Qualitative differences in perspective on children's quality of life between children with cerebral palsy and their parents

BACKGROUND

Cerebral palsy (CP) is one of the most common childhood disabilities, impacting many areas of a child's life. Increasingly, quality of life (QOL) measures are used to capture holistic wellbeing of children with CP. However most validated QOL measures for children are based on adult perspective only, with limited focus on child perspective. Conceptual differences between children's and adults' definitions of QOL may reflect different underlying QOL models which contribute to measurement score divergence. This qualitative study investigated the conceptual meaning of QOL for children with CP, comparing child and parent perspectives. Eighteen families completed 8 child interviews and 18 parent interviews. Children (11 boys, 7 girls) represented the spectrum of motor functioning, with comorbidities including epilepsy, intellectual disability, and communication impairments. Child and parent interviews were analysed separately using constructivist grounded theory methods and then findings were integrated to examine similarities and differences.

RESULTS

All participants sought child inclusion in social activities, education, and recreation, requiring negotiation, adaptations, and advocacy. Five conceptual categories emerged from child interviews: socialising, play, negotiating limitations, self-identity, and developing agency. This reflected an individual model of QOL supporting child development goals. Parent interview findings revealed concepts related to child-specific QOL (day-to-day functioning and enabling child goals), as well as parent and family functioning concepts aligned to models of "family QOL", embracing impacts of family relationships and the interdependence of QOL among family members.

CONCLUSIONS

This study identified similarities and differences in child and parent perceptions of QOL for the child with CP. Children provided insights into the importance of play and peer support, and their developing self-identity and sense of agency. Self-directed free play, especially, was identified by children but not parents as a central everyday activity promoting wellbeing and social inclusion. Parents discussed family functioning and aspects outside of child sight, such as managing time and financial resources. Relying on parents' perspective alone to model child QOL misses valuable information that children contribute. Equally, child report alone misses parent experiences that directly influence child QOL. There is value in incorporating family QOL into parent reports while developing a conceptually separate child self-report QOL instrument.

An intervention to improve the self-efficacy of key workers to support parental wellbeing at an early childhood intervention service in Australia: a stepped wedged randomized cluster trial

PURPOSE

It is well documented parents of children who have a disability are at an increased risk of poor mental health and wellbeing. A capacity building program designed to build key worker self-efficacy to support the mental health of parents accessing early childhood intervention services (ECIS) for their child was trialled.

MATERIALS AND METHODS

A stepped-wedge cluster randomised trial design was utilised to deliver and evaluate a 12-month intervention program, comprising tailored professional development, resource development and sustainability measures. The repeated measurements on individuals in six clusters over three follow-up periods were analysed using linear mixed models. Comparison of the control and new program statistical means (adjusted for period effects) were assessed with an F test.

RESULTS

Key workers reported increased confidence to talk to parents about their own wellbeing (d = 0.51, F(1, 51.8) = 4.28, p = 0.044) and knowledge of parental mental wellbeing improved (p = 0.006). A reduction in staff sick leave partially offset the cost of the intervention.

CONCLUSIONS

A multi-pronged intervention targeted at key workers was found to be an effective way to ensure parental wellbeing is supported at an ECIS in Australia.

TRIAL REGISTRATION

ACTRN12617001530314Implications for RehabilitationThere are implications for the development of children whose parents are experiencing high stress and poor mental health, whereby parents of children with disability or developmental delays are at increased risk.Findings from this study support the recommendation that a key worker is provided to holistically support families who access Early Childhood Intervention Services to aid in reducing poor parental wellbeing and child outcomes.Improved confidence to support and initiate conversations regarding parental wellbeing by key workers, in combination with support from management and the organisation to undertake this as part of their role, is a positive finding from this intervention study.

Co-Design and Co-Production of a Goal Setting Tool for Autistic Adolescents and Adults

Background

A review of existing tools suggested a need for a goal setting tool for autistic people that (1) addresses the heterogeneity of autistic people to the greatest degree possible; (2) addresses a broad range of goals in areas including self-care and home living, and social, community, educational, and employment participation; (3) incorporates autism-specific adaptations such as visual supports; (4) facilitates the initial identification of goals; and (5) enables the prioritization of goals.

Aim

This project aimed to develop a picture-based card-sort goal setting tool with relevant and comprehensible goal cards using a co-design and co-production process.

Methods

The first three of four phases of participatory action research (PAR) used to develop the tool are presented, including (1) initial design by autistic people and professional practitioners, and co-production with an autistic graphic designer; (2) survey of 15 autistic people and 11 family members to evaluate and refine the goals, pictures, and wording; (3) second survey of 23 autistic people and 19 family members to re-evaluate and re-refine the goals, pictures, and wording.

