Mental health-related quality of life in mothers of children with surgically repaired congenital heart disease: a 13-year longitudinal study.

AIMS: Having a child with congenital heart disease (CHD) can affect parental health-related quality of life (HR-QoL). We investigated the long-term trajectories of mental HRQoL (m-HRQoL) in mothers of children with CHD and examined risk factors for persistent low m-HRQoL. METHODS: One hundred twenty-five mothers of children with CHD completed a standardized questionnaire on m-HRQoL (mental subscale SF-12) after the children's first open-heart surgery and subsequently when the children were 1, 4, 6, 10, and 13 years old. A z-score for m-HRQoL was calculated with national norms. Latent class growth analysis (LCGA) was used to identify subgroups of mothers with regards to their m-HRQoL trajectories over time. Regression analysis investigated predictors for chronically low m-HRQoL. RESULTS: Compared to norms, mothers of children with CHD had significantly lower m-HRQoL immediately after open-heart surgery (ß = -0.30 (CI-95: -0.44, -0.15)). Subsequently, m-HRQoL increased to a normal level (m-HRQoL compared to the norm from 1 to 13 years: ß ranges between 0.05 and 0.27). LCGA revealed two distinct groups of m-HRQoL trajectories: A group with normal m-HRQoL (75% of mothers, means z-scores range between - 0.76 and 0.62) and a group with chronically low m-HRQoL (25% of mothers, mean z-scores range between -1.32 and -0.10). Chronically, low m-HRQoL was associated with poorer social support (OR = 3.39 (CI-95: 1.40, 8.49), p = 0.008) but not with parental education, migration background, number of open-heart surgeries, diagnosis of a univentricular CHD, or low IQ. CONCLUSION: A quarter of mothers of children with CHD have chronically low m-HRQoL throughout their child's development, especially those mothers with poor social support. Further studies of family-oriented approaches are needed to identify and support these mothers and reinforce parental well-being.

Mental sequelae of the COVID-19 pandemic in children with and without complex medical histories and their parents: well-being prior to the outbreak and at four time-points throughout 2020 and 2021.

The objective of this study is to understand the long-term mental sequelae for families over the course of the COVID-19 pandemic by longitudinally investigating the well-being of children with and without complex medical histories and their parents. Well-being of 200 children (between 7 and 18 years of age; 73 typically developing, 46 born very preterm, 73 with complex congenital heart disease) and 175 of their parents was assessed prior to and during the first (April-May 2020), second (October-November 2020), third (April-May 2021), and fourth wave (October-November 2021) of the pandemic with standardized questionnaires. Linear mixed models were used to investigate longitudinal changes in child and parent well-being compared to before the pandemic. Social and COVID-19-specific determinants were investigated as predictors of impaired well-being. To illustrate clinical relevance, the proportion of children and parents scoring > 1 SD below normative mean/median was reported. Compared to before the pandemic, child proxy-reported well-being was lower during the first but not the second, third, and fourth waves. Child self-reported well-being was not lower during the pandemic compared to before. Parent well-being dropped during the first wave and remained low throughout the subsequent waves. Proxy-reported child and self-reported parent well-being was lower in families with sparse social support and poor family functioning. Parents of typically developing children reported lower well-being than parents of children born very preterm or with a complex congenital heart disease. In November 2021, 20% of children (both self- and proxy-report) and 24% of parents scored below the normal range compared to 11% (child self-report), 10% (child proxy-report), and 16% (parent self-report), respectively, before the pandemic. The pandemic continues to impact the well-being of parents of school-aged children with and without complex medical histories more than 1 year after its outbreak. Children's well-being was specifically affected during the first wave of the pandemic and has recovered thereafter. Families with sparse social support and poor family functioning are particularly at risk for compromised well-being and support should be provided to them.

No wrong decisions in an all-wrong situation. A qualitative study on the lived experiences of families of children with diffuse intrinsic pontine glioma.

