A phenomenologic investigation of pediatric residents' experiences being parented and giving parenting advice.

Factors surrounding pediatricians' parenting advice and training on parenting during residency have not been well studied. The primary purpose of this study was to examine pediatric residents' self-reported experiences giving parenting advice and explore the relationship between parenting advice given and types of parenting residents received as children. Thirteen OUHSC pediatric residents were individually interviewed to examine experiences being parented and giving parenting advice. Phenomenological methods were used to explicate themes and secondary analyses explored relationships of findings based upon Baumrind's parenting styles (authoritative, authoritarian, permissive). While childhood experiences were not specifically correlated to the parenting advice style of pediatric residents interviewed, virtually all reported relying upon childhood experiences to generate their advice. Those describing authoritative parents reported giving more authoritative advice while others reported more variable advice. Core interview themes related to residents' parenting advice included anxiety about not being a parent, varying advice based on families' needs, and emphasis of positive interactions and consistency. Themes related to how residents were parented included discipline being a learning process for their parents and recalling that their parents always had expectations, yet always loved them. Pediatric residents interviewed reported giving family centered parenting advice with elements of positive interactions and consistency, but interviews highlighted many areas of apprehension residents have around giving parenting advice. Our study suggests that pediatric residents may benefit from more general educational opportunities to develop the content of their parenting advice, including reflecting on any impact from their own upbringing.

Erythrocyte L-aspartyl-L-phenylalanine hydrolase activity and plasma phenylalanine and aspartate concentrations in children consuming diets high in aspartame.

A deficit of alpha-aspartyl-phenylalanine (alpha-Asp-Phe) hydrolase activity has been suggested as a cause of possible adverse effects of aspartame ingestion. Twenty-five normal preschool children and 23 school-age children described by their parents as sensitive to sugar were fed diets high in sucrose, aspartame, or saccharin for three successive 3-wk periods. Blood samples were obtained at baseline (fasting) and within the last 3 d of each dietary period (postprandial). alpha-Asp-Phe concentrations were below detection limits (0.5 mumol/L) in all plasma samples and Phe and Asp concentrations remained within normal limits, alpha-Asp-Phe hydrolase activities in baseline hemolysate samples did not differ between groups. One subject had a plasma alpha-Asp-Phe hydrolase activity > 2 SD below the mean. Despite this low activity, this subject did not show consistent cognitive or behavioral anomalies that could be linked to low hydrolase activity.

Pediatricians' perceptions of mentally retarded individuals.

Three hundred randomly selected members of the American Academy of Pediatrics were surveyed to determine their perceptions of mildly, moderately, and severely mentally retarded individuals. For each of the three categories of mental retardation, pediatricians completed the Prognostic Beliefs Scale which consisted of 27 functional capabilities and choices of residential and vocational placement. Of the 169 (56%) questionnaires returned, 142 (47%) were available for analysis. The pediatricians' perceptions were different for mildly, moderately, and severely retarded individuals. Most pediatricians believed mildly retarded individuals could do all but tasks requiring judgment, could function in unskilled competitive employment, and were likely to live in their own apartments. They believed that those with moderate retardation were limited in their capacity to simple and supervised tasks, could function in sheltered workshops, and were likely to live in group-home settings. They believed that severely retarded individuals were restricted to simple feeding tasks and following one-stage commands, were not capable of any productive employment, and would most likely live in institutions. Pediatric expectations and prognostications for placements were significantly lower than those of other professionals caring for mentally retarded individuals.

Methylphenidate treatment of hyperactive children: effects on the hypothalamic-pituitary-somatomedin axis.

To further define the influence of methylphenidate on the growth hormone-somatomedin axis and prolactin secretion, serum growth hormone and prolactin concentrations were assessed over 24 hours and in response to provocative stimuli. The nine hyperactive subjects were all studied during methylphenidate therapy and after drug discontinuation, Diurnal patterns of growth hormone and prolactin concentrations were assessed using an ambulatory, continuous blood withdrawal procedure to ensure that activity, caloric intake, and sleep patterns mimicked normal schedules. No significant difference in integrated concentration of growth hormone, fasting somatomedin concentration, or prolactin integrated concentration was detected between subjects receiving or not receiving methylphenidate. There was a significant increase in peak growth hormone response to arginine stimulation among subjects receiving methylphenidate therapy; however, this appeared to correlate with acute methylphenidate administration. These data do not support the hypothesis that growth defects in hyperactive children treated with methylphenidate are caused by alteration in the hypothalamic-pituitary-somatomedin axis.

