The Mirroring Dance: Synchrony and Interaction Quality of Five Adolescents and Adults on the Autism Spectrum in Dance/Movement Therapy

Background: Individuals on the autism spectrum are often described as having atypical social interactions. Ideally, interactional synchrony helps any interaction flow smoothly with each individual responding verbally, non-verbally, and/or emotionally within a short timeframe. Differences in interactional synchrony may impact how individuals on the autism spectrum experience social encounters. Method: This mixed methods pilot study examined interactional synchrony in five cases of adolescents and adults on the autism spectrum through secondary analysis of video of the participants in movement-based mirroring tasks during dance/movement therapy. Raters described the movement and interactions of the participants while they were leading and following mirroring and engaged in open-ended free dances with a partner. Videos were also scored on measures of affective engagement, flow of the interaction, and synchrony. Results: One of the most striking findings of this study was the difference between engagement in the instructions of the task and engagement with the partner: participants often followed the instructions for the mirroring tasks with little further social engagement with their partner. When participants did engage in moments of social initiation, attunement to the partner, and interactive behaviors, these did not develop into longer interactions. A paired t-test of the correlation coefficients for each participant showed that scores on synchrony and affective engagement were more strongly positively correlated in the less structured open-ended dance and in video clips of interactive behaviors, than in the videos of simply leading or following mirroring. Synchrony was also significantly more strongly positively correlated with the observed flow of the interaction than with observed affective engagement. With the small sample size, however, most of the correlation coefficients were not significant and should be tested on a larger sample. Discussion: Interpersonal synchrony may not be sufficient to effectively support social engagement when individuals on the autism spectrum simply follow instructions to synchronize their movements. Synchrony-based interventions may therefore need to include more complex open-ended social scenarios as interactional synchrony may then be more correlated with perceived interaction quality. Therapists may also need to partner with participants to model using non-verbal social behaviors to develop interactions within mirroring tasks.

Evaluation of sex differences in preschool children with and without autism spectrum disorder enrolled in the study to explore early development

BACKGROUND AND AIMS

Research in school-aged children, adolescents, and adults with autism spectrum disorder (ASD) has found sex-based differences in behavioral, developmental, and diagnostic outcomes. These findings have not been consistently replicated in preschool-aged children. We examined sex-based differences in a large sample of 2-5-year-old children with ASD symptoms in a multi-site community-based study.

METHODS AND PROCEDURES

Based on a comprehensive evaluation, children were classified as having ASD (n = 1480, 81.55 % male) or subthreshold ASD characteristics (n = 593, 70.15 % male). Outcomes were behavior problems, developmental abilities, performance on ASD screening and diagnostic tests, and parent-reported developmental conditions diagnosed before study enrollment.

OUTCOMES AND RESULTS

We found no statistically significant sex differences in behavioral functioning, developmental functioning, performance on an ASD screening test, and developmental conditions diagnosed before study enrollment among children with ASD or subthreshold ASD characteristics. Males in both study groups had more parent reported restricted interests and repetitive behaviors than females, but these differences were small in magnitude and not clinically meaningful.

CONCLUSIONS AND IMPLICATIONS

Preschool males and females who showed risk for ASD were more similar than different in the outcomes assessed in our study. Future research could examine sex-based differences in ASD phenotypes as children age.

Wandering Among Preschool Children with and Without Autism Spectrum Disorder

OBJECTIVES

(1) Report the occurrence of wandering, or leaving a supervised space, among children with confirmed autism spectrum disorder (ASD), other developmental delay (DD) with a previous but unconfirmed ASD diagnosis (DDprevASD), DD without a previous ASD diagnosis, and a population comparison group (POP) at an age when wandering is no longer expected and (2) explore whether ASD status is associated with wandering independent of behavioral, developmental, and maternal factors.

METHOD

Parents and children aged 4 to 5 years enrolled in the Study to Explore Early Development Phase-1+2. All children were screened for ASD symptoms upon enrollment. Those with ASD symptoms and/or a previous ASD diagnosis received the Mullen Scales of Early Learning (MSEL) to determine their developmental level and 2 ASD diagnostic tests to determine their ASD status. All other children were evaluated with the MSEL alone. Mothers completed the Child Behavior Checklist/1½-5, which includes an item on whether the child wanders away (categorized as at least sometimes true vs not true) and items assessing behavior problems.

RESULTS

Children with ASD (N = 1195) were significantly more likely to wander than children classified as DDprevASD (N = 230), DD (N = 1199), or POP (N = 1272) (60.4%, 41.3%, 22.3%, and 12.4%, respectively, p < 0.01). ASD status, very low developmental level, and affective, anxiety, attention, and oppositional problems were each independently associated with wandering behavior.

CONCLUSION

Wandering is significantly more common among children with ASD and those with behavioral and developmental problems compared with other children. These findings can be used to increase the awareness of wandering among children with atypical development.

Brief Report: Prevalence of Self-injurious Behaviors among Children with Autism Spectrum Disorder-A Population-Based Study

Self-injurious behaviors (SIB) have been reported in more than 30 % of children with an autism spectrum disorder (ASD) in clinic-based studies. This study estimated the prevalence of SIB in a large population-based sample of children with ASD in the United States. A total of 8065 children who met the surveillance case definition for ASD in the Autism and Developmental Disabilities Monitoring (ADDM) Network during the 2000, 2006, and 2008 surveillance years were included. The presence of SIB was reported from available health and/or educational records by an expert clinician in ADDM Network. SIB prevalence averaged 27.7 % across all sites and surveillance years, with some variation between sites. Clinicians should inquire about SIB during assessments of children with ASD.

