A biopsychosocial model of NICU family adjustment and child development

BACKGROUND

Although infants in Neonatal Intensive Care Units (NICU) are at risk for developmental impairments and parents are at risk for emotional distress, factors that explain outcomes remain unknown. Here, we developed the first biopsychosocial model to explain family adjustment after NICU discharge.

METHODS

Participants included 101 families at The Children's Hospital of Philadelphia Neonatal Follow-Up Program who had been discharged 1.5-2.5 years prior. We gathered data using validated assessments, standardized assessments, and electronic medical records.

RESULTS

Our structural equation model, informed by the Double ABC-X Model, captured the dynamic relationships among infant, parent, couple, and family factors. Infant medical severity, posttraumatic stress, couple functioning, and family resources (e.g., time, money) were key for family adjustment and child development.

CONCLUSIONS

Interventions that target parental posttraumatic stress, couple dynamics, parental perception of time for themselves, and access to financial support could be key for improving NICU family outcomes.

Preliminary Validation of the Psychosocial Assessment Tool in the Neonatal Intensive Care Unit

OBJECTIVE

Research suggests families whose infants are admitted to the Neonatal Intensive Care Unit (NICU) experience elevated distress and may have pre-existing risk factors for maladjustment. This study sought to validate the newly developed Psychosocial Assessment Tool (PAT-NICU/Cardiac Intensive Care Unit [CICU]), a comprehensive screening measure for family psychosocial risk in the NICU.

METHODS

The sample included 171 mothers, who completed the PAT-NICU/CICU and other related measures within 2 weeks of their infant's NICU admission at a level 4 unit within a large pediatric hospital. PAT-NICU/CICU scores were compared to a companion risk survey completed by NICU social workers. Test-retest reliability was assessed through repeated measures at 2-month follow-up.

RESULTS

Analyses suggest the PAT-NICU/CICU is effective in classifying psychosocial risk. This is supported by statistically significant correlations between the PAT-NICU/CICU and validated measures, in addition to elevated scores on concurrent measures by risk classification. Internal consistency, test-retest reliability, and acceptability for the PAT-NICU/CICU were satisfactory.

CONCLUSIONS

This preliminary study demonstrates the validity, reliability, and acceptability of the PAT-NICU/CICU as a psychosocial screening tool to aid identification of families who may benefit from supportive services during NICU admission. This new measure is a more comprehensive tool that assesses a wide variety of risk factors and stress responses. However, future studies of this measure are needed with more diverse samples. Prompt screening of NICU parents may facilitate earlier linkage with appropriate levels of resources or intervention. This research is crucial in improving risk assessment and psychosocial care for families in the NICU.

Infant illness severity and family adjustment in the aftermath of NICU hospitalization

Up to 15% of parents have an infant who will spend time in a neonatal intensive care unit (NICU). After discharge, parents may care for a medically fragile infant and worry about their development. The current study examined how infant illness severity is associated with family adjustment. Participants included parents with infants who had been discharged from the NICU 6 months to 3 years prior to study participation (N = 199). Via a Qualtrics online survey, parents reported their infants' medical history, parenting stress, family burden, couple functioning, and access to resources. Multivariable regression analyses revealed that more severe infant medical issues during hospitalization (e.g., longer length of stay and more medical devices) were associated with greater family burden, but not stress or couple functioning. Infant health issues following hospitalization (i.e., medical diagnosis and more medical specialists) were associated with greater stress, poorer couple functioning, and greater family burden. Less time for parents was associated with increased stress and poorer couple functioning. Surprisingly, parents of infants who were rehospitalized reported less stress and better couple functioning, but greater family burden. Family-focused interventions that incorporate psychoeducation about provider-patient communication, partner support, and self-care may be effective to prevent negative psychosocial sequelae among families.

Family Functioning, Medical Self-Management, and Health Outcomes Among School-Aged Children With Sickle Cell Disease: A Mediation Model

Background

Informed by the Pediatric Self-Management Model, the present study tested relationships between parent and family functioning, sickle cell disease (SCD) self-management, and health outcomes for children with SCD.

