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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
• Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
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Perspectives

A Case Study of the Early Childhood Mental Health Therapeutic Consultation Protocol within a Specialty Multidisciplinary Pediatric Clinic for Adopted and Foster Care Children

Experiences of maltreatment, caregiver transitions, and other forms of chronic stress in early childhood have been related to an increased likelihood of health and mental health disorders. Despite having a number of well-developed and validated therapeutic options for fostered and adopted children, families are often overwhelmed by their child’s multiple health needs and have a difficult time accessing care. This case report describes a 2-year old female child in foster care who took part in a multidisciplinary program for fostered and adopted children ages 0 to 5 years old. This family’s experience highlights that patients can receive streamlined evaluations, short-term therapeutic interventions, and long-term service recommendations by providing families with a single point of contact in an integrated care setting. This approach decreases the time burden placed on parents, increases the effectiveness in understanding and addressing a child’s needs, and improves family and provider collaboration. Further, models of integrated care reduce the likelihood of misdiagnosis. Many symptoms of early childhood adversity and attachment disorders can present like other common mental (i.e., Autism Spectrum Disorder) and physical disorders (i.e., motor delays). Misdiagnosis can lead to recommendations that are ineffective or ultimately harmful to children with experiences of trauma. Given the range of general and mental health effects of multiple housing transitions, maltreatment, and/or neglect, this case underscores how a team approach is invaluable for promoting at-risk young children’s wellbeing and development.

Keywords: Foster Care; Adoption; Mental Health; Early Childhood; Integrated Care

Introduction

Over 443,000 children were involved in the foster care system in the United States during 2017 (Child Trends Databank, 2019). Children under the age of five are the largest group within foster care (~41%, N = 183,959; Child Trends Databank, 2019). Almost all children involved in these systems have experienced multiple transitions, maltreatment, and/or neglect. Many have also experienced malnourishment, pre-and post-natal substance exposure, premature birth, and exposure to infectious diseases. Environmental stress, bodily harm, and illness in early childhood can carry consequences for physical and mental health functioning across the lifespan (Cicchetti & Handley, 2019; Malionsky-Rummel & Hansen, 1993; Smith & Thornberry, 1995; Vachon, Krueger, Rogosch, & Cicchetti, 2015; Anda et al., 2006). Given the medical complexity of foster children, multi-disciplinary care models, including medical providers, mental health specialists, public health nurses, social workers, and occupational therapists (OT), are essential.

The purpose of this paper is to highlight the experience of a 2-year old female in foster care with a program that integrates early childhood mental health therapeutic consultation with a unique multidisciplinary medicine program for fostered and adopted children. We will, 1) illuminate the need for new ways for fostered and adoptive children under five to engage with health, mental health and other services, and 2) highlight an early mental health therapeutic consultation protocol within a pediatric setting. Ultimately we aim to motivate the development of this and similar programs across the United States to better serve young children facing threats to their life long trajectories of mental and physical illness due to early experiences of adversity.

Early Childhood Mental Health Evaluation in an Interdisciplinary Pediatric Team

Multiple housing transitions, maltreatment and/or neglect can be related to a range of medical, developmental, and emotional symptoms, with treatments located outside of the sphere of early childhood psychological intervention. Early childhood experiences of abuse and neglect have been linked to cardiovascular concerns, sensory processing disorders, failure to thrive, and chronic infections associate with immune system dysfunction (Anda et al., 2006; Felitti et al., 1998). Malnutrition, often associated with experiences of neglect, can have a detrimental impact on a child’s development trajectory if left unaddressed – including an increased risk for cardiovascular and metabolic disease in adulthood (Campbell et al., 2014), lower IQ scores in early adolescents (Liu et al., 2003), and micronutrient deficiencies that cause irreversible alterations to brain development (Monk et al., 2013).

While physicians in the United States are typically underprepared to address mental health ramifications of early childhood trauma, mental health providers similarly lack the training to fully conceptualize a child’s necessary medical interventions for their physical health needs. Due to this increased medical complexity for children who have faced early adverse experiences, it is invaluable to have a team approach that addresses concerns and efficiently rules out multiple etiologies for symptoms.

Further, many mental health symptoms related to trauma or attachment disorders can present like other common early childhood disorders. This may be difficult for providers without specialized training in early childhood trauma and attachment disorders to accurately determine the appropriate diagnosis. Misdiagnosis can lead to recommendations that are ineffective or ultimately harmful to children with experiences of trauma. For example, Autism Spectrum Disorder (ASD), trauma-related disorders, and attachment disorders have a similar profile of symptoms in early childhood. This includes delayed speech, delayed social cueing, difficulties with attention, and self-harm behaviors. However, for children with experiences of neglect, clinicians would recommend trauma-informed treatments focused on building attachment relationships and stability. For children with ASD, more behavioral oriented approaches would be recommended to target the growth of specific social skills. An ASD diagnosis for children with a trauma-related or attachment disorder could further disturb the child’s developmental trajectory by delaying appropriate services that focus on bolstering the child’s relational needs.

Access to Care and Therapeutic Consultation

Early childhood interventions that address parent-child attachment for children who have experienced early trauma have shown efficacy in reducing children’s negative behavioral and emotional outcomes (Reyes et al., 2017; Dozier et al., 2017; Cohen et al., 2000). However, a large number of children facing adversity do not ever receive the benefits of early interventions (Hartinger-Saunders et al., 2019). Specialty pediatric care settings that work with early mental health providers and their state’s department of human services have the unique opportunity to dramatically increase the likelihood that children who are at risk are identified and receive evidence-based interventions. However, to our knowledge, there are no standardized protocols, on how to incorporate early mental health and relationship-based evaluations into pediatric specialty care. This paper aims to highlight the benefits of a cross-systems integrated care model for addressing mental health concerns among young children in foster and adoptive care.

In the United States, foster care and adoption legislation is determined by the State. In Minnesota, children in foster care have a case review hearing 90 days after a child’s removal from parental care. After the court reviews the parent’s progress on their case plan, there may be a 6-month extension on the child’s foster care placement. Once a child has been in foster care for 12 months, the court will file a petition to decide on a permanency plan. Children in foster care can be adopted when their birth parents sign a voluntary consent, after which they have a ten-day period to change their mind. Children may also be made available for adoption through a court procedure to end parent rights. Birth parents have 20 days to appeal the court’s order.

The Adoption Medicine Clinic (AMC) at the University of Minnesota has been evaluating internationally adopted children since 1986 and in the past decade has focused on providing more services for children who have been domestically adopted or are in foster care. Funded by a grant from the Minnesota Department of Human Services the clinic has incorporated specialists into pediatrician visits, including psychology, OT, pediatric/public health nurses, and genetic counseling to address the far-reaching effects of early childhood adversity on physical and psychological functioning.

In 2019, approximately 48% (N = 188) of the population seen by AMC were children 5 years old or younger and were noted to have high rates of behavioral and emotional difficulties. Throughout 2019 and the beginning of 2020, the program spent large amounts of time doing community outreach to create partnerships and referral pathways. The program encouraged social workers across the state to refer young children and their foster families to the AMC for integrated care. All data and the case review were collected via chart review and approved by the University of Minnesota Institutional Review Board. At the onset of visits to the AMC, foster parents were provided with consents by check-in staff to choose to include their clinical information in research.

Early Childhood Mental Health Therapeutic Consultation Program Description

The over-arching goal of integrating the Early Childhood Mental Health Evaluation Protocol into AMC was to identify young children who are at high risk for long term mental health difficulties and displacement from their current foster or adoptive home. The mental health portion of the evaluation protocol consists of three components by which children are screened for (1) prenatal and postnatal experiences of trauma, (2) current behavioral, social, cognitive, and emotional concerns, as well as (3) current service access. In addition to the evaluation, the service includes referrals and a tailored psychoeducational intervention.

The first component of the evaluation consists of collecting information on pre and post-natal experiences of adversity. Prenatal risk factors can include the biological parent’s level of stress, access to prenatal care, prenatal substance use, and genetic liability for psychopathology. Postnatal risk factors for this population often include neglect, abuse, chronic mobility, food insecurity, and multiple separations or transitions from primary caregivers. We identify the duration and age of these experiences in order to integrate a developmental framework that considers how the developmental timing and duration of these experiences could affect functioning. The clinician utilizes a standardized traumatic event screening form to identify risk for post-traumatic stress disorder as well as the Disturbances of Attachment Interview (Smyke & Zeenah, 1999) which inquiries about symptoms of Reactive Attachment Disorder and Disinhibited Social Approach Disorder (DC:0-5; Klaehn, 2018).

The second component of the evaluation is collecting information on the child’s mental and behavioral health difficulties. Information is gathered via medical chart review, foster parent interview, and behavioral observations in the clinical setting. Providers review the child’s previous psychological evaluations and diagnoses. Clinicians complete a foster parent interview assessing the child’s developmental trajectory and the formation of their current attachment relationship using the Disturbances of Attachment Interview (Smyke & Zeanahm, 1999).

Mental health providers then observe child behavior in the context of a medical and occupational therapy exam. The observation protocol is designed to help mental health providers identify children’s difficulties in cueing distress elicited by the exam, using foster or adoptive parents for emotion regulation and support, as well as indiscriminate friendliness with unfamiliar medical staff. Mental health providers observe the parent-child relationship (Crowell, 2003; Cooper, Hoffman, Powell, & Marvin, 2011). The observation protocol captures a snapshot of how foster and/or adoptive parents attend to children’s distress and how, they provide structure, guidance and direction to their children. Children lacking a caregiver with these skills are the most likely to experience high levels of maladjustment related to early experiences of risk. Consistent and responsive caregiving has been shown to act as a buffer between young children and their environment, preventing the negative consequences of stress on mental and physical health (Johnson et al., 2018; Measelle & Albow, 2018; Liberman et al., 2004).

At the end of the exam, mental health providers review the foster parent and/or adoptive parents’ concerns and goals for the child’s mental health, and evaluate if there are any risks for these foster/adoptive parents requesting the child be removed from their current placements. Child placement instability has been related to a host of emotional, behavioral and developmental difficulties in children (Fisher et al., 2016). Unfortunately, many states have a high rate of foster care placement instability (U.S. Department of Health and Human Services, 2014). Foster parents who are at risk for requesting that children be moved to a different placement often have young children with high medical, behavioral, and emotional needs. Research suggests that children with more trauma symptoms are at an increased risk for foster care displacement (Clark et al., 2020). During the interview, foster/adoptive parents at risk often highlighted feeling exhausted by the child’s needs, feeling as if they do not have the skill set to help the child, and feeling like they don’t have the resources to identify those skills. Through our work, we have found it to be really important and impactful to have a candid discussion with foster parents about any of these concerns. Many foster parents were very grateful to have a space to talk through these concerns without judgement.

The third component of the evaluation consists of reviewing the child and their foster/adoptive family’s current service utilization and needs. This involves reviewing if full developmental assessments using the DC:0–5™ Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood have been completed as well as what mental health services the families may be using. In evaluating current mental health services, we review families’ satisfaction with those services as well as provide recommendations for evidence-based interventions and providers with whom those interventions can be accessed. Families then receive a brief educational therapeutic consultation, based on our conceptualization of the child’s current functioning and history. Foster/adoptive parents are provided with information on how to best emotionally and behaviorally support children’s development in the context of their early adverse experiences. Most foster/adoptive parents receive educational information based on the Circle of Security (Zanetti et al., 2011) as well as in the moment feedback during the end of the session based on the Attachment Biobehavioral Catch-Up protocol (Dozier et al., 2017). We also discuss ways young children signal distress and ways foster/adoptive can help buffer those responses.

Young children who are identified as high-risk for placement disruption or long-term mental health difficulties are referred for a full mental health evaluation (using the DC:0–5™) and trauma-informed as well as relationship-centered evidence-based treatment. Children that need immediate intervention and care because their current level of dysfunction is a risk for their wellbeing receive rapid access to a one to three session brief intervention while they wait for longer-term therapeutic options to become available.

Rationale for a Case Study

We chose to highlight Anna’s* participation in our program as a case study for multiple reasons. First, there is limited knowledge on the feasibility of integrated care consultation models for young children in foster care. We will highlight how a common point of contact can increase high-risk children’s access to appropriate and timely early intervention services. Relatedly, we hope to use this case to highlight the medical complexity of these young foster care children and hope to support program and policy development. Third, many of these children are at risk for experiencing multiple foster-care placements. Multiple placements have been related to increased maladaptive functioning (Lloyd & Barth, 2011). We hope to use this case to highlight how providing consultations services, short term emergency care, and facilitating the prioritization and referrals to community services, integrated care settings like these may decrease the likelihood of multiple placements.

Case Background

Anna is a 2-year 8-month-old Black female who presented to the AMC. Anna was accompanied by her foster mother Rachel*, who was interested in gaining a better understanding of Anna’s behaviors and wanted to learn additional techniques to help support her development. Rachel described Anna as bold, talkative, active, and loving. Rachel had an initial interest in adopting Anna, but had concerns about her ability to provide long term care due to Anna’s many medical and emotional needs.

Based on a medical record review and foster/adoptive parent interview, Anna was prenatally exposed to marijuana, cocaine, and alcohol. Anna’s biological mother experienced homelessness and engaged in sex work while pregnant. Anna’s biological mother has a history of substance use, an anxiety disorder, and depression. Anna was born at 36 weeks gestation via cesarean section due to maternal preeclampsia. At birth Anna weighed 3 lbs. and spent one week in the neo-natal intensive care unit due to her low birth weight. At birth, she had Δ9-tetrahydrocannabinol (THC) in her system and was potentially exposed to a Sexually Transmitted Disease. As a young infant, Anna was reported to have spent time with various caregivers for extended periods of time while under her biological mother’s care and experienced residential mobility. At 10 months, Anna had a documented emergency room visit after reportedly being dropped by her biological mother. At 11 months, she was removed from her biological mother’s care due to concerns for neglect and placed with her current foster family. At placement, Anna was malnourished – weighing only 11 lbs. – and was diagnosed with failure to thrive. Since being placed with her foster parent, Rachel reported multiple ear infections but otherwise noted that Anna had appeared to be medically healthy. At the time of the AMC visit Anna was living with her two foster parents, her biological sister (1-year-old), and three foster siblings (9, 5, and 2 years old). Anna did not have any contact with her biological mother or father since being in foster care.

At the initial foster care placement, Anna displayed flat affect and was socially uninhibited. At the time of evaluation, Anna displayed extreme difficulties with separating from her foster parents, often refused food, and had no independent self-soothing behaviors. Anna and Rachel had previously engaged with play therapy, but Rachel reported that it seemed to make Anna’s symptoms worse. Rachel noted high levels of intense meltdowns after play therapy sessions as well as regression in her toileting abilities. Due to these symptoms, they ceased services. Over the few months leading up to the appointment, Anna displayed high-intensity distress and anger at home and appeared inconsolable. In order to manage Anna’s emotional and behavior needs, Rachel took 6 months off of work and sent Anna’s 1-year old biological sister and foster siblings to daycare. This was a challenging experience financially and emotionally for Rachel and the other children. Additionally, there were concerns with sensory processing, speech development, and muscle reflex issues. Anna covered her ears during loud noises, displayed freezing behaviors in new or unfamiliar situations, and had a hard time with zippers and putting clothes on.

Implementing the Early Childhood Mental Health Therapeutic Consultation Protocol

Anna and her foster mother spent an hour with our multi-disciplinary team of occupational therapist, nurses, medical doctors and psychologists. All team members were present for the duration of the visit. Results of the medical exam noted generalized muscular weakness, vitamin D insufficiency, iron deficiency, and tonsillar hypertrophy. Anna was prescribed a series of vitamin supplements. The experience of traumatic stress and micro-nutritional deficit prenatally and in early childhood may cause an altered vitamin D metabolism in children (Terock et al., 2020). Further, iron deficiency – also related to micro-nutritional deficits – can worsen for children directly in proportion to the amount of rapid post-placement growth (Fugelstad et al., 2008). Both nutritional issues have been related to numerous long-lasting developmental and cognitive deficits (Doom et al. 2014; Terock et al., 2020).

Due to prenatal exposure to substances, the medical team assessed Anna for the facial features of prenatal alcohol exposure. Her facial feature measurements were not consistent with those seen in children with Fetal Alcohol Spectrum Disorder. The occupational therapy team noted a speech delay and slight sensory processing difficulties on their developmental screening. They recommended a full assessment with a speech language therapist.

In Visit Observations

The mental health team observed Anna’s interactions with her primary caregiver, Rachel, and her emotional reactivity/regulation during novel situations. During the visit, Anna started by cuddling into her foster mother and was not interested in exploring the toys in the room. Throughout the hour Anna became increasingly more interested in the toys and displayed more positive emotions. Anna looked to her foster mother for support when she was unsure of toys or new people. Her mother provided comfort as well as acknowledged and validated her emotional expressions (both positive and negative). Anna appeared to experience her foster mother as an emergent secure attachment figure. However, Anna appears to have a difficult time relying on Rachel to provide support when she became distressed. At those moments Anna would appear to freeze in the middle of the room. Anna appeared to become particularly distressed and cover her ears if she believed something would make a loud noise. Observations of Anna suggested that she was developmentally delayed in her fine motor movements, and speech. Anna also demonstrated potential delays in social-emotional development.

Mental Health Treatment and Therapeutic Outcomes

At the end of the initial visit, the mental health provider engaged in a short educational intervention, using augmented protocols from the circle of security program (Zanetti et al., 2011). We described the impact of children’s trauma on development and highlighted the ways Anna’s trauma was playing out in her relationship with Rachel. Trained Circle of Security providers ( https://www.circleofsecurityinternational.com/trainings/about-trainings/ ) introduced the circle and being with Anna on the circle. The provider and Rachel practiced identifying when Anna was on the top or bottom of the circle over the course of the medical exam. The mental health team referred Anna to receive a full DC-0-5 screening from our team and engaged with two brief emergency intervention sessions to build Rachel’s skills on identifying when Anna was experiencing distress and how to help soothe that distress. The team also assisted Rachel in setting up respite caregiving services. Anna was referred to and subsequently engaged in early childhood day-treatment therapy services. Rachel also engaged with a circle of security group through our partner community clinics. Outside of the mental health and medical interventions described above, Anna received OT services for her speech and sensory concerns. At a follow-up appointment approximately one year later with AMC, Anna was still placed with the same foster family. They reported that many of the interventions helped reduce Anna’s symptoms and that they are hoping to move forward with adoption.

Piloting the Early Childhood Mental Health Evaluation Protocol

In the pilot of the evaluation protocol that Anna took part in at the AMC, there were 105 children like Anna seen by the clinic team in the span of ten months. Children ranged from 0.7 to 71 months of age and were 41.38 months on average. They were 43.3% female and 72% (n = 75) of the children were in foster care. There were thirty-one domestically adopted children and twenty children adopted internationally. Of those adopted internationally, fourteen had experiences of institutional care. On average children experienced 2.35 transitions, but this ranged from one transition to seven. Children were 10.61 months old on average at their first primary caregiver transition, and children were 24.49 months at their most recent transition. All children had experienced some form of neglect or abuse, with the most common experience being parental drug use (n = 49 parental drug use; n = 64 prenatal drug exposure; n = 43 prenatal alcohol exposure). Of the children seen at the clinic, 21 experienced physical abuse, 19 witnessed domestic violence, and 36 experienced neglect.

