Publications

Abstract

Background: The incidence of abusive head trauma (AHT) is not declining in many countries with developed economies. The current understanding of factors associated with a high risk of AHT may need revision to better account for the complexity of the phenomenon.

Objective: To gain a better understanding of the multiple factors associated with AHT events based on the experience of professionals involved in AHT cases and non-offending parents of victims in order to inform prevention strategies.

Methods: Qualitative study based on thematic data analysis of semi-structured interviews.

Participants and setting: Sixteen professionals and 13 parents of infant victims.

Results: Coding and thematic analysis of the 28 interviews (total duration 27 h) brought up 21 sub-categories of AHT-related factors. Professionals identified infants' inconsolable crying and caregivers' overwhelming stress as the main factors related to AHT events, whereas parents emphasized shaking as a result of the caregiver's temporary unavailability to meet the infant's needs, along with a poor relationship with the victim, negative attributions for the infant's behavior, and lack of empathy.

Conclusions: An infant's persistent crying should not be considered the only factor triggering AHT. Rather, it is a vulnerability factor that, when combined with other perpetrator-related and situational factors, can explain AHT events. These findings may help improve the effectiveness of current prevention programs, which are primarily based on increasing parental knowledge and awareness of persistent crying, and contribute to theoretical models of AHT.

Abstract

Background: Childhood maltreatment (CM) is related to structural alterations in adult limbic regions. However, the change in limbic structures remains unclear in adolescents from the general population since most reports stem from clinical samples. Additionally, large longitudinal neuroimaging studies in community adolescents reporting CM are scarce. 

Objective: Hence, we aimed to investigate the cross-sectional and longitudinal associations between CM and the structure and function of the extended limbic and reward systems throughout adolescence.

Methods: We analysed data of 634 community adolescents from the IMAGEN cohort at age 14, followed up at age 18. CM was inferred from the Childhood Trauma Questionnaire completed at age 18, yielding subgroups with CM (N = 105) or without CM (N = 529). Using 3-Tesla T1 MRI, we performed between-group voxel-wise analyses at ages 14 and 18 to investigate grey matter volumes (GMV). In addition, GMV were investigated longitudinally between ages 14 and 18. Finally, using functional MRI and the Monetary Incentive Delay task, we measured reward anticipation and feedback sensitivity between groups at ages 14 and 18. 

Results: Both at ages 14 and 18, adolescents reporting CM had lower GMV in the right insula, left orbitofrontal cortex, putamen, superior medial frontal gyrus, paracentral lobule, and other paralimbic regions, but no significant differences in reward response. Longitudinal analyses revealed no GMV difference between age groups.

Conclusions: CM was associated with GMV alterations persisting from early to late adolescence in the limbic regions in community individuals. Therefore, these findings further support the need for research on targeted preventive interventions for adolescents who have experienced CM.

Abstract

Background: Differentiating accidental head trauma and abusive head trauma (AHT) may be challenging in infants.

Objective: To describe computed tomography (CT) scan findings following accidental low-velocity trauma in infants, focusing on features considered to be highly suggestive of AHT, such as rupture of bridging veins. 

Methods: A single-center, retrospective study (2014–2022) was performed in infants aged 1 month to 12 months. Inclusion criteria: (i) any kind of minor head trauma leading to an Emergency Department visit (fall from a height of less than 2 m, direct head impact, low-velocity road accident (below 15 km/h); (ii) available clinical data and head CT scan. 

Results: Three hundred and six infants were included (mean age 5 months 14 days, 56.5% male). Fractures were observed in 89 patients (71 simple linear fractures). Intracranial hemorrhage was observed in 34 patients: simple post-traumatic focal extra-axial hemorrhage in 26 patients and more complex hemorrhage on CT and magnetic resonance imaging in eight patients, including three with evidence of bridging vein rupture. Among these cases, the child protection team expressed concern that two patients might have experienced AHT, while the third patient had a condylar fracture and it remains unclear whether the injury was the result of AHT or an accidental fall. A significant link was found between intracranial hemorrhage and fractures (P-value < 0.001), scalp swelling (P-value < 0.001), or clots located at the vertex (P-value < 0.001) and between fractures and scalp swelling (P-value < 0.001), the trauma mechanism (P-value < 0.001), neurological symptoms (P-value = 0.03), and intracranial hemorrhage (P-value < 0.001). 