Method

83 children with SCD and a parent completed baseline data as part of a larger investigation of a family-based, problem-solving intervention for children with SCD (M age = 8.47). Youth and parents completed a measure of child health-related quality of life (HRQOL), and parents completed measures of family efficacy, parenting stress, and SCD self-management. SCD pain episodes and urgent health utilization information over the past year were obtained via medical chart review.

Results

SCD self-management mediated the relationship between parent-reported family efficacy and parent proxy HRQOL, as well as the relationship between parenting stress and child and parent proxy HRQOL. Mediation models were nonsignificant for outcomes beyond HRQOL, including SCD pain episodes and urgent health utilization.

Conclusion

Fostering family efficacy and reducing parenting stress may be meaningful intervention targets for improving SCD self-management and child HRQOL among school-aged children. Although findings were consistent with the Pediatric Self-Management Model in terms of HRQOL, the model was not supported for pain episodes or urgent health utilization, highlighting the need for multi-method, longitudinal research on the SCD self-management behaviors that are linked to preventable health outcomes.

Development and Pilot Testing of a Coping Kit for Parents of Hospitalized Children

OBJECTIVE

Serious pediatric illness places great stress on families. Parents who learn coping skills may better manage these stressors. This study sought to develop and refine a stress coping intervention for parents of hospitalized children, assess the intervention acceptability among these parents, and gather preliminary data on stress, negative and positive affect, anxiety, depression, and self-efficacy.

METHODS

We conducted an observational study in 2 phases, enrolling parents of children who were inpatients with serious illness, 10 in Phase 1 and 40 in Phase 2. All parents completed at baseline measures of stress and psychological well-being and were introduced to the Coping Kit for Parents. Follow-up interviews were conducted at 1 week (all parents) and 1 month (Phase 2 parents only) regarding the acceptability of the intervention.

RESULTS

At baseline, parents reported that stressful situations were frequent (mean = 30.6, standard deviation [SD] = 6.8) and difficult (mean = 26.2, SD = 7.1) and revealed elevated levels of negative affect (mean = 27.3, SD = 7.7), depression (mean = 8.5, SD = 3.7), and anxiety (mean = 11.3, SD = 3.1) and moderate levels of self-efficacy related to their child's illness (mean = 3.3, SD = 0.5). The majority of parents used the kit regularly and on a scale of 1 to 7 agreed that the kit was helpful (mean = 6.0, SD = 0.9), interesting (mean = 5.7, SD = 1.3), practical (mean = 5.7, SD = 1.4), enjoyable (mean = 6.0, SD = 1.3), and they would recommend it to other parents (mean = 6.4, SD = 0.9).

CONCLUSIONS

The Coping Kit for Parents is an acceptable stress management intervention that could be made available to parents of children with serious illness at pediatric hospitals with minimal staff training or time commitment.

Training Pediatric Psychologists for Perinatal Behavioral Health Services in a Pediatric Hospital

Although pediatric hospitals specialize in providing care to children and adolescents, at The Children's Hospital of Philadelphia (CHOP), our team has been providing behavioral health services for two unique parent populations-parents with a child in the Newborn Infant Intensive Care Unit and pregnant women carrying fetuses with specific birth defects and receiving prenatal care in the Center for Fetal Diagnosis and Treatment. A new training program was developed to expand the scope of pediatric psychologists' practice to include perinatal behavioral health services, specifically for these two unique parent populations served at CHOP. The program includes direct service provision for adult mental health concerns, as well as education and support to help families cope with the existing medical conditions. This article describes the training program and its implementation as a model of training for other pediatric hospitals. The roles of psychologists embedded in these units and hospital privileges are discussed.

Mistrust of Pediatric Sickle Cell Disease Clinical Trials Research

INTRODUCTION

Sickle cell disease (SCD) research is hampered by disparities in participation due in part to mistrust of research among racial/ethnic minorities. Beyond the historic context of research misconduct, little is known about the associations of social ecologic factors with mistrust and of mistrust with SCD clinical trials enrollment. This study evaluated proximal (age, gender, disease severity, perceived stress, SES) and distal (religious beliefs, social support, instrumental support) factors related to mistrust of research among caregivers of children with SCD and adolescents and young adults (AYAs) with SCD.

