Early childhood psychological factors and risk for bedwetting at school age in a UK cohort

There is evidence for a link between psychological factors and bedwetting, but the direction of this association is unclear. Using data on 8769 children from the Avon Longitudinal Study of Parents and Children, we examined whether difficult temperament (Toddler Temperament Scale at 24 months; Emotionality Activity Sociability Questionnaire at 38 months) and psychological problems (Revised Rutter Parent Scale for Preschool Children at 42 months) are linked to bedwetting at school age. We examined the association between these risk factors and different patterns of bedwetting from 4 to 9 years using multinomial regression. Difficult temperament and psychological problems in early childhood were associated with increased odds of bedwetting at 4–9 years. The strongest associations were most often found for the pattern of bedwetting that was both frequent (at least twice a week) and persistent (up to age 9) e.g. the temperament traits of ‘adaptability’ and ‘mood’ were associated with a 33 % increase (95 % confidence interval = 1.14–1.55) and a 27 % increase (1.10–1.47) respectively in the odds of persistent and frequent bedwetting per one standard deviation increase in risk score. Early behaviour problems (e.g. conduct problems [1.43 (1.25, 1.63)] and hyperactivity [1.29 (1.11, 1.50), p < 0.001]) were also associated with frequent and persistent bedwetting, but there was less evidence that early emotional difficulties were risk factors for bedwetting. Adjustment for confounders did not alter these conclusions. The presence of difficult temperament and behaviour problems in early childhood might help to identify children who will continue to experience bedwetting at school age.     

Perceived social support and dysfunctioning in “clinical” and “normal” adolescents

The purpose of this study was to examine the extent to which inpatient and non-patient samples of youngsters differ from each other with regard to prevalence and co-occurrence of emotional and behavioural problems and negative perceptions of family, school and peers. The sample comprised 202 12–21-year-old adolescents: 101 psychiatric inpatients and 101 matched “community-based” youngsters. Possible differences between the subgroups were tested by means of multi-variate analysis of variance and relative risk ratios.All specific problems and combination patterns were reported significantly more often by the “inpatient” than by the “non-patient” youngsters. However, after correcting for differences in base rates, only the combination of emotional and/or behavioural problems and family problems remained significant. The combination of emotional and family problems was reported about 12 times more often and the combination of behavioural and family problems even about 21 times more often by adolescents in the “clinical” sample than by those in the “normal” sample.Two important conclusions were drawn: (1) co-occurrence in itself did not appear to be the distinguishing factor between the “clinical” and the “normal” sample; and (2) a dominant role of negatively perceived family support in adolescent functioning was suggested. The implications of these findings are discussed.     

Low birth weight, developmental milestones, and behavioral problems in Chinese children and adolescents

This study examined the association of low birth weight (LBW) and developmental milestones with behavioral and emotional problems in a general population sample of 3344 Chinese children and adolescents aged 6-16 years in 1997. Parents completed a self-administrated questionnaire including information about birth weight and developmental milestones (i.e. lifting the head up, tooth eruption, speech, walking and bedwetting cessation), and the Child Behavioral Checklist (CBCL). Teachers completed the Teacher's Report Form (TRF) to assess classroom behavior problems. Results indicated that LBW and delayed developmental milestones were significantly associated with an increased risk for almost all parent- and teacher-reported behavioral problems after controlling for the potential effects of child's gender, age and birth order, parental ages at birth, education, occupation, complications at birth and number of children in the family. LBW was significantly associated with delay in achieving all developmental milestones including lifting of the head, tooth eruption, sitting without support, walking without help, speech as saying words with meaning, and bedwetting cessation. It is concluded that LBW and delayed early childhood development may predict the occurrence of a wide range of behavioral and emotional problems in later childhood and adolescence.     

Emotional and behavioural difficulties of children and young people at entry into care

Emotional and behavioural difficulties of a sample of children and young people were identified at the point of entry to local authority care by analysis of social work case files. The files indicated high levels of need, including that in children aged under 5. Bedwetting was identified as an important issue related to the physical health and emotional well-being of looked-after children. There was an association between bedwetting and emotional and behavioural problems. Analysis of placement types at entry to care showed that significantly more boys than girls were first placed in residential care.     

