Psychological and family characteristics of adolescents with vocal cord dysfunction.

Vocal cord dysfunction (VCD) is a respiratory disorder often confused with asthma. Although previous case reports have implicated family and/or individual psychopathology in the etiology of this condition, this is the first paper to present prospective, case-control empirical data on a group of pediatric patients with VCD. A case-control methodology was employed to examine patients in terms of both family and individual functioning. Results indicate that patients with VCD were not different from asthmatic controls on measures of family functioning. However, they did experience significantly higher levels of anxiety and received a higher number of anxiety-related diagnoses such as separation anxiety and generalized anxiety disorder on a structured psychiatric interview. The nature of the relation between VCD and psychological symptoms in children is discussed. Etiologic and treatment issues are examined in the context of the findings.

Posttraumatic distress in children and families after intubation.

BACKGROUND: Posttraumatic stress disorder symptoms are seen in children who have experienced significant trauma. Respiratory arrest with subsequent intubation can be associated with terror, helplessness, and the threat of death. METHODS: Three case reports are presented where emergency intubation was followed by symptoms of psychologic distress in the intubated child and his or her family members. RESULTS: Although the medical literature documents posttraumatic distress symptoms after other medical procedures, this is the first account of symptoms following intubation. Children and other family members were found to have symptoms of reexperiencing the traumatic event, avoidance of thoughts or feelings related to the intubation, and hyperarousal. Issues around diagnosis and treatment are discussed. CONCLUSIONS: Children with a history of emergency intubation should be evaluated for possible posttraumatic stress disorder symptoms.

Cardiovascular effects of tricyclic antidepressants in childhood asthma: a case series and review.

Children with asthma frequently have significant anxiety and depression that interfere with treatment outcome. Although the use of antidepressants may be helpful, in the one published study of antidepressant use in pediatric asthma, significant side effects necessitated discontinuance; these side effects were increased motor activity, impulsive behavior, insomnia, postural hypotension, premature auricular contractions, diastolic hypertension, and generalized seizure. The objective of this retrospective chart review was to examine whether antidepressants could be tolerated and administered safely to children on asthma medications. Forty pediatric inpatients (mean age 13.3 years, range 7-19) with varying levels of asthma severity (5 mild, 11 moderate, 24 severe) and an average duration of asthma treatment of 10.0 years were administered antidepressants while also taking an average of 5 medications for asthma (range 2-7). Ten of the patients had an additional comorbid medical diagnosis. There were 17 children diagnosed with a primary affective disorder; 7 with a primary anxiety disorder; and 16 with both an affective and anxiety disorder. Thirty-six children ultimately were continued on an antidepressant: 13 on desipramine, 9 on nortriptyline, 6 on imipramine, 4 on fluoxetine, 3 on bupropion, and 1 on sertraline. Significant cardiovascular side effects (tachycardia, hypertension, and postural hypotension) occurred in 4 subjects on tricyclic antidepressants (TCAs) and 1 subject on a non-TCA (fluoxetine); 3 of these subjects were able to continue treatment with an antidepressant. Two subjects were taken off antidepressants because of hypomanic symptoms (increased motor activity, mood lability, impulsive behavior, and insomnia). No medications were discontinued because of electrocardiogram changes, arrhythmias, or seizures. Doses of TCAs were comparable to those in previous studies, but the asthma medications differed. Discussion of current anti-asthmatic medications and potential for interactions with antidepressants is included.

Parental criticism and treatment outcome in adolescents hospitalized for severe, chronic asthma.

This pilot study investigated the relationship between parental criticism and medical treatment outcome across an inpatient hospitalization in 19 adolescents with severe, chronic asthma. Parental criticism toward their asthmatic adolescent was assessed using the Five Minute Speech Sample technique (FMSS) at the beginning of the adolescent's inpatient stay at a national asthma referral center. Those adolescents whose parents were rated as high in criticism on the FMSS were found to have greater improvement in their overall asthma severity, greater reduction in their steroid medication dose, and shorter lengths of stay in the hospital than those whose parents were rated as low in criticism. The adolescents whose parents were rated as high in criticism also showed lower compliance with their prescribed theophylline and oral steroid medication at admission than the low criticism group. These findings do not appear to be due to misdiagnosis secondary to the presence of vocal cord dysfunction or to the allergy status of the children. Clinical implications and possible causal mechanisms underlying these findings are discussed.

Reactions to disclosure of childhood sexual abuse. The effect on adult symptoms.

This study examines the effect disclosing childhood sexual abuse had on adult psychological functioning as measured on symptom checklists. One hundred eighty-eight adults filled out questionnaires regarding childhood trauma experiences and the reaction they received from the first person they told of their sexual abuse, and symptom checklists measuring depression, trauma symptoms, posttraumatic stress disorder symptoms, and dissociation. Data were analyzed using multiple regression analysis and path modeling. Those who told in childhood (N = 66) reported a significantly worse reaction to disclosing abuse than individuals who waited until adulthood (N = 112). For those who told in childhood, primarily to close family members, reaction to disclosure had a mediating effect between childhood abuse and adult symptoms, with those experiencing a bad reaction from the first person told having worse scores on general trauma symptoms, posttraumatic stress disorder symptoms, and dissociation. These results support other studies showing childhood sexual abuse to be associated with adult psychological symptoms. It also suggests the importance of the reaction received from family members responding to disclosure of abuse as a contributor to adult psychopathology.

Factitious food allergy and failure to thrive.

