Protective Services Research Articles

Disparities in child protective services involvement in pediatric traumatic brain injury.

Traumatic brain injury (TBI) is a leading cause of pediatric death and disability. Abusive head trauma confers greater morbidity and mortality compared with accidental TBI. National trends reveal disproportionate involvement of minority children in the child welfare system. The study investigates socioeconomic disparities in child protective services (CPS) involvement in pediatric TBI. Retrospective chart review was conducted for TBI patients (n = 596) admitted to an academic pediatric level I trauma center from 2015 to 2022, where institutional policy dictates automatic CPS referral for TBI patients ≤ 2years. Analysis of variance, chi-squared, and logistic regressions compared racial and ethnic groups and calculated adjusted odds of CPS case acceptance. Rates of non-accidental trauma, CPS involvement, insurance, and marital status differed across racial and ethnic backgrounds (p < 0.05). Of patients ≤ 2years, Hispanic patients (OR: 0.38, 95%CI [0.16,0.91]) had decreased odds of CPS involvement compared to non-Hispanic White patients when adjusting for confounders including injury severity, injury type, and socioeconomic status. We highlight racial and ethnic differences in incidence of pediatric TBI and CPS involvement, even in the setting of an automatic CPS referral policy for pediatric TBI patients ≤ 2years.

Who's behind the wheel? Work and health backgrounds of new transit bus operators.

Investigate new bus operators' (n = 293) occupational and health backgrounds to inform how transit authorities can support their future health and job success. New bus operators completed surveys and direct measurements that addressed demographics, work history, and 10 health risk factors. Participants averaged 42.76 years of age and were predominantly male (73.5%). Many (45.7%) came from minority backgrounds and most (66.3%) had no prior commercial driving experience. Transportation and material moving occupations were operators' most common prior jobs followed by protective service and sales and related occupations. Study-specific criteria classified operators as having low (49.5%), medium (37.9%), and high (12.6%) health risk levels. About half of the sample had medium-to-high health risks and most lacked commercial driving experience. Such information may help employers proactively support new bus operators' health and job success.

Acceptability and feasibility of trauma- and violence-informed care for intimate partner violence

Background/objectivesIntimate partner violence (IPV) and child physical abuse frequently co-occur, yet IPV-exposed children are not routinely evaluated for abuse. Furthermore, IPV survivors often seek care for their children but not for themselves, making pediatric visits an opportunity to address IPV. We developed a trauma- and violence-informed care (TVIC)-based model that 1) evaluated IPV-exposed children and 2) linked survivor-caregivers to an IPV advocate.We aimed to assess the feasibility and acceptability of the model. ParticipantsChildren < 3 who were reported to Child Protective Services (CPS) for exposure to IPV and their survivor-caregiver. MethodsTo examine feasibility, we calculated the percentage of 1) eligible children evaluated and 2) caregivers who met with an IPV advocate during the child's visit and followed up with the advocate. To assess acceptability, we conducted qualitative interviews with 30/41 caregivers about their perceptions of the model. ResultsFrom 7/1/20–6/30/22, 49 (22.7 %) of 216 eligible children were evaluated. Of 41 caregivers, six already were receiving IPV services; Of the remaining 35, 24 (68.6 %) met with an IPV advocate, and 22 (91.7 %) had ≥1 follow-up visit with an advocate.We identified three themes: 1) Motivations for the visit, 2) Engagement with the model, and 3) Benefits. Caregivers attended the visit due to behavioral concerns about the child and a desire to comply with CPS. Engagement occurred as medical providers established rapport and provided support without judgment. Benefits included recognizing the impact of IPV on the child and immediate linkage to advocacy services. ConclusionA TVIC-based model is feasible and acceptable and could improve caregivers' engagement with the evaluation of IPV-exposed children for abuse and with IPV services, which have the potential to improve safety and promote well-being.

