Sustainable transition process for young people with chronic conditions: a narrative summary on achieved cooperation between paediatric and adult medical teams.

BACKGROUND: Transfer of young people (YP) with chronic conditions to adult-centred multi-professional care (AdCC) has been discussed for decades. Generic principles for transition have been proposed, but resulting outcomes have not, on the whole, been documented and the burden of ensuring suitable transition continues to lie in the field of paediatrics. The emerging knowledge of the brain maturing into the twenties together with the enforced transfer of patients at 18.0 years of age has made paediatric clinics in Sweden reconsider their transition protocols. METHODS: Paediatrics-centred multi-professional care (PedCC) teams and AdCC teams in one administrative area participated in joint small group discussions on principles for transition during 2 days. The suggested principles were then given to next group in another administrative area for evaluation and elaboration. Thirteen such seminars with small group discussions took place consecutively. RESULTS: After this process, six core principles emerged as acceptable and essential. 1 The age of 18.0 was accepted as a reasonable age for the transfer of all patients from PedCC to AdCC. 2 A draft was developed of the knowledge and skills that PedCC should teach patients and parents before age 18, to make transfer viable. 3 A draft was made of the psychosocial needs of YP for the latter part of transition, which would be the responsibility of AdCC. 4 A self-referral note was developed, where patients present their own needs. 5 YP dropping out of needed care after transfer was considered a violation of ethical codes that required finite action. 6 Joint small group discussions between PedCC and AdCC were found to be instrumental for cooperation. Follow-up seminars demonstrated sustainability and spontaneous spreading of the principles. CONCLUSION: Small group discussions between PedCC and AdCC were pivotal in creating a sustainable process for transition. It was possible to agree on six core principles and share the responsibility between PedCC and AdCC.

Adolescent-friendly services.

UNLABELLED: The time has come to discuss adolescent-friendly services and what these should entail. CONCLUSION: The attitudes and skills of the staff are the keys to successful healthcare for the adolescent. Communication skills include providing time without parental presence. Confidentiality in the patient-provider context is important but rules and practices vary from country to country and have to be learned. The United Nations Convention on the Rights of Children is a generic framework that makes a good starting-point. Ambiguous cases should be referred to groups of professionals and lay people trained in medical ethics.

Adolescent homosexuality: we need to learn more about causes and consequences.

UNLABELLED: In this issue a descriptive study of various aspects of homosexual orientation among adolescents is presented. In agreement with previous American studies, the authors identify three separate domains of homosexuality: attraction, fantasy and self-identification. This knowledge is important in understanding an adolescent struggling with homosexual thoughts. CONCLUSION: The development of an homosexual identity is a process connected with serious health hazards related to both physical and mental health. Most adolescents are not given adequate support because heterosexuality is considered the norm in most cultures.

Health, health-compromising behaviour, sexuality and involvement in pregnancy among 18-year-old Swedish males: a cross-sectional survey.

UNLABELLED: The aim of this study was to determine whether there are differences regarding well-being, health habits and health-compromising behaviour between Swedish young men who had never had sexual intercourse (group I), those who were sexually active but without a pregnancy record (group II), and those who had caused pregnancies (group III). A self-report questionnaire was used covering questions regarding health, health habits and risk behaviour. Tests of significance for differences between the three groups were performed with chi 2-tests. Differences were found in health, health behaviour and risk-taking behaviour between the three groups of young men, with an apparent tendency towards riskier lifestyles from group I, through group II, to group III. Two especially striking findings were the more frequent use of anabolic steroids and the reported high rate of sexual offences in group III compared with groups I and II. CONCLUSION: This study highlights serious health-compromising behaviours in 18-y-old men involved in pregnancies in a medium-sized Swedish city. This group has been largely ignored both in clinical practice and in scientific studies, in contrast to the huge efforts directed towards pregnant adolescent females. Public health workers, school health programmes and adolescent clinics need to acknowledge this and work accordingly.

Cervical lymph node infections with non-tuberculous mycobacteria in preschool children: interferon gamma deficiency as a possible cause of clinical infection.

UNLABELLED: Epidemiological studies have demonstrated a prevalence of positive PPD reactions to non-tuberculous mycobacteria (NTM) in 9% of 4-5-y-old children in the Göteborg area. Very few children of this age develop suppurative infections in lymph nodes that require surgical procedures. The hypothesis was that these children might have T cell deficiencies with abnormalities of macrophage functions, particularly with type 1 cytokines. Twenty-four children who needed operations were investigated immunologically and compared to 10 children of the same age operated on for non-infectious reasons. The methods used were flow cytometry analysis of lymphocytes in blood, blood lymphocyte stimulation assays and interferon gamma analyses. The patients had significantly lower levels of interferon gamma than the controls after stimulation with Candida antigens or Con A. The numbers of T and B lymphocytes were higher in patients than in controls. CONCLUSION: Children with necrotic lymph node infections in the cervical region due to NTM had lower interferon gamma production after stimulation than healthy age-matched controls.

