Maternal distress, child behaviour, and disclosure of psychosocial concerns to a paediatrician

BACKGROUND

Despite the availability of effective screening measures, primary care providers continue to fail to identify and manage many children with psychosocial problems. One of the best predictors of identification by a primary care physician is whether mothers disclose concerns about their child's psychosocial functioning to their child's physician. This study examined if maternal distress and child behaviour predicted whether mothers had and discussed concerns about their child's behaviour and emotions with paediatricians.

METHODS

Participants were 138 mothers who accompanied their 4-12-year-old children to a health supervision visit at an urban teaching hospital. Mothers completed a demographic questionnaire, the Pediatric Symptom Checklist, the Beck Depression Inventory, and an exit questionnaire. Results Logistic regression correctly classified 97.3% of mothers who did not disclose child problems. Only 34.5% of mothers who did disclose were correctly classified.

CONCLUSIONS

The results supported the hypothesis that mothers' psychosocial functioning is significantly related to concern about child behaviour and disclosure of concerns to the paediatrician. The inability of child behaviour and maternal functioning to predict which mothers were concerned and disclosed concerns supports the hypothesis that disclosure and identification of psychosocial problems in primary care is complex and requires a multifactor model.

Bidirectional child-family influences on outcomes of traumatic brain injury in children

Child behavior problems, injury-related family burden, and parent psychological distress were assessed longitudinally over the first year post injury in 40 children with severe traumatic brain injury (TBI), 52 with moderate TBI, and 55 with orthopedic injuries not involving brain insult. Parents rated children's preinjury behavior soon after injury. Postinjury child behavior and family outcomes were assessed at 6- and 12-month follow-ups. Findings from path analysis revealed both direct and indirect effects of TBI on child behavior and family outcomes, as well as cross-lagged child-family associations. Higher parent distress at 6 months predicted more child behavior problems at 12 months, controlling for earlier behavior problems; and more behavior problems at 6 months predicted poorer family outcomes at 12 months, controlling for earlier family outcomes. Support for bidirectional influences is tentative given that limited sample size precluded use of structural equation modeling. The findings nevertheless provide impetus for considering the influences of person-environment interactions on outcomes of TBI.

The relationship of caregiver coping to family outcomes during the initial year following pediatric traumatic injury

This study identified coping strategies associated with caregiver outcomes following pediatric injury and examined injury type as a moderator of coping efficacy. Families of 103 children with traumatic brain injury (TBI) and 71 children with orthopedic injuries were followed prospectively during the initial year postinjury. The groups had comparable preinjury characteristics and hospitalization experiences but differed on neurological insult. In hierarchical regression analyses, acceptance was associated with lower burden and denial was associated with greater distress in both groups. Active coping resulted in higher distress following TBI but not orthopedic injuries. Conversely, the use of humor was related to diminishing distress following TBI but unrelated to distress following orthopedic injuries. Results are discussed in terms of the implications for intervention following TBI.

Child and family functioning 6 and 12 months after a serious pediatric fracture

BACKGROUND

Previous findings indicate that pediatric fractures can have adverse consequences for child adjustment and family functioning immediately after injury. However, longer term effects of the fractures are unknown. The purposes of the present prospective study were to examine the child and family outcomes of pediatric traumatic fractures at 6 months and 1 year after injury, and to identify injury and treatment factors associated with these outcomes.

METHODS

We evaluated 57 children 6 to 12 years of age with traumatic fractures requiring hospitalization. Using standardized measures and parent interview, we obtained measures of pre- and postinjury child and family functioning.

RESULTS

Although outcomes were primarily positive at 1 year after injury, child functional limitations and family stress were observed up to 6 months after injury. Lower extremity fractures had a more negative impact on families across all three assessment points. Children with fracture interventions that involved prolonged immobilization had more functional limitations at 6 months than children who were ambulatory. Family burden was higher at 1 month for the immobilized children, but not at later follow-up.

