The pediatrician and disaster preparedness

Recent natural disasters and events of terrorism and war have heightened society's recognition of the need for emergency preparedness. In addition to the unique pediatric issues involved in general emergency preparedness, several additional issues related to terrorism preparedness must be considered, including the unique vulnerabilities of children to various agents as well as the limited availability of age- and weight-appropriate antidotes and treatments. Although children may respond more rapidly to therapeutic intervention, they are at the same time more susceptible to various agents and conditions and more likely to deteriorate if not monitored carefully. The challenge of dealing with the threat of terrorism, natural disasters, and public health emergencies in the United States is daunting not only for disaster planners but also for our medical system and health professionals of all types, including pediatricians. As part of the network of health responders, pediatricians need to be able to answer concerns of patients and families, recognize signs of possible exposure to a weapon of terror, understand first-line response to such attacks, and sufficiently participate in disaster planning to ensure that the unique needs of children are addressed satisfactorily in the overall process. Pediatricians play a central role in disaster and terrorism preparedness with families, children, and their communities. This applies not only to the general pediatrician but also to the pediatric medical subspecialist and pediatric surgical specialist. Families view pediatricians as their expert resource, and most of them expect the pediatrician to be knowledgeable in areas of concern. Providing expert guidance entails educating families in anticipation of events and responding to questions during and after actual events. It is essential that pediatricians educate themselves regarding these issues of emergency preparedness. For pediatricians, some information is currently available on virtually all of these issues in recently produced printed materials, at special conferences, in broadcasts of various types, and on the Internet. However, selecting appropriate, accurate sources of information and determining how much information is sufficient remain difficult challenges. Similarly, guidance is needed with respect to developing relevant curricula for medical students and postdoctoral clinical trainees.     

Clinical characteristics and efficacious treatment of posttraumatic stress disorder in children and adolescents

Children in the United States are exposed to a variety of traumatic events. Psychosocial sequelae to these events vary in their nature and severity. PTSD is a common, debilitating response to traumatic events that may alter the normal developmental course for children. Risk and protective factors in the development of PTSD include child, caregiver, and family characteristics. To date, empirical evidence reveals the efficacy of psychosocial treatments, especially cognitive-behavior therapy. Caregiver involvement in treatment is indicated. Aside from participation in psychosocial interventions, caregivers should be encouraged to convey belief of and empathy for their children, provide a forum for children to discuss the trauma if they choose, and promote coping skills that have been helpful following other stressful events. Emerging studies suggest the potential adjunctive effects of pharmacologic treatments. Additional investigations of the efficacy of school-based group CBT, combined CBT and pharmacotherapy, and CBT for more severely impaired children are warranted. Children and families also might benefit from research on community-based interventions (eg, following disasters, terrorism, war, and community violence) and preventive interventions (designed to prevent the development of PTSD following traumatic events).     

Depressed parents and their children. General health, social, and psychiatric problems

Two hundred twenty children (aged 6 to 23 years) from families with either depressed or normal (nonpsychiatrically ill) parents of comparable sociodemographic backgrounds were studied. The children from families in which at least one parent had experienced a major depression were reported to have had more adverse perinatal events; were later in achieving some developmental landmarks; had more convulsions, head injuries, operations, and psychiatric disorders (particularly major depression); and made more suicide attempts. Overall, there were no significant differences in IQ between children in both groups. Mothers in families with a depressed parent reported more medical problems during pregnancy and labor, and the children were reported to have experienced more distress at birth. Since major depression is a highly prevalent disorder in women of childbearing ages, these findings have direct clinical implications for pediatricians. Their specificity for major depression, as contrasted with other psychiatric disorders or chronic illnesses in the parents, requires further study.     

Stressful family life events and nonspecific somatic complaints in school children.

The relationship between stressful family life events and somatic complaints in 477 school children was studied. There was a significant association between life events and somatic complaints, with a general trend for somatic complaints to increase in almost direct proportion to the number of family life events. Overall occurrence of these nonspecific symptoms was more in girls. The somatic complaints were significantly more in children from nuclear families and of illiterate or poorly educated mothers. No significant association was observed between somatic complaints and number of children in the family or socio-economic status. Assessment of psychodevelopmental tasks and family environment during routine check up of children by the school health teams and their appropriate training in this field should be stressed upon.     

