Coercive parenting: modifiable and nonmodifiable risk factors in parents of children with developmental disabilities

BACKGROUND

Parents of children with developmental or intellectual disabilities tend to report greater use of coercive parenting practices relative to parents of typically developing children, increasing the risk of adverse child outcomes. However, to date, there is limited research exploring the role and relative contribution of modifiable and nonmodifiable risk factors in parents of children with a disability. The present study aimed to explore the role of various modifiable and nonmodifiable parenting, family and sociodemographic factors associated with the use of coercive parenting practices in parents of children with a disability.

METHODS

Caregivers (N = 1392) enrolled in the Mental Health of Young People with Developmental Disabilities (MHYPeDD) programme in Australia completed a cross-sectional survey about their parenting and their child aged 2-12 years with a disability. Measures covered a range of domains including relevant demographic and family background, use of coercive parenting practices, intensity of child behavioural difficulties and questions relating to parent and family functioning such as parental self-efficacy, adjustment difficulties and quality of family relationships.

RESULTS

Parents of older children, those who were younger at the birth of their child, and parents who were co-parenting or working reported more use of coercive parenting practices. Greater intensity of child difficulties, poorer parental self-efficacy and parent-child relationships, and more parental adjustment difficulties were also significantly associated with more use of coercive parenting. Examination of the relative contribution of variables revealed parent-child relationship was a key contributing factor, followed by intensity of child behaviour problems, parent adjustment and parent confidence.

CONCLUSIONS

These findings highlight a range of factors that should be targeted and modified through upstream prevention programmes and further inform our understanding of how coercive practices may be influenced through targeted parenting interventions.

Mechanisms Through Which Supportive Relationships with Parents and Peers Mitigate Victimization, Depression and Internalizing Problems in Children Bullied by Peers

This study investigated how supportive relationships with peers and parents protect children against ongoing victimization, internalizing problems and depression. The longitudinal data set tracked progress of 111 children recruited for the trial of Resilience Triple P, and previously bullied by peers. Informants included children, parents and teachers. Higher levels of facilitative parenting (warm parenting that supports peer relationships) and peer acceptance predicted lower later levels of both depression and victimization over time. Higher levels of child friendedness predicted lower levels of child reports of internalizing problems. Children's friendships, acceptance by same sex peers and facilitative parenting all played moderating roles in protecting against ongoing victimization and internalizing problems. Peer acceptance mediated the relationships between facilitative parenting and victimization. Facilitative parenting mediated the relationship between peer acceptance and depression. It was concluded that supportive relationships with parents and peers play important and complementary roles in protecting children against ongoing victimization and depression.

Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness

Both babies and their parents may experience a stay in the newborn intensive care unit (NICU) as a traumatic or a 'toxic stress,' which can lead to dysregulation of the hypothalamic-pituitary-adrenal axis and ultimately to poorly controlled cortisol secretion. Toxic stresses in childhood or adverse childhood experiences (ACEs) are strongly linked to poor health outcomes across the lifespan and trauma-informed care is an approach to caregiving based on the recognition of this relationship. Practitioners of trauma-informed care seek to understand clients' or patients' behaviors in light of previous traumas they have experienced, including ACEs. Practitioners also provide supportive care that enhances the client's or patient's feelings of safety and security, to prevent their re-traumatization in a current situation that may potentially overwhelm their coping skills. This review will apply the principles of trauma-informed care, within the framework of the Polyvagal Theory as described by Porges, to care for the NICU baby, the baby's family and their professional caregivers, emphasizing the importance of social connectedness among all. The Polyvagal Theory explains how one's unconscious awareness of safety, danger or life threat (neuroception) is linked through the autonomic nervous system to their behavioral responses. A phylogenetic hierarchy of behaviors evolved over time, leveraging the mammalian ventral or 'smart' vagal nucleus into a repertoire of responses promoting mother-baby co-regulation and the sense of safety and security that supports health and well-being for both members of the dyad. Fostering social connectedness that is mutual and reciprocal among parents, their baby and the NICU staff creates a critical buffer to mitigate stress and improve outcomes of both baby and parents. Using techniques of trauma-informed care, as explained by the Polyvagal Theory, with both babies and their parents in the NICU setting will help to cement a secure relationship between the parent-infant dyad, redirecting the developmental trajectory toward long-term health and well-being of the baby and all family members.

Neonatologists' perspectives of palliative and end-of-life care in neonatal intensive care units

OBJECTIVE

Determine palliative and end-of-life care practices, barriers and beliefs among US neonatologists, and relationships between practice characteristics and palliative care delivery.

STUDY DESIGN

A descriptive cross-sectional survey with ordinal measurements. The survey was sent to 1885 neonatologists.

RESULTS

There were 725 responses (38.5%) with 653 (34.6%) completing the survey. Of those, 58.0% (n=379) have palliative care teams and 72.0% (n=470) have staff support groups or bereavement services. Palliative care education was deemed important (n=623) and needed. Barriers include emotional difficulties, staff disagreements and difficulty forming palliative care teams. Palliative care teams or staff bereavement groups were significantly predictive of willingness to initiate palliative care and more positive views or experiences.

CONCLUSION

Neonatologists believe that palliative care is important. Education and palliative care teams help provide quality care. Exploration of differing views of palliative care among team members is needed.

Predictors of psychological adjustment, experienced parenting burden and chronic sorrow symptoms in parents of children with cerebral palsy

AIM

To investigate the role of child behaviour, parental coping and experiential avoidance in predicting the psychological outcomes of: (i) psychological symptoms; (ii) chronic sorrow symptoms; and (iii) experienced parenting burden in parents of children with cerebral palsy (CP).

METHOD

This study is a cross-sectional, correlational study. Ninety-four parents of children (aged 2-12 years) with CP (various levels of motor functioning GMFCS I-V) participated.

