pediatrics

PEDIATRICS

Medical Research in Biblical Times from the Viewpoint of Contemporary Perspective Liubov Ben-Nun

Ben-Gurion University of the Negev Liubov Ben-Nun Professor Emeritus Faculty of Health Sciences, Dept. of Family Medicine Beer-Sheva, Israel

The present book describes the broad spectrum of diseases and psychosocial disorders that afflicted a variety of patients. These diseases and disorders include: male circumcision, cardiopulmonary resuscitation, breastfeeding, fraternal domestic violence, twins, polygamous family, dreams of adolescent, prevention of pediatric plant poisoning, adoption, speech and language disorder, sexual abuse, pediatric injury, unprotected sexual relations, coping with a disabled child, causes of a newborn death, the mourning process following the death of a newborn infant and an adolescent child.

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Ben-Gurion University of the Negev Liubov Ben-Nun Professor Emeritus Faculty of Health Sciences, Dept. of Family Medicine Beer-Sheva, Israel

Published by: B.N. Publication House, Israel Fax: +(972) 8 6883376 Mobile 050 5971592 E-Mail: [email protected]

Graphics and Cover: Ilana Ben-Nun © All rights reserved

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Biblical Exegesis It should be noted and stressed that this research is in no way concerned with a discussion of any interpretations of the Bible by the great commentators such as Rambam, the sages of the Talmud and the Mishnah, or interpretation based on knowledge of the ancient world found in Julius Preuss’ book, Medicine in the Talmud, as translated by Ferrer Rosner. The research is based solely on the actual words on the verses of the Bible.

Medical Research in Biblical Times from the Viewpoint of Contemporary Perspective

CONTENTS PREFACE FOREWORD INTRODUCTION MALE CIRCUMCISION BREAST-FEEDING CARDIOPULMONARY RESUSCITATION FRATERNAL DOMESTIC VIOLENCE ADOPTION SPEECH AND LANGUAGE IMPEDIMENT MOSES: "SLOW OF SPEECH AND SLOW OF TONGUE" PEDIATRIC INJURY COPING WITH CHILD'S DISABILITY PSYCHODYNAMIC CHARACTERISTICS OF TWINS POLYGAMOUS FAMILY EVALUATION OF ADOLESCENT DREAMS EATING DISORDERS SEXUAL ABUSE UNPROTECTED SEXUAL RELATIONS PREVENTION OF PEDIATRIC PLANT POISONING A DISEASE THAT AFFLICTED THE NEWBORN SON OF KING DAVID MOURNING FOR A NEWBORN INFANT MOURNING FOR AN ADOLESCENT

9 10 12 13 26 70 98 131

159 174 180 184 195 207 219 226 252 269 282 290 297

ABBREVIATIONS ADHD AAP AIDS AHA AN BED BN CBCL CDC CI CMV CNS CPA CPCR CPR CRA CSF DSM EATD ED EDNOS EMS FEV FVC GAD HIE HIV HPV IGT IPCU IRVs MC NM NREM NVDRS OCD OHCA OR(adj) OR

Attention-Deficit/Hyperactivity Disorder American Academy of Pediatrics Acquired immune deficiency syndrome American Heart Association Anorexia nervosa Binge eating disorder Bulimia nervosa Child Behavior Checklist Centers for Disease Control and Prevention Confidence interval Cytomegalovirus Central nervous system Cardiopulmonary arrest Cardiopulmonary cerebral resuscitation Cardiopulmonary resuscitation Cardiorespiratory arrest Cerebrospinal fluid Diagnostic and Statistical Manual Eating disorder Emergency department Eating disorders not otherwise specified Emergency medical services Forced expiratory volume Forced vital capacity Generalized anxiety disorder Hypoxic ischemic encephalopathy Human immunodeficiency virus Human papillomavirus Intrauterine growth retardation Intensive pediatric care unit Injury-related visits Male circumcision Neonatal mortality Non-rapid eye movement National Violent Death Reporting System Obsessive compulsory disorder Out-of-hospital cardiac arrest Adjusted odds ratio Odds ratio

PBI PCA PCR PD PEA PEF PID PTSD REM RDS RR SIDS STD STI TRF UTI VF VSD VT WIC WHO YSR

Parental Bonding Instrument Pediatric cardiac arrest Polymerase chain reaction Purging disorder Pulseless electric activity Peak expiratory flow Pelvic inflammatory disease Posttraumatic stress disorder Rapid eye movement Respiratory distress syndrome Relative risk Sudden infant death syndrome Sexually transmitted disease Sexually transmitted infection Teacher's report form Urinary tract infection Ventricular fibrillation Ventricular septal defect Ventricular tachycardia Women, Infants and Children World Health Organization Youth self report

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PREFACE The purpose of this research is to analyze the medical situations and conditions referred to in the Bible, as we are dealing with a contemporary medical record. These are scientific medical studies incorporating verses from the Bible, without no interpretation or historical descriptions of places. Fundamentally, the Research is constructed purely from an examination of passages from the Bible, exactly as written. This research is part of a long series of published studies on the subject of biblical medicine from a modern medical perspective. This is not a laboratory research. The Research is built entirely on a secular foundation. With due to respects to people faith, this Research takes a modern look at medical practices. Each to his own beliefs.

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FOREWORD The field of pediatrics in the US began in late-nineteenth century urban slums, where young children were monitored to ensure they received safe milk and mothers were educated about nutrition and hygiene. The subsequent reduction of infectious disease through sanitation and vaccination and a continuing appreciation of the powerful impact of the social context of children's well being reinforced this early emphasis on preventive care. The past several decades have seen a shift in the distribution of childhood morbidity, as changing social patterns of family life and access to health care have increased the prevalence of chronic illnesses and developmental and emotional problems. More recently, practitioners and policymakers have recognized the importance of children's social and physical environments on life-long health and social competence. These changes are casting increasing attention on the preventive care available to young children and their families. Whereas public policies have provided most children with access to health care, questions have been raised about the content and quality of that care. Recommendations to improve the quality of preventive care include strategies as risk-based individualized care plans; greater use of tested practice management tools, such as flow sheets and e-mail; team care; and standardized data collection, including structured screening. Both the content of preventive care and the training of practitioners to provide that care should be guided by a predetermined set of measurable outcomes for which providers should be held accountable, as well as other outcomes to which they should be expected to contribute (1). Pediatric practice in this millennium will require greater knowledge of new morbidities, such as AIDS and social and behavioral disorders, reemerging old disorders, such as tuberculosis, and disorders rarely seen now in the United States; but being brought by recent immigrants, such as malaria and other parasitic diseases. Diversity in ethnic and cultural backgrounds and beliefs will continue to increase, and it will need to be understood in order to prevent and treat diseases of children effectively. Although the current antagonism toward immigrants may lead to a decrease in this particular source of diversity, changes in family structure such as divorce, gay and lesbian couples as parents, and corporate pressure on families will continue, requiring pediatricians to understand and to accept this diversity if they are the health care providers of children. The increased isolation