METHODS

Over an 18-month period (2009-2010), participants completed questionnaires of perceived barriers and benefits to clinical trials enrollment, perceived stress, and self-reported demographic and disease-related information. Analyses (January-June 2015) used multivariable linear regressions to evaluate predictors of mistrust.

RESULTS

Data were analyzed for 154 caregivers (mean age, 38.75 years; SD=9.56 years; 90.30% female) and 88 AYAs (mean age, 24.76 years; SD=7.25 years; 46.40% female). Among caregivers (full model, R(2)=0.14, p≤0.001), greater mistrust was explained by higher perceived stress (β=0.04, p=0.052); religious beliefs (β=0.61, p≤0.001); and greater instrumental support (β=0.07, p=0.044). Among AYAs (full model, R(2)=0.18, p≤0.001), higher mistrust was explained by being male (β=-0.56, p≤0.001) and lower instrumental support (β=-0.11, p=0.016). Mistrust was significantly greater among caregivers that reported no prior involvement in medical research (p=0.003).

CONCLUSIONS

By understanding the complexity through which social ecologic factors contribute to mistrust, researchers may create targeted strategies to address mistrust and increase engagement in SCD research for caregivers and AYAs.

Lessons Learned From a Randomized Controlled Trial of a Family-Based Intervention to Promote School Functioning for School-Age Children With Sickle Cell Disease

OBJECTIVE

Tested a family-based group problem-solving intervention, "Families Taking Control," (FTC) to improve school functioning and health-related quality of life (HRQL) for children with sickle cell disease.

METHOD

Children and caregivers completed questionnaires assessing HRQL and school functioning and children completed performance-based measures of IQ and achievement at baseline and 6 months later. Families were randomized to the intervention (FTC, n = 42) or delayed intervention control (DIC, n = 41) group. FTC involved a full-day workshop followed by 3 booster calls.

RESULTS

There were no differences between FTC completers (n = 24) and noncompleters (n = 18). FTC group (n = 24) and DIC group (n = 38) did not differ significantly on primary outcomes at follow-up: number of formal academic and disease-related accommodations, individualized education plan/504 service plan, school absences, school HRQL, or academic skills.

CONCLUSIONS

Although families found FTC to be acceptable, there were no intervention effects. Challenges of the trial and implications for future research are discussed.

Parental problem-solving abilities and the association of sickle cell disease complications with health-related quality of life for school-age children

Children with sickle cell disease (SCD) are at risk for poor health-related quality of life (HRQOL). The current analysis sought to explore parent problem-solving abilities/skills as a moderator between SCD complications and HRQOL to evaluate applicability to pediatric SCD. At baseline, 83 children ages 6-12 years and their primary caregiver completed measures of child HRQOL. Primary caregivers also completed a measure of social problem-solving. A SCD complications score was computed from medical record review. Parent problem-solving abilities significantly moderated the association of SCD complications with child self-report psychosocial HRQOL (p = .006). SCD complications had a direct effect on parent proxy physical and psychosocial child HRQOL. Enhancing parent problem-solving abilities may be one approach to improve HRQOL for children with high SCD complications; however, modification of parent perceptions of HRQOL may require direct intervention to improve knowledge and skills involved in disease management.

Safety assessment of consumption of glabrous canary seed (Phalaris canariensis L.) in rats

Canary seed is a nutrient-rich cereal grain; however, it has not been used in human food in part due to concerns regarding safety of consumption. Glabrous or hairless canary seed has potential human food use as trichomes are absent. The objective of the oral feeding studies reported here was to assess the safety of yellow and brown glabrous canary seed cultivars as human cereal foods. The first study was a 90-day rat oral toxicity study, which compared the effects of diets containing 50% of either brown dehulled glabrous, brown hulled glabrous, or brown hulled pubescent (hairy) hulled canary seed to a diet containing 50% wheat. No significant adverse effects were observed. In a 28-day and a 90-day study rats were fed yellow or brown glabrous canary seed groats in the AIN-76 diet at concentrations levels of 2.5%, 5% and 10%. The NOAELs in 90-day study were 5.15 g/kg/d and 5.23 g/kg/d for yellow and brown canary seed groats. Consumption of canary seed was associated with reduced incidence and severity of liver lipidosis as compared to controls. The combined results of these studies clearly demonstrate the safety of consumption of glabrous canary seed, and support its use as a human cereal grain.

