Quantifying practice effects in longitudinal research with the WISC-R and WAIS-R: a study of children and adolescents with hemophilia and male siblings without hemophilia

OBJECTIVE

To quantify practice effects associated with annual administrations of WISC-R and WAIS-R in children and adolescents with and without hemophilia.

METHODS

Participants were young men (age: 7-19; 80 with hemophilia, 30 siblings) enrolled in the Hemophilia Growth and Development Study. Participants with hemophilia completed age-appropriate Wechsler scales at baseline and at four annual follow-ups; the siblings, at baseline and one 2-year follow-up. Regression analyses were used to quantify average changes in scores, adjusting for variables related to test performance.

RESULTS

Consecutive annual evaluations were free of significant practice effects for 4 years with the Verbal Scale and for 2 years with the Performance Scale. VIQ decreased, and PIQ increased over time. Baseline VIQ was related to changes in VIQ; baseline PIQ and number of test-specific retests were related to changes in PIQ.

CONCLUSIONS

The findings support use of Wechsler scales for annual evaluations to monitor cognitive development in children and adolescents.

Psychosocial factors associated with quality of life in Japanese patients with human immunodeficiency virus infection

The purpose of this study was to identify psychosocial factors, including coping style, that are associated with quality of life (QOL) in Japanese patients with human immunodeficiency virus (HIV) infection and to clarify the difference in coping style between patients with hemophilia and patients with sexually transmitted infection. We administered the World Health Organization QOL-26 questionnaire, the Mental Adjustment Toward Cancer scale, and the Social Support scale to 50 patients with HIV infection. Regarding QOL scores, Fighting Spirit was the positive coping style; Helplessness/Hopelessness and Anxious Preoccupation were negative coping styles. Psychological QOL scores in patients with hemophilia were lower than those in patients with sexually transmitted infection. Patients with hemophilia had a significantly weaker Fighting Spirit than patients with sexually transmitted infection.

Predictors of retention among HIV/hemophilia health care professionals

Health care professionals working with individuals with chronic medical illness, especially those infected with the Human Immunodeficiency Virus (HIV), may be at risk for burnout and departure due to various job stresses such as the death of patients and social stigma. Factors that prevent burnout and employee attrition are seldom studied. Two hundred thirteen staff (doctors, nurses and mental health workers) at a representative sample of Hemophilia Treatment Centers (HTC) completed instruments to measure Burnout (Maslach Burnout Inventory), and perceived job stresses and satisfaction (job tasks, interactions with colleagues and patient care). The staff were surveyed again after two years and their job status determined after 4 years. After 4 years, 35% of the staff had left the field of Hemophilia/HIV care. Univariate tests found that retention was significantly associated with initial job satisfaction, being married and low levels of stress with colleagues. Burnout, as measured by the Maslach Burnout Inventory, at baseline, was unrelated to job retention over 4 years. An adjusted multiple logistic regression of all significant variables found that colleague support was most related to retention (OR=2.8, CI=1.49,5.1). We conclude that attrition of highly trained staff is a significant issue for patients and HTCs. These data suggest the important role that a well-functioning team can have in buffering the inevitable stresses associated with HIV care. Mental Health professionals have considerable expertise in addressing these issues.

"Camping up" self-esteem in children with hemophilia

Children with hemophilia have often been viewed at greater risk for altered self-esteem than their healthy counterparts. Our article shares the positive effects of the camp experience on children with hemophilia and subsequent enhancement of self-esteem. Interaction and support in the camp environment provide an opportunity for these children to gain independence and "prove" their self-worth and ability. Previous literature has provided a variety of findings on the relationship between chronic illness, such as hemophilia, and self-esteem alterations. We identify many opportunities for future education and research to provide quality nursing support to this unique population.