Stimulant medication use by primary care physicians in the treatment of attention deficit hyperactivity disorder.

Treatment of attention deficit hyperactivity disorder (ADHD), one of the most common behavioral disorders in children in the United States, remains controversial because of concern about stimulant medication use. Extending a previous study of pediatricians, the present study surveyed a random national sample of family practitioners and then directly screened 457 patients of 10 pediatricians and family practitioners in two small midwestern cities. Responses to the national survey indicated that stimulant medication remains the main treatment prescribed by primary care physicians for children with ADHD. In the direct patient screening, the prevalence of ADHD diagnoses was 5.3% (pediatricians) and 4.2% (family practitioners) of all elementary-school-aged children screened. Eighty-eight percent of these children were treated with methylphenidate. Although medication was considered an effective treatment by the parents of 85% of the children given the medication, efficacy was unrelated to the accuracy of diagnosis. When explicit DSM-III-R criteria were used, only 72% of those assigned a diagnosis of ADHD by the physicians would have received that diagnosis based on a structured psychiatric interview with the parents and only 53% received that diagnosis based on teacher report of symptoms, even when the child was not receiving medication. Although the majority of physicians (in both the surveys and the direct screenings) reported using at least some behavioral treatments with their patients, parents reported infrequent use of nonpharmacologic forms of therapy, such as behavior modification. These data thus indicate a relatively modest rate of stimulant medication use for ADHD, but a serious underuse of systematic behavioral treatments in primary care.(ABSTRACT TRUNCATED AT 250 WORDS)

American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health. The child in court: a subject review.

When children come to court as witnesses, or when their needs are decided in a courtroom, they face unique stressors from the legal proceeding and from the social predicament that resulted in court action. Effective pediatric support and intervention requires an understanding of the situations that bring children to court and the issues that will confront children and child advocates in different court settings.

Comparison of diagnostic criteria for attention deficit disorders in a German elementary school sample.

OBJECTIVE: This study compares teacher-reported prevalence rates for disruptive behavior disorders using DSM-IV, DSM-III-R, and DSM-III criteria within the same population of elementary school students and examines the relationships between DSM "subtypes" and academic performance, perceived behavior problems, and demographic variables. METHOD: Teacher rating scales were obtained on 1,077 students in five rural and five urban public schools in Regensburg, Germany. Rating scales included DSM-III-R items (attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder), DSM-IV items (attention-deficit/hyperactivity disorders [AD/HDs], oppositional defiant disorder), and DSM-III items (attention deficit disorder, with and without hyperactivity). Factor analyses of significance were performed. RESULTS: Overall prevalence for attention deficit disorders increased from 9.6% (DSM-III) to 17.8% (DSM-IV) primarily because of new cases identified as AD/HD-AD (inattentive type) and to a lesser degree, AD/HD-HI (hyperactive-impulsive type). Inattention in any subtype was associated with academic problems, and perceived behavior problems were associated with more than 80% of the cases that included hyperactivity-impulsivity. DSM-IV AD/HD subtypes showed significant behavioral, academic, and demographic differences. CONCLUSION: Application of DSM-IV criteria increased total AD/HD prevalence rates by 64% and identified the majority of children with academic and/or behavioral dysfunction. The data show significant heterogeneity between the subtypes and imply that many children screened into these subtypes require further evaluation to ensure appropriate management.

Comparison of diagnostic criteria for attention-deficit hyperactivity disorder in a county-wide sample.

