Developing a measure of health outcomes in survivors of childhood cancer: a review of the issues

Impact of atopic dermatitis on quality of life: a large web-based survey from Argentina

BACKGROUND

Atopic dermatitis (AD) is a chronic, recurrent, inflammatory skin condition that is associated with detrimental effects on the lives of patients and their families, including an impact on quality of life (QOL). Studies about QOL on Latin American AD patients are scarce and have generally included few patients.

OBJECTIVE

describing AD impact on the QOL in a large cohort in Argentina.

METHODS

a structured web-based survey including 1,650 AD pediatric and adult patients was performed.

RESULTS

according to retrieved data, AD symptoms onset started during childhood in most patients, but 20 % of participants reported that manifestations of AD were initially perceived during late adolescence and adulthood. Important differences were observed among country regions, with a shorter time-to-diagnosis in most populated and richer districts. Main affected domains included frustration, anger, mood alterations, stress, sleep alterations, routine alterations, pain and economic impact of AD.

LIMITATIONS

biases inherent to survey design.

CONCLUSIONS

we consider that our study contributes to a better understanding of AD in Argentina, as well as its physical, social and financial impact on affected patients.

Psychometric Validation of the PERMA-Profiler as a Well-Being Measure for Young Adult Survivors of Pediatric Central Nervous System Tumor

This study aims to validate a measure of well-being, the PERMA-Profiler, among a sample of young adult survivors of pediatric central nervous system (CNS) tumor. Measurement structure of the PERMA-Profiler was evaluated using exploratory factor analysis and confirmatory factor analysis using pretest–posttest data. Reliability and concurrent validity of the PERMA-Profiler were examined. This study included 127 young adult survivors of pediatric CNS tumor between the ages of 18 and 30 ( M = 23.83, SD = 3.00) years. The results of factor analyses yielded a single-factor solution for well-being. Significant relationships between well-being and happiness, life satisfaction, perceived stress, and physical health were observed, providing support for the concurrent validity of the PERMA-Profiler. The PERMA-Profiler displayed good internal consistency and test–retest reliability. The PERMA-Profiler can help rehabilitation researchers and counselors better evaluate well-being in young adult survivors of pediatric CNS tumor, which provides opportunity for more targeted psychosocial interventions.

Improving the Quality of Life for Children with Cancer

There are now more than one million new cases of cancer every year in the European Community (EC) including the children to whom particular needs should be addressed. Besides the disease-free survival other outcomes reflecting the impact of treatment on the patient and their families must also be assessed and include their physical, psychological and social functioning throughout their care: during therapy, after completion of treatment or, for some, in the terminal phase of their illness. To provide optimal care and thus improve the quality of life for these children needs:

a) an appropriately structured Paediatric Cancer Unit;

b) well trained and permanent staff members: comprising doctors, nurses, psychologists, social workers and other health care professionals;

c) facilities such as a specific out-patient clinic, a hospital school, a residence for parents;

d) a well defined programme for the terminally ill children;

e) a well defined programme for controlling the late effects of therapy.

The Impact of Atopic Dermatitis on Quality of Life

Approximately 5-20% of children worldwide suffer from atopic dermatitis (AD), a kind of dermatitis characterized as an inflammatory, relapsing, noncontagious and itchy skin disorder. Children often develop AD during their first year of life. An increased rate of sensitization to both food and aeroallergens has been shown to coexist in patients with AD. Sensitization to well-known allergens such as cow's milk protein can occur on average in 50% of children with AD. In general, quality of life (QoL) is perceived as the quality of an individual's daily life, that is, an assessment of their well-being or lack thereof. QoL is a broad concept that includes such things as standard of living, community, and family life. Patients with skin diseases experience a wide range of symptoms ranging from trivial problems to major handicaps which affect their lives. The misery of living with AD cannot be overstated for it may have a profoundly negative effect on the health-related QoL of children and their families in many cases. Physicians taking care of children with AD should consult parents on how their child's illness has impacted their lifestyle and recommend professional intervention if deemed necessary.

Quality of life in children following treatment for a malignant primary bone tumour around the knee

Purpose. We report on the quality of life following treatment for a malignant primary bone tumour around the knee in skeletally immature children.

Patients. Patients (n = 41; mean age = 18 years; range 8–28) had all experienced chemotherapy in a neo-adjuvant setting, surgical excision of the tumour and endoprosthetic replacement.

Methods. Interviews were conducted separately with the child and mother and focused on mobility, body image and the impact of treatment on schooling, employment and plans for the future.

Results. Mobility in the group was variable. Only 12% reported that they could run with any confidence. The proportion who were able to swim (49%) or ride a bike (46%) was higher. All had experienced major disruption in schooling (mean absence following diagnosis = 12 months). Eight had repeated a school year and 41% patients reported that their schoolwork was affected. As a result of their experience, eight (six females and two males) chose health-related employment. Concerns for the future were highest among males and those with manual jobs. Three patients were receiving psychiatric support, in relation to extreme concern about the risk of recurrence. All expressed satisfaction with treatment, and older patients believed that the prosthesis gave a better quality of life than amputation.

Discussion. Our data suggest that outcome following limb-salvage surgery is variable. Education is disrupted. Even so, only two left school with no qualifications. Employment is most restricted among males with few qualifications who may benefit from sensitive vocational counselling.

Validation of the Japanese version of the Pediatric Quality of Life Inventory (PedsQL) Cancer Module

Background

The PedsQL 3.0 Cancer Module is a widely used instrument to measure pediatric cancer specific health-related quality of life (HRQOL) for children aged 2 to 18 years. We developed the Japanese version of the PedsQL Cancer Module and investigated its reliability and validity among Japanese children and their parents.

Methods

Participants were 212 children with cancer and 253 of their parents. Reliability was determined by internal consistency using Cronbach's coefficient alpha and test-retest reliability using intra-class correlation coefficient (ICC). Validity was assessed through factor validity, convergent and discriminant validity, concurrent validity, and clinical validity. Factor validity was examined by exploratory factor analysis. Convergent and discriminant validity were examined by multitrait scaling analysis. Concurrent validity was assessed using Spearman's correlation coefficients between the Cancer Module and Generic Core Scales, and the comparison of the scores of child self-reports with those of other self-rating depression scales for children. Clinical validity was assessed by comparing the on- and off- treatment scores using Kruskal-Wallis and Mann-Whitney U tests.