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of individuals from society and separation from families of origin will require to be more active in communities and schools and to participate with other disciplines and social support groups. Increased survival of children who previously had fatal illnesses will mean more emphasis on care of children who have chronic illnesses (2). A variety of diseases and psychosocial problems affect children. In order to better understand our future we should study our past. Thus, study of the past may provide an insight into different aspects of pediatric care that may help us to handle a number of situations arising in any busy clinical practice. These fascinating topics present a diagnostic challenge to health care providers and like a mirror represents our remote past. The present book may widen the horizons of our knowledge and may help to understand many health problems in the children. The evaluation of the children health problems is based on contemporary scientific knowledge. It is important therefore to study ancient descriptions of the children healthcare in order to provide appropriate care to the modern children. References 1. Schor EL. The future pediatrician: promoting children's health and development. J Pediatr. 2007;151(5 Suppl):S11-6. 2. Haggerty RJ. Child health 2000: new pediatrics in the changing environment of children's needs in the 21st century. Pediatrics. 1995;96(4 Pt 2):804-12.

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INTRODUCTION Pediatrics is the branch of medicine that deals with the development, diseases, and care of children (1). According to an arbitrary definition, an “infant“ refers to a child in the first year of life (2), children are aged from 1 year to about 8-10 years (2,3), and adolescents from 12 to 19 years (4). Pediatrics is concerned with disturbances of any system or function that might have impact upon health or orderly growth and development of the child. The health problems of children vary widely among the nations of the world in accordance with many factors which include [1] the prevalence and ecology of infectious agents and their hosts; [2] climate and geography; [3] agricultural resources and practices; [4] educational, economic, and sociocultural considerations; and [5] in many instances, the gene frequencies for some disorders. These factors are often interrelated (5). Pediatrics is a dynamic ever-changing profession. The experience of a diagnostic challenge with its various treatment possibilities plus attitudes towards issues associated with the health of the pediatric patients give us an excellent opportunity to examine some topics from the past that are relevant to modern times.

The importance of this book is in that it provides tools for a better comprehension of the nature of various aspects of pediatric problems drawn from the logical conclusion concerning various diseases and psychosocial situations in biblical times. It gives health care providers an excellent opportunity to re-examine and re-evaluate the clinical manifestations of many diseases and psychosocial situations and in some cases the therapeutic approaches towards these diseases and psychosocial problems.

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All biblical texts were therefore examined and verses relating to various diseases and psychosocial problems associated with pediatric patients were studied closely. References 1. The Penguin English Dictionary. 2nd ed. Allen R ed. Penguin Books. England, USA, Australia. 2003. 2. 2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Pediatric Basic Life Support. Pediatrics. 2006;117: e989-e1004. 3. 2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Pediatric Basic Life Support. Part 11: Pediatric Basic Life Support. Circulation. 2005;112: IV-156-IV-166. 4. Park CB, Shin SD, Suh GJ, et al. Pediatric out-of-hospital cardiac arrest in Korea: A nationwide population-based study. Resuscitation. 2010;81:5127. 5. Vaughan VC. The field of pediatrics. In: Nelson Textbook of Pediatrics. Behrman RE, Vaughan V, eds. 12 ed. Saunders, Philadelphia, London, Toronto. 1983, pp. 1-9.

MALE CIRCUMCISION The performance of ritual circumcision is rooted in the Bible and is discussed in the earliest Jewish sources. The practice has been observed across the generations in every Jewish community in Israel and the Diaspora (1). Brit milah, the ritual circumcision of male infant in Judaism, is an obligatory commandment performed on the eight day of life: "This is my covenant, which you shall keep between me and you and thy seed after thee; Every man child among you shall be circumcised. And you shall circumcise the flesh of your foreskin; and it shall be a token of the covenant between me and you. And he that is eight days old shall be circumcised among you, every man child in your generations, he that is born in the house, or bought with money of any stranger, who is not of thy seed. And Abraham was ninety nine years old, when he was circumcised in the flesh of his foreskin. And Ishmael his son was thirteen years old, when he was circumcised in the flesh of his foreskin (Genesis 17:10-12, 24,25).

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Is MC still carried out in the contemporary times? What are the modern attitudes towards circumcision? What are consequences? What are the pros and cons towards MC? What are benefits? Is this procedure acceptable? What are the adverse effects of this type of surgery? Is it advisable to follow the biblical precept on this matter? This research aims to answer these questions by evaluating biblical verses concerning MC.

Description The term circumcision refers to partial or complete excision of the foreskin. There are three types of circumcision: ritual circumcision, performed for religious practice, as a rite of passage, usually during neonatal or transpubertal age; prophylactic circumcision, as preventive measure against future potential diseases; therapeutic circumcision, performed because of an evident pathology of the foreskin with clear medical indications. Prophylactic circumcision spread among Englishspeaking peoples in the nineteenth century as a means against masturbation. In the twentieth century prevention against cancer, UTIs, STDs and, eventually, AIDS took over. The controversy about prophylactic circumcision is increasing nowadays in the United States, whereas in the other English-speaking countries the procedure has almost disappeared and this represents what Edward Wallerstein calls "the uniquely American medical enigma". There are many interpretations for prophylactic circumcision and its lasting success in the United States. Each explanation probably hits the target only partially because the procedure takes its roots in the cultural history of the country in the relation with its puritan origins. Therapeutic circumcision is also performed because of a clear and evident pathology of the prepuce (2). MC is practiced in different religions and cultures (3). Global estimates suggest that one in three males worldwide is circumcised (4). Most circumcised males in the world are Muslims (3). References 1. Gesundheit B, Greenberg D, Walfish S, et al. Infectious complications with herpes virus after ritual Jewish circumcision: a historical and cultural analysis. Harefuah. 2005;144:126-32, 149, 148. 2. Calcagno C. Circumcision: what do we cut when we are cutting? Urologia. 2007;74:73-79. 3. Amir J. Ritual circumcision and urinary tract infection in Israel. IMAJ. 2010;12:303-4.

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4. WHO/UNAIDS. Male circumcision: global trends and determinants of prevalence, safety and acceptability. In: Geneva: World health Organization, 2008.