RESULTS

Together, the three predictors of child behaviour, parental coping and experiential avoidance explained 36.8% of the variance in psychological symptoms with child behavioural problems and experiential avoidance as significant unique predictors. In addition, 15.8% of the variance in chronic sorrow symptoms was explained by the three predictors with experiential avoidance alone as a significant unique predictor. Lastly, the predictors together explained 24.3% of the variance in experienced parenting burden with child behavioural problems and experiential avoidance as significant unique predictors.

CONCLUSIONS

This study demonstrates a relationship between child behavioural problems and parental psychological symptoms and experienced parenting burden as well as a relationship between experiential avoidance and parental psychological symptoms, experienced parenting burden and chronic sorrow symptoms.

Parenting knowledge and its role in the prediction of dysfunctional parenting and disruptive child behaviour

BACKGROUND

There is a paucity of research on the relationship between parental knowledge, parenting and parenting self-efficacy, and some inconsistencies have been reported in the literature.

METHOD

Parent knowledge of effective parenting strategies was assessed among 68 parents from a non-clinic sample, who also completed questionnaires relating to parenting confidence, quality of parenting and child behaviour.

RESULTS

Parents with greater knowledge tended to be less dysfunctional, and reported significantly higher education and income levels. Parenting confidence explained a significant proportion of the variance in reported frequency of disruptive child behaviour while knowledge did not independently contribute to the prediction. However, the relationship between parenting confidence and dysfunctional parenting was moderated by the level of knowledge. There was a stronger negative relationship between confidence and dysfunctional parenting when knowledge level was low than when it was high. Post hoc analyses indicated that the relationship between parenting knowledge and disruptive child behaviour was moderated by the level of parenting dysfunction. Parenting knowledge and reported frequency of disruptive behaviour were positively related when the level of dysfunction was low, but were unrelated when it was high.

CONCLUSIONS

Parents with low levels of knowledge and confidence in their parenting may be at greater risk of dysfunctional parenting and might benefit from interventions designed to enhance both knowledge and confidence. Results are interpreted in relation to inconsistencies with previous research and implications for future methodologies.

Using household survey data to inform policy decisions regarding the delivery of evidence-based parenting interventions

BACKGROUND

This study used household survey data on the prevalence of child, parent and family variables to establish potential targets for a population-level intervention to strengthen parenting skills in the community. The goals of the intervention include decreasing child conduct problems, increasing parental self-efficacy, use of positive parenting strategies, decreasing coercive parenting and increasing help-seeking, social support and participation in positive parenting programmes.

METHODS

A total of 4010 parents with a child under the age of 12 years completed a statewide telephone survey on parenting.

RESULTS

One in three parents reported that their child had a behavioural or emotional problem in the previous 6 months. Furthermore, 9% of children aged 2-12 years meet criteria for oppositional defiant disorder. Parents who reported their child's behaviour to be difficult were more likely to perceive parenting as a negative experience (i.e. demanding, stressful and depressing). Parents with greatest difficulties were mothers without partners and who had low levels of confidence in their parenting roles. About 20% of parents reported being stressed and 5% reported being depressed in the 2 weeks prior to the survey. Parents with personal adjustment problems had lower levels of parenting confidence and their child was more difficult to manage. Only one in four parents had participated in a parent education programme.

CONCLUSIONS

Implications for the setting of population-level goals and targets for strengthening parenting skills are discussed.

Concurrent predictors of dysfunctional parenting and maternal confidence: implications for parenting interventions

BACKGROUND

The often intense nature of the conflict between parents and their toddlers requires better understanding of what happens during this stage of development and how difficulties can be prevented from escalating in the future. Clarification of the nature of family and parenting factors related to toddler behaviour allows better capacity for intervention development and tailoring to individual families.

METHODS

A total of 126 mothers of toddlers completed a self-report assessment battery, examining child behaviour, parenting style and confidence, as well as broader family adjustment measures.

RESULTS

The study found that maternal confidence and dysfunctional parenting were interrelated and were also predicted best by parenting variables, in contrast to socio-demographic and child variables. Maternal confidence also mediated the relationships between family income and toddler behaviour.

CONCLUSIONS

Parenting style and confidence are important modifiable factors to target in parenting interventions. The implications for the development, implementation and delivery of parenting interventions are discussed.

Predictors of care-giver stress in families of preschool-aged children with developmental disabilities

BACKGROUND

This study examined the predictors, mediators and moderators of parent stress in families of preschool-aged children with developmental disability.

METHOD

One hundred and five mothers of preschool-aged children with developmental disability completed assessment measures addressing the key variables.

RESULTS

Analyses demonstrated that the difficulty parents experienced in completing specific care- giving tasks, behaviour problems during these care-giving tasks, and level of child disability, respectively, were significant predictors of level of parent stress. In addition, parents' cognitive appraisal of care-giving responsibilities had a mediating effect on the relationship between the child's level of disability and parent stress. Mothers' level of social support had a moderating effect on the relationship between key independent variables and level of parent stress.

CONCLUSIONS

Difficulty of care-giving tasks, difficult child behaviour during care-giving tasks, and level of child disability are the primary factors which contribute to parent stress. Implications of these findings for future research and clinical practice are outlined.

The relationship between maternal self-efficacy and parenting practices: implications for parent training

The present study examined the relationship between maternal self-efficacy, dysfunctional discipline practices and child conduct problems. Specifically, three levels of self-efficacy, global, domain and task-specific self-efficacy, were assessed in mothers of 2- to 8-year-old children with conduct problems (clinic group, n=45) and non-clinic mothers from the community (non-clinic group, n=79). Measures of global, domain and task-specific self-efficacy were completed by mothers. Clinic mothers reported significantly lower self-efficacy than non-clinic mothers for all but one of the parenting tasks assessed. Both groups of mothers reported lowest self-efficacy for similar parenting tasks. In the sample as a whole self-efficacy measures were significant predictors of maternal discipline style after controlling for other parent, child and risk factors. Of the self-efficacy variables behavioural self-efficacy was the best predictor of mothers discipline style. The findings support the importance of developing parenting strategies that enable parents to generalize their parenting skills to a diverse range of diverse parenting contexts both in the home and in the community.