Results

Responses to open-ended survey questions recommended changing many of the pictures and some of the words on the goal cards. As the majority of respondents rated each of the 72 goals as important, they were all retained. The mean percentage approval of the pictures improved from 78% for survey 1 to 86% for survey 2. The mean percentage approval of the wording improved from 87% for survey 1 to 97% for survey 2.

Conclusions

The use of a co-design and co-production methodology over three phases of PAR involving autistic people and their families resulted in many refinements to the goal cards. These iterations in the design process maximized the extent to which the goal cards are easily understood and relevant to the needs of autistic people.

A Rights-Based Approach for Service Providers to Measure the Quality of Life of Children with a Disability

BACKGROUND

This paper identifies the best instruments for service providers to measure the quality of life (QoL) of children with a disability, with a focus on their alignment with the Convention on the Rights of Persons with a Disability (CRPD).

METHODS

This study reviewed systematic reviews to identify generic QoL instruments for children and adolescents, followed by an appraisal process using newly developed criteria. QoL instruments with a health status, functioning, and condition-specific focus were excluded.

RESULTS

Twenty generic QoL instruments for children were identified from existing systematic reviews to undergo further review. Only 2 of the 20 instruments were recommended for service providers to measure the QoL of children with a disability (KIDSCREEN and KINDL). Many pediatric QoL instruments (N = 9) focus on functioning and are not consistent with the CRPD, confounding a child's functioning with their feelings about their life. KIDSCREEN and KINDL have self-report and parent report versions, are applicable for childhood and adolescence, demonstrate adequate reliability and validity, involved children in their development, focus on wellbeing, are likely to be able to be completed by a child with a disability, and are low in cost.

CONCLUSIONS

Many instruments focus on functioning rather than wellbeing and thus may not capture the QoL of children with a disability. A child's functional limitations may not be consistent with their feelings about life. Two instruments that assess wellbeing and meet the criteria important for service providers now require further testing to explore their usefulness and validity for children with varying abilities.

Supporting the mental health of mothers of children with a disability: Health professional perceptions of need, role, and challenges

BACKGROUND

Mothers of children with a disability have a higher risk of mental health difficulties than mothers of typically developing children. Very little is known about how health professionals perceive their role in supporting mothers' mental health. We aimed to explore the perspectives of health professionals working with families of children with a disability about how they provide support for maternal mental health in their roles. Specifically, whether professionals consider it their role and responsibility to provide support, the types of actions that they engage in to do this, and the challenges that they experience.

METHODS

This qualitative semi-structured interview study included 13 health professionals (allied health professionals, general practitioners, and paediatricians) working with families of a child with a disability. Thematic analysis was conducted on transcribed interview data.

RESULTS

Four overlapping themes were identified from the data indicating that professionals knew that mothers needed mental health support but were not always clear about their roles and responsibilities to support maternal mental health. Professionals also found it difficult to address maternal mental health difficulties, were not always aware of the best strategies to support maternal mental health, and faced difficulties that could be overcome with training and system improvements.

CONCLUSIONS

Although all health professionals were aware of the frequent occurrence of maternal mental health difficulties and the importance of addressing them, several challenges were identified to managing them successfully. Providing health professionals with training in discussing mental health and clearer referral pathways would contribute to mothers being better supported, in addition to policy change that allows parental support in child health services.

Overcoming functional impairment in postpartum depressed or anxious women: a pilot trial of desvenlafaxine with flexible dosing

OBJECTIVES

Antidepressants are the first line treatment for moderate to severe major depressive disorder (MDD) in perinatal and general populations. However, there appears to be paucity of evidence around antidepressant use in women with postpartum depression or anxiety. Selection of an appropriate antidepressant is crucial in promoting efficacy, optimizing tolerability, and managing comorbid anxiety or depression. Our aim was to investigate the treatment effect and tolerability profile of desvenlafaxine, and to examine the functionality of women with postpartum depression or anxiety after desvenlafaxine treatment.

METHODS

Fifteen postpartum women with depression or anxiety completed this 12-week prospective pilot study with a flexible dose of desvenlafaxine (50-100 mg). Participants were recruited at a tertiary care level program. Measures of depression (Montgomery-Åsberg Depression Rating Scale, MADRS), anxiety (Hamilton Anxiety Rating Scale, HAM-A), worry (Penn State Worry Questionnaire, PSWQ) and functional impairment (Sheehan Disability Scale, SDS) were completed at baseline, 8 weeks, and 12 weeks.