CONCLUSION

Some children and families experience adverse effects during the year after a serious pediatric fracture, especially if sustained in a lower extremity. Fracture stabilization that allows for greater ambulation may offer some benefits related to functional outcomes and family impact.

The relationship of caregiver coping to family outcomes during the initial year following pediatric traumatic injury

This study identified coping strategies associated with caregiver outcomes following pediatric injury and examined injury type as a moderator of coping efficacy. Families of 103 children with traumatic brain injury (TBI) and 71 children with orthopedic injuries were followed prospectively during the initial year postinjury. The groups had comparable preinjury characteristics and hospitalization experiences but differed on neurological insult. In hierarchical regression analyses, acceptance was associated with lower burden and denial was associated with greater distress in both groups. Active coping resulted in higher distress following TBI but not orthopedic injuries. Conversely, the use of humor was related to diminishing distress following TBI but unrelated to distress following orthopedic injuries. Results are discussed in terms of the implications for intervention following TBI.

Neurobehavioral symptoms in childhood closed-head injuries: changes in prevalence and correlates during the first year postinjury

OBJECTIVE

To examine changes in the prevalence and correlates of neurobehavioral symptoms during the first year following childhood closed-head injuries (CHIs).

METHODS

Participants included 31 children with severe CHIs, 38 with moderate CHIs, and 53 with orthopedic injuries (OIs). Children and their families were assessed shortly after injury and at 6- and 12-month follow-ups. Parents rated 15 symptoms classified as either cognitive/somatic (C/S) or emotional/behavioral (E/B).

RESULTS

Both kinds of symptoms were more common in the CHI groups than in the OI group. C/S symptoms declined in the CHI groups over time, whereas E/B symptoms became relatively more common. Measures of injury severity, children's premorbid behavioral adjustment, and concurrent cognitive functioning predicted C/S symptoms. E/B symptoms were predicted by injury severity, concurrent cognitive functioning soon after the injury, and concurrent parent and family functioning later in time. Both types of symptoms contributed to the prediction of perceived family burden, with the relationships strengthening over time.

CONCLUSIONS

The findings indicate that the prevalence and correlates of neurobehavioral symptoms in childhood CHIs vary as a function of symptom type and time since injury.

Prevalence and correlates of depressive symptoms following traumatic brain injuries in children

The prevalence and correlates of depressive symptoms following childhood traumatic brain injuries (TBI) were examined using data drawn from a prospective longitudinal study. Participants included 38 children with severe TBI, 51 with moderate TBI, and 55 with orthopedic injuries (OI). Assessments occurred shortly after injury (baseline) and at 6- and 12-month follow-ups. Children completed the Child Depression Inventory (CDI). Parents rated depressive symptoms using the Child Behavior Checklist (CBC), with baseline ratings reflecting premorbid status. Assessments also included measures of children's neurocognitive functioning and the family environment. The three groups did not differ overall in self-reported symptoms on the CDI, but did display different trends over time. The three groups did not differ on parent ratings of premorbid depressive symptoms on the CBC, but parents reported more depressive symptoms in the TBI groups than in the OI group at 6- and 12-month follow-ups. Child and parent reports were correlated for children in the TBI groups, but not for those in the OI group. Depressive symptoms were related to socioeconomic status in all groups. Socioeconomic status also was a significant moderator of group differences, such that the effects of TBI were exacerbated in children from more disadvantaged homes. Although self-reports of depressive symptoms were related inconsistently to children's verbal memory, parent reports of depressive symptoms were unrelated to IQ or verbal memory. The findings suggest that TBI increases the risk of depressive symptoms, especially among more socially disadvantaged children, and that depressive symptoms are not strongly related to post-injury neurocognitive deficits.

A psychological behavioral screening service: use, feasibility, and impact in a primary care setting

OBJECTIVE

To describe a psychology behavioral screening service and the use of the service in subsequent primary care provider (PCP) treatment decisions.

METHODS

The goal of the behavioral screening service was to obtain standardized parent and teacher rating scale data for children identified by PCPs as having possible behavioral problems. Medical chart review data were collected on 147 children for 1 year following screening to evaluate (1) PCP follow-up of the behavioral concern, (2) prescription of psychotropic medications, (3) referral to mental health services, and (4) receipt of mental health services.