Mental and neurodevelopmental health needs of Aboriginal children with experience of out-of-home care: a Western Australian data-linkage study

ObjectiveTo identify additional mental and neurodevelopmental health needs of Aboriginal children born in Western Australia, who are placed in out-of-home care (OOHC), relative to Aboriginal children born in Western Australia who were not placed. MethodsData-linkage of hospitalisations, health registries and child protective services data for all Aboriginal children born in WA between 2000 and 2013 was used. Children placed in out-of-home care between 2000 and 2019 were matched to children never placed and prevalence and cumulative incidence estimates of mental and neurodevelopmental health conditions were compared. ResultsChildren placed in out-of-home care had a three times greater prevalence of mental and neurodevelopmental health conditions generally. The prevalence of foetal alcohol spectrum disorder was ten times higher, and post-traumatic stress disorder was seven times higher for those placed in out-of-home care. Cumulative incidence plots highlighted for different conditions the ages at which the rate of diagnosis diverges between the two groups. ConclusionsChildren placed in out-of-home care had greater mental and neurodevelopmental health needs generally when compared to children never placed in out-of-home care . Implications for Public HealthChild protective services must ensure culturally safe, comprehensive, wrap-around services for Aboriginal children and their families are provided. Approaches should build on the strength of children, families and culture and avoid stigmatising children and their parents.

The Environmental Legal Framework of Mexican Caribbean Dunes: A Retrospective Case Study of Vegetation and Coastal Dune Loss in the Sian Ka’an Biosphere Reserve

The Mexican Caribbean coastal dune is protected by national and international environmental legislation. However, through permits, concessions and authorizations for changes in land use, the coastal dune has been fragmented or suppressed, mainly for touristic activities, causing a decline in protective and ecological ecosystem services. In this study, we evaluated the strength and weakness of Mexican legislation to protect the Caribbean coastal dune ecosystem and estimated the historical and current effects on coastal dune vegetation and dune geomorphology, associated with legal allowances of land use change in the Sian Ka’an Biosphere Reserve (SKBR). Legislation at the federal, state and local level were critically reviewed, and with remote sensing techniques and the Remotely Piloted Aircraft System (RPAS), we conducted a case study in the SKBR to estimate coastal dune vegetation alteration trends during the period 2011–2020 and modifications on the dune geomorphology associated with land use change allowances. At the federal (four laws), state (eight laws) and local (nine Local and Territorial Planning Programs (POEL and POET) levels, we found a lack of consensus and alignment between regulations, starting with a lack of definition of ecosystems subject to protection. For coastal dunes, none of them consider topography, ecological function and a way to identify it in the field, making the surveillance highly complex and favoring land use changes, the removal of vegetation and dune geomorphology alteration. Remote sensing techniques showed that areas with land use authorizations exhibit negative vegetation cover trends (Mann–Kendall &lt;−0.4), indicating a decline in vegetation cover density that is mostly anthropogenically induced. The RPAS analysis demonstrated drastic alterations to complete elimination of the coastal dune geomorphology in areas with land use change. In the Mexican Caribbean, the loss of coastal dune and associated ecosystem by the lack of congruent legislation threatens the environmental stability of the coastal areas.

Spatial Evaluation and Modelling of Fire Stations Layout to Access Forest Fires by Roads (Case Study: Krasnoyarsk Region, Russia)

Regional forest fire protection services on the ground usually have a fire station infrastructure with firefighting vehicles capable of moving by public and forest roads. The location of fire stations is a subject of evaluation on the regional scale and a matter of constant research interest. Infrastructure and transport accessibility, as well as the spatial location of fire stations worldwide and in Russia, were discussed. Location-Allocation ArcGIS tool and the access routes database for Krasnoyarsk region (archived data of 2002-2022 forest fires detected by MODIS containing 60637 records) were the base of methodology to evaluate fire station layout. The settlement dataset from Open Street Map (OSM) was used to analyze new locations as candidates for a fire station. Standard Deviational Ellipse ArcGIS tool was applied to define an optimal area for the current fire station from which routes to the nearest fires are built. OSM settlements inside of 1-sd area of the ellipse were used to generate the candidate list of settlements to find new locations instead of the current fire station. Results have been evaluated for 3 groups of access routes: 3 hours and less, more than 3 hours, and access routes of any duration according to the Russian forestry rules. The proposed fire station layout has improved forest fire accessibility with OSM candidates for 39 stations; 20 of 59 remain spatially unchanged. Total regional forest fire accessibility changed from the current to the proposed layout in absolute values from 47331 to 48905 fires. Analysis of 39 relocated stations showed that the new fire station layout is more optimal than the current one because it provides access to an additional 20 % of forest fires with a decrease in average weighted time to reach them by 30 %. The described methodology could make an emergency response during a fire-hazardous period more effective.

Estimated prevalence of obstructive sleep apnea by occupation and industry in England: a descriptive study.