Gender differences in early adolescence in factors related to outcome of healthy behaviours two years later.

In this study, 390 students comprising 89.7% of the student population answered a questionnaire on health and health behaviours, socioeconomic status (SES), school, family and peer relationships, and intentions regarding behaviours at 13.5 and 15.5 y of age. The aim was to investigate whether there were gender differences in predictors of outcome of behaviours with impact on health at 15.5 y of age. Outcome dealt with three domains: health habits, acquisition of adult lifestyles, and problem behaviours. The material was analysed for correlations. Significant results were entered into multiple regression stepwise procedures. As expected, having already initiated adult lifestyles or exhibiting problem behaviours at 13.5 y were the most important factors associated with such behaviours 2 y later. Further analyses were then limited to those students who had not started such lifestyles to see what factors kept them from doing so in a 2-y period and what gender differences existed, if any. Results differed for the genders, with more boys being more concrete and behaviour-oriented, representing a sample of boys with late to normal puberty. Girls more often expressed intentions regarding behaviour, which predicted positive outcomes. Both genders were prudent in most areas studied: they were well adapted at school, had positive self-esteem and were not moving in circles where smoking and drinking were abundant. The conclusion is that young adolescents who do not start risky behaviours between the ages of 13 and 15 y live in a supportive context, which allows for positive interactions. The next step would be to investigate if alternative strategies may be used to implement similar options for those who lack such support in their natural environment.

Do adolescents' own intentions regarding healthy behaviours affect outcome? A two-year prospective study.

Adolescents' own intentions regarding health behaviours, in addition to their context, are believed to be important for the health habits they chose. This was studied prospectively over a 2-y period. A total of 552 students, 391 aged 13 y and 161 aged 15 y, reported their health and problem behaviours, socioeconomic background and intentions regarding health behaviours through questionnaires in 1991 and in 1993. Outcome dealt with three domains: health habits; acquisition of adult lifestyles; and problem behaviours. The material was analysed for correlations. Significant results were entered into multiple regression stepwise procedures. As expected, already having initiated adult lifestyles or problem behaviours were the most important factors associated with such behaviours 2 y later. Further analyses were then limited to those students who had not started such lifestyles, in order to determine what factors kept them from doing so in a 2-y span. Key predictors for healthy behaviours were adolescents' own decisions not to engage in adult lifestyles or risky behaviours, family processes consistent with support and school satisfaction. Association with peer groups where smoking and drinking were commonplace predicted less optimal behaviours. Gender or socioeconomic factors were not predictive. The results support a comprehensive approach to health promotion during adolescence.

Health and health behaviours among Swedish adolescents during a period of social change.

In Sweden there have been cutbacks in the welfare system and increasing unemployment during the 1990s. In what way have these external factors influenced health and behaviour among adolescents? The study describes health profiles and behaviours among students in three schools in Gothenburg, Sweden. Results are based on 2284 self-reports, representing 88% of available students in 7th and 9th grades with mean ages of 13.5 and 15.5 y, respectively. The study questionnaire was administered four times, in 1990, 1992, 1994 and 1996. The reported health and behaviours showed remarkable stability over the period. When the surveys from 1990 and 1992 were aggregated and compared with the surveys of 1994 and 1996 there was a small increase in psychosomatic symptoms, mental health symptoms and risk-taking behaviours. Despite the drastic social changes during the 1990s there was only a small change for the worse in reported health and behaviours. It is possible that the external changes had little impact on adolescent networks, or that the period was too short to have had much impact on health and behaviour.

Depot medroxyprogesterone acetate (Depo-Provera) and levonorgestrel (Norplant) use in adolescents among clinicians in Northern Europe and the United States.

PURPOSE: To compare attitudes and practices related to clinicians' use of depot medroxyprogesterone acetate [Depo-Provera (DMPA)] and levonorgestrel implants in adolescents in three northern European countries and the United States. METHODS: Between the fall of 1993 and the winter of 1995, surveys eliciting clinician attitudes and practices with the two contraceptive methods were collected from practitioners who provide contraceptive care to teens in Sweden (n = 282), The Netherlands (n = 197), Great Britain (n = 108), and the United States (n = 548). RESULTS: Clinicians in Great Britain and the United States reported prescribing of DMPA, selected DMPA in their top three choices for contraception in teens, and had patients ask about DMPA more frequently than clinicians in Sweden or The Netherlands (p < 0.0001). U.S. clinicians were more likely to report prescribing of the implants, list them as a top choice, and have patients ask for it more frequently than were providers in the other three countries (p < 0.0001). Noncompliance with previous contraceptives was the most common indication for use of either method in this age group. "Worst fears" with DMPA use included infertility, particularly among Swedish clinicians (p < 0.0001), as was pregnancy and loss to follow-up, particularly among British clinicians (p < 0.0001). Condom nonuse was a concern associated with both methods. Breakthrough uterine bleeding was a concern related to implant use, particularly among Swedish practitioners (p < 0.0001). CONCLUSION: Clinicians in the United States and Great Britain display more enthusiasm toward the use of the long-term progestins in adolescents than do clinicians in Sweden or The Netherlands. Continuing education programs could be designed to educate clinicians to allay their concerns about these contraceptives in countries where teen pregnancy is considered a problem.