Benefits Urinary Tract Infection Since the first report by Wiswell and colleagues, a significant number of studies have confirmed the lower incidence of UTI in circumcised compared with uncircumcised boys (1-5). The clearest medical benefit of circumcision is the relative reduction in the risk for a UTI, especially in early infancy. Although this risk is real, the absolute numbers are small (risk ranges from 1 in 100 to 1 in 1000), and it may take approximately 80 neonatal circumcisions to prevent one UTI. In the case of a patient with known urologic abnormalities that predispose to UTI, neonatal circumcision has a clearer role in terms of medical benefit to the patient (6). Of infants with UTI, 10% will have simultaneous bacteremia and 3–5% of children will develop concurrent meningitis (7). Other severe acute complications of UTI during infancy include renal failure and death (8). Thus, for a small lifetime net cost estimated at US$17, a circumcised male infant can expect an average 10-fold decrease in RR of UTI, including a 15-fold reduction in RR of serious UTI requiring hospitalization, not to mention the decreased risk of severe concomitant complications (4). It is not so inconsequential after all to be able to reduce 10-fold the risk of UTI early in life and its associated cost, even in the face of its low incidence. Randomized controlled trials and observational studies comparing the frequency of UTI in circumcised and uncircumcised boys were identified from the Cochrane controlled trials register, MEDLINE, EMBASE, reference lists of retrieved articles, and contact with known investigators. Two of the authors independently assessed study quality, using the guidelines provided by the MOOSE statement for quality of observational studies. A random effects model was used to estimate a summary OR with 95% CI. Data on 402.908 children were identified from 12 studies (one randomized controlled trial, four cohort studies, and seven case-control studies). Circumcision was associated with a significantly reduced risk of UTI (OR 0.13, 95% CI 0.08-0.20; p4 times than that the general-population rate. The mortality rate among female youth was nearly 8 times than that in the general-population rate. African American male youth had the highest mortality rate (887 deaths per 100.000 person-years). Thus, early violent death among delinquent and general-population youth affects racial/ethnic minorities disproportionately and should be addressed as other health disparities (39). All cases referred to the Forensic Pathology Section of the Medical University of South Carolina between January 1991 and May 2006 were reviewed retrospectively. Cases included in the study were homicides in which 1 or more assailants were 19 years of age or younger. The cases were examined as to the cause and manner of death, victim age, gender, race, incident location, weapon used, assailant-victim relationship, assailant age, gender, race, motive, and postmortem toxicology results. Assailant information was obtained

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from forensic records at Medical University of South Carolina, police department records, and online search engines of South Carolina State newspaper archives confirmed by law enforcement reports. The youth assailants were predominantly black men, 15 to 19 years of age (range, 4-19 years). Most victims were black male acquaintances, and the motive was most often an argument. The most common cause of death was cerebral laceration because of a gunshot wound. The incident occurred in the home in 41% of cases, followed by the street in 31%. Victim toxicology was frequently positive for cocaine, marijuana, and alcohol (40). A retrospective, comparative study was carried out in France on 118 sharp force fatalities, including 70 homicides and 48 suicides, and covering a 22-year period from 1986 to 2008. The objective was to identify relevant parameters to distinguish between these two manners of death. The following parameters were analyzed: age, gender, number of wounds, type of wounds, anatomical sites of the wounds, and the presence of wounds affecting bones or cartilage, and the longitudinal axis of stab wounds located at the anterior part of the trunk, Injury Severity Score, and associated traumatic injuries. Homicide victims were younger than those who had committed suicide. Homicide cases showed predominantly associated stab and cut wounds, whereas suicide cases isolated cut wounds. Wounds that were located in the head, limbs, hands, nape of the neck, or back were predictive of a homicide, whereas wounds located solely in the anterior parts of the trunk, neck, or forearms were predictive of a suicide. The presence of bone or cartilage wounds was predictive of a homicide and their absence was predictive of a suicide. A vertical longitudinal axis of stab wounds located in the anterior part of the trunk was predictive of a homicide whereas a horizontal axis was predictive of a suicide. Injury Severity Score was significantly higher in homicide cases than in suicide cases. The presence of defensive or violence-associated traumatic wounds was predictive of a homicide whereas the presence of hesitation-associated wounds or the absence of associated traumatic wounds was predictive of a suicide (41). In Sri Lanka, six members of one family were murdered at their own residence. Four of the family members had been killed with large heavy sharp weapons which produced multiple deep cut injuries predominantly on the neck and face. In these victims, death occurred because of hemorrhage. Two family members were killed by ligature strangulation and hanging. The victim, who was hanged, was sexually abused before she was killed. An unusual finding was the presence of an alleged assailant of the murders with multiple blunt weapon

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traumas to his body, at the scene of crime. The homicides of the family were because of personal disputes between the perpetrators who were their neighbors. Three of the alleged assailants were charged for murder and rape. The fourth assailant was charged for rape. No conclusive evidence as to who caused the death of the alleged perpetrator was reached (42). The main aim of this study was to evaluate whether the underlying reasons (motives) for killing has a relationship to the methods employed for killing. A retrospective descriptive study based on autopsy reports, magistrate orders and case notes attached was carried out on all the cases examined at the office of the JMO Colombo and Ragama from July 2005 to June 2006. Out of 265 autopsy examinations alleged to be homicides, 39% of deaths were related to terrorist acts while previous enmity was recorded in 35% of cases. The commonest method of homicide was firearms (31%) followed by explosives (28%). Blunt force and sharp force trauma were the reasons for 23% and 14% of homicides, respectively. Almost all the deaths related to war were caused by firearms and bombs (96%), where 47% of previous enmity deaths were caused by firearms. Firearms were never used in homicides of sudden provocation or drunken brawls. The increased use of firearms was not only in terrorism related homicides, but also in homicides related to previous enmity (43). Homicide patterns vary from country to country and are influenced by many factors. In the two-year period, from January 1998 to December 1999, at the Department of Forensic Medicine, Kasturba Medical College, India, homicide victims were autopsied. The sex ratio was about three males for one female. The largest number of victims was in the age group of 21-30-years. Assaults with blunt weapons were the most common means. Acquaintances committed 34% of homicides. By contrast to males, the killing of a female by a stranger was rare. Revenge was the most common reason followed by arguments. In 40.2% of cases, the location of crime was outdoors, 37.8% were at the victim's house and in 9.7% of cases, crime was committed at another domicile such as the offender's house, and lodgings or a relative's house. In 14.7% of cases, the dead bodies were located away from the scene of crime (44). An empirical study of characteristics and types of homicidesuicides in Hong Kong, 1989-2005, was carried out. Data of homicide-suicide offenders from Coroner's Court were analyzed through a two-step cluster analysis. Number of clusters and appropriate allocations of cases were obtained. External background