RESULTS

In the intention-to-treat analysis (n = 17), the majority of women responded to medication (88.2%, n = 15), and reached remission of depressive (82.4%, n = 14) and anxiety symptoms (82.4%, n = 14). Remission of depression was achieved in a mean of 6.9 weeks [standard deviation (SD) = 3.01] at a mean dose of 71 mg/day (SD = 25.7). Significant decreases were observed on PSWQ worry scores (p < 0.0001) and SDS scores for social (p < 0.0001) and family life impairment (p < 0.0001). The medication was generally well tolerated.

CONCLUSION

The results of our prospective pilot study suggest that treatment with desvenlafaxine of postpartum mothers with depression or anxiety can lead to symptom remission and restoration of functionality.

Perinatal Generalized Anxiety Disorder: Assessment and Treatment

Perinatal generalized anxiety disorder (GAD) has a high prevalence of 8.5%-10.5% during pregnancy and 4.4%-10.8% postpartum. Despite its attendant dysfunction in the patient, this potentially debilitating mental health condition is often underdiagnosed. This overview will provide guidance for clinicians in making timely diagnosis and managing symptoms appropriately. A significant barrier to the diagnosis of GAD in the perinatal population is difficulty in distinguishing normal versus pathological worry. Because a perinatal-specific screening tool for GAD is nonexistent, early identification, diagnosis and treatment is often compromised. The resultant maternal dysfunction can potentially impact mother-infant bonding and influence neurodevelopmental outcomes in the children. Comorbid occurrence of GAD and major depressive disorder changes the illness course and its treatment outcome. Psychoeducation is a key component in overcoming denial/stigma and facilitating successful intervention. Treatment strategies are contingent upon illness severity. Cognitive behavior therapy (CBT), relaxation, and mindfulness therapy are indicated for mild GAD. Moderate/severe illness requires pharmacotherapy and CBT, individually or in combination. No psychotropic medications are approved by the FDA or Health Canada in pregnancy or the postpartum; off-label pharmacological treatment is instituted only if the benefit of therapy outweighs its risk. SSRIs/SNRIs are the first-line treatment for anxiety disorders due to data supporting their efficacy and overall favorable side effect profile. Benzodiazepines are an option for short-term treatment. While research on atypical antipsychotics is evolving, some can be considered for severe manifestations where the response to antidepressants or benzodiazepines has been insufficient. A case example will illustrate the onset, clinical course, and treatment strategies of GAD through pregnancy and the postpartum.

Quitting activity and tobacco brand switching: findings from the ITC-4 Country Survey

OBJECTIVE

Among Australian smokers, to examine associations between cigarette brand switching, quitting activity and possible causal directions by lagging the relationships in different directions.

METHODS

Current smokers from nine waves (2002 to early 2012) of the ITC-4 Country Survey Australian dataset were surveyed. Measures were brand switching, both brand family and product type (roll-your-own versus factory-made cigarettes) reported in adjacent waves, interest in quitting, recent quit attempts, and one month sustained abstinence.

RESULTS

Switching at one interval was unrelated to concurrent quit interest. Quit interest predicted switching at the following interval, but the effect disappeared once subsequent quit attempts were controlled for. Recent quit attempts more strongly predicted switching at concurrent (OR 1.34, 95%CI=1.18-1.52, p<0.001) and subsequent intervals (OR 1.31, 95%CI=1.12-1.53, p=0.001) than switching predicted quit attempts, with greater asymmetry when both types of switching were combined. One month sustained abstinence and switching were unrelated in the same interval; however, after controlling for concurrent switching and excluding type switchers, sustained abstinence predicted lower chance of switching at the following interval (OR=0.66, 95%CI=0.47-0.93, p=0.016).

CONCLUSIONS

The asymmetry suggests brand switching does not affect subsequent quitting.

IMPLICATIONS

Brand switching does not appear to interfere with quitting.

Australian smokers' support for plain or standardised packs before and after implementation: findings from the ITC Four Country Survey

BACKGROUND

Plain packaging (PP) for tobacco products was fully implemented in Australia on 1 December 2012 along with larger graphic health warnings. Using longitudinal data from the Australian arm of the ITC Four Country Survey, we examined attitudes to the new packs before and after implementation, predictors of attitudinal change, and the relationship between support and quitting activity.

METHODS

A population-based cohort study design, with some cross-sectional analyses. Surveys of Australian smokers assessed attitudes to PP at four time points prior to implementation (from 2007 to 2012) and one post-implementation wave collected (early/mid-2013).

