Diagnosis and management of ADHD: a pediatric perspective on practice and challenges in Switzerland.

BACKGROUND: Attention deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders in childhood. In Switzerland, the complex diagnosis and treatment are being carried out by adolescent-/child psychiatrists, and pediatricians. Guidelines recommend a multimodal therapy for patients with ADHD. However, it has been questioned whether health professionals follow this approach or favor drug therapy. This study aims to provide insights into the practice of pediatricians in Switzerland regarding diagnosis and treatment of ADHD and their perceptions of these processes. METHOD: An online survey (self-report) about current practices of diagnosis and management as well as challenges regarding ADHD was distributed to office-based pediatricians in Switzerland. One hundred fifty-one pediatricians participated. Results show that therapy options were almost always discussed with parents and older children. Exchange with parents (81%) and level of child's suffering (97%) were central when selecting therapy options. RESULTS: Therapies about which pediatricians informed most often were: pharmacological therapy, psychotherapy, and multimodal therapy. Challenges voiced were the subjectivity of diagnostic criteria and dependence on third parties, low availability of psychotherapy, and a rather negative public attitude towards ADHD. Needs that were expressed were further education for all professionals, support for coordination with specialists and schools as well as improvement of information on ADHD. CONCLUSIONS: Pediatricians do consider a multimodal approach when treating ADHD and take the families` and children's opinions into account. Improvements of the availability of child and youth psychotherapy, the strengthening of the interprofessional cooperation with therapists and schools, and efforts to increase public knowledge about ADHD are proposed.

Prevention and Reduction of Obesity through Active Living (PROACTIVE): rationale, design and methods.

The Prevention and Reduction of Obesity through Active Living (PROACTIVE) is a randomised controlled trial to evaluate the effectiveness of a behaviourally based physical activity and diet composition programme to prevent and reduce obesity and related comorbidities in a primary healthcare setting. 491 abdominally obese men and women 25-75 years of age who were patients of primary care physicians were randomly assigned to either a usual care group (N = 242) or a behavioural intervention group (N = 249). Those in usual care received general advice from the physician regarding the merits of physical activity and a healthy diet as a strategy for obesity reduction. Those in the behavioural intervention group received an individually designed counselling programme from a specially trained health educator, with respect to physical activity, diet and obesity reduction. The study was designed to provide 95% power in both men and women to detect a 2% (2 cm) difference in waist circumference and 80% power to identify a 15% reduction in the prevalence of the metabolic syndrome, the two primary outcomes. PROACTIVE is the first behavioural intervention study to assess the effects of physical activity and diet on abdominal obesity and associated metabolic risk factors in a primary healthcare setting, include a generalised sample of men and women and examine long-term (24 months) effects. PROACTIVE has the potential to provide the basis for changing clinical practice (primary care) with respect to the prevention and reduction of obesity and related health risks. The purpose of this report is to present and discuss the rationale, design and methods of PROACTIVE.

Exercise and the transtheoretical model: a longitudinal test of a population sample.

BACKGROUND: The purpose of this study was to test the ability of the Transtheoretical Model (TTM) to predict exercise stage transition of individuals in a large, untreated-population-based, random sample of Canadian adults (18-65 years of age) over two consecutive time periods. METHODS: Assessments of TTM's stage of exercise behavior change, self-efficacy, pros, cons, experiential processes, and behavioral processes were made at baseline (time 1), 6 months (time 2), and 1 year (time 3). Six hundred eighty-three men and women, identified through random-digit telephone dialing, completed all measures across the three time points. Within each time period (time 1-2; time 2-3) participants were categorized as having regressed (moved back at least on stage), remained (no stage change), or progressed (moved forward at least one stage). Baseline TTM constructs were analyzed for their ability to predict change transition across the two time periods. RESULTS: Of 40 possible predictions (20 for each time period) 18 (45%) were supported. CONCLUSIONS: Overall, the findings demonstrate partial support for the internal validation of TTM in the exercise domain. Implications of the findings are discussed and future directions for researchers, practitioners, and program planners are provided.

Predicting exercise stage transitions over two consecutive 6-month periods: a test of the theory of planned behaviour in a population-based sample.

OBJECTIVES: To predict exercise stage transitions over two consecutive 6-month periods using the theory of planned behaviour (TPB). It was hypothesized that different social cognitive constructs would predict different stage transitions. DESIGN: Prospective and longitudinal in order to predict multiple stage transitions over time. Assessments were made at baseline, 6 months and 1 year. METHOD: Participants were a randomly selected population-based sample of 683 adults who completed two telephone interviews (baseline and 6 months) that assessed exercise stage, intention, perceived behavioural control, attitude, subjective norm, and social support, and a mailed survey (1 year) that assessed exercise stage. RESULTS: Progression from pre-contemplation was predicted by intention, attitude and subjective norm; progression/regression from contemplation was predicted by intention, perceived behavioural control, attitude, and social support; progression/regression from preparation was predicted by intention and attitude; and regression from action/maintenance was predicted by intention, attitude and social support. CONCLUSIONS: Different social cognitive constructs predicted different stage transitions, which indicates that exercise behaviour change may be represented by a series of stage transitions. Moreover, the TPB may be a useful model for highlighting the key social cognitive constructs that are important for exercise stage transitions.