Special needs of children following a disaster

A great deal has been written recently regarding disaster management. Much of the recent literature focuses on the role of emergency medicine and the population's response as a whole. Little attention has been paid, however, to the special circumstances surrounding children and how they are affected by disasters. The impact on children is unique and brings forth a set of issues that are not applicable to the adult population. This article addresses the special needs of children in the post-disaster setting, specifically, the social issues surrounding the care of children separated from their parents, special staffing needs in regard to caring for children, shelter issues when caring for children, special supplies that may be needed to care for these children, and finally, strategies to prepare for such events with the special needs of children in mind.     

Children with chronic illness. The prevention of dysfunction

Children with long-term illnesses are at risk of developing problems in psychological adjustment and in functioning in activities of daily life. Their families face increased risks of marital and economic dysfunction, and siblings too face special tasks living with a chronically ill child. A variety of interventions can help children and families to cope effectively with the tasks of chronic illness. Pediatricians should be alert to effects on the family. Children respond to family stress in very predictable ways. Inasmuch as the stress of chronic illness may affect the marital relationship, there is a likelihood of concurrent behavioral and school problems. Relatively sudden changes in behavior may signal family issues that require professional attention. Drotar et al. maintain that professionals should serve as guides or advocates for children with chronic illness and their families. The relationship that develops between families and professionals is based on trust. They believe that "trust appears to evolve from the following principles: (1) continuity of relationship, (2) active participation by professional caregivers, (3) mutual participation of child and family, (4) advocacy, (5) a focus on coping and competence, (6) a developmental perspective, and (7) a family-centered focus." Cadman et al. identified a similar set of elements that characterizes an efficacious preventive intervention approach. In addition, they propose specific programmatic efforts that are associated with less morbidity. These include ongoing education and counseling for the child, family, and community regarding chronic illness and its management, use of stress management techniques to promote mastery and reduce the impact of stressful life events, and facilitation of social support mechanisms for families with chronically ill children. We have added consideration of the child's performance in school.     

The Importance of Family Reunification in Pediatric Disaster Planning

In the aftermath of a disaster, families may become separated. With greater than 60 million children being apart from their families during the day, one could imagine a disaster resulting in great difficulties in reuniting these children with their families. History has shown us that widespread events can prove particularly challenging as was shown during Hurricane Katrina when it took up to 6 months to reunite all displaced children with their families. This article will discuss the history of pediatric disaster preparedness efforts, highlighting some of the available resources in the development of a family reunification plan. Next will be a discussion of basic features of a well-thought-out family reunification plan, including critical areas to establish as part of an institution's plan. Key partners necessary to engage will be discussed, as well as the importance of testing any plan through drills. Finally, future work will be highlighted.     

Influence of family history of morbid cardiovascular events on blood pressure levels of school children

The influence of family history of hypertension, myocardial-infarction and/or stroke on the blood pressure levels of 3,194 children in the age group 5-15 years was studied. Compared to children of normotensive parents, subjects coming from families with history of uncomplicated hypertension, complicated hypertension (hypertension plus myocardial infarction or stroke) and myocardial infarction or stroke without history of hypertension tended to have significantly higher levels of both systolic and diastolic pressures (p less than 0.001) in both the sexes in all age groups studied. Further, 15 (4.83%) of the children coming from families with positive history of one of the aforesaid morbid cardiovascular events had persistent hypertension (BP greater than mean +2 SD for age and sex). On the contrary only one (0.03%) of the 2,884 children belonging to normal parents had persistent hypertension. All the 16 children with sustained hypertension had only mild hypertension and were asymptomatic. Ten (62.5%) of them were obese (weight/height2 greater than 2.26). Baseline investigations failed to detect underlying cause to account for raised blood pressures in 9 of the 16 cases that could be investigated. These findings suggest that children of people with hypertension or other morbid cardiovascular events are more likely to have persistently elevated blood pressures than children from families without such a history.     

American Academy of Pediatrics. Committee on Hospital Care. Child life services

Child life programs have become the standard in large pediatric settings to address the psychosocial concerns that accompany hospitalization and other health care experiences. Child life programs facilitate coping and the adjustment of children and families in 3 primary service areas: 1) providing play experiences; 2) presenting developmentally appropriate information about events and procedures; and 3) establishing therapeutic relationships with children and parents to support family involvement in each child's care. Although other members of the health care team share these responsibilities for the psychosocial concerns of the child and the family, for the child life specialist, this is the primary role. The child life specialist focuses on the strengths and sense of well-being of children while promoting their optimal development and minimizing the adverse effects of children's experiences in a hospital setting.     

