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2.  Maternal Depressive Symptoms and Participation in Early Intervention Services for Young Children 
Maternal and Child Health Journal  2012;16(2):336-345.
Many young children with developmental delay who are eligible for early intervention (EI) services fail to receive them. We assessed the relationship between depressive symptoms in mothers, a potentially modifiable risk, and receipt of EI services by their eligible children. We conducted multivariable analyses of a nationally representative sample of children eligible for EI services at 24 months using data from the Early Childhood Longitudinal Study-Birth Cohort. Maternal depressive symptoms were assessed at 9 and 24 months. Birthweight <1,000 g, genetic and medical conditions associated with developmental delay, or low scores on measures of developmental performance defined EI eligibility. Service receipt was ascertained from parental self-report. Models were adjusted for sociodemographic and child risk. Among the 650 children who were eligible to receive EI services as infants, 33.2% of children whose mothers were depressed received services compared to 27.0% whose mothers were not depressed (aOR 1.8; 95% CI 0.8, 4.0). Among the 650 children who became eligible to receive services as toddlers, 13.0% of children whose mothers were depressed received services compared to 2.6% whose mothers were not depressed (aOR 4.6, 95% CI 1.5, 14.6). Among children receiving EI services, prevalence of depressive symptoms was 23.0% for mothers whose children became eligible as infants and 57.5% for mothers whose children became eligible as toddlers. Depressive symptoms in mothers of children eligible to receive EI services did not appear to limit participation. EI programs may be an appropriate setting in which to address maternal depressive symptoms.
doi:10.1007/s10995-010-0715-3
PMCID: PMC3108048  PMID: 21140201
Early intervention; Maternal depression; Developmental delay; Part C services; Early Child Longitudinal Study
3.  Thoracic pedicle subtraction osteotomy in a pediatric patient: a case report 
Study design: Case report.
Objective: To describe a case of thoracic pedicle subtraction osteotomy (PSO) for congenital kyphosis in a child.
Background information: Although congenital kyphosis is rare, it is a challenging cause of pediatric myelopathy and frank paralysis. Even less common is the use of PSO for the surgical management of focal congenital kyphosis. We present the case of a child with congenital kyphosis that was managed with a pedicle subtraction osteotomy.
Methods: A detailed history and physical examination were performed with careful review of the patient’s medical records and x-ray studies. A PSO at T11 was performed along with T9 through L1 instrumented posterolateral fusion.
Case description: A 10-year-old girl was evaluated for walking difficulty and a lump on her back. Physical examination revealed a sharp gibbus kyphosis in the lower thoracic spine with tenderness and bilateral back muscle spasms. The patient displayed difficulty with balance lacking a smooth, regular gait rhythm. Clonus and radiculopathy were not present. Plain x-ray of the thoracolumbar spine revealed hyperkyphosis and failure of anterior wall segmentation between T10 and T11 vertebral bodies. Cobb’s angle measured 65 degrees. Due to her symptoms and degree of correction required, we elected to perform a PSO at T11 along with T9 to L1 posterolateral instrumentation fusion. No intraoperative complications occurred. There was a significant improvement in her posture and gait.
Discussion: A thoracic PSO for congenital kyphosis was safely performed with an excellent outcome. To our knowledge, this is the first PSO procedure performed in Uganda.
doi:10.1055/s-0031-1298618
PMCID: PMC3516457  PMID: 23230419
4.  The impact of race on participation in Part C early intervention services 
Objective
To quantify racial differences in receipt of early intervention (EI) services among children ages birth to three.
Methods
We conducted multivariable analyses of a nationally representative sample of children eligible for EI services using data from the Early Child Longitudinal Study, Birth Cohort. Birthweight <1000 grams, genetic and medical conditions associated with developmental delay, or low scores on a standardized measure of developmental performance defined EI eligibility. Receipt of EI services was ascertained from parent self-report. The effect of race on receipt of EI services was examined in main effect models and models stratified by EI qualifying condition, which was defined as either established medical condition or developmental delay in the absence of an underlying medical diagnosis.
Results
At 9 months of age, among the 1000 children eligible for EI services, 9% of children received services; there were no Black-white racial differences in receipt of services. At 24 months of age, among the 1000 children eligible for EI services, 12% received services; Black children were 5 times less likely to receive services than white children (aOR 0.19; 95% CI 0.09, 0.39). In models stratified by qualifying condition, Black children who qualified for services at 24 months based on developmental delay alone were less likely to receive services (aOR 0.09; 95% CI 0.02, 0.39); there were no differences by race among children who qualified based on established medical conditions (aOR 0.56; 95% CI 0.18, 1.72).