Obstructive sleep apnea (OSA) can induce excessive sleepiness, causing work-related injuries and low productivity. Most individuals with OSA in the United Kingdom are undiagnosed, and thus, theoretically, workplace screening, might by identifying these individuals improve both their individual health and overall productivity. However, the prevalence of OSA in different workplaces is unclear. This study aimed to estimate the prevalence of OSA by industries and occupations in England. The Health Survey for England 2019 dataset was combined with Sleep Heart Health Study dataset. We applied multiple imputation for the combined dataset to estimate OSA in the English population aged 40-64. We estimated the pooled prevalence of OSA by both industry and occupation by separating samples by Standard Industry Classification and Standard Occupation Classification. The overall OSA prevalence estimated by imputation for ages 40-64 was 17.8% (95% CI=15.9% to 19.9%). Separating those samples into industrial/occupational groups, the estimated prevalence of OSA varied widely by industry/occupation. Descriptive analysis revealed that the estimated prevalence of OSA was relatively higher in the Accommodation and food, Public administration and defence; compulsory social security, Construction industries, and Protective service occupations, health and social care associate professionals, and skilled construction and building trades occupations. In England in 2019, Accommodation and food, Public administration and defence; compulsory social security, Construction industries, and Protective service occupations, health and social care associate professionals, and skilled construction and building trades occupations showed a relatively higher prevalence of OSA indicating that they may be target populations for workplace screening.

Multilevel factors associated with HIV-related stigma among women living with HIV in Guangdong Province, China: a social-ecological model-informed study

BackgroundHIV-related stigma continues to hinder optimal HIV care, and its determinants should be understood at multiple levels. Based on the social-ecological model, this study aimed to explore factors associated with HIV-related stigma among women living with HIV in Guangdong Province, China.MethodsA cross-sectional study was conducted from July to August 2022 to recruit newly reported women living with HIV with a history of pregnancy or current pregnancy in 2021 in 21 cities in Guangdong Province. HIV-related stigma was assessed using an abbreviated Chinese version of Berger's HIV Stigma Scale. Univariate and multivariable hierarchical regression analyses based on the social-ecological model were conducted to explore factors associated with HIV-related stigma and its four dimensions (personalized stigma, disclosure concerns, negative self-image and concerns about public attitudes) at the community/hospital, interpersonal, and individual levels.ResultsA moderate level of HIV-related stigma was found among the 360 participants included, with a mean score of 45.26. Multivariable hierarchical regression analysis showed that at the community/hospital-level, individuals were more likely to experience high levels of HIV-related stigma if they had experienced the discriminatory behaviors from health care workers (aOR = 2.34, 95%CI: 1.48–3.70) and if they rated serostatus disclosure services as less helpful (aOR = 0.69, 95%CI: 0.48–0.98). At the interpersonal-level, individuals with an HIV-positive partner (aOR = 1.71, 95%CI: 1.01–2.90) were more likely to experience high levels of HIV-related stigma than those with an HIV-negative or unknown partner. Individuals with high resilience (aOR = 0.22, 95%CI: 0.13–0.35) had lower levels of HIV-related stigma at the individual-level. In addition, ever experiencing discriminatory behaviors from health care workers, thinking serostatus disclosure services helpful, having ever seen publicity about personal interest protection services and complaint channels for people living with HIV(PLHIV), knowing about care and support services for PLHIV from social organizations at the community/hospital-level, partner notification and support at the interpersonal-level, and violations of personal interests, resilience at the individual-level were also associated with different dimensions of HIV-related stigma.ConclusionsHIV-related stigma was moderate among women living with HIV. The social-ecological model can facilitate a better understanding of factors associated with HIV-related stigma. Multilevel intervention strategies need to be tailored to reduce HIV-related stigma.

How the COVID-19 Pandemic Influenced Veteran Parents’ Harsh Parenting: Do Parental PTSD and Parental Role Matter?

Prior studies show a heightened risk of child maltreatment during the COVID-19 pandemic because of financial difficulties and parenting stress, but little is known about what happened to the veteran families. This study aimed to examine the influences of the COVID-19 pandemic on veteran parents’ harsh parenting – creating a potential for child maltreatment. Further, we explored the potential moderating effects of parental PTSD and parental role on the association between COVID-19 impacts and veteran harsh parenting. We recruited 509 veteran parents from Qualtrics online research panel and assessed the impacts of the COVID-19 pandemic (e.g., perceived threat, financial and psychological impacts) on the participants, parental PTSD, and parents’ past year prevalence of corporal punishment and psychological aggression. We used Mplus 8.8 to build main models, two-way moderation models, and three-way moderation models. There was a significant association between COVID-19 pandemic impacts and harsh parenting (Corporal punishment: β = 0.09, p < 0.05; Psychological aggression: β = 0.10, p < 0.05), while parental PTSD was a significant moderator (Corporal punishment: β = 0.10, p < 0.05; Psychological aggression: β = 0.08, p < 0.05). Parents with higher levels of PTSD were more vulnerable to the negative influences of COVID-19 on their harsh parenting. However, the association between COVID-19 pandemic impacts and harsh parenting did not differ by parental role. Our study findings contribute to the current knowledge of veteran families during the COVID-19 pandemic and provide implications for both Veteran Affairs services and child protective services.

