Continuous source of care among young underserved children: associated characteristics and use of recommended parenting practices.

OBJECTIVES: The aim of this study was to 1) assess sociodemographic and health characteristics associated with having a continuous source of care (CSOC) among young children and 2) determine the relationship between having a CSOC and use of parenting practices. METHODS: We conducted a prospective, community-based survey of women receiving prenatal care at Philadelphia community health centers. We conducted surveys at the first prenatal visit and at a mean age +/- standard deviation of 3 +/-1, 11 +/- 1, and 24 +/- 2 months postpartum, obtaining information on sociodemographic and health characteristics, child's health care provider, and 6 parenting practices. Group differences were tested between those with and without a CSOC by using the chi-square test for categorical variables and the Student's t test for continuous variables. Logistic regression analysis was conducted to adjust for potential confounding variables. RESULTS: Our sample consisted of 894 mostly young, African American, single women and their children. In the adjusted analysis, mothers of children with a CSOC, when compared with those without a CSOC, were more likely to have a high school education or less, be born in the United States, have a postpartum checkup, have stable child health insurance, and initiate care for their child at a site other than a community-based health center. Use of parenting practices was similar for children with and without a CSOC. CONCLUSIONS: Maternal nativity, postpartum care, child health insurance, and initial site of infant care were associated with CSOC, but infant health characteristics were not. Use of parenting practices did not differ for those with and without a CSOC.     

Understanding babies from the standpoint of experience

Abstract

This paper raises questions about the use of psychoanalysis as a frame of meaning in infant observation. It is part of an ongoing dialogue with Michael Rustin and others about the meanings and justifications of infant observational research. The author begins with his experience as a teacher of infant observation together with some introductory comments on his approach to understanding. He elaborates on the experience of understanding by comparing the use of infant observation in teaching and research.     

Transitions from care to adulthood: messages to inform practice

Transition is the process of moving from a child focussed system to an adult orientated system. It is complicated for all children and a well-recognised point of weakness in health care. For looked after children transition is more complex with movements from social worker to personal advisor, from foster care (or children's home) to independent accommodation, from school to work, further or higher education or to none of these. It is also a time when the young person moves from children's health services to adult health services. Looked after children navigate these transition points with less support than many other children. Coincidentally, it occurs at an age when mental illness most commonly emerges. This paper describes the transitions in detail, considers the legislative framework, pathway plans and the mental health transition.     

Patient- and family-centered care of children in the emergency department

Patient- and family-centered care is an innovative approach to the planning, delivery, and evaluation of health care that is grounded in a mutually beneficial partnership among patients, families, and health care professionals. Providing patient- and family-centered care to children in the emergency department setting presents many opportunities and challenges. This technical report draws on previously published policy statements and reports, reviews the current literature, and describes the present state of practice and research regarding patient- and family-centered care for children in the emergency department setting as well as some of the complexities of providing such care. This technical report has been endorsed by the Academic Pediatric Association (formerly the Ambulatory Pediatric Association), the American College of Osteopathic Emergency Physicians, the National Association of Emergency Medical Technicians, the Institute for Family-Centered Care, and the American College of Emergency Physicians. This report is also supported by the Emergency Nurses Association.     

Bearing a beautiful daughter: conflicting identifications for a new mother and for the observer

Abstract

This paper describes a particular aspect of an infant observation which highlights Meltzer's theory of the aesthetic conflict and his ideas concerning the overwhelming nature of the aesthetic impact, not only for the mother in her identification with her infant, but also for the observer in witnessing the ‘beauty of mother and her daughter's world’. The paper gives a detailed account of an infant observation in which the more ordinary and imaginative relationship between mother and her infant daughter was fleetingly interrupted by absences in the mother's ongoing attentive link with her infant. These moments are explored through the observer's experience of being disorientated and disappointed. The role of the observer and seminar group is considered as facilitating an essential containing function for the split off and projected aspects of the mother and shows an increasing capacity to manage her envy and jealousy through the course of the observation.     

