Societal costs and quality of life of children suffering from attention deficient hyperactivity disorder (ADHD).

BACKGROUND: The impact of attention deficit hyperactive disorder (ADHD) in the Netherlands on health care utilisation, costs and quality of life of these children, as well as of their parents is unknown. OBJECTIVE: The aim of this study was to assess the direct medical costs of patients suffering from ADHD and their quality of life as well as the direct medical costs of their mothers. STUDY DESIGN: We selected a group of 70 children who were being treated by a paediatrician for ADHD based on the DSM-IV diagnostic criteria for ADHD. For comparison's sake, we also included a non-matched group of 35 children with behaviour problems and 60 children with no behaviour problem from a large school population-based study on the detection of ADHD. We collected information on the health care utilisation of the children applying the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness' (TiC-P). Their health related quality of life was collected by using the Dutch 50-item parent version of the Child Health Questionnaire (CHQ PF-50). Measurements were at baseline and at 6 months. Subsequently, we collected data on the health utilisation of the mothers and their production losses due to absence from work and reduced efficiency. RESULTS: The mean direct medical costs per ADHD patient per year were euro 2040 or euro 1173 when leaving out one patient with a long-term hospital admission, compared to euro 288 for the group of children with behaviour problems and euro 177 for the group of children with no behaviour problems. The direct medical costs for children who had psychiatric co-morbidities were significantly higher compared to children with ADHD alone. The mean medical costs per year for the mothers of the ADHD patients were significantly higher than for the mothers of the children with behaviour problems and the mothers of children with no behaviour problems respectively euro 728, euro 202 and euro 154. The physical summary score showed no significant differences between the groups. However, the score on the Psychosocial Summary Score dimension was significantly lower for ADHD patients compared to the scores of the children in the two other samples. The mean annual indirect costs due to absence from work and reduced efficiency at work were euro 2243 for the mothers of the ADHD patients compared to euro 408 for the mothers of children with behaviour problems and euro 674 for the mothers of children with no behaviour problems. CONCLUSION: Our study showed that the direct medical costs of ADHD patients were relatively high. Additionally, our study indicated that ADHD appears to be accompanied by higher (mental) health care costs for the mothers of ADHD patients and by increased indirect costs for this group.

Comparison of behavior modification with and without swaddling as interventions for excessive crying.

OBJECTIVE: To test the hypothesis that swaddling is an effective method to reduce crying, we compared a standardized approach of regularity and stimulus reduction with the same approach supplemented with swaddling. STUDY DESIGN: Healthcare nurses coached 398 excessively crying infants up to 12 weeks of age for 3 months. Outcome measurements were crying as measured by Barr's 24-hour diary and parental perception of crying. RESULTS: Crying decreased by 42% in both groups after the first intervention week. Swaddling had no added benefit in the total group. Young infants (1-7 weeks of age at randomization) benefited significantly more from swaddling as shown by a larger decrease of crying over the total intervention period. Older infants (8-13 weeks of age at randomization) showed a significantly greater decrease in crying when offered the standardized approach without swaddling. The actual difference in crying time was 10 minutes. CONCLUSION: For older babies, swaddling did not bring any benefit when added to regularity and stimuli reduction in baby care, although swaddling was a beneficial supplementation in excessively crying infants <8 weeks of age.

Infant care practices related to cot death in Turkish and Moroccan families in the Netherlands.

From 1979 to 1993 Turkish infants had a significantly higher cot death risk compared to Dutch infants. In contrast Moroccan infants had a risk of cot death that was approximately three times lower compared to Dutch infants during the same period. This study shows that these differences have disappeared, while differences still exist in infant care practices between these ethnic groups. At 28 well-baby clinics, questionnaires were distributed for this sample selection. The response was 82%. Data were collected on 55 Turkish, 54 Moroccan, and 210 Dutch families. Less than 7% of these three ethnic groups still placed infants in the prone position. Moroccan mothers hardly smoked. Turkish people used pillows and Moroccan people used soft mattresses more often. Moroccan families practised swaddling more widely. Length of maternal residence influenced some care giving practices. As a result of this study, subgroup specific intervention campaigns for safe sleeping can be developed for Turkish and Moroccan families.

[Medical education in the Netherlands: little attention paid to the cultural diversity of patients]. / Medisch onderwijs in Nederland: weinig aandacht voor culturele diversiteit van patiënten.

