Sleep in mammals: ecological and constitutional correlates.

The interrelationships between sleep, ecological, and constitutional variables were assessed statistically for 39 mammalian species. Slow-wave sleep is negatively associated with a factor related to body size, which suggests that large amounts of this sleep phase are disadvantageous in large species. Paradoxical sleep is associated with a factor related to predatory danger, which suggests that large amounts of this sleep phase are disadvantageous in prey species.

Reliability of depression and associated clinical symptoms.

Interrater reliability assessments were undertaken for the Hamilton Depression Rating Scale, the Raskin Depression Rating Scale, and the Degree of Mental Illness Scale. Levels of reliability ranged from "poor" to "excellent" and varied as a function of (1) temporality (assessments made at termination of clinical trial more reliable than those made at randomization into treatment) and (2) unit of scoring (factor or total scores more reliable than single-item assessments). The implications of these results may be considered in the context of further studies evaluating the efficacy of treatment interventions on reduction of symptoms of clinical depression.

Detection of dissociative disorders in psychiatric patients by a screening instrument and a structured diagnostic interview.

OBJECTIVE AND METHOD: Diagnosis and treatment of the dissociative disorders may be delayed for many years because of difficulties in detecting patients at high risk for dissociative disorders. This study investigates the utility of the Dissociative Experiences Scale (DES), a self-report instrument for dissociative experiences, in detecting patients at high risk for dissociative disorders. The clinician-administered Structured Clinical Interview for DSM-III-R Dissociative Disorders (SCID-D) was used as the diagnostic standard, and 36 outpatients with mixed diagnoses and nine normal subjects were evaluated for the presence and absence of a dissociative disorder. DES scores were then compared. RESULTS: Results indicate that a DES cutoff score of 15-20 yields good to excellent sensitivity and specificity as a screening instrument. However, for higher cutoff points the sensitivity can be much lower. CONCLUSIONS: Thus, although the DES can be used to identify some high-risk patients, they should be further evaluated with such diagnostic instruments as the SCID-D or by in-depth clinical follow-up.

The Structured Clinical Interview for DSM-III-R Dissociative Disorders: preliminary report on a new diagnostic instrument.

The authors describe the Structured Clinical Interview for DSM-III-R Dissociative Disorders (SCID-D), which investigates five groups of dissociative symptoms (amnesia, depersonalization, derealization, identity confusion, and identity alteration) and systematically rates both the severity of individual symptoms and the evaluation of overall diagnosis of dissociative disorder. Preliminary findings from a study of 48 subjects with and without psychiatric diagnoses indicate good to excellent reliability and discriminant validity for the SCID-D as a diagnostic instrument for the five dissociative disorders and as a tool for the evaluation of dissociative symptoms encountered within nondissociative syndromes.

Borderline syndromes in childhood: criteria for diagnosis.

There is currently a great deal of confusion regarding the diagnostic status of children with borderline disorders and a tendency to apply criteria for borderline adults to the diagnosis of these children without allowing for developmental differences. On the basis of their experience with 24 latency-age children, the authors propose diagnostic criteria in an effort to establish a uniformity in the diagnosis of these children. Major areas of psychopathology include fluctuation of functioning, nature and extent of anxiety, thought content and processes, relationships to others, and lack of control. The authors also found a high frequency of organic impairment, physical abuse, and familial disturbance.

DSM-III and DSM-III-R diagnoses of autism.

The authors examined the reliability, sensitivity, and specificity of DSM-III and DSM-III-R criteria for autism in relation to each other and to clinical diagnoses in 114 children and adults (52 diagnosed by clinicians' best judgment as autistic and 62 as nonautistic but developmentally disordered). They used a standard, structured coding scheme to evaluate each patient. The reliability of specific criteria was generally high. Although DSM-III criteria were highly specific, they were less sensitive; the reverse was true for DSM-III-R. The authors conclude that the diagnostic concept of autism in DSM-III-R appears to have been substantially broadened.

Field trial for autistic disorder in DSM-IV.

OBJECTIVE: This project focused on the development of the definition of autism for DSM-IV. METHOD: Multiple sites were involved in obtaining information regarding 977 patients with the following clinician-assigned diagnoses: autism (N = 454), other pervasive developmental disorders (N = 240), and other disorders (N = 283). A standard coding system was used, and the raters (N = 125) had a range of experience in the diagnosis of autism. Patterns of agreement among existing diagnostic systems were examined, as was the rationale for inclusion of other disorders within the class of pervasive developmental disorders. RESULTS: The DSM-III-R definition of autism was found to be overly broad. The proposed ICD-10 definition most closely approximated the clinicians' diagnoses. Inclusion of other disorders within pervasive developmental disorders appeared justified. Partly on the basis of these data, modifications in the ICD-10 definition were made; this and the DSM-IV definition are conceptually identical. CONCLUSIONS: The resulting convergence of the DSM-IV and ICD-10 systems should facilitate both research and clinical service.

