Publications

Poverty interferes with parents’ breastfeeding, child-care, and employment options and ability to meet their parenting goals. This study—the first randomized controlled trial of early childhood poverty reduction in the United States—investigates how increased economic resources affect 1,000 low-income US mothers’ breastfeeding, child-care, and employment practices and the ability to meet their intentions for these practices in the first year of their infant’s life. The likelihood and length of breastfeeding, use of nonparental child care, and maternal employment did not statistically differ among mothers who received a high (333) or low (20) monthly unconditional cash gift. The higher monthly cash gift, however, delayed the starting age of child care by almost 1 month and increased mothers’ ability to meet their breastfeeding intentions reported at birth.

Recently, U.S. advocates and funders have supported direct cash transfers for individuals and families as an efficient, immediate, and non-paternalistic path to poverty alleviation. Open questions remain, however, about their implementation. We address these using data from debit card transactions, customer service call-line logs, and in-depth interviews from a randomized control study of a monthly unconditional cash gift delivered via debit card to mothers of young children living near the federal poverty line. Because much of the impact of the intervention occurs through mothers’ decisions about how to allocate the Baby’s First Years (BFY) money, we argue that implementation science must recognize the role of policy targets in implementing policy, not just in terms of policy outcomes but also policy implementation processes. Further, our analysis shows that mothers experience key aspects of the cash intervention’s design as intended: they viewed the cash gift as unconditional and knew the money was reliable and would continue monthly, receiving the correct amount with few incidents. Delivering funds via debit card worked well, offering mothers flexibility in purchasing. We also illuminate how design features shaped mothers’ experiences. First, although they knew it was unconditional, the social meaning of the BFY money to mothers—seen as “the baby’s money”—shaped their engagement with and allocation of it. Second, low public visibility of mothers’ receipt of this money limited the financial demands or requests from others, potentially facilitating more agency over and a greater ability to use the money as they chose, without claims from kin.

To prevent missed cases and standardize care, health systems are beginning to implement EHR-based screens (EHR-CA-S) and clinical decision supports systems (EHR-CA-CDSS) for the identification and management of child maltreatment. This study aimed to 1) document the existing research evidence on the performance of EHR-CA-S and EHR-CA-CDSS and 2) examine clinical perspectives regarding the use of such tools and factors that affect uptake. We searched MEDLINE, Embase, EBSCO, Scopus, and CINAHL databases for English language articles published prior to November 2021 that describe and/or evaluated an EHR-CA-S and/or EHR-CA-CDSS involving 0 to 18-year olds. We performed semistructured interviews with 20 individuals who have experience in identifying, evaluating, and/or treating child maltreatment and/or conducting research on these topics. Our search identified 574 articles; 16 met inclusion criteria. Studies examined screening, alerts and triggers, and quality improvement. None evaluated long-term clinical outcomes. Sensitivity ranged from 0.14 to 1.00, specificity from 0.865 to 1.00, positive predictive value from 0.03 to 1.00 and negative predictive value from 0.55 to 1.00. A variety of EHR-CA-S and/or EHR-CA-CDSS have been implemented at institutions in our sample. Interviewees cited missed cases, policy requirements, and the lack of standardization of care as impetuses for adopting these tools, yet expressed concerns regarding insufficient evidence, bias, and time-intensiveness of implementation. Interviewees and the literature agree that current evidence does not support adoption of a particular CA-S or CA-CDSS. Further refinement and research on EHR-CA-S and EHR-CA-CDSS is necessary for these tools to be feasibly implemented and sustained, reliable for clinical practice, and not cause any unintentional harms.

Child abuse and neglect (CAN) medical experts provide specialized multidisciplinary care to children when there is concern for maltreatment. Their clinical notes contain valuable information on child- and family-level factors, clinical concerns, and service placements that may inform the needed supports for the family. We created and implemented a coding system for data abstraction from these notes. Participants were 1,397 children ages 0–17 years referred for a consultation with a CAN medical provider at an urban teaching and research hospital between March 2013 and December 2017. Coding themes were developed using an interdisciplinary team-based approach to qualitative analysis, and descriptive results are presented using a developmental-contextual framework. This study demonstrates the potential value of developing a coding system to assess characteristics and patterns from CAN medical provider notes, which could be helpful in improving quality of care and prevention and detection of child abuse.

Background: Child maltreatment leads to substantial adverse health outcomes, but little is known about acute health care utilization patterns after children are evaluated for a concern of maltreatment at a child abuse and neglect medical evaluation clinic.

Objective: To quantify the association of having a child maltreatment evaluation with subsequent acute health care utilization among children from birth to age three.

Participants and setting: Children who received a maltreatment evaluation (N = 367) at a child abuse and neglect subspecialty clinic in an academic health system in the United States and the general pediatric population (N = 21,231).

Methods: We conducted a retrospective cohort study that compared acute health care utilization over 18 months between the two samples using data from electronic health records. Outcomes were time to first emergency department (ED) visit or inpatient hospitalization, maltreatment-related ED use or inpatient hospitalization, and ED use or inpatient hospitalization for ambulatory care sensitive conditions (ACSCs). Multilevel survival analyses were performed.

Results: Children who received a maltreatment evaluation had an increased hazard for a subsequent ED visit or inpatient hospitalization (hazard ratio [HR]: 1.3, 95% confidence interval [CI]: 1.1, 1.5) and a maltreatment-related visit (HR: 4.4, 95% CI: 2.3, 8.2) relative to the general pediatric population. A maltreatment evaluation was not associated with a higher hazard of health care use for ACSCs (HR: 1.0, 95% CI: 0.7, 1.3).

Conclusion: This work can inform targeted anticipatory guidance to aid high-risk families in preventing future harm or minimizing complications from previous maltreatment.