Häufigkeit psychischer Auffälligkeiten und Begleitsymptome bei drei- bis sechsjährigen Kindern: Ergebnisse der Braunschweiger Kindergartenstudie

Zusammenfassung: Fragestellung: Im Rahmen der Braunschweiger Kindergartenstudie wurde die Häufigkeit psychischer Auffälligkeiten und Begleitsymptome bei Kindern im Alter zwischen 3 und 6 Jahren untersucht. Methode: Die Untersuchung wurde im November 1998 in allen städtischen Kindertagesstätten Braunschweigs mit einer leicht modifizierten Version des Elternfragebogens über das Verhalten von Kindern und Jugendlichen/CBCL 4-18 durchgeführt. Von N = 809 Kindern liegen Elterneinschätzungen vor. Ergebnisse: Die Prävalenzraten für psychische Störungen bei Kindergartenkindern liegen zwischen 0,5% und 5,0%, wobei in dieser Altersgruppe Aggressives Verhalten, Aufmerksamkeitsprobleme und Soziale Probleme am häufigsten auftreten. Es werden außerdem Komorbiditätsraten für die einzelnen Syndromskalenpaare der CBCL berichtet. Diskussion: Abschließend werden die vorliegenden Ergebnisse mit anderen Untersuchungen verglichen und Implikationen vor allem für die Prävention kindlicher Verhaltensauffälligkeiten diskutiert.

Can skills training prevent relationship problems in at-risk couples? Four-year effects of a behavioral relationship education program

Eighty-three couples were stratified into groups at high and low risk for relationship distress and randomized to either the Self-Regulatory Prevention and Relationship Enhancement Program (Self-PREP) or a control condition. As predicted, there were differential effects of Self-PREP on high-risk and low-risk couples. Because of low statistical power, results must be interpreted cautiously, but at 1-year follow-up high-risk couples in Self-PREP showed trends toward better communication than control couples. However, there was no difference in the communication of Self-PREP and control low-risk couples. High-risk couples receiving Self-PREP exhibited higher relationship satisfaction at 4 years than control couples, but in low-risk couples relationship satisfaction was higher in the control condition. High-risk couples seemed to benefit from skills-based relationship education, but low-risk couples did not.

Experience with newborn intensive care deaths in a tertiary setting

The purpose of this paper is to report the longitudinal experience with deaths in a United States' newborn intensive care unit. Retrospective analysis comparing infant deaths in two epochs: Epoch 1: 1985-1988 (n = 127) and Epoch 2: 1991-1994 (n = 75). Data included demographic factors, age at death, episodes of cardiopulmonary resuscitation, do not resuscitate status, and whether withdrawal of support occurred. Infants in Epoch 2 were significantly younger at birth (28.7 +/- 0.7 vs. 30.6 +/- 0.5 wks', p = 0.02) and death (31.5 +/- 0.9 vs. 34.0 +/- 0.7 wks', p = 0.02) than those in Epoch 1. There was no difference in length of stay (19.5 +/- 5.1 vs. 24.4 +/- 4.2 days, Epoch 2 vs. Epoch 1). Infants were more likely to receive cardiopulmonary resuscitation in Epoch 2 than Epoch 1 (60 vs. 41%, p = 0.008). However, more infants in Epoch 2 also had do not resuscitate status (80% vs. 59%, p = 0.002) or withdrawal of support (72% vs. 52%, p = 0.005). The majority of newborn intensive care deaths currently occur with do not resuscitate status and/or withdrawal of support.

Community-based parenting and family support interventions and the prevention of drug abuse

This paper presents a model for the development of a comprehensive, multilevel, preventively-oriented parenting and family support strategy to reduce family risk factors associated with drug abuse in young people. If parenting interventions are to make a significant impact at a population level on the prevalence of dysfunctional parenting practices, there is a need for an ecological approach to parenting support. Such an approach needs to target a variety of social contexts that are in a position to provide parents with access to evidence-based parenting interventions. The Triple P-Positive Parenting Program is discussed as an example of such an approach to illustrate the distinguishing features of a population level strategy. The core constructs underpinning the Triple P system include the promotion of parental self-regulation (self-sufficiency, self-efficacy, self-management, personal agency, and problem solving), through making parenting programs of adequate intensity widely available in the community through flexible delivery modalities (individual, group, telephone assisted and self-directed). The system comprises a tiered continuum of increasingly intensive parenting interventions ranging from media interventions with wide reach, to intensive behavioural family interventions with narrow reach for high-risk families where parenting problems are complicated by other factors including marital conflict, parental mood disturbance, and lack of social support. The scientific basis of the system of intervention and possible directions for future research is discussed.

The mass media and the prevention of child behavior problems: the evaluation of a television series to promote positive outcomes for parents and their children

This paper examines the impact of a 12-episode television series, "Families", on disruptive child behavior and family adjustment. This media intervention comprises the first of a five-level early intervention parenting and family support strategy, known as Triple P (Positive Parenting Program). Fifty-six parents of children aged between 2 and 8 years were randomly assigned to either watching the television series or to a waitlist control group. Compared to the control group, parents in the television viewing (TV) condition reported significantly lower levels of disruptive child behavior and higher levels of perceived parenting competence, immediately following intervention. Prior to intervention approximately 42.9% of the children in the TV condition were in the clinically elevated range for disruptive child behavioral problems. This had reduced to 14.3 % following intervention. In addition, a high level of consumer acceptability was reported by parents in the TV condition. All post-intervention effects were maintained at 6-month follow-up. Implications for public health approaches to family mental health are discussed.