Improvement of patient education and information: development of a patient's information dossier

The demand for patient information in modern medical care is increasing and sound information for patients is becoming a necessity. For haemophilia patients, information about their disease and its complications is already widely available. In order to increase the organization of this information, a 'Patient Information Dossier' (PID) and communication check lists were developed at the Dutch National Hemophilia Center, the Van Creveldkliniek, in cooperation with the Department of Patient Education of the University Medical Center Utrecht. The PID has an unique double function: (1) it contains patient tailored information about the practical facts of hospital care; and (2) it provides a communication checklist used by various members of the comprehensive care team, in order to supply patients with more uniform information. In order to gain a better insight of the gaps in information supply, according to patients and healthcare workers, the Department of Patient Education formulated a questionnaire. The PID itself was written by a study group consisting of members of the comprehensive care team. The entire process was developed, edited and coordinated by an advisor of the Department of Patient Education. The above-mentioned study group developed a specific PID on haemophilia care. Its 10 chapters provide information and guidelines, and advise patients where to find more information about this subject. Each chapter includes a checklist for patients, enabling them to prepare subjects for discussion during clinical visits. The team also developed a communication checklist to be used by various team members during a patient's visit to the clinic, as well as specific checklists covering the possible problem subjects of the PID. The PID is the lifelong property of the patient, and can be used during each visit to the clinic. The PID was implemented in February 2000, and within 4 months, was distributed among 200 patients visiting the Van Creveldkliniek. Evaluation by use of a questionnaire showed that most patients found the information in the PID sufficient and in accordance with that which they had received previously.

Multivariate analysis of factors influencing quality of life and utility in patients with haemophilia

BACKGROUND AND OBJECTIVES

Although several studies have determined quality of life (QOL) in patients with hemophilia, generic questionnaires have rarely been used. The objectives of our study were; 1) to measure QOL and utility in patients with hemophilia using the Short Form 36 (SF-36) and the EuroQOL questionnaires; 2) to evaluate the influence of some clinical variables on QOL and utility; 3) to assess the correlation between the two questionnaires.

DESIGN AND METHODS

All consecutive patients with hemophilia were asked to complete the SF-36 and the EuroQOL questionnaires. The following information was recorded from each patient: age, type of hemophilia, severity of disease, HCV and HIV infection, number of bleeding episodes and cumulative dose of coagulation factors over the previous year. These items were entered into a multivariate analysis to assess their effect on QOL. Correlation analyses were conducted to evaluate the relationship between the EuroQOL and SF-36.

RESULTS

Fifty-six patients completed the SF-36 and the EuroQOL questionnaires. The mean scores of the SF-36 ranged from 55.2 (general health) to 74.7 (social functioning). The EuroQOLself-classifier and the EuroQOLvas showed a mean score of 0.67 (SD=0.26) and 0.66 (SD=0.17), respectively. Among the clinical variables, age significantly influenced both the EuroQOL and the SF-36 scores. The EuroQOL indices showed a statistically significant correlation with each dimension of the SF-36.

INTERPRETATION AND CONCLUSIONS

Our study quantified the degree to which QOL is impaired in patients with hemophilia by using both a generic questionnaire and a utility-based approach.

[Community genetics and hemophilia in a Brazilian population]

Hemophilia is an important hemorrhagic disease in Brazil, affecting about 1 out of every 10,000 males. Patient's self-perception of hemophilia and interaction with the community are relevant to the clinical management of this disease. We investigated several social, psychological, and community aspects of hemophilia in a Brazilian population (Campinas, São Paulo State), interviewing 30 hemophiliac males, a control sample comprised of 73 non-hemophiliac brothers, and 641 individuals from the community. According to our results, more severe social disability in the hemophiliac patient was related to economic factors, mainly unemployment; however, no difference was found in relation to marital status, reproduction, or education. Self-perception of changes in health and lifestyle by individuals with hemophilia showed frequent self-stigmatization, along with depression, anxiety, and insecurity. The community showed a widespread lack of familiarity with hemophilia (49%), viewing people with hemophilia with the kinds of prejudices often observed in relation to people with infectious diseases, like AIDS. The paper concludes by recommending that a community-based program be implemented to improve the social adjustment status of individuals with hemophilia.

