A primary interest of the field of infant mental health is in the early conditions that place infants at riskfor less than optimal development. The fundamental problem of what constitutes normal and abnormal development is now a focus of developmental psychology, infant psychiatry, and devel- opmental neuroscience. In the second part of this sequential work, I present interdisciplinary data to more deeply forge the theoretical links between severe attachment failures, impairments of the early develop- ment of the right brain's stress coping systems, and maladaptive infant mental health. In the following, I offer thoughts on the negative impact of traumatic attachments on brain development and infant mental health, the neurobiology of infant trauma, the neuropsychology of a disorganized/disoriented attachment pattern associated with abuse and neglect, trauma-induced impairments of a regulatory system in the orbitofrontal cortex, the links between orbitofrontal dysfunction and a predisposition to posttraumatic stress disorders, the neurobiology of the dissociative defense, the etiology of dissociation and body- mind psychopathology, the effects of early relational trauma on enduring right hemispheric function, and some implications for models of early intervention. These findings suggest direct connections between traumatic attachment, inefficient right brain regulatory functions, and both maladaptive infant and adult mental health.

/pdf/the-effects-of-early-relational-trauma-on-right-brain-42wojx34bw.pdf

The effects of early relational trauma on right brain development, affect regulation, and infant mental health.

ContextAbusive head trauma (AHT) is a dangerous form of child
abuse that can be difficult to diagnose in young children.ObjectivesTo determine how frequently AHT was previously missed
by physicians in a group of abused children with head injuries and to
determine factors associated with the unrecognized diagnosis.DesignRetrospective chart review of cases of head trauma
presenting between January 1, 1990, and December 31, 1995.SettingAcademic children's hospital.PatientsOne hundred seventy-three children younger than 3 years
with head injuries caused by abuse.Main Outcome MeasuresCharacteristics of head-injured children in
whom diagnosis of AHT was unrecognized and the consequences of the
missed diagnoses.ResultsFifty-four (31.2%) of 173 abused children with head
injuries had been seen by physicians after AHT and the diagnosis was
not recognized. The mean time to correct diagnosis among these children
was 7 days (range, 0-189 days). Abusive head trauma was more likely to
be unrecognized in very young white children from intact families and
in children without respiratory compromise or seizures. In 7 of the
children with unrecognized AHT, misinterpretation of radiological
studies contributed to the delay in diagnosis. Fifteen children
(27.8%) were reinjured after the missed diagnosis. Twenty-two (40.7%)
experienced medical complications related to the missed diagnosis. Four
of 5 deaths in the group with unrecognized AHT might have been
prevented by earlier recognition of abuse.ConclusionAlthough diagnosing head trauma can be difficult in the
absence of a history, it is important to consider inflicted head trauma
in infants and young children presenting with nonspecific clinical
signs.

http://www.nccpeds.com/rotations/AFCCP/Reading%20List/AHT/Jenny%20classic%20missed%20AHT.pdf

Analysis of missed cases of abusive head trauma.

Anybody can write down a list of questions and photocopy it, but producing worthwhile and generalisable data from questionnaires needs careful planning and imaginative design 

The great popularity with questionnaires is they provide a “quick fix” for research methodology No single method has been so abused 1

Questionnaires offer an objective means of collecting information about people's knowledge, beliefs, attitudes, and behaviour2 3 Do our patients like our opening hours? What do teenagers think of a local antidrugs campaign and has it changed their attitudes? Why don't doctors use computers to their maximum potential? Questionnaires can be used as the sole research instrument (such as in a cross sectional survey) or within clinical trials or epidemiological studies

Randomised trials are subject to strict reporting criteria,4 but there is no comparable framework for questionnaire research Hence, despite a wealthof detailed guidance in the specialist literature,1–3> 5 w1-w8 elementary methodological errors are common1 Inappropriate instruments and lack of rigour inevitably lead to poor quality data, misleading conclusions, and woolly recommendationsw8 In this series we aim to present a practical guide that willenable research teams to do questionnaire research that is well designed, well managed, and non-discriminatory and which contributes to a generalisable evidence base We start with selecting and designing the questionnaire

 ![][1] 

You and your co-researchers may have different assumptions about precisely what information you would like your study to generate A formal scoping exercise will ensure that you clarify goals and if necessary reach an agreed compromise It will also flag up potential practical problems—for example, how long the questionnaire will be and how it might be administered

As a rule of thumb, if you are not familiar enough with the research area or with a particular population subgroup to predict the range …