The triple P-positive parenting program: a comparison of enhanced, standard, and self-directed behavioral family intervention for parents of children with early onset conduct problems

Three variants of a behavioral family intervention (BFI) program known as Triple P were compared using 305 preschoolers at high risk of developing conduct problems. Families were randomly assigned to enhanced BFI (EBFI), standard BFI (SBFI), self-directed BFI (SDBFI), or wait list (WL). At postintervention, the 2 practitioner-assisted conditions were associated with lower levels of parent-reported disruptive child behavior, lower levels of dysfunctional parenting, greater parental competence, and higher consumer satisfaction than the SDBFI and WL conditions. Overall, children in EBFI showed greater reliable improvement than children in SBFI, SDBFI, and WL. By 1-year follow-up, children in all 3 conditions achieved similar levels of clinically reliable change in observed disruptive behavior. However, the EBFI and SBFI conditions showed greater reliable improvement on parent-observed disruptive child behavior.

Diagnosis and management of spinal epidural space extravasation complicating percutaneous central venous line placement in a premature infant: case report and review of literature

Percutaneous central venous lines are commonly used to establish long-term venous access in the care of premature infants. Misplacement of these catheters can occur and may lead to significant morbidity and mortality. Here we report a very-low-birth-weight premature infant whose percutaneous central venous line was inadvertently placed into the spinal epidural space. The anatomical basis of this complication as well as a comprehensive review of literature are provided.

Repeating the errors of our parents? Family-of-origin spouse violence and observed conflict management in engaged couples

Based on a developmental social learning analysis, it was hypothesized that observing parental violence predisposes partners to difficulties in managing couple conflict. Seventy-one engaged couples were assessed on their observation of parental violence in their family of origin. All couples were videotaped discussing two areas of current relationship conflict, and their cognitions during the interactions were assessed using a video-mediated recall procedure. Couples in which the male partner reported observing parental violence (male-exposed couples) showed more negative affect and communication during conflict discussions than couples in which neither partner reported observing parental violence (unexposed couples). Couples in which only the female partner reported observing parental violence (female-exposed couples) did not differ from unexposed couples in their affect or behavior. Female-exposed couples reported more negative cognitions than unexposed couples, but male-exposed couples did not differ from unexposed couples in their reported cognitions.

Triple P-Positive Parenting Program: towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children

This paper outlines the theoretical and empirical foundations of a unique multilevel parenting and family support strategy designed to reduce the prevalence of behavioral and emotional problems in preadolescent children. The program known as Triple P-Positive Parenting Program is a multilevel system of family intervention, which provides five levels of intervention of increasing strength. These interventions include a universal population-level media information campaign targeting all parents, two levels of brief primary care consultations targeting mild behavior problems, and two more intensive parent training and family intervention programs for children at risk for more severe behavioral problems. The program aims to determine the minimally sufficient intervention a parent requires in order to deflect a child away from a trajectory towards more serious problems. The self-regulation of parental skill is a central construct in the program. The program uses flexible delivery modalities (including individual face-to-face, group, telephone assisted, and self-directed programs) to tailor the strength of the intervention to the requirements of individual families. Its multidisciplinary, preventive and community-wide focus gives the program wide reach, permitting the targeting of destigmatized access points through primary care services for families who are reluctant to participate in parenting skills programs. The available empirical evidence supporting the efficacy of the program is discussed and its implications for research on dissemination are discussed.

Impact of the perception of viability on resource allocation in the neonatal intensive care unit

OBJECTIVE

To understand how neonatologists' perceptions of viability impact their willingness to recommend or provide medical interventions for infants born at 23 to 24 weeks' gestation.

STUDY DESIGN

A 25-question survey mailed to 3056 neonatologists in the United States in 1992 yielded 1131 responses. Seven hundred seventy-five (775 of 1131, 69%) reported they believed that the lower limit of viability was 23 to 24 weeks' gestation. These respondents were asked if they were willing to recommend or provide a series of medical interventions for infants born at 23 and 24 weeks' gestation.

RESULTS

Most respondents would provide ventilation (82% and 95%) and surfactant (62% and 78%) for infants born at 23 and 24 weeks' gestation, respectively. The respondent's prediction of <100% mortality, infant factors, and parental wishes were significant predictors of willingness to resuscitate infants born at 23 weeks' gestation.

CONCLUSION

There is considerable variation among neonatologists in their willingness to recommend or provide medical interventions for infants born at 23 to 24 weeks' gestation.

The Raf-1 protein mediates insulin-like growth factor-induced proliferation of erythroid progenitor cells

Previous studies from this and other laboratories have shown that insulin-like growth factor-1 (IGF-I) and insulin-like growth factor-2 (IGF-II) support erythroid colony formation in cultures supplemented with serum substitute and recombinant erythropoietin. Subpopulations of IGF-I- and IGF-II-dependent, erythropoietin-independent colony-forming unit-erythroid (CFU-E)-derived colonies and BFU-E-derived colonies were identified under serum-substituted conditions for adult bone-marrow-derived erythroid progenitors which proliferate in the absence and presence of exogenous anti-erythropoietin receptor monoclonal antibody and in serum-substituted medium that was preadsorbed with anti-erythropoietin IgG. To assess whether Raf-1 is required for the formation of IGF-dependent, erythropoietin-independent human erythroid colonies, 5-15 microM sense or antisense oligomer to raf-1 were added to serum-substituted cultures containing either 2 U/ml recombinant human erythropoietin (rHuEpo) alone or 0-1,000 ng/ml IGF-I or IGF-II with/without 2 U/ml rHuEpo. Both erythropoietin-induced and IGF-induced erythroid colony formation were completely blocked by antisense (but not sense) oligomers to raf-1. Purified human CFU-Es were examined for Raf-1 message and protein. Total RNA was extracted, and raf-1 mRNA was detected on Northern blots. Furthermore, a 74 kD protein, corresponding to Raf-1, was also detected in CFU-Es purified from human adult sources. Together, these studies support the hypothesis that the Raf-1 protein mediates both erythropoietin-induced and IGF-induced signal transduction in human erythroid progenitor cells.

Impact of gastroesophageal reflux on growth and hospital stay in premature infants

BACKGROUND

Gastroesophageal reflux (GER) is associated with failure to thrive in term infants with severe GER; however, this association has not been shown in premature infants. A retrospective case-control study of growth velocities, caloric intake, and length of hospital stay in premature infants with GER was conducted to determine the impact of GER on their growth.