"Set in Stone" or "Ray of Hope": Parents' Beliefs About Cause and Prognosis After Genomic Testing of Children Diagnosed with ASD

Despite increasing utilization of chromosomal microarray analysis (CMA) for autism spectrum disorders (ASD), limited information exists about how results influence parents' beliefs about etiology and prognosis. We conducted in-depth interviews and surveys with 57 parents of children with ASD who received CMA results categorized as pathogenic, negative or variant of uncertain significance. Parents tended to incorporate their child's CMA results within their existing beliefs about the etiology of ASD, regardless of CMA result. However, parents' expectations for the future tended to differ depending on results; those who received genetic confirmation for their children's ASD expressed a sense of concreteness, acceptance and permanence of the condition. Some parents expressed hope for future biomedical treatments as a result of genetic research.

Parents' perceptions of the usefulness of chromosomal microarray analysis for children with autism spectrum disorders

Clinical guidelines recommend chromosomal microarray analysis (CMA) for all children with autism spectrum disorders (ASDs). We explored the test's perceived usefulness among parents of children with ASD who had undergone CMA, and received a result categorized as pathogenic, variant of uncertain significance, or negative. Fifty-seven parents participated in a semi-structured telephone interview, and 50 also completed a survey. Most parents reported that CMA was helpful for their child and family. Major themes regarding perceived usefulness were: medical care, educational and behavioral interventions, causal explanation, information for family members, and advancing knowledge. Limits to utility, uncertainties and negative outcomes were also identified. Our findings highlight the importance of considering both health and non-health related utility in genomic testing.

Autism spectrum disorder symptoms among children enrolled in the Study to Explore Early Development (SEED)

This study examined the phenotypic profiles of children aged 30-68 months in the Study to Explore Early Development (SEED). Children classified as autism spectrum disorder (ASD), developmental delay (DD) with ASD symptoms, DD without ASD symptoms, and population comparison (POP) differed significantly from each other on cognitive, adaptive, behavioral, and social functioning and the presence of parent-reported conditions. Children with ASD and DD with ASD symptoms had mild to severe ASD risk on several measures compared to children with other DD and POP who had little ASD risk across measures. We conclude that children in SEED have varying degrees of ASD impairment and associated deficits. SEED thus provides a valuable sample to explore ASD phenotypes and inform risk factor analyses.

Mothers' appreciation of chromosomal microarray analysis for autism spectrum disorder

PURPOSE

The aim of this study was to examine mothers' experiences with chromosomal microarray analysis (CMA) for a child with autism spectrum disorder (ASD).

DESIGN AND METHODS

This is a descriptive qualitative study using thematic content analysis of in-depth interview with 48 mothers of children who had genetic testing for ASD.

RESULTS

The principal theme, "something is missing," included missing knowledge about genetics, information on use of the results, explanations of the relevance to the diagnosis, and relevance to life-long care. Two subordinate themes were (a) disappreciation of the helpfulness of scientific information to explain the diagnosis, and (b) returning to personal experience for interpretation.

PRACTICE IMPLICATIONS

The test "appreciated" in value when results could be linked to the phenotype.

Bridges and barriers to successful transitioning as perceived by adolescents and young adults with Asperger syndrome

In this thematic content analysis we examined the expectations, and perceived facilitators of (referred to as bridges) and barriers to transition to community as reported by adolescents and young adults with Asperger syndrome. Participants were adolescents/young adults, ages 18-23 years were from the East Coast of the United States. Seventy percent of adolescents hoped for employment (n = 10). Thirty percent desired to find a partner and raise a family. Perceived barriers were: self-assessed behavioral problems, self-assessed associated features, other personal factors, and institutional factors. Bridges to facilitate transition were: accommodations in the community, cognitive abilities, personal qualities/strengths, and mentor's qualities.

Frequency and pattern of documented diagnostic features and the age of autism identification

OBJECTIVE

The DSM-IV-TR specifies 12 behavioral features that can occur in hundreds of possible combinations to meet diagnostic criteria for autism spectrum disorder (ASD). This paper describes the frequency and variability with which the 12 behavioral features are documented in a population-based cohort of 8-year-old children under surveillance for ASD, and examines whether documentation of certain features, alone or in combination with other features, is associated with earlier age of community identification of ASD.

METHOD

Statistical analysis of behavioral features documented for a population-based sample of 2,757 children, 8 years old, with ASD in 11 geographically-defined areas in the US participating in the Autism and Developmental Disabilities Monitoring Network in 2006.

RESULTS

The median age at ASD identification was inversely associated with the number of documented behavioral features, decreasing from 8.2 years for children with only seven behavioral features to 3.8 years for children with all 12. Documented impairments in nonverbal communication, pretend play, inflexible routines, and repetitive motor behaviors were associated with earlier identification, whereas impairments in peer relations, conversational ability, and idiosyncratic speech were associated with later identification.

CONCLUSIONS

The age dependence of some of the behavioral features leading to an autism diagnosis, as well as the inverse association between age at identification and number of behavioral features documented, have implications for efforts to improve early identification. Progress in achieving early identification and provision of services for children with autism may be limited for those with fewer ASD behavioral features, as well as features likely to be detected at later ages.

