Growing up in Uppsala. Part II. Could adolescents with severe psychosocial problems have been identified by symptoms observed in school at age 10 years?

The study comprised all 1715 children born in 1965 and resident in Uppsala at age 10 and 18 years. Data were collected through teacher interviews and analysis of school health records in grade 3 at the age of 10 years. The psychosocial burden up to the age of 18 years was assessed on the basis of all registered contacts with official institutions outside school (authorities for care of the handicapped, Department of Child Psychiatry, social agencies, legal authorities). Approximately 12% of the adolescents were clearly in a situation of manifest psychosocial risk on the threshold of adult life. These adolescents were assigned to five mutually exclusive problem groups comprising different sex distribution, symptoms and utilization of institutional care. The analysis of the relationship between data from grade 3 and the psychosocial burden up to 18 years of age showed that the information available to the school did not permit reasonably secure predictions of the child's psychosocial situation at the end of adolescence. Observations in school of pre-adolescent children cannot be used as a basis for risk-group strategies aiming at concentrating early treatment measures and resources to a restricted number of children at risk. However, the prognosis is apparently serious for a limited number of 10-year-olds with serious problems in school.     

Rationality of routine health examinations by physicians of 18-month-old children: experiences based on data from a Swedish county

Abstract The aim of the present study was to evaluate the rationality of health check-ups by a physician of 18-month-old children. The study population consisted of all 4075 children in Uppsala county who were 18 months old in 1994 and should have had a routine health examination at that point. Information about the 18-month health examination came from primary data in a longitudinal child health register regarding all children of preschool age. The children in the study population were classified into two main categories, namely children with no newly detected health problem (92.6%) and children in whom a new health problem was detected (3.3%). Data from the register and other sources were analysed to categorize the health problems by severity and type and to determine who (parents, nurse or physician) had identified each. Among the 4075 children in the study population, 135 children were identified as having a newly detected health problem. One-third of them were actually healthy (false positive). Among the 92 verified new health problems (2.3%), 48 were minor, 42 were moderate and 2 were severe. More than half of the moderate health problems were transient infections. The main conclusion of the study is that, undercurrent conditions in Sweden, it would be reasonable to replace the 18-month examination by a physician with an examination by a nurse, this examination being particularly orientated towards developmental and psychosocial problems.     

Child health services in transition: I. Theories, methods and launching

AIM: To describe an evidence-based model for preventive child health care and present some findings from baseline measurements. METHODS: The model includes: parent education; methods for interaction and language training; follow-up of low birthweight children; identification and treatment of postnatal depression, interaction difficulties, motor problems, parenthood stress, and psychosocial problems. After baseline measurements at 18 mo (cohort I), the intervention was tested on children from 0 to 18 mo at 18 child health centres in Uppsala County (cohort II). Eighteen centres in other counties served as controls. Two centres from a privileged area were included in the baseline measurements as a "contrasting" sample. Data are derived from health records and questionnaires to nurses and mothers. RESULTS: Baseline experiment (n = 457) and control mothers (n = 510) were largely comparable in a number of respects. Experiment parents were of higher educational and occupational status, and were more frequently of non-Nordic ethnicity. Mothers in the privileged area (n = 72) differed from other mothers in several respects. Experiment nurses devoted considerably fewer hours per week to child health services and to child patients than did control nurses. CONCLUSIONS: Despite certain differences, experiment and control samples appeared comparable enough to permit, in a second step, conclusions about the effectiveness of the intervention.     

Unmet health care needs and impact on families with children with disabilities in Germany.

