Discrepancies between self- and adult-perceptions of social competence in children with neuropsychiatric disorders.

BACKGROUND: The present study examines discrepancies between self- and adult-perceptions of social competence in children with attention deficit-hyperactivity disorder (ADHD), autism spectrum disorders (ASD) and possible co-morbid disruptive behaviour disorders (DBD). METHOD: Self-reported questionnaires were collected from multiple informants at the baseline of a multi-systemic family intervention programme for children (aged 5-12) with ADHD, ASD and possible co-morbid DBD. In total, out of the 154 families eligible for the study, information was received concerning children from 124 families (children n = 121; mothers n = 117; fathers n = 86; teachers n = 97). In addition to this, a comparison community sample of 318 school-aged children (approximately 10 years old) was utilized to examine the perceptions of children's social competence across intervention and population groups in more detail. RESULTS: Children's self-perceptions in the prosocial dimension of social competence (i.e. cooperating skills, empathy) did not differ between the intervention and comparison groups. Interestingly, the children in the intervention sample expressed more impulsivity and disruptiveness - the antisocial dimension of social competence - when compared with the children in the comparison sample. Adult ratings demonstrated that mothers, fathers and teachers reported decreased prosocial behaviour and increased antisocial behaviour across overall dimensions and sub-dimensions when compared with adults' ratings of elementary school children. Informant discrepancies between self-ratings and adult ratings across intervention groups yielded significant effect sizes (eta-squared) across all domains of social competence ranging from .09 to .25. CONCLUSION: Children's positive self-ratings of social competence relative to adult ratings increased within intervention sample when compared with population sample. The intervention sample children appeared to acknowledge their social competence deficits, yet self-perceptions were inflated relative to adult ratings when focusing on peer relationship difficulties, particularly, aggression to peers.

Two sides of the mirror: parents' and service providers' view on the family-centredness of care for children with cerebral palsy.

BACKGROUND: In order to best meet the needs of both families and their children with cerebral palsy, many rehabilitation service providers have adopted a family-centred service (FCS) approach. In FCS parents are seen as experts on their child's needs, and the family and professionals collaborate in the rehabilitation process. However, parents and service providers might look at FCS from different points of view, i.e. look into the mirror from two different sides. The objective of this study was to explore the degree to which parents experience the service as being family-centred and to which extent the service providers experience their service provision as family-centred. METHODS: A translated version of The Measure of Processes of Care 20 (MPOC-20) questionnaire was used to evaluate parents' experience of FCS, and a Measures of Processes of Care for Service Providers (MPOC-SP) questionnaire was used to evaluate the FCS provided by professionals. Parents visiting two university hospital neuropediatric wards (n= 67) during a 2-month period and who were willing to participate received the questionnaire. Also the service providers working on the same wards (n= 49) were invited to participate. RESULTS: A total of 53 families and 29 service providers completed the questionnaires. Both parents and professionals generally rated the FCS positively. General information was rated lowest and respectful treatment the highest by both parents and professionals. The results revealed that written information about the child's condition, the possibility to choose when to receive information, and contact with other families in the same situation are areas in need of improvement. CONCLUSIONS: The possibility to regularly evaluate services both from the families' and the professionals' perspectives should be part of quality development. Providing general information is a challenge for all service providers. The MPOC questionnaires can be used to highlight important areas of improvement in FCS.

Professional background and the comprehension of family-centredness of rehabilitation for children with cerebral palsy.

BACKGROUND: Children with cerebral palsy have difficulties in several areas of functioning, and they need long-lasting rehabilitation with a clear focus on the individual's needs. Finnish guidelines emphasize family-centred service. The values of family-centred service are widely known, but how the principles of family-centred service are adopted in clinical practice is not well documented. The objective of this study was to analyse the family-centred behaviour of professionals working with children and adolescents with cerebral palsy. METHODS: A translated version of the Measure of Processes of Care for Service Providers (MPOC-SP) questionnaire was used to evaluate the family-centred service. The questionnaire was sent to all the professionals in the multidisciplinary rehabilitation teams at all the hospitals and governmental special schools treating children and adolescents with cerebral palsy in Finland (n= 327). Furthermore, 438 physiotherapy service providers working in the children's home region were invited to participate. RESULTS: A total of 201 multidisciplinary team members and 311 physiotherapy service providers completed the questionnaire. Both the team members and the service providers generally rated their family-centred behaviour positively. There was statistically significant difference in how the team members in the multidisciplinary teams self-assessed their family-centred service. Physiotherapists working in multidisciplinary teams rated their family-centred service higher than physiotherapy service providers. The professional's apprehension of family-centred service increased with work experience. CONCLUSIONS: Professional background and professional context seem to affect the apprehension of family-centred service. Also work experience and being part of a multidisciplinary team have an influence on how the professionals embrace the family-centred service delivered. The MPOC-SP can be used to identify areas for improvement.