Psychologic distress among spouses of patients undergoing cardiac rehabilitation.

OBJECTIVE: The goal of this study was to identify common sources of distress in spouses of patients undergoing cardiac rehabilitation and to compare spouses classified as being in distress and those classified as nondistressed on demographic variables, their experiences of stress, coping strategies employed, marital intimacy, and level of family functioning. The study aimed to describe the needs of spouses with respect to possible interventions. DESIGN: A cross-sectional analysis was used. SETTING: The study was located at the University of Ottawa Heart Institute Prevention and Rehabilitation Centre's cardiac rehabilitation program. OUTCOME MEASURES: Scores on the Brief Symptom Inventory, Heart Disease Hassles Scale, Coping Strategies Inventory, Miller Intimacy Scale, and McMaster Family Assessment Device were used as outcome measures. RESULTS: Two hundred thirteen female spouses of patients undergoing cardiac rehabilitation participated in this study. Sixty-six percent of the spouses met the criteria for distress. This was more common in younger spouses (51.99 +/- 9.94 years) than in older spouses (55. 74 +/- 10.54 years) (t = -2.45; P =.013). Distressed spouses used disengagement coping strategies significantly more than the nondistressed spouses (t = 6.91; P =.0001). Distressed spouses also reported significantly less intimacy in their marriages (t = -3.99; P =.0001) and poorer family functioning (t = 5.86; P =.0001). The most prevalent symptoms of psychologic distress included feeling tense, having trouble falling asleep and feeling easily hurt. The most prevalent stressors were as follows: (1) worries about treatment, recovery, and prognosis (75.5%); (2) moodiness of the patient (66.7%); (3) worries about the patient returning to work and about money (38.8%); (4) sexual concerns (36.7%); and (5) helplessness or apathy on the part of the patient and increased spousal responsibility (36.1%). CONCLUSIONS: Spouses of patients undergoing cardiac rehabilitation should be screened for psychologic distress, and those in distress should be offered interventions focused on assisting them to deal with specific stressors related to their experience with a spouse with heart disease. Interventions indicated include stress-management techniques and encouraging the use of engagement coping strategies. In addition, marital and family concerns need to be directly addressed in support interventions.

Exercise behavior in a community sample with diabetes: understanding the determinants of exercise behavioral change.

PURPOSE: The purpose of this study was to investigate the factors associated with exercise behavior among adults with diabetes. METHODS: Exercise behavior (stage of exercise readiness and energy expenditure) and potential determinants were measured on a subsample (n = 46) of adults with type 1 or type 2 diabetes from a randomized population-based telephone survey. Participants were assessed at baseline and at a 6-month follow-up. RESULTS: Sociodemographic and biomedical characteristics did not significantly differ between the stages of exercise behavior. Scores on the psychosocial constructs of self-efficacy, behavioral processes, self-concept, and social support were significantly higher for those in the action stage than those in the preaction stage of exercise readiness. Self-efficacy and behavioral process of change were significantly associated with energy expenditure; self-efficacy was the strongest predictor in the longitudinal analysis. CONCLUSIONS: These findings may generate direction for theory development and guide health and medical practitioners when intervening on the specific constructs. Population- and community-based surveys have utility for assessing diabetes health-related behavior (e.g., exercise behavior).

Extracellular matrix interactions during the in vivo degradation of collagen membranes in the rat skin: immunohistochemical distribution of collagen types IV, V, and VI.

The role of collagen implant material (CIM) in periodontology is of considerable interest to the clinical dentist because of the capacity of connective tissue (CT) regeneration and partial prevention of epithelial cell migration onto the root surface. The aim of this study was to demonstrate alterations of the CT matrix after the use of CIM in subcutaneous pockets in the rat skin. We used 15 rats in this study. After sedation, two subcutaneous pockets (2 cm in length) were surgically made in the animals' backs. Collagen membranes were implanted in one of the two pockets (test site). The other pocket served as control. Then, 4, 7, 14, 21, and 28 days after implantation, the animals were sacrificed and biopsies preserved for histologic and immunohistochemical examination. Incubation with antibodies against CT matrix components (collagen type IV, V, and VI) were used for immunostaining. Histologically, the CIM was migrated by inflammatory cells in the first 7 days. Newly formed fibroblasts and blood vessels (BV) were present 14 days postimplantation. Collagen type IV was localized in the basement membranes of the epithelium, BV, and nerves. An increase in the BV amount was demonstrated around (and later in) the implant material. Collagen type V was found in a filament pattern of distribution and was inserted into the implant after 4 weeks of healing. Collagen type VI showed a microfibrillar pattern of distribution with a delayed formation in the graft mass. The data showed the alterations of the matrix after implantation of collagen type I membranes in the rat skin.(ABSTRACT TRUNCATED AT 250 WORDS)

Fat-related dietary behaviour: behavioural science concepts for public health practice.

