[Maternal conceptions of infantile diarrhea] / Concepções maternas sobre a diarréia infantil.

OBJECTIVE: To understand maternal conceptions of infantile diarrhea, encouraging reflection on the importance of communication between mothers and health services. METHODS: Survey carried out in selected areas of six towns in the state of Pernambuco, all of which participated in the diarrhea control project coordinated by the State Health Secretariat. The information was obtained through interviews with 770 mothers, producing a representative sample of 1,026 children younger than five years. RESULTS: In general, mothers associated the occurrence of diarrhea with some kinds of food (fatty or undercooked). Better educated mothers, regardless of their place of residence, attributed it to improper hygiene and sanitation, whereas illiterate and poorly educated mothers, from the metropolitan region of Recife, blamed it on hot weather, and those living in the countryside believe the occurrence of diarrhea is related to teething. Circa 24.2% (63.4% living in the countryside) do not know how to prevent the disease. The two preventive measures most frequently adopted consist in drinking treated water and cooking food thoroughly. Only 0.5% mentioned breast-feeding. The number of children still alive and their ages influence maternal conceptions. The main sources of information about the prevention of diarrhea are the support network (45.5%), the health sector (35.9%) and the media (33.2%). CONCLUSIONS: The insufficient participation of the health sector in the information network about diarrhea, misinformation, and sharp disagreement over maternal conceptions and technical knowledge, which are the cornerstone of institutional measures, show that it is necessary to value the communicative dimension of the educational approach in child care.

[Organization of health practices and vulnerability to childhood diarrhea] / Organização das práticas de saúde e vulnerabilidade à diarréia infantil.

OBJECTIVES: This study aimed to characterize, the organization of health practices related to the reduction of vulnerability to childhood diarrhoea. METHODS: A longitudinal study was carried out, with two interconnected transversal cuts, in 14 health services (11 health centres and 3 hospitals), located in six municipalities of Pernambuco that participated of the Diarrhoea Control Implementation Project coordinated by the Health State Department. The data collection was performed through observation, interviews with professionals and mothers of the children, and clinic histories revision. RESULTS: Overall, there was a high proportion of patients who either did not get consulted or had to wait for a long time after their arrival at the health service. No orientation was given on the use of oral rehydration salts at home; little advice on the signs and symptoms of an aggravating episode was given, an elevated number of drugs were prescribed to the children with diarrhoea; and there was high degree of omission to record the patients hydration status and the treatment offered. The educational practice is systematic only in 3 services, and only in these services there is delegation of activities to the nursing team and articulation with community health agents. On the 2nd phase of the study, one of the few changes identified was a discrete increase in weight measurement and its recording on a Chart. However, in the intervention period 69.6% of the health team members noticed an improvement on the pediatric assistance. CONCLUSIONS: The results reveal the great deficiency of the evaluated services in operating educational and healing activities related to diarrhoea control. So the observed practices concerning the attention to the children have contributed to increase childhood vulnerability, which shows the need to reorganize disease control actions, among the myriad of other actions related to this social group.

[Early diagnosis of Hansen disease: study of the health services in Recife (Pernambuco), Brazil]. / Diagnóstico precoce da hanseníase: o caso dos serviços de saúde no Recife (Pernambuco), Brasil.

