Thesis advisor: Thomas M. Crea / Child sexual abuse is a major public health problem in the United States, but identifying risk, especially in young children with suspicion of abuse, poses many challenges. The aim of this study is to understand how clinicians judge the possible presence of sexual abuse in children where serious suspicion exists but without substantiated abuse. This study used data from randomly selected sexual abuse and trauma evaluations of preschool and school-aged children presenting to Boston Children’s Hospital (BCH) Outpatient Child Protection Program between 2000-2007 (N=100) to examine the association between child and family risk factors and level of clinician concern regarding likelihood of child sexual abuse. Multi-nomial logistic regression analysis was used to examine the relationship between child and family risk factors and level of clinician concern regarding suspicion of abuse, moderated by child’s gender and age. Results indicated that a child’s disclosure and trauma presentation were the key factors that clinicians considered within the higher level of clinician concern regarding likelihood of sexual abuse. Implications for future research and clinical practice include attention to methodology research to assist with the development and validation of assessments for evaluation of risk in complex cases of suspicion of sexual abuse that can be offered in clinical setting, without sole reliance on the child’s ability to disclose in order to access help. Additionally, it is essential that research focuses on the development of clinical models to help with clinical decision making protocols in ambiguous cases of sexual abuse with children who may not be in a position to disclose, but serious concerns have been raised, with focus on increasing their safety. The findings in this research strongly suggest that it is essential to continue to focus on assisting children who present with suspicion of sexual abuse in complex cases that do not fit neatly into our current forensic and child protective services systems. This is especially necessary with the most vulnerable children where disclosure is unlikely, but clinical evaluations can yield recommendations that maximize efforts at increasing safety, child mental health, and family cohesion, and build on strengths while simultaneously accounting for risks. / Thesis (PhD) — Boston College, 2015. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

This study was a pilot investigation of the initial validity of a newly developed behaviour-screening instrument for early intervention service providers. Group Special Education, Early Intervention (GSE/EI) (2005) adapted the Canterbury Behaviour Screening Protocol (CBSP) from a widely used behaviour-screening instrument the Early Screening Project. The CBSP consisted of 49 items in 2 checklists. GSE/EI identified 10 early childhood centres with a total roll of 712 to participate in the study. Staff were asked to categorise children's problem behaviours as either withdrawn/isolated or aggressive/oppositional, using profiles provided. Next, they were asked to nominate 2 children in each category, and an additional 2 children in either category, and to rank them from most concerning to least concerning. Centres identified 25 children in the withdrawn/isolated category, and 28 children in the aggressive/oppositional category. Staff completed checklists for children with parent/carer consent, which were scored according to preset protocols. Scores on the CBSP were assigned risk values ranging from "extreme" to "no risk". The estimated prevalence of "high" to "extreme" behaviour problems was 7.2% based on CBSP protocols and teacher nominations. The level of agreement between teacher rank and CBSP score was 79%, and this determined the initial specificity. Next, independent observations of the behaviour of the nominated children were conducted during free play periods at the centres by an observer blind to the children's nominated category, teacher ranking or checklist score. Risk levels were assigned based on the observation scores, using a cut-off value of 37% time spent in problem behaviour for girls and 40% for boys. There was agreement in terms of teacher rank and observation scores, (categorised into either "no risk" and "at/high/extreme risk) for 65% for children in the withdrawn/isolated category, and 75% for children in the aggressive/oppositional category. The level of agreement between the CBSP score and the observations (categorised into either "no risk" or "at/high/extreme" risk) was 40% for children in the withdrawn/isolated category, and 46% for children in the aggressive/oppositional category. Using the cut-off values, a prevalence estimate for high risk or extreme risk for behaviour disorders, based on independent observation of children, was 3.2%. Centre staff completing a feedback form determined the social validity of the CBSP. Although responses were generally favourable, a number of suggestions were also made to improve the procedure. Despite limitations in the design of the draft, the CBSP shows promise for a first step in a screening procedure designed to screen New Zealand early childhood centres for children who may be at risk for developing behaviour and/or social emotional problems. The independent observation may also be useful as a second step, prior to extensive eligibility assessment. A number of suggestions were made for future drafts such as addressing the limitations specified, conducting the CBSP with a greater number of children, and determining the concurrent validity, and test-retest reliability.