OBJECTIVE: To ascertain how much attention is given to cultural diversity in the eight medical faculties in Dutch universities. DESIGN: Interviews. METHOD: In the period January-June 2001 interviews were held with 76 people in medical faculties: policy makers, teachers and students. RESULTS: Medical courses scarcely devoted any attention to the fact that physicians need to deal with a multicultural society. Only the medical courses at the Free University of Amsterdam and Nijmegen University had included a compulsory module in this subject. The other universities were aiming for a more integrated treatment of the subject. However, for the time being, the acquisition of information about cultural diversity (specific diseases in different ethnic groups, different conceptions about health and disease and possibilities for solving communication problems) depended mainly on the personal interest of the teacher and the choices of the medical students. CONCLUSION: Cultural diversity receives little attention in the medical courses at the eight Dutch university medical faculties. A national approach to this problem is therefore recommended, with the setting up of an interfaculty workgroup to develop good teaching material on subjects related to cultural diversity.

Religious circumcision under local anaesthesia with a new disposable clamp.

OBJECTIVE: To compare the results using a new disposable clamp (the Taraklamp Circumcision Device, TCD, Taramedic Europe BV, Bilthoven, The Netherlands), used since 1998 in one clinic, and the conventional dissection technique (CDT) in another clinic, for religious circumcision in infants. SUBJECTS AND METHODS: The TCD and CDT were compared prospectively; the duration of the procedure, complications and postoperative pain were recorded. The cosmetic result and the degree to which the parents were satisfied were evaluated after 6 weeks. After obtaining informed consent, 275 boys were included in the study (median age 3 years). RESULTS: The median operative duration was 8 min less for the TCD (15 vs 7 min; P < 0.001). There was no difference in complication rate (bleeding in one vs two; infection in two vs three) and postoperative pain was comparable in both groups. The cosmetic results were better for the TCD group (P < 0.001). The parents' satisfaction score for the procedure was equal in the groups, at 8, on a scale of 1 (very bad) to 10 (extremely good). CONCLUSION: A religious circumcision outside the hospital with the TCD is quicker and leads to a better cosmetic result than with the CDT, without increasing morbidity.

Results of group-circumcision of Muslim boys in Malaysia with a new type of disposable clamp.

This study evaluates the safety and results of surgery usingTaraKlamp Circumcision Device during a group circumcision. Atotal of 64 circumcisions of Muslim boys were performed by Medical Assistants supervised by Medical Doctors in a hall in Kuala Lumpur, Malaysia. A new type disposable clamp was used, which was removed 4 days after the operation. No major complications occurred and the boys experienced in general mild pain postoperatively. Mostly good cosmetic results were obtained and 90% of the parents would recommend this new clamp to others. Group circumcisions withTaraKlamp Circumcision Device (Kuala Lumpur, Malaysia) are safe, although proper patient selection and adequate training in using the device are mandatory.

Gonadotrophin releasing hormone agonist treatment with or without recombinant human GH in adopted children with early puberty.

BACKGROUND: Early onset of puberty is frequently observed in adopted children. During treatment with a gonadotrophin releasing hormone agonist (GnRHa), a decrease in height velocity (HV) precludes height gain. OBJECTIVE AND DESIGN: We studied the effect of the addition of GH to GnRHa treatment in a 3-year prospective randomized trial in 30 adopted children with early puberty. PATIENTS: Mean age (SD) at start of treatment was 9.6 (0.9) years in girls and predicted adult height (PAH) using a segmented bone age (BA) assessment method was 148.0 (5.3) cm. RESULTS: HV decreased gradually in both groups with a higher HV in the group with GH addition (group B). No significant difference between the rates of bone maturation [change in bone age (DeltaBA)/change in chronological age (DeltaCA)] of both treatment groups was observed. After 3 years of treatment, PAH increase was 5.7 (3.8) cm in group A (GnRHa alone) and 10.1 (3.8) cm in group B (P < 0.01). IGF-I levels were higher in group B. HV decreased slowly in both groups during treatment, unlike stabilization of IGF-I levels. CONCLUSION: We conclude that, after 3 years of treatment, the addition of GH to GnRHa results in higher HV and a significant increase in PAH compared to GnRHa alone.

Intercultural training of medical students.

Until recently the Utrecht Medical School had a traditional curriculum with a predominantly biomedical orientation and strong emphasis on curative medicine. In 1997 an experimental 'Multi-cultural Family Attachment Course' started at the Utrecht Medical School with 20 second-year medical students. Each student was attached to a native Dutch and an ethnic minority family with a newborn or chronically ill child. In a period of 1.5 years students had to visit each family at home four times. The students monitored growth and development of the child and discussed several aspects of health and disease with the parents according to a structured schedule. In regular group sessions students reported back their experiences. In this way, the influence of socioeconomic circumstances, culture and environment on health becomes a real-life experience. This paper aims to describe some aspects of this pilot-course and the reactions of the students.

