Coercive and disruptive behaviors in pediatric obsessive compulsive disorder: a qualitative analysis

OCD is a common disorder in children and adolescents. Disruptive or coercive behaviors among children with OCD have not been a focus of much research until recently. Family accommodation of OCD is strongly related to symptom severity, level of impairment, and treatment outcomes. The possibility of family accommodation being forcefully imposed on family members against their will has not been investigated systematically, although clinical experience points to the existence of such situations. The present study represents an early, qualitative exploration of such situations. The parents of 10 children and adolescents with OCD, who reported the existence of violent or disruptive behavior on the part of the child, were interviewed and their narratives analyzed using grounded theory methodology. Findings from the interviews point to the existence of a pattern of coercive behaviors in which rules and prohibitions, driven by the child's OCD, are aggressively imposed on parents and siblings. The emergent themes are analyzed in relation to obsessive compulsive symptom dimensions and in relation to the means and goals they represent for the obsessive compulsive children.     

Military nurses and combat-wounded patients: a qualitative analysis of psychosocial care

PURPOSE: The aims were to explore the lived experience of combat‐wounded patients and the military nurses who care for them. DESIGN AND METHODS: The study was a qualitative phenomenological design, and focus groups were conducted with 20 nurses and 8 combat‐wounded patients. FINDINGS: Themes common to nurses and patients were coping, shared experiences, finding meaning, psychosocial nursing care, families, and bureaucratic structure. Thematic differences were the patients' perspectives “changed self” while nurses described “professional boundaries.” PRACTICE IMPLICATIONS: The importance of finding meaning presents ideas that could help nurses and patients cope better with stressful situations regardless of the setting.     

Self-rated assessment of needs for mental health care: a qualitative analysis

This study explored perceived mental health-related needs and barriers to meeting them in primary and mental health care settings. Fifty-one participants completed the Perceived Need for Care Questionnaire and an interview to qualitatively explore the meanings behind self-identified needs for medication, information, counselling, practical help, and skills development. Qualitative content analysis indicated perceived needs for care are multifaceted. Dissatisfaction with taking medication may coexist with perceiving medication needs as met; information needs predominantly concerned wanting to better understand one’s illness; and communication was the main perceived barrier to meeting these needs. Counselling-related needs included being listened to, supported or assisted with problem-solving, with service attitudes, staff expertise or cost seen as limiting access. Needs for practical help and skills development were described as unmet or addressed by family, and help-seeking for these needs constrained by efforts to self-manage, insufficient information, and affordability. Collaborative care and information-sharing appear important to better meet mental health-related perceived needs.     

Care coordination in epilepsy: Measuring neurologists' connectivity using social network analysis

ObjectiveThe study sought to quantify coordination of epilepsy care, over time, between neurologists and other health care providers using social network analysis (SNA).MethodsThe Veterans Health Administration (VA) instituted an Epilepsy Center of Excellence (ECOE) model in 2008 to enhance care coordination between neurologists and other health care providers. Provider networks in the 16 VA ECOE facilities (hub sites) were compared to a subset of 33 VA facilities formally affiliated (consortium sites) and 14 unaffiliated VA facilities. The number of connections between neurologists and each provider (node degree) was measured by shared epilepsy patients and tallied to generate estimates at the facility level separately within and across facilities. Mixed models were used to compare change of facility-level node degree over time across the three facility types, adjusted for number of providers per facility.ResultsOver the time period 2000–2013, epilepsy care coordination both within and across facilities significantly increased. These increases were seen in all three types of facilities namely hub, consortium, and unaffiliated site, relatively equally. The increase in connectivity was more dramatic with providers across facilities compared to providers within the same facilities.ConclusionEstablishment of the ECOE hub and spoke model contributed to an increase in epilepsy care coordination both within and across facilities from 2000 to 2013, but there was substantial variation across different facilities. SNA is a tool that may help measure coordination of specialty care.     

Preoperation anxiety: a qualitative analysis

Twenty-eight patients were investigated psychologically before surgery. The purposes of the study were (1) to discover the nature of preoperative anxiety, and (2) to compare direct questioning with an indirect method. The merits and shortcomings of the two types of assessment emerged. The findings suggest that, in addition to worries about the operation and the anaesthetic, there was concern about leaving the home and family, which was accentuated by lack of communication and contact with hospital staff, including the surgical team. Pain was found to have a variety of implications including loneliness. These and other findings are discussed in relation to psychological theories.     