Smoking strongly predicts disability retirement due to COPD: the Finnish Twin Cohort Study.

No previous studies on the association of smoking behaviour with disability retirement due to register verified chronic obstructive pulmonary disease (COPD) exist. This 30-yr follow-up study examined how strongly aspects of cigarette smoking predict disability retirement due to COPD. The study population consisted of 24,043 adult Finnish twins (49.7% females) followed from 1975 to 2004. At baseline the participants had responded to a questionnaire. Information on retirement was obtained from the Finnish pension registers. Smoking strongly predicted disability retirement due to COPD. In comparison to never-smokers, age adjusted hazard ratio (HR) for current smokers was 22.0 (95% CI 10.0-48.5) and for smokers with ≥ 12 pack-yrs was 27.3 (95% CI 12.6-59.5). Similar estimates of risk were observed in within-pair analyses of twin pairs discordant for disability retirement due to COPD. Among discordant monozygotic pairs those with disability pension due to COPD were more often current smokers. The effect of early smoking onset (< 18 yrs) on the risk of disability retirement due to COPD remained after adjustment for the amount smoked (HR 1.70, 95% CI 1.08-2.68). Smoking strongly predicts disability retirement due to COPD. Preventive measures against disability retirement and other harmful consequences of tobacco smoking should receive greater emphasis.

Evidence on physiotherapeutic interventions for adults with cerebral palsy is sparse. A systematic review.

OBJECTIVES: To identify evidence evaluating the effectiveness of physiotherapy in adolescents (>16 years of age) and adults with cerebral palsy. DATA SOURCES: Systematic literature search from the earliest available time until March 2009. Additional studies were identified through reference and citation tracking. REVIEW METHODS: Two reviewers independently agreed on eligibility, methodological quality and quality of evidence assessment. Standard methods were used for quality assessments. RESULTS: Included were 13 studies, two of which were randomized controlled trials. No article met the criteria for high methodological quality. Evidence of moderate quality was found on gait after strength training. Evidence of low quality was found on balance after strength training and workstation interventions. Low-quality evidence was also found on functionality after strength training in four studies evaluating gross motor capacity. There was very low-quality evidence on increased muscle strength and in outcome measures used to evaluate range of motion. CONCLUSION: Evidence for the effect of physiotherapy on adolescents and adults with cerebral palsy is sparse, and therefore there is an urgent need for well-designed physiotherapeutic trials for these people.

Prenatal alcohol exposure alters the patterns of facial asymmetry.

Directional asymmetry, the systematic differences between the left and right body sides, is widespread in human populations. Changes in directional asymmetry are associated with various disorders that affect craniofacial development. Because facial dysmorphology is a key criterion for diagnosing fetal alcohol syndrome (FAS), the question arises whether in utero alcohol exposure alters directional asymmetry in the face. Data on the relative position of 17 morphologic landmarks were obtained from facial scans of children who were classified as either FAS or control. Shape data obtained from the landmarks were analyzed with the methods of geometric morphometrics. Our analyses showed significant directional asymmetry of facial shape, consisting primarily of a shift of midline landmarks to the right and a displacement of the landmarks around the eyes to the left. The asymmetry of FAS and control groups differed significantly and average directional asymmetry was increased in those individuals exposed to alcohol in utero. These results suggest that the developmental consequences of fetal alcohol exposure affect a wide range of craniofacial features in addition to those generally recognized and used for diagnosis of FAS.

Automated diagnosis of fetal alcohol syndrome using 3D facial image analysis.

OBJECTIVES: Use three-dimensional (3D) facial laser scanned images from children with fetal alcohol syndrome (FAS) and controls to develop an automated diagnosis technique that can reliably and accurately identify individuals prenatally exposed to alcohol. METHODS: A detailed dysmorphology evaluation, history of prenatal alcohol exposure, and 3D facial laser scans were obtained from 149 individuals (86 FAS; 63 Control) recruited from two study sites (Cape Town, South Africa and Helsinki, Finland). Computer graphics, machine learning, and pattern recognition techniques were used to automatically identify a set of facial features that best discriminated individuals with FAS from controls in each sample. RESULTS: An automated feature detection and analysis technique was developed and applied to the two study populations. A unique set of facial regions and features were identified for each population that accurately discriminated FAS and control faces without any human intervention. CONCLUSION: Our results demonstrate that computer algorithms can be used to automatically detect facial features that can discriminate FAS and control faces.

Treatment of spastic equinus gait with botulinum toxin A: Does dose matter? Analysis of a clinical cohort.

