Health screening of four-year-olds in a Swedish county. II. Effectiveness in detecting health problems

Idiopathic Toe-Walking: Prevalence and Natural History from Birth to Ten Years of Age

BACKGROUND

Children with idiopathic toe-walking, a common pediatric condition, walk some or all of the time on their toes. This condition often causes parental concern, with repeated medical contacts and a range of interventions including stretching, casts, injection of botulinum toxin A, and surgical procedures. The purpose of this cohort study was to document the natural history of this condition.

METHODS

In a population-based cohort of 1,401 healthy 5.5-year-old Swedish children, we found the prevalence of idiopathic toe-walking to be approximately 5% (63 of 1,401). Of the 63 children who had ever been a toe-walker, 26 still were at the age of 5.5 years and were followed in the current study at 8 and 10 years of age. At the 8-year follow-up, parents were asked by telephone whether their child had received any treatment or diagnosis since the 5.5-year assessment, as well as to what extent (approximately 25%, 50%, 75%, or 100% of the time) the child still walked on the toes. At the visit when the children were 10 years of age, their parents were asked the same questions. All 26 children also underwent a neurological examination and an orthopaedic examination focusing on the lower extremities.

RESULTS

At 8 years of age, 6 of 26 children had ceased toe-walking, and by the age of 10 years, 50 (79%) of the original 63 patients had spontaneously ceased toe-walking. Idiopathic toe-walking did not result in contractures of the triceps surae. One subgroup of children displayed early contracture of the ankle and should thus not be considered idiopathic toe-walkers. Four of the children who still toe-walked at the age of 10 years demonstrated some neurodevelopmental comorbidity.

CONCLUSIONS

By the age of 10 years, 79% of the children who have ever been a toe-walker spontaneously develop a typical gait, without intervention or contractures of the ankle dorsiflexion. The diagnosis of short tendo Achilles should be retained as a separate diagnosis as there is a subset of children with this entity who should be treated early in childhood. Neurodevelopmental comorbidities are common among those who continue to toe-walk.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

The prevalence and course of idiopathic toe-walking in 5-year-old children

BACKGROUND

Children walking on their toes instead of with a typical gait, without evidence of an underlying medical condition, are defined as idiopathic toe-walkers. The prevalence of idiopathic toe-walking is unknown.

METHODS

A cross-sectional prevalence study of 5.5-year-old children (n = 1436) living in Blekinge County, Sweden, was performed at the regular 5.5-year visit to the local child welfare center. Children were assessed for a history of toe-walking or whether they still walked on their toes. Additionally, all 5.5-year-old children (n = 35) admitted to the clinic for children with special needs in the county were assessed.

RESULTS

Of the 1436 children in the cohort (750 boys, 686 girls), 30 children (2.1%, 20 boys and 10 girls) still walked on their toes at age 5.5 years and were considered as active toe-walkers. Forty children (2.8%, 22 boys and 18 girls) had previously walked on their toes but had stopped before the 5.5-year visit and were considered as inactive toe-walkers. At age 5.5 years, the total prevalence of toe-walking was 70 (4.9%) of 1436. For children with a neuropsychiatric diagnosis or developmental delay, the total prevalence for active or inactive toe-walking was 7 (41.2%) of 17.

CONCLUSIONS

This study establishes the prevalence and- early spontaneous course of idiopathic toe-walking in 5.5-year-old children. At this age, more than half of the children have spontaneously ceased to walk on their toes. The study confirms earlier findings that toe-walking has a high prevalence among children with a cognitive disorder.

Is participation in labour market programmes related to mental health? Results from a 14-year follow-up of the Northern Swedish Cohort

Aims: There is a lack of empirical studies assessing the possible impact of active labour market programmes (ALMP) on health. The aim of this study was to analyze whether participation in ALMP, in contrast to being unemployed and not participating in ALMP (UNALMP), was related to mental health at different ages. Methods: The study was carried out in a medium-sized industrial town in the north of Sweden. The cohort, consisting of all 1,083 pupils who attended or should have attended the last year of compulsory school in 1981, was followed up at the ages of 16, 18, 21 and 30. Data on 381 individuals at age 21, and 281 at age 30 were used in the study. The main health measurement was psychological symptoms among participants of ALMP in contrast to UNALMP at ages 21 and 30, and was analyzed by propensity score matching method (PSM) and multivariate logistic regression. Results: Generally, ALMP had higher scores of psychological symptoms than UNALMP. Nevertheless, participation in ALMP was not related to mental health. Due to methodological shortages our results have to be interpreted with caution. Adjustment for either all background selection variables or the propensity score in multivariate logistic regression showed similar associations, suggesting that propensity score could be used to adjust for background selection variables. Conclusions: There is a need for more well-designed studies, using a theoretical framework, within the field, that are based on larger samples.