This paper presents the results of a descriptive study carried out in the city of Recife, state of Pernambuco, Brazil, between March and September 1994. The study aimed at health services available for performing early diagnosis of Hansen's disease with emphasis on accessibility and quality of the services provided. The sample consisted of 32 health clinics visited for diagnostic purposes by 183 patients with Hansen's disease. Information on organizational infrastructures was collected by means of interviews with health clinic managers. Information regarding routine procedures in the 32 clinics was collected by observation, with special attention given to archival and inspection activities. A total of 1,998 patients were interviewed to determine accessibility of services. Time spent in consultation with the physician was determined for 1,000 patients who were seen by 123 physicians at the clinics during the interviews. To explore physicians' attitude and knowledge regarding Hansen's disease, 133 were randomly selected from a list of names. The following factors were identified as hindering early diagnosis of Hansen's disease: the large number of people seeking service who could not be seen by a physician on the same day; the long time elapsed between appointment scheduling and the actual visit (for those not seen on the same day); the long wait for the consultation; the brevity of the consultation; the low availability of trained personnel; the low proportion of physicians who examined all body surfaces; difficulties in the clinical recognition of the disease; and physicians not prepared to make a differential diagnosis. These obstacles can precipitate the physical deterioration of Hansen's disease patients and stimulate the persistence of transmissibility; therefore, they need to be overcome if Hansen's disease is to be eliminated.

[Perceptions regarding leprosy and resulting handicaps prior to diagnosis in Recife, Brazil]. / Percepción de la lepra y las discapacidades antes del diagnóstico en Recife, Brasil.

This article reports on a case-control study conducted in Recife, Brazil, between November 1993 and July 1994, to determine how leprosy patients' perceptions and notions influence disease management and use of health services. The sample was composed of 183 residents of Recife between the ages of 20 and 70 years who sought diagnostic services in the dermatology clinics of two referral centers situated in the third, fourth, and sixth political and administrative regions. Sixty-four patients having handicaps or their precursor lesions were classified as cases; the remaining 119 were used as controls. All were diagnosed during the study period. For the analysis, adjustments were made for sex, age, schooling, and a previous history of Hansen's disease among patients. The study revealed the simultaneous presence of two types of "invisibility" of the disease in an area where endemicity is increasing: 1) for patients in both groups, the low frequency of spontaneous explanatory models related to the illness, even in the presence of disease, and 2) for health professionals, the limitations of detection methods. Since such deficiencies affect decisions bearing on individual and collective disease management, they are a risk factor in and of themselves and stand in the way of eliminating leprosy as a public health problem.

[Are mothers encouraged to identify the risk signs of diarrhea?] / As mães são estimuladas a valorizar os sinais de risco da diarréia?

OBJECTIVES: To acknowledge the mothers' perception of the diarrhea episode and their ability in identifying the signs of risk; to characterize, in the health services, at ambulatory level, the activities that stimulate a timely attention to the disease.METHODS: An inquiry was applied to a representative sample of 1026 children under 5 years old who live in the pilot areas of Pernambuco selected to receive interference concerning diarrhea, and an interconnected transversal study in 14 health services: 11 health centres and 3 hospitals.RESULTS: A high proportion of the mothers of children with diarrhea give importance clinical manifestations that do not allow an early identification of dehydration. Only one fourth of them mentions dehydration as a complication. The mothers perception of the episode has a striking influence on the adopted conduct, particularly in the Metropolitan Area, in which, in the absence of preoccupation, no children were taken to the physician and a significant smaller proportion received care to hydration. In the health services, in general, collective educational programs are not the routine, the consult with the physician is limited to the main complaint, there is no post-consult with the nurses nor articulation with community health agents. Besides that, half of the mothers did not know the signs of dehydration.CONCLUSIONS: The findings of both the inquiry and the evaluation of the health services showed a quite critical situation: mother's little perception of the mothers of diarrhea worsening signs, as well as the insufficiency of these services concerning educational activities towards stimulating mothers to recognize and valorize them.

[Opinions about disease among members of the social network of patients with Hansen's disease in Recife]. / Opiniões sobre a doença entre membros da rede social de pacientes de hanseníase no Recife.

