Taking Charge of Supervisory Neglect. Overview

Transcription

1 Taking Charge of Supervisory Neglect Jordan Greenbaum MD Stephanie V. Blank Center for Safe and Healthy Children Children s Healthcare of Atlanta Overview General overview of supervisory neglect Questions to consider Neglect and caregiver drug abuse Unsafe sleeping practices Children left in cars 1

2 Supervisory Neglect AAP: Supervisory neglect occurs when a caregiver s supervisory decisions or behaviors place a child in his/her care at significant ongoing risk for physical, emotional or psychological harm AAP, AAP, Peds, Supervisory Neglect Several types More likely to have critical event Can occur at any age Very common form of maltx (65% of maltreated kids) Effects catastrophic and abrupt or more general and long term 2

3 WISQARS, CDC, 2013 Unintentional Injury Deaths in U.S., 2013 Percent WISQARS, CDC,

4 Questions to Consider in Supervisory Neglect What does it mean to adequately supervise a child? 4

5 What does it mean to adequately supervise a child? Depends on factors related to: Child Caregiver Environment Background Community/culture Cultural and individual variations in opinion Child Factors to Consider What is child s age, developmental ability? Does child have any disabilities? Has child demonstrated good judgment before? Does child know what to do in emergency? Was child comfortable being unsupervised? AAP, Peds, 2006 AAP,

6 Caregiver Factors to Consider Caretaker must be able to respond to crisis Was he/she: Sober? With adequate cognitive and physical abilities? Within close range? Mobile? Able to easily access help (phone)? What was the caregiver s reasoning and understanding of the situation? AAP, 2006 Consider Caretaker Factors Any evidence of active mental health issues? Post partum depression Chronic depression Bipolar disorder Schizophrenia Others Is mom off meds b/o breastfeeding? Was behavior a conscious decision? Could caretaker have taken steps to prevent the injury? Had caretaker been warned in the past? AAP,

7 Consider Caretaker Factors Did caretaker understand the risks involved? Environmental Factors to Consider Was a caregiver or other specific adult easily accessible to the child? What were the number and ages of other children in caregiver s charge? What was the time of day? How long was the child left unattended? What was child doing while left unattended? Any inherent dangers in the environment? Was there an acute stressful event that distracted the caretaker? Did the event occur in usual environment or an unfamiliar one? AAP, Peds, 2006 AAP,

8 Consider Background Factors Any evidence of other types of neglect? Co existing abuse? Prior reports for maltreatment? Prior concerns of medical providers for noncompliance, delay in seeking healthcare? Prior history of accidental injuries related to poor supervision? AAP, 2006 Consider Community and Societal Factors Is there relevant law? Is this common practice in community? Do most people know the risks? Are there cultural considerations? Are there uncontrollable environmental factors? Were there unused resources? 8

9 Neglect Associated With Caretaker Drug Abuse Methamphetamine Use & Neglect Acute effects last up to 24 hours Speed runs may last days to weeks Post run sleep, depression w/ intense craving (withdrawal) Tolerance builds Supervisory neglect may be profound and prolonged Predisposes to all complications of supervisory neglect 9

10 Acute Effects of Meth on Caretaker Euphoria Agitation Aggression Anxious and volatile behavior Psychosis (resembles paranoid schizophrenia) Hallucinations Hypersexual behavior Compulsive behaviors Effects of Other Drugs Cocaine Very similar to meth Stimulant Agitation, aggression, volatile behavior Addictive behavior (drug seeking when not high) Opiods (Rx, heroine) Sedative effects Respiratory depression, coma Addictive behavior 10

11 Drug Use & Supervisory Neglect Children at risk for Physical abuse Sexual abuse Drug Use & Neglect Children at risk for Malnutrition and dehydration Injury 11

12 Drug Use and Neglect Educational neglect No one wakes child for school Older sibs must stay home to care for younger ones Medical neglect Chronic medical problems leading to preventable complications Delayed medical care for acute illness (DM, asthma) Drug Intoxication of Child Ingestion (accidental or intentional) Passive inhalation Intravenous use (older children) 12

13 Accidental meth exposure in child Rapid heart rate, high blood pressure Agitation Irritability Protracted vomiting Seizures High body temperature Muscle breakdown Roving eye movements (hypervigilant) Grant, 2006 Meth Labs: Hazards Chemicals used in production Depends on production method Hydrochloric acid, anhydrous ammonia, organic solvents, red phosphorous, iodine Toxic to liver, bone marrow Cause airway irritation, pulmonary edema Lethargy Caustic burns Grant,

14 So, would these cases involve supervisory neglect? 8 year old left home alone with 4 year old while mom takes meth intoxicated boyfriend to hospital for seizure 4 year old shoots self with gun used to protect parents drugs from intruders. 11 year old tries using heroin after mom and her friends have become high and unaware of their surroundings. Unintentional Suffocation in Infancy 14

15 Accidental Asphyxia Typically occurs with unsafe sleep practices Prone position Soft and/or excessive bedding Co sleeping with parents or sibs Sleeping on couch Unsafe crib Accidental Asphyxia Potential causes of asphyxia Facial obstruction and suffocation Wedging Overlaying 15

