Development and pilot-testing of a health-related quality of life chronic generic module for children and adolescents with chronic health conditions: a European perspective

Living with Pompe disease: results from a qualitative interview study with children and adolescents and their caregivers

BACKGROUND

Children and adolescents with Pompe disease (PD) face chronic and progressive myopathy requiring time-intensive enzyme replacement therapy (ERT). Little is known about their perspectives on the disease and its treatment. This study explored their perceptions of disease symptoms and functioning status, and more subjective feelings about the impacts on their lives as part of developing a disease-specific questionnaire.

METHODS

Eleven pediatric patients aged 8-18 years and 26 caregivers from six children's hospitals in Germany, Austria, and Switzerland underwent semi-structured interviews. Data were recorded, transcribed using MAXQDA software, and analyzed using qualitative content analysis. A system of meaningful categories was developed.

RESULTS

Sixteen main categories were derived across four major thematic areas: perceptions of symptoms and limitations, experiences to do with the biopsychosocial impact of PD, treatment experiences, and general emotional well-being/burden. Participants demonstrated broad heterogeneity in symptom perceptions such as muscle weakness, breathing difficulties, pain, and fatigue. Emotional appraisals of limitations were not directly proportional to their severity, and even comparatively minor impairments were often experienced as highly frustrating, particularly for social reasons. The main psychosocial topics were social exclusion vs. inclusion and experiences to do with having a disease. The main finding regarding treatment was that switching ERT from hospital to home was widely viewed as a huge relief, reducing the impact on daily life and the burden of infusions. Emotional well-being ranged from not burdened to very happy in most children and adolescents, including the most severely affected.

CONCLUSION

This study provided qualitative insights into the perceptions and experiences of pediatric PD patients. Interestingly, biopsychosocial burden was not directly related to disease severity, and tailored psychosocial support could improve health-related quality of life. The present findings ensure the content validity of a novel questionnaire to be tested as a screening tool to identify patients in need of such support.

A patient empowerment program for primary immunodeficiency improves quality of life in children and adolescents

Aim: To assess a patient empowerment program (PEP) for children/adolescents with primary immunodeficiency (PID) on IgG replacement therapy regarding quality of life (QoL) in patients and proxy.Patients & methods: Health-related QoL was assessed using KIDSCREEN-27 and DISABKIDS-37 before and 6 months after PID-PEP kids in 19 children/adolescents and their parents.Results: The following three dimensions of the KIDSCREEN-27 significantly increased in children/adolescents after PID-PEP kids as compared with baseline: Psychological Well-Being, Parents & Autonomy and School Environment. Total DISABKIDS-37 index, as well as 5 of the 6 DISABKIDS-37 dimensions, significantly increased, in other words, Independence, Emotion, Social Inclusion, Social Exclusion and Physical. Evaluation of proxy instruments showed comparable results.Conclusion: PID-PEP kids significantly improved QoL in patients with PID.

Suitability of quality of life outcome measures for children with severe cerebral palsy receiving postural care interventions: a scoping review

Children with Cerebral Palsy (CP) have complex conditions affecting their health which makes it challenging for assistive technology professionals to achieve desired intervention outcomes. Health professions examining quality of life (QOL) changes must use measurement tools capable of capturing intervention-related changes for the specified population. Investigators aimed to complete a scoping review of QOL-related postural care (PC) publications, identify QOL-based assessments and critically analyze their suitability in measuring intervention outcomes for children with non-ambulatory CP. Investigators searched articles published between 1998-2022 relevant to children with CP that addressed QOL-related: meanings/domains, outcome measures and clinical intervention outcomes. Investigators followed standardized published guidelines throughout each step of the scoping review process from search through data analysis. Subsequently, investigators used a published guideline for analyzing the PC outcome measures identified during the review process, examining their suitability for the target population. Results of this review will help care teams understand QOL and choose outcome assessments capable of measuring QOL-related intervention changes. Thus, making it possible for them to better serve children with severe CP.

A critical evaluation of the content validity of patient-reported outcome measures assessing health-related quality of life in children with cancer: a systematic review

BACKGROUND

With increasing survival rates in pediatric oncology, the need to monitor health-related quality of life (HRQOL) is becoming even more important. However, available patient-reported outcome measures (PROMs) have been criticized. This review aims to systematically evaluate the content validity of PROMs for HRQOL in children with cancer.

METHODS

In December 2021, a systematic literature search was conducted in PubMed. PROMs were included if they were used to assess HRQOL in children with cancer and had a lower age-limit between 8 and 12 years and an upper age-limit below 21 years. The COSMIN methodology for assessing the content validity of PROMs was applied to grade evidence for relevance, comprehensiveness, and comprehensibility based on quality ratings of development studies (i.e., studies related to concept elicitation and cognitive interviews for newly developed questionnaires) and content validity studies (i.e., qualitative studies in new samples to evaluate the content validity of existing questionnaires).

RESULTS

Twelve PROMs were included. Due to insufficient patient involvement and/or poor reporting, the quality of most development studies was rated 'doubtful' or 'inadequate'. Few content validity studies were available, and these were mostly 'inadequate'. Following the COSMIN methodology, evidence for content validity was 'low' or 'very low' for almost all PROMs. Only the PROMIS Pediatric Profile had 'moderate' evidence. In general, the results indicated that the PROMs covered relevant issues, while results for comprehensiveness and comprehensibility were partly inconsistent or insufficient.

DISCUSSION

Following the COSMIN methodology, there is scarce evidence for the content validity of available PROMs for HRQOL in children with cancer. Most instruments were developed before the publication of milestone guidelines and therefore were not able to fulfill all requirements. Efforts are needed to catch up with methodological progress made during the last decade. Further research should adhere to recent guidelines to develop new instruments and to strengthen the evidence for existing PROMs.

Self-concept development in children with limb differences: A scoping review

Having a visible physical difference, such as a limb difference, can have a significant impact on a child's psychosocial development, as children with limb differences may experience negative psychosocial sequelae. The aim of this scoping review was to investigate the findings of literature pertaining to self-concept of children with limb differences. Using the PRISMA ScR guidelines, a literature search was conducted in Embase, CINAHL, PsycINFO and PubMed databases. Nine articles met the inclusion criteria and were included in this review. Two studies focused on evaluating self-concept, whereas the remaining seven studies focused on associated constructs of self-concept (i.e., self-perception and self-esteem). The findings of these studies indicated that the social environment directly impacted the development of psychopathology and self-concept in children with limb differences. This review demonstrated a need for a gold standard instrument with which to assess children's self-concept. CLINICAL RELEVANCE: Level IV: Evidence derived from guidelines developed from a systematic review of existing qualitative, quantitative, and mixed methods research studies.

Translation and linguistic validation of the DISABKIDS chronic generic module into simplified Chinese (DCGM-37) for use among children with cancer

PURPOSE

To develop a simplified Chinese version of the DISABKIDS chronic generic module-37 (DCGM-37), and to test the translated measures in children with cancer by employing a cognitive interviewing technique.

DESIGN AND METHODS

The English version of DCGM-37 was translated forward and backward into simplified Chinese by bilingual translators, following the guidelines from its copyright holders, which also involved a cultural adaptation component. Twelve Chinese children aged 8-18 years and eight parents were cognitively interviewed.