Predictors of Academic Achievement for School Age Children with Sickle Cell Disease

BACKGROUND

Children with sickle cell disease (SCD) are at risk for neurocognitive impairment and poor academic achievement, although there is limited research on factors predicting academic achievement in this population. This study explores the relative contribution to academic achievement of a comprehensive set of factors, such as environmental (socioeconomic status), disease-related (stroke, transfusion therapy, adherence), and psychosocial variables (child behavior, child quality of life (QoL)), controlling for intellectual functioning (IQ).

METHODS

Eighty-two children with SCD completed measures assessing IQ and academic achievement, while parents completed questionnaires assessing adherence, child behavior, and child quality of life. Medical chart reviews were conducted to determine disease-related factors.

RESULTS

Hierarchical regression analyses indicated that 55% of the variance in academic skills was accounted for by IQ, parent education, chronic transfusion status, and QoL [R² = .55, F(5, 77) = 18.34, p < .01]. Follow-up analyses for broad reading [R² = .52, F(5, 77) = 16.37, p < .01], and math calculation [R² = .44, F(5, 77) = 12.14, p < .01] were also significant.

CONCLUSION

The findings suggest a significant contribution of factors beyond IQ to academic achievement. Findings allow for identification of children with SCD at risk for academic difficulties for whom psychoeducational interventions may enhance academic achievement.

Initial development of a questionnaire evaluating perceived benefits and barriers to pediatric clinical trials participation

OBJECTIVE

To evaluate perceived benefits and barriers to pediatric clinical trials participation to improve decision-making and enhance recruitment and retention among minority youth with chronic health conditions (sickle cell disease, asthma) and their caregivers.

METHODS

A questionnaire was developed based on the social ecological model using input from medical experts and community-based public health organizations. Parallel caregiver, adolescent/young adult (AYA; 16-39 years old), and child (8-15 years old) versions were field tested. Patients and caregivers completed the questionnaire, which included demographic items, perceived life stress and social desirability measures.

RESULTS

Exploratory factor analysis rendered a four-factor solution for the caregiver version (direct treatment benefit, mistrust of research/researchers, trust in healthcare team to engage in safe research, and opportunity cost) and the AYA version (mistrust/no direct benefit, safety, direct treatment benefit/practical considerations, and social support for research). Factor structures differed for SCD and asthma caregivers; results were equivocal for the child version. Summated subscales were not significantly associated with patient demographics or social desirability, but significant correlations with perceived life stress and prior participation in research were identified.

CONCLUSIONS

While the factor structure should be confirmed with larger samples, findings indicate potential benefit, perceived harm due to mistrust of researchers, and logistics are primary factors in decision-making about participation in pediatric clinical trials. By addressing these benefits/barriers through adjustments to recruitment and informed consent procedures, researchers may address misperceptions of research, improve decision-making, and increase recruitment and retention particularly for ethnic minority children with chronic health conditions.

A problem-solving intervention for children with persistent asthma: a pilot of a randomized trial at a pediatric summer camp

BACKGROUND

Pediatric summer camps are emerging as a means to increase social support and improve children's attitudes about their chronic illness. Because of the high rate of camp attendance, it may be feasible to implement interventions within that setting; however, it has yet to be determined what components of camp are beneficial.

OBJECTIVE

The objective of this pilot study was to determine the efficacy of a problem-solving intervention targeting disease management in improving psychosocial functioning of children with persistent asthma, over and above the benefits of participation in a pediatric summer camp.

METHODS

Fifty campers were randomly assigned to receive camp plus a nightly problem-solving intervention activity or camp as usual. Changes in self-reported asthma knowledge and problem-solving skills and self- and parent-reported child self- and social competence health-related quality of life were assessed thrice: before camp, on the last day of camp, and 3-months post-camp.