Conclusions
Racial disparities in EI service receipt, which were not present during infancy, emerged as children became toddlers. These disparities were found most consistently among children who qualified for services based on developmental delay alone.
doi:10.1097/DBP.0b013e3182142fbd
PMCID: PMC3138901  PMID: 21389865
5.  T8 spinal cord transection in a 6-year-old child 
Study design: Case report.
Objective: To describe a case of spinal cord transection in a 6-year-old child.
Background information: Non-missile injury of the spinal cord is not common and its incidence varies according to the country. In addition, to our knowledge, there are no published reports of spinal cord injury (SCI) from a penetrating nail. Here, we report the case of a child who developed complete SCI because of cord transection by a nail.
Methods: A detailed history and physical examination were performed along with careful review of the patient's medical records. In addition, a review of the literature was conducted to assess the incidence and treatment of similar injuries.
Case description: A 6-year-old boy was admitted to the hospital after falling from a tree and landing on a nail. His physical examination revealed an emaciated child with multiple decubitus ulcers, lying on his side in bed. Visible was a well-healed posterior puncture wound at the T8 vertebral level. On neurological examination, the patient had 0/5 muscle strength in his lower extremities, symmetrical areflexia, and hypoesthesia below the T8 level. Plain x-ray of the thoracolumbar spine was normal. Magnetic resonance imaging revealed a transected spinal cord at the T8 vertebra, consistent with his nail puncture wound.
Discussion: This report describes an unusual case of a complete SCI in a pediatric patient caused by penetrating trauma from a nail. To our knowledge, this is the first case to report on complete SCI due to trauma from a nail.
doi:10.1055/s-0032-1327811
PMCID: PMC3592763  PMID: 23526907
6.  The potential impact of trauma on the ability to prevent depression among low-income mothers 
Depression and anxiety  2011;28(6):478-484.
Background
Violent trauma is common in urban communities. We explored the hypothesis that past trauma could moderate the effect of a cognitive behavioral intervention designed to prevent depression among urban, low-income mothers.
Methods
Synthesis of two pilot randomized trials of problem solving education (PSE), among 93 mothers of children hospitalized in the neonatal intensive care unit or enrolled in community-based Early Intervention programs. Outcomes included depressive symptoms, perceived stress, social functioning. Results were adjusted for baseline depressive symptoms, then stratified according to subjects’ trauma history.
Results
Fifteen of 44 PSE subjects (34%) experienced a moderately severe depressive symptom episode during the four-month follow-up period, as opposed to 21 of 45 control subjects (47%) – for a nearly significant adjusted odds ratio (aOR) of 0.36 (95% CI 0.13, 1.02). Among mothers without trauma histories, far fewer PSE mothers (5 of 24; 21%) experienced an episode of moderately severe depressive symptoms than control mothers (12 of 26; 46%), for a significant aOR of 0.15 (95% CI 0.03, 0.79). Conversely, among mothers with trauma histories, a similar proportion of PSE mothers (10 of 19; 53%) experienced an episode of moderately severe depressive symptoms as control mothers (9 of 19; 47%). Similar trends held for perceived stress and social functioning.
Conclusions
PSE may be more effective at preventing depression among mothers without trauma histories. Our results are consistent with the depression treatment literature, but are novel because they support the principle of intervention moderation in a risk-prevention – as opposed to treatment – paradigm.
doi:10.1002/da.20817
PMCID: PMC3110557  PMID: 21506207
7.  When the Subject Is More than Just the Subject: Two Case Studies of Family Involvement in Human Subjects Research 
Institutional review boards (IRBs) protect human research subjects by reviewing research to ensure compliance with federal regulations and institutional policies. One of the most important functions of IRBs is to ensure that investigators anticipate, plan for, and minimize risks to subjects. Under certain circumstances, however, participation in research may pose risks to nonsubject family members or other members of a subject’s social network. In the context of a research protocol designed to test an intervention to prevent depression among a population of culturally diverse, urban mothers, we present two case studies of unanticipated problems, which demonstrate how nonsubject family members can either impact, or be impacted by, an individual’s participation in research. The case studies illustrate the incongruence between federal regulations addressing IRB approval of research— which focus specifically on risks to subjects—and regulations on reporting incidents that occur during the conduct of the research, which extend to risks involving “others” as well. The cases also illustrate how risks to “others” can be accentuated in certain cultures where codependent family structures may increase the role that family members play in an individual’s decision to participate in research. The question is raised as to whether this incongruence can inadvertently result in investigators and IRBs under-appreciating the risks that participation in research can pose to nonsubjects.
doi:10.1525/jer.2011.6.1.33
PMCID: PMC3273779  PMID: 21460585
maternal depression; secondary subjects; family involvement in research
8.  Maternal Depression, Perceptions of Children’s Social Aptitude, and Reported Activity Restriction among former Very Low Birth Weight Infants 
Archives of disease in childhood  2010;95(7):521-525.