RESULTS

The findings support the relevance, comprehensibility, and efficacy of the Chinese version. Consideration was given, and improvements were made, to the language, cultural concerns, and content, which improved functionality and increased validation. The patients/caregivers understood the instructions, questions, and answer choices. Some revisions, however, were made to address patient/caregiver feedback obtained through cognitive interviews. Conceptually and semantically, the simplified Chinese version of the DCGM-37 version was identical to the original. Conclusions The simplified Chinese version of the DCGM-37 was semantically and conceptually equivalent to the English version. Chinese children aged 8 to 18 years were able to comprehend this instrument.

CONCLUSIONS

The simplified Chinese version of the DCGM-37 was semantically and conceptually equivalent to the English version. Chinese children aged 8 to 18 years were able to comprehend this instrument and express their experiences and feelings about their life.

PRACTICE IMPLICATIONS

The simplified Chinese version of the DCGM-37 was translated, and cross-cultural adaptation and validation were performed. Chinese children found the tool easy to use and were able to express their experiences and feelings about their health-related quality of life.

Moving From Spending to Investment: A Research Agenda for Improving Health Care Financing for Children and Youth With Special Health Care Needs

Children and youth with special health care needs (CYSHCN) use disproportionately more health care resources than non-CYSHCN, and their unique needs merit additional consideration. Spending on health care in the United States is heavily concentrated on acute illnesses through fee-for-service (FFS). Payment reform frameworks have focused on shifting away from FFS, addressing health outcomes and the experience of care while lowering costs, particularly for high resource utilizers. The focus of payment reform efforts to date has been on adults with chronic illnesses, with less priority given to investment in children's health and life course. Spending for children's health is also considered an investment in their growth and development with long-term outcomes at stake, so research questions should focus on where and how such spending should be targeted. This paper discusses high-priority research topics in the area of health care financing for CYSHCN in the context of what is currently known and important knowledge gaps related to investment for CYSHCN. It proceeds to describe 3 potential research projects that can address these topics, following a framework informed by the priority questions identified in a previous multistakeholder research agenda development process. We focus on 3 areas: benefits, payment models, and quality measures. Specific aims and hypotheses are offered, as well as suggestions for approaches and thoughts on potential implications.

Quality of life of Moroccan children with celiac disease: Arabic translation and validation of a specific celiac disease instrument

PURPOSE

Gluten-free diet (GFD) is a lonely lifelong management for patients with celiac disease (CD), which may affect their quality of life (QoL). This can be evaluated by generic or specific instruments. We aimed to translate, validate and cross-culturally adapt a specific-CD instrument to Moroccan-Arabic version (M-CD-DUX), and then apply it to evaluate the QoL of Moroccan celiac children.

DESIGN AND METHODS

CD-DUX instrument was translated and culturally adapted, and preliminarily evaluated on 15 children and their proxies. The reproducibility and internal consistency of M-CD-DUX were measured by intra-class coefficient (ICC) and Cronbach α tests respectively. The statistical analysis of data consisted was conducted using SPSS, and the Goodness-of-Fit test was measured by SPSS AMOS.

RESULTS

The reliability of M-CD-DUX instrument showed a good internal consistency and reproducibility. The psychometric properties of M-CD-DUX were acceptable, and the instrument's Model fit was good [(Root Mean Square Error of Approximation = 0.062; χ2 = 603.08, p < 0.001]. M-CD-DUX was completed by 52 celiac children and their proxies. It showed a worse QoL for all items and subscales, and no difference was observed between the QoL of celiac children already under GFD and those recently diagnosed.

CONCLUSION

M-CD-DUX was the first reliable and adapted instrument used to evaluate the QoL of celiac children in an Arab country, emphasizing a negative impact of CD on their QoL.

PRACTICE IMPLICATIONS

Therefore, improving their QoL requires to make gluten-free products available to them at an appropriate price as well as a good integration into society.

Engaging the Voices of Children: A Scoping Review of How Children and Adolescents Are Involved in the Development of Quality-of-Life-Related Measures

OBJECTIVES

Patient-reported outcomes are increasingly recommended to guide patient care, develop and evaluate interventions, and modify health systems. However, not enough is known about whether and how children and adolescents, as "experts" in their own health and quality of life (QoL), are being engaged in the development of instruments. Our goals in this review were (1) to identify all QoL-related instruments that have included children and/or adolescents in the development of questionnaire content, including identification of themes and items; and (2) to report how this was done; and (3) to highlight those that used qualitative methods.

METHODS

MEDLINE and Embase were searched for child- or adolescent-completed QoL-related instruments, supplemented by hand-searching of relevant reviews until 2020. Original development papers were identified and retrieved when possible, from which instrument characteristics and details of qualitative development methods were extracted.

RESULTS

We identified 445 instruments, of which 88 used qualitative methods for content development. Interviews and focus groups were the most common methods. A variety of play techniques were used to engage the child and adolescent participants. The specific criteria for the inclusion of children and adolescents (age, developmental stage, duration, and nonclinical location) varied considerably.

CONCLUSIONS

Researchers frequently involve children and adolescents in qualitative methods when developing QoL-related measures; however, there is little information about the methods used. Better reporting of methodology, improved dissemination of methods guidelines, and research into optimal ways of including children and adolescents in the process of instrument development would be useful.

Transitional Care Interventions for Youth With Disabilities: A Systematic Review

CONTEXT

Transition from the pediatric to the adult health care system is a complex process that should include medical, psychosocial, educational, recreational, and vocational considerations.

OBJECTIVE

In this systematic review, we aim to synthesize the evidence on transitional care interventions (TCIs) to improve the quality of life (QoL) for adolescents and young adults with childhood-onset disabilities, including neurodevelopmental disorders.

DATA SOURCES

Four electronic databases (Medline, Embase, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature) were searched.

STUDY SELECTION

In the included studies, researchers examined TCIs for adolescents and young adults (12-24 years of age) with childhood-onset disabilities. Studies were experimental, quasi-experimental, and observational studies published in the last 26 years.

DATA EXTRACTION

Two reviewers independently completed study screening, data extraction, and risk-of-bias assessment.

RESULTS

Fifty-two studies were included. Five studies reported on QoL, but statistically significant improvements were noted in only 1 of these studies. Significant improvements were also found in secondary outcomes including disability-related knowledge and transitional readiness. TCIs targeted patients, families and/or caregivers, and health care providers and exhibited great heterogeneity in their characteristics and components.

LIMITATIONS

Inconsistent reporting on interventions between studies hindered synthesis of the relationships between specific intervention characteristics and outcomes.

CONCLUSIONS

Although there is limited evidence on the impact of TCIs on the QoL for youth with childhood-onset disabilities, there is indication that they can be effective in improving patient and provider outcomes. The initiation of transition-focused care at an early age may contribute to improved long-term health outcomes in this population.