Conclusions: The main CT scan features following minor accidental trauma in infants are simple skull fractures and scalp swelling. Diffuse hemorrhage with rupture of bridging veins is exceptional in this context.

Abstract

Background: Timely and accurate diagnosis of early child physical abuse (CPA) is crucial to avoid recurrence and protect victims. Ruling out differential diagnoses is also important to avoid misdiagnosis of CPA. We evaluated the risk of hospitalization for early CPA before hospitalization for its 2 main differential diagnoses: osteogenesis imperfecta (OI) and severe hemophilia (SH).

Methods: This population-based cohort study used the national administrative database covering all hospitals in France. We followed infants born from 2010 to 2019 until age 2. We identified infants with a first discharge code for early CPA, OI, and SH and calculated crude absolute and relative risks.

Results: Among the 6,315,216 infants included, 2088 (33/100,000 infants per year) were hospitalized for early CPA, 160 (3/100,000) for OI, and 402 (6/100,000) for SH before age 2. Among infants hospitalized for early CPA, 2085 (99.86 %) had no further hospitalization for OI or SH, 3 (0.14 %) were further hospitalized for OI with a 9-month median interval between hospitalizations, and 0 were further hospitalized for SH. The absolute risk of hospitalization for early CPA before hospitalization for OI was 1.9 % (3/160, 95 % confidence interval [CI] 0.39–5.38), and the relative risk as compared with infants without hospitalization for OI was 56.8 (95 % CI 18.5–174.3).

Conclusions: The very low to null absolute risks of hospitalization for early CPA before OI or SH probably reflect excellent current clinical practices in ruling out differential diagnoses. A better implementation of existing guidelines could further shorten the time to diagnosis of OI before age 2.

Abstract

Background: Intimate partner violence (IPV) is associated with children's emotional and behavioral difficulties. Psychological-IPV (P-IPV) is most common, and occurs alone or along other forms of IPV. Little is known about the longitudinal course of P-IPV exposure and its consequences on children taking into account whether or not they are present during parental arguments.

Objective: To identify longitudinal trajectories of P-IPV from preconception through the child's second year of life and examine associations with children's emotional-behavioral outcomes at age five years, depending on the child's presence during parental arguments in the second year of life.

Participants and setting: Data from the nationally representative French birth cohort ELFE including children born in 2011 were used.

Methods: P-IPV exposure was assessed before conception, during pregnancy, at two months and at two years postpartum. Parents completed the Strengths and Difficulties Questionnaire (SDQ) at five years. Group-based trajectory modelling was used to identify P-IPV trajectories. Multivariate logistic regression models were used to study the relationship between P-IPV trajectories and SDQ.

Results: 9639 children were included. Five trajectories of exposure to P-IPV were identified: minimal (70.6 %), prenatal (10.0 %), increasing (6.4 %), decreasing (7.5 %), persistent (5.5 %). Persistent and decreasing P-IPV trajectories and frequent child presence during parental arguments were associated with children's increased odds of having abnormal total SDQ scores (OR 2.31 95 % CI 1.54–3.47; OR 1.64 95%CI: 1.11–2.43; OR 1.88 95%CI:1.17–3.02, respectively).

Conclusions: Early identification and consideration of children living in a home where IPV occurs could allow provision of timely and appropriate support.

Abstract

Background: Adverse childhood experiences (ACEs) may negatively affect prenatal mental health. However, the use of a cumulative ACEs score may obscure the identification of which specific types of adversity are most strongly associated with unfavorable mental health outcomes.

Aim: This study aims to evaluate the association between ACEs and prenatal symptoms of depression and anxiety using a cumulative score, a person-centered approach, and the dimensional model of adversity and psychopathology (DMAP).