Families' experiences of living with pediatric epilepsy: A qualitative systematic review

Living with epilepsy in childhood has implications for the child and their family beyond the physical effects associated with epileptic seizures. Qualitative research has emerged, aiming to deliver a greater depth of understanding of the experiences of living with epilepsy from the perspectives of children with epilepsy, their parents, and their siblings. This review of qualitative research had three aims: first, to synthesize the demographic and epilepsy profiles of research participants in eligible studies in order to provide a clear picture of who are included and excluded when studying families' experiences; second, to present and discuss the methodological concerns and implications of research involving children with epilepsy; and third, to synthesize the findings arising from qualitative research with families in order to identify common themes across all relevant studies to date.Papers published in the English language prior to January 2016 were identified following a search of eight electronic databases: Embase, Psychinfo, Medline, CINAHL, Web of Knowledge, ASSIA, Web of Science, and SCOPUS. Studies were included if they involved a sample of children with epilepsy (up to 18 years of age), parents, or siblings of children with epilepsy and used qualitative methods. Twenty-one studies were identified as eligible for inclusion in the review.Findings in relation to the three aims were the following: 1) Researchers were seeking an understanding of children's experiences directly from children rather than by parental proxy. However, children with learning disabilities were often excluded from research, meaning that their views are not being heard. Parental research was predominantly with mothers, and father experiences were not often accessed. There was very little research with siblings. 2) The rationale for and ethical implications of the choice of research methods adopted were not always clear, and not all studies gave adequate attention to the development of appropriate methods for research involving children. 3) Two dominant themes emerged across the studies: normalcy and children's agency. Cutting across many of the challenges that living with epilepsy presented was the desire (by parents and children) for a ‘normal’ childhood. The studies also highlighted that children have knowledge about their own condition and epilepsy more generally and that they are involved in managing the ways in which they cope with epilepsy, both in terms of seizure prevention and managing their relations with others, particularly peers.Future research should ensure that appropriate design, data collection, and analytic strategies are adopted to facilitate the participation of all family members. Enhancing the quality of the research will, in turn, optimize validity and opportunities for the translation of findings into better health, education, and social practices to improve care for children and their families affected by epilepsy.     

Habilitation of very preterm infants at a Post Acute Care Inpatient Rehabilitation (PACIR) center after neonatal intensive care unit (NICU) discharge

Objective: To investigate whether Post-Acute Care Inpatient Rehabilitation (PACIR) admission after NICU stay affects the total length of stay (LOS) of very preterm (VPT: ≤30 weeks of gestation) infants.

Methods: A retrospective case control study of VPT infants d/c’d from the NICU at Maria Fareri Children’s Hospital (MFCH) to either a PACIR (Blythedale Children’s Hospital: BH) for convalescent care (cases) or directly home (controls).

Results: 35 cases and 70 controls. Total LOS (MFCH + BH) was longer for cases [196 vs. 97 days]. At the time of d/c from MFCH, Special Health Care Needs (SHCN) amongst cases were greater than controls, however, became similar at the time of home d/c. The majority of cases achieved habilitation goals at the PACIR.

Conclusions: Although LOS was longer for patients transferred to a PACIR, habilitation at BH Hospital reduced the SHCN at the time of home d/c amongst cases.     

Treatment for Chiari 1 malformation (CIM): analysis of a pediatric surgical series

We report follow-up data on the efficacy of natalizumab therapy on neuropsychological impairment on an italian MS group of 39 patients at 1 year and of 11 patients at 2 years. Results show a significant reduction in relapse rate, in the number of impaired neuropsychological tests as well as in several single executive function and reasoning tests scores at 1 year. Improvement persisted at 2 years, including also memory and speed processing tasks. These data support the efficacy of natalizumab therapy in all the clinical domains, including cognitive deterioration, in multiple sclerosis patients.     

Improving care in care homes: A qualitative evaluation of the Croydon care home support team

Objectives: The Croydon care home support team (CHST) was developed in response to reports of patient abuse within long-term care. It presents a novel strategy for improving standards of care within care homes. A qualitative methodology was used to assess the perceived impact of the CHST.

Method: In-depth interviews were conducted with 14 care home managers and 24 members of care home staff across 14 care homes. Grounded theory principles guided the collection and analysis of the data.

Results: Reports of improved communication between staff, improved staff development and confidence, and improved quality of care point towards the effectiveness of the CHST model. The collaborative approach of the CHST was considered pivotal to its success and presented as an effective method of engaging care home managers and staff. The CHST adopted a systemic approach that placed an equal emphasis on the social, mental health and nursing needs of residents and aimed to address the whole culture of care within the individual homes.

Conclusions: The data demonstrate the potential for specialist multi-disciplinary teams to raise standards of care across long-term care settings. Increased awareness of safeguarding issues, improved staff morale and communication and ongoing opportunities for discussion and problem solving promised to sustain improvements. Such services could be instrumental in meeting the government priority of preventing abuse among vulnerable adults.     