Quality of Life in Romanian Children with Type 1 Diabetes: A Cross-Sectional Survey Using an Interdisciplinary Healthcare Intervention

Background: The purpose of this study was to assess the quality of life in Romanian type 1 diabetes mellitus (T1DM) children attending an early interdisciplinary healthcare intervention. Hypothesis: engaging T1DM children in leisure sports leads to a better quality of life. Methods: This research embeds a cross-sectional observational study, incorporating some clinical characteristics relevant for diabetes management. The Kidscreen 27 questionnaire was issued to 100 T1DM children aged between 7 and 17 years. Parents completed the questionnaire. All subjects received interdisciplinary healthcare in the previous year. Statistics were performed using SPSS, v20. The required sample size of 100 subjects was obtained with a confidence interval of 95% and a sampling error of 0.009. The tests were two-sided, with a type I error set at 0.05. Results: Subjects reached an increased level of physical well-being, psychological well-being, autonomy, parent relationships, peer and social support, and school inclusion. There was a significant difference (p < 0.05) between children who practice leisure activities and children who only participated in physical education (PE) classes, regarding their physical well-being (t = 2.123). ANOVA demonstrated significant differences between age groups regarding physical well-being. Conclusion: The interdisciplinary healthcare intervention increased the efficiency of T1DM management with positive effects on life quality.

Measuring quality of life in Duchenne muscular dystrophy: a systematic review of the content and structural validity of commonly used instruments

Duchenne muscular dystrophy (DMD) is an inherited X-linked neuromuscular disorder. A number of questionnaires are available to assess quality of life in DMD, but there are concerns about their validity. This systematic review aimed to appraise critically the content and structural validity of quality of life instruments for DMD. Five databases (EMBASE, MEDLINE, CINAHL, PsycINFO, and Cochrane Library) were searched, with supplementary searches in Google Scholar. We included articles with evidence on the content and/or structural validity of quality of life instruments in DMD, and/or instrument development. Evidence was evaluated against the Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria. Fifty five articles featured a questionnaire assessing quality of life in DMD. Forty instruments were extracted and 26 underwent assessment. Forty-one articles contained evidence on content or structural validity (including 37 development papers). Most instruments demonstrated low quality evidence and unsatisfactory or inconsistent validity in DMD, with the majority not featuring direct validation studies in this population. Only KIDSCREEN received an adequate rating for instrument design and a satisfactory result for content validity based on its development, yet, like the majority of PROMs, the measure has not been directly validated for use in DMD. Further research is needed on the validity of quality of life instruments in DMD, including content and structural validity studies in this population.

A Systematic Review of the Use and Quality of Qualitative Methods in Concept Elicitation for Measures with Children and Young People

BACKGROUND

Qualitative research is recommended in concept elicitation for patient-reported outcome measures to ensure item content validity, and those developing measures are encouraged to report qualitative methods in detail. However, in measure development for children and young people, direct research can be challenging due to problems with engagement and communication.

OBJECTIVES

The aim of this systematic review was to (i) explore the qualitative and adapted data collection techniques that research teams have used with children and young people to generate items in existing measures and (ii) assess the quality of qualitative reporting.

METHODS

Three electronic databases were searched with forward citation and reference list searching of key papers. Papers included in the review were empirical studies documenting qualitative concept elicitation with children and young people. Data on qualitative methods were extracted, and all studies were checked against a qualitative reporting checklist.

RESULTS

A total of 37 studies were included. The quality of reporting of qualitative approaches for item generation was low, with information missing on sampling, data analysis and the research team, all of which are key to facilitating judgements around measure content validity. Few papers reported adapting methods to be more suitable for children and young people, potentially missing opportunities to more meaningfully engage children in concept elicitation work.

CONCLUSIONS

Research teams should ensure that they are documenting detailed and transparent processes for concept elicitation. Guidelines are currently lacking in the development and reporting of item generation for children, with this being an important area for future research.

Assessing health-related quality of life in Japanese children with a chronic condition: validation of the DISABKIDS chronic generic module

Background

This study examined the reliability and validity of the Japanese versions of the DISABKIDS-37 generic modules, a tool for assessing the health–related quality of life (HRQOL) of children and adolescents with a chronic condition.

Methods

The study was conducted using a sample of 123 children/adolescents with a chronic medical condition, aged 8–18 years, and their parents. Focus interviews were performed to ensure content validity after translation. The classical psychometric tests were used to assess reliability and scale intercorrelations. The factor structure was examined with confirmatory factor analysis (CFA). Convergent validity was assessed by the correlation between the total score and the sub-scales of DISABKIDS-37 as well as the total score of KIDSCREEN-10.

Results

Both the children/adolescent and parent versions of the score showed good to high internal consistency, and the test-retest reliability correlations were r = 0.91 or above. The CFA revealed that the modified models for all domains were better fit than the original 37 item scale model for both self-report and proxy-report. Moderate to high positive correlations were found for the associations within DISABKIDS-37 sub-scales and between the subscales and total score, except for the treatment sub-scale, which correlated weakly with the remaining sub-scales. The total score of the child-reported version of KIDSCREEN-10 correlated significantly and positively with the total score and all the sub-scales of the child-reported version of DISABKIDS-37 except the Treatment sub-scale in adolescents.

Conclusions

The modified models of Japanese version of DISABKIDS generic module were psychometrically robust enough to assess the HRQOL of children with a chronic condition.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0911-1) contains supplementary material, which is available to authorized users.

Health-related quality-of-life outcome measures in paediatric palliative care: A systematic review of psychometric properties and feasibility of use

BACKGROUND

The number of children worldwide requiring palliative care services is increasing due to advances in medical care and technology. The use of outcome measures is important to improve the quality and effectiveness of care.

AIM

To systematically identify health-related quality-of-life outcome measures that could be used in paediatric palliative care and examine their feasibility of use and psychometric properties.

DESIGN

A systematic literature review and analysis of psychometric properties.

DATA SOURCES

PsychInfo, Medline and EMBASE were searched from 1 January 1990 to 10 December 2014. Hand searches of the reference list of included studies and relevant reviews were also performed.

RESULTS

From 3460 articles, 125 papers were selected for full-text assessment. A total of 41 articles met the eligibility criteria and examined the psychometric properties of 22 health-related quality-of-life measures. Evidence was limited as at least half of the information on psychometric properties per instrument was missing. Measurement error was not analysed in any of the included articles and responsiveness was only analysed in one study. The methodological quality of included studies varied greatly.

CONCLUSION

There is currently no 'ideal' outcome assessment measure for use in paediatric palliative care. The domains of generic health-related quality-of-life measures are not relevant to all children receiving palliative care and some domains within disease-specific measures are only relevant for that specific population. Potential solutions include adapting an existing measure or developing more individualized patient-centred outcome and experience measures. Either way, it is important to continue work on outcome measurement in this field.

Beneficial Effect of Growth Hormone Treatment on Health-Related Quality of Life in Children with Prader-Willi Syndrome: A Randomized Controlled Trial and Longitudinal Study

BACKGROUND/AIMS

Growth hormone (GH) treatment is beneficial for children with Prader-Willi syndrome (PWS), but data about health-related quality of life (HRQOL) and effects of GH treatment are scarce. We, therefore, investigated the effects of GH treatment on HRQOL in PWS children.

METHODS

In a randomized controlled GH trial including 26 PWS children and during an 11-year longitudinal GH study in 76 children, we annually assessed HRQOL recorded by patients and parents, using a generic questionnaire (DUX25), containing 4 subdomains (Physical, Home, Social, and Emotional) and a PWS-specific questionnaire (DUXPW).