The occupational burden of mental disorders in theU.S. military: psychiatric hospitalizations, involuntary separations, and disability

OBJECTIVE: A recent study showed that among U.S. military personnel, mental disorders were the leading medical correlate of separation from military service. The reasons for this association have not been determined. The purpose of this study was to characterize the risk and reasons for service separation for soldiers hospitalized with mental disorders compared with those hospitalized for other illnesses. METHOD: Population-based electronic health care data were linked with data on separations and disability. The authors constructed a cohort of 13,971 U.S. Army soldiers first hospitalized in 1998 and followed them for up to 2 years following this first hospitalization. RESULTS: The rate of service separation 6 months after first hospitalization was 45% among personnel whose primary hospital discharge diagnosis was a mental disorder, 27% among those with a secondary mental disorder discharge diagnosis, and 11% among those hospitalized for all other medical conditions. Separation from military service due to medical disability, misconduct and other legal problems, unauthorized work absences, behavior related to personality disorders, and alcohol rehabilitation failure was significantly more common following hospitalization for a mental disorder than for other medical conditions. Mental disorders were also significantly associated with medical separations in which there was evidence that the condition existed prior to service. CONCLUSIONS: In the military, the occupational impact of mental disorders compared with other medical conditions appears to be mediated not only by greater disease chronicity and severity but also by a variety of behavioral problems including misconduct, legal problems, unauthorized absences, and alcohol/drug-related problems. The study also points to the difficulties inherent in screening for mental disorders prior to entry into military service.     

Survey of sleep problems amongst Singapore children in a psychiatric setting

Background Sleep problems are common among children and range from transient ones to chronic problems like snoring, somnambulism and bedwetting. Sleep problems in turn impact on children’s health, learning, school performance, quality of life and are often closely related to mental health problems. Population based surveys have also revealed a strong association between sleep problems and behavioral and emotional symptoms in children. The objectives of our study were to estimate the prevalence of sleep problems in children and adolescents attending psychiatric services in Singapore and to identify the correlates of sleep problems in this population. Methods A total of 490 parents/guardians accompanying their children to the child guidance clinic consented to complete a questionnaire, which was used to collect both sociodemographic data and the frequency of sleep problems. These included sleep starts, confusional arousal, sleep talking, bruxism, sleep walking, sleep terrors, nightmares, sleep paralysis and nocturnal enuresis. Psychiatric diagnosis was determined from case record survey of the participating subjects. Results About 62.2% (95% CI 57.8%–66.6%) of the children suffered from at least one problem. Girls were significantly more likely to suffer from sleep problems when compared with boys (χ² = 8.5, P < 0.005). The significant predictors for sleep problems were gender, diagnosis of developmental disorders and a family history of sleep problems. Conclusions The study highlights the need for child and adolescent psychiatrists to enquire about sleep problems since sleep disturbances of children are frequent and may not be self-reported. This project was supported by an Institutional Block Grant Received from the National Medical Research Council, Singapore     

“Selected truth”

Professional staff in the National Health Service tend to assume without question that the patients they meet are genuine, honest, and well-intentioned in the problems that they present. The same applies to the parents and relatives of patients, and to professional associates. The large majority are, so that any rare exceptions appear almost incredible. In this respect interviews with doctors and other health workers differ from those with lawyers and the police where the veracity and goodwill of the client is not automatically taken for granted. Downright deliberate dishonesty or premeditated manipulation of truth on the part of patients, their relatives, and people caring for them may be construed as reflecting some personality or psychiatric disorder. Milder forms and shades of “near truth”, “selected truth”, “graduated truth”, “white lies”, “exaggerated facts”, and data chosen for maximum impact, are more frequent and are probably not always suspected or detected. In all communications between people, degrees of licence and flexibility are found, and are institutionalised in different societies and cultures. For example, it has been good manners in Britain not to be too outspoken or blunt, and to use understatement. This is reminiscent of Voltaire's “Speech was given to man to conceal his thoughts.” The term “graduated truth” is used in medical work when it is thought to be in the interests of the patient to deliberately and knowingly conceal or modify the truth. This paper considers some facets of services for mentally handicapped people where “graduated truth” is used in practice. These are: selectivity of data; differential behaviour; fabrication, fantasy and make-believe; and patient management.     

