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The National Survey of Children’s Health (NSCH) provides rich data on multiple, intersecting aspects of children’s lives—including physical and mental health, access to and quality of health care, and the child’s family, neighborhood, school, and social context. The National Survey of Children's Health is funded and directed by the Health Resources and Services Administration (HRSA)   Maternal and Child Health Bureau (MCHB) . A revised version of the survey was conducted as a mail and web-based survey by the Census Bureau in 2016, 2017, 2018, 2019, 2020, 2021 and 2022. Among other changes, the 2016 National Survey of Children’s Health started integrating two surveys: the previous NSCH and the National Survey of Children with Special Health Care Needs (NS-CSHCN) .  See the  MCHB website  for more information on the 2016, 2017, 2018, 2019, 2020, 2021 and 2022 National Survey of Children's Health administration, methodology, survey content, and data availability.   The previous version of the NSCH was conducted three times between 2003 and 2012. In 2003, 2007, and 2011/12, the NSCH was conducted using telephone methodology, and was conducted by the National Center for Health Statistics at the Centers for Disease Control under the direction and sponsorship of the federal Maternal and Child Health Bureau  (MCHB).

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Center for Leadership Education in Maternal & Child Public Health

School of public health, children’s mental health case study about depression.

Those using the case studies will:

• Utilize research in making practice decisions
• Examine the needs of children from an interdisciplinary perspective
• Recognize the importance of prevention/early intervention in children’s mental health
• Apply ecological and developmental perspectives to children’s mental health
• Predict probable outcomes for children based on services they receive

Explore the case of Steven, a 15-year-old male with depression,  here .*

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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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Hartinger-Saunders, R. M., Jones, A. S., & Rittner, B. (2016). Improving Access to Trauma-Informed Adoption Services: Applying a Developmental Trauma Framework. Journal of Child & Adolescent Trauma, 12 (1), 119–130. doi:10.1007/s40653-016-0104-1

Johnson, A. B., Mliner, S. B., Depasquale, C. E., Troy, M., & Gunnar, M. R. (2018). Attachment security buffers the HPA axis of toddlers growing up in poverty or near poverty: Assessment during pediatric well-child exams with inoculations. Psychoneuroendocrinology, 95 , 120–127. doi:10.1016/j.psyneuen.2018.05.030

Klaehn, R. L. P. (2018). DC:0-5: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood. Infant Mental Health Journal, 39 (4), 489–491. doi:10.1002/imhj.21714

Lavigne, J. V., Gibbons, R.D., Christoffel, K. K., Arend, R., Rosenbaum, D., Binns, H., Dawson, N., Sobel, H., & Isaacs, C. (1996). Prevalence Rates and Correlates of Psychiatric Disorders among Preschool Children. Journal of the American Academy of Child & Adolescent Psychiatry, 35 (2), 204–214. doi:10.1097/00004583-199602000-00014

Lieberman, A. F. (2004). Traumatic stress and quality of attachment: Reality and internalization in disorders of infant mental health. Infant Mental Health Journal, 25(4) , 336–351. doi:10.1002/imhj.20009

Liu, J., Raine, A., Venables, P., Dalais, C., & Mednick, S. (2003). Malnutrition at age 3 years and lower cognitive ability at age 11 years. Archives of Pediatrics & Adolescent Medicine., 157 , 593-600.

Lloyd, E. C., & Barth, R. P. (2011). Developmental outcomes after five years for foster children returned home, remaining in care, or adopted. Children and Youth Services Review, 33 (8), 1383-1391.

Malinosky-Rummell, R., & Hansen, D. J. (1993). Long-term consequences of childhood physical abuse. Psychological Bulletin, 114 (1), 68–79. doi:10.1037/0033-2909.114.1.68

Measelle, J. R., & Ablow, J. C. (2017). Contributions of early adversity to pro-inflammatory phenotype in infancy: the buffer provided by attachment security. Attachment & Human Development, 20 (1), 1–23. doi:10.1080/14616734.2017.1362657

Reyes, V., Stone, B. J., Dimmler, M. H., & Lieberman, A. F. (2017). Child-Parent Psychotherapy: An Evidence-Based Treatment for Infants and Young Children. Evidence-Based Treatments for Trauma Related Disorders in Children and Adolescents , 321–340. doi:10.1007/978-3-319-46138-0_15

Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., McGuinn, L., Pascoe, J., Wood, D. L., Committee on Psychosocial Aspects of Child and Family Health and Committee on Early Childhood, Adoption, and Dependent Care. (2012). The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics, 129 (1), e232–e246. doi:10.1542/peds.2011-2663

Smith, C., & Thornberry, T. P. (1995). The relationship between childhood maltreatment and adolescent involvement in delinquency. Criminology, 33 (4), 451-481.

Smyke, A. T., Zeanah C. (1999) Disturbances of attachment interview. Unpublished manuscript .

Terock, J., Hannemann, A., Van der Auwera, S., Janowitz, D., Spitzer, C., Bonk, S., … Grabe, H. J. (2020). Posttraumatic stress disorder is associated with reduced vitamin D levels and functional polymorphisms of the vitamin D binding-protein in a population-based sample. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 96 , 234-238. doi:10.1016/j.pnpbp.2019.109760

U.S. Department of State. (2020, February). Adoption Statistics . https://travel.state.gov/content/travel/en/Intercountry-Adoption/adopt_ref/adoption-statistics1.html?wcmmode=disabled .

U.S. Department of Health and Human Services (2014). Preliminary estimates for FY 2013. Administration on children, youth and families, children’s bureau . Retrieved at www.acf.hhs.gov/programs/cb .

Vachon, D. D., Krueger, R. F., Rogosch, F. A., & Cicchetti, D. (2015). Assessment of the harmful psychiatric and behavioral effects of different forms of child maltreatment. JAMA psychiatry, 72 (11), 1135-1142.

Zanetti, C. A., Powell, B., Cooper, G., & Hoffman, K. (2011). The circle of security intervention: Using the therapeutic relationship to ameliorate attachment security in disorganized dyads. In J. Solomon & C. George (Eds.), Disorganized attachment and caregiving (p. 318–342). The Guilford Press. New York

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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Expanding Mental Health Access for Children and Youth Through System Change, Human-Centered Design, and Community Partnership

By ICTS and Washington University in St. Louis | August 14, 2024

Translational Science Benefits

Suicide is the second-leading cause of death for youth ages 10 to 14 years and the third for 15 to 24-year-olds. 1 According to the Youth Behavioral Risk Factor Survey, nearly one in five high school students have had suicidal thoughts, and 8.9% have attempted suicide. 2 The COVID-19 pandemic further increased mental health distress among youth. Recognizing this growing issue, in 2021, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared a national emergency in children’s mental health.

Pediatric providers identified several barriers to addressing this emergency, including a lack of time, inadequate mental health training, provider burnout, clinic system inefficiencies, limited resources for youth and their families, and the lack of a robust mental health system. Despite these barriers, pediatricians reported being committed and willing to screen patients for mental health issues and suicide risk. However, they expressed wanting more support to offer individuals who screened positive. In response to these challenges, this project focused on achieving the following system change goals: (1) increase access to community-based mental health services for youth and families during times of distress, (2) provide practice facilitation support to pediatric providers, and (3) build a more robust system for youth mental health.

Our research team used a Human Centered Design (HCD) workshop, focus group, and survey input from multiple community partners, youth, families, and pediatric clinicians to identify projects to improve youth mental health. HCD aims to align system design with the needs of users. 3, 4 During the workshop, participants were given an overview of youth mental health and suicide epidemiology. They then engaged in activities to generate ideas for systemic changes to improve youth mental health. Through this process, our team chose to focus on enhancing a follow-up care coordination role through Missouri’s Child Psychiatry Access Project (MO-CPAP). 5 This master’s level behavioral health clinician role identifies needed resources while supporting families’ linkage to mental health services over a 90-day period and communicates information back to the referring pediatric clinician.

Through collaboration and feedback, further improvements were made to the MO-CPAP follow-up care coordination service, including easier online intake forms and improved follow-up communication. The Washington University Pediatric and Adolescent Ambulatory Research Consortium (WU PAARC), a practice-based research network of more than 60 pediatric primary care practices caring for over 175,000 patients, completed additional provider outreach, education, coaching and programmatic updates to promote follow-up care coordination. 6 Preparation for this effort involved several steps, including creating a one-pager for families describing follow-up care coordination, making the online service request link more prominent on MO-CPAP’s website, and then adding the link to WU PAARC’s website. Refinement of flow charts for providers and updated protocols for follow-up were also completed.

Significance

This project made it easier for pediatric providers to connect patients who screened positive for mental health issues to appropriate follow-up care. Previously, the MO-CPAP follow-up care coordination service was only accessible by phone. Busy clinicians identified this time-consuming process as a barrier to using the service. Our work supported the development and implementation of an easy-to-use online form. Providers can now submit referrals asynchronously and request psychiatry consultation or follow-up care coordination. Resource materials explaining the process were created and shared with pediatricians, youth, and families. Pilot testing with a smaller group of providers ensured system effectiveness and improved communication between clinicians and families regarding the follow-up care coordination process, specifically informing caregivers on what to expect once referred. The usage of both follow-up care coordination and the online form significantly increased, benefiting families and increasing access to youth mental health services statewide in Missouri.

This collaborative approach strengthened our mental health system for children, enhanced community partnerships, and led to an increase in service use by providers. Early usage data from statewide providers shows nearly 70% of requests for assistance come through an online mechanism, and 70% of all MO-CPAP requests now include follow-up care coordination.

This project also had important equity impacts. The follow-up care coordinator service is now available to every child and family in Missouri through their pediatric clinician. This means rural patients and children of diverse racial and ethnic backgrounds have access to this support, and the service is free of charge.

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Expanded the follow-up care coordination services throughout the state of Missouri through MO-CPAP. demonstrated.

Increased usage of follow-up care coordination by pediatric providers to give greater access to mental health services for youth and their families. demonstrated.

Enhanced a follow-up care coordinator role to effectively refer and link families to mental health services. demonstrated.