Results

Cronbach's coefficient alpha was over 0.70 for the total scale and over 0.60 for each subscale by age except for the 'pain and hurt' subscale for children aged 5 to 7 years. For test-retest reliability, the ICC exceeded 0.70 for the total scale for each age. Exploratory factor analysis demonstrated sufficient factorial validity. Multitrait scaling analysis showed high success rates. Strong correlations were found between the reports by children and their parents, and the scores of the Cancer Module and the Generic Core Scales except for 'treatment anxiety' subscales for child reports. The Depression Self-Rating Scale for Children (DSRS-C) scores were significantly correlated with emotional domains and the total score of the cancer module. Children who had been off treatment over 12 months demonstrated significantly higher scores than those on treatment.

Conclusions

The results demonstrate the reliability and validity of the Japanese version of the PedsQL Cancer Module among Japanese children.

I'll Show Them: The Social Construction of (In)Competence in Survivors of Childhood Brain Tumors

Multimodal therapy for the treatment of childhood cancer has resulted in increased survival rates, yet as growing cohorts of children mature, late effects are becoming apparent. Specifically, brain tumor survivors tend to have poor social skills, peer relationship problems, academic difficulties, and delayed college entry. This article addresses findings specific to the unique experience of childhood cancer survivors as they transition from adolescence to adulthood. Qualitative methods involving focus groups and in-depth interviews with 14 childhood cancer survivors and 22 family members were used. The dialectic of incompetence/competence pervaded all narratives. Contradictory concepts of integration/ isolation, realistic/unrealistic goals, and the need for special help/no help were underscored by respondents. The struggle to deal with these contradictory factors led to the simultaneous resistance and acceptance of feelings of competence.

Self-perceived health-related quality of life of former extremely low birth weight infants at young adulthood

OBJECTIVES

The goals were to compare the self-reported, health-related quality of life of former extremely low birth weight and normal birth weight infants at young adulthood and to determine whether there were any changes over time.

METHODS

A prospective, longitudinal, population-based study with concurrent control subjects was performed. We interviewed 143 of 166 extremely low birth weight survivors (birth weight: 501-1000 g; 1977-1982 births) and 130 of 145 sociodemographically comparable, normal birth weight, reference subjects. Neurosensory impairments were present for 27% extremely low birth weight and 2% normal birth weight young adults. Health Utilities Index 2 was used to assess health status, and standard gamble technique was used to measure directly the self-reported, health-related, quality of life and 4 hypothetical health states.

RESULTS

Extremely low birth weight young adults reported more functional limitations in cognition, sensation, mobility, and self-care, compared with control subjects. There were no differences between groups in the mean self-reported, health-related, quality of life or between impaired (n = 38) and nonimpaired (n = 105) extremely low birth weight subjects. However, with a conservative approach of assigning a score of 0 for 10 severely disabled, extremely low birth weight subjects, the mean health-related quality of life was significantly lower than control values. Repeated-measures analysis of variance to compare health-related quality-of-life measurements obtained for young adults and teens showed the same decline in scores over time for both groups. There were no differences between groups in the ratings provided for the hypothetical health states.

CONCLUSIONS

At young adulthood, health-related quality of life was not related to size at birth or to the presence of disability. There was a small decrease in health-related quality-of-life scores over time for both groups.

Study protocol: SPARCLE--a multi-centre European study of the relationship of environment to participation and quality of life in children with cerebral palsy

BACKGROUND

SPARCLE is a nine-centre European epidemiological research study examining the relationship of participation and quality of life to impairment and environment (physical, social and attitudinal) in 8-12 year old children with cerebral palsy. Concepts are adopted from the International Classification of Functioning, Disability and Health which bridges the medical and social models of disability.

METHODS/DESIGN

A cross sectional study of children with cerebral palsy sampled from total population databases in 9 European regions. Children were visited by research associates in each country who had been trained together. The main instruments used were KIDSCREEN, Life-H, Strength and Difficulties Questionnaire, Parenting Stress Index. A measure of environment was developed within the study. All instruments were translated according to international guidelines. The potential for bias due to non response and missing data will be examined. After initial analysis using multivariate regression of how the data captured by each instrument relate to impairment and socio-economic characteristics, relationships between the latent traits captured by the instruments will then be analysed using structural equation modelling.

DISCUSSION

This study is original in its methods by directly engaging children themselves, ensuring those with learning or communication difficulty are not excluded, and by studying in quantitative terms the crucial outcomes of participation and quality of life. Specification and publication of this protocol prior to analysis, which is not common in epidemiology but well established for randomised controlled trials and systematic reviews, should avoid the pitfalls of data dredging and post hoc analyses.

Quality of life of patients treated during childhood for a bone tumor: assessment by the Child Health Questionnaire

To determine which factors impact on quality of life of patients with bone tumor, we used the Children Health Questionnaire French version. Thirty-seven patients (25 males, 19 osteosarcoma, 18 Ewing sarcoma) were studied. At assessment, median age was 15 years, median follow-up was 4 years. Mean scores were 60, 81, 76, 74, 70, 87 for general health, physical functioning, pain, mental health, self-esteem, and family activity, respectively. Lower results were observed for mental health in girls, for physical functioning, and self-esteem in patients with endoprosthesis, and for family activity and pain in patients who had relapsed.

The Minneapolis-Manchester Quality of Life instrument: Reliability and validity of the Youth Form

OBJECTIVE

Improvements in survival after childhood cancer have increased emphasis on health-related quality of life (HRQoL) of survivors. We developed the Minneapolis-Manchester Quality of Life-Youth Form (MMQL-YF) as a standardized patient self-report instrument designed to assess HRQoL in childhood cancer survivors between the ages of 8 and 12 years.

STUDY DESIGN

To validate the instrument, the MMQL-YF was administered to 643 children (481 healthy, 162 with cancer). Factor analysis was conducted to refine the instrument, and Cronbach's alpha coefficient was used to measure its internal reliability. Known-groups validity was determined by comparing healthy children with those with cancer. Construct validity was studied by a comparison of similar domains in the MMQL-YF and the Child Health Questionnaire (CHQ). Stability was tested by re-administration of the MMQL-YF 2 weeks later.

RESULTS

Internal consistency reliability was in the acceptable range for this instrument. The MMQL-YF was able to distinguish between known groups, and its scales correlated highly with similar CHQ domains. Test-retest reliability showed that the instrument was extremely stable in all scales tested.

CONCLUSION

Data provide evidence for the validity and reliability of the MMQL-YF as a comprehensive, multidimensional, self-report instrument for measuring HRQoL among childhood cancer survivors.

