Physical health outcomes of childhood exposure to intimate partner violence: A systematic review.

A Systematic Review Physical Health Outcomes of Childhood Exposure to Intimate Partner Violence: http://www.pediatrics.org/cgi/content/full/117/2/e278 located on the World Wide Web at: The online version of this article, along with updated information and services, is The authors have indicated they have no financial relationships relevant to this article to disclose. ABSTRACT BACKGROUND. Children exposed to intimate partner violence (IPV) are at increased risk for adverse mental and behavioral health sequelae, as has been documented by both systematic reviews and meta-analyses. Studies addressing the physical health impact of childhood IPV exposure, however, have not been summarized in a manner that might facilitate additional hypothesis-driven research and accelerate the development of targeted interventions

Addressing Psychosocial Adversity Within the Patient-Centered Medical Home: Expert-Created Measurable Standards

The Patient-Centered Medical Home (PCMH) may be improved by embedding identification and response for patients’ experiences with psychosocial adversity, but how this might optimally occur in practice has not been well-specified. We sought input from an expert panel to define feasible elements that could adapt the PCMH to adequately respond to patients’ experiences with psychosocial adversity. From December 2012 through September 2013, we used a Delphi process to systematically obtain expert opinions and reach consensus. We invited 37 experts to participate in three successive and iterative rounds of questionnaires, with each round based on aggregated, de-identified data from the prior round. We first asked experts to generate elements to adapt the PCMH, using the National Committee for Quality Assurance (NCQA’s) established six PCMH standards as the foundation. We then asked the experts to rate these elements on a 5-point Likert scale, and finally specify what they considered the most and least valuable elements. Eighteen of the 37 (49%) invited experts responded to the first survey, and constituted our sample. Experts identified 35 elements that fell under the six NCQA standards. The top rated elements included using a screening tool to identify adversity; training providers to address psychosocial adversity; having a team member with mental health expertise; providing culturally-competent care; and having written patient information related to adversity and coping. This study derived key elements that may enhance the PCMH’s ability to improve patient outcomes by purposefully identifying and responding to their psychosocial adversity

The context of violent disagreements between parents: a qualitative analysis from parents’ reports

Intimate partner violence (IPV) is a prevalent public health problem that affects millions of families. Much of what is known about IPV comes from quantitative studies that often "count" acts of IPV without exploring in depth the circumstances surrounding the violence, thereby leaving critical questions unanswered; existing qualitative studies tend to focus solely on women’s perspectives. There is a dearth of dyadic qualitative research exploring the context of IPV in families with children, thus hindering the development of effective interventions for families experiencing IPV. Seven heterosexual couples were recruited from a University-based family therapy clinic to participate in qualitative interviews. Couples were eligible if they had experienced severe verbal or any physical aggression during the past 4 months; had ≥ one child living in the household; were English-speaking; and were ≥ 18. Each individual was interviewed separately. Key topics explored included specific types of violence used by men and women; primary triggers and the context surrounding aggressive disagreements; degree to which the child(ren) were exposed; and perceived consequences for adults and children. All couples listed household responsibilities and parenting as key IPV triggers. Couples with infants reported that parenting disagreements were particularly heated, with women using aggression due to frustration about their partners’ lack of support. Couples also described substance use, wanting to be heard, and prior violence histories as triggers or as the background context for IPV episodes. Children were present during IPV and often intervened in conflicts involving severe violence. Parents’ perceptions of the effects of IPV on their children ranged from minimal to major emotional distress, with men describing more significant impact than women. When describing acute triggers, parents most commonly mentioned that arguments were instigated by concerns about the division of household labor and parenting, a finding that may have significant implications for intervention development; this was particularly notable for parents of infants. Our findings emphasize the need for innovative programs that help parents cope with the stresses of raising a family as well as programs that directly address the consequences of IPV for children.https://doi.org/10.1186/1471-2458-14-132

Early identification of anxiety disorders: The role of the pediatrician in primary care

Anxiety disorders are the most common psychiatric disorder of childhood, and are associated with high risk for development of future psychopathology. Yet, pediatric anxiety disorders continue to be under diagnosed in primary care, leaving many children untreated. Pediatricians in primary care settings are in a unique position to detect child anxiety within the context of well-child visits. While important efforts are currently under way, such as increased behavioral screening, one of the most important challenges is that pediatricians do not receive an adequate level of training in the evaluation, management, and treatment of anxiety disorders. We review recent assessment initiatives in this area and call for increased efforts to promote early detection in primary care and reduce potential barriers for pediatricians, consistent with the movement toward integrated behavioral health models. Finally, we describe a current initiative that utilizes collaboration between psychologists and pediatric faculty to train pediatric residents to detect, diagnose, counsel, and refer young children with anxiety

Pediatric Pulmonologists' Perceptions of Family Socioeconomic Status in Asthma Care