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variables were tested through post hoc tests to explore the differences among clusters. People (n=231) died in 98 episodes during the study period. The majority of homicide-suicide offenders were males (n=68, 68.7%) aged 30-49 years (n=62, 62.6%). Domestic killing was the major type of homicide-suicide in which over 60% of the homicide motivation was related to spousal conflicts or altruistic reasons. Spouses (n=46, 46.5%) and children (n=47, 47.5%) were predominantly the victims. The common killing methods included chopping with weapons (n=33, 33.3%) and charcoal burning (n=22, 22.2%). Six clusters of homicide-suicide were derived from the cluster analysis and were further reduced to four major classes. Four major classes were dispute, conflicts in a relationship, altruistic, and mental illness. These classes could be differentiated by methods of homicide and suicide, gender of perpetrator, relationship with victim, and indebtedness. Financial problem, dispute and domestic violence were significant precipitants of homicide-suicide in Hong Kong. These people associated with the precipitating factors should be the targets for intervention and prevention (45). Assessment: in different countries, differing rates of homicides are observed. In general, homicides occurred at higher rates among males aged 20-24 years. The majority of homicides occur in the victim's house, followed by the offender's house, lodgings or a relative's house, or on a street/highway. Homicides are precipitated primarily by arguments and interpersonal conflicts, quarrels, revenge, disputes, reprisals, mental-health problems, recent crises, robbery, financial problem, conflicts in a relationship, mental illness, or in conjunction with another crime. Deaths are caused by gunshot, blunt force and sharp force, stab/slash, mechanical asphyxia, head injury, firearm, strangulation, hanging, stabbing, bomb, and explosives. Most of the victims of homicide are killed outdoors.

Characteristics of Offenders An independent inquiry has been mandatory for all homicides committed by persons in contact with mental health services in England and Wales since 1994. The aim of this study was to provide a detailed description of the characteristics of the perpetrators of homicides covered by the independent inquiries between 1994 and 2002. Ninety-seven published inquiry reports were collected for analysis. Descriptive case data regarding the perpetrator was manually abstracted from each report using a structured questionnaire. Ninety-

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nine individuals committed 109 homicides. Most perpetrators of homicide were males, with a diagnosis of schizophrenia or other psychotic illness. Victims were most likely to be a family member or an acquaintance. Psychotic symptoms as well as alcohol or substance misuse were present at the time of homicide (46). The research was conducted at the Department of Forensic Psychiatry in Neuropsychiatric Hospital "Dr. Ivan Barbot" in Popovaca, Croatia. The sample in this study consisted of domestic homicide group (n=162). The results showed certain characteristics within the group of domestic homicide offenders. The offenders in domestic homicide cases were often married and were living with their families. Moreover, they were brought up in families with both parents and they had history of regular military service. Furthermore, offenders in domestic homicide cases were less involved in intervention from social services with rare history of home runaway and substance abuse during adolescence. Finally, the same group of offenders had less often mothers or close friends with antisocial personality disorder but had frequent language and speech problems during adolescent period. The victims of domestic homicide were often aged females. The offenders usually commit crime in their living space, either in the house or in the apartment (47). A current study examined the psychiatric characteristics and rate of subsequent violence among those who uttered explicit threats to kill. Data were drawn from 144 referrals of adults to a community-based forensic mental health consultation and treatment service, Centre for Forensic Behavioral Science, Australia. Each had explicitly threatened to kill a person other than himself or herself. Assaults were made by over 20%, including one homicide, within 12 months of assessment. Two participants committed suicide in the follow-up period. Factors that contributed to violence risk were substance abuse, prior violence, limited education and untreated mental disorders. Threateners were often habitual in their threatening behavior and typically targeted those they interacted with on a daily basis. Clinical characteristics showed a psychiatrically complex group who shared many features with other offender groups. The type of threat that led to referral for a mental health assessment was rarely followed by violence. Factors enhancing risk resemble findings from other groups of offenders. Those referred for clinical evaluation typically have complex clinical presentations and marked deficits in effectively managing interpersonal conflict (48). A nonrandom sample (n=30) of mass murderers in the United States and Canada during the past 50 years was studied. Such

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individuals were single or divorced males in their fourth decade of life with various Axis I paranoid and/or depressive conditions and Axis II personality traits and disorders, usually Clusters A and B. The mass murder was precipitated by a major loss related to employment or relationship. A warrior mentality suffused the planning and attack behavior of the subject, and greater deaths and higher casualty rates were significantly more likely if the perpetrator was psychotic at the time of the offense. Alcohol played a minor role. A large proportion of subjects will convey their central motivation in a psychological abstract, a phrase or sentence yelled with great emotion at the beginning of the mass murder; but in this study sample, only 20% directly threatened their victims before the offense. Suicide or death at the hands of others was the usual outcome for the mass murderer (49). Assessment: in general, offenders are males in their fourth decade of life with paranoid condition, schizophrenia or other psychotic illness, and/or depressive conditions, and personality traits and disorders. Factors that contribute to the risk of violence include substance abuse, prior violence, limited education and untreated mental disorders. Threateners are often habitual in their threatening behavior and typically target those they interacted with on a daily basis. Victims are females, a family member, or an acquaintance. Psychotic symptoms as well as alcohol or substance misuse are often present at the time of homicide. The offenders usually commit crime within their living space. Mass murder is precipitated by a major loss of employment or relationship. A warrior mentality suffuses the subject's planning and attack behavior and higher casualty rates are more likely if the perpetrator is psychotic at the time of the offense.

Mental Illness and Violence Are people with mental illness more violent than other people? In general, most patients with mental illness do not exhibit increased violence (50), even young adults, in whom the peak period for violence is observed (51), as shown by self-reporting (52), victimization reports (53), arrest data (54), and rehospitalization records (55). In patients with mental illnesses, violence, including serious violence, occurs in response to psychotic illness (56-60). Mental illnesses such as schizophrenia (61,62), schizophrenia spectrum disorders (63), and delusional disorder (64) are related to violence with delusions in unipolar depression as a strong predictive