Telephone support group intervention for persons with hemophilia and HIV/AIDS and family caregivers

The purpose of this pilot project was to test the feasibility of a telephone support group intervention for persons with hemophilia and HIV/AIDS and for their family caregivers. Their support needs were unique because they did not identify with predominant groups of persons with AIDS and were geographically dispersed from peers. The 12 week intervention involved separate telephone support groups for hemophiliacs and for family caregivers. The two groups, comprised of a predetermined maximum of six people, were co-led by a professional and a peer. The support group for family caregivers involved six people and the group for men with hemophilia included five people, including one peer facilitator and one professional facilitator in each group. The telephone support group discussions were taped, transcribed, and analyzed for prevalent themes. The peer and professional facilitators maintained weekly field notes. All participants reported that the telephone groups had a positive impact on meeting their support needs. They believed that they had benefitted from sharing information and that the support groups had decreased their feelings of isolation and loneliness. Participants, however, contended that the intervention should be longer than 12 weeks.

Nondisclosure of human immunodeficiency virus and hepatitis C virus coinfection in a patient with hemophilia: medical and ethical considerations

This article discusses a medical and ethical dilemma: whether to disclose a positive HIV (human immunodeficiency virus)/HCV (hepatitis C virus) coinfection to an adolescent boy without symptoms with hemophilia despite the objections of his parents. An actual case history is presented and the dilemma faced by the medical team is discussed. Numerous family conferences, all excluding the patient, held during the last 5 years discussed the medical team's obligation for full disclosure, the emerging autonomy of the patient, and the potential for medical disaster (e.g., HIV transmission) if full disclosure were not permitted. Despite this, the family did not agree to allow disclosure. The patient and parents assured us of his sexual inactivity. Legal opinion was sought from the university counsel. The dilemmas are multiple. Is there a convincing argument to insist on disclosure of these facts to this patient, particularly when there is ambiguity regarding the appropriateness of HIV and HCV treatment? Does the ethical argument that he is at potential risk for transmitting HIV/HCV outweigh the rights of the family? What are the rights of the rest of the family? What are the rights of the minor? Is it our ethical responsibility to disclose a probably fatal diagnosis?

Validity of health status measurement with the Dutch Arthritis Impact Measurement Scale 2 in individuals with severe haemophilia

The aim of this study was to investigate the validity of the Dutch Arthritis Impact Measurement Scales 2 (D-AIMS2). Hence, D-AIMS2 data of individuals with severe haemophilia were correlated with clinical and perceived health-related quality of life data. Patients with severe haemophilia, who visit the Van Creveldkliniek on a regular basis, were administered the D-AIMS2. In addition, health-related quality of life was measured by the Sickness Impact Profile (SIP). As clinical indices, range of movement (which was converted into Joint Alignment and Motion scores) and muscle strength were recorded during the routine visit. Extensive descriptive and correlational (linear) analyses between corresponding datasets were performed. Thirty-one individuals with severe haemophilia were included. Their scores on the D-AIMS2 demonstrated moderate to very high internal consistency for scales and components (Cronbach's alpha = 0.62-0.92). The physical health components of the D-AIMS2 and the SIP were significantly correlated (Pearson's r = 0.53; P < 0.05). The psychological health and social interaction components of the D-AIMS2 did not correlate significantly with the psychosocial component of the SIP. The physical health component of the D-AIMS2 correlated significantly with the clinical data for the lower extremities (r = 0.52 and r = -0.45; P < 0.05). These data support the reliability and validity of the physical aspects of the D-AIMS2 in patients with severe haemophilia. The next step should be to extend the investigation of psychometric qualities of this health-related questionnaire in a larger population.

Coping strategies, pain, and disability in patients with hemophilia and related disorders

OBJECTIVE

To analyze the use of various coping strategies in homogeneous groups of patients with hemophilia and von Willebrand's disease and to investigate the relationship between the state of the disease, the use of coping strategies, and management of the disease.