RESULTS

At baseline, PWS children rated HRQOL similar to or higher than healthy and obese children. GH-treated children reported an increase in HRQOL in the Physical and Social subdomains and the DUXPW compared to untreated children. Parents reported an increase in the Physical and Emotional subdomains and borderline in the total DUX25 compared to parents of untreated children. During the 11 years of GH treatment, the Physical subdomain continued to improve, according to parents, whereas the Home, Social and Emotional subdomains, the total DUX25, and the DUXPW remained similar, according to children and parents.

CONCLUSIONS

PWS children rated HRQOL equally to or better than healthy and obese children. HRQOL increased during GH treatment, in contrast to HRQOL of untreated children. This effect was sustained during long-term GH treatment. PWS children consider themselves quite happy, despite some difficulties related to the syndrome.

When children with profound multiple disabilities are hospitalized: A cross-sectional survey of parental burden of care, quality of life of parents and their hospitalized children, and satisfaction with family-centered care

PURPOSE

We aimed to assess parental burden of care, satisfaction with family-centered care, and quality of life (HRQoL) of parents and their hospitalized children with profound intellectual and multiple disabilities (PIMD), and determine the relationship among these factors.

DESIGN

A cross-sectional study using printed questionnaires and qualitative questions was undertaken at a Swiss University Children's Hospital.

RESULTS

The 117 parents (98 mothers, 19 fathers) studied indicated a substantial impact on burden of care and parental health-related quality of life. Significant correlations with the hospitalized children's well-being were rs = .408 for burden of care and rs -.368 for quality of life. Qualitative results showed parents struggling to safeguard their children and worrying most about the children's well-being.

PRACTICE IMPLICATIONS

Health professionals need to be aware of parental burden and that the perception of the children's well-being and the parents' efforts determine their support needs. Easing parents' burden and fostering confidence in the hospitalized children's well-being requires coordination of care provided by advanced nurse specialists, with an institutional framework that clarifies parental collaboration.

Measurement properties of multidimensional patient-reported outcome measures in neurodisability: a systematic review of evaluation studies

AIM

To identify and appraise the quality of studies that primarily assessed the measurement properties of English language versions of multidimensional patient-reported outcome measures (PROMs) when evaluated with children with neurodisability, and to summarize this evidence.

METHOD

MEDLINE, Embase, PsycINFO, CINAHL, AMED, and the National Health Service Economic Evaluation Database were searched. The methodological quality of the papers was assessed using the COnsensus-based Standards for selection of health Measurement INstruments checklist. Evidence of content validity, construct validity, internal consistency, test-retest reliability, proxy reliability, responsiveness, and precision was extracted and judged against standardized reference criteria.

RESULTS

We identified 48 studies of mostly fair to good methodological quality: 37 papers for seven generic PROMs (CHIP, CHQ, CQoL, KIDSCREEN, PedsQL, SLSS, and YQOL), seven papers for two chronic-generic PROMs (DISABKIDS and Neuro-QOL), and four papers for three preference-based measures (HUI, EQ-5D-Y, and CHSCS-PS).

INTERPRETATION

On the basis of this appraisal, the DISABKIDS appears to have more supportive evidence in samples of children with neurodisability. The overall lack of evidence for responsiveness and measurement error is a concern when using these instruments to measure change, or to interpret the findings of studies in which these PROMs have been used to assess change.

How to assess quality of life in child and adolescent psychiatry

This article provides an overview of the conceptual foundations of measuring health-related quality of life (HRQoL) in children and adolescents in child and adolescent psychiatry, and of the current state of research in this field. The available procedures for determining quality of life are presented according to their areas of use and their psychometric characteristics. The internationally available generic instruments for measuring HRQoL in children are identified and assessed in terms of their strengths and weaknesses with regard to selected criteria. As a result, seven generic HRQoL instruments and two utility procedures have been identified which satísfy the following criteria: (i) psychometric qualíty; (ii) age-appropriate measurement; (iii) versions for self-reporting and external rating; and (iv) cross-cultural measurement. The identified instruments satisfy the individual criteria to different degrees. They are increasingly being used in health services research, treatment studies, and epidemiological research; however, they are not yet widely used as part of the clinical routine in child and adolescent psychiatrics.

Informing the NHS Outcomes Framework: evaluating meaningful health outcomes for children with neurodisability using multiple methods including systematic review, qualitative research, Delphi survey and consensus meeting

Background

The identification of suitable outcome measures will improve the evaluation of integrated NHS care for the large number of children affected by neurodisability, and has the potential to encourage the provision of more appropriate and effective health care. This research sought to appraise the potential of patient-reported outcome measures (PROMs) for children and young people with neurodisability.

Aim

This research aimed (i) to identify key outcomes of health care for children with neurodisability, beyond morbidity and mortality, from the perspectives of children, parents and professionals; (ii) to critically appraise existing generic multidimensional PROMs; and (iii) to examine whether or not the key outcomes might be measured by existing PROMs. We also sought agreement on a definition of neurodisability.

Methods

Data were gathered in three main ways, (i) a systematic review identified eligible generic multidimensional PROMs and peer-reviewed studies evaluating psychometric performance using English-language questionnaires. Studies were appraised for methodological quality and psychometric performance was appraised using standard criteria. (ii) Focus groups and interviews with children and young people with neurodisability, and separately with parents, sought to identify important outcomes of NHS care, and their feedback on example PROM questionnaires. (iii) An online Delphi survey was conducted with a multidisciplinary sample of health professionals to seek agreement on appropriate NHS outcomes. In addition, we convened a consensus meeting with a small nominal group of young people, parents and professionals; the group sought agreement on a core set of important health outcomes.

Results

From the systematic review, we identified 126 papers that reported eligible evidence regarding the psychometric performance of 25 PROMs. Evidence of psychometric robustness was more favourable for a small number of PROMs: KIDSCREEN (generic), DISABKIDS (chronic-generic) and Child Health Utility 9D (preference-based measure). The Pediatric Quality of Life Inventory and KINDL offer both self-report and a proxy report version for a range of age bands, but evidence of their psychometric performance was weaker. Evidence was lacking in one or more respects for all candidate PROMs, in both general populations and those with neurodisability. Proxy reporting was found generally to be poorly correlated with self-report. Focus groups and interviews included 54 children and young people, and 53 parents. The more important health outcomes were felt to be communication, emotional well-being, pain, mobility, independence/self-care, worry/mental health, social activities and sleep. In addition, parents of children with intellectual impairment identified behaviour, toileting and safety as important outcomes. Participants suggested problems with the face validity of example PROM questionnaires for measuring NHS care. In the Delphi survey, 276 clinicians from a wide range of professions contributed to at least one of four rounds. Professionals rated pain, hearing, seeing, sleep, toileting, mobility and communication as key goals for the NHS but also identified treating neurological symptoms as important. Professionals in the Delphi survey and parents working with the research team agreed a proposed definition for neurodisability. The consensus meeting confirmed overlap between the outcomes identified as important by young people, parents and professionals, but not complete agreement.

