Showing posts with label development. Show all posts
Showing posts with label development. Show all posts

Monday, October 12, 2015

An Ugly Reality: A Study of Developmental Behavior Of Children Born From Sexual Violence


By: Lydia Furman, MD,  Assistant Editor

      In a recently released study in Pediatrics, Dr. Rouhani et al. (doi: 10.1542/peds.2014-3373) presented us with a must read article about the burdens and experiences of women who are raising children conceived through sexual violence in the Democratic Republic of Congo (DRC) (ref here).  My first thought on reading this incredible article was that one does not need to go to the Democratic Republic of Congo (DRC) to meet women who are raising children conceived through sexual violence. Their conclusions are logical and intuitive, yet ground breaking, and I believe I can apply their “lessons” in my own practice. These authors interviewed over 700 women who are raising a child conceived through sexual assault. They used a specific method of locating hard-to-reach populations, called respondent driven sampling, in which ten initial identified women each recruited three other women, who then recruited three other women, and so on until the full population was identified.
      Please read the article to immerse yourself in the study, because likely you will find other parts of the work more meaningful than what captured me. What impressed me most was the extraordinary resilience of the women and of the maternal-child relationship.  Over one third of women reported that their community stigmatized their child, and over one third reported that their community stigmatized them personally. “Perceived acceptance of the child” by spouse, community and family seemed surprisingly low to me, given that the entire community was exposed to known, ongoing and multiple sexual assaults. Yet, despite all of this, 80.5% of women had “positive regard” (questions drawn from the Parental Stress Scale) for their child and 73.0% had “high attunement” (defined as “…awareness of, sensitivity to, and responsiveness to the child’s needs…”). So in the face of incomprehensible stress and challenge, including seeing their assailant and recalling the assault when looking at their child, the great majority of women are raising their children with engagement and kindness, as best one can understand. The authors’ multivariate analysis examines this question quantitatively and expands understanding further.
      While the upheaval in The DRC is notorious for the horror of widespread sexual violence, utilized as a weapon of war, the problems that women must face in raising a child who is the product of a rape respect no geographic boundaries. An issue that clinicians practicing in the US may have to recognize among women raising a child conceived through sexual violence is the complex racism of skin tone, which rears its ugly head when mother and child have obviously different skin colors or eye colors, prompting family or non-family members to ask about paternity. In the United States (US) it may be more possible for women to avoid stigma by non-acknowledgement of the sexual violence (e.g. by asking for non-inclusion of the information in the child’s medical record), but this does not permit future providers to treat the mother optimally (since she may have depression, anxiety, or other sequelae that are then not recognized), and this also makes support of any discussion she may want or need to have about conceiving in the setting of sexual violence   almost impossible.
       While Dr. Rouhani and colleagues studied a population in whom approximately 40% of women experienced sexual violence, it is sobering to realize that the Centers for Disease Control and Prevention (CDC) reports that “nearly one in five (18.3%) of women (in the US) … reported experiencing rape at some time in their lives” (http://www.cdc.gov/ViolencePrevention/pdf/SV-DataSheet-a.pdf ). While a continent and world away for some, this is a reality we cannot ignore. Ultimately prevention is the best cure, but in the meantime, removing stigma is critical.  Work is underway to support de-stigmatization of sexual violence in the DRC, for example through the Harvard Humanitarian Initiative (http://hhi.harvard.edu/sites/default/files/publications/women-in-war-stigmatization.pdf), and a brief search reveals relatively limited initiatives in the US, most primarily focused on domestic violence (for example, Triumph, a network for survivors of domestic violence, http://www.seethetriumph.org/). We have work to do, and the superb research of Dr. Rouhani and colleagues in the DRC is a wakeup call to all of us.

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Monday, August 17, 2015

Getting the Right Beat: How Do Children with Congenital Heart Disease Do in School?