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factor for suicide (65), and psychotic depression for suicide attempt (66). Most patients with schizophrenia never endanger the lives of others at any time during the course of their illness (67). However, in a minority of these patients violent behavior and threats, as mentioned above, can be related to their symptoms such as delusions of being poisoned (67). Other mental disorders linked to severe violence include personality disorders (68,69), substance abuse or dependence such as alcohol, or marijuana (68), or substance misuse (69), and conditions where substance abuse is combined with severe mental illness (70,71). All 50 states and the District of Columbia have legal mechanisms to try juveniles as adults in criminal court. This study examined the prevalence of psychiatric disorders among youths transferred to adult criminal court and youths processed in the juvenile court. Participants were a stratified random sample of 1.829 youths, ten to 18 years of age, who were arrested and detained in Chicago. Data from version 2.3 of the Diagnostic Interview Schedule for Children were presented for 1.715 youths, 13 to 18 years of age, including 1.440 youths processed in juvenile court and 275 youths processed in adult criminal court. Males, African Americans, Hispanics, and older youths had greater odds of being processed in adult criminal court than females, non-Hispanic whites, and younger youths, even after the analyses were controlled for felony-level violent crime. Among youths processed in adult criminal court, 68% had at least one psychiatric disorder and 43% had two or more types of disorders. Prevalence rates and the number of comorbid types of disorders were insignificantly different between youths processed in adult criminal court and those processed in juvenile court. Among youths processed in adult criminal court, those sentenced to prison had significantly greater odds than those receiving a less severe sentence of having a disruptive behavior disorder, a substance use disorder, or comorbid affective and anxiety disorders. Community and correctional systems must be prepared to provide psychiatric services to youths transferred to adult criminal court and especially to youths sentenced to prison. When developing and implementing services, psychiatric service providers must also consider the disproportionate representation of individuals from racial-ethnic minority groups in the transfer process (72) This study examined the prevalence of PTSD and comorbid psychiatric disorders among juvenile detainees. The sample consisted of a stratified random sample of 898 youths aged ten to 18 years who were arrested and detained in Chicago. Among participants with PTSD, 93% had at least one comorbid psychiatric disorder; however,

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among those without PTSD, 64% had at least one comorbid psychiatric disorder. Over half (54%) of the participants with PTSD had two or more types of comorbid disorders - that is, affective, anxiety, behavioral, or substance use disorders, and 11% had all four types of comorbid disorders. Among males, having any psychiatric diagnosis significantly increased the odds of having comorbid PTSD. Among females, alcohol use disorder and both alcohol and drug use disorders significantly increased the odds of having PTSD. Insignificant difference in prevalence rates of PTSD was between males and females with specific psychiatric disorders. The prevalence of any comorbid psychiatric disorder was significantly higher for males than females with PTSD (OR=3.4, CI 1.1-10.6, p17300 children from Guatemala. This study assessed the health, growth, and developmental status of 103 Guatemalan adopted children (48 girls; 55 boys) after arrival in the United States. Physical evidence suggestive of prenatal alcohol exposure and adequacy of vaccinations administered were also reviewed. Retrospective chart review was conducted of children who were evaluated after arrival in the United States in an international adoption specialty clinic, and a case-matched study was conducted of a subgroup of 50 children who resided in either an orphanage or foster care before adoption. Mean age at arrival was 16 +/- 19 months. Before adoption, 25 children resided in orphanages, 56 in foster care, and 22 in mixed-care settings. The 25 children who had resided in orphanages before adoption were matched for age at arrival, interval from arrival to clinic visit, and gender with a child adopted from foster care. Health and developmental status of these matched pairs were compared, allowing the first direct comparison of children raised in orphanages or foster care before adoption. Mild growth delays were frequent among the children. Mean z scores for weight, height, and

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head circumference were, respectively, -1.00, -1.04, and -1.08. Children from foster care had significantly better z scores for height, weight, and head circumference than those from orphanage or mixed care. Among children who were younger than 2 years at arrival, growth measurements correlated inversely with age at arrival. Infectious diseases included intestinal parasites (8%) and latent tuberculosis infection (7%). Other medical conditions included anemia (30%), elevated lead levels (3%), and (using strict criteria) phenotypic facial features suggestive of prenatal alcohol exposure (28%). Adequacy of vaccine records from Guatemala was assessed: 28% met AAP standards for vaccine administration. Unsuspected significant medical diagnoses, including congenital anomalies and ocular, neurologic, and orthopedic problems were found in 14% of children. Most of children were doing well developmentally (80-92% of expected performance), but 14% had global developmental delays. Cognition, expressive and receptive language, and activities of daily living skills correlated inversely with age at arrival for children who were younger than 2 years at adoption. Matched children, who resided in foster care before adoption, had better measurements for height, weight, and head circumference at arrival in the United States. Moreover, those who resided in foster care scored significantly better for age-expected cognitive skills than those who had previously resided in orphanages (96.3% vs. 88.3%); other skills did not differ between the 2 groups. No differences were found between the 2 groups of children related to prevalence of medical diagnoses or phenotypic evidence suggesting prenatal alcohol exposure. Guatemalan adoptees display similar overall patterns of growth and developmental delays as seen in other groups of internationally adopted children, although not severe. Younger children had better growth and development (cognition, language, and activities of daily living skills) than older children did, regardless of location of residence before adoption. Children were matched for age, gender, and interval from adoption to evaluation, those residing in foster care had better growth and cognitive scores than children residing in orphanages before adoption. These findings support the need for timely adoptive placement of young infants and support the placement of children in attentive foster care rather than orphanages when feasible (36). Since 2000, American families have adopted 1.700 children from Ethiopia. On arrival, retrospective chart review was conducted of 50 (26 females: 24 males) children from Ethiopia/Eritrea seen in the International Adoption Clinic. Prior to adoption, most children resided

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with relatives; 36% were >18 month-old prior to entry into care. More than 50% were true orphans, often due to HIV. Arrival age ranged from 3 months to 15 years (mean +/- SD 4 years +/- 43.8 months). At arrival, growth z scores were near average (weight -.59, height -.64, head circumference -.09); significantly better than adopted children from Guatemala, China, or Russia seen in this clinic. However, some Ethiopian children were significantly growth delayed (WAZ ≤-2, 8%, HAZ 12%, HCZ 18%). Age at adoption did not relate to growth delays. Medical issues on arrival included intestinal parasites (53%, 14% with ≥3 types), skin infections (45%), dental caries (25%), elevated liver transaminases (20%), latent tuberculosis (18%), and hepatitis B (2%). Age-appropriate vaccines had been administered in 15-77% of children (depending on specific vaccine). Behavior problems were uncommon. Gross/fine motor and cognitive skills were approximately 86% of expected for age. Age correlated inversely with developmental scores for cognition (r=-0.49, p=0.003). Five children had age reassignments. Ethiopian/Eritrean adoptees differed from other groups of internationally adopted children: they resided for relatively long periods of time with relatives prior to institutionalization, often had uncertain ages, exhibited few behavioral problems at arrival, had better growth and less severe developmental delays (37). More than 6.800 children from India have been adopted in Sweden over the last four decades. At arrival, many were undernourished and suffered from infectious diseases. Catch-up growth was common. Unexpectedly, cases of early pubertal development were subsequently reported. In order to investigate the growth and development of adopted children more in detail, 114 children adopted from India during two years were studied prospectively. The majority were stunted at arrival and caught up in height and weight after two years. Psychomotor retardation and common infections diminished soon. Those who were stunted did not attain the higher catch-up levels in comparison with those not stunted at arrival. Low birth weight also limited the degree of catch-up growth. Girls (n=107) were analyzed retrospectively in another study. The median menarcheal age was 11.6 years (range 7.3-14.6 years), which was significantly earlier than the mean in Swedish and privileged Indian girls (13.0 and 12.4-12.9 years, respectively). The pubertal linear growth component was normal in duration and magnitude but likewise started 1.5 years earlier. The final height/age was 154 cm (-1.4 SDS) and the weight/age 46.9 kg (-1.1 SDS), 8% were 145 cm or shorter. Stunting limited catch-up growth and final height. Those who were most