16 Autopsy Findings Typically no evidence of asphyxia on autopsy Findings the same as in SIDS High risk age group similar to SIDS Circumstances rarely clear Diagnosis can be very difficult The Issue of Bed sharing... Lots of studies, lots of results Meta analysis of 11 studies Bedsharing increases risk of SIDS (summary OR 2.89) Esp high risk if mom smokes (OR 6.27) Esp high risk if baby <12 weeks (OR 10.37) Not significant if bedsharing is routine, but if not routine, OR is 2.18 No study showed decreased risk with bedsharing Vinnemann MM, 2012 Vennemann,

17 Is it Neglect? Co sleeping very popular Differences in education regarding sleep practices Strong influence of relatives over mom s practices Cultural differences Mechanical Suffocation Deaths, Infants <13 mo Percent of Deaths By Age Most frequent causes Wedge between bed and wall (40%) Face obstruction (24%) Overlain (8%) Drago, Peds,1999;103(5). Drago,

18 Cause varied with age Number of Children (N 2178) Drago, 1999 Drago, Peds,1999;103(5). Risk Factors for Non Intentional Asphyxia General sleep factors Prone position Soft bedding Sofa/chair Adult bed Young infant age Co sleep (esp. with obese adult or deep sleeper) Wedging Faulty crib Space between mattress and wall or headboard Ill fitting crib mattress Misassembled crib Slat spaces too wide (2 3/8 ) 18

19 Aspiration: Small hard objects Strangulation More Risk Factors Hanging or loose cords, strings Projecting objects on crib Upper airway occlusion Occlusive objects (plastic bags) Recommendations for Safe Sleep Supine sleep position always Even with reflux Rare exceptions (can t protect airway) American Academy of Peds, 2011 Moon RY, AAP,

20 AAP Recommendations for Safe Sleep Firm sleep surface: Use fitted sheet Crib/bassinet/portable crib conforming to safety standards No broken (or fixed ) equipment No pillow/waterbed/quilt under sheet No gaps between mattress and crib edge NICHHD American Moon Academy RY, AAP, of 2011 Peds, 2011 Also, No sleeping on couches, chairs No safety hazards near sleep site Cords, exposed hooks, electrical wires No prolonged sleep in sitting devices Car seats, swings, slings, carriers Assure face not blocked American Academy of Peds, 2011 Moon RY, AAP,

21 Avoid soft objects, loose bedding Risk of suffocation, entrapment, strangulation Bumper pads don t prevent injury Avoid bedclothes that can cover baby s face American Academy of Peds, 2011 Moon RY, AAP, 2011 More Recommendations Room share, but don t cosleep Can reduce SIDS risk by up to 50% Avoids overlay, wedging, suffocation Increases monitoring of baby since parent is near American Academy of Peds, 2011 Moon RY, AAP,

22 Unsafe vs. Safe NICHHD /BTS_safe_environment.pdf 22

23 So, is this neglect? 3 month old dies from co sleeping and mom had been advised by pediatrician about safe sleep 17 month old dies of self strangulation when paci cord gets caught on new crib with a protruding screw 3 year old dies from choking on a grape. Babies In Hot Cars 23

24 September in Atlanta: 6 month old infant left in car seat while mom drops off package at aunt s home. Mom finds distraught aunt in a crisis; mom is delayed and forgets about infant. Child found dead in car two hours later. Null,

25 637 child vehicular heatstroke deaths ( ) Null, 2015 Why is this so dangerous? Null,

26 Car Temperatures Closed doors and windows: Temp rose from 97 degrees to 150 degrees in 15 minutes Slightly lower temps for light colored cars 75% of maximum temp reached within 5 minutes Only safe when windows half open King, et al, Pediatrics,1981;68:579. McLaren,

27 Temperature, fluid losses rise Greenhouse effect of car Clothing, car seat restricts heat loss from evaporation Infant below window: decreased convection High temp increases fluid loss Crying, restlessness increase losses Heat Exhaustion and Stroke Exhaustion Profuse sweating Headache Nausea/vomit Muscle weakness Visual disturbances Stroke Hot dry skin High body temp Disorientation Seizures Coma 27

28 So, is this neglect? 6 month old forgotten by 25 year old mom when she drops off package at aunt s home 3 year old left in car for 4 hours while dad went to neighborhood bar 3 month old left in car when mom comes home and unloads groceries; forgets child in car and 70 year old GM takes car to church. Child left in church parking lot for 2 hours. Conclusions Supervisory neglect is complicated Many factors to consider Cultural influences can present a challenge A common background for supervisory neglect involves caregiver substance use or stress 28

29 References CDC, WISQARS database, accessed at bin/broker.exe Drago DA, Dannenberg AL. Infant mechanical suffocation deaths in the U.S., Peds, 1999;103: Grant P. Evaluation of children removed from a clandestine methamphetamine laboratory. Clin Pediatr Emerg Med,2006;7: Hymel KP, COCAN, When is lack of supervision neglect? Peds,2006;118(3): References Kin K, Negus K, Vance JC. Heat stress in motor vehicles: A problem in infancy. Peds, 1981;68: McLaren C, Null J, Quinn J. Heat stress from enclosed vehicles: Moderate ambient temperatures cause significant temperature rise in enclosed vehicles. Peds,2005;116:e Null J. Accessed at Vennemann MM, et al. Bed sharing and the risk of sudden infant death syndrome: Can we resolve the debate? J Peds,2012;160:

30 Contact info: Jordan Greenbaum, MD 30