Friday, May 30, 2008

This study might be a bit peripheral, but touches on why education in the hospital is important: parents and child may not get to the doctor's office.

Uninsured kids in middle class have same unmet needs as poor

Nationwide, uninsured children in families earning between $38,000 and $77,000 a year are just as likely to go without any health care as uninsured children in poorer families. More than 40 percent of children in those income brackets who are uninsured all year see no physicians and have no prescriptions all year, according to new research from the University of Rochester Medical Center.

“There’s an assumption that children in families with higher income levels don’t need insurance, that they are uninsured but are somehow still receiving health care anyway,” said Laura Shone, an assistant professor of pediatrics at the University of Rochester Medical Center and author of the study.

“This study shows that in reality, a large percentage of these children don’t receive any care at all – which pediatricians say is unacceptable, and parents know is unrealistic. Even healthy, older children need to see their physicians at least once over the course of a year.”

Overall, almost 3 million uninsured children had no medical care and no prescription use for a full year, according to an analysis of nationally representative data from the 2004 Medical Expenditure Panel Survey.

The percentage of uninsured children who forego all health care for a full year is:
55 percent at 0 to 100 percent of the federal poverty level ($0 to $19,157 for a family of four)
51 percent at 101 to 200 percent of the federal poverty level ($19,158 to $38,314)
42 percent at 201 to 300 percent of the federal poverty level ($38,315 to $57,471)
44 percent at 301 to 400 percent of the federal poverty level ($57,472 to $76,628)
30 percent for those over 400 percent of the federal poverty level ($78,629 and above)

Saturday, May 24, 2008

There have been four or five shaking cases (at least that I've read about) where a person who shook a child was reported to have seen an educational video in the hospital.

In response to a question about a recent case in Albany (where it is unknown whether the father had seen the video), I had some thoughts on video education programs...

- first, it's important to recognize that the law in New York and other states usually doesn't require that parents watch the video: it requires that hospitals offer all new parents the opportunity to do so.

The effectiveness of the program is a function of several things, including whether the hospital sets up an effective and efficient way to make that opportunity available, how it is managed by the staff, and how the educational opportunity is presented to the parents.

"Do you want to watch a video about shaken baby syndrome?" is a very different question than "We'd like to show you a video that will help you learn how you can help keep your child safe from shaking injuries. Is that OK?"

As I recall, the stats last year indicated that the "watch" rate varies in the hospitals supported by the regional program here varies between 45% to 75%.

Some of the hospitals close to the NYC metro area have problems because they rely on a signfiant number of per diem nurses to provide care, and those nurses don't necessarily get training on the program.

That's still better than the participation was at Albany Medical Center a couple of years ago, when I was told that about 25% of the parents watched the video. They were not involved with either of the regional prevention support programs and I was told by one parent that the nurses basically asked the first question: "do you want to watch a video about SBS?"

On the other hand, when I was at a baby safety fair in the Albany area a couple of years ago, I informally sampled parents with infants and it seemed that St. Peter's Hospital was doing the best job of the 5 maternity hospitals in the Albany area.

- second, while all of the hospitals make an effort to show the video to both parents, I believe they usually manage to get only about 60% of the fathers.

- third, and in some respects most critically, there are individuals who see the video and either don't get the information or don't acknowledge and act upon it.

I don't think there are any simple explanations that fits all cases.

For many fathers, the birth experience is not only the opening of a door into a strange, new world with new and enormous responsibilities, but it is a time of disruption, confusion and chaos. It's frequently the beginning of a long period of intermittent exhaustion, coupled with anxiety and apprehension.

In those circumstances, even when the father is present, getting him to stop, participate and focus on the video, and not just to watch it, but to understand and apply it to themselves, is a challenge. I suspect the an appeal to fathers to learn how "you can protect your baby" theme is most likely to be effective, but this is an area that requires some real psychologically based outcomes research.

- Fourth, some of those fathers (and the relatively few articles reporting on a shaking event by a parent who has seen the video all involved males) are going to watch that video and refuse to accept that it has any lessons which apply to them.