Conclusions

There was agreement between young people, parents and professionals regarding a core suite of more important health outcomes: communication, emotional well-being, pain, mobility, independence/self-care, worry/mental health, social activities and sleep. In addition, behaviour, toileting and safety were identified as important by parents. This research suggests that it would be appropriate to measure these constructs using PROMs to assess health care. None of the candidate PROMs in the review adequately captures all of the identified constructs, and there is inadequate evidence that candidate PROMs are psychometrically robust for use across children with neurodisability. Further consultation with young people, families and professionals is warranted to support the use of PROMs to measure NHS outcomes. Research to test potential PROMs with different age groups and conditions would be valuable.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Considering quality of life for children with cancer: a systematic review of patient-reported outcome measures and the development of a conceptual model

OBJECTIVES

An appraisal of pediatric cancer-specific quality-of-life (QOL) instruments revealed a lack of clarity about what constitutes QOL in this population. This study addresses this concern by identifying the concepts that underpin the construct of QOL as determined by a content analysis of all patient-reported outcome (PRO) instruments used in childhood cancer research.

METHODS

A systematic review was performed of key databases (i.e., MEDLINE, CINAHL, PsychINFO) to identify studies of QOL in children with cancer. A content analysis process was used to code and categorize all items from generic and cancer-specified PRO instruments. Our objective was to provide clarification regarding the conceptual underpinnings of these instruments, as well as to help inform the development of theory and contribute to building a conceptual framework of QOL for children with cancer.

RESULTS

A total of 6,013 English language articles were screened, identifying 148 studies. Ten generic and ten cancer-specific PRO instruments provided 957 items. Content analysis led to the identification of four major domains of QOL (physical, psychological, social, and general health), with 11 subdomains covering 98 different concepts. While all instruments reflected items relating to the broader domains of QOL, there was substantial heterogeneity in terms of the content and variability in the distribution of items.

CONCLUSIONS

This systematic review and the proposed model represent a useful starting point in the critical appraisal of the conceptual underpinnings of PRO instruments used in pediatric oncology and contribute to the need to place such tools under a critical, yet reflective and analytical lens.

The Importance of General Self-Efficacy for the Quality of Life of Adolescents with Chronic Conditions

We investigated the influence of general self-efficacy perceived by adolescents with chronic conditions and parents on quality of life. This cross-sectional study used the general self-efficacy scale and DISABKIDS condition-generic module to survey adolescents (92/293; 31 %) with type I diabetes, juvenile rheumatoid arthritis, cystic fibrosis, kidney/urological conditions, and neuromuscular disorders; and parents (121/293; 41 %). Self perceived and parents' perceived general self-efficacy of adolescents was compared using paired t-tests, and adolescents' quality of life and general self-efficacy were compared among conditions using analysis of variance. Bivariate correlations between general self-efficacy and quality of life were identified, and multiple regression sought predictors of quality of life after controlling for background variables. Social quality of life was lowest among those with neuromuscular disorders. General self-efficacy was highest among adolescents with cystic fibrosis and lowest among those with urological conditions. Parents' perceptions of general self-efficacy were higher than adolescents' (p ≤ 0.05), although absolute differences were small. General self-efficacy perceived by parents and adolescents was related to emotional, physical, and social quality of life. Adolescents' perceived self-efficacy predicted all quality of life domains. Parents' perceptions of the adolescents self-efficacy predicted the adolescents' social quality of life (β = 0.19; p ≤ 0.01). General self-efficacy of adolescents with chronic conditions as perceived by themselves and their parents is important for adolescents' quality of life. Interventions to improve general self-efficacy should benefit quality of life among these adolescents.

The Longitudinal Relationship Between Satisfaction with Transitional Care and Social and Emotional Quality of Life Among Chronically Ill Adolescents

This study aimed to identify the relationship between satisfaction with transitional care and quality of life of chronically ill adolescents over time. This longitudinal study included adolescents with type I diabetes, juvenile idiopathic arthritis (JIA), and neuromuscular disorders (NMD). At baseline 138 respondents (response rate 31 %) filled in a questionnaire and 188 about 1 year later (response rate 43 %). Analysis of variance showed that adolescents with diabetes reported the highest physical quality of life, followed in order by those with NMD and JIA (p ≤ 0.01). Adolescents with diabetes reported the highest social quality of life, followed in order by those with JIA and NMD (both at p ≤ 0.001). Univariate analyses showed that satisfaction with transitional care at T0 was significantly related to emotional and physical quality of life at T1 (both at p ≤ 0.05). At T1, satisfaction with transitional care was significantly related to the emotional, physical, and social domains of quality of life (all at p ≤ 0.001). Multiple regression analyses revealed that satisfaction with transitional care at T1 was related to emotional (β -0.20; p ≤ 0.05) and social (β -0.35; p ≤ 0.01) quality of life domains over time. This indicates that lower gap scores, which measured differences between 'best care' and 'current care,' are associated with better social and emotional quality of life in this sample of adolescents. Satisfaction with transitional care and social and emotional quality of life are related over time.

Health-related quality of life in children and adolescents with celiac disease: from the perspectives of children and parents

Aim. To examine how celiac children and adolescents on gluten-free diet valued their health-related quality of life, and if age and severity of the disease at onset affected the children's self-valuation later in life. We also assessed the parents' valuation of their child's quality of life. Methods. The DISABKIDS Chronic generic measure, short versions for both children and parents, was used on 160 families with celiac disease. A paediatric gastroenterologist classified manifestations of the disease at onset retrospectively. Results. Age or sex did not influence the outcome. Children diagnosed before the age of five scored higher than children diagnosed later. Children diagnosed more than eight years ago scored higher than more recently diagnosed children, and children who had the classical symptoms of the disease at onset scored higher than those who had atypical symptoms or were asymptomatic. The parents valuated their children's quality of life as lower than the children did. Conclusion. Health-related quality of life in treated celiac children and adolescents was influenced by age at diagnosis, disease severity at onset, and years on gluten-free diet. The disagreement between child-parent valuations highlights the importance of letting the children themselves be heard about their perceived quality of life.

Reliability and validity of the Norwegian child and parent versions of the DISABKIDS Chronic Generic Module (DCGM-37) and Diabetes-Specific Module (DSM-10)

Background

International guidelines on type 1 diabetes advocate routine screening of health-related quality of life (HRQOL). DISABKIDS questionnaires are the first instruments developed across cultures and nations to provide age-appropriate measures of HRQOL in children with chronic diseases. DISABKIDS includes a Chronic Generic Module 37 (DCGM-37) and disease-specific modules. The purpose of this study was to examine reliability and validity of the Norwegian versions of the DISABKIDS questionnaires in children and adolescents with type 1 diabetes.

Methods

The DCGM-37 and the Diabetes Specific Module-10 (DDM-10) were translated into Norwegian using standard forward-backward translation. Eight to 19 year old children and adolescents with type 1 diabetes scheduled for routine follow-up at three diabetic clinics in Norway and one of their parents were invited to complete the DCGM-37 and the DDM-10. Internal consistency was determined using Cronbach's alpha. Results were compared with those of the Child Health Questionnaire Children Form-87 (CHQ-CF87) and Child Health Questionnaire Parent Form-50 which are established generic questionnaires. DISABKIDS results were related to age, gender, duration of diabetes, mode of insulin delivery and metabolic control. Clinical data were obtained from the Norwegian Childhood Diabetes Registry.