Validation of the German version of the Pediatric Quality of Life Inventory (PedsQL) in childhood cancer patients off treatment and children with epilepsy

The Pediatric Quality of Life Inventory (PedsQL) is a relatively new instrument developed in the US to assess health-related quality of life (HRQL) in healthy and ill children and adolescents. It is quick and easy to use, suitable for assessment by children and parents and based on a modular approach with a generic measure addressing all general domains of HRQL and disease-specific modules. We report here the results of translating the original US generic core instrument and the cancer module into German and testing the German PedsQL in samples of paediatric patients who have been treated for cancer or epilepsy. Like in studies with the original instrument, score distributions tended to be skewed toward higher HRQL, but a full response range was demonstrated for each item. The German PedsQL is reliable in terms of internal consistency with the majority of scales exceeding a Cronbach's alpha of 0.70. Clinical validity was confirmed by differences between the cancer and epilepsy groups in the expected direction and by the ability of the PedsQL to discriminate between subjects with different degrees of medical and psychosocial sequelae. Comparing our findings to US results, the German PedsQL seems to be equivalent to the original version. Future methodologic research should evaluate construct validity, sensitivity and responsiveness, and test the usefulness of the instrument in other clinical populations and healthy children.

Psychological outcomes in long-term survivors of childhood brain cancer: a report from the childhood cancer survivor study

PURPOSE

To evaluate and compare psychological outcomes in long-term survivors of pediatric brain cancer and siblings of childhood cancer survivors, and to identify significant correlates of psychological distress.

METHODS

One thousand one hundred one adult survivors of childhood brain cancer and 2,817 siblings completed a long-term follow-up questionnaire allowing assessment of symptoms associated with depression, somatization, and anxiety, as well as demographic, health, and medical information.

RESULTS

A large majority of siblings and survivors report few, if any, symptoms of psychological distress. The prevalence of distress approximating clinically significant levels for both survivors (11%) and siblings (5%) reflects rates found in the general population. Yet when accounting for significant sociodemographic, socioeconomic, and health-status variables, survivors of childhood brain cancer, in the aggregate, appear to report significantly higher global distress and depression scores than do siblings. As in the general population, higher levels of distress among survivors and siblings were associated with female sex, low household income, lower educational attainment, being unmarried, not being employed in the past 12 months, and poor physical health status. No diagnostic or treatment-related variables were directly and significantly associated with increases in distress symptoms for survivors of childhood brain cancer.

CONCLUSION

Cancer treatment does not appear to contribute directly to increased psychological distress. Instead, distress appears to be associated with diminished social functioning that may be related to cancer type or treatment. Implementation and evaluation of supportive interventions that enhance survivors' social and vocational skills should be considered.

Assessment of health-related quality of life in children: a review of conceptual, methodological, and regulatory issues

Recently, the FDA has encouraged testing of medications among pediatric patients during drug development. Pharmaceutical companies have responded by conducting more clinical trials among children, and researchers are becoming aware of the unique challenges of assessing pediatric health outcomes, including health-related quality of life (HRQL). Like adults, children experience effects of illness and treatment beyond physiologic outcomes. Further pediatric HRQL research is necessary to examine these broader psychosocial outcomes and provide a thorough understanding of the effects of treatment on children's health status. The purpose of the current review is to discuss key regulatory and methodologic developments and provide guidance for future research on pediatric HRQL. This review of pediatric HRQL assessment includes five sections: 1). recent pediatric regulatory developments in the United States; 2). issues in defining and conceptualizing pediatric HRQL, including the importance of contextual variables such as family and peer systems; 3). methodologic issues (e.g., the proxy question, developmental differences, response sets) with recommendations for addressing these issues in clinical trials; 4). validated generic and condition-specific pediatric HRQL measures; and 5). a recommendation for additional research on the HRQL impact of childhood psychiatric disorders. It is advocated that assessment of HRQL among children should be conducted regularly as an integral part of drug development.

Development and validation of a tool to measure the impact of childhood disabilities on the lives of children and their families

OBJECTIVE

Information on registers of children with special needs will be more meaningful if a validated measure of the severity of impact of a child's disability on life and family is included.

DESIGN

We describe the development and initial validation of a parent-completed questionnaire (Generic Lifestyle Assessment Questionnaire LAQ-G) aimed at measuring such impact.

RESULTS

Data were collected on 95 case children, representing various disabilities, and 65 control children without disability, and analysed for case-control, test-re-test and inter-reporter reliability. Multidimensional scaling techniques were then used to derive six domains, representing impact of disability in a structure analogous to the participation domains of the revised International Classification ICF (WHO 2001).

CONCLUSIONS

Initial results suggest that the LAQ-G is a reliable measure of the impact of disability for children with a range of common disabling conditions.

The Minneapolis-Manchester Quality of Life instrument: reliability and validity of the Adolescent Form

PURPOSE

With improvement in survival after childhood cancer, increasing emphasis is being placed on the impact of treatment and its sequelae on the health-related quality of life (HRQL) of survivors. The Minneapolis-Manchester Quality of Life Instrument (MMQL) is a standardized patient self-report instrument designed to assess HRQL in survivors of childhood cancer. The MMQL is being developed for three age groups to address the changing developmental need of different ages: MMQL-Youth (8 to 12 years), MMQL-Adolescent (13 to 20 years), and MMQL-Young Adult (21 to 45 years). This report focuses on the development and testing of the MMQL-Adolescent Form.

PATIENTS AND METHODS

To validate the instrument, the MMQL-Adolescent Form was administered to 397 adolescents (129 healthy individuals, 110 patients with cancer undergoing therapy, and 158 subjects off therapy for cancer). Factor analysis was conducted to refine the instrument. Construct validity was conducted by comparing similar constructs in the MMQL-Adolescent Form and the Child Health Questionnaire (CHQ). Discriminate validity was determined by comparing healthy children with children with cancer either on or off therapy. Stability of the MMQL was tested by readministering the MMQL-Adolescent Form 2 weeks later.

RESULTS

Internal consistency reliability was in the acceptable range for this instrument. The MMQL was able to discriminate between the three study populations. There were high correlations between the MMQL scales and similar CHQ domains. Test-retest reliability of the MMQL-Adolescent Form demonstrated that the instrument was extremely stable in all scales tested.

