Clinical implications of current findings in neurodevelopment

The quality of health services provided to remote dwelling aboriginal infants in the top end of northern Australia following health system changes: a qualitative analysis

Background

In Australia the health outcomes of remote dwelling Aboriginal infants are comparable to infants in developing countries. This research investigates service quality, from the clinicians’ perspective and as observed and recorded by the researcher, in two large Aboriginal communities in the Top End of northern Australia following health system changes.

Methods

Data were collected from semi-structured interviews with 25 clinicians providing or managing child health services in the two study sites. Thirty hours of participant observation was undertaken in the ‘baby-rooms’ at the two remote health centres between June and December 2012. The interview and observational data, as well as field notes were integrated and analysed thematically to explore clinicians’ perspectives of service delivery to infants in the remote health centres.

Results

A range of factors affecting the quality of care, mostly identified before health system changes were instigated, persisted. These factors included ineffective service delivery, inadequate staffing and culturally unsafe practices. The six themes identified in the data: ‘very adhoc’, ‘swallowed by acute’, ‘going under’, ‘a flux’, ‘a huge barrier’ and ‘them and us’ illustrate how these factors continue, and when combined portray a ‘very chaotic system’.

Conclusion

Service providers perceived service provision and quality to be inadequate, despite health system changes. Further work is urgently needed to improve the quality, cultural responsiveness and effectiveness of services to this population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0849-1) contains supplementary material, which is available to authorized users.

Socioeconomic disadvantage and neural development from infancy through early childhood

BACKGROUND

Early social experiences are believed to shape neurodevelopment, with potentially lifelong consequences. Yet minimal evidence exists regarding the role of the social environment on children's neural functioning, a core domain of neurodevelopment.

METHODS

We analysed data from 36 443 participants in the United States Collaborative Perinatal Project, a socioeconomically diverse pregnancy cohort conducted between 1959 and 1974. Study outcomes included: physician (neurologist or paediatrician)-rated neurological abnormality neonatally and thereafter at 4 months and 1 and 7 years; indicators of neurological hard signs and soft signs; and indicators of autonomic nervous system function.

RESULTS

Children born to socioeconomically disadvantaged parents were more likely to exhibit neurological abnormalities at 4 months [odds ratio (OR) = 1.20; 95% confidence interval (CI) = 1.06, 1.37], 1 year (OR = 1.35; CI = 1.17, 1.56), and 7 years (OR = 1.67; CI = 1.48, 1.89), and more likely to exhibit neurological hard signs (OR = 1.39; CI = 1.10, 1.76), soft signs (OR = 1.26; CI = 1.09, 1.45) and autonomic nervous system dysfunctions at 7 years. Pregnancy and delivery complications, themselves associated with socioeconomic disadvantage, did not account for the higher risks of neurological abnormalities among disadvantaged children.

CONCLUSIONS

Parental socioeconomic disadvantage was, independently from pregnancy and delivery complications, associated with abnormal child neural development during the first 7 years of life. These findings reinforce the importance of the early environment for neurodevelopment generally, and expand knowledge regarding the domains of neurodevelopment affected by environmental conditions. Further work is needed to determine the mechanisms linking socioeconomic disadvantage with children's neural functioning, the timing of such mechanisms and their potential reversibility.

Discontinuities between maternity and child and family health services: health professional's perceptions

BACKGROUND

Continuity in the context of healthcare refers to the perception of the client that care has been connected and coherent over time. For over a decade professionals providing maternity and child and family health (CFH) services in Australia and internationally have emphasised the importance of continuity of care for women, families and children. However, continuity across maternity and CFH services remains elusive. Continuity is defined and implemented in different ways, resulting in fragmentation of care particularly at points of transition from one service or professional to another.This paper examines the concept of continuity across the maternity and CFH service continuum from the perspectives of midwifery, CFH nursing, general practitioner (GP) and practice nurse (PN) professional leaders.

METHODS

Data were collected as part of a three phase mixed methods study investigating the feasibility of implementing a national approach to CFH services in Australia (CHoRUS study). Representatives from the four participating professional groups were consulted via discussion groups, focus groups and e-conversations, which were recorded and transcribed. In total, 132 professionals participated, including 45 midwives, 60 CFH nurses, 15 general practitioners and 12 practice nurses. Transcripts were analysed using a thematic approach.