METHODS

Twenty-three patients with clinically significant GER were identified from a database containing records for all infants admitted to the University of Connecticut Health Center Neonatal Intensive Care Unit. Patients and control subjects (n = 23) were matched for gestational age, birth weight, gender, and severity of bronchopulmonary dysplasia. Each infant's average weekly weight gain and average weekly caloric intake were calculated, using daily bedside nursing flow sheets. Comparisons were also made of the number of days it took each infant to achieve full oral feedings, number of days from full oral feedings to discharge, and length of hospital stay.

RESULTS

There were no significant differences between patients and control subjects for each week in average weekly weight gain, caloric intake, grams gained per calorie given, or weekly increments gained in length and head circumference. There were, however, significant differences in time required to achieve full oral feedings (32 +/- 13 days versus 19 +/- 12 days; p < 0.0008) and length of hospital stay (99 +/- 27 days versus 70 +/- 31 days; p < 0.002) as well as postmenstrual age (PMA) at discharge (43 +/- 3 weeks versus 39 +/- 3 weeks, p < 0.001).

CONCLUSIONS

GER did not have a significant impact on caloric intake, effective use of calories, or growth velocities in the study population. It is more likely that the constant monitoring of weight gain and caloric intake while in the intensive care environment protects against the failure to thrive often seen in older infants with GER. Premature infants with GER had a significantly increased length of hospital stay. More aggressive medical management and consideration of alternative feeding strategies may help facilitate discharge for premature infants diagnosed with GER.

Mealtime behavior and parent-child interaction: a comparison of children with cystic fibrosis, children with feeding problems, and nonclinic controls

Examined the role of family interaction factors in dietary compliance problems reported by parents of children with cystic fibrosis (CF). The family mealtime interactions of children with CF, children with feeding problems and nonclinic controls were observed, and parents monitored children's eating behavior at home. Parents of children with CF reported more concern about feeding problems and recorded more disruptive mealtime behavior than parents of nonclinic children. Observational data showed children with CF to display overall rates of disruptive mealtime behavior not significantly different from either comparison group. Mothers of children with CF were observed to engage in higher rates of aversive interaction with their child than did mothers of nonclinic controls. Fathers of children with CF reported lower marital satisfaction than fathers of controls. Both mothers and fathers of children with CF reported lower parenting self-efficacy than non-CF families. Clinical implications are discussed.

Self-directed behavioral family intervention for parents of oppositional children in rural and remote areas

Twenty-four parents of oppositional preschoolers were randomly assigned to either a self-directed behavioral family intervention condition (SD) or to a waitlist control group (WL). The self-directed parent training program, based on self-regulation principles, consisted of a written information package and weekly telephone consultations for 10 weeks. At posttest, in comparison to the WL group, children in the SD group had lower levels of behavior problems on parent report measures of child behavior. At posttreatment, parents in the SD condition reported increased levels of parenting competence and lower levels of dysfunctional parenting practices as compared to parents in the WL condition. In addition, mothers reported lower levels of anxiety, depression, and stress as compared to mothers in the WL condition at posttreatment. Using mother's reports, gains in child behavior and parenting practices achieved at posttreatment were maintained at 4-month follow-up.

Level of nutrition modulates the dynamics of oestradiol feedback on plasma FSH in ovariectomized ewes

The frequency of multiple ovulations in mature, cyclic ewes is strongly influenced by the level of nutrition, but it is difficult to demonstrate concurrent changes in plasma concentrations of gonadotropins. The failure to do so might be a consequence of rapid compensation by the homeostatic feedback mechanism linking secretion by the hypothalamus/pituitary gland and ovarian hormones. Most experimental models have examined the components of the homeostatic feedback system after steady state relationships had been established. We hypothesised that the effects of nutrition might be observed more readily if the system were disrupted and then examined while equilibrium was being re-established. This hypothesis was tested in three experiments in Merino ewes by allowing gonadotropin secretion to escape feedback for 5 days after ovariectomy and then replacing ovarian hormones and examining effects of feeding regimen on the return of plasma concentrations of FSH to baseline values. In all three experiments, oestrogen replacement caused plasma concentrations of FSH to decline more rapidly (P < 0.05) in ewes fed at 0.5x maintenance, than in ewes fed at 1.4x maintenance, with groups fed at maintenance being intermediate. No effect of diet was observed on plasma FSH concentrations in the absence of oestradiol, and neither progesterone nor charcoal-treated bovine follicular fluid influenced the effect of nutrition. Plasma concentrations of oestradiol were 9.8% lower on average (NS) in ewes fed above maintenance than in the sheep fed below maintenance over the three experiments, suggesting that there may have been a reduced clearance of oestradiol which contributed to the result. We conclude that feeding regimen affects the secretion or clearance of gonadotropins in mature ewes, as in the mature ram, and that this is one mechanism by which ovulation rate may be affected.

Perceptions of the limit of viability: neonatologists' attitudes toward extremely preterm infants

Although recent technologic advances have dramatically improved the survival of preterm infants, little information exists regarding the attitudes of neonatologists toward their smallest patients, infants born at the "limit of viability." In this pilot study we sent a single mailing of a 25-question survey designed to provide information about the medical treatment of extremely preterm infants (< 22 to 27 weeks' gestational age) to 3056 neonatologists practicing in the United States in September 1992. The 1131 (37%) respondents were well distributed geographically and by nature of practice (i.e., academic, academic affiliate, and community hospitals). Most of the respondents counseled parents that all infants < or = 22 weeks' gestational age die and that at least 75% of infants born at 23 weeks' gestation die. Only for infants born at > or = 26 weeks' gestational age did most of the neonatologists counsel parents that mortality is < or = 50%. Nonintervention or compassionate care in the delivery room was believed to be appropriate for infants less than 23 weeks' gestational age by virtually all neonatologists, by 52% of respondents for infants 23 weeks' gestational age, and by only 1% of respondents for infants 25 weeks' gestational age. Approximately two thirds of neonatologists considered parental wishes regarding resuscitation, and one quarter considered parental parity/fertility history in their medical decision making for infants born at 23 to 24 weeks' gestation. If an infant who had been previously resuscitated decompensated in spite of maximal medical treatment, most of the neonatologists were not willing to provide full resuscitation for infants born at any gestation less than 27 weeks. However, the number of neonatologists who would actively encourage withdrawal of support in a decompensating infant decreased markedly for infants born at > or equal 25 weeks' gestation. Neonatologists who responded to this survey in 1992 considered 23 to 24 weeks of gestation the limit of viability and had great concerns regarding medical decision making for these infants.