Results

Of 198 eligible child-parent dyads, 103 (52%) completed the questionnaires. Mean age was 13.6 (2.6), range 8-19 yrs, 52% were boys. Cronbach's alpha was > 0.70 for all the DISABKIDS sub-scales except two (physical ability and social inclusion). There were moderate to high correlations (0.65-0.81) between the DISABKIDS scales and mental/emotional sub-scales of CHQ-CF87. Increasing age and higher HbA1c were significantly associated with reduced HRQOL scores. Parents tended to score their child's HRQOL lower than the children/adolescents themselves.

Conclusions

The study shows that the DISABKIDS instruments are applicable to a Norwegian childhood diabetes population. They seem to be a relevant supplement to other clinical indicators in medical practice and research.

The proxy problem anatomized: child-parent disagreement in health related quality of life reports of chronically ill adolescents

Background

Discrepancy between self-reports and parent-proxy reports of adolescent health-related quality of life (HRQoL) has been repeatedly acknowledged in the literature as the proxy problem. However, little is known about the extent and direction of this discrepancy. The purpose of this study is to explore to what extent and in what direction HRQoL self-reports of adolescents with chronic conditions and those of their parents differ.

Methods

A cross-sectional survey was conducted among adolescents suffering from chronic conditions and their parents. Socio-demographic and disease-related characteristics were collected and information about consequences of the chronic condition was assessed. HRQoL was measured with KIDSCREEN-10 and DISABKIDS condition generic measure (DCGM-10). Agreement was analysed through defining a threshold of agreement based on half of the standard deviation of the HRQoL score with the highest variance. Agreement occurred if the difference between adolescent and parent scores was less than or equal to half of the standard deviation. Intra-class correlation coefficients and Bland-Altman plots were also computed. The characteristics associated with direction of disagreement were statistically tested with one-way ANOVA and Chi-square tests.

Results

584 paired HRQoL scores were obtained. Ratings from both adolescents and parents were high, compared to European norm data. Differences between adolescents and parents were statistically significant, yet relatively small. Disagreement existed in both directions: in 24.5% (KIDSCREEN-10) and 16.8% (DCGM-10) of the cases adolescents rated their HRQoL lower than did their parent, while in 32.2% (KIDSCREEN-10) and 31.7% (DCGM-10) of the cases the opposite was true. Adolescent's age, educational level and type of education, parent's educational level, number of hospital admissions and several other disease-related factors influenced direction of disagreement.

Conclusions

In a reasonable proportion of cases the adolescent and parent agreed on the adolescent's HRQoL (43-51% of the cases) and most disagreement tended to be minor. Thus, the proxy problem may be smaller than presented in the literature and its extent may differ per population. As adolescents are expected to become partners in their own health care, it is recommended to focus on adolescents' own perceptions of HRQoL.

Can one question be a useful indicator of psychosocial problems in adolescents with diabetes mellitus?

AIM

A screening tool for psychosocial functioning of adolescents with diabetes is unavailable. We investigated whether one question using a Visual Analogue Scale that indicates a rating from the worst (0) to the best possible life (10) is related to standardized indices of psychosocial functioning and well-being in adolescents with diabetes mellitus type 1 (T1DM).

METHOD

One hundred and fifty-one adolescents with T1DM and 122 healthy peers between 12 and 18 years of age were asked to rate their life on a scale, varying from 0 to 10. Behaviour problems and depressive symptoms were measured with the Youth Self-Report (YSR) and the Children's Depression Inventory (CDI).

RESULTS

Adolescents with T1DM rated their life less positive in comparison with their healthy peers (F(1,269) = 14.01, p = 0.000). Adolescents with T1DM who rated their life with a 6 or lower reported more depressive symptoms and behaviour problems (F(2,131) = 24.19, p = 0.00) compared to those with higher scores (7 or up).

CONCLUSION

One question the 'rate your life scale' identified most of the adolescents at risk of internalizing behaviour problems, especially depression. The results of this first step in exploring the validity of this question as a screening tool for psychological functioning are promising.

Assessing health-related quality of life in European children and adolescents

Childhood health and illness have changed considerably over the past century calling for an increasing awareness of mental health problems. Consequently, the assessment of mental health problems is of major importance, not only focussing on mental health diagnoses but also on components of health-related quality of life (HRQOL) and functioning with regard to the impact of an illness or injury, medical treatment, or health care policy. Recently, a number of HRQOL measures for children and adolescents have been developed and applied in a number of studies. The current paper presents multi-cultural tools for the assessment of HRQOL, which were developed within European projects, describes the application of these tools in cross-national studies and pinpoints important determinants of HRQOL and mental health problems. Future research needs are discussed.

Cross-cultural adaptation and psychometric properties of the Brazilian-Portuguese version of the VSP-A (Vécu et Santé Perçue de l'Adolescent), a health-related quality of life (HRQoL) instrument for adolescents, in a healthy Brazilian population

Background

Health-related quality of life (HRQoL) assessment, encompassing the adolescents' perceptions of their mental, physical, and social health and well-being is increasingly considered an important outcome to be used to identify population health needs and to provide targeted medical care. Although validated instruments are essential for accurately assessing HRQoL outcomes, there are few cross-culturally adapted tools for use in Brazil, and none designed exclusively for use among adolescents. The Vécu et Santé Perçue de l'Adolescent (VSP-A) is a generic, multidimensional self-reported instrument originally developed and validated in France that evaluates HRQoL of ill and healthy adolescents.

Purpose

To cross-culturally adapt and validate the Brazilian-Portuguese version of the VSP-A, a generic HRQoL measure for adolescents originally developed in France.

Methods

The VSP-A was translated following a well-validated forward-backward process leading to the Brazilian version. The psychometric evaluation was conducted in a sample of 446 adolescents (14-18 years) attending 2 public high schools of São Gonçalo City. The adolescents self-reported the Brazilian VSP-A, the validated Psychosomatic Symptom Checklist and socio-demographic information. A retest evaluation was carried out on a sub-sample (n = 195) at a two-week interval.

The internal construct validity was assessed through confirmatory factor analysis (CFA), multi-trait scaling analyses, Rasch analysis evaluating unidimensionality of each scale and Cronbach's alpha coefficients. The reproducibility was evaluated by intra-class correlation coefficients (ICC). Zumbo's ordinal logistic regression analysis was used to detect differential item functioning (DIF) between the Brazilian and the French items. External construct validity was investigated testing expected differences between groups using one-way analysis of variance (ANOVA), Mann-Whitney tests and the univariate general regression linear model.

Results

CFA showed an acceptable fit (RMSEA=0.05; CFI=0.93); 94% of scaling success was found for item-internal consistency and 98% for item discriminant validity. The items showed good fit to the Rasch model except 3 items with an INFIT at the upper threshold. Cronbach's Alpha ranged from 0.60 to 0.85. Test-retest reliability was moderate to good (ICC=0.55-0.82). DIF was evidenced in 4 out of 36 items. Expected patterns of differences were confirmed with significantly lower physical, psychological well being and vitality reported by symptomatic adolescents.

Conclusions

Although DIF in few items and responsiveness must be further explored, the Brazilian version of VSP-A demonstrated an acceptable validity and reliability in adolescents attending school and might serve as a starting point for more specific clinical investigations.

A systematic review of the psychometric properties of Quality of Life measures for school aged children with cerebral palsy

Background

This systematic review aimed to evaluate the psychometric properties and clinical utility of all condition specific outcome measures used to assess quality of life (QOL) in school aged children with cerebral palsy (CP).

