The use of primary/national school absenteeism as a proxy retrospective child health status measure in an environmental pollution investigation

As a result of community concerns over animal and human ill health centred around a rural town in the Republic of Ireland, a series of epidemiological studies were conducted. The absence of adequate health-information systems forced researchers to investigate alternative methods of assessing child health in the 'at-risk' area. This study aimed to examine annual primary/national school attendance data over a 10 year period as a proxy health status measure. Data from six geographical areas were analysed; one of these six areas was designated the 'high-risk' area on the basis of reports of animal ill health. Significantly higher absenteeism rates were noted in the 'high-risk' area in nine of the 10 years examined. Although caution is urged in the interpretation of these results, this study demonstrates that primary/national school absenteeism data can act as a useful, albeit crude, proxy measure of health status.

Dead cattle, lead and child health

This study was carried out as part of a larger interagency investigation in response to concerns about human health following the death of three cattle from lead poisoning in an old lead mining area in Silvermines, Tipperary. Its aim was to screen for lead toxicity in the local child population. Screening consisted of measurement of blood lead concentrations and the completion of questionnaires regarding exposure to lead and general health. Pre-school and primary school children resident in four surrounding district electoral divisions (DEDs) were specifically targeted. One out of 334 (0.3%) children screened had an elevated blood lead concentration. The geometric mean lead concentration was 2.6 microg/dl which is below the intervention lead concentration of 10 microg/dl recommended by the CDC. The mean lead concentration in those aged under three years was statistically significantly higher than in those aged three years and over (3.4 microg/dl vs 2.5 microg/dl; p=0.000581). No specific health problems were identified by the questionnaires. This study concluded that the elevated environmental lead levels which were demonstrated by other agencies involved in this investigation are not currently being transferred to children. It recommends further blood screening of children in the area and ongoing education to minimise the risk of lead toxicity in the area in the future.

Functional limitations of school-aged children seen in primary care

OBJECTIVE

The purpose of the present study was to assess the prevalence of functional limitations in children seen in a large paediatric practice network and to identify sociodemographic, family and psychosocial factors related to functional limitations.

STUDY DESIGN

Cross-sectional analysis.

POPULATION

Children were recruited from two large, practice-based primary care research networks during their paediatric office visits. For the present study, participants included 14 630 school-aged children (ages 6-15 years) and their caregivers.

OUTCOMES MEASURED

Parents completed written questionnaires including the Pediatric Symptom Checklist, the Family Apgar and the Functional Limitations Index.

RESULTS

Findings indicated that 15% of children surveyed had some limitation in their daily functioning. More children had schoolwork and physical function limitations than limitations in personal and self-care. Logistic regression equations predicted functional limitations and health status in children from a model of sociodemographic factors, psychosocial symptoms and family functioning.

CONCLUSIONS

A low but significant number of school-age children seen in the primary care setting experience functional limitations. Children with any psychosocial symptoms were at increased risk for functional limitations, indicating the critical need to screen for functional impairment in children with suspected behavioural or emotional problems. A screening tool of functional limitations may be useful for assessing the presence or absence of such limitations in children's daily function and warrants further investigation.

Monitoring and enforcing cultural competence in Medicaid managed behavioral health care

In recent years cultural competence has expanded beyond language provisions to include understanding and factoring into services provision the cultural perspectives clients may have that are different from the majority culture. The federal government requires state Medicaid programs to offer culturally competent services, but little is known about how states implement such mandates and monitor and enforce them. We reviewed the origins and implications of cultural competence mandates and conducted a brief case study of 5 states to learn about the implementation of cultural competence provisions in behavioral managed care contracts. We found that states and managed behavioral health organizations (MBHOs) vary in their definitions and implementation of standards to ensure mental health care access for vulnerable populations. Although states had a variety of oversight mechanisms, varying contractual requirements ranging from optional to required, vague contract language, no existing standardized indicators or definitions, and scant data on the cultural characteristics of the populations enrolled in Medicaid managed care hamper monitoring and enforcement of cultural competence by states. Implications for MBHOs, states, and the federal government, as well as services researchers, follow.