The Impact of Child Protection Service Experience and Secondary School Completion on Employment Outcomes

This study utilizes registry data and logistic regression to investigate the relationship between Child Protection Service (CPS) experience, completion of upper secondary school, and subsequent gainful employment. The findings show that completion of upper secondary school is associated with later gainful employment. However, when control variables are included to adjust for substantial differences between the two groups, the results reveal that completion of upper secondary school has a more substantial impact on future gainful employment for former CPS clients compared to non-CPS clients.

“My heart is in the right place, but I don’t feel the court’s heart is beating”: perspectives on feeling valued from multiple nonprofessional stakeholders in child welfare court

ABSTRACT Though the experiences of individual non-professional stakeholders involved with dependency courts overseeing child protective services cases have been documented, this article provides a unique comparison across four non-professional stakeholder groups. Through analysis of focus groups and individual interviews, we compare the perspectives of birth parents (n=6), kinship caregivers (n=14), young adults removed from their homes as children (n=15), and foster parents (n=57) involved with the dependency courts in Maryland. Despite their different roles, the experiences of all groups are characterized by common themes including time, consistency, role, voice, and what is best under the broader context of feeling valued.

Impact of being taken into out-of-home care: a longitudinal cohort study of First Nations and other child welfare agencies in Manitoba, Canada

Across Canada, Child Protection Services (CPS) disrupt Indigenous families by apprehending their children at alarmingly high rates. The harms borne by children in out-of-home care (OoHC) have been extensively documented. We examined the impact of OoHC on Manitoba children's health and legal system outcomes to provide rigorous evidence on how discretionary decision-making by CPS agencies can affect these outcomes. In partnership with First Nations researchers, we used linked administrative data to identify Manitoba children (born 2007-2018) served by First Nations and other Manitoba CPS agencies. We compared those taken into OoHC (n=19,324) with those never in care but with an open CPS file due to child protection concerns (n=27,290). We used instrumental variable analysis (CPS agency rates of OoHC as the instrument) to obtain odds ratios (aOR) and 95% confidence intervals adjusted for child, maternal, and family factors. Mean age (yrs±standard deviation) at first CPS contact for children taken into OoHC was 2.8±3.7 (First Nations) and 3.0±3.8 (other), and for children never in care was 4.5±4.5 (First Nations) and 5.1±4.7 (other). Among children served by a First Nations agency, males made up 50.6% (n=5496) in OoHC and 51.0% (n=6579) never in care. Among children served by other agencies, males made up 51.0% (n=4324) in OoHC and 51.0% (n=7428) never in care. Odds of teen pregnancy (First Nations aOR 3.69, 1.40-9.77; other aOR 5.10, 1.83-14.25), teen birth (First Nations aOR 3.23, 1.10-9.49; other aOR 5.06, 1.70-15.03), and sexually transmitted infections (other aOR 7.21, 3.63-14.32) were higher for children in care than children never in care, as were odds of being accused (other aOR 2.71, 1.27-5.75), a victim (other aOR 1.68, 1.10-2.56), charged with a crime (other aOR 2.68, 1.21-5.96), or incarcerated (First Nations aOR 3.64, 1.95-6.80; other aOR 1.19, 1.19-8.04). Being in OoHC worsened children's health and legal system outcomes. The importance of reducing the number of children taken into care was emphasized in briefings to provincial and First Nations governments. The government response will be monitored. Social Sciences and Humanities Research Council (no. 890-2018-0029).