METHODS

The coping strategies measured by the Coping Strategies Questionnaire were analyzed in 3 homogeneous groups of 224 patients. Psychosocial well-being (PWB) measured by the Rand 36-item Health Survey 1.0 was used as an indicator of management of the disease. The pain factor consisted of the following variables: pain intensity, use of analgesics, Functional Disability Index, and physical activity level.

RESULTS

The groups of patients differed significantly only in the use of the catastrophizing strategy (CAT). In all pain groups, distraction was the most commonly used coping strategy. A significant interaction effect of pain factor and age on PWB (P = 0.04) was found. The mediating function of the CAT strategy was confirmed by the series of regression analyses.

CONCLUSION

The coping strategy profile in hemophilia was found to be similar to those in other chronic pain states. The use of the strategies does not depend on the severity of the disease. We confirmed the role of age and the use of the CAT strategy as, respectively, moderator and mediator in the pattern of relationships between the clinical state of the disease and psychosocial well-being.

Safer sex decision-making among men with haemophilia and HIV and their female partners

An exploratory qualitative study of adult heterosexual men with haemophilia and HIV and women who were their sexual partners was conducted as formative research to better understand cognitive factors involved in behavioural intentions and practices which comprise HIV risk-reduction for sexual transmission. The study sought to generate hypotheses, uncover themes, and develop a broad perspective on possible determinants of behaviours related to HIV transmission risk reduction. Qualitative analysis of these data served as a basis for developing a subsequent quantitative, hypothesis-testing survey and an intervention. Face-to-face interviews were conducted with 23 single men and 28 married men with haemophilia and HIV infection, and 28 married women partners selected through stratified, purposeful sampling. The interviews identified beliefs, attitudes, and values underlying decisions regarding target behaviours related to preventing sexual transmission of HIV, including (1) using condoms consistently during vaginal intercourse and (2) talking to partners about risk reduction. The interviews elicited information about perceived advantages and disadvantages of performing each of the targeted behaviours, and factors that facilitate or prevent performing them. Qualitative analysis of coded responses yielded important themes regarding how choices are made about sexual activity and safer sex. Most notably, communication between partners (1) plays a direct, key role in facilitating condom use and (2) forms the basis for maintaining emotional intimacy in these relationships. The link between condom use and communicating about safer sex was viewed as pivotal in achieving HIV prevention for individuals in serodiscordant couples. Recommendations for risk reduction intervention development are discussed.

The responsibility of separating truth from myth to patient and family

The choice of treatment for patients with haemophilia is influenced by the availability of replacement products, evidence-based knowledge and the beliefs of patients and their medical practitioners. Decisions are often restrained by wider political and domestic administrative directives to keep within budgetary limits. Issues about the optimal and most cost-effective care still pose a challenge. When choosing treatments there are as yet no certain answers in many areas and myths can develop around a variety of issues. This article addresses the question of whose responsibility it is to separate truth from myth to patient and family, and suggests some basic counselling principles on which to base practice.

Clinical severity of disease, functional disability and health-related quality of life. Three-year follow-up study of 150 Finnish patients with coagulation disorders

A questionnaire-based follow-up study of 150 Finnish patients with coagulation disorders was conducted to evaluate the changes in clinical manifestation of the disease, pain intensity, functional disability and patient's health-related quality of life, occurring during a 3-year period. Health-related quality of life was assessed using the MOS-36 health survey. The clinical severity of the disease manifestation was estimated using the frequency of bleeding episodes into joints and soft tissue during the previous 12 months. Severity of musculoskeletal morbidity, which reflects simultaneous presence of pain and disability, was estimated using intensity of pain and level of disability. Results showed that clinical severity of the disease remained unchanged during the 3-year period for the majority of patients. Nonetheless, the annual number of bleeds in patients with severe or moderately severe haemophilia was still disconcertingly high and the number of bleeding episodes into soft tissue had increased. The clinical severity of the disease manifestation, rather than the severity of the disease based on molecular classification, was a factor that negatively influenced the intensity of pain (both acute and chronic), as well as level of disability. Severity of musculoskeletal morbidity at time 1 and changes in severity of musculoskeletal morbidity over time were found to be significant predictors of physical role, bodily pain, vitality and social functioning. In conclusion, the disease can be relatively well controlled by the availability of coagulation products, thus stabilizing the clinical severity of the disease manifestation during the 3-year period studied. The findings stress the importance of preventing haemorrhages to avoid resulting permanent joint impairment and disability.