OBJECTIVES: We sought to determine the independent effect of unmet health needs on family burden, in addition to the effects of functional impairment and parental care load, in children and adolescents with disabilities. METHODS: We conducted a cross-sectional survey of 273 families with children with disabilities using ambulatory services at an academic children's hospital in Germany. We measured family burden using a translated version of the Impact on Family Scale (FABEL). Independent variables were unmet health needs in 4 areas (medical care, care coordination, health education, and psychosocial services), level of functional disability, and nursing care load at home. Control variables included the child's age and gender, maternal employment status, and parental educational attainment. RESULTS: Most children had complex health conditions such as brain injury, congenital malformations, metabolic disease, myopathies, and brain tumors. Nearly half of families (44.6%) received home nursing cash benefits, indicating high care load. Parents reported most unmet needs in the areas of psychosocial counseling (17.2%) and care coordination (8.1%). After controlling for sociodemographic factors, unmet health needs predicted family burden independently of type (mental retardation or mobility impairment) and number of disabilities and nursing care load. Although only a few parents reported lack of medical services, this factor also contributed significantly to family burden. Multivariate analysis with these variables explained 45% of the variance in impact on the family. CONCLUSIONS: Addressing unmet health needs may alleviate the impact of caring for a child with a disability. Further studies are needed to show more definitively that families can benefit from integrated services including psychosocial counseling.     

Mental Health Beliefs and Barriers to Accessing Mental Health Services in Youth Aging out of Foster Care

ObjectiveTo examine the perspectives of youth on factors that influence mental health service use after aging out of foster care.MethodsFocus groups were conducted with youth with a history of mental health needs and previous service use who had aged out of foster care. Questions were informed by the Health Belief Model and addressed 4 domains: youth perceptions of the “threat of mental health problems,” treatment benefits versus barriers to accessing mental health services, self-efficacy, and “cues to action.” Data were analyzed using a modified grounded-theory approach.ResultsYouth (N = 28) reported ongoing mental health problems affecting their functioning; however, they articulated variable levels of reliance on formal mental health treatment versus their own ability to resolve these problems without treatment. Past mental health service experiences influenced whether youth viewed treatment options as beneficial. Youth identified limited self-efficacy and insufficient psychosocial supports “cueing action” during their transition out of foster care. Barriers to accessing mental health services included difficulties obtaining health insurance, finding a mental health provider, scheduling appointments, and transportation.ConclusionsYouths' perceptions of their mental health needs, self-efficacy, psychosocial supports during transition, and access barriers influence mental health service use after aging out of foster care. Results suggest that strategies are needed to 1) help youth and clinicians negotiate shared understanding of mental health treatment needs and options, 2) incorporate mental health into transition planning, and 3) address insurance and other systemic barriers to accessing mental health services after aging out of foster care.     

Chronic illness, disability, and mental and social well-being: findings of the Ontario Child Health Study

Chronic childhood illness, disability, and psychosocial problems are receiving major attention in current pediatric care. Much of the evidence associating chronic physical problems and mental health and adjustment problems has come from clinic-based studies and is often inconsistent in its conclusions. This paper reports the findings of the Ontario Child Health Study, an epidemiologic survey of 3,294 children 4 to 16 years of age in the general community, concerning the relationship of psychiatric disorders and social adjustment problems among children with chronic illness, medical conditions, and long-term disability in contrast to children free of chronic physical health problems. Age- and sex-adjusted risks for psychiatric disorders and social problems, compared with those for healthy peers, were calculated: children with both chronic illness and associated disability were at greater than threefold risk for psychiatric disorders and considerable risk for social adjustment problems. Children with chronic medical conditions, but no disability, were at considerably less risk: about a twofold increase in psychiatric disorders but little increased risk for social adjustment problems was observed. A relative underuse of specialized mental health services by children who might benefit supports the opinion that all physicians in the community who care for children with chronic health problems should become skilled in the recognition of existing or incipient mental health and social problems and familiar with preventive and treatment approaches that may lessen the excessive burden of psychosocial problems among those with chronic ill-health.     