RESULTS

There were no significant differences between the problem-solving intervention group and the camp as usual group in change across psychosocial variables from before camp to last day of camp or before camp to 3-months post-camp. Increases in asthma knowledge and problem-solving were found 3-months post-camp when groups were combined.

CONCLUSIONS

Although support was found for improvements in disease knowledge and problem-solving skills after camp participation, there were no identified benefits to the problem-solving intervention. Children with asthma who participated in camp were functioning at a high level in terms of knowledge, problem-solving, and social and self-competence, suggesting that interventions may be more effective if targeted to patients with identified problems with disease management.

Symptoms of depression and anxiety in adolescents with sickle cell disease: the role of intrapersonal characteristics and stress processing variables

Sickle cell disease (SCD) complications place patients at risk for poor psychosocial adaptation, including depression and anxiety symptoms. This study aimed to test a mediator model based on the Risk and Resistance model to explore the role of intrapersonal characteristics and stress processing variables in psychosocial functioning. Participants were 44 adolescents with SCD, 15 healthy siblings, and 43 primary caregivers, recruited from an East Coast comprehensive sickle cell center. The participants completed paper and pencil measures of resilience factors (attributional style, hope, coping) and internalizing symptoms (depression, anxiety). Internalizing symptoms among adolescents with SCD and healthy siblings did not differ and were within non-clinical ranges. Self-esteem of adolescents with SCD was correlated with less depression and anxiety and sense of inadequacy was associated with poorer functioning. There were no findings to support the role of coping in psychosocial adjustment. Although the mediation hypothesis was not supported, findings highlighted the resilience of this sample of adolescents with SCD. Determining how these resilience factors protect adolescents with SCD may aid in the development of psychosocial interventions. In particular, interventions should focus on improving intrapersonal skills and coping with stress and investigate ways to tailor these interventions to African-American populations.

Quality of life among adolescents with sickle cell disease: mediation of pain by internalizing symptoms and parenting stress

BACKGROUND

This study aimed to clarify associations between pain, psychological adjustment, and family functioning with health-related quality of life (HRQOL) in a sample of adolescents with sickle cell disease (SCD) utilizing teen- and parent-report.

METHODS

Forty-two adolescents (between the ages of 12 and 18) with SCD and their primary caregivers completed paper-and-pencil measures of pain, teen's psychological adjustment, and HRQOL. In addition, primary caregivers completed a measure of disease-related parenting stress. Medical file review established disease severity.

RESULTS

Pearson correlations identified significant inverse associations of pain frequency with physical and psychosocial domains of HRQOL as rated by the teen and primary caregiver. Generally, internalizing symptoms (i.e. anxiety and depression) and disease-related parenting stress were also significantly correlated with lower HRQOL. Examination of possible mediator models via a series of regression analyses confirmed that disease-related parenting stress served as a mediator between pain frequency and physical and psychosocial HRQOL. Less consistent were findings for mediation models involving internalizing symptoms. For these, parent-rated teen depression and teen anxiety served as mediators of the association of pain frequency and HRQOL.

CONCLUSION

Results are consistent with extant literature that suggests the association of pain and HRQOL and identify concomitant pain variables of internalizing symptoms and family variables as mediators. Efforts to improve HRQOL should aim to address internalizing symptoms associated with pain as well as parenting stress in the context of SCD management.

Maternal and fetal implications of anticonvulsive therapy during pregnancy

A team approach with close communication among the obstetrician, neurologist, pediatrician, and patient will result in an uneventful pregnancy in most epileptic women. Women should be counseled regarding the greater than 90% likelihood of a favorable outcome. Maternal and neonatal outcome can be optimized by carefully evaluating the clinical necessity of anticonvulsant medications preconceptionally. One can then prescribe an appropriate choice based on seizure type and history of response, with a goal of achieving monotherapy at the lowest effective dose. Nonpharmacologic intervention, such as avoiding high levels of stress and sleep deprivation, will also help the patient to remain seizure-free during the pregnancy. In addition, folic acid and vitamin K can help optimize neonatal outcome. In short, most epileptic women will experience a normal pregnancy, labor, and delivery of a healthy baby and can breastfeed if desired. Although the incidence of congenital malformations with any anticonvulsant is increased, the actual incidence remains relatively low. Despite the shortcomings and risks of anticonvulsants, adequate therapy is clearly preferable to uncontrolled seizure activity. Women should be encouraged to optimize their anticonvulsive therapy prior to pregnancy, usually resulting in adequate therapy throughout the pregnancy and postpartum, with a happy and healthy outcome for mother and infant.