Psychosocial implications of disaster or terrorism on children: a guide for the pediatrician

During and after disasters, pediatricians can assist parents and community leaders not only by accommodating the unique needs of children but also by being cognizant of the psychological responses of children to reduce the possibility of long-term psychological morbidity. The effects of disaster on children are mediated by many factors including personal experience, parental reaction, developmental competency, gender, and the stage of disaster response. Pediatricians can be effective advocates for the child and family and at the community level and can affect national policy in support of families. In this report, specific children's responses are delineated, risk factors for adverse reactions are discussed, and advice is given for pediatricians to ameliorate the effects of disaster on children.     

Maternal outcomes of a randomized controlled trial of a community-based support program for families of children with chronic illnesses.

BACKGROUND: Parents of children with chronic illnesses are at high risk for secondary mental health problems, such as anxiety and depression. OBJECTIVE: To evaluate maternal outcomes of a support intervention for families of children with selected chronic illnesses. DESIGN: A randomized controlled clinical trial design with repeated measures 1 year apart. SETTING: A community-based family support intervention linked to subspecialty and general pediatric clinics and practices in a metropolitan area. PARTICIPANTS: A population-based sample of 193 mothers of children aged 7 to 11 years; the children were diagnosed as having diabetes, sickle cell anemia, cystic fibrosis, or moderate to severe asthma. About 15% of the persons contacted refused to participate in the research, and 14% of the families were lost to follow-up. INTERVENTION: The 15-month intervention, the Family-to-Family Network, was designed to enhance mothers' mental health by linking mothers of school-aged children with selected chronic illnesses with mothers of older children with the same condition. The program included telephone contacts, face-to-face visits, and special family events. MAIN OUTCOME MEASURES: Beck Depression Inventory score and the Psychiatric Symptom Index. RESULTS: Maternal anxiety scores for participants in the experimental group decreased during the intervention period for all diagnostic groups and for the total group; scores for the control group increased (F = 5.07, P =.03). In multiple regression analyses, the intervention group was a significant predictor of posttest anxiety scores (P =.03). Effects were greater for mothers with high baseline anxiety (P<.001) and for those who were themselves in poor health (P<.01). CONCLUSIONS: A family support intervention can have beneficial effects on the mental health status of mothers of children with chronic illnesses. This type of intervention can be implemented in diverse pediatric settings.     

ENCOPRESIS: A Review of Thirty-two Cases

Thirty-two children attending a child psychiatric department with encopresis are described. Twenty-six were discontinuous and only 6 were continuous soilers. As a group they came from low socio-economic, socially incompetent families and a number of children had evidence of developmental lags or neurological impairment. Coercive toilet training featured very rarely in the case histories. Twenty-three of the 26 discontinuous soilers had experienced stressful events prior to the onset of the symptom and many came from disrupted families. They were, as a group, anxious children whose associated symptoms fell into the categories of neurotic or developmental disorders rather than of conduct or mixed disorders.     

Childhood sibling loss. A family tragedy

The loss of a significant object, the loss of a home (security, personal possessions, familiar space that has emotional meaning), the dislocation from one's home or land as occurs in wars or disasters, gives rise to stress-strain responses that may have short-term or long-term effects, eg, post-traumatic stress disorder. The hidden or neglected victims of such occurrences frequently are children--be they siblings or direct descendants. In childhood sibling loss, the effects of the loss are mediated through different members of the family. The acute stressors can give rise to later adversity unless it is recognized that there is a social context in which life and death events occur. Recognizing these individual responses in the family can lead to interventions that may prevent later difficulty. Understanding the meaning of the events to the child, appreciating the fact that events are not just single occurrences, but interact with what existed before as well as with other concomitant events, helps in our therapeutic recommendations and interventions. Sibling loss, though initially related to the death of a sibling, can now be expanded to include the loss of a sibling through chronic illness (emotional, medical, surgical, long-term hospitalization), birth injuries, disabled children (accidents or illness with body changes), chronic illness with visible as well as non-visible changes that require special parental and nursing care, medication on an ongoing basis, and restrictions in diet and activities. The impacts of these losses without death can have devastating effects.(ABSTRACT TRUNCATED AT 250 WORDS)     

The relationship of immigrant status with access, utilization, and health status for children with asthma.