Physician gender and psychosocial care for children: attitudes, practice characteristics, identification, and treatment

OBJECTIVE

To examine differences by physician gender in the identification and treatment of childhood psychosocial problems.

DESIGN

Survey of patients (n = 19,963) and physicians (n = 366) in primary care offices in 2 large, practice-based research networks. Multivariate regressions were used to control for patient, physician, and visit characteristics, with a correction for the clustered sample.

SUBJECTS

Children ages 4 to 15 years seen consecutively for nonemergent care.

MEASURES

Physician report of attitudes, training, practice factors, and identification and treatment of psychosocial problems. Parental report of demographics and behavioral symptoms.

RESULTS

Compared with male physicians, female physicians were less likely to view care for psychosocial problems as burdensome. They were more likely to see children who were female, younger, black or Hispanic, in single-parent households, enrolled in public or managed health plans, and with physical health limitations. Children seen by male physicians had higher symptom counts. Male physicians were more likely to report having primary care responsibility for their patient and that parents agree with their care plan. Female physicians spent more time with patients. After controlling for these differences, female physicians did not differ from male physicians in identification or treatment of childhood psychosocial problems.

CONCLUSIONS

Male and female physicians see different kinds of children for different visit purposes and have different kinds of relationships with their patients. After controlling for these factors, management of childhood psychosocial problems does not differ by physician gender. Improving management of psychosocial conditions depends on identifying modifiable factors that affect diagnosis and treatment; our work suggests that characteristics of the practice environment, physician-patient relationship, and patient self-selection deserve more research.

A case of haemophagocytic syndrome and Kikuchi-Fujimoto disease occurring concurrently in a 17-year-old female

An unusual case in which a young Asian female presenting with fever, lymphadenopathy and cytopaenia was found to have distinct histological features of both haemophagocytic syndrome (HS) and histiocytic necrotising lymphadenitis (Kikuchi-Fujimoto disease, KFD) is presented. We review the clinical features of each of these rare, but important, diagnoses and propose the hypothesis that they may form part of a disease continuum, rather than representing separate entities.

Prospective study of displaced children's symptoms in wartime Bosnia

BACKGROUND

This study examines the psychological symptoms of Bosnian children exposed to war and trauma, and detects changes in these symptoms over time.

METHOD

A total of 147 displaced children residing in refugee centers in Bosnia completed self-report assessments of anxiety, depressive, and posttraumatic stress symptoms at two time points.

RESULTS

Symptoms of posttraumatic stress, anxiety, and depression showed a greater decrease in boys relative to girls over time.

CONCLUSION

Gender may be an important factor in the natural course of trauma-related symptoms among war traumatized children. Further research is needed to better understand the psychological effects of war trauma on children, and the natural course of posttraumatic symptoms, so as to improve interventions targeted to this vulnerable population.

Sex differences in anterior commissure size in the rat

Earlier studies have shown that the corpus callosum of rats tends to be larger in males than in females. We report here that the anterior commissure of rats is also larger in males than in females. The sizes of the two commissures were positively correlated in both sexes, but significantly more so in females than in males. The anterior commissure size difference in rats reported here is opposite in direction from that reported elsewhere for humans, and we speculate that this may derive from differences in the relative proportions of the constituent fibers that make up the anterior commissure in the two species.

The family APGAR and psychosocial problems in children: a report from ASPN and PROS

BACKGROUND

Our study examined whether the lack of social support as measured by the Family APGAR was related to parents' and physicians' identification of child psychosocial problems and sociodemographic and symptom characteristics of the children screened.

METHODS

The parents of 9626 children, ages 4 to 15 years, seen for outpatient medical visits participated in this national study. Parents completed the Family APGAR and the Pediatric Symptom Checklist (PSC), a measure of psychosocial dysfunction. Physicians rated the presence of a new or recurrent psychosocial problem in the child.