Toddlers’ relationships to peers in the processes of separation: from the discussion of observational accounts to the development of theory

In most books and papers about the separation process of infants and young children, the focus is on the relationship between parents and children. In this Viennese research about toddlers’ transitions from home care to day care, the impact of relational experiences became increasingly evident in the way young children experience, and work through, separation. Against that background observational material is used to describe interactions between observed children and caregivers as well as interactions between the children and their peers. The paper also discusses ways in which peer relationships were helpful or not for toddlers struggling with primitive anxieties and other strong feelings. The paper goes on to consider young child observation used as a single-case research tool in order to develop a more general theory. It takes into account endeavours to develop a theory already undertaken by Esther Bick and in many subsequent publications where observational material is discussed. Methodological investigations of this issue, however, are rare. The authors argue that the acceptability of using the Tavistock Observation Model as a research tool is supported by discussing its methodology.     

Health of Australian children in out-of-home care: needs and carer recognition

Aim: Following research highlighting high levels of health need in New South Wales children in out‐of‐home care, this study aimed to quantify health need in a sample of Queensland children in care based on multidisciplinary child health assessments. The study also sought to examine the concordance between foster carers' health concerns for children for whom they are providing care and health need as established through referrals made as a result of health assessment. Methods: Children entering out‐of‐home care in the north Brisbane area within the previous month were referred for baseline child health assessment. Child health was assessed by paediatricians and clinical nurses utilising a pro forma‐based methodology. Analysis of initial carer concerns, health referrals and immunisation status in the sample was undertaken. Results: Of the 63 children assessed, 70% were found to require multiple referrals to various health services. The most frequently made referrals included paediatrician follow‐up (41% of children), counselling services (30%) and audiology (26%). Only 68% of the sample was found to be fully immunised. A discrepancy was noted between foster carers' child health concerns and level of referral need established during assessment. Conclusions: Queensland children in care have high health needs similar to those evidenced by children in care in other areas of Australia. Foster carers appear to underestimate the health needs of children in their care, demonstrating the necessity of multidisciplinary health screens and foster carer training in order to detect child health problems in this population.     

Translating observation into practice: how has infant observation helped a primary care mental health worker understand families’ experiences of loss?

Abstract

This paper explores how psychoanalytic infant observation helped a primary care mental worker (PCMHW) work with two children and their parents, who presented with anxiety related to loss. Three areas of focus are identified from the infant observation as being useful for understanding loss, which include early defence mechanisms, parental experiences of loss, and containment. These three areas are then explored in relation to clinical work with a 5-year-old boy and a 10-year-old boy. When discussing each area of focus, the paper draws upon vignettes from infant observation to illustrate how the observation informed the PCMHW's practice. The paper concludes that a psychoanalytic infant observation is useful for a PCMHW who offers brief work to children and their parents who are experiencing anxiety related to loss.     

Maternal relationship style, paediatric health care use and infant health

OBJECTIVE:

The aim of the current exploratory study was to examine the relationships between maternal relationship style, paediatric health care use and infant health variables in a sample of middle-class and ethnically diverse mother-infant dyads.

METHODS:

An initial cross-sectional cohort study obtained demographic and self-report data on mothers’ relationship styles. As an extension of the original study, infants’ patient files were reviewed for the year following initial recruitment to obtain data regarding the use of paediatric health care services and infant health. The final sample included 64 mothers and their infants.

RESULTS:

Correlational analyses revealed that mothers’ higher endorsement of a dismissive relationship style were associated with fewer acute care visits and fewer reported infant illnesses.

CONCLUSIONS:

Compared with other relationship styles, mothers who highly endorsed a dismissive relationship style tended to use fewer acute paediatric health care services and reported fewer infant health problems. However, further longitudinal research is needed to clarify these relationships.     

The predictors of unsuccessful transition to foster care

The placement movements of 235 children entering foster care over a 12-month period were followed up 4 months after referral into care. Baseline and follow-up measures of the 170 children who were still in care at follow-up were also compared. Results indicated that adolescents with mental health or behavioural problems were the least likely to achieve placement stability or to display improved psychological adjustment in care. In fact, unsatisfactory transition to foster care was found to be so prevalent among these children that conventional foster family care should be considered unsuitable for them. The paper concludes that there is an urgent need for a wider range of alternative care options for the adolescent population.     