The Study to Explore Early Development (SEED): a multisite epidemiologic study of autism by the Centers for Autism and Developmental Disabilities Research and Epidemiology (CADDRE) network

The Study to Explore Early Development (SEED), a multisite investigation addressing knowledge gaps in autism phenotype and etiology, aims to: (1) characterize the autism behavioral phenotype and associated developmental, medical, and behavioral conditions and (2) investigate genetic and environmental risks with emphasis on immunologic, hormonal, gastrointestinal, and sociodemographic characteristics. SEED uses a case-control design with population-based ascertainment of children aged 2-5 years with an autism spectrum disorder (ASD) and children in two control groups-one from the general population and one with non-ASD developmental problems. Data from parent-completed questionnaires, interviews, clinical evaluations, biospecimen sampling, and medical record abstraction focus on the prenatal and early postnatal periods. SEED is a valuable resource for testing hypotheses regarding ASD characteristics and causes.

Transition to community by adolescents with Asperger syndrome: staying afloat in a sea change

BACKGROUND

Transition to community (TC) is the movement out of secondary school to independent living or higher education. It is challenging for young people who have typical neurodevelopment and daunting for those who have neurodevelopmental characteristics associated with Asperger syndrome (AS).

OBJECTIVE

This grounded theory study describes the phenomenon of transition to community among adolescents and young adults with AS.

METHODS

Audiotaped interviews were transcribed verbatim and analyzed using constant comparison to explore the socially constructed phenomenon of TC. Our sample comprised 36 participants from four groups deemed central to the phenomenon including: individuals with AS age 18-22 years (N = 13), parents (n = 13); and five each of educators and potential employers.

RESULTS

The core psychosocial problem of TC is to stay afloat while feeling "adrift." This problem was experienced by the individual with AS, and parents and others were observers and facilitators. Adolescents, with the support of parents, teachers and sympathetic employers solved this problem by using three psychosocial processes of structuring, anchoring, and embarking.

CONCLUSIONS

Clinicians who work with this population, potential employers, and educators are stakeholders who can apply our findings to the development of effective and personalized transition services. Findings from our study are grounded in the experiences of participants, and therefore, have explicit practical value. The conceptual model of TC can be used by health care providers, educators, employers and parents to guide adolescents as they transition to community.

Genomics and autism spectrum disorder

PURPOSE

To present the current state of the evidence regarding translation of genetics (the study of single genes) and genomics (the study of all genes and gene-gene or gene-environment interactions) into health care of children with autism spectrum disorder (ASD).

METHODS

This article presents an overview of ASD as an international health challenge, the emerging science related to broad diagnostic criteria, and the role of the nurse in research, education, and practice.

FINDINGS

Much progress is being made in the understanding of genetics and genomics of ASD. Environmental factors are thought to contribute to the risk of developing ASD by interacting with a number of genes in different ways, thus suggesting causal heterogeneity. The rising identified prevalence of ASD, the changing diagnostic criteria for ASD, and the complexity of the core and associated features have made it difficult to define the ASD phenotype (observable behaviors that result from gene-environment interaction). Because early identification improves opportunities for intervention, researchers are looking for a useful biomarker to detect ASD. This search is complicated by the likelihood that there are multiple causes for multiple expressions that are defined as the autism spectrum.

CONCLUSIONS

To date, genetic and genomic research on ASD have underscored the complexity of the causes of ASD indicating that there are very complex genetic processes involved that are still not well understood.

CLINICAL RELEVANCE

Nurses will benefit from new knowledge related to early identification, diagnosis, and implications for the family to promote early intervention. Families who have a child with ASD will require nursing support for advocacy for optimal health outcomes.

Genomic literacy and competent practice: call for research on genetics in nursing education

This article presents an argument for research on the practical outcomes of genetics education in professional nursing programs. Nurse educators should aggressively conduct educational outcomes research on the translation of genetics core competencies at all levels of clinical practice. There should be a systematic examination of the factors, that influence graduate nurses' applications of concepts to patient care including type of educational preparation in genetics. The best way to improve health is to understand normal genome biology and its relationship to disease biology. Assuring genetics and genomic literacy among all nurses is a crucial task for contemporary nursing education programs.

Research participation among Asian American women at risk for cervical cancer: exploratory pilot of barriers and enhancers

The purposes of this exploratory pilot were to describe perceived barriers to participation in cervical cancer prevention research, and identify culturally-appropriate communication strategies to recruit Asian women into cancer prevention research. This thematic analysis of transcripts, from focus groups and in-depth interviews, was conducted in English, Vietnamese, and Mandarin Chinese, at a community clinic in Philadelphia, Pennsylvania. Thirty participants were either Vietnamese (35%) or Chinese (65%). Mean age was 36.8 (SD 9.9 years). Reasons for non-participation were: lack of time, inconvenience, mistrust of institutions and negative experiences, lack of translated materials, feeling intimidated by English, and the lack of translation of key words or terms. Enhancers of participation were: endorsement by a spouse, monetary compensation, and a personalized approach that offers a benefit for Asian women. To increase participation, first one must remove language barriers and, preferably, use specific dialects. Second, one must specify if benefits are indirectly or directly related to the family or cultural group. Asian research participants in our study consistently expressed that a significant motivator was their desire to be of help, in some way, to a family member or to the Asian community in general.

A comparison of autism spectrum disorder DSM-IV criteria and associated features among African American and white children in Philadelphia County

BACKGROUND

Racial differences are documented in the timing and type of autism spectrum disorder (ASD) diagnosis among white and African American children. Differences in clinical presentation by race may contribute to these disparities. This study explores documented differences in core ASD symptoms and associated behavioral features among African American and white children.

METHODS

This project is a secondary data analysis from the Pennsylvania Autism and Developmental Disabilities Surveillance Program and utilized methodology that evaluates existing records, reviews, and codes for DSM-IV criteria for ASD and 12 associated behavioral features. The sample comprised 343 children meeting surveillance case definition for ASD, from 3 population-based cohorts of children in Philadelphia County.