Reliability and accuracy of localization by scalp ictal EEG.

One hundred forty-four scalp ictal EEGs from 54 patients were analyzed independently by three electroencephalographers for side and lobe of seizure onset. Observers did not know the patients' identities. Accuracy was determined by depth EEG. We found 58 to 60% agreement between observers for lobe, and 64 to 74% for side, of seizure onset; 21 to 38% agreement with depth EEG for lobe, and 46 to 49% agreement for side, of seizure onset; best accuracy for lateralization of seizure onset in temporal lobe seizures, but erroneous in 3 to 17%. More formal criteria are needed before scalp ictal records can be used reliably or accurately for localization.

Child abuse and neglect--usefulness of the animal data: comment on Maestripieri and Carroll (1998)

Issues related to definition, epidemiology, and etiology in the human literature are examined to explore possible contributions that D. Maestripieri and K. A. Carroll's (1998) discussion of nonhuman primate research can make to an understanding of child maltreatment. Similarities and differences between maltreatment in nonhuman primates and humans are discussed, and recommendations are proffered that could be useful in advancing research on child abuse and neglect in both monkeys and humans.

Understanding of acquired immunodeficiency syndrome by elementary school children--a developmental survey.

OBJECTIVES: The developmental process by which young children acquire an understanding of the concepts of causality, treatment, and prevention of illness as related to acquired immunodeficiency syndrome (AIDS) is poorly understood. Previous studies have focused on adolescent populations and have measured the facts that children seem to know rather than their understanding of relevant concepts. Such approaches are likely to overestimate the child's true level of understanding and obscure significant misconceptions. The aims of this project are to measure directly the level of understanding of the concepts of causality, treatment, and prevention of AIDS in healthy, elementary school children and to assess the sociodemographic variables associated with their conceptual understanding. METHODS: Using a new, developmentally based, semistructured interview protocol (ASK, AIDS Survey for Kids), 361 children (57% black, 24% Hispanic, 19% white) in kindergarten through sixth grade at four public schools in New Haven, CT were interviewed. Responses to questions about causality, treatment, and prevention were scored for each of three illnesses (AIDS, and for comparison, colds and cancer) based on the level of conceptual sophistication of the response, irrespective of its factual accuracy. RESULTS: Scores for each of the concepts were highly intercorrelated and were correlated most strongly with grade level (R = .31 to .50, P < .0001 for each of these correlations, with the exception of the treatment of AIDS). Gender, race, and socioeconomic status did not contribute significantly to the variance observed for any of the concept scores in a linear regression model. Over-all, children's level of understanding of causality was significantly less sophisticated for AIDS than for colds (P < .0001); their level of conceptual understanding for the causality of AIDS was not significantly different from that of cancer (P = .9). CONCLUSIONS: Children's understanding of causality, treatment, and prevention of AIDS, as measured by the ASK, follows the same developmental sequence reported for children's understanding of general physical illness. Sociodemographic variables, such as race, gender, and socioeconomic status do not affect children's level of sophistication of these developmental concepts. These results have implications for the creation of developmentally appropriate and effective AIDS education curricula for primary and elementary grades. They also offer guidance to health care providers in their efforts to educate parents and young children about this important topic.

Predictive value of abnormal physical examination findings in ill-appearing and well-appearing febrile children.

In order to study the occurrence and positive predictive value of history and physical examination findings suggestive of serious illness in ill-appearing and well-appearing febrile children, 103 consecutive children aged less than or equal to 24 months with fever greater than or equal to 38.3 degrees C were evaluated from July 1, 1982 to Nov 24, 1982. Patients were initially classified by an attending physician (A) as to whether they appeared ill (Yale Observation Scale score greater than 10) or well (scale score less than or equal to 10). The history was then taken by two attending physicians (A and B) and a resident; the physical examination was performed by attending physician B and the same resident. As history and physical examination findings were elicited, they were scored as to whether they did or did not suggest a serious illness. Serious illness was defined as the presence of a positive laboratory test. Ill-appearing patients had a significantly greater (P less than .001, Fisher's exact test) occurrence of physical examination findings suggesting serious illness (14 of 22, 64%) than well-appearing children (12 of 81, 15%). The positive predictive values of abnormal physical examination findings for serious illness in ill-appearing (11 of 14, 79%) and well-appearing children (3 of 12, 25%) were significantly different (P = .02 by Fisher's exact test). The trends for abnormal history findings in ill-appearing and well-appearing children were similar to those for abnormal physical examination findings but did not achieve statistical significance. The results, indicating an important interaction between a febrile child's appearance and physical examination findings, are discussed in terms of probability reasoning in clinical decision making.