CONCLUSION

Overall, the data provide evidence for the validity and reliability of the MMQL-Adolescent Form as a comprehensive, multidimensional self-report instrument for measuring HRQL among adolescent survivors of childhood cancer.

Family impact of child oral and oro-facial conditions

OBJECTIVES

The aim of this study was to develop and evaluate the Family Impact Scale, a measure of the family impact of child oral and oro-facial disorders. This formed one component of the Child Oral Health Quality of Life Instrument.

METHODS

The scale was developed using a process described by Guyatt et al. (1987) and Juniper et al. (1996). An item pool was developed using a review of existing child health status and family impact questionnaires, interviews with 41 parents-caregivers of children with paedodontic, orthodontic and oro-facial conditions and discussions with dental specialists. The resulting pool of 21 items was used in an item impact study in which 93 parents-caregivers provided data on the frequency and importance of these items. The 14 items identified most frequently or rated the most important were selected for the final questionnaire. The discriminant and construct validity and internal consistency reliability of this 14-item scale were assessed in a study of 266 parents-caregivers from the three clinical groups. Seventy-nine of these participants completed a second copy of the questionnaire to facilitate assessment of test-retest reliability.

RESULTS

Family Impact Scale scores ranged from 0 to 33, indicating that the measure was sensitive to variations in family impact. Floor effects were minimal with only 10.2% of subjects having a score of zero and there were no ceiling effects, that is, subjects with maximum scores. Almost three-quarters of parents-caregivers reported some family impact 'sometimes' or 'often/everyday' over the previous 3 months. Impact on parental or family activities of this frequency was reported by 53.0%, impact on parental emotions by 44.0%, conflict in the family by 31.6% and financial difficulties by 31.2%. The measure and its component items were reasonably good at discriminating between the three clinical groups included in the study and showed good construct validity. It had excellent internal consistency reliability with a Cronbach's alpha of 0.83 and was reproducible for parent-caregivers who reported that their child's condition was stable (ICC = 0.80).

CONCLUSIONS

The study provides some data to suggest that child oral and oro-facial conditions have a pervasive impact on the family. The Family Impact Scale had good technical properties. Its evaluative properties need to be tested in longitudinal studies.

Body composition of long-term survivors of acute lymphoblastic leukaemia

BACKGROUND

Long-term quality of life is of growing importance in children previously treated for malignancy. Obesity defined indirectly from indices of height and weight, has been described in long-term survivors of acute lymphoblastic leukaemia (ALL) and hypothesised to be a consequence of previous cranial irradiation.

PROCEDURE

In this study, measures of whole and regional body composition using skinfold and dual energy X-ray absorptiometry (DEXA) measurements have been made in 35 long-term survivors of ALL who had received cranial irradiation and chemotherapy. To assess the influence of cranial irradiation, results were compared with those obtained in 21 children treated for other malignancies, who received chemotherapy alone and with 31 healthy sibling controls.

RESULTS

Girls treated for ALL were significantly fatter than those treated for other malignancies or healthy control siblings whether measured by skinfold thickness (median (range) 37.4% (17.9-41.3) vs. 24.6% (19.1-35.0) and 28.8% (19.6-43.1), respectively, P<0.01) or DEXA (33.5% (20.5-42.8) vs. 25.5% (16.5-31.0) and 24.5% (18.8-53.6), respectively, P<0.01). Boys treated for ALL were not significantly fatter than boys in the other two groups. Measures of whole body percent fat derived from DEXA were persistently less than those derived from skinfold measurements with a mean (95% CI) difference of 2.4% (1.7-3.1, P<0.001) for all groups combined. In ALL survivors, using regression equations for skinfold thicknesses derived from controls with DEXA as the 'gold standard' method, fat mass was significantly overestimated.

CONCLUSION

Female survivors of ALL are significantly fatter than those of other malignancies and healthy sibling controls. Caution should be observed in the application of published equations, derived from the normal population, for the calculation of body composition in children treated for ALL. The mechanism of onset of obesity remains unclear, but is probably multifactorial and related to previous cranial irradiation.

Design and baseline characteristics for the ACE Inhibitor After Anthracycline (AAA) study of cardiac dysfunction in long-term pediatric cancer survivors

PURPOSE

The ACE Inhibitor After Anthracycline (AAA) study is a randomized, double-blind, controlled clinical trial comparing enalapril with placebo to determine whether treatment can slow the progression of cardiac decline in patients who screen positive for anthracycline cardiotoxicity.

METHODS

The primary outcome measure is the rate of decline, over time, in maximal cardiac index (in liters per minute per meters squared) at peak exercise; the secondary outcome measure is the rate of increase in left ventricular end systolic wall stress (in grams per centimeters squared). Patients >2 years off therapy and <4 years from diagnosis, aged 8 years and older, were eligible if they had received anthracyclines and had at least one cardiac abnormality identified at any time after anthracycline exposure.

RESULTS

A total of 135 patients were randomized to enalapril or placebo. Baseline characteristics were similar across treatment groups.

CONCLUSIONS

The AAA study will provide important information concerning the efficacy of using angiotensin-converting enzyme inhibitors to offset the effects of late anthracycline cardiotoxicity.

Art therapy as support for children with leukemia during painful procedures

BACKGROUND

Children with leukemia undergo painful procedures such as lumbar puncture and bone marrow aspiration. To overcome pain, certain units offer total anesthesia; others offer generic support; others offer no preparation at all. Since September, 1997, we have provided leukemic children with art therapy (AT), a nonverbal and creative modality that develops coping skills. Our goal is to prevent anxiety and fear during painful interventions as well as prolonged emotional distress.

PROCEDURE

We treated 32 children aged 2-14 years. The modes of AT before, during, and after the punctures were as follows: clinical dialogue to calm children and help them cope with painful procedures; visual imagination to activate alternative thought processes and decrease the attention towards overwhelming reality and raise the peripheral sensitivity gate; medical play to clarify illness, eliminate doubts, and offer control over threatening reality; structured drawing to contain anxiety by offering a structured, predictable reality (the drawing) that was controllable by children; free drawing to allow children to externalize confusion and fears; and dramatization to help children accept and reconcile themselves to body changes.

RESULTS

Children hospitalized before September, 1997, exhibited resistance and anxiety during and after painful procedures. By contrast, children provided with AT from the first hospitalization exhibited collaborative behavior. They or their parents asked for AT when the intervention had to be repeated. Parents declared themselves better able to manage the painful procedures when AT was offered.