This article describes a study done in Recife, Brazil, between November 1993 and July 1994 to explore the opinions of the members of the social network (for example, family members, friends, and neighbors) of carriers of Hansen's disease regarding their estimation, interpretation, and management of physical manifestations of the disease in the time leading up to diagnosis. The sample consisted of 93 members of the social network, ranging in age between 20 and 70 years, who supported the course of action of 83 patients diagnosed in the study period. The analysis sought to detect differing capacities among the members of the patients' social network to discriminate between persons classified as cases (presence of disabilities or precursor lesions) or controls. The study found a lack of information about transmission of Hansen's disease and revealed a transitional phase in which there was expectation of cure along with a stigmatizing view of the consequences of the disease. Only one-quarter of the study subjects suspected prior to diagnosis that the patient had Hansen's disease, which suggests low perception of the risk represented by the disease and reinforces the idea that its physical manifestations can be invisible. The results reveal a profile of perception and management of Hansen's disease that favors its propagation and the development or worsening of its physical and social consequences.

Eating disorders and maladaptive dietary/insulin management among youths with childhood-onset insulin-dependent diabetes mellitus.

OBJECTIVE: To determine the prevalence of DSM-III eating disorder and the conjoint symptoms of maladaptive dietary/insulin management (irrespective of eating disorder) and their psychiatric and biomedical correlates among youths with childhood-onset insulin-dependent diabetes mellitus (IDDM). METHOD: Forty-four girls and 35 boys, 8 to 13 years old at IDDM onset, were repeatedly interviewed during an interval of up to 14 years (mean = 9 years) to ascertain psychiatric disorders and behaviors related to diabetes care. Metabolic control and IDDM-related hospitalizations also were monitored. RESULTS: By the mean age of approximately 21 years, 3.8% of the sample had DSM-III eating disorders and 11.4% had "eating problems," defined as the conjoint symptoms of severe dietary indiscretion and repeated insulin omission (irrespective of eating disorders). Youths with "eating problems" were nine times more likely to have had a psychiatric disorder than the rest of the patients, and they had a significantly higher rate of pervasive noncompliance with medical treatment. No between-group differences were found in metabolic control and rates of multiple hospitalizations. CONCLUSIONS: The diabetes-specific symptom-pair of serious dietary indiscretion and repeated insulin omission appears to identify youths who have had other problems as well. The association of eating problems with psychiatric disorders (other than eating disorders) suggests that a subgroup of diabetic youths have various difficulties in coping with the medical illness and require close monitoring and psychosocial intervention.

A controlled prospective study of DSM-III adjustment disorder in childhood. Short-term prognosis and long-term predictive validity.

OBJECTIVES: Using DSM-III criteria for adjustment disorder (AD), further operationalized by requiring at least three clinically significant symptoms, we sought to characterize this diagnosis in terms of presenting features, recovery, and predictive validity among juveniles. DESIGN: The samples included clinically referred, 8- to 13-year-old patients with the research diagnosis of AD (N = 30) and a high rate of comorbid disorders and age-and comorbid disorder-matched psychopathologic controls (N = 26). As part of a naturalistic, longitudinal, nosologic study, patients were repeatedly examined during an average follow-up interval of 7 to 8 years. RESULTS: Adjustment disorder was associated with six symptoms, on average, and 60% of the patients had other, specific psychiatric disorders. Adjustment disorder had a median episode length of 7 months and a 97% recovery rate. Comorbidity had no appreciable effect on recovery. Patients with adjustment disorder and controls had similar rates of new psychiatric disorders and other dysfunctional outcomes during the follow-up. CONCLUSIONS: Among psychiatrically referred youths, the diagnosis of AD has clinical information value and identifies a syndromatic presentation that can be the focus of concern or treatment. It has a reasonably good short-term prognosis, in spite of the fact that patients with this diagnosis typically present with comorbid specific psychiatric disorders. Controlling for the effects of comorbidity, AD does not predict later dysfunction. To achieve a convergence of findings from research and clinical practice, it would be important to ensure a uniform application of specific, operational diagnostic criteria for AD.

Childhood-onset dysthymic disorder. Clinical features and prospective naturalistic outcome.