RESULTS

Children screened by this psychology service had clinically significant behavioral problems, according to both parent and teacher data; PCPs appeared to use screening results to guide decisions about medication prescription but not mental health referrals. Children with more behavioral problems were more likely to be prescribed psychotropic medications and to be seen by a mental health professional.

CONCLUSIONS

These data suggest that a psychology behavioral screening service is feasible and may help guide PCP treatment decisions for children with behavior problems, particularly regarding the prescription of psychotropic medication.

The family burden of injury interview: reliability and validity studies

OBJECTIVE

To assess the reliability and validity of a new instrument, the Family Burden of Injury Interview (FBII) was designed to assess the impact of childhood traumatic head injuries (THI) on the family.

PARTICIPANTS

99 Mothers of school-age children who experienced THI.

RESULTS

The FBII Total Score revealed group differences between families of children with severe THI and families of children with moderate THI. The measure also showed concurrent and predictive relationships to measures of the general impact of injury on families and maternal and child functioning.

CONCLUSION

The FBII is a promising tool for measuring the impact of injury-related stressors on the family.

Influences on first-year recovery from traumatic brain injury in children

This study examined recovery over the first year following traumatic brain injury (TBI) in children 6-12 years of age. Forty-two children with severe TBI and 52 with moderate TBI were compared to 58 children with orthopedic injuries. The children and their families were evaluated at a baseline assessment and at 6- and 12-month follow-ups. Findings documented cognitive, achievement, and behavioral sequelae of TBI, with only limited evidence for recovery over the first year postinjury. Outcomes were predicted by preinjury factors, TBI severity, and measures of the postinjury family environment. Some of the sequelae of severe TBI were more marked in the context of higher compared with lower levels of family burden or dysfunction. The findings confirm the need to consider environmental contributions to outcomes of TBI in children.

Influences on first-year recovery from traumatic brain injury in children

This study examined recovery over the first year following traumatic brain injury (TBI) in children 6-12 years of age. Forty-two children with severe TBI and 52 with moderate TBI were compared to 58 children with orthopedic injuries. The children and their families were evaluated at a baseline assessment and at 6- and 12-month follow-ups. Findings documented cognitive, achievement, and behavioral sequelae of TBI, with only limited evidence for recovery over the first year postinjury. Outcomes were predicted by preinjury factors, TBI severity, and measures of the postinjury family environment. Some of the sequelae of severe TBI were more marked in the context of higher compared with lower levels of family burden or dysfunction. The findings confirm the need to consider environmental contributions to outcomes of TBI in children.

Acute psychosocial impact of pediatric orthopedic trauma with and without accompanying brain injuries

BACKGROUND

The acute psychosocial effects of orthopedic injuries on children and their families are poorly understood. Previous studies have relied on retrospective reports or failed to take into account accompanying brain injuries. The purpose of the present study was to examine prospectively the psychosocial impact of pediatric orthopedic traumatic fractures with and without accompanying brain injuries.

METHODS

Participants were 108 children 6 to 12 years old with orthopedic injuries requiring hospitalization: group 1 (n=80) had fractures only, group 2 (n=28) also had moderate or severe brain injuries. Using standardized measures and parent interviews, we obtained preinjury estimates of family functioning and child behavior problems and postinjury measures of parental distress, family stresses, and child behavior.

RESULTS

Parents reported significant clinical distress (35% in group 1, 57% in group 2), family burdens (group 2 > group 1), and child behavioral changes (41% in group 1, 89% in group 2). Multiple regression analyses indicated that preinjury family status and brain injuries predicted postinjury parental and family distress.

CONCLUSION

Pediatric orthopedic injuries have greater social effects on children with accompanying brain injuries and poorer preinjury family functioning.