Background: Physicians' assumptions about patients' socioeconomic status (SES) have been shown to influence clinical decision making in adult patients. The goal of this study is to assess the factors associated with pediatric pulmonologists' (PPs') subjective ratings of their patients' SES, and whether these factors differ by patient race/ethnicity. Methods: Parents of children with asthma (n=171) presenting for pulmonary care reported their SES using the MacArthur Subjective SES 10-rung ladder. The PPs (n=7) also estimated each family's SES. Two-level linear regression models with random intercepts (level 1: PP's SES ratings; level 2: PPs) were used to assess the predictors of PP-estimated family SES. The analyses were then stratified by race/ethnicity. Results: Parental educational, insurance type, age, and race/ethnic background were associated with PPs' SES ratings. Black/African American families were rated lower than white families, accounting for other demographic factors (b=−0.60, p<0.01), but families of other races/ethnicities were not (b=−0.10, p=0.29). Even when comparing families with the same level of parental education, black/African American families, but not families of other backgrounds, were judged to have lower SES than white families (from 0.77 rungs lower among parents with some college, to 1.2 rungs lower among parents with high school or less; both p<0.05). Conclusions: Racial differences in PPs' ability to estimate families' subjective SES in asthma care may be a function of unconscious societal biases about race and class. Collecting subjective SES from families and PPs during the office visit could facilitate discussions about material and psychosocial needs and resources that influence treatment effectiveness

Pediatric Pulmonologists' Perceptions of Family Socioeconomic Status in Asthma Care

Background: Physicians' assumptions about patients' socioeconomic status (SES) have been shown to influence clinical decision making in adult patients. The goal of this study is to assess the factors associated with pediatric pulmonologists' (PPs') subjective ratings of their patients' SES, and whether these factors differ by patient race/ethnicity. Methods: Parents of children with asthma (n=171) presenting for pulmonary care reported their SES using the MacArthur Subjective SES 10-rung ladder. The PPs (n=7) also estimated each family's SES. Two-level linear regression models with random intercepts (level 1: PP's SES ratings; level 2: PPs) were used to assess the predictors of PP-estimated family SES. The analyses were then stratified by race/ethnicity. Results: Parental educational, insurance type, age, and race/ethnic background were associated with PPs' SES ratings. Black/African American families were rated lower than white families, accounting for other demographic factors (b=-0.60, p&lt;0.01), but families of other races/ethnicities were not (b=-0.10, p=0.29). Even when comparing families with the same level of parental education, black/African American families, but not families of other backgrounds, were judged to have lower SES than white families (from 0.77 rungs lower among parents with some college, to 1.2 rungs lower among parents with high school or less; both p&lt;0.05). Conclusions: Racial differences in PPs' ability to estimate families' subjective SES in asthma care may be a function of unconscious societal biases about race and class. Collecting subjective SES from families and PPs during the office visit could facilitate discussions about material and psychosocial needs and resources that influence treatment effectiveness

Maternal intimate partner violence exposure, child cortisol reactivity and child asthma

Psychosocial stressors like intimate partner violence (IPV) exposure are associated with increased risk of childhood asthma. Longitudinal studies have not investigated the role of hypothalamic-pituitary-adrenal (HPA) axis reactivity (and associated alterations in cortisol release) in the child IPV exposure-asthma association. We sought to investigate this association, and to assess whether this relationship differs by child HPA reactivity. This secondary analysis used longitudinal cohort data from the Family Life Project. Participants included 1,292 low-income children and mothers; maternal interview and child biomarker data, including maternal report of IPV and child asthma, and child salivary cortisol obtained with validated stress reactivity paradigms, were collected when the child was 7, 15, 24, 35, and 48 months. Using structural equation modeling, maternal IPV when the child was 7 months of age predicted subsequent reports of childhood asthma (B=0.18, p=.002). This association differed according to the child's HPA reactivity status, with IPV exposed children who were HPA reactors at 7 and 15 months of age--defined as a ≥10% increase in cortisol level twenty minutes post peak arousal during the challenge tasks and a raw increase of at least .02μg/dl--being significantly at risk for asthma (7 months: B=0.17, p=.02; 15 months: B=0.17, p=.02). Our findings provide support that children who are physiologically reactive are the most vulnerable to adverse health outcomes when faced with environmental stressors

Maternal intimate partner violence exposure, child cortisol reactivity and child asthma

Psychosocial stressors like intimate partner violence (IPV) exposure are associated with increased risk of childhood asthma. Longitudinal studies have not investigated the role of hypothalamic-pituitary-adrenal (HPA) axis reactivity (and associated alterations in cortisol release) in the child IPV exposure-asthma association. We sought to investigate this association, and to assess whether this relationship differs by child HPA reactivity. This secondary analysis used longitudinal cohort data from the Family Life Project. Participants included 1,292 low-income children and mothers; maternal interview and child biomarker data, including maternal report of IPV and child asthma, and child salivary cortisol obtained with validated stress reactivity paradigms, were collected when the child was 7, 15, 24, 35, and 48 months. Using structural equation modeling, maternal IPV when the child was 7 months of age predicted subsequent reports of childhood asthma (B=0.18, p=.002). This association differed according to the child's HPA reactivity status, with IPV exposed children who were HPA reactors at 7 and 15 months of age--defined as a ≥10% increase in cortisol level twenty minutes post peak arousal during the challenge tasks and a raw increase of at least .02μg/dl--being significantly at risk for asthma (7 months: B=0.17, p=.02; 15 months: B=0.17, p=.02). Our findings provide support that children who are physiologically reactive are the most vulnerable to adverse health outcomes when faced with environmental stressors