Methods

Relevant outcome measures were identified by searching 8 electronic databases, supplemented by citation tracking. Two independent reviewers completed data extraction and analysis of the measures using a modified version of the CanChild Outcome Measures Rating Form.

Results

From the 776 papers identified 5 outcome measures met the inclusion criteria: the Care and Comfort Hypertonicity Questionnaire (C&CHQ), the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD), CP QOL-Child, DISABKIDS and PedsQL 3.0 CP Module. There was evidence of construct validity for all five measures. Content validity was reported for all measures except PedsQL 3.0. The CPCHILD and CP QOL-Child were the only outcome measures to have reported data on concurrent validity. All measures, with the exception of one (C&CHQ) provided evidence of internal reliability. The CPCHILD and the CP-QOL-Child had evidence of test-retest reliability and DISABKIDS had evidence of inter-rater reliability. There were no published data on the responsiveness of these outcome measures.

Conclusions

The CPCHILD and the CP QOL-Child demonstrated the strongest psychometric properties and clinical utility. Further work is needed, for all measures, on data for sensitivity to change.

Development of the EQ-5D-Y: a child-friendly version of the EQ-5D

Purpose

To develop a self-report version of the EQ-5D for younger respondents, named the EQ-5D-Y (Youth); to test its comprehensibility for children and adolescents and to compare results obtained using the standard adult EQ-5D and the EQ-5D-Y.

Methods

An international task force revised the content of EQ-5D and wording to ensure relevance and clarity for young respondents. Children’s and adolescents’ understanding of the EQ-5D-Y was tested in cognitive interviews after the instrument was translated into German, Italian, Spanish and Swedish. Differences between the EQ-5D and the EQ-5D-Y regarding frequencies of reported problems were investigated in Germany, Spain and South Africa.

Results

The content of the EQ-5D dimensions proved to be appropriate for the measurement of HRQOL in young respondents. The wording of the questionnaire had to be adapted which led to small changes in the meaning of some items and answer options. The adapted EQ-5D-Y was satisfactorily understood by children and adolescents in different countries. It was better accepted and proved more feasible than the EQ-5D. The administration of the EQ-5D and of the EQ-5D-Y causes differences in frequencies of reported problems.

Conclusions

The newly developed EQ-5D-Y is a useful tool to measure HRQOL in young people in an age-appropriate manner.

Quality of life and rare diseases

HRQOL assessment in patients with rare diseases can help to identify health needs, to evaluate the impact of disease and treatments, and to assess the evolution in health status through the natural history of disease. Several studies have shown that although some rare diseases do not necessarily affect life expectancy, the majority lead to physical, emotional and/or psychosocial limitations with a wide range of disabilities. Reliability as well as content, criterion, and construct validity, and also responsiveness should be taken into account in selecting the instrument to be used assessing individuals with rare diseases. The use of proxy-report may be essential in some cases where the patient is cognitively impaired or unable to communicate. Criteria for selecting a HRQOL instrument, as well as the more common strategies proposed help interpret scores on HRQOL instruments are addressed in the chapter. Given the impact of rare diseases on the quality of life of both patients and carers, it is likely that interest in its measurement will continue to increase among professionals, patients, and the general public. Improving the quality of life of people with rare diseases should be one of the most important goals of any health care intervention or multidisciplinary approach.

Health-related quality of life in intensively treated young patients with type 1 diabetes

This study aimed to analyse the impact of the disease and treatment on health-related quality of life (HRQOL) in intensively treated young patients with diabetes. Our main hypothesis was that metabolic control, gender, age and socio-economic status predict HRQOL. All children and adolescents (n = 400, 191 girls) and parents in a geographic population of two paediatric clinics in Sweden [mean age 13.2 yr, +/-SD 3.9, range 2.6-19.6; mean duration of diabetes 5.1 yr, +/-SD 3.8, range 0.3-17.6; yr mean haemoglobin A1c (HbA1c) 7.1%, +/-SD 1.2, range 4.0-10.7] received the DISABKIDS questionnaire, a validated combined chronic generic and condition-specific HRQOL measure for children, and the EuroQol-5D questionnaire. Parents as proxy perceived HRQOL lower than their children. Adolescents with separated parents reported lower generic HRQOL (GeHRQOL) and diabetes-specific HRQOL (DiHRQOL) than those with parents living together (p = 0.027 and p = 0.043, respectively). Adolescent girls reported lower GeHRQOL (p = 0.041) and DiHRQOL (p = 0.001) than boys did. Parents of girls <8 yr of age reported lower DiHRQOL (p = 0.047) than did parents of boys <8 yr. In addition, a difference was found in HRQOL between centres. Intensive insulin therapy did not seem to lower HRQOL. If anything, along with better metabolic control, it increased HRQOL. A correlation between DiHRQOL and HbA1c was found in adolescents (r = -0.16, p = 0.046) and boys aged 8-12 yr (r = -0.28, p = 0.045). We conclude that the diabetes team can influence the HRQOL of the patients as there was a centre difference and because HRQOL is influenced by glycaemic control and insulin regimen. Girls seem to need extra support.

Cough affects quality of life in asthmatic children aged 8-14 more than other asthma symptoms

BACKGROUND

Asthma may influence children's health-related quality of life (QoL) differently by various symptoms, at different severity. The primary aim of this study was to evaluate the QoL in children with asthma and describe the impact of each asthma symptom on the child's well-being at different severity levels.

MATERIAL AND METHODS

Two hundred randomly selected children and one of their parents who consulted an outpatient asthma clinic, participated in the study. Qol was assessed with DISABKIDS-Smiley measure for children aged 4-7 years and with DISABKIDS DCGM-37 and Asthma Module for children 8-14 year old.

RESULTS

Most of the children suffered from mild or moderate persistent asthma. Children with uncontrolled asthma stated lower QoL compared to partly controlled or controlled in both age groups (p < 0.05 in all domains). Cough appeared to affect QoL of 8-14 year olds more than other symptoms, especially in girls. In younger children, sex (boys, p = 0.039), age (p = 0.045), proxy sex (father, p = 0.048), frequency of doctor visits (4-6 months, p = 0.001), use of beta-2 agonists (p = 0.007) and father's smoking habits (p = 0.015) were associated with the QoL of coughing children but no correlation between cough and QoL was detected. In the 8-14 year age group coughers reported lower QoL compared to their counterparts; moreover, cough was found to affect QoL more than other symptoms (p < 0.05 in all domains).

CONCLUSIONS

Cough has a direct effect on asthmatic children's QoL but there is still an obvious need for research to reveal all the determinats of this effect.

Short forms of subjective quality of life assessments from cross-cultural studies for use in surveys with different populations

Among several advances in quality of life (QOL) assessment development, such as cross-cultural comparability of measurements, inclusion of more specific target populations, and assessment on different levels of QOL generality, economy of measurement has become of increasing importance. As a consequence, construction of short forms and indices of original measures is common in QOL assessment development. The present paper puts special emphasis upon the issue of shortening measures and developing short forms in QOL assessment in relation to this development. Some basic principles and procedures of short-form development in general are outlined, and selected prominent examples of short-form development as applied to QOL assessment are described.