Annotation: Pathways to care for children with mental health problems

BACKGROUND: Although many children with mental health problems are in contact with primary health care services, few receive appropriate help. METHODS: Using a pathways to care model, this paper systematically reviews the literature relating to access to services. It separates out the various stages of help-seeking: parental perception of problems, use of primary care services, recognition within primary care, and referral to or use of specialist health services. RESULTS: Following parental awareness of child symptoms, parental perception of problems is the key initial step in the help-seeking process. Although children with mental health problems or disorders are regular attenders within primary care and most parents acknowledge that it is appropriate to discuss concerns about psychosocial issues in this setting, few children are presented with mental health symptoms even if their parents have such concerns. Subsequently, less than half of children with disorders are recognised in primary care. Amongst recognised children, about half are referred to specialist services. Overall, up to one-third of children with disorders receive services for mental health problems. Factors such as the type and severity of disorder, parental perceptions, child age and gender, and family and social background factors determine which affected children access services. CONCLUSIONS: As there are inequities in patterns of service use, a greater emphasis on developing resources at population and primary care levels is required. Barriers involving parental perceptions and expression of concerns within consultations should be minimised at these levels. This requires both public education approaches and improved training and specialist support for primary care services to enhance their ability to provide for these children.     

Effects on later adjustment of living in a stepfamily during childhood and adolescence

This paper examines the effects of living in a stepfamily during childhood and adolescence on a range of psychosocial outcomes at age 18 years. Data collected during an 18-year longitudinal study were used to examine a sample of 907 children with respect to: exposure to living in a stepfamily during the period from age 6 to 16 years; measures of psychosocial outcomes including mental health, antisocial behaviour, substance use, restricted life opportunities, and sexual risk-taking at age 18 years; and measures of prospectively collected confounding factors. The analyses revealed that children exposed to living in a stepfamily for the first time between ages 6-16 years had elevated risks of a range of psychosocial outcomes at 18 years. These included elevated risks of: (1) juvenile offending; (2) nicotine dependence; (3) abuse or dependence on illicit substances; (4) leaving school without qualifications; (5) early onset of sexual activity; and (6) multiple sexual partners. However, these risks were reduced substantially when psychosocial outcomes were adjusted for the confounding effects of antecedent factors such as: family socioeconomic characteristics: family history of instability, adversity, and conflict; mother's age, religiosity, and smoking; child gender; and preexisting child conduct and attentional problems. After adjustment, the odds ratios between exposure to a stepfamily and adolescent outcomes were nonsignificant. Additional analysis revealed that there were no significant differences in outcomes for boys and girls exposed to stepfamilies. It was concluded that although young people exposed to living in a stepfamily had increased risks of poor psychosocial outcomes, much of this association appeared to be spurious, and arose from confounding social, contextual, and individual factors that were present prior to the formation of the stepfamily.     

Congenital tracheoesophageal fistula and coordination of care: Expectations and realities

BACKGROUND

Tracheoesophageal fistula (TEF) is a rare congenital anomaly with chronic morbidities. Aside from health care costs, the authors suspected that additional burden rests on the family due to hospitalizations, radiological and surgical procedures, and frequent outpatient visits. It was speculated that this complex care is poorly coordinated. The objective of the present study was to document utilization and coordination of health care services for children with TEF at the Alberta Children’s Hospital (Calgary, Alberta).

METHODS

Medical records of children with TEF (primary surgical repair at Alberta Children’s Hospital between April 1994 and September 1999) were reviewed for demographics, TEF type, associated anomalies, age at diagnosis and repair, health services utilization data, and radiological and surgical procedures.

RESULTS

Twenty-two children were identified, of whom 18 survived beyond one year. Ten of these 18 children were male. Average gestational age and birth weight were 37.4 weeks (range 32 to 42 weeks) and 2512 g (range 780 g to 3950 g), respectively. Seventy-eight per cent of children had at least one associated anomaly. Median initial hospital and intensive care unit stays were 27.5 days and 12 days, respectively. During year 1 of life, there was a median of 31 radiological examinations, five surgical procedures, 2.5 hospital admissions and five outpatient clinic visits. Coordination of procedures and outpatient visits was poor. In year 2 of life, children had fewer procedures, admissions and outpatient visits; between years 2 and 5, procedures or admissions were rare.

CONCLUSIONS

Children with TEF endure multiple procedures and lengthy hospital admissions in early life. There was easy access to, but minimal coordination of, subspecialist care, procedures and admissions. A dedicated multidisciplinary clinic for children with TEF should improve care.     