Demographic, clinical, and psychosocial predictors of the reliability of mothers' clinical judgments.

The purpose of this study was to investigate to what extent selected adverse demographic, clinical, and psychosocial data measured at the 2-week well child visit could predict poorer reliability of mothers' judgments during acute illness episodes over the next 32 months. The study was a randomized trial of the Acute Illness Observation Scales (AIOS); 369 mothers participated, 183 in the intervention group using the Acute Illness Observation Scales and 186 in the control group using a three-point global assessment scale. There were 704 acute illnesses judged simultaneously and independently by mothers and pediatricians. Standard Pearson r correlations were performed between the independent variables, taken singly and in all possible combinations, and the dependent variable, reliability of mothers' judgments as measured by weighted kappa (kappa W). Group assignment was entered as an independent variable. Analyses were performed separately for all first, second, and third acute illness visits to control for any "practice effect" (analysis 1). To control for consistency of observers, the first, second, and third visits of mothers with three visits were also analyzed (analysis 2). Depending on the visit number, adverse demographic, clinical, and psychosocial characteristics did correlate with poorer reliability independent of group assignment. The correlations ranged from small (analysis 1, first visit, multiple variable r2 = 4%) to large (analysis 2, second visit, multiple variable r2 = 29%). Controlling for both visit number and consistency of observers vs visit number alone (analysis 2 vs analysis 1) increased multivariate correlations to kappa W. The results support the untoward impact that adverse demographic, clinical, and psychosocial factors have on mothers' clinical judgment. These data may assist pediatricians in identifying parents who might benefit from more intensive teaching and support about acute illness episodes in their children.

A randomized, controlled trial of a school-based, multi-faceted AIDS education program in the elementary grades: the impact on comprehension, knowledge and fears.

OBJECTIVE: Several educational theorists have suggested that young children are unlikely to benefit from detailed instruction regarding AIDS prevention because of inherent developmental cognitive limitations. This study aims to determine whether AIDS education in the elementary grades can advance young children's understanding of this illness. METHODS: A randomized, controlled trial was used to measure the impact of a 3-week, multifaceted AIDS education program on conceptual understanding, factual knowledge, and fears about AIDS in 189 students in grades kindergarten through 6th. The ASK (AIDS Survey for Kids), a standardized, semistructured interview that measures conceptual understanding, factual information, and fears about AIDS, was administered before and after the intervention. RESULTS: Children in the intervention group, as compared to those in the control group, showed significant (P < .0001) gains in their level of understanding of the concepts of causality and prevention of AIDS. These results were unaffected by controlling for grade, gender, race, socioeconomic status, and verbal fluency. The gains in children's understanding of causality of AIDS represented at least 2 years' growth in the level of conceptual sophistication and persisted at a follow-up evaluation several months later. After the intervention, more children (P < .001) in the intervention group than in the control group accurately identified causes of AIDS in response to open-ended questions: germ/germ theory (41% vs 13%), mother-to-infant transmission (54% vs 15%), blood transmission (83% vs 40%), and sexual transmission (56% vs 30%). Fewer than half as many children in the intervention group responded incorrectly to each of five direct questions about transmission of HIV through casual contact. The intervention did not increase children's fears about the illness. CONCLUSIONS: A short, developmentally based, multifaceted AIDS education program in the elementary grades can advance children's conceptual understanding and factual knowledge about AIDS and decrease their misconceptions about casual contact as a means of acquiring the illness, without increasing their fears. Significant advances in conceptual understanding about AIDS can be achieved through direct educational interventions.

Screening for lead poisoning in an urban pediatric clinic using samples obtained by fingerstick.