Despite being central to Canadian health objectives, reduction in fat consumption remains a difficult health target to reach. Strong epidemiological data associate high dietary fat intake with cardiovascular disease (CVD). There has been considerable interest in applying concepts from psychosocial models of behaviour change to enhance the effectiveness of CVD prevention programs. This review suggests that the determinants of fat-related dietary behaviours can be integrated within a comprehensive model useful to public health practice. The Transtheoretical Model (TTM) is suggested as an organizing framework for variables empirically related to diet. The TTM holds that dietary change occurs through successive stages, defined according to people's readiness to adopt new behaviours. Furthermore, readiness to change can be explained by variables that are amenable to public health interventions. The integration of important variables within the TTM framework may prove helpful in designing, implementing and evaluating effective dietary change intervention programs in the community.

Stress and cardiovascular disease risk behaviours: implications for health behaviour change.

This brief paper presents an integrative framework helpful in understanding the relationships between stress and cardiovascular disease risk behaviours. Key concepts such as cardiovascular reactivity, type A behaviour and hostility, ways of coping with both life and illness-related stressors, and the challenges associated with changing risk behaviours can support a patient's behaviour change efforts if communicated in a personally salient manner. Assessing the determinants of health behaviour change facilitates tailoring of interventions and can more precisely identify a patient's needs for referral to a psychologist with expertise in health behaviour issues.

A self-efficacy scale for heart-healthy eating.

Self-efficacy is an important mediator of behaviour change. We have developed a brief measure of self-efficacy related to ability to make dietary changes to lower serum cholesterol. An initial pool of 37 items was tested on 85 third-year nursing students. Factor analysis revealed two primary factors ('self-efficacy for resistance to temptation' and 'self-efficacy for change') composed of 13 items. This instrument was validated in a sample of 125 blue collar workers. Analyses confirmed that the scale structure accounted for 37% of the variance. Evidence of discriminant validity was provided by moderate correlations between factors (r = 0.41). Item-scale correlations also supported the discriminant validity. Cronbach's alpha ranged between 0.7 and 0.79 for both factors. This short instrument might be useful as an adjunct tool to identify potential responders for cholesterol modification interventions, to help understand the determinants of dietary behaviour changes and to guide the tailoring of interventions toward specific client/population subgroup needs.

Depression in primary care. Why do we miss the diagnosis?

Depressed patients are often undiagnosed, misdiagnosed, or underdiagnosed. Is this because family physicians are trained mainly to treat somatic complaints? Are patients reluctant to accept psychological causes for their physical symptoms? High volume of patients and short visits make it difficult for doctors to recognize depression. We propose strategies for identifying depressed patients in primary care.

The role of stress in interpreting the dexamethasone suppression test.

Stress has been implicated as a major confounding factor in the interpretation of Dexamethasone Suppression Test (DST) results. This study was designed to examine the effects of stress on DST results. Fifty patients with high levels of acute, chronic, and environmental stress participated in the study. Each patient was given a comprehensive psychiatric and psychological assessment, a routine administration of dexamethasone, and blood tests of cortisol values. The results indicate that the three measures of stress do not appear to affect levels of cortisol suppression, however, all three measures of stress predicted depression. As expected, DST cortisol levels were related to depression. Results are discussed in terms of their implications for understanding the associations among stress, depression and DST results.

Adjustment to Heart Disease: Helping families cope.

Many cardiac patients experience compromised psychologic and social adjustment, which can persist for a significant period. Worsened marital and family functioning have also been reported. This paper reviews the literature, provides a framework to identify adjustment problems, and discusses strategies to facilitate recovery and enhance the well-being of the patient, couple, and family.

The prevalence and impact of pain after day-care tubal ligation surgery.

Empirical data from controlled studies using standardized, reliable measures on the amount and quality of pain after laparoscopic tubal ligation and the consequences of this pain on the activities of daily living are extremely scarce. In a study of 54 women admitted to a day-care unit for this procedure, validated measures were utilized to assess the incidence, intensity and duration of pain after tubal ligation (McGill Pain Questionnaire) and the impact of pain on the activities of daily living (Modified Functional Assessment Inventory). Psychological measures (Brief Symptom Inventory, Kranz Health Opinion Survey, and the State-Trait Anxiety Inventory) were employed to test their use as possible predictors for pain, analgesic usage and the time taken to resume a normal activity level after tubal ligation surgery. The results showed that pain is a significant problem after tubal ligation although pain rating scores over the 7-day study period were lower than those reported after major abdominal surgery. Eighty-five percent of our sample reported that pain and/or fatigue impacted on their recovery and contributed to an average delay of return to normal activity level of 4.4 days, not including the day of surgery. The psychological measures did not prove to be strong predictors of postoperative pain, time of return to normal activity level or analgesic usage. The most powerful predictor of return to normal activity was the total amount of pain experienced, as measured by the McGill Pain Questionnaire, during the 7 day post-operative period.