Family burden and adaptation during the initial year after traumatic brain injury in children

OBJECTIVE

Traumatic brain injury (TBI) often leads to long-term behavioral and cognitive deficits in children. However, little is known about the burden and psychosocial morbidity of pediatric TBI for families. The purpose of this study was to test the hypothesis that moderate and severe TBI in children has more adverse consequences than orthopedic trauma.

DESIGN

The sample was comprised of children between the ages of 6 and 12 recruited from hospital trauma and inpatient units including 53 with severe TBI, 56 with moderate TBI, and 80 with orthopedic injuries not involving central nervous system insult. Measures of injury-related burden, parental distress, and family functioning were administered to the child's primary caregiver at baseline assessment conducted soon after injury and at 6- and 12-month follow-ups. Multivariate repeated measures analysis of covariance was used to examine group differences in these outcomes over time.

RESULTS

Caregivers in the severe TBI group reported significantly higher levels of family burden, injury-related stress, and parental psychological symptoms than caregivers in the orthopedic injury group (ORTHO). The groups did not differ with respect to marital distress. Caregivers in the severe TBI group were significantly more likely than caregivers in the ORTHO group to exceed the clinical cutoff on the Brief Symptom Inventory and to report clinically significant levels of family dysfunction at follow-up.

CONCLUSIONS

The findings suggest that severe TBI is a source of considerable caregiver morbidity, even when compared with other traumatic injuries. Caregivers in the severe TBI group had persistent stress associated with the child's injury, as well as the reactions of other family members, and a relative risk of clinically significant psychological symptoms nearly twice that of the ORTHO comparison group. These findings underscore the need for interventions that facilitate family adaptation after pediatric TBI.

A long-term prospective study of varicella vaccine in healthy children

BACKGROUND

Studies in Japan and the United States have shown that varicella vaccine is both safe and efficacious. In 1984, we undertook a 10-year prospective study using a research lot of Oka/Merck varicella vaccine to assess antibody persistence and breakthrough chickenpox rates. In 1987, we began a similar prospective study with lots made in production facilities that ended after 6 years because many children were given a second dose. The purpose of this study is to report humoral antibody persistence and breakthrough chickenpox rates after 6 to 10 years of prospective follow-up.

METHODS

One hundred forty-three seronegative children received a research lot (950 plaque-forming units/dose) with 97.9% seroconversion by an assay for fluorescent antibody to membrane antigen (FAMA). One hundred thirty-eight children received production lots (1145 to 3265 plaque-forming units/dose) with 93.5% seroconversion. Yearly chickenpox exposure surveys were completed by phone, and children were seen by a study nurse whenever chickenpox was suspected. A subset in each group had serum collected every 2 years and tested for FAMA antibody.

RESULTS

In the research group there have been 25 cases of chickenpox in 137 seroconverters in a period of more than 10 years (yearly rate of 1.7%). In the production lot group there have been 22 cases of chickenpox in 129 seroconverters in a 6-year period (yearly rate of 2.8%). In the research group the median titer rose from 1:16 to 1:64 between 1 and 10 years. In the production group, the median titer did not change between 1, 2, and 4 years. Median antibody titers were compared between the research and production groups at 1, 2, and 4 years and did not differ. The rate of development of modified chickenpox has not increased with time since vaccination, and neither has the case severity. Children with FAMA titers </=8 at 6-weeks' postvaccination were four times more likely to develop chickenpox than those with titers >/=64.

CONCLUSIONS

1) Modified chickenpox has occurred in approximately 2% to 3% of vaccinees per year, regardless of the vaccine lot given. 2) FAMA titers have risen between 1 and 10 years in research lot recipients and remained the same in production lot recipients. 3) The likelihood of modified chickenpox developing is inversely related to the 6-week postvaccination FAMA titer.