RESULTS

A higher frequency of white children compared to African American children with ASD have documented DSM-IV criteria of inflexible adherence to nonfunctional routines/rituals (92% vs 81%; p = .005) and persistent preoccupation with parts of objects (67% vs 50%; p = .002). A higher frequency of white children with ASD compared to African American children with ASD have documented abnormal motor development (74% vs 60%; p = .008) and odd responses to sensory stimuli (76% vs 51%; p < .001). There were no significant differences in externalizing behaviors or reciprocal social interaction.

CONCLUSIONS

This study suggests differences in the types of ASD symptoms and associated behavioral features exhibited by African American as compared to white children with ASD. Further research is needed to determine if these differences contribute to disparities in the timing or type of ASD diagnosis.

Sex differences in the evaluation and diagnosis of autism spectrum disorders among children

BACKGROUND

One of the most consistent features of the autism spectrum disorders (ASDs) is the predominance among males, with approximately four males to every female. We sought to examine sex differences among children who met case definition for ASD in a large, population-based cohort with respect to age at first developmental evaluation, age of diagnosis, influence of cognitive impairment on these outcomes, and sex-specific behavioral characteristics.

METHODS

We conducted a secondary analysis of data collected for a population-based study of the prevalence of ASD. The sample comprised 2,568 children born in 1994 who met the case definition of ASD as established by the Autism and Developmental Disabilities Monitoring (ADDM) Network for ASD surveillance. Children who had a history of developmental disability and behavioral features consistent with the DSM-IV-TR criteria for autistic disorder, Asperger's disorder, and Pervasive Developmental Disorder-Not Otherwise Specified in existing evaluation records were classified as ASD cases via two paths: streamlined and nonstreamlined. Streamlined reviews were conducted if there was an ASD diagnosis documented in the records. Data were collected in 13 sites across the United States through the ADDM Network, funded by the Centers for Disease Control and Prevention.

RESULTS

Males constituted 81% of the sample. There were no differences by sex in average age at first evaluation or average age of diagnosis among those with an existing documented chart diagnosis of an ASD. Girls were less likely than boys to have a documented diagnosis (odds ratio [OR] = 0.76, p = .004). This analysis was adjusted for cognitive impairment status. In the logistic model, with the interaction term for sex and cognitive impairment, girls with IQ of 70 or less were less likely than boys with IQ of 70 or less to have a documented diagnosis (OR = 0.70, 95% confidence interval [CI] = 0.50-0.97, p = .035). Boys with IQ greater than 70 were less likely than boys with IQ of 70 or less to have a documented diagnosis (OR = 0.60, 95% CI = 0.49-0.74, p < .001). This finding (less likely to have a documented diagnosis) was also true for girls with IQ greater than 70 (OR = 0.45, 95% CI = 0.32-0.66, p < .001). Girls were more likely to have notations of seizure-like behavior (p < .001). Boys were more likely to have notations of hyperactivity or a short attention span and aggressive behavior (p < .01).

CONCLUSIONS

Girls, especially those without cognitive impairment, may be formally identified at a later age than boys. This may delay referral for early intervention. Community education efforts should alert clinicians and parents to the potential of ASDs in boys and girls.

The adolescent research participant: strategies for productive and ethical interviewing

Nurse researchers who seek to study the experiences of adolescents have limited resources to assist them with the process. Although some elements of interviewing are standard practice, special approaches are needed for the adolescent participating in research. Interviews are especially challenging. The purpose of this article is to present strategies to assist researchers as they engage this cohort in research. These strategies include evaluating the adolescent's developmental level, designing developmentally appropriate questions, and refining interviewing techniques to optimize the experience for the participants. Strategies presented are useful to clinicians who wish to establish a therapeutic rapport with young patients.

Developmental disabilities and behavioral problems among school children in the Western Cape of South Africa

AIM

This descriptive cross-sectional study estimates the frequencies and kinds of potential developmental disabilities (DD) and behavior problems (BP) among children in grades R and 1 who attend a primary public school in rural Western Cape Province, South Africa.

METHODS

Data were collected on 174 children aged 5.1-8.8 years using the Ten Question Screener (10QS) and the Developmental Behaviors Checklist-Short form.

RESULTS

For the entire sample, 42% (n=73) screened positive for 1 or more possible DD on the 10SQ. Twenty-one percent (n=36) screened positive for one or more possible DDs. Thirty-six percent (n=63) of the sample scored above the cutoff for a behavioral problem that may be clinically significant. For this group the proportion of females (n=36, 39%) was slightly higher than males (n=28, 35%).

CONCLUSION

The percent of possible DDs and BP among children in grades R and 1 is higher than the number of learners with special needs reported by the Principal for the entire school (18.7%). The findings from this study suggest that there may be more learners than formally designated who have special educational needs that may benefit from special educational programs (e.g. speech, occupational, language, etc.). There may be a need for expanded remedial educational and behavioral services in this school and elsewhere in the district.