Increased access to community health services and provided additional outreach, education, and programmatic updates to promote follow-up care coordination. demonstrated.

Strengthened our mental health system for children, potentially increasing life expectancy and quality by reducing the risk of suicide and improving emotional distress. potential.

Provided free referral services to providers and families through MO-CPAP. demonstrated.

This research has community and economic implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis. 7

This project increased access and linkage to needed care, added funding resources, redesigned an available resource for greater use by pediatric clinicians, and enhanced partnerships for future work in children’s mental health. The referral coordination system was improved based on user needs and preferences and now utilization has increased, thanks to the collaborative nature of MO-CPAP and Behavioral Health Response (BHR) staff and the trust and shared values among all entities. Among the 21 pilot requests including care coordination, 10 families (48%) were connected with resources.

MO-CPAP referral services are free for providers and families. WU PAARC helped secure federal and state funds for this free care coordination service by sharing provider feedback and committing to partner with MO-CPAP to develop an easier online process for psychiatric consultation and care coordination. WU PAARC data gathered around needs and pediatric clinician feedback strengthened a HRSA grant proposal, which ultimately led to greater funding for MO-CPAP to expand and bolster these care coordination services.

Lessons Learned

This project strengthened our mental health system for children, enhanced community partnerships, and led to an increase in service use by providers.  Advocacy and system change work increased access and linkage to needed care, added funding resources, redesigned an available resource for greater use by pediatric clinicians, and deepened partnerships for future work in children’s mental health. Building strong relationships around shared goals can lead to important system change that can strengthen mental health access for youth. The collaborative relationships between MO-CPAP, BHR, WU PAARC, parents, youth, community agencies, and pediatric clinicians are critical. The referral coordination system was improved based on user needs and preferences and utilization has increased. This project demonstrates that system change can occur through collaborative efforts among partners managing different aspects of the system. The HCD process helped identify opportunities that aligned with desirability, feasibility, and acceptability, while fostering trust and mutual understanding. The project began with achievable system changes and evolved into sustained and enhanced efforts through deepened partnerships.

References Arrow Down

• Heron M. Deaths: Leading Causes for 2017 . Natl Vital Stat Rep . 2019;68(6):1-77.
• Ivey-Stephenson AZ, Demissie Z, Crosby AE, et al. Suicidal Ideation and Behaviors Among High School Students — Youth Risk Behavior Survey, United States, 2019 . MMWR Suppl . 2020;69(1):47-55.
• Abookire S, Plover C, Frasso R, Ku B. Health Design Thinking: An Innovative Approach in Public Health to Defining Problems and Finding Solutions. Front Public Health . 2020;8:459.
• Hartung H, Rottenberg S. Human-Centered Design: Understanding Customers’ Needs Through Discovery and Interviewing . Academic Entrepreneurship for Medical and Health Sciences . 1st ed. PubPub; 2021.
• Missouri Child Psychiatry Access Project . University of Missouri School of Medicine. Accessed November 20, 2023.
• Washington University Pediatric & Adolescent Ambulatory Research Consortium . Washington University School of Medicine in St. Louis. Accessed November 20, 2023.
• Luke DA, Sarli CC, Suiter AM, et al.  The Translational Science Benefits Model: A New Framework for Assessing the Health and Societal Benefits of Clinical and Translational Sciences .  Clin Transl Sci . 2018;11(1):77-84.

• About Steven: A children’s mental health case study about depression
• Courses and events

The About Steven case study is an interactive, web-based tool that helps professionals and would-be-professionals explore children’s mental health. 

The case study focuses on a young white family and their son Steven, from his infancy through adolescence.

This case study is currently offered to instructors and their staff and students in graduate and undergraduate level courses. It is designed to supplement existing course curricula.

By completing the About Steven case study, participants will:

Use research in making practice decisions regarding infant and early childhood mental health.

Examine the needs of children from an interdisciplinary perspective.

Think holistically about working with other providers to serve children.

Recognize the importance of prevention and early intervention in children’s mental health.

Apply ecological and developmental perspectives to children’s mental health.

Predict probable outcomes for children based on services they receive.

Currently, the About Steven case study is only available as part of an academic course. The About Steven case study is ideal for use within graduate course settings but can also be used in undergraduate course settings. It is designed to be used as a supplement to existing course curricula. This case study has been incorporated into courses and trainings related to:

Child welfare.

Nursing, psychology, public health, social work, psychiatry, medicine, and other disciplines.

This case study consists of 11 chapters. Each chapter includes case story content, questions, critical learning components, and links to research.

The way this case study is set up, people can either:

Read through and complete the activities fairly quickly.

Dive in more deeply to the research and resources.

The exact length of time for completion is a function of how much an individual user wishes to engage with the content they have access to.  Participants average 15-25 minutes per chapter. They generally take an average of 2-3 hours to complete the whole case study.

Evaluation data has been collected from instructors, trainers, and users for the past ten years.

Feedback from instructors and trainers

“We love this case because it provides information at each major stage and it allows the students to see the developmental progression, and explore the supports and risk factors”

“I really like the format. Nice way to look at the whole situation.”

“I am currently developing an education module for school nurses to increase their awareness of teenage depression and teach them how to use the PHQ-9 as a screening tool.”

“Everyone was really engaged in the discussion. It was fun to hear the discussion again this year with a really different group of fellows!”

Feedback from participants

“The real-life information presented in this seminar series was incredibly helpful when thinking about the mental health of young people. I appreciated that we focused on one aspect of public health, so we could really dig deep into it. Our discussions were engaging and thought-provoking.”

“Solid case study as a way to discuss depression in pediatric and adolescent populations. Appreciated the interdisciplinary approach.”

“[This module] has been one of the few opportunities where we have been able to have interdisciplinary conversations, where each of us brings to the table their own trainings”.

“Interdisciplinary research is critical to seeing the various players in the lives of young people; great to think about how each profession has a separate role.”

“Very applicable!  These are situations that I encounter in my clinical work regularly.  I found the discussion insightful for how to approach my practice in a new way.”

“[The course discussions] pushed me to think of framework of mental health in a new way.”

Cost and registration

Now available free.

Fees are now removed from this curriculum. To support the need for online learning, instructors, trainers and their students may use this curriculum free of charge.

The About Steven case study is only available as part of an academic course. 

To get started, the primary instructor for the course needs to register by clicking the "Register now" button below. Once you register for the course, you will have access to the case study for the length of the course(s) you list. Instructors should then direct their co-instructors, teaching assistants, and students to this page and invite them to register as well (they will need instructor name and course name to complete registration). Get tips  about integrating this case study with your course. You may use this form to  contact us  if you have any issues accessing the course. 

Questions or comments about this case study? Interested in using this case in a setting besides an academic course? Contact us .

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DBP Community Systems-Based Cases

Introduction.

Following are case studies of children with typical developmental behavioral issues that may require a host of referrals and recommendations.

Case Studies

Case 1:                    case 2:                      case 3: sophie                     mark                     alejandro.

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What Causes Dangerous Inflammation in Children With Covid?

The sometimes fatal condition, MIS-C, may be driven in part by a misdirected immune system, a new study finds.

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By Apoorva Mandavilli

When exposed to a virus, the human body marshals the immune system to fend off the intruder. Sometimes, the defense goes awry, and the body mistakenly turns against itself instead of the attacker.

This sort of friendly fire drives multi-inflammatory syndrome in children, or MIS-C, a mysterious condition that in rare cases strikes children who have had a severe bout of Covid-19, according to a new study .

In a subset of children with the syndrome, immune cells become confused by the similarity between a protein carried by the coronavirus and one found throughout the human body, said Joseph DeRisi, an infectious disease expert and the president of the Chan Zuckerberg Biohub in San Francisco, who led the study. This phenomenon is called molecular mimicry, Dr. DeRisi said.

The study was published on Wednesday in the journal Nature. The results offer the first direct proof that Covid-19 sets off an autoimmune reaction that leads to MIS-C.

“This adds a very clear layer of evidence that there is an autoimmune component to MIS-C,” said Dusan Bogunovic, a pediatric immunologist at Columbia University who was not involved in the work.

Scientists have long known that infections can befuddle the body into attacking itself , but the new study is among the first to identify the series of events and cast of immune characters involved in the process.

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Harvard T.H. Chan School of Public Health Case-Based Teaching & Learning Initiative

Teaching cases & active learning resources for public health education, case library.

The Harvard Chan Case Library is a collection of teaching cases with a public health focus, written by Harvard Chan faculty, case writers, and students, or in collaboration with other institutions and initiatives.

Use the filters at right to search the case library by subject, geography, health condition, and representation of diversity and identity to find cases to fit your teaching needs. Or browse the case collections below for our newest cases, cases available for free download, or cases with a focus on diversity. 

Using our case library

Access to cases.

Many of our cases are available for sale through Harvard Business Publishing in the  Harvard T.H. Chan case collection . Others are free to download through this website .

Cases in this collection may be used free of charge by Harvard Chan course instructors in their teaching. Contact  Allison Bodznick , Harvard Chan Case Library administrator, for access.

Access to teaching notes

Teaching notes are available as supporting material to many of the cases in the Harvard Chan Case Library. Teaching notes provide an overview of the case and suggested discussion questions, as well as a roadmap for using the case in the classroom.

Access to teaching notes is limited to course instructors only.

• Teaching notes for cases available through  Harvard Business Publishing may be downloaded after registering for an Educator account .
• To request teaching notes for cases that are available for free through this website, look for the "Teaching note  available for faculty/instructors " link accompanying the abstract for the case you are interested in; you'll be asked to complete a brief survey verifying your affiliation as an instructor.

Using the Harvard Business Publishing site

Faculty and instructors with university affiliations can register for Educator access on the Harvard Business Publishing website,  where many of our cases are available . An Educator account provides access to teaching notes, full-text review copies of cases, articles, simulations, course planning tools, and discounted pricing for your students.