Care mapping: A common sense approach

Because of trends in the health care environment, hospitals are searching for ways to continuously improve the quality of care and to decrease the costs of care. One approach that is gaining widespread recognition throughout the United States is the use of case management and practice guidelines such as critical paths, CareMaps, and in the neonatal field, NeoMaps. The NeoMap is a clinical tool which delineates practice guidelines for each discipline that provide care to a specific infant population. It reduces variation in clinical process and thereby has been shown to improve the quality of infant care. When practice guidelines are linked to both health and economic outcomes, they have significant impact on health care costs. In this paper, case management and the development of the NeoMap will be described in relation to the Intensive Care Nursery (ICN) at Pennsylvania Hospital.     

Making space for a fourth,unplanned child with the help of the observer's holding and receptive capacity

Creating a space for more than one child is a challenge for the mother that already has other children at a pre-school age. The present case study was carried out based on a research application of the Bick method of infant observation. The baby and his family were observed weekly, for 12 months. He belonged to a family, consisting of a mother, a father and their four boys, a baby and three siblings aged two, three, and four years old. The mother gradually created a space for welcoming the observer as well as the baby. The observer′s countertransference reactions were essential and the receptiveness of the observer enabled the mother to use her for expressing her feelings albeit silently.     

Children in out‐of‐home care: Does routine health screening improve outcomes?

Aim:   Children in out-of-home care have high and frequently unidentified health needs. The Child Protection Unit at Sydney Children's Hospital offers comprehensive health screening to children in care. Recommendations for remediation are made, but follow-up in the clinic is not offered. Current research has failed to establish whether health screening results in health benefits for the children screened. The aim of this study was to assess the impact of the health screening clinic on children's health outcomes by tracking the first 100 children screened, determining how many of the health recommendations made for each child had been implemented and, if possible, what the health outcome had been.
Methods:   Research questionnaires were sent to the Department of Social Services caseworkers of the first 100 children screened.
Results:   Adherence to health recommendations was high; however, it was not possible to quantify the degree of health benefit to the children screened. A number of systemic problems were identified, which are likely to hinder the accessibility of health care for children in care.
Conclusions:   Comprehensive health screening of children in care is likely to benefit a child's health, although this could not be determined. Agencies responsible for placing children in care need systems in place to ensure better inter-agency collaboration between the health system and community services. This should help improve health outcomes.     

A focused ethnographic assessment of Middle Eastern mothers' infant feeding practices in Canada

The aim of this study was to examine the barriers to following complementary feeding guidelines among Middle Eastern mothers and the cultural considerations of practitioners from an emic perspective. This is a two‐phase focused ethnographic assessment of infant feeding among 22 Middle Eastern mothers in Western Canada who had healthy infants aged <1 year. Data were collected through four focus groups conducted in Arabic/Farsi, and were further complemented by comprehensive survey data collected in the second phase of study. Mothers' main criterion for choosing infant foods was whether or not foods were Halal, while food allergens were not causes for concern. Vitamin D supplements were not fed to 18/22 of infants, and mashed dates (Halawi), rice pudding (Muhallabia/Ferni) and sugared water/tea were the first complementary foods commonly consumed. Through constant comparison of qualitative data, three layers of influence emerged, which described mothers' process of infant feeding: socio‐cultural, health care system and personal factors. Culture was an umbrella theme influencing all aspects of infant feeding decisions. Mothers cited health care professionals' lack of cultural considerations and lack of relevance and practicality of infant feeding guidelines as the main reasons for ignoring infant feeding recommendations. Early introduction of pre‐lacteal feeds and inappropriate types of foods fed to infants among immigrant/refugee Middle Eastern mothers in Canada is cause of concern. Involving trained language interpreters in health teams and educating health care staff on cultural competency may potentially increase maternal trust in the health care system and eventually lead to increased awareness of and adherence to best practices with infant feeding recommendations.     

Annotation: Pathways to care for children with mental health problems

BACKGROUND: Although many children with mental health problems are in contact with primary health care services, few receive appropriate help. METHODS: Using a pathways to care model, this paper systematically reviews the literature relating to access to services. It separates out the various stages of help-seeking: parental perception of problems, use of primary care services, recognition within primary care, and referral to or use of specialist health services. RESULTS: Following parental awareness of child symptoms, parental perception of problems is the key initial step in the help-seeking process. Although children with mental health problems or disorders are regular attenders within primary care and most parents acknowledge that it is appropriate to discuss concerns about psychosocial issues in this setting, few children are presented with mental health symptoms even if their parents have such concerns. Subsequently, less than half of children with disorders are recognised in primary care. Amongst recognised children, about half are referred to specialist services. Overall, up to one-third of children with disorders receive services for mental health problems. Factors such as the type and severity of disorder, parental perceptions, child age and gender, and family and social background factors determine which affected children access services. CONCLUSIONS: As there are inequities in patterns of service use, a greater emphasis on developing resources at population and primary care levels is required. Barriers involving parental perceptions and expression of concerns within consultations should be minimised at these levels. This requires both public education approaches and improved training and specialist support for primary care services to enhance their ability to provide for these children.     