BACKGROUND: Diffuse intrinsic pontine glioma (DIPG) is a rare, but lethal pediatric brain tumor with a median survival of less than 1 year. Existing treatment may prolong life and control symptoms, but may cause toxicity and side effects. In order to improve child- and family-centered care, we aimed to better understand the treatment decision-making experiences of parents, as studies on this topic are currently lacking. PROCEDURE: The data for this study came from 24 semistructured interviews with parents whose children were diagnosed with DIPG in two children's hospitals in Switzerland and died between 2000 and 2016. Analysis of the dataset was done using reflexive thematic analysis. RESULTS: For most parents, the decision for or against treatment was relatively straightforward given the fatality of the tumor and the absence of treatment protocols. Most of them had no regrets about their decision for or against treatment. The most distressing factor for them was observing their child's gradual loss of independence and informing them about the inescapability of death. To counter this powerlessness, many parents opted for complementary or alternative medicine in order to "do something." Many parents reported psychological problems in the aftermath of their child's death and coping strategies between mothers and fathers often differed. CONCLUSION: The challenges of DIPG are unique and explain why parental and shared decision-making is different in DIPG compared to other cancer diagnoses. Considering that treatment decisions shape parents' grief trajectory, clinicians should reassure parents by framing treatment decisions in terms of family's deeply held values and goals.

Sexualized Behavior Among Adolescents Who Sexually Offended.

Early or excessive sexualized behaviors and preoccupations with sexuality (SB) exhibited by juveniles who have sexually offended (JSO) are considered risk factors for sexual recidivism. However, research into SB among JSO is scarce. The present study retrospectively examined prevalence rates and patterns of SB among JSO prior to sexual offending and their relation to psychopathology and sexual recidivism. We systematically assessed information from psychiatric and psychological expert reports in case files of 230 JSO aged 12-18 years (M = 14.46, SD = 1.49) from a population sample of JSO with contact sexual offenses. A total of 93 (40.4%) JSO exhibited SB prior to the index sexual offense. Latent class analysis revealed three SB profiles: (1) "low/no SB" (n = 188), (2) "preoccupied SB" (preoccupation with sexuality, e.g., early pornography consumption, excessive masturbation; n = 29), and (3) "dysregulated SB" (exhibiting inappropriate sexualized behaviors toward others, e.g., sexualized speech, touching others inappropriately; n = 13). The preoccupied SB and the dysregulated SB groups showed higher prevalence of psychiatric disorders than the low/no SB. However, none of the JSO of the preoccupied SB or dysregulated SB groups reoffended sexually within 365 days after conviction for the sexual index offense (low/no SB: 12.8%). Overall, our findings do not support a general notion of the presence of SB as an indicator of high risk for persistent sexual offending among JSO. Instead, JSO with SB appear particularly burdened regarding a range of psychiatric disorders that should be treated accordingly.

Health-related quality of life in paediatric patients with intoxication-type inborn errors of metabolism: Analysis of an international data set.

Acute intoxication-type inborn errors of metabolism (IT-IEM) such as urea cycle disorders and non-acute IT-IEM such as phenylketonuria have a major impact on paediatric patients' life. Patients have to adhere to a strict diet but may face neurocognitive impairment and - in acute diseases - metabolic decompensations nevertheless. Research on the subjective burden of IT-IEM remains sparse. Studies with appropriate sample sizes are needed to make valid statements about health-related quality of life (HrQoL) in children and adolescents with IT-IEM. Six international metabolic centres contributed self-reports and proxy reports of HrQoL (assessed with the Paediatric Quality of Life Inventory) to the final data set (n = 251 patients; age range 2.3-18.8 years). To compare HrQoL of the patient sample with norm data and between acute and non-acute IT-IEM, t tests were conducted. To examine the influence of child age, sex, diagnosis and current dietary treatment on HrQoL, multiple linear regression analyses were conducted. Self-reports and proxy reporst showed significantly lower HrQoL total scores for children with IT-IEM compared to healthy children. Current dietary treatment significantly predicted lower proxy reported total HrQoL. Children with non-acute IT-IEM reported significantly lower psychosocial health and emotional functioning than children with acute IT-IEM. The patient sample showed significantly impaired HrQoL and a diet regimen remains a risk factor for lower HrQoL. Differences in HrQoL between acute and non-acute IT-IEM subgroups indicate that factors beyond symptom severity determine the perception of disease burden. Identifying these factors is of crucial importance to develop and implement appropriate interventions for those in need.

Topical Review: Medical Trauma During Early Childhood.