OBJECTIVE: Despite their high levels of poverty and less access to health care, children in immigrant families have better than expected health outcomes compared with children in nonimmigrant families. However, this observation has not been confirmed in children with chronic illness. The objective of this study was to determine whether children with asthma in immigrant families have better than expected health status than children with asthma in nonimmigrant families. METHODS: Data from the 2001 and 2003 California Health Interview Survey (CHIS) were used to identify 2600 children, aged 1 to 11, with physician-diagnosed asthma. Bivariate analyses and logistic regression were performed to examine health care access, utilization, and health status measures by our primary independent variable, immigrant family status. RESULTS: Compared with children with asthma in nonimmigrant families, children with asthma in immigrant families are more likely to lack a usual source of care (2.6% vs 1.0%; P < .05), report a delay in medical care (8.9% vs 5.2%; P < .01), and report no visit to the doctor in the past year (7.0% vs 3.8%; P < .05). They are less likely to report asthma symptoms (60.8% vs 74.4%; P < .01) and an emergency room visit in the past year (14.1% vs 21.1%; P < .01), yet more likely to report fair or poor perceived health status (25.0% vs 10.5%; P < .01). Multivariate models revealed that the relationship of immigrant status with health measures was complex. These models suggested that lack of insurance and poverty was associated with reduced access and utilization. Children in immigrant families were less likely to visit the emergency room for asthma in the past year (odds ratio 0.58, confidence interval, 0.36-0.93). Poverty was associated with having a limitation in function and fair or poor perceived health, whereas non-English interview language was associated with less limitation in function but greater levels of fair or poor perceived health. CONCLUSIONS: Clinicians should be aware of important barriers to care that may exist for immigrant families who are poor, uninsured, and non-English speakers. Reduced health care access and utilization by children with asthma in immigrant families requires policy attention. Further research should examine barriers to care as well as parental perceptions of health for children with asthma in immigrant families.     

Premature Termination from Treatment among Children Referred for Antisocial Behavior

The present study examined differences between children and families who complete treatment versus those who terminated prematurely. Children (N = 81, ages 7-13 years) referred to outpatient treatment for severe antisocial behavior and their families participated. It was predicted that families who terminate treatment prematurely would show greater dysfunction in four domains: child severity and breadth of antisocial behavior, maternal stress, maternal psychopathology, and socioeconomic disadvantage. The results indicated that among cases who terminate treatment prematurely children evinced more severe conduct disorder symptoms and more delinquent behaviors; mothers reported greater stress from their relations with the child, their own role functioning, and life events; and families were at greater socioeconomic disadvantage than those who remained in treatment. The implications of the present findings for the design and implementation of treatment of antisocial children and their families are discussed.     

Negative life events as an account of age-related differences in the genetic aetiology of depression in childhood and adolescence

BACKGROUND: Many twin studies have reported that the genetic aetiology of depression differs according to age, with genetic influences being more important for adolescents than younger children. We sought to examine whether this age-related increase in the relative importance of genetic factors is due to an increase in gene-environment correlation specifically involving negative life events. METHOD: Questionnaires were sent to the families of a population-based sample of twins aged between 8 and 17 years. Parents of all the twins and adolescents aged 11 and over were asked to complete the Mood and Feelings Questionnaire (Costello & Angold, 1988) and a modified version of the Life Events Checklist (Johnson & McCutcheon, 1980). Responses were obtained from 1468 families and data were analysed using genetic model fitting. Bivariate analysis of 1) negative life events and 2) behaviour-dependent life events and depression symptoms was undertaken separately for children (aged 8 to 10 years) and adolescents (aged 11 to 17 years). Differences in genetic and environmental parameters across age groups were tested. RESULTS: Adolescence was associated with a greater number of behaviour-dependent life events. Genetic covariation of negative life events and depression was greater for adolescents than for children. CONCLUSIONS: Bivariate model fitting was consistent with the greater heritability of depression seen in adolescence being due to an increase in gene-environment correlation involving negative life events. However, the effects of genes associated specifically with maturation in adolescence, the possibility of 'person' effects and the role of other environmental factors also need to be considered.     