OBJECTIVE: To assess the false positive rate of blood lead (BPb) determinations on samples obtained by fingerstick from children screened in an urban clinic. METHOD: From a single fingerstick (N = 1573), blood was collected in a capillary tube for determining lead concentration (CPb) by graphite furnace and an additional sample was absorbed onto a filter paper for determining lead concentration (FPb) by atomic absorption spectrophotometry with Delves cup. Zinc protoporphyrin (ZPP) was measured immediately and a confirmatory venous lead (VPb) specimen was obtained at the same visit if the ZPP was > or = 35 micrograms/dL (0.6 mumol/L); children with either a CPb or FPb > or = 15 micrograms/dL (0.7 mumol/L) were later recalled for determining VPb. RESULTS: For the 172 children who had a VPb on the same day as the screening tests, the false positive rates (95% confidence intervals) at a lead threshold of 15 micrograms/dL (0.7 mumol/L) were: CPb, 13.5% (6.7-20.3); FPb, 19.1% (11.8-26.4). Analyses using all 679 screens with a paired venous specimen (mean delay between screen and venous testing = 30 days) yielded much higher false positive rates (CPb, 31.3%; FPb, 46.0%). CONCLUSIONS: Screening for lead poisoning is feasible within an urban pediatric clinic by direct measurement of lead concentration in blood samples obtained by fingerstick. The false positive rate that can be obtained is acceptable given the precision of measuring BPb concentration. Practitioners using a staged screening protocol may incorrectly attribute a higher false positive rate to the screening tests, when much of the error may be due to the temporal variability of BPb resulting from both biologic variability in BPb concentration and intermittent exposures.

High agreement but low kappa: I. The problems of two paradoxes.

In a fourfold table showing binary agreement of two observers, the observed proportion of agreement, p0, can be paradoxically altered by the chance-corrected ratio that creates kappa as an index of concordance. In one paradox, a high value of p0 can be drastically lowered by a substantial imbalance in the table's marginal totals either vertically or horizontally. In the second pardox, kappa will be higher with an asymmetrical rather than symmetrical imbalanced in marginal totals, and with imperfect rather than perfect symmetry in the imbalance. An adjustment that substitutes kappa max for kappa does not repair either problem, and seems to make the second one worse.

High agreement but low kappa: II. Resolving the paradoxes.

An omnibus index offers a single summary expression for a fourfold table of binary concordance among two observers. Among the available other omnibus indexes, none offers a satisfactory solution for the paradoxes that occur with p0 and kappa. The problem can be avoided only by using ppos and pneg as two separate indexes of proportionate agreement in the observers' positive and negative decisions. These two indexes, which are analogous to sensitivity and specificity for concordance in a diagnostic marker test, create the paradoxes formed when the chance correction in kappa is calculated as a product of the increment in the two indexes and the increment in marginal totals. If only a single omnibus index is used to compared different performances in observer variability, the paradoxes of kappa are desirable since they appropriately "penalize" inequalities in ppos and pneg. For better understanding of results and for planning improvements in the observers' performance, however, the omnibus value of kappa should always be accompanied by separate individual values of ppos and pneg.

Blood cultures in private pediatric practice: an eleven-year experience.

We describe an 11-year experience with bacteremia in a two-physician suburban private pediatric practice. Patients studied were ages 3 to 24 months with a body temperature of greater than or equal to 39.4 degrees C and nonfocal illness. During these 11 years, 23 such babies had bacteremia, 21 with Streptococcus pneumoniae. Three risk factors for bacteremia were identified: absolute neutrophil counts greater than or equal to 10,500/microliters; cool season (November to April), and Yale observation score greater than 10. The positive predictive values for bacteremia were 33, 41 and 57%, respectively, when (1) absolute neutrophil count was greater than or equal to 10,500, (2) absolute neutrophil count was greater than or equal to 10,500 and it was the cool season, and (3) all 3 risk factors existed. Of 158 babies at low risk for bacteremia by these criteria, none was treated and none developed serious complications of bacteremia. Eight of the 23 bacteremic infants received no expectant antibiotic therapy and 15 received presumptive amoxicillin treatment in dosages ranging from 20 to 174 mg/kg/day. Twelve bacteremic infants either were not treated or received dosages of 100 mg/kg/day or less; complications developed in 5 of the 12 (persistent bacteremia, 2; facial cellulitis, 3). The remaining 11 bacteremic babies received approximately 150 mg/kg/day (range, 136 to 174) and none had complications (P = 0.03 by Fisher's exact test). The costs of identifying and treating infants suspected of having possible occult bacteremia were examined.

Improving participation and interrater agreement in scoring Ambulatory Pediatric Association abstracts. How well have we succeeded?