OBJECTIVE: Early childhood is a high-risk period for exposure to traumatic medical events due to injury/illness. It is also one of the most important and vulnerable periods due to rapid development in neurobiological systems, attachment relationships, cognitive and linguistic capacities, and emotion regulation. The aim of this topical review is to evaluate empirical literature on the psychological impact of medical trauma during early childhood (0-6 years) to inform models of clinical care for assessing, preventing, and treating traumatic stress following injury/illness. METHODS: Topical review of empirical and theoretical literature on pediatric medical traumatic stress (PMTS) during early childhood. RESULTS: There are important developmental factors that influence how infants and young children perceive and respond to medical events. The emerging literature indicates that up to 30% of young children experience PMTS within the first month of an acute illness/injury and between 3% and 10% develop posttraumatic stress disorder. However, significant knowledge gaps remain in our understanding of psychological outcomes for infants and young children, identification of risk-factors and availability of evidence-based interventions for medical trauma following illness. CONCLUSIONS: This topical review on medical trauma during early childhood provides: (a) definitions of key medical trauma terminology, (b) discussion of important developmental considerations, (c) summary of the empirical literature on psychological outcomes, risk factors, and interventions, (d) introduction to a stepped-model-of-care framework to guide clinical practice, and (e) summary of limitations and directions for future research.

Validity of Risk Assessment Instruments Among Juveniles Who Sexually Offended: Victim Age Matters.

Research has identified meaningful subtypes among the heterogeneous population of juveniles who sexually offended (JSO). However, studies that test the validity of risk assessment tools with JSO subtypes are limited. This study compared JSO who offended against a child victim (JSO-C) and JSO who offended against an adolescent/adult victim (JSO-A) with regard to rates of recidivism and the predictive validity of two risk assessment tools (Estimate of Risk of Adolescent Sexual Offense Recidivism [ERASOR] and Juvenile Sexual Offender Assessment Protocol-II [J-SOAP-II]). Data were analyzed from case files of 185 JSO-C and 297 JSO-A aged 12 to 18 years (M = 14.11, SD = 1.44) from a consecutive sample of JSO with contact sexual offenses. A total of 34 (7.1%) juveniles reoffended sexually, with no significant difference between the subtypes. The present results suggest that the ERASOR, particularly the structured professional judgment, and to a lesser degree the J-SOAP-II are better suited to predicting sexual recidivism in JSO-A than in JSO-C.

Preventive intervention for trauma reactions in young injured children: results of a multi-site randomised controlled trial.

BACKGROUND: Young children are at particular risk for injury. Ten per cent to twenty-five per cent develop posttraumatic stress disorder (PTSD). However, no empirically supported preventive interventions exist. Therefore, this study evaluated the efficacy of a standardised targeted preventive intervention for PTSD in young injured children. METHODS: Injured children (1-6 years) were enrolled in a multi-site parallel-group superiority prospective randomised controlled trial (RCT) in Australia and Switzerland. Screening for PTSD risk occurred 6-8 days postaccident. Parents of children who screened 'high-risk' were randomised to a 2-session CBT-based intervention or treatment-as-usual (TAU). Primary outcomes were PTSD symptom (PTSS) severity, and secondary outcomes were PTSD diagnosis, functional impairment and behavioural difficulties at 3 and 6 months postinjury using blinded assessments. Trials were registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000325606) and ClinicalTrials.gov (NCT02088814). Trial status is complete. RESULTS: One hundred and thirty-three children screened 'high-risk' were assigned to intervention (n = 62) or TAU (n = 71). Multilevel intention-to-treat analyses revealed a significant intervention effect on PTSS severity over time (b = 60.06, 95% CI: 21.30-98.56). At 3 months, intervention children (M = 11.02, SD = 10.42, range 0-47) showed an accelerated reduction in PTSS severity scores compared to control children (M = 17.30, SD = 13.94, range 0-52; mean difference -6.97, 95% CI: -14.02 to 0.08, p adj. = .055, d = 0.51). On secondary outcomes, multilevel analyses revealed significant treatment effects for PTSD diagnosis, functional impairment and behavioural difficulties. CONCLUSIONS: This multi-site RCT provides promising preliminary evidence for the efficacy of a targeted preventive intervention for accelerating recovery from PTSS in young injured children. This has important clinical implications for the psychological support provided to young children and parents during the acute period following a single-event trauma.

Dysfunctional posttraumatic cognitions, posttraumatic stress and depression in children and adolescents exposed to trauma: a network analysis.