What's New

Atkinson, M.K. , 2023. Organizational Resilience and Change at UMass Memorial , Harvard Business Publishing: Harvard T.H. Chan School of Public Health. Available from Harvard Business Publishing Abstract The UMass Memorial Health Care (UMMHC or UMass) case is an examination of the impact of crisis or high uncertainty events on organizations. As a global pandemic unfolds, the case examines the ways in which UMMHC manages crisis and poses questions around organizational change and opportunity for growth after such major events. The case begins with a background of UMMHC, including problems the organization was up against before the pandemic, then transitions to the impact of crisis on UMMHC operations and its subsequent response, and concludes with challenges that the organization must grapple with in the months and years ahead. A crisis event can occur at any time for any organization. Organizational leaders must learn to manage stakeholders both inside and outside the organization throughout the duration of crisis and beyond. Additionally, organizational decision-makers must learn how to deal with existing weaknesses and problems the organization had before crisis took center stage, balancing those challenges with the need to respond to an emergency all the while not neglecting major existing problem points. This case is well-suited for courses on strategy determination and implementation, organizational behavior, and leadership.

The case describes the challenges facing Shlomit Schaal, MD, PhD, the newly appointed Chair of UMass Memorial Health Care’s Department of Ophthalmology. Dr. Schaal had come to UMass in Worcester, Massachusetts, in the summer of 2016 from the University of Louisville (KY) where she had a thriving clinical practice and active research lab, and was Director of the Retina Service. Before applying for the Chair position at UMass she had some initial concerns about the position but became fascinated by the opportunities it offered to grow a service that had historically been among the smallest and weakest programs in the UMass system and had experienced a rapid turnover in Chairs over the past few years. She also was excited to become one of a very small number of female Chairs of ophthalmology programs in the country. 

Dr. Schaal began her new position with ambitious plans and her usual high level of energy, but immediately ran into resistance from the faculty and staff of the department.  The case explores the steps she took, including implementing a LEAN approach in the department, and the leadership approaches she used to overcome that resistance and build support for the changes needed to grow and improve ophthalmology services at the medical center. 

This case describes efforts to promote racial equity in healthcare financing from the perspective of one public health organization, Community Care Cooperative (C3). C3 is a Medicaid Accountable Care Organization–i.e., an organization set up to manage payment from Medicaid, a public health insurance option for low-income people. The case describes C3’s approach to addressing racial equity from two vantage points: first, its programmatic efforts to channel financing into community health centers that serve large proportions of Black, Indigenous, People of Color (BIPOC), and second, its efforts to address racial equity within its own internal operations (e.g., through altering hiring and promotion processes). The case can be used to help students understand structural issues pertaining to race in healthcare delivery and financing, to introduce students to the basics of payment systems in healthcare, and/or to highlight how organizations can work internally to address racial equity.

Kerrissey, M.J. & Kuznetsova, M. , 2022. Killing the Pager at ZSFG , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case is about organizational change and technology. It follows the efforts of one physician as they try to move their department past using the pager, a device that persisted in American medicine despite having long been outdated by superior communication technology. The case reveals the complex organizational factors that have made this persistence possible, such as differing interdepartmental priorities, the perceived benefits of simple technology, and the potential drawbacks of applying typical continuous improvement approaches to technology change. Ultimately the physician in the case is not able to rid their department of the pager, despite pursuing a thorough continuous improvement effort and piloting a viable alternative; the case ends with the physician having an opportunity to try again and asks students to assess whether doing so is wise. The case can be used in class to help students apply the general concepts of organizational change to the particular context of technology, discuss the forces of stasis and change in medicine, and to familiarize students with the uses and limits of continuous improvement methods. 

Yatsko, P. & Koh, H. , 2021. Dr. Joan Reede and the Embedding of Diversity, Equity, and Inclusion at Harvard Medical School , Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract For more than 30 years, Dr. Joan Reede worked to increase the diversity of voices and viewpoints heard at Harvard Medical School (HMS) and at its affiliate teaching hospitals and institutes. Reede, HMS’s inaugural dean for Diversity and Community Partnership, as well as a professor and physician, conceived and launched more than 20 programs to improve the recruitment, retention, and promotion of individuals from racial and ethnic groups historically underrepresented in medicine (UiMs). These efforts have substantially diversified physician faculty at HMS and built pipelines for UiM talent into academic medicine and biosciences. Reede helped embed the promotion of diversity, equity, and inclusion (DEI) not only into Harvard Medical School’s mission and community values, but also into the DEI agenda in academic medicine nationally. To do so, she found allies and formed enduring coalitions based on shared ownership. She bootstrapped and hustled for resources when few readily existed. And she persuaded skeptics by building programs using data-driven approaches. She also overcame discriminatory behaviors and other obstacles synonymous with being Black and female in American society. Strong core values and sense of purpose were keys to her resilience, as well as to her leadership in the ongoing effort to give historically marginalized groups greater voice in medicine and science.

Cases Available for Free Download

Gordon, R. , 2014. Who Owns Your Story? , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case uses a role play simulation to illustrate ethical implications when research practices violate cultural taboos and norms. In Who Owns Your Story? the Trilanyi - a fictional Native American tribe based on a real community that is not identified or located in the case – is adversely affected by a high prevalence of diabetes. They ask a university professor with whom they have a close relationship to study their tribe, and they agree to give samples of their blood – which they consider sacred – for the study. Tribe members signed a consent form to participate but it was unclear whether they realized that the consent covered the university potentially using their blood for other possible research topics beyond diabetes. Ultimately, the study does not discover that the tribe has a genetic predisposition to diabetes. Years later, however, tribe members learn that their samples had also been used to study topics they considered objectionable. The case is based on true events between the Havasupai tribe and the University of Arizona which ultimately led to a legal suit that was settled out of court. In the case, students are asked to develop and simulate role play negotiations toward an acceptable resolution for all the parties involved. 

This case summarizes the toxic water crisis in Flint, Michigan between 2011 and the end of 2016, which followed the decision to switch the city’s public water supply from Lake Huron to the more corrosive Flint River. It outlines the factors that led to the initial government decision, and the social, economic, health, and policy consequences that followed. The case highlights the role of citizens, scientists, and activists in raising public awareness of the crisis and the toxic long-term effects of lead poisoning on affected children. It also illustrates the challenges and questions such a crisis poses for other communities in the United States and globally.

The case is accompanied by an instructor’s note, role play exercise, and discussion guide with an accompanying teaching graphic.

Guerra, I., et al. , 2019. SALUDos: Healthcare for Migrant Seasonal Farm Workers , Harvard University: Social Medicine Consortium. Download free of charge Abstract The SALUDos program began in 2008 as a response to an influx of migrant seasonal farm workers (MSFWs) at a mobile medical unit serving homeless persons in Santa Clara County in Northern California. The program offered patients free and low-cost primary care services, linkage to resources, and advocacy.  As the farm workers involved in this program became more involved in their primary care, they advocated for evening hours, transportation, linkage to coverage programs, and health education resources to better understand their medical and psychological conditions. During continual modifications of the SALUDos program, the team sought to understand and address large-scale social forces affecting migrant health through interventions to mitigate health inequities. Teaching note available for faculty/instructors.

Teaching note available for faculty/instructors .

Weinberger, E. , 2014. Beauty and the Breast: Mobilizing Community Action to Take on the Beauty Industry , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract How does one learn to become an effective advocate? “Beauty and the Breast: Mobilizing Community Action to Take on the Beauty Industry” tells the story of protagonist Joe Wendell, known as Wendell, an emergency room nurse and widower raising a teenage daughter in Franklin, a largely working class town in the fictional US state of Columbia. One day his daughter announces she would like to have breast implants. The distressing news prompts Wendell into new, unforeseen directions as he learns all he can about implants and surgery, the “beauty culture” permeating society especially in his community, and the psychological development of teenagers. Though relieved to find out that as long as she is a minor she cannot legally obtain the surgery without his consent (and, no doubt, without his cash), Wendell starts to believe that greater protections for teen girls in Columbia are needed. In this effort he is guided by the confident figure of Anna Pinto, director of a community center in an East Franklin neighborhood with a vibrant Brazilian-American community where cosmetic surgery, especially for girls and young women, is something she perceives to be a particular problem and has some ideas about how to address. Teaching note available for faculty/instructors .

Focus on Diversity, Equity, and Inclusion

This teaching case study examines psychological trauma in a community context and the relevance, both positive and negative, of social determinants of health. Healthy People 2020 views people residing in communities with large-scale psychological trauma as an emerging issue in mental health and mental health disorders (Healthy People, 2016). The case study, which focuses on Newark, New Jersey, addresses three of the five key determinants of health: social and community context, health and health care, and neighborhood and built environment. The three key determinants are addressed using psychological trauma as an exemplar in the context of trauma-informed systems. The social and community context is addressed using concepts of social cohesion, civic participation, and discrimination. Access to health and health care are addressed with discussion of access to mental health and primary care services, health literacy, and the medical home model. Neighborhood and built environment are viewed through the lens of available government and NGO programs and resources to improve the physical environment with a focus on quality of housing, crime and violence, and environmental conditions. Upstream interventions designed to improve mental health and well-being that support trauma-informed systems are analyzed. The use of Newark as the case study setting allows a real-life exploration of each of these three key determinants of health.

This case study has four sections – introduction, case study, side bar, and vignettes. Learners should work through the case, access appropriate resources, and work in a team for successful completion.

Elizabeth, a middle-aged African American woman living in Minnesota, develops chest pain and eventually presents to a local emergency room, where she is diagnosed with stress-related pain and given Vicodin. Members of a non-profit wellness center where she is also seen reflect on the connection between her acute chest pain and underlying stress related to her socioeconomic status. On a larger level, how much of her health is created or controlled by the healthcare system? What non-medical policy decisions impacted Elizabeth such that she is being treated with Vicodin for stress?

Jessie Gaeta, the chief medical officer for Boston Health Care for the Homeless Program (BHCHP), learned on April 7, 2020 that the City of Boston needed BHCHP to design and staff in 48 hours one half of Boston Hope, a 1,000-bed field hospital for patients infected with COVID-19. The mysterious new coronavirus spreading around the world was now running rampant within BHCHP's highly vulnerable patient population: people experiencing homelessness in Boston. A nonprofit community health center, BHCHP for 35 years had been the primary care provider for Boston's homeless community. Over the preceding month, BHCHP's nine-person incident command team, spearheaded by Gaeta and CEO Barry Bock, had spent long hours reorganizing the program. (See Boston Health Care for the Homeless (A): Preparing for the COVID-19 Pandemic.) BHCHP leaders now confronted the most urgent challenge of their long medical careers. Without previous experience in large-scale disaster medicine, Gaeta and her colleagues had in short order to design and implement a disaster medicine model for COVID-19 that served the unique needs of people experiencing homelessness.

