Annual Research Review: Universal and targeted strategies for assigning interventions to achieve population impact

This article proposes that universal and targeted preventive interventions should be compared and evaluated in terms of their benefit–cost ratio in achieving population-wide impact on mental disorders and related outcomes. Universal approaches attempt to affect every individual in a population, whereas targeted approaches select candidates for intervention based on screening of demographic or behavioral characteristics. Unique assets and challenges of each approach in achieving population impact in a cost-efficient way are discussed, along with spillover effects, sensitivity and specificity, developmental processes, timing of intervention, and the relation between severity of risk and plasticity. A general targeted-efficiency framework is proposed as a heuristic to evaluate the collective merits of universal and targeted approaches in specific cases. A tiered approach that combines universal and targeted identification strategies is proposed, and examples are described. Issues for high-priority research are identified.     

Un nouveau regard sur la dyslexie dysorthographie. Plaidoyer pour une reconnaissance précoce de ce handicap

Dyslexia is a primary development disorder characterized by reading and writing disability. Although frequent, it remains underdetected at school and badly known by practitioners. As a consequence, many children remain severely handicapped in their school life, and later on in their adult social life, although being fairly intelligent. Pediatricians must be involved in its early detection and management ERTL4 test is a useful test of detection to be applied in 5-7-year-old children.     

Intervention targeting development of socially synchronous engagement in toddlers with autism spectrum disorder: a randomized controlled trial

Background: Social and communication impairments are core deficits and prognostic indicators of autism. We evaluated the impact of supplementing a comprehensive intervention with a curriculum targeting socially synchronous behavior on social outcomes of toddlers with autism spectrum disorders (ASD). Methods: Fifty toddlers with ASD, ages 21 to 33 months, were randomized to one of two six‐month interventions: Interpersonal Synchrony or Non‐Interpersonal Synchrony. The interventions provided identical intensity (10 hours per week in classroom), student‐to‐teacher ratio, schedule, home‐based parent training (1.5 hours per month), parent education (38 hours), and instructional strategies, except the Interpersonal Synchrony condition provided a supplementary curriculum targeting socially engaged imitation, joint attention, and affect sharing; measures of these were primary outcomes. Assessments were conducted pre‐intervention, immediately post‐intervention, and, to assess maintenance, at six‐month follow‐up. Random effects models were used to examine differences between groups over time. Secondary analyses examined gains in expressive language and nonverbal cognition, and time effects during the intervention and follow‐up periods. Results: A significant treatment effect was found for socially engaged imitation (p = .02), with more than doubling (17% to 42%) of imitated acts paired with eye contact in the Interpersonal Synchrony group after the intervention. This skill was generalized to unfamiliar contexts and maintained through follow‐up. Similar gains were observed for initiation of joint attention and shared positive affect, but between‐group differences did not reach statistical significance. A significant time effect was found for all outcomes (p < .001); greatest change occurred during the intervention period, particularly in the Interpersonal Synchrony group. Conclusions: This is the first ASD randomized trial involving toddlers to identify an active ingredient for enhancing socially engaged imitation. Adding social engagement targets to intervention improves short‐term outcome at no additional cost to the intervention. The social, language, and cognitive gains in our participants provide evidence for plasticity of these developmental systems in toddlers with ASD. http://www.clinicaltrials.gov/ct2/show/NCT00106210?term = landa&rank = 3.     

Improving adherence to medications in pediatric liver transplant recipients

Abstract:  We describe results from a clinical program, which aimed at improving adherence to medications in children who had a liver transplant. We followed the medical outcomes of 23 children and adolescents who participated in a clinical adherence-improvement protocol during the years 2001–2002. The protocol included identification of non-adherent patients by examining tacrolimus blood levels and intervention by increasing the frequency of clinic visits for non-adherent patients. In the two-yr preintervention (1999–2000), there was no improvement in any of the outcomes. After the intervention, the number of patients with high alanine aminotransferase levels (100 and above) decreased significantly, from eight before the intervention to four afterwards. Other outcomes, including the number of rejection episodes (three before, none after) and the degree of adherence to tacrolimus, also improved, but the improvement did not reach statistical significance. Although non-adherent patients were called to clinic more often under the protocol, the intervention did not lead to increased outpatient costs. This adherence--improvement intervention appears to be promising in improving outcomes in pediatric liver transplant recipients. Larger, controlled studies are needed to establish the efficacy of this or other approaches.     