CONCLUSION

AT was shown to be a useful intervention that can prevent permanent trauma and support children and parents during intrusive interventions.

The Pediatric Cancer Quality of Life Inventory: a modular approach to measuring health-related quality of life in children with cancer

Measurement of pediatric cancer patients' health-related quality of life (HRQL) in phase III randomized, controlled clinical trials is being recognized increasingly as an essential component in evaluating the comprehensive health outcomes of modern anti-neoplastic treatment protocols. Use of a brief core measure of HRQL plus disease-specific symptom modules is a way to assess specific HRQL outcomes with a minimum of subject burden. Demonstrating a measure's feasibility, reliability and validity also represents children's ability to provide reliable and valid responses to HRQL questions. The Pediatric Cancer Quality of Life Inventory (PCQL) Modular Approach consists of a 15-item core measure of HRQL and 2 specific symptom modules: pain and nausea. To validate a patient-report form and a parent-report form, the PCQL was administered to 291 pediatric cancer patients and to their parents. Feasibility and range of measurement, as well as patient-parent concordance, were assessed. Internal consistency reliability was assessed via Cronbach's alpha. Validity was determined by the known-groups approach and by correlating PCQL scores with days missed from school. Patients had minimal missing data, and the range of measurement for the items was good. Patient-parent concordance was large but not perfect. For both patient and parent forms, internal consistency reliability of the PCQL core scale (0.83 and 0. 86, respectively) was strong. The internal consistency reliabilities of the 2 symptom modules for both patient and parent forms were in the acceptable range for group comparisons. Regarding clinical validity, the core scale and the 2 symptom modules distinguished between patients on and off treatment for both patient and parent reports. Further, both patient and parent reports correlated with days of missed school in the past 6 and 12 months. The PCQL Modular Approach has demonstrated acceptable internal consistency reliability and clinical validity for both patient-report and parent-report forms. By implication, children are capable of providing reliable and valid responses to these HRQL questions.

Assessment of health-related quality of life in acute in-patient settings: use of the BASES instrument in children undergoing bone marrow transplantation

The Behavioral, Affective and Somatic Experiences Scale (BASES) represents a set of tools for assessing aspects of health-related quality of life (HRQL) in patients undergoing active, intensive therapy. Separate versions have been developed for parent, nurse and patient reports. The scales were constructed to be sensitive to change and appropriate for repeated measures in longitudinal designs. We report preliminary results with these measures from a sample of 105 children undergoing bone marrow transplantation (BMT). Adequate reliability of the instruments is documented through measures of both internal consistency and cross-informant consistency. Several analyses provide evidence of the clinical validity of the measures. Repeated-measures ANOVAs indicated reliable patterns of change over time, with trajectories that conformed to a priori predictions. Discriminative validity was demonstrated through detection of significant differences in the predicted direction between patients undergoing allogeneic and autologous BMT. Additional evidence for validity comes from the very similar symptom trajectories in parent, nurse and patient reports. Differences between the BASES and other measures of HRQL are identified and alternative uses of the instruments are discussed.

Standardized quantitative assessment of brain tumor survivors treated within clinical trials in childhood

Important morbidity and impairment of life quality arises from both the primary pathology and therapeutic interventions in children with central nervous system (CNS) tumors. Standardized and systematic collection of morbidity data is a prerequisite of clinical trials in this field. The perception of the survivor is paramount in the determination of quality of life as this variable is dependent on the beholder. Comprehensive assessment of outcome following therapeutic intervention should evaluate this in parallel with other physical and psycho-social outcome parameters. A structured, simple schema for the evaluation of survivors of childhood CNS tumors is presented. It is intended to be easily applicable by clinicians within the everyday clinical setting. Information relating to pre- and post-operative states, function, health status and emotional and psychological well-being is collected at regular intervals from diagnosis. Re-integration into society and independence are evaluated. Children self-complete health-status assessments where appropriate. Evidence to support this is presented. The schema is intended to provide a basic framework for the monitoring of health status following treatment of CNS tumors in childhood. Regular assessments may identify individuals in need of more detailed investigation and further understanding of the evolution of morbidity in this cohort. Survivors' perception of the impact of documented dysfunction on their health-related quality of life will be determined. Optimization of the planning of future clinical service provision and therapies will result.

Measurement of health status and quality of life in neonatal follow-up studies

Mortality and neuro-developmental outcome can be precisely measured but in order to interpret the significance of changes in them, further information is needed about health status, the effect of health status on lifestyle of survivors and their families, the quality of life experienced by survivors and the value placed by the public and survivors on different health states. The ability to measure such aspects of health now allows more relevant follow-up studies to be designed. This article discusses concepts of health status and quality of life and the problems in applying these to children. There follows a critique of modern instruments for measuring health status and quality of life and their application in neonatal follow-up studies. We recommend that only a small number of well-established instruments should be considered so that results are valid and can be compared with other studies.

Managed care: the new context for social work in health care--implications for survivors of childhood cancer and their families

The changing organization of health care requires social workers to deal with a variety of new demands, and in some cases alter their traditional professional practice. Using the specific case of childhood cancer as a framework (or set of case examples), this paper identifies key issues faced by oncology social workers in hospital settings under managed care and ways they have responded to them. The general content involves pressures on oncology social workers to adapt to the new corporate culture and ideals fundamental to managed care at the same time that the expressed psychosocial needs and desires of survivors of childhood cancer necessitate increased attention and expansion of service provision. Caught in conflicts that challenge them to reconcile simultaneous commitments to client service/empowerment and institutional conformity, social workers must establish a more powerful position to negotiate institutional and public policies that uphold the primacy of a core Social Work ethic: A commitment to client-centered service.