Process variables in intervention: A qualitative analysis

This paper describes the development of a model of evaluation for an intervention project with mentally handicapped children and their parents involving student speech therapists, a speech pathologist and a psychologist. The model incorporated features of transactional and formative approaches to qualitive evaluation and had as its objective to increase understanding of the processes underlying change in a situation of intervention. The feasibility, usefulness and applicability of the model are also discussed.     

Ultrastructural organization of normal and transplanted rat fascia dentata: I. A qualitative analysis of intracerebral and intraocular grafts

Few studies have dealt with the general ultrastructure and synaptic organization of grafted brain tissue. This study was therefore performed to extend current light microscopic observations on intracerebral and intraocular grafts of hippocampal tissue to the ultrastructural level. Blocks of tissue containing the hippocampus and fascia dentata from day 21 embryonic rats were grafted into the brain of developing and adult rats and to the anterior eye chamber of adult rats. After 100 or 200 days of survival the recipient rat brains or eyes were processed for electron microscopy. Tissue containing the graft dentate molecular layer and adjacent granule cell layer was selected for ultrastructural analysis, together with a few samples of the hilus and CA3. Normal dentate tissue was analyzed as control. At the light microscopic level most intracerebral and intraocular grafts displayed an organotypic organization with clearly recognizable cell and neuropil layers. Under the electron microscope the grafted granule cells had normal-appearing dendrites bearing the normal types of spines and forming the normal types of synapses. This was the case even in the absence of the normal major extrinsic afferents like the perforant path. The graft dentate granule cells formed axons and terminals with characteristics of the normal mossy fiber system in the hilus and CA3, in addition to aberrant supragranular mossy fiber terminals known from light microscopic studies of dentate transplants. Abnormal structures included a few dendritic growth cones and an increased occurrence of polyribosomes in spines. Their occurrence indicates ongoing dendritic plasticity even 100 days after transplantation. There was also an increased density of glial elements, particularly in the intraocular grafts. In some of these grafts the granule cells displayed immature traits in terms of nuclear indentations. Dentate interneurons of the basket cell type were present in both the intracerebral and the intraocular grafts. We conclude that grafted dentate granule cells, in different surroundings and without the normal, major perforant path input, can develop a basically normal cellular morphology, which includes the normal ultrastructural characteristics of the dendrites with spines and synapses, and the mossy fibers and its terminals.     

Exploring dimensions of social support and resilience when providing care at the end of life: a qualitative study

Background: Research shows that formal and informal social support can facilitate resilience in carers. There is a paucity of research exploring social support and resilience amongst recently bereaved informal carers.

Aim: To examine how the presence or absence of distinct dimensions of social support facilitate or hinder resilience in recently bereaved informal carers.

Participants: 44 bereaved carers, who had been identified by GP as ‘main carer’ of someone recently deceased (3–12 months), aged between 38 and 87 years old (mean= 67).

Methods: Thematic analysis then the Ecological Framework of Resilience as an organisational tool to develop overarching themes in the data. We used the Sherbourne and Stewart model to identify social support that was lacking as well as social support that was present.

Results: A range of social support types were identified. There was an emphasis on the importance of relationships with both health professionals and family members, including the care recipient. However, social support was not necessary for resilience if the participant had other resources.

Conclusions: Social support for carers providing end of life care is almost exclusively based around end of life care ‘work’. In comparison to other research our study suggests that relationships with family and health professionals are paramount. Multidimensional support is needed for carers to enhance their resilience.     

Nonepileptic seizures in the pediatric population: A qualitative study of patient and family experiences

ObjectiveThe objective of this study was to characterize the experience of nonepileptic seizures (NES) in young people (0–19 years) and their families, referred to a UK specialist (tertiary) pediatric hospital. The topics investigated include: accessing healthcare, how the diagnosis was first explained, impact on home life and school, coping strategies, and ideas about naming and causes.MethodsTen young people with NES and 29 family members took part in focus groups and telephone interviews. The data generated were analyzed qualitatively with thematic analysis.ResultsSix themes were identified from participant experiences: upset and afraid, missing out, feeling misunderstood, confusion and uncertainty, less than epilepsy, and making sense and moving on. Participants described severe disruption to multiple domains of functioning at home, educationally, and in social activities. Young people felt guilty but also overprotected, while family members felt that they were failing as parents. The journey to diagnosis and treatment was seen as unnecessarily tortuous, with access to care and treatment pathways poorly defined. Participants described feeling that a wide variety of professionals did not believe their experiences, showed pejorative attitudes, and left them feeling isolated and marginalized. The young people and family members found NES a difficult disorder to understand and sometimes could not differentiate it from epilepsy. Epilepsy was used as a benchmark for several comparisons, including highlighting the lack of support for and information about NES. Families disliked being told that it was “good news” that their child did not have epilepsy and questioned if their child should be present during initial diagnostic discussions. Participants described stressful situations as a common trigger for NES. Young people showed ambivalence towards the need to understand the condition or the choice of name used for it, whereas family members considered this crucial for achieving recovery.ConclusionsYoung people and families who live with NES experience considerable distress and impairment. Pathways to diagnosis need to be streamlined, and better integration of pediatric, mental health, and educational services is required. The use of the “good news” story to discuss the diagnosis with families should be reconsidered, as families seem to interpret this as indicating that there is no effective treatment. Educational resources and support groups for young people and families are needed. Greater understanding of experiences may allow investigation of the pathogenic mechanism and inform possible management approaches. Training of health professionals in communicating with young people and families with NES must be improved.     