OBJECTIVES: To characterize the clinical presentation, course, and outcome of childhood-onset dysthymic disorder and assess the predictive validity of this diagnosis. DESIGN: As part of a longitudinal prospective study, school-age, clinically referred youngsters (n = 55) whose first depression was dysthymic disorder and a comparison group of youngsters (n = 60) whose first affective episode was major depressive disorder (MDD) were repeatedly examined during a 3- to 12-year interval. The diagnoses were based on DSM-III criteria. RESULTS: Dysthymic disorder was associated with earlier age at onset than MDD, similarly frequent symptoms of affective dysregulation, but low rates of anhedonia and neurovegetative symptoms and greater overall risk of any subsequent affective disorder. The affective disorders that dysthymic children developed, including first-episode MDD (76%) and bipolar disorder (13%), far outnumbered nonaffective conditions. After the first episode of MDD, the clinical course of the initially dysthymic youths was similar to the course of the comparison patients with regard to rates of recurrent major depression, bipolar disorder, and certain nonaffective disorders. CONCLUSIONS: Childhood-onset dysthymic disorder is an early marker of recurrent affective illness. Although on long-term follow-up, dysthymic disorder and MDD are associated with similar rates of certain outcomes, there exist sufficient differences to warrant diagnosis of each disorder. Dysthymic children who have subsequent mood disorders are most likely first to have an episode of MDD, and that episode appears to be the "gateway" to recurrent affective illness. The interval between the onset of dysthymia and the first major depression provides a window of opportunity for intervention and possible prevention of later episodes.

Secular trends in age at onset of major depressive disorder in a clinical sample of children.

Using a psychiatrically referred, depressed, school-age sample, we sought to cross-validate the clinically pertinent epidemiologic finding that the distribution of age at onset of first episode of major depressive disorder (MDD) is subject to birth-cohort and period effects. Demographic and historical variables also were considered in attempting to explain the variability in age-at-onset. The results indicated a birth-cohort effect, but no discernable period effect on age at onset of MDD; successive birth cohorts were younger when they first developed MDD even after stringent analyses were conducted that corrected for structural sampling biases in the sample. In view of the relatively small size and clinical nature of the sample and the restricted birth-year span that characterizes children, the results are presented to stimulate further discussion of this topical area.

Biomedical and psychosocial predictors of early rehospitalization among children with insulin-dependent diabetes mellitus: a longitudinal study.

The purpose of the present study was to determine the cumulative probability of the first diabetes-related rehospitalization within the initial 2.5 years after the onset of insulin-dependent diabetes mellitus (IDDM) among newly diagnosed children, and to identify risk factors that can be determined shortly after IDDM-onset. The sample consisted of 88 children, 8 to 13 years old at the onset of IDDM, who had been participating in a longitudinal study. In this sample, there was a 0.25 cumulative probability of an early readmission. Poor control was the most frequent reason for readmissions. Four variables significantly increased the risk of early rehospitalization: severity of child's externalizing symptoms at IDDM-onset, lower socio-economic status, younger age at onset of IDDM, and higher levels of glycosylated haemoglobin, reflecting poorer metabolic control. Because externalizing symptoms and poor control are amenable to change, some early rehospitalizations can potentially be prevented. Furthermore, information about the risk of early rehospitalization should be part of initial diabetes education in order to better prepare families for the possibility of such an event.

Early onset psychopathology and the risk for teenage pregnancy among clinically referred girls.