RESULTS

Children from families with a lack of social support were 4.3 times as likely to receive scores indicating impairment on the PSC and 2.2 times as likely to be identified as having psychosocial problems by physician report. Families with low social support were significantly more likely to report low parental educational achievement, single parent status, and a history of mental health services for the child. Fifty percent of children from families with low social support were identified as having a psychosocial problem by either the PSC or physician rating, or both; however, only 21% of the children identified with psychosocial impairment by these two measures had scores indicating poor family functioning on the Family APGAR.

CONCLUSIONS

A lack of family social support is associated with child psychosocial dysfunction as assessed by two different measures. However, the Family APGAR was not a sensitive measure of child psychosocial problems, and thus it supplements, but does not replace, information concerning the child's overall psychosocial functioning.

Teaching pediatric residents about early intervention and special education

We compared two educational interventions (didactic lecture with handouts vs guidelines placed in patient charts) and assessed their impact on knowledge of early developmental services and identification of children eligible for these services. Forty-nine pediatric residents participated in preintervention and postintervention tests of knowledge of such services. Mean scores for all residents were 54% (pre-test) and 60% (post-test). First-year residents scored significantly lower than 2nd- and 3rd-year residents on pre- (p = .0001) and post-tests (p < .02). From our convenience sample of 1204 patients, ages newborn to 6 years, seen in the resident continuity clinic during the study period, residents identified children eligible for early developmental services. The mean percentage of identifying eligible children was 13% (range, 0-40%). We did not detect a statistically significant impact of either educational strategy. We conclude, therefore, that more comprehensive strategies are needed to change physician knowledge of and behavior toward early developmental services.

A genetic selection for isolating cDNAs encoding secreted proteins

We describe a simple, rapid technique for simultaneously isolating large numbers of cDNAs encoding secreted proteins. The technique makes use of a facile genetic selection performed in a strain of Saccharomyces cerevisiae deleted for its endogenous invertase gene. A cDNA cloning vector which carries a modified invertase gene lacking its leader sequence is used in conjunction with this strain. Heterologous secreted genes fused appropriately upstream of this defective invertase provide the necessary signals to restore secretion, allowing the yeast to grow on sugars such as sucrose or raffinose. This microbial growth selection facilitates scanning cDNA libraries containing millions of clones, enabling the wholesale identification of novel secreted proteins without the need for specific bioassays. The technique is similar to one previously described (Klein et al. (1996) Proc. Natl. Acad. Sci. USA 93, 7108-7113). We describe results using a cDNA library derived from activated human peripheral blood mononuclear cells (PBMC). Genes identified from this library encoded signal sequences of proteins of diverse structure, function, and cellular location such as cytokines, type 1 and type 2 transmembrane proteins, and proteins found in intracellular organelles. In addition, a number of novel secreted proteins were identified, including a chemokine and a novel G-protein-coupled receptor. Since signal sequences possess features conserved throughout evolution, the procedure can be used to isolate genes encoding secreted proteins from both eukaryotes and prokaryotes.

Increased neurite outgrowth of cultured rat dorsal root ganglion cells following transection or inhibition of axonal transport of the sciatic nerve

Dissociated dorsal root ganglion cells (DRGs), taken from rats 2 weeks after sciatic nerve transection, have an increase in the percentage of cells with neurites compared to DRGs taken from normal animals. This study examines the possible factors that may contribute to the nerve injury-induced increase in neuritogenesis. Topical application of the local anaesthetic, bupivicaine, either to the nerve trunk prior to transection or to the proximal nerve stump for 2 weeks had no effect on the increased neurite outgrowth induced by nerve transection. Neurite outgrowth was also not influenced by administration of either nerve growth factor (NGF) via the femoral artery into normal rats or anti-NGF antiserum to the proximal nerve stump. Inhibition of axonal transport by topical application of vinblastine, however, induced a significant increase in neurite outgrowth compared to untreated controls. In addition, vinblastine-treated animals also develop hyperalgesia to mechanical stimulation and transganglionic labelling of sensory neurons with choleragenoid-horseradish peroxidase shows that the area of termination of myelinated sensory neurons in the spinal cord expands into lamina II. The results suggest that nerve injury-induced increase in neurite outgrowth is not dependent on NGF nor nerve impulses generated at the site of injury and supports the view that the absence of an inhibitory factor(s), that in normal animals may regulate neuronal outgrowth.