This case study recounts the decisive actions BHCHP leaders took to uncover unexpectedly widespread COVID-19 infection among Boston's homeless community in early April 2020. It details how they overcame their exhaustion to quickly design, staff, and operate the newly erected Boston Hope field hospital for the city's homeless COVID-19 patients. It then shows how they adjusted their disaster medicine model when faced with on-the-ground realities at Boston Hope regarding patients' psychological needs, limited English capabilities, substance use disorders, staff stress and burnout, and other issues.

On February 1, 2020, Jessie Gaeta, the chief medical officer for Boston Health Care for the Homeless Program (BHCHP), received news that a student in Boston had tested positive for the novel coronavirus virus that causes COVID-19 disease. Since mid-January, Gaeta had been following reports of the mysterious virus that had been sickening people in China. Gaeta was concerned. Having worked for BHCHP for 18 years, she understood how vulnerable people experiencing homelessness were to infectious diseases. She knew that the nonprofit program, as the primary medical provider for Boston’s homeless population, would have to lead the city’s response for that marginalized community. She also knew that BHCHP, as the homeless community’s key medical advocate, not only needed to alert local government, shelters, hospitals, and other partners in the city’s homeless support network, but do so in a way that spurred action in time to prevent illness and death. 

The case study details how BHCHP’s nine-person incident command team quickly reorganized the program and built a detailed response, including drastically reducing traditional primary care services, ramping up telehealth, and redeploying and managing staff. It describes how the team worked with partners and quickly designed, staffed, and made operational three small alternative sites for homeless patients, despite numerous challenges. The case then ends with an unwelcome discovery: BHCHP’s first universal testing event at a large city shelter revealed that one-third of nearly 400 people there had contracted COVID-19, that most of the infected individuals did not report symptoms, and that other large city shelters were likely experiencing similar outbreaks. To understand how BHCHP and its partners subsequently popped up within a few days a 500-bed field hospital, which BHCHP managed and staffed for the next two months, see Boston Health Care for the Homeless (B): Disaster Medicine and the COVID-19 Pandemic.  

Yatsko, P. & Koh, H. , 2017. Dr. Jonathan Woodson, Military Health System Reform, and National Digital Health Strategy , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract Dr. Jonathan Woodson faced more formidable challenges than most in his storied medical, public health, and military career, starting with multiple rotations in combat zones around the world. He subsequently took on ever more complicated assignments, including reforming the country’s bloated Military Health System (MHS) in his role as assistant secretary of defense for health affairs at the U.S. Department of Defense from 2010 to 2016. As the director of Boston University’s Institute for Health System Innovation and Policy starting in 2016, he devised a National Digital Health Strategy (NDHS) to harness the myriad disparate health care innovations taking place around the country, with the goal of making the U.S. health care system more efficient, patient-centered, safe, and equitable for all Americans. How did Woodson—who was also a major general in the U.S. Army Reserves and a skilled vascular surgeon—approach such complicated problems? In-depth research and analysis, careful stakeholder review, strategic coalition building, and clear, insightful communication were some of the critical leadership skills Woodson employed to achieve his missions.

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Browse our case library

Quelch, J.A. & Rodriguez, M.L. , 2015. Mérieux NutriSciences: Marketing Food Safety Testing , Harvard Business Publishing. Available from Harvard Business Publishing

“Alameda Health System” (AHS) describes a county-owned safety net health system adapting to the implementation of the Affordable Care Act and an increasingly competitive health delivery environment. It takes the perspective of senior management, specifically the Chief Medical Officer for the system, who has been in his job for just over one year. The case begins in late 2014, when the CEO of 9 years announced that he was leaving AHS to become CEO of a Detroit health system. He was leaving behind a senior management team that had been in place for 1–2 years, and had turned over several times throughout his tenure. At the same time, the system was experiencing a financial downturn, brought on in part by the loss of many low-income, formerly county indigent patients who selected subsidized private health insurance plans on the new state health exchange that contracted primarily with AHS’s two largest competitors. AHS also had yet to integrate clinically or administratively with two community hospitals, both of which were in poor financial health, recently acquired as part of a strategy to diversify the AHS payer mix.

The system faced operating challenges common to many publicly-owned safety net hospitals, including: a unionized workforce; an independent, mission-driven medical staff that had grown weary of administrative turnover; a poorly functioning revenue collection system; unprofitable contracts with managed care plans; relatively few commercially insured patients or contracts; long wait times for care; lack of telephone and transportation access to providers; and a low-income population with multiple poorly managed chronic diseases, including mental illness and substance abuse, as well as a high rate of violent crime.  

The case requires that students understand key aspects of the ACA and can synthesize other relevant environmental and organizational trends in order to recommend and evaluate the actions that senior management should take.

Moon, S. & Gordon, R. , 2014. Ensuring Vaccine Supply for the Next Pandemic Flu , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case highlights the challenges of managing externalities and sovereignty through the example of pandemic flu. Recent outbreaks of both the H5N1 and H1N1 influenza strains have illustrated that the global institutions charged with preventing and responding to these pandemics are not up to the task. With both, there were significant problems with the development, production, and distribution of flu vaccines. Indeed, stemming a modern day pandemic depends on the rapid development, sufficient production, and equitable, timely access to influenza vaccines, all within a complex global context. Compounding these challenges are the disease-specific “unknowns” related to the emergence of a new virus, including severity levels, transmission ease, human immunity, and drug vulnerability. Specific themes covered in "Ensuring Vaccine Supply for the Next Pandemic Flu: Will the World Be Ready?" include issues of sovereignty; the legitimacy, authority, and credibility of the World Health Organization (WHO); uncertainty and risk; world dependence on private vaccine manufacturers for an essential public health good; health as a security issue; and equity issues in vaccine distribution.

How might health insurance exchanges make health insurance more accessible and affordable for employers in the small group market (with 2–50 workers)? While the Massachusetts Health Connector—the state’s first-in-the-nation health insurance exchange—successfully enrolled nearly a quarter of a million individuals in subsidized and non-subsidized individual coverage, small businesses remained elusive as customers. The Health Connector needed to increase its scale in the small group market to be able to improve the affordability and quality of health insurance products for this sector, but finding ways to create value had been challenging indeed.  

In 2017, the small group market would expand, when the ACA would permit SHOPs (Small Business Health Options Programs) to sell to employers with up to 100 employees. But deciding whether, and how, to enter this market, or even whether to stay in the existing small group market, was a major strategic question for the Connector and other SHOPs across the country. SHOPs everywhere could also soon face more competition in the small employer market, as brokers and consultants nationally began to create private exchanges to target small businesses. A state waiver request from the ACA could include deciding to eliminate its SHOP altogether.

The Health Connector’s leadership had long grappled with how to crack the small employer market, and now other states are facing the same challenge. What should they do next?

Trivellato Andrade, G. & Atun, R. , 2016. Unlocking Social and Economic Growth: The Delivery Approach to Government Performance , Harvard University: Harvard Kennedy School of Government. Available from Harvard Business Publishing Abstract In June 2001, after winning the UK general elections by a landslide, which gave him a second term, Tony Blair invited Michael Barber (case protagonist) to establish and lead the Prime Minister Delivery Unit (PMDU): a small, dedicated performance management structure charged with driving improvements of a few, well-specified service delivery outcomes. Having become keenly aware of the chasm between policy ideas and outcomes on the ground during his first term, Blair wanted to strengthen the British government’s ability to deliver results that mattered to citizens. This case provides background on the delivery approach, developed by Barber and his team, designed to improve government performance. It tracks Barber’s experience as the Head of the PMDU during Blair’s second mandate. The case focuses on the processes involved in establishing foundations, planning, implementing and monitoring delivery, as well as the outcomes achieved during the PMDU’s first four years of operation. The goal of reducing accident and emergency wait times in the National Health System is investigated as an exemplar of how the delivery approach worked in practice. This case is designed to enable discussions on the challenges of implementing an innovative performance management system in the public sector, designed to achieve demonstrable results to citizens and embed a cultural change in government. Also available through Harvard Kennedy School's case program .

Ratleff, C. & Tucker-Seeley, R. , 2019. The Rhode Island Commission of Health Advocacy and Equity: Developing a Report on Health Disparities (Parts A, B, & C) , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract In 2011, the Rhode Island (RI) legislature established the Commission on Health Equity and charged this group with writing a report on health disparities every two years. The case protagonist, Dr. Harper Avery, Director of Minority Health at the RI Department of Health, has recently assumed the co-chair position on the Commission of Health Advocacy and Equity in RI. Through the experiences of Dr. Avery, the reader sees the issues involved when a multidisciplinary and multi-sectoral group must work together to create the health disparities/health equity report. Such issues include how to define "health disparities" and related terms, what health outcomes and behaviors to choose to report, where to get the data required for the report, and how to measure disparities with the data obtained. Additionally, the reader is encouraged to consider the multiple perspectives of the Commission members and the various constituencies they represent. This case study takes the students through the process of developing a state-level health disparities report.

Siegrist, R. , 2011. Sweetbriar Hospital (Parts A, B, & C) , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract Lucy Normen, Chief Operating Officer of Sweetbriar Hospital, had just gotten off the phone with her Emergency Department Director, Dr. Max Warner. He was very upset with the present situation in the ED: people currently boarding in the ED hallways because there were no open inpatient beds; some patients waiting over 24 hours to be admitted; stressed out medical staff.” Dr. Warner worried about possible mistakes—and likely drops in patient satisfaction scores. Lucy was puzzled. They had just spent millions of dollars on expanding the hospital’s emergency department, yet in the three months since it re-opened things had gotten worse rather than better. She had a strong feeling that her problems were all related to inefficient patient flow throughout the hospital, but didn’t quite know how to address them. 