Child health service's response to early feeding and behaviour problems: changes in parental perceptions 1970-93

Objective: This health systems study was done to measure changes over time concerning parents' perceptions of feeding and behavioural problems in children 6-18 mo of age, parents' willingness to use child health services and their evaluation of the advice received. Method: The study had a repetitive cross-sectional design. Three largely identical surveys were performed in 1970, 1988 and 1993. Questionnaires were sent to a random sample of all parents of children 6-18 mo living in Uppsala, Sweden. Results and conclusions: The frequency of different perceived feeding and/or behavioural problems was stable or declined between 1970 and 1988, but increased in 1993. For most problems, inclination to seek help and perceived benefit of advice decreased between 1970 and 1988, but increased again in 1993. The parents sought more help and perceived the advice they received as more beneficial when the service was in the hands of paediatric nurses (1970) or of district nurses focusing on the care of infants and preschool children (1993) than when the district nurses also had responsibilities for adults and the elderly (1988). No correlation was seen with societal and sociodemographic trends. Although the cross-sectional (hence non-experimental) design of the study makes it impossible to prove causality, the findings suggest that parents' willingness to use the child health service and their evaluation of that service may depend in part on organization, including the degree to which nurses with “first-line” contacts are focused on paediatric services.     

It''s time: The future of school health in Australia

School medical services in Australia have a long tradition of providing community-based services to school-aged children, and in some states to preschool children. Conceived as a public health measure early this century, doctors and nurses worked in schools to address the health issues of the time, which were largely to do with nutrition, hygiene, and infectious diseases. It was perceived that many children had poor access to medical care, and began school with unaddressed health problems which often had a deleterious effect on their learning. Doctors were often employed by education authorities and only transferred to health departments many years later. In some states the service was expanded subsequently to include preschool children, based on the concept that the earlier problems were detected the earlier they could be treated appropriately and the greater the benefits to the child. While social structures, community needs and paediatric morbidity patterns have changed dramatically over recent years, there is a widespread perception that in some states school medical services have not yet embraced fully the changing needs of the population of school children they are designed to serve. Hamstrung by political expediency (with decision-making driven by political rather than scientific considerations) and bureaucratic inertia, school nurses and doctors often operate in structures and systems that are urgently in need of review and reorganization. In this paper the rationale for current processes will be reviewed critically, a model of school health services focused on contemporary paediatric needs is proposed, and a set of factors which are considered essential to the development of the school health services of the future is outlined.     

Primary care referral of children with psychosocial problems

OBJECTIVES: To examine primary care provider referral patterns for patients with psychosocial problems and to understand the factors that influence whether a mental health referral is made. DESIGN: Secondary analysis of the Child Behavior Study data collected during 1994-1997 from background survey of providers, visit survey of providers and parents, and follow-up survey of parents. SETTING: Two hundred six primary care offices in the United States, Canada, and Puerto Rico. PATIENTS: Four thousand twelve of 21 150 patients aged 4 to 15 years in the Child Behavior Study with a clinician-identified psychosocial problem. MAIN OUTCOME MEASURES: Referral for psychosocial problem at index visit and reported follow-up with mental health care provider within 6 months. RESULTS: Six hundred fifty (16%) of 4012 patients with psychosocial problems were referred at the initial visit. In multivariate analysis, significant factors associated with likelihood of referral included patient factors (severity, type of problem, academic difficulties, prior mental health service use) and family factors (mental health referral of parent); however, none of the provider factors were significant. Clinicians reported frequent barriers to referral and mental health services in the general background survey; however, these factors were rarely reported as influences on individual management decisions. Only 61% of referred families reported that their child saw a mental health care provider in the 6-month period after the initial primary care referral. CONCLUSIONS: Most psychosocial problems are initially managed in primary care without referral. However, referral is an important component of care for patients with severe problems, and many families are not effectively engaged in mental health services, even after a referral is made.     