Evidence-based overview of ophthalmic disorders in deaf children: a literature update

BACKGROUND

Deaf children are heavily reliant on the sense of vision in order to develop efficient communication skills and explore the world around them. Any ophthalmic disorder may thus negatively impact on this process, especially if it is unrecognised in the early years of life. These disorders may be correctable (such as myopia) or treatable (such as cataract), and their early identification is of the utmost importance to optimise language development (spoken or sign, or both) and develop social cognition. Those children with non-correctable and non-treatable visual disorders, like retinitis pigmentosa in Usher syndrome, require multiple environmental adaptations and appropriate support services and information.

AIM

: To review the accumulated scientific knowledge on ophthalmic disorders in deaf children and assess the quality of evidence published in the literature in order to contribute to better diagnosis and management of these conditions.

MATERIAL AND METHODS

The project reviewed more than 1000 published papers and other sources. 191 papers complied with the aims of the study and were used in the project. From these studies, 95% were based on type III or IV evidence (mainly descriptive studies or case reports). Only 3% were based on type II evidence and 2% on type I evidence.

RESULTS-CONCLUSIONS

The main conclusions of this project are: a) the overall quality of evidence in the literature concerning deaf children and their ophthalmic problems is very low, b) the prevalence of ophthalmic problems in deaf children is very high (approximately 40% to 60%) and these problems may remain undetected for years although they may have a serious impact on children's acquisition of communication skills, c) screening for ophthalmic problems in deaf children should be encouraged and specialist ophthalmic examination should be carried out as soon as the diagnosis of deafness is confirmed irrespective of age, and may need to be repeated at intervals following diagnosis, d) families should be informed about the nature of the screening process in discussion with the relevant professionals and appropriate information should be available in a range of formats and in different community languages, e) professionals administering the tests should be familiar with the needs of deaf children with ophthalmic problems and should be sensitive to the communication needs of the child, especially undertaking behavioural testing where their collaboration is needed, f) while orthoptists can perform the majority of psychophysical tests (visual and stereo acuity tests, ocular motility tests, etc.) a comprehensive opthalmologic assessment by slit lamp biomicroscopy, streak retinoscopy, direct and indirect ophthalmoscopy, intraocular pressure measurement etc is required. Electrophysiologic testing to help identification of Usher syndrome may also be required, and finally g) serial hearing assessments of children with dual sensory deficits are needed to monitor hearing thresholds, to optimise hearing aid use and to ensure timely referral for cochlear implantation for those who need it.

The effectiveness of routine health examinations at 2, 6, 9 and 12 months of age: experiences based on data from a Swedish county

AIM

The aim of this study was to elucidate the role of health surveillance for infants during the first year of life in detecting severe health problems. Two central questions were addressed: (1) what health problems were detected by routine health examinations at the Child Health Centre at the 2-, 6- and 12-month check-ups by a physician and at the 9-month check-up by a nurse; and (2) to what extent did the health examinations contribute to early identification of children with following key abnormalities: congenital heart disease, congenital dislocation of the hip, abnormalities as registered at the habilitation centre and severe hearing impairments? MATERIAL AND INCLUSION CRITERIA: The study population included all children in Uppsala county, born January 1995 to October 1996, who had participated in at least one of the four health check-ups. There were 3107-3487 children in the respective check-ups.

METHOD

Data from a county health register as well as child health records and information regarding referrals were analysed to categorize the health problems by type, severity and action taken. Data on children with key abnormalities were obtained from specialist units.

RESULTS

The rate of suspected new health problems varied between 1.9% and 2.8% at the respective check-ups. Of the new problems detected by the physician, 21%-36% were false-positive, 34%-44% were minor and 10%-15% were moderate. Only two severe health problems were detected among all the children during the four check-ups. Of all key abnormalities, 20% were detected by way of child health surveillance during the first year of life.

IMPLICATIONS

Severe health problems and key abnormalities in infants were detected only to a limited extent through routine health examinations at 2, 6, 9 and 12 months of age. The minor and moderate problems detected justify a health surveillance programme, but the organization and content of the programme could be reconsidered.