Methods: Data were collected from 1887 pregnant women in the French Etude des Déterminants du développement et de la santé de l’ENfant (EDEN) cohort. To operationalize our exposure, we calculated a cumulative ACE score, threat and deprivation scores, and conducted latent class analysis (LCA). Depressive and anxious symptoms were assessed with the Center for Epidemiologic Studies-Depression Scale (CES-D) and the State-Trait Anxiety Inventory state subscale (STAI-S) questionnaires, using cutoffs of 16 and 38 indicating high symptoms. Participants were categorized into four outcome groups: (1) no symptoms, (2) high depressive symptoms only, (3) high anxious symptoms only, and (4) comorbid high symptoms. Multinomial regressions were performed.

Results: LCA identified three ACE classes: low-risk, family discordance, and multidimensional adversity. Women reporting two or more ACEs had higher odds of depressive and comorbid symptoms, compared to those with zero ACEs. Compared to the low-risk class, women in the family discordance class had increased odds of high depressive symptoms (adjusted odds ratios [aOR] 95% confidence interval [CI] = 1.80 [1.33, 2.56]) and comorbid high symptoms (aOR [95% CI] = 2.04 [1.43, 2.89]). Threat experiences were significantly linked to high depressive symptoms (aOR [95% CI] = 1.48 [1.22, 1.79]) and comorbid high symptoms (aOR [95% CI] = 1.53 [1.25, 1.87]).

Conclusion: Using the DMAP and LCA approaches, we found that ACEs related to the familial environment and relationships during childhood were most strongly associated with prenatal high depressive and comorbid symptoms. This highlights the importance of operationalizing ACEs beyond a cumulative score to better capture their role in the development of prenatal mental health difficulties.

Abstract

Background: Polygenic risk scores (PRSs) for several psychiatric disorders have been associated with the clinical presentation of bipolar disorder (BD). PRSs have also been suggested to moderate the associations between childhood maltreatment and BD severity.

Aim: In this study, we investigated how PRSs for BD, schizophrenia, major depressive disorders (MDD) and attention-deficit/hyperactivity disorder (ADHD) might disentangle the clinical and dimensional heterogeneity of BD in a sample of 852 affected individuals.

Methods: We used logistic and linear regressions, moderation and mediation models to test the associations between PRSs, dimensions in childhood/adulthood and clinical indicators of severity of BD. All models were adjusted for age, sex, BD type and depressive symptoms.

Results: None of the PRSs were significantly associated with the clinical expression of BD when considered in terms of mode of onset, course, or psychiatric comorbidities. Nevertheless, the PRS-ADHD significantly and positively correlated with the levels of childhood maltreatment, childhood ADHD symptoms, and of some adulthood measures (affective lability, impulsivity and hostility) with p values ranging from 3.10−8–4.10−4. None of the PRSs moderated the effects of childhood maltreatment on the clinical or dimensional variables. Mediation model suggested paths from both PRS-ADHD and PRS-MDD to childhood ADHD symptoms and childhood maltreatment. The links between PRS-ADHD to all adulthood dimensions were mediated by childhood ADHD symptoms (p < 0.002). In turn, some adulthood dimensions (mainly affect intensity and affective lability) were associated with the clinical severity of BD, as defined by rapid cycling, suicide attempts and anxiety disorders. 

Conclusion: In conclusion, this study disentangles the associations between the genetic liability for four psychiatric disorders and the clinical/dimensional heterogeneity of BD. We suggest a continuum from the genetic risk for ADHD and MDD through dimensions in childhood/adulthood to a severe/complex clinical expression of BD.

Abstract

Background: Abusive Head Trauma (AHT) is a leading cause of morbidity and mortality in infants requiring rapid neuroimaging performance and prognostic rapid diagnosis. The Pittsburgh Infant Brain Injury Score (PIBIS) clinical prediction rule (CPR) was derived to identify infants most likely to present brain injury, whose diagnosis would benefit from head CT. Our study aimed to externally validate the PIBIS CPR in a pediatric French population.

Methods: A retrospective study was conducted in a French pediatric emergency department between 2015 and 2017. We included all consecutive infants who underwent a neurological imaging. Medical data were collected, and PIBIS score was determined, both retrospectively.

Results: We included 129 infants among which 33 cases (including 20 with a diagnosis of AHT). The sensitivity and specificity of the PIBIS CPR were 75.8 % (95 % CI 57.7-88.9) and 61.4 % (51.0-71.2) and negative and positive predictive values 88.1 % (77.8-94.7) and 40.3 % (33.0-48.2). Among the 20 infants with a diagnosis of AHT, 19 (95.0 %) were correctly identified by the PIBIS CPR.