General medicine expanded role nurse: role description

In an effort to cope with the changing health care environment, University Hospital, London, Canada provided the opportunity for two nurses to develop expanded nursing roles in general internal medicine. Direct care functions centre on the expert practitioner role. Whereas, indirect care functions include educator, consultant/resource person and researcher. Although the expanded roles are in the beginning stages of development, these nurses have articulated their activities and responsibilities as expanded role nurses in the medicine service.

Chronic sulfonylurea therapy augments basal and meal-stimulated insulin secretion while attenuating insulin responses to sulfonylurea per se

OBJECTIVE

To examine changes in glycemia and insulin secretion in response to SU per se and in response to a standard diet plus OD or TD SU therapy during chronic GP and GB therapy.

RESEARCH DESIGN AND METHODS

Randomized (between agents and in order of dosing regimens), prospective, open, crossover study among 14 NIDDM patients to compare glucose, insulin, and C-peptide responses to a standard diet and to 10 mg of oral GP or GB taken without food 1) after 2 wk without therapy, 2) after 4 wk of either GP (n = 7) or GB (n = 7) treatment OD, and 3) after 4 wk of TD therapy with the same agent. Each patient received the same drug for maintenance therapy and for assessment of the response to the drug alone.

RESULTS

We observed a comparable reduction in overall glycemia with both agents, with more marked postprandial effects for GP. Similar glucose, insulin, and C-peptide profiles for both agents during OD and TD therapy. Augmented insulin secretion in response to meals contrasting with reduced insulinotropic effects of the drugs per se with chronic therapy.

CONCLUSIONS

Therapeutic equivalence of OD and TD dosing with GP and GB during chronic therapy. In view of the improved insulin secretion in response to nutrient stimuli, the attenuation of responses to SU per se during chronic therapy does not imply impairment of beta-cell secretory capacity or represent a therapeutic disadvantage.

Comparative sequence of the helper component (HC) region of potato virus Y and a HC-defective strain, potato virus C

Potato virus C (PVC), a non-aphid transmissible strain of potato virus Y (PVY), was found to code for a protein (PVC-HC) which is similar in molecular weight and immunological reactivity to the helper component protein of PVY (PVY-HC). PVC-HC, however, was inactive with respect to its ability to effect aphid transmission of either PVC or PVY. The 5'-terminal 2.7-kb regions of PVC and PVY were sequenced. Within the HC region there was 92% nucleotide homology between the two strains; comparison of the derived amino acid sequences revealed 24 amino acid differences. Comparison of the PVC-HC sequence with that of five potyviruses revealed 2 amino acid changes which were specific to PVC-HC. These amino acids are prime targets for mutational analysis of HC activity.

Antenatal and intrapartum factors associated with the occurrence of seizures in term infant

To identify antenatal and intrapartum risk factors associated with seizures in term newborns, 40 infants who had seizures within 72 hours of birth were compared with 400 controls using logistic regression analysis. The risk of seizure in the term newborn was approximately one per 1000 in the population studied. The logistic regression model identified a group of infants in whom the risk of seizure was approximately one per 100. The risk factors included in the model were antepartum anemia, antepartum bleeding, asthma, meconium-stained amniotic fluid, presentation other than occiput anterior, fetal distress, and shoulder dystocia. Consistent with other studies, our analysis confirmed a strong association between seizures and factors that increase the risk of fetal asphyxia.

D-penicillamine in the treatment of rheumatoid arthritis

Forty-four patients with definite or classic rheumatoid arthritis and failure to tolerate or respond to gold therapy were treated with D-penicillamine on a so-called go-slow, go-low regime. Seventeen patients tolerated the drug and had a 3-13 month follow-up assessment; 8 were markedly improved, 6 moderately or slightly improved, and 3 unimproved. Penicillamine had to be discontinued in 9 patients because of toxic side effects.