Onset of physical abuse and neglect: psychiatric, substance abuse, and social risk factors from prospective community data

Studies of psychiatric and social risk factors for child maltreatment have been limited by retrospective methodologies and reliance on officially reported or identified samples. Using data from both Waves I and II of the National Institute for Mental Health's Epidemiologic Catchment Area survey, 7,103 parents from a probabilistic community sample who did not self-report physical abuse or neglect of their children at Wave I were followed to determine the risk factors associated with the onset of self-reported physical abuse or neglect identified at Wave II. Social factors considered included age, socioeconomic status, social support, education, household size, and gender. In addition, several psychiatric disorders, including substance abuse disorders and depression were examined. Risk models were developed using hierarchical logistic regression. Physical abuse and neglect were found to have distinct sets of risk factors, with minimal overlap between the groups. Social and demographic variables were found to be limited predictors of maltreatment, while substance abuse disorders were strongly associated with the onset of both abuse and neglect (relative risks = 2.90 and 3.24 respectively). Depression was found to be a strong risk factor for physical abuse (relative risk = 3.45). Implications of the findings are discussed in terms of major causal models of maltreatment.

Health status of preterm low-birth-weight infants. Comparison of maternal reports

BACKGROUND

Developers of measures of child health status have documented acceptable reliability and some validity, but less attention has been paid to the concurrent and predictive validity of these measures.

METHODS

We examined the concurrent and predictive validity of the RAND General Health Rating Index, the Stein-Jessop Functional Status II-R, and the mother's global assessment of her child's health on a 5-point scale, in a sample of preterm low-birth-weight children (n = 608) who were followed up as controls in the Infant Health and Development Program. We compared maternal-reported measures assessed at 24 months with other measures of growth, morbidity, functioning, and health care utilization assessed concurrently and at 36 months in bivariate and multivariate analyses.

RESULTS

After controlling for other factors, the RAND General Health Rating Index and the Stein-Jessop Functional Status II-R were unrelated to the growth, utilization, or functioning measures. The RAND General Health Rating Index was significantly, but weakly, related to future morbidity. The mother's global perception of health was significantly related to outpatient utilization and behavior problems.

CONCLUSIONS

Clinicians may find that maternal assessment of overall child health is a sensitive but nonspecific indicator of the mother's concern. For researchers, none of these measures seems likely to serve as a proxy for health care utilization or morbidity in studies of other phenomena, or as an indicator of detailed health outcomes.

Increased plasma levels of pancreatic polypeptide and decreased plasma levels of motilin in encopretic children

OBJECTIVE

Abnormalities of hormones affecting gastrointestinal motility have been found in "functional" disorders of the gastrointestinal system in adults. One such disorder of childhood, encopresis, is frequently associated with constipation, the treatment of which often eliminates the soiling. We hypothesized that hormones affecting gastrointestinal motility were different between encopretic patients and matched controls.

METHODS

Ten encopretic patients were matched by age, race, and sex with controls who had no history of encopresis or constipation. After an overnight fast, each child consumed a meal of Ensure, the amount of which was based on body weight. Plasma levels of gastrin, pancreatic polypeptide, cholecystokinin, motilin, thyroxine, estrogen, and insulin were measured 20 and 5 minutes before the meal, and 5, 10, 15, 30, 45, 60, 90, 120, 150, and 180 minutes after the meal.

RESULTS

Postprandial levels of pancreatic polypeptide remained consistently higher and peaked earlier (P < .05) for encopretic patients. The motilin response was lower (P < .03) for encopretic children than for controls.