From “cabbages” to “kings”* in one month: or,with the deaf-blind,you never know till you try

In 1974 L. G. Stewart wrote a paper on the problems and needs of severely handicapped deaf persons and suggested programmes that were needed to meet these needs. He entitled his paper “We have met the enemy and he is us”. He concluded that we have not met the needs of severely handicapped deaf persons, largely because we have not tried hard enough. Though Stewart was writing solely about deafness, this situation can be said to be true of sensory handicap in general. Kropka and Williams (1980) wrote that research into the blind and partially sighted had brought to light hitherto unsuspected service deficiencies for this “hidden” minority, as well as for the hearing impaired minority investigated earlier (Kropka, 1979). It was concluded that fine grain analysis of specific sub-groups within mental handicap institutions would highlight the under-estimation of the number of people involved and the lack of suitable programmes for them.     

The relative importance of psychopathology,training procedure,and urological pathology in nocturnal enuresis

Summary Statistically significant contrasts of ratings of enuretics, dry-organics, and wet-organics (defined after exhaustive urological examination) revealed that the enuretic group had the poorest adjustment at school, more sibling rivalry, more anger and dissatisfaction, more parental conflict, more parental inconsistency, less trust in parents, and less exposure to good training procedures. Results were integrated under the hypothesis that three conditions are necessary for bedwetting to persist: (a) the child feels insecure in the specific sense that he feels he has been or is about to be abandoned; (b) the feeling of abandonment must occur during the critical age range of 2 1/2 to 5 years; and (c) the child expects or experiences that the adult reaction to bedwetting reassures him against abandonment. The symptoms of poor relations with peers, poor adjustment at school, and anger and dissatisfaction are not directly related to enuresis; rather, they, like enuresis, are correlates of the insecurity arising from fear of abandonment.The hypothesis that bedwetting is associated with fear of abandonment was confirmed on a sample of 40 normal pediatric outpatient children and 26 children from a residential treatment center. Significant findings were: (a) children having experienced separation from an important child-caring person between ages 2 1/2 and 5 had more bedwetting than those having had no separations or having had them out of the critical age range; (b) fear of abandonment was greatest in the group having had separation experience during the critical age range of 2 1/2 to 5; and (c) fear of abandonment was higher in bedwetters than in children who did not wet the bed at night.The use of a computer for statistical analysis was made possible by a grant through the University Research Committee of Funds from the National Science Foundation and the Wisconsin Alumni Research Fund. The authors thank William Serdahely for his assistance in the first study and Susan Palmer for her help in the second.     

“Non nocere: but we both care”: Commentary on “Non nocere if you really care” by Dr Kripke, MD

Chronic primary insomnia is a recurrent condition that negatively effects the daily functioning of patients, diminishing the quality of their lives. It is associated with, and in some situations, is a risk factor in both psychiatric (depression) and physical (cardiovascular) illness. Treatment effectiveness has been shown in the short term for both drug (benzodiazepine and benzodiazepine agonists) and behavioral treatment. Expert opinion has strongly advised against long-term drug treatment because of concerns about residual sedative effects, memory impairment, falls, respiratory depression, rebound insomnia, medication abuse, dose escalation, dependency and withdrawal difficulties, and an increased risk of death possibly associated with the current hypnotic medications. Many of these concerns could be made against using these agents at all. Worries about these potential problems are challenged by the widespread clinical practice of using hypnotic drugs long-term without any of these difficulties developing and with patients who feel their sleep and daily function function is improved with the nightly use of their sleeping pill. The ability to mount a randomized, placebo-controlled, parallel group, double-blind trial of hypnotic medication in primary insomnia may not be possible. We may have to develop large systematic clinical databases, a number of case series in effect, to monitor both emergent symptoms and possible clinical effectiveness. There is the additional concern that there is a reluctance to examine the long-term drug treatment of insomnia. This reluctance may reflect a negative moral judgement about treating primary insomnia with drugs, a sort of ««pharmacological Calvinism»», rather than just a data based judiciousness.     