BACKGROUND: The latest version of the International Classification of Diseases (ICD-11) proposes a posttraumatic stress disorder (PTSD) diagnosis reduced to its core symptoms within the symptom clusters re-experiencing, avoidance and hyperarousal. Since children and adolescents often show a variety of internalizing and externalizing symptoms in the aftermath of traumatic events, the question arises whether such a conceptualization of the PTSD diagnosis is supported in children and adolescents. Furthermore, although dysfunctional posttraumatic cognitions (PTCs) appear to play an important role in the development and persistence of PTSD in children and adolescents, their function within diagnostic frameworks requires clarification. METHODS: We compiled a large international data set of 2,313 children and adolescents aged 6 to 18 years exposed to trauma and calculated a network model including dysfunctional PTCs, PTSD core symptoms and depression symptoms. Central items and relations between constructs were investigated. RESULTS: The PTSD re-experiencing symptoms strong or overwhelming emotions and strong physical sensations and the depression symptom difficulty concentrating emerged as most central. Items from the same construct were more strongly connected with each other than with items from the other constructs. Dysfunctional PTCs were not more strongly connected to core PTSD symptoms than to depression symptoms. CONCLUSIONS: Our findings provide support that a PTSD diagnosis reduced to its core symptoms could help to disentangle PTSD, depression and dysfunctional PTCs. Using longitudinal data and complementing between-subject with within-subject analyses might provide further insight into the relationship between dysfunctional PTCs, PTSD and depression.

Mind the treatment gap: the prevalence of common mental disorder symptoms, risky substance use and service utilization among young Swiss adults.

BACKGROUND: Common mental disorders (CMDs) are highly prevalent and contribute significantly to the global burden of disease, yet there is evidence of a large treatment gap. We aimed to quantify this gap among young adults with symptoms of CMDs and examine the relationship between substance use and perceived need for care and mental health service utilization. METHODS: In a nationally representative, cross-sectional survey of young Swiss adults' mental health and wellbeing, we assessed symptoms of anxiety, depression, and attention deficit hyperactivity disorder (ADHD) with widely used screening instruments and asked about participant suicidal ideation, suicide attempts, mental health-related quality of life, alcohol and drug use, perceived need for mental health care, and mental health service utilization. We used these variables to calculate the treatment gap and weighted all analyses according to the stratified sampling plan. RESULTS: Around a quarter of young adults screened positive for at least one CMD. Participants who screened positive for anxiety and/or depression reported significantly more suicidal ideation and lifetime suicide attempts and reported worse mental health-related quality of life than participants who did not screen positive for a disorder. Women's prevalence of anxiety and depression symptoms was significantly higher than men's, while men were more likely to report most types of risky drug use. Among those with a CMD, only around half perceived lifetime need for care, and less than 20% reported currently utilizing mental health services. Young adults with a CMD reporting risky weekly use of alcohol were less likely to be currently using services. CONCLUSION: The high prevalence of CMD symptoms could reflect a rising prevalence of these disorders mirroring increasing trends observed in other countries. To address the large treatment gap, interventions promoting mental health literacy and more research on additional barriers to inform further interventions are needed.

A step beyond the hygiene hypothesis-immune-mediated classes determined in a population-based study.

BACKGROUND: Comorbidity patterns of childhood infections, atopic diseases, and adverse childhood experiences (ACE) are related to immune system programming conditions. The aim of this study was to make a step beyond the hygiene hypothesis and to comprehensively classify these patterns with latent class analysis (LCA). A second aim was to characterize the classes by associations with immunological, clinical, and sociodemographic variables. METHODS: LCA was applied to data from the CoLaus|PsyCoLaus study (N = 4874, age range 35-82 years) separately for men and women. It was based on survey information on chickenpox, measles, mumps, rubella, herpes simplex, pertussis, scarlet fever, hay fever, asthma, eczema, urticaria, drug allergy, interparental violence, parental maltreatment, and trauma in early childhood. Subsequently, we examined how immune-mediated classes were reflected in leukocyte counts, inflammatory markers (IL-1ß, IL-6, TNF-α, hsCRP), chronic inflammatory diseases, and mental disorders, and how they differed across social classes and birth cohorts. RESULTS: LCA results with five classes were selected for further analysis. Latent classes were similar in both sexes and were labeled according to their associations as neutral, resilient, atopic, mixed (comprising infectious and atopic diseases), and ACE class. They came across with specific differences in biomarker levels. Mental disorders typically displayed increased lifetime prevalence rates in the atopic, the mixed, and the ACE classes, and decreased rates in the resilient class. The same patterns were apparent in chronic inflammatory diseases, except that the ACE class was relevant specifically in women but not in men. CONCLUSIONS: This is the first study to systematically determine immune-mediated classes that evolve early in life. They display characteristic associations with biomarker levels and somatic and psychiatric diseases occurring later in life. Moreover, they show different distributions across social classes and allow to better understand the mechanisms beyond the changes in the prevalence of chronic somatic and psychiatric diseases.