Relative osteopenia after treatment for acute lymphoblastic leukemia

Osteoporosis in adult life is associated with a significant morbidity and may be predisposed to by osteopenia and failure to reach peak bone mass in childhood. Children treated for acute lymphoblastic leukemia (ALL) may be at risk of osteopenia as a result of previous therapy or as a consequence of the disease process itself. Dual energy x-ray absorptiometry measurements of bone mineral content (BMC) for the whole body and at the lumbar spine and hip were taken in 35 (14 male) long-term survivors of ALL and compared with results in 20 (10 male) survivors of other malignancies and 31 (17 male) healthy sibling controls. The measured BMC was expressed as a percentage of a predicted value derived from the control group and based on the variables that had influence upon it. BMC (%) was reduced at the spine in the ALL group compared with controls [92.4 (8.0)% versus 100.4 (9.7)%, respectively; p < 0.005] and at the hip compared with both other malignancies and controls [89.0 (11.5)% versus 96.1 (11.7)% and 100.4 (9.2)%, respectively; p < 0.0005]. Increasing length of time off therapy was associated with a significant increase in %BMC at both the spine and the hip. For the spine, this association was significantly different between the ALL group and other malignancies, suggesting that any gain in %BMC after therapy was slower in children treated for ALL. Both exercise capacity and levels of physical activity were correlated with %BMC at the hip (r = 0.44, p < 0.001 and r = 0.29, p < 0.01, respectively). Previous exposure to methotrexate, ifosfamide, and bleomycin was associated with a reduction in %BMC at the spine. Exposure to 6-mercaptopurine and cisplatin was associated with a reduction at the hip. In conclusion, children treated for ALL are osteopenic. The mechanism is probably multifactorial but is partially related to previous chemotherapy, limited exercise capacity, and relative physical inactivity.

Health-related quality of life in survivors of tumours of the central nervous system in childhood--a preference-based approach to measurement in a cross-sectional study

There is an evident need to measure the comprehensive burden of morbidity experienced by survivors of brain tumours in childhood. To this end, a questionnaire based on the Health Utilities Index mark 2 (HUI2) and mark 3 (HUI3) systems was completed independently for a cohort of such children by their parents, by a nurse, by physicians and by a selected group of the children themselves. Each of the HUI2 and HUI3 systems consists of a multi-attribute health status classification scheme linked to a preference function which provides utility scores for levels within single attributes (domains of health) and for global health states. All eligible families (n = 44) participated. Even cognitively impaired children of at least 9.5 years of age could complete the questionnaire. The greatest burden of morbidity, occurring in two-thirds of children, was in the attribute of cognition. Surprisingly, almost one-third of children experienced pain. Global health status was lowest in children who underwent radiotherapy before the age of 5 years and the corresponding utility scores were related inversely to the volume irradiated. Children with demonstrable disease had lower scores than those in whom disease was not evident. There was a high level of agreement (intraclass correlation coefficients > 0.5) on formal assessment of inter-rater reliability for global health-related quality of life utility scores. The usefulness of measures of health status and health-related quality of life, in children surviving brain tumours, has been demonstrated by this study.

Applicability of the Health Utilities Index to a population of childhood survivors of central nervous system tumours in the U.K

This paper describes the application of a multi-attribute, preference-linked health status and health-related quality of life measurement system--the Health Utilities Index (developed in Canada)--to a group of subjects in the U.K. Children who had survived tumours of the central nervous system (n = 30, age 6-16 years) formed the study group. Respondents (children, parents, physicians and physiotherapists) found the activity (completion of a 15-item questionnaire) to be acceptable and not burdensome (it was accomplished easily by all children > or = 10 years of age). Instrumental reliability was established by acceptable intra- and interobserver agreement and construct validity was supported by strong similarities between the results obtained in this study and those reported from a similar group of children in Canada. The greatest burden of morbidity was reported for the attributes of emotion and cognition (each affected in > 50% of the children). Pain was surprisingly prevalent (affected in approximately one-third of children). The finding of a large number of unique health states emphasises the complex morbidity burden experienced by these children who self-reported poorer overall health (as reflected in utility scores) than did the proxy respondents. The information obtained from this study is readily interpretable and clinically useful. The results of this study also illustrate that extreme caution must be exercised in undertaking linguistic modifications to established instruments for, in this instance, these resulted in a loss of the ability to detect the most severe emotional morbidity and reduced the comparability of results between studies. With this provision, the Health Utilities Index is evidently applicable in the U.K. and the original version has been recommended for use in brain tumour studies by the U.K. CCSG (the U.K. Children's Cancer Study Group).

Systemizing childhood cancer care in Hungary: twenty-five years of progress

Steady and significant progress has been made in the organization of Hungarian pediatric oncology. This has been done through the mobilization of social, scientific, medical, and economic resources of Hungary, a small nation. The lessons learned, and the measures adopted, may prove useful to other countries facing similar limitations and problems.

The lifestyle assessment questionnaire: an instrument to measure the impact of disability on the lives of children with cerebral palsy and their families

Suitable measures of health and morbidity are less readily available for children than they are for adults. We present a measure, which is used to describe the impact of impairment and disability on the lives of children with cerebral palsy and their families. The development of this measure involved data collected from 691 children with cerebral palsy contained within the North-East England Cerebral Palsy Register and born between 1960 and 1985. Uniquely, multidimensional scaling techniques were used to derive dimensions analogous with those described in the International Classification of Impairments, Disabilities, and Handicaps. We present the analyses undertaken to test the properties of the tool, which show that it is a reliable and valid measure of the disadvantages experienced by children with cerebral palsy.

Quality of life and psychosocial adjustment of young patients after treatment of bone cancer

BACKGROUND

The aim of this study was to collect information about the psychosocial situation of young patients after multimodality therapy for bone cancer.

METHODS

Selection criteria for patients were ages 15-30 years, tumor localization at the extremities, and an interval of at least 1 year since the end of treatment. Of 110 patients, 60 were willing to participate. Evaluation of psychosocial quality of life included assessment of psychosocial adjustment and age-appropriate achievements as well as identification of problems typical for this patient group.

RESULTS

Approximately 80% of patients revealed, at the very most, only minor psychosocial problems. They were able to adapt well to their new living conditions, although strong efforts were necessary for them to deal with problems such as restricted mobility, catching up with school, or changing jobs or job orientation. Differences between patients and control subjects emerged in the areas of marital status, independent living, and parenthood. The most recently determined levels of education and income were similar. Neither clinical data nor physical or functional sequelae affected psychosocial adjustment, with one exception: patients diagnosed in adolescence had significantly more problems, especially in the area of social well-being, than patients diagnosed in childhood or early adulthood.

CONCLUSIONS

Given the limitations of this study, the findings suggest that survivors of bone cancer are not necessarily at risk of developing long term emotional or social problems and are not precluded from leading active and independent lives.