Approximately 68% (n =71) of primary caregivers noted behavioral, social, or emotional concerns for their children at the onset of the visit. Concerns included failure to thrive, broad developmental delays, sleep difficulties, feeding difficulties, high amounts of emotional distress and difficulty soothing. Clinical observations noted that 24% (n = 25) of children exhibited maladaptive stress behaviors. However, the vast majority of children sought and received comfort from their caregivers effectively (n = 82; 79%). There were five children who exhibited significant levels of indiscriminate friendliness by clinician observation.

Only 32% (n = 23) of these children were accessing psychological services at the time of their visit, and 29% (n = 30) of all children had seen a neuropsychologist. Three of those receiving neuropsychological evaluations were based in DC:0-5 protocols (2016). DC:0-5 evaluations review the development and functioning of young children in the context of their relationship with caretakers and other environmental inputs such as traumatic events. Of the children who had caregiver reported emotional and behavioral concerns or exhibited difficulties in the clinic, six were referred for an immediate consultation or brief therapeutic interventions with the early childhood mental health team.

At the time of this manuscript, four of those referrals have been fulfilled. Of the two whose referral has not been fulfilled, one lived out of state and the other is unknown. Further, twenty-six individuals were referred for a full mental health assessment with our team and eleven of those have been fulfilled. Many families traveled to the clinic from multiple hours away and either preferred to see a provider closer to them and/or we also recommended they could receive services from a member of the community closer to their homes. We recommended that forty-eight children (46.7%) receive a trauma-informed diagnostic assessment and pursue evidence-based therapeutic treatment.

Conclusions and Clinical Recommendations

We found that social, emotional, and behavioral concerns are highly prevalent and a central concern for foster care and adopted children (Measelle & Ablow, 2018; Shonkoff et al., 2012). These concerns often present in addition to the many medical symptoms’ that foster children are experiencing. Working with an interdisciplinary collaborative team can offer the opportunity for an efficient consideration of other etiologies for behavior and intervention programs to address sensory, physical, genetic, or neurodevelopmental issues. In Anna’s case, she was able to benefit from all aspects of these interventions including medical interventions for micronutrient deficiencies, as well as OT services. Collaborative consultation programs lower the amount of time families spend going to appointments as well as the time demands on providers. This is particularly a positive for families who live in rural communities, who have to travel far distances to receive care. It is essential to not only provide recommendations but also explicitly state how families should prioritize these recommendations. Anna needed help to first address her emerging attachment relationship with Rachel in addition to her immediate medical concerns. Following these services, additional pediatric rehabilitation and sensory-based interventions were effectively introduced.

Collaborative environments should create access points to care while also decreasing the strain of accessing care on families who are balancing the many needs of their children. Potential community mental health referrals should be located in a convenient location for families and operate under a developmental and trauma-informed lens and offer evidence-based treatment. Creating referral lines and professional relationships with community clinics that provide this care was an element central to this program’s success.

However, we also found that for cases like Anna’s it is essential to have opportunities for immediate longer therapeutic sessions with a mental health provider. Many families seeking our care are families currently in crisis where children are facing potential long-term harm to their developmental trajectory. This includes highly distressing child symptoms such as self-harm behaviors or those that are highly challenging for caregivers to manage and who are at risk for placement disruption due to these symptoms.

Integrated care settings that specialize in foster and adoptive care experiences in early childhood could greatly reduce the probability that children will sustain long term consequences of early childhood stress. This case study demonstrated the feasibility and need for these services. Future work should evaluate if access to multiple service providers in one meeting decreased the number of appointments for those children and if it increased knowledge, and access to appropriate therapeutic care for families. Further, studies should evaluate if access to therapeutic care reduces the child’s likelihood of foster care displacement.

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Palmer, Alyssa R., Institute of Child Development, University of Minnesota

Dahl, Claire, Department of Pediatrics, University of Minnesota

Eckerle, Judith K., Department of Pediatrics, University of Minnesota

Spencer, MaryJo, Department of Pediatrics, University of Minnesota

Gustafson, Kimara, Department of Pediatrics, University of Minnesota

Kroupina, Maria, Department of Pediatrics, University of Minnesota

Author Note:

Corresponding author is Maria Kroupina, PhD, LP. Department of Pediatrics, University of Minnesota, 717 Delaware St SE, Minneapolis, MN 55414; e-mail: [email protected]

This work was supported by the Minnesota Department of Human Services [1501MNAIPP-75-1516-1536]; The National Institute of Health [T32 MH015755] and the University of Minnesota Interdisciplinary Fellowship to the first author.

We thank the children and families who participated in our services and the work of Amina Qureshi for data processing.

Ethics Statement: The case study and descriptive pilot data provided were approved by the BLINDED Institutional Review Board. All participants provided consent for their data to be included in scientific research and their related products.

*All names presented in this publication have been changed for privacy.

Data Availability: The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Behavior Management in Young Children Exposed to Trauma: A Case Study of Three Evidence-Based Treatments

• Published: 21 September 2023
• Volume 16 , pages 839–852, ( 2023 )

Cite this article

• Allison B. Smith   ORCID: orcid.org/0000-0003-4335-6237 1 ,
• Daryl T. Cooley   ORCID: orcid.org/0000-0002-8689-4759 1 ,
• Glenn R. Mesman   ORCID: orcid.org/0000-0002-0120-2486 1 ,
• Sufna G. John   ORCID: orcid.org/0000-0002-7555-6340 1 ,
• Elissa H. Wilburn   ORCID: orcid.org/0000-0002-8087-6410 1 ,
• Karin L. Vanderzee   ORCID: orcid.org/0000-0001-9664-5652 1 &
• Joy R. Pemberton   ORCID: orcid.org/0000-0002-4424-7326 1  

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Young children are particularly vulnerable to traumatic events and the development of posttraumatic stress symptoms, including comorbid disruptive behaviors. Fortunately, several evidence-based interventions have been shown to be effective at decreasing both posttraumatic stress symptoms and disruptive behaviors in young children. This paper provides an overview of three such interventions—Child-Parent Psychotherapy (CPP), Parent-Child Interaction Therapy (PCIT), and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). An illustrative case study is used to compare how each intervention addresses disruptive behaviors, with a focus on theoretical underpinnings, model similarities, and model differences. The models each have empirical evidence for the treatment of disruptive behavior in young children, and therefore, may be appropriate for treating children with a history of trauma exposure and comorbid disruptive behaviors. Child, caregiver, and environmental factors are essential to consider when identifying an evidence-based intervention for this population.

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Trauma-Focused Cognitive-Behavioral Therapy

Systematic Review on the Application of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for Preschool-Aged Children

Austen McGuire, Ric G. Steele & Mehar N. Singh

Trauma-Focused Cognitive Behavioral Therapy

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Smith, A.B., Cooley, D.T., Mesman, G.R. et al. Behavior Management in Young Children Exposed to Trauma: A Case Study of Three Evidence-Based Treatments. Journ Child Adol Trauma 16 , 839–852 (2023). https://doi.org/10.1007/s40653-023-00573-7

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Innovations in maternal and child health: case studies from Uganda

• Phyllis Awor 1 ,
• Maxencia Nabiryo 1 &
• Lenore Manderson 2 , 3 , 4  

Infectious Diseases of Poverty volume  9 , Article number:  36 ( 2020 ) Cite this article

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Nearly 300 children and 20 mothers die from preventable causes daily, in Uganda. Communities often identify and introduce pragmatic and lasting solutions to such challenging health problems. However, little is known of these solutions beyond their immediate surroundings. If local and pragmatic innovations were scaled-up, they could contribute to better health outcomes for larger populations. In 2017 an open call was made for local examples of community-based solutions that contribute to improving maternal and child health in Uganda. In this article, we describe three top innovative community-based solutions and their contributions to maternal health.

In this study, all innovations were implemented by non-government entities. Two case studies highlight the importance of bringing reproductive health and maternal delivery services closer to populations, through providing accessible shelters and maternity waiting homes in isolated areas. The third case study focuses on bringing obstetric imaging services to lower level rural health facilities, which usually do not provide this service, through task-shifting certain sonography services to midwives. Various health system and policy relevant lessons are highlighted.

Conclusions

The described case studies show how delays in access to health care by pregnant women in rural communities can be systematically removed, to improve pregnancy and delivery outcomes. Emphasis should be put on identification, capacity building and research to support the scale up of these community-based health solutions.

Every day, about 300 neonates and infants and 20 mothers die from preventable causes in Uganda [ 1 ]. Most of these deaths occur during delivery and within the first month of life. These deaths are mainly caused by complications to the mother and child in labour and during delivery, and in association with infectious diseases of poverty including malaria, pneumonia, sepsis and HIV/AIDS [ 2 ]. These statistics have remained almost the same over the past 10 years, while the Ugandan government (like others in low income countries) is grappling with low human resources for health, lack of medicines, equipment and diagnostics, weak governance, and limited funding for health [ 3 ].

In Uganda, maternal mortality is mainly attributed to the “three delays”: delay in making the decision to seek care; delay in reaching a health facility in time; and delay in receiving adequate treatment [ 4 ]. The first delay is attributed to the failure of the mother, her family, or the community to recognize a life-threatening condition; in this context, lack of awareness of pregnancy-related health risks is a major reason for the low uptake of maternal health services [ 5 ]. The second delay is associated with delays in reaching a health centre, due to road conditions, lack of or cost of transportation, or location of the facility: over 40% of rural women in Uganda report distance-related barriers to accessing healthcare [ 6 ]. The third delay occurs at the facility where, upon arrival, women receive inadequate care or ineffective treatment because most health facilities in Uganda, especially in rural areas, persistently lack the necessary medicines and equipment to care for mothers during pregnancy and at the time of and after delivery [ 7 ]. The ‘three delays’ model reveals the complexity of maternal health challenges. To tackle these issues, there is need for multi-disciplinary and inclusive approaches that engage various stakeholders, including community members, in solving these problems [ 8 ].

Communities often identify and introduce pragmatic and lasting solutions to challenging health problems. Little is known of these solutions beyond their immediate surroundings, but if some of these were scaled-up, they could contribute to better health outcomes for larger populations. In this article, we focus on community-based solutions for maternal health in Uganda.

Study design

The three case studies described in this article were identified through a six-week crowdsourcing call, in May and June 2017, which invited individuals and community organizations to share their community-based solutions to improve maternal and child health in Uganda. The call was launched through newspaper advertisements in the five main local languages in Uganda and through multiple seminars at Makerere University and with the Ministry of Health technical working groups on maternal and child health, e-health and monitoring and evaluation and operational research. The call was further disseminated through different online platforms, print media, and radio advertisements.

Twenty nine nominations were received from diverse implementers across the country. The submitted nominations were within the following categories: improving access to delivery care, for example, by providing maternal waiting homes; phone apps for pregnancy information and for sexual and gender-based violence reporting; improving neonatal care; ultra sound scanning devices; and creating better social and economic opportunities for disadvantaged women and children. Twenty one nominations were eligible and these were reviewed by an external independent panel of judges that included experts from academia, non-governmental organizations and the Ministry of Health. Five top solutions were selected for further case study research.

Data collection

To better understand the successful social innovations in health, we investigated for novel processes, products, policies, market mechanisms, and practices addressing the health challenges. A descriptive and explorative case study research approach was utilized to understand the selected projects better and to explore the role of social innovation in improving the lives of women and children in Uganda. Further, exploration of cross-case themes that have transferable properties within and between different contexts was undertaken.

Data collection followed the case study methodology as proposed by Yin and Eisenhardt [ 9 ] [ 10 ] This approach allows for an in-depth systematic exploration of a phenomenon via the collection and analysis of multiple forms of data. Yin proposed the use of six sources of evidence as a way to achieve construct validity in case study research. These include documentation, archival records, interviews, direct observations, participant observations, and physical artefacts [ 9 ]. The various forms of data enable an enriched, multi-dimensional layout of the phenomenon of query and supports construct validity.

In this research, data was both qualitative (in depth interviews, observations) and quantitative (evaluation data on the impact of the solution and existing disease and systems indicators on the local health context). Field visits were conducted, and implementers and beneficiaries of the solutions were interviewed. The interviews were recorded and transcribed, and supplementary information was received from the organizations’ records, including reports. This triangulation of multiple forms of qualitative and quantitative data enabled the research team to examine certain aspects in depth, to compare different forms of data around the same aspects, and to constitute or support the coding of a concept using multiple forms of data. Traingulation was also useful for quality control. The collected information was analysed to generate case study reports that reflect the innovative components of each case study and the key health system recommendations for policy makers and implementers.

To support the construction of the social innovation case, data collected through different methods was triangulated as per Table  1 below.

Case studies

Below, we describe three case studies of social innovation in maternal and child health, and provide health system and policy relevant recommendations. Two case studies demonstrate the importance of bringing reproductive health and maternal delivery services closer to recipient populations, through providing accessible shelters and maternity waiting homes in isolated areas. The third case study focuses on bringing obstetric imaging services to lower level rural health facilities, which usually do not provide this service. Figure  1 shows the location of the case studies in Uganda.

Map of Uganda showing locations of the case studies

Case 1: mothers’ waiting hostel at Bwindi community hospital

Bwindi Community Hospital (BCH) is a private not-for-profit health facility in South Western Uganda, that has sought to address some of the delays in women’s access to health care by providing a maternity waiting home for pregnant women from remote and hard-to-reach areas for about 1 month prior to expected date of delivery. BCH began as an outreach clinic without fixed facilities — it literally operated under a tree — but it has expanded to a 112-bed hospital which provides health care and health education to the surrounding population.

The hospital serves over 100 000 people, including the Batwa pygmies who lived in the Bwindi forest, and were evicted when the area was made a national park in 1991. The Batwa have been subject to systematic structural violence, with extremely poor health as a result of poverty and displacement. The hospital initially aimed to serve the Batwa, but then expanded to provide health care for other people also in the surrounding sub-counties of Kayonza, Kanyantorogo and Mpungu. The terrain is mountainous and settlements isolated; in consequence, women often walk for approximately 8 h to reach a health care centre [ 11 ].

The waiting hostel was established in 2008 within the BCH to provide pregnant women with a place to stay prior to delivery, so that they did not have to endure long journeys through difficult terrain when they were in labour. By its location within the hospital, the waiting hostel ensured that pregnant women would have access to a skilled birth attendant at delivery. It also ensures that women who are HIV infected are enrolled onto the prevention of mother to child transmission (PMTCT) program, to protect their children from infection. Women are required to make a one-time payment of United States Dollars (USD) 1.5 for the duration of their stay in the hostel. BCH leverages funding from other hospital programs and existing structures, such as sexual and reproductive health services and the Community Based Health Insurance Scheme (CBHI). These services have now been in operation for 10 years.

BCH utilizes existing hospital staff to take care of the women in the waiting hostel. A full time nurse checks each day women’s general condition and vital signs (blood pressure, fetal heart rate etc.). In case of emergency, the fully equipped hospital operating theatre is available and a full time obstetrician is on duty. At the hostel, women prepare their own meals and contribute to cleaning. They also receive basic health education, including on how to prepare nutritious meals for their infants and young children. First time mothers are also engaged in peer learning on how to care for a new-born. The nurses and midwives also conduct sexual health sessions on child spacing, the advantage of small families, and family planning methods, so that women make an informed choice about contraceptive use.

The community health worker outreach program

BCH has a community health outreach department with three community health nurses, who work with 502 community health workers in 101 villages to conduct health promotion activities and identify women with high risk pregnancies. Women in the high-risk category as per the WHO definition are especially encouraged to stay at the hostel a few weeks before their expected date of delivery.

Impact on health care delivery

From July 2006 to 2012, on average 106 deliveries occurred monthly and an estimated 30% of the mothers utilized the hostel. In 2014, there was a 10.5% increase in women’s utilization of the mothers’ waiting hostel by women from distant sub-counties; and a fourfold increase in the utilization of delivery services at BCH. By 2017, the hospital was delivering an average of 150 babies monthly, and approximately 45–60% of the women utilized the waiting hostel. Thus increasing numbers of women marginalized by location have been accessing the hostel, the antenatal care it provides, and the PMTCT program. In total, following the launch of the health insurance scheme March 2010, there has been a consistent increase in outpatient attendance, inpatient admissions, and deliveries at BCH. Further, about 150 children receive immunization services weekly and all new-born babies received. Bacille Calmette-Guerinand polio vaccines on the maternity ward.

The idea of a maternity waiting hostel is not new in African or other settings. Global guidance on waiting homes in hard-to-reach areas exit, and many countries have related policies [ 12 ]. However, in Uganda, there are no publicly run maternity waiting homes. Over 30% of women in rural areas deliver at home, because of continuing barriers to seeking, reaching and receiving quality maternal health care [ 13 ]. Distance to a health facility, limited transport services and the direct and indirect costs of travel all influence women’s delivery location, with women living the farthest away from facilities most likely to deliver at home [ 13 , 14 , 15 ]. Maternity waiting homes like this one in BCH can contribute to increased access to skilled birth attendants, timely interventions, and better delivery outcomes.

Case 2: imaging the world, Africa

Due to low income and lack of advanced medical imaging technology, rural women living in remote and under-served areas are unable to access diagnostic imaging, and so have difficulty in receiving timely diagnosis of pregnancy complications. This increases the risk of severe morbidity and mortality among pregnant women. Imaging the World Africa (ITWA) is a Ugandan-registered NGO which focuses on incorporating low-cost ultrasound services into remote health care facilities which routinely do not provide this service, which lack the standard infrastructure required of imaging systems, and where there is a shortage of radiologists. ITWA integrates technology, training and community participation to bring medical proficiency and high-quality imaging services to the population [ 16 ].

The imaging the world model

The ultrasound program was originally introduced in 2010 to identify high-risk pregnancies in one health facility in eastern Uganda, and expanded to six other districts and 11 facilities by 2016. The model incorporates point of care ultrasound imaging devices, task shifting, training and innovative real-time external radiological expert reviews, using telemedicine services. It combines these services with community awareness and pragmatic funding models that promote self-sufficiency. ITWA provides the program by training nurses and midwives at remote health centres to perform basic ultrasound scans. ITWA developed software to compress and transmit full ultrasound images via the internet to an offsite team of participating radiologists, both in Uganda and abroad, for real-time interpretation, enabling them to review the images, provide a diagnosis, and relay the results back to the transmitting centre.

Task-shifting training program

ITWA equips nurses and midwives with the skills and knowledge to conduct obstetric ultrasound scans. They developed a 6 to 8 week certified training program for non-specialist health workers located in rural areas, delivered at the Ernest Cook Ultrasound Research and Education Institute (ECUREI), a private for-profit sonography training centre located in Kampala. Selected midwives or nurses with an expressed interest in sonography undertake practical and theoretical training on how to conduct abdominal sweeps and transmit the images for interpretation. Once health professionals have successfully completed the training course, they are awarded a certificate of completion and ITWA then provides the health facilities in which they are based with ultrasound machines to perform scans.