CONCLUSIONS

We conclude that pancreatic polypeptide and motilin responses to a meal are different in encopretic children than in children in the control group. These gastrointestinal hormone findings may in part explain and/or be the result of the severe constipation that frequently underlies the fecal soiling found in these patients. These findings also suggest the motility of the stomach and small intestine may be abnormal in encopresis.

The adolescent child health and illness profile. A population-based measure of health

This study was designed to test the reliability and validity of an instrument to assess adolescent health status. Reliability and validity were examined by administration to adolescents (ages 11-17 years) in eight schools in two urban areas, one area in Appalachia, and one area in the rural South. Integrity of the domains and subdomains and construct validity were tested in all areas. Test/retest stability, criterion validity, and convergent and discriminant validity were tested in the two urban areas. Iterative testing has resulted in the final form of the CHIP-AE (Child Health and Illness Profile-Adolescent Edition) having 6 domains with 20 subdomains. The domains are Discomfort, Disorders, Satisfaction with Health, Achievement (of age-appropriate social roles), Risks, and Resilience. Tested aspects of reliability and validity have achieved acceptable levels for all retained subdomains. The CHIP-AE in its current form is suitable for assessing the health status of populations and subpopulations of adolescents. Evidence from test-retest stability analyses suggests that the CHIP-AE also can be used to assess changes occurring over time or in response to health services interventions targeted at groups of adolescents.

Alcohol and drug disorders among physically abusive and neglectful parents in a community-based sample

OBJECTIVES

The purpose of this study was to compare the frequency of substance use disorders and symptoms between adults reporting child physical abuse or neglect and individually matched control subjects in a community sample.

METHODS

In a nested case-control study, 169 adults reporting physical abuse of a child and 209 adults reporting neglect of a child from 11,662 individuals successfully interviewed in a probabilistic survey in four communities were individually matched with control subjects drawn from the participants. Case subjects were compared with control subjects on the number of alcohol- or drug-related symptoms and disorder diagnoses as determined by symptoms from the Diagnostic Interview Schedule.

RESULTS

Respondents reporting either physical abuse or neglect of children were much more likely than their matched control subjects to report substance abuse or dependence. These differences persisted after potential confounding variables were controlled for.

CONCLUSIONS

Parental substance abuse and dependence, independent of confounding factors, are highly associated with child maltreatment. Inconsistent results in previous studies may have arisen from reliance on referred samples and unstandardized assessment methods. Agencies involved in the care of abused or neglected children and their families should consider incorporating routine substance abuse evaluations with treatment, or referral for treatment, where indicated.

Physician management preferences and barriers to care for rural patients with depression

OBJECTIVE

To describe rural primary care physicians' current preferences in treating depression and the barriers they face in providing effective care for this condition.

DESIGN

Cross-sectional survey of randomly selected practicing primary care physicians registered in Arkansas.

SETTING

Primary care practices in nonmetropolitan counties.

PARTICIPANTS

Forty of 50 eligible physicians completed a face-to-face interview; one physician, an interview by telephone; and two physicians, an interview in questionnaire form. Total response rate was 86%.

MAIN OUTCOME MEASURES

Physician preferences for and barriers to the effective management of depression.

RESULTS

An estimated 44% of rural physicians consider medication alone to be the best initial approach to treating depression; 30% prefer to prescribe medication and refer patients to mental health care professionals for counseling; and 26% prefer to prescribe medication and conduct counseling themselves. The greatest barriers to treatment were the physician's lack of time and the patient's failure to recognize depression. Most physicians had recently referred one or more depressed patients to specialty care and had encountered few referral sources, long waiting lists, and inadequate follow-up.

CONCLUSIONS

The majority of rural primary care physicians prefer to treat depressed patients in their practices themselves. Except for the limited availability of specialty services, most of the barriers to the provision of effective care for depression perceived by rural physicians do not appear to be unique to rural practices.