Influences of ethnicity on perinatal and child mortality in the Netherlands.

AIMS: To investigate the differences in perinatal death and child mortality between different ethnic groups in the Netherlands. METHODS: Retrospective analysis of data collected between 1990 and 1993 in the national obstetric registry comprising 569 743 births. Retrospective analysis of all death certificates of 0 to 15 year old children routinely collected between 1979 and 1993, comprising 20 211 deaths. RESULTS: Black mothers had the highest perinatal death rate compared with indigenous Dutch mothers (odds ratio 2.2). Hindustanis (West Indian Asians) had an odds ratio of 1.4 and Mediterraneans 1.3. The increased rate for black and Hindustani women could be fully explained by preterm birth. In the Mediterranean group the differences were explained by teenage pregnancy, grand multiparity, and socioeconomic status rather than prematurity. The death rate of Turkish and Moroccan children was twice as high as that of native Dutch children. For the different diagnostic categories this was: infectious diseases, relative risk (RR) 2.2; hereditary (metabolic) disorders, RR 2.0; accidents and drowning, RR 1.9. One quarter of the Turkish and Moroccan children died while on holiday in their country of origin. Sudden infant death syndrome was twice as high for Turkish infants as for Dutch children and four times higher than for Moroccan infants. CONCLUSION: Ethnic minorities in the Netherlands have a higher perinatal and child mortality rate than the indigenous Dutch. Apart from socioeconomic differences, sociocultural and lifestyle factors play an important role.

[Ethical shortcomings of skeletal age determination to establish minority for single young asylum seekers]. / Ethische tekortkomingen van het leeftijdsonderzoek ter beoordeling van minderjarigheid van alleenstaande asielzoekers.

Each year tens of thousands of asylum seekers from all over the world come to the Netherlands. Amongst them are minors who come alone. They are eligible for a separate, less severe, admittance procedure than for adults and their under-age children. Because of abuse of this procedure by adults an X-ray age examination of the claviculae and hand-wrist has been introduced to determine minority. A person who claims to be a minor but appears to be an adult is invited to submit to the examination on a 'voluntary' basis. The selection procedure, the informed consent, the voluntariness and the technical aspects of the age measurement suffer from ethical shortcomings. An ethical committee should ensure that the procedures conform to the generally accepted Dutch ethical principles laid down in the Dutch Medical Treatment Act. In addition, the selection of asylum seekers for age determination should be carried out by specialized officials (an alternative would be to subject all single minor asylum seekers to age measurement). The waiting time for age measurement should be reduced to prevent the medial clavicular epiphyseal disc from closing during the waiting time. Age should not be judged on the basis of a partially closed epiphyseal disc, as this is controversial. It is recommended that the age for the single minor asylum seeker regulation be reduced from 18 to 16 years.

Immunisation status of children adopted from China.

Many children adopted from China have antibody titres that do not correlate with those expected from their medical records. We have compared the concentrations of antibodies to poliomyelitis, diphtheria, and tetanus in children adopted from China, those adopted from other countries, and those vaccinated in the Netherlands and the UK. About 30% of children adopted from China did not have adequate protection from tetanus, diphtheria, or poliomyelitis, despite having complete vaccination recorded in their vaccination documents. These children, unlike those adopted from other countries who have documented evidence of adequate vaccination status, should be tested for antibody concentrations or reimmunised.

[Missed infections in immigrant children]. / Gemiste pathogenen bij immigrerende kinderen.

Three African children who migrated to the Netherlands developed serious infections after they arrived. The first patient, a girl of 3 years adopted from the Zaire, was discovered to be a chronic hepatitis B carrier. Advice to vaccinate her whole adoption family was not followed. Her adoptive mother became infected with hepatitis B. The second patient, an Ethiopian girl of 13 years, was not adequately screened for infections on arrival. She was a chronic hepatitis B carrier and infected her adoptive mother. Seven years later she developed pulmonary tuberculosis with cavity formation and infected four contacts. The third patient, a 15-year-old political refugee from Zaire, who developed paediatric aids and later died of it, was not screened according to the screening protocol advised for immigrating children. All immigrating children should be fully and adequately screened for infectious diseases upon arrival in the Netherlands.

[Medical care of underage refugees]. / De medische zorg voor jeugdige asielzoekers.