Predictors of Health-related Quality of Life and Psychological Adjustment in Children and Adolescents With Congenital Melanocytic Nevi: Analysis of Parent Reports.

Objectives This cross-sectional study assessed health-related quality of life (HRQOL) and psychological adjustment in children and adolescents affected by congenital melanocytic nevi (CMN) and identified potential predictors of adjustment. Methods Participants were recruited worldwide with the help of patient organizations. Data were obtained from parents of 235 children affected by CMN, aged between 1 month and 18 years (M = 6.3 y; SD = 5.0 y), using a web-based survey. Measures included the Pediatric Quality of Life InventoryTM 4.0 and the Strengths and Difficulties Questionnaire. Sample scores were compared to normative data. Demographic characteristics as well as CMN-related variables were examined as possible predictors of outcome, using multivariate analyses. Results Parents of children and adolescents born with a CMN reported significantly lower HRQOL and somewhat higher emotional and behavioral problems compared to community norms. Impairments in HRQOL and psychological adjustment were predicted by lower socioeconomic status, neurological problems, skin-related discomfort (e.g., itch or pain), and perceived stigmatization. The size of the CMN and whether or not the CMN had been (partially) removed by surgery were no significant predictors. The relationship between visibility of the skin lesion and psychological adjustment and psychosocial health was found to be mediated by perceived stigmatization. Conclusions In children and adolescents affected by CMN, those experiencing neurological problems, skin-related discomfort or high levels of perceived stigmatization are particularly vulnerable for impaired HRQOL and psychological maladjustment and therefore might need special monitoring and support.

Child neglect and its relation to emotional and behavioral problems: A cross-sectional study of primary school-aged children in Tanzania.

Child maltreatment is known to engender negative emotional and behavioral consequences. Although neglect is the most frequent form of maltreatment, it has thus far only received little attention, especially when looking at low-resource countries. The current study investigated possible associations between neglect and internalizing and externalizing problems. As neglect and abuse often co-occur, the latter was controlled for. In total, 409 Tanzanian primary school students (52% boys, M = 10.5 years, range = 6-15) participated in the cross-sectional study. Structured clinical interviews were conducted assessing maltreatment, internalizing problems, and externalizing problems. Overall, 31% (n = 128) of the children reported at least one type of physical neglect and 31% (n = 127) of emotional neglect. Using structural equation modeling, we found a significant association between neglect and internalizing (ß = 0.59, p < .01) and externalizing problems (ß = 0.35, p < .05). However, these associations could only be detected in younger children (ages 6-9), whereas in older children (ages 10-15), mental health problems were significantly related to violence and abuse. Our findings suggest that the current age may influence the association between maltreatment type and the development of internalizing and/or externalizing problems.

Health-related quality of life in pre-school age children with single-ventricle CHD.

BACKGROUND: Little is known about health-related quality of life in young children undergoing staged palliation for single-ventricle CHD. The aim of this study was to assess the impact of CHD on daily life in pre-schoolers with single-ventricle CHD and to identify determinants of health-related quality of life. METHOD: Prospective two-centre cohort study assessing health-related quality of life using the Preschool Paediatric Cardiac Quality of Life Inventory in 46 children at a mean age of 38 months and 3 weeks. Children with genetic anomalies were excluded. Scores were compared with reference data of children with biventricular CHD. Multiple linear regression analysis was used to identify determinants of health-related quality of life. RESULTS: Health-related quality of life in pre-schoolers with single-ventricle CHD was comparable to children with biventricular CHD. Preterm birth and perioperative variables were significant predictors of low health-related quality of life. Notably, pre-Fontan brain MRI findings and neurodevelopmental status were not associated with health-related quality of life. Overall, perioperative variables explained 24% of the variability of the total health-related quality of life score.InterpretationDespite substantial health-related burden, pre-schoolers with single-ventricle CHD showed good health-related quality of life. Less-modifiable treatment-related risk factors and preterm birth had the highest impact on health-related quality of life. Long-term follow-up assessment of self-reported health-related quality of life is needed to identify patients with poorer health-related quality of life and to initiate supportive care.