Impact of out-of-home care on children’s outcomes: A longitudinal cohort study using linked administrative data from Manitoba, Canada

ObjectiveTo provide rigorous quantitative evidence about the impact of out-of-home care on children’s outcomes. ApproachGuided by an Advisory Circle of First Nations (FN) Knowledge Keepers and conducted in partnership with FN researchers, we used linked administrative data to identify all Manitoba children served by Child Protection Services (CPS) at FN agencies (FNA) and other agencies (OA) (2007-2018). We compared health, education, and legal system outcomes of those in care (FNA n=10,856; OA n=8,468) to those with protection concerns but not in care (FNA n=12,896; OA n=14,394). Using instrumental variable analysis with CPS agency rate of out-of-home care as the instrument, outcomes between groups were compared using 2-stage multivariate probit regressions adjusted for child and family factors. ResultsOdds of teen pregnancy (FNA OR 3.69, 95% CI 1.40-9.77; OA 5.10 (1.83-14.25)), teen birth (FNA 3.23 (1.10-9.49); OA 5.06 (1.70-15.03)), and positive STI tests (FNA ns; OA 7.21 (3.63-14.32)) were higher and odds of vaccination at age 2 (FNA ns; OA 0.49 (0.29-0.80)) were lower for children in care than children not in care. Odds of being accused (FNA ns; OA 2.71 (1.27-5.75)), victim (FNA ns; OA 1.68 (1.10-2.56)), or charged with a crime (FNA ns; OA 2.68 (1.21-5.96)), and odds of being incarcerated (FNA 3.64 (1.95-6.80); OA 1.19 (1.19-8.04)) were higher for children in care. ConclusionsOut-of-home care negatively affects children’s health, social and legal system outcomes. ImplicationsCPS agencies should work with FN leaders to develop and implement strategies to reduce the number of children taken into care.

Multiple risks for children of incarcerated mothers: A descriptive study

Objectives and ApproachSurvey data suggests that children of incarcerated mothers are exposed to a range of risk factors that can have negative impacts on life-course outcomes. This retrospective cohort study uses a population sample to describe the extent and mix of risk factors to which children of incarcerated mothers are exposed. Administrative data from health, justice, child protective services, births, and deaths were merged for 9,380 children exposed to maternal incarceration and an unexposed comparison group of 22,716 children. Risk ratios and 95% confidence intervals were calculated for birth complications and adverse childhood experiences (ACEs) for children exposed to maternal incarceration compared to those not exposed, adjusted for sociodemographic risk factors. A multiple risk score summed the number of recorded risk factors (0-17) for children with and without maternal incarceration exposure. ResultsCompared to unexposed children, children of incarcerated mothers had a higher risk of preterm birth, low birthweight, and all ACEs, including a 15-times (95%CI 14.2, 16.3) higher risk of exposure to maternal substance use disorders and 18-times (95%CI 16.8, 20.7) higher risk of placement in out-of-home care. Only 1% of children of incarcerated mothers did not experience any of the included risk factors, compared to 26% of unexposed children (p&lt;0.001). ConclusionsChildren of incarcerated mothers disproportionately experience multiple risks, especially maltreatment, placement in out-of-home care, and maternal substance use. ImplicationsThere is a significant public health opportunity to identify and address the needs of children of incarcerated mothers at the points of maternal arrest, sentencing, and incarceration.

Evaluation of Social Protection Programs to Improve the Welfare of Indonesian Migrant Workers Deported from Malaysia at the Rumah Perlindungan Trauma Center (RPTC) Tanjungpinang, Riau Islands Province

This study aims to evaluate social protection programs to improve the welfare of Indonesian Migrant Workers who are deported from Malaysia who are then provided with social protection services starting from pick-up, shelter at RPTC to repatriation to the area of origin. From the CIPP evaluation model used in this study, it was found: Context evaluation, social protection for migrant workers at RPTC is a crucial step in efforts to improve their welfare. Input evaluation, evaluation of the inputs that have been provided for the social protection of PMI at RPTC aims to measure the extent to which existing resources have been optimally utilized in improving the welfare of PMI which includes human resources, budget, facilities, policies, partnerships and information and data. In the Process Evaluation, researchers focus on activities or agendas that will or have been carried out by RPTC officers/employees. in this case the author found several processes of implementing the agenda, assisting personnel and the supervision process, namely by interviewing, validating the process and filling out questionnaires. Evaluation of results (product) is used to determine what decisions will be made next, the researcher concluded several interviews that said that this social protection service could improve the welfare of Indonesian Migrant Worker.

