Managing Prader-Willi syndrome in families: an embodied exploration

Mothering a Child With Complexity and Rarity: A Narrative Inquiry Exploring Prader-Willi Syndrome

Daily experiences of mothers caring for children with Prader-Willi syndrome (PWS) are largely unknown and unvoiced. Knowledge of PWS has generally focused on pathology of the disorder. This emphasis overlooks the challenging moments of everyday life caring for children with PWS. Storied accounts of mothers caring for children with PWS offer expanded narratives to medicalized descriptions of experience. An understanding of everyday challenges in managing physical and mental health issues of PWS including hyperphagia and anxiety may create shifts in social and clinical perspectives. This understanding could improve practices in health and social care for families with PWS. This narrative inquiry studied everyday experience using storied accounts. Participants were mothers caring for children aged 3-17 years with genetically confirmed PWS who were experiencing hyperphagia. Four participants were recruited, and each interviewed 8-12 times over 12 months. Field texts and narrative accounts were co-composed through a collaborative process of analysis. Engaging with participants' day-to-day experiences offered insights into their work of nurturing, caring, and contributing to the care of a child with PWS. Narrative threads focused on complexity and rarity and include the desire to be normal, how ordinary becomes extraordinary, isolation, behaviors and normative standards, and alternative stories of mothering. Recommendations for practice and policy include (a) challenges of mothering a child with complexity, (b) moving beyond functionality and impairment to participation and quality of life, (c) re-storying narratives and supports for families, and (d) engaging with mothers to determine care priorities.

"Unable to Feed My Hungry Child": Experiences of Mothers Caring for Children With Prader-Willi Syndrome

Mothers' experiences of caring for children with Prader-Willi Syndrome (PWS) is largely unknown. With no treatment for PWS, parents undertake (extra)ordinary care practices to keep children safe from overeating and self harm. Knowledge of these care practices could lead to effective interventions. Narrative inquiry was used to study everyday experience with Canadian mothers. Participants cared for a child 3 to 17 years old who had hyperphagia. Participants were interviewed 8 to 12 times each over the course of a year. Narrative accounts were co-composed through a collaborative process of analysis. Engaging with participants' everyday experiences amplified complex care needs for families and gaps in health and social care systems. Narrative threads focused on engaging in (extra)ordinary care practices, rigid care work to keep children healthy and safe, tension from others while enacting these care practices, and difficulty conforming to social expectations with childrearing and care work. Recommendations for practice and policy include (a) shifting from untenable care practices, (b) reconceptualizing care work, and (c) alternative care models.

Food socialization of children with Prader-Willi syndrome: an interdisciplinary problematization

Eating "disorders" of people with Prader-Willi syndrome are frequently reported in the biomedical literature. The eating behaviors are presented as a syndrome-specific trajectory over the course of a lifetime. Infants initially show anorexic behavior, which then develops into hyperphagia that lasts from childhood to adulthood and is characterized by strong cravings for food and relentless thinking about it. However, the sociocultural determinants of these food practices are not fully understood. In the first section of this article, we carry out a literature review of medical articles published on disordered eating in children with PWS. The second section draws on a social science perspective and offers an interdisciplinary problematization using the concept of food socialization. To conclude, the third section explores the challenges facing research and new questions that emerge from the alternative problematization that is the PWS Food Social Norms Internalization (FSNI) theory.

Experiencing illness as a crisis by the caregivers of individuals with Prader-Willi Syndrome

Background

The behavioural phenotype of Prader-Willi Syndrome (PWS) implies a specific emotional and social-interactive burden for the caregivers of the individuals with PWS. The aim of the study was to perform an in-depth exploratory analysis of experiences of the familial caregivers of individuals with PWS.

Method

The study was carried out using a sociological methodology of the grounded theory (qualitative research). A purposively selected sample of 20 familial caregivers of children/adults with PWS was invited to take part in individual, semi-structured in-depth interviews which included questions pertaining to coping with problems arising from the condition, including its impact on social interactions, as well as to the meanings of PWS.

Results

The core category emerging from our analysis emphasized “experiencing PWS as a crisis”. The phases in the process of experiencing PWS were specified, each of which is characterised by specific cognitive, emotional and social problems, implying relevant requirements in the care of individuals with PWS. I. Crisis in response to the diagnosis; II. Crisis in response to lack of control over the hunger of individuals with PWS; III. Crisis in response to the social milieu’s failure to understand the nature of the condition; IV. Crisis in response to attempts to plan the future of individuals with PWS. The specificity of the PWS caregiver’s experience is primarily determined by the need to reconstruct the entire family’s lifestyle. The experiences of caregivers of PWS persons, at the time when they were available for study, had the characteristics of crisis. Moreover the psychosocial consequences of PWS were not subject to normalization and attempts to attribute any meaningful existential sense to the PWS were ineffective in the time period under scrutiny.

