visual field indexes between two consecutive automated visual field tests. Methods. Normal subjects, subjects with ocular hypertension, and subjects with glaucoma had two automated visual field tests on the Humphrey Field Analyzer. The Glaucoma Hemifield Test results, mean deviation, and corrected pattern standard deviation of the two consecutive visual field tests were compared. Results. Forty-one normal subjects were tested within 1 and 2 years of each other. Four hundred seven subjects with ocular hypertension and 95 subjects with glaucoma were tested 1 year apart. The proportion of normal subjects who met a criterion for abnormality on two consecutive tests was 2.4%. The proportion of subjects with glaucoma with normal results of two tests was 10.5%. The specificity of automated visual field testing was improved from 80.8% to 89.9%, with a modest loss of sensitivity if two rather than one abnormal test result was required for entry into a clinical trial enrolling patients with glaucomatous field loss. Similarly, specificity increased from 84.2% to 89.5% if two normal tests were required for entry into an ocular hypertensive clinical trial. Among subjects with more closely spaced tests, the agreement between consecutive tests was similar for tests spaced 4 versus 12 months apart. Conclusions. Although mere is concordance of Glaucoma Hemifield Test results on consecutive testing, there is enough disagreement to result in improved specificity from the use of a second test in a clinical trial setting. Invest Ophthalmol Vis Sci. 1995; 36:1658-1664. J. he definition and diagnosis of glaucoma depends on visual field testing as a method of identifying and quantifying optic nerve damage. Several studies have used automated perimetry to estimate the variability of mean sensitivity and sensitivity at individual locations in the field over relatively short periods of time. 1 " 8 These studies have found substantial variability, particularly among subjects with glaucoma and those at high risk for glaucoma. The magnitude of variability is important for defining limits beyond which true disease progression is thought to have occurred. However, researchers and clinicians often need to mak

Diarrhea as a risk factor for acute lower respiratory tract infections among young children in low income settings

Diarrhea and acute lower respiratory tract infections (ALRI) are leading causes of morbidity and mortality among children under 5 years of age. We sought to quantify the correlation of diarrhea and respiratory infections within an individual child and to determine if infection with one illness increases the risk of infection with the other during the same time period

Family Members with Overlapping Mental Health Needs Require the Transformation of Systems and Services

Women and men with a lifetime prevalence of psychiatric disorder are at least as likely to be parents as are adults without psychiatric disorder. The majority of adults in all diagnostic categories are parents, including those meeting criteria for affective and anxiety disorders, PTSD, and non-affective psychosis. Children with Serious Emotional Disturbance (SED) receiving services in Systems of Care (SOCs) programs may have multiple family risk factors. Family-centered, strengths-based practices require a paradigm shift in the way administrators and providers view and intervene with children and adults. Presented at The Santa Fe Summit on Behavioral Health, the American College of Mental Health Administration, Santa Fe, New Mexico, March 2005

Risk and burden of adverse intrapartum-related outcomes associated with non-cephalic and multiple birth in rural Nepal: a prospective cohort study

Objectives Intrapartum-related complications are the second leading cause of neonatal death worldwide. We estimate the community-level risk and burden of intrapartum-related fetal/neonatal mortality and morbidity associated with non-cephalic and multiple birth in rural Sarlahi District, Nepal. Design Community-based prospective cohort study. Setting Rural Sarlahi District, Nepal. Participants Pregnant women residing in the study area. Methods We collected data on maternal background characteristics, conditions during labour and delivery, fetal presentation and multiple birth during home visits. We ran log-binomial regression models to estimate the associations between non-cephalic/multiple births and fresh stillbirth, early neonatal mortality and signs of neonatal encephalopathy, respectively, and calculated the per cent attributable fraction. To better understand the context under which these adverse birth outcomes are occurring, we also collected data on maternal awareness of non-cephalic presentation and multiple gestation prior to delivery. Primary outcome measures Risk of experiencing fresh stillbirth, early neonatal encephalopathy and early neonatal mortality associated with non-cephalic and multiple birth, respectively. Results Non-cephalic presentation had a particularly high risk of fresh stillbirth (aRR 12.52 (95% CI 7.86 to 19.95), reference: cephalic presentation). 20.2% of all fresh stillbirths were associated with non-cephalic presentation. For multiple births, there was a fourfold increase in early neonatal mortality (aRR: 4.57 (95% CI 1.44 to 14.50), reference: singleton births). 3.4% of early neonatal mortality was associated with multiple gestation. Conclusions Globally and in Nepal, a large percentage of stillbirths and neonatal mortality is associated with intrapartum-related complications. Despite the low incidence of non-cephalic and multiple birth, a notable proportion of adverse intrapartum-related outcomes is associated with these conditions. As the proportion of neonatal deaths attributable to intrapartum-related complications continues to rise, there is a need to investigate how best to advance diagnostic capacity and management of these conditions. Trial registration number NCT01177111; pre-results

Long-term culture of human breast cancer specimens and their analysis using optical projection tomography

Breast cancer is a leading cause of mortality in the Western world. It is well established that the spread of breast cancer, first locally and later distally, is a major factor in patient prognosis. Experimental systems of breast cancer rely on cell lines usually derived from primary tumours or pleural effusions. Two major obstacles hinder this research: (i) some known sub-types of breast cancers (notably poor prognosis luminal B tumours) are not represented within current line collections; (ii) the influence of the tumour microenvironment is not usually taken into account. We demonstrate a technique to culture primary breast cancer specimens of all sub-types. This is achieved by using three-dimensional (3D) culture system in which small pieces of tumour are embedded in soft rat collagen I cushions. Within 2-3 weeks, the tumour cells spread into the collagen and form various structures similar to those observed in human tumours1. Viable adipocytes, epithelial cells and fibroblasts within the original core were evident on histology. Malignant epithelial cells with squamoid morphology were demonstrated invading into the surrounding collagen. Nuclear pleomorphism was evident within these cells, along with mitotic figures and apoptotic bodies. We have employed Optical Projection Tomography (OPT), a 3D imaging technology, in order to quantify the extent of tumour spread in culture. We have used OPT to measure the bulk volume of the tumour culture, a parameter routinely measured during the neo-adjuvant treatment of breast cancer patients to assess response to drug therapy. Here, we present an opportunity to culture human breast tumours without sub-type bias and quantify the spread of those ex vivo. This method could be used in the future to quantify drug sensitivity in original tumour. This may provide a more predictive model than currently used cell lines.Publisher PDFPeer reviewe