Psychometric properties of the Health Utilities Index Mark 2 system in paediatric oncology patients

This study examined the reliability and validity of the Health Utilities Index (HUI) Mark 2 system, a health-related quality of life (QoL) instrument, in children with cancer. The sample consisted of 61 mothers of paediatric oncology patients, aged 4.1-17.3 years, who were either on treatment (n = 20) or off treatment (n = 41). The test-retest reliability was very good for the HUI Mark 2 system global score and all of its dimensions except pain. The HUI Mark 2 dimensions of emotion, pain and self-care as well as its overall score showed moderate convergent validity with other measures. In addition, the HUI Mark 2 system demonstrated good discriminant validity. However, the content validity of the HUI Mark 2 system when considered as a multiattribute descriptive health profile is questionable because it falls to assess domains such as neuropsychological and psychosocial functioning. Overall, the results indicate that the HUI Mark 2 system is reliable and valid as a measure of health-related QoL for paediatric oncology patients.

Daily energy expenditure and physical activity in survivors of childhood malignancy

Changes in body composition, in particular the onset of obesity, may result from reductions in total daily energy expenditure (TDEE) as a consequence of relative physical inactivity. Children previously treated for acute lymphoblastic leukemia (ALL) become obese, yet the mechanism remains undefined. TDEE and physical activity levels [PAL = TDEE/basal metabolic rate (BMR)] were measured in 34 long-term survivors of ALL and compared with results from 21 survivors of other malignancies and 32 healthy sibling control subjects using the flex-heart rate technique. Body composition was measured by dual energy x-ray absorptiometry. The median TDEE was reduced in the ALL group (150 kJ x kg d(-1)) compared with other malignancies and controls (207 and 185 kJ x kg d(-1), respectively, p < 0.01). This reduction was accounted for mainly by a relative decrease in the PAL of the ALL group (1.24) compared with both other malignancies and controls (1.58 and 1.47, respectively, p < 0.01). TDEE and PAL were correlated with percentage body fat (r = -0.39, p < 0.001 and r = -0.24, p < 0.05, respectively). Obesity in survivors of ALL may, in part, be explained by a reduction in TDEE as a consequence of reduced PAL. The cause of such reduction is uncertain.

The health status of adult survivors of cancer in childhood

The success of treatment for children with cancer has resulted in a growing population of adult survivors, yet these individuals may be at risk of serious long-term health problems as a result of the treatment they have received. This study explores the pattern of morbidity within a population of 290 adult survivors of cancer in childhood assessed at a median of over 15 years from diagnosis. Acute lymphoblastic leukaemia (33%) and Hodgkin's disease (15%) were the most common primary diagnoses represented. 85% of the whole group had received treatment with chemotherapy, 81% with radiotherapy, 48% with significant surgery and 28% with all three modalities. Overall, 58% of the survivors had at least one 'chronic medical problem' and 32%, two or more. Infertility (14%), nephrectomy (11%), thyroid hormone deficiency (9%), visual handicap (9%), sex hormone (7%) and growth hormone (7%) replacement therapy were the most common problems. Compliance with long term follow-up was good and an audit of an unselected sub group of all the survivors in the study showed that 84% had attended for surveillance over a period of 1 year, accounting for 222 visits of follow up clinics: 15% were also attending other specialist follow-up including psychiatry, orthopaedic, endocrine, dental and cardiac clinics. In conclusion, survivors of cancer in childhood experience actual or potential threats to future health. More than half have at least one chronic medical problem and demonstrate a significant use of medical resources. These data support the need for the continuing follow-up of survivors of cancer in childhood into adult life and the provision of the resources to do so. Optimal patterns of care and future approaches to the reduction of sequelae in future generations of survivors are discussed.

The pediatric cancer quality of life inventory-32 (PCQL-32): I. Reliability and validity

BACKGROUND

Multidimensional measurement of pediatric cancer patients' health-related quality of life (HRQOL) in Phase III randomized controlled clinical trials is being recognized increasingly as an essential component in evaluating the comprehensive health outcomes of modern antineoplastic treatment protocols. The Pediatric Cancer Quality of Life Inventory-32 (PCQL-32) is a standardized patient self-report and parent proxy-report assessment instrument designed to assess systematically pediatric cancer patients' HRQOL outcomes.

METHODS

To validate a patient-report form and a parent-report form, the PCQL-32 was administered to 291 pediatric cancer patients and to their parents. Both forms yield a total score and five a priori multidimensional scales. Clinical validity was determined by the known-groups approach by comparing patients classified as either on or off treatment. To determine construct validity, a battery of standardized psychosocial measures was administered and a multitrait-multimethod matrix was constructed.

RESULTS

For both patient and parent forms, internal consistency reliability of the PCQL-32 total scale was high (0.91 and 0.92, respectively). The internal consistency reliabilities of the five component scales for both patient and parent forms were in the acceptable range for group comparisons. With regard to clinical validity, the PCQL-32 total scale and the disease/treatment and physical functioning scales of the PCQL-32 distinguished between patients on and off treatment for both patient- and parent-report. The results of the multitrait-multimethod matrix approach were consistent with hypotheses and lent evidence for the construct validity of the patient and parent forms of the PCQL-32 total scale and the psychological functioning, social functioning, cognitive functioning, physical functioning, and disease/treatment scales.

CONCLUSIONS

The PCQL-32 has demonstrated acceptable internal consistency reliability, clinical validity, and construct validity for both patient-report and parent-report forms. Further field testing of the PCQL-32 will determine its practicality and utility in multisite pediatric cancer randomized controlled clinical trials.

Otitis media health status evaluation: a pilot study for the investigation of cost-effective outcomes of recurrent acute otitis media treatment

There are no reliable and valid instruments that measure otitis media clinical or functional health status in children ages 1 to 3 years. This study develops and tests three new instruments of clinical and functional otitis health status: the Otitis Media Clinical Severity Index (OM-CSI), the Otitis Media Functional Status Questionnaire (OM-FSQ), and the Otitis Media Diary (OMD). The OM-CSI was found to be a reliable measure of clinical acute otitis media (AOM) severity, with high internal consistency (Cronbach's alpha) scores, as well as an accurate indicator of AOM severity. The OM-FSQ and OMD were demonstrated to be reliable and valid measures of otitis-specific functional health status, with reproducible scores over time, high internal consistency alpha scores, and high correlation with measures of AOM clinical severity and other functional health status instruments. These three new instruments were also sensitive and specific indicators of AOM episodes.