Relationships between multiple births and autism spectrum disorders, cerebral palsy, and intellectual disabilities: autism and developmental disabilities monitoring (ADDM) network-2002 surveillance year

Since the 1970s, the prevalence of multiple births (MBs) in the United States has increased significantly. This has been attributed, in large part, to iatrogenic MBs resulting from infertility treatments that include ovulation stimulation. A past study has indicated that children from MBs have an increased prevalence of cerebral palsy (CP). Other studies also have suggested an association between MBs and intellectual disabilities (ID) and autism spectrum disorders (ASDs); however, results have been inconsistent. From the Autism and Developmental Disabilities Monitoring (ADDM) Network, a surveillance project among several US populations, we obtained MB estimates among children born in 1994 and classified by 8 years of age as having: an ASD (n=1,626 total children from 11 sites; 50 born as part of an MB); CP (n=302 total children from 3 sites; 25 born as part of an MB); or ID (n=1,195 total children from 3 sites; 45 born as part of an MB). All three MB estimates were notably higher than age-adjusted expected estimates of naturally conceived MBs derived from 1971 US natality data. However, when MB estimates from the ADDM Network were compared with expected MB estimates derived from 1994 natality data for the states corresponding to the relevant ADDM Network sites, we observed no association with ASDs (observed/expected=1.08 [0.78-1.38]), a moderate, but not statistically significant association with ID (observed/expected=1.34 [0.95-1.73]), and a strong association with CP (observed/expected=2.96 [1.80-4.12]). Further investigation of specific types of MBs (natural vs. iatrogenic) is warranted.

Self-surveillance by adolescents and young adults transitioning to self-management of a chronic genetic disorder

Adolescents and young adults with Marfan syndrome (MFS) use information from self-surveillance to manage their disorder. Thirty-seven male and female adolescents with MFS aged 14 to 21 years were interviewed. They identified 58 distinct self-surveillance behaviors that fell into four categories and multiple subcategories (SCs): tracking phenotype (SCs: physical appearance, physical fitness, medical problems, and other observations); tracking medical care (SCs: medical evaluations and treatments, and pharmacotherapy); tracking behavior (SCs: personal choices and social relations); and tracking emotions (SCs: positive emotional impact and negative emotional impact). The frequency and range of self-monitoring increased with the age of the child. On average, a child of 14 self-monitored from 1 to 3 times per day, whereas a person aged 21 might self-monitor many more times per day. The patient-parent-physician relationship is the context for teaching adolescents and young adults self-surveillance skills. Self-surveillance by patients is first-line symptom assessment and an adjunct to medical monitoring.

Racial/ethnic disparities in the identification of children with autism spectrum disorders

OBJECTIVES

We sought to examine racial and ethnic disparities in the recognition of autism spectrum disorders (ASDs).

METHODS

Within a multisite network, 2568 children aged 8 years were identified as meeting surveillance criteria for ASD through abstraction of evaluation records from multiple sources. Through logistic regression with random effects for site, we estimated the association between race/ethnicity and documented ASD, adjusting for gender, IQ, birthweight, and maternal education.

RESULTS

Fifty-eight percent of children had a documented autism spectrum disorder. In adjusted analyses, children who were Black (odds ratio [OR] = 0.79; 95% confidence interval [CI] = 0.64, 0.96), Hispanic (OR = 0.76; CI = 0.56, 0.99), or of other race/ethnicity (OR = 0.65; CI = 0.43, 0.97) were less likely than were White children to have a documented ASD. This disparity persisted for Black children, regardless of IQ, and was concentrated for children of other ethnicities when IQ was lower than 70.

CONCLUSIONS

Significant racial/ethnic disparities exist in the recognition of ASD. For some children in some racial/ethnic groups, the presence of intellectual disability may affect professionals' further assessment of developmental delay. Our findings suggest the need for continued professional education related to the heterogeneity of the presentation of ASD.

Adolescents' transition to self-management of a chronic genetic disorder

Self-management of chronic illness requires acquisition of self-care skills such as seeking knowledge, adhering to recommendations, practicing healthy behaviors, and life-long self-surveillance. This article describes the core problem and psychosocial processes by which parents transfer, and children take on, the responsibility for managing a chronic genetic condition. Individuals with Marfan syndrome (MFS), their parents, and health care providers were the sources of empirical data. A sample of 108 providers, parents, and individuals with MFS were recruited through a genetics clinic and the National Marfan Foundation. The core problem of "becoming fit and fitting in" is resolved via concurrent psychosocial processes: shifting perspective, shifting orientation, shifting sphere, shifting ownership, and shifting reasoning. Transition to self-management is more than planning the transfer of services from pediatric to adult care, and involves gradual changes in knowledge, attitudes, and behavior influenced by parents, peers, and health care providers. Transition to self-management is part of an evolving model of participation in life-long surveillance.

The epidemiology of autism spectrum disorders

Autism spectrum disorders (ASDs) are complex, lifelong, neurodevelopmental conditions of largely unknown cause. They are much more common than previously believed, second in frequency only to mental retardation among the serious developmental disorders. Although a heritable component has been demonstrated in ASD etiology, putative risk genes have yet to be identified. Environmental risk factors may also play a role, perhaps via complex gene-environment interactions, but no specific exposures with significant population effects are known. A number of endogenous biomarkers associated with autism risk have been investigated, and these may help identify significant biologic pathways that, in turn, will aid in the discovery of specific genes and exposures. Future epidemiologic research should focus on expanding population-based descriptive data on ASDs, exploring candidate risk factors in large well-designed studies incorporating both genetic and environmental exposure data and addressing possible etiologic heterogeneity in studies that can stratify case groups and consider alternate endophenotypes.