Management of Suspicions of Child Maltreatment at Child and Family Clinics: A Mixed-Methods Study

This study investigated Norwegian public health nurses working in child and family health clinics’ decision-making practices concerning child maltreatment. A one-phase convergent mixed-method design was utilized, with quantitative and qualitative data concurrently collected and separately analyzed from a questionnaire that included patient vignettes. These vignettes described three potential child maltreatment scenarios to assess public health nurses’ competence and clinical decision-making processes. A total of 554 public health nurses participated in the study conducted from October 24 to December 31, 2022. Findings reveal a high level of recognition of child maltreatment among public health nurses. However, despite their self-perceived confidence, the qualitative data underscore the complexity and uncertainty inherent in their assessment process. The most supported management approaches involved further exploration of the situation. Few public health nurses would file a report of concerns to Child Protective Services or report the police despite their level of concerns. The findings underscore the necessity for additional training and support to enhance public health nurses’ confidence and competence in reporting suspected child maltreatment cases, as well as the need for increased information exchange regarding the procedures and services provided by the child if Child Protective Service is involved.

SARS-CoV-2 infection among Colorado adults working outside the home: Occupation, race and ethnicity and mask use.

The workplace is an important setting for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposure and transmission. Using data from a large case-control study in Colorado during 2021 and 2022, we aimed to evaluate working outside the home and SARS-CoV-2 infection, the racial and ethnic distribution of workers in occupations associated with infection, and workplace face mask use. Cases were Colorado adults with a positive SARS-CoV-2 test by reverse transcription-polymerase chain reaction (RT-PCR) reported to Colorado's COVID-19 surveillance system selected from surveillance data ≤12 days after their specimen collection date. Control participants were randomly selected adult Coloradans with a RT-PCR-confirmed negative SARS-CoV-2 test result reported to the same surveillance system. Working outside the home was associated with infection (odds ratio [OR] = 1.46, 95% confidence interval [CI]: 1.39-1.54). Among participants working outside the home, "Food Preparation and Serving Related" (aOR = 2.35, 95% CI: 1.80-3.06), "Transportation and Material Moving" (aOR = 2.09, 95% CI: 1.62-2.69), "Construction and Extraction" (aOR = 1.88, 95% CI: 1.36-2.59), "Protective Service" (aOR = 1.60, 95% CI: 1.15-2.24), and "Sales and Related" (aOR = 1.44, 95% CI: 1.22-1.69) were occupational categories most strongly associated with infection. American Indian/Alaskan Native, Black, and Hispanic/Latino participants were more likely than others to work in occupational categories with the highest odds of infection (p < 0.05). Cases were less likely than controls to report always wearing a mask (31.9% vs. 41.5%) and wearing a KN95/N95/KF94 mask (16.8% vs. 27.2%) at work. These findings emphasize the importance of occupation and workplace mask use in the COVID-19 pandemic and its disproportionate racial/ethnic impact on workers.

Implementation of the Integrated Justice System as an Effort to Prevent Sexual Violence against Children: A Case Study in Indonesia

Sexual violence against children is a serious problem that threatens the safety and well-being of the younger generation. This study aims to analyze the implementation of the integrated justice system as an effort to prevent sexual violence against children in Indonesia. The integrated justice system integrates various institutions, including the police, prosecutor's office, courts, and child protection services, to ensure comprehensive protection for children as potential victims. This study uses a case study approach with a focus on policy implementation at the national and regional levels, as well as evaluating the effectiveness of collaboration between institutions in preventing sexual violence against children. The results show that although the integrated justice system has been well designed, there are still challenges in coordination between institutions, policy understanding at the local level, and limited resources that affect the effectiveness of prevention. The recommendations of this study include strengthening the capacity of related institutions, increasing coordination between institutions, and wider socialization about the importance of protecting children from sexual violence. Thus, it is hoped that the implementation of an integrated justice system can be an effective solution in preventing sexual violence against children in Indonesia.

Transcultural Psychiatry in Medical Ethics: Assessing Decision-Making Capacity within the Lens of an East African Refugee.

AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient's court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient's choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.

Addressing the Impacts of Racism on American Indian and Alaska Native Child Health

The legacy of racism toward Native Americans is far-reaching. We will review the topic using the conceptual model of racism as a form of violence as it is inherent in racism, as are prejudice and power. Using the basic frameworks of racism as internalized, interpersonal, institutional, and structural, we will discuss the many types of racism affecting Native Americans today. Racism is the bedrock of generations of trauma experienced in Native communities. The generational/historical trauma of racism has led to epigenetic-level changes affecting Native American people today. We will cover the health impacts of racism and the many institutions built in racist frameworks that continue to perpetuate racism, such as family separation and child removal by child protective services, adverse policing, and disparate incarceration. These allow reflection on policies and the intentionality of racist structures. We will conclude with what can and should be done, particularly as clinicians who work within and adjacent to existing systems of oppression.