OBJECTIVE: To examine teacher-reported prevalence rates for attention-deficit hyperactivity disorder (ADHD) based on DSM-III-R and DSM-IV in the same population. METHOD: Teachers completed questionnaires in which they rated all their students on all DSM-III-R and DSM-IV symptoms for disruptive behavior disorders except for seven conduct disorder symptoms but including seven symptoms screening for anxiety or depression. This constituted all children in kindergarten through fifth grade in a middle Tennessee county during the 1993-1994 academic year (16 schools, 398 teachers, and 8,258 children). Also included were questions about the children's diagnosis of ADHD, treatment with stimulants, and the presence of behavior or academic problems. RESULTS: The prevalence rates were 7.3% for ADHD (DSM-III-R); 11.4% for ADHD, total (TOT); 5.4% for ADHD, inattentive type (AD); 2.4% for ADHD, hyperactive-impulsive type (HI); and 3.6% for ADHD, combined type (CT). Factor analysis identified five factors: opposition/defiance-conduct, inattention, hyperactivity/impulsivity, anxiety/depression, and stealing-truancy. The rates of problems differed mostly between ADHD-AD and ADHD-HI (40% versus 80%) for behavior and (75% versus 23%) for academics. Few (15% to 40%) had an ADHD diagnosis or stimulant treatment (21% to 32%). CONCLUSION: DSM-IV criteria are likely to increase the prevalence of this disorder in comparison with DSM-III-R rates, but they may better characterize its heterogeneity.

Results of clean intermittent catheterization for children with neurogenic bladders.

Forty-nine patients were placed on a regimen of clean intermittent catheterization one to four years prior to this review. The children were intermittently catheterized, and a silver nitrate solution 1:1000 was instilled after each catheterization. Nurse practitioners, and community and school personnel contributed to the management. Twenty-one patients were continent with anticholinergics, and 18 also required alpha-adrenergic agents. Eighty-eight per cent were essentially bacteriuria-free, 65 per cent were essentially infection-free, and forty-nine per cent were totally continent. The remaining 25 had mild incontinence. Eleven had clearances below 85 mm/min with 8 reverting to normal on therapy. Nine had reflux prior to the study and one improved. In 8 patients reflux developed during therapy; 4 had severe reflux which required ureteral reimplantation. The results demonstrated that a clean intermittent catheterization program is feasible in a rural setting and that a genitourinary irrigant does decrease bacteriuria.

Follow-up of clean intermittent catheterization for children with neurogenic bladders.

Intermittent catheterization remains the primary method of treatment in the management of patients with neurogenic bladders such as those with meningomyelocele. In a follow-up of a previous study, we re-examined the urologic status of patients with neurogenic bladders continuing on a regimen of clean intermittent catheterization five years after the completion of the first study. Thirty-seven of the original 49 patients were available for follow-up, and no significant differences were found between those lost to follow-up and those included in this study. Among the patients re-evaluated, reflux remained unchanged or improved in most patients, renal function was maintained, and the urinary tract infection rate remained low. Additionally, continuation of an intermittent catheterization program does provide independence and social continence in most young adults with meningomyelocele. We conclude that a long-term intermittent catheterization program is associated with stable reflux status, renal function, and infection rate, and that compliance with a catheterization program can result in improved social continence and independence.

Dietary characteristics of hyperactive and control boys.

The purpose of this study was to examine the relationship between dietary habits and behavioral problems in hyperactive boys and to determine how successful parents are in maintaining their children on sugar-free diets. The mothers of 32 hyperactive boys aged 7 to 12 years and 26 matched controls completed 3-day diet records and food frequency interviews. The hyperactive boys were also evaluated in a playroom for impulsivity, compliance, attention, motor activity, memory, and learning. No differences were found in any of the measures of dietary content between the hyperactive and control groups. The only significant differences between those two groups were a lower socioeconomic status and a greater number of parents attempting sugar-restricted diets in the hyperactive group. Boys on sugar-restricted diets had only one significant dietary difference from those not restricted. Correlations between the information obtained in food frequency interviews and in 3-day diet histories were not significant (r = .06 to .33) for the hyperactive group, but the food frequency interviews were significant for the control group (r = .41 to .47). Four behavioral variables showed significant partial correlations with reported sugar intake. Overall, the results demonstrated that the diets of a group of hyperactive boys were similar to those of a control group. There appeared to be little difference between the diets of the families that attempted to restrict sugar and those that did not.

Stimulant medication therapy in the treatment of children with attention deficit hyperactivity disorder.