E-health/telemedicine ultrasound radiology service

ITWA developed software (utilizing Digital Imaging and Communications in Medicine) that compresses and transmits full ultrasound images via the internet. During ultrasonography, the probe is passed across the abdomen of the pregnant woman in a series of six prescribed sweeps using a low-frequency transducer, so acquiring a series of static images. These images are de-identified and stored locally on a computer before being compressed and transmitted digitally via an internet connection. They can then be immediately viewed by participating radiologists, the majority of whom are local Ugandan radiologists who volunteer to interpret the scans. An abbreviated report of the findings is sent via SMS to the nurse/midwife’s cell phone, and a full report is sent by email, usually within an hour. In order for this to happen, there must be a laptop, a cell-phone, internet connection, and an ultrasound machine at the point-of-care.

ITWA has rolled out ultrasound services in 11 rural health facilities in Uganda and has trained 150 health workers to perform obstetric ultrasound. Since 2010, 200 000 ultrasound scans have been conducted, with each scan generating data to aid decision making. ITWA maintain that obstetric ultrasound results have helped change the management in 23% of pregnancies with complications. The others did not require imaging for decision making.

The availability of ultrasound scans has allowed pregnant women to receive timely care at the appropriate level of health facility, thereby reducing unnecessary delays and complications of delivery. This has led to an increase in the number of women seeking antenatal care, increased male involvement in ANC services and attendance, because of their interest in seeing an image of the unborn child, and improved birth planning.

Ultrasound sonography has been extended to include echocardiography through a cardiac ultrasound pilot program, with radiologists in the US usually viewing and supporting the interpretation of these images. The pilot program identified 58 pregnant women with heart disease, who were monitored and treated at the clinic close to home. Seven women were monitored for specialized delivery, and one had her first baby after multiple late pregnancy fetal deaths [ 16 ]. The US-based radiologists also provide support in interpreting other complex images, such as those taken to determine breast cancer.

Case 3: action for women and awakening in rural environment (AWARE-Uganda)

AWARE-Uganda is a non-governmental organization operating in three districts of Karamoja region in northeast Uganda: Kaabong, Kotido and Abim districts. Karamoja is the least developed region in the country, with low levels of employment, high levels of illiteracy, food insecurity, poverty and poor health care services, intimate partner violence, and a history of armed conflict, abduction and war-related gender-based violence [ 17 ]. The consequences of these challenges, coupled with unfavourable attitudes towards women’s education and community beliefs in the value of early marriage for wealth, have caused great suffering to women and girls in the area [ 18 , 19 ].

The AWARE holistic approach to women’s health and empowerment

AWARE Uganda was established in 1989 by a group of local women in Kaabong district with the aim of advancing the social, cultural and economic status of women in the region [ 20 ]. AWARE utilizes a holistic approach to address development issues through women’s empowerment and engagement to improve their own and others’ livelihoods in their community. AWARE provides supportive conditions for women to engage in small business enterprises and agricultural practices, and to increase their roles in leadership and decision making. Women are also sensitized about their rights.

With the establishment of a maternity waiting house, the organization has also improved access to maternal and child health care services, bringing pregnant women closer to Kaabong hospital. As a result, maternal and perinatal morbidity has been reduced.

AWARE-Uganda has engaged and empowered over 5000 women in its activities, including the delivery of an integrated package of services to address the health, economic and social needs of women. Most activities at AWARE are offered by local volunteers, often previous beneficiaries, contributing to the sustainability of the program. Working with men to address negative gender dynamics and to change beliefs around the value of women has been critical, illustrating how empowering and engaging with vulnerable groups and their communities is an effective approach to creating social change.

Impact on women’s health

AWARE has conducted community sensitization and capacity building on gender-based violence and intimate partner violence to police officers, health workers, elders, district leaders, and in schools, where child rights clubs have been established in Kaabong district. Community members, including children, are also sensitized on all forms of discrimination against women and human rights, case handling, and reporting procedures. Over 50 girls have been rescued from various forms of violence including gender-based violence and forced marriages, and have received counselling from AWARE staff who also link them to treatment at Kaabong hospital.

In 2016, AWARE Uganda conducted 28 training workshops for ten women’s groups on the use of modern farming methods, including the use of ox ploughs, crop spacing, and making and using composite manure to improve soil quality and crop yields. These skills were shared with over 370 households. AWARE purchased 25 ploughs and 25 ox chains, and 550 hoes, pangas and axes to assist women in agriculture. About 200 women from four communities were involved in chilli and honey production, improving their livelihood and those of their families.

AWARE also runs a mother’s waiting home in the semi-arid Karamoja region. The 20-bed maternal waiting home at the AWARE centre was established in 2010 and is the only one of its kind in the area. Since this date to time of writing (2019), over 500 women have received services at this facility per annum, including antenatal case, clinical monitoring when the pregnant women is resident at the home, and skilled delivery care; many more receive health education information. About 1000 people have utilized family planning services provided at AWARE.

With support from partners, AWARE distributed 12 040 home health care kits, including condoms, to community members in Kaabong district. AWARE registered and trained 32 Village Health Teams (VHTs) to operate in five sub-counties, with VHTs following up on those who need care at household or community level.

Leveraging community social capital as a resource for this organization was pivotal. The founders did not wait for funding opportunities to start organizing women, but rather, drew on women’s ideas, energy and time. Women asked for land from the district government and were granted this. They then bought and planted 150 fruit tree seedlings, and this marked the start of their activities.

Utilizing volunteers and beneficiaries was key to sustaining AWARE’s efforts, and it has operated for 30 years in these rural areas. Women have become empowered to support other women in similar situations. AWARE believes in working with partners to strengthen and advance work, and in this context, the police and Kaabong Main Hospital work together to support the organization in addressing gender-based violence, receiving and attending to referrals from the organization. One major challenge that AWARE had was to overcome negative attitudes towards women, and to change men’s mind set, AWARE started involving men in activities while working to empower women. AWARE has therefore shown that it is possible to overcome discriminatory cultural perceptions and practices through committed long-term involvement.

These three cases provide innovative and pragmatic solutions to the three delays in access to health care, which are known to significantly contribute to maternal mortality in Uganda. When pregnant women in remote and hard to reach locations access and utilize maternal waiting homes prior to the onset of labour and delivery, this immediately removes the problem of recognition of danger signs in pregnancy, as well as that of delayed health care decision making and lack of access to a skilled birth attendant. In addition, taking ultrasound imaging closer to pregnant women, also directly contributes to reductions in all the three delays. This is through early recognition of high risk pregnancies like multiple pregnancies and placenta previa and decision making related to birth planning and delivery.

Key health system lessons

Based on these case studies, three key health system lessons emerge:

The first is that while maternity waiting homes for high-risk pregnant women in remote areas are recommended in national and global health policies, they are almost non-existent in Uganda and other low income settings. Maternity waiting homes can contribute to increasing institutional deliveries, reducing obstetric delays and improving maternal and perinatal health outcomes in remote areas. In hard to reach areas, maternity waiting homes may contribute to reducing the high maternal deaths. As shown above, the waiting home can also provide opportunities for health education for mothers to improve the wellbeing of their new born children and families. For stronger effect, CHW outreach programs can contribute to identifying and getting women into hospital in remote and inaccessible areas.

The second health system lesson relates to the important role of shifting some acceptable health care roles from higher qualified to less qualified health workers (task shifting). The majority of community-based innovations identified within the SIHI involved some task-shifting activities. As we have illustrated for ITWA, task shifting can create an effective way to deliver ultrasound services to low resource settings. Trained midwives can conduct the ultrasound scan, reducing the cost of hiring a sonographer in low resource and remote settings. In addition, the integration of telemedicine for the interpretation of ultrasound scans is feasible and provides an opportunity to improve the quality of care to patients.

Thirdly, in order to contribute to effective social change for women experiencing discrimination and violence, full community and multi-sectoral action is necessary, including men’s participation in women’s empowerment and increased decision making. The bottom up approach utilised by AWARE is important for effective change. AWARE works to ensure that all community members (men and women) have skills to improve their livelihoods and to support gender equality. Past program beneficiaries, for example, women and girls who experienced GBV, can become active providers of services to new beneficiaries, sensitizing them about gender-based violence and contributing to sustainability.

Principles of social innovation

All these cases also demonstrate the principles of social innovation [ 21 , 22 ]. These are: strong community participation; multi-stakeholder engagement; addressing gaps in health and wellbeing (needs-based); and contribution to transformation in the health and lives of beneficiaries. Additional characteristics of the three case studies are that they are complementary to public health care provision and they focus on improving access to health care (affordability of services, bringing services closer to the people, and utilization of task-shifting mechanisms).

Affordability is a key component of these social innovation solutions, as services must be provided at an affordable price, so that communities can access them consistently, and sustainably. Two of the solutions request a user fee of about USD 1.5, while AWARE provides free services, sustained by the grants it receives.

Finally, availability of health services and geographical access are key components, which are addressed in these case studies through the utilization of lay community health workers to provide health services and through task shifting and training midwives for obstetric imaging service provision.

The ability of communities to identify and implement practical solutions to health care challenges in low income settings needs to be recognised and embraced. The described case studies show how delays in access to health care by pregnant women in rural communities can be systematically removed, to improve pregnancy and delivery outcomes. Stronger emphasis should be put on identification, capacity building and research, in order to support the scale up of these community-based health solutions.

Availability of data and materials

Original case studies are available online at https://socialinnovationinhealth.org/uganda/

Abbreviations

Antenatal care

Action for Women and Awakening in Rural Environment

Bacille Calmette-Guerín

Bwindi Community Hospital

Community Based Health Insurance Scheme

Chief executive officer

Community health worker

Ernest Cook Ultrasound Research and Education Institute

Gender Based Violence

Imaging the World Africa

Mothers’ Waiting Hostel

Non-governmental organization

Social Innovation in Health Initiative

Special Programme for Research and Training in Tropical Diseases

United States dollar

Village health team

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Acknowledgements

We acknowledge the individuals who supported the data collection and case study writing: Juliet Nabirye, Christine Nalwadda and Lindi van Niekerk. We also acknowledge input from participants from the case studies who provided input toward their individual case studies that are available online. They are: Grace Luomo, Birungi Mutahunga, Renny Ssembatya and Matovu Alphonse.

The Social Innovation in Health Initiative (SIHI) Uganda received funding from the Special Programme for Research and Training in Tropical Diseases (TDR) to conduct this research.

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Phyllis Awor & Maxencia Nabiryo

School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

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School of Social Sciences, Monash University, Melbourne, Australia

Institute at Brown for Environment and Society, Brown University, Providence, RI, USA

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PA contributed to the development of the research protocol. PA and MN engaged in data collection and writing of the first drafts of the case studies. LM reviewed the drafted case studies and the manuscript and provided professional expertise that improved the writings. PA wrote the first draft of the manuscript. All authors provided input and endorsed the final version. All authors read and approved the final manuscript.

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Awor, P., Nabiryo, M. & Manderson, L. Innovations in maternal and child health: case studies from Uganda. Infect Dis Poverty 9 , 36 (2020). https://doi.org/10.1186/s40249-020-00651-0

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• Community-based solutions
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• Social innovations in health
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Infectious Diseases of Poverty

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In this chapter we present a number of practical examples related to pediatric public health for health professionals and other colleagues. The first describes the general approach to making a community diagnosis and establishing a response strategy; the rest address specific timely problems. For each example, a case scenario is described and followed by a short review of the epidemiology or relevant background, a survey of the evidence, a list of the stakeholders likely to be involved, and a suggested practical approach to tackling the problem.

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Traditional Versus Equity-Based Approaches

Implications, call to action, addressing child health equity through clinical decision-making.

FINANCIAL DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose.

POTENTIAL CONFLICTS OF INTEREST : The authors have indicated they have no potential conflicts of interest to disclose.

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Jeffrey P. Yaeger , Amina P. Alio , Kevin Fiscella; Addressing Child Health Equity Through Clinical Decision-Making. Pediatrics February 2022; 149 (2): e2021053698. 10.1542/peds.2021-053698

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The COVID-19 pandemic has thrust a spotlight on the reality that pediatricians have long understood: Children from disadvantaged groups, including children of color and those living in poverty, experience worse health outcomes relative to their more privileged peers. 1 – 3   This is the very definition of health inequity. 4   Health inequity is largely attributed to differences in a child’s psychosocial, physical, and economic environments or to social determinants. However, these differences and subsequent health inequities are not chance events, but are deeply rooted in societal and health care structures characterized by systemic racism. 5   Health systems have a substantial impact on health equity, largely through access to services, clinicians’ decisions, and quality of care. 6   Decision support tools based on clinical practice guidelines (CPGs) can reduce cognitive load for clinicians, standardize care, and improve outcomes. 7   When we consider equity and implementation principles from the outset, CPGs can reduce inequities. 8   Conversely, CPGs can paradoxically exacerbate inequities through differential access and uptake or by providing greater benefit to advantaged (lower-risk) groups relative to disadvantaged (higher-risk) groups. 8   For example, after publication of a CPG for attention-deficit/hyperactivity disorder, 9   African American and Hispanic children were more likely to stop medication and disengage from treatment all together, possibly reflecting suboptimal communication related to addressing concerns of the parent and/or child about taking medications. 10   Another example is the American Academy of Pediatrics (AAP) CPG for urinary tract infections, which included race as a risk factor for urinary tract infections and suggested differential race-based evaluation and management. 11 , 12   Published in 2011 and reaffirmed in 2016, this CPG was retired in May 2021. 13   CPGs endorsed and/or developed by the AAP are particularly important because they often become the standard of practice, informing clinical decision-making for pediatricians and child health providers throughout the United States and the world. 14  

In 2010, the AAP published the policy statement Health Equity and Children’s Rights, laying a foundation for pediatricians to consider social determinants of health and helping every child to achieve their fullest potential through advocacy and community engagement. 15   This policy statement recommended the integration of child health equity principles into clinical practice but did not explicitly describe how to do so. Now is the time to build on this policy statement and formally apply an equity lens to CPGs, clinical reports, and clinical decision-making, thereby helping all children to attain optimal physical, mental, and social health and well-being. In this perspective, we compare traditional CPG development with an equity-based approach, discuss implications of using an equity lens to inform clinical-decision making, and provide recommendations to integrate equity principles into future CPGs.

Traditionally, professional societies and institutions use rigorous processes and the best available evidence to develop CPGs and clinical reports that inform clinical decision-making. 16   Objectives include reducing inappropriate variation, optimizing outcomes, minimizing harm, and promoting cost-effective practices. 14   CPGs address specific questions and collect, summarize, and assess evidence, including important aspects of the study design, anticipated benefits and harms, risk of bias, and magnitude of effect. 14 , 16   Although the process prioritizes transparency to ensure credibility and acceptability, 16 , 17   implementation barriers often limit clinical adoption. 18 , 19  

An equity-based approach maintains this foundational structure, but also explicitly includes equity principles. Eslava-Schmalbach et al 8   proposed 9 equity-focused steps to develop and implement CPGs ( Table 1 ). Integrated with the traditional approach, these steps fundamentally restructure CPG development by (1) explicitly embedding equity principles and (2) viewing development and implementation as 2 equally important phases considered in concert at the outset. For example, by identifying disadvantaged groups and quantifying current health inequities in the development phase, CPG authors can send a clear signal that disease burden is not uniformly distributed, endorsing recommendations that reflect these differences. CPG workgroups can use the PROGRESS acronym (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital) to define disadvantaged populations. 20 , 21   The implementation phase underscores the need to identify implementation barriers in different settings, design strategies to overcome these challenges, and plan approaches to monitor and evaluate effects of recommendations in disadvantaged and privileged populations. This equity-based approach may be applied to all CPGs, ranging from those focusing specifically on equity issues to those with broader relevance to the general population in which a subset of recommendations would target disadvantaged populations and inequities. 8  

Steps in Consideration of Equity for CPG Development and Implementation

The implications of an equity-based approach to CPG development are profound. First, unanticipated barriers (ie, money, time, pain, stress), typically related to obtaining important predictors such as biomarkers, often limit clinical adoption of CPGs and decision support aids. 22 , 23   An equity-based approach that considers implementation barriers in the initial stages of CPG development may lead to increased clinical adoption. Second, although it is likely unrealistic to account for every scenario in which a CPG may be used, an equity-based approach would inherently consider contextual factors related to the diverse array and combinations of clinic and practice types (eg, hospital-based, private, rural practice) and patient/caregiver access barriers and preferences. Thus, scarce and finite institution- and practice-level resources, previously reserved to enhance CPG implementation, may now be directed toward other high-priority initiatives. Additionally, by considering patient/caregiver preferences, the CPG could lay a path toward shared decision-making. Third, by applying the standard tenets of high-quality critical appraisals of the literature to equity-related outcomes, CPGs would inherently identify gaps in knowledge. Therefore, CPGs can serve an additional role of helping to establish an agenda for child health equity research. Finally, building equity into CGPs aligns practice with the AAP’s position on diversity, inclusion, and health equity and its Equity Agenda. 24 , 25  

It is essential to retain stringent and rigorous processes to develop CPGs, identifying and qualifying evidence while summarizing limitations. Additionally, to ensure that clinical decisions improve outcomes for all children, CPG and clinical report recommendations should also identify equity as an important outcome and consider implementation barriers in different settings. We propose a call to action with the following recommendations to the AAP as starting points in achieving child health equity. First, CPG development should be grounded in an equity-based approach, integrating development and implementation phases. Second, authors and workgroup members of CPGs and clinical reports should reflect the diversity of the children affected by the guideline in terms of race, ethnicity, disability, and so forth. Content experts and organizational liaisons are essential, but so are context experts who understand the perspectives of individuals affected by clinical decisions and subsequent consequences. The AAP should ensure that members of its Committee on Native American Child Health; the Section on Minority Health, Equity, and Inclusion; the Council on Community Pediatrics; and the Council on Immigrant Child and Family Health participate in developing CPGs and clinical reports. Additionally, caregivers, school representatives, providers from federally qualified health centers and America’s Essential Hospitals, 26   a Family Voices representative, 27   and community-based organizations should also be included. This diverse network of individuals would be well equipped to inform an equity-based approach while maintaining the scientific rigor expected by pediatricians. Third, members of the AAP Partnership for Policy Implementation group, who collaborate with CPG workgroups to produce clear recommendations and facilitate implementation efforts, should also embrace an equity-based approach. Finally, a formalized task force charged with monitoring outcomes and implementation challenges, particularly in disadvantaged groups, should assess each CPG and report findings to drive future research and inform revisions.

To address child health equity in the 21st century, we need a bold and multifaceted approach. By using an equity-based approach to develop and implement CPGs, pediatricians will gain one more tool to help reduce inequities and improve outcomes for all children.

Dr Yaeger conceptualized and designed the manuscript, drafted the initial manuscript, and revised the manuscript; Drs Alio and Fiscella helped to refine the concept for the manuscript and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

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Children and Families Policy Research Unit

NIHR Children and Families Policy Research Unit

Case Study: The Healthy Child

Family formations and health: how and why family structure affects children's health.

Does family structure impact physical and mental health in children?

Around one quarter of UK children live in lone parent families, and there are over half a million step-families. So, any impact that family structure might have on a child's well-being would have far-reaching consequences on a country-wide scale.

