Comparison of balance assessment modalities in emergency department elders: a pilot cross-sectional observational study.

BACKGROUND: More than one-third of US adults 65 and over fall every year. These falls may cause serious injury including substantial long-term morbidity (due declines in activities of daily living) and death. The emergency department (ED) visit represents an opportunity for identifying high risk elders and potentially instituting falls-related interventions. The unique characteristic of the ED environment and patient population necessitate that risk-assessment modalities be validated in this specific setting. In order to better identify elders at risk of falls, we examined the relationship between patient-provided history of falling and two testing modalities (a balance plate system and the timed up-and-go [TUG] test) in elder emergency department (ED) patients. METHODS: We conducted a cross-sectional observational study of patients > or = 60 years old being discharged from the ED. Patient history of falls in the past week, month, 6 months, and year was obtained. Balance plate center of pressure excursion (COP) measurements and TUG testing times were recorded. COP was recorded under four conditions: normal stability eyes open (NSEO) and closed (NSEC), and perturbed stability eyes open and closed. Correlation between TUG and COP scores was measured. Univariate logistic regression was used to identify the relationship between patient-provided falls history and the two testing modalities. Proportions, likelihood ratios, and receiver-operating-characteristic (ROC) curves for prediction of previous falls were reported. RESULTS: Fifty-three subjects were enrolled, 11% had fallen in the previous week and 42% in the previous year. There was no correlation between TUG and any balance plate measurements. In logistic regression, neither testing modality was associated with prior history of falls (p > 0.05 for all time periods). Balance plate NSEO and NSEC testing cutoffs could be identified which were 83% sensitive and had a negative likelihood ratio (LR-) of 0.3 for falls in the past week. TUG testing was not useful for falls in the past week, but performed best for more distant falls in the past month, 6 months, or year. TUG cutoffs with sensitivity over 80% and LR(-) of 0.17-0.32 could be identified for these time periods. CONCLUSION: Over 40% of community-dwelling elder ED patients report a fall within the past year. Balance plate and TUG testing were feasibly conducted in an ED setting. There is no relationship between scores on balance plate and TUG testing in these patients. In regression analysis, neither modality was significantly associated with patient provided history of falls. These modalities should not be adopted for screening purposes in elders in the ED setting without validation in future studies or as part of multi-factorial risk assessment.

Is child psychiatric service different when provided by attendings versus clinicians-in-training?

OBJECTIVE: This study examines the clinical management characteristics of outpatient child and adolescent psychiatric care provided by attendings and clinicians-in-training in an academic institution. The authors hypothesized that no significant differences would exist between initial evaluations conducted by attendings and those conducted by clinicians-in-training. METHODS: The amount of information obtained during an initial evaluation and the number and type of services recommended postevaluation were assessed for 429 patients treated in the child and adolescent psychiatry clinics at Stanford University by attending psychiatrists and clinicians-in-training. RESULTS: No significant differences were found for the evaluations conducted by attendings and clinicians-in-training for the amount of data collected during an evaluation of the number or type of recommendations made postevaluation. CONCLUSION: These findings lend themselves to the conclusion that attendings and clinicians-in-training offer comparable services in the assessment of new patients. Study limitations and future areas of study are discussed.

Group cognitive-behavior therapy with family involvement for middle-school-age children with obsessive-compulsive disorder: a pilot study.

OBJECTIVE: Middle-school-aged children with obsessive-compulsive disorder (OCD) are poised in development between the dependency of elementary-school-aged children and growing independence of adolescence. OCD patients of this age group may differ from older ones in the quality of symptoms and level of insight. We report the results of a naturalistic, pilot study of group Cognitive-behavior Therapy (CBT) for school-aged children with OCD with parents involved. The authors predicted symptom improvement and format acceptability. METHOD: Over a 1.5 year period, 14 children with OCD aged 8-14 years and their parents received 14-week group CBT based on March and Mulle's OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual in three consecutive sessions of four to six families. Age of onset averaged 8.7 years, 36% had undergone at least one medication trial, and 36% had previous CBT experience. RESULTS: OCD symptoms measured by the Children's Yale-Brown Obsessive Compulsive Scale improved significantly, both statistically and clinically (25%) from moderate-severe to mild-moderate. Mean Clinical Global Impression of Impairment (NIMH-CGI) Impairment ratings fell from clinical to sub-clinical and CGI Improvement ratings were "much improved". Children's self-reported depression decreased significantly from pre- to post-group. Parent ratings of the negative impact of OCD symptoms on the Children's OCD Impact Scale and of behavior problems on the Child Behavior Checklist each improved significantly. CONCLUSIONS: This pilot study, which included a non-selected clinical sample, demonstrates that a manual-based treatment protocol may be effectively adapted for group treatment of different developmental levels and be exported for clinical use. Clinical improvement justifies further investigation in a controlled study.

Patterns of agreement between parent and child ratings of emotional and behavioral problems in an outpatient clinical setting: when children endorse more problems.

This study examined clinically relevant patterns of agreement between parent and child ratings of child behavior problems and factors associated with these patterns. Subjects were 274 children, ages 11 to 18 years, and their parents. Overall agreement between parent-child ratings was modest. Twenty-five percent of parent-child pairs agreed children's behavior problems were clinically elevated ("both" group), 29% agreed problems were nonclinical ("neither" group), in 39% of pairs only parents reported clinically elevated problems ("parent only" group) and in 8% of pairs only children rated clinically elevated problems ("child only" group). Maternal stress and child age, but not child gender, were associated with parent-child agreement patterns. Children with depressive/mood disorders were more likely to be in the "child only" group than in any other group. This study discusses the importance of paying attention to child reports of elevated behavior problems, particularly when parents report that child behavior problems are not clinically elevated.