Research & Innovation

Abstract:

Boarding across pediatric healthcare systems is on the rise during the pandemic. Children with positive COVID-19 test results awaiting psychiatric placements in the emergency department or medical unit settings are at increased risk for decompensation with unmet psychiatric needs during a time of crisis marked by vulnerability. There is scant literature unveiling best practices on delivery of care for these patients to achieve acute crisis stabilization. Recent studies have uncovered substantial increases in mental health disorders among children during the pandemic compared to previous incidence and prevalence rates prior to the pandemic. From the published literature, two healthcare systems have initiated long-term planning, development, and implementation of biodome psychiatric units for patients with COVID-19 in need of acute crisis stabilization services. We sampled 100 acute inpatient child and adolescent psychiatric programs to discern their post-COVID positive clearance policies for admission. Findings were mixed among days of quarantine required, symptomology, covid-designated spaces vs. self-isolated rooms for psychiatric treatment, number of COVID negative retests, and additional considerations. We also review a range of considerations and recommendations for clinical practice and the health system in achieving parity in mental health care for these patients which in turn could contribute towards mitigating the rising global mental health crisis. Furthermore, increasing access to acute psychiatric services for these patients will also contribute towards the larger goal of the World Health Organization, Sustainable Developmental Goals of the United Nations, and Healthy People 2030 in increasing accessibility, quality and equity of mental health care for individuals on both global and national frontiers.

"A Separate Peace" was published in the Journal of Social Work in End-Of-Life & Palliative Care. 

Overview:

This past summer, a 4-month-old baby named Heidi with microcephaly and subsequent autonomic instability was hospitalized for 1 month in an intermediate care unit at a hospital on the eastern seaboard. She was diagnosed with microcephaly at 2 months of age at the same hospital. During her most recent hospitalization, Heidi presented with significant neuroirritability. Her parents felt uncomfortable having her return home unless she was sleeping through the night without needing any pain medications. The family and the medical team had different perspectives on the management of Heidi’s care. Both recognized that Heidi had a progressive, degenerative illness; however, her parents felt that her illness would progress to death a lot sooner than the medical team’s prediction that she could potentially live for longer than 6 months. The medical team and nursing staff involved in her care were emotionally impacted by this hospitalization in several different ways. This was evident in behavioral responses such as distress, anger, fear, and defensiveness. As the social worker supporting Heidi’s family, I found myself as a gatekeeper and holder of information as well as an advocate and educator. The rest of the care team, especially our nursing staff, felt a sense of protection over the child which affected their objectivity in approaching the child’s case. This was a unique situation where the family’s peace about their child’s limited life span clashed with the care team’s expectation that the family would still be coming to terms with her illness.

"Years of life lost: A call to achieve equitable end-of-life care among children" was published in Health Promotion Perspectives

Significant disparities continue to exist in access to inpatient pediatric hospice care among children at the end-of-life. Increasingly more children at this stage are dying in the hospital or at home on hospice which is not always an acceptable option to the children and their families. Two clinical case examples illustrate implementation of these options in practice. A missing link exists in healthcare systems across developed and developing countries in pediatric end-of-life care. Currently, the primary options involve selecting between hospital and home-based hospice care. Proposing to increase access to inpatient pediatric hospice services could potentially increase acceptability of this option to honor the child in line with the family’s preferences, goals, wishes, and values. In addition, inpatient pediatric hospice could offset costs from preventable hospitalizations and overall high-cost healthcare utilization. Oftentimes, readmissions impact decision-making among caregivers that include changes in code status from Do Not Resuscitate/Do Not Intubate (DNR/DNI) to full curative care, thereby resulting in medicalization or overmedicalization of the child. It follows that reduced healthcare expenditures will increase cost efficiency across the healthcare system. Achieving health equity in palliative care among adult and pediatric patients at the end-of-life is a longstanding goal of the World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF). Proposing to mitigate disparities in palliative care among children through inpatient hospice as another viable option for their families could contribute to the larger overarching goal of achieving health equity in end-of-life care across the world.

“Navigating the broken road: A call to strengthen access, equity, and inclusivity in the care of children with developmental disabilities and neurobehavioral disorders” was published in Health Promotion Perspectives.