Pediatric oncology and hematology in Manchester, England

The Manchester pediatric oncology unit is the third largest unit in the United Kingdom, with approximately 120 new referred cases per annum (10% of the U.K. total). Research activities include a gene therapy program, peripheral blood stem cell studies, the genetic epidemiology of childhood cancer, late-effects research (growth, body composition, pulmonary, quality of life), psychosocial studies, and clinical trial organization. Both the clinical oncology service and research activities involve close team coordination and collaboration with scientists both within and outside Manchester. A comprehensive pediatric hematology service is provided. The unit contains the second largest children's hemophilia service in the United Kingdom, serving 200 patients with congenital blood disorders. Twenty-five bone marrow transplants are performed each year (allogeneic, unrelated donor, autologous, and peripheral stem cell) for malignant and nonmalignant disorders. These activities are closely related to local, national, and international research groups.

Brain atrophy in children undergoing systemic chemotherapy for extracranial solid tumors

It has been shown that intrathecal chemotherapy may cause brain damage, which can be depicted in neuroimaging studies. The aim of this work was to examine possible morphologic alterations in the brain of children with extracranial solid tumors, without CNS complications, treated with systemic chemotherapy. Brain CT images of 69 children with extracranial malignancies were reviewed and the extent of 12 CSF compartments was measured in 49 CT examinations performed during intravenously given chemotherapy and in 20 after therapy completion. Measurements were compared with corresponding normative data. About half of the children undergoing chemotherapy and half of the patients examined after treatment were found to have diffuse brain atrophy. Focal lesions that might be associated with therapy toxicity were not observed. Chemotherapy, even when administered via the systemic route, may cause brain damage, which is observed long after the end of treatment.

Symptom distress and life situation in adolescents with cancer

Having a life-threatening disease like cancer during adolescence poses a number of problems. The purpose of this study was to identify the adolescent's own experience of areas of the life situation affected by the disease and problems related to it. Ten adolescents with varying diagnoses and treatment were interviewed. They also completed a quantitative measurement of problems. The result shows eight domains and 24 subdomains influencing the experience of life situation. Those were disease and treatment (side effects, isolation, medical procedures), identification (others are ill, appearance), feelings and reactions (mood, self-image, meaning, hope), coping (positive thinking, distraction, positive effects), togetherness (family, friends, school), support (family and friends, the youth association, professional support), reactions of the families (parents, siblings), and quality of care (professionalism, information, organization, equipment). The problems mentioned in the interviews are also compared with the quantitative measurement used. The adolescents mentioned 77 problems in the interviews, of which 17 were not on the list of problems. Of those 17, seven dealt with physical problems, and six were problems concerning the quality of care. They ranked wanting and depending on parents as the worst problems for themselves from the list of problems.

School behaviour and health status after central nervous system tumours in childhood

This study was designed to assess the overall morbidity burden of survival from central nervous system (CNS) tumours and its impact on return to a normal lifestyle. School behaviour and health status of 27 children after treatment for CNS tumours, of 25 of their school-aged siblings, plus age- and sex-matched controls is reported. Spinetta school behaviour, Lansky play-performance and Health Utilities Index (mark II and III) assessments have been made. Patients had reduced mobility and increased pain levels. They demonstrated a reluctance to participate in organized physical activities. Impaired cognition, emotion and self-esteem were reported. They worried more than controls but attended school willingly, interacted normally with their peers and viewed the future confidently. Their siblings were reluctant to express openly concern for others or feelings of joy. Teachers were reliable proxies for most attributes, notable exceptions being speech and emotion. This is the first study to have assessed the school behaviour of a cohort solely composed of survivors of childhood CNS tumours. The good social reintegration is reassuring and likely to reflect a high level of psychosocial support. However, the results presented identify these young people as a 'special educational needs' group as defined by the 1981 and 1993 Education Acts.

Influence of proxy respondents and mode of administration on health status assessment following central nervous system tumours in childhood

Central nervous system (CNS) tumours account for 20% of childhood cancers. Survivors often experience severe physical, neuropsychological and social sequelae of the disease and its treatment. Health status assessment in these individuals is an essential clinical outcome measure, yet little consensus exists regarding the optimum methodology. The influence of proxy respondents (parents, physiotherapists and doctors) and mode of administration (home and clinic) in which assessments is performed has been evaluated in a cohort of 37 survivors of childhood CNS tumours. A health-related quality of life (HRQOL) questionnaire, incorporating the Mark II and III Health Utilities Indices, was completed at home and in clinic by patients and parents. Doctors and physiotherapists completed this questionnaire plus Lansky Play-Performance and Karnofsky Performance scores. No significant differences between raters for single attribute scores occurred either at home or in clinic, although a wide range of agreement (kappa = 0.05-1.00, percentage agreement 53-100%) between observers was revealed. Most agreement occurred between parents and patients: this was greatest on home completion (kappa = 0.48-1.00, percentage agreement 53-100%). Doctors and physiotherapists agreed less on subjective attributes (emotion, cognition and pain). Better if responses were classified as normal and abnormal. Inter-observer agreement was greater for the HRQOL questionnaire than for Karnofsky and Lansky scores. Home completion of questionnaires provides a reliable, acceptable and convenient method of assessing health status.

Quality of life in children with Crohn's disease

In a 10-week randomised cross-sectional study we used an 88-item questionnaire to assess the quality of life in 16 children (ages 8-17 years) with Crohn's disease and their families. The questionnaire covered six domains of health-related quality of life, including disease and its treatment, social, emotional, family, education, and future aspects. Crohn's disease affected education, with absenteeism in 12 and distraction during school work in six. Three children had had a home tutor, and five stated their need for one. Engaging in sports was a problem for eight children, mainly because of a lack of energy in five and the presence of a stoma in three children. Three children had missed every PE lesson in 1 year. Five children cited the social problem of being unable to stay over at friends' houses. Bullying concerned parents more than the children. Holiday difficulties included long distance traveling or lack of toilet facilities during school trips. Elemental diet was the preferred treatment, although the majority complained about the taste. Surgery was the most effective method of symptom control, though the resulting stoma was upsetting and restricted sports activities. Children on steroids had more depressive symptoms. Using the Rutter A Questionnaire, five children were designated "neurotic." Parents' views of the severity of symptoms significantly correlated with their children's views regarding rectal bleeding, poor growth, lack of energy, and poor appetite (p < 0.01). The main parental concerns were the side effects of medications and issues concerning their children's future, including schooling, job prospects, and marriage. The parents of 11 children cited problems with children's behaviour. The parents of seven cited disruption of work, and those of six named taking holidays. Crohn's disease in children, in addition to being a symptomatically disabling condition, has a great impact on the health-related quality of life of both sufferers and their parents. The questionnaire was a useful instrument, and with some adjustment it can be used again in large group studies.