Conclusions

Identifying phases of the PWS experience process from the perspective of the caregivers of individuals with PWS may be used to profile interventions supporting PWS individuals’ families in a manner corresponding to the flow of the illness experience.

Embodied risk for families with Li-Fraumeni syndrome: Like electricity through my body

INTRODUCTION

Experiences of illness change the physical body and embodiments, or the ways in which the world and the self are known through the body. When illness is anticipated, such as with inherited cancer predisposition syndromes, risk becomes embodied and shared in family groups. Embodied risk is experienced whether or not symptoms have manifested. To examine how individuals and families with genetic risk experience the world and understand their disease through their bodies, we employ Li-Fraumeni syndrome (LFS) as an exemplar. LFS is a rare, genetic, cancer predisposition syndrome with nearly 100% lifetime cancer risk starting from birth, limited opportunities for prevention, rigorous screening protocols, and early mortality.

METHODS

Forty-five families, including 117 individuals aged 13-81 years, enrolled in the National Cancer Insitute's LFS study (NCT01443468) completed 66 open-ended interviews regarding LFS experiences. An interdisciplinary team used modified grounded theory to explore physical aspects of living with LFS in psychosocial contexts.

FINDINGS

The physicality of living with LFS included constant monitoring of LFS bodies across the family to identify physical change that might indicate carcinogenesis. Cancer screening, risk reduction, and treatment acted as dually protective and invasive, and as an unavoidable features of LFS. Connections between family members with similar embodiments normalized aesthetic changes and supported coping with visible markers of difference. In some circumstances, participants objectified the body to preserve the self and important relationships. In others, intense pain or loss created thresholds beyond which the self could no longer be separated from the body to support coping.

DISCUSSION

This paper focuses on Li-Fraumeni syndrome, a familial condition with a well-established genetic identity in which the body-self is experienced in relation to important others, to medical imaging, and to historical experiences with cancer. We expand on theories of embodied risk and inter-embodiment to describe experiences across disease trajectories, with attention to division and union between body, self, and other.

Multifactorial influences on successful health outcomes for an adolescent with Prader-Willi syndrome: a qualitative case study

PURPOSE

Prader-Willi syndrome (PWS) is the most common syndromic cause of childhood obesity. This qualitative case study aimed to identify and describe lifestyle themes of an adolescent with PWS that resulted in maintenance of a healthy body mass index (BMI).

CASE DESCRIPTION

The 16-year-old female demonstrated failure to thrive upon birth and underwent 9 months supplemented tube feeding, achieving 50^th percentile weight for height. Throughout childhood she received treatment of physical, occupational, and speech therapies, and has maintained a healthy BMI ranging from 25-50^th percentile weight for height.

METHODS AND RESULTS

Two video interviews were completed separately. Qualitative analysis of the transcribed data identified two overarching themes for maintaining a healthy BMI in this adolescent: 1) adolescent and parent individual characteristics; and 2) family dynamics and lifestyle. Adolescent and parental characteristics included: high level of cognitive function for diagnosis, mild hyperphagia, desire for a regimented schedule, parental type A personalities, intentionality in parental decisions/actions. Family lifestyle characteristics included strong parental involvement and well-defined expectations for their daughter, purposeful integration of physical activity into lifestyle, and presence of a strong family support system.

CONCLUSION

The convergence of multiple optimal influences provided an ideal health outcome in the adolescent.

Parental experiences of adopting healthy lifestyles for children with disabilities living with overweight and obesity

BACKGROUND

Children with disabilities present with high obesity rates.

OBJECTIVE

This study explored the parental experience of adopting healthy lifestyle choices, for children with disabilities, who received dietetic weight management advice.

METHODS

Semi-structured qualitative interviews were carried out with eight parents/carers in their own homes or healthcare setting in an inner London locality, or by telephone. Data was analyzed using an interpretative phenomenological analysis (IPA) approach.

RESULTS

Five superordinate themes emerged: 1. Strategies to promote healthy lifestyles: encouraging physical activity, limiting access to food and taking a gradual approach to making lifestyle changes. 2. Challenges to adopting healthy lifestyles: selective eating patterns, the high cost of healthy foods and parental/carer lack of time. 3. The role of healthcare professionals (HCPs): revealed that not all parents/carers received advice or support, prior to dietetic referral, when managing their child's weight. Feeling reassured by HCPs was valued. Parents/carers reported a positive experience of seeing the dietitian, as they appreciated receiving practical and individualized advice. 4. Support needs: family support and support from families with children with disabilities was explored. 5. Parent/carer wellbeing: such as stress was found to have a detrimental impact on parents making healthy lifestyle changes.