Bossert, T. , 2007. Lowering the Cost of Drugs in the Philippines: A Health Sector Reform Agenda , Harvard T.H. Chan School of Public Health. Abstract Governor A was preparing for a forum on health sector reforms to be held the next week. The Governor wanted to make health reform one of her flagship programs during the upcoming local elections, and, in particular, wanted to consider ways of lowering the cost of drugs for the poor who were faced with huge out-of-pocket expenses for medications. The case focuses on issues of health reform implementation, using the problem of high cost pharmaceuticals as an example. Case available upon request from author .

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
• Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
• Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright

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Impacts of technology on children’s health: a systematic review

Impactos da tecnologia na saúde infantil: revisão sistemática, raquel cordeiro ricci.

a Universidade Federal de Mato Grosso do Sul, Três Lagoas, MS, Brazil.

Aline Souza Costa de Paulo

Alisson kelvin pereira borges de freitas, isabela crispim ribeiro, leonardo siqueira aprile pires, maria eduarda leite facina, milla bitencourt cabral, natália varreira parduci, rafaela caldato spegiorin, sannye sabrina gonzález bogado, sergio chociay, junior, talita navarro carachesti, mônica mussolini larroque.

The authors declare no conflict of interests.

Authors’ contribution

To identify the consequences of technology overuse in childhood.

Data source:

A systematic review was carried out in the electronic databases PubMed (National Library of Medicine of the National Institutes of Health) and BVS (Virtual Health Library), considering articles published from 2015 to 2020, in English, Portuguese and Spanish using the terms “Internet”, “Child” and “Growth and Development”.

Data synthesis:

554 articles were found and 8 were included in the analysis. The studies’ methodological quality was assessed by the Strobe and Consort criteria, being scored from 17 to 22 points. The articles showed positive and negative factors associated with the use of technology in childhood, although most texts emphasize the harmful aspects. Excessive use of internet, games and exposure to television are associated with intellectual deficits and mental health issues, but can also enable psychosocial development.

Conclusions:

Preventing the use of the internet is a utopic measure ever since society makes use of technologies. The internet is associated with benefits as well as with harms. It is important to optimize the use of internet and reduce risks with the participation of parents and caregivers as moderators, and training of health professionals to better guide them.

Identificar as consequências do uso excessivo da tecnologia na infância.

Fontes de dados:

Foi realizada uma revisão sistemática nas bases de dados eletrônicas PubMed (National Library of Medicine — National Institutes of Health) e Biblioteca Virtual em Saúde (BVS) com artigos publicados de 2015 a 2020, em inglês, português e espanhol, utilizando os termos internet, child e growth and development .

Síntese dos dados:

Foram localizados 554 artigos, resultando em oito artigos incluídos nesta pesquisa. Os estudos foram avaliados quanto à sua qualidade metodológica pelos critérios Strengthening the Reporting of Observational Studies in Epidemiology (Strobe) e Consolidated Standards of Reporting Trials (Consort) e receberam pontuações que variaram de 17 a 22 pontos. Os artigos evidenciaram que há fatores positivos e negativos associados ao uso de tecnologias na infância, embora a maioria dos textos ressalte seu aspecto prejudicial. O uso excessivo de internet, jogos e exposição à televisão ocasionaram alterações intelectuais e da saúde mental, porém também possibilitaram o desenvolvimento psicossocial.

Conclusões:

Impedir o uso da internet é uma medida utópica, visto que a sociedade faz uso de tecnologias. Considerando que a internet pode trazer benefícios, mas também malefícios, são importantes a otimização do uso e a redução dos riscos, como a participação dos pais e responsáveis como moderadores dessa utilização, além da atualização dos profissionais da saúde para melhor orientá-los.

INTRODUCTION

Nowadays, information and communication technologies increasingly make up children’s daily routines. Data from the Brazilian Institute of Geography and Statistics (IBGE) state that, among Brazilian children aged 10 years and over, internet use rose from 69.8% in 2017 to 74.7% in 2018. Exchange of messages, voice and/or video calls and, finally, watching videos, such as series and movies, are the most frequent activities performed requiring internet services. 1

Studies on digital technologies have been carried out in several fields, since the contents of activities on the internet may vary, reflecting the broad range of information available online. From this perspective, much has been questioned about the impacts of information and communication technologies on children’s physical and psychosocial development. In the cognitive sphere, the influence on sleep, memory, reading ability, concentration, the ability to communicate in person are commonly cited, in addition to anxiety symptoms when children are away from their cell phones. 2 , 3

This construction of self-image by means of technological tools results in potentializing a phenomenon of modernity and the emergence of large cities: placing intimacy as the focus of spectacularization. Furthermore, intense consumption of content can cause anxiety, panic and even depression. In the case of children with previous mental health conditions and who require monitoring, these effects can be even more intense. 4

With this in mind, the World Health Organization (WHO) published a series of recommendations to parents regarding the exposure of children of different age groups to digital technologies. Children under the age of 5 should not spend more than 60 minutes a day in passive activities in front of a smartphone, computer or TV screen. Children under 12 months of age should not spend even a minute in front of electronic devices. The goal is for boys and girls up to 5 years old to change electronics for physical activities or practices that involve interactions in the real world, such as reading and listening to stories with caregivers. 5 These guidelines are part of the strategy for awareness on sedentary lifestyle and obesity by the Organization of United Nations (UN).

Thus, it is clear that this spectrum of influence can culminate or intensify various pathologies. Therefore, the aim of the study was to identify the positive and negative consequences of technology overuse in childhood.

The selection process and the development of this systematic review were based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Prisma) protocol. 6 This review was registered with the International Prospective Registry of Systematic Reviews (Prospero), under number CRD42021248396.

The National Library of Medicine — National Institutes of Health (PubMed) and Virtual Health Library (VHL) electronic databases were searched from March to July 2020. The purpose was to systematically analyze original studies addressing information technologies and communication (Internet, social media, etc.) in child development based on a guiding question: what is the impact of information and communication technologies on childrens physical and psychosocial development?

The Medical Subject Headings (MeSH) was used to define the search term. Then, an exploratory investigation was carried out with the purpose of identifying keywords within the theme. The terms “internet”, “child” and “growth and development” were used, in English language, along with “AND”, to combine them. Additionally, the bibliographic references of articles selected were checked.

For the articles to be included, the following aspects were considered:

• Original articles.
• Studies conducted with children.
• Research regarding information and communication technologies (Internet, television, etc.) related to child development.
• Published from 2015 to 2020.
• Articles written in English, Portuguese and Spanish.

Studies carried out with adolescents, adults and the elderly, as well as theses, dissertations, monographs, duplicate studies and case studies were excluded.

The search and selection of articles took place at two different times. The articles were selected first by title and abstracts and, then, the full texts were accessed and evaluated.

Studies that met the eligibility criteria were fully analyzed by two independent researchers, whose evaluations were then compared to verify common points. In cases of uncertainty about the eligibility of the study, a third evaluator took part. Then, the data was extracted and input in predefined data tables.

The methodological quality of observational articles included was assessed according to the initiative Strengthening the Reporting of Observational Studies in Epidemiology (Strobe), based on various evaluation criteria for this type of studies. The maximum score is 22 points, which are distributed over several items: title and/or abstract (one item), introduction (two items), methodology (nine items), results (five items), discussion (four items), and funding (one item). 7 , 8 All observational studies were evaluated, and each item, when present, added up to 1 point; then the sum was scored according to Table 1 .

The methodological quality of the one randomized trial was based on the Consolidated Standards of Reporting Trials (Consort) strategy, which contains a checklist with 25 items, divided into: title and abstract (one item with two sub-items); introduction (one item with two sub-items); methods (five items) and a topic with information about randomization (five items); results (seven items); discussion (three items); and other information, such as registration, protocols and funding (three items). 9 , 10 Each item, if met, equals 1 point, and they were all added up according to the analysis of the papers. The score of methodological quality of this randomized trial is shown in Table 1 .

In order to synthesize the description of characteristics as main results and descriptive approach, the following information was extracted from each selected article: name of the main author, year of publication, country where the study was performed, design, sample size, type of technology evaluated, statistical variables, main results, and limitations.

Searches on PubMed and VHL using the descriptors “internet”, “child” and “growth and development” retrieved 550 articles. After applying inclusion criteria, 221 studies were selected and, after reading the titles and abstracts, 125 were excluded. 92 articles were read in full and, per the inclusion criteria and a detailed analysis, four studies were selected. Four other articles were included after an additional search in the reference list of primarily selected articles; the studies should have the same inclusion criteria defined in the methodology. Thus, eight articles made up the sample. The flowchart is shown in Figure 1 .

Most studies were epidemiological. Almost all of them were observational (n=7), and only one was an intervention study. The observational studies included were longitudinal and/or cross-sectional (n=5), case-control (n=1) and cohort studies (n=1). Only one experimental study was included, a randomized controlled trial (n=1), as shown in Table 1 .

Their methodological quality was based on their scores ( Table 1 ). Most studies were observational (n=7) and, therefore, were evaluated according to the Strobe criteria 7 . The score ranged from 17 to 22, and most articles reached 20 points (n=4), which is good methodological quality. The quality of the randomized trial with 18 points—according to the Consort 2010 criterion, which has a maximum score of 25—was also considered good. 9

The main results about the implications of technology in childhood are detailed in Tables 2 and ​ and3 3 .

After reading and analysis, the articles were classified and distributed into two categories according to their approach: negative aspects (n=6) and positive aspects (n=2). The review results are reported below.

Negative aspects

Six of the studies linked technologies to negative aspects. The papers highlitghed intellectual complications, 3 , 11 , 12 body image dissatisfaction 13 , 14 and encouragement of unhealthy food consumption. 15 Table 2 shows the main information.