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stunted at arrival had the fastest catch-up growth, and the earliest menarche. Good maternal and child nutrition is necessary for full expression of a child's growth potential. What is lost in growth early in life can only partially be recovered by catch-up growth. Such growth is associated with risk for early pubertal development which abbreviates the childhood growth period and limits final height (38). To examine the effects of early emotional neglect on children's affective development, children who had experienced institutionalized care prior to adoption into family environments were assessed. One task required children to identify photographs of facial expressions of emotion. A second task required children to match facial expressions to an emotional situation. Internationally adopted, post institutionalized children had difficulty identifying facial expressions of emotion. In addition, post institutionalized children had significant difficulty matching appropriate facial expressions to happy, sad, and fearful scenarios. However, post institutionalized children performed as well as comparison children when asked to identify and match angry facial expressions (39). Assessment: children at adoption exhibit a variety of physical and psychological problems. Did some physical disease afflict Moses? Moses’ medical file, that is the biblical text, indicates no physical diseases. It can therefore be concluded that Moses was a healthy child who did not suffer from any physical disease. Was Moses afflicted by some psychological disorder? An answer is found in a subsequent event. When Moses was an adult, he killed an Egyptian man because he was beating a Hebrew slave. This episode indicates that Moses knew his identity, that he was Jew, and opposed the repressive policies towards the Jews of his adoptive father, Pharaoh, the powerful ruler of Egypt. Moses was raised and educated in an Egyptian family and could have remained an Egyptian. Nevertheless, as a Jew he relinquished his luxurious life and a bright future as an Egyptian and devoted himself entirely to a single mission – to lead the Jewish people out of Egypt. So duality of feelings, on the one side his connection with his Egyptian family and on the other the devotion to his Jewish people, led to some emotional distress expressed by the upheaval when Moses killed an Egyptian oppressor. Nevertheless, there is no data to indicate any mental disorder in Moses.

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Developmental Delays Developmental delays include gross motor impediment, fine motor delay (11), and speech and language delays (40-42). Adopted children are more likely to develop learning and school adjustment problems than their non-adopted peers, despite the fact that learning potential appears to be comparable in the two groups. In an effort to explain this phenomenon, the present study examined cognitive behavior repertoires in healthy 5-month-old first infants and their mothers during their normal daily routine in families by adoption and by birth. Two areas of functioning, vocal/verbal communication and exploration, were examined. Infants and mothers in both groups were similar in the frequency and ranking of a full array of age-appropriate cognitive behaviors. Both groups of babies experienced rich and comparable opportunities for the development of language competence. In the exploratory realm, group differences emerged for some infant measures; infants by birth were in an alert state and mouthed objects more than infants by adoption. Examination of the linkages among infant behaviors and between mothers and infants suggested that, while mothers by birth and adoption provided comparable opportunities for exploration, infants by birth were engaging in exploratory behavior to a somewhat greater extent (43). This meta-analysis of 62 studies (17.767 adopted children) examined whether the cognitive development of adopted children differed from that of (a) children who remained in institutional care or in the birth family and (b) their current (environmental) nonadopted siblings or peers. Adopted children scored higher on IQ tests than their nonadopted siblings or peers who stayed behind, and their school performance was better. Adopted children did not differ from their nonadopted environmental peers or siblings in IQ, but their school performance and language abilities lagged behind, and more adopted children developed learning problems. Taken together, the metaanalyses document the positive impact of adoption on the children's cognitive development and their remarkably normal cognitive competence but delayed school performance (44). As analyzed separately, Moses was afflicted by speech and language impediments that could be related to his adoption. The biblical text states that his biological mother attempted to save her child’s life from the cruel decree of Pharaoh to kill all newborn Jewish males, by putting him into a crib among the reeds on the banks of the Nile. Fortunately, Moses was saved when Pharaoh’s daughter adopted him. In addition, baby Moses was lucky since his biological

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mother suckled him even after his adoption. This factor had a positive effect on the child’s development and provided Moses with the selfconfidence he needed in his entire life. Yet in spite of this confidence, Moses suffered from some speech and language impediment (45). Assessment: adopted children may develop gross motor impediment, fine motor delay, speech and language delays, and learning and school adjustment problems. Moses, the first adopted child, to be described in the Bible, was a great leader who lives in the hearts of Jewish people. Based on what is written in the Bible, with no interpretation, we can say that Moses suffered from an impediment of speech and language that can be linked to his adoption. Other significant physical or psychological problems were not detected in Moses. In spite of his speech and language impediment, Moses left a remarkable mark on Jewish history, taking the Jewish people from the slavery to freedom. References 1. Okun BF, Andersen CM. Understanding diverse families. What practitioners need to know. New York: Guilford Press. 1996, p. 376. 2. Community Paediatrics Committee, Canadian Paediatric Society. Position Statements. Understanding adoption: a developmental approach. Pediatrics & Health. 2001;6:281-3. 3. Kim SP. Adoption. In Kaplan HI and Sadock BJ (eds). Comprehensive Textbook of Psychiatry, Vol 2, Fourth ed. Baltimore, London: Williams & Wilkins. 1995, pp. 1829-31. 4. Johnson DE, Albers L, Iverson S, et al. Health status of eastern European (EE) orphans referred for adoption. Pediatric Res. 1996;39:790. 5. Johnson DE. The family physician and international adoption. Am Fam Physician. 1998;58:1958-63. 6. Gracey M. The challenges of fostering infants and children. Acta Paediatr. 2003;92:787-9. 7. Sarkar NR, Biswas KB, Khatun UHF, Datta AK. Characteristics of young foster children in the urban slums of Bangladesh. Acta Paediatr. 2003;92:839-42. 8. Almgren G, Marcenko MO. Emergency care use among a foster care sample: the influence of placement history, chronic illness, psychiatric diagnosis, and care factors. Brief Treatment Crisis Intervention. 2001;1:5564. 9. Stoval KC, Dozier M. The development of attachment in new relationships: Single subject analyses for 10 foster infants. Dev Psychopathol. 2000;12:133-56.