Health habits and risk behavior among youth in three communities with different public health approach.

BACKGROUND: There is a consensus today that comprehensive public health activities including many actors are needed for impact on health compromising behaviors. However, few studies are available to document long term effects regarding youth. We identified three rural, demographically comparable communities dominated by nuclear middle class families. One of these communities demonstrated comprehensive public health activities directed towards adolescents' needs and life-styles for a duration of at least 15 years, while the other two had an outspoken ideology of relying only on national health promotion. METHODS: Local health planners and pediatricians performed in-depth interviews with key people and checked relevant reports to trace the local public health history and to assess conventional and unconventional activities regarding health promotion for adolescents in the three communities. The outcome of at least 15 years of different policy regarding health promotion was studied in 1991 through self-reports of 915 subjects, 13-16 years old, with a questionnaire distributed through schools with questions on health, health habits and health compromising behaviors. The study itself turned out to be an important intervention. The two "inactive" communities changed their policy and methods. For this reason a second survey was done in 1993 with 593 subjects 13-16 years in the "active" and in one of the "inactive" communities. RESULTS: The adolescents in the "active" community with a long duration of energetic and comprehensive public health activities consistently demonstrated better mental health, health habits and less risk behavior in contrast to the state in the two "inactive" communities. Two years of active work in the "inactive" communities marginally improved health there. CONCLUSION: This study suggests that consistent and comprehensive public health activities might have reduced risk taking behavior and improved health and health habits during mid-adolescence.

Self-assessment of sexual maturity by mid-adolescents based on a global question.

The objective of this research was to investigate the use of a global question for evaluation of body development relative to age-mates in addition to graded statements on sexual maturity (SM) as part of self-reports on pubertal development. In total, 4516 adolescents answered written questions on pubertal development and the global question. They represented a normative Swedish sample. To validate these results, 100 mid-adolescents were asked to answer the statements regarding SM and the global question. This was compared with ratings made by two professional examiners for each young person. The outcome of the population study was evaluated against standard biological timetables and demonstrated adequate agreement. In the validation study, the inter-rater agreement between the professionals was excellent and so were professional ratings against those of the adolescents, with one exception: boys rating of their public hair. The global question alone gave the best agreement on pubertal progress. We can conclude that the global question is a valid tool for evaluation of pubertal development during mid-adolescence in population surveys.

Physical fighting and associated health behaviours among Swedish adolescents.

OBJECTIVE: To investigate the prevalence of physical fighting among Swedish adolescents and to compare the health profile and risk-taking behaviour of the fighters with a non-fighting "diplomatic" group. METHODS: Results are based on 4516 self-reports, representing 82% of available students with mean age of 13.5, 15.5 and 17.5 years. RESULTS: Among 13.5-year-olds, 22% of males and 5% of females reported three or more fights. Fighting decreased with age. Significantly more fighters reported problem behaviours and fewer had healthy habits than the "diplomats". Significantly more fighters also suffered from psychosomatic disorders and injuries requiring medical services. Twenty percent of the fighting males stated that they would definitely continue to fight. CONCLUSION: The data indicate that physical fighting is strongly associated with other problem behaviours, which needs to be considered when designing prevention and intervention.

Adaptation of adopted foreign children at mid-adolescence as indicated by aspects of health and risk taking--a population study.

PURPOSE: There is very little data available on adaptation at adolescence after "visible adoptions" (children adopted from abroad), in terms of mental health, risk-taking and problem behaviour in comparison with nonadopted adolescents. This study describes such an outcome. MATERIAL AND METHOD: Data derived from self-reports from 125 adolescents aged 13-18 years who identified themselves as adopted, and who participated in two epidemiological surveys of 9329 adolescents. Their number was representative for children adopted from abroad. The other adolescents served as controls. RESULTS: Family life styles showed no differences between groups. Health was similar to that of the controls. Foreign adopted adolescents significantly often evaluated themselves as shorter and with early puberty. The proportion of adopted girls with suicidal thoughts was significantly larger, they also reported school truancy, not using safety belts, sexual intercourse, unpleasant sexual encounters, and contact with illicit drugs more often than the controls. The stress of early puberty could only partly explain this. CONCLUSIONS: Girls adopted from abroad, representing "visible adoptions", need additional attention and study during adolescence to expose causes for maladaption among some of them.