CONCLUSIONS

Adopting a healthy lifestyle involved a variety of strategies and challenges, some of which are specific to this population group and should be considered by HCPs, when having weight-related discussions and offering advice. Parental/carer support needs and wellbeing should also be taken into consideration when planning weight management services for this population group.

Associations Between Hyperphagia, Symptoms of Sleep Breathing Disorder, Behaviour Difficulties and Caregiver Well-Being in Prader-Willi Syndrome: A Preliminary Study

Prader-Willi syndrome (PWS) is a rare genetic disorder characterised by neurodevelopmental delays, hyperphagia, difficulties with social communication and challenging behaviours. Individuals require intensive supervision from caregivers which may negatively affect caregiver quality of life. This study used data collected in the Australasian PWS Registry (n = 50, mean age 11.2 years) to evaluate associations between child behaviours and caregiver mental well-being. Symptoms of sleep-related breathing disorder, child depression and social difficulties were associated with poorer caregiver mental and physical well-being. Growth hormone therapy use was associated with better caregiver mental and physical well-being. Optimising management of problematic behaviours and sleep disturbances have the potential to support caregivers who are the most vital network of support for individuals affected by PWS.

Treino parental para manejo comportamental de crianças com Síndrome de Prader-Willi: impacto sobre a saúde mental e práticas educativas do cuidador

RESUMO Objetivo: verificamos os indicadores de impacto na saúde mental de cuidadores de um programa de treinamento parental para manejo de crianças e adolescentes com Síndrome de Prader-Willi. Métodos: a amostra foi composta por 5 mães de crianças/adolescentes com Síndrome de Prader-Willi entre 6 a 18 anos. Os instrumentos de coleta de dados foram: a) Questionário para verificação de conhecimentos das mães sobre a síndrome, b) Inventário de Auto-avaliação para Adultos de 18 a 59 anos, c) Inventário de Estilos Parentais/Práticas educativas maternas e paternas; d) Levantamento de dificuldades e preocupações sobre os filhos. O estudo foi realizado em quatro fases: pré-intervenção, intervenção, pós-intervenção e seguimento. Resultados: as mães passaram a adotar práticas parentais educativas baseadas na monitoria positiva, diminuíram as práticas de risco. Conclusão: houve melhora em indicadores de dificuldades emocionais das mães, apreenderam a identificar e manejar fatores que prejudicavam a saúde física, o comportamento e a aprendizagem escolar dos filhos e a necessidade do envolvimento de outros familiares no cuidado do filho.

The High Direct Medical Costs of Prader-Willi Syndrome

OBJECTIVE

To assess medical resource utilization associated with Prader-Willi syndrome (PWS) in the US, hypothesized to be greater relative to a matched control group without PWS.

STUDY DESIGN

We used a retrospective case-matched control design and longitudinal US administrative claims data (MarketScan) during a 5-year enrollment period (2009-2014). Patients with PWS were identified by Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 759.81. Controls were matched on age, sex, and payer type. Outcomes included total, outpatient, inpatient and prescription costs.

RESULTS

After matching and application of inclusion/exclusion criteria, we identified 2030 patients with PWS (1161 commercial, 38 Medicare supplemental, and 831 Medicaid). Commercially insured patients with PWS (median age 10 years) had 8.8-times greater total annual direct medical costs than their counterparts without PWS (median age 10 years: median costs $14 907 vs $819; P < .0001; mean costs: $28 712 vs $3246). Outpatient care comprised the largest portion of medical resource utilization for enrollees with and without PWS (median $5605 vs $675; P < .0001; mean $11 032 vs $1804), followed by mean annual inpatient and medication costs, which were $10 879 vs $1015 (P < .001) and $6801 vs $428 (P < .001), respectively. Total annual direct medical costs were ∼42% greater for Medicaid-insured patients with PWS than their commercially insured counterparts, an increase partly explained by claims for Medicaid Waiver day and residential habilitation.

CONCLUSION

Direct medical resource utilization was considerably greater among patients with PWS than members without the condition. This study provides a first step toward quantifying the financial burden of PWS posed to individuals, families, and society.