Objective
Maternal depression is common among mothers of very low birth weight (VLBW) infants. In a cohort of mother-VLBW infant dyads followed to preschool age, we assessed the impact of maternal depression on mothers’ perceptions of their children’s social aptitude, and reported participation in age-appropriate preschool activities.
Methods
Longitudinal multivariable analysis of a nationally representative sample of VLBW infants in the United States. Models were adjusted for children’s developmental abilities according to the Bayley Scales of Infant Development, Mental Development Index.
Results
800 VLBW singletons (mean gestational age 28.9 weeks) were analyzed. During the preschool years, depressed mothers perceived their children’s social abilities more negatively than non-depressed mothers. Specifically, they saw their children as less likely to be able to share with others (aOR 0.37, 95% CI 0.14, 0.96), make friends (aOR 0.58 95% CI, 0.35, 0.96), or play independently (aOR 0.30 95% CI, 0.16, 0.58). These negative perceptions were not shared by the children’s preschool teachers. Children of depressed mothers were also less likely to participate in age-appropriate preschool activities (aOR 0.30 95% CI, 0.16, 0.58). Each of these associations either lost significance or were substantially attenuated in a separate population of former healthy term infants.
Conclusion
Among former VLBW infants, maternal depression is associated with negative perceptions of children’s social abilities and decreased participation in preschool activities. Maternal mental health should be considered in ongoing efforts to maximize the social-emotional development of preterm infants.
doi:10.1136/adc.2009.181735
PMCID: PMC3158425  PMID: 20522473
prematurity; maternal depression; vulnerable child
10.  The Receipt of Special Education Services Following Elementary School Grade Retention 
Objective
To estimate the proportion of children who receive an Individualized Education Program (IEP) following grade retention in elementary school.
Design/setting
Descriptive analysis of a nationally representative, longitudinal cohort.
Participants
Children retained in K/1 and 3rd grade for presumed academic reasons, followed through fifth grade.
Outcome measure
Presence or absence of an IEP.
Results
300 children retained for presumed academic reasons in K/1, and 80 in 3rd grade were included in the study. Of the K/1 retainees, 68% never received an IEP over the subsequent four to five years; of the 3rd grade retainees, 73% never received an IEP. K/1 retainees in the highest SES quintile and suburban K/1 retainees were less likely to receive an IEP than retained children in all other SES quintiles (aOR 0.17; 95% CI 0.05-0.62) and in rural communities (aOR 0.16; 95% CI 0.06-0.44), respectively. Among K/1 retainees with persistent low academic achievement in reading and math (as assessed by standardized testing), 37% and 28%, respectively, never received an IEP.
Conclusions
The majority of children retained in K/1 or 3rd grade for academic reasons, including a many of those who demonstrate sustained academic difficulties, never receive an IEP during elementary school. Further studies are important to elucidate whether retained elementary school children are being denied their rights to special education services. In the meantime, early grade retention may provide an opportunity for pediatricians to help families advocate for appropriate special education evaluations for children experiencing school difficulties.
doi:10.1001/archpediatrics.2009.54
PMCID: PMC3154013  PMID: 19487611
grade retention; individualized education program; special education; school readiness
11.  Kyphoplasty: Traditional imaging compared with computer-guided intervention—time to rethink technique? 
Study design: Equivalence trial (IRB not required for cadaveric studies).
Objective: To compare computer-guided and fluoroscopic kyphoplasty. Factors of interest were radiation exposure, position of cannula within pedicles and procedure time.
Methods: Kyphoplasty was performed on two cadavers. Computer-navigated, cross-sectional images from a cone-beam CT were used for one and fluoroscopic imaging for the other. In each, T6–9 and T11–L2 vertebrae were selected. For both imaging methods, anteroposterior and lateral x-rays were taken. Radiation exposure for both procedures was measured by four dosimeters. Procedure time, radiation to surgeon and cadaver, and position of cannula placement within pedicles were recorded. The surgeon wore one under the lead gown, another on the lead gown at shoulder level, and a third as a ring on the dominant hand. A dosimeter was also placed on the cadaver.