The growing number of people seeking asylum in the Netherlands compromises the provision of adequate medical services to all. This development may have a negative impact on refugee children especially. International literature indicates that many children, especially the ones coming from tropical areas or the ones who resided in refugee camps, are suffering from diseases such as tuberculosis, hepatitis B, anaemia, parasitic diseases, caries, malnutrition, hearing and seeing impairments. Many children have psychosocial problems due to traumatic experiences in their country of origin and/or during their flight. These problems lead to a diversity of complaints such as difficulty to sleep, enuresis, feeding problems and hyperactivity. Both the somatic and the psychosocial problems may impede the growth and development of these children. It is therefore imperative to identify the children at risk and to formulate guidelines for providing medical care to refugee children. Special care should also be given to the housing, the living conditions and the provision of specialised personnel and to limiting the duration of the asylum procedure in the case of families with children and other minors.

[Good results from circumcisions of Muslim boys performed outside the hospital]. / Gunstige resultaten bij circumcisie van moslimjongens buiten het ziekenhuis.

OBJECTIVE: To describe the experience with circumcision of Moslem boys under local anaesthesia outside the hospital. DESIGN: Prospective, descriptive. METHOD: A total of 94 circumcisions under local anaesthesia were performed from April through November 1997 in a Health Centre of the Municipal Health Service, Utrecht, the Netherlands. Pain and unrest of the boys were scored on a scale from 1 to 10 by the operating surgeon (1 = no pain/patient fully calm; 10 = unbearable pain/patient in panic). Postoperative follow-up was only done on request of the parents/fosterers. The reasons for these follow-ups were recorded. One week after the circumcision the parents/fosterers were asked if there were any complications and whether they were satisfied with this method. RESULTS: The median age was 3 years (range: 2-24). The pain during the operation was scored by the surgeon with a median of 1 (1-6) while unrest scored a median of 3 (1-9). Thirteen children were seen again because of bleeding (n = 4), haematoma (n = 2), swelling (n = 7). One week after the operation 89% of 70 parents/fosterers interviewed by telephone were content with the treatment. The social aspect of this way of circumcision was much appreciated. CONCLUSION: Circumcisions under local anaesthesia outside the hospital are feasible. Complications were according to published figures and most parents were content. With this procedure a cost reduction of 70% may be achieved in comparison with clinically performed circumcision under general anaesthesia.

[Genetic carrier screening for hemoglobinopathies in the Netherlands is not opportune]. / Screening op dragerschap van hemoglobinopathieën in Nederland niet opportuun.

OBJECTIVE: To investigate whether screening for carriership of sickle-cell anaemia and thalassaemia is desirable in the Netherlands, given the prevalence of the diseases, the possibilities of a screening test and the knowledge of the population at risk. DESIGN: Descriptive. SETTING: Wilhelmina Children's Hospital, Clinical Genetic Centre, Utrecht, the Netherlands. METHODS: In September 1992 Dutch paediatricians were treating 128 children with sickle-cell anaemia and 31 with thalassaemia major. Between October 1992 and December 1994, sickle-cell anaemia was diagnosed in 40 children and thalassaemia major in 14; of these, 16 and 4, respectively, had been born in the Netherlands. A protocol for the screening for carriership adjusted to the Dutch situation was drawn up in the past, with an estimate of the corresponding costs. Patients with sickle-cell anaemia or thalassaemia major, their families, care givers and persons without disease but originating from Surinam, the Netherlands Antilles, Turkey or Morocco were interviewed about their knowledge of these two diseases. RESULTS: The knowledge of the diseases was low among the Turkish and Moroccan populations, and very global among the Surinamese and Antillian populations. There was more belief in supernatural causes than in a genetic predisposition. CONCLUSION: Given the low number of newly diagnosed haemoglobinopathies in children born in the Netherlands, the poor knowledge of the disease of the population at risk, the difficulty in identifying the best moment in life for screening and the rather complicated screening method, a screening programme for carriership of haemoglobinopathies in the Netherlands is not opportune. Where sickle-cell anaemia is concerned, screening for this disease during the neonatal period might be considered.

Perinatal death in ethnic minorities in The Netherlands.