Excessive internet use is transversally associated with lower cognitive functioning and reduced volume of several areas of the brain. In longitudinal analyses, a higher frequency of internet use was associated with a decrease in verbal intelligence and a smaller increase in the regional volume of gray/white matter in several brain areas after a few years. These areas relate to language processing, attention and executive functions, emotion and reward. 3

In a study conducted with 80 British girls aged 8 and 9 years, appearance-focused games led participants to have a greater dissatisfaction with their appearance compared to control girls, who were not exposed to such games. Therefore, internet games that address appearance can be harmful to girls’ body self-image. 13

It’s not just appearance-focused games that have a negative impact on body image. TV shows, depending on the approach, can also impact negatively psychological development. In a study with Australian girls, some TV shows aimed for the age group of 6-9 years focused on sexualization were absorbed or internalized as social messages by children. The authors stated that the exposure made these girls whish to wear sexualized clothes and create negative relationship with their body image. 14

Furthermore, a study with 562 Dutch and Spanish children reported that, among Dutch children, games with advertisements (advergames) for high-calorie foods stimulated the consumption of unhealthy foods, while those who played other games with advertisements other that food-related, were less inclined to this eating habit. 15 Thus, depending on what the child is exposed to, some influences may not be beneficial.

Video games were associated with increased mean diffusivity in cortical and subcortical areas. That is, prolonged video game use was associated with negative consequences, as it can directly or indirectly interrupt the development of neural systems and cause unfavorable neurocognitive development, especially when it comes to verbal intelligence. 11

Another study on children’s exposure to television, identified a negative effect on the gray matter of the frontal area of the brain with consequences for verbal language. No changes were identified in sensorimotor areas as related to TV watching time; the effect may not be direct, since watching this media is often associated with less physical activity, which, in turn, causes changes in the volume of gray matter in sensorimotor areas. 12

Positive aspects

Only two studies brought the positive aspects of technology use, related to cognitive and psychosocial development 16 and forms of interpersonal relationships. 17 Main information is shown in Table 3 .

Associations of electronic media use with psychosocial development and the executive function among 3- and 5-year-olds, particularly related to total screen time, TV shows viewing, and application use were assessed by the authors, who concluded that cognitive and psychosocial development in children 12 months later was positive when exposure to these media lasted less than 30 minutes a day. 16

In a study conducted with 2,840 students in South Korea, children with depressed mood were more likely to use the internet to socialize, exchange ideas and talk about their concerns as a way to meet their friendship needs. The Internet can be beneficial for children, who can take advantage of online opportunities for socialization and friendships based on common interests. 17

The studies analyzed, in general, show that children currently spend a significant amount of time on the Internet or other means of information, and consider that this exposure can have positive and negative impacts on children’s cognitive development and learning skills.

As for the negative impacts of this habit in childhood, the higher frequency of internet use is associated with a significant decrease in verbal intelligence, mainly related to language skills and concentration/attention abilities. One study reported frequent internet use by children as related to decreased memory performance. 18

Another issue that must be taken into account is the number of games emerging all the time with new elements of fun and entertainment to attract children. An alert should be raised, however, about destructive websites such as the Blue Whale Challenge, which target vulnerable children and young people, threaten their physical integrity and are completely unethical, leading to the gradual destruction of society. 19

On the other hand, researchers have identified, among the most frequent purposes in allowing children access technology declared by parents, the promotion of problem-solving skills (56.7%), learning of basic mathematics (53.8%), developing hand-eye coordination (46.2%), introduction to reading (51%), language (47.1%) and science (26%), as well as entertainment (56.7%). 20

Based on the studies selected, we point out an unexpected result for parents: the problematic use of electronic devices at an early age can have children show low levels of openness to experiences, increasing the level of emotional instability, impulsive or other behaviors related to attention. Then, we must reinforce that exposure to media must be carefully pondered by parents and guardians as to avoid media dependence and misuse.

Problematic internet use (PIU) is associated with less openness and agreeableness, as children with higher levels of PIU end up with a deficit in social skills and difficulties in establishing interpersonal relationships, which can lead to being less open and visible, or less friendly externally. It was also found that these children tend to experience negative emotions and use the internet as a means of feeling better about their everyday problems or unpleasant feelings. Relationships were also between problematic video game use and behavior problems, specifically related to thoughts, attention, and aggressive behavior. 21

In order to bypass the negative effects of inappropriate use of the internet, one cannot ignore, on the one hand, the positive side of these technologies. Technology is extensively available and it is almost impossible to remove it from children’s daily lives. 22 But the negative effects mentioned during the discussion deserve the same attention, as the authors place parental control and moderation as key factors. 23 In this sense, there is a directly proportional link between parental participation and attention and a less harmful relationship between children and technologies, especially regarding social factors. 24

Currently, children spend their lives immersed in the world of digital media, and research has consistently shown the growing, early and diversified use of this media. Children exposed to electronics tend to develop a desire for continued use, creating a potentially harmful cycle. Even more worrisome are the effects of digital media on young children by disrupting parent-child interaction, which is critical to a healthy emotional and cognitive development. 25

There are potential benefits of digital technology as a tool to enhance early childhood development, creativity and social connection, but it is imperative that parents monitor what their children are consuming and help them learn from it. 26

A review of the literature about media reported an adverse association between screen-based media consumption and sleep health, mainly due to delays in bedtime and reduced total sleep duration. The underlying mechanisms of these associations include:

• Time replacement, that is, time on screens replacing sleep time and time spent other activities.
• Psychological stimulation based on media content.
• Effects of light emitted by devices on circadian timing, sleep physiology, and alertness. 27

There is, therefore, and evident need to identify the warning signs of excessive technology use in this age group and define the appropriate limit of daily screen time. Children can make a balanced use of technologies, taking advantage of them without exaggeration, favoring communication and the search for information that is relevant to learning.

It is important to emphasize that pre-judgments about technology-dependent children should be avoided, and knowing their feelings about themselves, as well as the factors that bother them, is important, as well as having a sensitive listening to form a vision of ideal approach in this condition of technology dependence by means of suggested strategies to effectively face these difficulties. 28

Although this review has important and interesting results, some limitations must be listed. First, there the number of studies identified with the criteria of our work was limited. Also, most of the studies were observational. Therefore, experimental research must be carried out as a means to understand the cause-consequence dynamics between media and their implications for child development. Further studies with larger samples and specific age groups, which would be relevant to increase statistical power, are needed.

The analysis of the articles showed positive and negative factors associated with the use of technologies by children. The main losses caused by technology use in childhood are excessive time connected to the internet, worsening of mental health, and changes in the circadian rhythm. The articles mentioned as negative factors the development of intellectual impairments, including verbal intelligence and attention, emotional instability, internet addiction, binge eating and physiological changes.

The main benefits of the use of technologies by children found were the strengthening of friendships and the possibility of greater social connection. For the preschool age group, there is evidence of improvement in cognitive and psychosocial development. Thus, in order to have technology as an ally for healthy child development, parents and guardians should limit the time of use and control the type of content seen and shared by children.

Currently, preventing internet use is an unrealistic measure, since parents and guardians also make great use of technologies. However, because of the new settings imposed by the COVID-19 pandemic, many services have moved towards digitization, including education and social interaction. Internet use nowadays is a reality for all age groups and makes this study relevant; measures aimed at optimizing its use and reducing risks must, therefore, be adopted. Once again, we emphasize the importance of parents and guardians as moderators and update training of health professionals to better guide them.

Further studies are suggested so the notion of risk-benefit of internet use and its long-term consequences for child development is kept up to date.

The study did not receive any funding.

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AI for Improving Children's Health: A Community Case Study

Affiliation.

• 1 Saathealth, Mumbai, India.
• PMID: 33733204
• PMCID: PMC7944137
• DOI: 10.3389/frai.2020.544972

The Indian health care system lacks the infrastructure to meet the health care demands of the country. Physician and nurse availability is 30 and 50% below WHO recommendations, respectively, and has led to a steep imbalance between the demand for health care and the infrastructure available to support it. Among other concerns, India still struggles with challenges like undernutrition, with 38% of children under the age of five being underweight. Despite these challenges, technological advancements, mobile phone ubiquity and rising patient awareness offers a huge opportunity for artificial intelligence to enable efficient healthcare delivery, by improved targeting of constrained resources. The Saathealth mobile app provides low-middle income parents of young children nflwith interactive children's health, nutrition and development content in the form of an entertaining video series, a gamified quiz journey and targeted notifications. The app iteratively evolves the user journey based on dynamic data and predictive algorithms, empowering a shift from reactive to proactive care. Saathealth users have registered over 500,000 sessions and over 200 million seconds on-app engagement over a year, comparing favorably with engagement on other digital health interventions in underserved communities. We have used valuable app analytics data and insights from our 45,000 users to build scalable, predictive models that were validated for specific use cases. Using the Random Forest model with heterogeneous data allowed us to predict user churn with a 93% accuracy. Predicting user lifetimes on the mobile app for preliminary insights gave us an RMSE of 25.09 days and an R2 value of 0.91, reflecting closely correlated predictions. These predictive algorithms allow us to incentivize users with optimized offers and omni-channel nudges, to increase engagement with content as well as other targeted online and offline behaviors. The algorithms also optimize the effectiveness of our intervention by augmenting personalized experiences and directing limited health resources toward populations that are most resistant to digital first interventions. These and similar AI powered algorithms will allow us to lengthen and deepen the lifetime relationship with our health consumers, making more of them effective, proactive participants in improving children's health, nutrition and early cognitive development.

Keywords: artificial intelligence; digital health; health systems; low and middle income countries; machine learning.

Copyright © 2021 Ganju, Satyan, Tanna and Menezes.

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Conflict of interest statement

All authors were employed by the company Saathealth during the publication of this research.

Screenshots of the Saathealth app.

A mother using the Saathealth…

A mother using the Saathealth app.

Prediction of user churn through…

Prediction of user churn through machine learning modeling.

Comparison of DOA before and…

Comparison of DOA before and after revised targeted notifications strategy.

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University of Cincinnati, Cincinnati Children’s part of statewide mental health research initiative

Soar study to identify risk and resiliency factors to improve behavioral health outcomes.

The University of Cincinnati and Cincinnati Children’s Hospital are part of a collaborative research initiative designed to identify contributors to the ongoing epidemic of persistent emotional distress, suicide and drug overdose in the state of Ohio. 