基于多元统计和社会网络分析的中国儿童保健学科知识发展可视化研究

目的 通过多元统计和社会网络分析法中主题词共现的方式,研究中国儿童保健学科知识发展和分布,研究学科知识聚类,预测未来发展趋势。方法 检索《中华儿科杂志》、《临床儿科杂志》、《中国实用儿科杂志》和《中国儿童保健杂志》,双人手工筛选儿童保健相关文献,按照文献数量和中国人均GDP水平分为1978至1994年、~2003年和~2011年3个阶段,使用Endnote X4软件提取主题词,建立共词矩阵;使用SPSS 17.0软件对共现矩阵进行转换、降维和聚类分析,并根据聚类分析结果绘制战略坐标图;使用Ucinet 6.0软件绘制可视化网络图形。结果 共提取文献5 771篇,成功建立并直观展示了中国儿童保健学科知识可视化图谱及发展趋势。1978至1994年17年儿童保健发文总量162篇（年均9.5篇）,1995年后17年发文总量5 618篇（年均330篇）,后者是前者发文总量的34 .8倍;1978年至累积发文近百篇历经了14年（1991年）,累积发文超千篇又经过了7年（1998年）,以后每3年约增加1 000篇。1978至1994年阶段中国儿童保健学科发展缓慢,方向零散,聚类归纳欠佳,佝偻病研究突出。~2003年阶段以儿童营养性疾病为研究核心,聚类归纳较好,构建了中国儿童保健学科基本框架,新兴研究领域发展稍显不足。~2011年阶段儿童社会心理行为研究成为核心,研究方法更加科学,各个聚类发展较之前平衡,知识更新迅速。结论 中国儿童保健学科研究起步于20世纪90年代初,新千年后有了长足的进步,知识网络是一个逐渐完善的过程,并与国家的重视和经济发展相吻合。儿童保健研究方法学和儿童心理和社会行为发育规律等8个聚类形成了目前中国儿童保健学科架构,其中儿童发育和流行病学为最核心主题词。     

A psychosocial follow-up of ten adolescents with low anorectal malformation

Ten adolescents, aged 12–16 (mean 14.5) years, with corrected low anorectal anomalies were assessed with regard to somatic condition, psychopathology and psychosocial functioning by semistructured interviews and questionnaires. Half of the patients still had a persistent dysfunction involving problems with constipation and/or soiling. Six of 10 adolescents met the criteria for a psychiatric diagnosis and had scores indicating mild to severe impairment of psychosocial function. Psychosocial functioning was correlated with chronic family difficulties. The findings are in contrast to previous studies and reveal hidden problems and unmet social needs. To optimize their mental health and psychosocial functioning, children with low anorectal anomalies need both somatic and psychosocial follow-up.     

Infant feeding and cost of health care: a cohort study

Aim: To compare the use and cost of health care in infants with different feeding patterns. Methods: Observational study on a cohort of 842 infants born in ten hospitals in northern Italy and followed up to age 12 months. Data on feeding gathered through telephone interviews with 24-hour recall. Data on use of health services reported by mothers and checked against records. Data on hospital cost derived from Disease Related Groups codes. Data on cost of other services obtained from maternal reports and available price lists. Results: At three months, 56% of infants were fully breastfed, 17% complementary fed and 27% not breastfed. Infants fully breastfed at three months had 4.90 episodes of illness requiring ambulatory care and 0.10 hospital admissions per infant/year compared with 6.02 and 0.17, respectively, in infants not or not fully breastfed. They had also a lower cost of health care: €34.69 versus 54.59 per infant/year for ambulatory care, and €133.53 versus 254.03 per infant/year for hospital care. Higher cost of health care was significantly associated with having a hospital admission and being a twin; cost of health care decreased with each additional gram of birth weight, each month of delayed return of the mother to work after the third month, and each extra month of breastfeeding. Conclusion: Lack of breastfeeding and higher use and cost of health care are significantly associated.     

Development and psychometric assessment of the collaborative care for attention-deficit disorders scale.