Rationality of routine health examinations by physicians of 18-month-old children: experiences based on data from a Swedish county

The aim of the present study was to evaluate the rationality of health check-ups by a physician of 18-month-old children. The study population consisted of all 4075 children in Uppsala county who were 18 months old in 1994 and should have had a routine health examination at that point. Information about the 18-month health examination came from primary data in a longitudinal child health register regarding all children of preschool age. The children in the study population were classified into two main categories, namely children with no newly detected health problem (92.6%) and children in whom a new health problem was detected (3.3%). Data from the register and other sources were analysed to categorize the health problems by severity and type and to determine who (parents, nurse or physician) had identified each. Among the 4075 children in the study population, 135 children were identified as having a newly detected health problem. One-third of them were actually healthy (false positive). Among the 92 verified new health problems (2.3%), 48 were minor, 42 were moderate and 2 were severe. More than half of the moderate health problems were transient infections. The main conclusion of the study is that, under current conditions in Sweden, it would be reasonable to replace the 18-month examination by a physician with an examination by a nurse, this examination being particularly orientated towards developmental and psychosocial problems.

Growing up in Uppsala: the "new morbidity" in the adolescent period. A longitudinal epidemiological study based on school data and some external sources

The study comprised all 1805 children, most born in 1967, who were in grade 9 of the compulsory school in Uppsala in the spring of 1983 (cross-sectional population) and all 1723 children born in 1967 and resident in Uppsala at ages 10 and 15 years (longitudinal population). The aims were (1) to describe and analyse a normal population of 9th graders in social, medical, educational and psychological respects, (2) to assess relationships between risk level at 10 years, school-identified difficulties at 15 years and psychosocial problems up to age 18, (3) to assess relationships between intervention in school at 15 years and psychosocial problems up to 18 years. Ten-year data had been collected through teacher interviews and analysis of school health records in grade 3. Fifteen-year data were collected through interviews with school health staff and analysis of school health records in grade 9. School marks were gathered at the end of grade 9. Psychosocial problems up to 18 years were assessed on the basis of all registered contacts with official institutions outside school (authorities for care of the handicapped, Department of Child Psychiatry, social agencies, legal authorities). CROSS-SECTIONAL POPULATION. Children older than the grade norm and children of lower social class manifested a more problematic school adjustment and had lower mean marks than younger children and those of higher social classes. Twenty-five per cent of the population had entries in official registers up to age 18, indicating psychosocial problems. Social conditions were related both to the learning process and to psychological health. Educational and psychological problems were mutually correlated. Social problems increased the risk of a number of medical conditions. There were certain relationships between medical and educational problems as well as between medical and psychological problems. LONGITUDINAL POPULATION. Both 10- and 15-year data, particularly the latter, contributed independently to the prediction of psychosocial problems up to age 18. There was a considerably increased risk of psychosocial problems if there had been numerous school difficulties at age 15. Children who had been offered intervention in school at 15 years did not escape psychosocial problems up to 18 years more frequently than children without interventions. In fact, the contrary was the case: with more interventions, the frequencies of psychosocial problems up to age 18 increased.

Growing up in Uppsala. Part II. Could adolescents with severe psychosocial problems have been identified by symptoms observed in school at age 10 years?

The study comprised all 1715 children born in 1965 and resident in Uppsala at age 10 and 18 years. Data were collected through teacher interviews and analysis of school health records in grade 3 at the age of 10 years. The psychosocial burden up to the age of 18 years was assessed on the basis of all registered contacts with official institutions outside school (authorities for care of the handicapped, Department of Child Psychiatry, social agencies, legal authorities). Approximately 12% of the adolescents were clearly in a situation of manifest psychosocial risk on the threshold of adult life. These adolescents were assigned to five mutually exclusive problem groups comprising different sex distribution, symptoms and utilization of institutional care. The analysis of the relationship between data from grade 3 and the psychosocial burden up to 18 years of age showed that the information available to the school did not permit reasonably secure predictions of the child's psychosocial situation at the end of adolescence. Observations in school of pre-adolescent children cannot be used as a basis for risk-group strategies aiming at concentrating early treatment measures and resources to a restricted number of children at risk. However, the prognosis is apparently serious for a limited number of 10-year-olds with serious problems in school.

Growing up in Uppsala. The role of public services in identification and treatment of health and adjustment problems. Part I. Definition and classification of dependent variables

A comprehensive prospective longitudinal study of health, development and social adjustment from the age of four to 18 years has been carried out in Uppsala, Sweden. This report presents the accumulated psychosocial burden up to 18 years of age for all 1715 children born in 1965 and resident in Uppsala from age 10 to 18 years. The psychosocial burden up to 18 years of age was assessed through analysis of records and register information from school health services, authorities for care of the handicapped, the Department of Child Psychiatry, social agencies and legal authorities. The analysis showed that 11.8% of the adolescents had a severe psychosocial burden up to the age of 18 years which could hamper their future life as adults. It was possible to categorize the whole birth cohort into one subgroup without manifest psychosocial problems and five different subgroups with serious problems: the six groups (severe mental or physical handicap, antisocial behaviour, psychiatric problems, social support, multiple problems, "normal") had specific profiles concerning sex distribution, symptoms, social background, utilization of care services and delinquency.