Preinjury family environment as a determinant of recovery from traumatic brain injuries in school-age children

Previous studies of childhood traumatic brain injury (TBI) have emphasized injury-related variables rather than environmental factors as predictors of recovery. We addressed this concern using data collected during a prospective study of children with either TBI or orthopedic injuries (OI) and their families. Participants included 53 children with severe TBI, 56 with moderate TBI, and 80 with OI, all from 6 to 12 years of age at the time of injury. Measures of the preinjury family environment were collected shortly after the injury (baseline). Child cognitive and behavioral outcomes were assessed at baseline and at 6- and 12-month follow-ups. Individual growth curve analyses showed that measures of the preinjury family environment consistently predicted both the level of cognitive and behavioral functioning at 12 months postinjury and the rate of intraindividual change during the 12-month follow-up period, even after taking into account group membership and injury severity. In some cases, the preinjury family environment was a significant moderator of the effect of TBI, buffering its impact in high-functioning families and exacerbating it in low-functioning families. Thus, preinjury environmental factors predict recovery following TBI in children, even after accounting for injury-related variables.

A review of behavioral screening practices in pediatric settings: do they pass the test?

We reviewed the current status of behavior screening methods, such as parental questionnaires, for identifying behavioral problems in children seen in pediatric settings. Information is organized around basic criteria for implementing screening procedures. We conclude that although use of parent-completed questionnaires, such as the Child Behavior Checklist and the Pediatric Symptom Checklist, can increase identification of child behavioral dysfunction in pediatric settings, it is unclear whether screening will cause a change in physician behaviors necessary to improve child functional outcomes. Clinical and research implications are discussed.

Childhood traumatic brain injury: initial impact on the family

Traumatic brain injury (TBI) is a significant source of morbidity and mortality in children, resulting in a wide range of cognitive and behavioral sequelae. However, little is known about the effects of pediatric TBI and its aftermath on families. The current investigation examined the impact of TBI on families during the first month following injury. Children with orthopedic injuries requiring hospitalization served as a control group. The sample consisted of 44 families of children of severe TBI, 52 families of children with moderate TBI, and 69 families of children with orthopedic injuries not involving the central nervous system (CNS). Families of children with severe TBI experienced significantly more injury-related stress than the other two groups of families. Parents of children with TBI also reported higher levels of psychological symptoms than parents of children with orthopedic injuries. Findings from regression analyses suggested that families facing multiple stressors in addition to the injury and those who cope poorly may be at greatest risk for adverse consequences. Future interventions could provide anticipatory guidance and support to at-risk families.

Assessing the effects of traumatic brain injury on family functioning: conceptual and methodological issues

Reviewed empirical literature published since 1975 on the effects of pediatric traumatic brain injury (TBI) on the family. Few systematic, hypothesis-driven investigations of the impact of TBI on family functioning have been conducted. However, existing findings indicate that severe TBI can adversely affect families and individual family members. Certain factors, such as poor preinjury functioning and parental psychological disorder, appear to place families at greater risk for long-term disruption. Issues associated with the conceptualization of the impact of TBI on various aspects of family functioning are discussed and methodological considerations are outlined. Special attention is given to novel strategies for studying these complex, multifaceted issues. Finally, a framework is proposed for examining the processes of family adaptation after pediatric TBI to guide future research directions.

The psychosocial effects of acne on adolescents

To describe the psychosocial impact of acne on adolescents, and, in particular, to assess whether self-concept is affected by medical treatment, we evaluated 39 teenagers presenting for care to a community-based dermatologist. Prior to and following treatment, subjects completed a self-assessment questionnaire, the Piers-Harris self-concept scale, and underwent an objective assessment of acne severity. Fifty-eight percent of subjects were dissatisfied with their facial appearance and this in turn was correlated with feelings of embarrassment and social inhibition (for each, r = 0.48, P less than or equal to 0.005). Subjects' rating of acne severity, but not the dermatologist's, was correlated with dissatisfaction with facial appearance (r = 0.45, P less than or equal to 0.005). Despite these findings, the mean Piers-Harris total t-score (55.4 +/- 7.4) was within the normal range. Fourteen subjects (36%) returned for follow-up and 71% of these were judged by both the dermatologist and themselves to have improved. Following therapy, significant reductions in the adverse consequences of acne were observed with 42% of subjects reporting that their facial appearance was more acceptable to peers, 50% being less embarrassed, and 58% feeling less socially inhibited. Minimal improvement in mean Piers-Harris total t-score was observed (54.6 to 57.4, P = 0.004, paired t-test). Our data demonstrate that acne is perceived by adolescents to have important negative personal and social consequences, and that improvement in these areas may accompany medical treatment.