Under the healthy child theme, the CPRU set out to explore the health impacts of family structure, in order to inform the development of welfare policy that best supports equal life opportunities for all UK children.

Key Points:

• Data analysis examined the health of children in different family structures: families with both natural parents, lone parent families and step-families 
• Physical health was worse in children who lived with a lone parent or in step-families, but these small differences were accounted for by the fact that lone parents and step families tend to be poorer
• Children's mental well-being was worse in step-families, and in other families where there had been family disruption, even after taking account of their increased risk of disadvantage
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Publication date: 2017

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Bowes L., Maughan B., Caspi A., Moffitt T., Arseneault L. Families promote emotional and behavioural resilience to bullying: Evidence of an environmental effect. The Journal of Child Psychology and Psychiatry. 2010; 51:(7)809-817 https://doi.org/10.1111/j.1469-7610.2010.02216.x

Bronfenbrenner U. Toward an experimental ecology of human development. American Psychologist. 1977; 32:(7)513-531 https://doi.org/10.1037/0003-066X.32.7.513

Chester K. L., Callaghan M., Cosma A., Donnelly P., Craig W., Walsh S., Molcho M. Cross-national time trends in bullying victimisation in 33 countries among children aged 11, 13 and 15 from 2002 to 2010. Eur J Public Health. 2015; 25:61-64 10.1093/eurpub/ckv029

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Eyuboglu M., Eyuboglu D., Pala S. C., Oktar D., Demirtas Z., Arslantas D., Unsal A. Traditional school bullying and cyberbullying: Prevalence, the effect on mental health problems and self-harm behaviour. Psychiatry Res. 2021; 297 10.1016/j.psychres.2021.113730

Gingerich W., Peterson L. Effectiveness of solution-focused brief therapy: A systematic qualitative review of controlled outcome studies. Research on Social Work Practice. 2013; 23:(3)266-283 https://doi.org/10.1177%2F1049731512470859

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A Path to Inclusiveness – Peer Support Groups as a Resource for Change. 2022. 10.1177/10598405221085183

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Kendrick K., Jutengren G., Stattin H. The protective role of supportive friends against bullying perpetration and victimisation. Journal of Adolescence. 2012; 35:(4)1069-1080 https://doi.org/10.1016/j.adolescence.2012.02.014

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Krusell M. K., Hohwü L., Bjereld Y., Madsen K. B., Obel C. The impact of childhood bullying on the daily lives of Nordic children and young adolescents. Acta Paediatr. 2019; 108:(6)1096-1102 10.1111/apa.14642

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Kvarme L.G., Eboh W, Monsen K The role of school nurses using a systematic framework (approach) to support schoolchildren affected by cyber bullying. Journal of Psychosocial Nursing and Mental Health Services. 2014; 52:(3)34-41

Lund I., Helgeland A. Mobbing i barnehage og skole.: Cappelen Damm Akademisk; 2020

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: Norwegian Directorate of Health; 2017 https://www.helsedirektoratet.no/retningslinjer/helsestasjons-og-skolehelsetjenesten

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Support group for a bullied schoolchild: A case study

Lisbeth Gravdal Kvarme

Professor, Oslo Metropolitan University, Oslo, Norway

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Ann Jeanette Heitman

Assistant professor, Oslo Metropolitan University, Oslo, Norway

Lisbeth Valla

Associate professor, Oslo Metropolitan University, Oslo, Norway

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Bullying among schoolchildren has long-term consequences for children's health. Support groups could be an effective method against this. The aim of this study was to explore the experiences of the children, mothers, and school nurse regarding bullying and support groups.

This study is a qualitative exploratory design case study, with interviews of the participants. Individual interviews were conducted with the bullied child, two mothers and the school nurse and focus group interviews were had with seven boys in the support group. The bullied boy coped better after receiving help from the support group, his family and the school nurse. We found that working together as a team is important to prevent bullying, and the school nurse reported being happy to have the support group as a tool.

Bullying among schoolchildren is a significant public health problem worldwide with long-term detrimental consequences on children's physical and mental health. The prevalence of being bullied is 36% and 15%, respectively in the USA and European countries ( Chester et al, 2015 ; Eyuboglu et al, 2021 ; Modecki et al, 2014 ) and ranges from 7% to 20% in Scandinavia ( Krusell et al, 2019 ). The Norwegian government maintains that in accordance with regulation for health promotion and prevention in the school health services, the school nurse will collaborate with the school to create a good psychosocial environment for the children ( Norwegian Directorate of Health, 2017 ). The United Nations Convention on the Rights of the Child reflects the international consensus on standards for ensuring the overall wellbeing of all children and young people up to the age of 18 years ( World Health Organization, 2013 ).

A solution-focused approach (SFA), designed to find solutions rather than focus on a specific problem, is an effective treatment strategy for a wide variety of behavioural and psychological outcomes ( DeJong and Berg, 2002 ; Gingerich and Peterson, 2013 ; Öztürk Çopur and Kubilay, 2021 ). This approach provides an opportunity for the children to feel that they are important contributors to their own lives and social circle. The SFA emphasises people's personal strengths and successes as valuable learning experiences ( Young and Holdorf, 2003 ). SFA acknowledges that people can change, and presumes that shifting from being a victim to taking a stand creates optimism, self-belief, and trust that a situation can be altered ( Young, 2009 ). The SFA uses the role of friendship to promote the social and emotional competence of students ( Heitmann et al, 2022 ; Kvarme et al, 2015 ).

In Norway, the government decided that different organisations working with children and youth must collaborate to prevent bullying. They established the Partnership Against Bullying coalition, which consists of 14 national organisations, including the Norwegian Public Health Nurses Organization. This coalition shares a vision of inclusive learning environments that are free from bullying for all children. This research has contributed to understanding bullying in school as repeated negative behaviour from one or more people together, aimed at someone who cannot defend themselves. Recently, this understanding has been challenged by Nordic researchers ( Lund and Helgeland, 2020 ; Søndergaard, 2012 ) who consider bullying as an expression of social marginalisation where exclusionary mechanisms in children and young people's communities create a fertile ground for bullying. This new thinking reflects a shift in focus from individual characteristics to the social processes that may lead to bullying. Inspired by this research, we sought to understand bullying using a systemic approach.

Bronfenbrenner's (1977) systemic approach was used as a framework for school bullying. Structures where children have direct contact are referred to as a microsystem, including peers, family, community, and schools. The interaction between the microsystems occurs in the mesosystem; for example, the interaction between the family and school, such as parental involvement in their child's school ( Bronfenbrenner, 1977 ).

To our knowledge, a systemic approach has not yet been used to understand the experience of bullied children and their supporters in SFA groups.

The aim of this study was to explore the experience of the children, mothers, and school nurse with regard to support groups.

This study has a case study design with a focus group and individual interviews. The data were collected and analysed in accordance with the guidelines for qualitative research, which imply a phenomenological hermeneutic mode of understanding. Qualitative methods of interviewing the participants regarding their experiences with support groups were used. Graneheim and Lundman's (2004) methodology for data analysis was applied. This study was approved by the Regional Ethical Committee.

The study sample consisted of 10 participants. The participants included seven schoolchildren: one boy who was bullied and six boys in the support group. Two mothers, one representing the bullied boy and one representing a child from the support group, and the school nurse were also interviewed. The boys were aged 9–10 years, and they lived with their parents and siblings. The participants volunteered after receiving the relevant information about the study.

Data collection

The data were collected at the children's school during March 2021. Individual interviews were conducted with the bullied child, mothers, and school nurse. A focus group interview was also conducted for the support group. The interviews were conducted by audio-recorder on school days and lasted for about one hour each. The first author, who is experienced in leading discussion groups with children of these ages, acted as the moderator for the focus group and individual interviews. The last author observed the group interview process and recorded the participants’ comments.

Interview guides

The interview guides contained open-ended questions covering aspects of being bullied and elements of the SFA that emphasised how the bullied children experienced having a support group or participating in such a group. The individual interviews with the mothers and school nurse included open questions regarding their experience with the bullied boy and support group. An example of the question to the bullied boy was: How is your experience of having a support group? What are the benefits or the disadvantages? As recommended by Kreuger and Casey (2000) , the interviews were started using neutral and unthreatening questions and were ended by providing the participants an opportunity to add comments before the session was closed.

Ethical approval and considerations

This study was approved by the Norwegian Social Science Data Services and the Regional Ethical Committee (REC 106944). Ethical issues are important in all research works, especially in research involving vulnerable children. Written informed consent to participate was obtained from all participants and their parents before the interviews were conducted. The moderator followed professional practice and ensured that no information in the findings of the study would identify any individual study participant. The information provided to the parents and children described the aims of the study, the data collection procedures, and the fact that participation was voluntary. The participants were also assured that they could withdraw from the study at any time without any consequences. The participants were asked not to talk about the content of the discussions in the focus group with anyone. They were also asked to create an atmosphere of trust by showing respect and listening carefully to the other participants.

Solution-focused approach

This study used the SFA to help a child who was bullied ( Heitmann et al, 2022 ; Kvarme et al, 2016; Young, 2009 ). SFA is a social constructionist approach established to facilitate change by highlighting students’ goals, strengths, and resources, and to identify exceptions to the problem. The intervention provides an opportunity for bullies to change their role in a positive and safe way with close follow-up from a teacher or school nurse. The nurse or teacher has weekly consultations with the child who needs help, to look for progress and make sure the situation improves. The bullied boy chose which children he would like to have in a support group. When the selected children were asked to join in the support group, they were informed about the situation of the bullied child, asked if they had experienced a similar situation, and if they wanted to help. The nurse or teacher held weekly consultations with the support group and individual talks with the bullied boy. Members of the support group were encouraged to suggest helpful ways to help the bullied child.

Data analysis

The interviews were analysed using qualitative content analysis ( Graneheim and Lundman, 2004 ). They were read several times to gain an understanding of the material as a whole and line by line to identify meaning units. The meaning units were condensed and coded, using descriptions close to the text. Then, guided by the research question, the codes were examined for similarities and differences across the interviews and sorted and abstracted into categories in line with the manifest content. To develop themes, the categories were abstracted and interpreted to enable us to be receptive to the latent content that was conveyed ( Table 1 ). Researcher triangulation was used to facilitate credibility. Each step of the analysis was conducted independently by the first and last authors. Then, they discussed each step and reached an agreement by consensus. Furthermore, the second author asked critical questions to enhance alternative interpretations and progress beyond the preconceptions.

The following main themes were found in this study:

• Feeling stronger, safer, and happier

They have done what a real friend does

Bullying affects the whole family, working together as a team.

• Support group as a useful tool.

Feeling stronger, safer and happier

The bullied boy reported that he had been bullied and felt like an outsider at school for years. A particular boy in the class often bullied him, said rude things to him, and made him feel unsafe:

‘I have anxiety, and he bullies me because I have managed to say it … so he bullies me because I have anxiety.’

He stated that he was proud of himself:

‘I have become better at ignoring him. Because if he says: “No one wants to be friends with you, they just do it to fool you and talk behind your back", then I say that you have told me so many lies that were not true. I try to contradict him many times. I experience fewer comments now because others back me.’

Moreover, he learned to focus on good things encouraged by the school nurse:

‘Like I'm going to focus on what I think is good, and it has helped me a lot. So, if I kind of have a slightly bad day, then I can try to think of something good.‘

The mother reported that he is happier now after receiving help from the support group. She described how her son had changed lately:

‘He experiences getting support when it is difficult. And his teacher also comments that he has become better … because he can kind of get a little stuck in situations. I feel that he has a better everyday life and is a happier boy now.’

The support group helped him when he was injured. ‘And then many have asked if I wanted them to be with me at home and how I feel.’ He said that the support group does what a real friend does:

‘They have sort of asked me if I would like to visit their home, and if I have been bullied, they have tried to back me up in a way. Yes, they have done what a real friend does. So, I'm glad that we have a lot of fun when we are at home with each other.’

The support group members reported that they felt nice to be a part of the support group, as did the boy who was bullied. They thought that it was nice to help and played a lot with the bullied boy and invited him home. They comforted him if he was sad and were kind to him and included him in games. One support group boy said:

‘I helped him when he was upset. Asked if it is going well and waited until the others had entered.’

They tried not to argue much. They did not tease or say stupid things to the bullied boy. They helped him, played with him, asked him how he was doing, and paid attention to him. A support group boy said:

‘When others are bad, I have supported him. I have told them that they should stop being naughty.’

The support group members also mentioned that the classroom environment was better now; it was rated 9 on a scale from 0 to 10, where 10 indicated the best classroom environment. They said:

‘In a good classroom environment, you argue less, are kind, and include everyone in play.’

The participants in the support group believed that not interrupting each other and raising their hands before speaking could help in making the classroom environment even better. They could imagine participating in support groups again and liked collaborating with the school nurse.

The mother of the bullied boy said:

‘The support group shows care. They are so sweet. He is a little scared of the dark and doesn!t like going home alone when it is dark. One boy followed him because he knows he is afraid to go in the dark. They kind of look after each other like that.’

Finding from this study shows that being bullied does not only affect the child, but his entire family.

The mother of the bullied boy described how it affects her to have a son who is bullied at school:

‘It affects everyday life. It hurts me when he comes home and is sad and crying and in pain. And then you feel quite frustrated because you feel you can do so little. Except I get to comfort him, I get to talk to him.’

His mother did also have contact with the mother of the boy who bullied her son:

‘I have a good dialogue with the other parents in the class and … it is specifically one boy with whom my son struggles. His mum is really nice, and we talk to each other, but there is a reason why he is the boy he is and does as he does. And we’re talking about it.’

Even his sister got involved when he is bullied. The mother also commented on her son's reactions when he came home from school:

‘It affects us that he comes home and is sad. He is frustrated. He just says mom now I just have to go to my room and scream a little. And then there's a little sister here, and she's also trying to take care of her big brother. And also, the bullying has become much harder and more physical.’

She explained how this situation affected the whole family, but her son was still allowed to show his feelings:

‘He is allowed to be angry and sad, and to get those feelings out. And then we talk about it and he says that sometimes it's hard to say things, but I know I feel better afterwards.’

The mother also reported that he had sleep problems:

‘He wakes up at night because he has nightmares again, and it affects our night's sleep. He wakes up in the morning and does not want to go to school. He is sad and I just allow him to stay home and watch movies together.’

The bullied boy and his family were working toward seeing improvements. The mother described talking with the school nurse on how to look for progress and what is better.

It is important to collaborate with the school to prevent bullying. The school nurse is also an important collaborator in bullying situations. The mother of the bullied child also commented on how the school nurse helped them:

‘The nurse also calls us. I think that it was a wise choice to get help from the support group, even if it feels a little scary, because in a way it makes him very vulnerable.’

The mother of a child in the support group reported that information about what participation in the support group entails is important for the parents. She stated: ‘Nice for us parents that our child can help others.’ She also stated that the support group can be an important intervention, and it had calmed the overall class environment. Furthermore, she mentioned:

‘I think it has affected in a positive sense. So do other parents in the class.’

‘No, my son is happy anyway, so I have never been worried or worried that it will affect him negatively. Rather, I'm very happy that he could help improve the class environment. As a mother, it is nice to see that my son gets a feeling of mastery and know that he contributes to something that is important to others.’

Support group as a useful tool

The school nurse described her own experiences with the support groups and emphasised the value of having an intervention that can help children who are exposed to bullying or who do not have friends. She said:

‘It is a fantastic tool that has been long awaited. It is important to be true to a solution-focused approach and plan the measure well with the school and parents. It is important to motivate the child to see what he or she can work on to get better at school. Anchor the initiative in the school and have a good collaboration between home and school.’

‘My experience and the school also has a few tools really. It's not so easy to develop friendship with a child.’

She mentioned that she had been provided a tool that helps her become more confident in her role as a school nurse:

‘Yes, I have been given a tool that I can use. So, to have something very concrete that we can work with, and then it is easier to work in a solution-oriented way.’

The school nurse stated that being true to an SFA, planning the measure well, and collaborating with teachers and parents were important.

She mentioned that it was important to work with a support group that would help children, but the vulnerable child also needed to work and perform some specific tasks. Moreover, it was crucial to work and motivate the vulnerable child to plan well and involve both the parents and the child. Furthermore, the initiative needed to be firmly set up in the school and planned well with the parents, school, and child. It was also important to work with the whole family of the vulnerable child:

‘Yes, in a way, anchor it in both the child and their parents, so that we sort of work together. Here, I have worked quite closely with the mother, for example, with them at home also focusing on what is good.’

She said that when you organise a support group, it may affect not only the individual child but also the class and whole school:

‘Yes, I have seen that it – and several teachers have also seen – that they see improvement in the whole class environment. Students worked with that team feeling of the support group. We included in the support group, the two boys in the class who were the worst, who said lots of rude comments. They got a more positive role.’

She also stated that because the teachers were with the students every day, it was important to work with them.

‘Teachers are also an important piece in it, and in helping the vulnerable child. Yes, so, it is important with collaboration that it is not just such a stunt from a teacher or nurse, but that there are many who participate in this.’

Furthermore, good cooperation with the teacher was necessary:

‘I think that the key here is to also involve the teacher. Then, there is perhaps a greater probability that it can also work in the class.’

The main theme identified in this study was that the bullied boy felt stronger, safer, and happier as a result of the support group. The support group members liked to help him and felt that the classroom environment had improved. It was noted that bullying affected the whole family of the bullied boy. Moreover, working together as a team is important to prevent and stop bullying. The school nurse was pleased to have the support group as a useful tool.

Positive impact on the victim

Our study supports the findings of previous studies that children who experience bullying feel lonelier and have greater difficulties in maintaining friendships ( Schafer et al, 2004 ; Holt and Espelage, 2007 ). In line with previous research ( Young, 2003 ; Kvarme et al, 2015 ; Öztürk and Kubilay, 2021 ), we found that the support group greatly helped the bullied boy. The support group members invited him home, comforted him, and included him in games. Previous research has found that peer support and friendship can protect children against bullying ( Kendrick et al, 2012 ). Moreover, having supportive friends may affect a person's feelings positively, such as making one feel stronger and safer.

The opportunity for a change of role for the bullied boy

The bullied boy in this study talked about how he thought differently about himself, after being helped by the support group. Some children are more vulnerable to become victims of bullying because of several reasons and some are affected by cyberbullying ( Kvarme et al, 2014 ). The combination of individual characteristics and social factors may account for children remaining in the role of the victim. The development of proactive and adaptive coping strategies that enable children to cope more successfully with victimisation is key. Those who continue to be victimised often have less effective coping skills. Coping behaviour can be influenced by both internal resources such as self-esteem, personality, and emotional health, and external resources, such as social support ( Wolke et al, 2009 ). Internal resources, such as increased self-esteem, are important to overcome victimisation ( Sapouna and Wolke, 2013 ). The victim in this study spoke of increased self-esteem after receiving help from his support group. He said that after receiving support, he managed to state his opinions, and being able to focus on his resources was helpful. Moreover, good relationships with friends and family appear to play a role in experiencing resilience to bullying ( Sapouna and Wolke, 2013 ). Furthermore, victims of bullying perceived that they had a low level of control, which may be due to an imbalance of power between themselves and the bullies. Previous research has found that peer support ( Wolke et al, 2009 ) and friendship can protect children from bullying ( Kendrick et al, 2012 ). Encouraging schoolchildren to practise safe strategies to support and defend their victimised peers can help in limiting bullying behaviour ( Poyhonen et al, 2012 ).