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10. Johnson DE, Miller LC, Iverson S, et al. The health of children adopted from Romania. JAMA. 1992;268:3446-51. 11. Albers LH, Johnson DE, Hostetter MK, et al. Health of children adopted from the former Soviet Union and Eastern Europe. Comparison with preadoptive medical records. JAMA. 1997; 278:922-4. 12. Blizzard RM. Psychosocial short stature. In: Lifshitz F, ed. Pediatric Endocrinology. New York, NY, Marcel Dekker Inc. 1990, pp. 77-91. 13. Powell GF. Failure to thrive. In: Pediatric Endocrinology. New York, NY, Marcel Dekker Inc. 1990, pp. 133-46. 14. Jenista JA, Chapman D. Medical problems of foreign-born adopted children. Am J Dis Child. 1987;141:298-302. 15. Adoption Support & Preservation. Accessed 11 January 2008 at http://www.nacac.org/ postadoptionservices.htm. 16. Johnson DE, Albers L, Iverson S, et al. Health status of eastern European (EE) orphans. Pediatric Res. 1996;39:790. 17. Hostetter MK, Iverson S, Thomas W et al. Medical evaluation of internationally adopted children. N Engl J Med. 1991;325:479-85. 18. Quarles C, Brodie J. Primary care of international adoptees. Am Fam Physician. 1998. Accessed 15 January 2007 at http://www.aafp.org/afp /981200ap/quarles.htm. 19. Mitchell MA, Jenista JA. Health care of internationally adopted child. Part 2. Chronic care long-term medical issues. J Pediatr Health Care. 1997;11:117-26. 20. Hobbs GF, Hobbs CL. Abuse of children in foster and residential care. Child Abuse Neglect. 1999;23:1239-52. 21. Moffat ME, Peddie M, Stulginskas J, et al. Health care delivery to foster children: a study. Health Soc Work. 1985;10:129-37. 22. Simms MD. The foster care clinic: a community program to identify treatment needs of children in foster care. J Dev Behav Pediatr. 1989;10:121-8. 23. Dubowitz H, Feigelman S, Zuravin S, et al. The physical health of children in kinship care. Am J Dis Child. 1992;146:603-10. 24. Simms MD, Halfon N. The health care needs of children in foster care: a research agenda. Child Welfare. 1994;73:505-24. 25. Morrison SJ, Ames EW, Chisholm K. The development of children adopted from Romanian Orphanages. Merril Palmer Q. 1995;41:411-30. 26. Rutter M, the English and Romanian Adoptee Study Team: Developmental catch-up and delay following adoption after severe global early privation. J Child Psychol Psychiatry. 1998;39:465-76. 27. Becket C, Bredenkamp D, Castle J, et al. Behavior patterns associated with institutional deprivation: a study of children adopted from Romania. J Dev Behav Pediatr. 2002; 23:297-303. 28. Stein MT. Challenging case. International adoption: a four-year-old child with unusual behaviors adopted at six months of age. J Dev Behav Pediatr. 2003;24:69.

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29. Weitzman C, Albers L. Long-term developmental, behavioral, and attachment outcomes after international adoption. Pediatr Clin North Am. 2005;52:1395-419, viii. 30. Loman MM, Wiik KL, Frenn KA, et al. Postinstitutionalized children's development: growth, cognitive, and language outcomes. J Dev Behav Pediatr. 2009;30:426-34. 31. Miller LC, Chan W, Litvinova A, et al. Medical diagnoses and growth of children residing in Russian orphanages. Acta Paediatr. 2007;96:1765-9. 32. Hellerstedt WL, Madsen NJ, Gunnar MR, et al. The International adoption project: population-based surveillance of Minnesota parents who adopted children internationally. Maternal Child Heart J. 2008;12:162-71. 33. Johnson DE, Guthrie D, Smyke AT, et al. Growth and associations between auxology, caregiving environment, and cognition in socially deprived Romanian children randomized to foster vs. ongoing institutional care. Arch Pediatr Adolesc Med. 2010;164:507-16. 34. van den Dries L, Juffer F, van Ijzendoorn MH, BakermansKranenburg MJ. Infants' physical and cognitive development after international adoption from foster care or institutions in China. J Dev Behav Pediatr. 2010;31:144-50 35. Cohen NJ, Lojkasek M, Zadeh ZY, et al. Children adopted from China: a prospective study of their growth and development. J Child Psychol Psychiatry. 2008;49:458-68. 36. Miller L, Chan W, Comfort K, Tirella L. Health of children adopted from Guatemala: comparison of orphanage and foster care. Pediatrics. 2005;115(6):e710-7. 37. Miller LC, Tseng B7, Tirella LG, et al. Health of children adopted from Ethiopia. Maternal Child Health J. 2008;12:599-605. 38. Proos LA. Growth & development of Indian children adopted in Sweden. Indian J Med Res. 2009;130:646-50. 39. Fries AB, Pollak SD. Emotion understanding in postinstitutionalized Eastern European children. Dev Psychopatol. 2004;16:355-69. 40. Dubrovina I. Psychological Development of Children in Orphanages. Moscow: Prosvechenic Press. 1991. 41. Groze V, Ileana D. A follow-up study of adopted children from Romania. Child Adoles Soc Work. 1996;13: 541-65. 42. Beckett C, Bredenkamp D, Castle J, et al. Behavior patterns associated with institutional deprivation: a study of children adopted from Romania. J Dev Behav Pediatr. 2002; 23:297-303. 43. Suwalsky JT, Hendricks C, Bornstein MH. Families by adoption and birth: II. Mother-infant cognitive interactions. Adop Q. 2008;11:126. 44. van Ijzendoorn MH, Juffer F, Poelhuis CW. Adoption and cognitive development: a meta-analytic comparison of adopted and nonadopted children's IQ and school performance. Psychol Bull. 2005;131:301-16. 45. Ben-Noun L. Speech Disorder in biblical times- Moses: A heavy mouth and a heavy tongue”. Harefuah.1999;136:906-8.

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ESTHER Esther left a remarkable mark on the Jewish history. This section therefore deals with an extraordinary woman who saved the Jewry from the destruction.

A Biblical Story This is the story of King Ahashverosh, who reigned in Persia and Midia. One day the King made a great feast in his kingdom, and invited his beautiful wife, Queen Vashti to attend the feast, but she refused. For this unacceptable, disobedient behavior Queen Vashti was punished by dismissal and a new queen was sought in the kingdom: “Now in Shushan the capital there was a certain Jew, whose name was Mordekhay...” (Esther 2:5). Mordekhay brought his beautiful adopted daughter Esther to the King’s house “And he (Mordekhay) brought up Hadassa, that is, Esther, his uncle’s daughter: for she had neither father nor mother, and the girl was fair and beautiful; and when her father and mother were dead Mordekhay took her for his own daughter” (2:7). Among all the young women brought to the King, he fell in love with Esther “... the king loved Esther more than all the women, and she obtained grace and favour in his sight more than all the virgins; so that he set the royal crown upon her head, and made her queen instead of Vashti” (2:17). Here Esther entered a new family system, this time as Queen.