Assessment of childhood diabetes-related quality-of-life in West Sweden

AIM

To investigate health-related quality-of-life (HrQoL) in childhood diabetes and the level of agreement between West Sweden and European reference data for the new multi-cultural European questionnaire - DISABKIDS.

METHOD

Twenty percent of the Swedish paediatric diabetes population was included in the survey. Child-parent pairs completed the DISABKIDS chronic generic (37 questions) and diabetes modules (10 questions) during their routine clinic visit. A one-page results summary, based on positive domains, was used to provide feedback to clinicians.

RESULTS

Three hundred and sixty-one child-parent pairs were included in the analysis. In Sweden, diabetes was perceived by the children as having less impact than the European average. Swedish parents rated the HrQoL of their children lower than did the European parents. Swedish girls had a lower HrQoL than boys and greater difficulty accepting their diabetes; adolescents had greater difficulty accepting the diagnosis than younger children. Parents reported greater impact of diabetes on their children than the children themselves but reported no difference between boys and girls. Parents reported better acceptance of treatment in boys. The child's reported quality-of-life (QoL) is related to age and gender.

CONCLUSION

Our results confirm the applicability of DISABKIDS to the Swedish paediatric diabetes population.

Normalization strategies of children with asthma

Despite understanding the physiologic effects of childhood asthma, less is known about how children perceive living with asthma. We undertook semistructured, in-depth interviews with 11 boys and 11 girls (all aged 11) drawn from a larger ongoing asthma study of Manitoba children born in 1995. All had asthma, as diagnosed by a pediatric allergist. We sought to further understand how children perceive asthma. Children spoke of feeling different and commonly used words such as "pain" and "hurt." We have categorized children's strategies to normalize their lives as (a) minimizing the health impact, (b) stressing normality, (c) emphasizing abilities, (d) making adaptations in daily living, and, (e) managing symptoms with medications. These findings suggest that aspects of other researchers' work regarding normalization efforts of children with various chronic diseases also apply in a chronic condition that is less obvious.

Impact of neurofibromatosis 1 upon quality of life in childhood: a cross-sectional study of 79 cases

BACKGROUND

Neurofibromatosis 1 (NF1) has a significant impact on quality of life (QoL).

OBJECTIVES

To evaluate QoL in NF1 according to phenotype from the viewpoint of children and proxy.

METHODS

One hundred and forty families with a child aged between 8 and 16 years, seen consecutively at the National Academic Paediatric Referral Centre for NF1 for a phenotype evaluation, were contacted by mail. Families agreeing to participate were sent two questionnaires, the DISABKIDS for children and proxy and the cartoon version of the Children's Dermatology Life Quality Index (CDLQI). QoL scores were compared with those in other major diseases and were analysed according to age, gender and phenotype.

RESULTS

Eighty families agreed to participate, and 79 returned the questionnaires. Using DISABKIDS, NF1 had a higher impact on health-related QoL than asthma (mean+/-SD 75.18+/-18.22 vs. 79.78+/-13.41; P=0.005). The total score was more altered when assessed by proxy than by children (71.20+/-17.94 vs. 75.18+/-18.22; P=0.002). Orthopaedic manifestations, learning disabilities and presence of at least two plexiform neurofibromas were independently associated with a higher impact (P<0.01). The CDLQI score was slightly altered (11.3%). Dermatological signs, such as café-au-lait spots and freckling, did not have a significant impact.

CONCLUSIONS

Orthopaedic manifestations, learning disabilities and plexiform neurofibromas are the main complications impacting on QoL during childhood NF1. QoL could be considered as an endpoint for intervention studies in this context.

Psychometric properties of the KINDL-R questionnaire: results of the BELLA study

BACKGROUND

The concept of health-related quality of life (HRQoL) involves the respondents' perception of well-being and functioning in physical, emotional, mental, social, and everyday life areas. Research in the area of subjective health has resulted in the development of a multitude of HRQoL instruments that meet satisfying psychometric standards with regard to reliability, validity, and sensitivity of the scales. One frequently used generic measure for children and adolescents is the KINDL-R questionnaire developed by Ravens-Sieberer and Bullinger (Qual Life Res 7:399-407, 1998).

METHODS

Within the representative sample of the BELLA study, analyses regarding psychometric properties (namely reliability as well as discriminant and construct validity) are performed.

RESULTS

Psychometric testing of the KINDL-R questionnaire reveals good scale utilisation and scale fit as well as moderate internal consistency. Correlations with the KIDSCREEN-52 subscales are shown. Differences in KINDL-R scores exist between chronically ill and healthy children as well as between SDQ problem scores.

CONCLUSION

The KINDL-R is a suitable instrument for measuring HRQoL in children and adolescents through self-report. The testing of the instrument in a representative sample of German children and adolescents as well as their parents provides reference values extending the potential of the KINDL-R questionnaire.

CDDUX: a disease-specific health-related quality-of-life questionnaire for children with celiac disease

OBJECTIVE

The development of a disease-specific, health-related, quality-of-life questionnaire for children ages 8 to 18 with celiac disease (CD), together with a parent-as-proxy version.

MATERIALS AND METHODS

We used a focus-group method (bottom-up approach) to investigate the impact of CD on children's everyday lives and selected 24 items to create a preliminary disease-specific questionnaire. This questionnaire, together with the complementary generic quality-of-life questionnaire DUX-25, was sent to 756 children with CD in the Netherlands and was returned by 530 of them. With the help of statistical analyses (Cronbach alpha, factor analysis, Pearson correlation, Student t test, paired samples t test, and item response theory), we tested the psychometric performance of the 24 items.

RESULTS

We reduced the questionnaire to 12 items: the Celiac Disease DUX (CDDUX). The CDDUX has 3 subscales: "Communication" (3), "Diet" (6), and "Having CD" (3). This questionnaire proved to be reliable, valid, and feasible and able to discriminate between perception of severity in cases of CD as assessed by parents.

CONCLUSIONS

Children with a better perception of their own health status have a higher score on the CDDUX questionnaire. The whole group seems to have a lower quality of life than the healthy reference group on all domains of the DUX-25. The new disease-specific questionnaire CDDUX provides information about how children with CD think and feel about their illness. The questionnaire may enable researchers and clinicians to determine the consequences of this illness and the effects of clinical interventions on several aspects of daily living.

Measuring children's health-related quality of life after trauma

Consideration of children's health-related quality of life (HRQOL) after injury is a critical aspect of outcome in assessing the effectiveness of trauma care. Numerous instruments are available today for measuring the HRQOL of injured children. HRQOL instruments reflect the subjective perspective of the impact an injury or disease has on a child's physical, emotional, and social well being. Most studies to date have examined children's HRQOL during the first year postinjury, relatively little is known about children's long-term HRQOL after trauma. Most trauma outcome studies have included children with heterogeneous injuries so the impact of specific injuries on HRQOL outcomes has not been well established. The majority of outcome studies have focused on injured children who have been hospitalized, however the research should be extended to the emergency department because a large proportion of injured children are treated and released from there. In addition to documenting recovery, investigators should use HRQOL instruments to evaluate the quality of care we offer injured children and their families. Rigorously conducted HRQOL assessment will provide valuable information that we can use to successfully optimize children's recovery after trauma.