Binge eating and purging in young women with IDDM

Case reports and empirical studies suggest that young women with insulin-dependent diabetes mellitus (IDDM) may be at high risk for developing eating disorders. In this study, self-reports of binge eating and purging from 59 IDDM women (aged 18-30 yr) were obtained. Most participants (58%) reported that they went on eating binges, and 12% met the DSM-III criteria for a diagnosis of bulimia. Nearly 40% admitted to controlling their weight by insulin purging, and 13.5% reported purging by other means. A group of bulimic participants had mean scores on an eating disorder questionnaire in the pathological range. Bulimic symptoms were positively related to reports of hospitalizations, episodes of ketoacidosis, and psychological symptoms. Implications of these results on the medical management of young women with IDDM are discussed.

Humoral immunity and clinical reinfections following varicella vaccine in healthy children

The duration of immunity following varicella-zoster vaccination in healthy children remains a critical issue. In a 3-year study of 140 OKA/Merck vaccine recipients, duration of immunity was assessed by two measures. The first was persistence of varicella-zoster antibody measured by modified fluorescent antibody to membrane antigen test. Thirty-six toddler vaccinees 12 to 24 months of age had sera obtained at 6 weeks, 1 year, and 2 years. Geometric mean titer +/- SD at 6 weeks was 57.7 +/- 2.9; at 1 year, it was 12.4 +/- 3.9; at 2 years, it was 9.9 +/- 3.9. Repeated-measures analysis of variance showed a significant overall decrease in antibody titer with time (F = 30.62, P less than .001). Post hoc comparisons indicated that the 6-week and 1-year titers were significantly different (P less than .001), but the difference between 1 and 2 years was not (P = .138). Clinical reinfections were also examined for 3 years after vaccination. Suspected varicella cases were confirmed by a fourfold or more increase in titer. Of 84 toddlers, 68 were exposed one or more times, and 6 became reinfected. Of 49 siblings, 45 were exposed, and one became reinfected. All 7 children had less than 70 vesicles and 6 of 7 were afebrile. No cases of zoster occurred. It is concluded that OKA/Merck varicella-zoster vaccination leads to antibody persistence for 2 years and the few reinfections that do occur are greatly attenuated.

High school athletes and the use of ergogenic aid

To determine high school athletes' attitudes toward and use of ergogenic aids, we surveyed 295 students presenting for preparticipation examinations. In general, young athletes believed that steroids and amphetamines were not efficacious in enhancing sports performance and that their use was potentially harmful. Subjects reported minimal use of steroids (1%) and amphetamines (2%), and only a minority would consider their use. As a group, however, male athletes were more likely to believe that steroids were effective (32% vs 13%) and to consider the future use of these agents (14% vs 0) compared with female athletes. The majority of high school athletes believed that supplemental protein or vitamins could improve performance and that their use caused little or no health risk. These data suggest that young athletes may require information regarding the limited benefits and potential risks associated with the use of ergogenic aids.

Validity of caregiver information on the developmental status of severely brain-damaged young children

Two studies were conducted to examine the validity of caregiver information on the developmental status of severely brain-damaged young children. First, developmental information on 106 severely brain-damaged young children, obtained from a caregiver-completed behavior inventory--the Kent Infant Development Scale, was compared to that obtained from the Bayley Scales of Infant Development (the Bayley Scales). Developmental age estimates from both tests were highly correlated and similar. Results suggest that it is possible to substitute the Kent Infant Development Scale for the Bayley Scales when measuring the developmental status of severely brain-damaged young children. In a second study examining the differential validity of caregivers' reports, we found that mothers' Kent Infant Development Scales yielded higher developmental age estimates than did teachers' Kent Infant Development Scales.