Combined nitrous oxide 70% with intranasal fentanyl for procedural analgosedation in children: a prospective, randomised, double-blind, placebo-controlled trial.

OBJECTIVE: Nitrous oxide 70% (N2O 70%) is an excellent medication for procedural analgosedation (PAS), yet the limit of its analgesic power remains uncertain; therefore, a combination with intranasal fentanyl (INF) was suggested. However, this combination seems to result in a higher rate of vomiting and deeper sedation. This study aimed at assessing the analgesic efficacy, sedation depth and rate of adverse events of PAS with N2O 70% with and without INF. METHODS: Patients aged 2-16 years who qualified for PAS with N2O 70% were randomly assigned to receive either INF or placebo prior to N2O inhalation in this randomised, double-blind study, which was performed in a tertiary children's hospital ED between September 2015 and October 2017. Behaviour during the procedure was evaluated using the Face, Leg, Activity, Cry and Consolability (FLACC) scale and the Modified Behavioural Pain Scale (MBPS); analgesic efficacy was assessed with a self-reported pain scale. Sedation depth using the validated University of Michigan Sedation Scale and adverse events in the ED and during the following 12 hours were documented. RESULTS: A total of 402 patients were included; 3 did not tolerate N2O and therefore had to be excluded. Overall, 399 patients were analysed, of whom 201 (50.4%) received INF. No significant group differences with regard to FLACC scale score, self-reported pain, MBPS score and sedation depth were found. In addition, the two groups did not differ with regard to all types of adverse events. CONCLUSION: Combining N2O 70% with INF resulted in no differences with regard to FLACC scale score, self-reported pain, MBPS score, patient and parental satisfaction rate, sedation depth, and adverse events. TRIAL REGISTRATION NUMBER: NCT02533908.

Nitrous Oxide 70% for Procedural Analgosedation in a Pediatric Emergency Department-With or Without Intranasal Fentanyl?

OBJECTIVES: Nitrous oxide 70% (N20 70%) is an excellent medication for procedural analgosedation in a pediatric emergency department. However, its analgesic efficacy remains uncertain for painful procedures; therefore, a combination with intranasal fentanyl (INF), an opioid, was suggested. This study aimed at observing and assessing the analgesic efficacy and rate of adverse events using N20 70% with and without INF. METHODS: Children who received N20 70% in a tertiary children's hospital emergency department from January 1, 2014 to June 30, 2015 were included in this observational study with prospective data collection. Physicians decided individually whether INF was administered. Medical staff documented the child's behavior during the procedure, adverse events, and satisfaction rate. RESULTS: A total of 442 children were included; 206 (46.6%) received INF. Group differences regarding patient behavior were not statistically significant; however, N20 70% application time was longer in the INF group (P = .02). Nausea was the most frequent adverse event with 13.1% in the INF group versus 8.1% without INF. Inadequate procedural analgosedation was documented only in the INF group, affecting 1.8% of all patients (P = .002). In contrast, anxiety was exclusively observed in the group without INF, which was presumably misjudged pain (P = .03); the satisfaction rate in the INF group was 95.6% compared with 98.7% without INF. CONCLUSIONS: Because of the study design and limitations, no conclusions about adding INF to N20 70% can be made. Additional research is needed to investigate the effect of combining N20 70% with INF.

Emotions experienced during the shedding of the first primary tooth.

AIM: To examine the different emotions expressed by children exfoliating their first primary tooth, evaluate their proportional distribution, and reveal possible influences of child- and parent-related variables on the reported emotions. DESIGN: A cross-sectional questionnaire was directed to parents of children who had recently shed at least one primary tooth. Primary outcome variables were the child's emotions at the time of exfoliation. Child-related determinants were sex, duration of tooth wiggle, previous accident- or caries-related visits at dentist, and having witnessed tooth exfoliation in older siblings. Parent-related determinants included socio-economic variables (education, religion, country of origin). RESULTS: One thousand two hundred and seventy-four of 3617 questionnaires were returned and analysed (35.2%). 82.0% of the parents reported positive, and 22.0% negative emotions in their child. Previous caries-related visits at the dentist diminished the likelihood of positive emotions (OR = 0.65), and accident-related visits increased the odds of positive emotions (OR = 1.57), as did an extended duration of tooth wiggle (OR = 1.98). Higher education of mothers (OR = 2.89) and fathers (OR = 1.96) and an origin from non-Western countries (OR = 2.56 and OR = 1.85, respectively) were also related to positive emotions. CONCLUSIONS: For most children, losing the first primary tooth is associated with positive emotions. Dental visits and parental factors influence these emotions. Parents and dentists should be aware of their impact on children's emotional development.