By: Joann Schulte  DO, MPH; Editorial Board Member   

         You want to get to the heart of the matter when a neonate has a  murmur or cyanosis.   About 1% of US infants are born with congenital heart disease (CHD) and their lives after discharge can be complicated with follow-up care.  But what happens when such children start school?  How do they  compare to other children?
            A new study published this month in Pediatrics from Riehle-Colarusso et al. (doi: 10.1542/peds.2015-0259) explores that issue with an innovative linkage of three databases to provide a picture about how such children do when school starts.  (This last sentence is the punch line and you state it below—so would not state it here.)
            The authors, epidemiologists from the Centers for Diseases Control and a cardiologist from Emory University, used data from Georgia birth certificates, the Atlanta Congenital Defects Program (population-based surveillance of birth defects) and the Special Education Database of Metropolitan Atlanta to study 3,744 children with CHD.  They tracked a cohort of children born during a 22-year period (1982 to 2004) and compared them to a group of children without major birth defects.
            Only children with isolated CHD, not including children whose conditions was complicated by other genetic diseases or birth defects were included in the study..  The comparison group of 860,715 children was identified through Georgia birth certificates. 
            The authors followed the entire group of 864,459 children to determine if they required special education between 1992 and 2012, using the database that tracked receipt of such services.  The special education database covers nine public school districts in the five counties that make up the metro Atlanta area.  
            The results of this study indicate that 15% of the children with CHD had received special education service compared to 9% of those without birth defects. Compared to the children without birth defects, those with CHD had a higher prevalence of intellectual disability, sensory impairment, and significant developmental delay among other neurodevelopmental impairments..
              This study has implications for what kind of care and follow-up attention might be needed for children with CHD.   Since 2011, screening for congenital heart disease has been recommended through pulse oximetry screening after 24 hours of age and before discharge.  This study suggests that pediatricians taking care of children with congenital heart disease might do well to track the developmental progress of those children.  Early identification of children with special education needs can help their success in school.  Examining twenty-two years’ worth of data for a group of Atlanta children with and without CHD provides important information on neurodevelopmental outcomes that can benefit the entire pediatric population with congenital heart disease..

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Wednesday, August 12, 2015

Are There Differences in School Readiness for Late Preterm Infants Compared to Term? New Study Says Yes!


By: Lewis First, MD, MS; Editor-in-Chief       

          How often do parents ask us if their child is ready to start kindergarten despite their meeting the age requirement?  This is especially common for parents of children born been born preterm—but what about late preterm infants 34 to 36 weeks gestation?
Woythaler et al. (doi: 10.1542/peds.2014-4043) opted to look at neurodevelopmental outcomes using a longitudinal cohort population of 950 late preterm babies, comparing them to more than 4900 term infants to see if their 24-month developmental assessment correlated with their “school readiness score” using a valid assessment tool once the subjects were age-appropriate for kindergarten.     
 The good news is that just because a late preterm infant has delayed neurodevelopment at 24 months does not mean he or she won’t be improved neurodevelopmentally by the time they are ready to enter kindergarten.  If a late preterm is developmentally on target at 20 months, the prognosis is good for moving into kindergarten when age-appropriate.  
 Have you noticed the same findings in your own patients? Do you note any developmental differences in your late preterm patients as they get older?  Share your thoughts and experience with us by responding to this blog, sending an e-letter or posting on our Facebook or Twitter sites.

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Monday, August 10, 2015

Tracking Cognitive Function of Very Preterm and Very Low Birth Weight Infants into Adulthood

By: Lewis First, MD, MS; Editor-in-Chief       

The ability to follow a cohort of high-risk infants from birth into adulthood is becoming more and more commonplace nowadays. What we are learning about the life trajectories of preterm or low birth weight infants from these cohorts is fascinating, and this important new knowledge may help us to do more to improve long-term quality of life.  
Take for example the study by Breeman et al. (doi: 10.1542/peds.2015-0608) that we are publishing this week. The authors look at how cognitive function in very preterm (VP) and very low birth weight (VLBW) infants progresses over time compared to term infants.  The authors followed more than 250 VP/VLBW babies in a cohort over their first 25 years of life assessing development and IQ at multiple points over that period of time.  The results show that cognitive function is generally stable after 20 months for the VP/VLBW children and predictive of adult IQ whereas the cognitive function of term infants is not predictive of adult IQ until at least 6 years of age.  
The implications of this study suggest that we should do an even better job of assessing our VP/VLBW patients in  infancy and early toddlerhood so that developmental support services, if needed, can be implemented as early as possible with the hope of improving cognitive function.  As to why the differences between VP/VLBW cognitive stability and that of term infants, you will need to read this study and see how the authors develop their interpretation of the data—and there is lots more to learn from this important study.  It provides a remarkable look at the longitudinal follow-up of this unique, yet more and more common cohort of at-risk preterm and low birth weight patients.


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