In particular, I think individuals with control issues are not disposed to learn the lessons being offered.

Video education is, I think, a very effective way to prevent shaking from ignorance - and while it didn't assess specific knowledge about the danger of shaking, the recent study which found 1/3 of parents are ignorant about important aspects of child development suggests there is significant ignorance about the nature of that danger too - and probably works to prevent many instances where parents are generally indifferent to the welfare of their child.

I think one thing that is needed is education for mothers that models ways to effectively engage their spouse in the routines of child care and child safety, especially in contexts where domestic violence is a concern.

One reason that education in the hospital is important is that research suggests education following birth takes advantage of a "teachable moment" - at least for mothers - when parents are usually receptive to education about how their behavior can affect children. It has been shown to increased the effectiveness of smoking prevention programs targeted at mothers.

In the Buffalo study area, there has been a sustained reduction in inflicted head injuries of 50%.

I believe that while some parents are involved in the cases that are still happening, the precentage is lower than the nationally reported statistics and many of those parents didn't actually see the video (I suspect partially because of the reasons noted above, and partially because some parents didn't want to watch a video about "child abuse" - another area where research needs to replace speculation).

Considering that a typical prevention program is touted as a success when there is a 10%-15% change in the targeted behavior, this is extraordinary success (as recognized by the Joint Commission on Accreditation of Healthcare Organizations).

That said, we all recognize that it won't be successful enough until there is a 100% change.

Sunday, May 18, 2008

The Washington Post has an interesting story on how one doctor has started a breast cancer education and prevention program for Latino immigrants.

The doctor is Elmer Huerta, who happens to be the current president of the American Cancer Society. The program is the Cancer Preventorium, a one-of-a-kind clinic that is part of the cancer institute at Washington Hospital Center. It is aimed at drawing in low-income Latino women, not for treatment but for prevention.

He's done some excellent outreach to the Hispanic community that should be a model for SBS education:

Huerta, the president this year of the American Cancer Society, used to be an oncologist in his native Peru. But he changed his focus in the late 1980s after seeing women with cancerous tumors bulging out of their breasts. "They didn't know anything about health," he said, "because they were ashamed to show anyone what was wrong and because they thought the absence of pain is the absence of anything wrong."

Many of these patients, however, knew the latest celebrity gossip, the subplots of every TV soap opera and the scores of every big soccer match. If radio and television were that powerful, Huerta recalls thinking, "would it be possible to sell health to the public through the media?"

In 1986, he began producing and then starring in a health education TV show in Lima; he discontinued the show in 1987 when he moved to the United States to complete a fellowship at the Johns Hopkins Oncology Center. He began a medical residency program in Baltimore and started recording five-minute health-care spots on a Spanish-language radio station in Laurel. In 1994, the same year the Cancer Preventorium opened, Huerta created a live weekly television program on health promotion and disease prevention.

Today, Huerta's radio spots, called "Cuidando Su Salud" ("Taking Care of Your Health"), air daily on more than 120 stations in the United States and more than 350 in Latin America. His television program, "Hablemos de Salud" ("Let's Talk About Health"), is distributed nationally.

Three months ago, Huerta's local call-in program expanded to two hours after being syndicated nationally. Now called "Cita Con el Doctor" ("Appointment With the Doctor"), it reaches Latinos in 14 states five days a week.

Framing "SBS" for Understanding and Action

A recent post on one of the SBS Listservs noted a blog post by a BMW owner that described an exhaust system problem as "shaken baby syndrome" and observed that the use of the term is finding its way into common speech.

In response, I offered two thoughts about why that's not necessarily good:

- as with many other technical phrases that find their way into common speech, being familiar with the phrase isn't necessarily understanding the phenomena.

When I do a Google blog search, it frequently finds SBS used as a modifier or adverb to connote an excessive, agitated or frantic level of an ordinary activity, such as "she danced so hard I thought she would get shaken baby syndrome" or "the ride was so bumpy I thought my baby would get shaken baby symdrome."