Bullying impacts the whole family

The mother of the bullied boy talked about the consequences of her son being bullied for the whole family. The family members felt sad when the boy was sad and tried to support him as much as they could as a family. Previous research showed that supportive familial relations can also buffer the impact of being involved in bullying ( Barboza et al, 2009 ). When victims of bullying have warm relationships with their families, they have more positive outcomes, both emotionally and behaviourally ( Bowes et al, 2010 ; Holt and Espelage, 2007 ).

It has been speculated that defending victims is stressful and can contribute to poor mental health. Recent studies have not supported those findings, however ( Malamut et al, 2021 ; Sjøgren et al, 2020 ). A longitudinal analysis among 4 086 children and young people showed that, for those with social resources, defending victims can have a protective effect on mental wellbeing. These findings are important for the further development of support groups as a tool to combat bullying, and they emphasise the importance of knowing who should participate in the groups, of the duration of the follow-up and of the knowledge and capacity to follow up the participants in a professional manner.

Overcoming a bystander role and becoming a person who stands up for others can influence a child's self-esteem to a great extent ( Salmivalli, 2010 ). According to Menesini and Salmivalli (2017) , involving parents seems to strengthen the programme. Nurses have a key role in safeguarding children's mental health and they are in an ideal position to initiate interventions to prevent bullying.

The family of the bullied boy supported him in collaboration with the support group, school, and school nurse. One person cannot prevent or stop bullying alone; it is dependent on collaboration with others. According to the system theory ( Bronfenbrenner, 1977 ), the microsystem includes peers, family, community, and schools, and the mesosystem comprises the interactions between the family and school, such as parental involvement in their child's school.

Bronfenbrenner's model helps understand the context of the child's situation, how the interaction between the different system levels affects the child, and the outcome of the intervention. It confirms the importance of including parents in the intervention. The system theory represents a shift in focus from individual characteristics to the social processes that may lead to bullying ( Lund and Helgeland, 2020 ; Søndergaard, 2012 ). Bullying is not simply an individual response to a particular environment, it is a peer-group behaviour. Moreover, improving children's ability to access family support systems and improving school environment are potentially useful interventions to limit bullying behaviour ( Barboza et al, 2009 ). Findings from this study demonstrate the importance of collaboration to prevent bullying in schools. It is crucial to collaborate with different professionals and organisations, such as politicians and the Partnership Against Bullying coalition, to prevent bullying.

Ethical considerations

Bullied children are vulnerable. Thus, it is necessary to be aware of the degree of benefit against risk of mental and emotional disturbances when performing research involving such children. In the present study, we attempted to minimise the risks involved by creating a safe atmosphere in the interviews. The interactions between the participants and interviewer were unrestrained and relaxed. This was important because good interactions significantly affect the trustworthiness of the data collected and their interpretation.

Limitations of this study

This study was small and was carried out in one school in Eastern Norway. Because the study sample was small, the findings cannot be generalised. However, the findings are probably transferable to other settings with schoolchildren of the same age. The analysis and interpretation of the findings were guided by a good understanding of bullying for the school nurses and researchers involved and by the selected theoretical framework.

Recommendations for future research

Further research could combine interdisciplinary school-based programmes, including support groups, and evaluate the effect of such programmes on the victims of bullying over time.

Conclusions

The main finding of this study was that the participants liked to help the bullied boy who in turn reported that he felt better after the help. Bullying affected the whole family of the bullied boy. Furthermore, working together as a team is important to prevent bullying, and the school nurse was pleased to have the support group as a useful tool.

The findings suggest that taking a systemic approach to bullying is helpful. In addition, close follow-up from school nurses, parents and teachers are important to prevent bullying.

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Sexual Violence and Trauma in Childhood: A Case Report Based on Strategic Counseling

Valeria saladino.

1 Department of Human, Social and Health Sciences, University of Cassino and Southern Lazio, 03043 Cassino, Italy

Stefano Eleuteri

2 Faculty of Medicine and Psychology, Sapienza University of Rome, 00178 Rome, Italy; [email protected]

Elisa Zamparelli

3 Institute for the Study of Psychotherapies, 00185 Rome, Italy; [email protected]

Monica Petrilli

4 Academy of Social and Legal Psychology, 00198 Rome, Italy; ti.liamtoh@illirtepacinom

Valeria Verrastro

5 Department of Medical and Surgical Sciences, University of “Magna Graecia”, 88100 Catanzaro, Italy; ti.zcinu@ortsarrevairelav

Children and adolescents are too often victims of sexual abuse and harassment. According to the World Health Organization (WHO), approximately 150 million girls and 73 million children <18 have been victims of violence and sexual exploitation during their childhood. Data show that females are more likely to be a victim of abuse and violence than males (20% vs. 5–10%). Such abuses lead to long-term psychophysical and relational consequences and victims are often afraid of asking for support from both parents and professionals. This case report shows the story of a 17-year-old adolescent, Sara, involved by her mother in a strategic counseling process, to solve BDSM-type sexual addiction (slavery and discipline, domination and submission, sadism and masochism), self-aggressive behavior, and alcohol abuse issues. The strategic counseling process is structured in 15 sessions and was based on problem-solving techniques and corrective behavioral strategies. During the sessions, it emerged that Sara had been a victim of sexual violence at the age of 6 and that she had never talked about the rape with anyone. At the age of 12, she began to experience social anxiety and shame, feelings that led her to use alcohol and seek violent sexual partners and bondage relationships. During the counseling sessions, Sara elaborated on her trauma, becoming more aware of her resources and her desires, and she learned to manage the sense of guilt and shame associated with the violence suffered, through alternative strategies. At the end of the process, Sara normalized her relationship with sex and alcohol, regaining her identity.

1. Introduction

1.1. sexual abuse in childhood: definitions, spread, and consequences of the phenomenon.

The World Health Organization defines “child maltreatment” as all the forms of abuse and neglect that involve children. This definition includes physical and emotional violence, sexual abuse, neglect, and exploitation. These abuses lead to damage to children’s health, impacting their development [ 1 ]. According to the fundamental rights of the European Union and the United Nations Convention on the Rights of the Child, children should be protected against all forms of violence, and adults should promote their well-being [ 2 , 3 ]. There are different definitions of child sexual abuse. For instance, sexual harassment can arise on a continuum of power and control, from non-contact sexual assault (such as exhibitionistic actions) to contact sexual assault (such as rape). Additionally, Internet sexual offending is included in the definitions of child sexual abuse. This category concerns the distribution, acquisition, and possession of child sexual exploitation material, child grooming, and online contact with children for gratifying sexual desire (e.g., receiving sexually explicit images or cybersex) [ 4 ]. Regarding the spread of this phenomenon, it is estimated that one billion children are a victim of some form of violence. Thus, one out of two children per year worldwide suffers from some form of violence. Furthermore, the COVID-19 pandemic has increased the risk of children being victims of violence within their families [ 5 , 6 ]. Indeed, social distancing and restrictions impacted the levels of stress and anxiety, reducing usual sources of support and increasing online abuse [ 7 , 8 ].

Our study focuses on sexual violence and sexual abuse, which means the involvement of children or teens in sexual coercion or sexual harassment. These experiences may not involve explicit violence or injury and could occur without physical contact or be experienced as observers. Sexual abuse can be divided into different categories depending on the relationship between the child and the perpetrator. Intra-familial abuse is implemented by family members, peri-familial abuse is implemented by people external to the family but who take care of the child; and extra-familial abuse involves perpetrators who are not part of the family environment [ 9 ].

Child sexual abuse is connected to several unpleasant consequences. Victims may develop mental health problems, such as affective disorders, suicidal ideas, drug or alcohol addiction, social anxiety, conduct disorder, borderline personality disorder, post-traumatic stress disorder, and eating disorders, in particular bulimia nervosa [ 4 ]. Furthermore, child sexual abuse harms the physical health of children, leading to urogenital complaints (e.g., genital pain, dysuria, genital bleeding, and incontinence problems) [ 10 ]. According to Adams et al. [ 11 ], the severity, duration, and onset of sexual abuse influence the level of depressive, anxiety, and post-traumatic stress disorder (PTSD) symptoms. Regarding gender differences, the authors found that sexual abuse produces the worst effects in females. Indeed, the early onset of sexual abuse may cause anxiety symptoms in females but not among males. In the same line, it seems that sexual abuse may determine PTSD mostly in females but not in male adolescents.

The stage of development in which children suffered from abuse (early childhood, childhood, adolescence) can influence the severity of the consequences for health. Traumatic experiences, such as violence and abuse, lived during the first few years of life have a stronger impact on the development than those experienced in another period [ 12 ]. Van Duin et al. [ 13 ] examined the impact of extra-familial sexual abuse among children under four years old and the consequences for their parents. The results show that 3% of children developed a PTSD diagnosis, 30% of them exhibited clinically significant sexual behavioral problems, while 24% of them showed internalizing problems, 27% attachment insecurity and 18% received a psychiatric disorder diagnosis. Regarding parents of children who suffered from abuse, 20% reported high levels of PTSD symptoms, with mothers reporting PTSD symptoms more often than fathers. They also suffered from feelings of guilt, shame, and anger. The authors hypothesized that the psychological treatment provided to 25% of the victims and 45% of parents mitigated the negative consequences.

Additionally, suffering from extreme abuse for a long period, having a close relationship with the perpetrator [ 14 ], and living in dysfunctional families are risk factors associated with the development of severe psychological symptoms [ 15 ]. Moreover, the risk of re-victimization is higher among children who suffered from sexual abuse compared to others. The disclosure of the trauma is hard because of feelings of shame, guilt, and intimidation by the perpetrators and the wish to not burden the family. The stigmatizing response by the social environment influences the development of shame and guilt linked to sexual victimization. This is also connected to the feeling of being blamed or judged.

These data underline the importance of educating society in understanding the consequences of sexual victimization and in supporting prompt reporting. These results might be useful in promoting therapeutic interventions to support victims and to decrease the dysfunctional cognitions of sex offenders [ 16 ].

1.2. Sexual Addiction and BDSM among Survivors of Childhood Sexual Abuse

Several authors have reported that 80% of people [ 17 ] who experienced child sexual abuse (CSA) developed compulsive sexual behavior and sexual addiction in adulthood. Pereira et al. [ 18 ] confirmed the relationship between childhood sexual abuse and a later disposition toward compulsive sexual behaviors. They found that sexual abuse experiences and poor family relationships during childhood enhance vulnerability to initiating and maintaining out-of-control sexual behaviors. They confirmed this association, with a prevalence in the male population that seems to be more susceptible to the development of sexual addiction and compulsion. Thus, this behavior is a transversal phenomenon that vulnerable people can use to manage intense and negative emotions related to the distress of abuse [ 19 ].

The experience of women with sexual compulsivity is intensely shame-based and difficult to deal with. The family preconditioning of abandonment in childhood emerges through inadequate care, experiences of abuse, abandonment, and the presence of other addictions, as shown by case studies analysis [ 20 , 21 ]. As children, these women were looking for something to ease their distress when they could not rely on their caregivers. Mostly, they use maladaptive coping mechanisms, such as compulsive masturbation, binge eating, and violent fantasies, to maintain their sanity in childhood.

According to Freud’s theory, at the basis of this behavior might be a trauma suffered by the children caused by the experience of impotence and the contact with a threatening adult [ 22 ]. This experience triggers strong anguish in the face of which the child activates a series of defenses to protect themselves, including the conversion of the trauma and identification with the aggressor. These modalities convert, to quote Stoller, “the infantile trauma into an adult triumph” [ 23 ].

Sexual atypia and paraphilias lead to reliving the traumatic experience while preserving the illusion of control and sexual gratification, which provides individuals with a false sense of power that preserves their integrity. The strong aggression and anguish distort the vision of the other, who becomes a dehumanized object. This is the mode implemented to cope with strong emotions derived from traumatic experiences [ 24 ].

Indeed, at the origin of masochism, there could be an infantile experience of passivity and annulment. In this case, the mechanism of reversal of the experience undergone is structured as a masochistic defense. In the adult re-perpetration of the trauma staged in the perversion, the person is no longer the passive victim of an executioner but the holder of control. It is the subject who asks the executioner to suffer and to be objectified. This perception gives masochistic pleasure to the person. From this point of view, the masochist’s pain is a defense against the greater and deeper pain of rejection [ 22 ].

In this way, sadomasochistic sexual practices could assume a key role in sexual trauma processing. BDSM (slavery and discipline, domination and submission, sadism and masochism) is receiving increasing attention from the scientific community. The term BDSM identifies a wide range of erotic practices between two or more consenting partners who share sexuality based on games of power, dominance, and submission from which they derive satisfaction and pleasure. Today, the BDSM phenomenon is viewed from a biopsychosocial perspective [ 25 ].

Studies show a positive correlation between BDSM interests and personality traits, adverse childhood experiences, education levels, sexual orientation, and biological indicators. The limitations of the research lie in the fact that most studies so far are only descriptive [ 26 , 27 ]. Some researchers have focused on better understanding the aspect of pain within a BDSM interaction [ 28 , 29 ], as experiencing afflicting or receiving pain is a relevant part of BDSM interaction. The result is that BDSM practitioners seem to have a higher pain threshold overall and, specifically, submissive BSDM interaction results in a constant increase in pain thresholds [ 28 ].

Further research focused on the rewarding biological mechanism associated with BDSM interaction. They found that submissive practitioners showed increased cortisol and endocannabinoid level due to the BDSM interaction, while dominant practitioners only showed increased endocannabinoid levels when the BDSM interaction was associated with power-plays [ 30 ].

1.3. Strategic Counseling

Strategic counseling is an intervention that refers to the theory of strategic psychotherapy and aims to reach a specific goal through techniques based on communication. Strategic counseling is efficient in modifying patients’ points of view and in promoting the solution of their issues [ 31 , 32 ].

Strategic counseling is effective in managing personal, relational, and working problems. One of the most important characteristics of strategic counseling is the focus on the function and the dynamic of the issue (“how my problem works”), instead of on the causes (“why I have a problem”). The focus is on the present and the future and not on the past, which represents a starting point to assess patients’ cognitions [ 33 ]. According to the process of strategic counseling, there are solutions as well as problems and these solutions are strongly related to the characteristics of the issue, akin to a dress tailored to the patient. Strategic counseling is a flexible type of counseling—it adapts to the specific problem until it leads the person to perceive the problem differently and therefore to change their behavior. The most used element of strategic counseling is communication, the so-called “strategic dialog” [ 34 , 35 ].

Strategic communication is characterized by a series of techniques that lead people to discover new ways of perceiving and managing problematic situations. Therefore, strategic dialogue leads to an experience of changing one’s own feelings and perceptions, modifying one’s perspective. Strategical problem solving is one of the most common techniques, which we could define as the “technology” to find solutions because of its effectiveness in finding alternatives [ 36 , 37 , 38 ].

Finding alternative solutions to a problem is not easy and leads to implementing the usual solutions, the so-called “attempted solutions”, but which turn out to be unsuccessful, only increasing the sense of inadequacy and dissatisfaction [ 39 ]. The attempted solutions have the function to maintain the problem and to create a vicious circle in which the person is psychologically trapped.

Strategic problem solving modifies the dynamics of rational linear thinking to find the solution, through stratagems of non-ordinary logic. This allows finding a solution in the present rather than an explanation in the past [ 38 ].

Therefore, strategic counseling is characterized by its flexibility and adaptability to the problem presented, since it makes use of strategies and techniques conceived and adaptable to the established purpose. Indeed, as the counseling intervention proceeds, it can be reoriented based on the observed effects. This intervention method guides clients to change their behavior, their feelings about the problem, and the perception of events, changing their perspective of observation and feelings connected to the problem. Clients experience new perceptions and discover different ways to manage and overcome difficulties. These sensations and perceptions become actions and behaviors that lead to higher individual awareness. According to this perspective, behavior change derives from a modification of perceptions that simultaneously generate a different way of conceiving and relating to reality or “to change to know” [ 35 ].

1.4. Strategic Behavioral Prescriptions

Prescriptions are tasks and indications that the therapist provides during the sessions. The patient must perform these tasks between sessions or during the session itself. In strategic counseling, behavioral prescriptions represent an important function, since to bring about a change one must go through concrete actions, acting on the problem even in the absence of the therapist [ 40 ]. This absence allows patients to demonstrate that they can change their situation from a concrete experience. Prescriptions can be direct, indirect, and paradoxical [ 41 ].

In the first case, these are clear indications about the actions that the patient should perform. These aim at achieving a specific and shared goal in the session. Collaborative patients with low resistance benefit from this type of prescription.

Indirect prescriptions are behavioral injunctions that hide their true goal and circumvent the individual’s resistance. These prescriptions are best suited to those who resist changing. They act persuasively through linguistic and hypnotic suggestions. The therapist shifts the patient’s attention from the problem to other elements that reduce the tension linked to the discomfort, allowing the individual to neutralize the problem.

The paradoxical prescriptions, on the other hand, provide for the use of the symptom of resistance to therapy, as actions to be voluntarily implemented or exasperated to increase the level of control perceived by the patient about a previously spontaneous situation [ 41 ].

The therapist reinforces the results obtained by the patients, redefining the situation and gratifying them [ 42 ]. Prescriptions play a key role in strategic counseling and are part of the change process as they create a bridge between the patient’s reality and the therapeutic setting.

2. Materials and Methods

2.1. procedure.

This case report illustrates the story of Sara, an Italian girl of 17 years of age. Sara suffers from BDSM-type sexual addiction, self-aggressive behavior, and alcohol abuse because she was a victim of sexual harassment when she was a child. Sara was involved by her mother in a strategic counseling program. The strategic counselor (SC) was a young woman, and the therapeutic process was divided into 15 weekly sessions which were 60 min long, as described in Table 1 :

Strategic counseling sessions and objectives.

2.2. Ethical Statement

Sara and her mother were informed by the strategic counselor that the therapy will be part of a scientific publication. The aims, the methods, and the procedure were explained to the minor and her mother in verbal and written forms. The SC obtained the informed consent of the participants to publish the therapy in online and paper journals. The participants were aware that their sensitive data (names, places, etc.) would be subject to change to protect privacy.

The informed consent was redacted according to the Italian Deontological Code of Psychologists of the National Council of the Order of Psychologists 2020 ( www.psy.it ) (accessed on 10 May 2021) and was based on the following Italian legislative references: Law 633/1941 Article 96 (Protection of copyright and other rights related); Civil Code Article 10 (Abuse of the image of others); Civil Code Article 23 (Consent for personal data processing); Legislative Decree n. 196/03 Article 13 and EU Regulation 2016/679 (GDPR) Article 13 (Information on the processing of personal data).

The collected materials are kept confidential under the responsibility of the SC.

3. Case report: Sara’s Story

3.1. assessment and therapeutic alliance.