Passport to Learning

Many children who are referred for therapy with school-related problems experiencedifficulty with impulsivity, task completion and theorganizationof information and ideas. School performanceoften improves when children learn to approach tasks systematically and to use cognitive strategies. In this paper, a short term, small group program is described that targets children's cognitive deficiencies and emphasizes a strategy-based, problem-solving approachtointervention.     

Evaluation of a community intervention programme for preschool behaviour problems

OBJECTIVES: To evaluate an early intervention project focused on improving child prereading skills and parent behaviour-management skills, for 4-year-old children in the western suburbs of Melbourne (Victoria, Australia). METHODOLOGY: Following screening of a large sample of preschoolers, four groups were constructed: (i) children receiving a phonological skills-based prereading package in their normal preschool programme; (ii) children whose parents attended six sessions of child behaviour management skill training; (iii) children who received both interventions; and (iv) a control group. Pre-, post-, 1 and 2 year follow-up measures were taken to assess effects on child behavioural and learning adjustment. RESULTS AND CONCLUSIONS: This community based intervention resulted in positive effects, despite being of low intensity, in achieving significantly less hyperactive/distractable behaviour in children from the combined intervention group at 2 years postintervention. Anxiety problems were also reduced at the post-treatment phase. The prereading package did not demonstrate any effects on reading skills and was deemed to be insufficiently intensive to affect a population of disadvantaged preschoolers. This universal-type of intervention was well accepted by the community, but there is need for further effort to increase recruitment of families of at-risk children into such programmes.     

Ultrasound-guided puncture of fetal urachal diverticulum

Ultrasound (US) evaluation of a fetal abdomen incidentally showed a large diverticulum of the frontal abdominal wall. The diverticulum passed the bladder, and a urachal diverticulum with a urethral stricture was suspected. At 20 weeks and 5 days gestational age. US-guided puncture of the diverticulum was performed. Preservation of renal function was successful.Presented at the 26th General Meeting of the Japanese Society of Pediatric Surgeons, Chiba, Japan, 7–9 June 1989     

Evaluation of attempted prevention of unexpected infant death in very high-risk infants by planned health care

Three hundred and ninety-six babies born in Sheffield between 1982 and 1990 identified as being at "very high risk" of unexpected infant death by means of a scoring system, received an intensive programme of health care including a case discussion between a paediatrician, the GP and the health visitor held in the family doctor's surgery, weekly visits from the health visitor and informal hospital admission. Significantly fewer sudden unexpected infant deaths occurred in this group than were expected by logistic regression anlysis or occurred in the best available control group with comparable scores ( p = 0.024). Problems in evaluation include identification of an adequate control population, ethical difficulties in introducing a controlled study when the programme is already perceived as effective, and the calculation of "expected death rates". The results of this study indicate that very energetic programmes of intervention may prevent some deaths in vulnerable infants.     

Interventional radiology: a modular approach

The authors offer a modular approach to the development of new procedures in the field of pediatric interventional radiology as a conceptual model and a springboard for further discussion.     

A Narrative Review of Generic Intervention Fidelity Measures

ABSTRACT

To increase the rigor of pediatric rehabilitation research, there is a need to evaluate the degree to which an intervention is conducted as planned (i.e., fidelity). Generic fidelity measures evaluate more than one intervention and often include nonspecific attributes of the therapy process common to both interventions. The objective of this study was to describe the characteristics of generic fidelity measures and examine how these attributes fit with pediatric rehabilitation. A review of generic fidelity measures was conducted utilizing health and education databases. Five generic fidelity measures are described and examined for their applicability to pediatric rehabilitation. The measures were used in nine studies meeting the inclusion criteria, involving people ages from 11 years to >65 years undergoing psychotherapy. From the 76 nonspecific items, 37 items were judged to be applicable to pediatric rehabilitation. Common characteristics of nonspecific attributes with pediatric rehabilitation are discussed, and investigator plans to conduct future testing.     