OBJECTIVE: To investigate whether early onset DSM-III depressive and conduct disorders and historical/familial variables increased the risk of teenage pregnancy among clinically referred girls, whose referral was unrelated to their reproductive status. METHOD: The sample of 83 girls, 8 to 13 years old at study entry, were participating in a longitudinal investigation of childhood-onset psychiatric disorders. They were repeatedly evaluated during an interval of up to 12 years. RESULTS: Twenty-nine girls had at least one pregnancy, and 25 had their first pregnancies as teenagers (< or = 18 years old). Several variables that predicted earlier age at first pregnancy in longitudinal univariate analyses became nonsignificant in the multivariate model. In the final model, childhood or adolescent onset conduct disorders (but not depressive disorders), and race were significantly associated with teenage pregnancy. Among the girls with conduct disorders, 54.8% became pregnant teenagers versus 12% of the rest, and 56% of the black adolescents versus 12% of the rest, had teenage pregnancies. CONCLUSIONS: After adjusting for race, early onset conduct disorder represents a risk factor for teenage pregnancy among psychiatrically referred girls. The mechanisms may entail behavioral dysregulation, delay in social-cognitive development, and misinformation about reproductive issues. Such girls may benefit from therapeutic and educational interventions to delay childbearing.

PIP: An existing longitudinal data set was used to investigate the hypothesis that a depressive disorder in childhood increases the risk of an adolescent pregnancy. Depression is characterized by low self-esteem, lowered concern about one's personal welfare, passivity, and impaired motivation--all of which may prevent teenage girls from taking steps to protect themselves from pregnancy. The 83 subjects had been referred to a child psychiatric clinic (86%) or a general medical facility (12%) in Pittsburgh, Pennsylvania, between the ages of 8-13 years (average age at intake, 11.5 years). They underwent 4 clinical assessments in the first year of study participation and 2 assessments in each subsequent year. 65 girls experienced 1 or more DSM-III-R defined depressive episodes during the study period; the rest, who served as psychopathologic controls, had conduct disorders. 25 of the 83 subjects (30%, compared to the national average of 24%) had documented pregnancies by the age of 18 years. 28% of the pregnant teens had a history of early onset depression compared with 66% of their nonpregnant counterparts. On the other hand, 76% of the pregnant teens had been diagnosed with a conduct disorder by the age of 18 compared with 24% of the nonpregnant girls. Preliminary analysis further indicated that teenage pregnancy was associated with having been born out of wedlock or to a mother aged 18 years or younger; living in an intact family at time of study enrollment and socioeconomic status were not significant correlates. In the multivariate analysis, however, only two factors retained significance: a conduct disorder diagnosis in childhood (mean time to first pregnancy was 17.3 years compared to 18.7 years among remaining subjects) and race (Blacks tended to become pregnant by 17.4 years compared to an average of 18.7 years for Whites). No significant interaction was detected between a conduct disorder and race. These findings suggest that educational interventions aimed at decreasing impulsivity and undesirable consequences should be targeted at girls with conduct disorders.

Prevalence and predictors of pervasive noncompliance with medical treatment among youths with insulin-dependent diabetes mellitus.

School-age children were assessed longitudinally for up to 9 years, after the onset of their insulin-dependent diabetes mellitus (IDDM), to determine the time-dependent risk of the psychiatric diagnosis of noncompliance with medical treatment and to examine protective and risk factors. The cumulative risk for this diagnosis over the 9 years was .45. Noncompliance tended to emerge in middle adolescence and was found to be protracted. Social competence, self-esteem, and aspects of family functioning at IDDM onset and initial psychiatric status did not predict noncompliance. However, noncompliance was associated with having major psychiatric disorder later in the course of IDDM.

Difficulties in diagnosing manic disorders among children and adolescents.

Four factors are delineated that account for the difficulties in identifying and diagnosing manic disorders among children and adolescents. These factors are the low base rate of the disorder, its variable clinical presentation within and across episodes, its symptomatic overlap with more common disorders of childhood, and the constraints placed on symptom expression by the developmental stage of a child. Each of these factors is discussed in terms of its impact on the likelihood of recognizing mania, and strategies are proposed to improve diagnostic accuracy.

Depressive disorders in childhood. IV. A longitudinal study of comorbidity with and risk for anxiety disorders.