Effect of diet on the clearance of estradiol-17 beta in the ewe

The twinning rate of ewes is poorly related to plasma concentrations of gonadotropins. In this study, we tested an alternative hypothesis for the control of twinning rate, by testing whether nutritional treatment sufficient to affect twinning could alter estrogen metabolism, with a particular focus on the enterohepatic recirculation. Groups of 5 ovariectomized ewes were fed either above maintenance (supplemented) or below maintenance (restricted). The metabolism of estradiol-17 beta was examined by following the fate of a single i.v. injection of 1.45 micrograms [3H]estradiol-17 beta. In both groups, 74% of the radioactivity was recovered from the feces within 10 days, predominantly as free estradiol-17 alpha, but excretion was slower in the nutritionally restricted ewes. A further 6% of injected radioactivity was excreted in the urine, mostly within 24 h, with no effect of dietary group. Radioactivity in plasma was characterized by ion-exchange chromatography and HPLC. Within 30 min of injection, the main circulating radioactive compound was estradiol-17 alpha sulfate. This remained at a greater concentration than free steroid for the next 48 h, and was greater after 16 h (p < 0.05) in plasma of nutritionally restricted ewes than in the supplemented group. At 0.5 and 2 h, the free steroid was almost entirely estradiol-17 beta, but a polar compound, which appeared by 4 h and probably arose by recirculation from the intestine, remained the major unconjugated metabolite in plasma for the next 24 h. Plasma concentrations of this compound were higher (p < 0.05) in the restricted ewes than in the supplemented ewes during this period.(ABSTRACT TRUNCATED AT 250 WORDS)

The treatment of recurrent abdominal pain in children: a controlled comparison of cognitive-behavioral family intervention and standard pediatric care

This study describes the results of a controlled clinical trial involving 44 7- to 14-year-old children with recurrent abdominal pain who were randomly allocated to either cognitive-behavioral family intervention (CBFI) or standard pediatric care (SPC). Both treatment conditions resulted in significant improvements on measures of pain intensity and pain behavior. However, the children receiving CBFI had a higher rate of complete elimination of pain, lower levels of relapse at 6- and 12-month follow-up, and lower levels of interference with their activities as a result of pain and parents reported a higher level of satisfaction with the treatment than children receiving SPC. After controlling for pretreatment levels of pain, children's active self-coping and mothers' caregiving strategies were significant independent predictors of pain behavior at posttreatment.

The treatment of recurrent abdominal pain in children: a controlled comparison of cognitive-behavioral family intervention and standard pediatric care

This study describes the results of a controlled clinical trial involving 44 7- to 14-year-old children with recurrent abdominal pain who were randomly allocated to either cognitive-behavioral family intervention (CBFI) or standard pediatric care (SPC). Both treatment conditions resulted in significant improvements on measures of pain intensity and pain behavior. However, the children receiving CBFI had a higher rate of complete elimination of pain, lower levels of relapse at 6- and 12-month follow-up, and lower levels of interference with their activities as a result of pain and parents reported a higher level of satisfaction with the treatment than children receiving SPC. After controlling for pretreatment levels of pain, children's active self-coping and mothers' caregiving strategies were significant independent predictors of pain behavior at posttreatment.

Morning glory syndrome in children. Association with endocrine and central nervous system anomalies

OBJECTIVE

To identify morning glory syndrome, an uncommon optic disc anomaly. Generally, it is an isolated ocular abnormality; however, some cranial facial and neurologic associations have been reported.

PATIENTS

We herein report two patients with morning glory syndrome and associated pituitary dwarfism. In one patient, the pituitary insufficiency was secondary to compression of the pituitary gland by a basal encephalocele; in the second patient, causative factors were not identified.

CONCLUSIONS

Patients with morning glory syndrome should have a complete general physical examination and growth evaluation so that early recognition and treatment of the patient with pituitary dwarfism can occur.

Frequent blood sampling changes the plasma concentration of LH and FSH and the ovulation rate in Merino ewes

During earlier studies we observed that ewes housed and sampled intensively to measure pulses of LH in plasma had a higher ovulation rate than similar ewes housed outside. In Expt 1, we pursued this observation by testing whether the increase was due to effects of housing or collection of blood samples. Ewes sampled at intervals of 4 h for 2 days before progestagen sponge removal and 2 days after sponge removal, and every 20 min for 12 h the day before sponge removal and every 10 min for 4 h on the day of sponge removal had a higher ovulation rate than ewes that were not sampled (1.72 versus 1.41; P < 0.05). The ovulation rate of the ewes housed indoors but not sampled was similar to that of ewes that remained in the paddock (1.43). In Expt 2, we studied the effects of blood sampling in three groups of 20 ewes sampled every 20 min for different periods of 24 h. Ewes from all three groups were sampled the day before sponge removal (day -1) and, in addition, one group of ewes was sampled for the previous 48 h (i.e. days -3 to -1) and another group was sampled on day -8. The frequency of LH pulses was lower (P < 0.05) in ewes sampled for the first time on day -1 compared with the frequency of LH pulses in groups also sampled earlier in the cycle (day -8 or days -3 and -2). In ewes sampled on days -3 to -1, the frequency of LH pulses was low for the first 24 h and then increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Children with persistent feeding difficulties: an observational analysis of the feeding interactions of problem and non-problem eaters