RESULTS

Trend analysis showed a slight rise in opposition to PP among smokers in the waves leading up to their implementation, but no change in support. Support for PP increased significantly after implementation (28.2% pre vs 49% post), such that post-PP more smokers were supportive than opposed (49% vs 34.7%). Multivariate analysis showed support either before or after implementation was predicted by belief in greater adverse health impacts of smoking, desire to quit and lower addiction. Among those not supportive before implementation, having no clear opinion about PP (versus being opposed) prior to the changes also predicted support post-implementation. Support for PP was prospectively associated with higher levels of quitting activity.

CONCLUSIONS

Since implementation of PP along with larger warnings, support among Australian smokers has increased. Support is related to lower addiction, stronger beliefs in the negative health impacts of smoking, and higher levels of quitting activity.

Reported planning before and after quitting and quit success: retrospective data from the ITC 4-Country Survey

Planning before quitting smoking is widely believed to be beneficial and is usually recommended in cessation counseling, but there is little evidence on the efficacy of specific planning activities. Using data from 1140 respondents who reported quit attempts at Wave 8 of the ITC 4-Country Survey, we analyzed use of 8 specific planning strategies before (5) and after (3) implementation of a quit attempt, in relation to cessation outcomes, delay in implementation of the attempt, and recent quitting history. Most participants reported some planning both before and after quitting, even among those reporting quitting 'spontaneously.' Younger smokers, those who cut down before quitting, and users of stop-smoking medication were more likely to report planning. Those who planned prequit were also more likely to plan postquit. Unexpectedly, we found no clear benefit of planning on short-term (1 month) cessation outcomes, whereas one prequit strategy (practicing not smoking) was negatively related to outcome. There was evidence for a predicted moderating effect of recent quitting experience on planning for the prequit task 'practice replacement strategies.' This predicted quit success among those with multiple quit attempts in the past year, but failure among those without. This finding suggests that the quality of planning may be critical. More research, particularly on the moderating effect of quit experience, and where measures of planning are collected before outcomes become evident, is needed before clear recommendations can be made on the utility of various forms of planning for the success of quit attempts.

Cigarette brand loyalty in Australia: findings from the ITC Four Country Survey

BACKGROUND AND AIM

There is little academic research on tobacco brand loyalty and switching, and even less in restrictive marketing environments such as Australia. This paper examines tobacco brand family loyalty, reasons for choice of brand and the relation between these and sociodemographic variables over a period of 10 years in Australia.

METHODS

Data from current Australian smokers from 9 waves of the International Tobacco Control Policy Evaluation 4-Country Survey covering the period from 2002 to early 2012. Key measures reported were having a regular brand, use for at least 1 year, brand stability (derived from same reported brand at successive waves), and reasons for choosing brands.

RESULTS

Measures of brand loyalty showed little change across the period, with around 80% brand stability and 95% reporting a regular brand. Older adults were more brand-loyal than those under 25. Young people's brand choice was influenced more by friends, whereas older adults were more concerned about health. Price was the most reported reason for brand switching. Those in the higher income tertiles showed more loyalty than those in the lowest. The least addicted smokers also showed less brand loyalty. We found no clear relationship between brand loyalty and policies that were implemented to affect tobacco use.

CONCLUSIONS

Levels of brand loyalty in Australia are quite high and consistent, and do not appear to have been influenced greatly by changes in tobacco control policies.

Effects of timing of initiation and planning on smoking cessation outcomes: study protocol for a randomised controlled trial

BACKGROUND

Recent theoretical and empirical work has led to debate over the benefit of delaying the implementation of a decision to quit smoking in order to plan the attempt. These two need not be linked, planning can occur before a commitment to quit is made, or after it is implemented, as well as in between. This study will test whether there are independent benefits for encouraging smokers to act immediately on a definite decision to quit smoking, and to engage in structured planning.

METHODS/DESIGN

A complex randomised controlled trial with a factorial design, testing the presence of a recommendation to quit immediately (or not) and encouragement to structured planning (or not) as additions to standard care, a web-based automated tailored advice program (QuitCoach). Participants are recruited from users of the QuitCoach who reside in Australia, do not report a mental health condition for which they are taking medication, are adult daily smokers, and at least open to the possibility of quitting. For the Immediate arm they could not have committed to quit within 2 days, while the Planning arm included all these and those quit within the last 4 days. This creates 6 groups: 2 × 3, with 2 × 2 fully randomised, and 2 only randomised for the planning arm. Follow-up assessments are conducted around 1 month (targeting two weeks after the quit attempt started), and 6 months later. The primary outcome is 6-month sustained abstinence at 6 months. Secondary outcomes include point-prevalence abstinence at both follow-ups, and making quit attempts during the intervention period. We will also explore differences in actual behaviour (timing and planning) by intervention, and relate this to outcomes.