Developing a U.K. protocol for collaborative care: a qualitative study

OBJECTIVE: This study aimed to explore the views of stakeholders including patients, general practitioners (GPs) and mental health workers on the feasibility, acceptability and barriers to a collaborative care model for treatment of depression within the context of U.K. primary health care. METHOD: We used semistructured interviews and focus groups with a purposive sample of 11 patients and 38 professionals from a wide selection of primary and secondary care mental health services, as well as framework analysis using a "constant comparative" approach to identify key concepts and themes. RESULTS: Regular contact for patients with depression is acceptable and valued by both patients and professionals. However, patients value support, whereas professionals focus on information. To be acceptable to patients, contacts about medication or psychosocial support must minimize the potential for patient disempowerment. The use of the telephone is convenient and lends anonymity, but established mental health workers think it will impair their judgments. While patients merely identified the need for skilled case managers, GPs preferred established professionals; however, these workers did not see themselves in this role. All involved were cautious about deploying new workers. Additional barriers included practical and organizational issues. CONCLUSIONS: Although a telephone-delivered mix of medication support and low-intensity psychological intervention is generally acceptable, significant issues to be addressed include the values of the current mental health workforce, fears about new workers' experience and competence, the balance of face-to-face and telephone contacts and case manager education in nonspecific skills necessary to develop a therapeutic alliance, as well as the knowledge and skills required for education, medication support and behavioral activation. Qualitative research can add value to careful modeling of collaborative care prior to international implementation.     

Long-term outcome of pediatric obsessive-compulsive disorder: a meta-analysis and qualitative review of the literature

OBJECTIVE: To review the extant literature on the long-term outcome of child/adolescent-onset obsessive-compulsive disorder (OCD). METHOD: Medline and Psychlit databases were systematically searched for articles regarding long-term outcomes of child/adolescent-onset OCD. Meta-analysis regression was applied to evaluate predictors and persistence of OCD. RESULTS: Sixteen study samples (n = 6-132; total = 521 participants) in 22 studies had follow-up periods ranging between 1 and 15.6 years. Pooled mean persistence rates were 41% for full OCD and 60% for full or subthreshold OCD. Earlier age of OCD onset (z = -3.26, P = 0.001), increased OCD duration (z = 2.22, P = 0.027) and in-patient vs. out-patient status (z = 2.94, P = 0.003) predicted greater persistence. Comorbid psychiatric illness and poor initial treatment response were poor prognostic factors. Although psychosocial function was frequently compromised, most studies lacked comprehensive outcome measures. CONCLUSION: Long-term persistence of pediatric OCD may be lower than believed. Future studies should include broader measures of outcome including symptomatic persistence and functional impairment in multiple domains.     

Management of patients with status epilepticus treated at a pediatric intensive care unit in Turkey

We investigated the etiology, treatment, and prognosis of patients treated for status epilepticus at a pediatric intensive care unit. Medical records of 89 patients admitted to a pediatric intensive care unit with status epilepticus were reviewed retrospectively. Patients ranged in age from 2 months to 18 years (mean age ± S.D., 4.7 ± 3.8 years). Seizure etiologies comprised remote symptomatic in 47 (52.7%), febrile in 15 (16.9%), acute symptomatic in 12 (13.5%), and unknown in 15 (16.9%). Seizure durations ranged from 30-60 minutes in 58 patients, whereas 31 manifested refractory seizures longer than 60 minutes. Seizure control was achieved within 30 minutes in 55 patients, from 30-60 minutes in 19, and after 60 minutes in 15. Rectal diazepam was administered to 38 (42.7%) patients before admission to the hospital. Length of intensive care unit stay increased with increasing seizure duration (P < 0.05). The total mortality rate was 3.4%. This lower mortality rate may be considered evidence of the effectiveness and reliability of the status epilepticus treatment protocol in our pediatric intensive care unit. Prehospital rectal diazepam administration and the treatment of brain edema in the intensive care unit may be useful in the management of patients with status epilepticus.