Cancer vaccines: a new frontier in prevention and treatment

Vaccines have been exceptionally effective against diseases such as smallpox, measles, chickenpox, and polio. They are among the safest and most cost-effective agents for disease prevention. In recent years, vaccination has been considered for other diseases, including AIDS and cancer. Cancer vaccines can be categorized as preventive or therapeutic. Preventive vaccines, which are commercially available for cervical cancer and liver cancer, block infection with the causative agents of human papillomavirus and hepatitis B virus, respectively. The benefit of cancer treatment vaccines lies in their ability to "boost" the immune system response to cancer cells, which is generally low. Using vaccines in the treatment of cancer is relatively new, however, and chiefly experimental. Therapeutic vaccines for breast, lung, colon, skin, renal, prostate, and other cancers are now being investigated in clinical trials. Oncology nurses may play a significant role in reducing barriers to uptake of preventive vaccines among the general public and in increasing patients' acceptance of therapeutic cancer vaccines.

Relationship of dietary intake to gastrointestinal symptoms in children with autistic spectrum disorders

BACKGROUND

Gastrointestinal (GI) symptoms and abnormalities in stool consistency are frequently reported by parents of children with autism spectrum disorders (ASD). The purpose of this study was to 1) describe dietary intake of a cohort of children with ASD compared with normative data and 2) determine whether GI symptoms and stool consistency are related to dietary intake.

METHODS

Data from diet diaries of children (3-8 years) with ASD (n = 62) were analyzed by a registered pediatric dietician to compare to RDA standards for total calories, protein, carbohydrate, and fat. Dietary intake was correlated with descriptors of stool consistency using cumulative logistic regression methods.

RESULTS

Intake of calories, carbohydrates, and fat were in the average range; protein intake was increased (211% of RDA). Reported frequency of GI abnormalities, including abnormal stool consistency (e.g., bulky or loose), was increased (54%). No statistically significant relationships between stool consistency and dietary intake were observed.

CONCLUSIONS

In this sample, there was a high rate of reported gastrointestinal symptoms, despite lack of medical causes. Intake was adequate for calories and carbohydrates and increased for protein. The children did not exhibit excessive carbohydrate intake. There was no association of nutrient intake to changes in stool consistency.

Smoking Cessation for Women: Evidence of the Effectiveness of Nursing Interventions

The association between cigarette smoke and disease is direct; cigarette smoking is a major cause of disease in the United States. More than 400,000 people die each year as a result of cigarette smoke. Smoking is responsible for almost 90% of all cases of lung cancer. Smoking cessation reduces the risk of lung cancer within five years. Cessation also may reduce the risk of other cancers, such as cancer of the head and neck, pancreas, and esophagus. Smoking causes skin wrinkling and sexual dysfunction, which can be mediated by smoking cessation. Even after a diagnosis of cancer, smoking cessation improves the odds of survival and reduces the risk of developing a second cancer.

Self-Surveillance for Genetic Predisposition to Cancer: Behaviors and Emotions

PURPOSE/OBJECTIVES

To describe the kinds of self-monitoring activities and the emotional responses associated with those activities in patients with a genetic predisposition to multiple endocrine neoplasia type 2a (MEN2a) or familial adenomatous polyposis (FAP).

RESEARCH APPROACH

Thematic analysis of the transcripts of patient interviews conducted for two previous grounded theory investigations of participation in lifelong surveillance for patients with cancer predisposition syndromes and their family members.

SETTING

In the original studies, participants were recruited through a high-risk gastrointestinal cancer clinic (for FAP) and pediatric and adult endocrinology clinics (for MEN2a) at two eastern U.S. medical centers and by patient referral.

PARTICIPANTS

58 transcripts of interviews with 29 patients; 17 diagnosed with FAP or the variants of Gardner syndrome and attenuated FAP and 12 patients diagnosed with MEN2a.

METHODOLOGIC APPROACH

Informants participated in two hour-long, in-depth interviews and completed a self-administered sociodemographic questionnaire.

MAIN RESEARCH VARIABLES

Types of self-surveillance activities.

FINDINGS

Patients engage in an elaborate set of self-surveillance activities that are grouped into five categories of behavior: Medication Appraisal, Phenotype Tracking, Intake and Output Monitoring, Laboratory and Treatment Recording, and Tracking of Visits. Self-surveillance behaviors are grouped independent of type of syndrome, penetrance, age, or gender of the patient. Each category comprises a variety of behaviors that correspond with treatment recommendations and understanding of the disorder.

CONCLUSIONS

Self-surveillance may be driven by a combination of anticipation and the need for control and understanding.

INTERPRETATION

Findings from the study could be used to create an assessment tool to evaluate the extent to which patients are involved in day-to-day self-monitoring. Clinicians may use the categories to better understand patients' knowledge deficits and the emotional impact of enhanced vigilance. Self-surveillance activities performed by patients with MEN2a and FAP also may be performed by patients with other cancer predisposition syndromes.

Images of cloning and stem cell research in editorial cartoons in the United States

Through semiotic analysis of manifest and latent meanings in editorial cartoons, the author uncovers how cloning and stem cell research are represented in a popular mass medium. She identified 86 editorial cartoons published in the United States between 2001 and 2004 that referred to cloning and 20 that referred to stem cell research. Cartoonists portrayed people individually 224 times and 4 times in groups of more than 10. Men were portrayed in 64% of cartoons. Stem cell research was depicted as having a potential positive value, and cloning was depicted negatively. Some major messages are that cloning will lead to the mass production of evil, cloning creates monsters, and politics will influence who or what will be cloned. Analyzing popular images can allow access to public understanding about genetic technology and evaluation of public beliefs, preconceptions, and expectations as the public is educated on the use and value of services.

Modifying Cancer Risk Factors: The Gene-Environment Interaction

OBJECTIVES

To examine the concept of risk modification in the context of cancer prevention.

DATA SOURCES

Published articles and research studies on genetic and environmental factors.