Temporary intrathoracic adenopathy in children--a response to infection caused by non-tuberculous mycobacteria?

Two children, 4 and 8 years old, were skin tested with sensitins and found to have indurations of 20 mm. Sensitins are tuberculins deriving from non-tuberculous mycobacteria. The children showed pathological enlargement of mediastinum on chest radiography. They were further examined, and no findings supported malignancy nor tuberculosis. The chest radiographs were normalizing within a few months. The large sensitin reactions together with the other findings indicate that the children had been infected with non-tuberculous mycobacteria.

Normative developmental behavior with implications for health and health promotion among adolescents: a Swedish cross-sectional survey.

I describe behavior with impact on health in adolescents against the background of characteristics of the Swedish society and analyse possible areas for improvement. A total of 4500 adolescents, aged 13-18 yr, in seven areas answered an anonymous questionnaire. Their socioeconomic backgrounds reflected mainstream adolescents. The response rate was 80-85%. Questions concerned health habits, exploratory behaviors regarding sexuality, use of alcohol and tobacco, problem behaviors, such as getting drunk, and life quality. There was very little experimentation with regard to health habits learned in childhood. Rapid adaptation to adult life-styles occurred, which was similar in both sexes in the younger age groups, but there were significant differences among older students. Alcohol use is of considerable concern. Adolescent prediction of future behavior indicated that negative behaviors require intervention. Parental influence on adolescent behavior needs to be explored. Peer groups could be an additional area for intervention.

Inhalation of racemic adrenaline in the treatment of mild and moderately severe croup. Clinical symptom score and oxygen saturation measurements for evaluation of treatment effects.

The aim of this study was to evaluate the immediate effect of inhaling racemic adrenaline to treat croup and to evaluate a scoring system. Two groups were investigated. One group inhaled a racemic adrenaline solution and the other group received the same solution with no racemic adrenaline. The study was double-blinded and placebo-controlled. Fifty-four children (0.4-10.8 years) with mild to moderately severe croup were included in the study after clinical evaluation. The clinical score was useful when evaluating the treatment effects in mild to moderately severe croup and may be used as a quality assurance tool when treatment protocols are re-evaluated. Oxygen saturation before and after treatment did not change significantly in either group and therefore its measurement did not provide additional information on the effect of treatment. In both groups, a significant improvement in total mean clinical scores was seen 30 min after inhalation, compared with before inhalation (p < 0.001). However, racemic adrenaline was significantly better than placebo in terms of improvement in total clinical score, inspiratory stridor, retractions and air entry, and should therefore be used as first-line treatment.

Palpable lymph nodes of the neck in Swedish schoolchildren.

We studied 3592 Swedish schoolchildren, 8 or 9 years old, examined for palpable submandibular, cervical and supraclavicular lymph nodes. All children were skin tested with 2 TU PPD RT23 and with 0.1 microgram of Mycobacterium avium sensitin or 0.1 microgram of M. scrofulaceum sensitin. A total of 991 children had palpable lymph nodes in any of the three locations. Among them, 811 had lymph nodes in one location, 162 in two locations and 18 in three. In 312 children, the lymph nodes were > or = 5 mm in size in any location. The most common location was submandibular. Boys had a significantly higher prevalence of palpable lymph nodes than girls. There was also seasonal variation. Children infected by atypical mycobacteria (sensitin reaction > or = 6 mm) did not have a higher prevalence of palpable lymph nodes than those not infected.

Self-reported health status and use of medical care by 3,500 adolescents in western Sweden. II. Could clustering of symptoms and certain background factors help identify troubled young people?

A descriptive study has been reported regarding some 3,500 persons aged 13-18, who anonymously answered a questionnaire regarding their health. This is a further analysis of the data from this study. The main finding is that students seem to say important things about themselves by "somatizing". Roughly one third of the students who stated that they were not feeling healthy had had suicidal thoughts, while only one tenth of those who stated they were healthy said they had had such thoughts. School drop-outs who might have serious troubles, were overrepresented among those with many medical complaints, suicidal thoughts and high rates of self-initiated medical visits. "Bad mood" turned out to be another such marker of distress with high rates of medical complaints and medical consultations. Admitting to use of alcohol, cigarettes and or illicit drugs was also related to aspects of bad health. Female gender and not living with both parents were correlated with significant adolescent distress. A factor called "perceived social age" also turned out to be significantly connected with distress. This factor was the difference between chronological age and the adolescent's estimation of what age others perceived him as being. Those who indicated a perceived social age of at least two years above their chronological age were more depressed, had more medical complaints and more often used alcohol and cigarettes than those who perceived themselves as "socially the right age". The present study does not permit conclusions as to what was considered the basis for "perceived social age".