 [1]: /embed/graphic-1gif

/pdf/selecting-designing-and-developing-your-questionnaire-1vpl150yog.pdf

Selecting, designing, and developing your questionnaire

There has been a major decrease in the incidence of sudden infant death syndrome (SIDS) since the American Academy of Pediatrics (AAP) released its recommendation in 1992 that infants be placed down for sleep in a nonprone position. Although the SIDS rate continues to fall, some of the recent decrease of the last several years may be a result of coding shifts to other causes of unexpected infant deaths. Since the AAP published its last statement on SIDS in 2000, several issues have become relevant, including the significant risk of side sleeping position; the AAP no longer recognizes side sleeping as a reasonable alternative to fully supine sleeping. The AAP also stresses the need to avoid redundant soft bedding and soft objects in the infant's sleeping environment, the hazards of adults sleeping with an infant in the same bed, the SIDS risk reduction associated with having infants sleep in the same room as adults and with using pacifiers at the time of sleep, the importance of educating secondary caregivers and neonatology practitioners on the importance of “back to sleep,” and strategies to reduce the incidence of positional plagiocephaly associated with supine positioning. This statement reviews the evidence associated with these and other SIDS-related issues and proposes new recommendations for further reducing SIDS risk.

The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk

The American Academy of Pediatrics has recommended since 1992 that infants be placed to sleep on their backs to reduce the risk of sudden infant death syndrome (SIDS). Since that time, the frequency of prone sleeping has decreased from >70% to ∼20% of US infants, and the SIDS rate has decreased by >40%. However, SIDS remains the highest cause of infant death beyond the neonatal period, and there are still several potentially modifiable risk factors. Although some of these factors have been known for many years (eg, maternal smoking), the importance of other hazards, such as soft bedding and covered airways, has been demonstrated only recently. The present statement is intended to review the evidence about prone sleeping and other risk factors and to make recommendations about strategies that may be effective for further reducing the risk of SIDS. This statement is intended to consolidate and supplant previous statements made by this Task Force.

Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position

Objective. To describe historic markers and clinical observations of life-threatening child abuse as diagnosed using covert video surveillance (CVS). Design. A descriptive, retrospective, partially controlled case study. Setting. Two hospitals (in London and North Staffordshire, UK) receiving referrals for the investigation of apparent life-threatening events (ALTE), with the availability of CVS. Patients. A total of 39 children (age range at CVS, 2 to 44 months; median, 9 months) in whom hospital CVS was used to investigate suspicions of induced illness. Thirty-six were referred for investigation of ALTE, one with suspected epilepsy, one with failure to thrive, and one with suspected strangulation. A control group consisted of 46 children with recurrent ALTE proven on physiologic recordings to be attributable to a natural medical cause (9 attributable to epileptic seizures, and 37 attributable to respiratory problems). Intervention. Collection of historic details from medical, social service, and police records; interagency collaboration in planning, investigations, and management; development and use of CVS as a clinical tool in the investigation of patients in whom there was suspicion of induced illness. Outcome. Confirmation of attempted suffocation or other child abuse from CVS. Results. CVS revealed abuse in 33 of 39 suspected cases, with documentation of intentional suffocation observed in 30 patients. Poisonings (with disinfectant or anticonvulsant), a deliberate fracture, and other emotional and physical abuse were also identified under surveillance. The first ALTE occurred at a median age corrected for the expected date of delivery of 3.6 months in the CVS patients and of 0.3 months in controls. Three CVS patients and 27 of the control children (including 20 at The 39 patients undergoing CVS had 41 siblings, 12 of whom had previously died suddenly and unexpectedly. Eleven of the deaths had been classified as sudden infant death syndrome but after CVS, four parents admitted to suffocating eight of these siblings. One additional sibling who had died suddenly with rotavirus gastroenteritis was reinvestigated after CVS of her sister revealed poisoning, and death was found to be caused by deliberate salt poisoning. Other signs of abuse were documented in the medical, social, and police records of an additional 15 of the siblings. In the 52 siblings of the 46 controls, 2 had died: one from hypoplastic left heart at 5 days and the other suddenly and unexpectedly (classified as sudden infant death syndrome) at 7 weeks. Twenty-three of the abusive parents were diagnosed by a psychiatrist as having personality disorders. Conclusions. Induced illness is a severe form of abuse that may cause death or permanent neurologic impairment. It may be accompanied by other severe forms of abuse, may result in behavioral disorders, and may be accompanied by immeasurable suffering. Detection of this abuse requires careful history-taking; thorough examination of the health, social, and police records; and close and focused collaboration between hospital and community child health professionals, child psychiatrists, social workers, and police officers. CVS may help investigate suspicions and ensure that children are protected from additional abuse. When parents have failed to acknowledge that they have deceived health professionals, partnership with them in seeking to protect their children may be neither safe nor effective.

Martin W. Banks

Papers

Covert Video Recordings of Life-threatening Child Abuse: Lessons for Child Protection

Covert video recordings of life-threatening child abuse — lessons for child protection