OBJECTIVE: To determine whether increasing the number and types of raters affected interrater agreement in scoring abstracts submitted to the Ambulatory Pediatric Association. METHODS: In 1990, all abstracts were rated by each of the 11 members of the board of directors of the Ambulatory Pediatric Association. In 1995, abstracts were reviewed by four to five raters, including eight members of the board of directors, two chairpersons of special interest groups, and 10 regional chairpersons, for a total of 20 potential reviewers. Submissions were divided into the following three categories for review: emergency medicine, behavioral pediatrics, and general pediatrics. Weighted percentage agreement and weighted kappa scores were computed for 1990 and 1995 abstract scores. RESULTS: Between 1990 and 1995, the number of abstracts submitted to the Ambulatory Pediatric Association increased from 246 to 407, the number of reviewers increased from 11 to 20, the weighted percentage agreement between raters remained approximately 79%, and weighted kappa scores remained less than 0.25. Agreement was not significantly better for the emergency medicine and behavioral pediatrics abstracts than for general pediatrics, nor was it better for the raters who reviewed fewer abstracts than those who reviewed many. CONCLUSIONS: The number and expertise of those rating abstracts increased from 1990 to 1995. However, interrater agreement did not change and remained low. Further efforts are needed to improve the interrater agreement.

Screening for lead poisoning by fingerstick in suburban pediatric practices.

OBJECTIVE: To assess the false-positive rate of blood lead determinations on samples obtained by fingerstick from children screened in private suburban and rural practices. METHODS: Screening capillary lead samples were obtained by fingerstick; children with capillary lead levels of 0.7 mumol/L (15 micrograms/dL) or greater were recalled for a confirmatory venous lead test that served as the criterion standard. Parents completed a five-question risk assessment questionnaire at the time of initial screening. SETTING: Four private suburban to rural practices that serve predominantly white, middle-class populations. PARTICIPANTS: Children seen for routine care between August 1992 and February 1993 (N = 1085; 98% between 6 months and 6 years of age). RESULTS: Capillary lead level was 0.7 mumol/L (15 micrograms/dL) or greater in 35 children (3% of total sample); venous lead samples were obtained in 30 patients. Nine of the elevated capillary lead results were true-positives (venous lead = 0.7, 0.8, 0.8, 0.9, 0.9, 0.9, 1.1, 1.1, and 1.7 mumol/L [15, 17, 17, 18, 18, 18, 22, 22, and 35 micrograms/dL]); parents of only two of these children answered yes to any question on the risk assessment questionnaire. Although the false-positive rate of the capillary lead screening test was 70% (21/30) in this setting, only 2% of the total sample had a false-positive screening test (an average of fewer than one false-positive per month per practice). Screening by fingerstick allowed phlebotomy to be avoided for 97% of the children. CONCLUSION: Fingerstick screening for lead poisoning is a reasonable alternative to direct venous testing within private suburban and rural practices, provided that care is taken to avoid specimen contamination, that appropriate caution is used in the interpretation of screening test results, and that medical and environmental interventions are based on the results of confirmatory venous testing.

Preoperative anxiety in children. Predictors and outcomes.

OBJECTIVE: To determine predictors and behavioral outcomes of preoperative anxiety in children undergoing surgery. DESIGN: A prospective, longitudinal study. SETTING: A university children's hospital. PARTICIPANTS: One hundred sixty-three children, 2 to 10 years of age (and their parents), who underwent general anesthesia and elective surgery. MAIN OUTCOME MEASURES: In the preoperative holding area, anxiety level of the child and parents was determined using self-reported and independent observational measures. At separation to the operating room, the anxiety level of the child and parents was rated again. Postoperative behavioral responses were evaluated 3 times (at 2 weeks, 6 months, and 1 year). RESULTS: A multiple regression model (R2 = 0.58, F = 6.4, P = .007) revealed that older children and children of anxious parents, who received low Emotionality, Activity, Sociability, and Impulsivity (EASI) ratings for activity, and with a history of poor-quality medical encounters demonstrated higher levels of anxiety in the preoperative holding area. A similar model (R2 = 0.42, F = 8.6, P = .001) revealed that children who received low EASI ratings for activity, with a previous hospitalization, who were not enrolled in day care, and who did not undergo premedication were more anxious at separation to the operating room. Overall, 54% of children exhibited some negative behavioral responses at the 2-week follow-up. Twenty percent of the children continued to demonstrate negative behavior changes at 6-month follow-up, and, in 7.3% of the children, these behaviors persisted at 1-year follow-up. Nightmares, separation anxiety, eating problems, and increased fear of physicians were the most common problems at 2-week follow-up. Multivariate analysis demonstrated that child's age, number of siblings, and immediate preoperative anxiety of the child and mother predicted later behavioral problems. CONCLUSIONS: Variables such as situational anxiety of the mother, temperament of the child, age of the child, and quality of previous medical encounters predict a child's preoperative anxiety. Although immediate negative behavioral responses develop in a relatively large number of young children following surgery, the magnitude of these changes is limited, and long-term maladaptive behavioral responses develop in only a small minority.