Sara goes to art school, she is an only child and has lived alone with her mother since her father left home when she was 10. Sara was involved in the strategic counseling process by her mother, worried about her daughter’s high-risk behaviors, such as engaging in sex with several occasional partners and binge drinking.

Although it is not her direct request, Sara immediately demonstrates a good motivation to undertake the therapeutic path. Moreover, despite her young age, Sara shows good awareness of her psychological, physical, and cognitive state, expressing her feelings and thoughts.

During the first session, the strategic counselor invites Sara’s mother to attend. However, Sara shows considerable difficulty in talking about herself in the presence of her mother, so the SC decides to be alone with Sara. In the absence of her mother, Sara discloses with the SC, although with slight difficulty, describing her problem in relations with other, especially males, and telling the SC about the trauma she experienced when she was six, namely a sexual assault by a man of 20. Sara expresses embarrassment and shame in telling of her traumatic experience, holding her head, avoiding the therapist’s gaze, and never using the word “rape”. Sara also affirms that since she was 12, she has had violent sexual intercourse and bondage relationships with peers. Furthermore, when she decides to have sex with someone, she also binge drinks alcohol. Sara’s mother is unaware of her daughter’s trauma and believes that her daughter’s destructive attitudes are part of her adolescence. Sara describes her mother as a “normal, slightly apprehensive housewife”. She considers her childhood quite happy. However, when she was very young, her mom went through a particularly intense moment of emotional distress due to numerous conflicts with her father, which is why she often had to care for her ailing mom. For this reason, Sara decided to avoid telling her mother about the sexual violence.

The SC uses the techniques of active listening and lets all the elements emerge that the girl is ready to share. At the end of the session, the SC thanks Sara for the trust and courage shown and gives the girl a task, called “my objectives”. According to the prescription, she is required to describe the personal goals which she wants to obtain by means of the therapy.

During the second session, Sara comes alone. She sits and starts to read the task without any encouragement from the SC. Sara identifies her sex life as a source of discomfort. Her sexuality is characterized by strong and uncontrollable impulses, which lead her to seek out sexual acts and physical violence. When she has these impulses, she often contacts some friends who practice BDSM, namely bondage (not professional), and she asks them to have violent sexual intercourse, after binge drinking. Her mother discovered her activity when Sara came home one night with marks and bruises all over her body. On that occasion, Sara admitted to her mother that she has a problem managing her sexuality and that she explicitly asks her partners to practice bondage and to inflict upon her asphyxiation and physical violence. The girl explains that this kind of suffering gives her the feeling of control, as she is the one who decides to feel pain and the level to which she does so. An aspect that Sara realizes in completing the prescription is that when she had homosexual intercourse, she never felt the need to suffer violence. With boys, however, she sought violence during penetration and, in particular in practicing bondage. Sara realizes that her sexual impulses never allowed her to have a relationship and she describes sex as a punishment that she uses because she thinks she does not deserve to be loved.

The SC and the patient identify the main objectives of the therapeutic process as elaborate on the trauma deriving from sexual abuse suffered in childhood, exploring sexuality without the use of alcohol or violence, and structuring a new self-image considering her desires and resources.

During the third session, the SC describes to the patient the process of trauma processing, explaining the role of repressed emotions and memories. Despite the fear of reliving her trauma, Sara shows a strong motivation to continue the process, saying that she stopped her sexual impulses after her mother discovered them. Additionally, Sara admits that during those nights in which she practiced bondage, she felt that she could have suffocated. That event impacted the perception of Sara towards her sexuality, leading her to relive the same fear she felt during the abuse she suffered. Sara is not ready to tell her mother the truth. However, she does not exclude the possibility of doing this in the future.

It appears immediately functional for Sara to have a young female figure as a therapist to project and analyze some dynamics of her behavior without fear of being judged and to gradually acquire confidence.

3.2. Sexual Violence-Trauma Processing and Positive New Identity Structure

The second part of the therapeutic process was focused on trauma-processing and on the possible evaluation of the dysfunctional coping strategies used by Sara to manage her negative feelings connected to the traumatic experience. First, Sara was instructed to explore the dynamics of her trauma, learning how to change the memories linked to the experience. Sara explored her body’s reaction during her processing of trauma, and she also understood what happens in talking about her sexual violence. She analyzed her physical and emotional reactions, living and exploring the situation in the therapeutic setting. The second step of the trauma-processing was to lead Sara to tell her traumatic story from multiple points of view, exploring it as if she could relive it but from the outside, as an observer. The goal was to teach Sara, progressively, how to understand the emotions connected to the trauma and be able to face them, and then live the experience as a story that is part of her life but that can no longer hurt her because it belongs to the past. To reach this goal, the SC gave to Sara a specific prescription: “imagine that you can do something to make your current condition worse, imagine the worst fantasy on your traumatic experience”. This prescription leads the patient to realize that she has control over the decision-making process about her malaise and to analyze all the attempted solutions she has implemented and continues to implement even though they are dysfunctional, to solve her problem.

At first, Sara expressed difficulty in imagining how her traumatic experience could have been worse; however, later she created alternative scenarios that saw her capable of worsening her fantasy about the past and about the present. Sara gained more control over her choices and realized that self-harm related to extreme sexuality and alcohol abuse stems from this idea of not having control over her body, as someone else has it instead. When she carries out these harmful behaviors, she allows another person to harm her, and this removes her responsibility and reduces her sense of guilt for not having protected herself during the aggression suffered as a child.

Sara analyzed her relationship with alcohol and stated that what she appreciates most is the sense of relaxation and the absence of tension. However, once this effect is over, Sara suffers a psycho-physical breakdown, sadness, and a sense of emptiness. The substance, therefore, mitigates the anxiety of the girl, who slowly undertook to reduce its use to monitor the effect that these changes in behavior have on well-being. Additionally, Sara practices bondage during sexual intercourse, and she feels very protected and accepted and can share an aspect of herself that is more complex to externalize. Sara does not share this aspect of her life with her mother and feels it is not understood. After she started the therapeutic path, however, Sara became more confident in her relationship with her body, asking her mother for advice and support.

The SC explained to the patient that she should not aim to reach a socially shared normal range, but the goal is to understand its functioning and progressively reduce everything that causes her discomfort. Bondage-related BDSM experiences are denial and defense mechanisms that Sara uses, along with alcohol, to avoid dwelling on her suffering. The two thematic areas, bondage and alcoholic binging, are intertwined during the sessions. These draw a parallel between the desire, the effects, and consequences of alcohol and the violent sexual experiences Sara sought. These two conditions have in common the associated emotions and the subsequent intense sense of emptiness and sadness. Sara now hypothesizes that she can do without the search for risky or self-harming situations and for the first time she reflects on the meaning that these actions have for her, as she said: “I thought I was in control by drinking and doing violence to me, but it was my addiction to violent sex and alcohol that had control over me”.

The SC explained to the patient the theory of the “self-fulfilling prophecy”, asking her to reflect on how she could change this prophecy. The last four sessions before the therapeutic restitution and closing phase were focused on the building of a new positive identity structure. Sara was required to learn and apply strategies to (a) monitor her psycho-physical sensations related to self-harming behaviors, alcoholic binges, and bondage, understanding the relationship with her emotions; (b) learn to respect her body more and to assume control of her decisions, passing from a passive to an active role; and (c) find alternatives to violent sexual behaviors.

To achieve these aims, the SC gave to Sara the following prescriptions:

• (a) A diary of emotions, structured to analyze the type of emotion, the antecedent, thoughts, actions, strategies, and consequences and to become more curious and attentive toward her feelings and reactions.
• (b) The use diaphragmatic breathing once per day, to get in touch with her body, focusing on physical needs.
• (c) Dedicating some time to her sexual pleasure, identifying new activities and modalities as alternatives to violent bondage, associated with alcohol abuse.

Regarding the first prescription, during the sessions, Sara reported having monitored her emotions related to negative feelings and the need to self-harm through sex and alcohol as her coping strategies. She described some events in which she felt alone and misunderstood by her mother or friends. However, analyzing the situations, she found inconsistencies between her interpretation and the reality, understanding how often she tends to blame others for her malaise. Doing this exercise every day and illustrating to the SC all the reported events and emotions, Sara progressively recognized that she has mental patterns that lead her to perceive others as threats and to feel misunderstood and alone. Her strategy is always to make others abuse her to confirm her attribution of guilt.

Sara is now more aware of the way she uses violent sex and alcohol and the psychophysical consequences that come with it. This careful analysis of her behavior, together with the other two prescriptions, allowed the girl to get in touch with the needs of her body, to focus on physical and sexual well-being, without feeling negative emotions and guilt or punishing herself sexually with bondage. In fact, during the weeks between sessions, Sara learned to dedicate herself to the well-being of her body and explored other activities related to sexual pleasure that did not involve the use of violence, such as masturbation and petting, only with people of who she trusts. Additionally, Sara progressively talked with her mother, telling her about her progress.

The emotions during the task related to the exploration of sexuality were positive, as Sara was able to give herself something satisfying. A very interesting and adaptive sensation for the patient’s functioning is that she felt pampered and protected by herself during masturbation and by her sexual partner during petting. Sara also decided to no longer engage in sexual activities that result from negative emotions. Bondage for her will always be an aspect of her sexuality but she wants to be able to decide and not let her trauma take over.

The new ways of exploring sexuality that Sara learned required considerable effort. Sara was very brave and found a personal space in which to find her own new identity. These sensations are new for her, as Sara has never explored her body or recognized her sexual needs, if not mediated by violence. The contact with the body, now experienced positively, reduces the sense of shame.

The SC positively reinforces Sara’s need to find herself, reflecting on her resources. Sara has already found her inner space, she just has to keep feeding it in order to not fall back into the old dysfunctional strategies. To do this, Sara needs to continue with the prescription for another two weeks, in which she will explore her autonomy from the SC. Sara can contact the professional if she needs to, but she does not come to the counselor’s office for two weeks. In addition, the SC gives Sara another prescription, to add to the previous ones: “What I want when I want”. According to this behavioral task, Sara will do something that she desires to do, just to experiment with the pleasure of doing this. Sara can do more than one thing, but she must do at least one per day.

3.3. Therapeutic Restitution and Follow-Ups

This conclusive part of the therapeutic process aims to reinforce the positive outcomes obtained by the patient and to restitute feedback on the acquired strategies for the future. To reach these goals, the SC used the suitcase metaphor, comparing the therapeutic experience to a journey during which Sara learned some coping strategies useful to manage stressful events and to better organize her new life and identity. The patient imagines having a suitcase in which she can collect and take these strategies with her, to cope with difficulties and to maintain her outcomes.

During the last session, the SC asked Sara to describe her therapeutic process, looking to herself as an observer and pointing out the main changes and results obtained. Sara was enthusiastic to describe her improvements. She reported some actions done for the “What I want when I want” prescription, such as spending time with friends, reading books, and taking long walks. Sara did not show any negative feelings, such as shame or embarrassment, in admitting her old habits and in recounting the trauma experienced in childhood. She now is more aware and less afraid of her impulsive and destructive behaviors and aims to build a “true” identity, not being influenced by the violence suffered. Sara, however, expresses her fear of falling back into the dysfunctional behaviors and harming herself again.

The SC explains therefore that the therapy foresees two follow-up sessions, one after one month and one after three months. These sessions are aimed at monitoring Sara’s progress and helping her to maintain them over time. This perspective reassures the patient, who greets the SC with affection and gratitude. The SC also explains to Sara that in the month in which they will not see each other, she will have the sole task of using the tools learned in therapy, metaphorically opening her suitcase, and pulling out the ones that best suit the situation she must deal with.

After one month, the SC meets Sara and she tells the professional about her progress. During the month, the teenager often confronted her mother, explaining her problems and asking for help when she felt aggressive impulses. The mother responded adequately to her daughter’s requests, showing herself to be present and welcoming. Sara also tells of having opened her suitcase on several occasions and having used some strategies learned in therapy. Sara decided to continue to explore her sexuality through masturbation and petting and only with people she trusts. She did not experiment with compulsions regarding sexuality or binge drinking, and she started to practice sport (running) to take care of her body. During the session, the SC reinforced the prescription of the suitcase, adding the task to identify other tools and strategies to add to it.

Three months later, the SC conducted the last follow-up with the patient. During the session, Sara was excited to tell the SC her improvements. Indeed, she was selected to participate in a competitive run, and she also had her first sexual intercourse without the use of violence or bondage. Sara felt satisfied with her progress and she also added a tool in her suitcase: get in touch with her physical sensations. Sara started to concentrate more on her body and her physical needs. The SC compliments Sara and positively strengthens her progress. The counselor asks her to continue filling her suitcase with useful strategies and tools for her future.

4. Discussion

According to the definition of child sexual abuse, sexual harassment can be described on a continuum of power and control from non-contact sexual assault to contact sexual assault [ 4 ].

This phenomenon is widespread among children; indeed, one out of two children per year worldwide suffers some form of violence [ 43 ].

The recent scientific literature on sexual abuse shows that the consequences of this traumatic event jeopardize both the physical and psychological health of the individual and cause lifelong distress. The gradual emergence of symptoms following exposure to traumatic events represents a conceptual challenge for psychology and psychiatry. Indeed, child sexual abuse is associated with mental health issues, drug or alcohol addiction, and post-traumatic stress disorder [ 4 ].

This work aims to explore the possible relationship between experiences of childhood abuse and the development of pathological compulsive sexual behavior, sexual addiction and BDSM conducts. These pathological sexual behaviors are characterized by inappropriate or excessive sexual acts or cognitions that lead to subjective distress or impaired functioning.

Sadomasochistic sexual practices are receiving greater attention from the scientific community than in the past. The acronym BDSM identifies a wide range of erotic practices between two or more consenting partners who share sexuality based on games of power, dominance, and submission from which they derive satisfaction and pleasure. Risk factors are thought to include family history and childhood abuse, and it seems that compulsive sex and BDSM practice represent a functional behavior to compensate for the traumatic experiences of abuse [ 44 ].

The case report illustrated herein shows an association between sexual violence and risky behavior in adolescence. Sara is a 17-year-old adolescent who suffered sexual violence when she was six and developed a sexual addiction relating to BDSM (bondage) and binge drinking. The mother of Sara, worried about her daughter, introduces Sara to the strategic counseling process. The SC sessions were divided into 15 sessions with specific goals and prescriptions. At first, Sara revealed her story, talking of the sexual abuse and of the tendency to have violent sexual intercourse, to practice BDSM, specifically bondage, and to drink alcohol before sex. The first step of strategic counseling’s process (three sessions) was to focus on the assessment and on establishing a therapeutic alliance. Specifically, the SC created a therapeutic alliance with the patient, who learned to manage negative emotions related to the abuse. Sara associated herself with the counselor, a young woman, and established a strong relationship of trust. The patient and the counselor used this positive relationship to co-build objectives for the other steps of the therapy.

The second (five sessions) and the third steps (four sessions) were focused on sexual violence-trauma processing and had the aim of elaborating the memories related to the trauma and on building a new identity. In this phase, Sara analyzed her relationship with alcohol and BDSM. She understood the role of substance abuse and violent sex in her life. Indeed, on the one hand, alcohol and sex mitigate the feeling of anxiety and she feels invincible, but on the other hand, Sara perceives a sense of shame and guilt. During this process of evaluation of her coping strategies, Sara started to communicate with her mother, asking for support. The SC guided Sara to discover more functional strategies for her well-being. The counselor explained the theory of the “self-fulfilling prophecy” and encouraged Sarah to make a positive prophecy about herself come true. At the end of this phase of counseling, Sara learned to monitor her psycho-physical sensations related to self-harming behaviors, alcoholic binges, and bondage, understanding the relationship with her emotions, and to respect and explore her body more, assuming the control of it and being active, as well as in her sexuality. These skills led Sara to find alternatives to violent sexual behaviors.

The final step (one session) was based on the therapeutic restitution and the SC positively reinforced the outcomes of the therapeutic process and restituted feedback on the acquired strategies for the future. To do so, the SC used the metaphor of the suitcase, according to which Sara can collect the strategies she learned into this suitcase and she can open it and use them anytime she feels the need.

The SC performed the first follow-up one month after the end of the therapy and a follow-up after three months. During both follow-ups, Sara demonstrated having maintained the positive outcomes of the therapy and using her suitcase to cope with difficulties. Sara practiced sport and stopped using BDSM, violent sex, and alcohol. Today, her relationship with sexuality is based on self-eroticism and petting with people she trusts.

5. Conclusions

The review of the literature and the case report presented highlighted the importance of exploring the possible connection between childhood sexual abuse and the development of compulsive sexual behavior and BDSM practices in adulthood. The recognition that comes from relationships with others (partner, sexual interest, work) confirms the value of our existence. Consequently, some individuals could undertake their search for contact through the forced transition from the passive to the active role, displaying risky behavior concerning fears and life experiences.

Hypersexuality and sadomasochistic practices might compensate for the missing part of the subject’s ego. The pain of self-esteem’s loss, parental affection, or childhood omnipotence is anesthetized through perverse action and fantasy. Sexual practices based on violence and coercion in some cases allow individuals to act out their fantasy of perfection. In this act, the sadist is reunited with his/her lost omnipotent self and the masochist abandons himself/herself in the other, rediscovering the fusion condition of childhood.

This division between reality and fantasy, between loss and the denial of grief, is also reflected in the thinking of these subjects as an inability to accept different views, without considering nuances or a middle ground.

Author Contributions

Conceptualization, V.S.; writing—original draft preparation, V.S., E.Z., S.E., M.P.; writing—review and editing, S.E., V.S.; supervision, V.V.; funding acquisition, V.V. All authors have read and agreed to the published version of the manuscript.

This research was published thanks to the contribute of the Institute for the Study of Psychotherapies, Rome, Italy; and the Department of Human, Social and Health Sciences of the University of Cassino and Southern Lazio, Cassino, Italy.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of the Institute for the Study of Psychotherapies, Rome on 26 April 2018.

Informed Consent Statement

Written informed consent has been obtained from the patient(s) to publish this paper.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Yale Medical School Student Amber Acquaye, BS will present at this third of six case conferences, with expert discussants Lashauna Cutts, LCSW and Carmen Black, MD. This in-person session will be interactive and attendees will be encouraged to engage in a round-table discussion. Registration is required.

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America is in the midst of a Youth Mental Health Crisis, but Black youth have been in crisis for over 20 years. Black youth suicide rates are rising faster than any other racial/ethnic group, Black children are the most likely to be physically restrained in emergency departments, and Black youth are more likely to be diagnosed with disruptive mood disorders than white children with comparable symptomatology. A mounting number of studies document the adverse mental health effects of anti-Black racism on Black children, even before birth. The stress of anti-Black racism experienced by Black mothers, including experiencing inferior care by healthcare providers, has been linked to low birthweight babies, putting Black infants at greater risk for developing depression and other mental health disorders. There is a clear lack of awareness, education, and accountability for the devastating lapses in care that Black children and families can receive in the healthcare system, which undoubtedly affect their mental and physical wellbeing. There is an urgent need for dynamic, expert-led conversations to generate ideas and transform mental healthcare for Black youth and families.