OBJECTIVES: To investigate differences in perinatal death rate and associated obstetric risk factors between ethnic groups in the Netherlands. DESIGN: Retrospective cohort study based on the 1990-1993 birth cohorts in the National Obstetric Registry. SUBJECTS: 569,743 births of which 85,527 were for women belonging to ethnic minorities. MAIN OUTCOME MEASURES: Perinatal death occurring between 16th week of pregnancy and 24 hours after birth. METHOD: Bivariate and multivariate analysis of perinatal death rate per ethnic group. A total of 42,282 women living in the three main cities of the Netherlands were classified on the basis of postal code districts into four socioeconomic (SES) classes for analysis of the relation between SES, perinatal death, and preterm birth. RESULTS: Black mothers had the highest perinatal death rate compared with indigenous Dutch (odds ratio 2.2, 95% CI 1.9, 2.4) followed by a group "others", consisting of women of mixed or unknown ethnicity (odds ratio 1.8, 95% CI 1.5, 2.0), Hindustani (odds ratio 1.4, 95% CI 1.2, 1.6), and Mediterraneans (odds ratio 1.3, 95% CI 1.2, 1.4). Asians (excluding West Indian Asians) and non-Dutch Europeans did not have higher rates than Dutch women. The increased rates of black and Hindustani women could be explained fully and that of the group "others" partially by higher rates of preterm birth. Controlling for age and parity lowered the odds ratio of the Mediterraneans slightly. The risk of ethnicity was independent of SES. CONCLUSION: Ethnic minorities in the Netherlands except immigrants from Asia and other European countries have higher rates of perinatal death than indigenous Dutch women. With a twofold increase, black women had the highest rate, which was related to an equally large increased rate of preterm birth.

The burden of nocturnal enuresis.

Nocturnal enuresis is a well-known "low-severity high-prevalence" condition in paediatrics, with extensive psychosocial suffering. This suffering is not always realized by paediatricians and other professionals. The aim of this study is to show that enuresis not only has an impact on the child, but also frustrates the entire family. The literature shows that nocturnal enuresis causes distress and low self-esteem for the child. It also has major social and economic implications for the family, with an increasing intolerance as the child grows older. An analysis of nine studies on the impact of successful treatment on the psychological condition of enuretic children showed improved behaviour and personality scores. In five studies the improvement in mental health was significantly related to treatment success. Timely treatment will prevent psychosocial damage, favour a normal development of the child and bring practical relief to the family.

[Bedwetting by Dutch, Surinam, Moroccan and Turkish 3-4, 5-6, and 11-12-year-old children]. / Bedplassen bij Nederlandse, Surinaamse, Marokkaanse en Turkse kinderen van 3-4, 5-6 en 11-12 jaar.

OBJECTIVE: To investigate whether ethnic origin is related to the prevalence of bedwetting among children and how parents handle bedwetters. DESIGN: Descriptive study. SETTING: Department of Youth Health Care in Amsterdam, the Netherlands. METHOD: Parents of children who attended a child health centre in 1992/1993 were interviewed using a questionnaire. A total of 1506 children aged 3-4, 2422 aged 5-6 and 2081 aged 11-12 years participated in the study. RESULTS: The prevalences of bedwetting were 24.6%, 15.7% and 5.4% at 3-4, 5-6 and 11-12 years of age respectively. Moroccan and Turkish 3-4-year-olds wet their beds just as often as Dutch children, Surinamese 3-4-year-olds less often. However, Surinamese, Moroccan and Turkish school children wet their beds more often than their Dutch classmates. For Dutch children the prevalence of bedwetting at the age of 5-6 was clearly lower than at the age of 3-4, in contrast with Surinamese, Moroccan and Turkish children. Non-Dutch bedwetters were rewarded less often for a dry night and punished more often for a wet night than Dutch bedwetters, even at the age of 3-4. CONCLUSION: Bedwetting by school children still occurs often, and more often among non-Dutch than among Dutch children. Possibly, differences between Dutch and non-Dutch parents in the ways they deal with bedwetting plays a part. Appropriate information and support of (especially non-Dutch) parents of young children can perhaps reduce the prevalence of bedwetting at later ages.

[Congenital syphilis as an imported disease]. / Congenitale lues als importziekte.

Two infants, a two-month-old boy and a two-month-old girl adopted from Sri Lanka, were diagnosed as having congenital syphilis and treated accordingly. The girl presented with only skin symptoms and a developing pseudoparalysis of Parrot. The boy was in quite a bad condition, having rhinitis, an oedematous appearance, skin symptoms, severe anaemia and hepatosplenomegaly. In both patients serological blood tests and cerebrospinal fluid tests for lues were positive. Both children showed osteochondritis and periostitis of the long bones on X-rays. This disease is rare in the Netherlands, but it is important to diagnose it early, because early adequate treatment may result in complete cure.