INTRODUCTION: This study reports the effects of various doses of BTX-A when treating equinus gait in cerebral palsy in a clinical setting at a tertiary hospital. PATIENTS: Twenty-nine children with CP (age 1.5-9.6 yrs, GMFCS I-IV) met the preset inclusion criteria. The treatment episodes per child ranged from 1 to 5 and the effects on a total of 80 legs in 55 treatment sessions were evaluated. METHODS: BTX-A doses injected into the gastroc-soleus muscle were divided into low- ( 6 units/kg bw) dose groups. The outcome measurements included active and passive ankle range of movement, Modified Ashworth Scale, dynamic muscle length, Selective Motor Control score, Observational Gait Scale score, and Goal Attainment Scale score at pre-treatment and 1, 2, and 4 months post-treatment. RESULTS: The only differences between the treatment groups were observed at 2 and 4 months in terms of change in passive ankle ROM and at 4 months in change in selective dorsiflexion, favouring the low-dose group. The incidence and severity of side-effects did not differ between the groups. CONCLUSION: Doses over 6 units/kg bw injected into the gastroc-soleus muscle do not necessarily yield superior results compared with lower doses.

Management of the upper limb with botulinum toxin type A in children with spastic type cerebral palsy and acquired brain injury: clinical implications.

The aim of this article is to describe our clinical experience in treating muscle imbalance in 49 children with spastic upper extremity involvement. We discuss four cohorts of children treated with botulinum toxin type A (BTX-A), each with different treatment objectives. In the first group, 27 children were treated for functional improvement and, of these, 23 had a positive effect, while four had no objective benefit. In the second group, eight children were treated for purposes of presurgical planning; of these, four were referred for surgery, three continued with serial treatment and one child did not benefit from injection. The third group comprised six children who were treated to improve posture and care: in this group, four children demonstrated clear benefit and two children lost some function subsequent to injection. Finally, a fourth group of seven children were treated after acquired brain injury (three with severe tetraplegia, four with hemiplegia). In this group, all children experienced spasticity relaxation and two children with hemiplegia also gained functional benefit. In terms of adverse events, deterioration of upper extremity function was poorly tolerated but limited to the first 1--3 weeks postinjection. Grip strength or thumb grip were diminished if too high doses were used. Overall, our results with BTX-A were rewarding in children with no fixed contracture, good motor learning capacity and high motivation to train. Additionally, BTX-A treatment has proven valuable for counteracting spasticity in children with acquired brain injury. This treatment modality may not, however, be an appropriate treatment option for all children with severe upper extremity spasticity, due to the shorter duration of effect and the potential reduction in functional abilities seen in this cohort. In all cases, the selection of muscles to be treated needs careful clinical assessment. Dynamic EMG analysis should be performed whenever required to aid muscle selection, especially in children with spasticity combined with dystonia. Evaluation of M-responses suggests that for the forearm muscles, doses of BTX-A above 1.5 U/kg/muscle should not be used.

Twelve-year follow-up of children exposed to alcohol in utero.

Eighty-two women who were consuming alcohol while pregnant attended a special clinic at the University Central Hospital, Helsinki with the aim of reducing heavy drinking during pregnancy. The children born to these women were followed up regularly. During their preschool years the children were assessed to have fetal alcohol syndrome, fetal alcohol effects, alcohol-related neurodevelopmental disorder, pre- and/or postnatal growth retardation, or they were assessed to have normal cognitive and somatic growth. Of the original children, 70 of 82 could be traced at the age of 12 years. Through semistructured interview and contact with the health and social care authorities, information was gathered about schooling, family structure, whether help had been sought for behavioural difficulties and major adverse events in the family. The longer the intrauterine alcohol exposure and the more severe the diagnosis related to prenatal alcohol exposure, the more often the children required special education, were temporarily or permanently taken into care, and had behavioural problems. There is a considerable need for prolonged multidisciplinary follow-up and support of all children whose mothers have not been able to reduce drinking in early pregnancy, whether or not cognitive disturbances are evident in early childhood.

Botulinum toxin injection as an adjunct when planning hand surgery in children with spastic hemiplegia.

The usefulness of botulinum toxin A treatment when planning hand surgery in eight children with spastic hemiplegia was evaluated. The hand function of the children was assessed before and after treatment using a test battery consisting of quantitative and qualitative functional assessment. The results of preoperative botulinum treatment supported surgical intervention in four children and serial botulinum treatment in three children. In one child, the preoperative botulinum treatment provided no additional information. We conclude that preoperative botulinum A treatment in most children with spastic hemiplegia, for whom hand surgery is being considered, identifies the patients who would not benefit from the planned surgery or for whom the functional benefit would probably not outweigh the burden of surgical procedure and postoperative rehabilitation.

Recommendations for the use of botulinum toxin type A in the management of cerebral palsy.