The impact of ammonia levels and dialysis on outcome in 202 patients with neonatal onset urea cycle disorders.

Neonatal onset hyperammonemia in patients with urea cycle disorders (UCDs) is still associated with high morbidity and mortality. Current protocols consistently recommend emergency medical and dietary management. In case of increasing or persistent hyperammonemia, with continuous or progressive neurological signs, dialysis is performed, mostly as ultima ratio. It is presently unknown whether the currently defined ammonia threshold (e.g., at 500 µmol/L) to start dialysis is useful to improve clinical outcome. A systematic review of clinical and biochemical data from published neonatal onset UCD patients was performed to identify factors determining clinical outcome and to investigate in which clinical and biochemical setting dialysis was most effective. A total of 202 patients (118 proximal and 84 distal UCDs) described in 90 case reports or case series were included according to predefined inclusion/exclusion criteria. Median age at onset was three days and mean ammonia that triggered start of dialysis was 1199 µmol/L. Seventy-one percent of all patients received any form of dialysis. Total mortality was 25% and only 20% of all patients had a "normal" outcome. In general, patients with higher ammonia levels were more likely to receive dialysis, but this had for most patients no influence on outcome. In conclusion, in severe neonatal onset hyperammonemia, the current practice of dialysis, which effectively clears ammonia, had no impact on outcome. It may be essential for improving outcome to initiate all available treatment options, including dialysis, as early as possible.

PTSD in Children Below the Age of 6 Years.

PURPOSE OF REVIEW: This review summarizes the latest evidence and developments in the validation of PTSD diagnostic criteria for children 6 years and under (PTSD<6Y), discusses the limitations of the current diagnostic criteria, and highlights areas for future research. RECENT FINDINGS: Research has found that the DSM-5 PTSD<6Y, and a similar version in the DC:0-5, currently provides the most developmentally sensitive classification of PTSD for young children. In contrast, preliminary evidence suggests that the ICD-11 criteria might not appropriately capture PTSD in young children. The inclusion of PTSD<6Y, the first developmental subtype in the DSM-5, represents an important step towards having a diagnostic system that is developmentally sensitive and relevant across the life span. However, further validation work and research with regard to the definition of trauma and functional impairment as well as with the age-appropriate description of symptoms is needed, especially in the youngest age group (0-3 years).

Posttraumatic Stress Disorder in Very Young Children: Diagnostic Agreement Between ICD-11 and DSM-5.

The prevalence of posttraumatic stress disorder (PTSD) in very young children depends on the diagnostic criteria. Thus far, studies have investigated the International Classification of Diseases (11th rev.; ICD-11) criteria for PTSD only in samples of children older than 6 years of age. The aim of this study was to test the diagnostic agreement between the ICD-11 and the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria for children who are 6 years old and younger. Caregivers of children aged 3-6 years in foster care in Germany (N = 147) and parents of children aged 1-4 years who had attended a hospital in Switzerland following burn injuries (N  = 149) completed a questionnaire about children's PTSD. Rates of PTSD were calculated according to ICD-11 (considering a specific and a more general conceptualization of intrusive memories) and DSM-5 criteria and were compared using McNemar's tests and Cohen's kappa. The proportion of children who met the ICD-11 criteria was 0.6-25.8% lower than the proportion of PTSD cases according to the DSM-5 criteria. The diagnostic agreement between each ICD-11 algorithm and DSM-5 was moderate, κ = 0.52-0.66. A systematic investigation of adaptions of the ICD-11 avoidance cluster identified alternative symptom combinations leading to higher agreement with the DSM-5 requirements. Furthermore, DSM-5 had higher predictive power for functional impairment than the ICD-11 algorithms. In conclusion, the findings suggest that the ICD-11 criteria show less sensitivity in very young children, which can be explained by the more stringent avoidance cluster.