Conclusion: Our external validation study found a lower diagnostic value of the PIBIS CPR than in the original study. This argues for adding biomarkers to improve its performance, notably in the context of suspected AHT.

Abstract

 Objective: To examine the association between intimate partner psychological violence (P-IPV) from before pregnancy to 2 years after the child’s birth and child’s sleep patterns, i.e. sleep onset difficulty (SOD), nighttime awakenings (NA), and nighttime sleep duration (NSD) between 2 and 5 years of child’s age. 

Méthods: Data come from the population-based French birth ELFE cohort launched in 2011. P-IPV was assessed before and during pregnancy, at 2 months and 2 years post-partum. Children’s sleep patterns were measured at 2, 3, and 5 years of age. Group-based trajectory modelling was used to identify trajectories of P-IPV and each child’s sleep patterns. Associations between P-IPV and children’s sleep trajectories were assessed by weighted multivariate logistic regressions. 

Results: Five P-IPV trajectories were identified: minimal (64%), prenatal (14%), decreasing (9%), increasing (8%), and persistent (5%). Two trajectories of SOD (few 65% and many 35%), three trajectories of NA (few 49%, decreasing 24%, and many 23%), and three trajectories of NSD (short 21%, medium 56%, and long 23%) were identified. About 9513, 9512, and 9499 children were included in comparative analyses, respectively, focused on SOD, NA, and NSD. Increasing and persistent P-IPV trajectories were both associated with the trajectory of many SODs [odds ratio (OR) = 1.53, 95% confident interval (CI) = 1.24–1.91; and OR = 1.71, 95% CI = 1.31–2.22, respectively] and the trajectory of many NA (OR = 1.66, 95% CI = 1.29–2.13); and (OR = 1.95, 95% CI = 1.42–2.69, respectively). Associations between persistent P-IPV and decreasing and many NA were significant among girls (OR = 1.76, 95% CI = 1.12–2.75 and OR = 2.27, 95% CI = 1.39–3.71, respectively), but not among boys.

Conclusion: Family interventions in response to IPV should pay particular attention to sleep patterns of children exposed to IPV.

Abstract

Background: Numerous strategies for preventing abusive head trauma (AHT) have been proposed, but controlled studies failed to demonstrate their effectiveness. Digital tools may improve the effectiveness of AHT prevention strategies by reaching a large proportion of the adult population.

Objective: This study aimed to describe the characteristics of videos of AHT prevention published on the internet, including their quality content, and to study their association with popularity.

Methods: From a systematic appraisal performed in June 2023, we identified videos addressing the primary prevention of AHT in children younger than 2 years that were published in English or French on the internet by public organizations or mainstream associations. We analyzed the characteristics of the videos; their quality with the Global Quality Scale (GQS); and their association with an index of popularity, the Video Power Index, using multivariable quasi-Poisson modeling.

Results: We included 53 (6.6%) of the 804 videos identified. Videos were mainly published by public organizations (43/53, 81%). The median time spent on the web was 6 (IQR 3-9) years, the median length was 202 (IQR 94-333) seconds, and the median GQS score was 4 (IQR 3-4). Infants were often depicted (42/53, 79%), including while crying (35/53, 66%) and being shaken (21/53, 40%). The characterization of shaking as an abuse and its legal consequences were cited in 47% (25/53) and 4% (2/53) of videos, respectively. The main prevention strategies in the videos were to raise awareness of the noxious outcome of shaking (49/53, 93%) and convince viewers of the effectiveness of coping strategies for infants’ cries (45/53, 85%). The Video Power Index was positively correlated with the GQS (r=0.38; P=.007) and was independently associated with depicting an infant being shaken (P=.03; β=1.74, 95% CI 1.06-2.85) and the use of text or headers (P=.04; β=2.15, 95% CI 1.08-4.26).

Conclusions: AHT prevention videos had high quality but did not frequently deal with parental risk factors. The characteristics identified as being associated with the popularity of AHT prevention videos could help improve the impact of future prevention programs by enhancing their popularity.