CONCLUSION

How the environment is defined frames how the gene-environment interaction is studied and understood. The development of a workable model for risk modification flexible enough to be individualized for a patient is an important step in making primary prevention the goal in cancer care.

IMPLICATIONS FOR NURSING PRACTICE

Nurses working in cancer care are well placed to advise patients on risk-management strategies, and to increase public awareness of the interdependence of environment and genomics on cancer risk.

Intervention pilot for parents of children with autistic spectrum disorder

Parents of children who receive the diagnosis of autistic spectrum disorder (ASD) experience a situational crisis related to receiving the diagnosis, which causes feelings of distress and urgency to access services for the affected child. This paper describes a randomized trial (n = 31) that was conducted at a regional diagnostic center of a large metropolitan children's hospital to (a) refine a nursing intervention designed for parents of children with ASD and (b) to identify methodological revisions for a larger study. A secondary purpose was to test the effects of a post-diagnosis nursing intervention on parents' reports of stress, impact of event (diagnosis), and use of services after a child is newly diagnosed with ASD. The intervention consisted of usual care plus 3 hours contact with a pediatric nurse practitioner (PNP) for counseling, instruction, and assistance with implementation of the recommended treatment plan. The control group received only the usual care post-diagnosis, which consisted of a 1-hour consultation session to receive the results of diagnostic tests and a written copy of the recommended treatment plan provided by a developmental pediatrician and/or PNP. Between group differences in measures of "impact of event" and "perceived stress" were not statistically significant. This was attributed to a small sample size. A larger study is feasible and recommended with an expanded nursing intervention and a significantly larger sample recruited from an additional recruitment site. Nurses working with this special population must recognize that parents have information and counseling needs that begin after they receive the diagnosis of ASD for their child and can address these needs with a standardized nursing intervention.

The role of nurses in screening for autistic spectrum disorder in pediatric primary care

This article addresses the issue of integration of routine screening for autism spectrum disorder (ASD) in pediatric primary care. The relationship between screening and patient outcome is discussed. The ASD screening recommendations of the American Academy of Pediatrics and practical issues associated with their application are then reviewed. Finally, data from a pilot project to prepare nurses to conduct ASD screening during routine pediatric health visits are presented. The authors discuss the role of nurses in establishing systems within pediatric primary care to identify and refer children at risk for ASD.

A model of survivorship in cancer genetic care

OBJECTIVES

To propose a shift in the paradigm of survivorship in genetic cancer care.

DATA SOURCES

Published articles and, studies.

CONCLUSION

Previous models of survivorship are insufficient to address the evolving needs of patients and families with heritable cancers. The construction of a new model of survivorship is needed to address the unique concerns of individuals who have undergone hereditary cancer risk assessment and counseling.

IMPLICATIONS FOR NURSING PRACTICE

Health care providers must be familiar with the recommendations for treatment, surveillance, and follow-up care for individuals and families with heritable cancers to maximize their quantity and quality of life.

"Not lighting up": a case study of a woman who quit smoking

PURPOSE/OBJECTIVES

To review the prevalence, incidence, and risks of smoking by American women; to outline services, treatments, and educational options for smoking prevention and cessation; and to present the conceptual link between the epidemiologic and research literature and experiences of one individual in the target population--an adult female former smoker with a 30-year habit who began smoking during her teenage years.

DATA SOURCES

Published literature, expert opinion, and an interview with a former smoker--a female healthcare professional who had a 30-year habit.

DATA SYNTHESIS

Literature was reviewed and the content was evaluated for relevance, accuracy, and timeliness. The relevant content was augmented with the author's practical experience and applied to the case study to make recommendations.

CONCLUSIONS

Oncology nurses may use a number of strategies to assist people to never start or to stop using tobacco products. The most effective strategy begins with collaboration between healthcare professionals and patients and a combination of instruction, counseling, and emotional support. Oncology nurses can participate in grassroots efforts to educate the public about addiction related to tobacco use, provide counseling for patients who smoke, and become actively involved in legislative solutions to the problem of tobacco use.

IMPLICATIONS FOR NURSING

Oncology nurses may intervene to affect positive behavioral change and participate in grassroots efforts to educate the public. Substantial resources are available to professionals and patients who wish to quit smoking or prevent tobacco use by friends and relatives. Nurses should take every opportunity to support smoking cessation and tobacco use prevention.

Bringing threat to the fore: participating in lifelong surveillance for genetic risk of cancer

PURPOSE/OBJECTIVES

To explain how patients with multiple endocrine neoplasia type 2a (MEN2a) and family members conceptualize participation in lifelong surveillance in genetic cancer care.

DESIGN

Qualitative naturalistic inquiry.

SETTING

Northeastern United States. Data were collected during interviews in informants' homes.

SAMPLE

12 adult patients and 9 family members were recruited purposively through endocrinology clinics at two East Coast medical centers.

METHODS

A grounded theory design was used. Subjects completed a demographic questionnaire and were interviewed on two occasions. In-depth interviews were audiotaped. The core concept and process variables emerged through three levels of narrative content analysis, theoretical sampling, and constant comparison. The generated theory was presented to the participants for validation.

MAIN RESEARCH VARIABLES

The basic psychological issue associated with participation in lifelong surveillance and the psychosocial processes used by individuals to deal with the issues.

FINDINGS

MEN2a patients and family members experience surveillance as a (Re)Minding of a threat to health. Once threat is brought to the fore, participants interpret the meaning and negotiate control of the impact of the diagnosis, related events, and consequences. Meaningful information from surveillance activities is incorporated into participants' self-image and daily lives through a process of (Re)Integration. The genetic nature of MEN2a did not emerge as a significant subcategory in relation to the core variable.