Idiopathic focal epilepsies: the “lost tribe”

The term idiopathic focal epilepsies of childhood (IFE) is not formally recognised by the ILAE in its 2010 revision (Berg et al., 2010 ), nor are its members and boundaries precisely delineated. The IFEs are amongst the most commonly encountered epilepsy syndromes affecting children. They are fascinating disorders that hold many “treats” for both clinicians and researchers. For example, the IFEs pose many of the most interesting questions central to epileptology: how are functional brain networks involved in the manifestation of epilepsy? What are the shared mechanisms of comorbidity between epilepsy and neurodevelopmental disorders? How do focal EEG discharges impact cognitive functioning? What explains the age‐related expression of these syndromes? Why are EEG discharges and seizures so tightly locked to slow‐wave sleep? In the last few decades, the clinical symptomatology and the respective courses of many IFEs have been described, although they are still not widely appreciated beyond the specialist community. Most neurologists would recognise the core syndromes of IFE to comprise: benign epilepsy of childhood with centro‐temporal spikes or Rolandic epilepsy (BECTS/RE); Panayiotopoulos syndrome; and the idiopathic occipital epilepsies (Gastaut and photosensitive types). The Landau‐Kleffner syndrome and the related (idiopathic) epilepsy with continuous spikes and waves in sleep (CSWS or ESES) are also often included, both as a consequence of the shared morphology of the interictal discharges and their potential evolution from core syndromes, for example, CSWS from BECTS. Atypical benign focal epilepsy of childhood also has shared electro‐clinical features warranting inclusion. In addition, a number of less well‐defined syndromes of IFE have been proposed, including benign childhood seizures with affective symptoms, benign childhood epilepsy with parietal spikes, benign childhood seizures with frontal or midline spikes, and benign focal seizures of adolescence. The term “benign” is often used in connection with the IFEs and is increasingly being challenged. Certainly most of these disorders are not associated with the devastating cognitive and behavioural problems seen with early childhood epileptic encephalopathies, such as West or Dravet syndromes. However, it is clear that specific, and sometimes persistent, neuropsychological deficits in attention, language and literacy accompany many of the IFEs that, when multiplied by the large numbers affected, make up a significant public health problem. Understanding the nature, distribution, evolution, risk and management of these is an important area of current research. A corollary to such questions regarding comorbidities is the role of focal interictal spikes and their enduring impact on cognitive functioning. What explains the paradox that epilepsies characterised by abundant interictal epileptiform abnormalities are often associated with very few clinical seizures? This is an exciting area in both clinical and experimental arenas and will eventually have important implications for clinical management of the whole child, taking into account not just seizures, but also adaptive functioning and quality of life. For several decades, we have accepted an evidence‐free approach to using or not using antiepileptic drugs in IFEs. There is huge international variation and only a handful of studies examining neurocognitive outcomes. Clearly, this is a situation ready for an overhaul in practice. Fundamental to understanding treatment is knowledge of aetiology. In recent years, there have been several significant discoveries in IFEs from studies of copy number variation, exome sequencing, and linkage that prompt reconsideration of the “unknown cause” classification and strongly suggest a genetic aetiology. The IFE are strongly age‐related, both with regards to age of seizure onset and remission. Does this time window solely relate to a similar age‐related gene expression, or are there epigenetic factors involved that might also explain low observed twin concordance? The genetic (and epigenetic) models for different IFEs, their comorbidities, and their similarities to other neurodevelopmental disorders deserve investigation in the coming years. In so doing, we will probably learn much about normal brain functioning. This is because these disorders, perhaps more than any other human brain disease, are disorders of functional brain systems (even though these functional networks may not yet be fully defined). In June 2012, an international group of clinical and basic science researchers met in London under the auspices of the Waterloo Foundation to discuss and debate these issues in relation to IFEs. This Waterloo Foundation Symposium on the Idiopathic Focal Epilepsies: Phenotype to Genotype witnessed presentations that explored the clinical phenomenology, phenotypes and endophenotypes, and genetic approaches to investigation of these disorders. In parallel, the impact of these epilepsies on children and their families was reviewed. The papers in this supplement are based upon these presentations. They represent an updated state‐of‐the‐art thinking on the topics explored. The symposium led to the formation of international working groups under the umbrella of “Luke's Idiopathic Focal Epilepsy Project” to investigate various aspects of the idiopathic focal epilepsies including: semiology and classification, genetics, cognition, sleep, high‐frequency oscillations, and parental resources (see www.childhood-epilepsy.org ). The next sponsored international workshop, in June 2014, was on randomised controlled trials in IFEs and overnight learning outcome measures.     