Despite the tremendous research advances that have increased our knowledge regarding the pharmacodynamics, clinical pharmacology, pharmacokinetics, and adverse effects of stimulant medications in the treatment of children with ADHD, our knowledge is yet incomplete. Perhaps the most central unresolved issue concerns our understanding of the pathogenesis, pathophysiology, and diagnosis of ADHD. This review has touched briefly on the controversy and confusion surrounding this issue. Although our understanding of the use of stimulant medications in this disorder is similarly incomplete, a review of the literature does allow certain conclusions to be made that are helpful to the practitioner. 1. Stimulant medications are an effective treatment modality for most children with ADHD. Short-term efficacy is well documented, and long-term outcome may be improved when stimulants are used with other therapeutic strategies. Stimulants in and of themselves are not a panacea. 2. It is impossible to predict which children will have a favorable response to stimulant medications and which children may have a placebo response. The use of individual single-blind medication trials is a practical solution to this problem and should be considered for all children who are candidates for stimulant therapy as a means for preventing overuse or inappropriate use of these medications. 3. The precise mechanism of action of stimulants is not yet completely understood, but stimulants appear to exert their therapeutic effects through their influence on multiple neurotransmitters in the catecholamine, dopamine, norepinephrine axis in the central nervous system. 4. The three major stimulants--methylphenidate, dextroamphetamine, and pemoline--appear to be equally efficacious, although methylphenidate has emerged as the most commonly used and most studied drug. Because of its potential for causing liver toxicity, pemoline has remained a second-line medication. 5. The three major stimulants appear to have somewhat different mechanisms of action so that failure of a patient to respond to one medication does not mean that he or she will not respond to another. 6. The recommended starting doses for the stimulants are 0.3 mg per kg of methylphenidate, 0.15 mg per kg of dextroamphetamine, and 37.5 mg of pemoline. There is a great deal of individual variability in dose response, so doses must be titrated for optimal effects in each child. Sustained release preparations are much more expensive than regular preparations and may be less effective. 7. There is no evidence that stimulants have any effect on ultimate adult height. 8. Although relatively uncommon, motor tics have been observed in children on stimulants, and all children on stimulants need to be carefully monitored for the development of tics. (ABSTRACT TRUNCATED AT 250 WORDS)

Situational effects on the communication behaviors of pediatric residents.

The variation in communication behaviors of pediatric residents in different interview circumstances was examined. Twenty-three residents were videotaped in three simulated counseling sessions. Two of the sessions entailed counseling a mother of a toddler with multiple handicaps during a well-child visit. The third, which took place between the other two sessions, entailed informing a new mother that her child has Down's syndrome. The residents' performances were evaluated using a subjective rating scale and an objective frequency count of behaviors. Analysis of variance demonstrated significant effects for both observation scales. Spearman correlations were not significant between any of the situations. The results suggest that residents' communication behaviors vary with the type of counseling situation.

Pediatric practitioners' knowledge of developmental disabilities.

The purpose of this study was to assess the level of knowledge and attitudes of pediatric practitioners about developmental disabilities and compare their level to the performance of pediatric residents before and after a 1-month rotation about developmental disabilities. The level of knowledge was measured using a 50-question multiple choice examination and the attitudes were measured utilizing a hypothetical question about allocation of funds, a scale which measured prognostic abilities about mental function and the Attitude Towards Disabled Persons Scale. The results showed that the practitioners' mean scores were near the resident pretest mean scores with the exception of knowledge of developmental landmarks and school behavior and learning problems. Only slight changes in the residents were seen on the attitudinal measures, and the practitioners tended to have less optimistic attitudes than other professionals. The results help document that residency training in developmental disabilities improves knowledge about the area and that practitioners without that training have not acquired it on their own.

Physicians' prognoses about the quality of life for infants with intraventricular hemorrhage.

There is an absence of definitive information concerning the long-term outcome of children born with intraventricular hemorrhage (IVH). Physicians, however, are called on to prognosticate about the future quality of life of these children. Our study examined pediatricians' and neonatologists' prognoses for infants with grade I- and grade-IV IVH and the impact of those prognoses on recommendations for treatment. A national random survey of 289 pediatricians and 283 neonatologists found that both groups expected infants with grade-I IVH to have slight impairments to future development, whereas infants with grade-IV IVH were expected to have severe impairments. Physicians prognosticated that infants with grade-IV IVH would function at a moderate to severe level of mental retardation, incapable of any employment, and residing in an institution. Furthermore, physicians would encourage parents to seek medical treatment of respiratory distress for the infant with grade-I IVH but were neutral or would discourage parents from seeking treatment for the infant with grade-IV IVH. Lastly, physicians' prognoses were significantly related to their recommendations for treatment. Several differences in physicians' prognoses and recommendations were found to be related to their discipline and training.