This study examined the relationship between parent's feeding practices and the feeding behavior of toddlers and preschool-age children with (n = 19) or without (n = 29) persistent feeding difficulties. Specifically, patterns of parent-child interaction were assessed during standardized family mealtime observations in the clinic. Parents also kept observational records of their children's mealtime behavior at home and rated the degree of difficulty they experienced in feeding their child during each meal on a daily basis. Observational results showed that feeding-disordered children engaged in higher levels of disruptive mealtime behavior (food refusal, noncompliance, complaining, oppositional behavior, and playing with food) and lower levels of chewing during mealtime. There were several significant age effects, with younger children (under age 3) engaging in more vomiting and less aversive demanding and verbalizations. Parents of feeding-disordered children were more negative and coercive in their feeding practices and engaged in higher levels of aversive instruction giving, aversive prompting, and negative eating-related comments. There were several significant associations between coercive parental behaviors and children's food refusal and noncompliance in the sample as a whole. Measures of children's disruptiveness at mealtimes in the clinic were significantly correlated with measures of mealtime behavior in the home.

A comparison of the generalization of behavioral marital therapy and enhanced behavioral marital therapy

This study examined the generalization of behavioral marital therapy (BMT) and enhanced behavioral marital therapy (EBMT), which added cognitive restructuring, affect exploration, and generalization training to BMT. Couples' communication and cognitions were assessed in the clinic and at home. Both BMT and EBMT were effective in decreasing negative communication behaviors and cognition across settings, but there was little evidence of differential generalization or change between the treatments. A series of regression equations showed no significant association between the extent of change in communication or cognitions and change in frequency of marital disagreements or marital satisfaction. It is concluded that BMT results in impressive generalization of communication and cognitive change, but it remains to be demonstrated that these changes are crucial to improvements in marital satisfaction.

Development of uterus-like redifferentiation in the cervix of the ewe after exposure to estradiol-17 beta

Prolonged treatment with estrogen causes the cervix of the ewe to redifferentiate to become more like uterus, and results in permanent infertility. Such permanent infertility has been observed only in ewes that have received two successive exposures to estrogen, raising the possibility that the initial exposure has a priming effect for subsequent treatment. In the study presented here, we examined whether any priming effects could be detected in the development of uterus-like histological changes in cervix of ewes given a single or two successive treatments with estradiol. Exposure to estradiol for 180 days resulted in stratified squamous hypertrophy of the cervical epithelium and also produced glandular hyperplasia, an increased proportion of lamina propria tissue in the endocervix, and fewer cervical folds. During the 30 days after treatment ceased, the epithelium returned to normal, while changes in cervical structure, as measured by reduced number of folds, became more marked. A second treatment with estradiol 180 days later produced a response similar to that after the first exposure, so it was not possible to identify any specific priming effect of the initial treatment with estrogen. However, treatment with estrogen established a process of cervical redifferentiation, and some aspects of this change appeared to be dependent on the withdrawal of estrogen.

A comparison of the generalization of behavioral marital therapy and enhanced behavioral marital therapy

This study examined the generalization of behavioral marital therapy (BMT) and enhanced behavioral marital therapy (EBMT), which added cognitive restructuring, affect exploration, and generalization training to BMT. Couples' communication and cognitions were assessed in the clinic and at home. Both BMT and EBMT were effective in decreasing negative communication behaviors and cognition across settings, but there was little evidence of differential generalization or change between the treatments. A series of regression equations showed no significant association between the extent of change in communication or cognitions and change in frequency of marital disagreements or marital satisfaction. It is concluded that BMT results in impressive generalization of communication and cognitive change, but it remains to be demonstrated that these changes are crucial to improvements in marital satisfaction.

Children with persistent feeding difficulties: an observational analysis of the feeding interactions of problem and non-problem eaters

This study examined the relationship between parent's feeding practices and the feeding behavior of toddlers and preschool-age children with (n = 19) or without (n = 29) persistent feeding difficulties. Specifically, patterns of parent-child interaction were assessed during standardized family mealtime observations in the clinic. Parents also kept observational records of their children's mealtime behavior at home and rated the degree of difficulty they experienced in feeding their child during each meal on a daily basis. Observational results showed that feeding-disordered children engaged in higher levels of disruptive mealtime behavior (food refusal, noncompliance, complaining, oppositional behavior, and playing with food) and lower levels of chewing during mealtime. There were several significant age effects, with younger children (under age 3) engaging in more vomiting and less aversive demanding and verbalizations. Parents of feeding-disordered children were more negative and coercive in their feeding practices and engaged in higher levels of aversive instruction giving, aversive prompting, and negative eating-related comments. There were several significant associations between coercive parental behaviors and children's food refusal and noncompliance in the sample as a whole. Measures of children's disruptiveness at mealtimes in the clinic were significantly correlated with measures of mealtime behavior in the home.

Improved feed intake and body weight change in sheep treated with dexamethasone at entry into pens or feedlots

Treatment with the synthetic glucocorticoid dexamethasone sodium phosphate increased the feed intake of sheep within 24 h. A single treatment with the longer-acting compound dexamethasone trimethylacetate had a slower effect, but resulted in improved feed intake and enhanced body weight gain over a period of 7 to 14 days. Treatment was effective in sheep housed individually and in sheep penned in groups. The improvement in body weight gain disappeared 15 to 20 days after a single treatment, but in most studies treated sheep had less variability in weight change than untreated sheep at this time. A statistically significant increase in body weight gain was observed in 8 of 11 trials; in the other 3 trials, it appeared that the feed intake of the untreated sheep was already maximal. Wethers treated with dexamethasone trimethylacetate on arrival at an assembly point for live export arrived in the Middle East 23 days later with a lower mean weight loss, partly because fewer sheep lost a significant amount of weight.