Challenges in conducting prospective research of developmentally directed care in surgical neonates: a case study

Background

Evaluation is fundamental to evidence-based practice. Due to practical constraints inherent in real-world clinical environments, however, innovations in clinical practice are often implemented without rigorous research. We set out to evaluate the effectiveness of developmentally directed care in surgical neonates using a randomised controlled trial with a Newborn Individualized Care and Assessment Program (NIDCAP) intervention.

Aim

The aim of this paper is to inform future studies by sharing lessons learnt in conducting prospective research of a practice-intervention in a critical care setting.

Method

Three intervention components were used to assess implementation: number of NIDCAP observations; infant allocation to project nurses, and consistency of care. Barriers to implementation were identified through discussions with nurses who had key roles.

Results

Insufficient episodes of NIDCAP observation and infant allocation to project nurses, and lack of consistency of care indicated that the intervention had not been successfully implemented. Barriers to implementation (fast ‘turnover’ of patients, unpredictable changes in medical status, staff/skill shortages, and inconsistent care) were attributed to the competing demands between service provision and research in a busy critical care context.

Conclusions

The findings regarding barriers to successful implementation of NIDCAP in this case study are relevant to any critical care setting where complex interventions are under consideration, as similar challenges are plausible across a range of clinical contexts. Adopting a critical methodologically-informed approach to appraise implementation and evaluate complex interventions is essential.     

Associations of maternal resources with care behaviours differ by resource and behaviour

Care is important for children's growth and development, but lack or inadequacy of resources for care can constrain appropriate caregiving. The objectives of this study were to examine whether maternal resources for care are associated with care behaviours specifically infant and young child feeding, hygiene, health‐seeking, and family care behaviours. The study also examined if some resources for care are more important than others. This study used baseline Alive & Thrive household surveys from Bangladesh, Vietnam, and Ethiopia. Measures of resources for care were maternal education, knowledge, height, nourishment, mental well‐being, decision‐making autonomy, employment, support in chores, and perceived instrumental support. Multiple regression analyses were conducted to examine the associations of resources for care with child‐feeding practices (exclusive breastfeeding, minimum meal frequency, dietary and diversity), hygiene practices (improved drinking water source, improved sanitation, and cleanliness), health‐seeking (full immunization), and family care (psychosocial stimulation and availability of adequate caregiver). The models were adjusted for covariates at child, parents, and household levels and accounted for geographic clustering. All measures of resources for care had positive associations with care behaviours; in a few instances, however, the associations between the resources for care and care behaviours were in the negative direction. Improving education, knowledge, nutritional status, mental well‐being, autonomy, and social support among mothers would facilitate provision of optimal care for children.     

Young people with spina bifida: Transfer from paediatric to adult health care

An expectation of health care for young people with disability is that quality coordinated care continues to be available as they pass from the paediatric to the adult health care system. While individual clinicians provide this service well, the widespread absence of coordinated multidisciplinary care for young people with spina bifida in the adult health care system is a major deficiency. This paper describes the planning and implementation that underpinned the transfer of 10 young people with spina bifida from a paediatric to an adult service. The range of structural, financial and ‘cultural’ barriers that need to be overcome before patients can be successfully transferred is highlighted; lessons learned from this model may serve to facilitate the development of other transfer services.     

Recommendations for medical care in the pediatric oncology camp setting: Consensus statements based on Delphi methodology

For many children with cancer, participation in oncology camp programs is an important component of healing that offers opportunities for fun and can have substantial impacts on social and physical well‐being. Optimal medical care and infectious screening for children attending oncology camp is critical to maximize safety and opportunities for participation. This paper describes recommendations for a series of common medical issues unique to the care of children with cancer in the camp setting generated by a modified Delphi consensus approach.