Feeding, eating and behavioral disturbances in Prader-Willi syndrome and non-syndromal obesity

BACKGROUND

Although most individuals with Prader-Willi syndrome (PWS) are obese, little is known about the impact of obesity-related psychosocial factors in PWS. In the present study we compared feeding, eating, and behavioral disturbances in children and adolescents with PWS, peers with non-syndromal obesity, and normal weight controls.

METHODS

Twelve persons with PWS, aged 7-22 years, age- and gender-matched obese and normal weight individuals were analyzed regarding parental feeding practices, eating disturbances, and behavioral problems via standardized questionnaires.

RESULTS

Parents of individuals with PWS reported significantly more restrictive feeding and monitoring than did parents of obese or normal weight children without PWS (p<0.05). Social problems were more common in the obese and the PWS group than in the normal-weight group (p<0.05). Behavioral problems were significantly correlated with parental restrictive feeding practices.

CONCLUSIONS

Our data show that children and adolescents with PWS are affected by psychosocial problems, and that restrictive feeding practices might be associated with more severe behavioral problems. Further studies in larger samples will be necessary to replicate these results and possibly provide new therapeutic approaches for the management of PWS.

Parent Recommendations for Family Functioning With Prader-Willi Syndrome: A Rare Genetic Cause of Childhood Obesity

Prader-Willi syndrome (PWS) is the most common genetic cause of childhood obesity. Neonates have hypotonia and may fail to growth and develop. Within a few years, behavioral problems occur along with insatiable hunger (hyperphagia) and the potential for excessive weight gain. The purpose of this study was to identify how families function when they have a child with PWS.

DESIGN AND METHODS

This qualitative descriptive study was based on 20 face-to-face, audio-taped interviews with parents. They were asked to identify family responses to PWS and offer recommendations. Data were transcribed, coded and analyzed for commonalities and themes.

RESULTS

There were twelve identified themes with two overarching themes of 1) taking action and 2) caring for oneself and family. Taking action was focused on achieving what was best for the child with PWS. Caring for oneself and family attempted to assure that all in the family were healthy, content, and living a fulfilling life under their circumstances.

CONCLUSIONS

This study revealed parental insight as to how they learned to creatively cope with a stressful family life. There was a recognition of inevitable sacrifice and the need for changes in expectations so as to help the child with PWS flourish while also focusing on the needs of all the members of the family.

PRACTICE IMPLICATIONS

Nursing and health care providers should be aware of these issues in the provision of anticipatory guidance to families contending with this genetic disorder.

Latino families with a child with Prader-Willi syndrome: exploring needs for support

Prader-Willi syndrome (PWS) is a complex, genetically based disorder; caring for a family member with a disability such as PWS brings significant challenges to the whole family. However, no research has been conducted focusing on the impact of PWS in the dynamics of Latino families. This qualitative study explored the challenges and need for support services among Latino families of children with PWS. Findings of the study suggest the need for support services geared toward the whole family unit to help members cope with daily challenges at home.

Comparison of body composition, basal metabolic rate and metabolic outcomes of adults with Prader Willi syndrome or lesional hypothalamic disease, with primary obesity

CONTEXT

The care of patients with hypothalamic obesity is challenging.

OBJECTIVE

To compare body composition, basal metabolic rate (BMR) and metabolic outcomes of adults, with lesional or genetic hypothalamic obesity, with obese patients suffering from primary obesity, once matched for body mass index (BMI).

DESIGN AND PATIENTS

Adults with hypothalamic obesity of genetic origin (Prader Willi syndrome (PWS)) or acquired hypothalamic damage (HD), such as craniopharygioma, were compared with obese control candidates awaiting bariatric surgery (C), with a BMI between 35 and 65 kg m(-)(2), and aged between 18 and 50 years.

MAIN OUTCOME MEASURES

Body composition measured by whole-body dual-energy X-ray absorptiometry scanning, BMR using indirect calorimetry, hormonal and metabolic assessments.

RESULTS

A total of 27 adults with a genetic diagnosis of PWS, 15 obese subjects with HD and 206 obese controls with similar BMI were studied. Compared with the control group, PWS patients had an increased percentage of fat mass (FM), and a decreased percentage of android FM. The BMR of PWS patients was significantly lower than controls and highly correlated with lean body mass in PWS and C patients. Body composition of HD was similar with those of obese patients. A trend toward an increased prevalence of diabetes in HD patients and of cytolysis in PWS was observed in comparison with primary obese patients.

CONCLUSION

Genetic and lesional hypothalamic obesities have different consequences for phenotypic features such as body composition or BMR compared with primary obese patients. The mechanisms of adipose tissue development and metabolic complications may be different between genetic and lesional obesities.