Carrier testing of children for two X-linked diseases: A retrospective study of comprehension of the test results and social and psychological significance of the testing

OBJECTIVE

To evaluate long-term consequences of genetic carrier testing performed in childhood in terms of awareness and comprehension of the test result, and the social and psychological significance of such testing.

STUDY DESIGN

The families of 66 young females who had been tested for carriership during childhood between 1984 and 1988 were approached. Of the 66 families, 23 young females in families affected by Duchenne muscular dystrophy (DMD), 23 young females in families affected by hemophilia A (HA), and their mothers participated in our study. We used a questionnaire including multiple-choice and open-ended questions.

RESULTS

Of the young female participants tested in the families affected by DMD or HA, 65% knew their test results. Only 65% of DMD mothers and 78% of HA mothers remembered correctly the test results of their daughters. The majority (83%) of the young females tested sought no genetic counseling when reaching adulthood. The reason for this was not determined. Most (78%) reported that the test result had not influenced their lives, whereas some felt relieved to know they had not been carriers. Talking about hereditary disease in the family and between friends was open, and results of the carrier test had usually been told to friends.

CONCLUSION

Carrier testing was in most cases correctly understood and the matter openly discussed. Our results do not suggest that testing in childhood had caused serious harm to the young individuals tested. On the other hand, we found no obvious benefits from this early testing.

HIV-associated changes in adaptive, emotional, and behavioral functioning in children and adolescents with hemophilia: results from the Hemophilia Growth and Development Study

OBJECTIVE

To assess changes in adaptive, emotional, and behavioral functioning over four years in children and adolescents with hemophilia and with or without HIV infection and to evaluate the relationship of these changes to immune status.

METHODS

Participants were 277 HIV-seropositive and 126 HIV-seronegative boys with hemophilia. Participants with HIV infection were divided into three groups based on trajectory of immune functioning (CD4+ cell counts) over the course of the study. Caregivers completed the Vineland Adaptive Behavior Scales and Pediatric Behavior Scale (PBS).

RESULTS

Results showed declining Vineland Communication scores for participants with consistently poor immune functioning. These participants also started with more PBS Attention Deficit and Deviation symptoms, which then decreased more sharply than for other groups. Low CD4+ counts were consistently associated with more Health and Depression-Anxiety symptoms on the PBS. However, with few exceptions, group means remained within normal limits.

CONCLUSIONS

According to their caregivers, boys with hemophilia and HIV infection showed considerable resilience with regard to adaptive behavior and emotional and behavioral problems. However, over time changes occurred in these areas that appear to be related to immune functioning.

Emotional and behavioural problems and family functioning in children with haemophilia: a cross-sectional survey

A comparative study is presented about emotional and behavioural problems in haemophilia and family functioning. This cross-sectional survey looked at boys, aged between 4 and 15 years, with haemophilia and compared them with a group of their healthy school peers. A basic demographic questionnaire was used for both groups along with the Child Behaviour Checklist (CBCL) and the Family Assessment Measure (FAM). Seventeen of 24 families of boys with haemophilia participated (70.8% response). The comparison group consisted of 12 boys, i.e. 70.6% of the haemophilia sample. The groups did not differ in terms of the children's ages and family sizes but significantly fewer of the mothers of the boys with haemophilia worked outside the home. The two groups were compared for scores on the CBCL and FAM. More problems were identified in the haemophilia group on both measures, i.e. there were more emotional, behavioural and family difficulties compared with the healthy group; however, because of the small sample sizes, the differences between the groups did not reach statistical significance. A larger study would be indicated in order to explore these differences further.