Gap junctions: the “kiss of death” and the “kiss of life”

Cells expressing herpes simplex-thymidine kinase (HSV-tk) can be killed “in vitro” within 5 days of treatment with 20 μM ganciclovir (GCV) and transmit this toxicity to adjacent cells lacking HSV-tk; this phenomenon was termed “bystander effect” or “kiss of death”. On testing a large number of cell lines in vitro, a wide range of sensitivity to GCV-mediated bystander killing has been reported. Although intercellular transfer of GCV metabolites through gap junction channels seems to be a likely mechanism for the “kiss of death”, some studies suggest that other pathways may contribute to induced apoptosis of neighboring cells. To further investigate the mechanism underlying cell death mediated by HSV-tk and to evaluate the efficacy of gap junction channels formed by different connexins in this process, we have stably transfected a virtually uncoupled mouse neuroblastoma cell line (N2A cells) with different connexin-types expressed by neural cells (Cx32, Cx37, Cx40, Cx43) and co-cultured these cells with N2A cells stably transfected with Cx37 and HSV-tk. Here, we confirm our previous studies and those of others that the extent of cell death and sensitivity to GCV depend on the degree of connexin expression in transfectants. Further, we show that the bystander effect also depends on which connexin is expressed; reported disparities regarding the extent of GCV-mediated cellular apoptosis are likely due both to the degree of functional coupling and the type of connexin expressed. These results support the notion that gap junction hemichannels formed of certain connexins are more likely than others to pair functionally with Cx37, and suggest co-transfection strategies that might prove effective in sensitizing tumor cell populations to GCV. In addition, potential applications are discussed for use of the “good Samaritan effect”, a mechanism by which bystander cells have been suggested to prevent cytotoxicity.     

A psychological comparison of patients in “open” and “closed” coronary care units

This study demonstrates subtle differences in psychological states of patients in two different coronary care units. In comparing the emotional states and medical course of patients on the two units, the net advantage of the “open unit” seems to be in providing more social contact with associated freedom of expression of hostile feelings, while the lack of privacy resulted in higher levels of “shame anxiety”. The “closed unit”, on the other hand, provided privacy at the expense of human interactions, resulting in increased feelings of loneliness and a displacement of hostile feelings. Certain individual patients may do much better in one or the other type of environment. It is hoped that with further study, it may be possible to identify the characteristics of patients who might be suited to a particular type of C.C.U. Better still, an ideal coronary care unit could be designed, combining the best of both possible worlds, where both “togetherness” and privacy are provided for the patients.

The association found in this and other studies between affective states and the incidence of serious medical complications underline the need to take the patients' emotional welfare into account in the design and staffing of the hospital environment.     

Developments in clergy malpractice: the case of Sanders v. Casa View Baptist Church

The courts have so far consistently refused to view misconduct by clergy counselors as constituting clergy malpractice. However, they have increasingly come to view it as a breach of fiduciary duty. More recently, they have also begun to differentiate between the secular and religious aspects of clergy counselors' work. The case discussed in this article (Sanders v. Casa View Baptist Church) provides an instructive example from the United States Court of Appeals, Fifth Circuit, in 1998. The court upheld a district court finding, based on a review of trial testimony, that the defendant's counseling work as a whole (and not merely his sexual misconduct itself) was essentially secular in nature. Thus the plaintiff recovered punitive damages for both breach of fiduciary duty and marriage counseling malpractice.     