In some respects, that's cause for concern because (1) when the term is used in common parlance, it tends to have a trivializing/desensitizing effect and (2) it reflects an inacurate understanding of the actual physical process.

A related issue: awareness of the term "SBS" doesn't mean understanding, and it doesn't necessarily translate into prevention action. Prevent Child Abuse American wrote some important policy memos a few years back lamenting that the increased awareness of child abuse hasn't translated into increased prevention efforts and emphasizing the need to reframe prevention.

Awareness of the term is necessary, but it's not sufficient for prevention.

And that's especially apparent when the media focuses on reporting the crime, not what could have been done to prevent it.

Watching news reports will make parents aware of SBS, but the psychological process they use to "make sure" it won't happen to their child is to focus on the distinctions between "those people" and "us".

That's what makes child care cases especially unnerving for folks who have kids in child care: they want to know what was wrong with that child care provider and how he/she was able to fool the parents.

The work that Prevent Child Abuse America has done on "reframing" abuse is essential reading in order to develop persisting and effective prevention measures.

- second thought is just that the use of this term as part of common speech is still fairly unusual. Blog searches bring us the hits, but they don't tell us how common the term is.


By the way, the term "frenetic" seems like it was made to apply to the actions that lead to SBS
Definitions of frenetic on the Web:

frantic: excessively agitated; transported with rage or other violent emotion; "frantic with anger and frustration"; "frenetic screams followed ...

Saturday, May 10, 2008

Not that we need more reasons to prevent inflicted head injuries, but here's another one anyway

APA Annual Meeting 2008: Consequences of abuse, neglect, and trauma on the development of mental health disorders and the implications for prevention, diagnosis, and treatment.

"Stress early in life is related to persistent sensitization of the pituitary-adrenal and autonomic stress response. Sensitization of the stress response is likely related to an increased risk for adulthood psychopathology.
And MIT Technology Review also reports that the general state of TBI research isn't much better:

Yet much about brain injuries remains unknown. Despite decades of research, no treatments yet target the underlying pathophysio­logical cause of progressive brain damage. For patients so severely injured that they are in a minimally conscious state, medical knowledge is particularly lacking; in such cases, we are just beginning to understand the damage and the possibility of treatment (see "Raising Consciousness").
* * *
Finding treatments for those injuries that do occur will depend on better understanding the complex cellular events triggered by a brain injury. In TBI, a rapid mechanical deformation of the brain both physically disrupts and mechanically stimulates cells. Some cell damage is immediate, but most of the damage develops over days, weeks, and even months. The delayed and progressive nature of the neurodegenerative cascade represents a critical therapeutic opportunity: targeted intervention could halt the progression of cell damage and death. However, no therapeutic strategies yet exist that target the degeneration mechanisms.

Friday, May 09, 2008

MIT's Technology Review looks at military TBI.

Here's a telling comment:

"With IEDs, the insurgents have by dumb luck developed a weapon system that targets our medical weakness: treating brain injury," says Kevin "Kit" Parker, a U.S. Army Reserve captain and assistant professor of biomedical engineering at Harvard University who served in southern Afghanistan in 2002.

The article goes on to conclude:

Military doctors are only beginning to get a grasp on the number of soldiers who have suffered mild traumatic brain injury, the medical term for a concussion. Mild injuries are by far the most common type of brain trauma, but they are more easily missed than moderate and severe injuries (they typically don't show up on standard brain scans), and the lasting effects, especially of repeated concussions, are not yet clear. Surveys of troops to be redeployed in Iraq suggest that 20 to 40 percent still had symptoms of past concussions, including headaches, sleep problems, depression, and memory difficulties. "We don't know what it means in terms of long-term functional ability," says William Perry, past president of the National Academy of Neuropsychology.

In young children, the brain possesses great plasticity and can recover from enormous insults. Recovery will be much harder for these folks. Hopefully, much of what we belatedly learn about the mechanism of injury and the nature of mild TBI wil not only help advance their rehabilitation from those injuries, but transfer to children who were victims of inflicted head injuries.