As part of a longitudinal nosologic study of major depressive disorder (MDD), dysthymic disorder (DD), and adjustment disorder with depressed mood (ADDM) in a school-age cohort, we examined the prevalence and clinical consequences of comorbid anxiety disorders. We also estimated the risk of a first anxiety disorder and examined its predictors. Of 104 cases, 41% had anxiety disorders in conjunction with their index depression, which was more likely with MDD and DD than with ADDM. The age-corrected risk of a first anxiety disorder was 0.47 up to age 18 years. Separation-anxiety disorder was the most frequent diagnosis of anxiety, followed by overanxious disorder of childhood. Among the MDD cases with comorbidity, the anxiety disorder preceded the depression about two thirds of the time and often persisted after the depression remitted. The effect of comorbid anxiety disorder on the length of index MDD depended on the presence of other clinical features, but it did not seem to affect the risk of subsequent MDD or the course of DD or ADDM. Concurrent maternal psychopathology and poor physical health increased the risk of anxiety disorder in the children, but a history of prior separation from parental figures did not seem to have an effect.

Depressive disorders in childhood. III. A longitudinal study of comorbidity with and risk for conduct disorders.

As part of a longitudinal nosologic study of major depressive disorder (MDD), dysthymic disorder, and adjustment disorder with depressed mood in 104 school-aged probands, the prevalence and consequences of comorbid conduct disorders (CD) were examined. During the index depressive episodes, 16% of the patients had comorbid CD; during the full study observation 23% had CD; and the estimated time-dependent risk of conduct disorder developing was 36% by age 19. For most cases, comorbid CD developed as a complication of the depression and persisted after the depression remitted. Comorbid CD was not differentially associated with the type of depression at study entry, did not affect depressive symptom presentation, was similarly distributed among boys and girls, and was unrelated to demographic factors. Additionally, comorbid CD did not affect recovery from the index depressive episodes and did not influence the symptom-free interval before a recurrent depression among cases with MDD. The risk of CD developing was not altered by chronologically earlier family variables or demographic factors. But girls who had attention deficit disorder, compared to those who did not, seemed to be at higher risk for CD during study observation. Finally, in this depressed cohort, having CD any time was associated with an increased rate of long-term functional problems.

Initial coping responses and psychosocial characteristics of children with insulin-dependent diabetes mellitus.

School-aged children with newly diagnosed insulin-dependent diabetes mellitus (IDDM) were studied longitudinally in order to document how they adjusted to the medical illness and to assess salient background factors. The extent of life stress and the prevalence of psychiatric disorders that predated the IDDM were within normative ranges, and there was no characteristic preexisting "diabetic personality." The initial strain of living with IDDM elicited two general modes of coping. The prototypical and subdued reaction (seen in 64% of the children) consisted of mild sadness, anxiety, feeling of friendlessness, and social withdrawal. The rest of the children (36%) exhibited reactions that met criteria for a psychiatric disorder; depressive syndromes were the most common presentations. Anamnestic factors and the parents' initial responses to their children's IDDM were unrelated to how the children themselves coped. However, psychiatrically diagnosable reactions were more likely among children whose parents were of low socioeconomic status and had marital distress. Coping with the diagnosis and the early impact of IDDM took no more than 7 to 9 months, no matter how severe the child's response was initially.

Desnutricao e hospital. III - Custos do tratamento do desnutrido grave a nivel hospitalar. / Malnutrition and hospital.III - Treatment costs of the severe malnourished infant in the hospital

Valendo-se da experiencia adquirida com o tratamento de 200 criancas portadoras de Desnutricao Proteico Calorica (DPC); os autores fazem uma estimativa dos custos da hospitalizacao e tentam extrapolar os resultados para a possibilidade de cobertura da populacao desnutrida da cidade do Recife. O numero reduzido de leitos, o longo tempo de permanencia exigido para recuperacao dos pacientes, levando a um baixo rendimento e custo muito elevados dos leitos, torna impossivel este tipo de assistencia e fortalece a ideia de que a solucao so podera ser encontrada em programas extra-hospitalares