RESULTS

'Continuity' was used and applied differently within and across groups. Aspects of care most valued by professionals included continuity preferably characterised by the development of a relationship with the family (relational continuity) and good communication (informational continuity). When considering managerial continuity we found professionals' were most concerned with co-ordination of care within their own service, rather than focusing on the co-ordination between services.

CONCLUSION

These findings add new perspectives to understanding continuity within the maternity and CFH services continuum of care. All health professionals consulted were committed to a smooth journey for families along the continuum. Commitment to collaboration is required if service gaps are to be addressed particularly at the point of transition of care between services which was found to be particularly problematic.

Structure and etiology of co-occurring internalizing and externalizing disorders in adolescents

Several studies suggest that a two-factor model positing internalizing and externalizing factors explains the interrelationships among psychiatric disorders. However, it is unclear whether the covariation between internalizing and externalizing disorders is due to common genetic or environmental influences. We examined whether a model positing two latent factors, internalizing and externalizing, explained the interrelationships among six psychiatric disorders (major depressive disorder, generalized anxiety disorder, separation anxiety disorder, attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder) in adolescents, and whether there are common genetic and environmental influences on internalizing and externalizing latent factors. Multivariate behavior genetic analyses of data from 1162 twin pairs and 426 siblings ascertained from the general population via the Colorado Center for Antisocial Drug Dependence (CADD) were conducted. We found support for a model positing two latent factors (internalizing and externalizing). These factors were moderately heritable and influenced by significant common genetic and nonshared environmental influences. These findings suggest that co-occurrence of internalizing and externalizing psychopathology in adolescents results from both genetic and environmental influences.

Practical guidelines for evaluating lead exposure in children with mental health conditions: molecular effects and clinical implications

Children in the United States are exhibiting extremely high levels of attentional and learning disabilities. Although lead has been eliminated from many industrial products, children continue to come into contact with it, such as in toys and cosmetics. Lead exposure occurs most commonly in poor, urban populations, and can exacerbate psychiatric disorders associated with stress. We present 1) an overview of lead exposure; 2) a detailed summary of current research on the molecular synergy of toxicity caused by lead and stress; 3) a review of human studies that appear to correlate with these molecular findings, including understanding nutrition, environmental enrichment, and caregiving as risk modifiers; and 4) a systematic approach for mental health practitioners in managing children presenting with multiple symptoms and risk factors for mental health conditions. In this article, we review some of the clinical and scientific challenges that relate to the assessment and treatment of children presenting for mental health care who may have potential lead exposure.

Cultural neuroscience and psychopathology: prospects for cultural psychiatry

There is a long tradition that seeks to understand the impact of culture on the causes, form, treatment, and outcome of psychiatric disorders. An early, colonialist literature attributed cultural characteristics and variations in psychopathology and behavior to deficiencies in the brains of colonized peoples. Contemporary research in social and cultural neuroscience holds the promise of moving beyond these invidious comparisons to a more sophisticated understanding of cultural variations in brain function relevant to psychiatry. To achieve this, however, we need better models of the nature of psychopathology and of culture itself. Culture is not simply a set of traits or characteristics shared by people with a common geographic, historical, or ethnic background. Current anthropology understands culture as fluid, flexible systems of discourse, institutions, and practices, which individuals actively use for self-fashioning and social positioning. Globalization introduces new cultural dynamics and demands that we rethink culture in relation to a wider domain of evolving identities, knowledge, and practice. Psychopathology is not reducible to brain dysfunction in either its causes, mechanisms, or expression. In addition to neuropsychiatric disorders, the problems that people bring to psychiatrists may result from disorders in cognition, the personal and social meanings of experience, and the dynamics of interpersonal interactions or social systems and institutions. The shifting meanings of culture and psychopathology have implications for efforts to apply cultural neuroscience to psychiatry. We consider how cultural neuroscience can refine use of culture and its role in psychopathology using the example of adolescent aggression as a symptom of conduct disorder.