Childhood depression and conduct disorder: I. Behavioral, affective, and cognitive aspects of family problem-solving interactions

We assessed the family interactions of depressed, conduct-disordered, mixed depressed-conduct-disordered, and nonclinic children, ages 7-14 years, during a standardized family problem-solving discussion in the clinic. The child's and the mother's problem-solving proficiency, aversive behavior, and associated affective behavior (depressed and angry-hostile) were observed. The child and mother also rated each other's affect during the interaction for the dimensions sad, angry, critical, and happy on Likert-type scales. The child's and mother's cognitive constructions about the interaction were assessed using video-mediated recall. Although all clinic groups had lower levels of effective problem solving than did nonclinic children, their deficiencies were somewhat different. Mixed and depressed children displayed high levels of depressed affect and low levels of angry affect, whereas conduct-disordered children displayed both angry and depressed affect. In addition, conduct-disordered children had lower levels of positive problem solving and higher levels of aversive content than did non-conduct-disordered children. Depressed and conduct-disordered children had higher levels of self-referent negative cognitions than did mixed and comparison children, and depressed children also had higher other-referent negative cognitions than did all other groups. The study provides support for theories and treatment that stress the importance of family problem-solving and conflict resolution skills in child psychopathology.

Childhood depression and conduct disorder: II. An analysis of family interaction patterns in the home

Few researchers have assessed family interaction patterns associated with childhood depression, especially using observations in natural settings. We directly sampled the interaction patterns of families with depressed, conduct-disordered, mixed depressed-conduct-disordered, and comparison children ages 7-14 years in their homes during the evening meal. Observational measures were taken of positive and aversive behaviors and affect expression for both parents, the referred children, and their siblings. Results replicated previous research showing that conduct-disordered children express high levels of aversive behavior and anger and are part of a family system marked by conflict and aggression. The depressed children were exposed to maternal aversiveness but did not show any evidence of elevated levels of anger or aversiveness in their own behavior. Surprisingly, this was also true for the mixed-disorder children. High levels of depression in both groups of depressed children were associated with low levels of conflict and anger in family members. Overall, siblings showed very similar patterns of behavior, and were exposed to similar patterns of parental behavior, as the referred children. Results are discussed in terms of family models that emphasize the function of aggression and depression in the maintenance of child psychopathology.

The relationship between children's treatment-related behaviour problems, age and clinical status in cystic fibrosis

This study examined the relationship between parents' and physicians' reports of treatment-related behaviour and adjustment problems of children with cystic fibrosis (CF), and children's clinical status as assessed by measures of pulmonary functioning and global ratings of clinical status. Parents completed a Cystic Fibrosis Problem Checklist which measures the extent to which children experience behaviour and adjustment difficulties with different aspects of treatment, including chest physiotherapy, medication taking and diet. A high proportion of parents in each age group reported at least some treatment-related behaviour difficulties, with significantly more problems being reported with younger children. There was no significant relationship, however, between the child's age, sex and clinicians' ratings of compliance. A stepwise multiple regression showed that the only variables which significantly predicted clinicians' ratings of the severity of the child's disease were forced expired volume and height. Clinicians' ratings of compliance explained a small amount of extra variance (2.4%). It was found that parental reports of treatment-related behaviour problems were not related to clinical status. The implications of the findings for clinical practice are discussed.

Treatment outcome of a group cognitive therapy program for depression

A 12-session group program of cognitive therapy, designed by the first author, was evaluated with 35 persons suffering from major or minor depressive disorders. Effect-size scores were generated using the method of Nietzel, Russel, Hemmings, and Gretter (1987) and compared with cut-off points calculated using the method of Jacobson and Revenstorf (1988) and the norms established by Nietzel et al. (1987) in their meta-analysis. The effects of the Group Cognitive Therapy Program were found to be clinically significant according to the criteria of Jacobson and colleagues (Jacobson and Revenstorf, 1988; Jacobson, Follette and Revenstorf, 1984) for 73% of patients. It is concluded that the Group Cognitive Therapy Program is a clinically efficacious and cost-effective treatment for persons suffering from nonpsychotic, primary, unipolar depression.

Immunization of ovariectomized ewes against progesterone, oestrogen or cortisol to detect effects of adrenal steroids on reproduction

Ovariectomized ewes were immunized against cortisol, oestrogen or progesterone to determine whether steroids of non-ovarian origin occur in sufficient amounts to influence the reproductive system. Ewes immunized against oestrogen (oestrone + oestradiol) had smaller uteri (P less than 0.05) and a lower concentration of oestradiol in uterine tissue (P less than 0.05), while the adrenal gland was heavier (P less than 0.05). In the peripheral plasma of immunized ewes, the concentration of FSH, but not LH, was increased (P less than 0.05). Ewes immunized against cortisol also had smaller uteri (P less than 0.05) and heavier adrenal glands (P less than 0.05), but gonadotrophins and the concentration of oestradiol in the uterus were unaffected. Immunization against progesterone, or injection with synthetic glucocorticoids, did not affect any of the characteristics measured. We conclude that the adrenal gland of the ewes produced sufficient oestrogen or aromatizable androgen to have significant effects on the reproductive system. In contrast, adrenal production of progesterone did not produce detectable biological effects. Immunization against cortisol did affect the reproductive system, but the mechanism of this action could not be determined.

Effects of oestradiol implants on the ovulation rate of the ewe

In a series of 5 experiments, ewes were treated with implants releasing oestradiol-17 beta and the effects on ovulation rate were observed. Large doses of oestradiol-17 beta (greater than 20 micrograms/day) produced anovulation while smaller amounts only reduced the proportion of twin ovulations. Amounts of exogenous oestradiol comparable to ovarian production rate in the luteal phase (less than 1 microgram/day) produced a significant (P less than 0.01) suppression in ovulation rate. Treatment during the follicular phase of the oestrous cycle was most effective, but treatment during the luteal phase alone also appeared to suppress ovulation rate. Furthermore, in 2 of 3 experiments ewes treated with low amounts of oestradiol during the first half of the luteal phase were less likely to have multiple ovulations at the subsequent oestrous period. The results support the hypothesis that oestrogen is involved in the physiological control of ovulation rate in the ewe, but this action is probably not restricted to the assertion of dominance by a maturing follicle during the follicular phase.