Short-term effects of severe hypoglycaemia in children and adolescents with type 1 diabetes. A cost-of-illness study

The aim of this study was to describe costs and other short-term effects of severe hypoglycaemia in children and adolescents with type 1 diabetes. The study comprised a geographic population of 129 patients <19 y of age with families prospectively registering detailed data after self-reported severe hypoglycaemia. In the period Jan.-Dec. 1998, 16 events were reported with unconsciousness and 95 events without unconsciousness but needing the assistance of another person. Of all events, 20-30% had effects requiring the assistance of people other than parents, school absence, parents' absence from work, extra transport and/or telephone calls. Patient (family) activities were cancelled after 10% (5%) of events. Increased worry for parents was reported after 8% and poor sleep after 7% of events. Hospital visits took place at 5% and hospitalizations at 3% of all events. Patients with severe hypoglycaemia indicated lower global quality of life (p=0.0114). The average socio-economic burden for events of severe hypoglycaemia was estimated at EURO 17,400 yearly per 100 type 1 diabetes patients. Average cost was estimated at EURO 239 per event of severe hypoglycaemia with unconsciousness or EURO 478 yearly per patient with unconsciousness, and EURO 63 per event of severe hypoglycaemia without unconsciousness but needing assistance from another person or EURO 307 yearly per patient in this category. These are conservative estimates and do not include unpaid time and other intangibles, possible road traffic accidents, disabling or premature deaths. Conclusions: The results suggest the potential for socio-economic savings and increased quality of life for patients and families from severe hypoglycaemia prevention programs.     

Major Life Events and Changes in the Behavioural Functioning of Children

The relationship between major life events and changes, across a 2-yr period, in the level of parent-reported behavioural/emotional problems in 1397 children from a general population sample was investigated using a highly modified version of the Coddington Life Events Record and the Achenbach Child Behavior Checklist. The life event questionnaire used in the present study proved to have a satisfactory reliability. The number of life events increased significantly with increasing age of the child, and a higher incidence of such events was found for families with lower socio-economic status. A significant relationship was found between the total score of negative life events across the 2-yr period and changes in the level of behavioural/emotional problems of the children.     

Les effets thérapeutiques des groupes de parole auprès d’enfants victimes de catastrophes naturelles en Haïti

Introduction

This article focuses on groupal traumatic experiences of children during natural disasters in Haiti. The group played a very important role for psychic survival of these children and even allowed them to dream a future. The objective of this study is to identify the functions of the group that helped a therapeutic effect for children.

Method

The study focused on a sample of 217 children and adolescents aged 6–18 years, encountered in schools and churches in different cities who were severely affected by the earthquake of 12 January 2010. In focus groups set up, the children were invited to discuss their families and events in their lives.

Results

The research results show that the work of the group mobilizes groups within each participant by providing a space where the container can put into words. The group offers a bracing and a space where the process of subjectivation and symbolization can be put in place.

Discussion

We have shown how the group welcomes trauma, how intersubjective links that are established mobilize intrapsychic scene and how the game is installed, allows figurability conflict and paves the way to a narrative. It is therefore important to maintain these discussion groups essential to allow subjects to enroll in continuity and historicity needed to pick up the thread of their stories.     

Sedative preference of families for lumbar punctures in children with acute leukemia: propofol alone or propofol and fentanyl

Propofol is a common sedative/anesthetic used for invasive procedures in children with cancer. The purpose of this study was to determine whether families of children with acute leukemia prefer propofol alone or propofol plus fentanyl for lumbar puncture (LP) sedation. We conducted a randomized, placebo controlled, double blind, crossover study. Each patient was studied twice, once with propofol/placebo and once with propofol/fentanyl. Data collected included the modified Yale Preoperative Anxiety Score (M-YPAS) at baseline and after placebo or fentanyl, Induction Compliance Checklist, recovery excitement, recovery time, and adverse events. After the study, families were asked which sedative regimen they preferred for future LPs. Twenty-two patients received 44 LP sedations: propofol 22, propofol/fentanyl 22. The average age was 6.4+/-4.2 years (mean+/-SD). There were no significant differences between groups in M-YPAS, Induction Compliance Checklist or recovery excitement. Adverse events occurred in 11/22 patients (50%) propofol and 4/22 (18.2%) propofol/fentanyl (P=0.0196). Average recovery time (mean+/-SD) was 36.86+/-17.1 minutes propofol versus 26.36+/-16.4 minutes propofol/fentanyl (P=0.047). Sixteen families (72.7%) chose propofol with fentanyl for future LP sedations (P=0.05). In conclusion, most families prefer propofol and fentanyl for LPs. Propofol with fentanyl was also associated with fewer adverse events and faster recovery.