OBJECTIVE: To examine the relationship between parental beliefs about factitious food allergies and failure to thrive in their children. RESEARCH DESIGN: Retrospective case review. SETTING: Tertiary care referral center in Denver, Colo. SELECTION PROCEDURES: A consecutive sample of more than 700 patients referred for evaluation of food allergies was screened for age; negative results to double-blind, placebo-controlled food challenges; and failure to thrive. MEASUREMENTS/RESULTS: After identifying two probands, we identified nine additional children with failure to thrive in the context of parents' beliefs in allergic reactions to multiple foods. The results of puncture skin tests conducted for foods suspected of causing allergic reactions were negative for seven (64%) of the 11 children. There were no allergic reactions to open challenges (ie, children, staff, and parents knew which food was being tested). Only two patients reacted during double-blind, placebo-controlled food challenges. One reacted to milk (one of 14 suspected foods) and the other reacted to eggs and milk (two of 15 suspected foods). CONCLUSIONS: Parental beliefs about food allergies can lead to dietary restrictions severe enough to cause failure to thrive in their children. Because of the wide-spread belief by parents that children are allergic to food, pediatricians are frequently faced with the question of whether to subject children to food restrictions. Their collaboration with unsubstantiated parental beliefs can have long-term, deleterious consequences.

Are children at risk for sexual abuse by homosexuals?

OBJECTIVE: To determine if recognizably homosexual adults are frequently accused of the sexual molestation of children. DESIGN: Chart review of medical records of children evaluated for sexual abuse. SETTING: Child sexual abuse clinic at a regional children's hospital. PATIENTS: Patients were 352 children (276 girls and 76 boys) referred to a subspecialty clinic for the evaluation of suspected child sexual abuse. Mean age was 6.1 years (range, 7 months to 17 years). DATA COLLECTED: Charts were reviewed to determine the relationships of the children to the alleged offender, the sex of the offender, and whether or not the alleged offender was reported to be gay, lesbian, or bisexual. RESULTS: Abuse was ruled out in 35 cases. Seventy-four children were allegedly abused by other children and teenagers less than 18 years old. In 9 cases, an offender could not be identified. In the remaining 269 cases, two offenders were identified as being gay or lesbian. In 82% of cases (222/269), the alleged offender was a heterosexual partner of a close relative of the child. Using the data from our study, the 95% confidence limits, of the risk children would identify recognizably homosexual adults as the potential abuser, are from 0% to 3.1%. These limits are within current estimates of the prevalence of homosexuality in the general community. CONCLUSIONS: The children in the group studied were unlikely to have been molested by identifiably gay or lesbian people.

Effects of childhood trauma on psychological functioning in adults sexually abused as children.

Standardized symptom measures were used to determine the effect of childhood trauma experiences on adults sexually victimized as children. One hundred eighty-eight sexually abused individuals were tested for mean scores for depression, self-esteem, general levels of trauma symptoms, sexual dysfunction, posttraumatic stress disorder symptoms, and dissociation. Childhood traumatic experiences (parents fighting, physical abuse by father or by mother, other childhood traumas) of a nonsexual nature correlated with increased symptom levels and accounted for significant changes in percentage of variance ranging from 5.2% (general trauma symptoms) to 12.3% (posttraumatic stress disorder). Even after controlling for nonsexual-abuse trauma, sexual trauma in childhood continued to contribute significantly to increased adult symptom levels. Variables tested included number of perpetrators; incest; age of first abuse; whether force, bribes, or threats were used by the perpetrator; and penetration. The use of force was the single most significant individual sexual abuse variable. Sexual abuse as a whole contributed significantly to all the symptom measures with the most change in variance noted for dissociation (20.5%). Gender contributed significant differences only for sexual dysfunction when men scored significantly worse.

Chemical dissociation in adults sexually victimized as children: alcohol and drug use in adult survivors.

Using a structured diagnostic interview, 65.9% of a clinical group of adult survivors of childhood sexual abuse met DSM-III-R criteria for lifetime prevalence of drug or alcohol abuse or dependence. Only 4.6% of the total were still using drugs or alcohol at the time of testing. Childhood risk factors predicted those survivors who used drugs or alcohol with users coming from more chaotic home environments. The data supports the hypothesis that many adults sexually victimized as children use substances to "chemically dissociate."

Family therapy of extrafamilial sexual abuse.

A significant portion of children referred for psychiatric treatment have been sexually abused. One of the most difficult symptom manifestations to treat in young children is the management of anger. In this case, a 4-year-old boy was sexually abused by persons outside the family. He showed symptoms of regressive behavior including encopresis, enuresis, difficulty sleeping, fearfulness, recurrent nightmares, and had hyperalertness and frequent outbursts of anger. Treatment initially involved group therapy, with a concurrent parents' group. After experiencing little improvement in group therapy, the youngster was put in individual play therapy and family therapy. Family therapy proved essential in creating a safe environment for the patient where he could learn to regulate his affect and process his traumatic experience successfully.

Network therapy using videotape disclosures for adult sexual abuse survivors.

Treatment of childhood sexual abuse survivors may be enhanced by a technique designed to generate a therapeutic constituency for the survivor around the disclosure of childhood abuse experiences. The need for validating relationships is hypothesized as a condition for successful treatment. The videotaped disclosure process proceeds in five stages: (1) Deciding to make a tape, (2) making a videotape following a semistructured interview format, (3) the patient viewing the tape, (4) showing the tape to potential therapeutic team members, and (5) possibly using the tape for a confrontation with the abuser. The technique has been used on 27 cases. Case histories are given to illustrate the procedure. Discussion includes potential mechanisms of action and issues in treatment that arise with the use of the method described.