CONCLUSIONS

Finding meaning in the outcomes of surveillance events is a psychosocial process that is central to participation in lifelong surveillance. Genetic predisposition to cancer was a peripheral concern to subjects as they dealt with surveillance issues.

IMPLICATIONS FOR NURSING

This investigation provides a model for the development of a grounded theory for understanding how people with other genetic cancer syndromes participate in lifelong surveillance.

Methodological issues in the use of published cartoons as data

When common understanding of a phenomenon is under investigation, mass media representation in general, and cartoon images in particular, are a useful source of data. Sample selection, data collection, and the analysis of constructed images differ from other kinds of data. Cartoonists may intend to stimulate multiple interpretations among readers. Uncovering these interpretations is essential to understanding public discourse of the phenomenon of interest. Semantic validation is used to assess the degree to which the meanings of text relative to their context are accurately represented. Analysis of the image and text of cartoons has the potential to yield important understanding of public discourse surrounding issues of the public's health and well-being.

Safeguarding being: a bioethical principle for genetic nursing care

This philosophical inquiry examines the nature of the technology of genetic predisposition testing and its relation to patients as whole persons. The bioethical principles of non-maleficence, beneficence, autonomy and justice are judged insufficient to resolve issues associated with use. A new principle of 'sustained being', drawn from philosophical propositions of Pellegrino, is suggested. The new principle is suited to an evolving practice and is compatible with consequentialist, deontological and relational ethics theories. The notion of 'taking care' is related to nursing in genetic health care to form a standard of conduct and a moral imperative to 'safeguard being'.

Prophylactic gastrectomy for CDH1 mutation carriers

Gastric cancer is difficult to diagnose at an early stage. Signs and symptoms of the disease often only occur when advanced or metastatic disease is present. A very small number of gastric cancers are hereditary. The mutation to the E-cadherin gene has high penetrance and confers a lifetime risk of gastric cancer of 80% for carriers. Because of the high penetrance of the mutation and the difficulty of diagnosing gastric cancer at an early stage, carriers of the mutation may be candidates for prophylactic gastrectomy. Although limited data are available about the complications and outcomes associated with prophylactic gastrectomy, nurses should be knowledgeable about prophylactic surgery for hereditary cancers and prepared to answer patients' questions about their prevention.

Multiple endocrine neoplasia type 2a (MEN2a): a call for psycho-social research

This paper summarizes what is known about the diagnosis, treatment, and follow-care of people with the inherited disorder multiple endocrine neoplasia type 2a (MEN2a). Several databases were searched throughout the year 2000, including MEDLINE, CINAHL, CancerLit, PsychINFO, and Dissertation Abstracts International. MEN2a is a complex disease involving cancer care and control by surgery, health maintenance, and life-long observation of gene mutation carriers. Genetic testing is the standard of care, prophylactic surgery is recommended during directive counseling, and life-long surveillance is encouraged for people with MEN2a. A substantial body of scientific literature describes morbidity and mortality outcomes of disease treatment, and the monitoring of multiple organ systems. Research is scant concerning the psychological consequences and social impact of the MEN2a diagnosis, treatment, and follow-up. Nearly all that is known from a psycho-social perspective comes from data in The Netherlands. Little is known of the psychological responses to and social consequences of genetic predisposition testing, prophylactic and curative surgery, and life-long surveillance. Psycho-social research is essential to provide comprehensive care for patients and family members with this disorder and it is necessary to guide the development of risk management strategies for patients with this inherited cancer syndrome. Since MEN2a has been labeled a prototype for medical genetics, information on MEN2a patient experiences may be relevant to the care of individuals with other inherited cancer syndromes.

A concept model for individual surveillance in genetic cancer care

OBJECTIVE

To present the concept of individual surveillance in genetic risk management as a complex collection of other concepts, and to propose a model that represents how these component concepts may relate to each other.

CONCEPT

The concept of "individual surveillance" has a set of lexical conditions, called critical attributes, antecedents, and consequence. The attributes are derived from the historical and contemporary use of the word and must be present for conceptualization. Antecedents are conditions that must exist before individual surveillance can occur, and consequences are those events that will always occur after individual surveillance. The popular association of surveillance with real or suspected criminal activity may design a predilection for critical attributes and confuse concept attainment. Before involving patients and family members in surveillance activities, clinicians should explore the subjective meaning of participation.

MODEL

The model can be used, by a clinician and a patient, to describe and understand the meaning of individual surveillance for participants in a systematic, holistic, and highly personal way.

The silent epidemic: tobacco and the evolution of lung cancer and its treatment

Considered a rare disease during the 19th century, lung cancer became the most virulent and lethal cause of cancer mortality by the end of the 20th century. In this paper, lung cancer and its treatment are addressed within the social, cultural, economic, and political context of the last century. Because lung cancer is related to the consumption of cigarettes, the battles over tobacco control are highlighted. Four time periods are addressed: the early years (1900-1930), beginning of the epidemic (1930-1960), defining the problem (1960-1980), and expanding options (1980-1990s). Although improvements have been made in science and technology, attempts at finding curative treatments have met with little success. Smoking cessation and efforts to control tobacco (especially among children and adolescents) remain the most important factors if the incidence of lung cancer is to be curtailed in the future. Providing care to individuals with the illness is a current challenge. Research examining the efficacy of treatments and their effect on survival, health-related quality of life, and cost outcomes is essential and can be best achieved through the efforts of multidisciplinary teams.