Is Group-Based or Individual-Based Intervention more Effective for Quality of Life Outcomes in Children with Developmental Coordination Disorder? A Systematic Review

Aims: To examine whether group-based or individual-based treatment programs are more effective for quality of life (QOL) outcomes in children with developmental coordination disorder (DCD). Methods: A systematic search of the literature was conducted, in accordance with the PRISMA guidelines. Quality of the papers was assessed using the Modified Downs and Black Checklist. Peer-reviewed clinical experimental studies of children diagnosed with DCD with any QOL related outcome measure were included, of all years, languages, and approaches of intervention. Results: Sixteen studies were identified for inclusion, of mixed methodological qualities (predominantly low). Improvement of QOL with both group-based and individual-based interventions were shown, though large degrees of heterogeneity were observed in study designs, participants, modes of interventions, durations, and outcome measures utilized. Conclusions: The effectiveness of group-based versus individual-based interventions on QOL of children with DCD is unclear. There is a pressing need for a high quality, powered trials, utilizing the randomized control trial paradigm, comparing both intervention approaches with standardized treatment approaches and outcome measures to determine and compare the effect on QOL of children with DCD.     

Activity-Focused Motor Interventions for Children with Neurological Conditions

SUMMARY

This article presents a model to guide activity-focused physical therapy and occupational therapy interventions for children with neurological conditions. Activity-focused interventions involve structured practice and repetition of functional actions and are directed toward the learning of motor tasks that will increase independence and participation in daily routines.

According to this model, the pediatric therapist: (1) develops activity-related goals in collaboration with the child and the family; (2) plans activity-focused interventions by adapting knowledge of motor learning to the child's individual learning strengths and needs; and (3) integrates impairment-focused intervention with activity-focused intervention.     

Book Review

Abstract

This article describes the author's experience working as a consultant to a home-based Early Head Start Program. The model that developed was a complex multilayered intervention, involving work of a supervisory nature with a home visitor, direct work with the mother-infant pair, and work with the agency. Both the dyad and the home visitor showed evidence of growth over the course of the intervention. Recommendations are offered regarding the potential benefits of introducing this model in similar programmes.     

婴儿早期教育的效果

目的 从新生儿期开始即进行早期教育，以达到优生优育的效果。方法 对每一位自协和医院出生的婴儿会员进行定期生长发育监测；婴儿喂养及营养的指导；心理行为测评和指导；疾病的早期发现和早期干预；高危儿的随诊。结果 俱乐部的工作保障了会员的体格发育正常，他们的身高、体重及头围的均值均高于1995年全国九城市儿童的生长发育标准的均值；精神发育，采用CDCC（婴幼儿智能发育测定）量表，精神发育指标（MEI）和运动发育指标（PDI）均在正常范围；在早产儿、窒息儿及高危儿的随诊中，起到了早期发现、早期干预的作用；创造了新型和谐的医患关系。结论 俱乐部的工作，保障了会员的精神发育、体格发育的健康生长，进一步验证了婴儿早期教育的效果。     

Cognitive Strategies and Motor Performance in Children with Developmental Coordination Disorder

Recently, researchers in occupational therapy have investigated the use of a cognitive or “top down” approach to improving the occupational performance of children with developmental coordination disorder. A cognitive approach is multifaceted in nature and one essential component of such an approach is the use of cognitive strategies. Although strategy use has a long history within the education and psychology literature, little discussion within the pediatric therapy literature has occurred. This paper reports the results of an in-depth videotape analysis of therapists using cognitive strategies during occupational therapy intervention. Eight domain specific strategies were identified and elucidated. This research will be beneficial to therapists who wish to incorporate a cognitive approach into their clinical practice.     

FACTORS INFLUENCING THE ASYMETRICAL TONIC NECK REFLEX IN NORMAL INFANTS

The purpose of this study was to evaluate the effect of the following factors on achievement of head position and incidence, strength, and duration of the asymmetrical tonic neck reflex: 1) method of eliciting the reflex, 2) extent of head turning, and 3) direction of head turning. Subjects included 20 - 4 to 10 week old infants. Supine infants were videotaped during eight trials representing all combinations of the three factors. Head turning was elicited actively by having the infant follow a rattle or, passively, by having the examiner turn the infant's head; the head was turned to approximately 70 degrees (full turn) or 30 degrees (partial turn) from vertical; and the head was turned to the left or right. Passively turning the head fully to the side was most effective in achieving the intended head position. Full head turns were most effective in eliciting the reflex, and the reflex was stronger and lasted longer during full head turns. No difference in the three measures of the reflex occurred as a result of turning the head actively or passively. The reflex was elicited more frequently and was stronger during left turns than during right turns.