Showing posts with label socioeconomic status. Show all posts
Showing posts with label socioeconomic status. 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” ( ). 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 (, 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, 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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Tuesday, September 15, 2015

The Great Divide: Examining Social Determinants of Health

By: Joann Schulte  DO, MPH; Editorial Board Member  
       And they lived happily ever after.  Surely you've heard that phrase ending fairy tales or rags to riches stories.  The plot is basically poor boy or girl pulls himself or herself up by the bootstraps with minimal help from anybody else. That myth has endured ever since Horatio Alger started penning his stories in the 1890s.  The reality is that most people who make themselves a success have help along the way from parents, teachers or somebody who cared and took an interest.  Of course,  children who face adversity have dreams, but often have barriers that Horatio Alger just didn't mention.
     One factor that gets short shrift in such stories is how the hero or heroine started out. Specifics such as dealing with hunger or  having to worry about apartment infestations may not be described in detail in a hard luck story, but these issues are common in reality.  Basics like food insecurity, poor housing or a stressed out single parent are among the social determinants of health (SDH) that can crush a child's dreams early on.  The toxic stress model suggests that social determinants of health often disrupt normal physiological processes, get "under a child's skin" and put a child's future and dreams at risk.
       Pediatricians often try to help individual children who go hungry or live in rat infested housing.  One patient at a time is good, but doesn't fix a community.  Recently  innovative programs called Medical - Legal Partnerships have shown some success in addressing SDH on a  broader community scale.
      Research by Lovegrove,et al. (doi:10.1542/peds.2015-2092), published this month in Pediatrics, documents some successes achieved in Ohio.  That's where the Division of General and Community Pediatrics at Cincinnati Children's Hospital Medical Centers has paired with the Legal Aid Society of greater Cincinnati.  The partnership is between pediatricians and attorneys who have experience helping those trying to overcome their poverty status..
      The pediatricians, who provide care for 15,000 children, did an anonymous survey of parents asking what unaddressed needs their children had.   The survey found that 29 % of parents reported living in poor housing with conditions such as cockroaches or mold.  One in five parents reported financial problems limiting their abilities to buy medication for themselves.  Thirty percent of children lived in household where food insecurity was a problem and 15% of families with infants had to stretch their allotted formula to last long enough to get their next allotment.
      Working together, the physicians and attorneys who comprise  the Cincinnati Child Health Law Partnership (Child HeLP) have identified and improved a cluster of substandard housing  areas where problems included pest infestations, broken windows and water leaks.  They also worked  to provide sufficient formula through donations to food banks that helped more than 1,500 families feed their infants.
       The Cincinnati program and others like it often use Maslow's hierarchy of needs   to assess common needs.   The pyramid assesses human needs, starting at a physiological base with food and shelter and progressing to self actualization (see Figure).  The programs then implement community interventions that benefit multiple children and their families with these needs.  The article by Longrove et al. provide a good overview of a process that can link clinical and community resources in programs that can intervene in economic, environmental and psychosocial areas.  That's a good way to reshuffle at least part of the deck that is often stacked against children from poor families.  A better start to the story is more likely to produce a happy ending.

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Wednesday, July 22, 2015

Home Foreclosures as an Indicator of Increased Need for Child Protective Services Involvement

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

          We are always trying to identify possible risk factors stressing parents and others living in a home with one of our patients that might increase the chance that a child might be endangered physically or emotionally by whatever the environmental stressor might be.  Yet how often do we ask about or hear about home foreclosures during health maintenance visits—and if we do, does that raise concerns for you regarding an increased risk for an abusive situation prompting possible involvement by Child Protective Services (CPS)?   
     It probably should—based on a concerning study being released this week by Berger et al. (doi: 10.1542/peds.2014-2832)  who looked at four years’ worth of foreclosure filings and then identified whether or not CPS involvement was involved in the year before, during  or after the filing.  More than 60,000 households were studied over a four period and a significant association is found between foreclosure filing and CPS involvement compared to families who did not foreclose on their homes.  The authors note that filing is only a harbinger for other financial problems in the home contributing to possible abuse and neglect but a good one when it comes to perhaps helping to provide additional services to a family in need before a child suffers.  
      Have you found similar outcomes in patients in your practice who have had to foreclose on their homes? How were you able to help these families or weren’t you?  We would welcome your comments via a response to this blog, an e-letter or by posting on our Facebook and Twitter websites.

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Monday, January 5, 2015

The Importance of Being Earnest in Making Sure You Ask About Social Determinants of Health

By: Lewis First, MD, MS; Editor-in-Chief 
Courtesy of Donnie Ray Jones@Flickr

     The more we take into account a family’s unmet social needs, the better the outcome for the child—or so we understand based on a myriad of articles published over the past few years in our journal and others. Yet if we not only screen but refer families to community resources to meet those unmet needs, does it improve the health and wellbeing of those families?  
     Gang et al. (doi: 10.1542/peds.2014-2888) elected to address this question through a cluster randomized controlled trial involving eight urban community health centers where four centers asked mothers to complete a self-report of unmet family needs and then made referrals to assist in those needs—and four provided routine care.       
     The results are dramatic and well worth your attention in what happened to those families receiving the intervention. Do you ask about social determinants of health in your patients or better yet—make referrals to community agencies and resources once those determinants have been identified?   
     To help further stress the import of what this study suggests, Dr. Robert (Bob) Block, former AAP President and now newly named director of the AAP’s  Center on Child Health and Resilience provides an accompanying commentary (10.1542/peds.2014-3656) that further highlights the need to screen for social needs of families, make referrals and in turn increase the opportunities for strengthening resiliency in these families and most importantly their children. Read both the article and the commentary and if you are not screening for social determinants of health in your patients, you will hopefully do so as a result of what you learn.

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