Examination of DSM-IV criteria for attention deficit/hyperactivity disorder in a county-wide sample.

This study replicated, in the subsequent academic year, teacher-reported prevalence rates for attention deficit/hyperactivity disorder (ADHD) based on DSM-IV. Teachers in grades K-5 in a Tennessee county (10 schools, 214 teachers, and 4323 children) completed questionnaires on all their students consisting of the DSM-IV symptoms for disruptive behavior disorders, except for eight conduct disorders symptoms, seven symptoms screening for anxiety or depression, ratings of performance, and questions about the presence of ADHD, stimulant medication treatment, and behavioral or academic problems. The prevalence rates were 16.1% for ADHD-all types, 8.8% for ADHD-inattentive type (AD), 2.6% for ADHD-hyperactive/impulsive type (HI), and 4.7% for ADHD-combined type and 6.8, 3.2, 0.6, and 2.9%, respectively, when impairment was taken into consideration. The rates of problems differed mostly between ADHD-AD AND ADHD-HI (30% vs. 68%) for behavior and (56% vs. 16%) for academics. Few (11-33%) had an ADHD diagnosis or were treated with stimulant treatment (8-26%). DSM-IV criteria are likely to increase the prevalence but may better characterize the heterogeneity of this disorder.

Obtaining systematic teacher reports of disruptive behavior disorders utilizing DSM-IV.

This study examines the psychometric properties of the Vanderbilt AD/HD Diagnostic Teacher Rating Scale (VADTRS) and provides preliminary normative data from a large, geographically defined population. The VADTRS consists of the complete list of DSM-IV AD/HD symptoms, a screen for other disruptive behavior disorders, anxiety and depression, and ratings of academic and classroom behavior performance. Teachers in one suburban county completed the scale for their students during 2 consecutive years. Statistical methods included (a) exploratory and confirmatory latent variable analyses of item data, (b) evaluation of the internal consistency of the latent dimensions, (c) evaluation of latent structure concordance between school year samples, and (d) preliminary evaluation of criterion-related validity. The instrument comprises four behavioral dimensions and two performance dimensions. The behavioral dimensions were concordant between school years and were consistent with a priori DSM-IV diagnostic criteria. Correlations between latent dimensions and relevant, known disorders or problems varied from .25 to .66.

Professionals' prognoses for individuals with mental retardation: search for consensus within interdisciplinary settings.

Previous studies have shown a lack of consensus in professionals' prognoses for individuals with mental retardation. The present study was designed to continue the investigation of professionals' prognoses for the achieved capabilities and residential and vocational placement of individuals with mild, moderate, or severe mental retardation. Four professional groups (N = 567 subjects) from 50 of the 52 University Affiliated Programs throughout the country were surveyed. The Prognostic Beliefs Scale was used. Results showed that physicians had significantly lower expectations and more pessimistic prognoses for children with moderate or severe mental retardation than did the other professionals. The only consensus on prognosis was for children with mild mental retardation. Results call into question one of the assumed benefits of interdisciplinary teams--communication--and its impact on professionals' expectations and prognoses for individuals with mental retardation.

Behavior modification therapy in hyperactive children. Research and clinical implications.

One hundred fifty-seven studies employing behavior modification in the management of hyperactive and disruptive children were reviewed. The studies were analyzed against standards of scientific validity. The review found: (1) behavior modification was effective in alleviating problem behaviors; (2) token programs were the most commonly used; (3) both positive reinforcement and punishment were effective; positive reinforcement, however, had the advantage of improving self-esteem; (4) behavioral problems occurring in the home most likely require a home-based program; (5) behavior modification and stimulant medication can be used simultaneously, often with additive effects; and (6) long-term benefits beyond one year have not been assessed.

The practical aspects of diagnosing and managing children with attention deficit hyperactivity disorder.

AD/HD is a behaviorally defined disorder with specific behavioral criteria. The most recent definitions decrease heterogeneity by defining subtypes although the current treatments tend to be more generic. The main well-established treatments are stimulant medication and behavior modification, which are most effective when used together.