There is a significant scarcity of resources to achieve behavioral stabilization among children and adolescents with moderate to severe developmental disabilities and neurobehavioral disorders. In total, there are currently 76 inpatient pediatric neurobehavioral programs to support these patients across the United States. Many states do not currently have programs of this nature. Across existing programs, there are substantial waiting lists. In addition, non-public school, intensive day program, in-home and additional outpatient services are not reaching these patients fast enough which further exacerbate the sequalae of suboptimal outcomes and future quality of life implications for these patients. In addition, disparities remain in how the chronicity of developmental disabilities and neurobehavioral disorders are addressed within our healthcare system. It is crucial to categorize this constellation of specialized conditions as chronic illnesses which warrant continued care and treatment, similar in nature to lifelong medical conditions. Further time and priority are warranted in increasing accessibility, equity, and inclusivity in our U.S. healthcare system to optimize a range of health and developmental outcomes for these patients. Future work in this domain could also contribute towards the larger goal of the World Health Organization, Healthy People 2030, and the Sustainable Development Goals of the United Nations in securing delivery of healthcare services that are inclusive, equitable and accessible for individuals with disabilities.

“Homeless in the hospital: A call to strengthen multidisciplinary care for children awaiting out-of-home and psychiatric placements” was published in Frontiers in Pediatrics.

Increasingly more school-age and adolescent children continue to await psychiatric or out-of-home placements across pediatric healthcare systems. These children comprise the growing overstay pediatric population. The medical, developmental, socioemotional, behavioral and academic needs of these patients are complex and diverse. The uncertainty of waiting times for placement further continues. This growing pediatric issue emphasizes the importance of mobilizing a myriad of resources across healthcare and community contexts to support these patients during this precarious time. The reality is that there is a significant scarcity of placement resources which contributes to extended waiting times for placement. This contemporary issue brings child development, ethical and moral considerations, and healthcare operations to the forefront. We discuss a myriad of dimensions surrounding this growing issue from our clinical practice. We present a wealth of recommendations in working through each of these dimensions through a multi-systems approach that include development of individualized care plan, access to consistent psychiatric services, and implementing short-term and long-term goals pertaining to treatment and placement. We also review our clinical practices that have supported these patients on a continuum at our healthcare institution which integrate our recommendations and also involve an open line of communication with established community partners involved in the care of these children. Furthermore, we propose suggestions from an operational perspective on developing a comprehensive, multidisciplinary care model for this fragile and oftentimes neglected patient population across the healthcare system as the basis to achieve equity and translational impact in the quality and delivery of healthcare care services across pediatric healthcare systems.

“When there is no air, the cradle will fall: A narrative review of tobacco-related content across infant safe sleep interventions” was published in Frontiers in Pediatrics.

Sudden Unexpected Infant Death (SUID) from sleep-related causes is a leading cause of infant mortality worldwide. Sudden Infant Death Syndrome (SIDS) is one of the primary causes of SUID attributed to one or more environmental or behavioral determinants surrounding safe sleep practices among infants. The focus of many interventions on mitigating sleep-related infant deaths have addressed visible determinants pertaining to bed sharing, safe sleep surfaces, and removal of blankets, toys and other choking or strangulation hazards. Tobacco reduction and cessation have not been at the heart of any infant safe sleep interventions although addressing tobacco exposure is one of the primary safe sleep recommendations of the American Academy of Pediatrics. To date, there has not been a comprehensive review published on tobacco-related components across safe sleep interventions to reduce the risk of SIDS and SUID as the basis to contribute towards decreasing the rate of infant mortality. This review synthesizes the best practices, strategies, education, and additional interventions centered on addressing tobacco exposure as a risk factor for sleep-related infant deaths. Ten peer-reviewed studies were identified between 1995 and 2021 and integrated into this narrative review. There were three cross-sectional studies, three campaigns, one multi-center case control study, two randomized controlled trials, and two group comparison studies. Strengths and limitations of each approach are delineated followed by recommendations for future campaign, research, program, and practice endeavors to account for the totality of pertinent modifiable risk factors that contribute towards heightened infant mortality from sleep-related causes.

Beginning with the premise that consent serves as a lever of entitlement, Amanda Bailey introduces a Shakespeare well aware that liberal selfhood has never been universally available. Bailey brings Shakespeare’s work into conversation with the Penn State Sandusky scandal, the Bill Clinton–Monica Lewinsky affair, the rise of "somnophilia," Jordan Peele’s documentary on Lorena Bobbitt, Larry David’s Curb Your Enthusiasm, and Harvey Weinstein’s Shakespeare in Love, amongst others. Bailey considers who is denied access to the apparatus of consent, under what circumstances, and how consent is vitiated by race, class, ethnicity, sexuality, disability, and gender. Shakespeare on Consent is a wake-up call for all implicated in the injurious outcomes of consent and will inspire those wanting to mobilize choice in the service of social and political transformation.

Abstract:

Drawing from a qualitative study, we share findings that demonstrate how students articulate and express emotion in reflection. As they reflect on their writing identities, processes and products, peer and instructor feedback, and assess their work, the students in our study routinely discuss their emotions. Our essay closes with pedagogical strategies for helping students reflect on their thinking and feeling about writing.

This anthology chapter will debut in 2023.

In progress.