Results: The radiation from the cone-beam, computer-guided imaging system was 0.0 mrem to the surgeon and 0.52 rads to the cadaver. Using fluoroscopic imaging, surgeon's and cadaver's exposure was 5 mrem and 0.047 rads, respectively. Procedure times were similar and neither device resulted in cannula malposition.
Conclusions: Cone-beam CT appears as accurate as the fluoroscopy; radiation exposure to the surgeon is eliminated, and radiation levels to the patient are acceptable.
doi:10.1055/s-0028-1100893
PMCID: PMC3609000  PMID: 23544024
12.  The Relationship Between Maternal Depression, In-Home Violence, And Use Of Physical Punishment: What Is The Role Of Child Behavior? 
Archives of disease in childhood  2008;94(2):138-143.
Context
Maternal depression and in-home violence are independently associated with the use of physical punishment on children; however, the combined impact of these factors on the practice of physical punishment is unknown, as is the extent to which their relationship to physical punishment varies with child behavior.
Objectives
1) Determine the combined impact of maternal depression and violence exposure on one physical punishment practice, smacking; 2) Explore the role of child behaviors in this relationship.
Methods
Multivariable regression analysis of a nationally representative sample of US kindergarten children. Maternal depressive symptoms, violence exposure, and use of smacking as a discipline technique were measured by parent interview. Child behaviors were reported by teachers.
Results
12,764 mother-child dyads were included in the analysis. The adjusted odds ratio (aOR) for smacking among mothers with depressive symptoms was 1.59 (95% CI 1.40, 1.80); among mothers exposed to in-home violence, 1.48 (95% CI 1.18, 1.85); among dually exposed mothers, 2.51 (95% CI 1.87, 3.37). Adjusting these models for child self-control or externalizing behavior yielded no change in these associations, and no effect modification by child behavior was detected. Among mothers reporting to smack their children, depression was associated with an increased smacking frequency (aIRR 1.12; 95% CI 1.01, 1.24); however, this association was reduced to borderline significance when adjusting the models for child self-control or externalizing behavior (aIRRs 1.10; 95% CI 1.00, 1.21). Depressed mothers who were also exposed to violence demonstrated higher rates of smacking (aIRR 1.29; 95% CI 1.09, 1.53); this remained stable when adjusting for child behaviors.
Conclusion
Maternal depression and violence exposure are associated with smacking as a means of punishment. The magnitude of this association is increased when depression and violence occur together. When coexistent, they also appear associated with the frequency of smacking. Child self-control and externalizing behavior do not appear to impact substantially the association between maternal depressive symptoms, violence exposure, and smacking.
doi:10.1136/adc.2007.128595
PMCID: PMC2829298  PMID: 18786952
Maternal Depression; Violence; Corporal Punishment; Spanking; Smacking; Child Behavior
13.  “You get what you get:” unexpected findings about low-income parents’ negative experiences with community resources 
Pediatrics  2008;122(6):e1141-e1148.
Context
Community-based resources are considered a critical part of the American healthcare system. However, studies evaluating the effectiveness of such resources have not been accompanied by rigorous explorations of the perceptions or experiences of those who use them.
Objective
In this paper, we aim to understand and classify types of negative perceptions that low-income parents have of community resources. This objective originated from a series of unexpected findings, which emerged during the analysis of qualitative data, initially collected for other purposes.
Methods
In-depth qualitative interviews with urban low-income parents. Themes emerged through a grounded theory analysis of coded interview transcripts. Interviews took place in two different cities as part of two studies with distinct objectives.
Results
We completed 41 interviews. Informants often perceived their interactions with people and organizations as a series of tradeoffs; and important choices, often as decisions between two suboptimal options. Seeking help from community resources was seen in that context. The following specific themes emerged: 1) Engaging with services sometimes meant subjecting oneself to requirements perceived as unnecessary; and in the extreme, having to adopt the value systems of others. 2) Accepting services was sometimes perceived as a loss of control over one's surroundings, which in turn was associated with feelings of sadness, helplessness or stress. 3) Individuals staffing community agencies were sometimes seen as judgmental or intrusive; and when many services were accessed concurrently, information sometimes became overbearing or a source of additional stress; and 4) Some services, or advice received as part of such services, were perceived as unhelpful because they were too generic or formulaic.
Conclusions
Our data suggest that definable patterns of negative perceptions of community resources may exist among low-income parents. Quantifying these perceptions may help improve the client-centeredness of such organizations, and may ultimately help reduce barriers to engagement.
doi:10.1542/peds.2007-3587
PMCID: PMC2596660  PMID: 19047215
community resources; access to care; qualitative interviews; qualitative research; vulnerable populations

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