Botulinum toxin type A (BTX-A) is increasingly being used for the treatment of childhood spasticity, particularly cerebral palsy. However, until very recently, all such use in this indication has been unapproved with no generally accepted treatment protocols, resulting in considerable uncertainty and variation in its use as a therapeutic agent. In view of the increasing awareness of, and interest in, this approach to the treatment of spasticity, and also the recent licensing in a number of countries of a BTX-A preparation for treating equinus deformity in children, it would seem timely to establish a framework of guidelines for the safe and efficacious use of BTX-A for treating spasticity in children. This paper represents an attempt, by a group of 15 experienced clinicians and scientists from a variety of disciplines, to arrive at a consensus and produce detailed recommendations as to appropriate patient selection and assessment, dosage, injection technique and outcome measurement. The importance of adjunctive physiotherapy, orthoses and casting is also stressed.

Botulinum toxin for amelioration of knee contracture in Duchenne muscular dystrophy.

An 11-year-old non-ambulant boy with Duchenne muscular dystrophy developed tightness in his left knee flexors, which caused difficulties in standing exercises. Botulinum toxin A (BTX-A) was injected into the medial and lateral hamstring muscles and the range of motion increased by 20 degrees but after 5 months, when the pharmacological effect of BTX-A had vanished, an increase of only 5 degrees in range compared with the initial finding was left. It is concluded that there may be a role for BTX-A in controlling contractures in Duchenne muscular dystrophy.

Cognitive impairments at two years of age after prenatal alcohol exposure or perinatal asphyxia.

The purpose of this follow-up study was to assess and describe early cognitive impairments in two-year-old children exposed to alcohol (1) until the second trimester (n = 20), (2) until the third trimester (n = 20), (3) throughout pregnancy (n = 20), (4) children to mothers with preeclampsia (n = 37), (5) children surviving acute birth asphyxia (n = 14), and (6) a normal control group (n = 48). Alcohol exposure throughout pregnancy was found to be associated with impairments in language (mean SD score = -1.3) and visuo-motor development (mean SD score = -2.0). Preeclampsia was related to impairment in visuo-motor development (mean SD score = -1.2) and attention (mean SD score = -0.7). Alcohol exposure until the third trimester was associated with attention deficit alone (mean SD score = -0.9). Alcohol exposure until the second trimester and acute birth asphyxia were not associated with an increased risk of cognitive impairment. The study also showed that neuropsychological test profiles of language, visuo-motor functions and attention may be obtained with the aid of an adapted version of the Bayley Mental Scale and an evaluation of attention.

Dysmorphic features in offspring of alcoholic mothers.

The frequencies of 60 minor physical anomalies and various craniofacial measurements in 52 children with alcohol exposure of various durations in utero were determined and compared with 48 non-exposed healthy children at a mean age of 27 months. Compared with non-exposed children a significantly higher total minor physical anomaly count was observed in those children exposed prenatally to alcohol throughout pregnancy. Binge drinking was not associated with an increased minor physical anomaly count. During the first year of life facial features were judged according to subjective impression: 10 children had typical facial features of fetal alcohol syndrome (FAS) and 19 children were judged to have possible fetal alcohol effects on their face. Only six of them fulfilled the strict craniofacial criteria for diagnosis of FAS at the age of 27 months. Our results stress the importance of recognising also the subtle dysmorphic facial features associated with prenatal alcohol exposure: 22 of 29 (76%) of exposed children judged to have typical or possible features of FAS during the first year showed signs of central nervous system dysfunction at the age of 27 months.

Mental development of 2-year-old children exposed to alcohol in utero.

In a prospective follow-up study, 60 children exposed to alcohol in utero were assessed by a psychologist (Bayley Mental scale) and a speech therapist (Reynell Verbal Comprehension scale) at a mean age of 27 months. Many mothers had been able to reduce their alcohol consumption during pregnancy, so the children could be divided into those exposed to heavy drinking during the first trimester only (group 1, n = 20), those exposed during the first and second trimesters (group 2, n = 20), and those exposed throughout pregnancy (group 3, n = 20). Forty-eight nonexposed children were examined to set the -2 SD limit for subnormal performance on the Bayley and Reynell tests. No definite effect of alcohol exposure on mental or language development was found in group 1. Children in group 3 scored significantly lower than children in group 1 both on the Bayley Mental scale and on the Reynell Verbal Comprehension scale; delay in language development was seen more often in group 2 than in group 1. The diagnosis of fetal alcohol syndrome was made in seven children (one in group 2 and six in group 3) and the diagnosis of fetal alcohol effects in 13 children (one in group 1, three in group 2, and nine in group 3). Efforts should be made to identify and find proper treatment for women who drink alcohol early in their pregnancies.