The  SOAR Study investigates the role of underlying biological, psychological and social factors. 

The Ohio Department of Mental Health and Addiction Services (OhioMHAS) is funding this statewide research project with an initial $20 million grant. Like other areas of the country, Ohio has seen a rise in mental illness, suicide and deaths related to drug overdose over the past decade, and the COVID-19 pandemic exacerbated these problems.  

“The causes of these diseases remain largely a mystery to clinical experts and the public,” said LeeAnne Cornyn, director of OhioMHAS. “The SOAR Study has the potential to help future generations better understand risk factors, effective mitigation strategies and techniques to build resiliency — in short, the study has the potential to curb disease and save lives.” 

SOAR is studying Ohioans in their local communities, using an integrated “bring science to the people” approach. It is creating a statewide medical research and development ecosystem to drive continued advances in mental health, substance use prevention and treatment interventions. 

The SOAR Study has two parallel but connected projects. 

Better understanding biomarkers of risk and resilience among Cincinnatians is in line with our department’s vision to advance the understanding and treatment of psychiatric disorders.

Cal Adler, MD

Focusing on breadth, the SOAR Wellness Discovery Survey is engaging as many as 15,000 people across all 88 Ohio counties. Researchers want to uncover how strengths and skills may be related to overcoming adversity. Those strengths will inform researchers about which factors to focus on to develop new treatments. This portion is underway, with more than 300,000 postcards mailed out to residents statewide. 

Focusing on depth, the SOAR Brain Health Study will comprehensively study as many as 3,600 Ohioans in family groups to examine the biological, psychological and social factors that help explain response to adversity, with longer-term goals of personalizing individual care.  

The SOAR Study will engage a multidisciplinary team of experts from UC and Cincinnati Children’s Hospital, Ohio State University, Bowling Green State University, Central State University, Kent State University, Nationwide Children’s Hospital, Northeast Ohio Medical University, Case Western/University Hospital-Cleveland, Ohio University, University of Toledo and Wright State University.  

Cal Adler, MD. Photo/University of Cincinnati.

Faculty and staff in UC’s Department of Psychiatry and Behavioral Neuroscience will enroll approximately 500 Ohioans who will complete study procedures such as MRIs, EEGs, neuropsychological assessments, biospecimen collection and questionnaires.  

“Better understanding biomarkers of risk and resilience among Cincinnatians is in line with our department’s vision to advance the understanding and treatment of psychiatric disorders,” said Cal Adler, MD, professor, vice chair of research, co-director of the Division of Bipolar Disorders Research, director of the Center for Imaging Research in the Department of Psychiatry and Behavioral Neuroscience at UC’s College of Medicine and a UC Health physician. “We have already begun to enroll Ohio families and anticipate engaging over 200 participants over the next year.”

“This important SOAR Study builds on our long-standing academic health mission, and we are proud to champion this vital research to help all Ohioans,” said John J. Warner, MD , chief executive officer at The Ohio State University Wexner Medical Center and executive vice president at Ohio State. “Mental health care is health care, and this study will help us inform prevention and treatment strategies to advance patient-centered care and influence the way we train our future care providers.” 

Leaders of the study say SOAR aims to do for addiction, mental illness and mental health what Framingham Heart Study researchers did for heart disease and heart health. Launched in 1948, the multigenerational Framingham Heart Study has enrolled more than 15,000 study participants over 75 years, resulting in major life-saving advancements about heart disease risk factors. 

“Our approach with the SOAR Study will allow us to identify the factors that can be modified to reduce risk and build resilience,” said SOAR Study principal investigator K. Luan Phan, MD, professor and chair of the Department of Psychiatry and Behavioral Health at Ohio State. “We won't be able to ‘bend the curve’ on the growing number of deaths of despair, such as those from addiction and suicide, until we go upstream to better understand their etiology. SOAR is the first statewide, multigenerational comprehensive study in the nation that will offer a new roadmap for developing better treatments and cures that will improve and save lives.” 

Impact Lives Here

The University of Cincinnati is leading public urban universities into a new era of innovation and impact. Our faculty, staff and students are saving lives, changing outcomes and bending the future in our city's direction.  Next Lives Here.

If you are interested in participating in this study, please reach out to the UC study coordinator, Rachel, at 513-558-5319.

If you or someone you know is struggling with thoughts of suicide, call or text the Suicide and Crisis Lifeline at 988.

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

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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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Researchers awarded $2.8M federal grant to study potential treatment of Sudden Infant Death Syndrome

Peter MacFarlane

Newswise — CLEVELAND—More than 3,400 Sudden Unexpected Infant Deaths are reported annually in the United States, making it the country’s biggest cause of death of infants from 1 month to 1 year old, according to the Centers for Disease Control and Prevention (CDC).

Most of these deaths are classified as Sudden Infant Death Syndrome (SIDS), a disorder with numerous, unexplained causes that have plagued researchers for decades.

Now, with a new five-year, $2.8 million grant from the National Institutes of Health , researchers from Case Western Reserve University and University Hospitals Rainbow Babies & Children’s will investigate SIDS, using a model they developed that mimics conditions associated with most SIDS cases.

They hope the federal support and new approach may provide a fresh perspective on what may cause SIDS. They may also be close to finding biomarkers in urine and blood that could help identify newborns who are more likely to die from it.

“A major challenge with SIDS research is developing an accurate model that reproduces many of the SIDS abnormal features,” said Peter MacFarlane , associate professor and director of neonatology basic research at the School of Medicine , UH Rainbow and lead investigator. “One of our model’s special features is that it allows us to simulate conditions surrounding many SIDS cases. We are then able to test some of our new theories about what can cause SIDS, like involuntary respiratory characteristics.”

In particular, MacFarlane and his team are focused on abnormal levels of certain proteins and cells in the brainstem and carotid body—two important components of the

central and peripheral nervous system involved in regulating breathing that they believe might lead to SIDS.

“We are also testing a unique drug that may one day be used to prevent many SIDS cases from occurring,” MacFarlane said. “Our hope is that this research offers new insights into the causes of SIDS and could lead to early identification of at-risk infants so that we can intervene early enough to prevent such a devastating form of death from happening.”

Case Western Reserve University is one of the country's leading private research institutions. Located in Cleveland, we offer a unique combination of forward-thinking educational opportunities in an inspiring cultural setting. Our leading-edge faculty engage in teaching and research in a collaborative, hands-on environment. Our nationally recognized programs include arts and sciences, dental medicine, engineering, law, management, medicine, nursing and social work. About 6,000 undergraduate and 6,300 graduate students comprise our student body. Visit  case.edu  to see how Case Western Reserve thinks beyond the possible.

About University Hospitals / Cleveland, Ohio: Founded in 1866, University Hospitals serves the needs of patients through an integrated network of 21 hospitals (including five joint ventures), more than 50 health centers and outpatient facilities, and over 200 physician offices in 16 counties throughout northern Ohio. The system’s flagship quaternary care, academic medical center, University Hospitals Cleveland Medical Center, is affiliated with Case Western Reserve University School of Medicine, Northeast Ohio Medical University, Oxford University, the Technion Israel Institute of Technology and National Taiwan University College of Medicine. The main campus also includes the UH Rainbow Babies & Children’s Hospital, ranked among the top children’s hospitals in the nation; UH MacDonald Women’s Hospital, Ohio’s only hospital for women; and UH Seidman Cancer Center, part of the NCI-designated Case Comprehensive Cancer Center. UH is home to some of the most prestigious clinical and research programs in the nation, with more than 3,000 active clinical trials and research studies underway. UH Cleveland Medical Center is perennially among the highest performers in national ranking surveys, including “America’s Best Hospitals” from U.S. News & World Report. UH is also home to 19 Clinical Care Delivery and Research Institutes. UH is one of the largest employers in Northeast Ohio with more than 30,000 employees. Follow UH on LinkedIn, Facebook and Twitter. For more information, visit UHhospitals.org.

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Chakraborty, S.; Dash, S.; Antara, N.A.; Roy, B.R.; Mamun, S.A.; Ali, M.; Naz, F.; Johura, F.-T.; Lewis, J.; Afroze, F.; et al. The Impact of Non-Dysentery Shigella Infection on the Growth and Health of Children over Time (INSIGHT)—A Prospective Case–Control Study Protocol. Microorganisms 2024 , 12 , 1677. https://doi.org/10.3390/microorganisms12081677

Chakraborty S, Dash S, Antara NA, Roy BR, Mamun SA, Ali M, Naz F, Johura F-T, Lewis J, Afroze F, et al. The Impact of Non-Dysentery Shigella Infection on the Growth and Health of Children over Time (INSIGHT)—A Prospective Case–Control Study Protocol. Microorganisms . 2024; 12(8):1677. https://doi.org/10.3390/microorganisms12081677

Chakraborty, Subhra, Sampa Dash, Nowrin Akbar Antara, Bharati Rani Roy, Shamim Al Mamun, Mohammad Ali, Farina Naz, Fatema-Tuz Johura, Jade Lewis, Farzana Afroze, and et al. 2024. "The Impact of Non-Dysentery Shigella Infection on the Growth and Health of Children over Time (INSIGHT)—A Prospective Case–Control Study Protocol" Microorganisms 12, no. 8: 1677. https://doi.org/10.3390/microorganisms12081677

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First case of polio confirmed in a 10-month-old child in Gaza, Palestinian health officials say

FILE - Palestinians displaced by the Israeli air and ground offensive on the Gaza Strip walk next a dark streak of sewage flowing into the streets of the southern town of Khan Younis, Gaza Strip, Thursday, July 4, 2024. Health authorities and aid agencies are racing to avert an outbreak of polio in the Gaza Strip after the virus was detected in the territory’s wastewater and three cases with a suspected polio symptom have been reported. (AP Photo/Jehad Alshrafi, File)

FILE - Palestinians displaced by the Israeli air and ground offensive on the Gaza Strip, walk past sewage flowing into the streets of the southern town of Khan Younis, Gaza Strip, Thursday, July 4, 2024. Health authorities and aid agencies are racing to avert an outbreak of polio in the Gaza Strip after the virus was detected in the territory’s wastewater and three cases with a suspected polio symptom have been reported. (AP Photo/Jehad Alshrafi, File)

FILE - Palestinians sort through trash at a landfill in Nuseirat refugee camp, Gaza Strip, Thursday, June 20, 2024. Health authorities and aid agencies are racing to avert an outbreak of polio in the Gaza Strip after the virus was detected in the territory’s wastewater and three cases with a suspected polio symptom have been reported. (AP Photo/Abdel Kareem Hana, File)

FILE - Palestinians displaced by the Israeli air and ground offensive on the Gaza Strip, walk through a dark streak of sewage flowing into the streets of the southern town of Khan Younis, Gaza Strip, on July 4, 2024. Health authorities and aid agencies are racing to avert an outbreak of polio in the Gaza Strip after the virus was detected in the territory’s wastewater and three cases with a suspected polio symptom have been reported. (AP Photo/Jehad Alshrafi, File)

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RAMALLAH, West Bank (AP) — Palestinian health officials on Friday reported the first case of polio in an unvaccinated 10-month-old child in the Gaza city of Deir al-Balah, the first case in years in the coastal enclave that has been engulfed in the Israel-Hamas war since Oct. 7.