Socio-economic status of the family and health problems in the preschool child. Lack of correlation in a Swedish sample

Recent reports from countries with a highly developed economic status point out the association of well-being of children with socio-economic factors. The aim of the present investigation was to examine the extent to which health problems, i.e. functional impairments, diseases and handicaps, in 4-year-old children are related to socio-economic factors. The analysis was based on data from 7 173 children who had undergone the routine general health screening of 4-year-olds in the county of Uppsala. In the statistical analysis the main emphasis was laid on an explanation of the variance on the individual plane. The results showed that the correlations between health problems and socio-economic factors in general were weak or non-existent. An explanation of the lack of correlation in our sample might be that Sweden had succeeded in largely eliminating the health problems associated with external living conditions of the family. If differences between population groups do exist--and in the light of findings from other investigations it seems highly probable that they do--then these differences are probably to be sought in families' way of functioning, in the internal and external pattern of communication, in the general emotional climate and in the degree of social integration in the society.

The state of health of Swedish children

An attempt is made briefly to describe the present health problems of Swedish children. The report is based on data available in official statistics or collected from special studies. It is concluded that the general state of health of Swedish children is good when assessed by commonly used criteria. The mortality pattern is dominated by perinatal and accidental deaths, but also neoplasms are of importance. There are indications that genetic and handicapping disorders, and psychosocial maladjustment will receive more attention in the future.

[Preschool screening examinations in medical practice]

In most European countries systematic screening programs for infants and preschool children are being introduced or are already established as a routine procedure. The contents and the possible effects of such programs are discussed critically in this paper, which also describes the present state in Switzerland as well as a pilot project initiated by the Bernese Pediatric Association.

Physical health of 7-year-old children. An epidemiological study of school entrants and a comparison with their preschool health

At 7 years of age, all 649 7-year-old children in a school district underwent a physical examination, a vision screening and an auditory screening. 210 of the children were previously examined in an extensive health control at 4 years of age. The purpose of the present study was to describe the children's health situation and to evaluate the special health control performed at 4 years of age. In 15% of the children, functionally important health problems were found. Visual defects were most common, comprising 7.5%, then came physical health problems such as motor disturbances, obesity, bacteriuria in 6.5%, and hearing defects in 1%. About half of the important health problems were previously known. Children who had passed the special health control at 4 years of age had fewer newly detected important health problems and more previously known ones than other children, which means that many children with above all visual defects but also motor disturbances, bacteriuria and testis retention, were detected and treated earlier than would have happened without the special control at 4 years. It is concluded that the "ordinary" preschool Child Health Services did fulfill their purpose to detect handicapping disorders in an acceptable way; by the introduction of the special health control at 4 years of age, this function was further improved.

School health and four-year-olds

The results of comprehensive physical, psychological and developmental assessments of 67 four-year-olds are described. The value of this type of review, and the use of nurses and teachers in preschool medical examinations is discussed.

General health screening of four-year-olds in a Swedish county. IV. An analysis of the effectiveness of the psychological examination program

Since 1969, 4-year-olds in the County of Uppsala have been offered extensive health screening at the Child Health Centres. In 1969 and 1970 a total of 3810 children underwent the screening procedure. The psychological screening instrument consisted of a questionnaire (to be answered by the parents), an interview of the parents, a psychomotor examination and an observation of the child's behaviour. 156 (4.1%) 4-year-olds were referred to a specialist team for investigation and decision concerning treatment. In the present study the effectiveness of the psychological screening instrument was assessed by its sensitivity, specificity and predictive value. The sensitivity was found to amount to a maximum of 0.73. The specificity was estimated to be 0.98-0.99, and the positive predictive value to 0.67. The authors consider the effectiveness to be sufficiently high to motivate continuation of the screening procedure for detection of psychological problems in pre-school age. Efforts should be made, however, to further improve the effectiveness.

Health screening of four-year-olds in a Swedish county. III. Variation of effectiveness among examining teams

The data gathered in connection with a routine health screening program for 4-year-olds were used in order to test a number of hypotheses concerning factors which might have influenced the effectiveness of the program, as well as concerning the quality of preventive care delivered to the children before the age of 4 years. It was found that preventive care of relatively high quality delivered to children 0-3 years of age had not reduced the prevalence of previously undetected health problems at 4 years of age. Furthermore, the analysis demonstrated substantial differences between physicians in the rates of correct and unnecessary referrals. Only a small part of these differences could be attributed to professional status or specific experience with the program. They consisted essentially in varying thresholds for what was perceived as a health problem needing treatment, and were considered as a matter of personal temperament. True differences of quality did occur but were less prominent. The implications of these findings with regard to the continuation of the program are discussed.