OBJECTIVE: To describe the development and assess the validity and reliability of the Collaborative Care for Attention-Deficit Disorders Scale (CCADDS), a measure of collaborative care processes for children with attention-deficit/hyperactivity disorder who attend primary care practices. METHODS: Collaborative care was conceptualized as a multidimensional construct. The 41-item CCADDS was developed from an existing instrument, review of the literature, focus groups, and an expert panel. The CCADDS was field tested in a national mail survey of 600 stratified and randomly selected practicing general pediatricians. Psychometric analysis included assessments of factor structure, construct validity, and internal consistency. RESULTS: The overall response rate was 51%. Most respondents were male (56%), 46 years old or older (59%), and white (69%). Common factor analysis identified 3 subscales: beliefs, collaborative activities, and connectedness. Internal consistency reliability (coefficient alpha) for the overall scale was .91, and subscale scores ranged from .80 to .89. The CCADDS correlated with a validated measure of provider psychosocial orientation (r = -.36, P < .001) and with self-reported frequency of mental health referrals or consultations (r = -.24 to -.42, P < .001). CCADDS scores were similar among physicians by race/ethnicity, gender, age group, and practice location. CONCLUSIONS: Scores on the CCADDS were reliable for measuring collaborative care processes in this sample of primary care clinicians who provide treatment for children with attention-deficit/hyperactivity disorder. Evidence for validity of scores was limited. Future research is needed to confirm its psychometric properties and factor structure and provide guidance on score interpretation.     

Health promotion and research in the Chinese community in Montreal: A model of culturally appropriate health care

In the past three decades, rapidly changing demographic characteristics have been witnessed in western society. Concurrently, numerous culture-related studies have attested to the disparity in health services among different ethnic groups. Reports have shown contributing factors that can render main stream services inaccessible to immigrants include cultural and language barriers, adaptation difficulties, racial discrimination and lack of culturally appropriate psychosocial services. Inadequate training of health professionals regarding cross-cultural issues may hinder patient compliance and therapeutic alliances. In a paediatric practice in Montreal, prevalent health problems among Chinese families were identified to be related to cultural beliefs and psychosocial factors. These included a low breastfeeding rate (8%) among Chinese newborns, prevalent iron deficiency anemia (12%), nursing caries, social isolation, delayed diagnosis of developmental delay, learning disabilities and psychosocial problems. The participation in community research and advocacy, the development of health promotional projects with an interdisciplinary approach and the preparation of Chinese health information such as perinatal programs, infant nutrition, dental hygiene and immunization, were described. Subsequent studies in this population illustrated an increased breastfeeding rate (48%), decreased incidence of iron deficiency (2.8%) and improved self-health maintenance practices. More culturally appropriate allied health services, including the Multiculturalism Department in the Montreal Children’s Hospital, have subsequently been developed for the community.In summary, identifying prevalent health problems of ethnic propensity may be the initiatives needed to develop research and health promotional projects for a target population. Comprehensive health care to different ethnic groups requires health professionals to incorporate cross-cultural issues in their services.     

Home care for medically fragile children: impact on family health and well-being.

The health status of 48 families providing home care for their medically fragile children was studied. Mothers, as the primary caregivers, experienced a greater decline in their physical health than did fathers or siblings. When the financial burden of providing care was greater and when the relationship with care providers was more strained, families had more physical illness symptoms. Who provided home care services for the medically fragile child influenced the psychosocial impact on the family. Care provided by home health aides was associated with greater negative impact, whereas care from professional nurses reduced the negative impact. The trend toward home care for medically fragile children has been accelerating; this study points to the importance of studying the impact on the family of this kind of care. Policy implications regarding the amount and quality of services and payment for them are discussed.     

Well-being of children with chronic illness. A population-based study in a Swedish primary care district

According to a previous study, 8% of all children in Dalby primary care district were chronically ill. The impact of the illness on the children's well-being was investigated using parental questionnaires. No difference in socio-demographic variables was found between responders (70%) and non-responders. The study comprised 98 index and 168 control children. Comfort and well-being in school and pre-school were lower among the index than among the control children and lower among the index children in normal compared with special schools. According to the parents many teachers had insufficient knowledge of disorders/handicaps. Children with a physical disability more often had special remedial education compared with healthy children. The chronically ill children were bullied more often, had fewer contacts with peers and more emotional problems than the control group. Improved knowledge of chronic childhood disorders/disabilities and recognition of the psychosocial consequences at school/pre-school and in the child health services is advocated.