“Leisure-Links”

This article describes research undertaken to assess the need for a community leisure service in Tower Hamlets, part of London's East End. The results replicate the findings of other researchers; that many people with mental handicaps, though “living” in the community, remain isolated from the “community” in its widest sense. People in this study spent the majority of their free time engaged in housebound, solitary, passive, and family oriented activities. Pursuits which did involve “going out” tended to be for groups, such as attending clubs or sports activities. It was found that 84 per cent of respondents, that is, potential consumers, felt they would like to take part in leisure activities that they were not pursuing at the time of the study. The development of Tower Hamlets “Leisure-Links” scheme is described, highlighting features of the scheme which distinguish it from other similar initiatives. Applications for funding are outlined.     

The “silent” imprint of musical training

Playing a musical instrument at a professional level is a complex multimodal task requiring information integration between different brain regions supporting auditory, somatosensory, motor, and cognitive functions. These kinds of task‐specific activations are known to have a profound influence on both the functional and structural architecture of the human brain. However, until now, it is widely unknown whether this specific imprint of musical practice can still be detected during rest when no musical instrument is used. Therefore, we applied high‐density electroencephalography and evaluated whole‐brain functional connectivity as well as small‐world topologies (i.e., node degree) during resting state in a sample of 15 professional musicians and 15 nonmusicians. As expected, musicians demonstrate increased intra‐ and interhemispheric functional connectivity between those brain regions that are typically involved in music perception and production, such as the auditory, the sensorimotor, and prefrontal cortex as well as Broca's area. In addition, mean connectivity within this specific network was positively related to musical skill and the total number of training hours. Thus, we conclude that musical training distinctively shapes intrinsic functional network characteristics in such a manner that its signature can still be detected during a task‐free condition. Hum Brain Mapp 37:536–546, 2016. © 2015 Wiley Periodicals, Inc.     

Associations between disturbed sleep and behavioural difficulties in 635 children aged six to eight years: a study based on parents' perceptions

Associations between sleep and behaviour in 635 children, aged six to eight years, were investigated using parental responses to a sleep habits questionnaire, and to a behavioural screening form, the Strengths and Difficulties Questionnaire (SDQ). Global reports of sleep problems in 4.9% of the children were associated with a total SDQ score indicative of behaviour problems in 36% of the cases. Conversely, 15% of children with behaviour problems had global reports of sleep problems. Associations between specific sleeping features and different dimensions of behaviour and emotions were also explored. Hyperactivity was associated with tossing and turning during sleep, and with sleep walking; conduct problems were related to bedtime resistance; and emotional symptoms were associated with night terrors, difficulty falling asleep and daytime somnolence. Peer problems were associated with somewhat shorter total sleep time. Finally, a total SDQ score indicative of behaviour problems was associated with bedwetting, nightmares, tossing and turning during sleep and sleep walking, as well as with a slightly shorter total sleep time. We conclude that sleep and behaviour problems are associated in children, and that characteristic associations exist between particular sleep disturbances and specific dimensions of behaviour. Accepted: 15 June 2000     

“Fearful cognitions associated with eating pathology” psychometric properties of a new scale

The psychometric properties of a new scale that measures fearful cognitions associated with eating problems were explored, using two independent samples of undergraduate females. In Study 1, an exploratory factor analysis was conducted to revise and shorten the scale. Study 2 reproduced the factor structure and positive relationship between fearful cognitions and eating pathology. Additionally, regression analyses demonstrated discriminant and incremental validity, since the scale explained 27% of the variance in eating pathology, and was independent of the effects of anxiety and depression. Implications for treatment, and a cognitive model of fears associated with eating disorders are discussed.     

Sexual boundary violations committed by female forensic workers

A vast literature has focused on sexual boundary violations in professional practice. Much of this analysis has focused on the intersection between gender and professional authority in cases of misconduct committed by male professionals against female clients and patients. Although certainly of importance, such power-based gender analysis may overlook instances of misconduct in which a female professional engages in a sexual encounter with a male client. This article provides a review and analysis of the literature regarding sexual misconduct committed by female forensic workers. Aspects considered include the characteristics of the male forensic patient or prisoner, the characteristics of the female forensic worker, the organizational milieu, and the consequences of the misconduct. Recommendations for practice are offered.