After discovering the child’s symptoms, tests were conducted in Jordan’s capital of Amman and the case was confirmed to be polio, the health officials said.

The potentially fatal, paralyzing disease mostly strikes children under the age of 5 and typically spreads through contaminated water. Pakistan and Afghanistan are the only countries where the spread of polio has never been stopped.

The World Health Organization did not immediately respond to requests to confirm the case. However, U.N. health and children’s agencies have called for seven-day pauses in the fighting , starting at the end of August, to vaccinate 640,000 Palestinian children against polio.

They said the polio virus had been discovered in wastewater in two major cities last month in Gaza, which has been polio-free for the last 25 years, according to the United Nations.

The humanitarian community has warned of the re-emergence of polio since the latest war erupted when Hamas attacked Israel on Oct. 7, killing around 1,200 people and taking more than 250 hostage. Israel’s devastating retaliatory offensive has killed more than 40,000 people in Gaza in the 10-month-long conflict and created a dire humanitarian situation, which health officials say has created a public health emergency.

In July, WHO said a variant of type 2 was discovered in wastewater samples from southern Khan Younis and central Deir al-Balah, linked to a variant of the polio virus last detected in Egypt last year.

While WHO did not confirm the polio case, it said earlier on Friday that three children in Gaza were found with acute flaccid paralysis — the onset of weakness or paralysis with reduced muscle tone, a common symptom of polio.

The children’s stool samples have been sent for testing to the Jordan National Polio Laboratory, the agency said.

More than 1.6 million doses of the polio vaccine are expected to arrive in Gaza by the end of August, WHO said, in time for the vaccination campaigns which would have to be conducted in two rounds. Children under 10 will be given two drops of the oral vaccine against type 2 of the polio virus.

Health officials in Gaza warned they would not be able to stop the spread of polio and treat people without an urgent cease-fire in place. The stark warning came as international mediators expressed hope that a cease-fire deal is within reach.

Two days of talks had wrapped up in Qatar on Friday, the mediators said, adding that they plan to reconvene in Cairo next week to seal an agreement to stop the fighting.

The mediators have spent months trying to hammer out a three-phase plan in which Hamas would release the hostages in exchange for a lasting cease-fire, the withdrawal of Israeli forces from Gaza and the release of Palestinians imprisoned by Israel.

Case study: Nemours Children’s Hospital by Stanley Beaman & Sears + Perkins and Will

Nemours Children’s Hospital is a 630,000-square-feet, 137-bed health centre in Orlando, Florida , that provides paediatric treatment to infants, children, teens, and young adults. Stanley Beaman & Sears, Architect of Record, developed the architectural concept in collaboration with Perkins+WIll , who designed the hospital’s interiors.

Upon initial public disapproval to open a new children’s hospital in Orlando, considering the existence of two in the region, Nemours’ recognized brand was approved by state officials and began construction in 2009, completed in 2012. Nemours prioritizes their young patients’ best interests, which inspired the design team to look for a clever solution. Their numerous stakeholders, including an advisory committee of parents and children, administrators, and practitioners, had worked together during the project’s concept development.

To answer the costly healthcare problem of a growing number of patients with chronic illnesses in children’s hospitals and clinics, several nurses collaborated with the architects during the design process. Consequently, a fresh concept that involves a new division known as “Kids Track” was developed, designed as a hybrid of a clinic and a “teen lounge.” This department would only focus on children with chronic illnesses to better manage these conditions. 

The clinical goal had been to instigate a model-Of-care where the patients’ caregivers stay the same from inpatient care to clinic visits. This is achieved by combining inpatient and outpatient care in one location.

The hospital has a pediatric clinic, an emergency department, diagnostic and ambulatory facilities, and education and research institutions. The master plan envisions installing more inpatient and outpatient rooms, medical offices, support facilities, and research labs. 

Design Philosophy

The design philosophy stems from Nemours’ ideology to support children from their earliest years to adulthood by prioritizing the natural landscape. The campus is therefore designed with a “Hospital-in-a-Garden” approach, intended to inspire, comfort, and delight its young patients. 

Design Solutions

The hospital’s design strategies stem from its family-centred approach and 24-hour visiting policy; patient rooms have overnight accommodations for parents and concierge desks on each floor aid in navigating the hospital.

The building is composed of a hospital wing and a day clinic wing. Children and their families can become accustomed to the same care team during clinic visits and inpatient stays with the help of the building’s shape and configuration; the location of outpatient clinics and inpatient rooms is dedicated to a specific medical speciality in neighbouring wings of the same floor. 

Extreme sun and humidity in Orlando ‘s subtropical climate were crucial considerations during the construction process. Solar studies determined the design and location of exterior shading devices that obscure direct sunlight, and large windows bathe the interior in natural daylight. The structure blends its interior and exterior environments to encourage holistic treatment through a high degree of site integration. The interior is influenced by a lush garden scenery, incorporating organic shapes, outdoor views, and vibrant colours that arouse the senses. The “porch light,” an illuminated reception desk that generates a warm, inviting atmosphere, welcomes the guests. The folding ceiling patterns and creative cutouts generate filtered light that simulates light from a tree canopy along the patterned terrazzo garden walk on the lobby floor. An enormous flower-like feature is suspended from the ceiling in the café dining room, enhancing the link to nature.

This interior setting is carried throughout the patient corridors, staff lounges, and patient rooms in addition to the public lobby areas. The family waiting rooms are filled with amusing features, such as the benches that resemble hedges and encircle “picnic blankets on the grass.” Together with the patient rooms, they have large windows allowing therapeutic landscape views and plenty of natural ligh t. Traditionally a dark space in the basement, the surgery corridor in this case, also has floor-to-ceiling windows with garden views. There are numerous outdoor leisure and play areas visible and accessible from lounges and playrooms, such as green rooftop terraces , interactive water elements, a discovery garden, and a stage for live performances. 

The lighting design created by CD+M produces a dynamic aesthetic by incorporating interactive lighting systems, allowing young patients to customize their rooms by selecting the colour of the LED lights. That translates into a unique multi-coloured façade.

The beige stone wall serves as a wayfinding aid, directing traffic to and from the main entrances. Service functions are housed in the basement. 

Construction

The building incorporates “smart” technology into its design, with a “command centre” keeping track of various clinical and facility-related parameters. As for materials selection, terracotta, precast, metal panels, curtainwall systems, and patterned glass form the structure’s exterior cladding, while the interiors have a clean, contemporary design thanks to a blend of specialist finishes, high-performance materials, and furniture in vibrant colours.

• Sustainability

Nemours Children’s Hospital is one of just three children’s hospitals in the US to receive LEED Gold certification. The design team was challenged to create a sustainable facility that embodies the latest technologies for patient-centred equipment and overall building performance. They built a curving ramp that lifts the entry road one level, which allows the daylight basement to handle the facility’s service functions as a convenient solution to the high water table on the 60-acre greenfield site. The ramp continues through the structure’s interior out its back, gently returning to grade. Rainwater runs off the roofs into retention ponds and bioswales. 

The hospital complies with Florida ‘s strict lighting codes and is designed to be 20% under regulatory limits. The lighting design is sustainable, energy-efficient, and maintenance-conscious. Only eight lamp types are used for 95% of all fixtures.

Reference List:

[1] ArchDaily (2013). Nemours Children’s Hospital / Stanley Beaman & Sears + Perkins and Will . [online]. (Last updated: October 2013). Available at: https://www.archdaily.com/439396/nemours-children-s-hospital-stanley-beaman-and-sears   [Accessed: 14 November 2022].

[2] Architect Magazine (2015). Nemours Children’s Hospital. [online]. (Last updated: February 2015). Available at: https://www.architectmagazine.com/project-gallery/nemours-childrens-hospital-6648   [Accessed: 14 November 2022].

[3] Wikipedia (/). Nemours Children’s Hospital . [online]. (Last updated: October 2022). Available at: https://en.wikipedia.org/wiki/Nemours_Children%27s_Hospital   [Accessed: 14 November 2022].

[4] Healthcare Design Magazine (2013). Nemours Children’s Hospital: Project Breakdown . [online]. (Last updated: March 2013). Available at: 

https://healthcaredesignmagazine.com/architecture/nemours-childrens-hospital-project-breakdown/

 [Accessed 14 November 2022]. 

[5] AIA Georgia (/). Nemours Children’s Hospital . [online]. (Last updated: /). Available at: https://aiaga.org/design-award/nemours-childrens-hospital/   [Accessed: 14 November 2022].

[6] CD+M Lighting Design Group (/). Nemours Children’s Hospital . [online]. (Last updated: /). Available at: https://cdmlight.com/index.php/portfolio-item/nemours-childrens-hospital/ [Accessed: 14 November 2022].

A graduated BSc. in Architecture and soon-to-be master’s student, aspiring to specialize in sustainable and energy-efficient built environment. Having lived in both the Middle East and Europe has ignited travel as a passion, which she considers a valuable learning experience in the architectural profession, contributing to a spark to explore further through writing at RTF.

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