Thursday, May 08, 2008

An interesting post from 2007 on Mindhacks discusses All in the Mind, an Australian TV program that looks at how neuroscientists are uncovering the neurobiological changes that take place during parental care, and how the brain can be markedly altered by abuse or neglect during the early years.

And there's a transcript

Thursday, May 01, 2008

Unfortunately, this case from Schuykill County PA seems like a "classic" case of SBS...,0,2300567.story
'Frustrated' father shook crying baby, police say
Schuylkill tot is 'critical'; Kyle Bluge faces assault charges.
By Chris Parker

Of The Morning Call

May 1, 2008

A 22-year-old Schuylkill County man who complained of being frustrated with his children was in county prison Wednesday, accused of shaking his 6-week-old son so hard the baby was hospitalized in critical condition with severe head trauma, police said.

Kyle J. Bluge of 512 E. Railroad Ave., New Ringgold, shook the baby between 12:55 a.m. and 1:05 a.m. Friday, state police at Frackville said. The baby was taken to Geisinger Medical Center in Danville, Montour County.

Bluge was arraigned before District Judge James Ferrier, Orwigsburg, on charges of aggravated and simple assault, endangering the welfare of children, reckless endangerment and harassment and jailed under $15,000 bail.

An affidavit of probable cause that state Trooper Collette M. Smith of Frackville filed with Ferrier gives this account:

The county Children and Youth Services agency notified police April 25 that the baby was in the hospital. About 1:30 a.m. that day, emergency medical crews arrived at the home Bluge shared with the infant, another child, his girlfriend and her father.

Bluge had called the ambulance, saying the infant was ''having trouble breathing because a toy was dropped on his abdomen,'' the affidavit says.

The baby was taken to Pottsville Hospital, then transferred to Geisinger. Smith was told the infant had severe head trauma, bleeding into his brain and retinal damage, all of which are common with shaken baby syndrome.

Bluge told police he had put the infant on the floor next to his crib while he went across the room to get diapers and wipes. He said he heard a ''bang'' and the infant began crying. Bluge told Smith he turned and saw a toy truck, apparently tossed by another child, near the baby's head and thought it had hit him in the abdomen, according to the affidavit.

Bluge later told Smith he had been trying to feed the infant, who was fussy. The baby cried and wouldn't take the bottle, he said. The baby was screaming and Bluge said he shook the bottle in the infant's mouth, causing his head to shake back and forth.

Bluge admitted having done that before, ''but never that severely,'' the affidavit says. Smith said he called 911.

The baby's mother, Jennifer Lynn Swope, told police Bluge sent her a text message at the fast-food restaurant where she works, saying he was ''frustrated with the kids'' and that the baby ''would not stop crying,'' according to Smith's affidavit.

Bluge told Swope he ''might have hurt'' the baby while trying to feed him.

Swope told police she had been concerned about leaving the children with Bluge. She said she was at work until about 1 a.m., and when she arrived home, her father told her the baby was hurt and the ambulance was on the way, according to the affidavit.

Swope said she held the infant, and ''saw that he could not open his eyes, he wasn't moving a whole lot and that he was having a hard time breathing,'' the affidavit says.

Police interviewed Bluge again April 28 at the Ronald McDonald House at Geisinger.

Bluge changed his story, admitting he had ''feelings building up from many things, money issues, living with Swope's father, the babies and the start of his new job being delayed,'' the affidavit says.

He said the children were crying and ''his feelings of everything seemed to explode in the wrong way,'' and he shook the baby's head roughly. The baby's head ''bounced off his arm hard on both sides and bounced up and down,'' Bluge said.

''After he realized what he did wrong he called 911,'' the affidavit says.

Police interviewed Swope later that day. She told them Bluge admitted he ''got frustrated and shook a bottle'' in the baby's mouth.

On April 28, pediatric optometrist Dr. Thomas Wilson of Geisinger told police the baby had retinal bleeding and other injuries that indicated he had been shaken. Attending physician Dr. Paul Bellino concurred.

Police then arrested Bluge.

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