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• Published: 19 March 2024

Malnutrition in children under five years in a squatter settlement of Karachi: a case-control study

• Gati Ara 1 ,
• Bina Fawad 2 &
• Shumaila Shabbir 3  

BMC Public Health volume  24 , Article number:  848 ( 2024 ) Cite this article

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Multidimensional factors such as socioeconomic or environmental factors influence malnutrition. Several studies have strongly linked malnutrition to poverty. Some international studies point to the worse nutritional status of urban slum children than rural children. Limited data is available regarding the nutritional status of slum children in Karachi. This study aimed to determine characteristics of malnourished children in an urban squatter settlement in Karachi, Pakistan.

A case- control study was carried out at the primary healthcare center of a squatter settlement in Karachi, Pakistan. All children under five years of age visiting the primary healthcare center were recruited consecutively. Cases were defined as children with z scores < -2 SD of WHO reference measurements of WFA, HFA, WFH and OFC. The controls were similar in terms of age group but had z scores between − 2SD and + 2SD. A self- structured risk factor questionnaire that included information about sociodemographic, economic and environmental factors as well as child- related characteristics was researcher administered via face-to-face interviews with the mothers of children. Univariate and multivariate logistic regression analyses were conducted. Crude and adjusted odds ratios were calculated with 95% confidence interval.

A total of 280 participants including 140 cases and 140 controls participated in the study. A larger proportion of the sample originated from individuals with low household income. After adjusting for the confounders, childhood malnutrition was significantly associated with a low education level of father (aOR 4.86, 95% CI 2.23–10.60), a monthly income less than 25,000 PKR (89 USD) per month (aOR 7.13, 95% CI 1.67–30.54), pour pit latrine type of toilet (aOR 4.41, 95% CI 2.67–7.3), less than six months of exclusive breast feeding (aOR 3.578, CI 1.58–8.08), inappropriate weaning age (aOR 3.71, 95% CI 1.53-9).

Malnutrition in children under five years of age in the community is associated with low family income, low paternal education, poor toilet facilities, lack of exclusive breastfeeding and inappropriate weaning age. The implementation of poverty reduction programs, sanitation provision at affordable rates, community-based breast feeding and weaning education intervention are urgently required to efficiently improve children’s nutritional status.

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Malnutrition refers to the deficiencies or immoderations in a person’s intake of energy and/or nutrients. Children are the most severely affected, and young children are significantly more vulnerable. The World Health Organization has identified malnutrition as the single most dangerous threat to global public health [ 1 ]. The maximum burden of malnourished children is in Asia, with almost 70% of malnourished children dwelling there [ 2 ]. In comparison to other developing countries, Pakistan has one of the highest burdens of child malnutrition [ 3 ]. As reported by the National Nutrition Survey (NNS) 2018, 40.2% children below the age of five years are stunted, 29% are underweight and 17.7% suffer from wasting in Pakistan [ 4 ]. Baluchistan and Sindh are two of Pakistan’s provinces with the highest prevalence of malnutrition and poverty [ 5 ]. In the province of Sindh, 42% of children under five years are underweight, and approximately half are stunted (48%) [ 6 ].

Multidimensional factors such as socioeconomic or environmental factors influence development of malnutrition. Several studies have strongly linked malnutrition to poverty [ 7 ]. Poverty is connected to insufficient food, poor sanitation, maternal depression, stress and low maternal education, as well as scarce stimulation at home [ 8 ]. All these factors detrimentally affect child development. According to the World Bank, the poverty ratio in Pakistan in 2020-21 is 39.3% based on a lower- middle- income poverty rate of $3.2 per day [ 9 ]. Several past studies have explored various risk factors for childhood malnutrition, such as education of mothers/parents, occupation of the head of the family, family income and size, residence location and land availability; these factors have all been documented to influence nutritional status of children [ 10 ].

In Pakistan, malnutrition studies mostly target rural populations. No recent studies have specifically targeted the under-five children of urban slums in Karachi. Studies that have targeted slums populations are either very old, related to older children or specific micronutrient deficiencies. One malnutrition survey was conducted in Karachi’s Mahmoudabad slum area in 1989 [ 11 ]. The latest national estimates are available from the National Nutrition survey (NNS) 2018. The NNS segregates population on the basis of province, city, district and urban/ rural residence, but it does not specify smaller urban squatter settlements. The findings of NNS 2018 are representative of the district level [ 4 ]. In the city of Karachi, the disparity within districts can be very high, with high- level housing areas attached to a squatter settlement within the same districts [ 12 ]. Some international studies point to a worse nutritional status of urban slum children compared to that of national, urban and rural children. Gosh S et al. stated that children residing in urban slums have the worst nutritional status among all urban groups and are even below the rural level [ 13 ]. The urban slums consist of marginalized communities and are often ignored. Several risk factors for malnutrition have been identified and may seem understood, but which risk factors should be prioritized targets for future nutritional intervention in urban squatter communities needs to be documented. The objective of this study was to measure the risk factors for malnutrition in children under five years of age in a squatter settlement in Karachi, Pakistan. This study highlighted the risk factors of malnutrition for under five children of urban slums and could help in further prioritizing selective risk factors for sustainable, cost-effective interventions for controlling and preventing malnutrition in urban squatters.

Study design and setting

This case-control study was conducted from December 2021 to December 2022 in the Gulshan- e- Sikenderabad area, an urban squatter settlement in the Keamari area of Karachi, Pakistan. The area is divided into five blocks and the estimated population was 35,000 approx. in 2010 [ 14 ]. The current (undocumented) population estimates by community health workers range from approximately 75,000 to 100,000. Most of the people in the community belong to lower socioeconomic status. There is no government healthcare facility running in the area. There are few dispensaries running in the area by quacks. Some private and nongovernmental organizations are operating in the vicinity. Most of the population consists of Pashtoon in-migrants from KPK or immigrants from Afghanistan with a small proportion of in-migrants from other parts of Pakistan, such as southern Punjab (Saraiki). The population consists of low-income, large, poorly spaced families with birth rate higher than the city average [ 14 ].

Study population and sampling

All children under five years of age visiting the primary healthcare center in Sikenderabad, and residents of the settlement were consecutively enrolled after informed written consent from parents. Screening for malnutrition was done using anthropometric measurements. Malnourished children were identified and selected as cases. The cases were defined as children with z scores less than − 2 SD from the median of the WHO reference for anthropometric measurements of Weight-for-age (WFA), Height-for-age (HFA), Weight-for-height (WFH) and head circumference. All children regardless of the type of malnutrition; underweight, stunting, wasting or combination of all were eligible. The controls were children who visited the same healthcare center and belonged to the same age group, however, had z scores between − 2SD and + 2SD measurements of WFA, HFA, WFH and head circumference.

All children under the age of five years and residing in the Sikenderabad area were eligible for inclusion. The Children who were diagnosed cases of special needs, had an ongoing serious or chronic illness, had physical challenges, diagnosed mental illness or mental retardation or were Pre- term babies (less than 37 weeks gestation) were excluded from the study. Children with severe acute illnesses or severe dehydration, hypothermia, hypoglycemia, or hyperpyrexia were also excluded.

Sample size determination

The sample size was calculated from openepi.com, Version 3, open-source calculator for case-control study. Since the local prevalence of other risk factors was lacking, poverty was the major risk factor and was taken as exposure. In Pakistan, the probability of exposure to poverty (< 3.2 USD) among controls is 0.393 [ 9 ]. The odds ratio for a poor household with malnourished children as compared to non-poor house hold is 2.15 [ 15 ]. The sample size was calculated at α = 0.05 with 80% power of study and a 1:1 ratio of cases to controls. The hypothetical proportion of controls with exposure was 39.3% and the hypothetical proportion of cases with exposure at the OR of 2.15 was 58.19. The sample size with continuity correction was thus calculated to be 120 cases and 120 controls making a total of 240. Data was collected from a total of 280 participants (140 cases and 140 controls) considering a non- response rate  ≥  16%. A total of 280 respondents were finalized for the study. Estimated 140 cases and 140 controls were included in the study.

Data collection and measurement of variables

After informed written consent was obtained from the parents, the anthropometric measurements were taken by the principal investigator and community health worker following WHO protocol for measurement of height, weight, and head circumference for the Indicators of Malnutrition: Underweight (low Weight-for-age), Stunting (low Height-for-age), Wasting (low Weight-for-height), and low Occipitofrontal circumference. The Mid Upper Arm Circumference (MUAC) was not measured. The nutritional status was examined, and the children were classified and enrolled based on the selection criteria. The children were not assessed for any co-morbidities other than those that warranted exclusion. The risk factors were assessed through self -structured questionnaire that included questions regarding sociodemographic, economic and environmental characteristics; feeding practices; and the frequency of common illnesses. The research investigator collected data on risk factors via questionnaire administered via face- to- face interviews with mothers of children in Urdu language. One child corresponded to only one household. Only mothers of children were interviewed to minimize recall bias. When the mothers were not living with the participants or were deceased, the primary guardian was interviewed.

The outcome variable was malnutrition, and the key risk factors were low income, history of migration, mother’s lack of education, father’s lack of education, nuclear family system, two or less rooms, inaccessibility to proper flush toilet facilities, large number of family members, high number of children, more than one child under the age of five years, home delivery, low birth weight, delivery by a relative or unskilled attendant. In-exclusive breast feeding of infants under 6 months, lack of two years breast feeding, early or late weaning, frequency of recurrent illnesses, history of worm infestation, incomplete EPI immunization.

Data processing and analysis

All duly filled forms were verified manually, and errors were identified and rectified. Incomplete forms were completed, and verified data were entered into SPSS version 24 for further processing. A backup depository was developed to prevent data loss. Descriptive statistics such as the mean and standard deviation were used for quantitative variables like age, weight, height, head circumference, birth weight, house hold size, number of siblings, number of siblings under two years of age, and house hold income. The percentage and frequency were utilized for qualitative variables such as sex, ethnicity, housing, water source, immunization status, parents’ educational status, parents working status, father’s job type, and father’s profession. Predictors of childhood malnutrition were investigated using logistic regression analysis. A variety of household, maternal and child- related factors were included. First a univariate analysis was conducted to determine the independent effect of each predictor on the outcome. All the predictors were subsequently included in multivariate analysis to investigate their net effect after adjusting for age of child, source of water, presence of cemented or uncemented house, number of people using one toilet and all other factors in the model. Adjusted ORs were calculated to study the predictive power of independent variables in relation to malnutrition. The statistical significance was set at a p value < 0.05.

Ethical approval

Approval for the research was obtained from the Institutional Review Board of Dow University of Health Sciences, Karachi, Pakistan. Reference: IRB-2345/DUHS/Approval/2021/892. Formal permission was obtained from Ziauddin University’s Department of Family Medicine for data collection from the Primary Healthcare Center.

The total sample size was n  = 280 with 140 cases and 140 controls. The mean age of the sample was 31.2  ±  18 months. The mean quantitative variables of cases and controls are given in Table  1 .

The sociodemographic factors, and the associations of various social, economic and environmental factors with malnutrition status are given in Tables  2 and 3 , respectively.

Breastfeeding practices

The mean age of exclusive breastfeeding was 4+/- 2.4 months. Mean age of in-exclusive breastfeeding was 19 +/- 9 months. Only 108 (38.5%) participants (Cases + Controls) were exclusively breastfed for first six months of life. A total of 145 (52%) participants had exclusive breastfeeding for less than six months, and 20 (7%) had exclusive breastfeeding for more than six months. Various other types of products were used during the first six months by the majority of the participants. Total 18% had used formula, 29% had Buffalo or Cow milk, and 2% had goat milk. A total 6.4% infants were given a tea whitener during the first six months of life, out of which 4.7% were cases and 1.7% were controls,

Among the 172 (61.5%) participants using products other than breast milk, feeding bottle was the most common method of giving products and was used by 148 (86%) participants. Only 9 (5%) participants were given non breast milk products via cup and spoon.

The mean age at weaning among the participants was 7.4  ±  3 months.

There was no significant association between malnutrition and having siblings under the age of 2 years (OR = 1.22, p value = 0.4). There was no association between living in a rented house and malnutrition (OR = 0.73, p value 0.2).

Most of the participants were weaned after 6.5 months ( n  = 154;55%). Only 88 (31.4%) mothers weaned their children at 6 months. Inappropriate weaning age was observed in 192 (68.5%) participants, a majority of whom were cases, as shown in Table  4 .

The significant results of the multivariate analyses are presented in Table  5 . After adjusting for the age of the child, source of water, presence of a cemented or uncemented house, number of people using one toilet and all other factors in the model.

Malnutrition is a multifactorial illness and children can be affected by a wide variety of modifiable and non-modifiable determinants. This study endorsed various risk factors that were consistent with the findings of previous studies and the risk of some factors was greater than that of others. The association between economic status and malnutrition is well documented [ 16 ]. This study showed similar findings. Although the community under study is overall a poor community, the malnutrition risk of households with low family income earning less than or equal to national minimum wage for unskilled work in Pakistan, i.e., PKR 25,000/= was very high after adjustment (aOR = 7.1). This reiterates that the role of economics in determining health can never be over emphasized.

The majority of the cases were males, and the majority of controls were females, similar to the findings by NNS 2018, which found higher percentage of malnourished children under five years of age to be males [ 4 ]. However, the association was not significant in our study (OR = 1.45, p value = 0.06). The educational status of parents is associated with the nutritional status of the child. Most previous studies have highlighted mothers’ education as an important factor [ 17 , 18 , 19 ]. In this study paternal education (primary or below) was found to be more strongly associated with malnutrition than low maternal education. A possible explanation could be that fathers play a leading role in patriarchal tribal communities even if they migrate and reside in urban squatters. Daily wagers are vulnerable in many ways and this was reflected in the current study, showing a daily wager father is 1.8 times more likely to be existing among cases ( p value = 0.008).

Although most of the participants were born in Karachi, their parents had moved to the city from other parts of Pakistan or from Afghanistan less than fifteen years ago (61.8%). The risk of malnutrition was 1.48 times greater for children whose parents had migrated less than fifteen years ago. However, the result was not significant ( p value 0.055). Reporting bias is very likely as many participants are suspected to have hidden their migration history from Afghanistan due to current sociopolitical issues, including the risk of deportation. Since most Afghans are ethnically Pashtoon, it is sometimes difficult for a non-Pashtun to differentiate between a Pakistani Pashtun and an Afghan Pashtun.

Environmental factors are strong predictors of malnutrition [ 20 , 21 ]. Some past studies point to crowding as a predictor of malnutrition [ 22 ]. In the current study, the number of rooms in the house being two or less was independently associated with undernutrition (OR = 2.1). The cases and controls were almost equally divided into nuclear and joint families. The majority of both cases and controls lived in joint families and no association was found with household type (OR = 1.03). The cases were much more likely to have three or more siblings (OR = 1.68). A large family size may be associated with poor care. A greater number of children is usually associated with other socioeconomic factors such as parents’ education and income and this finding was not significant after adjustment.

Six months exclusive breastfeeding of infants is recommended for achieving optimal growth and physical and mental development [ 23 ]. Breastfeeding should be continued for up to two years, along with initiation of weaning at six months. In this study, only 38.5% of the children were exclusively breastfed for 6 months [ 21 ]. Pakistan is the country with lowest exclusive breastfeeding rates in South Asia [ 24 ]. It has been observed that bottle feeding is widespread in poor households and higher than recommended dilutions are used by parents due to affordability issues. A low concentration of formula further deteriorates nutrition, on top of other bottle associated risks. The present study showed that not only formula but also buffalo and goat milk as well as tea whitener were given to infants. A staggering 6% of the children (mostly cases) were given tea whiteners instead of breastmilk or even formula. This is a very serious issue that needs to be addressed. Parents must be educated about the serious impact of such use. In the present study, the inappropriate duration of exclusive breastfeeding was associated with 3.58 times risk of malnutrition after adjustment. Breastfeeding promotion is thus an urgent and efficient intervention to fight malnutrition in the children under five years of age.

Weaning should be timely, adequate, safe and proper [ 25 ]. Majority of the participants (68.5%) showed inappropriate weaning age, mostly delayed. Only 31% participants were weaned at the WHO recommended age of six months. The association with malnutrition was strong, and inappropriate weaning age was associated with more than three times malnutrition chance in the present study (aOR = 3.7).

Several studies have shown an independent association between the incidence of common illnesses such as diarrhea, cough and cold and the development of malnutrition. Acute infections can lead to weight loss, and being underweight can suppress immunity increasing risk of infections. Thus, a vicious cycle occurs [ 15 , 21 ]. However, the current study failed to establish an association between frequent common illnesses and malnutrition.

The current study did not find any strong association with low birth weight (OR = 1.17). This finding contrasts with the previous studies [ 15 , 21 , 26 ]. However, a possible explanation is that most of the participants were born at home or so-called private clinics run by nontrained staff, and there was no documented evidence of birth weight. The mothers’ recall of weight could thus not be trusted. This study revealed an association between delivery at home/private clinic and malnutrition (OR = 1.87), but this finding lost significance after adjustment.

An association between a birth attendant being a relative or traditional attendant (Dai) and malnutrition was also established in the present study (OR = 1.91). Though, the adjusted rates did not verify this association perhaps because home deliveries by nontrained staff could be a result of various socioeconomic determinants that are independent risk factors for malnutrition, such as maternal education, low income, lack of assimilation in urban society, distrust of healthcare facilities and/or poor access to healthcare. This phenomenon needs to be explored.

This study showed significant association between pour/pit/open sewer and malnutrition, which was consistent after adjustment (aOR = 4.41). This study showed that environmental factors such as toilet facilities are important predictors. Children with access to VIPs or flush toilets had a decreased risk of malnutrition. Unhygienic conditions such as open defecation and pour or pit latrine are associated with malnutrition according to many past studies conducted in rural settings [ 27 ]. These findings are consistent with the findings of the present study, which showed four times higher risk of malnutrition in children using pour pit toilets.

Children with complete Immunization status did not have a lower risk of malnutrition, unlike in some previous studies on the subject [ 28 , 29 ] The children showed overall better immunization coverage ( n  = 215) than the national coverage, probably due to urban setting of a primary healthcare center providing immunization facilities.

One limitation of the current study is that it employed consecutive sampling technique in a primary healthcare setting. Further community bast studies with probability sampling and better generalizability are needed for a clearer picture.

A very disturbing experience while conducting the current study was that it was easier and quicker to enroll cases while it became very difficult to find controls who met the inclusion criteria. It took us extra months to find children who did not have z scores below − 2 SD of the WHO cut-off for WFA, HFA, WFH and OFC. It is therefore suspected that majority (> 50%) of the children under five years of age in the community are malnourished. A screening survey in the community could give a broad picture of the burden of malnutrition in the urban squatters of Karachi, that may well be above the national or district- level average. A very high prevalence of malnutrition is suspected in the community and a prevalence study in the same community is needed to highlight it.

Low family income, low paternal education, poor toilet facilities, lack of exclusive breastfeeding for first six months of life and inappropriate weaning age, were significant predictors of childhood malnutrition. Some variables which were found to be significant at univariate analyses were mother’s education, a daily wager father, number of siblings  ≥  3, number of rooms  ≤  2, and home delivery of a child or delivery by a nonskilled birth attendant, such as a child’s relative/Dai/LHV.

The implementation of poverty reduction programs and sanitation provision at affordable rates is needed for health improvement. The economic conditions of Pakistan are deteriorating, and improving the quality of life for urban slum residents may be long term and ambitious, but simple practical measures, such as exclusive breast feeding for six months, and appropriately timed weaning, are cost effective methods that can improve the nutritional status without financial burdens on parents. The parents need to be educated on this subject. Implementing strategies to create supportive environments for enabling underprivileged mothers to successfully employ best breastfeeding practices is urgently needed and should be given priority by stake holders. The nutritional status of urban squatter settlement children is very poor and needs special consideration.

Data availability

The data are from vulnerable and conservative tribal communities residing in urban squatters. Keeping in mind the vulnerability of the population, anonymized data will be shared after approval of the IRB committee of Dow University of Health Sciences if data requestors provide a methodically sound proposal. The corresponding author may be contacted for additional details.

Abbreviations

Weight-for-age

Height-for-age

Weight-for-height

Occipitofrontal circumference

Expanded Program on Immunization

Lady Health Visitor

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Acknowledgements

We are grateful to Ms. Shehla Farooq, a community health worker in the Department of Family Medicine, Ziauddin University, for her help during the data collection. We acknowledge Dr. Fatima Jehangir, head of the department of Family Medicine, for permission to collect data from the Primary Healthcare Center. We thank Dr. S.M. Ashraf Jahangeer Al’Saani, Assistant Professor, Dow University of Health Sciences, for sharing his valuable insights. We are indebted to parents and children who participated in the study.

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GA conceptualized the study, collected the data, performed the data analysis and interpretation, and drafted the manuscript. BF and SS drafted the manuscript. All the authors read and approved the final manuscript.

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Correspondence to Gati Ara .

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Approval for the research was obtained from the Institutional Review Board of Dow University of Health Sciences, Karachi, Pakistan. Reference: IRB-2345/DUHS/Approval/2021/892. Formal permission was obtained from Ziauddin University’s Department of Family Medicine for data collection in Primary Healthcare Center. Informed written consent was taken from parents of all participants. All parents could understand Urdu language. Fathers of most participants were also able to read and write Urdu. For parents who had no literacy, the informed consent form was clearly explained by the Principal Investigator. Consent form was also read and confirmed by a literate member of family who was also present on behalf of such parents, and could read and write Urdu. Thumb impression of parents and signature of the representative family member was taken thereafter. Data was pseudonymized and kept confidential.

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Dr. Gati Ara is an MBBS doctor who acquired her FCPS in Community Medicine. She is currently working as an Assistant Professor in the Department of Community Medicine at Dow Medical College, Dow University of Health Sciences. Her interests are Maternal, Neonatal and Child health (MNCH), Medical Education and Family practice.

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Ara, G., Fawad, B. & Shabbir, S. Malnutrition in children under five years in a squatter settlement of Karachi: a case-control study. BMC Public Health 24 , 848 (2024). https://doi.org/10.1186/s12889-024-18359-3

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Published : 19 March 2024

DOI : https://doi.org/10.1186/s12889-024-18359-3

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• Squatter settlement

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A simple blood test can detect colorectal cancer early, study finds.

Allison Aubrey

If the FDA approves it, a new blood test could become another screening option for colorectal cancer. Srinophan69/Getty Images hide caption

If the FDA approves it, a new blood test could become another screening option for colorectal cancer.

At a time when colorectal cancer is on the rise, a new study finds the disease can be detected through a blood test.

The results of a clinical trial, published Wednesday, in The New England Journal of Medicine, show that the blood-based screening test detects 83% of people with colorectal cancer. If the FDA approves it, the blood test would be another screening tool to detect the cancer at an early stage.

The test, developed by Guardant Health , can be done from a blood draw. The company says its test detects cancer signals in the bloodstream by identifying circulating tumor DNA.

Dr. Barbara Jung , president of the American Gastroenterological Association, says the test could help improve early detection of colorectal cancer.

"I do think having a blood draw versus undergoing an invasive test will reach more people," she says. "My hope is that with more tools we can reach more people."

Colorectal cancer is rising among Gen X, Y & Z. Here are 5 ways to protect yourself

But even if the blood test is approved, it will not replace the dreaded colonoscopy. "If the test is positive, the next step will be a colonoscopy," Jung says. That's because a colonoscopy can detect precancerous lesions — called polyps.

"And when you find those, you can also remove them, which in turn prevents the cancer from forming," Jung says.

The U.S. Preventive Services Task Force recommends regular screening should begin at age 45. But approximately 1 in 3 eligible adults are not screened as recommended, according to the American Cancer Society.

"Over 50 million eligible Americans do not get recommended screenings for colorectal cancer, partly because current screening methods are inconvenient or unpleasant," Guardant Health CEO, AmirAli Talasaz, wrote in a release about the results of the study.

Currently, effective screening options include stool tests and colonoscopies.

"It's never been easier to get the screening," T.R. Levin, a gastroenterologist at Kaiser Permanente told NPR last year.

Some of the early symptoms of colorectal cancer can include blood in your stool, a change in bowel habits, weight loss for no known reason, a feeling of bloating or fullness and fatigue. If you experience any of these symptoms, you should talk to your doctor.

And while colorectal cancer is still rare in young adults, the rate has been increasing. About 20, 000 people in the U.S. under the age of 50 are diagnosed each year.

"Colorectal cancer is rapidly shifting to diagnosis at a younger age," conclude the authors of an American Cancer Society report released last year. Since the mid-1990s, cases among people under 50 have increased by about 50%. It's one of the deadliest cancers in this age group.

Guardant Health has already filed for approval with the FDA. The decision is expected to come later this year.

This story was edited by Jane Greenhalgh.

• cancer screening
• colorectal cancer

CfCFS Newsletter – March 2024

Welcome to our March newsletter for the  Centre for Child and Family Studies .  As a dedicated team of researchers, we are excited to bring you updates, insights, and breakthroughs in the field of child and family studies. Our centre is interested in exploring the complexities of childhood development and influence, parenting dynamics, and family relationships through rigorous research and analysis. In this newsletter, we share links to our activities in research translation, the latest research from our dynamic HDR scholars, and our activities influencing policy and practice.

As always, we encourage you to continue to let us know of your work, successes, awards and news throughout the year.  You can email  me directly  or the Centre at  [email protected]    I look forward to seeing you at our events and hearing your news!

Ignite Quality Research Program

Our year has kicked off with the Centre’s Leader A/Prof Maryanne Theobald, launching the CfCFS new vision, the  Ignite Quality Research Program,  at our first member meeting for the year.

The vision aims to ignite quality through 3 key areas:  Quality Practices, Quality Partnerships and Quality People .

Igniting Quality Practices  focuses on capacity building, mentoring and research translation; 

Igniting Partnerships  focuses on activities to harness local, state and international connections,  

and the third but arguably the most important area focuses on 

Igniting Quality People  by harnessing and enhancing our members’ profiles, passion and engagement.

International connections

Trade and Investment Queensland (TIQ) recently reached out to the Centre to organise a visit by  Dr Daniel Huang from Taiwan . Dr Huang wears many different hats: he is a paediatric physician, an academic and a researcher, a YouTube Influencer, Podcast Host, Author and TV show host who focuses on parenting and early health, learning development and wellbeing. 

All of these topics are of keen interest to the CfCFS and Dr Huang specifically requested a meeting with our members and learn about our work in the early years. We were delighted to share a little about our work in initial early childhood teacher education, the ARC Centre of Excellence for the Digital Child, the Centre for Child and Family Studies and Centre for Childhood Nutrition Research. 

Response to Consultation Paper: Putting Qld Kids First Plan

Maryanne led the QUT and Centre for Child and Family Studies response to the  Queensland Government’s Putting Qld Kids First  plan. The releasedconsultation draft articulates a state vision of whole-of-government approach to promote the health and wellbeing of children and young people, with a focus on prevention and early intervention.  

This is an integrated policy framework, that includes priorities such as: enhancing wellbeing in the early years, supporting parents, promoting healthy child development and confident transitions to learning. Supporting families is key to supporting children, and we hope that this framework have impact toward an integrated support system across health, education and community. 

Research Forum – Parenting and its intersection with education and health

Our first Research Forum for 2024 was held this week, entitled,  Parenting and its intersection with education and health.  Our Early Career Mentor,  Dr Sally Savage  organised and hosted the session ,  which featured our shining HDR scholars , Pip Amery, Liz Briant  and  Yesika Ocktarani.

There were 40 registrations for the session, from those working in academic, private and government sectors across Australia and internationally, highlighting the significance of this topic for those working with children and young people. 

A feature of the session was the common challenges of parenting, particularly for mothers, evident across education, health and community. Pip presented on her research involving first-time mothers and their mobile phone use was highly engaging and provoked thoughtful conversation among the attendees. She raised some pertinent issues facing mothers and the tensions around mobile devices today, exposing the immense pressures mothers are under to conform to social expectations of ‘good’ motherhood. 

Liz’s presentation focused on parenting and tuition, and highlighted the extensive and intentional efforts parents make to seek advantages for their children to be successful. She clearly outlined the social instigators of such behaviours, particularly neoliberal ideologies that are prevalent in our society exerting pressures on parents. 

Yesika’s presentation introduced the audience to parenting support in Indonesia and how this community approach contrasts with parenting in Australia, which can be associated with isolation and a lack of support. She revealed the benefits of the approach and presented some of the challenges raised, offering a balanced perspective. 

The presentations were engaging and dynamic, and thought provoking, with insights stimulating valuable discussion and inspiration for HDR scholars, experienced researchers, leaders, policy makers, and practitioners alike.  

Congratulations to QUT  Adjunct Prof Julie Davis  on the publication of the third edition of  Young children and the environment: Early education for sustainability , co-edited this with colleague Sue Elliott from UNE. Topics covered include the science of sustainability, public health, children’s wellbeing, ethics and a broad range of environmental management topics. The book is full of practical case studies for preservice teachers and educators. Highlights, of course, are the chapters authored by CfCFS members including  Julie ,  Prof Kerryann Walsh, Dr Lyndal O’Gorman , and HDR student  Yvonne Paujik .

Exciting news!   This week new micro credentials were approved through QUT’s curriculum processes. These are linked to the  Victorian Educational Leadership CPE Program (VELP)  and have been accredited in accordance  with the  National Microcredentials Framework . There are two micro credentials linked to the two program offerings: VELP Foundations and VELP Advanced. Heartfelt congratulations to  A/Prof Megan Gibson  and the VELP team, with particular recognition and gratitude to  Dr Marie White  who provided skilled leadership in getting both of these approved.

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Double-blind, Placebo-controlled, Randomized Study of the Tolerability, Safety and Immunogenicity of an Inactivated Whole Virion Concentrated Purified Vaccine (CoviVac) Against Covid-19 of Children at the Age of 12-17 Years Inclusive"

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Recruitment of volunteers will be competitive. A maximum of 450 children aged 12 to 17 years inclusive will be screened in the study, of which it is planned to include and randomize 300 children who meet the criteria for inclusion in the study and do not have non-inclusion criteria, data on which will be used for subsequent safety and immunogenicity analysis.

Group 1 - 150 volunteers who will be vaccinated with the Nobivac vaccine twice with an interval of 21 days intramuscularly.

Group 2 - 150 volunteers who will receive a placebo twice with an interval of 21 days intramuscularly.

In case of withdrawal of volunteers from the study, their replacement is not provided.

Inclusion Criteria:

• Volunteers must meet the following inclusion criteria:

Type of participants • Healthy volunteers.

Age at the time of signing the Informed Consent

• from 12 to 17 years inclusive (12 years 0 months 0 days - 17 years 11 months 30 days).

Paul • Male or female.

Reproductive characteristics

• For girls with a history of mensis - a negative pregnancy test and consent to adhere to adequate methods of contraception (use of contraceptives within a month after the second vaccination). Girls should use methods of contraception with a reliability of more than 90% (cervical caps with spermicide, diaphragms with spermicide, condoms, intrauterine spirals).
• For young men capable of conception - consent to adhere to adequate methods of contraception (use of contraceptives within a month after the second vaccination). Young men and their sexual partners should use methods of contraception with a reliability of more than 90% (cervical caps with spermicide, diaphragms with spermicide, condoms, intrauterine spirals).

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• Written Informed consent of a volunteer (14 years and older) and one of the parents to participate in a clinical trial.
• Volunteers who are able to fulfill Protocol requirements (i.e. answer phone calls, fill out a Self-observation Diary, come to control visits).

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SARS-CoV-2 infection

• A case of established COVID-19 disease confirmed by PCR and/or ELISA in the last 6 months.
• History of contacts with confirmed or suspected cases of SARS-CoV-2 infection within 14 days prior to vaccination.
• Positive IgM or IgG to SARS-CoV-2 detected on Screening.
• Positive PCR test for SARS-CoV-2 at Screening / before vaccination.

Diseases or medical conditions

• Serious post-vaccination reaction (temperature above 40 C, hyperemia or edema more than 8 cm in diameter) or complication (collapse or shock-like condition that developed within 48 hours after vaccination; convulsions, accompanied or not accompanied by a feverish state) to any previous vaccination.
• Burdened allergic history (anaphylactic shock, Quincke's edema, polymorphic exudative eczema, serum sickness in the anamnesis, hypersensitivity or allergic reactions to the introduction of any vaccines in the anamnesis, known allergic reactions to vaccine components, etc.).
• Guillain-Barre syndrome (acute polyradiculitis) in the anamnesis.
• The axillary temperature at the time of vaccination is more than 37.0 ° C.
• Positive blood test for HIV, syphilis, hepatitis B/C.
• Acute infectious diseases (recovery earl

Exclusion Criteria:

- • Withdrawal of Informed consent by a volunteer and/or a parent of a volunteer;

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5 Cases When Parents Were Convicted After a Shooting by Their Child

The mother and father of a Michigan teenager who carried out a school shooting are among the parents who have been convicted of crimes in the aftermath.

By Adeel Hassan

A jury on Thursday found James Crumbley partially responsible for the deadliest school shooting in Michigan’s history. Mr. Crumbley’s son, Ethan, killed four people and injured seven more at Oxford High School in suburban Detroit on Nov. 30, 2021.

Ethan Crumbley, who was 15 at the time of the shooting, later pleaded guilty to 24 charges, including first-degree murder, and was sentenced last year to life in prison without the possibility of parole.

Mr. Crumbley’s wife, Jennifer, was convicted of identical charges of involuntary manslaughter last month. They were the first parents in the country to be directly charged for the deaths caused by a child in a mass shooting at a school.

Here is a look at their case and others in which parents have been found criminally liable after a shooting by their child.

Oxford High School, Michigan, 2021

Ms. Crumbley, 45, was convicted on Feb. 6 on four counts of involuntary manslaughter, one for each of the four students who were killed. She and her husband had given their son the pistol he used in the shooting as a gift.

Ms. Crumbley faces a maximum penalty of 15 years in prison; sentencing is scheduled for April 9.

The historic verdict in her case was built on evidence that included text messages and the accounts of a meeting with school officials just hours before the shooting, which jurors felt proved she should have known the mental state of her son. Ethan did not testify in his either of his parents’ trials.

But in the case of Mr. Crumbley, 47, the testimony focused more on the Sig Sauer pistol that he bought his son as an early Christmas present, just four days before the shooting.

Highland Park Fourth of July Parade, Illinois, 2022

Robert Crimo Jr. pleaded guilty to seven misdemeanor counts of reckless conduct for his role in helping his son own firearms, including a high-powered rifle that the authorities say was used in an attack on the Fourth of July parade in Highland Park, Ill., in 2022.

His son, Robert Crimo III, is accused of killing seven people at the parade. He was 21 at the time, has pleaded not guilty and is awaiting trial.

In Illinois, which has some of the strictest gun restrictions in the country, most firearms owners must first get a gun license, called a firearm owner’s identification card, which is issued by the Illinois State Police. Mr. Crimo sponsored his son’s FOID card.

The elder Mr. Crimo, prosecutors said, ignored obvious signs that his son was capable of violence: In 2019, months before the gun license was acquired, a family member contacted the authorities, reporting that the younger Mr. Crimo had threatened to “kill everyone.” Police officers removed 16 knives, a dagger and a sword from the home but decided that there was not probable cause to arrest him at that time.

Robert Crimo III later bought several weapons, including a high-powered rifle. On July 4, 2022, he climbed onto the roof of a building in downtown Highland Park, Ill., and opened fire on the parade crowd, the authorities said.

His father received a sentence of 60 days in jail — but was released halfway through — along with two years of probation and 100 hours of public service. He had to surrender his own guns, ammunition and his permit to own firearms. And he will not be allowed to sponsor an application for a gun permit.

Richneck Elementary School, Virginia, 2023

Deja Taylor, 26, the mother of a 6-year-old boy who shot his first-grade teacher in a classroom, was sentenced on Dec. 15 to two years in prison after pleading guilty to a charge of felony child neglect.

Earlier, she was sentenced to one year and nine months in prison after pleading guilty to using marijuana while owning a firearm and making false statements about drug use. Federal laws prohibit addicted or “unlawful” drug users from owning a gun. The two sentences will be served consecutively.

The shooting took place on Jan. 6, 2023, when the child, a student at Richneck Elementary School in Newport News, Va., took out the gun, aimed it and fired at his teacher, the police said. The teacher, Abigail Zwerner, was seriously injured by the single bullet that passed through her hand and struck her chest.

The child, who was not charged , is in the custody of his great-grandfather.

Waffle House Restaurant, Tennessee, 2018

Jeffrey Reinking, the father of a man who fatally shot four people and wounded four more at a Waffle House in Nashville in 2018, was sentenced last year to 18 months in prison for illegally providing his son with a weapon that was used in the shooting.

Travis Reinking, who was 29 at the time of the attack, was already known to the authorities. In Illinois, where he lived for most of his life before moving to Nashville, the police revoked his firearms license and ordered that his guns be transferred to his father.

The police said that the elder Mr. Reinking returned the guns to his son, enabling him to carry out the killings. One weapon, an AR-15, was used in the shooting. Officers had advised Jeffrey Reinking that “he might want to lock the guns back up until Travis gets mental help.” Mr. Reinking had said that he would do that, the police said.

Travis Reinking, who has paranoid schizophrenia, was found guilty of first-degree murder in 2022 and was sentenced to life without the possibility of parole.

Marysville Pilchuck High School, Washington, 2014

A federal jury in Seattle convicted Raymond Fryberg, of illegally owning six firearms, including a Beretta that his 14-year-old son used to kill four classmates and himself. Though the elder Mr. Fryberg was not charged in the shooting, he was sentenced to two years in prison.

Investigators determined that a prior restraining order against the father should have prohibited him from buying the gun, but the order was never entered in the federal database.

His son, Jaylen, took his father’s handgun to school in his backpack, then opened fire on a group of classmates whom he had texted to meet him, the authorities said. He shot five classmates, four fatally, before he turned the gun on himself.

Adeel Hassan is a reporter and editor on the National Desk. He is a founding member of Race/Related , and much of his work focuses on identity and discrimination. He started the Morning Briefing for NYT Now and was its inaugural writer. He also served as an editor on the International Desk.  More about Adeel Hassan