Esther before Achasveros. Giovanni Andrea Sirani.

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Later the King promoted Haman “...and set his seat above all the princes who were with him” (3:1). Now all the King’s servants, with the King’s consent, bowed, and showed obeisance to Haman, all except proud Mordekhay. So Haman began to hate Mordekhay, expanding his hatred to all the Jews living in the country. Haman convinced the King that the Jews should be killed, and the King sent the decree to all over the country “And the letters were sent by couriers to all the king’s provinces, to destroy, to kill, and to annihilate, all Jews, both young and old, little children and women, ..” (3:13). This was a real tragedy. Esther, who knew about the impending tragedy orchestrated by Haman, invited the King and Haman to her banquet “So, the king and Haman came to drink with Esther the queen” (7:1). Now Esther revealed her real status, that she was a Jew “..we are sold, I and my people, to be destroyed, to be slain, and to perish...” (7:4). She announced convincingly “...The adversary and enemy is this wicked Haman. Then Haman was afraid before the king and the queen” (7:6). He tried to beg forgiveness from the Queen “..Haman was fallen upon the divan whereon Eshter lay. Then the king said, Will he even assault the queen in my own presence in the house?” (7:8). The King believed that Haman’s behavior was a sexual assault on the Queen and he ordered that Haman be hanged on the same tree that he prepared for Mordekhay. The Jews’ enemy, Haman, was eliminated and the Jews were saved from death.

Reasons for Adoption As previously described, there are numerous reasons for adoption. In Esther’s case, adoption was related to the death of her biological parents. When her parents died, her nuclear family disintegrated. Fortunately, her uncle Mordekhay, took responsibility and raised Esther as his own daughter.

Physical and Psychological Problems Although children in foster care may suffer from various physical and mental health problems (1-3), many of them respond well to a loving new family environment, improved nutrition, and medical and developmental intervention (4). A current study used data from a large, representative sample in the United States to examine whether adopted children are more likely to have had mental health contacts or emotional or behavioral problems than nonadopted children. Age of placement in the adoptive home was

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examined as a variable contributing to the adjustment of adopted children. Adopted and foster children were more likely to have mental health contacts than nonadopted children. Results were mixed regarding whether adopted and foster children had more behavior problems than nonadopted children did. However, significant differences between adopted, foster, and nonadopted children disappeared when a small group of influential cases was removed. This suggested that the differences between the groups reflected a small number of cases that were not representative of the groups of adoptees and foster children as a whole. The vast majority of adopted children showed patterns of behavior problems similar to nonadopted children (5). The correlates of parent-reported and teacher-reported problem behavior in 7-year-old internationally adopted children (n=176) were investigated by examining these children's ego resiliency, ego control, and sociometric status, and exploring possible risks factors in the home and racial influences. Using the 25th percentiles lowest and highest scores on ego resiliency and ego control as cut-off criteria was found: (1) resilient children were almost free of behavior problems; (2) over controlled children showed predominantly internalizing behavior problems (33% at school, and 28% at home); (3) under controlled children showed high rates of externalizing behavior problems (50% at school, and 34% at home), and an elevated rate of comorbidity (21% at school, and 21% at home). Adopted children identified by peer report as controversial or rejected had significantly higher externalizing problem scores than popular, averaged or neglected adopted children. The adopted children did not experience much (racial) discrimination. Nevertheless, children who wished to be white (46%) presented more mother-reported behavior problems (6). The objectives of this study were (i) to describe and compare the epidemiology of emotional/behavioral problems and associated risk/protective factors among nationally representative samples of institutionally reared and similarly aged community-based adolescents brought up in their natural homes by means of YSRs, caregiver/parent, and teacher informants; and (ii) to identify mental health service needs and utilization. A cross-sectional survey was conducted, between November 2005 through April 2006, using an equal probability cluster sample of 11-18-year-old adolescents in institutional care settings (n=350; 163 males, 187 females) and results were compared with similarly aged community sample of youth living in their natural homes (n=2.206). The prevalence of problems behaviors by YSR, caregiver/parent CBCL, and TRF were: 47%, 15.1%, 20.5% for the

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institutional vs. 10.1%, 7.5% and, 9.5% for the community samples, respectively (p 10 million primary care office visits per year (a rate of 13.8 visits per 100 person-years). The most common diagnoses assigned to these injuries were open wounds, sprains and strains, contusions, and superficial injuries such as abrasions and splinters. Leading external causes of these injuries were sports and overexertion, accidental falls, natural factors such as bites and stings, and cutting instruments. The single most common cause of pediatric injuries was sports/overexertion. Children who had IRVs were more likely to be older (OR 1.10/year of age, 95% CI 1.08-1.12), to be male (OR 1.5, 95% CI 1.2-1.9), and to

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reside in the West (OR 1.9, 95% CI 1.4-2.6), or in a rural area (OR 1.4, 95% CI 1.1-1.9). They were less likely to be Asians (OR 0.2, 95% CI 0.1-0.5) or Hispanics (OR 0.5, 95% CI 0.3-0.8). At the visit, children with IRVs were more likely to see a physician who was not their primary care physician (OR 1.8, 95% CI 1.4-2.3), and to see a family physician rather than a pediatrician (OR 2.3, 95% CI 1.82.9) (4). The main objective of this study was to identify risk factors for unintentional injuries due to falls in children aged 0-6 years. Electronic databases from 1966 to March 2005 were comprehensively searched to identify empirical research that evaluated risk factors for unintentional injuries due to falls in children aged 0-6 years and included a comparison group. Studies (n=14) met the inclusion criteria. Studies varied by the type of fall injury that was considered (i.e., bunk bed, stairway, playground or infant walker) and with respect to the quality of evidence. In general, major risk factors for the incidence or severity of injuries due to falls in children included age of the child, sex, height of the fall, type of surface, mechanism (dropped, stairway or using a walker), setting (day care vs. home care) and socioeconomic status. Despite a high burden, few controlled studies have examined the risk and protective factors for injuries due to falls in children aged 0-6 years. The only study to examine falls from a population health perspective suggests that age, sex and poverty are independent risk factors for injuries due to falls in children (5). Hospital discharge data and death certificate data for California residents aged 0 to 19 years with a principal external cause of injury code (E-code) of E800 to E869, E880 to E929, or E950 to E999, calendar year 1997, were analyzed. Annual rates of injury hospitalization/death by year of age were calculated using combined hospital discharges and deaths as the numerator for major causes and important subcategories. For comparison, rates of injury hospitalization/death were calculated for conventional vital statistics age groups: