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REFERENCES

1. Nash TE, Herrington DA, Losonsky GA, Levine MM. Experimental human infections with Giardia lamblia. J Infect Dis 1987;156:974-84. 2. Shaw RA, Stevens MB. The reactive arthritis of giardiasis. JAMA 1987;258:2734-5. 3. Woo P, Panayi GS. Reactive arthritis due to infestation with Giardia lamblia [Letter ]. J Rheumatol 1984;11:719. 4. Goobar JR. Joint symptoms in giardiasis. Lancet 1977;2: 1010-1. 5. Hamriek H J, Moore GW. Giardiasis causing urticaria in a child. Am J Dis Child 1983;137:761-3. 6. Knox DL, King J Jr. Retinal arteritis, iridoeyclitis, and giardiasis. Ophthalmology 1982;89:1303-8. 7. Giordano N, Fioravanti A, Mariani A, Marcolongo R. Erythema nodosum and Giardia intestinalis. Clin Rheumatol 1985;4:481-3. 8. Roberts-Thomson IC, Anders RF, Bhathal PS. Granuloma-

9. 10. 11. 12.

13. 14.

tous hepatitis and cholangitis associated with giardiasis. Gastroenterology 1982;83:480-3. Drew JH. Biliary giardiasis and pancreatitis. Med J Aust 1981;1:196-7. Bassett ML, Danta G, Cook TA. Giardiasis and peripheral neuropathy. BMJ 1978;2:19. Farthing MJG. Host-parasite interactions in human giardiasis. Q J Med 1989;70:191-204. Ament ME, Oehs HD, Davis SD. Structure and function of the gastrointestinal tract in primary immunodeficiency syndromes: a study of 39 patients. Medicine 1973;52:227-48. Isaac-Renton JL. Giardiasis: a review. B.C. Medical Journal 1987;29:341-4. Kamath KR, Murugasu R. A comparative study of four methods for detecting Giardia lamblia in children with diarrheal disease and malabsorbtion. Gastroenterology 1974;66:1621.

Antecedents of child neglect in the first two years of life Robert M. Brayden, MD, William A. A l t e m e i e r , MD, Dorothy D. Tucker, Mary S. Dietrich, MS, a n d Peter Vietze, PhD From the Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, and the New York State Institute for Basic Research in Developmental Disabilities, Staten Island To determine the prenatal antecedents of child neglect by low-income women, data from a prospective study of child maltreatment were reviewed. Mothers determined to be at high risk prenatally for maltreatment were more likely to be identified as neglectful within 24 months of the interview, Neglectful mothers were less likely to have completed high school, had more children younger than 6 years of age, and had more aberrant responses on parenting skills and support systems scales. Neglected children were lower in birth weight, were rated more difficult temperamentally, and had poorer mental and motor developmental scores. (J PEDIATR1992;120:426-9) Child neglect is the failure of a caretaker to provide for child health, nutrition, shelter, education, supervision, affection or attention, and protection. 1 Neglect is common, and its Supported by the National Center on Child Abuse and Neglect; the Children's Bureau Administration on Children, Youth, and Families; the Office of Human Development Services, Department of Health, Education, and Welfare (grants 90-C-419 and 90-CA2138); and the National Institute of Mental Health (grant R01 MH31195-01). Submitted for publication Aug. 2, 1991; accepted Oct. 25, 1991: Reprint requests: Robert M. Brayden, MD, Department of Pediatrics, Metropolitan Nashville General Hospital, 72 Hermitage Ave., Nashville, TN 37210. 9/22/34608

causes, treatment, and prevention are complex. 2 Previous authors have linked poverty, l, 3 detachment from social networks, 4 residential transience, 4 substance abuse, 5 and undesired parenthood 6 with child neglect. Previous reports have indicated that an increased risk of physical abuse could be predicted and that nonorganic failure to thrive had associations with antenatal and perinatal events. 7, 8 The results of retrospective studies of child maltreatment may be biased by the effects of identification and investigation of the episode. Data from a prospective study were therefore analyzed to identify parental and childhood variables preceding, and thus predictive of risk for, child neglect. Analyses were conducted (1) to determine whether child neglect after delivery could be predicted during preg-

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nancy and (2) to describe a profile of characteristics of expectant mothers who were later considered neglectful of children. We hypothesized that at-risk women would be at an increased risk for neglect, that a self-report of poor maternal childhood nurturance would be associated with future child neglect, and that the predictive capability of the entry interview would be time limited. METHODS Subjects, All women registering for prenatal care at an u r b a n hospital for indigent persons between September 1975 and December 1976 were asked to participate, s Of HR MHI NHR

High risk Maternal History Interview Not high risk

1499 women, 99 (6.6%) refused to participate; the remaining 1400 women gave informed consent. The project was approved by the Vanderbilt Committee for the Protection of Human Subjects. Procedures. At study entry, demographic information was collected and the Maternal History Interview was administered. The following eight subscales were derived from the MHI: maternal nurture, parenting skills, social support, maternal personality and self-image, health stresses, pregnancy attitude, knowledge of developmental norms, and family stresses. The subscale scores were used to predict those women at high risk for child maltreatment. 9 Additionally, interviewers were asked to record any concern that they thought indicated risk of subsequent child maltreatment. Recording of a concern was also a means of HR designation. A total of 273 of the women (20%) were considered at HR for child maltreatment on the basis of these criteria; complete data were available on 255 of these women. The 1121 mothers who were not at high risk and on whom complete data were available constituted the comparison group. Two hundred fifty-five infants of H R mothers and 225 infants randomly selected from the N H R group composed the "followed" group. Project contacts with these mothers were made at 28 weeks of gestation, at birth, and when the infants were 1, 3, 6, 9, 12, and 18 months of age. I r a mother could not be contacted for three consecutive data points, she was considered "lost" to follow-up. Attrition from the study was primarily due to maternal transience. Few mothers who were located refused to complete the study measures. All project contacts were for the purpose of data collection; no intervention was intended. Neonatal and infant measures. Apgar scores, birth weight, and the presence of congenital anomalies were determined for followed infants. The Brazelton Neonatal Behavioral

427

T a b l e I. MHI subscale t ratios for neglectful and non-neglectful mothers Scale

Nurture Parenting skills Support Maternal personality and self-image Health stresses Pregnancy attitude Knowledge of developmental norms Family stresses Maternal Paternal

t Ratio (df)

p

1.749 (1374) 0.081" 2.291 (1374) 0.022* 1.947 (1374) 0.052* 0.955 (1374) NS 1.125 (1374) NS 1.081 (1374) NS 1.279(1372) NS 1.721 (1373) 0.085* 0.712 (1369) NS

df, Degreesof freedom;NS, not significant. *Neglect group scores are less optimalcomparedwith nonneglectgroup.

Assessment Scale was administered in the hospital by examiners trained and certified in psychology to 300 of these target infants at 24 to 48 hours of age. Six months after delivery, 160 of the mothers completed the Carey Infant Temperament Questionnaire. At 9 months of age, 132 infants were assessed by the Bayley Scales of Infant Development. Neglect. State and local records were searched for reports of suspected neglect when target children were between 21 and 48 months of age. 8 Information from agency reports was abstracted and rated for evidence of neglect. Reports rated as without compelling evidence or as fallacious were not included. Types of neglect included abandonment, leaving the child with an inappropriate caretaker, deprivation of environmental stimuli, and gross failure to obtain medical care, prevent injury, or protect the child from the elements. Analyses for this report were limited to those involving target children--those with whom the mothers were pregnant at the time of the interview. Children who were reportedly physically or sexually abused in addition to being neglected were included. RESULTS State and local records contained 62 neglect reports with substantive information involving the target child. Target children were a mean age of 12.4 months at the time a neglect report was made. More than 2 years after the interview, the percentage of women in the HR group reported for neglect (1.7%) did not differ from the percentage of neglect reports in the N H R group (1.1%; chi-square 0.67; p >0.10). Because of the inability to predict neglect risk more than 2 years after the interview, all of the following analyses were conducted on the 46 neglected target children whose reports were made during the 24-month period after the interview.

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T a b l e II. Postpartum data for neglectful and nonneglectful mothers

tors (Table II). Of the neglecting mothers, 54% rated their children in the most difficult temperament group, compared with 17% of the nonneglecting mothers. In comparison with nonneglecting mothers, the neglecting mothers also rated their infants' response to stress as less optimal. The Bayley Scales of Infant Development at 9 months revealed significant differences in Mental and Motor scale scores between neglected and nonneglected children (Table I1). The mean Mental scale score of the group that had been or would be neglected was 98.2; it was 116.5 for the nonneglected group. Children who were neglected had Motor scale scores of 82.5 compared with 104.9 for the nonneglected group. Of the 46 neglecting mothers, 7 (15%) had children who were victims of physical abuse, compared with 22 (2%) of 1330 mothers in the nonneglecting group (chi-square 39.6 [df = 1]; p <0.001 ). Neglecting mothers were presumably more likely to have been under closer observation by medical and social work providers, and were thus more likely to be identified as physical abusers.

Chi-square

t Ratio

(df)

(df)

p

Infant Temperament Questionnaire (n = 160) Global score (hard-easy) 10.08 (3) -0.018" Subscale scores Social and potentially 0.72 (2) -NS social Tone/motor control 0.10 (2) -NS State/organizational 0.38 (2) -NS process Stress/organizational 5.80 (1) -0.016" process Liability/organizational 1.81 (1) -NS process Bayley Scales of Infant Development (n = 132) Mental scale -3.30 (130) 0.001"~ Motor scale -3.78 (130) <0.001I" df, Degreesof freedom;NS, not significant. *Neglectedchildrenrated moredifficult,with poorerorganizationto stress. ]'Neglectedchildrenhave lowerdevelopmentalachievement.

During this interval, 20 (7.8%) of 255 HR mothers, compared with 26 (2.3%) of 1121 N H R mothers, were reported for neglect of target children (odds ratio 3.58; 95% confidence interval 2.0 to 6.5). The sensitivity of the M H I for predicting neglect within the first 2 years was 43%. Eventual neglectors had poorer scores on the Parenting Skills subscale of the M H I and reported social support as less adequate (Table I)~ No individual questions on the M H I distinguished neglectors from nonneglectors at a p value <0.01. Neither alcohol or drug problems i n t h e family, nor undesired pregnancy, nor parental imprisonment within the past 12 months differentiated neglectors from nonneglectors. Of the neglecting mothers, 11% had completed high school at study entry compared with 32% of nonneglecting mothers (p <0.01). Neglectors also had a mean of 0.83 other children less than 6 years of age compared with a mean of 0.57 other children for nonneglectors (p <0.05). Maternal age, race, marital status, and number of household moves were not significantly different between the groups. Infants who would be neglected had mean birth weights of 2945 gm compared with 3212 gm for nonneglected infants (p <0.05). No differences were found between the groups in Apgar scores, pregnancy complications, congenital anomalies, or Brazelton Neonatal Behavioral Assessment Scale scores. Carey Infant Temperament Questionnaires were col= lected on 11 of the 46 neglecting mothers and 149 of the remaining 487 mothers without neglect reports. Global scores indicated that neglecting mothers rated their infants significantly more difficult temperamentally than did nonneglec-

DISCUSSION Child neglect has received less research attention than physical or sexual abuse, and yet it continues to be a leading form of child maltreatment) Therefore it is important to identify conditions that are predictive of neglect. Prenatal maternal perception of lower levels of social support was associated with increased risk of child neglect, consistent with reports of other authors. 4, lo The association of maternal education with neglect, however, has received little attention.i~ We found an inverse relationship between years of education completed and neglect. Neglect may be prevented directly by learning parenting skills in the schools, or a parent-to-be may acquire skills needed for school attendance that also enable her to nurture her child (e.g., prepare breakfast, wash clothes, organize daily work). Education likely enhances employability, fostering financial stability and thus availability of material resources. The decrease in the birth weight of children who would be neglected suggests that some neglect is initiated prenatally. Whether neglecting mothers' descriptions of difficult temperament reflect maternal misperception, dyadic effects on infant behavior, or accurate differences in biologically mediated behavior is unknown. Lower developmental achievement in the neglected child suggests not only a lack of environmental stimulation but also the opportunity to provide effective developmental intervention. Genetic influences mediating both motor and mental development, however, cannot be ruled out as a cause of the poorer development in the neglected group. The predictive validity of data on child neglect decreased after 2 years, similar to the results reported for physical

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abuse. 9 We speculate that maternal lifestyles, resources, and stresses gradually change with time, modifying the risk of neglect in both Positive and negative directions. Alternatively, the MHI may detect risk of neglect of infants but be insensitive to the antecedent conditions of neglect of children after 2 years of age. The strengths of this study include its prospective method and the blinded protocol for assessment of neglect. These data are, however, more than 10 years old. During this time some conditions that may influence parenting (e.g., illicit drug use patterns) have changed, thus making these findings somewhat less pertinent. Despite extensive efforts to keep mothers in the study, the inability to retain more than two thirds of the participants requires that the results be viewed as preliminary. Many of the findings, however, appear to remain relevant.

REFERENCES

1. Wolock I, Horowitz B. Child maltreatment as a social problem: the neglectof neglect.Am J Orthopsychiatry 1984;54:53043.

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2. Starr RH, Dubowitz H, Bush BA. The epidemiology of child maltreatment. In: Ammerman RT, Hersen M, eds. Children at risk: an evaluationof factors contributing to child abuse and neglect. New York: Plenum Press, 1990:23-53. 3. Pelton LH. Child abuse and neglect: the myth of classlessness. Am J Orthopsyehiatry 1978;48:608-17. 4. PolanskyNA, Gaudin JM, Ammons PW, Davis KB. The psychological ecologyof the neglectful mother. Child Abuse Negl 1985;9:265-75. 5. Pavenstedt E. An intervention program for infants from highrisk homes. Am J Public Health 1973;63:393-5. 6. Watters J, Parry R, Caplan PJ, et al. A comparison of child abuse and neglect. Canadian Journal of Behavioural Science 1986;18:449-59. 7. Altemeier WA, O'Connor SM, Sherrod KB, Vietze PM. Prospective study of antecedents for nonorganic failure to thrive. J PEDIATR1985;106:360-5. 8. Altemeier WA, O'Connor SM, Vietze PM, Sandler HM, Sherrod KB. Antecedents of child abuse. J PEDIATR 1982; 100:823-9. 9. Altemeier WA, O'Connor SM, Vietze PM, Sandler HM, Sherrod KB. Prediction of child abuse: a prospective study of feasibility. Child Abuse Negl 1984;8:393-400. 10. Egeland B, Brunnquell D. An at-risk approach to the study of child abuse: some preliminary findings. J Am Acad Child Adolesc Psychiatry 1979;18:219-36.

Systemic lupus erythematosus in a child receiving long-term interferon therapy A s a d T o l a y m a t , MD, Brigid L e v e n t h a l , MD, A b d u l l a h S a k a r c a n , MD, Haskins Kashima, MD, a n d C a r m e l a Monteiro, MD From the Departments of Pediatrics and Pathology, Universityof Florida Health Science Center, Jacksonville, and the Departments of Oncology, Pediatrics, and Otolaryngology, Head and Neck Surgery, Johns Hopkins University,Baltimore, Maryland

Systemic lupus erythematosus (SLE) d e v e l o p e d in a 101~-year-old white boy with juvenile laryngeal papillomatosis who had been treated with interferon alfa-nl for 7 years. His age, gender, and fast recovery after discontinuation of interferon therapy and institution of appropriate treatment for SLE are compatible with a diagnosis of drug-induced SLE. Autoimmune disorders may occur as a complication of interferon therapy. (J PEDIATR1992;120:429-32) Interferon alfa has been used to treat viral diseases such as juvenile laryngeal papillomatosis and genital condylomatosis, and to treat some cancers), 2 Previously reported side effects included fever, chills, fatigue, anorexia, myalgia, nausea, vomiting, headache, dose-dependent reversible leuSubmitted for publication May 31, 1991; accepted Sept. 20, 1991. Reprint requests: Asad Tolaymat, MD, Department of Pediatrics, University of Florida Health Science Center, 653 West 8th St., Bldg. No. 1, Jacksonville, FL 32209. 9/22/33867

kopenia, and hepatic transaminase elevations. Proteinuria and acute interstitial nephritis with nephrotic syndrome have been reported in association with interferon (alfa and gamma) therapy. 3, 4 A syndrome similar to systemic lupus erythematosus developed in the patient who is the subject of this case report while he was being treated with interferon alfa for juvenile laryngeal papillomatosis. CASE REPORT Laryngeal papillomatosiswas diagnosed in a 12-year-oldwhite boy when he was 9 months of age. The family history is unknown;