DISCUSSION

This study will result in a better understanding of the roles of planning and delay in influencing the success of quit attempts.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry http://ACTRN12612000613808.

Paradoxical vocal cord dysfunction in an infant with stridor and gastroesophageal reflux

This article presents the case history of a 4 month old infant diagnosed with Paradoxical Vocal Cord Dysfunction (PVCD) secondary to gastroesophageal reflux. The child presented with intermittent stridor which responded promptly to treatment of her reflux. This is believed to be the youngest person with PVCD reported in the literature and supports the concept that PVCD may be associated with multiple etiologies.

A microcomputer-based wearable biofeedback device to improve transfer of treatment in parkinsonian dysarthria

Achieving transfer of treatment outside the clinic is a problem for almost all individuals with speech disorders but has been particularly difficult in the treatment of patients with Parkinsonism. Given this situation and the frequency of vocal intensity problems in this population, we developed a wearable biofeedback device that could provide a patient with information about speech intensity outside the clinic. Auditory-perceptual and acoustic analyses were performed on audiotaped samples of reading and spontaneous speech recorded in the clinic pre- and posttreatment and at 10- and 20-week follow-ups. Visual feedback of intensity was integrated with auditory cues from a microcomputer that was then worn outside the clinic. The results indicated that the subject did transfer a substantial portion of clinic improvement to the outside environment while wearing the feedback device and suggest the utility of a microcomputer-based wearable device for assessing treatment effects as well as for improving transfer.

Relationship between dimensions of cognitive style: field-articulation control and stimulus-intensity control

There has been only one study with normals which examines relationships among Silverman's three dimensions of attention (cf. Silverman & King, 1970). The present study examined the relationship between scores of normal females on tasks that correlate with factors interpreted as field-articulation control and stimulus-intensity control. No significant linear or curvilinear relationships were obtained from Ss' scores on the rod-and-frame test and the kinesthetic figural aftereffects' test. These results support the belief that field-articulation control and stimulus-intensity control are independent cognitive controls in normals.

Stimulable and spontaneous bioluminescence in the marine dinoflagellates, Pyrodinium bahamense, Gonyaulax polyedra, and Pyrocystis lunula

P. bahamense, G. polyedra, and P. lunula exhibit interspecies differences in stimulable and spontaneous bioluminescence. For each species the total number of photons that can be emitted upon mechanical stimulation is a constant, regardless of the time during scotophase at which stimulation occurs. Ratios of stimulable bioluminescence per organism during scotophase and photophase are as high as 950:1 for laboratory cultures and have been observed as high as 4000: 1 for natural populations of P. bahamense. Spontaneous emission in darkness shows flashing as well as low-level continuous emission. Natural populations of P. bahamense, placed in darkness during natural photophase, exhibit a dual character to their stimulable bioluminescence. Mechanical stimulation techniques are described for rapid and reproducible stimulation of bioluminescence.

BIOLUMINESCENCE AND CHLOROPLAST MOVEMENT IN THE DINOFLAGELLATE PYROCYSTIS LUNULA(1)

The lunate cysts of Pyrocystis lunula have a bioluminescent emission spectrum with a peak intensity of 477.5 ± 1 mμ. The light originates from the protoplasm in the center of the cysts. Six to eight hr after the cysts were placed in the dark, they produced 300 to 800 times more luminescence than controls maintained under constant, illumination. Plastids contract distally when the cysts are placed in the dark. If kept in the dark, the plastids contract distally and expand with a circadian rhythm persisting several days. At intensities of 2200 μm cm-'or less, the plastids are expanded. The plastids are contracted into the central area of the cysts at light intensities of 4000 μw cm-(2) and above. The Gymnodinium stage of the life cycle is not bioluminescent.

THE EFFECT OF pH ON THE DIVISION RATE OF THE COCCOLITHOPHORID CRICOSPHAERA ELONGATA(1)

The division rate of Cricosphaera elongata was measured as a function of pH in a medium buffered with the CO2 -bicarbonate-carbonate system. The optimum pH for cell division of the coccolithophorid was 7.8. A change of the partial pressure of CO2 in the medium from 0.03 to 5% did not affect the division rate. Between pH 6.4 and 7.8 changes in the bicarbonate concentration from 0.1 to 6.0 mm and carbonate concentration from 0.007 to 0.1 mm did not affect the rate of division. At loiv experimental pH, C. elongata was nonmotile and grew in clumps; at higher pH values, it was motile and solitary. Coccoliths were not found covering C. elongata if calcite was soluble in the medium.