Hemophilia treatment. Immune tolerance: the parent's perspective

A parent whose child affected by hemophilia develops an inhibitor has to cope with strong emotions and anxieties related to the acceptance of this second diagnosis when just having severe hemophilia seems nothing compared to having antibodies that neutralize factor infusions and the possibility of uncontrolled hemorrhages. During the initial stage of adaptation to this frightening reality, a parent needs constant support by the Center staff. The period during which medical personnel and parents decide about the possibility of putting a child on an immune tolerance protocol is a crucial one; if parents feel they have been well informed about this sort of treatment and feel adequately prepared to handle situations which may arise, they will take an active role in the care of their sons and maintain a positive attitude. The fears and worries are many, the greatest of which is the constant dread of a negative outcome. The commitment of staff during the formal period of instruction, the use of a local anesthetic, play therapy and the very young age of the child were variables that made peripheral, home infusion in a 1 1/2 old on immune tolerance possible. The needs of siblings, of the parents themselves and the strong bonding between mother and child are only but a few of the psychological aspects related to immune tolerance.

Participation in sports by Dutch persons with haemophilia

Patients with haemophilia are now widely advised to participate in sports. However, no extensive data are available about their actual participation. A self-administered questionnaire was used to investigate sports participation by persons with haemophilia in the Netherlands. All 293 questionnaires that were distributed have been returned; 217 were from people with severe haemophilia A or B (this is 40% of the severely affected Dutch population with haemophilia). Of this group, 155 (71%) participate in one or more sports: 66 swim, 36 cycle, 21 play tennis, 18 do fitness exercises, 16 ice skate, 10 ski and 10 play table tennis; in total 44 different sports are mentioned. Of a group of 16 persons with haemophilia who are unable to run, 10 (63%) participate in sport and of a group of 91 who can only run sometimes, 64 (70%) engage in sports. This shows that there are ample opportunities for persons with haemophilia to participate in sports, even if they are unable to run. Severely affected persons with haemophilia are as active as the general Dutch population; in fact, a higher proportion swims and/or cycles. In conclusion, sports participation in the Netherlands by persons with haemophilia is in accordance with World Federation of Hemophilia directives.

Declining immune function in children and adolescents with hemophilia and HIV infection: effects on neuropsychological performance. Hemophilia Growth and Development Study

OBJECTIVE

To determine whether declines in immune functioning are associated with changes in neuropsychological performance in children and adolescents with hemophilia who are infected with the human immunodeficiency virus (HIV).

METHODS

Participants were 333 males with hemophilia, ages 6-19 years at entry. A baseline and four annual neuropsychological evaluations were given. A longitudinal growth curves analysis of data was performed to detect changes associated with declining immune function. The cohort was stratified into four groups: (1) HIV- (n = 126); (2) HIV+, average of first two and last two CD4 counts > or = 200, (n = 106; High CD4 group); (3) HIV+, average first two counts > or = 200, average last two counts < 200 (n = 41; CD4 Drop group); and (4) HIV+, average first two and last two counts < 200 (n = 60; Low CD4 group).

RESULTS

There were significant differences among the four groups over time in nonverbal intelligence, perceptual/performance skills, nonverbal memory, academic achievement, and language. The Low CD4 group consistently showed the greatest decrement in performance. On measures showing a practice effect for repeated measurements, the Low CD4 group participants' scores remained stable over time, suggesting opposing effects of practice and HIV-related declines. Lowered academic performance relative to IQ was found in all groups.

CONCLUSIONS

Declines in neuropsychological functioning are directly related to declines in immune functioning in HIV+ children, adolescents, and young adults with hemophilia. Hemophilia itself may be a risk factor for academic underachievement.