This study was a pilot investigation of the initial validity of a newly developed behaviour-screening instrument for early intervention service providers. Group Special Education, Early Intervention (GSE/EI) (2005) adapted the Canterbury Behaviour Screening Protocol (CBSP) from a widely used behaviour-screening instrument the Early Screening Project. The CBSP consisted of 49 items in 2 checklists. GSE/EI identified 10 early childhood centres with a total roll of 712 to participate in the study. Staff were asked to categorise children's problem behaviours as either withdrawn/isolated or aggressive/oppositional, using profiles provided. Next, they were asked to nominate 2 children in each category, and an additional 2 children in either category, and to rank them from most concerning to least concerning. Centres identified 25 children in the withdrawn/isolated category, and 28 children in the aggressive/oppositional category. Staff completed checklists for children with parent/carer consent, which were scored according to preset protocols. Scores on the CBSP were assigned risk values ranging from "extreme" to "no risk". The estimated prevalence of "high" to "extreme" behaviour problems was 7.2% based on CBSP protocols and teacher nominations. The level of agreement between teacher rank and CBSP score was 79%, and this determined the initial specificity. Next, independent observations of the behaviour of the nominated children were conducted during free play periods at the centres by an observer blind to the children's nominated category, teacher ranking or checklist score. Risk levels were assigned based on the observation scores, using a cut-off value of 37% time spent in problem behaviour for girls and 40% for boys. There was agreement in terms of teacher rank and observation scores, (categorised into either "no risk" and "at/high/extreme risk) for 65% for children in the withdrawn/isolated category, and 75% for children in the aggressive/oppositional category. The level of agreement between the CBSP score and the observations (categorised into either "no risk" or "at/high/extreme" risk) was 40% for children in the withdrawn/isolated category, and 46% for children in the aggressive/oppositional category. Using the cut-off values, a prevalence estimate for high risk or extreme risk for behaviour disorders, based on independent observation of children, was 3.2%. Centre staff completing a feedback form determined the social validity of the CBSP. Although responses were generally favourable, a number of suggestions were also made to improve the procedure. Despite limitations in the design of the draft, the CBSP shows promise for a first step in a screening procedure designed to screen New Zealand early childhood centres for children who may be at risk for developing behaviour and/or social emotional problems. The independent observation may also be useful as a second step, prior to extensive eligibility assessment. A number of suggestions were made for future drafts such as addressing the limitations specified, conducting the CBSP with a greater number of children, and determining the concurrent validity, and test-retest reliability.

Background: Frozen shoulder or idiopathic adhesive capsulitis is an enigma of musculo-skeletal medicine. It is a difficult condition to treat and its etiology is still unknown. Aim: The aim of this study is to investigate whether acupuncture has a role in the management of frozen shoulder. Objectives: An in-depth literature review was conducted on all aspects related to the current concepts and treatments for frozen shoulder. Although there were discussions on associated conditions and possible causes of frozen shoulder, there is currently no consensus on its management. Acupuncture has been used successfully as a treatment for frozen shoulder by many eastern practitioners. Unfortunately, their claims could not be substantiated due to a lack of properly conducted clinical trials. An acupuncture treatment protocol for the management of frozen shoulder was designed based on both Traditional Chinese Medicine (TCM) and Anatomical principles. This protocol was then tested with a clinical trial. Methods: A pilot study, using a prospective case series of 20 patients suffering with the “adhesive phase” of frozen shoulder, was conducted to test the effectiveness of the acupuncture treatment protocol. This study included specific selection and exclusion criteria; an objective assessment of the range of movement and subjective assessments on the quality of life and pain. All data were collated and analysed with SPSS version 12. The pretreatment and post-treatment data were tested using both parametric paired sample t test and non-parametric Wilcoxon signed-rank test. Results: The patients’ profile confirmed the affected age group and gender distribution to be similar to those in the literature search. Unfortunately, due to the small sample size, there were no significant associated conditions demonstrated. There were twice as many cases of primary frozen shoulder than secondary frozen shoulder in this study. These analyses suggested that there were significant changes in all three areas of assessment – range of shoulder movement, quality of life and visual analogue pain scale (p&lt0.001). At completion of treatment, the result revealed that the acupuncture treatment protocol was successful in 60%, and moderately successful in 15%, of the 20 cases tested. This outcome was compared with the study by Omari and Bunker which showed only 12% success with conservative western medical treatments, suggesting that acupuncture may be better than conservative western medical treatments. Conclusion: Acupuncture treatment is less costly and has minimal side effects. It should be part of the non-procedural modalities offered to patients suffering with frozen shoulder. For patients who have failed western conservative managements, a trial of acupuncture treatment should be considered prior to embarking on the more invasive interventions..

Patients with acute spinal cord injury (SCI) have a high risk of venous thromboembolism (VTE) despite receiving thromboprophylaxis. The current standard of care recommended by guidelines is to use low-molecular-weight heparin (LMWH) for thromboprophylaxis for 90 days. This entails once- or twice-daily subcutaneous injections of LMWH for this duration, which is inconvenient for the patients and only partially effective. There are uncertainties about risk factors and the true incidence of SCI-associated VTE, the optimal time to commence thromboprophylaxis, and the optimal duration of thromboprophylaxis. Furthermore, there are currently no studies on the use of direct oral anticoagulants (DOACs) for thromboprophylaxis in patients with SCI. The use of DOACs for prophylaxis in this group can eliminate the inconvenience associated with daily subcutaneous injections for 3 months. To examine the incidence and risk factors of SCI-associated VTE, we performed a retrospective chart review of consecutive adult patients with acute SCI admitted to Hamilton General hospital from 2009 to 2015. The incidence of symptomatic VTE despite the use of thromboprophylaxis was 11% within 90 days of acute SCI; age and presence of other sites of injuries (such as lower limb fractures or pelvic fractures) along with SCI were independent risk factors for symptomatic VTE. To determine the opinion of Canadian spine surgeons about the optimal timing of starting LMWH after acute SCI, a short 5-question electronic survey was sent to the Canadian Spine Society. Data from our survey showed that the understanding about thromboprophylaxis after acute SCI was variable and that most spine surgeons were comfortable with starting LMWH after consultation with the surgeon. Future studies should focus on educational strategies to improve the knowledge base in this area. We will perform a pilot study at the Hamilton General Hospital comparing apixaban versus LMWH for thromboprophylaxis in patients with acute SCI. The use of apixaban for this indication can contribute to cost savings for the healthcare system and increased convenience for the patient. The protocol for the pilot study as well as steps towards a multi-center randomized controlled trial will be detailed in this thesis. / Thesis / Master of Science (MSc)

Breastfeeding is recommended as the optimal source of nutrition for newborns for the first 6 months of life and beyond with the addition of complementary foods. While breastfeeding initiation rates have been increasing, duration rates remain a concern as many women prematurely discontinue due to difficulties encountered rather than maternal choice. In addition, there is a sizable gap between rates of exclusive breastfeeding and current recommendations. Targeting modifiable variables that may be amenable to intervention is one strategy to improve breastfeeding outcomes. One such modifiable variable is breastfeeding self-efficacy. Although research has clearly shown that breastfeeding self-efficacy is predictive of breastfeeding duration and exclusivity, it is unknown whether it can be enhanced to improve breastfeeding outcomes. The purpose of this pilot randomized controlled trial was to examine the feasibility and compliance of a newly developed trial protocol and the acceptability of an intervention to increase breastfeeding self-efficacy in the immediate postpartum period. Secondary outcomes included determining whether there were any trends between groups related to breastfeeding self-efficacy, duration, and exclusivity. Participants included 150 primiparous mothers who were breastfeeding their healthy, full-term infants. Eligible and consenting mothers were randomized to either a control group (standard postpartum care) or an intervention group (standard postpartum care plus the self-efficacy intervention). Participants allocated to the intervention group received three individualized, self-efficacy enhancing sessions with the researcher; two sessions were conducted in hospital, and one was administered via telephone 1 week following hospital discharge. A research assistant blinded to group allocation collected outcome data at 4 and 8 weeks postpartum. The results suggested that the administration of the intervention was feasible and that there was a high degree of protocol compliance; the majority of participants reported that the intervention was beneficial. Secondary outcomes identified that there was a trend among participants in the intervention group to have improved breastfeeding outcomes, including higher rates of breastfeeding self-efficacy, duration, and exclusivity at 4 and 8 weeks postpartum. Preliminary evidence also suggested that the self-efficacy intervention may have assisted to decrease perceptions of insufficient milk supply among the intervention group participants. Overall, the findings from this pilot trial indicated that a larger trial is warranted.

This thesis seeks to assess the exposure of children in outdoor play areas of early childhood centres in Auckland City to traffic-related PM10 pollution. An estimated 400 premature deaths occur each year in New Zealand due to motor vehicle emissions. In addition to premature deaths, acute and chronic health effects including asthma, chronic obstructive pulmonary disease (COPD), heart disease and bronchitis, as well as increased hospitalisations and restricted activity days (sick days) are also associated with vehicle emissions. Epidemiological studies have shown that respiratory diseases such as asthma can be exacerbated by increases in the concentration of particulates of less than 10 microns in diameter (PM10) from motor vehicle emissions. Significant positive associations have been found between proximity to heavily travelled roads and increased childhood respiratory disease symptoms including hospitalisations for childhood asthma. In spite of this evidence, many early childhood centres in Auckland are located adjacent to busy roads. Children at these early childhood centres spend much of their time playing in the outdoor areas of these centres with the potential for particulates from motor vehicle emissions to exacerbate symptoms in those children already suffering from respiratory disease and asthma. Very little research has been carried out either in New Zealand or internationally on the air quality of outdoor play areas of early childhood centres in relation to motor vehicle emissions and childhood respiratory disease and asthma. The extent of monitoring is also limited and the amount of exposure data available in New Zealand relatively sparse, particularly in comparison with Europe. Levels of traffic-related PM10 in the outdoor play areas of early childhood centres were measured in centres located adjacent to busy roads and in centres away from a quiet road or adjacent to a very quiet road for comparison. Two of five early childhood centres located alongside busy roads had PM10 levels that exceeded the World Health Organization (WHO) guideline value. While PM10 levels monitored at the other three centres located alongside busy roads did not exceed the WHO guideline value, results were often only marginally within this guideline value. In contrast, PM10 levels monitored at two centres located away from a quiet road and one centre located adjacent to a very quiet road were well within the WHO guideline value. This pilot study provides preliminary evidence that children attending early childhood centres located alongside busy roads have greater exposure to traffic-related PM10 pollution than those attending early childhood centres located away from a quiet road or adjacent to a very quiet road. If the link between PM10 exposure and health effects is causal, as suggested by epidemiological studies, then children attending early childhood centres proximal to busy roads are at a greater risk of respiratory illness than children attending early childhood centres adjacent to quiet roads. Further work is required to confirm the findings in this small sample of air quality around early childhood centres in a larger sample, and possibly to undertake an epidemiological study to confirm the link to health effects. Drawing on the precautionary principle, prudent territorial local authorities should be encouraged to introduce regulations ensuring that any new early childhood centres are located at a specified distance from major roads, and that information for parents, ongoing PM10 monitoring and processes for issuing PM10 advisories when limits are exceeded are available in existing early childhood centres that are adjacent to busy roads.

Substance use during pregnancy can adversely affect both health and social outcomes for the infant and the mother. Many practices related to the care of infants with prenatal substance exposure are not consistent from one facility to another and have been developed on an anecdotal basis rather than based on empirical research. A replication study of a 2002 national practice survey is being planned that will describe some of the practices related to daily care, discharge planning, and community support for this group of infants and their caregivers. In this thesis, I present the findings of a pilot study that was conducted as a prelude to this larger national study. A summary of a literature review of recent survey research is presented along with a description of the process of revising a previously developed instrument to survey the practices used when caring for infants with prenatal drug and alcohol exposure and their mothers in the hospital setting. Content validity of this revised instrument was established with the support of a content expert group and the revised instrument was pilot tested with a small sample of nurses who practice in hospitals that will not be eligible for the national study. The findings from this pilot study will guide the research team in developing and conducting the national survey. / Graduate / 0539 / 0380 / 0573

Breastfeeding is recommended as the optimal source of nutrition for newborns for the first 6 months of life and beyond with the addition of complementary foods. While breastfeeding initiation rates have been increasing, duration rates remain a concern as many women prematurely discontinue due to difficulties encountered rather than maternal choice. In addition, there is a sizable gap between rates of exclusive breastfeeding and current recommendations. Targeting modifiable variables that may be amenable to intervention is one strategy to improve breastfeeding outcomes. One such modifiable variable is breastfeeding self-efficacy. Although research has clearly shown that breastfeeding self-efficacy is predictive of breastfeeding duration and exclusivity, it is unknown whether it can be enhanced to improve breastfeeding outcomes. The purpose of this pilot randomized controlled trial was to examine the feasibility and compliance of a newly developed trial protocol and the acceptability of an intervention to increase breastfeeding self-efficacy in the immediate postpartum period. Secondary outcomes included determining whether there were any trends between groups related to breastfeeding self-efficacy, duration, and exclusivity. Participants included 150 primiparous mothers who were breastfeeding their healthy, full-term infants. Eligible and consenting mothers were randomized to either a control group (standard postpartum care) or an intervention group (standard postpartum care plus the self-efficacy intervention). Participants allocated to the intervention group received three individualized, self-efficacy enhancing sessions with the researcher; two sessions were conducted in hospital, and one was administered via telephone 1 week following hospital discharge. A research assistant blinded to group allocation collected outcome data at 4 and 8 weeks postpartum. The results suggested that the administration of the intervention was feasible and that there was a high degree of protocol compliance; the majority of participants reported that the intervention was beneficial. Secondary outcomes identified that there was a trend among participants in the intervention group to have improved breastfeeding outcomes, including higher rates of breastfeeding self-efficacy, duration, and exclusivity at 4 and 8 weeks postpartum. Preliminary evidence also suggested that the self-efficacy intervention may have assisted to decrease perceptions of insufficient milk supply among the intervention group participants. Overall, the findings from this pilot trial indicated that a larger trial is warranted.

This thesis seeks to assess the exposure of children in outdoor play areas of early childhood centres in Auckland City to traffic-related PM10 pollution. An estimated 400 premature deaths occur each year in New Zealand due to motor vehicle emissions. In addition to premature deaths, acute and chronic health effects including asthma, chronic obstructive pulmonary disease (COPD), heart disease and bronchitis, as well as increased hospitalisations and restricted activity days (sick days) are also associated with vehicle emissions. Epidemiological studies have shown that respiratory diseases such as asthma can be exacerbated by increases in the concentration of particulates of less than 10 microns in diameter (PM10) from motor vehicle emissions. Significant positive associations have been found between proximity to heavily travelled roads and increased childhood respiratory disease symptoms including hospitalisations for childhood asthma. In spite of this evidence, many early childhood centres in Auckland are located adjacent to busy roads. Children at these early childhood centres spend much of their time playing in the outdoor areas of these centres with the potential for particulates from motor vehicle emissions to exacerbate symptoms in those children already suffering from respiratory disease and asthma. Very little research has been carried out either in New Zealand or internationally on the air quality of outdoor play areas of early childhood centres in relation to motor vehicle emissions and childhood respiratory disease and asthma. The extent of monitoring is also limited and the amount of exposure data available in New Zealand relatively sparse, particularly in comparison with Europe. Levels of traffic-related PM10 in the outdoor play areas of early childhood centres were measured in centres located adjacent to busy roads and in centres away from a quiet road or adjacent to a very quiet road for comparison. Two of five early childhood centres located alongside busy roads had PM10 levels that exceeded the World Health Organization (WHO) guideline value. While PM10 levels monitored at the other three centres located alongside busy roads did not exceed the WHO guideline value, results were often only marginally within this guideline value. In contrast, PM10 levels monitored at two centres located away from a quiet road and one centre located adjacent to a very quiet road were well within the WHO guideline value. This pilot study provides preliminary evidence that children attending early childhood centres located alongside busy roads have greater exposure to traffic-related PM10 pollution than those attending early childhood centres located away from a quiet road or adjacent to a very quiet road. If the link between PM10 exposure and health effects is causal, as suggested by epidemiological studies, then children attending early childhood centres proximal to busy roads are at a greater risk of respiratory illness than children attending early childhood centres adjacent to quiet roads. Further work is required to confirm the findings in this small sample of air quality around early childhood centres in a larger sample, and possibly to undertake an epidemiological study to confirm the link to health effects. Drawing on the precautionary principle, prudent territorial local authorities should be encouraged to introduce regulations ensuring that any new early childhood centres are located at a specified distance from major roads, and that information for parents, ongoing PM10 monitoring and processes for issuing PM10 advisories when limits are exceeded are available in existing early childhood centres that are adjacent to busy roads.